Pain Management in Nursing Practice
Publication Year: 2015
Pain is a challenging area to understand for any healthcare professional, and quality training on the subject is required if nurses are to provide effective pain management and person-centred care. Based on the curriculum developed by the International Association for the Study of Pain, this book offers an essential guide to managing pain. It begins with an examination of the biology of pain, and then goes on to consider pain management across the lifecourse, looking at key topics including acute pain, cancer pain and pharmacology. Case scenarios are included throughout the book to help readers apply the knowledge they have learned to their own practice.It will be valuable reading for undergraduate nurses, and essential for those taking continuing professional development and postgraduate courses in pain ...
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Leaders in Pain Care: An Historic Overview
- Chapter 2: The Biopsychosocial Model of Pain: Rehumanizing Care
- Chapter 3: The Neuropsychophysiology of Pain
- Chapter 4: Epidemiology of Chronic Pain
- Chapter 5: The Assessment and Measurement of Pain
- Chapter 6: Communication in Pain Management
- Chapter 7: Pharmacological and Interventional Pain Management
- Chapter 8: Acute Pain
- Chapter 9: Chronic Non-malignant Pain
- Chapter 10: Cancer Pain
- Chapter 11: Pain Management in Palliative Care and at End of Life
- Chapter 12: Stress Management and Nonpharmacological Interventions for Pain
- Chapter 13: Quality, Safety and Organizational Issues in Pain Management
- Chapter 14: Pain and Human Rights
SAGE Publications Ltd
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© Shelagh Wright 2015
First published 2015
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, this publication may be reproduced, stored or transmitted in any form, or by any means, only with the prior permission in writing of the publishers, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.
Library of Congress Control Number: 2014940396
British Library Cataloguing in Publication data
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ISBN 978-1-4462-8200-7 (pbk)
Editor: Alex Clabburn
Associate editor: Emma Milman
Production editor: Katie Forsythe
Proofreader: David Hensley
Indexer: David Rudeforth
Marketing manager: Camille Richmond
Cover design: Naomi Robinson
Typeset by: C&M Digitals (P) Ltd, Chennai, India
Printed in Great Britain by Henry Ling Limited, at the Dorset Press, Dorchester, DT1 1HD
This book is dedicated to the memory of my husband Tom, brave endurer of rheumatic heart disease, proud father and loving grandfather[Page vi]
List of Figures and Tables[Page viii]Figures
- 1.1Descartes' (1664) concept of the pain pathway 6
- 2.1Loeser's Onion: the four components that are necessary and sufficient to describe the phenomenon of pain 24
- 3.1Basic reflex arc 36
- 3.2(Two-way) pain pathway from periphery to brain 42
- 3.3The Gate Control Theory of pain 46
- 3.4Top-down factors in pain 49
- 4.1The psychobiological model of chronic pain 64
- 4.2Mechanisms of normal sensitization and central sensitization 66
- 5.1Spinal nerves give rise to peripheral nerves which innervate dermatomes 80
- 5.2Pain impacts the dimensions of quality of life 81
- 5.3Initial Pain Assessment Tool 83
- 5.4Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2) 84
- 5.5Basic pain measurement tools: The Number Rating (Pain Intensity) Scale, Verbal Rating (Pain Intensity) Scale, Visual Analogue Scale and Wong-Baker FACES® Pain Rating Scale 85
- 5.6Faces Pain Scale-Revised 87
- 5.7Premature Infant Pain Profile 89
- 6.1The common and distinct components of the patient-centred approach and biopsychosocial model 100
- 6.2Watson's theory of human caring – a practical model 104
- 7.1Analgesia system of the brain and spinal cord 120
- 7.2Caudal epidural block 128
- 7.3Power device for spinal cord stimulation, the Restore Utra® SureScan® Neurastimulator 130
- 7.4A flexible, non-stepwise approach to chronic pain management 136
- 8.1Pain of myocardial infarction is often poorly localized and referred because of dermatomal origin in another location 155
- 9.1A model regarding brain circuitry involved in the transition from acute to chronic pain 166
- 9.2Level of evidence for pharmacological therapies for central pain states 172
- 9.3Relationship between musculoskeletal ageing and the development of osteoarthritis 175[Page ix]
- 10.1A four-step Analgesic Ladder 189
