7–10 — Severe: Step 3, IV analgesia, urgent review, reassess 30 min
📏 Visual Analogue Scale (VAS)
100mm horizontal line. Patient marks point representing pain intensity. More sensitive than NRS for detecting small changes. Used in research settings.
No painWorst pain
0 cm10 cm
Score: <30mm mild, 30–60mm moderate, >60mm severe. Less suitable for elderly or cognitively impaired patients.
😊 Wong-Baker FACES Pain Scale
Suitable for: children (3+ years), cognitive impairment, language barriers, low literacy.
😊
0 No hurt
🙂
2 Hurts little
😐
4 Hurts more
😟
6 Hurts even more
😖
8 Hurts whole lot
😭
10 Hurts worst
Explain to patient: "Point to the face that shows how much pain you have right now." Do not ask about crying — facial expression only.
🧮 FLACC Scale — Interactive Calculator
Behavioural scale for infants, children (2 months–7 years), or any patient unable to self-report pain.
Face
Legs
Activity
Cry
Consolability
0
Relaxed / Comfortable
Total FLACC Score (0–10)
🏥 CPOT — Critical Care Pain Observation Tool
For intubated/sedated ICU patients unable to self-report. Score ≥3 indicates significant pain requiring treatment.
Facial Expression
Body Movements
Ventilator Compliance / Vocalisation
Muscle Tension
0
No pain indicated
Total CPOT Score (0–8)
🧓 PAINAD Scale — Dementia Patients
Pain Assessment in Advanced Dementia. Observational scale, total 0–10.
Cultural variation in pain expression is well-documented in the GCC region. Nurses must combine objective tools with culturally informed observation.
Arab culture (stoic expression): Some patients may underreport pain due to religious acceptance of suffering or cultural expectations of endurance. Use objective tools (FLACC, CPOT) and observe non-verbal cues.
Filipino & South Asian staff/patients: Patients may minimise pain to avoid being a "burden." Proactively ask about pain; do not wait for requests.
Gender considerations: Some female patients may not openly express pain to male clinicians. Ensure same-gender nurse assessment when appropriate.
Spiritual beliefs: Pain may be perceived as atonement — offer analgesia as a right, not a weakness. "Managing your pain helps healing and recovery."
Language barriers: Use translated NRS cards, pictorial scales (FACES), certified interpreters — not family members for pain history.
Trust in authority: Patients may agree with the nurse's suggestion ("Is your pain 3/10?") rather than self-report honestly — use open questioning: "Tell me about your pain."
WHO Analgesic Ladder
The WHO 3-step analgesic ladder provides a systematic approach: start at the appropriate step for pain severity, titrate upward if uncontrolled, and always combine with adjuvants and non-pharmacological measures.
Step 1 — Mild Pain (NRS 1–3): Non-Opioids
First-line agents
Paracetamol: 1g QDS (IV or oral — equivalent bioavailability). Regular dosing preferred over PRN. Maximum 4g/24h (reduce to 2–3g in hepatic impairment/elderly/low weight <50kg).
Ibuprofen: 400mg TDS with food. Avoid in renal impairment, elderly, GI history.
Diclofenac: 75mg BD (oral/IM). Avoid post-cardiac surgery. Add PPI (omeprazole 20mg OD) if prolonged use.
Naproxen: 500mg BD — longer half-life, useful for musculoskeletal pain.
Celecoxib: COX-2 selective; GI-safer but same renal/CV risks.
Codeine: 30–60mg QDS. Pro-drug converted by CYP2D6. Ultra-rapid metabolisers (common in Arab/North African populations) — risk of toxicity. Avoid in children under 12.
Dihydrocodeine: 30mg QDS — similar profile to codeine.
Combination approach: Continue paracetamol ± NSAID from Step 1. Add weak opioid. This reduces opioid dose requirement.
If Step 2 inadequate after 24–48 hours, escalate to Step 3. Do not rotate between Step 2 agents — escalate.
