NLE Perioperative & Pain Nursing — Pain ManagementRevision Notes

Exam Tips

• NLE items often ask which process is targeted by a specific intervention. NSAIDs act at Transduction; epidural analgesia acts at Transmission; opioids act at Perception and Modulation.
• When asked about the rationale for massage, TENS, or heat/cold therapy, the correct answer always references Gate Control Theory.
• The statement 'Pain is whatever the patient says it is' is a foundational NLE answer for questions about the most reliable pain assessment method — always choose the patient's self-report over behavioral observations when the patient can communicate.

Key Points

• Pain is a subjective, protective experience. The gold standard definition: 'Pain is whatever the patient says it is, existing whenever the patient says it does' (McCaffery). This means the patient's self-report is always the most reliable indicator — never doubt or minimize what the patient reports.
• Nociceptive (pain-sensing) transmission follows four sequential processes: Transduction → Transmission → Perception → Modulation.
• Transduction: A noxious (harmful) stimulus — mechanical (cut, pressure), thermal (burn, extreme cold), or chemical (inflammation mediators) — activates peripheral nociceptors (pain receptors) and converts the stimulus into a nerve impulse.
• Transmission: The nerve impulse travels along peripheral nerves (A-delta fibers for sharp pain, C fibers for dull/burning pain) into the spinal cord's dorsal horn, then ascends to the brain via the spinothalamic tract.
• Perception: The brain (thalamus and cortex) becomes conscious of the pain and gives it meaning. Cultural background, past experiences, and emotions all influence perception.
• Modulation: The body's own system of pain control. Endogenous opioids (endorphins, enkephalins) released from descending pathways bind opioid receptors in the spinal cord and dampen the pain signal. This is the basis for opioid analgesia.
• Gate Control Theory (Melzack and Wall): Non-painful stimuli (such as rubbing, heat, massage, or TENS) stimulate large-diameter nerve fibers that 'close the gate' in the spinal cord's dorsal horn, reducing pain signal transmission to the brain. This is the scientific rationale for non-pharmacologic pain management.

Definitions

Section Title

Pain Physiology: The Four Processes and Gate Control Theory

Common Mistakes

• Confusing the four processes: Remember the order is always Transduction → Transmission → Perception → Modulation (mnemonic: 'Terrible Tigers Pursue Mice').
• Thinking modulation only amplifies pain — modulation can BOTH amplify (sensitization in chronic pain) and dampen (endorphins, opioids) the signal.
• Forgetting that pain perception is influenced by psychological and cultural factors — never assume a patient is not in pain because they appear calm or stoic.

Exam Tips

• NLE scenario: A post-op patient is quiet, reading, and has a normal heart rate but reports pain of 8/10. The correct nurse response is to BELIEVE the patient and intervene — do NOT assume they are not in pain based on appearance.
• When the question describes 'burning, shooting, electric' pain, the answer is NEUROPATHIC. Adjuvant choice: gabapentin/pregabalin.
• Referred pain patterns are high-yield for NLE assessment questions: memorize MI → left arm/jaw, cholecystitis → right shoulder, appendicitis → McBurney's point (RLQ).

