Pain Management Consultant Professor : Dr Yekefallah Seyedeh
Hedyeh Banihashemi & Mahtab Salehi Master students of critical
care nursing (entrance Mehr 92) Automn 1392 2
Slide 3
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 patients pain & know different assessment tools
Determine nursing process Know geriatric & pediatric
consideration 3
Slide 4
Pain It is an unpleasant sensory & emotional experience
associated with actual or potential tissue damage. 4
Slide 5
Are these sentences true or false? 1. The best judges of the
existence and severity of patients pain are the physicians and
nurses caring for the patients. False 5
Slide 6
2. Patients should not receive analgesic until the cause of
pain is diagnosed. False 6
Slide 7
3. Pain makes anxiety worse. True 7
Slide 8
4. Patients who are knowledgable about opioid analgesics and
who make regular efforts to obtain them are drug seeking (Addicted)
False 8
Slide 9
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 9
Slide 10
6. Patients with PTSD (Post Traumatic Stress Disorder) show low
sensitivity to acute pain and rarely have chronic pain. False
10
Slide 11
Pain pathophysiology There are four basic processes involved in
acute pain : Transduction Transmission Perception Modulation
11
Slide 12
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 12
Slide 13
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. 13
Slide 14
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 14
Slide 15
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. 15
Slide 16
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. 16
Slide 17
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. 17
Slide 18
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 affective-
motivational response to pain such as looking at and assessing the
injury to the hand once it has been removed form the hot saucepan.
18
Slide 19
peception Limbic system This is responsible for the emotional
and behavioural responses to pain for example, attention, mood, and
motivation 19
Slide 20
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. 20
Slide 21
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. 21
Slide 22
Pain theories Specificity theory Pattern theory Intensity
theory Gate control theory 22
Slide 23
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. 23
Slide 24
24
Slide 25
25 By inferred pathology Nociceptive pain Somatic pain Arises
from bone,joint,muscle,s kin or connective tissue (well-localised )
Visceral pain Arises from visceral organs such as : GI tract and
pancreas. Tumor involvement of the organ.(fairly well-localised)
Obstruction of hollow viscus,causes intermittent cramping (poorly
localised) Neuropathic pain Central pain Deafferentation pain
Injury the PNS or CNS Phantom pain/burning pain below the spinal
cord. 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
Slide 26
Phantom pain 26
Slide 27
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. 27
Slide 28
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. 28
Slide 29
The perception of phantom pain 29
Slide 30
30
Slide 31
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. 31
Slide 32
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. 32
Slide 33
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. 33
Slide 34
Phantom pain treatment It includes : Pharmacological therapy
Noninvasive therapy Minimally invasive therapy Surgery 34
Slide 35
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.
35
Slide 36
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. 36
Slide 37
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.
37
Slide 38
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. 38
Slide 39
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. 39
Slide 40
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.
40
Slide 41
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. 41
Slide 42
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. 42
Slide 43
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 43
Slide 44
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 amputees brains cells,
essentially fooling the brain into thinking the amputees missing
hand is being massaged. 44
Slide 45
45
Slide 46
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. 46
Slide 47
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. 47
Slide 48
48
Slide 49
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) 49
Slide 50
Pain intensity Mild 4/10 Moderate = 5-6 Severe 7/10 50
Slide 51
51
Slide 52
52
Slide 53
53 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
Slide 54
Pain Assessment 54
Slide 55
Patient barrier to pain assessment : Communication Altered
level of consciousness Elderly patient Neonate & Infants
Cultural influence Lack of knowledge 55
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? 62
Slide 63
63
Slide 64
5. Numeric rating scale(NRS) 64
Slide 65
6. Wong Baker faces pain rating scale(FACES) 65
Slide 66
7. Faces pain scale-revised(FPS-R) 66
Slide 67
8. Iowa pain thermometer(IPT) 67
Slide 68
9. Faces pain thermometer(FPT) 68
Slide 69
10. Multiple language pain assessment scale 69
Slide 70
11. Memorial pain assessment scale 70
Slide 71
12. Pain scale combined 71
Slide 72
13. Behavioral pain scale(BPS) 72
Slide 73
14. Critical care pain observation tool(CPOT) 73 Face expresion
Body movement Compliance with the ventilator(intubated patient)
Vocalisation(nonintubated patient) Muscle tention
Slide 74
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:
patients perception of the problem or cognitive experience of pain
74
Slide 75
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 75
Compliance with the ventilator (Intubated patient) 78
Slide 79
Vocalisation (nonintubated patients) 79
Slide 80
Muscle tension 80
Slide 81
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 81
Slide 82
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 82
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.
87
Slide 88
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. 88
Slide 89
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 pain-
sensing areas of the brain. This interplay within the prefrontal
cortex may trigger a release of pain-relieving opioids in the
midbrain. 89 placebo
Slide 90
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 dont receive
gamma amino butyric acid, which is the core problem for people with
this desease. 90
Slide 91
Cordotomy It is a surgical procedure that disables selected
pain- conducting 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.
91
Slide 92
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 92
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) 94
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 96
Slide 97
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 97
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. 100
Slide 101
TENS Control of acute or chronic pain Management of
postsurgical pain Reduction of post-traumatic acute pain 101
Slide 102
Nonpharmacologic Control 102
Slide 103
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 clients ability or willingness to participate in
pain-relief measures. Choose pain-relief measures on the basis of
the clients behavior reflecting the severity of pain. Use measures
that the client believes are effective. 103
Slide 104
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 104
Slide 105
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 105
Slide 106
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 106
Slide 107
107
Slide 108
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. 108
Slide 109
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 childs response
to pain. 109
Slide 110
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 110
Slide 111
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) 111
Slide 112
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 112
Slide 113
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 113
Slide 114
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 114
Slide 115
Disbelief from others Stablish a supportive accepting
relationship acknowledge the pain listen attentively to the clients
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 115
Slide 116
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
116
Slide 117
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 clients 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 117
Slide 118
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
118
Slide 119
Monotony Discuss with the client and family to use distraction
method for relief (watching TV, listening to music) Vary the
environment if possible 119
Slide 120
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 120
Slide 121
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 121
Slide 122
other diagnosis Loss of activity: vocational, recreational,
related to family Loss of identity: reassessing self image,
grieving lost abilities, reassessing relationships and roles
122
Slide 123
123
Slide 124
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. 124
Slide 125
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. 125
Slide 126
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 / / /1382 126
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