11.4 Pain Management
Open Resources for Nursing (Open RN)
Pain management requires collaboration with the interdisciplinary team, including nurses, health care providers, pharmacists, and sometimes pain specialists. There are many different types of pain medications (called analgesics) that can be administered by various routes. Analgesics are classified as nonopioids, opioids, or adjuvants. An adjuvant is a medication that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when administered with opioids. Examples of adjuvant medications include antidepressants (e.g., amitriptyline) and anti-seizure medications (e.g., gabapentin).
A general rule of thumb when administering analgesics is to use the lowest dose of medication, with fewest potential side effects and the least invasive route of administration, to effectively treat the level of pain as reported by the client. The WHO ladder was originally developed by the World Health Organization for selecting analgesics for clients with cancer pain, but it can be broadened to illustrate this rule of thumb for managing pain appropriately for all clients. See Figure 11.6[1] for an image of the WHO ladder.
For example, if a client reports a pain level of “2,” then a nurse typically starts at the lowest rung of the WHO ladder and administers a prescribed nonopioid via the oral route. If the nonopioid is not effective, then a prescribed adjuvant medication may be administered, or the nurse may decide to step up a rung on the ladder and administer a prescribed oral opioid for mild to moderate pain. On the other hand, if a client reports severe pain, the nurse may start at the top rung of the ladder and administer a prescribed opioid for moderate to severe pain via the intravenous route for rapid relief.
Nonopioid Analgesics
Nonopioid analgesics include acetaminophen and NSAIDs.
Acetaminophen
Acetaminophen (Tylenol) is used to treat mild pain and fever but does not have anti-inflammatory properties. Acetaminophen is safe for all ages and can be administered using various routes, such as orally, rectally, and intravenously. Many over-the-counter (OTC) medications contain acetaminophen, along with other medications. See Figure 11.7[2] for an image of acetaminophen (Tylenol) and acetaminophen and diphenhydramine (Tylenol PM).
A potential severe side effect of acetaminophen is hepatotoxicity (severe liver damage). Severe liver damage may occur if an adult client takes more than 4,000 mg of acetaminophen in 24 hours (or 3,200 mg for older adults or 2,000 mg for chronic alcoholics) or consumes three or more alcoholic drinks every day while using acetaminophen.
Because some medications are combined with acetaminophen or are prescribed “as needed,” the nurse must calculate the cumulative dose of acetaminophen over the previous 24-hour period before administering an additional dose. For example, Percocet 5/325 contains a combination of oxycodone 5 mg a