Pain Mgmt RN cheat sheet

Nociceptive pain results from activation of peripheral nociceptors by mechanical, thermal, or chemical stimuli and is commonly described as aching, throbbing, or pressure-like.

Neuropathic pain arises from a lesion or disease of the somatosensory nervous system and is commonly burning, shooting, electric-shock, or pins-and-needles in quality.

Acute pain lasts less than 3 months and usually resolves with tissue healing; chronic or persistent pain lasts beyond 3 months or past normal healing time.

Pain is multidimensional, including sensory-discriminative, affective-motivational, and cognitive-evaluative components; patient self-report is the primary pain source.

The 0-10 Numeric Rating Scale is used for adults and children able to self-report; Wong-Baker FACES is used for young children or those unable to use numbers.

FLACC is a behavioral scale for children aged 2 months to 7 years; PAINAD is used for advanced dementia and CPOT for intubated or unable-to-report adults.

Vital signs are not a reliable sole indicator of pain because physiologic responses may be absent in chronic pain or masked by beta-blockers and other medications.

Central sensitization is increased responsiveness of nociceptive neurons, producing allodynia (nonpainful stimulus perceived as painful) and hyperalgesia (increased pain response).

Descending pain modulation involves the periaqueductal gray, rostral ventromedial medulla, and endogenous opioids; stress, expectation, and placebo can alter this modulation.

The WHO analgesic ladder starts with a nonopioid for mild pain, adds a weak opioid for moderate pain, and uses a strong opioid for severe pain, with adjuvants at any step.

Adult acetaminophen maximum is 4,000 mg/day; limit to 3,000 mg/day or less with hepatic impairment, chronic alcohol use, low body weight, or prolonged use, and count all combination products.

NSAIDs inhibit cyclooxygenase and carry risks of GI bleeding, renal injury, and cardiovascular events; they are avoided in eGFR below 30, active peptic ulcer, and anticoagulation.

Equianalgesic approximations: morphine 10 mg parenteral equals about 30 mg oral morphine; hydromorphone 1.5 mg parenteral equals about 7.5 mg oral; oxycodone 20 mg oral equals about 30 mg oral morphine.

Morphine milligram equivalents use conversion factors: oral morphine factor 1, oral oxycodone 1.5, oral hydromorphone 4, and methadone variable; MME = dose times factor.

Opioid-induced constipation does not resolve with tolerance; a prophylactic bowel regimen is required when opioids are initiated, especially in older adults.

Naloxone for opioid-induced respiratory depression is titrated at 0.04-0.4 mg IV every 2-3 minutes to restore adequate breathing; intranasal 4 mg is used for community overdose.

Combining tramadol, meperidine, or fentanyl with SSRIs, SNRIs, or MAOIs increases serotonin syndrome risk, marked by hyperthermia, rigidity, clonus, and autonomic instability.

Adjuvant analgesics include gabapentinoids and SNRIs for neuropathic pain, tricyclics for neuropathic pain and sleep, topical lidocaine for localized pain, and ketamine or lidocaine infusions for refractory pain.

Procedural sedation requires continuous monitoring of oxygenation, ventilation, circulation, and level of consciousness; capnography is recommended to detect hypoventilation early.

Informed consent for invasive pain procedures includes diagnosis, proposed procedure, risks, benefits, alternatives, and consequences of refusal.

Maximum lidocaine dose is about 4.5 mg/kg without epinephrine and 7 mg/kg with epinephrine; bupivacaine maximum is about 2-3 mg/kg, and intravascular injection must be avoided.

Local anesthetic systemic toxicity presents with neurologic excitation or depression and cardiovascular instability; treatment includes stopping injection, 100% oxygen, and 20% lipid emulsion.

Epidural steroid injection risks include bleeding, infection, dural puncture headache, nerve injury, and transient pain flare; anticoagulants and antiplatelets are held per procedural guidelines.

Radiofrequency ablation creates a heat lesion of medial branch or other targeted nerves; diagnostic blocks are typically performed first, and post-procedure neuritis can occur.

Spinal cord stimulator therapy uses a temporary trial before permanent implantation; systems vary in paresthesia-based versus high-frequency programming and MRI compatibility.

Trigger point injection uses local anesthetic with or without corticosteroid; thoracic sites carry pneumothorax risk, and aseptic technique is required.

Peripheral nerve blocks require pre- and post-block sensory and motor assessment; lower extremity blocks increase fall risk and require fall precautions until resolution.

Gate control theory states that nonpainful sensory input from massage, heat, cold, or TENS activates large-diameter fibers that inhibit pain transmission in the dorsal horn.

TENS is avoided over the carotid sinus, pregnant abdomen, pacemaker or implanted electronic device site, and areas of impaired sensation or active malignancy unless specifically approved.

Heat causes vasodilation and muscle relaxation and is avoided in acute inflammation or bleeding; cold causes vasoconstriction and reduces edema and muscle spasm, typically for up to 20 minutes.

Cognitive behavioral therapy targets catastrophizing and maladaptive pain beliefs and improves function and coping in chronic pain.

Mindfulness-based stress reduction uses meditation and body scanning and reduces pain interference, anxiety, and distress in persistent pain.

Acupuncture modulates endogenous opioid release, descending inhibitory pathways, and local blood flow; evidence supports use for chronic low back pain, neck pain, and osteoarthritis.

