ⓘIASP Definition (2020): Pain is "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." Pain is always subjective — the patient's report is the gold standard.
Pain as the 5th Vital Sign
Pain should be documented alongside temperature, pulse, BP, and RR at every assessment. Failure to assess pain is a failure of care. The nurse must proactively ask — not wait for the patient to volunteer the complaint.
Assess pain at rest and on movement
Reassess within 30–60 min after any analgesic intervention
Document tool used, score, and response to treatment
Undertreated pain leads to DVT, pneumonia, delayed mobilisation
Pain Characteristics — PQRST
Letter
Meaning
Question to Ask
P
Provocation / Palliation
What makes it worse or better?
Q
Quality
Sharp, dull, burning, stabbing, throbbing?
R
Region / Radiation
Where is it? Does it spread?
S
Severity / Score
Rate 0–10; effect on function/sleep
T
Timing
Onset, duration, constant vs intermittent?
Assessment Tools
Self-Report (Communicative)
★NRS 0–10 — Numerical Rating Scale. Most used in GCC hospitals. Simple, validated across cultures. 0 = no pain, 10 = worst imaginable.
─VAS — Visual Analogue Scale. 100 mm line; patient marks position. More precise but requires pen/paper.
Verbal Rating Scale: None / Mild / Moderate / Severe — useful when language barrier makes numbers difficult.
Wong-Baker FACES: 6 face drawings (0–10). For paediatrics (>3 yrs) and patients with cognitive impairment. Faces range from smiling to crying.
Observational (Non-Verbal)
☺FLACC Scale — Face, Legs, Activity, Cry, Consolability. 0–2 per domain (total 0–10). Validated for infants and non-verbal patients.
PAINAD — Pain Assessment in Advanced Dementia. Breathing, negative vocalisation, facial expression, body language, consolability. Score 0–10. Use in dementia patients who cannot self-report.
0–3 Mild
4–6 Moderate
7–10 Severe
GCC-Specific Assessment Barriers
Language Barriers
GCC healthcare workforce and patient population are highly diverse. Patients may describe pain primarily in Arabic, Malayalam, Tagalog, Hindi, or Urdu. Key points:
Use validated tools with pictures (FACES, FLACC) when language is a barrier
Access hospital interpreter services — do not rely on family members for translation of clinical pain descriptions
Bilingual NRS cards improve reliability across languages
Non-verbal cues (guarding, grimacing, bracing) are cross-cultural pain signals
Document language used during assessment
⚠Numeric scales remain usable across language barriers — hold up fingers or show the scale card rather than asking verbally.
Cultural Stoicism
Cultural norms significantly influence pain expression in GCC. Male Arab patients in particular may under-report pain due to cultural expectations of stoicism and strength.
Do not interpret quiet behaviour as absence of pain
Use behavioural cues and observe at movement/procedures
Frame pain assessment as clinical necessity: "I need to know your pain score to give the right medication"
Avoid gender-specific assumptions — assess all patients equally
Reassure that reporting pain is not weakness; it enables better treatment
Some South Asian patients may express pain with dramatic emotional language — take this seriously and assess systematically
Pain Assessment Checklist
ⓘThe WHO Analgesic Ladder (1986, updated) provides a stepwise approach to analgesia. The principle is to start at the appropriate step for the pain intensity, titrate upwards if inadequate, and use "by the clock" dosing rather than PRN alone for persistent pain.
△Recommended for persistent or predictable pain. Maintains steady analgesic plasma levels, prevents pain cycling, reduces total analgesic consumption.
Paracetamol 1g QDS — scheduled regardless of pain score
SR opioids (morphine SR, oxycontin) — BD scheduled
Regular NSAIDs with meals (if not contraindicated)
Appropriate for post-operative, oncology, and musculoskeletal pain
PRN (As Needed)
▽PRN-only analgesia is inadequate for persistent pain. Patients are forced to suffer until pain peaks before relief is available. PRN has a role as breakthrough dosing alongside scheduled medication.