Key Points

• Pain is classified by duration, origin, and mechanism. Understanding each type guides assessment and management.
• Acute pain: Sudden onset, caused by an identifiable tissue injury (surgery, trauma, acute illness). Duration: less than 3–6 months. It serves a protective warning function. Accompanied by sympathetic nervous system responses: tachycardia, hypertension, diaphoresis (sweating), pallor, and dilated pupils. Resolves as the underlying cause heals.
• Chronic (persistent) pain: Lasts beyond the expected healing time (longer than 3–6 months). May not show the dramatic physiologic signs of acute pain because the body adapts over time (parasympathetic adaptation). Associated with depression, anxiety, fatigue, sleep disturbance, and functional limitation. Examples: chronic low back pain, fibromyalgia, cancer pain.
• Nociceptive pain — from actual tissue damage, intact nerve function:
• • Somatic pain: From skin, muscle, bone, and connective tissue. Well-localized. Described as aching, throbbing, or sharp. Example: postoperative incision pain.
• • Visceral pain: From internal organs (stomach, intestines, kidneys). Poorly localized, deep, cramping, or squeezing. May be referred to a distant site (e.g., MI pain referred to the left arm, gallbladder pain referred to the right shoulder).
• Neuropathic pain — from nerve damage or dysfunction. Described as burning, shooting, electric-like, tingling, or stabbing. Examples: diabetic peripheral neuropathy, post-herpetic neuralgia, phantom limb pain, chemotherapy-induced neuropathy. Responds less well to standard analgesics; requires adjuvant drugs (gabapentin, pregabalin, tricyclic antidepressants).
• Referred pain: Visceral pain perceived at a site distant from the actual organ. Important examples for NLE: Appendicitis → initially periumbilical, then McBurney's point (RLQ); MI → left arm/jaw; Liver/gallbladder → right shoulder; Kidney → flank, groin.

Definitions

Section Title

Types of Pain: Classification and Clinical Features

Common Mistakes

• Assuming a patient with chronic pain is not in real pain because they lack tachycardia or diaphoresis — chronic pain patients adapt physiologically and these signs are often ABSENT.
• Confusing visceral and neuropathic pain: Visceral pain is from organ damage (intact nerves); neuropathic pain is from nerve damage itself.
• Forgetting that phantom limb pain is neuropathic, not psychosomatic — it is a real physiologic phenomenon requiring real treatment.

Exam Tips

• NLE item: 'Which pain scale is MOST appropriate for a 2-year-old post-tonsillectomy patient?' → FLACC (the child cannot self-report at this age).
• NLE item: 'A patient rates pain as 8/10. Which is the MOST reliable indicator of pain?' → The patient's self-report (NOT the nurse's observation or vital signs).
• Remember the reassessment timeframes: IV analgesic = 15–30 minutes; Oral analgesic = 30–60 minutes. These are commonly tested in NLE pharmacology/nursing care items.

Key Points

• Because pain is subjective, systematic assessment is essential. Always use a standardized tool appropriate for the patient's age, cognitive status, and communication ability.
• PQRST Framework — a structured way to characterize any pain complaint:
• P – Provocation and Palliation: What makes the pain WORSE? What makes it BETTER? (Activity, rest, position, medications, heat/cold)
• Q – Quality: How does it FEEL? (Sharp, dull, burning, cramping, throbbing, aching, stabbing)
• R – Region and Radiation: WHERE is it? Does it SPREAD anywhere?
• S – Severity: How INTENSE on a scale of 0–10 (or appropriate tool)?
• T – Timing: When did it START? How LONG does it last? Is it CONSTANT or intermittent? Does it follow a PATTERN?
• Numeric Rating Scale (NRS, 0–10): 0 = no pain, 10 = worst possible pain. Standardly used for adults and older children (approximately 8 years and up) who can self-report. Mild pain = 1–3; Moderate = 4–6; Severe = 7–10.
• Wong-Baker FACES Pain Rating Scale: Six cartoon faces ranging from smiling (0, no pain) to crying (10, worst pain). Used for children approximately 3 years and older and for adults with communication barriers (language differences, mild cognitive impairment).
• FLACC Scale (Behavioral): For infants, preverbal children, and nonverbal or unconscious patients. Observational, not self-report. Five parameters, each scored 0–2:
• F – Face (0=relaxed, 1=occasional grimace, 2=frequent grimace/clenched jaw)
• L – Legs (0=relaxed/normal, 1=uneasy/restless, 2=kicking/drawn up)
• A – Activity (0=lying quietly, 1=squirming/tense, 2=rigid/arched)
• C – Cry (0=no cry, 1=moans/whimpers, 2=crying steadily/screaming)
• C – Consolability (0=content/relaxed, 1=reassured by touch, 2=difficult to console)
• Total score: 0 = relaxed/no pain; 1–3 = mild; 4–6 = moderate; 7–10 = severe pain.
• Reassessment is mandatory after every pain intervention: 30–60 minutes after ORAL analgesic, 15–30 minutes after IV analgesic. Document the pain score before and after intervention to evaluate effectiveness.
• Also assess: Effect of pain on function (ability to walk, sleep, perform ADLs), mood, cultural factors influencing pain expression, and current medications.

