PAIN MANAGEMENT

Susan Kelly, BSN, RN, CLNC

King University
Case Study
 A 24 year old Caucasian male
 Chief Complaint: Right foot pain
 HPI: Onset 1 day ago, worsening throughout the night, continuous throbbing pain
worsens with activity. Limited range of motion with swelling to the posterior
aspect of the foot, after a horse stepped on his foot. Denies taking any medication
for pain however, he has elevated and iced his foot while sitting.
 Allergies: NKA
 Medications: Not pertinent
 Past Medical History: Not pertinent
 Family History: Denies family history reports his mother and father are both
living and in good health also reports he is an only child.
 Social History: Married a year ago lives in a 2 story home, no children at this
time. He attends a Baptist church regularly with his wife. They enjoy horseback
ridding. Denies tobacco, alcohol, or illicit drug use.
Review of Systems

 Subjective
General: Well rested averages 6 to 8 hours sleep at night. Denies fever, chills, recent
weight loss
Skin: Denies rashes, ulcerations, breaks in skin, does report swelling to the right foot.
Diet: Regular, report eating three meals a day with a mixture of baked, broiled, and
fried foods. Drinks 8 to 10 glasses of water a day and two glasses of milk per day.
Rarely easts fast food or frozen meals.
MS: Reports pain in the right foot.
GI: Denies heartburn, reflux, ulcers, nausea or vomiting
GU: Denies frequency, hesitancy, urgency, incontinence, dysuria, hematuria, or
nocturia.
Review of Systems

 Objective
 V/S: Temp 98.6, HR 80, RR 22, BP 120/76 SpO2 99% (room air) 160 pounds,
6’0”, BMI 21.70. Pain 8/10
 Constitutional: Pleasant, well-groomed Caucasian man, dressed appropriately for
age. Cooperative answering all questions appropriately. No grimacing, or acute
distress noted however, he was guarding the right foot.
 Skin: Warm, dry and intact
 MS: Edema noted to the poster and lateral aspect of the right foot with limited
ROM
 Neuro: No deficits identified
 GU: Not pertinent
What is my diagnosis?

Acute Pain
Acute Pain

 Normal mechanism to protect alerting individuals to a condition or experience that

is immediately harmful to the body so the individual can take immediate action to
relieve the pain (Huether, & McCance, 2017).
 Duration is only through the expected recovery phase whether it has a sudden or
slow onset and regardless of intensity.
 Intensity is rated on a pain scale from 0 to 10
 10 Worse pain possible
 7 to 10 Severe pain
 4 to 6 Moderate pain
 1 to 3 Mild pain Richards, 2009)
Pathophysiology

Pain impulse travels from the peripheral nerve fibers to the spinal cord, transmission
from the spinal cord and ascension via spinothalmic tracts, to the brain stem and
thalamus. Transmission from the thalamus to the somatic sensory cortex where pain
perception occurs.

Pain control takes place during the transmission from the spinal cord and ascension
via spinothalmic tracts as opioids block the release of neurotransmitters which stops
the pain at the spinal level.
Who is at Risk?

Anyone with injury

Prevention

AVOID INJURY
Treatment
Ketorolac
Brand name Toradol

Nonsteroidal anti-inflammatory drug (NSAID)

Pregnancy category C;D (third trimester)

Action: Inhibits prostaglandin synthesis by decreasing an enzyme needed for

biosynthesis, analgesic, anti-inflammatory, antipyretic effects.
Therapeutic outcome: Decreased pain, inflammation, ocular itching
Usage: Mild to moderate pain (short term); decreased ocular itching in seasonal
allergic conjunctivitis (ophthalmic)

(Skidmore-Roth, 2015)
Treatment

Contraindications: Pregnancy D (3rd trimester), hypersensitivity, asthma, hepatic

disease, peptic ulcer disease, CV bleeding.

BLACK BOX WARNING: Breastfeeding, severe renal disease, labor and delivery,
perioperative pain in CABG, prior to major surgery, epidural/intrathecal
administration, GI Bleeding, hypovolemia

Precautions: Pregnancy C, GI/cardiac disorders hypersensitivity to other anti-

inflammatory agents, CCr<25 ml/min

BLACK BOX WARNING: Children, geriatric, bleeding, MI, Stroke

(Skidmore-Roth, 2015)
Treatment
Dosage and Routes: Patient received 60 mg IM one time dose
Other Dosages and Routes: IV and PO
Adults >17 > 50kg
IV/IM 20mg then 10mg Q4-6 hours prn max 40 mg/day
Nasal: 1 spray (15.75mg/spray) each nostril (31.5mg/spray) Q6-8hours max 4
doses/day for 5 days.
Adults > 17 < 50kg
IM 30 to 60mg (single dose)
IV 15 to 30mg (single dose)
IV/IM 15 to 30mg can be given Q 6hours max of 60mg/day for 5 days
Nasal: 1 spray (15.75mg/spray) in one nostril Q Q6-8 hours max 4 doses/day for 5
days

