Pain Management
Pain is purely subjective
No two people experience pain in the same way, and no two painful events create identical responses or feelings in a person
IASP defines pain as "an unpleasant, subjective sensory and emotional experience associated with actual o
Pain management should be patient centered, with nurses practicing patient advocacy, patient empowerment, compassion, and respect
Why Treat Pain?
Improves quality of life
Reduces physical discomfort
Promotes earlier mobilization and return to previous baseline functional activity levels
Results in fewer hospital and clinic visits
Decreases hospital lengths of stay, resulting in lower health care co
Nature of Pain
Involves physical, emotional, and cognitive components
Pain is subjective and individualized
Reduces quality of life
Not measurable objectively
pain is subjective
May lead to serious physical, psychological, social, and financial consequences
There are four physiological processes of normal pain:
1.Transduction
2.Transmission
3.Perception
4.Modulation
A patient who is experiencing pain cannot discriminate between these four factors
Transduction
converts energy produced by these stimuli into electrical energy.
it begins in the periphery when a pain-producing stimulus (e.g exposure to pressure, or a hot surface) sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating
transmission
Sending of impulse across a sensory pain nerve fiber (nociceptor)
Nerve impulses
Pain impulses
Physiology of Pain
Nerve impulses resulting from the painful stimulus travel along afferent (sensory) peripheral nerve fibers.
Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C fibers.
Perception
The point at which a person is aware of pain.
The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex, primarily the limbic system, determines how a person feels about it. There is no single pain center.
Modulation
inhibits pain impulse
a protective reflex response occurs with pain reception
pain is a protective mechanism
The A fibers
send sharp, localized, and distinct sensations that specify the source of the pain and detect its intensity.
Immediate sharp pain
The C fibers
relay impulses that are poorly localized, visceral, and persistent.
slower, after A-fibers
Gate-control theory of pain (Melzack and Wall)
Pain has emotional and cognitive components, in addition to a physical sensation.
Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses.
Pain impulses pass through when a gate is open and are blocked when a gate is closed.
Pain threshold
the point at which a person feels pain
Physiological Responses
As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the
autonomic nervous system (ANS)
Fight or flight
a set of physiological changes such as increases in heart rate, arterial blood pressure, blood glucose, initiated by the sympathetic nervous system to mobilize body systems in response to stress.
Continuous, severe, or deep pain typically involving the visceral organs activates the
parasympathetic nervous system
Acute/transient pain
protective, usually has an identifiable cause, is of short duration, and has limited tissue damage and emotional response
Clenching the teeth, facial grimacing, holding or guarding the painful part, and bent posture are common indications of acute pain.
Chronic/persistent noncancer pain
is not protective and thus serves no purpose, but it has a dramatic effect on a persons quality of life.
affects a patient's activity. (eating, sleeping, socialization, thinking, emotions, productivity)
low back pain, fibromyalgia, arthritis
Behavioral Responses
Patients who have a
low pain tolerance
(level of pain a person is willing to accept) are sometimes inaccurately perceived as complainers
[Teach patients the importance of reporting their pain sooner rather than later to facilitate better control and optim
Chronic episodic pain
Occurs sporadically over an extended duration
migraine
Cancer pain
Can be acute or chronic
referred pain
Idiopathic pain
Chronic pain without identifiable
physical or psychological cause
Factors Influencing Pain
Physiological
Age, fatigue, genes, neurological function
Fatigue increases the perception of pain and can cause problems with sleep and rest
Social
Attention, previous experiences, family and social support, spiritual
Spirituality includes active searchin
Box 44-2 common biases and misconceptions about pain
the following statements are false:
-patients who abuse substances overreact to discomforts
-patients with minor illnesses have less pain than those with severe physical alteration
-administering analgesics regularly lead to drug addiction
-the amount of
Critical Thinking
Knowledge of pain physiology and the many factors that influence pain help you manage a patient's pain.
Nursing Process and Pain
Pain management needs to be systematic.
Pain management needs to consider the patient's quality of life.