Definitions

Section Title

Pain Assessment: Tools and the PQRST Framework

Common Mistakes

• Using the FLACC scale for a conscious, communicating adult — FLACC is for NONVERBAL patients. Use NRS for verbal adults.
• Forgetting to REASSESS after giving pain medication — documentation of both pre- and post-intervention scores is required.
• Using the Wong-Baker FACES scale and assuming the smiling face means the patient feels happy — each face represents a pain level, not an emotion.
• Not considering cultural influences: Filipino patients may underreport pain due to cultural stoicism (tiis) — always ask directly and use appropriate tools.

Exam Tips

• NLE item: 'A patient with chronic kidney disease has moderate pain. Which analgesic should the nurse AVOID?' → NSAIDs (renal toxicity). Safe option: acetaminophen (at appropriate dose).
• NLE item: 'What is the antidote for acetaminophen (paracetamol) overdose?' → N-Acetylcysteine (NAC/acetylcysteine).
• NLE item: 'Which non-opioid analgesic has an anti-inflammatory effect?' → NSAIDs. Acetaminophen does NOT have significant anti-inflammatory effects.
• Remember WHO ladder steps by pain severity: Mild → non-opioids; Mild-Moderate → weak opioids + non-opioids; Severe → strong opioids + non-opioids + adjuvants.

Key Points

• The WHO (World Health Organization) Analgesic Ladder is a three-step framework originally developed for cancer pain but applied broadly. It guides stepwise escalation of analgesic therapy based on pain severity.
• Step 1 — Mild Pain (1–3/10): Non-opioid analgesics ± adjuvants. Drugs: Acetaminophen (paracetamol), NSAIDs (ibuprofen, naproxen, ketorolac, mefenamic acid).
• Step 2 — Mild to Moderate Pain (4–6/10): Weak opioids added to non-opioids ± adjuvants. Drugs: Codeine, tramadol (often combined with paracetamol).
• Step 3 — Moderate to Severe Pain (7–10/10): Strong opioids + non-opioids ± adjuvants. Drugs: Morphine, fentanyl, hydromorphone, oxycodone.
• Key WHO ladder principles: (1) By the CLOCK — give around-the-clock (ATC) for continuous pain, not just PRN (as needed). (2) By the MOUTH — use oral route when possible. (3) By the LADDER — start at the appropriate step for the pain level and escalate as needed.
• Adjuvant drugs (co-analgesics): Used at any step to enhance analgesia or treat specific pain types.
• • Neuropathic pain: Gabapentin (Neurontin), Pregabalin (Lyrica), Tricyclic antidepressants (amitriptyline), SNRIs (duloxetine)
• • Bone/inflammatory pain: Corticosteroids (dexamethasone)
• • Muscle spasm pain: Muscle relaxants (methocarbamol, baclofen)
• Acetaminophen (Paracetamol): Analgesic AND antipyretic. Minimal anti-inflammatory effect. Mechanism: central prostaglandin inhibition. Maximum adult dose: 4 g/day (4,000 mg/day); REDUCE to 2 g/day with liver disease, malnutrition, or chronic alcohol use. KEY DANGER: HEPATOTOXICITY (liver damage) with overdose. Antidote for acetaminophen overdose: N-ACETYLCYSTEINE (NAC). Signs of hepatotoxicity: right upper quadrant pain, jaundice, elevated liver enzymes (AST, ALT).
• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Ibuprofen, naproxen, ketorolac, mefenamic acid, celecoxib. Mechanism: Inhibit COX enzymes → reduce prostaglandin synthesis → reduce pain, fever, AND inflammation. Route: ketorolac (Toradol) is available IV/IM for acute pain (maximum 5 days use).
• NSAID Nursing Considerations (HIGH PRIORITY):
• • Give WITH FOOD or milk to reduce GI irritation
• • Monitor for GI bleeding: black tarry stools (melena), hematemesis, epigastric pain
• • Monitor renal function (BUN, creatinine): NSAIDs reduce renal prostaglandins → vasoconstriction → decreased GFR → renal impairment
• • Monitor for increased bleeding time: NSAIDs inhibit platelet aggregation (especially aspirin — irreversible; others reversible)
• • Use CAUTIOUSLY in: older adults, peptic ulcer disease (PUD), chronic kidney disease (CKD), dehydration, patients on anticoagulants (warfarin, heparin)
• • Celecoxib (COX-2 selective) has less GI risk but SAME renal risk and increased cardiovascular risk