- 10.2Screening tools for measuring distress 199
- 11.1Proposed model for integration of palliative care 208
- 11.2Opioid conversion chart 215
- 12.1Mechanism for regulation of glucocorticoid secretion 227
- 13.1Pain management domains and core competencies 248
- 13.2Opioid Risk Tool 255
- 3.1Different types of nerve fibres, diameters, speed and response function 35
- 3.2Most frequent pro-inflammatory mediators following injury 40
- 4.1The Pain Proposal Patient Survey (ECR, 2010) findings across 15 European countries 57
- 4.2Prevalence rates by pain type in children and adolescents 61
- 5.1Comparison of somatic and visceral nociceptive pain 79
- 6.1Definitions of patient-centred care, 2001–2012 99
- 6.2Humanizing and dehumanizing communication attitudes 108
- 6.3Facilitative and blocking behaviours used by nurses when communicating with patients with cancer 110
- 8.1Starting dose for patient-controlled analgesia 147
- 8.2Harmful effects of unrelieved pain 149
- 9.1Outline of pain types with responsiveness to and inhibition by therapies (each individual with pain has potential for variation in pain processing mechanisms; their pain experience may comprise possible combinations of pain types) 174
- 12.1Changes in stress hormones related to emotions and behaviours (Gregson and Looker, 1996) 227
- 13.1Patient education – essential topics 252
About the Author
I am delighted to endorse Pain Management in Nursing Practice the first written format of the official nursing curriculum for the International Association for the Study of Pain (IASP) co-published by SAGE and IASP.
Undergraduate and newly qualified nurses need to develop their professional nursing knowledge and skills for competency in pain management in nursing practice which is a truly vital area of patient care in primary, secondary and tertiary settings.
Pain-related research-based knowledge, investigative technologies and range and types of pain treatments and interventions are advancing rapidly. Multidisciplinary team service delivery of pain prevention and management is a key aspect of population health. Nurses have a major influence on patients and their families and their health outcomes through patient education and support, promoting monitoring of and adherence to treatment regimens and modification of lifestyles.
In providing a readable and up-to-date synthesis of pain theories and models and their application to modern day, individualised, patient-centred pain management in nursing practice, this book will be an invaluable contribution to the continuing pain management education of undergraduate and newly qualified nurses in Ireland and internationally.
Finally I wish to acknowledge and recognise the valuable contribution Dr Wright has made to the development of a strong evidence base to guide safe practice.Chief Nursing Officer, Department of HealthDublin, Ireland2014
This book, first suggested in early 2011, is the product of a collaboration between the Editor in Chief of the International Association for the Study of Pain, Professor Maria Adele Giamberardino, and her team and the Senior Commissioning and Associate Editors of SAGE, London, Alex Clabburn and Emma Milman, and their team. I owe each a debt of gratitude for their expert guidance during the lengthy process of project development for this book.
I am exceptionally privileged to have been granted permission to write this book, the fruition of an idea based on my academic years of experience teaching pain management (based on the curriculum of the International Association for the Study of Pain (IASP)) to undergraduate nurses in several universities in Ireland. This book aims to provide undergraduate nursing students with easy access to the IASP nursing curriculum content and basic concepts and theories of pain required for entry-level qualified nurses. I hope this book will facilitate the continued promotion of quality patient care in pain management in nursing practice worldwide.
I am indebted to President Professor Brian MacCraith, colleagues in Senior Management, Dr Gerry Moore, Head of Department of the School of Nursing and Human Sciences, Dublin City University (DCU) and DCU Information Systems and Services for their kind support throughout the writing of this book. I am also indebted to DCU Nursing Librarian Amanda Halpin for her guidance in establishing excellent book and online library resources in pain management. This book was also made possible through the kind assistance of librarians in Trinity College Dublin.
