Pain Management

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Chapter 43

• Pain Management

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Importance

• Pain management is a primary nursing
  responsibility
• Nurse have a legal and ethical duty to
  control/relieve pain
• Pain relief is a basic human right
• Patients need to know we CAN and WILL relieve
  their pain

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Why?

• Effective pain management
• Improves quality of life
• Reduces disability
• Promotes early mobility and return to work
• Results in less hospital / office visits
• Reduces length of stay, complications
• Reduces health care cost
• Improves patient satisfaction

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Nature of Pain

• Physical
• Emotional
• Cognitive
• Subjective

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Physiology of Pain

• Transduction
• Thermal,chemical,mechanical stimulation
• ? electrical impulse in nerve fiber
• Transmission
• A fibers sharp, localized, distinct sensation
• C fibers generalized, persistent sensation
• E.g. Burn finger spot pain ? ache
• Peripheral ? spinal ? brain

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Physiology of Pain

• Perception
• Brain interprets impulse, perceives as pain
• Experience, memory, context, knowledge
• Ascribes meaning to sensation
• Modulation
• Body response
• Endogenous opiods, serotonin, norepinephrine,
  GABA
• ? transmission of impulse, analgesic effect
• These deplete over time with continued pain

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Gate-Control Theory of Pain

• Gating mechanisms along the CNS
• Can block transmission of impulses
• Pain relief measures to close the gate
• Light touch effleurage
• Pain threshold
• Level at which you feel pain
• Genetic, learned,
• Runners high, endogenous opiods
• Individual not transferrable!

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Physiological Response to Pain

• Mild moderate pain 1-6 superficial
• ? autonomic response sympathetic
• fight or flight, general adaptation
• ?HR, RR, B/P, BG, diaphoresis, peripheral
  vasoconstriction
• Severe or deep 7-10, visceral pain
• ? parasympathetic response
• ? HR, B/P, muscle tension, immobility, irreg resp
• may cause harm
• Physiologic response VS is short-term
• VS are not reliable pain indicators over time

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Behavioral responsesto Pain

• Dependent on context, meaning, culture, pain
  tolerance
• It is supposed to hurt
• Men dont cry
• I dont want to be a complainer, bother
• Nonverbal indicators
• Body movements restless or still, holding,
  guarding
• Facial expression grimace, frown, clenched
  teeth, posture,
• Lack of expression of pain does not mean it isnt
  there!

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Types of Pain

• Acute pain
• Protective, identifiable cause, short duration,
  limited tissue damage, ? emotional response
• Causes harm by ? mobility, energy
• Goal is to control pain so patient can
  participate in recovery
• ? Pain ? ?Mobility ? decreased complications,
  decreased length of stay

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Types of Pain

• Chronic pain
• Serves no purpose not protective
• Lasts longer than anticipated
• May or may not have an identifiable cause
• Impacts every part of patients life
• Depression, Suicide
• Disability, isolation, energy drain, ADLs
• Pseudoaddiction seeking pain relief
• not drug-seeking

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Types of Pain

• Cancer pain
• May be acute or chronic, constant or episodic,
  mild to severe
• Up to 90 of Ca pts have pain
• Pain by inferred pathology
• Known cause characteristic pain neuropathic
• Idiopathic pain
• No known cause BUT still pain
• Excessive pain for a condition

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Knowledge, Attitudes, and Beliefs

• Subjective nature of pain
• Pain is what the patient says it is, not what the
  nurse thinks it should be
• Same procedure, different pain
• Expectations, context, culture affect perception
  and expression of pain

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Knowledge, Attitudes, and Beliefs

• Nurses Response to Pain
• Bias
• I go to work with 5/10 pain every day
• Its only a minor surgery
• I had three kids and didnt scream
• Fallacies
• Infants dont feel pain like we do
• Regular pain med use causes addiction
• Older people all are in pain

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Factors Influencing Pain

• Physiological
• Age interpretation/communication
• Fatigue
• increases pain,
• sleep not sign pain is relieved
• Genes
• Pain threshold
• Neurological function
• Interpretation, communication, reflex

