NLE Perioperative & Pain Nursing — Pain ManagementDetailed Explanation

Pain Physiology: Understanding How Pain Works

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The most important clinical principle is: PAIN IS WHATEVER THE PATIENT SAYS IT IS, EXISTING WHENEVER THE PATIENT SAYS IT DOES. This statement, attributed to pain pioneer Margo McCaffery, is fundamental — the patient's self-report is the MOST RELIABLE indicator of pain. Never dismiss or minimize a patient's pain report. The body processes pain through four sequential steps: 1. TRANSDUCTION: A harmful (noxious) stimulus — mechanical (cut, pressure), thermal (burn, cold), or chemical (acid, inflammation mediators like prostaglandins and bradykinin) — activates specialized nerve endings called NOCICEPTORS. These convert the stimulus into a nerve impulse (electrical signal). Think of it as the 'alarm trigger.' 2. TRANSMISSION: The nerve impulse travels from the nociceptors along peripheral nerves (A-delta fibers for sharp, fast pain and C fibers for slow, dull, burning pain) to the DORSAL HORN of the spinal cord, then ascends via the spinothalamic tract to the BRAIN. This is the 'message delivery' phase. 3. PERCEPTION: The brain (thalamus, cortex, limbic system) becomes CONSCIOUS of the pain. This is where the sensation becomes an experience — including the emotional and cognitive dimensions of pain. This is the 'awareness' phase. 4. MODULATION: The body attempts to MODIFY or control the pain signal through descending pathways. The body releases endogenous opioids (endorphins, enkephalins) that bind to opioid receptors and reduce pain transmission. This is the 'natural painkiller' phase — and the same mechanism exploited by opioid drugs. GATE CONTROL THEORY (Melzack and Wall, 1965): This theory proposes that there is a 'gate' mechanism in the DORSAL HORN of the spinal cord. Non-painful stimuli (rubbing, massage, heat, vibration) traveling along large A-beta fibers can CLOSE this gate and reduce the transmission of pain signals from A-delta and C fibers. This is why rubbing an injured area feels better — and it is the scientific basis for non-pharmacologic pain interventions like massage, heat, cold, and TENS (Transcutaneous Electrical Nerve Stimulation).

Types of Pain: Classification and Clinical Features

Understanding pain types is essential for selecting the right management approach. Pain is classified by DURATION, PATHOPHYSIOLOGY, and ORIGIN. CLASSIFICATION BY DURATION: 1. ACUTE PAIN: - Duration: Recent onset, typically resolves within 3–6 months as healing occurs - Cause: Identifiable tissue injury (surgery, trauma, infection) - Physiologic signs: Sympathetic nervous system activation — TACHYCARDIA, HYPERTENSION, DIAPHORESIS (sweating), dilated pupils, increased respiratory rate - Behavioral signs: Guarding, grimacing, crying - Purpose: Protective — signals the body to take action - Example: Postoperative incision pain, dental pain, fracture pain 2. CHRONIC (PERSISTENT) PAIN: - Duration: Persists beyond expected healing time (longer than 3–6 months) - May have no identifiable ongoing tissue injury - Physiologic signs: Often ABSENT — the body adapts; no tachycardia or diaphoresis - Behavioral signs: May appear normal or stoic — DO NOT underestimate! - Associated with: Fatigue, depression, anxiety, sleep disturbance, functional limitation - Examples: Low back pain, osteoarthritis, cancer pain, fibromyalgia - NLE PITFALL: Do not deny pain relief to a chronic pain patient just because they show no sympathetic signs! CLASSIFICATION BY PATHOPHYSIOLOGY: 3. NOCICEPTIVE PAIN — from actual tissue damage; the pain system is working normally a. SOMATIC nociceptive pain: - Origin: Skin, muscles, bones, joints - Character: Well-localized, aching, throbbing, sharp - Example: Surgical incision, fracture, arthritis b. VISCERAL nociceptive pain: - Origin: Internal organs (viscera) - Character: Deep, cramping, poorly localized, may be REFERRED to a distant site - Example: Appendicitis pain referred to the right shoulder (Kehr's sign), cardiac ischemia referred to the left arm and jaw, cholecystitis referred to the right shoulder tip - NLE TIP: Know common referred pain patterns! 4. NEUROPATHIC PAIN — from damage or dysfunction of the nervous system itself - The pain system is MALFUNCTIONING - Character: Burning, shooting, electric shock-like, tingling (paresthesia), stabbing - Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia (after shingles/herpes zoster), phantom limb pain (pain in an amputated limb), trigeminal neuralgia, chemotherapy-induced neuropathy - Management: Standard opioids are less effective; ADJUVANTS (tricyclic antidepressants like amitriptyline, anticonvulsants like GABAPENTIN and PREGABALIN) are first-line - NLE IMPORTANT: When you see 'burning, shooting, electric-like pain' — think NEUROPATHIC; think GABAPENTIN/PREGABALIN

