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Pain Management
Consultant Professor : Dr Yekefallah
Seyedeh Hedyeh Banihashemi & Mahtab Salehi
Master students of critical care nursing
(entrance Mehr 92)
Automn 1392
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objective
 Explain the pain definition & its pathophysiology
 Know different pain theories especially Gate-control
 Describe different types of pain
 Explain pain treatment (Drug & Nondrug)
 Assess patient’s pain & know different assessment tools
 Determine nursing process
 Know geriatric & pediatric consideration
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Pain
It is an unpleasant sensory & emotional
experience associated with actual or
potential tissue damage .
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Are these sentences true or false?
1. The best judges of the existence and
severity of patient’s pain are the
physicians and nurses caring for the
patients .
False
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2. Patients should not receive
analgesic until the cause of pain is
diagnosed.
False
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3. Pain makes anxiety worse .
True
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4. Patients who are knowledgable about
opioid analgesics and who make regular
efforts to obtain them are drug seeking
(Addicted)
False
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5. Critically ill patients , especially those who
appear to be unconscious or have received a
neuromuscular blocking agents , do feel
pain and recall painfull episodes in ICU.
True
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6. Patients with PTSD (Post Traumatic Stress
Disorder) show low sensitivity to acute pain
and rarely have chronic pain .
False
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Pain pathophysiology
There are four basic processes involved in acute pain :
 Transduction
 Transmission
 Perception
 Modulation
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 C fibres
Primary afferent fibres
Small diameter
Unmyelinated
Slow conducting
Pain quality
Diffuse
Dull
Burning
Aching
Referred to as ‘slow’ or
second’ pain
 A-delta fibres
Primary afferent fibres
Large diameter
Myelinated
Fast conducting
Pain quality
Well-localised
Sharp
Stinging
Pricking
Referred to as ‘fast’ or ‘first’
pain
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Transduction
 Transduction begins when the free nerve endings
(nociceptors) of C fibres and A-delta fibres of primary
afferent neurones respond to noxious stimuli.
Nociceptors are exposed to noxious stimuli when
tissue damage and inflammation occurs as a result of,
for example, trauma, surgery, inflammation, infection,
and ischemia.
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… transduction
 The cause of stimulation may be internal, such as
pressure exerted by a tumour or external, for example,
a burn. This noxious stimulation causes a release of
chemical mediators from the damaged cells including:
prostaglandin
bradykinin
serotonin
substance P
potassium
histamine
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Transmission
 The transmission process occurs
in three stages. The pain impulse is transmitted:
 from the site of transduction along
the nociceptor fibres to the dorsal horn
in the spinal cord;
 from the spinal cord to the brain stem;
 through connections between
the thalamus, cortex and higher
levels of the brain.
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… transmission
 In order for the pain impulses to be transmitted across
the synaptic cleft , excitatory neurotransmitters are
released , these neurotransmitters are:
 adenosine triphosphate;
 glutamate;
 calcitonin gene-related peptide;
 bradykinin;
 nitrous oxide;
 substance P.
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Perception
 Perception of pain is the end result of the neuronal
activity of pain transmission and where pain becomes
a conscious multidimensional experience.
 The multidimensional experience of pain has
affective-motivational, sensory-discriminative,
emotional and behavioural components.
 When the painful stimuli are transmitted to the brain
stem and thalamus, multiple cortical areas are
activated and responses are elicited.
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… perception
 The reticular system:
- This is responsible for the
autonomic and motor response to
pain and for warning the individual
to do something, for example,
automatically removing a hand
when it touches a hot saucepan.
- It also has a role in the affectivemotivational response to pain such
as looking at and assessing the
injury to the hand once it has been
removed form the hot saucepan.
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… peception
 Limbic system
This is responsible for the emotional and
behavioural responses to pain for example,
attention, mood, and motivation
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… perception
 Somatosensory cortex
- This is involved with the perception
and interpretation of sensations. It
identifies the intensity, type and
location of the pain sensation and
relates the sensation to past
experiences, memory and cognitive
activities.