PRN breakthrough = 1/6 of total 24-hour opioid dose
Acceptable for intermittent/unpredictable pain
Should supplement (not replace) scheduled analgesia
Reassess if >3 PRN doses needed in 24hrs — consider increasing background
Strong Opioid Selection
Opioid
Routes
Key Feature
Caution
Morphine
Oral, IV, SC, PR
First-line strong opioid; versatile; well studied
Active metabolite (M6G) accumulates in renal impairment → sedation/respiratory depression
Oxycodone
Oral, IV
Less histamine release than morphine; less itch/nausea
Active metabolite oxymorphone; reduce in hepatic impairment
Hydromorphone
Oral, IV, SC
More potent (7.5× oral morphine); option in renal impairment
Fewer active renal metabolites than morphine; still use caution
Fentanyl
IV continuous, Patch, Buccal, IN
No active renal metabolites; patch for stable chronic/cancer pain
Patch not for acute pain titration; chest wall rigidity with rapid IV bolus
Buprenorphine
Patch, SL, IV
Partial agonist; ceiling for respiratory depression; safe in renal impairment
Partial antagonist at high doses; naloxone less effective for reversal
⚠ALWAYS prescribe a laxative when commencing regular opioids. Opioid-induced constipation does NOT develop tolerance — it persists throughout treatment.
Side Effect
Management
Constipation
Stimulant laxative (senna/bisacodyl) ± osmotic laxative (lactulose, macrogol). Consider methylnaltrexone for refractory opioid-induced constipation. Do NOT use bulking agents alone.
Nausea/Vomiting
Metoclopramide 10mg TDS, ondansetron 4mg TDS, or haloperidol 0.5–1.5mg nocte. Usually resolves within 1–2 weeks. Consider antiemetic cover at opioid initiation.
Sedation / Confusion
Reduce opioid dose by 25%. Opioid rotation if persistent. Exclude other causes (infection, metabolic). Stimulants (methylphenidate) — specialist use only.
Urinary Retention
In-out catheter or IDC. Usually resolves with dose reduction or opioid rotation. More common in men with BPH.
Pruritus (Itch)
Antihistamines (chlorphenamine). Ondansetron (5-HT3 mechanism). LOW-dose naloxone infusion (0.25–1 mcg/kg/hr) for neuraxial opioid pruritus — does NOT reverse analgesia at this dose. Do NOT give standard naloxone doses for itch.
Sedation score: 3 (difficult to rouse) or 4 (unrousable)
RR <8/min or shallow/irregular breathing
SpO2 falling despite supplemental oxygen
Pinpoint miosis (bilateral)
Cyanosis, apnoea
Naloxone Administration
⚡Titrate naloxone carefully — over-reversal causes acute pain, catecholamine surge, pulmonary oedema, arrhythmias. The goal is to restore adequate ventilation, not full reversal.
Dilute: Naloxone 400mcg in 10mL saline = 40mcg/mL
Give: 40–80mcg (1–2 mL) IV every 2–3 minutes
Titrate until RR >10/min and patient rousable
Max initial: 400mcg if not responding — consider infusion
Duration: Naloxone half-life shorter than most opioids — monitor >2–4hrs; repeat doses may be needed
IM route if no IV access: 400mcg IM
PCA — Patient-Controlled Analgesia Nursing
PCA Setup Parameters
Parameter
Typical Setting (IV Morphine)
Demand dose
1–2 mg morphine per bolus
Lockout interval
5–10 minutes
Background infusion
Generally avoided in opioid-naive patients (increases risk of respiratory depression without improving analgesia). Consider 0–1 mg/hr only in opioid-tolerant patients.
1-hour maximum
10–15 mg/hr (adjust per protocol)
4-hour maximum
Per institutional protocol
PCA Monitoring Protocol
Sedation score and RR: every 1–2 hours (first 12hrs), then every 4 hrs
SpO2: continuous monitoring (or at minimum with each sedation check)
ETCO2 capnography: if available and high-risk patient (OSA, obesity)
Pain score at rest and movement: every 4 hours
Nausea/vomiting assessment
Bowel chart — laxative prescribed?
PCA attempt/success ratio: >3:1 suggests inadequate demand dose or lockout too long
Only the patient should press the button — educate family members
⚠PCA by proxy: If a family member or nurse presses the button when the patient is sleeping — this bypasses the safety mechanism and can cause respiratory depression. Strict education essential.
Somnolent — STOP opioid, consider naloxone, call team
Opioid Dose Conversion Calculator
⚠For clinical decision support only. Always verify with your clinical pharmacist and senior clinician. Conversion factors are approximate — individual variation exists. When rotating opioids, reduce calculated equivalent dose by 25–30% due to incomplete cross-tolerance.