Pain Assessment: Tools, Techniques, and Reassessment

Accurate pain assessment is the foundation of effective pain management. The nursing process begins with assessment — and for pain, this means using VALIDATED TOOLS systematically. Assessment includes not just intensity but also character, location, timing, and impact on function. PQRST FRAMEWORK — Use this for comprehensive pain characterization: P — PROVOCATION and PALLIATION - What makes the pain WORSE? (e.g., movement, eating, breathing) - What makes the pain BETTER? (e.g., rest, ice, position change, medications) Q — QUALITY - Describe the CHARACTER of the pain - Words: Sharp, dull, aching, throbbing, burning, stabbing, cramping, pressure-like, squeezing - NLE TIP: Quality helps identify pain type — burning/shooting = neuropathic; cramping = visceral R — REGION and RADIATION - WHERE exactly is the pain? - Does it RADIATE (spread) anywhere? - Use a body diagram if needed S — SEVERITY (Intensity) - Rate on a validated pain scale (see below) - This is the MOST frequently assessed dimension T — TIMING - When did it START? (onset) - How long does it LAST? (duration) - Is it CONSTANT or INTERMITTENT? - Is there a pattern? (e.g., worse in the morning, worse after meals) PAIN RATING SCALES — Choose the appropriate tool for the patient: 1. NUMERIC RATING SCALE (NRS) 0–10: - 0 = no pain; 10 = worst imaginable pain - Use for: ADULTS and older children who can communicate and understand numbers - Interpret: 1–3 = mild; 4–6 = moderate; 7–10 = severe - MOST COMMONLY USED in Philippine hospital settings - NLE: When asked which scale to use for a cognitively intact adult → NRS 0-10 2. WONG-BAKER FACES PAIN RATING SCALE: - Six cartoon faces ranging from a big smile (0, no hurt) to a crying face (10, worst hurt) - Use for: CHILDREN approximately 3 years and older, elderly patients, patients with LIMITED English/communication, patients who prefer visual tools - Also used for patients with mild cognitive impairment - NLE: When the patient is a child or has communication barriers → Wong-Baker FACES 3. FLACC SCALE (Behavioral Observation Tool): - F = Face (0–2: no expression / grimacing / constant frown or clenched jaw) - L = Legs (0–2: normal / tense or restless / kicking) - A = Activity (0–2: lying quietly / squirming, shifting / arched, rigid, or jerking) - C = Cry (0–2: no cry / moans or whimpers / crying steadily or screaming) - C = Consolability (0–2: content / reassured by touch / inconsolable) - TOTAL SCORE: 0–10 (same interpretation: 1–3 mild, 4–6 moderate, 7–10 severe) - Use for: INFANTS (ages 2 months to 7 years), NON-VERBAL PATIENTS, UNCONSCIOUS patients, patients who CANNOT SELF-REPORT - NLE: When the patient is an infant or cannot communicate → FLACC REASSESSMENT — CRITICAL SAFETY STEP: - ALWAYS reassess pain after an intervention to evaluate EFFECTIVENESS - Timing for reassessment: * After ORAL analgesics: 30–60 minutes (time to absorption and peak effect) * After IV/IM analgesics: 15–30 minutes (faster absorption) * After non-pharmacologic measures: 15–30 minutes - Document: pain score before AND after intervention, response to treatment ADDITIONAL ASSESSMENT DIMENSIONS: - Effect on FUNCTION: Can the patient walk, eat, sleep, work? - Effect on MOOD: Is the patient anxious, depressed, irritable? - CULTURAL factors: Some cultures (including certain Filipino communities) tend to under-report or tolerate pain stoically; others may be more expressive — neither is 'wrong'; use objective tools - PAST pain experiences and current medications - Substance use history (for safe opioid prescribing) NURSING DIAGNOSIS (NANDA) related to pain: - Acute Pain related to surgical tissue trauma as evidenced by patient-reported pain 8/10 and grimacing - Chronic Pain related to degenerative joint disease as evidenced by patient-reported pain 6/10 for 6 months and impaired mobility - Impaired Physical Mobility related to pain - Disturbed Sleep Pattern related to chronic pain

