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Pain and Its Management

Persis Mary Hamilton, RN, CNS, MS, EdD

Courses are approved by CECBEMS and the California Emergency Medical Services Authority. For more information about accreditation, click here. Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.

Also available:
Oregon: Pain and Its Management (meets OR-mandated requirements)
Michigan: Pain and Symptom Management (meets MI BoN requirements)
West Virginia: End of Life Transition Including Pain Management (meets WV-mandated requirements)

PART 1     The Nature and Experience of Pain

THE NATURE OF PAIN

Pain is a universal human experience and the most common reason people seek medical care. Pain tells us something is wrong in the structure or function of our body and we need to do something about it. Because pain is such a strong motivator for action, it is considered one of the body's most important protective mechanisms.

Definitions of Pain

The International Association for the Study of Pain defined pain as "an unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (1979)." Pain, however, is much more than a physical sensation caused by a single entity. It is subjective and highly individual, a complex mechanism with physical, emotional, and cognitive components.

Pain cannot be objectively measured in the same way as, for example, the chemical content of urine or the oxygen content level of blood. Only the person who is suffering knows how the experience feels. For these reasons, McCaffery defined pain as "whatever the experiencing person says it is and whenever he says it does (1979)." The American Pain Society goes further by stating that it is "not the responsibility of clients to prove they are in pain; it is the nurse's responsibility to accept the client's report of pain (2005)."

Comfort: The Absence of Pain

Pain alters the quality of life more than any other health-related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization. Surprisingly, even though pain is such an important obstacle to comfort, it is one of the least understood, most under-treated and oft-discounted problems of healthcare providers and their clients. For this reason, some nurses add "comfort" to Maslow's hierarchy of basic human needs (1968). The American Pain Society goes further, declaring the relief of pain a "basic human right (2005)" and the American Bar Association called it a "basic legal right (2000)."

Characteristics of Pain

Traditionally, pain was considered merely a physical symptom of illness or injury, a simple stimulus-response mechanism. Though the historic role of nurses has been to relieve pain and suffering, there has been little understanding of the complexity of pain and there have been only limited ways to manage it. Recent research shows pain to be a distinct disorder, with physical, emotional, and cognitive components. This view of pain has broadened our understanding of pain and given us new ways to understand its characteristics, as described in Box 1-1.

Types of Pain

Acute pain has an identifiable cause and occurs soon after an injury to tissues in the body, such as bone, skin, or muscle. Acute pain is protective in that it motivates a person to take action. Its onset may be sudden or slow and its intensity may vary from mild to severe. Acute pain is temporary and subsides as healing takes place. Severe acute pain activates the sympathetic nervous system, causing diaphoresis, increased respiratory and pulse rates, and elevated blood pressure.

Chronic pain lasts beyond the expected healing phase, is nonprotective in that it serves no purpose, and may not have an identifiable cause (Patterson, 2007). When pain lasts more than 3 months it crosses from a "symptom" to a "condition." It is described as nonmalignant (noncancerous) and malignant (cancerous). Nonmalignant, noncancerous chronic pain typically accompanies such conditions as osteoarthritis and peripheral neuropathy. The lack of purpose, and uncertainty of duration, of chronic pain may lead to depression, fatigue, insomnia, anorexia, apathy, and learned helplessness. Severe, chronic pain—like prolonged stress—activates the parasympathetic nervous system, resulting in muscle tension, decreased heart rate and blood pressure, and failure of body defenses. Chronic pain is one of the most pervasive and intractable medical conditions in the United States, afflicting more than 1 in 5 Americans.

Malignant, cancerous chronic pain may be due to tumor progression, invasive procedures, toxicities of treatment, infection, and physical limitations. Such pain may be felt at the tumor site or some distance from it. Since clients with cancer may experience both chronic and acute pain, caregivers need to investigate any new pain in these clients immediately.

Sources of Pain

The sources of pain are divided into three main categories: nociceptor, non-nociceptor, and psychogenic, as shown in Table 1-1, below.

Nociceptor pain results when tissue damage produces a pain-producing stimulus that sends an electrical impulse across a pain receptor (nociceptor) by way of a nerve fiber to the central nervous system. Nociceptor pain in further divided into visceral and somatic pain. Visceral pain results from stimulation of nociceptors in the abdominal cavity, and thorax. Somatic pain is divided into deep somatic and cutaneous pain. Deep somatic pain arises from bones, tendons, nerves, and blood vessels. Cutaneous pain originates in the skin or subcutaneous tissue. Some body tissues, such as the brain and lung, have no nociceptors and some tissues have many.

Non-nociceptor (neuropathic) pain is caused by direct injury to structures of the nervous system.

Psychogenic pain is pain for which there is little or no physical evidence of organic disease or identified injury to tissues in the body. However, lack of evidence does not mean the client is not suffering or is malingering.

TABLE 1-1

PHYSIOLOGIC SOURCES OF PAIN

Nociceptor: visceral
Physiologic structures	Organs and linings of body cavities
Mechanism	Activation of nociceptors
Characteristics	Poorly localized, diffuse, deep, cramping or splitting
Sources of acute pain	Chest tubes, abdominal tube drains, bladder and intestinal distention
Sources of chronic pain syndromes	Pancreatitis, liver metastases, colitis
Nociceptor: somatic
Physiologic structures	Cutaneous: skin and sub-cutaneous tissues Deep somatic: blood, muscle, blood vessels, connective tissue
Mechanism	Activation of nociceptors
Characteristics	Well-localized, constant and achy
Sources of acute pain	Incisional pain, insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms
Sources of chronic pain syndromes	Bony metastases, osteo- and rheumatoid arthritis, low-back pain, peripheral vascular disease
Non-nociceptor: neuropathic
Physiologic structures	Nerve fibers, spinal cord, and central nervous system
Mechanism	Non-nociceptive injury to nervous system structures
Characteristics	Generalized along distribution of damaged nervous structures
Sources of acute pain	Poorly localized: shooting, burning, fiery, shock-like, sharp, painful numbness
Sources of chronic pain syndromes	Nervous tissue injury due to diabetes, HIV, chemotherapy, neuropathies, postherpetic neuralgia
Psychogenic
Physiologic structures	No organic structures
Mechanism	Emotional
Characteristics	Variable, often numerous
Sources of acute pain	Nonorganic
Sources of chronic pain syndromes	Nonorganic psychological factors
Source: Adapted with permission from Ignatavicius et al., 1999.

PHYSIOLOGY OF PAIN

Though a person is not consciously aware of the process, the experience of pain involves a complex sequence of biochemical and electrical events or processes beginning with tissue damage, followed by transduction, transmission, perception, and modulation. See Figure 1-1.

Figure 1-1    Neurological transmission of pain stimuli. Illustration by Jason McAlexander. Copyright © Wild Iris Medical Education.

Tissue Damage

Typically, when tissue damage occurs it releases inflammatory chemicals, called excitatory neurotransmitters, such as histamine and bradykinin, a powerful vasodilator. These substances cause the injured area to swell, redden, and become tender. Bradykinin also stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.

Transduction

Transduction occurs as the energy of the stimulus is converted to electrical energy.

Transmission

Transmission of the stimulus takes place when energy crosses into a nociceptor at the end of an afferent nerve fiber. Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C-fibers. A-fibers send sharp, distinct sensations that localize the source of the pain and detect its intensity. C-fibers relay impulses that are poorly localized, burning, and persistent. For example, after burning a finger, a person initially feels a sharp localized pain as a result of A-fiber transmission.

Within a few seconds the pain becomes more diffuse and widespread, as a result of C-fiber transmission. Pain stimuli travel quickly to the substantia gelatinosa in the dorsal horn of the spinal cord where the "gating" mechanism (discussed later) occurs. Pain impulses then cross over to the opposite side of the spinal cord and ascend to the higher centers in the brain via the spinothalamic tracts and on to the thalamus and higher centers of the brain, including the reticular formation, limbic system, and somatosensory cortex.

Perception

When pain stimuli reach the cerebral cortex, the brain interprets the signal, processes information from experiences, knowledge, and cultural associations, and perceives pain. Thus, perception is the awareness of pain. The somatosensory cortex identifies the location and intensity of pain, and the associated cortex determines how an individual interprets its meaning.

Modulation

Once the brain perceives the pain, the body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and gamma aminobutyric acid. These chemicals hinder the transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition of the pain impulse is called modulation. The descending paths of the efferent fibers extend from the cortex down to the spinal cord and may influence pain impulses at the level of the spinal cord.

Gate-Control Theory

Melzack and Wall proposed the gate-control theory to explain the relationship between pain and the emotions (1982). According to the theory, a gating mechanism occurs when a pain impulse travels to the substantia gelatinosa in the dorsal horn of the spinal cord. There, trigger cells (T-cells) influence the transmission of pain impulses. When their activity is inhibited, the gate closes and impulses are less likely to be transmitted to the brain. This mechanism is controlled by descending nerve fibers from the thalamus and cerebral cortex, areas of the brain that regulate thought, beliefs, and emotions. The gate-control theory helps explain how the thoughts and emotions of a person modify the perception of pain and why interventions such as imagery and distraction help relieve it.

FACTORS THAT INFLUENCE PAIN

The perception of pain is influenced by physiologic, psychological, and cultural factors, all of which must be considered by caregivers.