- It identifies the nature of the stimulus
before it triggers a response, for
example, where the pain is, how strong
it is and what it feels like.
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Modulation
 The modulation of pain involves changing or inhibiting
transmission of pain impulses in the spinal cord.
 The multiple, complex pathways involved in the modulation of
pain are referred to as the descending modulatory pain pathways
(DMPP) and these can lead to either an increase in the
transmission of pain impulses (excitatory) or a decrease in
transmission (inhibition).
 Inhibitory neurotransmitters include:
 endogenous opioids (enkephalins and endorphins);
 serotonin (5-HT);
 norepinephirine (noradrenalin);
 gamma-aminobutyric acid (GABA);
 neurotensin;
 acetylcholine;
 oxytocin.
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Pain theories
Specificity theory
Pattern theory
Intensity theory
Gate control theory
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Gate control theory
 Proposed by Ronald Melzack and Patrick Wall during
the early 1960s
 Gate control theory suggests that the spinal cord
contains a neurological "gate" that either blocks pain
signals or allows them to continue on to the brain
 Pain signals traveling via small nerve fibers are allowed
to pass through, while signals sent by large nerve fibers
are blocked.
 Gate control theory is often used to explain phantom
or chronic pain.
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By
inferred
pathology
Nociceptive
pain
Somatic
pain
Neuropathic
pain
Visceral
pain
Arises from
bone,joint,muscle,s
kin or connective
tissue
(well-localised)
Arises from visceral
organs such as : GI
tract and pancreas .
Deafferentation pain
Injury the PNS or CNS
Phantom pain/burning
pain below the spinal
cord.
Tumor
involvement of
the organ.(fairly
well-localised)
Central
pain
Sympathetic pain
associated with
dysregulation of
autonomic nervous
system complex regional
pain syndrome
Peripheral
pain
Painfull
polyneuropathies
:Diabetic
neuropathy ,
Guillain-Barre
syndrom
Painfull
mononeuro
pathy :
trigeminal
neuralgya
Obstruction of hollow
viscus,causes
intermittent cramping
(poorly localised)
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Phantom pain
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Phantom pain
 Phantom pain sensations are described as
perceptions that an individual experiences relating
to a limb or an organ that is not physically part of
the body.
 Limb loss is a result of either removal by
amputation or congenital limb deficiency.
 Sensations are recorded most frequently following
the amputation of an arm or a leg, but may also
occur following the removal of an internal organ .
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… phantom pain
There are various types of sensations that may be felt:
 Sensations related to the phantom limb's posture, length and
volume e.g. feeling that the phantom limb is behaving just like a
normal limb like sitting with the knee bent or feeling that the
phantom limb is as heavy as the other limb.
 Sensations of movement (e.g. feeling that the phantom foot is
moving).
 Sensations of touch, temperature, pressure and itchiness. Many
amputees report of feeling heat, tingling, itchiness, and pain.
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The perception of phantom pain
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Pathophysiology
 mechanisms of phantom pain are
often separated into peripheral,
spinal, and central mechanisms.
 Neuromas formed from injured
nerve endings at the stump site
are able to fire abnormal action
potentials, and were historically
thought to be the main cause of
phantom limb pain.
 Although stump neuromas
contribute to phantom pains, they
are not the sole cause. This is
because patients with congenital
limb deficiency can sometimes,
although rarely, experience
phantom pains.
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Stump pain
 Stump pain that occurs immediately
after
amputation is acute nociceptive pain
and
usually resolves after a few weeks as the
wound heals.
 Infection or wound dehiscence
may prolong postoperative pain in some
cases.
 Stump pain can persist for much longer
than the initial period of wound healing,
lasting
months or years, and occurs in 13--71%of
cases.
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Phantom pain
 The precise incidence of phantom pain is not known.
recent evidence suggests rates of approximately 50-78%.