Step 3 — Severe Pain (NRS 7–10): Strong Opioids
Morphine (IV/SC/oral): Titrate to effect. IV: 2–5mg bolus, repeat q15min. Oral: 5–10mg q4h. SC infusion via syringe driver.
Oxycodone: More predictable oral bioavailability (~80%), useful in opioid-naive patients. 5–10mg q4–6h oral.
Hydromorphone: 5–7.5x more potent than morphine IV. Used in renal impairment (less active metabolite accumulation).
Fentanyl patch: For chronic stable pain only. NOT for opioid-naive or acute pain. 25–100mcg/h, 72h change.
Methadone: Complex pharmacology, specialist only.
Always prescribe alongside:
Laxatives (senna + docusate) — mandatory
Antiemetic PRN (first 3–5 days)
Rescue dose: 1/6th of 24h oral morphine dose
Adjuvant Analgesics (Any Step)
Adjuvants enhance analgesia by acting on different pain pathways. Used at any ladder step, especially for neuropathic, bone, or mixed pain.
Combining agents that act at different sites/mechanisms achieves additive or synergistic analgesia while reducing opioid requirements — and therefore opioid side effects.
Peripheral
NSAIDs, COX-2 inhibitors, local anaesthetics block peripheral sensitisation
Spinal
Epidural LA/opioids, intrathecal agents act at dorsal horn
Naloxone 400mcg IV/IM — dilute 400mcg in 10mL saline → give 1–2mL (40–80mcg) increments every 2–3 min
Repeat up to 3 doses maximum (1200mcg total)
If no IV access: IM, SC, or intranasal naloxone 800mcg–2mg
Onset IV: 2 min, IM: 5 min. Duration: 30–90 min — shorter than most opioids
Start naloxone infusion if reversal achieved: 2/3 of reversal dose per hour
Document time, dose, response — report as adverse incident
Review entire opioid prescription — reduce or omit subsequent doses
Naloxone duration < most opioids. Patient MUST be monitored for re-narcotisation for 4–6 hours. Never leave unobserved after reversal.
Patient-Controlled Analgesia (PCA)
🖲️ PCA Principles & Settings
Standard Morphine PCA Settings
Parameter
Typical Value
Bolus dose
1–2mg morphine
Lockout interval
5–10 minutes
Background infusion
None (opioid-naive) / 1mg/h (chronic users)
4-hour limit
20–30mg
Solution concentration
1mg/mL in NaCl 0.9%
Fentanyl PCA (if morphine intolerant)
Parameter
Value
Bolus dose
20–25mcg
Lockout interval
5 min
Concentration
10mcg/mL
Benefits of PCA over nurse-administered analgesia:
Patient controls timing — reduces peaks and troughs
Reduced nursing workload
Higher patient satisfaction
Lower total opioid consumption in many studies
Psychological benefit — sense of control
PCA Monitoring (Hourly):
NRS pain score (rest & movement)
RASS / sedation score
Respiratory rate (alert <10/min)
SpO2 (alert <94%)
Urine output
PCA attempts vs delivered doses
Contraindications: Unable to press button (unconscious, neurological deficit), lacks understanding, under 5 years old. Never allow family to press for patient.
Fentanyl Transdermal Patches
🩹 Fentanyl Patch Prescribing & Application
WARNING: Fentanyl patches are for CHRONIC, STABLE pain only — NOT for acute pain, opioid-naive patients, or breakthrough pain management.
Available Strengths
12mcg/h25mcg/h50mcg/h75mcg/h100mcg/h
Change every 72 hours (some patches 96h — check brand)
Onset: 12–24 hours to reach steady state
Offset: 12–24 hours after removal for levels to fall
Cover prescribed oral opioid for first 12–24h after application
Application rules: Dry, non-irritated, flat skin. No hair clipping with razor (use scissors). No moisturiser. Press for 30 seconds. Write date/time on patch. Dispose in sealed container.