Pharmacologic Pain Management: The WHO Analgesic Ladder and Drug Classes

Pharmacologic pain management is the most heavily tested area of pain management in the NLE. The WHO Analgesic Ladder, non-opioid analgesics, opioids, and adjuvants each have specific indications, mechanisms, nursing responsibilities, and safety concerns you MUST master. THE WHO ANALGESIC LADDER (3-Step Approach): Developed in 1986 for cancer pain but applicable to all persistent pain. The principle is 'BY THE CLOCK, BY THE MOUTH, BY THE LADDER' — dose around the clock, use oral route when possible, titrate upward as needed. STEP 1 — MILD PAIN (1–3/10): - Drugs: Non-opioids (ACETAMINOPHEN + NSAIDs) ± Adjuvants - Start here unless pain is already moderate or severe STEP 2 — MILD TO MODERATE PAIN (4–6/10): - Drugs: WEAK OPIOIDS (codeine, tramadol) + Non-opioids ± Adjuvants - Add a weak opioid to Step 1 drugs STEP 3 — MODERATE TO SEVERE PAIN (7–10/10): - Drugs: STRONG OPIOIDS (morphine, fentanyl, hydromorphone, oxycodone) + Non-opioids ± Adjuvants - Titrate strong opioids to effect; no ceiling dose for opioids in cancer/palliative care ADJUVANT MEDICATIONS (add at any step for specific pain types): - For neuropathic pain: Gabapentin (Neurontin), Pregabalin (Lyrica), Tricyclic antidepressants (amitriptyline), SNRIs (duloxetine) - For inflammation/bone pain: Corticosteroids (dexamethasone) - For muscle spasm: Muscle relaxants (methocarbamol, baclofen) - For anxiety component: Benzodiazepines (short-term, with caution) NON-OPIOID ANALGESICS: 1. ACETAMINOPHEN (PARACETAMOL — most common in Philippines): - Mechanism: Exact mechanism unclear; acts centrally; ANTIPYRETIC and ANALGESIC but minimal anti-inflammatory effect - Indications: Mild to moderate pain, fever; SAFE for gastric mucosa (unlike NSAIDs) - Brand names in Philippines: Biogesic, Panadol, Tempra - MAXIMUM DOSE: 4 g/day in healthy adults; REDUCE to 2 g/day in liver disease, alcoholism, malnutrition - KEY DANGER: HEPATOTOXICITY (liver toxicity) — the NUMBER ONE adverse effect of paracetamol overdose - Signs of hepatotoxicity: RUQ pain, jaundice, elevated ALT/AST, liver failure - ANTIDOTE: N-ACETYLCYSTEINE (NAC / Fluimucil) — replenishes glutathione to prevent liver damage; most effective within 8–10 hours of ingestion - NLE KEY: 'Paracetamol overdose → hepatotoxicity → antidote is acetylcysteine' 2. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): - Examples: Ibuprofen, Naproxen, Aspirin, Ketorolac (IV/IM), Celecoxib (COX-2 selective) - Mechanism: Inhibit CYCLOOXYGENASE (COX) enzymes → reduce PROSTAGLANDIN synthesis → reduce pain, inflammation, and fever - Common brands in Philippines: Mefenamic acid (Ponstan), Ibuprofen (Advil, Medicol), Celecoxib (Celebrex) - Nursing considerations and adverse effects: * GI EFFECTS: Gastric irritation, ulceration, GI BLEEDING (black tarry stools = melena) — MOST COMMON AND IMPORTANT adverse effect * ALWAYS GIVE WITH FOOD or MILK to reduce gastric irritation * RENAL IMPAIRMENT: Prostaglandins maintain renal blood flow; NSAIDs can precipitate acute kidney injury (AKI), especially in dehydrated or elderly patients * PLATELET INHIBITION: Increased bleeding time — HOLD before surgery