Physiologic Factors

Age affects the way people respond to pain. It influences both the development and decline of the nervous system. Aging affects the whole body, exposing the older adult to painful degenerative disorders such as osteoarthritis, painful secondary injuries such as skin abrasions and fractures, and painful surgical procedures such as cataract and hip replacement. Age also affects the way nurses and families respond to a complaint of pain. For example, a nurse may be more sympathetic toward a toddler than an adolescent or a young adult. Table 1-2 gives a brief overview of the perception of pain relative to age. The management of pain in children and older adults will be discussed in greater depth in Parts 4 and 5 of this course.

TABLE 1-2

AGE AND THE PERCEPTION OF PAIN

Age	Pain perception
Pre-term infants	Have anatomical and functional ability to process pain by mid to late gestation; seem to have greater sensitivity to pain than term infants or children
Newborn infants	Response to pain is inborn and does not require prior learning; respond to pain with behavioral cues: facial, crying, body movement
Infants 1 month	Infants can metabolize analgesics and anesthesia effectively; can increasingly recognize caregiver as comforter
Toddlers / Preschoolers	Can describe pain, its location and intensity; respond to pain by crying, anger, and sadness; may consider pain a punishment; may hold someone accountable for pain and remember experiences in a certain location such as a clinic
School-age children	May try to be brave when facing a painful procedure; may regress to earlier stage of development; seek to understand reasons for pain
Adolescents	May be slow to acknowledge pain; may consider showing signs of pain a weakness; with persistent pain may regress to earlier stages of development
Adults	Fear of pain may prevent some adults from seeking care; may believe admission of pain is a weakness and inappropriate for age or sex; may consider pain a punishment for moral failure
Older adults	May have decreased sensations or perceptions of pain; may consider pain an inevitable part of aging; chronic pain may produce anorexia, lethargy, and depression; may not report pain due to fear of expense , possible treatment, and dependency; often describe pain in nonmedical terms such as "hurt" or "ache"; may fear addiction to analgesics; may not want to bother nurses or be a "bad client"

FATIGUE

Fatigue decreases coping abilities and heightens the perception of pain. When people are exhausted from physical activity, stress, and lack of sleep, their perception of pain is heightened. Thus, rest from physical, emotional, and social demands as well as sleep are important measures that reduce pain.

GENETIC MAKEUP

Recent research suggests that sensitivity to and tolerance for pain may a genetically linked trait (Ruda et al., 2000). This factor does not negate the need for adequate pain management of all clients.

MEMORY

Memory of painful experiences, especially experiences that occur when a child was very young, may increase sensitivity and decrease tolerance to pain. This may be due to anticipation and fear of a specific painful event, such as repeated immunization injections. Sensitivity to pain is increased when there is nonspecific memory of a painful event, such as newborn circumcision without anesthesia. Fortunately, modern medicine no longer condones such draconian practices.

STRESS RESPONSE

Research has shown that "severe, unrelieved pain can cause an overwhelming stress response in both pre-term and full term infants which can lead to serious complications and even death (Pasero, 2004).

NEUROLOGIC FUNCTION

Any factor that interrupts or interferes with normal pain transmission affects the awareness and response of clients to pain and places them at risk for injury. Analgesics, sedatives, and alcohol depress the functioning of the central nervous system and some diseases (such as leprosy, or Hansen's disease) damage peripheral nerves, decrease sensitivity to touch and pain, and render affected individuals more vulnerable to injury.

Psychological Factors

FEAR AND ANXIETY

The relationship between pain and anxiety is complex and difficult to manage. Fear tends to increase the perception of pain and pain increases feelings of fear. This connection occurs in the brain because painful stimuli activate portions of the limbic system believed to control emotional reactions. People who are seriously injured or critically ill often experience both pain and heightened levels of anxiety due to their helplessness and lack of control. Nurses need to address both pain and anxiety, using all appropriate measures to relieve suffering.

COPING

People manage pain and other stressors of life in different ways. Some see themselves as self-sufficient, internally controlled, and independent. As a result, they may deny or be slow to admit they are in pain. Others see themselves as insufficient, externally controlled, and dependent on others to treat their pain. Self-sufficient, internally controlled people may do better with patient-controlled analgesia (PCA), whereas dependent, externally controlled individuals may prefer nurse-administered analgesia. No matter what the coping style, it is the responsibility of caregivers to relieve pain.

Cultural Factors

Cultural beliefs and values affect the way people respond to pain. As children they learn what is and what is not acceptable behavior when in pain. In some cultures, any expression of pain is considered cowardly and shameful. In others, noisy demonstrations of pain are expected and acceptable. The meaning of pain itself may be markedly different in different cultures. Some ethnic groups see pain as a punishment for wrongdoing. Others see pain as a test of faith, and still others view pain as a challenge to be overcome. Recent immigrants to America are more likely to view pain from their cultural roots. Regardless of language, religion, or situation, nurses respect every individual and strive to alleviate pain and suffering.

STANDARDS AND GUIDELINES FOR PAIN MANAGEMENT

Because pain is so important to the provision of healthcare today, many organizations have developed standards by which those who provide healthcare can measure their practice. Two such organizations are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, Box 1-2) and American Academy of Pediatrics (AAP, Box 1-3). These standards indicate how seriously these national organizations view the reduction of pain and provision of comfort for people of all ages.

PART 2     Pain and the Nursing Process

The nursing process includes assessment, diagnosis, planning, intervention, and evaluation. All are involved as the nurse addresses pain management.

ASSESSING PAIN

Pain is a red flag, telling us there is a problem somewhere in the body that needs fixing. In fact, it is such an important indicator of health, pain assessment has been called the "fifth vital sign," joining temperature, pulse, respiration, and blood pressure. However, until we know more about the pain, we cannot fix the problem. To do this, like detectives solving a murder mystery, nurses gather information from as many sources as possible, especially the primary source, the person in pain. The investigation includes a comprehensive pain history, behavioral observations, appropriate physical examination, and consultation with other healthcare professionals.

History

The pain history can be obtained from written documents and from interviews with persons in pain, parents, and/or caregivers. The pain history asks specific questions about the location, intensity, quality, and history of the pain, as shown in Box 2-1. In some facilities these questions are printed on an assessment form, with space for answers to be recorded beside each question. Parts 4 and 5 of this course discuss the assessment of pain in children and special populations.

BEHAVIORAL OBSERVATIONS

People who suffer pain usually show it, either by verbal complaint or nonverbal behaviors. Table 2-1 lists some typical nonverbal behaviors nurses may observe when they assess people are in pain.

TABLE 2-1

NONVERBAL BEHAVIORS INDICATING PAIN

Facial expressions	Vocalizations	Body movement	Social interaction
Clenched teeth Wrinkled forehead Biting lips Scowling Closing eyes tightly Widely opened eyes or mouth	Crying Moaning Gasping Groaning Grunting	Restlessness Protective body movement Muscle tension Immobility Pacing Rhythmic movement	Silence Withdrawal Reduced attention span Focus on pain relief measures

PHYSICAL EXAMINATION

When clients complain of pain or show it by their behavior, nurses immediately take action to find the cause. Assessment is most effective if the pain history interview and behavioral observations are conducted at the same time as the physical examination. For example, if a client complains of acute pain on the sole of a foot, the nurse visually examines the foot for unusual signs, observes the person for behavioral cues of pain, and asks about the onset, intensity, quality, and pattern of the pain and what makes it worse or better. If the cause is not identified immediately, the nurse refers the client for further assessment.

DIAGNOSING PAIN

An accurate diagnosis depends on a appropriate assessment, focusing on the exact nature of the pain. The more specific the diagnosis, the more effective the intervention to alleviate the pain and minimize complications. The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic. A complete nursing diagnosis, however, goes further. After identifying whether the pain is acute or chronic, it adds, "related to" the medical diagnosis. For example, "chronic pain related to osteoarthritis of the left hip." Then, it adds, "manifested by" and lists the various symptoms experienced by the client. Thus, a complete diagnosis might be "chronic pain, related to osteoarthritis, manifested by stabbing pain in the left hip with weight-bearing." The advantage of clear, specific information is that it leads to more effective interventions. In this case, an appropriate intervention might be an assistive devise such as a cane or walker and referral to an orthopedic surgeon for further evaluation.

PLANNING AND INTERVENING TO MANAGE PAIN

During the planning stage, nurses synthesize information from many sources and plan appropriate interventions. The goal of interventions is to relieve pain and facilitate the highest possible level of functioning. Practically speaking, this means identifying what activity the pain is preventing and what level of pain is permissible for return of function. For the client described above who had chronic hip pain, the activity the pain is preventing is mobility.

Basic to every strategy for managing pain is showing respect for the validity of a client's experience of pain. To communicate respect, nurses:

• Acknowledge pain and take action to manage it.
• Give accurate information, to reduce anxiety and facilitate relief of pain.
• Reduce environmental stressors that add to the experience of pain.
• Encourage disclosure of feelings and fears.
• Provide privacy and maintain confidentiality.

Planning interventions means setting goals and collaborating with clients and other healthcare professionals to provide specific measures to manage the pain. These interventions may be independent or collaborative. Independent nursing actions fall within the scope of nursing practice and include controlling the environment, giving emotional support, and providing comfort. Collaborative nursing actions involve cooperative interventions with other members of the healthcare team.

Goal setting involves identifying attainable objectives and reasonable priorities. Because every person is different, the nurse discusses various alternatives with the client and together they set priorities. For example, after consulting an orthopedic surgeon, the person with osteoarthritis decides to delay hip replacement surgery and maintain mobility as long as possible, using analgesics for pain and a cane for safer mobility.

