Y
Y


 



Y
 
 
Y  Y
  
  
  Y
‡ Comfort Level
‡ Medication Response
‡ Pain Control
Y 
  Y

 
    
  Y
‡ Analgesic Administration
‡ Conscious Sedation
‡ Pain Management Patient-Controlled Analgesia
Assistance
Y Y

 
‡ Unpleasant sensory and emotional experience
arising from actual or potential tissue damage or
described in terms of such damage
(International Association for the Study of Pain);
sudden or slow onset of any intensity from mild
to severe with an anticipated or predictable end
and a duration of less than 6 months
‡ Pain is a highly subjective state in which a variety of
unpleasant sensations and a wide range of
distressing factors may be experienced by the
sufferer. Pain may be a symptom of injury or illness.
Pain may also arise from emotional, psychological,
cultural, or spiritual distress. Pain can be very
difficult to explain, because it is unique to the
individual; pain should be accepted as described by
the sufferer. Pain assessment can be challenging,
especially in elderly patients, where cognitive
impairment and sensory-perceptual deficits are
more common.

 
 

‡ Guarding behavior, protecting body part

‡ Self-focused
‡ Narrowed focus (e.g., altered time perception, withdrawal
from social or physical contact)
‡ Relief or distraction behavior (e.g., moaning, crying, pacing,
seeking out other people or activities, restlessness)
‡ Facial mask of pain
‡ Alteration in muscle tone: listlessness or flaccidness; rigidity
or tension
‡ Autonomic responses (e.g., diaphoresis; change in blood
pressure [BP], pulse rate; pupillary dilation; change in
respiratory rate; pallor; nausea)
 


‡ Postoperative pain
‡ Cardiovascular pain
‡ Musculoskeletal pain
‡ Obstetrical pain
‡ Pain resulting from medical problems
‡ Pain resulting from diagnostic procedures or
medical treatments
‡ Pain resulting from trauma
‡ Pain resulting from emotional, psychological,
spiritual, or cultural distress.
 

O
 


 
‡ ^

(e.g., sharp, burning, shooting)
o Severity (scale of 1 to 10, with 10 being the most
severe) Other methods such as a visual analog scale
or descriptive scales can be used to identify extent of
pain.
‡ 
 (anatomical description)
‡  (gradual or sudden)
‡

 (how long; intermittent or continuous)
‡ 


‡ Observe or monitor signs and symptoms associated with
pain, such as BP, heart rate, temperature, color and
moisture of skin, restlessness, and ability to focus. Some
people deny the experience of pain when it is present.
Attention to associated signs may help the nurse in
evaluating pain.
‡ Assess for probable cause of pain. Different etiological
factors respond better to different therapies.
‡ Assess patient¶s knowledge of or preference for the array
of pain-relief strategies available. Some patients may be
unaware of the effectiveness of nonpharmacological
methods and may be willing to try them, either with or
instead of traditional analgesic medications. Often a
combination of therapies (e.g., mild analgesics with
distraction or heat) may prove most effective.
‡ Evaluate patient¶s response to pain and medications or
therapeutics aimed at abolishing or relieving pain. It is
important to help patients express as factually as
possible (i.e., without the effect of mood, emotion, or
anxiety) the effect of pain relief measures. Discrepancies
between behavior or appearance and what patient says
about pain relief (or lack of it) may be more a reflection
of other methods patient is using to cope with than pain
relief itself.
‡ Assess to what degree cultural, environmental,
intrapersonal, and intrapsychic factors may contribute to
pain or pain relief. These variables may modify the
patient¶s expression of his or her experience. For
example, some cultures openly express feelings, while
others restrain such expression. However, health care
providers should not stereotype any patient response but
rather evaluate the unique response of each patient.
‡ Evaluate what the pain means to the individual. The meaning
of the pain will directly influence the patient¶s response. Some
patients, especially the dying, may feel that the "act of
suffering" meets a spiritual need.
‡ Assess patient¶s expectations for pain relief. Some patients
may be content to have pain decreased; others will expect
complete elimination of pain. This affects their perceptions of
the effectiveness of the treatment modality and their
willingness to participate in additional treatments.
‡ Assess patient¶s willingness or ability to explore a range of
techniques aimed at controlling pain. Some patients will feel
uncomfortable exploring alternative methods of pain relief.
However, patients need to be informed that there are multiple
ways to manage pain.
‡ Assess appropriateness of patient as a patient-controlled
analgesia (PCA) candidate: no history of substance abuse; no
allergy to narcotic analgesics; clear sensorium; cooperative and
motivated about use; no history of renal, hepatic, or respiratory
disease; manual dexterity; and no history of major psychiatric
disorder. PCA is the intravenous (IV) infusion of a narcotic
(usually morphine or Demerol) through an infusion pump that is
controlled by the patient. This allows the patient to manage pain
relief within prescribed limits. In the hospice or home setting, a
nurse or caregiver may be needed to assist the patient in
managing the infusion.
‡ Monitor for changes in general condition that may herald need
for change in pain relief method. For example, a PCA patient
becomes confused and cannot manage PCA, or a successful
modality ceases to provide adequate pain relief, as in relaxation
breathing.
 


  O


 
‡ Pain relief The basal or lock-out dose may need to be increased
to cover the patient¶s pain.
‡ Intactness of IV line If the IV is not patent, patient will not
receive pain medication.
‡ Amount of pain medication patient is requesting If demands for
medication are quite frequent, patient¶s dosage may need to be
increased. If demands are very low, patient may require further
instruction to properly use PCA.
‡ Possible PCA complications such as excessive sedation,
respiratory distress, urinary retention, nausea/vomiting,
constipation, and IV site pain, redness, or swelling Patients may
also experience mild allergic response to the analgesic agent,
marked by generalized itching or nausea and vomiting.