per order * CARDIOVASCULAR: Increased risk of MI and stroke with long-term use (especially selective COX-2 inhibitors) * KETOROLAC (Toradol): IV/IM NSAID for short-term use ONLY (maximum 5 days) — high GI and renal risk with prolonged use - Contraindications: Peptic ulcer disease (PUD), renal failure, bleeding disorders, third-trimester pregnancy, patients on anticoagulants - Use cautiously in: Elderly (reduced renal reserve), patients with asthma (aspirin-sensitive asthma), heart failure OPIOID ANALGESICS (CRITICAL SAFETY CONTENT — HIGH NLE FREQUENCY): - Examples: MORPHINE (reference standard), Fentanyl, Hydromorphone (Dilaudid), Oxycodone, Codeine, Tramadol - Mechanism: Bind to MU (μ), KAPPA (κ), and DELTA (δ) opioid receptors in CNS and periphery → inhibit pain transmission - Indications: Moderate to severe pain (Step 2–3) - Morphine reference dose: 2–10 mg IV or 10–30 mg orally every 3–4 hours (always per physician order and institutional protocol) ADVERSE EFFECTS OF OPIOIDS (memorize all): a. RESPIRATORY DEPRESSION — THE MOST DANGEROUS AND LIFE-THREATENING effect - Signs: Respiratory rate less than 12/min, shallow breathing, decreasing oxygen saturation, unresponsiveness - NURSING ACTION: Assess RR BEFORE EVERY DOSE; HOLD THE DOSE AND NOTIFY PHYSICIAN if RR is below 12 breaths per minute - ANTIDOTE: NALOXONE (Narcan) — opioid antagonist; reverses ALL opioid effects b. SEDATION — precedes respiratory depression; monitor LOC - Sedation scale: Awake → Occasionally drowsy → Frequently drowsy → Somnolent, minimal response - Increasing sedation is an early warning of impending respiratory depression c. CONSTIPATION — DOES NOT DEVELOP TOLERANCE; ALWAYS manage proactively - Give stimulant laxatives (bisacodyl, senna) prophylactically when starting opioid therapy - Do NOT rely on bulk-forming laxatives alone (inadequate for opioid-induced constipation) - Increase fluids, fiber, and activity as tolerated d. NAUSEA AND VOMITING — common especially with first doses; tolerance usually develops e. URINARY RETENTION — especially in males with BPH; monitor urinary output f. HYPOTENSION (especially orthostatic) — change positions slowly g. PRURITUS (itching) — especially with IV/epidural opioids h. MIOSIS (pinpoint pupils) — a CLASSIC SIGN of opioid use/overdose NALOXONE (NARCAN) — THE OPIOID ANTIDOTE: - Mechanism: Competitive opioid receptor antagonist — DISPLACES the opioid from the receptor - Indications: Opioid overdose with respiratory depression (RR less than 12, unresponsiveness, miosis, SpO2 dropping) - Administration: IV (preferred), IM, SQ, or intranasal - CRITICAL CAUTION: Naloxone has a SHORTER HALF-LIFE than most opioids → The naloxone wears off BEFORE the opioid does → respiratory depression can RETURN → Monitor patient closely; REPEAT DOSES or an IV INFUSION may be needed → This is called 'RENARCOTIZATION' — patient improves then deteriorates again - Naloxone also precipitates ACUTE OPIOID WITHDRAWAL in dependent patients: sudden onset of pain, agitation, tachycardia, hypertension, diaphoresis, nausea, vomiting — dose titrate carefully - NLE KEY: 'Naloxone reverses opioid toxicity BUT its effect is SHORT — monitor and redose as needed'

