Part of the ICU Emergencies Hub — browse every related guide in one place.
| Scale | Use | Key Points |
|---|---|---|
| Numeric Rating Scale (NRS 0–10) | Adults who can self-report; most commonly used | 0 = no pain; 10 = worst pain imaginable; ≤3 = mild; 4–6 = moderate; ≥7 = severe; reassess within 30–60 min after intervention |
| Visual Analog Scale (VAS) | Adults who can self-report; research settings | 10 cm horizontal line; patient marks their pain level; more precise but requires fine motor ability |
| Wong-Baker FACES Scale | Children 3+; adults with cognitive impairment, communication barriers | 0–10 faces from smiling to crying; child points to the face that shows how they feel |
| FLACC Scale | Infants and non-verbal children 2 months to 7 years; non-verbal adults | Face, Legs, Activity, Cry, Consolability; 0–2 for each; total 0–10 |
| CPOT (Critical Care Pain Observation Tool) | Critically ill and mechanically ventilated patients | Facial expression, body movements, muscle tension, compliance with ventilator or vocalization; 0–8 total; CPOT ≥3 indicates significant pain |
| BPS (Behavioral Pain Scale) | Mechanically ventilated non-verbal patients (ICU) | Facial expression, upper limb movements, compliance with ventilation; 3–12; ≥5 = pain |
PQRSTU Pain Assessment Tool: Provokes/Palliates | Quality | Radiates/Region | Severity | Timing | Understanding (what does patient think is causing pain) + impact on activities
Originally developed for cancer pain; now applied broadly to guide escalation of pain management:
The ladder guides escalation ("by the ladder"), with medications given regularly on a schedule ("by the clock"), and appropriate to the patient ("by the patient/mouth").
| Drug | Dose (Adult) | Mechanism | Key Nursing Points |
|---|---|---|---|
| Acetaminophen (Tylenol) | 325–1000 mg q4–6h; MAX 4g/day (3g/day in elderly, liver disease, alcohol use) | Central COX inhibition; antipyretic | Check ALL sources of acetaminophen (combination OTC products); hepatotoxic in overdose; safe in renal disease; no anti-inflammatory effect |
| Ibuprofen (Advil/Motrin) | 400–800 mg q6–8h; MAX 3200 mg/day; with food | Non-selective COX-1/COX-2 inhibitor; anti-inflammatory, analgesic, antipyretic | Avoid in renal impairment, GI ulcers, heart failure, elderly, >32 weeks pregnancy; GI protective agent (PPI/misoprostol) if long-term use |
| Ketorolac (Toradol) | 15–30 mg IV/IM q6h; MAX 5 days total; 30 mg IM single dose | NSAID; parenteral NSAID for moderate–severe pain | Do NOT use >5 days (renal toxicity); avoid in elderly, renal disease, GI bleeding; potent anti-inflammatory; no opioid side effects (respiratory depression) |
| Celecoxib (Celebrex) | 100–200 mg BID | Selective COX-2 inhibitor | Less GI risk than non-selective NSAIDs; cardiovascular risk; avoid in sulfa allergy |
| Gabapentin (Neurontin) | 100–900 mg TID (titrated) | Calcium channel modulation; neuropathic pain adjuvant | Reduces opioid requirements; AVOID in CKD (renal dose adjustment); sedation, dizziness; preoperative dose reduces post-op opioid use |
| Pregabalin (Lyrica) | 50–300 mg BID–TID | Same as gabapentin; neuropathic pain | Fibromyalgia, neuropathic pain; sedation; dose adjust for renal impairment; Schedule V controlled substance |
| Opioid | Route | Onset (IV) | Duration | Key Facts |
|---|---|---|---|---|
| Morphine | PO/IV/SQ/IM/epidural | 5–10 min IV | 3–6 hr | Reference opioid for equianalgesic calculations; active metabolite (M6G) accumulates in renal failure → prolonged effect; releases histamine → itching, hypotension |
| Hydromorphone (Dilaudid) | PO/IV/SQ | 5 min IV | 3–4 hr | 5–10x more potent than morphine; less histamine release; good choice when morphine causes excessive itching or renal failure |
| Fentanyl | IV/transdermal/buccal/intranasal/epidural | 1–2 min IV | 30–60 min IV | 100x more potent than morphine; lipophilic → rapid CNS entry; transdermal patch: onset 12–17 hr, do NOT apply heat; NO histamine release; good for hemodynamically unstable (less hypotension) |
| Oxycodone | PO (oral only); OxyContin = extended-release | N/A PO; 10–15 min PO | 4–6 hr (IR); 12 hr (ER) | ~1.5x more potent than oral morphine; ER formulation must NOT be crushed (rapid release = overdose risk); frequently combined with acetaminophen (Percocet) |
| Tramadol (Ultram) | PO | 30–60 min PO | 4–6 hr | Weak opioid + NE/serotonin reuptake inhibition; lowers seizure threshold; serotonin syndrome risk with SSRIs/SNRIs/MAOIs; Schedule IV; max 400 mg/day |
| Methadone | PO/IV | Complex; variable | Very long (24–36+ hr); accumulates | Used for opioid dependence treatment + chronic pain; QTc prolongation; complex pharmacokinetics; NEVER start without equianalgesic expertise; dangerous in opioid-naive |
| Side Effect | Prevention/Management | Priority? |
|---|---|---|
| Constipation | Stimulant laxative from DAY 1 (senna); stool softener; docusate; adequate hydration and activity; methylnaltrexone (Relistor) for opioid-induced constipation; ONLY side effect with NO tolerance development | Universal; always address proactively |
| Nausea/vomiting | Ondansetron (Zofran), promethazine, prochlorperazine, scopolamine patch; tolerance usually develops within days | Common; usually temporary |
| Sedation | Reduce dose; switch opioids; add stimulant (methylphenidate); assess for other sedating medications; tolerance develops | Monitor carefully; dose-dependent |
| Respiratory depression | Monitor RR, SpO2, sedation level; reduce dose; naloxone reversal; keep Narcan at bedside for high-risk patients | MOST SERIOUS; assess q1–2h when initiating or increasing dose |
| Pruritus (itching) | Diphenhydramine (Benadryl); hydroxyzine; switch to non-histamine releasing opioid (fentanyl, hydromorphone); low-dose naloxone infusion; nalbuphine | Common with morphine, less with fentanyl |
| Urinary retention | Bladder assessment q4h; bethanechol; in-and-out catheterization; switch opioids; reduce dose | Monitor urine output; common in elderly males |
Multimodal analgesia uses multiple drug classes and non-pharmacologic strategies to achieve pain control while minimizing opioid use and side effects. Evidence shows it reduces opioid consumption by 30–50% in surgical patients:
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