Nursing 102 Fundamentals of Nursing Module D: Vital Signs-Pain Assessment Reading assignments: Potter & Perry, Chapter 43-

3- Pain Management Bring NUR 102 syllabus pgs. 55, 56, & 57.

What is pain? According to the International Association for the Study of Pain, pain is an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 2000-2010 1. Decade of Pain Control and Research declared by Congress. 2. Providing pain relief is a basic human right and is in the Pain Care Bill of Rights ( American Pain Foundation, 2001) 3. http://www.painfoundation.org/Publications/BORenglish.pdf 4. Amaerican Bar Association declared pain relief a basic legal right. Nurses are legally and ethically responsible for pain management. 5. Pain is whatever the experiencing person says it is, existing whenever he says it does, McCaffery, 1979. 6. http://www.addiction-free.com/cost-of-pain-conditions.html Nature of Pain, pg 1052 Subjective 1. Individualized 2. Involves physical, cognitive, and emotional components 3. Is exhausting 4. Can interfere with personal relationships and influence the meaning of life Processes of pain 1. Transduction (depolarization)- Pain is usually caused by thermal, chemical, or mechanical stimuli. The stimuli energy is converted to electrical energy. Transduction is the energy conversion. Begins in the periphery when a painproducing stimulus sends an impulse across a nociceptor (peripheral pain nerve fiber). This initiates an action potential.

2. Transmission of the pain impulse begins once the transmission is complete. Transmission is the process by which these stimuli proceed along primary afferent (sensory) nociceptive axons to the spinal cord and then on to higher centers. Gate-Control Theory of Pain, pg 1053 Wall and Malzack, 1965 1. Pain has obligatory emotional and cognitive components. 2. Pain impulses can be regulated or even blocked by gating mechanisms located along the CNS. 3. Pain impulses pass through when a gate is open and impulses are blocked when a gate is closed. 4. Closing the gate is from pain relief interventions. Nurses can gain a useful conceptual framework for pain management by understanding what can influence these gates. Pain threshold The point at which a person feels pain. 1. Stress, exercise, and other factors increase the release of endorphins. Physiological Responses pg 1054, Table 43-1 Low-moderate intensity & superficial= (fight-or-flight ) sympathetic Continuous, severe, or deep= parasympathetic nervous system is activated

Behavioral Responses Clenching the teeth Holding the painful part Bent posture Grimaces Cry Moan Restless

Terminology 1.Acute pain- has identifiable cause, short duration (< 6 months), usually has limited tissue damage and emotional response. 1. Usually resolves with/out treatment. 2. Usually treated aggressively but can turn into chronic pain. Considered protective. 2. Chronic pain- may not have an identifiable source, last longer than anticipated, and leads to personal suffering. Can/not be caused from cancer

Types of Pain, pg 1055 Chronic Episodic Pain Cancer Pain Pain by Inferred Pathological Process Idiopathic

Non-cancer pain Non-life threatening May lead to psychological depression and suicide Major cause of psychological and physical disability Symptoms- fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, anger Pseudo addiction doctor-shops Often labeled as drug seekers Discourage patient from using multiple health care providers, refer him to a pain expert Emphasize that the pain may not be cured but it can be managed

Cancer Pain 90% of cancer patients can have their pain managed with simple means Variety of ideologies

Pain by Inferred Pathology Process p. 1235 Nociceptive (Normal pain ) 1. Somatic-musculoskeletal 2. Visceral- internal organs Neuropathic- from abnormal pain receptors 1. Centrally generated 2. Peripherally generated Idiopathic pain Unidentifiable source Pain perceived as excessive for the extent of organic pathological condition

Factors influencing pain Social factors 1. 2. 3. attention previous experience family and social support

Psychological factors 1. Anxiety

2. Coping style Cultural factors 1. meaning of pain

2. Ethnicity Characteristics of Pain Onset 1. When did the pain begin? 1. 2. Time Duration

2. Does the pain come and go? 3. Does it hurt all the time? 4. Do you have both types of pain (acute and chronic)? Intensity (0-10) 1. Script: On a scale of 0-10, with 0 being no pain at all and 10 being the worst pain you can imagine 2. What is your pain now? 3. What has the average been Location 1. Where is the pain? 2. Elderly, cancer and AIDS patients average three separate sites of pain 3. Document all pain sites Classification of pain by location Superficial or cutaneous Deep or visceral Referred Radiating over the last 5 days (chronic pain) over the last 24 hours (acute)

Quality Adjective to describe the pain Burning Aching Tender Shooting Tingling Cramping

Radiating Pressure Numbness Throbbing

Nonverbal Indicators Write down some nonverbal indicators of pain.

Aggravating and Alleviating Factors What makes the pain better? What makes the pain worse?

