Pain Experience
involves physical emotional and cognitive components
Nociceptor
sensory peripheral pain nerve fiber
Substance P
causes vasodilation and edema
Serotonin
inhibits pain transmission
Prostaglandins
increase sensitivity to pain
Bradykinin
binds to receptos on peripheral nerves increasing pain stimuli
Neuromodulators
bodys natural supply of morphinelike substances
Perception
the point at which a person is aware of pain
Modulation
inhibition of the pain impulse of the nociceptive process
Pain threshold
the point at which a person feels pain
Pain Tolerance
level of pain a person is willing to put up with
Acute Pain
is protective, has a cause, is of short duration and has limited tissue damage and emotional response
Chronic Pain
last longer than anticipated, does not always have a cause, and leads to great personal suffering
Chronic Episodic Pain
pain the occurs sporadically over an extended duration of time.
Idiopathic Pain
pain is chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for for the extent of an organic pathological condition.
Nociceptive Pain
normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids or opioids
Somatic Pain
comes from bone joint muscle skin or connective tissue. it is usually aching or throbbing in quality and is well localized
Visceral Pain
arises from visceral organs such as the GI tract and pancreas
Neuropathic pain
abnormal processing of sensory input by the peripheral or CNS; treatment usually includes adjuvant analgesics
deafferentation pain
injury to either the peripheral or CNS.
Ex: phantom pain reflects injury to the peripheral nervous system; burning pain below the level of the spinal cord lesions reflects injury to CNS
sympatheically maintained pain
associated with dysregulation of the autonomic nervous system.
ex: pain associated with reflex sympathetic dystrophy or causalgia (complex regional pain syndrome, type one and type two)
polyneuropathies
patient feels pain along the distribution of many peripheral nerves.
ex: diabetic neuropathy, alcohol nutritional neuropathy, guillain barre syndrome
mononeuropathies
usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve.
ex: nerve roo compression, nerve entrapment, trigeminal neuralgia
Physiological factors that influence pain
1. age
2. fatigue
3. genes
4. neurological function
social factors that influence pain
1.attention
2. previous experience
3. family and social sport
4. spiritual factors
psychological factors that influence pain
1. anxiety
2.coping styles
cultural factors that can influence pain
1. meaning of the pain
2. ethnicity
ABCDE clinical approach to pain assessment and management
1. Ask about the pain regularly. Assess pain systematically
2. Believe the patient and family in their report of pain and what relieves it
3. choose pain-control options appropriate for the patient, family, and setting
4. deliver interventions in a timely
common characteristics of pain that the nurse would assess
1. onset and duration
2. location
3. intensity
4. qaulity
5. pain pattern
6. relief measures
7. contributing symptoms
8. effects of pain on the patient
9. behavioral effects
10. influence on activities of daily living
potential or actual nursing diagnosis related to patient in pain
Activity intolerance
Anxiety
Hopelessness
Powerlessness
Chronic low self-esteem
Insomnia
Fear
Impaired social interaction
Impaired physical mobility
Fatigue
Spiritual distress
Imbalanced nutrition: less than body requirements
Ineffective coping
patient outcomes appropriate for the patient experiencing pain
1. Patient reports that pain is a 3 or less on a scale of 0-10 does not interfere with ADLs or personal pain intensity goal attained
2. patient identifies factors that intensify pain and modifies behavior accordingly
3. patient uses pain-relief measures s
Nonpharmacologic intervention that lessen pain: Relaxation
in mental and physical freedom from tension or stress that provides individuals with a sense of self control
Nonpharmacologic intervention that lessen pain: Distraction
directs a patients attention to something other than pain and thus reduces the awareness of pain
Nonpharmacologic intervention that lessen pain: Music
diverts the person attention away from the pain and creates a relaxation response
Nonpharmacologic intervention that lessen pain: Cutaneous stimulation
(including massage, warm bath, ice bag, and TENS) reduces pain perception by the release of endorphins, which block the transmission of painful stimuli
Nonpharmacologic intervention that lessen pain: Herbals
are not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements
nonopioids (acetaminophen and nonsteroidal antiinflammatory drus NSAIDS)
include acetaminophen and nonsteroidal anti-inflammatories (NSAIDs). Acetaminophen has no anti-inflammatory or antiplatelet effects. NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDs work on peripheral nerve receptors to red
Nonpharmacologic intervention that lessen pain: Reducing pain perception
one simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback.