Nontraditional Interventions

Because of society's expectation that pain and suffering can be controlled, an increasing number of people have turned to nontraditional, folk-healing theories and practices. In 1991, to protect the public from fraud and quackery, the federal government established the Office of Alternative Medicine. In 1998 it re-established the agency as the National Center for Complementary and Alternative Medicine (NCCAM), making the center one of 27 institutes and centers of the National Institutes of Health within the Department of Health and Human Services.

The mission of NCCAM is to explore "complementary and alternative healing practices in the context of rigorous science, train…researchers, and disseminate authoritative information to the public and professionals (NCCAM, 2007).

In this context, "complementary" means the use of nontraditional healing theories and practices to supplement traditional, science-based theories and practices. For example, holistic nurse practitioners, holistic medical doctors, and doctors of osteopathy use nontraditional healing practices to supplement traditional interventions. Holistic medicine views health and illness as affecting the whole person—body, mind, and spirit (Diluzio & Spillane, 2002). "Alternative" means the sole use of nontraditional, folk medicine. The major categories of nontraditional medicine are:

• Biologic (herbal mixtures, macrobiotic diets; orthomolecular: megadoses of vitamins, magnesium, melatonin, etc.)
• Energy fields (acupuncture, therapeutic touch, pulse fields, Reiki, etc.)
• Manipulative and body-based: (chiropractic, lymphatic drainage, reflexology, aromatherapy, deep-muscle massage, shiatsu, etc.)
• Mind-body (biofeedback, hypnosis, art therapy, prayer, etc.) (Diluzio & Spillane, 2002)

Examples of these four categories follow.

BIOLOGIC INTERVENTIONS

Herbal mixtures made from plants have been used to treat human ailments throughout history. Their therapeutic effects are due to the chemical compounds they contain. Such chemicals may be administered to patients by giving some part of a plant or by extracting or synthesizing the essential chemical. When in a purified form, the dose is more precise than it can be from the crude plant. Common active chemicals derived from plants are: digitaloid found in foxglove (digitalis), saponins found in sarsaparilla (irritant laxatives), alkaloids found in nightshade (atropine), and alkaloids found in the opium poppy (morphine) (McGuigan HA, Krug EE, 1942).

ENERGY-FIELD INTERVENTIONS

Acupuncture is an invasive procedure that involves insertion of very fine, solid needles at various points in the body to relieve pain. It is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body. When they are out of balance, pain and illness result. There are about a thousand acupuncture points along these meridians, each of which correspond roughly to hypersensitive areas in muscle and connective tissue. The theory posits that pain is relieved when the correct point is stimulated. Acupuncture may also release endorphins and stimulate large nerve fibers to "close the gate" in the spinal cord to pain impulses (Wikipedia, 2007).

MANIPULATIVE AND BODY-BASED INTERVENTIONS

Chiropractic is a system of therapy founded by David Palmer, a grocer in Davenport, Iowa. In 1895, Palmer is said to have delivered a sharp thrust to a prominent vertebra in the upper spine of a deaf man, where upon the man's hearing returned. Palmer believed, as do his followers, that adjustment of bones of the spine releases pressure on nerves and heals the body. Thus, many chiropractors identify themselves as family practitioners, though in most states they are not licensed to prescribe drugs or perform surgery. Research as to the effectiveness of chiropractic treatment for pain is complicated because of the subjective nature of pain. For this reason, some mainstream healthcare systems offer chiropractic treatment for patients who choose it.

Osteopathy is a medical specialty that combines traditional and nontraditional medicine. Practitioners, or doctors of osteopathy (DOs), practice traditional, science-based medicine, and are licensed to perform surgery and prescribe drugs. They "take a holistic view of the body as an integrated system and approach prevention, diagnosis, and treatment by way of the musculoskeletal system" (Asher, 2007).

MIND-BODY INTERVENTIONS

Biofeedback is a method of treating chronic pain and some stress-related conditions. It uses an electric device to gather information about physical responses and report them back to clients. The information goes to the biofeedback machine by way of electrode sensors placed on the person's skin. The machine displays information as visual signals on a monitor. As clients watch the signals, they learn to control their responses.

Traditional Interventions

PHARMACOLOGIC INTERVENTIONS

There are two primary groups of pain medications: nonopioids and opioids. A third group of drugs called adjuvants or co-analgesics, address symptoms that often accompany pain, such as insomnia, anxiety, muscle spasm, anorexia, and depression.

Nonopioid Analgesics

Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site to decrease the level of inflammatory mediators. This group of analgesics includes drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin). The specific actions and dosages of these analgesics vary. Generally speaking, however, they have analgesic, antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain.

With the exception of acetaminophen, most nonopioids are potent anti-inflammatory agents. These drugs are especially effective when the primary cause of pain is inflammation, as occurs in rheumatoid arthritis and bone cancer. When tissue is damaged, a series of biochemical events leads to the release of prostaglandin, which causes edema, inflammation, and pain. Two isoenzymes, cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) play an important part in this biochemical process. Drugs that inhibit their action, especially that of COX-2, reduce prostaglandin production and the inflammation it creates. However, these drugs must be used with caution because the safety of long-term use has not been verified. Table 2-2 lists some common nonopioid analgesics.

TABLE 2-2

COMMON NONOPIOID ANALGESICS

Drug	Adult dose	Considerations
Acetaminophen (Tylenol)	650–975 mg q 4 hr	Used for headaches, osteoarthritis; lacks peripheral anti-inflammatory activity of NSAIDs
Aspirin	650–975 mg q 4 hr	Used for headaches, osteoarthritis, general pain; antipyretic; inhibits platelet aggregation, causing bleeding
Ibuprofen (Motrin)	400 mg q 4–6 hr	Used for osteoarthritis; antipyretic; multiple brand names; available as liquid
Indomethacin (Indocin)	150–200 mg/day	Used for gout; anti-inflammatory; anti-rheumatic
Naproxen (Naprosyn)	500 mg initial dose, then 250 mg q 6–8 hr	Used for gout, headaches; anti-inflammatory; anti-rheumatic; available in liquid preparation

While nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site, opioids work at the level of the central nervous system, decreasing the perception of pain. Thus, nonopioids work in an entirely different way than opioids. Some medications combine nonopioid with opioid analgesics to offer two different levels of pain relief in one tablet. Acetaminophen and codeine is such a medication.

Opioid Analgesics

Opioid (narcotic, CNS-acting) analgesics are derivatives of opium and include such drugs as morphine, codeine, and methadone. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Opiate receptors have various names—Greek letters mu (μ), sigma (σ), kappa (κ). Many of the characteristics of particular opioids relate to the receptor to which they bind. For example, morphine binds to μ receptors and follow μ receptor control.

Opioid analgesics are classified as full agonists, partial agonists, and mixed agonist-antagonists. Full agonists bind to μ receptor sites, block pain impulses, and produce maximum pain control, an "agonist effect." Full agonists include such drugs as morphine (Kadian, Avinza, Rylomine intranasal), meperidine (Demerol), fentanyl (Duragesic patch, Fentanyl oralets), propoxyphene (Darvon), oxycodone hydrochloride (OxyContin) and hydromorphine (Dilaudid).

Partial agonists produce a lesser response than full agonists and include such drugs as buprenorphine (Buprenex) and nalbuphine (Nubain). Mixed agonist-antagonist analgesics include such drugs as pentazocine hydrochloride (Talwin), and butorphanol tartrate (Stadol). An antagonist is a drug that competes with opioid receptor sites. Naloxone hydrochloride (Narcan) is such a drug. It is used for opioid overdoses and physical dependency.

The primary action of opioids (narcotics) is to alleviate moderate-to-severe pain. Many of the unwanted effects of this class of drugs are related to their actions on systems of the body other than the CNS, causing such effects as constipation and respiratory depression. Table 2-3 shows common opioid side effects and preventative measures.

TABLE 2-3

OPIOID ADVERSE EFFECTS AND PREVENTIVE MEASURES

Body system	Adverse side effects	Preventative measures
Cardiovascular	Hypotension, palpitations, flushing	Monitor blood pressure and heart rate
CNS	Sedation, disorientation, euphoria, dysphoria, light-headedness, lower seizure threshold, tremors	Inform client that tolerance may develop over 3–5 days; administer stimulants as needed
Gastrointestinal	Constipation, nausea and vomiting	Offer anti-emetic or change analgesic; increase fluid and fiber intake; increase exercise; administer laxatives
Genitourinary	Urinary retention	Catheterize as needed; administer opioid antagonist
Integumentary	Itching, rash, wheal formation	Apply cool packs, lotion, etc.; administer antihistamine
Respiratory	Respiratory depression; aggravation of asthma	Monitor respirations closely; administer opioid antagonist such as naloxone hydrochloride (Narcan)

Drug Tolerance and Dependence

Drug tolerance is a physiologic condition in which humans require larger and larger doses of drugs to provide the same effect provided by the original dose. The first sign of tolerance is a decrease in the duration of the analgesic effect. This condition is followed by a decrease in total analgesic effect. Decreasing the time between doses or increasing the dosage may helps overcome tolerance. Even so, drug tolerance is not the only reason drugs become less effective. They may become less effective because there is advancing tissue damage and greater resulting pain.

Pseudotolerance is the need to increase opioid dosage for reasons other than the physical adaptation of continuous use. These other needs include drug-to-drug interaction, drug-to-food interaction, increased physical activity, psychological dependence (addiction), and changes in opioid formulation.