 Phantom pain normally occurs within the first week
after amputation.
 Phantom pain has been described in various terms
(e.g.shooting, burning, cramping and aching) and is
characteristically localized in the distal area of the
phantom limb.
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Phantom pain treatment
It includes :
 Pharmacological therapy
 Noninvasive therapy
 Minimally invasive therapy
 Surgery
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Pharmacological therapy
 Antidepressants. Tricyclic antidepressants often can
relieve the pain caused by damaged nerves. Examples
include amitriptyline and nortriptyline (Pamelor).
 Anticonvulsants. Epilepsy drugs — such as gabapentin
(Gralise, Neurontin), pregabalin (Lyrica), and
carbamazepine (Carbatrol, Tegretol) — are often used to
treat nerve pain. They work by quieting damaged nerves to
slow or prevent uncontrolled pain signals.
 Narcotics. Opioid medications, such as codeine and
morphine, may be an option for some people, they may
help control phantom pain.
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Noninvasive therapy
 Nerve stimulation. In a procedure called
transcutaneous electrical nerve stimulation (TENS) , a
device sends a weak electrical current via adhesive
patches on the skin near the area of pain. This may
interrupt or mask pain signals, preventing them from
reaching your brain.
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 Electric artificial limb. A type of artificial limb called
a myoelectric prosthesis has motors controlled by
electrical signals that occur during voluntary muscle
activation in the remaining limb. Using a myoelectric
prosthesis may reduce phantom pain.
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 Mirror box. This device contains mirrors that make it
look like an amputated limb exists. The mirror box has
two openings one for the intact limb and one for the
stump. The person then performs symmetrical
exercises, while watching the intact limb move and
imagining that he or she is actually observing the
missing limb moving. Studies have found that this
exercise helps relieve phantom pain in a significant
number of people.
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 Acupuncture. It's thought that acupuncture
stimulates your central nervous system to release the
body's natural pain-relieving endorphins.
Acupuncture is generally considered safe when
performed correctly.
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Minimally invasive therapy
 Injection. Sometimes injecting pain-killing
medications local anesthetics, steroids or both into
the stump can provide relief of phantom limb pain.
 Spinal cord stimulation. Your doctor inserts tiny
electrodes along your spinal cord. A small electrical
current delivered to the spinal cord can sometimes
relieve pain.
 Intrathecal delivery system. This procedure allows
medication to be delivered directly into the spinal
fluid.
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Surgical therapy
 Brain stimulation. Deep brain stimulation and
motor cortex stimulation are similar to spinal cord
stimulation except that the current is delivered within
the brain. A surgeon uses a magnetic resonance
imaging (MRI) scan to position the electrodes
correctly.
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 Stump revision or neurectomy. If phantom pain is
triggered by nerve irritation in the stump, surgical
resection or revision can sometimes be helpful. But
cutting nerves also carries the risk of making the pain
worse.
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Newer approaches to relieve phantom pain
 Virtual reality goggles The computer program for the
goggles mirrors the person's intact limb, so it looks
like there's been no amputation. The person then
moves his or her virtual limb around to accomplish
various tasks, such as batting away a ball hanging in
midair. Although this technique has been tested on
only a few people, it appears to help relieve phantom
pain
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 Researchers at University of California, San Diego,
reported results of a new study that found amputees
find relief from phantom limb pain by simply
watching someone else rub their hands together.
 The researchers believe the act of watching another
person rub their hands together activates the
amputee’s brains cells, essentially fooling the brain
into thinking the amputee’s missing hand is being
massaged.
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THE EFFECT OF ACUPRESSURE ON PHANTOM PAIN IN
CLIENT WITH EXTREMITIES AMPUTATION
 Z. Pouresmail *, A. Saberi Shaheed Beheshti
University of Medical Sciences, Tehran, Iran
 Analyzing statistical tests, indicates that
acupressure treatment can decrease intensity of
phantom pain (p < 0.0001) and decrease amount of
medications (p < 0.005) and both of hypothesis
were accepted.