Patient-Controlled Analgesia (PCA): Safety and Nursing Responsibilities

Patient-Controlled Analgesia (PCA) is a method of pain management that allows the PATIENT to self-administer pre-programmed doses of IV analgesic (usually an opioid, most commonly morphine or hydromorphone) by pressing a button. PCA provides STEADIER pain control than nurse-administered PRN dosing, reduces delays, and gives the patient a sense of CONTROL over their pain. HOW PCA WORKS: - The PCA pump contains the opioid at a set concentration - When the patient presses the button (handset/controller), a DEMAND DOSE is delivered IV - The pump is programmed with: a. DEMAND (bolus) dose: Amount delivered per button press b. LOCKOUT INTERVAL: Time period during which NO further dose will be delivered even if the button is pressed again (safety feature — prevents overdose). Typical lockout: 5–15 minutes c. 1-HOUR or 4-HOUR LIMIT: Maximum cumulative dose in the set time period d. BASAL (continuous) RATE: Some pumps also deliver a low continuous background infusion (controversial — increases risk of over-sedation, especially in opioid-naive patients) - A second nurse (double-check) MUST verify the PCA program settings before use NURSING RESPONSIBILITIES FOR PCA: 1. PRE-PCA SETUP: - Verify the FIVE RIGHTS + two-nurse verification of drug, concentration, dose, lockout interval, and hourly limit - Ensure NALOXONE and resuscitation equipment are IMMEDIATELY AVAILABLE - Assess baseline respiratory rate, pain score, LOC, and oxygen saturation 2. PATIENT TEACHING (Critical — PCA fails if patient is not educated): - Explain that PCA lets THEM control their pain relief - Instruct to press the button when pain BEGINS (not when pain is severe — better to stay ahead of pain) - MOST IMPORTANT SAFETY TEACHING: ONLY THE PATIENT PRESSES THE BUTTON - NEVER allow family members to press the button — this is called 'PCA BY PROXY' and is UNSAFE and can cause OPIOID OVERDOSE because the family member cannot assess the patient's level of consciousness as the patient can - Reassure the patient that the lockout prevents overdose from pressing too often 3. ONGOING MONITORING: - Assess at regular intervals (per hospital protocol — commonly every 1–2 hours): a. RESPIRATORY RATE (hold if less than 12/min) b. SEDATION LEVEL (use sedation scale) c. OXYGEN SATURATION (SpO2 — alert if below 95%) d. BLOOD PRESSURE e. PAIN SCORE f. PCA machine: number of ATTEMPTS vs DELIVERIES (if the patient is pressing frequently but not getting relief — assess for opioid tolerance, pump malfunction, or undertreated pain; if deliveries are low but pain is high — patient may not understand how to use it) 4. DOCUMENTATION: - Document drug, concentration, settings, number of doses attempted and delivered, amount of drug used, patient's pain score, and response - Controlled substance accounting (per RA 9165 requirements in Philippine hospitals) 5. SAFETY CONCERNS: - PCA BY PROXY: Only the patient presses the button — family members must not - PUMP MALFUNCTION: Check tubing, connections, and alarms regularly - LOCK the pump and follow controlled substance protocols for opioid vials PCA CONTRAINDICATIONS: - Patient is TOO SEDATED or ALTERED to press the button — defeats the safety mechanism - Infant, young child, or patient who cannot understand/cooperate - Patient refuses or is afraid to use it - Severe respiratory compromise