Definitions

Section Title

Pharmacologic Management: WHO Analgesic Ladder and Non-Opioid Drugs

Common Mistakes

• Forgetting that acetaminophen has minimal anti-inflammatory effect — for inflammation, an NSAID is needed.
• Not reducing acetaminophen dose in patients with liver disease or alcoholism — this is a common CLINICAL error with serious consequences.
• Giving NSAIDs without food — always administer with food or milk to protect the gastric mucosa.
• Thinking ketorolac can be given indefinitely — maximum use is 5 days due to high risk of GI and renal toxicity.
• Confusing the antidotes: Acetaminophen overdose → N-Acetylcysteine (NAC); Opioid overdose → Naloxone. Do NOT mix these up on the NLE.

Exam Tips

• HIGHEST PRIORITY NLE RULE: Before giving any opioid, ASSESS RR. If RR < 12/min → HOLD and NOTIFY. This is the single most important opioid nursing action.
• NLE item: 'A nurse is caring for a patient receiving morphine via PCA. The patient's RR is 8/min and SpO2 is 90%. What is the PRIORITY action?' → Administer naloxone and notify the physician.
• NLE item: 'Which opioid side effect does NOT improve with tolerance?' → CONSTIPATION.
• NLE item: 'A patient who received naloxone for opioid overdose is resting quietly. What should the nurse do NEXT?' → Continue to MONITOR closely for re-narcotization (return of respiratory depression).
• Maslow prioritization: Respiratory depression from opioids = PHYSIOLOGIC (survival) need = HIGHEST PRIORITY. Always address airway/breathing before other concerns.