My sincere gratitude is extended to President Professor Laserina O'Connor, officers and colleagues on the committee of the Irish Pain Society, Chapter of the International Association for the Study of Pain, for their truly invaluable support and encouragement during the writing of this book.
I would like to thank my family and my extensive support network for their kindness to me during the writing of this book. A special thank you to my current and former mentors globally who continue to inspire and encourage me. Latest research developments provide more hope for prevention, innovative treatments and educational interventions to improve quality of life for patients with pain – people working together to reduce pain and its associated evil.
Publisher's Acknowledgements[Page xiii]
Every effort has been made to contact the copyright holders of third-party materials in the text. However, if any copyright owners have not been contacted, the publishers will be pleased to make the necessary arrangements at the first opportunity.
Figure 2.1: Loeser's Onion is from Loeser, J.D. (2005) Pain, suffering and the brain: a narrative of meanings. In D.B. Carr, J.D. Loeser and D.B. Morris (eds), Narrative, Pain, and Suffering: Progress in Pain Research and Management (Vol. 34). Seattle, WA: IASP. Copyright (2005). Republished with permission of IASP.
Figure 3.2: (Two-way) Pain pathway from periphery to brain is from D'Mello, R. and Dickenson, A.H. (2008) Spinal cord mechanisms of pain. British Journal of Anaesthesia, 101: 8–16. Copyright (2008). Republished with permission of Oxford University Press.
Figure 3.3: The Gate Control Theory is from Adams, N. (1997) The Psychophysiology of Low Back Pain. Churchill Livingstone, p.48. Republished with permission of Elsevier.
Figure 3.4: Top-down factors in pain is from Fields, H.L. (1992) Is there a facilitating component to central pain modulation? American Pain Society Journal, 1: 139–141, Figure 1. Republished with permission of Elsevier.
Figure 4.1: The psychobiological model of chronic pain is from Flor, H. and Turk, D.C. (2011) Chronic Pain: An Integrated Biobehavioural Approach. Seattle, WA: International Association of the Study of Pain (IASP). Copyright (2011). The figure has been reproduced with permission of the International Association for the Study of Pain® (IASP). The figure may NOT be reproduced for any other purpose without permission.
Figure 4.2: Mechanisms of normal sensitization and central sensitization is from Woolf, C.J. (2011) Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152: S2-S15. Copyright (2011). The figure has been reproduced with permission of the International Association for the Study of Pain® (IASP). The figure may NOT be reproduced for any other purpose without permission.
Table 4.2: Prevalence rates by pain type in children and adolescents is from King, S., Chambers, C.T., Huguet, A., MacNevin, R.C., McGrath, P.J., Parker, L. and [Page xiv]MacDonald, A.J. (2011) The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain, 152: 2729–2738. Copyright (2011). Republished with permission of Elsevier.
Table 5.1: Comparison of somatic and visceral nociceptive pain is from Griffin, R.S., Fink, E. and Brenner, G.J. (2010) Functional neuroanatomy of the nociceptive system. In S.M. Fishman, J.C. Ballantyne and J.P. Rathmell (eds), Bonica's Management of Pain (4th edn). Riverwoods, IL: Wolters Kluwer/Lippincott Williams and Wilkins. Copyright (2010). Republished with permission of Lippincott Williams and Wilkins.
Figure 5.1: Spinal nerves give rise to peripheral nerves which innervate dermatomes is from Gray's Anatomy for Students (2nd edn), by Drake, R.L., Vogl, A.W. and Mitchell, A.W.M. (2010). Copyright Elsevier (2010). Republished with permission of Elsevier Mosby.
Figure 5.2: Pain impacts the dimensions of quality of life. Copyright (1995). Republished with permission of Betty Ferrell and Marcia Grant, City of Hope Medical Center.