How does the pain affect? Sleep Appetite Energy Activity Relationships Mood

Pain scales A. Visual analog p. 1243 B. Oucher p. 1244 C. Wong-Baker FACES p. 1244 D. FLACC Pain Rating Scale p. 61 Nursing 102 Syllabus

E. Use facilities pain scale

Principles of pain assessment in children QUESTT Question the child. Use a pain rating scale.

Evaluate behavioral and physiologic changes Secure parents involvement. Take the cause of pain into account. Take action and evaluate results. Infant Pain Scale Universal Pain Assessment Pain Behavioral Scale Assessing the Demented Patient

Recognizing pain behaviors facial grimacing guarding any areas restless impatient motion isolation increasing time in bed/alone negative vocalizations decreased appetite aggressive behavior

Pain scale for dementia Pain Assessment in the Elderly 1. Poor memory, depression and sensory impairment may make getting pain information from the patient difficult Use of standard tools 1. Assess Patient on Routine Rounds

2. At minimum, when you make rounds at the beginning of your shift Other assessments during the shift as the patients condition warrants; or, as ordered List nursing strategies to assist the patient cope with pain. Ask and assess about pain regularly, systematically

Believe the patients report and what helps Choose pain control appropriately Deliver interventions timely and logically Empower and enable patient and family to control their course

Nursing Diagnosis Acute pain Self-care deficit Chronic pain Plan/ Intervention

Special needs of the patient taken into consideration (i.e.. developmental level, aphasia, etc.) Personal, cultural, spiritual &/or ethnic beliefs considered

Give pain meds as ordered If no orders, call physician

Implementation Drug therapy Relaxation techniques Cutaneous stimulation (massage, heat, cold) In your next lecture, you will be learning more about comfort measures.

Evaluation Reassess pt. w/in 30min-1hr Review & modify plan of care for pts who have unrelieved pain Goal is to relieve pain or reduce to a level acceptable to patient Documentation of Pain Admission assessment On the clinical path Charting by exception sheet

Narrative notes Meds follow-up pathway in MIS Discharge assessment form

DOCUMENTATION IS REQUIRED NOT OPTIONAL JCAHO Standard: Patients have the right to appropriate assessment and management of pain.

Pain assessed on all patients Admission assessment Regular/routine assessment When the patient asks for med Follow-up within 2 hours Discharge pain assessment JCAHO Standard: Patient involved in all aspects of care Education Care Notes Documentation of patient education Existing patient education pathway

Documentation Nursing 102 syllabus, p55: Pain Management Flow Sheet NUR 102 syllabus pgs. 65-67

Scenerio: 1100- A 53 y/o/w/f presented to the ER with C/C of lower back pain. The pain started hurting this AM at 0500. She describes the pain as a sharp shooting pain that originates over the spinal column area and radiated down to the left leg. She noticed this pain upon arising for the day. She rates her pain a 4/5.

Walking makes her pain worse but the heating pad made it better. PTA she has Tylenol 500mg . Denies N/V. The doctor orders Demerol 25mg IM. 45 minutes after the shot, her pain is 1/5. Remember.

Always, Evaluate, Re-evaluate!! Review

1. Which organization declared pain relief a basic legal right? State Boards of Nursing American Bar Association American Nurses Association National League for Nursing 2. Pain is viewed as a: Separate disease Symptom of an illness Symptom of a condition Objective finding 3. This type of pain lasts longer than anticipated, may not have an identifiable cause, and leads to great personal suffering: Cancer pain Chronic pain Acute pain Idiopathic pain 4. One of the reasons many nurses avoid acknowledging a clients pain is: Inadequate pain management skills Insufficient time to respond to the client Fear that the intervention may cause addiction Inability to manage their increased client load

5. Cognitively this age-group is unable to recall explanations about pain or associate pain with experiences that can occur in various situations. Preschoolers Adolescents Young adults Elderly 6. The client requested medication for her abdominal incision pain, which she rates 5 on scale 0-10. One hour after administration of her pain medicine, she was able to walk in the hall for 10 minutes and rated her pain as a 7. This indicated that the dosage for pain was: Adequate Excessive Insufficient Unnecessary 7. Approx. 30 minutes after administering a complementary treatment such as heat therapy or back massage, the nurse should: Turn and reposition the client Document the pain assessment data Evaluate the effectiveness of the treatment Administer the prescribed medication 8. A preventive approach for acute pain relief means that analgesic medications are given: Before the pain is experienced With complimentary therapies Before the pain becomes severe When the pain tolerance level is exceeded 10. One of the reasons that PCAs are frequently used for postop. Pain management is to : Increase client satisfaction

Decrease the frequency of client complaints Control client use of narcotics and reduce the chance of addiction Encourage the use of pain medications before the client experiences severe pain