acute versus chronic. Acute pain is short in duration and generally resolves once the initial insult has healed. Contrarily, chronic pain lasts longer to heal than the initial insult, lasting months to years in duration. Acute postoperative pain is a fairly common and expected phenomenon.
Figure 10-1. Nociception. A, A physical insult, in this case, a nail to soft tissue (i.e., skin), occurs causing actual and/or potential tissue damage. Nerve cells within the tissue are activated. B, Afferent neuronal impulses leave the site of injury and reach the spinal cord’s dorsal horn. Here pain is transmitted and processed. Permission for use granted by Scientific Animations under Creative Commons license BY-SA 4.0 (creativecommons.org/licenses/by-sa/4.0/). Image can be found at www.scientificanimations.com/wiki-images
standard of pain assessment is patient self-report, and having a first-hand account of the patient’s pain is vital. Choosing the correct scale is the initial point of assessment, done in conjunction with a comprehensive assessment. Conducting a pain interview using a pneumonic such as PQRSTU (Table 10-2) may be useful to ensure that the entire pain experience is captured and adequately assessed. Generally assessed on a numerical scale of 0 to 10, other instruments such as a visual analog scale may be used in those who are nonverbal. In children under 7 years of age, or unable to conceptualize the 0 to 10 concept, it may be helpful to utilize a visual scale such as Wong-Baker FACES pain rating scale (Wong-Baker Faces Foundation, 2016). If one is unable to provide a verbal account of pain, such as in the case of children or adults with neurocognitive impairment, it may be appropriate to use behavioral scales, such as the Faces, Legs, Arms, Crying, and Consolability (FLACC) scale (Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997). Though the gold standard is self-report, a proxy may be necessary in those who are unable to communicate (i.e., a caretaker or parent).
Table 10-1. Increased Postoperative Pain Risk Factors
Table 10-2. PQRSTU Pain Interview
Figure 10-2. Analgesic ladder for postoperative pain. NSAID, nonsteroidal anti-inflammatory drug. Adapted from World Health Organization (1986).
and abuse. Statistics from the current opioid epidemic both nationwide and at the state levels are enough to raise concern regarding opioid prescribing in the hospital setting . It is important to note that the majority of opioid use stems from opioids that have been legally prescribed and obtained. In 2015, there were 12.5 million people nationwide misusing prescription opioids, which subsequently cost the United States $78.5 billion (United States Department of Health and Human Services, 2017).
Table 10-3. Equianalgesic Chart of Strong Opioids Used for Postoperative Pain