Figure 5.3: Initial Pain Assessment Tool is from Pasero, C. and McCaffery, M. (2011) Pain Assessment and Pharmacologic Management. St Louis, MO: Elsevier Mosby. Copyright (2011). Republished with permission of Elsevier.
Figure 5.4: Short-Form McGill Pain Questionnaire (SF-MPQ-2). Copyright (2009). SF-MPQ-2 © R. Melzack and the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 2009. All Rights Reserved. Contact information and permission to use: Mapi Research Trust, Lyon, France. E-mail: PROinformation@mapi-trust.org – Internet: www.proqolid.org. Republished with permission of MAPI.
Figure 5.5: Wong-Baker FACES® Pain Rating Scale. Copyright (1983). © 1983 Wong-Baker FACES® Foundation, www.WongBakerFACES.org. Originally published in Whaley and Wong's Nursing Care of Infants and Children. © Elsevier Inc. Republished with permission of Wong-Baker FACES® Foundation (2014).
Figure 5.6: The Faces Pain Scale-Revised is from Hicks, C.L., von Baeyer, C.L., Spafford, P.A. van Korlaar, I. and Goodenough, B.L. (2001) The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain, 93: 173–183. Copyright (2001). Republished with permission of Elsevier.
Figure 5.7: The Premature Infant Pain Scale is from Stevens, B., Johnston, C., Pteryshen, P. et al. (1996) Premature Infant Pain Profile: development and initial validation. Clinical Journal of Pain, 1: 13–22. Republished with permission of Lippincott Williams and Wilkins. Copyright (1996). Republished with permission of Lippincott Williams and Wilkins.[Page xv]
Figure 6.1: The common and distinct components of the patient centred approach and biopsychosocial model is from Creed, F. (2005) Are the patient-centered and biopsychosocial approaches compatible? In P. White (ed.) Biopsychosocial Medicine: An Integrated Approach to Understanding Illness. Oxfrod: Oxford University Press. Copyright (2005). Republished with permission of Oxford University Press.
Table 6.2: Humanizing and dehumanizing communication attitudes is from Duldt, B.W. (1991). ‘I-Thou’: research supporting humanistic nursing communication theory. Perspectives of Psychiatric Care, 27 (3): 5–12. Copyright (1991). Republished with permission of John Wiley and Sons.
Table 6.3: Facilitative and blocking behaviours used by nurses when communicating with patients with cancer is from Wilkinson, S. (1991) Factors which influence how nurses communicate with cancer patients. Journal of Advanced Nursing, 16, 677–688. Copyright (1991). Republished with permission of John Wiley and Sons.
Figure 7.1: Analgesia system of the brain and spinal cord. Copyright (2011). This figure was published in Hall, J.E. (2011) Guyton and Hall Textbook of Medical Physiology (12th edn). Copyright Elsevier. Republished with permission.
Figure 7.2: Caudal epidural block. Copyright (2014) This figure was published in O'Connor, T. and Abram, S. (2014) Atlas of Pain Injection Techniques (2nd edn). Copyright Elsevier. Republished with permission.
Figure 7.3: RestoreUltra® SureScan® MRI Neurostimulator. Copyright (2012) Republished with permission of Medtronic, Inc. © 2012.
Figure 7.4: A flexible, non-stepwise approach to chronic pain management is from The Essence of Analgesia and Analgesics. Sinatra, R.S., Jahr, J.S. and Watkins-Pitchford, J.M. (eds), p.70. Copyright (2011). Republished with permission of Cambridge University Press.
Table 8.1: Starting dose for patient-controlled analgesia is from Greco, C. and Berde, C.B. (2010) Acute pain management in children. In S.M. Fishman, J.C. Ballantyne and J.P. Rathmell (eds), Bonica's Management of Pain (4th edn). Riverwoods, IL: Wolters Kluwer/Lippincott Willliams and Wilkins. Copyright (2010). Republished with permission of Wolters Kluwer/Lippincott Williams and Wilkins.
