Acute Pain
Moya Cook, Jill C. Cash, and Kathleen Bradbury-Golas
Definition
A.Acute pain is defined as pain of a short, limited duration, usually the result of an injury, surgery, or medical illness (disease/inflammation) that generally arises from tissue injury; however, it may be experienced even with no identifiable cause. Acute pain usually resolves when the tissue injury improves with the healing process. Most acute pain resolves in less than 6 weeks or less than 3 months.
B.General statements about pain:
1.Pain is a distressing sensory and emotional experience. It is an actual physical discomfort. It is the result of many factors; therefore it is multidimensional.
2.Pain is what the patient says it is, totally subjective.
Patients do not always verbalize their pain but may express it in nonverbal ways. Therefore a provider must assess the patient using various methods.
3.The initial assessment of pain is to characterize the pathophysiology of the pain, identify its cause, determine its intensity, and evaluate its impact on the patient’s ability to function.
Incidence
A.Acute pain is the most common reason for self-medication and presentation for treatment in the healthcare system. Acute pain is very individual, and if not treated properly it can have devastating physiological and psychological effects. Because everyone experiences some type of acute pain, it is very difficult to determine the incidence and prevalence of pain. Because pain is very subjective, the patient care plan needs to be individualized to meet the patient’s needs. Proper treatment of acute pain could prevent the development of some types of chronic pain syndromes.
Pathogenesis
A.Acute pain is usually the result of stimulation of the sympathetic nervous system.
B.Types of pain:
1.Nociceptive pain: Normal response to peripheral tissue injury or damage (sprains, fractures).
2.Neuropathic pain: Originates from injury or dysfunction of the peripheral nervous system or central nervous system structures or both (postherpetic neuralgia, diabetic neuropathy).
3.Inflammatory pain: Nociceptive pain with a localized immune response due to proinflammatory mediators (arthritis).
4.Centralized pain: Peripheral and central sensitization with no detectable origin (fibromyalgia, headaches).
Common Complaints
A.Pain at the specific site.
B.Increased heart rate.
C.Increased respiratory rate.
D.Elevated blood pressure.
E.Sweating.
F.Nausea.
Other Signs and Symptoms
A.Urinary retention.
B.Dilated pupils.
C.Pallor.
Subjective Data
A.Elicit location of pain.
B.Note effects of pain on activities of daily living (ADLs).
C.Note intensity of pain at rest and during activity.
D.List precipitating factors.
E.Identify alleviating factors.
F.Note the quality of pain.
G.Is there radiation of pain?
H.Rate pain on a pain scale (usually on the 0–10 scale, with 0 being no pain and 10 being the worst pain).
Physical Examination
A.Check temperature, pulse, respiration, and blood pressure.
B.Inspect:
1.Observe overall appearance.
2.Note affect and ability to express self and pain.
3.Note facial grimaces with movement.
4.Note gait, stance, and movements.
5.Inspect area at pain site.
C.Auscultate:
1.Auscultate heart and lungs.
2.Auscultate neck and abdomen.
D.Palpate: Palpate affected area of pain.
E.Percuss:
1.Percuss chest.
2.Percuss abdomen.
F.Perform musculoskeletal exam:
1.Perform complete musculoskeletal exam, concentrating on the area of pain.
2.Assess deep tendon reflexes (DTRs).
When performing a musculoskeletal exam, identify the location of pain, presence of trigger points, evidence of injury or trauma, edema, erythema, warmth, heat, lesions, petechiae, tenderness, decreased range of motion, pain with movement, crepitus, laxity of ligaments or cords, spasms, or guarding.
G.Neurologic exam:
1.Perform complete neurologic exam.
2.Identify change in sensory function, skin tenderness, weakness, muscle atrophy, and/or loss of (DTRs).
Diagnostic Tests
A.No diagnostic testing is required unless clearly indicated to rule out organic cause of pain.
If organic disease is suspected, diagnostic testing may include the following:
1.CT imaging.
2.MRI.
3.Blood chemistries.
4.Radiographic x-ray.
5.Lumbar puncture.
6.Ultrasound.
7.ECG/echocardiogram.
Differential Diagnosis
The differential diagnoses depend on the location of the acute pain.
A.Head:
1.Migraine.
2.Cluster headache/migraine headache.
3.Temporal arteritis.
4.Intracranial bleeding or stroke.
5.Sinusitis.
6.Dental abscess.
B.Neck:
1.Meningitis.
2.Muscle strain/sprain.
3.Whiplash injury.
4.Thyroiditis.
C.Chest:
1.Pulmonary emboli.
2.Myocardial infarction.
3.Pneumonia.
4.Costochondritis.
5.Angina.
6.Gastroesophageal reflux disease/esophagitis.
D.Abdomen:
1.Peritonitis.
2.Appendicitis.
3.Ectopic pregnancy/uterine pregnancy.
4.Endometriosis.
5.Pelvic inflammatory disease.
6.Peptic ulcer.
7.Cholelithiasis.
8.Colitis/diverticulitis.
9.Constipation.
10.Gastroenteritis.
11.Irritable bowel syndrome.
12.Urinary tract infection, kidney stone, pyelonephritis.
13.Prostatitis.
E.Musculoskeletal:
1.Muscle sprain/strain/tear.
2.Skeletal fracture.
3.Viral infection.
4.Gout.
5.Vitamin D deficiency.
Plan
A.General interventions:
1.Acute pain is a symptom, not a diagnosis. Try to identify the cause or source of the acute pain, depending on the location. If the pain is organic in nature, make the appropriate referral. The overall goal is to treat the acute pain appropriately.
B.Patient teaching:
1.The pain management plan must include patient and family/significant other education regarding preventing and controlling pain, potential medication side effects, and how to prevent the side effects.
2.Discussion must include addiction concerns and a possible addiction risk assessment. Explain addiction is low when the medication is used as directed for a short duration. Explain that complete pain relief may not be achievable initially, but the overall goal is to decrease the pain, thus allowing some daily activities at home to begin recovery.
C.Pharmaceutical therapy.
Source of acute pain:
1.Visceral pain: Treatment of choice is corticosteroids, intraspinal local anesthetic, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.
2.Somatic pain: Acetaminophen, cold packs, corticosteroids, localized anesthetics, NSAIDs, opioids, and tactile stimulation.
3.Neuropathic pain: Tricyclic antidepressants, using amitriptyline or imipramine as the first-line treatment for neuropathic pain. Anticonvulsants like carbamazepine (Tegretol), phenytoin (Dilantin), and valproic acid (Depakene) can be useful in treating neuropathic pain but should be reserved for second-line treatment. Carbamazepine and oxcarbazepine can be used for first-line treatment of trigeminal neuralgia. Other treatments include local anesthetics, tramadol (Ultram), and glucocorticoids.