Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 5: Pain: The Fifth Vital Sign Key Points Print Chapter 5 discusses the assessment and management of acute and chronic pain. Pain is a universal, complex, and subjective experience. Pain is the most common reason to seek medical care and take medication and a major cause of economic problems and disability. About 9 in 10 Americans regularly suffer pain. The nurses primary role and legal and ethical responsibility in pain management is to advocate for the patient by believing reports of pain. The American Pain Foundation has developed a Pain Care Bill of Rights. Multidisciplinary pain teams, consisting of one or more nurses, pharmacists, case managers, and physicians, consult with staff and prescribers on how best to control the patients pain. How is pain defined? The experience of pain is individual. It is whatever the person experiencing it says it is. The two major types of pain are acute and chronic. o Acute pain results from acute injury, disease, or surgery. Acute pain serves as a warning signal and activates the sympathetic nervous system. o Chronic pain is divided into two subtypes of chronic cancer pain and chronic noncancer pain. Chronic pain or persistent pain is defined as pain that persists or recurs for indefinite periods usually for more than 3 months. The onset of chronic pain is gradual and changes over time. Pain is also categorized as either nociceptive, meaning normal processing, or neuropathic, meaning abnormal pain processing. o Nociceptive pain is visceral, arising from organs, or somatic, arising from the skin and musculoskeletal structures. o Neuropathic pain results from some type of nerve injury. Lets briefly review the transmission of pain. Painful stimuli often originate in the periphery of the body. To be perceived, the stimuli must be transmitted from the periphery to the spinal cord and then to the central areas of the brain. The gate control theory involves a gating mechanism in the spinal cord. When the gate is opened, pain impulses ascend to the brain; when closed, the impulses do not get through and pain is not perceived. Perceptions of pain and pain management vary among professionals and patients. The attitudes of health care professionals influence the way they perceive and interact with patients in pain. Factors such as age, gender, sociocultural background, and genetics influence the patients ability to process and react to pain. Another factor is the patients prior experience with pain. The incidence of pain in older adults is high, as is risk for undertreatment.
Copyright 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

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Now we will review the definitions of terms associated with pain medication use or misuse. Addiction is a disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. o Addiction is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and craving. o Addiction occurs over time, with multiple experiences of drug use. Pseudoaddiction is an iatrogenic syndrome created by the undertreatment of pain. o Pseudoaddiction is characterized by patient behaviors such as anger and escalating demands for more or different medications resulting in suspicion and avoidance by staff. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a decrease in one or more of the drugs effects over time. Physical dependence results in a withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, and decreasing blood level of the drug. Withdrawal or abstinence syndrome results when a patient who is physically dependent on opioids abruptly ceases using them. o Abstinence syndrome may also occur if a patient on opioids receives a reversal agent, such as naloxone. Nurses are responsible for thorough pain assessment. The American Pain Society refers to pain as the fifth vital sign. Initial and ongoing pain assessments are required. Ask the patient about the pain experience, including precipitating, aggravating, and relieving factors, the nature of adjustments in life or family responsibilities, localization, character and quality, duration, and beliefs. Though physiologic changes occur in response to acute noxious stimuli, these are usually not reliable indicators of pain. Pain may be described as localized, projected, radiating, and referred pain. Pain intensity scales assess and measure pain and determine the effectiveness of pain relief interventions in the clinical or home setting. Remember that nonverbal, intubated, and cognitively impaired patients do feel pain that needs to be managed. Lets move on to review interventions for pain. Three groups of drugs used to manage pain are non-opioids, opioids, and adjuvants. The World Health Organization recommends guidelines to help prescribers select the most appropriate medications based on the patients level of pain. Never use placebos for any patient as their use in nonresearch-based practice is unethical. Equianalgesic charts are useful when changing from one opioid to another, using 10 mg morphine as the standard dose against which other opioids are measured. Nurses caring for patients at the end of life should generally continue the same opioid regimen before the last weeks of life, though some circumstances, such as cancer pain control, may require more or different opioids in the last weeks of life.

Copyright 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

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Epidural analgesia refers to the instillation of an opioid analgesic alone or in combination with a local anesthetic, such as bupivacaine, into the epidural space, usually for the management of acute pain. o Multimodal (balanced) analgesia for epidural pain management combines opioids, non-opioids, and/or local anesthetics to relieve acute pain. Intrathecal analgesia involves administration of a pain-blocking agent into the space between the arachnoid mater and pia mater of the spinal cord for long-term management of intractable pain. Adjuvant analgesics may provide additional pain relief and help control other discomforts, such as anxiety, depression, nausea, and insomnia. Nonpharmacologic interventions may be used alone, for mild to moderate pain, or in combination with drug therapy for more severe pain. Nonpharmacologic therapies are classified as either physical measures or cognitivebehavioral measures. Cutaneous stimulation strategies to relieve pain have been used for years, such as application of heat, cold, and pressure, therapeutic touch, massage, and vibration. Physical and occupational therapy is used to increase function, decrease pain, compensate for decreased function, and prevent further deterioration. Transcutaneous electrical nerve stimulation involves the use of a battery-operated device capable of delivering small electrical currents to the skin and underlying tissues. Cognitive-behavioral measures, such as distraction, imagery, relaxation, hypnosis, music therapy, aromatherapy, prayer and meditation, and other coping skills to relieve pain have long been used, mainly as adjuncts to drug therapy. o The effectiveness of these measures reflects the gate control theory. Nerve blocks and surgical techniques are less common, invasive techniques performed by health care specialists to treat debilitating or intractable pain; rhizotomy and cordotomy are examples of surgeries. When the patient is ready to return home, the following steps should be taken: The health care team determines whether modifications are necessary for maintaining a reasonably pain-free regimen after discharge. Teach the patient and family about analgesic regimens, including technical skills needed, purpose and action of drugs, side effects, and dosage intervals. Explain how to prevent or treat the constipation commonly associated with taking opioid analgesics and other pain medications. Explain that the analgesic regimen should ideally not interfere with the patients sleep, rest, appetite, level of physical mobility, or driving ability. Coordinate the patients plan of care as he or she transfers between health care agencies, communicating the plan clearly. Refer patients whose pain is difficult to manage pain specialists and/or pain centers. REVIEW Choose the statement which is true concerning pain management: A. Pain is the most common reason to seek medical care and take medication. B. Pain must be objectively verified to be managed effectively. C. Chronic pain is defined as pain persisting more than a year.

Copyright 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Key Points Print D. The incidence of pain in the elderly tends to be low and easily treated.

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Copyright 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.