Key Points

• Opioids are the cornerstone of moderate-to-severe pain management (WHO Step 2 and 3). They bind to mu, kappa, and delta opioid receptors in the CNS and periphery to produce analgesia, sedation, and euphoria.
• Common opioids and their clinical uses:
• • Morphine: The reference standard opioid. IV: 2–10 mg every 3–4 hours; Oral: 10–30 mg every 3–4 hours (always per physician order). Available in immediate-release and extended-release forms.
• • Fentanyl: Highly lipid-soluble, rapid onset (IV/transdermal patch). Transdermal fentanyl patch is for STABLE CHRONIC pain — NOT for acute pain or opioid-naive patients.
• • Hydromorphone (Dilaudid): More potent than morphine; used when morphine is not tolerated.
• • Oxycodone: Oral strong opioid; often combined with acetaminophen (e.g., Percocet).
• • Codeine: Weak opioid (WHO Step 2); often combined with paracetamol (e.g., Co-codamol).
• • Tramadol: Atypical opioid with additional serotonin/norepinephrine reuptake inhibition; WHO Step 2; lower abuse potential than strong opioids.
• CRITICAL OPIOID ADVERSE EFFECTS (memorize all):
• 1. RESPIRATORY DEPRESSION — THE MOST DANGEROUS AND POTENTIALLY FATAL. Watch for: RR < 12/min, SpO2 decreasing, increasing sedation, shallow breathing.
• 2. Sedation — often precedes respiratory depression; use a sedation scale (Pasero Opioid-Induced Sedation Scale: S=sleeping, 1=awake, 2=slightly drowsy, 3=frequently drowsy, 4=somnolent/difficult to arouse). Level 3–4 = hold dose, notify MD.
• 3. Constipation — DOES NOT develop tolerance (unlike other side effects); give PROPHYLACTIC stimulant laxatives (senna, bisacodyl) from day 1 of opioid therapy. Stool softeners alone are insufficient.
• 4. Nausea and vomiting — common initially, usually improves with continued use.
• 5. Urinary retention — especially in older males and post-spinal opioid use.
• 6. Hypotension (orthostatic) — monitor BP before and after administration; instruct patient to change positions slowly.
• 7. Pruritus (itching) — especially with neuraxial (epidural/intrathecal) opioids.
• 8. Miosis (pinpoint pupils) — a classic sign of opioid effect/overdose.
• KEY OPIOID NURSING SAFETY RULES — THESE ARE NLE-CRITICAL:
• RULE 1: ALWAYS ASSESS RESPIRATORY RATE BEFORE GIVING AN OPIOID.
• RULE 2: HOLD the dose and NOTIFY the physician/provider if RR is BELOW 12 breaths per minute (or per institutional policy). Also hold if SpO2 drops below 95% or sedation level is 3–4.
• RULE 3: MONITOR: Level of consciousness (LOC), oxygen saturation (SpO2), respiratory rate (RR), and blood pressure (BP) regularly after giving opioids.
• NALOXONE (Narcan) — Opioid Reversal Agent:
• • Mechanism: Competitive opioid receptor antagonist — displaces opioids from receptors → rapidly reverses respiratory depression, sedation, and miosis.
• • Indication: Opioid-induced respiratory depression/overdose.
• • Route: IV (fastest), IM, intranasal (IN), subcutaneous.
• • Typical adult dose: 0.4–2 mg IV; may repeat every 2–3 minutes up to 10 mg.
• • CRITICAL: Naloxone has a SHORT DURATION OF ACTION (30–90 minutes). The opioid may OUTLAST the naloxone, causing RE-NARCOTIZATION (return of respiratory depression). MONITOR CLOSELY and be prepared to repeat doses or start an infusion.
• • WARNING: Naloxone precipitates ACUTE OPIOID WITHDRAWAL in physically dependent patients (severe pain, agitation, hypertension, tachycardia, diaphoresis, vomiting) — use the smallest effective dose.
• • WARNING: Naloxone REVERSES ANALGESIA — the patient's pain will suddenly return when given naloxone.
• • Always keep naloxone AND resuscitation equipment immediately available when opioids are being used.
• Equianalgesic Dosing: When switching from one opioid to another or changing routes, use equianalgesic conversion tables to ensure equivalent pain relief without under- or over-dosing.

Definitions

Section Title

Opioid Analgesics: Safety, Adverse Effects, and Naloxone

Common Mistakes

• Giving an opioid without first checking the respiratory rate — this is a critical nursing error and a common NLE trap.
• Thinking constipation from opioids will resolve with tolerance — it does NOT. Prophylactic laxatives must be started with the first opioid dose.
• Confusing physical dependence with addiction — they are NOT the same. Physical dependence is physiologic and expected; addiction is a behavioral disorder.
• Not knowing that naloxone wears off FASTER than most opioids — patients can go back into respiratory depression after initial reversal.
• Applying a fentanyl transdermal patch for acute postoperative pain — patches are for STABLE CHRONIC pain only, not acute pain.
• Not believing a patient with a history of substance use needs opioids for pain — all patients deserve adequate pain management.

Exam Tips

• NLE item: 'The patient's daughter is pressing the PCA button for her mother who appears to be sleeping. What is the PRIORITY nursing action?' → STOP the daughter from pressing the button and educate her that only the patient should use PCA.
• NLE item: 'Which PCA feature PRIMARILY prevents opioid overdose?' → The lockout interval.
• NLE item: 'A PCA patient has attempted the button 20 times in the last hour but only received 4 doses. What does this indicate?' → Inadequate pain control (lockout prevented extra doses); notify the physician for dose review.
• Two-nurse check for PCA is the same priority as two-nurse check for blood transfusion — always required for safety.