Clinical guidelines are available to manage pain:
American Pain Society
Sigma Theta Tau
National Guidelines Clearinghouse
Assessment
Through the patient's eyes
Ask the patient's pain level
Use ABCs of pain management
Pain is not a number
In selecting a tool to be used with a patient, be aware of the clinical usefulness, reliability, and validity of the tool in that specific patient pop
ABCDE pain assessment and management
A:
Ask
about pain regularly. Assess pain systematically.
B:
Believe
the patient and family in their report of pain and what relieves it.
C:
Choose
pain control options appropriate for the patient, family, and setting.
D:
Deliver
interventions in a timely,
assessment cont'd
Patient's expression of pain
Pain is individualistic
[severity is most subjective]
Characteristics of pain
Timing
Onset, Duration, Pattern
When did it begin? How long has it lasted? Does it occur at the same time each day? Is it intermittent, constant, or
pain by location:
Superficial or Cutaneous
pain resulting from stimulation of skin
charecteristics
pain is of short duration and localized. It usually is a sharp sensation
examples of causes
needle stick, small cut or laceration
pain by location:
Deep or Visceral
pain resulting from stimulation of internal organs
characteristics
pain is diffuse and radiates over several directions. Duration varies, but it usually lasts longer than superficial pain. Pain is sharp, dull, or unique to organ involved
Examples
crushing
pain by location:
referred
common in visceral pain because many organs themselves have no pain receptors (the entrance of sensory neurons from affected organ into same spinal cord segment as neurons from areas where individual feels pain causes perception of pain in unaffected area
pain by location:
Radiating
sensation of pain extending from initial site of injury to another body part
characteristics
pain feels as though it travels down or along body part. it is intermittent or constant
examples
low back pain from ruptured intervertebral disk accompanied by pa
Planning
Analyze information from multiple sources.
Apply critical thinking
Adhere to professional standards
Use a concept map
Goals and outcomes-set realistic expectations w/ patient
Setting priorities
Teamwork and collaboration
Maintaining wellness
Help patient understand
-patients are better prepared to handle any situation when they understand it
Health literacy
-affects the pain experience & understanding of pain management strategies
Patients actively participate in their own well-being whenever
Nonpharmacological pain-relief interventions
Nonpharmacological pain-relief interventions
Cognitive and behavioral approach
Relaxation and guided imagery
Distraction
Music
Cutaneous stimulation (gate control theory)
Cold and heat application
Transcutaneous electrical nerve stimulator (TENS)
Herbals
Relaxation
Is a mental physical freedom from tension or stress that provides individual a sense of self control
Decrease pulse, BP, anxiety, decreased oxygen consumptions
Meditation, yoga, Zen, guided imagery, and progression relaxation techniques
Guided Imagery
Is a relaxation technique
is the use of relaxation and mental visualization to improve mood and/or physical well-being.
Acute care: pharmacological pain therapies
Analgesics
Nonopioids
Opioids (narcotics)
Adjuvants/co-analgesics (antidepressants)
analgesics
-anything that helps w/ pain
Acetaminophen (Tylenol)
has no anti-inflammatory or antiplatelet effects.
Can be liver toxic (hepatotoxicity)
NSAIDs (ibuprofen)
NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief
Most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli
Long-term use of NSAIDS is associated with gastrointestinal (GI)bleeding and renal insufficiency.
Opioids (narcotics)
are prescribed for moderate to severe pain.
They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes.
Careful assessment and critical thinking is requir
sedation
is an adverse effect of opioids that always precedes
respiratory depression.
One way to maximize pain relief while potentially decreasing opioid use
is to administer analgesics around the clock (ATC) rather than on a prn basis.
good thing to give medicine around the clock low dosages rather than PRN
common opioid side effects
table 44-13
Nursing Principles for Administering Analgesics
box 44-14
patient characteristics associated with higher risk for opioid related adverse drug events
box 44-15
Patient-controlled analgesia (PCA)
Allows patient to self-administer with minimal risk of overdose
Maintains a constant plasma level of analgesic
family and friends should not operate PCA
Pros to PCA pump:
The patient gains control over pain
Pain relief does not depend on nurse availability
Patients also have access to medication when they need it
This decreases anxiety and leads to decreased medication use.