Oral Morphine Equivalent (OME) Conversion Factors
Opioid & Route
To get Oral Morphine Equivalent
Notes
Oral Morphine
× 1 (reference)
Reference standard
IV / SC Morphine
× 3 (oral ÷ 0.33)
Oral:parenteral ratio 3:1
Oral Oxycodone
× 1.5
Oxycodone more potent than oral morphine
Oral Hydromorphone
× 7.5
Highly potent; careful titration
Fentanyl Patch (mcg/hr)
× 2.4 per mcg/hr = OME mg/24hr
e.g. 25 mcg/hr patch ≈ 60 mg oral morphine/24hr
Oral Tramadol
÷ 10 (100mg tramadol ≈ 10mg oral morphine)
Weak opioid; ceiling effect
Oral Codeine
÷ 10 (100mg codeine ≈ 10mg oral morphine)
Prodrug; variable metabolism
Multimodal Analgesia — Principle
ⓘMultimodal analgesia combines drugs and techniques with different mechanisms of action to achieve better pain control while reducing the dose (and side effects) of each individual agent — especially opioids.
▲
Better Analgesia
Synergistic effect on different pain pathways
▼
Lower Opioid Dose
Opioid-sparing reduces side effects
★
Faster Recovery
Early mobilisation, shorter hospital stay
●Standard multimodal regimen: Paracetamol 1g QDS (scheduled) + NSAID (if not contraindicated) + opioid PRN breakthrough + adjuvant (e.g. pregabalin for neuropathic component) + regional technique if appropriate.
Epidural Analgesia — Nursing Care
⚠Epidural analgesia provides excellent pain control but requires close nursing monitoring. Complications can be serious and subtle.
Indications & Context
Thoracic epidural: post-thoracotomy, major abdominal surgery
Contains: local anaesthetic (bupivacaine/ropivacaine) ± opioid (fentanyl/morphine)
Nursing Monitoring
Parameter
Frequency
Action if Abnormal
Sensory level (ice/cold test)
2–4 hourly
High block (>T4): call anaesthesia immediately
Motor block — Bromage scale
4 hourly
Bromage >1: reduce/stop infusion, assess motor return
Blood pressure
1 hourly (first 4hrs), then 2–4 hourly
Systolic <90: IV fluid bolus, call team
Epidural site inspection
Each shift
Leakage, redness, swelling: call anaesthesia
Headache (post-dural puncture)
Each assessment
Postural headache: blood patch — call anaesthesia
Urinary retention
Ongoing
IDC usually in situ during epidural
Sedation & RR
2 hourly
Epidural opioid → respiratory depression possible
⚠Epidural haematoma / abscess: New severe back pain + motor weakness + sensory loss = spinal emergency. Stop epidural, urgent MRI, neurosurgical consult within 6–12 hours.
Peripheral Nerve Blocks
Block
Indication
Duration
Femoral / Adductor Canal
Total knee replacement (TKR), femur fracture
12–24hr (single shot) or infusion
Brachial Plexus
Shoulder, upper limb surgery (interscalene, axillary, infraclavicular)
12–24hr
TAP Block (Transversus Abdominis Plane)
Abdominal surgery, C-section, laparotomy
12–18hr
Popliteal / Sciatic
Ankle, foot surgery
12–24hr
Serratus Anterior
Thoracic / rib pain, VATS
12–18hr
PECS I & II
Breast surgery, mastectomy
12–24hr
Erector Spinae Plane
Thoracic pain, mastectomy, rib fractures
12–24hr or infusion
Nursing Monitoring — Nerve Blocks
Neurovascular observations: circulation, sensation, movement distal to block
Report weakness or numbness beyond expected block distribution
Fall precautions: femoral block → quadriceps weakness → falls risk
Continuous catheter: check insertion site, rate, volume, signs of infection
Local anaesthetic systemic toxicity (LAST): metallic taste, circumoral tingling, tinnitus, confusion, seizures, arrhythmia — have lipid emulsion 20% available
Ketamine — Low-Dose Analgesic Use
●Ketamine is an NMDA receptor antagonist. At sub-anaesthetic doses, it provides opioid-sparing analgesia and prevents opioid-induced hyperalgesia. It is particularly useful in opioid-tolerant patients.