Table 8.2: Harmful effects of unrelieved pain is from McCaffery, M. and Pasero, C: Pain: Clinical Manual, p. 24. Copyright 1999. Republished with permission of Elsevier Mosby.
Figure 9.1: A model regarding brain circuitry involved in the transition of acute to chronic pain is from Apkarian, A.V., Hashmi, J.A., Baliki, M.N. (2011) Pain and the [Page xvi]brain: specificity and plasticity of the brain in clinical chronic pain. Pain, 152: S49–S64. Copyright (2011). The figure has been reproduced with permission of the International Association for the Study of Pain® (IASP). The figure may NOT be reproduced for any other purpose without permission.
Figure 9.3: Relationship between musculoskeletal ageing and the development of osteoarthritis. Copyright (2009). Source: Hazzard's Geriatric Medicine and Gerontology (6th edn), Halter, J.B., Ouslander, J.G., Tinetti, M.E., Studenski, S., High, K.P. and Asthana, S. (eds), Chapter 112: Aging of the muscles and joints, Figure 112–5; p. 1360. McGraw Hill Medical. Copyright. Republished with permission of McGraw Hill (2009).
Figure 10.2: Screening tools for measuring distress. Reproduced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management V.2.2014. © 2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
Figure 11.1: Proposed model for integration of palliative care. Copyright. Source: S.M. Fishman, J.C. Ballantyne and J.P. Rathmell (eds), Bonica's Management of Pain (4th edn). Riverwoods, IL: Wolters Kluwer/Lippincott Williams and Wilkins. Republished with permission of Lippincott Williams and Wilkins.
Figure 11.2: Opioid conversion chart. Republished with permission of Our Lady's Hospice and Care Services Dublin.
Figure 12.1: Mechanism for regulation of glucocorticoid secretion. Copyright (2011). Source: Guyton and Hall Textbook of Medical Physiology (12th edn). J.E. Hall. Chapter 77: Adrenocortical hormones, p.932, Figure 77.7. Republished with permission of Elsevier.
Figure 13.1: Pain management domains and core competencies is from Fishman et al. (2013) Core competencies for pain management: results of an interprofessional consensus summit. Pain Medicine, 14: 971–981. Copyright (2013). Republished with permission of John Wiley and Sons.
Table 13.1: Patient education - essential topics. Copyright (2011). Source: Institute of Medicine (2011) Relieving Pain in America: A Blue Print for Transforming Prevention, Care, Education and Research. Washington, DC: The National Academies Press. Reprinted with permission from the National Academy of Sciences, courtesy of the National Academies Press.
Figure 13.2: Opioid Risk Tool is from Webster, L.R (2005) Predicting aberrant behaviours in opioid-treated patients: preliminary validation of the Opioid Risk Tool. [Page xvii]Pain Medicine, 6 (6): 432–442. Copyright (2005). Republished with permission of John Wiley and Sons.
The extract from The Declaration of Montréal is reprinted with permission of the International Association for the Study of Pain® (IASP). The Declaration may NOT be reproduced for any other purpose without permission.
The extract from the Desirable Characteristics of National Pain Strategies: Recommendations in Chapter 14 is reproduced with permission of the International Association for the Study of Pain® (IASP). The extract may NOT be reproduced for any other purpose without permission.
The extract from the Australian National Pain Strategy in Chapter 14 is from National Pain Strategy (Pain Australia) (2010), www.painaustralia.org.au/images/pain_australia/NPS/National%20Pain%20Strategy%202011.pdf. Republished with permission of Pain Australia.
The extract from the Prague Charter in Chapter 14 is from The Prague Charter (2010), www.eapcnet.eu/Themes/Policy/PragueCharter.aspx. Republished with permission of the European Association for Palliative Care.
The extract from the SIP Road Map in Chapter 14 is from Societal Impact of Pain (SIP) Societal Impact of Pain. Available at: www.sipplatfonn.eu/home.html. Republished with permission of Grünenthal Europe and Australia.