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Pulsed Radiofrequency of Lumbar Dorsal Root Ganglion
for Chronic Postamputation Phantom Pain
 Farnad Imani 1*, Helen Gharaei 1, Mehran Rezvani 1
 Global clinical improvement was good in one patient, with
a 40% decrease in pain on the visual analogue scale (VAS)
in 6 months, and moderate in the second patient, with a
30% decrease in pain scores in 4 months.
 PRF of the dorsal root ganglia at the L4 and L5 nerve roots
may be an effective therapeutic option for patients with
refractory phantom pain.
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Phantom limb pain after amputation in diabetic patients does
not differ from that after amputation in nondiabetic patients
 There is a commonly held belief that diabetic amputees
experience less phantom limb pain than nondiabetic
amputees because of the effects of diabetic peripheral
neuropathy
 Participants with diabetes were further divided into those
with long-duration diabetes (>10 years) and those with
short-duration diabetes .
 Our findings suggest that there is no large difference in the
prevalence, characteristics, or intensity of PLP when
comparing diabetic and nondiabetic amputees .
 prevalence in DM group (82.0%) and the ND group
(89.4%) (P = 0.391)
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Mild ≤ 4/10
Pain intensity
Moderate = 5-6
Severe ≥ 7/10
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Muscle pain : excessive exersion or during
inflammation such as : myalgia
Colicky pain : cyclic in nature like : menstrual
period
Referred pain : reflective pain such as MI
Post operative pain
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Pain Assessment
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Patient barrier to pain assessment :
 Communication
 Altered level of consciousness
 Elderly patient
 Neonate & Infants
 Cultural influence
 Lack of knowledge
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Assessment Tools:
1. Initial pain assessment tool
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2. Brief pain inventory
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3. Visual analogue scale(VAS)
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4. Mcgill pain questionnaire
 Where is your pain?
 What Does Your Pain Feel Like?
 How Does Your Pain Change with Time?
 How Strong is Your Pain?
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5. Numeric rating scale(NRS)
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6. Wong – Baker faces pain rating scale(FACES)
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7. Faces pain scale-revised(FPS-R)
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8. Iowa pain thermometer(IPT)
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9. Faces pain thermometer(FPT)
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10. Multiple language pain assessment scale
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11. Memorial pain assessment scale
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12. Pain scale combined
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13. Behavioral pain scale(BPS)
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14. Critical care pain observation tool(CPOT)
•Face expresion
•Body movement
•Compliance with the
ventilator(intubated patient)
•Vocalisation(nonintubated patient)
•Muscle tention
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The patient self-report is possible
PQRSTU Questionaire :
P: Provocative and Palliative or aggravating factors
Q: Quality(pain sensation)
R: Region or location , Radiation
S: Severity and other Symptoms
T: Timing(onset,duration,frequency)
U: Understanding: patient’s perception of the problem
or cognitive experience of pain
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Patient self-report is impossible
In this condition patient is intubated so nurse can rely
on observation of behavioral & physiological indicators .
1. Behavioral Pain Scale (BPS)
Advantages : use quickly
(2-5 min) & ease of use
Disadvantages :
Relative complexity
Can not use for paralysed & sedate
patients
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2. Critical pain observation tool(CPOT)
 Facial expression
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 Body movement
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 Compliance with the ventilator (Intubated patient)
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 Vocalisation (nonintubated patients)
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 Muscle tension
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Directions for using CPOT
 Score 0-8
 The patient is observed at rest for 1 minute to obtain baseline
value .
 The patient is observed during nociceptive procedures to detect
any changes in the patients behavioral responses to pain :
Turning (change position)
ETT suctioning
Wound drain removal
Femoral cath removal
Placement of CVP line
Chest tube removal
Non burn wound dressing change
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Continued…
 The patient is evaluated before and at the peak effect
of an analgesic agents.