Physical dependence is a physiologic adaptation of tissues to the drug. If a person who is physically dependent on opioids abruptly stops using them, withdrawal symptoms occur. These symptoms result from an autonomic nervous system response, and may include excessive yawning, nausea and vomiting, hypertension, tachycardia, muscle twitching, diaphoresis, delirium, and convulsions. When opioid analgesics are to be discontinued, physical withdrawal symptoms can be reduced or eliminated by a slow reduction of dose.

Psychological dependence (addiction) is the compulsive use of a substance characterized by a continuous craving for a drug's nonanalgesic emotional effects. Opioids (narcotics) with an affinity for both μ and σ receptor sites produce euphoria and hallucinations. These drugs are the most frequently abused opioids. When people take opioids to relieve pain, tolerance and physical dependence may occur, but addiction will not necessarily follow. Psychological dependence is far more complex and involves emotional, social, and cultural issues. Pain management in clients with addictive disease is discussed in Part 5 of this course.

Pseudoaddiction is a term used to describe people who, because of severe, unrelieved pain, focus on finding relief. As a consequence, they seem preoccupied with obtaining opioids. This preoccupation is not truly "drug-seeking" but "relief-seeking." Their quest for opioids is directly related to inadequate pain relief caused by an inappropriate opioid or an inadequate dose spaced too far apart.

Because of widespread misconceptions about treatment of chronic pain and addiction, in 1990 the World Health Organization (WHO) recommended the following three-step approach when a client complains of pain.

Step 1: Use nonsteroidal anti-inflammatory drugs and adjuvants. If pain persists,
Step 2: Use weak opioids and adjuvants. If pain persists,
Step 3: Use strong opioids and adjuvants.

To prevent undertreatment of malignant cancer pain, some authorities recommend a different approach. They beginning the treatment of malignant pain with strong opioids, providing immediate relief, then slowly reduce the type and dosage until pain relief is achieved at the lower level (Jackson & Stanford, 2003).

Adjuvant Analgesics

Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain, but have been found to enhance the effects of analgesics. Nurses need to remember that these are "helper drugs," not substitutes for analgesics. Clients in pain still need analgesics. Table 2-4 lists some common adjuvant analgesics.

TABLE 2-4

COMMON ADJUVANT (CO-ANALGESIC) DRUGS

Class of adjuvant drugs	Indications and primary effects
Antidepressants: Tricyclics and serotonin, reuptake inhibitors	Burning, neuropathic pain, improves sleep, enhances mood and analgesic effects
Anti-epileptic drugs	Neuralgic and neuropathic pain (sharp, shooting pain)
Antispasmodic	Reflex sympathetic dystrophy syndrome
Anxiolytic drugs: Benzodiazepines, buspirone, venlafaxine	Anxiety and sedation
Botulinum toxin	Migraine headache
Lidocaine	Neuralgic pain and diabetic neuropathic pain
Psychostimulants	Offset sedating side effects and enhances analgesic effects of opioids
Steroids	Inflammatory and chronic pain of cancer, malignant cord compression, headaches, and arthritis

PLACEBOS

A placebo is a "sugar pill" with no active ingredients. Even so, research has found that placebos produce hoped-for results in 30% to 50% of the people who take them (Thompson, 2000). This so-called placebo effect has been exploited for centuries by hucksters and charlatans who sell tonics, treatments, and gadgets to people in pain. Legitimate medical practice does not use placebos, because their purpose is to deceive and strip individuals of the right to make informed decisions. Such acts violate the ethical principles of honesty and autonomy. The only exception to this prohibition is made in research studies, when subjects give prior consent for the possible use of placebos.

ROUTES OF ADMINISTRATION

Analgesics can be administered by many routes. Each has advantages and disadvantages, indications and contraindications. The overriding considerations are effectiveness and safety. Table 2-5 lists some of the most common routes for the administration of analgesic drugs.

TABLE 2-5

ROUTES OF ANALGESIC DRUG ADMINISTRATION

Route	Indications	Contraindications
Oral (per os = PO)	Preferred route due to lower cost and convenience; multiple preparations: liquids, tablets, powders, lozenges, capsules	Gastrointestinal irritation; inability to swallow; need for more potent analgesic
Rectal (R)	Inability to take oral drugs; can be self-administered; longer duration than oral	Anal or rectal lesions, diarrhea, thrombocytopenia
Intramuscular (IM)	Acute, short-term pain relief	Need for prolonged pain relief; absorption may be poor; possible muscle or nerve damage; costly
Intravenous bolus (IV)	Offers most rapid pain relief (5–15 min) but lasts less than 60 min	Requires IV access; need for prolonged pain relief; brief duration
Continuous intravenous infusion (IV)	Gives constant opioid blood level when other methods ineffective	Requires infusion pumps with alarms and close monitoring
Client controlled analgesia (PCA)	Allows predetermined IV bolus of opioid when client desires pain relief	Requires IV access, client cooperation, close supervision; does not give continuous pain relief
Subcutaneous opioid infusion (SC)	Continuous, prolonged parenteral opioids when IV not possible; allows home use	Requires site change every 7 days of 27-gauge butterfly needle; possible site irritation
Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular	Labor contractions; also intractable pain when client cannot tolerate systemic opioids by other routes	Requires expert insertion of catheter into intended space; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Regional nerve blocks	Continuous or single dose control of acute and chronic pain for trauma, burns, and labor	Requires expert insertion of catheter to specific nerve root; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Topical (cream-laden anesthetic)	Reduce pain of venipuncture and needle-stick	Must be applied 30–60 min in advance of need
Transdermal	Continuous dose of opioid via skin patch for those who cannot tolerate other analgesic regimens; allows home use	Body temperature over 102°F accelerates absorption; costly
Nasal sprays	Alternative to IV, IM, & oral opioid administration; rapid onset of action	Nasal exudates or mucosal swelling may prevent consistent absorption

Nonpharmacologic Interventions

Although there are a myriad of drugs to relieve pain, all have some risk and cost. Fortunately, there are many nonpharmacologic interventions to give pain relief, especially when used in conjunction with pharmacologic measures. Described as physical and cognitive-behavioral interventions, many of these approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the scope of nursing practice. Physical interventions give comfort, increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter the perception of pain, reduce fear, give clients a greater sense of control, and are considered holistic nursing practice.

PHYSICAL INTERVENTIONS

Comfort measures such as clean, smooth sheets, soft, supportive pillows, warm blankets, and a soothing environment have been used by nurses throughout history to relieve pain and suffering. These measures may be difficult to provide in the noisy, mechanized healthcare facilities of today. Nonetheless, they are important to the mental and physical health of clients.

Position change and movement are well-known pain-relieving interventions. Moving the body, even a small amount, relieves muscle spasm and provides a degree of pain relief. So important is movement of the body to health, an entire profession has developed specializing in physical therapy. However, nurses need not wait for a specialist to offer these important pain-relieving interventions.

Massage relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While there are many different massage techniques, they all involve rubbing the skin in various patterns and degrees of pressure. Once considered an expected part of basic nursing care, backrubs offer an important noninvasive way to relieve pain and provide comfort.

Applications of hot and cold are effective pain-relieving measures when used appropriately. Heat decreases muscle spasm and increases blood flow to an area. Cold decrease blood flow, edema, and inflammation and may decrease muscle spasm and pain. Many devices are available to provide hot and cold, including electric heating pads, patches, and ice packs. Soaks and baths relieve muscle spasm and are an important means of providing comfort.

Transcutaneous electrical nerve stimulation (TENS) provides a continuous, mild electric current via 2 to 4 electrodes placed on the skin near a painful site. The stimulator is a small, battery operated devise worn by the client. Experienced as a tingling sensation, TENS works by stimulating large nerve fibers to close the "gate" in the spinal cord. It also may stimulate endorphin production. TENS may be used for acute postoperative pain or for chronic conditions, such as low back pain, phantom limb pain, and neuralgia.

Surgical interventions may be recommended when severe pain persists despite medical treatment. If pain is due to a known condition, such as osteoarthritis of a joint, joint replacement surgery may be offered. When specific interventions are not available and conservative measures do not relieve pain, surgical interruption of pain pathways may be undertaken. Rhizotomy and cordotomy are two such procedures. In a rhizotomy the surgeon destroys dorsal posterior nerve roots as they enter the spinal cord, either by delivering neurolytic chemicals, heat, or extreme cold by way of a catheter or by performing a laminectomy, isolating the nerve roots, and directly destroying the nerve. A chordotomy is more extensive than a rhizotomy, involving resection of the spinothalamic tract. Both procedures cause permanent loss of pain and thermal sensations and may cause paralysis due to motor nerve damage.

COGNITIVE-BEHAVIORAL INTERVENTIONS

Relaxation exercises are useful ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate. They induce a state of altered consciousness and give individuals a sense of control and peace of mind. Meditation, Zen, yoga, and other such interventions may effectively relieve pain. One such exercise involves controlled breathing. The coach speaks in a calm, clear voice, suggesting the subject begin by breathing slowly and diaphragmatically, allowing the abdomen to rise slowly and the chest to expand fully. Then, the coach suggests the subject locate an area of muscle tension, contract the muscles in that area and then relax them. As the subject relaxes, pain perception and anxiety diminish.

Guided imagery is similar to relaxation exercises in that the coach leads subjects in a calm, clear voice, often beginning with a relaxation exercise. The coach then suggests subjects imagine themselves in some peaceful place where they experience various sensory pleasures such as the warmth of the sun, the sound of ocean waves, and the smell of salt water. The purpose of the exercise is to provide an experience of relaxation and relief from stress and pain.