Non-Pharmacologic Pain Management

Non-pharmacologic (non-drug) pain management is an essential component of comprehensive pain care. These strategies complement medications, are cost-effective, have minimal adverse effects, and are especially valuable for chronic pain, pediatric patients, pregnant women, elderly patients, and those who wish to minimize drug use. They work primarily through the Gate Control Theory (activating large A-beta fibers to close the pain gate) and by activating descending inhibitory pathways (enhancing endorphin release through relaxation and positive emotions). CLASSIFICATION OF NON-PHARMACOLOGIC METHODS: 1. CUTANEOUS (PHYSICAL) STIMULATION: a. HEAT THERAPY: - Vasodilation → increased blood flow → reduced muscle spasm and stiffness - Use for: Chronic muscle pain, arthritis, menstrual cramps, muscle stiffness - Types: Hot packs, warm compress, heating pad, warm bath/shower, paraffin wax - CAUTION: Do NOT apply heat to acute inflammation, open wounds, areas with impaired sensation (risk of burns — especially diabetics), or immediately after acute injury (first 24–48 hours) - Temperature range: 40–45°C; always place a cloth barrier between heat source and skin b. COLD THERAPY (CRYOTHERAPY): - Vasoconstriction → reduced inflammation, edema, and metabolism → numbs nerve endings - Use for: Acute injuries (sprains, fractures), acute inflammation, headache, insect bites - Types: Ice pack, cold compress, cooling spray - CAUTION: Do NOT apply ice directly to skin (wrap in cloth); do NOT use for prolonged periods (risk of frostbite); avoid in patients with Raynaud's disease or peripheral vascular disease - Recommended duration: 15–20 minutes at a time - NLE TIP: RICE (Rest, Ice, Compression, Elevation) is first-line for acute musculoskeletal injury c. MASSAGE THERAPY: - Manual manipulation of soft tissues → increases blood flow, reduces muscle tension, promotes relaxation, stimulates large A-beta fibers (Gate Control Theory) - Use for: Muscle pain, tension headache, postoperative recovery - CAUTION: Avoid over areas of skin breakdown, thrombosis (risk of dislodging clot), tumor sites, or fractures d. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS): - Small electric current applied to skin via electrodes → stimulates A-beta fibers → closes pain gate in spinal cord; also promotes endorphin release - Use for: Chronic back pain, osteoarthritis, postoperative pain, labor pain - Non-invasive, patient-controlled, minimal adverse effects - CONTRAINDICATIONS: Demand pacemakers (electrical interference), pregnancy (especially over abdomen/pelvis), over carotid sinus, epilepsy - Available in Philippine rehabilitation centers and tertiary hospitals 2. COGNITIVE-BEHAVIORAL STRATEGIES: a. RELAXATION TECHNIQUES: - Deep breathing, progressive muscle relaxation (PMR), meditation - Reduces anxiety → decreases sympathetic arousal → reduces perceived pain intensity - Promotes endorphin release through central pathways b. GUIDED IMAGERY (VISUALIZATION): - Patient mentally pictures a peaceful, pain-free scene or the pain 'dissolving' - Activates higher cortical centers → modulates pain perception - Effective for chronic pain, cancer pain, procedural pain (e.g., wound dressing changes) c. DISTRACTION: - Redirects attention away from pain → reduces pain perception - Methods: TV, music, games, conversation, hobbies, prayer - Simple but effective — especially for acute procedural pain - In Philippine pediatric settings: cartoons, toys, and parental presence during procedures d. MUSIC THERAPY: - Reduces pain intensity, anxiety, and need for analgesics - Patient selects preferred music for maximum benefit e. BIOFEEDBACK: - Electronic monitoring of physiologic parameters (muscle tension, HR) to train voluntary control - Used for headache, chronic low back pain, TMJ 3. POSITIONING AND REST: - Proper body alignment reduces mechanical strain and pain - Elevating injured extremities reduces edema and pain - Pillows for support (semi-Fowler's for abdominal pain, side-lying for back pain) 4. COMPLEMENTARY AND ALTERNATIVE THERAPIES: a. ACUPUNCTURE/ACUPRESSURE: - Traditional Chinese medicine; stimulates specific points to restore energy flow and activate endorphins - Evidence-based for low back pain, osteoarthritis, headache b. AROMATHERAPY, HERBAL PREPARATIONS: - Used as complementary measures; always inform the healthcare team - In Philippine cultural context: 'hilot' (traditional massage), 'sambong', 'lagundi' (DOH-approved herbal medicines) KEY TEACHING POINT: Non-pharmacologic measures REDUCE THE NEED FOR DRUGS but do NOT replace them for moderate-severe pain. The goal is MULTIMODAL ANALGESIA — using multiple approaches together for optimal pain control with minimal drug adverse effects.

