Types of Pain Scales

Visual Analogue Scale (VAS)

Numeric Rating Scale (NRS)
Simple descriptor scale
Wong-Baker Faces Pain (kids/cognitive impairment)
Rating Scale
MOPAT
Richmond Agitation Scale (RASS)
Pain Assessment in Advanced Dementia (PAINAD)
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Nerve Blocks
-injected into or around the nerve or network of nerves (plexus) that supplies sensation
to a specific part of the body. -may be used for short-term pain relief after surgical
procedures or for long-term management of chronic pain
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Special Nursing Considerations
Misconceptions about pain management
-no pain no gain

Managing pain in the elderly

-falls, metabolism, polypharmacy (start low and go slow)

Managing post-op pain

-come back 30 min after
-use scale before and after
-get ahead of the pain/ hard to come down from a 10

Managing pain in clients with addictions

-phisical dependence vs. psycological dependance
-taper the does to get them off

Use of placebos
-Although use of placebos may be appropriate in clinical trials, they are not suitable for
pain management

Teach patient/family
-Nonpharmacological ways to manage their pain

Document
-plan and response to pain

Rarely Missed

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Routes of Administration
Oral
Nasal
Transdermal
Rectal
Subcutaneous
IM
IV
Epidural
PCA (Button)
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Whats important for PCA use?
no family use
monitor q2h
respirations

Never Missed

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What is Pain?
Whatever the patient says it is, existing whenever the patient says it does
*The fifth vital sign
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Describe Pain and how it's classified
Unpleasant sensory /emotional experience associated with actual or potential tissue
damage.
-Can have destructive effects
-Can warn of potential injury
-A multidimensional experience
-Classified by:
Origin
Cause
Duration
Qulaity
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What are Origins of pain? 7 types
Where the pain is felt

Superficial/Cutaneous:
-burn or abrasion

Visceral:
-the stimulation of deep internal pain receptor
-most often in the abdominal cavity, cranium or thorax

somatic:
-originates in the ligaments, tendons, nerves, blood vessels, and bones
- deep somatic more diffuse than cutaneous pain and tends to last longer

Radiating:
-starts at the origin but extends to other locations
-sore throat pain in ears and head

Referred:
-distant from original site
-heart attach felt in left arm

Phantom:
-pain in an area that has been surgically removed

Psychogenic:
-believed to come from the mind
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What are The Two causes of Pain?
Nociceptive
-most common type
-described as aching
-Either visceral or somatic
(Organism, skin, muscle, bones, or connective tissue)

Neuropathic
-complex and often chronic
-arises from injury to one or more nerves
-poorly controlled diabetes, stroke, a tumor, alcoholism, amputation, viral infection
-Described as burning, numbness, itching, and 'pins and needles' prickling pain

(chart in powerpoint)
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3 Types of Pain Duration
Acute
-Short duration with rapid onset

Chronic
-3 to 6 months or longer and often interferes with daily activities

Intractable
-highly resistant to relief
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3 Types of Pain Quality
Quality
sharp or dull, aching, throbbing, stabbing, burning, ripping, searing, or tingling.

Periodicity
episodic, intermittent, or constant.

Intensity
-mild, distracting, moderate, severe, or intolerable.
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Physiology of Pain
Transduction

Transmission

Pain Perception
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Pain Modulation:Endogenous Analgesia System
-Bind to opioid receptor sites in central and peripheral nervous system at four receptor
sites: mu, kappa, delta, sigma
-These sites are involved in reception when patients take pain medicines. Each receptor
has a different affinity for various medications
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Pain Modulation: Gate Control Theory
-Pain is perceived by the interplay between fibers that produce pain and those that
inhibit pain
-Pain messages encounter "nerve gates" that open or close
In spinal cord
-C (small,slow)fibers-open to pain
-Delta(large, fast)fibers- close pain gate (promoted by massaging,acupuncture)
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What are Factors that Influence Pain?
Past experience with pain
Emotions
Developmental stage
Sociocultural factors
Communication skills
Cognitive impairments
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Assessing Pain: PQRST
Provocation
Quality
Radiating
Severity
Timing
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Assessing Pain: OLD CARTS
Onset
Location
Duration