Distraction diverts the attention of individuals away from painful stimuli. When people focus on something that gives pleasure, they are less likely to feel acute pain. This phenomenon occurs because the reticular activating system briefly inhibits the awareness of pain. Distraction works best for short acute pain, such as a needle stick. Such things as listening to music, watching an intense scene on television, or describing something of special interest may temporarily distract a person from pain. However, it is important to remember that distraction does not work for chronic, long-term pain.

EVALUATING THE EFFECTIVENESS OF INTERVENTIONS

Evaluation is one of the most critical phases of the nursing process. It tells us the degree to which an intervention achieved an expected outcome. If the expected outcome is pain reduction, evaluation tells us if the intervention did, in fact, reduce pain.

To find out, we gather data from the best source of information, the client, or the second-best source, the client's caregivers. To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, nurses gather data about adverse effects of an intervention, such as an allergic reaction, hypotension, or respiratory depression.

This feedback is essential if we are to revise the plan of care effectively. A positive evaluation means that an intervention was successful and probably should be continued. A negative evaluation means that an intervention was not satisfactory and change needs to be made. Hence the adage "Negative feedback makes for change."

COMMUNICATING, DOCUMENTING, AND TEACHING

Communication about pain and the response of clients to interventions is facilitated by accurate and thorough documentation. This communication needs to be conveyed from nurse to nurse, shift to shift, and nurse to other healthcare providers. Various tools have been devised to facilitate this communication, including pain flow sheets, running diaries, and bedside computer charting (known as "point-of-care" charting). When communicating information about pain, it is important accurately to describe the time and exact nature of an intervention, including the analgesic and dosage administered, level of pain before and after the intervention, and adverse effects, such as respiratory depression. The more specific and timely a report, the more effective the evaluation.

Because pain is a potent motivator for change, people who suffer are open to suggestions. They deserve accurate information about the many interventions now available. It is the responsibility of healthcare professionals, especially nurses, to give patients information about new pain-relieving devices, medication, physical activities, and psychological strategies in clear, understandable ways. By doing so, caregivers demonstrate respect, accurate empathy, nonpossessive warmth, and genuine concern.

PART 2     Ethical and Legal Issues

ETHICAL CONCERNS

Ethics, A Branch of Philosophy

Many folks roll their eyes and change the subject when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. Nonetheless, ethics is a significant concern of thinking, caring persons, especially nurses who manage the care of people in pain.

Ethics is the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. Ethics assumes that people have the ability to make choices about their behavior. For that reason it has been the subject of philosophical discussion for centuries and has generated an enormous body of literature. Students of ethics have divided these writings into three general categories: descriptive (characterizing), analytical (metaethics), and prescriptive (normative). Descriptive ethics reports and describes the moral choices people make. Analytical ethics scrutinize the language people use to discuss issues of right and wrong. Prescriptive ethics offers advice about how people decide what is good or bad behavior. It does this from two very different perspectives: teleological and deontological.

A teleological (consequential, utilitarian, situational) perspective affirms that the rightness or wrongness of an act is determined by the end results of an action. The term comes from the Greek teleos, meaning "end." If the end result harms others, the act is considered wrong or bad. If the end result benefits others, the act is considered good or right. The central issue of this perspective is the principle of the "greatest good." The utilitarian teachings of John Stuart Mill and the situation ethics teaching of Joseph Fletcher maintained that end results and circumstances are essential factors in considering the rightness or wrongness of any human behavior (Hamilton, 1996).

Teleological theories foster morality by developing the capacity of humans to make choices. These theories reject fixed moral rules of conduct such as the biblical command "Thou shalt not kill" (Exodus 20:13). For example, a man is suffering with intractable pain caused by an incurable disease. He begs his physician to perform a surgical procedure that will relieve his suffering but may hasten his death. According to teleological perspective, the physician should perform the surgery because the end result (relieving pain) is a greater good than keeping the man alive with intractable pain.

The deontological (nonconsequentialist) perspective fosters morality by teaching humans to accept and obey fixed laws. The term comes from the Greek deontos, meaning "duty to obey." Immanuel Kant is the theorist most often identified with deontological ethics. He maintained that certain acts are inherently right or wrong, regardless of the situation or the end results. In deontological ethics, there are no exceptions or mitigating circumstances. According to this perspective, preserving the life of the man with intractable pain is a greater good than relieving his pain and hastening his death. The physician's duty is to obey the commandment "Thou shalt not kill," regardless of the situation or end results. Thus, the deontological perspective simplifies ethical decision-making by removing the issue of mitigating circumstances.

Bioethics and Related Concepts

Bioethics is the application of ethics to matters of human life. As scientific knowledge expands and healthcare providers have greater control over pain and pain relief, life and death, it is vital that nurses address issues of right and wrong behavior.

Although some authors use the term morals to refer to human behavior and ethics to refer to formalized codes of conduct, both words mean the same thing. Ethics comes from the Greek word ethos and morals from the Latin word mores. In recent years, some politicians have substituted the word values for morality; however the word values has a much broader meaning.

Values are treasured ideals or attributes, such as creativity, achievement, adventure, power, friendship, and belief systems. Understanding one's values brings purpose and clarity to life. The desirability of such clarity was recognized by Socrates, who is credited with saying "An unexamined life is not worth living." To help people examine their lives and clarify their values, Louis Raths (1979) suggested a seven-step process that he called "values clarification." Box 3-1 presents Raths' process.

Belief systems are organized patterns of thought regarding the origin, purpose, and place of humans in the universe. These systems seek to explain the mysteries of life and death, good and evil, health and illness. Typically, belief systems include an ethical code of conduct about how people should relate to the world and its inhabitants. Religions are patterns of thought and action that typically include belief systems, devotional rituals, organizational structures, and faith in a mystical power. Often, however, people develop their own belief systems, independent of organized religions.

Ethical Principles

Ethical principles are fundamental concepts by which people judge behavior. These principles help individuals make decisions and serve as criteria against which they measure behavior. Laws, on the other hand, are rules made by an authority with the power to enforce them. Although laws flow from ethical principles, they are limited to specific situations. Ethical principles are guiding ideals of conduct that speak to the spirit of a law, not necessarily to its letter.

Throughout recorded history, leaders of world religions have taught an overarching ethical principle commonly called the Golden Rule: "Do unto others as you would they do unto you." Other teachers have proposed different choices: Kant held that duty was the central issue; Mills, the interest of all; Fletcher, love; Thiroux, human dignity; Nodding, care; and Gilligan, care and justice.

A single, global principle for ethical behavior is an attractive approach, but when people face real-life situations they seek more precise guidance. Over the years, five ethical principles have emerged as especially applicable to nursing. They include: respect for human life and dignity, beneficence, autonomy, honesty, and justice. These principles take on special significance as we consider the management of pain.

HUMAN LIFE AND DIGNITY

Respect for human life and dignity is one of the most basic of ethical principles. It requires that "individuals be treated as unique and equal to every other individual and that special justification is required for interference with an individual's own purposes, privacy, and behavior" (Rawls 1971). This ethical principle elevates respect for the life, freedom, and privacy of all humans. Thiroux says this principle is necessary for any moral system because "there can be no human being, moral or immoral, if there is no human life" (1990). When applied to pain management, respect for human life and dignity means nurses:

• Attend to every report of pain by clients or their families.
• Regard the personal privacy of clients as they deal with pain.
• Respect the lifestyle, personhood and belief systems of clients.
• Strive to sustain human life and dignity while relieving pain and suffering.
• Believe patients when they report pain.

BENEFICENCE

Beneficence means doing good to benefit others. Although some writers separate beneficence (doing good) from nonmalfeasance (not doing harm), Frankena (1973) suggested the ethical principle of beneficence represents a continuum from not harming to doing good, specifically: (1) not inflicting harm, (2) preventing harm, (3) removing harm, and (4) promoting and doing good.

For nurses, beneficence means more than providing technically competent client care. It means acting in ways that demonstrate genuine and accurate empathy with nonpossessive warmth, including listening, empathizing, supporting, and nurturing. In fact, the central task of nursing—its very essence—is doing good for others. When applied to pain management, beneficence means nurses:

• Attend to the needs and complaints of clients, carefully assessing their level of pain.
• Provide timely, appropriate interventions to relieve pain.
• Accurately evaluate the effectiveness of an intervention.
• Communicate the effectiveness of interventions to other healthcare members.
• Give clients nonpossessive warmth, accurate empathy, and unconditional positive regard.

AUTONOMY

Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out that choice. Nurses carry out the principle of autonomy by providing information to clients, assisting them to understand the information, and helping them make decisions based on knowledge they have gained. When applied to pain management, autonomy means nurses:

• Inform clients about available options for pain management.
• Make sure clients fully understand the actions and risks of pain relieving options.
• Allow clients enough time to consider pain-relieving alternatives.
• Accept decisions clients make regarding management of their pain.
• Implement and evaluate pain-relieving interventions chosen by clients.

HONESTY (TRUTHFULNESS)

Honesty means communicating the truth in word and deed. Even when nurses must convey unwelcome information to clients about an illness, injury, or treatment option, they do so truthfully. Withholding information from a client is appropriate only when the client is a minor child or an adult under the care of a legal guardian. When applied to pain management, the ethical principle of honesty means nurses:

• Provide factual information about treatment options, including benefits and risks.
• Use language that is clear and appropriate to the age and capacity of the client.
• Encourage client participation in pain management decisions.
• Convey genuine concern when giving unwelcome information.
• Accurately report and record critical data, regardless of personal consequences.