Key Points

• PCA (Patient-Controlled Analgesia) is a method of pain management where the patient self-administers a pre-programmed IV opioid dose (bolus) by pressing a hand-held button connected to an infusion pump.
• PCA BENEFITS: Provides more consistent plasma drug levels (avoiding peaks and troughs of scheduled doses), gives the patient a sense of control over their pain management, reduces total opioid consumption compared to nurse-administered doses, and leads to better patient satisfaction.
• HOW PCA WORKS: The physician orders the specific opioid (usually morphine, fentanyl, or hydromorphone), the DEMAND DOSE (amount delivered per button press), the LOCKOUT INTERVAL (minimum time between doses — prevents overdose even if button is pressed repeatedly), and optional BASAL RATE (continuous background infusion, usually only for opioid-tolerant patients).
• Lockout interval: Typically 5–15 minutes. During this time, pressing the button delivers NO drug — the pump 'locks out.' This is the PRIMARY safety feature of PCA.
• PCA is most commonly used for: Postoperative pain, trauma pain, labor pain (PCEA — epidural PCA), and cancer pain.
• CRITICAL PCA SAFETY RULE: ONLY THE PATIENT should press the PCA button. This is called 'PCA by proxy' when anyone else presses it — family members, nurses, or visitors pressing the button for the patient (even with good intentions) can cause OPIOID OVERDOSE because the pump's safety feature (lockout) is based on the patient being awake and responsive enough to press the button themselves.
• NURSING RESPONSIBILITIES FOR PCA:
• 1. EDUCATION: Teach the patient to press the button when pain begins or slightly BEFORE painful activities (e.g., ambulation, deep breathing exercises). Teach that it is SAFE to press when needed.
• 2. VERIFICATION: Perform a TWO-NURSE CHECK of the drug, concentration, demand dose, lockout interval, and hourly limit before initiating PCA.
• 3. MONITORING: Regularly assess and document: Pain intensity (NRS score), Respiratory rate (RR), Level of sedation (sedation scale), Oxygen saturation (SpO2), Blood pressure (BP), Number of demands (attempts) versus actual deliveries.
• 4. DOCUMENTATION: Record amounts delivered and attempted; a high demand-to-delivery ratio (many presses, few deliveries) suggests inadequate pain control — notify the physician to consider dose adjustment.
• 5. AVAILABILITY: Ensure NALOXONE and resuscitation equipment are immediately available at the bedside.
• 6. PREVENT PCA BY PROXY: Educate family members clearly that they must NOT press the button for the patient.
• 7. ROUTINE ASSESSMENT: Assess IV site for patency, infiltration, or phlebitis.

Definitions

Section Title

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

Common Mistakes

• Allowing family members to press the PCA button — this is a critical safety violation regardless of good intentions.
• Not performing a two-nurse check before initiating PCA — this is a required safety protocol.
• Not monitoring sedation level — sedation precedes respiratory depression with PCA opioids.
• Forgetting to keep naloxone at the bedside — always available when opioids are being administered.
• Not reassessing pain after PCA doses — a high demand-to-delivery ratio indicates the dose needs adjustment, not that the PCA is malfunctioning.

Exam Tips

• NLE item: 'What is the scientific rationale for using massage and TENS for pain relief?' → Gate Control Theory.
• NLE item: 'Which therapy is MOST appropriate for a patient with an acute ankle sprain 2 hours after injury?' → Cold therapy (cryotherapy/ice), NOT heat.
• NLE item: 'A patient refuses opioids. Which non-pharmacologic interventions can the nurse implement?' → Relaxation, guided imagery, distraction, TENS, positioning, music therapy.