Three analgesics used for pain
1. nonopioids
2. opioids
3. adjuvants or coanalgesics
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. Sedation is an adverse effect of opioids that alwa
Define adjuvants or coanalgesics
are a variety of medications that enhance analgesics or have analgesics properties that were originally unknown
what is patient controlled analgesia (PCA) what is the goal of PCA
PCA allows patients to self administer opioids with minimal risk of overdose; the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing
explain the purpose of perineural local anesthetic infusion
the purpose is to manage pain from a variety of surgical procedures with a pump that is set as a demand or continuous mode and left in place for 48 hours
Local anesthesia
is intended for local infiltration of an anesthetic medication to induce loss of sensation to a body part
regional anesthesia
is the injection of a local anesthetic to block a group of sensory nerve fibers
epidural analgesia
permits control or reduction of severe pain and reduces the patients overall opioid requirement; can be short or long term.
Complications of opioid epidural analgesia are
nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus.
Goals for care of a patient with epidural infusions describe one action for each goal
1. prevent catheter displacement: secure the catheter (if not connected to an implanted reservoir) carefully to outside skin
2. Maintain catheter function: check the external dressing around catheter site for dampness or discharge (leak of cerebrospinal f
Transdermal fentanyl
is 100 times more potent than morphine in predetermined doses that provide analgesic for 48-72 hours; useful when unable to take oral medications
transmucosal fentanyl
is used to treat breakthrough pain in opioid-tolerant patients; the unit is place in the mouth and dissolved not chewed
breakthrough pain: incident pain
paint that is predictable and elicited by specific behaviors such as physical therapy or wound dressing changes
breakthrough pain: end of dose pain
Pain that occurs toward the end of the usual dosing interval of regularly scheduled analgesic
breakthrough pain: spontaneous pain
pain that is unpredictable and not associated with any activity or event
Barries to effective pain management
Patient fear
health care provider
health care system
Physical dependence
a state of adaptation that manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, or administration of an antagonist
drug tolerance
a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effects over time
addiction
a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its developmental and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, co
define placebo
is a medication or procedure that produces positive or negative effects in patients that are not related to the placebos specific physical or chemical properties.
Pain clinics
treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain-relief measures.
palliative care
provided with the goal is to live life fully with an incurable condition
hospice
is provided at the end of life; it emphasizes quality of life over quantity.
some principles to evaluate related to pain management
evaluate the patient for the effectiveness of the pain management after an appropriate period of time; entertain new approaches if no relief; evaluate the patients perception of pain
Pain is protective mechanism warning of tissue injury and is largely an
subjective experince
A substance that can cause analgesia when it attaches to opiate receptors in the brain is
endorphin
to adequately assess quality of a patients pain which question would be appropriate
tell me what your pain feels like
the use of patient distraction in pain control is based on the principle that
the reticular formation can send inhibitory signals to gating mechanisms
teaching a child about painful procedures is best achieved by
Relevant play directed toward procedure activities
When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judge
B
A patient has just undergone an appendectomy. When discussing with the patient several pain relief interventions, the most appropriate recommendation would be
A. Adjunctive therapy.
B. Nonopioids.
C. NSAIDs.
D. PCA pain management.
D
A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when
A. You compare assessed pain w/baseline pain.
B. Body language is incongruent with reports of pain relief.
C. Family members report that pain has subsided.
D.
A
Which of the following signs or symptoms in an opioid-na�ve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
Difficulty arousing the patient
Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.
A health care provider writes the following order for an opioidnaive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action:
Calls the health care provider, and questions the order
Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.
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?
Stimulant laxative
Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation.
A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question?
The time interval
Controlled- or extended-release opioid formulations such as OxyContin are available for administration every 8 to 12 hours ATC. Health care providers should not order these long-acting formulations prn.
The nurse notices that a 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 amount of daily acetaminophen
The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successf
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
Physical dependence.
After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient' s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action:
Assess patient's vital signs every 15 minutes for 2 hours
Reassess patients who receive naloxone every 15 minutes for 2 hours following drug administration because the duration of the opioid may be longer than the duration of the naloxone and respiratory
Which one 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?
Only the patient should push the button.
A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads as follows: "Vicodin 1 tab, per tube, q4 hours, p
Request to have the ordered changed to ATC for the first 48 hours.
The American Pain Society (2003) states that, if you anticipate pain for most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient w
A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to:
Assess the characteristics of the pain.
It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number.
The 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 assess
The patient's report of pain is the best method for assessing the pain.
When using ice massage for pain relief, which of the following are correct? (Select all that apply.)
Apply ice using firm pressure over skin.
Apply ice until numbness occurs and remove the ice for 5 to 10 minutes.
When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include?
TENS electrodes are applied near or directly on the site of pain.
TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a batte
While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends:
Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids.
The WHO analgesic ladder transitions from the use of nonopioids (NSAIDS) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recomme
A postoperative patient is currently asleep. Therefore the nurse knows that:
The sedative administered may have helped him sleep, but assessment of pain is still needed.
Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness and impaired coordination, judgment, and mental a