The extract from Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (Institute of Medicine, USA) in Chapter 14 is republished with permission from the National Academies Press.
The extract from the World Medical Association resolution in Chapter 14 is republished with permission of the World Medical Association. Copyright, World Medical Association. All Rights Reserved.
The extract from the Canadian Pain Strategy in Chapter 14 is from Canadian Pain Summit (2012) Rise Up Against Pain. Available at: http://canadianpainstrategy.ca/en/home/about-the-2012-summit.aspx. Republished with permission of the Canadian Pain Society.[Page xviii]
unpleasant sensory and emotional experience associated with tissue damage and with activation of nociceptor transducers at the site of local tissue damage.
a behavioural pattern of craving for and compulsive use of a substance despite harm.
neurons (nerve fibres) which conduct nerve impulses from the body periphery to the central nervous system via the spinal cord.
a chemical (drug) substance capable of combining with a cell receptor and initiating the same action or response typically produced by the binding of an endogenous substance.
pain due to a stimulus which does not normally provoke pain.
absence of pain in response to stimulation which would normally be painful.
a chemical that opposes the action of a drug or an endogenous substance by combining with and blocking its receptor.
the act of making a judgment; in pain management a clinical judgement about the nature of the range of pain characteristics and their impact on the patient's health and well being.
quality or state of being self-governing.
stimulus which causes avoidance behaviour because of its noxious or punishing nature; chronic pain is an aversive stimulus which may result in reduced physical activity in order to avoid the associated pain.
response to avoid an (anticipated) aversive stimulus.
the death of a family or close friend; the state of being bereaved (deprived) of someone close.
regarding a person's personal context, comprised of any computation of biological, genetic, racial, sex and age (bio), emotional, cognitive and spiritual (psycho) and cultural, environmental and ethnic (social) factors.
a compilation of acute and chronic pain associated with any aspects of the person's experience of cancer including disease progression and associated treatments [Page 283](e.g. consequences of chemotherapy, radiotherapy and/or surgery) the term ‘cancer pain’ does not distinguish between acute and chronic pain in the context of cancer.
a temporary reduction of blood flow to the brain causing faintness due to abnormalities of the heart such as abnormal heartbeat, valve or muscle structure or function.
responsibility for or attention to health, well-being and safety of another person or persons.
magnification of pain-related stimuli accompanied by negative outlook and sense of loss of control.
Central neuropathic pain
pain caused by a lesion or disease of the central somatosensory nervous system.
increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold afferent input.
unpleasant sensory and emotional experience which may be elicited by injury or disease, usually perpetuated by factors that are removed from the original cause of pain and extending beyond the expected period of healing.
sympathetic awareness of another's distress with a desire to alleviate it.
having the required qualities of abilities and skills.
a constituent part.
quality or state of agreeing; in communication, accepting the person's perspective.
interrelated conditions in which something exists or occurs.
beliefs, customs, behaviours and attitudes of a particular society or group.
a course of treatment (for example, pharmacological, surgical or other type of appropriate therapy) which results in remission of signs and/or symptoms of a disease especially during a prolonged period of observation.
a cognitive disorder characterised by a confusional state with varying psychomotor agitation, illusions and hallucinations.
segmental fields of sensation on the skin, each innervated by a spinal nerve.
a thing that controls or influences future events in a given context, e.g. socio-economic determinants of health.
The identification of a disease by examination of the patient, their signs and symptoms and relevant tests.
inability to function socially or pursue an occupation because of physical or mental impairment causing loss of capacity; refers to optimal functionality obtained after full rehabilitation.
a condition which impairs normal functioning and is typically manifested by distinguishing signs and symptoms.
