Pain Management Module E (Lecture) Objectives

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Identify types and categories of pain R/T location,

etiology, and duration Identify subjective and objective data to collect and Identify examples of nursing diagnosis for clients with analyze when assessing pain

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State outcome criteria to evaluate a client’s response to

interventions for pain. Identify barriers to effective pain management Describe non-pharmacologic pain control interventions Describe pharmacologic interventions for pain

Nature of Pain

“An unpleasant sensory and emotional experience

associated with actual or potential damage or described in terms of such damage” (International Association for the Study of Pain, 1979).

Pain is “Whatever the experiencing person says it is,

existing whenever he/she says it does” (McGaffery 1999) How Much Pain do we have?

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About 20% of Americans live with chronic pain It’s the leading reason people seek medical help.

Chronic Pain. • – – – – Pain can be categorized according to its origin: Cutaneous Deep somatic Visceral Neuropathic Pain Cutaneous Pain • • – Originates in the skin or subcutaneous tissue Example: a paper cut Deep Somatic Pain • – – Example: Injuries to ligaments. tendons. bones.pain lasting only through the expected recovery period.lasts beyond the usual course for recovery (six months duration).Types of Pain • • Acute Pain. blood vessels & Arthritis. bone metastasis. post-op incisions nerves .

muscle spasms.• • – – – – Ex: ankle sprain Characteristics: Usually well localized Continuous Aching. cranium & thorax. or feeling of pressure. ischemia. gnawing. dull. aching. Pain described as to where it is experienced • • Radiating pain Referred pain Intractable Pain • – highly resistant to relief Advanced malignancy . Visceral • • • • Results from stimulation of pain receptors in the abd Poorly localized Burning. or cavity. nagging Tends to last longer than cutaneous pain. Usually caused by stretching of the tissues.

sharp. May not have a stimulus. shooting. Example: Post-herpetic neuralgia Phantom Pain Painful sensation felt in a body part that is missing or paralyzed by spinal cord injury – Pain Syndromes • – • • yrs. tingling Intermittent. Neuropathic Pain • • • – • Constant. Peripheral Pain Syndromes Post-herpetic Neuralgia – herpes has 2 phases Vesicular eruption Neuralgic pain that often encircles body and can last for – Phantom Limb Pain Pain Syndromes • Central Pain Syndromes .Neuropathic Pain • • Result of current or past damage to peripheral or CNS. pain. such as tissue or nerve damage. burning. electrical.

stiffness. muscle strain Cancer Pain Syndrome – Progression of the disease or • from efforts to cure or control disease. thermal. pain & pressure. or chemical stimuli. & weakness. heat. Myofacial Pain Syndrome – muscle spasm.common somatic pain either intracranial or extra-cranial. Concepts Associated with Pain • Pain Threshold/ Sensation– the amount of pain stimulation a person needs to feel pain.– Trigeminal neuralgia Pain with Underlying Pathology • – Headache. . cold. Pain Tolerance – maximum amount & duration of pain that an individual is willing to endure. Meningitis vs. • Pain receptors are called nociceptors and can be excited by mechanical. Nociception • Peripheral nervous system includes neurons specialized to detect tissue damage & evoke the sensations of touch. tenderness. limitation of movement.

aching pain) A-delta fibers (sharp. • Pain meds work at this phase by blocking production of prostaglandin (ibuprofen) or be decreasing movement of ions across cell membrane (local anesthetic) 2. Substance P acts as a neurotransmitter. serotonin. substance P) that sensitize nociceptors. localized pain) (2nd segment) Transmission occurs from spinal cord to • brain stem & thalamus. . • cord – – 2 types of nociceptor fibers cause transmission to spinal C fibers (dull. Transduction • Tissue injury triggers the release of biochemical mediators (prostaglandins. bradykinin. histamine. Transmission 1st pain impulse travels from peripheral nerve fibers to spinal cord.4 processes involved in nociception • • • • Transduction Transmission Perception Modulation 1.