 Muscle tension is evaluated last when patient is at rest
 The validity of this scale is recommended by experts
 Advantages :
 Quick enough to be used in ICU
 Simple to understand
 Easy to complete
 Helpful for nursing practice
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Pharmacologic control
 Opioid analgesic
Morphin,Fentanyl,Meperidin,Codein,Coffein,Methadon
(potent opioid)Remifentanyl & Sufentanyl
 Nonopioid analgesic
Acetaminophen,NSAID,(adjuvant)Anticonvulsant,
Ketamin,Lidocain
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Placebo
 A placebo is defined as any medication or procedure that
produces an effect in patients resulting from its implicit or
explicit intent and not from its specific physical or
chemical properties (Bok, 1974).
 Placebos often take the form of sugar pills, saline
injections, miniscule doses of drugs, or sham procedures
designed to be void of any known therapeutic value.
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… placebo
 It's well known among doctors that people can get pain
relief from a placebo. Now, they're closer to
understanding the phenomenon called the placebo
effect.
 Positive placebo effects may include symptom
reduction or improvements in physiological
parameters (e.g., blood pressure) and are believed to
be due to mind-body or interpersonal (e.g., attitude
and intent of caregiver) factors (Arnstein, 2003).
 Negative placebo effects, ranging from minor
discomforts to life-threatening complications .
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… placebo
 When the placebo was used, the response of the
brain's pain-sensing regions was ratcheted down.
 These studies showed "placebo effect patterns" in the
prefrontal cortex. The prefrontal cortex is the brain
region that becomes activated in anticipation of pain
relief which triggers a reduction of activity in painsensing areas of the brain.
 This interplay within the prefrontal cortex may trigger
a release of pain-relieving opioids in the midbrain .
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Surgical control
 Rhizotomy
It is a term chiefly referring to a neurosurgical procedure that selectively
destroys problematic nerve roots in the spinal cord, most often to
relieve the symptoms of neuromuscular conditions such as spastic
cerebral palsy.
rhizotomy precisely targets and destroys the damaged nerves that don’t
receive gamma amino butyric acid, which is the core problem for
people with this desease.
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 Cordotomy
It is a surgical procedure that disables selected painconducting tracts in the spinal cord, in order to
achieve loss of pain and temperature perception.
For patients experiencing severe pain due to cancer or
other diseases for which there is currently no cure
Cordotomy is usually done percutaneously with
fluoroscopic guidance while the patient is under loca
anesthesia.
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 Intercostal nerve block
An intercostal nerve block is an injection of a steroid or
other medication around the intercostal nerves that
are located under each rib.
It reduces pain, and other symptoms caused by
inflammation or irritation of the intercostal nerve and
surrounding structures.
Herpes zoster or shingles pain in the chest
Pain around a chest scar after a chest surgery
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Delivery Methods
 PCA(Patient-Controlled Analgesia)
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Spinal Analgesia(Subarachnoid,Intrathecal)
 Injection of analgesic in to the cerebral spinal fluid with a
fine needle.
 As a means of reducing pain for chronic medical condition
or lower back injury.
 Injection below the abdomen
wide awareness
 Injection higher spinal
affect the respiratory
muscle(paralyze)
no consciousness
 Complication
immediate (operation room)
late(ward,PACU)
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Complication:
 Nerve root injury
 Hypothermia
 Hypotension
 Infection
 Bleeding
 Swelling
 Headache
 Back pain
 Trouble breatthing
 Cardiac arrest
 Nausea & vomiting
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Epidural analgesia
 Injection of analgesic in to the epidural space.
 This procedure is high risk for :
Anatomical abnormalities (Spina Bifida)
Previous spinal surgery
Certain CNS problem
 Contraindication
Lack of consent
Bleeding disorder or who takes anticoagulant like warfarin
Infection near the site
Sepsis
Uncorrected hypovolemia
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 Note
Very large dose can cause paralysis of intercostal muscles , diaphragm &
loss of sympathetic function to the heart
HR , RR
Airway Support
Risk of fall
Sensation for urination diminish
 Complication
Epidural hematoma
Seizure
Neurological injury
Paraplesia
Arachnoditis
Death
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TENS(Transcutaneous Electrical
Nerve Stimulation)
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… TENS
 It sends electrical impulses to the skin via electrodes.