JUSTICE

Justice implies fairness and equality. It requires impartial treatment of clients. Like other ethical principles, justice is based on respect for human life and dignity. The traditional image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources are to be distributed equally, using the same criteria for everyone. When applied to pain management, the ethical principle of justice means nurses:

• Attend to complaints of pain by clients, no matter how difficult they may be.
• Assess pain and intervene to relieve pain with equal diligence for all clients.
• Evaluate and communicate information about pain with fairness and lack of bias.

Ethical Dilemmas

A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between two or more opposite actions, each of which is based on an ethical principle. For example, a nurse weighs whether to fully disclose the risks of a proposed treatment for pain, honoring the ethical principle of autonomy, or to withhold information about the risk of a treatment to reduce the client's anxiety, honoring the ethical principle of beneficence. (See the preceding section titled Honesty.) Healthcare professionals are faced with many such dilemmas.

Resolution of ethical dilemmas requires careful evaluation of all the facts of the case, consultation with all concerned parties, and honest appraisal of the decision makers' ethical stance (whether it is teleological, considering end-results, or deontological, obeying fixed laws of behavior).

Nowadays, ethical dilemmas in healthcare facilities arise more frequently because modern medicine can keep hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of ethics committees is to help decision makers resolve ethical dilemmas. They often use an ethical decision-making process such as the following:

1. Gather relevant facts about the client's age, diagnosis, circumstances and the ethical stance of the decision maker (deontological or teleological).
2. Identify and clearly state the problem.
3. List alternative actions, together with ethical principles that support each action.
4. Determine who can make the decision and assist that person to make it.
5. Provide emotional support to all the involved parties.

In support of the ethical principle of autonomy and to reduce ethical dilemmas, the Joint Commission on Accreditation of Healthcare Organizations recommends that all adults discuss their wishes regarding artificial life support and sign a legal document, called an Advance Healthcare Directive, appointing someone to make healthcare decisions in their stead if they should become incapacitated (JCAHO, 2003).

Codes of Ethics

Codes of ethics are formal statements that set standards of ethical behavior for groups of people. In fact, one of the hallmarks of a profession is a code of ethics to which its members subscribe. Box 3-2, American Nurses Association's Code of Ethics for Nurses with Interpretive Statements and Box 3-3, International Council of Nurses' Code of Ethics for Nurses, make explicit the goals and values of the profession and provide guidance for carrying out nursing responsibilities.

LEGAL ISSUES

Federal Pharmaceutical Legislation

Although there are many modalities in the pain management arsenal, drugs constitute one of its most effective and often-used weapons. Until the beginning of the twentieth century, no federal rules or regulations protected consumers from ineffective or harmful drugs. After several drug-induced tragedies, the U.S. Congress passed the Pure Food and Drug Act of 1906. This act recognized the United States Pharmacopeia, a publication that lists drugs that met certain standards for dosage, therapeutic use, client safety, quality, purity strength, and packaging. These drugs were called "official" and were permitted to print "USP" after the name of the drug. The act also empowered the federal government to take legal action against manufacturers of drugs that did not comply with standards. Since then, many laws have been passed to further ensure the safety and effectiveness of drugs. Table 3-1 lists some of the most important legislation.

TABLE 3-1

FEDERAL PHARMACEUTICAL LEGISLATION

Year	Title of Law	Major Provisions
1906	Pure Food and Drug Act	Designated official standards for drugs and their labeling in the USP and National Formulary
1912	Sherley Amendment	Prohibited manufacturers from making fraudulent claims about drug efficacy and therapeutic effects
1914	Harrison Narcotic Act	Legally classified habit-forming drugs as narcotics: regulated the importation, manufacture, sale, and use of narcotic substances
1938	Federal Food, Drug, and Cosmetic Act	Added the Homeopathic Pharmacopeia as a third drug standard; required that drugs be approved as safe by the FDA before marketing; further outlined criteria for drug labeling
1945	Amendment to the Food and Drug Act	Provided for certification of biological products used as drugs (antibiotics, insulin, etc.) on batch basis; allowed for direct supervision and inspection of drug manufacture
1952	Durham-Humphrey Amendment	Distinguished between prescription and nonprescription drugs
1962	Kefauver-Harris Amendment	Authorized FDA to supervise drug manufacture to ensure safety and efficacy and to establish official drug names and specified greater controls on experimental drugs
1971	Comprehensive Drug Abuse, Prevention, and Control Act, also known as the Controlled Substances Act	Set strict controls on the manufacture and distribution of controlled substances; made the possession of these drugs unlawful without a prescription; established government programs to promote prevention and treatment of dependence
1997	Food and Drug Administration Modernization Act	Tightened regulation of food, drug, devices, and biological products
1998	Drug Regulation Reform Act	Shortened the drug investigation process to hasten release of drugs to the public

Controlled Substance Act

In 1971, in response to the growing misuse and abuse of drugs in the 1960s, Congress passed the Comprehensive Drug Abuse, Prevention, and Control Act. Known as the Controlled Substance Act, the legislation is of particular concern to healthcare professionals concerned with the management of pain. The act created a schedule of controlled substances, ranking them according to their potential for abuse. Specifically, it identified five categories or schedules of drugs, from those with the highest abuse potential (C-I) to those with the lowest abuse potential (C-V) as shown in Table 3-2.

TABLE 3-2

CONTROLLED SUBSTANCES AND DISPENSING RESTRICTIONS

Category/ schedule	Abuse potential	Dispensing restrictions	Examples
C-I	High: possible severe physical and psychological dependency; no approved medical use	Only with approved protocol	Heroin, marijuana, LSD, mescaline, peyote, psilocybin, methaqualone
C-II	High; possible severe physical and psychological dependency	Written prescription only (if phoned in, written prescription required within 24 hours) no prescription refills, container warning label required	Codeine, cocaine, hydromorphone, morphine meperidine, methadone, oxycodone, secobarbital, pentobarbital, amphetamine, methylphenidate
C-III	Less than C-II drugs; moderate to low physical or high psychological dependency	Written or oral prescription that expires in 6 months; Maximum refills: 5 in 6 months; container warning label required	Combination drugs containing hydrocodone, codeine, dihydrocodeine, oxycodone, paregoric, morphine; non-narcotic compounds of pentazocine, propoxyphene
C-IV	Less than C-III; limited physical or psychological dependency	Written or oral prescription that expires in 6 months; no more than 5 refills in 6 months; container warning label required	Barbital, phenobarbital, chloral hydrate, meprobamate, fenfluramine, benzodiazepines, dextropropoxyphene, pentazocine etc.
C-V	Less than C-IV; limited physical or psychological dependency	Written prescription or over-the-counter; varies with state law	Medications used for relief of coughs or diarrhea containing limited amounts of opioids

State Legislation

In addition to federal laws, legislative bodies of the states and territories pass laws regulating the manufacture and distribution of food, drugs, and medical devices. This authority is derived from the Tenth Amendment to the U. S. Constitution, which says "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." Of special concern to nurses are laws that affect the management of pain, and, specifically, laws that authorize the medicinal use of marijuana.

MARIJUANA

Marijuana is made from the chopped leaves and flowers of the Cannabis sativa plant, a native of India. It is grown for its fiber (hemp) and resin, which contains the active ingredient cannabinol. Since ancient times the plant has been chewed, smoked, and drunk by people everywhere in the world for its psychic effects. The drug produces a calm, mildly euphoric state with slowed reaction time, heightened sensations, and distorted time perception.

Long-term use does not seem to cause physiologic dependence, but may cause psychological dependence and lung damage from smoke inhalation. The chemical, tetrahydrocannabinol (THC), is synthesized and marketed as the drug dronabinol (Marinol). Its two approved uses are to treat: (1) anorexia associated with weight loss in clients with HIV-AIDS, and (2) nausea and vomiting associated with cancer chemotherapy (Unimed Pharmaceuticals, 2005).

MEDICAL MARIJUANA LAWS

Because of vigorous enforcement of the Controlled Substance Act by the federal Drug Enforcement Administration (DEA), and harsh penalties imposed on individuals who use marijuana, many states, including Oregon, California, Nevada, Hawaii, Maine, and North Carolina, have passed laws asserting their right to regulate drugs within their borders. These laws remove state-level criminal penalties on the use, possession, and cultivation of marijuana for medicinal purposes.

MEDICAL MARIJUANA LAW OF OREGON

Oregon provides an example of the evolving laws regarding medical marijuana. In 1998 Oregon voters approved Measure 67, a measure that removed state-level criminal penalties on the use, possession, and cultivation of marijuana by individuals who possess a signed recommendation from their physician stating that marijuana "may mitigate" debilitating symptoms. Under the act, a diagnosis of one of the following illnesses affords legal protection:

• Cachexia
• Cancer
• Chronic pain
• Epilepsy and other disorders characterized by seizures
• Glaucoma
• HIV/AIDS
• Multiple sclerosis and other disorders characterized by muscle spasticity and nausea

Other conditions are subject to approval by the Heath Division of the Oregon Department of Human Resources. Clients or their primary caregivers may legally possess no more than three ounces of usable marijuana, and may cultivate no more than seven marijuana plants, of which no more than three may be mature. The law establishes a confidential state-run client registry that issues identification cards to qualifying clients. Clients who do not join the registry or possess greater amounts of marijuana than allowed by law may argue the "affirmative defense of medical necessity" if they are arrested on marijuana charges.

In July 1999 the Oregon legislature passes a law mandating that patients or their caregivers may only cultivate marijuana in one location and requires that patients must be diagnosed by their physician at least 12 months prior to an arrest in order to present an affirmative defense. This bill also states that law enforcement officials who seize marijuana from a client pending trial do not have to keep those plants alive. In 2004 the Oregon Board of Health added "agitation due to Alzheimer's disease" to the list of debilitating conditions qualifying for legal protection.