The body takes these back.• • 3rd transmission of signals between thalamus & somatic Opioids block release of neurotransmitters (esp. . • • • Gate Control Theory • According to theory. substance P) at spinal level. 3. which allows for cognitive behaviors to pain reduction such as distraction. guided imagery & music. 4. which limit their usefulness. Perception • • Person is conscious of pain Possibly occurs in cortical structures. peripheral nerve fibers carrying pain to the spinal cord can have their input modified at the spinal cord level before transmission to the brain. sensory cortex where pain perception occurs. Modulation (Descending System) • • – – Neurons in brain stem send signals back down dorsal These descending fibers release substances endogenous opioids serotonin & norepinephrine Which can inhibit ascending noxious impulses. Pts /w chronic pain may be prescribed SSRI’s horn of spinal cord.

• – – Ascending Modulation Large diameter sensory fibers. electrical stimulation is applied to skin • Descending modulation Factors Affecting the Pain Experience • • • • • • Ethnic and Cultural Values Developmental Stage Environment and Support People Past Pain Experience Meaning of Pain Anxiety and Stress Ethnic and Cultural Values • There is little variation in pain threshold but cultural background can affect the level of pain an individual is willing to tolerate. heat and cold applications Transcutaneous electrical nerve stimulation (TENS) unit.• Synapses can act as gates that close to keep impulses from reaching the brain or open to allow impulses thru. . message.

• – Part of socialization process. Nurses must be aware of their own attitudes and expectations about pain. Elderly - Environment and Support People Strange environment such as hospital can compound Lack of supportive people Some like to withdraw Others like the distraction of other people and activity Girls usually allowed to express pain more openly than • • • • around them. Express pain or do not express it. Developmental Stage Newborns • • pain. . boys. Ethnic and Cultural Values • • • Some groups self-inflect pain Pain may signify strength & endurance.

anxiety. Unwillingness to trouble staff • • • Fear of injectable route of analgesic administration Belief that pain is to be expected as part of recovery Concern about addiction . & depression. Meaning of Pain If person believes pain will have a positive outcome may with stand it amazingly well as woman giving birth. Anxiety and Stress • • • • Often accompany pain Threat of unknown Inability to control pain Fatigue reduces person’s ability to cope Why are some clients reluctant to report pain? . may see intensely pain as threat to body image or lifestyle or sign of possible death.Past Pain Experience • Persons who have previous experience /w pain either their own or someone else’s are more often threatened by anticipated pain than someone without a pain experience. • • Pts with unrelenting chronic pain may suffer more Respond with despair.

Pain is subjective and experienced uniquely by every individual Nurses need to assess all factors affecting the pain experience. Pain History • • • • • Previous pain treatment and effectiveness When and what analgesics were last taken Allergies to medications.• • • Fear about cause of pain or that reporting pain will lead to further tests and expenses Concern about unwanted side effects. especially of opioid drugs Difficulty expressing personal discomfort Pain Assessment Pain is the fifth vital sign • • • Accurate pain assessment is essential for effective pain management. other medications being taken Location (abdomen) Intensity (scale of 0-10) .

• • • • cold) Quality (perceiving like a knife) Pattern (onset. • • • work. heat or Alleviating factors (herbal teas. walking) • • • Coping resources (prayer or other religious practices) Affective Responses (nurse to explore feelings) Observation of Behavioral and Physiologic Responses Nursing Diagnosis • – – • NANDA Acute pain Chronic pain Acute pain R/T Abd Incision AEB C/O “It hurts when I Pain may also be the etiology of other nursing DX Ineffective airway clearance R/T weak cough secondary move.. school. driving. diarrhea) Effects on ADL’S (Sleep.” • – to postop incisional abd pain . dizziness. prayer) Associated Symptoms (N/V. duration. TV. rest. concentration. appetite. Pain diary Precipitating Factors (Environmental factors. and recurrence of intervals without pain.

