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VI
Pain Management
Jaime C. Paz
In t.he acute care setting, physical therapists encounter patients who
are experiencing pain for a variety of reasons, most commonly from
surgical intervention. This appendix provides information on tools to
evaluate and manage pain that can facilitate the therapist's ability to
provide care for a patient.
Evaluation
The subjective complaint of pain is often difficult to objectify in the
clinical setting. However, an effective pain treatment plan depends on
an accurate evaluation of the pat.ient's pain,l.2 Each evaluation
requires a complere physical and diagnostic examination of the
patient's pain. The goal for evaluation should be toward individualization while maintaining consistency among patients. To assist with this process, various pain rating rools have been developed. Table
VI-l describes some of the pain rating tools that are used in the acute
care setting, with the visual analogue and numeric raring scales being
the mOst commonly used.I•3,4
877
878 ACUTE. CARE HANDBOOK FOR PHYSICAL THERAPISTS
Table VI-l. Pain Assessment Tools
Tool
Description
Verbal descriptor scales
The patient describes pain by choosing from a list
of adjectives representing gradations of pain
intensiry.
Numeric rating scale
The patient picks a number from 0 to 10 to rate
his or her pain, with 0 indicating no pain, and
10 indicating the worst pain possible.
Visual analog scales
Line scale
The patient marks his or her pain intensiry on a
10-cm line, with one end labeled "no pain,"
and the other end labeled "worst pain
possible. "
Faces scale
The patient chooses one of six faces, portrayed on
a scale that depicts graduated levels of distress,
to represent his or her pain level.
Pain diary
A daily log is kept by the patient denOting pain
severity, by using the numeric rating scale,
during activities of daily living.
Medication and alcohol use (if out of the hospital), along with emotional responses, are also
helpful pieces of information to record.
Sources: Data from KP Kirrelberger, AA leBel, 0 Sorsook. Assessmem of Pain. In 0
Sorsook, AA LeBel, B McPeek (cds). The Massachusc:rts Genc:ral Hospital Handbook
of Pain Management. BoslOn: Little Brown, 1996;27; and Carey Sj, Turpin C, Smith J,
et al. Improving pain management in an acute care setting: the Crawford Long Hospital
of Emory Universiry experience. Orthop Nurs 1997; 16(4}:29.
Clinical Tip
•
The validiry of these scales may be improved by asking
the patient about his or her current level of pain, rather
than asking the patient to speculate about "usual" or
"previous" levels of pain.5
•
The patient's self-reporting of pain is the most accurate indicator of the existence or intensity of his or her pain, or both.6
APPENDIX VI: PAIN MANAGE...\1ENT 879
• Be sensitive and respectful to how different cultures perceive pain, as certain cultures may be very stoic about their
pain, whereas others are very demonstrative.
Physical Therapy Considerations for Pain Evaluation
•
Be aware of the nonverbal indicators of pain, such as behavior
changes, facial expressions, and body language, in patients who
have an impaired ability to communicate their pain, as with an
unconscious patient or an adult with dementia.
•
Monitoring vital signs during the pain evaluation may provide
insight into the sympathetic tone of the patient, which can be indicative of their level of pain. This can be performed easily in the intensive care setting, because the patient'S hemodynamic status is
being continuously monitored.
• The physical therapist should recognize when the patient is
weaning from pain medication (e.g., transitioning from intravenous to oral administration), as the patient may complain of increased pain with a concurrent reduced activity tolerance during
this time period.
• To optimize consistency in the health care team, the physical
therapist should use the same pain rating tool as the medical-surgical team to determine adequacy of pain management.
•
Often the best way to communicate the adequacy of a patient's
pain management to the nurses or physicians is in terms of the
patient'S abiliry to complete a given task or activity (e.g., the
patient is effectively coughing and clearing secretions).
Management
Nonsteroidal anti-inflammatOry drugs (Table VI-2) and systemic opioids (Table Vl-3) are the most common pharmacologic agents prescribed for postOperative pain. Aspirin and acetaminophen (Tylenol) are also common medications prescribed for pain relief and are categorized as non-narcotic analgesic and antipyretic drugs.7·8 Alterna-
880 ACtrrE CARE HANDBOOK FOR PHYSICAL THERAPISTS
Table VI-2. Nonsteroidal Anti-Inflammatory Drugs
Indications:
Used as the sole therapy for mild to moderate pain
For patients with osteoarthritis, rheumatoid arthritis, and dysmenorrhea
Used in combination with opioids for moderate postoperative pain, especially
when weaning from stronger medications
Useful in children younger than 6 mos of age
Contraindicated in patienes undergoing anticoagulation therapy, with peptic
ulcer disease, or with gastritis
Mechanism of action:
Accomplish analgesia by inhibiting prostaglandin synthesis, which leads to antiinflammatory effects (Prostaglandin is a potent pain-producing chemical.) A useful alternative or adjunct to opioid therapy
General side effeces:
Platelet dysfunction and gastritis, nausea, abdominal pain, anorexia,
dizziness, and drowsiness
Severe reactions include nephrowxicity (dysuria, hematuria) and cholesratic
hepatitis
Medications: Generic name (trade name)
Celecoxib (Celebrex)
Diclofenac potassium (Caraflam)
Diclofenac sodium (Voltaren, Voltarol)
Erodolac (Lodine, Lodine XL)
Fenoprofen calcium (Fenopron, Nalfon)
F1urbiprofen (Ansaid, Apo-Flurbiprofen, Froben, Ocufen, Opthalmic)
Ibuprofen (Morrin, Advil. Excedrin, Medipren, Nuprin, Pamprin, Nurofen,
Pedia Profen, Rafen, Saleto-200, 400, and 600, Trendar)
Indomethacin (Apo-Indomethacin, (ndocin)
Ketoprofen (Actron, Apo-Keto, Novo-Keto, Orudis, Rhodis)
Ketorolac tromethamine (Toradol)
Nabumerone (Relafen, Relifex)
Naproxen (Naprosyn)
Naproxen sodium (Aleve)
Oxaprozin (Daypro)
Piroxicam (Apo-Piroxicam, Feldene, Novo-Pirocam, Pirox)
Rofecoxib (Vioxx)
Sulindac (Adin, Apo-Sulin, elinoril, Novo-Sundae, Saldac)
Tolme,in (Tolectin)
Sources: Data from JC B3lbnryne. D Borsook. PostOperative l)ain. In D Borsook, AA
LeBel, B McPeek (eds), The Massachuserts General Hospitall-l3ndbook of Pain Managemenr. Boston: Linle, Brown, 1996;247; Nursing 2001 Drug Handbook (21st ed).
Springhouse, PA: Springhouse Corporation, 2001 ;346-367; and L Skidmore-Roth (ed).
Mosby's Nursing Drug Reference. Sr. Louis: Mosby, 200 1;56-57,924.