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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Table of Contents
    Part I: Principles of Pain Management

    General Principles Pain Pathophysiology Pharmacologic Approaches to Pain Management

    General Principles

    General Principles of Pain Assessment

    • The process of pain management starts with adequate assessment of the pain
    • The absence of appropriate assessment is the leading reason for poor pain management
    • A comprehensive pain assessment addresses the pain's:

    Pain assessment is discussed in detail in Module 3: Whole Patient Assessment

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    General Principles of Pain Management

    A comprehensive pain management strategy includes:

    • Use of appropriate interventions
      • Pharmacologic
      • Nonpharmacologic
    • Education of the patient, family, and all caregivers about the plan
    • Ongoing assessment of treatment outcomes
    • Regular review of the plan of care
    • Use of other members of the interdisciplinary team, including:
      • Nurses
      • Social workers
      • Pharmacists
      • Chaplains
      • Physiotherapists
      • Occupational therapists
      • Child life specialists
    • Flexibility is essential—successful plans are tailored to the individual patient and family
    • Willingness to ask for help from colleagues with more expertise when the plan is not effective at controlling the patient’s pain

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    Pain Pathophysiology

    Acute vs. Chronic Pain

    Acute pain

    • Is usually related to an easily identified event or condition
    • Usually resolves within a period of days or weeks
    • Is usually nociceptive

    Chronic pain

    • May or may not be related to an easily identified pathophysiologic phenomenon
    • May be multifactorial
    • May be present for an indeterminate period

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    Nociceptive Pain

    • Nociceptive pain is presumed to involve:
      • Direct stimulation of intact mechanical, chemical, or thermal nociceptors
      • Transmission of electrical signals along normally functioning nerves
    • It can be subdivided into 2 subgroups:
      1. Somatic pain
        • Involves skin, soft tissue, muscle, and bone
        • Due to stimulation of the somatic nervous system
        • Patients may describe this as sharp, aching, and/or throbbing pain that is easily localized

      2. Visceral pain
        • Involves cardiac, lung, GI and GU tracts
        • Results from stimulation of the autonomic nervous system
        • Patients may find this pain difficult to describe or localize
    • Nociceptive pain generally responds well to opioids and/or coanalgesics

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    Neuropathic Pain

    • Neuropathic pain is presumed to result from disordered function of the peripheral or central nervous system (CNS) due to any of many potential causes, including:
      • Compression
      • Transection
      • Infiltration
      • Ischemia
      • Metabolic injury
    • There are varied subtypes, including:
      • Those sustained by peripheral processes (e.g., painful neuroma)
      • Those sustained by CNS processes (e.g., phantom pain)
      • Complex regional pain syndromes (previously referred to as causalgia or reflex sympathetic dystrophies)
    • These pains can also be classified by syndrome (e.g., malignant plexopathy, painful polyneuropathy, phantom pain, postherpetic neuropathy, etc)
    • Patients tend to describe neuropathic pain with words like burning, tingling, numbness, shooting, stabbing, or electric-like feelings
    • The intensity of pain involved may exceed observable injury
    • Although neuropathic pain may respond well to opioids, adjuvant analgesics (tricyclic antidepressants, anticonvulsants, antiarrhythmics, etc) are often required in combination with opioids to achieve adequate relief

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    Additional Information about Pain Pathophysiology

    • Acute and chronic pain may be conceptualized as either nociceptive or neuropathic in origin
    • A broad description of the predominating pain pathophysiology can usually be inferred through:
      • Patient description
      • Physical findings
      • Results of laboratory tests and imaging studies
    • The International Association for the Study of Pain (IASP) has published precise definitions and made them available on their web site http://www.iasp-pain.org
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