Dosing for Acute Pain
IV infusion: 0.1–0.3 mg/kg/hr — standard sub-anaesthetic range
Burns pain: ketamine preferred for dressing change procedural analgesia
Duration of infusion: typically 24–72 hours peri-operatively
Side Effects & Monitoring
Dysphoria / hallucinations — co-administer midazolam 1–2mg if significant
Hypersalivation — glycopyrrolate if needed
Nystagmus — expected, not concerning at low dose
Increased ICP — avoid in head injury (traditional teaching; controversial)
Increases HR and BP — caution in hypertensive crises, ischaemic heart disease
Monitor level of consciousness, RR, BP, HR every 1–2 hours during infusion
⚠Ketamine at sub-anaesthetic doses does NOT typically require airway management. However, have resuscitation equipment available per institutional policy.
Post-Operative Pain — ERAS
△Enhanced Recovery After Surgery (ERAS) protocols mandate multimodal analgesia, early mobilisation, and opioid minimisation to reduce post-op complications.
Post-operative: scheduled paracetamol + NSAID + opioid PRN breakthrough only
Early oral intake — prevents need for IV analgesia prolonged
Early mobilisation — reduces DVT, pneumonia, ileus, deconditioning
Target NRS ≤3 at rest, ≤5 on movement for adequate functional recovery
ⓘAdequate post-operative analgesia is not optional — undertreated post-op pain directly increases complication rates and length of stay.
Sickle Cell Crisis Pain
⚠Sickle cell disease is prevalent in GCC populations — Gulf Arab nationals, African expatriates (particularly from Sudan, Nigeria, Chad). Painful vaso-occlusive crises (VOC) require prompt, adequate opioid analgesia. Under-treatment is the most common failure.
Acute Painful Crisis Management
IV morphine titration: 0.1 mg/kg IV bolus Q20 min until pain controlled (NRS ≤6); then transition to PCA or regular dosing
Do NOT delay analgesia — goal: meaningful pain reduction within 30–60 minutes
IV fluids: 1–1.5× maintenance (avoid over-hydration) — promotes haemodilution
Oxygen: only if SpO2 <95% — do NOT give routine supplemental O2
Warmth, rest, reassurance — non-pharmacological
Identify and treat triggers: infection, dehydration, cold, stress, exertion
⚠Patients with sickle cell disease who are opioid-tolerant may require higher doses than expected. Do not withhold based on perceived "drug-seeking" — chronic pain patients have legitimate high needs. Treat the pain.
Burns Pain
●Burns pain is complex: background (constant), procedural (during dressing changes), and breakthrough pain — each requiring different management strategies.
Type
Management
Background
Regular oral/IV morphine or oxycodone (by the clock); PCA for self-management
Procedural
Ketamine 0.5–1 mg/kg IV bolus ± midazolam 1–2mg IV; Entonox (N2O/O2) where available; intranasal fentanyl; plan 30–60 min before dressing change
Breakthrough
Oral transmucosal fentanyl citrate or IV morphine PRN; reassess and increase background if >3 breakthrough doses/day
Neuropathic
Pregabalin 75mg BD or gabapentin — common in healing burns and skin grafts
Psychological
Anxiety and PTSD are common — consider psychology referral; non-pharmacological (distraction, VR where available)
Colic Pain — Renal / Biliary / Ureteric
Renal / Ureteric Colic
Diclofenac 75mg IM/IV or 50mg PR — first-line (if renal function OK and not dehydrated)
Ketorolac 30mg IV — alternative parenteral NSAID
Hyoscine butylbromide (Buscopan) 20mg IV — reduces smooth muscle spasm
IV morphine: if NSAID contraindicated or inadequate
IV fluids: maintain hydration; monitor UO
Monitor renal function — obstruction can cause AKI
Biliary Colic
NSAIDs: diclofenac equally effective as opioids
Hyoscine butylbromide 20mg IV for spasm
Morphine: historically avoided in biliary colic (Sphincter of Oddi spasm) — evidence weak; use if required
Pethidine: historically used; now avoided (norpethidine toxicity)
Antiemetics for associated nausea
Cancer Breakthrough Pain
ⓘBreakthrough pain is a transient flare of severe pain over a background of controlled chronic pain. Cancer breakthrough pain often requires rapid-onset, short-duration opioids.