Character
Aggravating Factors
Reliving Factors
Timing
Severity
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Assessing pain includes?
Obtaining a complete pain history
(e.g., onset, location, aggravating/alleviating factors)
Perform pain assessments routinely
Use words pain, hurt, ache
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Nonverbal signs of pain
Especially with children and elderly
Elevated pulse/blood pressure
Crying, moaning
Grimacing
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Nonpharmacologic Pain Management
Cutaneous stimulation (Based on "gate control" theory)
TENS (electronic pads)
PENS (electronic needles)
Acupuncture
Acupressure
Massage
Use of heat and cold
Contralateral stimulation (ex:right arm pain relived when lotion is applied to left arm)
immobilization and rest
cognative-behavioral intervention
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Non Pharm Pain management: Cognitive-behavioral interventions
Distraction
Progressive muscle relaxation
Guided imagery
Hypnosis
Therapeutic touch
Humor
Journaling
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Pain Management Pharmacological Measures
Nonopioid analgesics
-NSAIDs
-Acetaminophen

Opioid analgesics
-Includes IV, IM, transdermal, PO, buccal and epidural forms
-Client-controlled analgesia pumps
-Long acting

Adjuvant
-Antidepressants
-Anticonvulsants
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What are some Patient Opioid Misconceptions?
Respiratory depression
-monitor and prevent

Tolerance
-increase dose and change route

Physical dependence
-decrease the does over time

Psychological dependence
-addiction fear should not prevent patient from getting opioids
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Other Pain Relief Measures
Nerve blocks
Epidural injections
Local anesthesia
Topical anesthesia
Radiofrequency Ablation Therapy
Surgical procedures
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Reasons to use a Local Anesthesia
minor surgical procedures.

injected into joints and muscle for pain relief.

Pumps are commonly used to administer at surgical sites for postoperative pain relief.
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Radiofrequency Ablation Therapy
-uses electromagnetic waves that travel at the speed of light to target nerves that carry
pain impulses
-used to provide longer-term pain relief than that provided by injections of steroids,
analgesics, and nerve blocks
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Misconceptions about pain management
One older patient may fear that severe pain is a sign of weakness and try to endure it.

Another might perceive pain as a part of the normal physical declines that accompany
aging instead of an acute situation that requires treatment.

An athlete might believe "no pain, no gain," but actually, pain can signal a problem.

One family member may worry that pain medication may make the patient
nonfunctional, whereas others might fear addiction to pain medication even though non-
narcotic analgesics are not addictive.
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Behaviors that indicate substance abuse or addiction include the following:
-Repeated requests for injections of an opioid or atypical high dosing when pain should
normally be diminishing (e.g., after an injury or surgery)

-Refusal to try oral medication for pain relief

-"Doctor shopping"—moving from provider to provider in an effort to obtain multiple

prescriptions for the drug(s) the person abuses

-"Pharmacy shopping"—using multiple pharmacies to dispense controlled substances If

you observe these signs, consult with pain management specialists as well as addiction
and dependency professionals.

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Transduction
-Mechanical stimuli=
external forces that result in pressure or friction against the body1

-thermal stimuli=
from exposure to extreme heat or cold

-chemical stimuli=can be internal (heart attack chest pain) or external (lemon juice)
Pain Perception
Threshold
=the point at which the brain recognizes and defines a stimulus as pain.

Tolerance
=the duration or intensity of pain that a person can endure
Transmission
-A-delta fibers
=larhe-diameter myelinated fibers that transmit impulse 6-32 meters per second

-C Fibers
=smaller unmylelnated fibers that transmit slow pain impulses
dull, diffuse pain impulses that travel at a slow rate.