 The goal of these tingling electrical impulses is to block
pain signals and to stimulate the release of naturally
produced pain killers such as endorphins.
 TENSis a non-invasive, low-risk nerve stimulation.
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… TENS
 Control of acute or chronic pain
 Management of postsurgical pain
 Reduction of post-traumatic acute pain
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Nonpharmacologic Control
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Guidelines for Individualizing Pain Relief
 Establish a relationship of mutual trust
 Use different types of pain-relief measures
 Provide pain-relief measures before pain becomes
severe.
 Consider the client’s ability or willingness to
participate in pain-relief measures.
 Choose pain-relief measures on the basis of the
client’s behavior reflecting the severity of pain.
 Use measures that the client believes are effective.
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… guideline
 If therapy is ineffective at first, encourage the client to try it
again before abandoning it.
 Keep an open mind about what might relieve pain
 Keep trying
 Protect the client
 Educate the client about pain
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Educational approaches
 Recognize and reduce stigma attached with chronic pain
 Recognize and reduce stigma attached with use of pain
medications
 Assist client to explore personality traits and impact upon pain
 Recognize the impact upon pain of catastrophizing and fear of
pain
 Help client develop an acceptance of pain and to move from a
passive to an active orientation in addressing their pain
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… educational approach
 Address sleep hygiene and the utilization of
diaphragmatic breathing and self-hypnosis skills
 Recognize and reduce client isolation
 Encourage and foster interpersonal support systems
 Emphasize importance of physical conditioning and
general good health habits
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Geriatric Consideration
 They accept pain as a normal & unavoidable with aging.
 They may not demonstrate objective signs & symptoms because of




years of adaptation & increased pain tolerance.
The effect of opioid analgesic are prolonged because of decreased
metabolism & clearance of drug.
Take multiple drugs
side effects
drugs be started at a lower
dosage
Monitoring drugs interaction is necessary.
Taking drugs with toxic metabolism that excrete renally shoild be
avoided esp in those who are at risk for renal insufficiency.
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Pediatric Considerations
 Studies have shown that, when adults and children
undergo the same surgery, children are under
medicated . In one study, 52% of the children received
no analgesic postoperatively, whereas the remaining
48% received aspirin or acetaminophen.
 Maturational and chronologic age, cause of pain,
coping style, parental response, culture, past pain
experiences, and whether pain is acute or chronic
influence the child’s response to pain.
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… pediatric considerations
Infant
 Associates environment with painful experience
 Cries loudly and makes verbal protests long after the
stimulus is withdrawn
Toddler
 Fears body intrusion
 Does not understand rationale for pain or have ability
to conceptualize the duration of the experience, even if
told
 Seeks out parental figures as a source of comfort
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… pediatric considerations
Pre-schooler
 Engages in magical thinking or fantasies (e.g., believes
something they thought or did caused the pain)
 Uses increased verbal skills to communicate pain
 Has limited understanding of time
 After pain passes, talks to toys or other children about the
pain experience
 Denies pain, especially if he or she associates it with
adverse consequences (e.g., injection, ridicule if not brave)
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… pediatric considerations
School-Aged
 Fears body injury
 Can describe the cause, type, quality, and severity of pain
 Can rate the severity of pain
 Attempts to relate the pain experience to previous events
and gain control over actions
 Denies pain, especially if he or she associates it with
adverse consequences
 May be influenced by presence of parents in expressing
pain
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… pediatric considerations
Adolescent
 Considers body image as very important
 May use overconfidence to compensate for fear
 May use more “socially acceptable” behavioral
responses to pain than do younger children, but fear
and anxiety are not decreased
 May be influenced by presence of parents in
expressing pain