Small doses of medications are delivered at short
Pharmacological Pain Therapies
Topical analgesics
Creams, ointments, patches
Local anesthesia
Local infiltration of an anesthetic medication to induce loss of sensation to a body part
Regional anesthesia
Perineural local anesthetic infusion (block a group of sensory nerve fibers)
Epidu
Local anesthetics
cause side effects such as pruritus or burning of the skin or a localized rash
Application to vascular mucous membranes increases the chance of systemic effects such as a change in heart rate.
The use of local anesthetics in peripheral nerve and epidural
Nursing implications
You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia.
After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return.
Nursing implications
nursing care for patients with epidural infusions
table 44-6
Nursing implications for local and regional anesthesia
Provide emotional support
Protect patient from injury
Patient education
Invasive interventions for pain relief
implantable pumps or injections, deep brain stimulation, trigger point injections etc.
cancer pain =
breakthrough pain
non cancer pain =
increase patient function
WHO Analgesic Ladder
Step 1: mild to moderate pain
-Nonopioid analgesic
-NSAIDs and acetaminophen
Step 2: more severe pain
-Add opioid analgesic, oxycodone, hydrocodone
Step 3: severe pain
-Substitute powerful opioid�morphine, fentanyl
Physical dependence:
A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
Addiction:
A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
Drug tolerance:
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time
Placebos
jeopardizes trust between patient
(saline given instead of morphine)
Pain centers
treat patients on an inpatient or outpatient basis.
The goal of palliative care is
to learn how to live life fully with an incurable condition.
Hospices
are programs for end-of-life care.
The American Nurses Association (ANA) supports
aggressive treatment of pain and suffering, even if it hastens a patient's death.
Evaluation
Through the patient's eyes
Patients help decide the best times to attempt pain treatments
They are the best judge of whether a pain-relief intervention works
Patient outcomes
Evaluate for change in the severity and quality of the pain
Safety Guidelines
The patient
is the only person who should press the button to administer the pain medication when PCA is used.
Monitor the patient for signs and symptoms of oversedation and respiratory depression.
Monitor for potential side effects of opioid analgesics.
When using ice massage for pain relief, which of the following is correct?
Select all that apply.
Apply ice using firm pressure over skin.
Apply ice for 5 minutes or until numbness occurs.
Apply ice no more than 3 times a day.
Limit application of ice to
Apply ice using firm pressure over skin.
Apply ice for 5 minutes or until numbness occurs.
Use a slow, circular steady massage.
When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include?
TENS works by causing distraction.
TENS therapy does not require a health care provider's order.
TENS requires an electrical source for use
TENS electrodes are applied near or directly on the site of pain.
While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes:
Select all that apply.
Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids.
Stopping acetaminophen when the pain b
Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids.
The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.
Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
Oxygen saturation of 95%
Difficulty arousing the patient
Respiratory rate of 10 breath
Difficulty arousing the patient
A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following
Calls the health care provider and questions the order
Fentanyl patches are not indicated for acute pain. They are indicated for patients with chronic pain who are opioid tolerant.
A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessin
Patient's self-report
A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for t
Transcutaneous electrical nerve stimulation (TENS)
Provide back massage
Reposition the patient
A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question?
The drug
The time interval
The dose
The route
The time interval
Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine?
Select all that apply.
Only the patient should push the button.
Do
Only the patient should push the button.
The PCA system can set limits to prevent overdoses from occurring.
Do not push the button to go to sleep.
A patient is prescribed morphine patient-controlled analgesia (PCA). What is the correct order for administering PCA?1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval.2. Check label of medication 3 times: when rem
1, 2, 5, 4, 6, 3
The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most?
The patient's level o
The amount of daily acetaminophen
A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication?
Opioid antagonists
Antiemetics
Stool softeners
Muscle relaxants
Stool softeners
Constipation is a common opioid-related side effect, and patients do not become tolerant to it.
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes t
Opioid withdrawal.
A postoperative patient currently is asleep. Therefore the nurse knows that:
The sedative administered may have helped him sleep, but it is still necessary to assess pain.
The intravenous (IV) pain medication given in recovery is relieving his pain effect
The sedative administered may have helped him sleep, but it is still necessary to assess pain.
A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before h
Request to have the order changed to around the clock (ATC) for the first 48 hours.