Distress (NCCN definition)
a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis; the term equally applies to people with pain and is chosen to avoid stigmatization.
one of three kinds of endogenous opioids.
neurons which conduct nerve impulses from the central nervous system towards internal organs, tissues or the body periphery.
the ability to be sensitive to (putting oneself in another's shoes) and to try to understand the thoughts and feelings of another person, while recognising separateness from the other and acknowledging the uniqueness of their experience (without losing the ‘as if’ quality).
to give power to a person or people; in the healthcare context to afford the patient/close other status to facilitate him or her to proactively engage in their own healthcare/that of a close other.
family of peptide neurotransmitters.
one of three kinds of endogenous opioids.
one of three kinds of endogenous opioids.
the study of the incidence, prevalence and control of diseases in populations.
a particular kindred affiliation or group with shared traditions and customs.
the distinguishing guiding beliefs of a person, group, or institution.
a theory or system of moral values referring to and defining good or bad behaviour.
the cause of a disease or abnormal condition.
Prosencephalon the front division of the neural tube containing the cerebral hemispheres, thalamus and hypothalamus.
relating to or caused by genes.
major distress usually associated with severe loss and/or suffering.
Rhombencephalon the rear division of the brain containing the cerebellum pons and medulla.
philosophy which stresses an individual's value, dignity, and capacity for self-actualization through reason.
an increased pain response to a stimulus that is normally painful.
a diminished pain response to a stimulus that is normally pain.
the subjective biopsychosocial experience of a disease or condition.
the rate of occurrence of new cases of a particular disease in a given population.
patient care which is coordinated among and between different disciplines; represents the ideal of interdisciplinary care and may be based on formulated care pathways.
Interdisciplinary team (see also multidisciplinary team)
the dynamic interaction of the multidisciplinary team implying optimal communication and cooperation between and among the healthcare professional team members, including the patient.
Measurement: in pain
a quantified subjective pain experience.
a type of induced hypnotic trance based on the principle of Animal Magnetism promulgated by Anton Mesmer in the 18th century.
drug constituent following metabolism. For example, the liver metabolizes about two-thirds of a dose of oral morphine to inactive M3G metabolites and one-third to active M6G metabolites.
spread of a primary cancer tumour to another site in the body by the spread of cancer cells through the body's circulatory systems.
Mesencephalon the area of the brain situated below the hypothalamus and above the pons.
a reversible change in histological structure due to physiological factors.
a time of sadness following a bereavement when grief is experienced.
concept first formulated by Professor John Bonica, anaesthetist and founder of the Internal Association for the Study of Pain, to have a team of healthcare professionals with different professional skills and competencies to facilitate the patient's optimal functional recovery in all spheres of quality of life.
[Page 286]Neural tube
embryonic structural divisions corresponding to the undeveloped fore-, mid- and hindbrain.
pain caused by a lesion or disease of the somatosensory nervous system.
a disturbance of function or pathological change in a nerve.
nociceptive input to the nervous system as changed responses to stimuli, leading to structural and functional neuronal change.
particularly relevant to chronic, especially visceral pain, related to the autonomic nervous system and limbic system; the patient may show signs of emotional distress, nausea, vomiting, anxiety and changes in vital signs.
the adverse treatment effects induced by a dummy medicine or intervention which contains no detrimental or toxic substance.
the neural process of encoding noxious stimuli.
a central or peripheral neuron of the somatosensory nervous system that is capable of encoding noxious stimuli.
pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.
an actual or potentially damaging event transduced and encoded by nociceptors.
a high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli.
a stimulus that is damaging or threatens damage to normal tissues.
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
observable verbal and non-verbal actions which indicate that a person may be experiencing pain and suffering.
the minimum intensity of a stimulus that is perceived as painful.
Pain tolerance level
the maximum intensity of a pain-producing stimulus a person is willing to tolerate.
treatments and management interventions which aim to control the signs and symptoms of a malignant (especially metastatic cancer) or non-malignant (for example, multiple sclerosis) incurable disease to improve the patient's quality of life; (from Latin palliare: to cloak).
awareness of elements of the environment through the five senses; also implies additional cognitive awareness through organisation and interpretation of information.
