Nurse

• Diagnosis of a cause for abdominal pain is based on the site and characteristics of the pain together with a knowledge of likely pathology.

• For foregut pathology pain is epigastric.

• For midgut pathology pain is central (peri-umbilical).

• For hindgut pathology pain is in the lower abdomen.

• Once there is inflammation, pain and tenderness become localized to the abdominal wall overlying the organ concerned.

Pain in patients with cancer occurs because of a variety of different causes and has both nociceptive and neuropathic pain components.

It is essential that a thorough assessment of the pain is carried out in order to institute appropriate treatment.

Whilst the WHO Pain Ladder is a good place to start, there are many other treatments available to treat pain in cancer.

Any pharmacological or interventional treatment will be more successful if appropriate psychological support is provided.

Age and maturity affect the perception and expression of pain in children.

A variety of pain assessment tools are needed to cover different age groups.

The British National Formulary for Children is a source of correct formulations and doses of analgesics for children of different ages.

Neonates show very high interindividual response to analgesic drugs.

Between 2yrs and 12yrs, the clearance of drugs exceeds that of adults and relatively higher doses may be needed.

Patient-controlled, nurse-controlled, and neuraxial analgesia can all be used in infants and children.

Reducing procedural pain in children is important and requires a combination of pharmacological and non-pharmacological methods.

The main goals in treating perioperative pain are effective analgesia and prevention of withdrawal.

An acute pain management plan should be formulated and agreed with the patient.

Discharge planning is only successful if the psychosocial background of the patient is considered.

The use of painkillers ranging from simple analgesics to strong opioids is a common feature in the acute pain management of haematological conditions.

However, each disease also has its own specific aetiological factors for pain, requiring specific treatment.

Haematological patients with chronic pain on long-term opioid therapy may require multidisciplinary pain management to improve quality of life and prevent chronic escalation of opioid doses.

Intramuscular injections should be avoided in all patients.

The use of pethidine (meperidine) is not recommended.

The metabolism and excretion of many analgesic drugs will be altered in the presence of renal or hepatic impairment.

Some analgesic drugs can cause renal or hepatic damage.

Protein binding of drugs may be altered by hepatic reduction in production or uraemic displacement from binding sites.

In renal disease, paracetamol is the simple analgesic of choice.

Morphine can be used with care in mild to moderate renal disease, but fentanyl or oxycodone may be better alternatives.

Non-steroidal anti-inflammatory drugs should be avoided in renal disease.

In hepatic disease with significant impairment, doses of morphine must be reduced and the dosage interval lengthened.

Fentanyl should be avoided in severe hepatic disease.

Pain in vascular disease is often severe.

Atherosclerosis is the commonest cause of ischaemic pain.

Angioplasty, stents, and surgical revascularization should be attempted to treat the underlying cause.

Pain relief is also aimed at neuropathic and sympathetic components of pain.

In end stage ischaemic disease, amputation may be necessary often leading to long-term pain.

Labour pain can be severe, and relieving this pain can reduce physiological stress on mother and baby.

Epidural and spinal analgesia is by far the most effective modality.

Epidurals do not increase the likelihood of Caesarean delivery.

Entonox is the next best choice for labour analgesia.

Intravenous opioids, especially pethidine, have very little analgesic effect and cause sedation as well as other negative effects on the mother and baby.

Transcutaneous electrical nerve stimulation has a limited role confined to early labour.

Physiological changes that occur with age affect the pharmacokinetics and pharmacodynamics of drugs used in acute pain management.

Elderly patients are often reluctant to complain of pain and seek treatment and may sometimes be unable to express pain due to impaired cognition or language.

Evidence suggests the elderly as a group that receive inadequate analgesia and are often in pain.

Health care professionals are often reluctant to administer sufficient analgesia due to fear of encouraging addiction or inducing side effects.

The approach to pain management in this group should follow the World Health Organization (WHO) analgesic ladder with close monitoring for potential side effects and with escalation of treatment till sufficient analgesia is achieved.

Choice of drugs and the route of administration should be tailored to the individual patient and should consider the nature of their pain and any disability or co-morbidity that will affect their response to the chosen agent.

Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with extreme caution, monitoring for potential gastrointestinal (GI) and renal side effects and long-term use should be avoided if possible.

Opioids are effective analgesics and should not be denied to the elderly but their use should be monitored carefully and side effects such as nausea and constipation anticipated and treated.

Acute pain is a common presenting symptom in patients with neurological conditions.

Acute onset headache may indicate a life-threatening underlying condition.

Lumbosacral and cervical spine pain are commonly caused by degenerative disease but there are sometimes clues to indicate alternative pathologies.

Acute pain arising from the peripheral nervous system and muscles are usually inflammatory in origin.

A careful history and examination is crucial to assess patients with neurological pain.

Opioids may be used in combination of an anti-epileptic or antidepressant drug in the treatment of acute neuropathic pain.