In 2001 program administrators established temporary procedures further defining the relationship between physicians and patients. The new rule defines the attending physician as a "physician who has established a physician/patient relationship with the patient, is primarily responsible for the care and treatment of the patient, has reviewed a patient's medical record at the patient's request, has conducted a thorough physical examination of the patient, has provided a treatment plan and/or follow-up care, and has documented these activities in a patient file" (NORML, 2005).

In 2006, Senate Bill 1085 raised the quantity of cannabis which authorized patients could possess; however, at trial, those who exceed the limits can no longer raise an "affirmative defense." An "affirmative defense" means the person met the spirit (essence) of a law even if they did not meet the letter of the law. Other amendments define the size of a "mature plant" and establish a state registry for authorized growers (NORML, 2007).

PART 4     Pediatric Pain

PAIN MANAGEMENT IN CHILDREN

Unbelievable as it may seem, only recently has the medical profession taken seriously the pain and suffering of infants and children. Not long ago, newborn infants were circumcised without anesthesia or analgesia and seriously injured or burned children were given pain medication "as needed." Happily, such under-treatment of pain in children is changing as a result of research by caring nurses and other healthcare professionals. Better assessment tools, new pharmaceuticals, and innovative delivery systems are contributing to these advances.

Research has shown that neonates and infants do feel and remember pain. In fact, by 6 months of age, when children are taken to places where they experienced pain in the past, they demonstrate anticipatory fear (Pasero, 2004). One study measured the long-term effect of newborn circumcision without analgesia on behavioral response to immunizations. When pain was measured by observable indicators such as facial expression, length of crying, and body movement, 4- to 6-month old infants circumcised without analgesia had higher pain scores than those circumcised with analgesia (Anand, 1997).

Other research found some children so traumatized by past injections that were intended to relieve pain that they were afraid to admit having present pain (Stevens, 1999). These and other studies have corrected many misconceptions about pain in infants and children, as described in Table 4-1.

TABLE 4-1

MISCONCEPTIONS ABOUT PAIN IN INFANTS AND CHILDREN

Misconceptions	Correct information
Preterm infants are less sensitive to pain than term infants and older children due to an immature nervous system.	Preterm infants have the anatomical and functional ability to process pain and an even greater sensitivity to pain than term infants.
Infants and children have a diminished perception of pain and no memory of its occurrence.	Perception of pain is present with the first insult, requires no prior experience, and is remembered.
Infants are incapable of expressing pain.	Although infants cannot verbalize pain, they give physical signs and behavioral cues.
Pain in infants cannot be assessed accurately.	Behavioral cues and physiologic signs of pain can be reliably and validly assessed; facial expressions are the most valid indicators.
Anesthetics and analgesics cannot be given to neonates and infants because of an immature ability to eliminate drugs.	Infants older than 1 month metabolize drugs in the same way as older infants and children.
Opioids are too dangerous to give to infants and children because the risk of adverse effects and addiction are great.	Adverse effects of opioid and nonopioids can be minimized by careful monitoring, drug titration, and weaning.
Infants and children tolerate pain well and become accustomed to pain.	Pain is pain, whether it occurs in an infant, child, or adult.
Postoperatively, children should not receive the next analgesic dose until they show obvious signs of pain.	Opioids are most effective if administered as a continuous infusion rather than "as needed," thus avoiding the need of children to complain.
Infants and children cry or complain at the slightest discomfort even when they are not in pain.	Often children are afraid to complaint of pain because their fear of an injection is greater than their pain.

COMMUNICATING WITH CHILDREN AND ADOLESCENTS

To manage pain effectively in children and adolescents, nurses and other healthcare professionals need to be able to communicate with them. Such communication must be appropriate to age and stage of development. Table 4-2 describes some approaches nurses can use to refine their interactions with children and, at the same time, model effective communication skills for family members.

TABLE 4-2

COMMUNICATING WITH CHILDREN AND ADOLESCENTS

Age and state	Approaches and communication modes
Infants (birth–12 mos)	Communicate through touch. Speak in a soft tone. Maintain eye contact without staring or intruding. Avoid over-stimulation. Comfort by holding, rocking, singing softly. By 8 months, infant may be fearful of strangers. Infant interacts by reaching out.
Toddlers (1–3 yr)	Give child time to complete thoughts without interruption. Avoid discussion of frightening issues in child's presence. Set limits by using distraction and alternative choices. State specifically what you want the child to do. Speak with child at eye level. Use parallel play to teach behavior, with child imitating adult. Child shows rapid language development. Imagination is vivid, merges with the real world.
Preschoolers (4–5 yr)	Use simple, direct language. To avoid imagined fears, speak with understood vocabulary. Use play to allow child to act out thoughts and feelings. Child thinks in concrete, egocentric ways, not conceptual. Plays actively, expressively. Child has relatively short attention span.
School-age children (6–12 yr)	Avoid overly grim descriptions or predictions. Give children opportunity to speak for themselves. Child able to grasp seriousness of events in family. Heightened ability to use logic and understand events. Can grasp seriousness of events around them. Less egocentric and more empathetic. May assume inappropriate role reversal. May be reluctant to communicate their own needs. Responds to third-person conversation prompts: "I knew a girl who was afraid to get an x-ray because the machine was so big."
Adolescents (13–18 yr)	Show respect by listening and explaining clearly, not talking "down." Give adolescents opportunity for confidential communication. Think in extremes of all or nothing, good or bad, cool or clueless. A large issue for adolescents is trust of adults. Topics of conversation: Home, Education, Employment, Activities, Drugs, Sexuality, Suicide, Weight (HEADSSW)
Source: Cohen, 1991.

PHYSIOLOGIC RESPONSES TO PAIN

Because infants and children may not be able to tell us they are in pain, nurses and caregivers must use other means to gather information about their distress. Acute pain initiates a response known as the general adaptation syndrome (GAS). This begins with the sympathetic nervous system, causing initial physiologic signs such as tachycardia, rapid respirations, hypertension, pupil dilation, pallor, and increased perspiration, the alarm reaction.

As the stress response continues, the body adapts physiologically in the resistance stage and the vital signs return to near normal and perspiration decreases. For this reason, measurement of the vital signs is not a reliable indication of pain in children. Other means must be used to gather this information. Eventually, when severe, prolonged pain goes unrelieved, the body enters the exhaustion stage, causing release of catecholamines, cortisol, aldosterone, and other corticosteroids and decreased insulin, which leads to hyperglycemia.

BEHAVIORAL RESPONSES TO PAIN

Long before pain pushes infants and children to the exhaustion stage, they show behavioral signs, in developmental- and age-appropriate behavioral responses. Table 4-3 summaries some common responses of infants and children to pain.

TABLE 4-3

BEHAVIORAL RESPONSES TO PAIN IN CHILDREN

Age	Behavioral response	Verbal response
Infants (birth–6 mos)	Generalized body movement, facial grimacing, chin quivering, poor feeding	Crying
Infants (6–12 mos)	Disturbed sleep, irritability, reflex withdrawal to stimulus	Crying
Toddlers (1–3 yr)	Disturbed sleep, aggressive behavior, localized withdrawal	Crying, screaming, unable to describe intensity of pain
Preschoolers (3–6 yr)	Low frustration level, active physical resistance, strikes out when hurt	Able to identify location, intensity, general character of pain
School age (7–9 yr)	Resists passively, holds body rigidly, emotional withdrawal, plea bargains for relief of pain	Able to identify location, intensity, and characteristics
School age (10–12 yr)	May regress with stress and anxiety, pretend not to hurt to project bravery, perform poorly in school	Able to describe location, intensity, and characteristics in detail, and psychic pain
Adolescents (13–18 yr)	Controls behavior to be socially acceptable; may perform poorly in school; irritable, unable to concentrate	Detailed, able to give a more complete description of pain and its meaning
Source: Adapted from Ball & Binder, 1999.

ASSESSING PAIN IN CHILDREN

The assessment of pain in children should include all the same details as in adults, namely the location, intensity, quality, chronology, pattern, precipitating events, alleviating actions, and accompanying symptoms. Information about these factors is gained by means of a pain history, physical examination, observations, and various pain assessment scales.

Pain History

In today's information age, healthcare providers have ready access to earlier medical and surgical events in the life of infants and children. However, details about their pain, effective pain-relieving measures, and the family's customary approach to pain may not be included in the record. This information may be gathered in a pain history, using tools such as the questionnaire shown in Table 4-4.

TABLE 4-4

PAIN EXPERIENCE ASSESSMENT QUESTIONNAIRE

Child	Parent or caregiver
Can you tell me what a pain or hurt is?	What word or words does your child use in regard to pain?
Have you ever had a pain (hurt, ow-y, sting-y, etc.) before?	What painful experiences has your child had before?
When you have a hurt, who do you tell?	Does your child tell you or others when in pain?
What do you want others to do for you when you hurt?	How do you know when your child is in pain?
What do you do for yourself when you are hurting?	How does your child usually react to pain?
What helps the most to take away your hurt?	What works best to decrease or take away your child's pain?
Is there something special you want me to know about you when you hurt? If so, what is it?	Is there something special you want me to know about your child and pain? If so, what is it?

Physical Examination and Observation

Complaints and signs of pain in children need to be taken seriously and investigated appropriately. Although procedural and postoperative pain is anticipated, unexpected intense pain should be assessed immediately, particularly if it is accompanied by altered vital signs. Such pain may signal serious complications, such as internal bleeding, hematoma, constricting bandages, allergic reaction, infection, or even wound dehiscence.