Key Points

• Non-pharmacologic interventions complement (not replace) analgesics. They reduce pain perception, decrease anxiety, promote relaxation, and reduce opioid requirements — thereby reducing opioid-related adverse effects.
• RATIONALE: Most non-pharmacologic measures work through the GATE CONTROL THEORY — competing non-painful stimuli 'close the gate' in the spinal cord, reducing pain signal transmission.
• CUTANEOUS STIMULATION TECHNIQUES:
• • Heat therapy (thermotherapy): Vasodilation, increased blood flow, muscle relaxation, reduces stiffness. Best for: chronic muscle pain, arthritis, non-inflamed injuries (after 48 hours), spasms. CAUTION: Do NOT apply to areas with impaired circulation, open wounds, or inflammation/acute injury (first 24–48 hours — ice first).
• • Cold therapy (cryotherapy): Vasoconstriction, reduces edema, numbs area, decreases inflammation. Best for: acute injuries (first 24–48 hours — RICE: Rest, Ice, Compression, Elevation), post-op edema, acute sprains. CAUTION: Do NOT apply directly to skin (wrap in cloth); limit to 15–20 minutes; avoid in vascular disease.
• • Massage: Promotes circulation, muscle relaxation, reduces anxiety. Works via gate control theory. Contraindicated over areas with phlebitis, fractures, or skin breakdown.
• • TENS (Transcutaneous Electrical Nerve Stimulation): Delivers low-level electrical impulses through skin electrodes → stimulates large-diameter nerve fibers → closes pain gate. Useful for chronic musculoskeletal pain.
• COGNITIVE-BEHAVIORAL TECHNIQUES:
• • Relaxation techniques: Deep breathing (diaphragmatic breathing), progressive muscle relaxation, mindfulness — reduce muscle tension, anxiety, and sympathetic pain response.
• • Guided imagery: Using mental visualization of peaceful scenes to distract the mind from pain.
• • Distraction: Redirecting attention away from pain (watching TV, music, prayer, conversation). Very effective for procedural pain.
• • Biofeedback: Teaching patients to control physiologic responses (muscle tension, heart rate) through electronic monitoring feedback.
• • Music therapy: Evidence-based; reduces pain, anxiety, and opioid use in postoperative patients.
• OTHER APPROACHES:
• • Positioning and immobilization: Proper alignment and splinting reduce pain from movement and pressure.
• • Acupuncture and acupressure: Traditional Chinese medicine; stimulates specific points to modulate pain pathways.
• • Prayer and spiritual support: Important in Filipino cultural context — acknowledge spiritual beliefs as part of holistic pain management.
• • Hypnotherapy: Altered state of focused attention that modifies pain perception.
• IMPORTANT: Non-pharmacologic measures are especially valuable for: chronic pain management, reduction of opioid requirements, patients who cannot take analgesics (allergy, organ failure), procedural pain in children, and patients who prefer non-drug approaches.
• NURSING ROLE: Assess patient preference, cultural beliefs, and contraindications before applying non-pharmacologic measures. Document effectiveness. Include family in non-pharmacologic care (e.g., family providing massage or distraction in pediatric patients).

Definitions

Section Title

Non-Pharmacologic Pain Management

Common Mistakes

• Applying heat immediately to an acute injury — use COLD first for acute injuries (first 24–48 hours) to reduce inflammation; switch to heat after.
• Applying cold or heat directly to the skin without a barrier — always wrap in a cloth to prevent burns or frostbite.
• Dismissing non-pharmacologic measures as 'not really helpful' — evidence strongly supports their use as part of multimodal pain management.
• Forgetting cultural and spiritual dimensions of pain in Filipino patients — prayer, hilot (traditional massage), and family support are important adjuncts.

Exam Tips

• NLE item: 'A patient on chronic opioids needs a higher dose to achieve the same pain relief as before. This is BEST described as:' → TOLERANCE (not addiction, not dependence).
• NLE item: 'A cancer patient's pain is not relieved by the current opioid dose. The nurse's BEST action is:' → Notify the physician; advocate for dose titration (no ceiling in cancer/palliative pain).
• Remember: Tolerance = need more drug; Physical dependence = withdrawal if stopped suddenly; Addiction = compulsive use despite harm. These are DIFFERENT concepts tested in NLE pharmacology.