Planning / Goal • Client will verbalize pain at 3 or less on 1 – 10 pain scale within 30 minutes of pain med administration Key Factors in Pain Management • • • • • • • • • • • Assess for pain Acknowledge and accept Assist Support Persons Reduce misconceptions about pain Reduce fear and anxiety Prevent Pain Individualizing Care for Clients with Pain Establish a trusting relationship Consider the clients ability and willingness to participate actively in pain relief measures Use a variety of pain relief measures Provide measures to relieve pain before it becomes severe. Individualizing Care for Clients with Pain • • Use pain relieving measures that the client believes are effective Base the choice of pain relief measure on the client’s report of he severity of the pain .

Barriers to Pain • • • Misconceptions and biases Clients’ respond to pain based on their culture. personal Clients may not report pain because they expect experiences and the meaning the pain has for them. Pharmacologic Pain Management • • • Involves the use of opioids (narcotics) Nonopioids/NSAIDS (nonsteroidal anti-inflammatory drugs) Categories of analgesic drugs . nothing to be done.• If a pain relief measure is ineffective encourage the client to try it once or twice before abandoning it Individualizing Care for Clients with Pain • • • • Maintain an unbiased attitude about what might relief the pain Keep trying Prevent harm to the client Educate the client and support people about pain. or because they feel it would distract or prejudice the healthcare provider. they think it is not severe enough.

Darvon. and Codeine) Relieve pain and provide a sense of euphoria binding to opiate receptors and activating endogenous pain suppression in the CNS. Talwin. Demerol. MS.. They can block other opioid analgesics when given to a client who has taken pure opioids Drugs /w antagonist effect: Dalgan. • • Examples of opiate receptors are MU.pure opioid drugs bind tightly to MU receptors. Codeine. Stadol & They block MU receptors & activate kappa receptor site.Opioid Analgesics • • Opium derivatives (M. (Remember that opioids work at the MU receptors) Types of Opioids . MU most commonly associated with pain relief.S. Nubain. Dilaudid- Types of Opioids • • • • Mixed agonist-antagonist – act like opioids when given to client who has not taken any pure opioids. delta & kappa receptors. Types of Opioids • – Full agonist.

NSAIDs Act on peripheral nerve endings at injury • • • • • • • Decrease level of inflammatory mediators Interfere with production of prostaglandins at injury site Side effects – GI disturbances such as heartburn or Should take with food or water Interfere with platelet aggregation Can reduce dose of opioids needed when given Acetaminophen can cause hepatotoxicity indigestion together .• – Partial agonists – block MU receptors or are neutral at that receptor but bind at a Kappa receptor site Buprenex Nursing Actions • – – – – Review side effects Drowsiness n/v Constipation Respiratory depression With prolonged use tolerance develops to sedation & • respiratory depressive effects of the drug.

Placebos • • • • Any med or procedure that effects client by means Used in research Do placebos work? Are they ethical? other than specific physical or chemical properties. at an acupressure point. Thought to activate lg diameter fibers r/t nociceptive receptors (closes pain gate) . along peripheral nerve areas that innervate the pain area. NONPHARMOCOLOGIC PAIN MANAGEMENT • – Physical InterventionsProvide Comfort Cutaneous StimulationMassage application of heat or cold acupressure • – – – Transcutaneous Electrical Nerve Stimulation • TENS is a method of applying low voltage electrical stimulation directly over identified pain areas. or along the spinal column.

auditory. tactile. Flow sheet records and diaries are helpful in this process to evaluate the effectiveness of methods of pain control. Barriers to Effective Pain Management • • • Low priority given to pain management Inadequate reimbursement Problems with access to treatment Healthcare Professional Barriers to Effective Pain Management • • • – Inadequate training in pain management Poor assessment of pain Concern about: Regulation of controlled substances .NONPHARMOCOLOGIC PAIN MANAGEMENT • Contralateral Stimulation Stimulate skin in an area opposite to the painful area NONPHARMOCOLOGIC PAIN MANAGEMENT • • • • Immobilization Distraction (visual. intellectual) Pain Evaluation The nurse and client must determine if overall goals and outcomes are achieved.

– – Tolerance Side effect management Fear of addiction • .

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