Chronic Pain Management and Special Populations

Chronic pain (pain lasting more than 3–6 months beyond expected healing) requires a specialized, MULTIMODAL, INTERDISCIPLINARY approach that differs significantly from acute pain management. It is a complex condition that affects every dimension of a patient's life — physical, psychological, social, and spiritual. KEY PRINCIPLES OF CHRONIC PAIN MANAGEMENT: 1. MULTIMODAL APPROACH: - Pharmacologic + Non-pharmacologic + Psychological + Rehabilitative - No single treatment is sufficient; combine multiple strategies - Goal: Improved FUNCTION, not necessarily zero pain (pain elimination is often unrealistic) - Set FUNCTIONAL GOALS: Better sleep, improved mobility, return to work or hobbies, improved mood 2. INTERDISCIPLINARY TEAM: - Physician (pain specialist, physiatrist, oncologist) - Nurse (assessment, medication management, patient education) - Physical therapist (exercise, mobilization) - Psychologist/psychiatrist (CBT, antidepressants) - Social worker (coping resources, support systems) - Pharmacist (medication reconciliation) - Chaplain/pastoral care (spiritual support) 3. PHARMACOLOGIC MANAGEMENT OF CHRONIC PAIN: a. Around-the-clock long-acting opioids (e.g., MS Contin, extended-release oxycodone, fentanyl patch) for cancer pain b. Short-acting breakthrough doses for episodes of severe pain (breakthrough dose = typically 5–15% of the total daily opioid dose) c. Adjuvants for neuropathic component (gabapentin, pregabalin, TCAs) d. Antidepressants (duloxetine/SNRIs) — dual benefit: treat depression AND neuropathic pain e. Topical agents (lidocaine patches, diclofenac gel) for localized pain f. Fentanyl TRANSDERMAL PATCH: - For STABLE chronic pain; NOT for acute, postoperative, or opioid-naïve patients - Takes 12–24 hours to reach peak effect when first applied; 72-hour duration - Apply to dry, intact, hairless skin (upper outer arm, chest, back) - Rotate sites to prevent skin irritation - DISPOSE PROPERLY — even used patches contain residual drug (fentanyl remains in dead layers of skin) - Do NOT expose to heat (heating pad, hot bath, sunlight) — accelerates absorption and causes overdose 4. ADDRESSING CO-MORBIDITIES: - DEPRESSION is common in chronic pain — treat aggressively (SNRIs/SSRIs) - SLEEP DISORDERS — optimize sleep hygiene, consider medication - ANXIETY — relaxation techniques, CBT, medication as needed - Social isolation — encourage support groups, family involvement 5. IMPORTANT TERMINOLOGY DISTINCTIONS (CRITICAL FOR NLE): a. TOLERANCE: The body requires HIGHER DOSES of opioid to achieve the SAME analgesic effect over time. This is a PHYSIOLOGIC phenomenon, NOT addiction. Management: dose titration upward. b. PHYSICAL DEPENDENCE: The body adapts to the presence of opioid and experiences WITHDRAWAL SYMPTOMS if the drug is abruptly stopped. This is also PHYSIOLOGIC, NOT addiction. Management: taper dose gradually, never abrupt cessation. Withdrawal symptoms: anxiety, agitation, diaphoresis, tachycardia, rhinorrhea, nausea, vomiting, diarrhea, muscle aches, gooseflesh (piloerection/cold turkey) c. TRUE ADDICTION (Substance Use Disorder): PSYCHOLOGICAL compulsive drug-seeking behavior DESPITE HARM; loss of control; continued use despite negative consequences. This is a PSYCHOLOGICAL and NEUROBIOLOGICAL disease. d. PSEUDO-ADDICTION: Behavior that LOOKS like addiction (drug-seeking, clock-watching for next dose) but is actually caused by UNDERTREATED PAIN. Resolves when pain is adequately managed. The nurse should advocate for better pain control, not label the patient as addicted. 6. SPECIAL POPULATIONS: A. ELDERLY PATIENTS: - More sensitive to opioids (reduced metabolism, lower albumin, altered receptor sensitivity) - Increased risk of NSAID-related GI and renal harm - Principle: 'START LOW, GO SLOW' — begin with lower doses and titrate carefully - Monitor for falls (sedation + orthostatic hypotension from opioids) - Preferred: Acetaminophen for mild pain; lowest effective NSAID dose with PPI cover - AVOID in elderly: Long-acting benzodiazepines, meperidine/pethidine (active metabolite normeperidine causes seizures), indomethacin (high toxicity) B. PEDIATRIC PATIENTS: - Dose analgesics by WEIGHT (mg/kg) - Children do FEEL pain — never deny analgesics to a child because of age - Use age-appropriate tools (FLACC for infants; Wong-Baker FACES for 3+; NRS for older children) - Parental presence reduces anxiety and pain perception - Non-pharmacologic: Sucrose for neonatal procedures, breastfeeding, skin-to-skin C. PATIENTS WITH SUBSTANCE USE DISORDER (SUD): - STILL DESERVE ADEQUATE PAIN RELIEF — withholding is unethical and illegal - Coordinate with addiction medicine specialist - Set clear treatment agreements (drug contracts) - Monitor for aberrant behavior but do not assume - Use non-opioid and non-pharmacologic strategies maximally D. CANCER AND PALLIATIVE CARE: - Opioids used generously — pain relief is a fundamental right - NO CEILING DOSE for cancer pain — titrate to relief - Comfort measures take priority over concerns about addiction or respiratory depression in terminal patients - Philippine Palliative Care framework: DOH guidelines and PhilHealth coverage for cancer pain management 7. NURSING ROLE: ADVOCATE FOR PAIN RELIEF - Under RA 9173, nurses have the professional and ethical duty to advocate for adequate pain relief - UNDERTREATING PAIN (oligoanalgesia) is a patient safety and human rights issue - Nurses must document pain systematically and communicate unrelieved pain to the care team