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Factors Influencing Pain

• Social
• Attention/ distraction
• Previous experience
• May increase or decrease tolerance
• Family and social support
• Spiritual
• Meaning of pain, suffering
• Support system

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Factors Influencing Pain

• Psychological
• Anxiety
• Coping style
• Control PCA
• Cultural
• Meaning of pain
• Expression of pain
• Role in Family
• Ethnicity

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Assessment of Pain

• Clients expression of pain
• Description is most valid indicator
• Characteristics of pain
• Onset and duration
• Location
• Intensity
• Quality
• Pattern

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Assessment of Pain

• Characteristics of pain (cont'd)
• Relief measures
• Contributing symptoms
• Behavioral effects on the client
• Influences on ADLs
• Client expectations
• What pain level would allow you to function well?
  
• walk the hall, do ADLs, resume job

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Assessment

• Can we do a full assessment of pain when the
  client is in severe pain?
• No!
• Alleviate severe 7-10 pain before talking it to
  death
• Pain rated gt7 needs immediate attention

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Nursing Diagnoses

• Anxiety
• Ineffective coping
• Fatigue
• Acute pain
• Chronic pain
• Ineffective role performance
• Disturbed sleep pattern

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Planning

• Goals and outcomes
• Client is using pain relief measures safely
• Pain level reported at lt/___ and congruent
  nonverbal behaviors seen
• Demonstrate understanding of need to premedicate
  before activity
• Splint abdomen with cough
• Setting priorities
• What is important for the client? What does he
  need to do?
• Control pain enough to eat, sleep? Be mobile to
  prevent complications? Work? PT? Maintain
  dignity, relationships while dying?
• Maslow Pain relief is basic need

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Implementation Health Promotion

• Client education
• Expectations, when to seek treatment
• Preparation before pain
• Holistic care
• Whole self physical, emotional, spiritual
• Education, rest, exercise, nutrition,
  relationships

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Nonpharmacological Pain Relief

• Relaxation and guided imagery
• Distraction
• Biofeedback
• Cutaneous stimulationmassage, application of
  hot/cold, TENS
• Herbals
• Reducing painful stimuli and perception

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Controlling Painful Stimuli

• Managing the clients environmentbed, linens,
  temperature
• Positioning
• Changing wet clothes and dressings
• Monitoring equipment, bandages, hot and cold
  applications
• Preventing urinary retention and constipation

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Implementation Pain Management

• Pharmacological pain relief
• Administer analgesics as ordered/ reassess pain
  in 30 minutes and hourly
• Analgesics NSAIDs and nonopioids, opioids,
  adjuvants
• Patient-controlled analgesia (PCA)
• Local analgesic infusion pump
• Topical analgesics and anesthetics
• Local and regional anesthetics

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ImplementationPain Management

• Surgical interventions
• Procedural pain management
• Chronic and cancer pain management

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Implementation Pain Management

• Barriers to effective pain management pts,
  nurses, doctors, system
• Fear of addiction - 1 barrier
• Terms
• Dependence physical adaptation resulting in
  withdrawal symptoms
• tolerance physical adaptation resulting in
  diminished drug effect over time
• Addiction impaired control over use, use despite
  harm
• pseudoaddiction drug seeking behavior to
  relieve undertreated pain

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Implementation Pain Management

• Nursing implications for pain management
• Accurate safe medication administration
• Assess effectiveness and side effects
• Patient education families too
• Use the appropriate drug when given a choice
• Treat pain before it gets severe

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Implementation Restorative Care

• Pain clinics
• Palliative care
• Hospices

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Evaluation

• Effectiveness
• Assess at peak of drug effect
• 30 minutes IV, 1 hour PO
• Add complementary therapies for partial effect
• Talk with M.D. about options if approach is
  consistently ineffective
• Side effects
• Document and communicate
• Most effective relief

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Evaluation

• Client expectations
• Validate experience
• Relieve the pain
• Show you care
• Did client achieve goal?
• Walk hall w/o pain?
• Pain lt 3/10 all day except with PT
• Able to return to work, enjoy visit, T,C,DB?
• Pain report congruent with nonverbal?