[Page 287]Peripheral sensitization
increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields.
practice of holistic care in which the patient is a person at the centre of their care.
a dummy medicine, surgical procedure or therapeutic intervention, which, in the context of a clinical trial (the only situation in which giving a dummy intervention for pain is ethical) the patient believes could be the real thing; frequently used to control patients’ expectations about the efficacy of an intervention.
the positive benefits experienced by the recipient of the placebo intervention, which are generally only achieved with an active treatment intervention.
predication about the likelihood of duration of and recovery from a disease/illness.
percentage of a specific population with a particular disease at a given time.
a person's unchangeable genetic and biological characteristics such as eye and skin colour.
restoration of maximum physiological and psychosocial functioning from a state of impairment.
in pain measurement: the extent to which a measuring tool yields the same results on repeated trials.
objective evidence of disease.
an event that prompts a change or a reaction.
a substance acted upon; base, underlayer.
subjective perceived threat to the integrity of the person (in response to unrelieved pain) associated with feelings of helplessness, hopelessness and lack of controllability.
subjective evidence of disease or physical disturbance.
the junction point from one neuron to the next and the point of information transmission.
theory with broad applicability to all types of sciences; in the context of health care: complex, adaptable and self-regulating relationships between the person and his or her environment; recognising health services as potentially adaptive systems with many interacting elements and computations, with the service user as the actively participating patient experiencing illness influenced by social, psychological and cultural factors.
action or process of converting something (especially energy) into another form.
the quality or extent of usefulness.
relevant and meaningful; in pain measurement: that a scale measures what it purports to measure.
characterised by changes or variations; in pain measurement, measurable characteristics of pain which may vary such as intensity, temporality, location and quality.
temporal summation of pain mediated by repetitive noxious stimulation of C-fibres.
The following table is a general guide only for non-opioid and weak opioid medications for Steps 1 and 2 of the WHO Analgesic Ladder. Please check the relevant, up-to-date National Formulary for all drug dosages, routes and schedules of administration, adverse effects (many of which are not listed on this table) and contraindications, especially in pregnancy, pre-term infants and lactating mothers, for which many drugs are contraindicated. Drugs can usually be given through a number of different routes, in varying formats and dosages, which must be prechecked. Time to analgesic onset is highly variable and half-life is often the dose and route taken. Many drugs interact with alcohol and may also impair driving ability.
[Page 295]Commonly used adjuvant medications for Steps 1, 2 and 3 of the WHO Analgesic Ladder; all doses (based on BNF Formularies) are approximate only, and need to be adjusted according to patient response. Please check the relevant up-to-date National Formulary for all drug dosages, routes and schedules of administration, adverse effects (many of which are not listed on this table), contraindications especially in pregnancy, pre-term infants and lactating mothers, for which many drugs are contra-indicated. Drugs can usually be given through a number of different routes, in varying formats and dosages which must be prechecked; time to analgesic onset is highly variable and half-life is often dependent on dose and route. Many drugs interact with alcohol and may also impair driving ability.
[Page 302]Commonly used mu agonist (unless stated otherwise) strong opioids for Step 3 WHO Analgesic Ladder: initial doses for moderate to severe pain.
All doses (based on BNF Formularies) are approximate only, and need to be adjusted according to patient response! (NR = not recommended)
Please check the relevant up-to-date National Formulary for all drug dosages, routes and schedules of administration, adverse effects (many of which are not listed on this table), contraindications especially in pregnancy, pre-term infants and lactating mothers, for which many drugs are contra-indicated. Drugs can usually be given through a number of different routes, in varying formats and dosages which must be prechecked; time to analgesic onset is highly variable and half-life is often dose and route. Many drugs interact with alcohol and may also impair driving ability. NB all opioids can induce potentially fatal respiratory depression at therapeutic doses: Naloxone must be available to counter respiratory depression/coma.
GRAM: Milligrams= mg: 1 thousand
Micrograms = mcg: 1 millionth