This problem integrates WHO ladder application, pain type classification, and opioid safety in a cancer pain scenario — a common integrated NLE question format. Key points: (1) Stage IV cancer with 9/10 pain needs Step 3 immediately; (2) Burning/shooting descriptors require neuropathic adjuvants on top of opioids; (3) Cancer pain has no ceiling dose on opioids; (4) Around-the-clock dosing is required for continuous cancer pain.

This problem tests opioid overdose recognition and emergency response — a PATIENT SAFETY CRITICAL NLE topic. The correct priority order follows ABCs: secure airway and oxygenation BEFORE administering antidote. The short half-life of naloxone means continuous monitoring is essential — the nurse cannot leave after giving the antidote.

This problem tests tool selection across age groups and consciousness levels — a classic multi-patient NLE question. Key rules: (1) FLACC = any patient who CANNOT self-report (infants AND unconscious adults); (2) Wong-Baker = children approximately 3 years and up and communication-impaired adults; (3) NRS = cooperative adults and older children. Understanding the FLACC scoring components (FLACC = Face, Legs, Activity, Cry, Consolability) is essential.

This problem tests conceptual understanding of MULTIMODAL ANALGESIA and the nurse's ability to articulate clinical rationale — skills assessed in NLE critical thinking questions. The answer must link mechanisms (Gate Control Theory + prostaglandin inhibition), clinical safety (lower drug doses = fewer side effects), and professional responsibility (RA 9173).