Because infants and children are dependent on the adults in their lives and in many ways molded by them, observation of interactions between children and family members informs nurses about how they respond to pain. Children who have been punished or shamed for crying may not report pain and may suffer in silence. Others who had been neglected or ignored may have found that crying was the only way they could get attention. Thus, nurses may discover that these children need affection more than pain medicine.

Pain Assessment Scales

Children are in a state of constant change, physically, mentally, and emotionally. For this reason, pain assessment strategies are more effective it they are adapted to chronological age, developmental level, functional status, cognitive ability, and emotional status (JACHO, 1999). Although a complete pain assessment includes many variables, the most urgent one in hospitalized children is intensity. Thus, most assessment scales focus on that issue. Table 4-5 lists some well-known assessment scales according to the age and developmental level of children.

TABLE 4-5

PAIN ASSESSMENT SCALES FOR INFANTS AND CHILDREN

Age group	Scale	Description of scale
Preterm: 28–36 weeks' gestation	Premature Infant Pain Profile (PIPP)	Assessor observes for 5–30 sec on various pain indicators, including physiologic signs; gestational age affects scoring (Pasero, 2002).
Preterm to 6 weeks of age	Neonatal Infant Pain Scale (NIPS)	Assessor scores infant on 7 criteria: cry, facial expression, breathing pattern, arm movement, leg movement, state of arousal (Lawrence et al., 1993).
Preterm to 6 weeks of age	Neonatal facial responses	Illustration of a neonate in pain.
Birth to 6 weeks of age	CRIES Neonatal Post-Op Pain Scale	Assessor scores infant's crying, requiring oxygen, increased vital signs, expression, sleeplessness as 0 to 2; severe pain = 10 (Pasero, 2002).
Birth to 3 years	Netherlands Comfort Scale	Assessor scores 0 to 5: child's alertness, agitation, respirations, crying, physical movement, muscle tone, facial tension; severe pain = 35 (van Dijk, 2005).
Two months to 7 years of age	FLACC Behavioral Pain Assessment Scale	Assessor observes child for 1–5 min; then scores face, legs, activity, cry, consolability as 0 to 2; severe pain = 10 (Pasero, 2002).
Ages 3 to 6 years	Finger Span Scale	Assessor uses span of index finger and thumb to indicate degree of pain. Asks, "How big is your pain?" (Merkel S, 2002).
Ages 3 to 7 years	Oucher Scale (photographs)	Photos of 3 children of different skin colors in 6 levels of pain, from no pain to severe pain (Ball & Binder, 1999).
Ages 3 to 7 years	Poker chips	Assessor uses piles of poker chip, from 1 to 5; asks "How much is your pain?" (Ball & Binder, 1999).
Ages 4 to 16 years	FACES Pain Scale	Illustration of 6 round faces, smiling to crying.
Ages 4 to 16 years	FACES Pain Scale—Revised (FPS-R)	Illustration of 6 egg-shaped faces, "no pain" to "very much pain."
Ages 9 to 18 years	Number Scale	Assessor asks child "On a scale of 0 to 10, with 10 the most, how much is your pain?

DIAGNOSING PAIN IN CHILDREN

The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain, acute and chronic. Acute pain is sudden and of short duration (less than 6 months). It includes the pain caused by surgical and medical procedures and by trauma and burns. For example, the nursing diagnosis of pain in for a child with burns might be "acute pain related to tissue damage manifested by continuous, searing pain."

Chronic pain lasts for 6 months or longer and is generally associated with a prolonged disease process. For example, the nursing diagnosis of pain in a child with juvenile rheumatoid arthritis might be "chronic pain related to inflammation of right knee, manifested by aching pain."

PLANNING AND IMPLEMENTING INTERVENTIONS TO MANAGE PAIN

During the planning stage, nurses synthesize the information they have gained from the pain history, physical examination, and assessment and plan appropriate interventions. The goal of interventions is to relieve pain both physically and emotionally, reduce complications, and facilitate a return of function. Of course, there may be many other diagnoses, such as anxiety and a risk of infection, each of which includes specific interventions and expected outcomes.

Pharmacologic Interventions

As with adults, there are both pharmacologic and nonpharmacologic interventions for pain in children. Pharmacologic interventions include nonopioids, opioids, and adjuvant drugs. Nonpharmacologic interventions include physical and cognitive-behavioral measures. While all drugs used to alleviate pain in adults may be prescribed for infants and children, they must be in preparations appropriate to the development of the child, such as a liquid rather than a tablet, and they must be in safe and effective dosages relative to the body weight of the child. As new analgesics gain FDA approval, manufacturers publish suggested dosages according to body weights. Often equianalgesic doses are calculated for children and adults weighing more than 50 kilograms (110 pounds) and those who weigh less than 50 kilograms (110 pounds). As a cautionary measure, many physicians prescribe these potent drugs in smaller-than-recommended initial doses.

Pain relief for children should be continuous, not sporadic or "as needed." The preferred routes of administration are intravenous and oral, intravenous for acute pain and oral as the child recovers. Continuous infusion analgesia eliminates the highs and lows of pain control and is recommended to maintain constant drug levels, particularly in children with severe, persistent pain. If oral preparations are prescribed, they should be scheduled to reduce the likelihood of breakthrough pain and the expectation of its return. When analgesics are given "as needed," greater amounts of drugs are needed to restore control of the pain.

Client-controlled analgesia (PCA) is not just for adults. It is an effective method to administer intravenous analgesics such as morphine to children 5 years of age or older. The nurse programs a computerized pump to deliver a fixed dose of analgesic at certain intervals, controlled by the child. After initial pain control has been achieved, the child presses a button to receive a smaller analgesic dose for episodic pain relief. In addition, the PCA monitor can be set up with a continuous infusion to prevent pain while sleeping. As the child's pain lessens, the PCA is discontinued and oral analgesics are prescribed.

Regional nerve blocks and continuous epidural infusions of analgesics via the lumbar or caudal space are being used with increasing frequency. In these procedures only small doses are required to achieve pain relief because a high concentration is delivered to opioid receptor sites. Though these methods of pain control require specialized knowledge, they are increasingly popular because they avoid many adverse effects of opioids on other body systems.

Nonpharmacologic Interventions

Because pain is a subjective experience, influenced by the emotions, stress, sleep, activity, and even nutrition, it can be controlled by a variety of interventions. Fortunately, children respond well to nonpharmacologic pain reduction measures, especially when they are used in conjunction with appropriate pharmacologic interventions. Some of these interventions are: comforting, distraction, relaxation, hypnosis, imagery, applications of hot and cold, and cutaneous stimulation of various types.

Comforting is one of the most important nondrug measures to relieve pain. The enfolding arms of a parent or caregiver around a frightened, hurting child provide far more than a warm soft place to rest. They give the child many of the basic needs so important to survival, such as safety, security, acceptance, and recognition. In fact, studies show that infants who do not receive adequate amounts of touch, fail to thrive, even when they are fed and otherwise cared for (Polan, 1999). As a consequence, nurses encourage parents to participate in the care of children in pain. If parents are not available, surrogates may be found to provide this valuable intervention.

Distraction is a useful way to divert a child's attention away from a painful event, such as a needle stick. Focusing on something of pleasure, such as listening to music, watching an intense scene on television, or listening to a gripping story may temporarily distract a child from pain or reduce the amount of analgesic required to eliminate pain. However, distraction works best for short acute pain, not for severe or chronic pain.

Relaxation, hypnosis, and imagery, used in conjunction with analgesics are especially effective measures to relieve pain in children. Children are more able to disassociate from present reality to imaginary scenes than adults because they have an active imagination, unhampered by beliefs and experiences. Thus, these measures are especially useful for painful and frightening procedures.

Applications of hot and cold have been used for centuries to dull the pain of an acute injury and treat painful muscle spasms. Young athletes are well acquainted with the use of cold to contract blood vessels, reduce inflammation, and numb peripheral nerves, and with heat to decrease muscle spasms and increases blood flow. Children of all ages find warm baths and soaks comforting and pain relieving.

Back rubs, massage, and touch stimulate the skin and comfort people of all ages, even tiny pre-term infants. These measures give both children and adults the nonpossessive warmth and unconditional positive regard so needed when people are suffering and frightened.

Transcutaneous electrical nerve stimulation (TENS) delivers small amounts of electrical stimulation to the skin by electrodes. This stimulation may interfere with the transmission of pain from the peripheral nerves to the spinal cord. It is used for both acute and chronic pain in children of school age and older.

EVALUATING AND DOCUMENTING

As with adults, pain relieving interventions of children are judged for their effectiveness and the severity of adverse effects. The process is continuous, minute by minute and hour by hour. To effect change, evaluation must be documented and communicated to those who provide ongoing care. If pain is not relieved adequately or if adverse effects occur, caregivers immediately take corrective action. Children of any age, for any reason, should not suffer pain.

PART 5     Special Populations

All people deserve pain management of the highest quality, including those who sustain injuries, undergo invasive procedures, give birth, or suffer from painful diseases. However, some individuals are especially vulnerable and some have complex disorders; these people include older adults, people with cognitive and mental disabilities, individuals with addictions, and those who suffer from neuropathic syndromes and headaches. These individuals need special care and understanding and are the focus here.

OLDER ADULTS

Unrelieved pain is so common among older adults that it is accepted as inevitable and cynically described as "better than the alternative" (death). This lack o