  





‡ Pain relief Intermittent epidurals require redosing at
intervals. Variations in anatomy may result in a "patch
effect.³
‡ Numbness, tingling in extremities, a metallic taste in the
mouth These symptoms may be indicators of an allergic
response to the anesthesia agent, or of improper catheter
placement.
‡ Possible epidural analgesia complications such as
excessive sedation, respiratory distress, urinary
retention, or catheter migration Respiratory depression
and intravascular infusion of anesthesia (resulting from
catheter migration) can be potentially life-threatening.
K
  
  
‡ Anticipate need for pain relief. One can most effectively deal
with pain by preventing it. Early intervention may decrease
the total amount of analgesic required.
‡ Respond immediately to complaint of pain. In the midst of
painful experiences a patient¶s perception of time may become
distorted. Prompt responses to complaints may result in
decreased anxiety in the patient. Demonstrated concern for
patient¶s welfare and comfort fosters the development of a
trusting relationship.
‡ Eliminate additional stressors or sources of discomfort
whenever possible. Patients may experience an exaggeration
in pain or a decreased ability to tolerate painful stimuli if
environmental, intrapersonal, or intrapsychic factors are
further stressing them.
‡ Provide rest periods to facilitate comfort, sleep,
and relaxation. The patient¶s experiences of pain
may become exaggerated as the result of fatigue.
In a cyclic fashion, pain may result in fatigue,
which may result in exaggerated pain and
exhaustion. A quiet environment, a darkened
room, and a disconnected phone are all
measures geared toward facilitating rest.
 
 

 

  

1. Pharmacological methods include the following:

Nonsteroidal antiinflammatory drugs (NSAIDs)
that may be administered orally or parenterally (to
date, ketorolac is the only available parenteral
NSAID).
2. 2. Use of opiates that may be administered orally,
intramuscularly, subcutaneously, intravenously,
systemically by patient-controlled analgesia (PCA)
systems, or epidurally (either by bolus or
continuous infusion). Narcotics are indicated for
severe pain, especially in the hospice or home
setting.
[. Local anesthetic agents.
1. Nonpharmacological methods include the following: Cognitive-
behavioral strategies as follows:
‡ Imagery The use of a mental picture or an imagined event involves
use of the five senses to distract oneself from painful stimuli.
‡ Distraction techniques Heighten one¶s concentration upon
nonpainful stimuli to decrease one¶s awareness and experience of
pain. Some methods are breathing modifications and nerve
stimulation.
‡ Relaxation exercises Techniques are used to bring about a state of
physical and mental awareness and tranquility. The goal of these
techniques is to reduce tension, subsequently reducing pain.
‡ Biofeedback, breathing exercises, music therapy
2. Cutaneous stimulation as follows:
‡ Massage of affected area when appropriate Massage
decreases muscle tension and can promote comfort.
‡ Transcutaneous electrical nerve stimulation (TENS)
units.
‡ Hot or cold compress Hot, moist compresses have a
penetrating effect. The warmth rushes blood to the
affected area to promote healing. Cold compresses
may reduce total edema and promote some
numbing, thereby promoting comfort.
‡ Give analgesics as ordered, evaluating effectiveness and
observing for any signs and symptoms of untoward effects. Pain
medications are absorbed and metabolized differently by
patients, so their effectiveness must be evaluated from patient to
patient. Analgesics may cause side effects that range from mild
to life-threatening.
‡ Notify physician if interventions are unsuccessful or if current
complaint is a significant change from patient¶s past experience
of pain. Patients who request pain medications at more frequent
intervals than prescribed may actually require higher doses or
more potent analgesics.
‡ Whenever possible, reassure patient that pain is time-limited
and that there is more than one approach to easing pain. When
pain is perceived as everlasting and unresolvable, patient may
give up trying to cope with or experience a sense of hopelessness
and loss of control.
‡ If patient is on PCA: Dedicate use of IV line for PCA only;
consult pharmacist before mixing drug with narcotic being
infused. IV incompatibilities are possible.
‡ If patient is receiving epidural analgesia: Label all tubing (e.g.,
epidural catheter, IV tubing to epidural catheter) clearly to
prevent inadvertent administration of inappropriate fluids or
drugs into epidural space.

‡ For patients with PCA or epidural analgesia: Keep Narcan or

other narcotic-reversing agent readily available. In the event
of respiratory depression, these drugs reverse the narcotic
effect.
‡ Post "No additional analgesia" sign over bed. This prevents
inadvertent analgesic overdosing.
w        ! 


‡ Provide anticipatory instruction on pain causes,

appropriate prevention, and relief measures.
‡ Explain cause of pain or discomfort, if known.
‡ Instruct patient to report pain. Relief measures
may be instituted.
‡ Instruct patient to evaluate and report
effectiveness of measures used.
‡ Teach patient effective timing of medication
dose in relation to potentially uncomfortable
activities and prevention of peak pain periods
‡ For patients on PCA or those receiving epidural
analgesia: Teach patient preoperatively.
Anesthesia effects should not obscure teaching.

‡ Teach patient the purpose, benefits, techniques

of use/action, need for IV line (PCA only), other
alternatives for pain control, and of the need to
notify nurse of machine alarm and occurrence of
untoward effects.
Kw