(Skidmore-Roth, 2015)
Treatment

Administer crushed or whole

Give with full glass of water; give with food or milk to decrease gastric symptoms
Give 30 minutes before or 2 hours after meals (absorption may be slowed)
Give IV undiluted > 15 seconds
Give IM deep into large muscle
Store at room temperature and protect from light
Incompatible with Morphine, Phenergan, Demerol, and Hydroxyzine
Compatible with D5W, 0.9%NaCL, LR, plasmalate

(Skidmore-Roth, 2015)
Adverse Effects

CNS: Seizures, dizziness, drowsiness, tremors

CV: CV thrombotic events, hypertension, flushing, syncope, vasodilation, edema,
MI, Stroke
EENT: Tinnitus, hearing loss, blurred vision, transient burning/stinging
GI: Nausea, anorexia, vomiting, diarrhea, constipation, flatulence, cramps, dry
mouth, peptic ulcer, GI bleeding, perforation, taste change, hepatitis, hepatic failure
GU: Nephrotoxicity, dysuria, hematuria, oliguria, azotemia
HEMA: Blood dyscrasias, prolonged bleeding
INTEG: Rash, purpura, pruritus, sweating, angioedema, Stevens-Johnson syndrome,
toxic, epidermal necrolysis

(Skidmore-Roth, 2015)
Pharmacokinetics

Absorption rapidly, completely absorbed

Distribution bound to plasma protein (99%)
Metabolism liver (<50%)
Excretion kidney metabolites (92%) breast milk (6%) feces
Half-life 6 hours (IM) increased in renal disease
Onset IM up to 10 minutes
Peak 50 minutes IM, 2-3 hours PO, 0.5 – 2 hours nasal
Duration 4-6 hours PO

(Skidmore-Roth, 2015)
Interactions (Individual Drugs)
Alcohol Picamycin
Asaprin Ticlopidine
Cefamandole Tirofiban
Cefoperazone Valproic acid
Cefotetan Cyclosporine
Clopidogrel Lithium
Epthifibatide Methotrexate

(Skidmore-Roth, 2015)
Interactions (Drug class)

ACE Inhibitors
Antihypertensives
Salicylates
Corticosteroids
Diuretics
NSAIDs

(Skidmore-Roth, 2015)
Drug/Labs/Nursing

Increased AST, ALT, LDH, bleeding time

Black Box Warning: Monitor renal, hepatic, blood studies, BUN, creatinine, AST,
ALT, Hgb, before treatment, periodically thereafter, check for dehydration. GI
Bleeding,

Monitor for aspirin sensitivity

*Asthma patients may be more likely to develop hypersensitivity

(Skidmore-Roth, 2015)
Patient Education

 Avoid alcohol, ASA, Tylenol, and other NSAIDs

 Report bleeding, bruising, fatigue
 Use caution when driving as drowsiness or dizziness may occur
 Take with full glass of water to increase absorption
 May cause eye redness, burning if contact lens are worn
 Report change in urination pattern or blood in urine, weight increase, edema, pain
in joints, fever, black tarry stools, pregnancy

(Skidmore-Roth, 2015)
Non-Pharmacological

Cryotherapy via the utilization of ice as it works by decreasing nerve conduction

velocity

Rest

Elevation of affected extremity

(Skidmore-Roth, 2015)
 Family Clinic Kingsport
123 School Lane
Abington, VA 37811
Telephone: (123) 456-7890 Fax: (098) 765-4321
Dr. John Doe NPI# 0000000000 DEA# 000000000
Susan Kelly, MSN, FNP-BC NPI# 1234567890 DEA# MN1234567

Name: J.S. Date: 05-29-2017

Address: 1234 Pharmacology Drive, Abington, VA 37660 Date of Birth: 2/14/1993
Rx: Ketorolac 20mg
Sig: take one tablet P.O. one time dose
# 1 (one)
Refill: none
Signature of Prescriber: Susan Kelly, FNP-BC
 Family Clinic Kingsport
123 School Lane
Abington, VA 37811
Telephone: (123) 456-7890 Fax: (098) 765-4321
Dr. John Doe NPI# 0000000000 DEA# 000000000
Susan Kelly, MSN, FNP-BC NPI# 1234567890 DEA# MN1234567

Name: J.S. Date: 05-29-2017

Address: 1234 Pharmacology Drive, Abington, VA 37660 Date of Birth:2/14/1993
Rx: Ketorolac 10mg
Sig: take one tablet P.O. every 4-6 hours not to exceed 40mg/day
# 10 (ten)
Refill: none
Signature of Prescriber: Susan Kelly, FNP-BC
Therapeutic Regimen

 Unpleasant sensory and emotional experience associated with actual and potential
tissue damage, or described in terms of such damage. (American Pain Society)

 Physical and emotional

(Skidmore-Roth, 2015)
References

 Huether, S., & McCance, K. (2017). Understanding pathophysiology. St. Louis, MO.:
Elsevier.
 Richards, K. (2009). Using the pain scale effectively. Health Central. Retrieved from
http://www.healthcentral.com/chronic-pain/coping-403768-5.html
 Skidmore-Roth, L. (2015). Mosby's drug guide for nursing students. St. Louis, MO.:
Elsevier Mosby.