Key Points

• Chronic pain management requires a MULTIMODAL, INTERDISCIPLINARY APPROACH — no single drug or intervention is adequate alone. The team includes physicians, nurses, pharmacists, physical therapists, psychologists, and social workers.
• TREATMENT GOALS for chronic pain: Set FUNCTIONAL goals rather than complete pain elimination. Goals include: Improved sleep quality, Increased activity and mobility, Return to work or usual activities, Improved mood and quality of life (QOL). Complete pain elimination is rarely achievable; reducing pain from 8/10 to 4/10 with improved function is a realistic success.
• PHARMACOLOGIC APPROACH for chronic pain:
• • Around-the-clock (ATC) dosing: Long-acting opioids (MS Contin, OxyContin, fentanyl patch) for baseline/background pain, PLUS short-acting opioids for breakthrough pain episodes.
• • Adjuvant drugs for neuropathic component: Gabapentin, pregabalin, duloxetine, tricyclic antidepressants.
• • Opioid rotation: Switching to a different opioid when current one causes intolerable side effects or tolerance.
• • Cancer pain: Opioids are titrated generously to relieve suffering — NO arbitrary ceiling or dose limit in palliative care. The goal is comfort.
• NON-PHARMACOLOGIC for chronic pain: Physical therapy, occupational therapy, cognitive-behavioral therapy (CBT), mindfulness, acupuncture, TENS, exercise programs, and support groups.
• PSYCHOLOGICAL COMORBIDITIES must be addressed: Depression and anxiety are common in chronic pain patients (bidirectional relationship — pain causes depression; depression worsens pain). Treat both simultaneously.
• THREE KEY CONCEPTS TO DISTINGUISH:
• • TOLERANCE: The body needs MORE drug to achieve the SAME effect. Normal pharmacologic adaptation. Managed by dose increase or opioid rotation.
• • PHYSICAL DEPENDENCE: Withdrawal symptoms occur if drug is ABRUPTLY stopped. Normal physiologic adaptation. Managed by GRADUAL TAPERING when discontinuing opioids.
• • ADDICTION (Substance Use Disorder): Compulsive, uncontrolled drug use despite harm. A complex neurobiologic disease. Distinct from tolerance and dependence. Requires specialized treatment.
• PSEUDOADDICTION: Drug-seeking behavior that MIMICS addiction but is actually caused by UNDERTREATED PAIN. Resolves when pain is adequately treated. Important concept — do not mislabel a patient as 'addicted' when they are simply undertreated.
• OPIOPHOBIA: Unfounded fear of prescribing or administering opioids for pain. Leads to undertreating pain. Under RA 9173, nurses are responsible for advocating for adequate pain relief — undertreating pain is an ethical and potentially legal issue.
• SPECIAL POPULATIONS:
• • Older adults (geriatric): More sensitive to opioids, slower drug clearance (decreased renal/hepatic function), higher fall risk with sedation. Principle: 'Start low, go slow.' NSAIDs are HIGH RISK in elderly (GI bleeding, renal failure). Avoid NSAID use in elderly when possible.
• • Children: Dose by weight (mg/kg). Use age-appropriate assessment tools (FLACC for infants; FACES for 3+ years; NRS for 8+ years). Pain in children is UNDERTREATED due to misconceptions — children feel pain as acutely as adults.
• • Opioid-naive patients: Have no opioid tolerance; require extra monitoring for respiratory depression at standard doses.
• • Patients with substance use disorder history: STILL deserve adequate pain management. Treat pain while coordinating a clear opioid management plan; consider consultation with addiction medicine specialist.

Definitions

Section Title

Chronic Pain Management and Special Considerations

Common Mistakes

• Setting the goal of 'zero pain' for chronic pain patients — functional improvement is the realistic and appropriate goal.
• Withholding opioids from cancer or palliative care patients due to fear of overdose or addiction — this constitutes under-treatment and violates ethical principles.
• Confusing tolerance with addiction and stopping opioids abruptly — always taper gradually to prevent withdrawal.
• Not addressing depression and anxiety in chronic pain patients — psychological comorbidities must be treated as part of the pain management plan.
• Not believing patients with a history of substance use disorder who report pain — they still deserve adequate pain management, though with careful monitoring.