Relaxation techniques include diaphragmatic breathing, progressive muscle relaxation, and guided imagery and reduce sympathetic arousal associated with pain.

Distraction and virtual reality reduce procedural pain and distress, with effectiveness influenced by developmental age and patient preference.

Graded exercise and physical therapy improve function in chronic pain; aggressive exercise during an acute flare can worsen symptoms.

Multimodal postoperative analgesia combines scheduled acetaminophen, an NSAID when not contraindicated, and opioid only as needed to reduce opioid requirements and adverse effects.

Preemptive analgesia given before incision or a painful stimulus reduces central sensitization and subsequent postoperative pain.

Enhanced recovery pathways use early ambulation, early oral intake, opioid-sparing analgesia, and regional anesthesia to improve postoperative outcomes.

Postoperative pain is assessed at rest and with movement such as coughing, deep breathing, and ambulation; analgesia is provided before painful activity.

Patient-controlled analgesia must be activated only by the patient; family or nurse activation can cause overdose, and sedation and respiratory status are monitored.

Increasing sedation is an early warning of opioid-induced respiratory depression and often precedes a decline in respiratory rate.

Thoracotomy and upper abdominal surgery require attention to splinting and incentive spirometry; inadequate analgesia impairs deep breathing and increases pulmonary complications.

Knee arthroplasty with femoral or adductor canal block requires fall precautions because quadriceps weakness may persist after the block.

Discharge planning after surgery includes a multimodal prescription, bowel regimen, naloxone when risk factors exist, and counseling against driving while using opioids.

Chronic pain is explained by the biopsychosocial model, in which biological, psychological, and social factors interact to influence pain and disability.

Fibromyalgia presents with widespread pain, fatigue, sleep disturbance, and cognitive fog; first-line treatments include exercise, CBT, duloxetine, pregabalin, and amitriptyline.

Neuropathic pain first-line options include gabapentinoids, SNRIs such as duloxetine, and tricyclics; topical lidocaine is used for localized neuropathic pain.

Low back pain red flags include saddle anesthesia, bowel or bladder dysfunction, fever, cancer history, unexplained weight loss, major trauma, and progressive neurologic deficit.

Chronic opioid therapy requires individualized goals, prescription drug monitoring program review, urine drug testing, treatment agreements, and reassessment of function.

Opioid tolerance is reduced drug effect over time requiring higher doses; physical dependence is withdrawal on stopping; addiction is compulsive use despite harm.

Pain catastrophizing includes rumination, magnification, and helplessness and predicts greater pain interference and poorer treatment response.

Myofascial pain involves trigger points with referred pain patterns and is treated with stretch, injection, dry needling, and physical therapy.

Medication overuse headache can result from frequent use of acute analgesics or triptans and requires limitation of acute medications and preventive treatment.

Children able to self-report use age-appropriate scales such as FACES or the Numeric Rating Scale; preverbal children use FLACC or behavioral observation.

Codeine and tramadol are contraindicated in children younger than 12 years and after tonsillectomy or adenoidectomy in those younger than 18 because of CYP2D6 variability and respiratory depression risk.

Older adults require lower starting doses and slower titration; the Beers criteria advise avoiding meperidine and chronic NSAID use because of delirium, falls, GI, and renal risks.

Pregnancy analgesia generally favors acetaminophen; NSAIDs are avoided in the third trimester because of ductus arteriosus constriction and oligohydramnios risk.

Sickle cell vaso-occlusive crisis requires rapid opioid analgesia, hydration, and incentive spirometry; meperidine is avoided because of neurotoxic metabolite accumulation.

Palliative care focuses on relief of pain and other symptoms and on quality of life; opioid titration is based on symptom severity and patient goals.

Hospice care is comfort-focused; opioids treat dyspnea and pain, and benzodiazepines may treat anxiety or refractory dyspnea.

PAINAD assesses pain in advanced dementia through breathing, negative vocalization, facial expression, body language, and consolability, each scored 0-2.

The doctrine of double effect permits an action intended to relieve suffering even if a foreseeable but unintended harmful effect, such as respiratory depression, may occur.

The Joint Commission requires pain assessment and reassessment, patient education about pain management, and discharge planning related to pain.

Patients have a right to adequate pain assessment and management; nurses advocate by documenting unrelieved pain and requesting appropriate reevaluation.

Prescription drug monitoring program review before initiating or changing opioid therapy identifies multiple prescribers, overlapping controlled substances, and high-risk combinations.

Opioid informed consent and treatment agreements address risks, benefits, safe storage, disposal, refill policy, urine drug testing, and conditions for discontinuation.

Ethical principles in pain care include beneficence, nonmaleficence, autonomy, and justice; autonomy supports patient participation in analgesic decisions.

Controlled substances require secure storage, accurate counting, witnessed waste by two licensed clinicians per policy, and immediate reporting of discrepancies.

Teach-back is a health literacy method in which the patient explains instructions in their own words, confirming understanding of medications and warning signs.

Pain documentation includes location, quality, intensity, timing, aggravating and alleviating factors, associated symptoms, and response to intervention.

Nursing pain education includes pharmacologic effects, adverse effects, safe use, nonpharmacologic strategies, and when to seek urgent care.