Rapid-Onset Opioid Options
Oral transmucosal fentanyl citrate (OTFC / Actiq lozenge): absorbed buccally; onset 15 min. Dose titrated independently of background opioid. Start with lowest dose (100–200 mcg).
Buccal fentanyl (Effentora / Fentora tablet): faster onset than oral morphine; onset 10–15 min
Sublingual fentanyl (Abstral): similar rapid onset
Intranasal fentanyl: useful when oral route unavailable
Oral morphine IR: standard breakthrough — 1/6 of total 24-hr opioid dose; onset 30–45 min — less ideal for very rapid episodes
⚠Rapid-onset fentanyl products are NOT interchangeable with standard fentanyl doses — each product has its own titration schedule. NEVER convert doses between products without specialist guidance.
Acute Neuropathic Pain
▽Neuropathic pain responds poorly to opioids alone. Adjuvant analgesics targeting neural pathways are essential.
Characteristics
Burning, shooting, stabbing, electric shock quality
Allodynia (pain from non-painful stimulus), hyperalgesia
Dermatomal distribution (nerve root), stocking-glove (peripheral neuropathy)
⚠GCC healthcare has historically been conservative with opioid prescribing — even for cancer pain. Stigma around opioids exists at both physician and societal levels. This is improving, but under-treatment of pain remains a clinical reality.
Historical Barriers
Fear of addiction (often misapplied to medically appropriate use)
Physician concerns about regulatory scrutiny
Limited palliative care training historically
Family / patient refusal of "strong drugs" — fear of dependency
Cultural equation of suffering with virtue in some contexts
Current Progress
WHO has identified GCC countries as improving access to opioid analgesia
DHA (Dubai) and HAAD/DoH (Abu Dhabi) have issued pain management guidelines
HMC (Qatar) has established palliative and acute pain services
KFSH&RC (Saudi Arabia) has advanced pain management protocols
Cleveland Clinic Abu Dhabi — comprehensive acute pain service
Untreated acute pain → central sensitisation → chronic pain syndrome
Aggressive early analgesia reduces incidence of chronic post-surgical pain
Psychological impact
Uncontrolled pain → anxiety, depression, PTSD
Treat pain early; psychological support if needed
Nurse-Initiated Analgesia in GCC
ⓘNurse-initiated analgesia (NIA) protocols allow nurses to administer pre-approved analgesics without individual prescriptions, improving response time and patient outcomes. Adoption is growing in GCC.
Current Landscape
Standing orders for paracetamol/NSAIDs: Increasingly common in GCC private/JCI-accredited hospitals; nurses can administer first-line non-opioid analgesia per protocol
Opioid PRN protocols with nurse titration: Still rare in GCC public sector; more established in KFSH, HMC, Cleveland Clinic AD, Aga Khan
PCA: Standard in most major GCC hospitals with trained nursing staff
Epidural infusion management: Nurse-managed per protocol — established in tertiary centres
Advocacy for NIA
Document pain scores and delays in treatment — data builds case for NIA protocols
Complete pain management continuing education
Engage nurse managers and medical directors with evidence of outcome improvement
JCI and CBAHI accreditation standards support proactive pain management — cite these standards
Ramadan & Analgesia
▶Islamic ruling: Taking medication during Ramadan is permitted when medically necessary. Patients should be clearly informed: illness requiring treatment is a valid reason to use medication. Most Islamic scholars agree that injectable medications do not break the fast.
Practical Guidance
Route
Fasting Status
Recommendation
IV Paracetamol
Acceptable while fasting
Use IV form when patient fasting and analgesia required
IV / SC Morphine
Acceptable — injection does not break fast per majority ruling
Use IV/SC opioids without delay if clinically indicated
Oral Tablets
Breaks fast — patient may decline
Explain medical necessity; offer IV alternative; document discussion
PR (Suppository)
Breaks fast per some scholars
Discuss with patient; respect preference; offer IV alternative
Fentanyl Patch
Does NOT break fast — transdermal
Acceptable during Ramadan fasting
Epidural
Does NOT break fast
Acceptable — not ingested orally
●Patients may delay or refuse oral analgesia during Ramadan. Proactively discuss and offer IV/transdermal alternatives. Do not allow religious observance to result in undertreated pain — the religious ruling explicitly permits medication for illness.