Pain Management Module E (Lecture) Objectives

pain

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

State outcome criteria to evaluate a clients 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?

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

Types of Pain

Acute Pain- pain lasting only through the expected

recovery period. Chronic Pain- lasts beyond the usual course for

recovery (six months duration).

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, blood vessels & Arthritis, bone metastasis, post-op incisions

nerves

Ex: ankle sprain Characteristics: Usually well localized Continuous Aching, dull, gnawing, nagging Tends to last longer than cutaneous pain.

Visceral

Results from stimulation of pain receptors in the abd Poorly localized Burning, aching, or feeling of pressure, Usually caused by stretching of the tissues, ischemia, or

cavity, cranium & thorax.

muscle spasms. Pain described as to where it is experienced

Radiating pain Referred pain

Intractable Pain

highly resistant to relief Advanced malignancy

Neuropathic Pain

Result of current or past damage to peripheral or CNS. May not have a stimulus, such as tissue or nerve

damage. Neuropathic Pain

Constant, burning, tingling Intermittent, sharp, shooting, electrical, pain. 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.

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

Trigeminal neuralgia

Pain with Underlying Pathology

Headache- common somatic pain either intracranial or

extra-cranial. Meningitis vs. muscle strain Cancer Pain Syndrome Progression of the disease or

from efforts to cure or control disease. Myofacial Pain Syndrome muscle spasm, tenderness, stiffness, limitation of movement, & weakness. Concepts Associated with Pain

Pain Threshold/ Sensation the amount of pain

stimulation a person needs to feel pain. Pain Tolerance maximum amount & duration of pain that an individual is willing to endure. Nociception

Peripheral nervous system includes neurons specialized

to detect tissue damage & evoke the sensations of touch, heat, cold, pain & pressure.

Pain receptors are called nociceptors and can be

excited by mechanical, thermal, or chemical stimuli.

4 processes involved in nociception

Transduction Transmission Perception Modulation

1. Transduction Tissue injury triggers the release of biochemical mediators (prostaglandins, bradykinin, serotonin, histamine, substance P) that sensitize nociceptors. Pain meds work at this phase by blocking production of prostaglandin (ibuprofen) or be decreasing movement of ions across cell membrane (local anesthetic) 2. Transmission 1st pain impulse travels from peripheral nerve fibers to spinal cord. Substance P acts as a neurotransmitter.

cord

2 types of nociceptor fibers cause transmission to spinal C fibers (dull, aching pain) A-delta fibers (sharp, localized pain) (2nd segment) Transmission occurs from spinal cord to

brain stem & thalamus.

3rd transmission of signals between thalamus & somatic Opioids block release of neurotransmitters (esp.

sensory cortex where pain perception occurs. substance P) at spinal level. 3. Perception

Person is conscious of pain Possibly occurs in cortical structures, which allows for

cognitive behaviors to pain reduction such as distraction, guided imagery & music. 4. 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. The body takes these back, which limit their usefulness. Pts /w chronic pain may be prescribed SSRIs

horn of spinal cord.

Gate Control Theory

According to theory, peripheral nerve fibers carrying

pain to the spinal cord can have their input modified at the spinal cord level before transmission to the brain.

Synapses can act as gates that close to keep impulses

from reaching the brain or open to allow impulses thru.

Ascending Modulation Large diameter sensory fibers, message, heat and cold

applications Transcutaneous electrical nerve stimulation (TENS)

unit, 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.

Part of socialization process. Express pain or do not express it.

Ethnic and Cultural Values

Some groups self-inflect pain Pain may signify strength & endurance. Nurses must be aware of their own attitudes and

expectations about pain. Developmental Stage Newborns

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. boys.

Past Pain Experience

Persons who have previous experience /w pain either

their own or someone elses are more often threatened by anticipated pain than someone without a pain experience. Meaning of Pain If person believes pain will have a positive outcome may with stand it amazingly well as woman giving birth.

Pts with unrelenting chronic pain may suffer more Respond with despair, anxiety, & depression, may see

intensely pain as threat to body image or lifestyle or sign of possible death. Anxiety and Stress

Often accompany pain Threat of unknown Inability to control pain Fatigue reduces persons ability to cope

Why are some clients reluctant to report pain? . 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

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. 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, other medications being taken Location (abdomen) Intensity (scale of 0-10)

cold)

Quality (perceiving like a knife) Pattern (onset, duration, and recurrence of intervals

without pain. Pain diary Precipitating Factors (Environmental factors, heat or Alleviating factors (herbal teas, rest, TV., prayer) Associated Symptoms (N/V, dizziness, diarrhea) Effects on ADLS (Sleep, appetite, concentration, school,

work, driving, 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.

to postop incisional abd 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 clients

report of he severity of the pain

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.

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.

nothing to be done, they think it is not severe enough, or because they feel it would distract or prejudice the healthcare provider. Pharmacologic Pain Management

Involves the use of opioids (narcotics) Nonopioids/NSAIDS (nonsteroidal anti-inflammatory

drugs) Categories of analgesic drugs

Opioid Analgesics

Opium derivatives (M.S., and Codeine) Relieve pain and provide a sense of euphoria binding to

opiate receptors and activating endogenous pain suppression in the CNS.

Examples of opiate receptors are MU, delta & kappa

receptors. MU most commonly associated with pain relief.

Types of Opioids

Full agonist- pure opioid drugs bind tightly to MU

receptors. MS, Demerol, Codeine, Darvon, Dilaudid-

Types of Opioids

Mixed agonist-antagonist act like opioids when given

to client who has not taken any pure opioids. They can block other opioid analgesics when given to a

client who has taken pure opioids Drugs /w antagonist effect: Dalgan, Talwin, Stadol & They block MU receptors & activate kappa receptor site. Nubain.

(Remember that opioids work at the MU receptors) Types of Opioids

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. 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

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.

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, at an acupressure point, along peripheral nerve areas that innervate the pain area, or along the spinal column. Thought to activate lg diameter fibers r/t nociceptive receptors (closes pain gate)

NONPHARMOCOLOGIC PAIN MANAGEMENT

Contralateral Stimulation

Stimulate skin in an area opposite to the painful area NONPHARMOCOLOGIC PAIN MANAGEMENT

Immobilization Distraction (visual, auditory, tactile, intellectual)

Pain Evaluation The nurse and client must determine if overall goals

and outcomes are achieved. 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

Tolerance Side effect management Fear of addiction