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Nursing diagnosis
 Decreased pain tolerance related to :
disbelief from others and uncertainty of prognosis
fatigue
fear(exp of addiction , loss of control)
monotony
financial & social stressors
lack of knowledge
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Disbelief from others
 Stablish a supportive accepting relationship
acknowledge the pain
listen attentively to the client’s discussion of pain
 Assess the family for any misconception about pain or its treatment
explain the concept of pain as an individual experience
discuss factors related to increased pain & options to manage
encourage family members to share their concerns privately
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Lack of knowledge / uncertainty
 Explain the cause of the pain , if known
 Explain the severity of the pain & how long it will last
 Explain the diagnostic tests & procedures in detail
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Fear
 Provide accurate information to reduce fear of addiction
 Assist in reducing fear of losing control
Include the client in setting a realistic pain goal
Provide privacy for the client’s pain experience
Attempt to limit the number of health care providers who provide care
allow the client to share intensity of pain
Involve the social worker or case manager if social or financial concerns
exist
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Fatigue
 Determine the cause of fatigue (sedatives , analgesics ,




sleep deprivation)
Explain that pain contributes to stress which increases
the fatigue
Assess present sleep pattern & the influence of pain on
sleep
Provide opportunities to rest during the day & with
period of uninterrupted sleep at night
Consult with physician for an increases dose of pain
medication at bedtime
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Monotony
 Discuss with the client and family to use distraction
method for relief (watching TV , listening to music…)
 Vary the environment if possible
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Some desired outcome
 The client will experience diminished pain as
evidenced by :
Verbalization of decrease in or absence of pain
Relaxed facial expression and body positioning
Increased participation in activities
Stable vital signs
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Other diagnosis
 Anxiety, fear, crisis reaction, stress
 Impact on spirituality and meaningfulness; hope and




hopelessness
Psychological effect of unrelieved pain on perceptions
of control and self-efficacy
Depression, wish to die, suicidal risks, grief
Impact of persistent pain on habits, roles,
occupational performance, and future quality of life
Personality and gender influences on pain experience
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… other diagnosis
 Loss of activity: vocational, recreational, related to
family
 Loss of identity: reassessing self image, grieving lost
abilities, reassessing relationships and roles
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Case report
 Brief patient history
Ms Nikjoo is a 63 y/o woman with type 2 DM & peripheral arterial
occlusive disease with neuropathy. She is disabled because of limited
mobility & chronic pain associated with lower extremity claudication &
neuropathic pain. Her pain has been managed with gabapentin 600 mg
TDS & 3 mg morphine PRN.
 Clinical assessment
She is admitted to the ICU after an 8hr surgical revascularization of
the right lower extremity. She is awake , alert & oriented .she complains
of right lower extremity & bilateral foot pain. Her skin is warm and dry
& the sensation to touch is intact and she is able to move her toes on
command however she is complaining of severe burning on both feet.
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 Diagnostic procedure
She reports that her pain is a 10 on the Baker-Wong Faces Scale .
 Medical diagnosis
The diagnosis is acute postoperative incisional pain superimposed
on chronic neuropathic pain involving both lower extremities.
Neuropathic pain is likely worsened because of missed doses of
gabapentin.
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References
 Carpenito/Nursing diagnosis to clinical practice /forth
edition/Lippincott Williams & Wilkins/2013
 Bates’ nursing guide physical examination & history taking /Lippincott
Williams & Wilkins/2012
 Linda D Urden – kathleen M Stacy – Mary E Lough /Critical Care
Nursing (Diagnosis & Management)/sixth edition/mosby elsevier
2010
 Ulrich , Canale/Nursing care planning guide /sixth edition/2005
‫ جلد دوم‬/ ‫ اعضای هیئت علمی دانشکده پرستاری شهید بهشتی‬/ ‫ اصول مراقبت از بیمار دوگاس‬
1382/
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Thanks for your
attention
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