Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 11: Pain Management

FACT OR FICTION???? Visceral pain is pain that is processed abnormally by the nervous system Despite the fact that the client is the only reliable source for quantifying pain, nurses are not consistent in responding to the client’s description of pain intensity with pain-relieving interventions There are 5 components of a pain assessment: onset, quality, intensity, location & magnitude

Pain Pain is a privately experienced, unpleasant sensation usually associated with disease or injury. It also has an emotional component known as “suffering”.

Types of Pain Introduction Classification Source-nocicepetive, neuropathic Onset, intensity, and duration – Acute or chronic Nociceptive Pain Noxious stimuli transmitted from point of cellular injury through pathways to the cerebral cortex of the brain Subdivided into somatic and visceral

Types of Pain Nociceptive Pain Somatic pain Causes: Mechanical, chemical, thermal, or electrical injuries or disorders Affects bones, joints, muscles, skin, or other structures composed of connective tissue Types: Superficial somatic pain, also known as cutaneous pain; deeper somatic pain from trauma

Types of Pain Nociceptive Pain Visceral pain Diseased or injured heart, kidneys, and intestine Causes: Ischemia, organ compression, intestinal distention with gas or contraction Referred pain Discomfort perceived in a general area of the body

Figure 11-2 Common areas of referred pain, pg 99 Types of Pain Figure 11-2 Common areas of referred pain, pg 99

Types of Pain Neuropathic Pain Damaged Pain pathways in peripheral nerves Pain processing centers in the brain Cause of nerve damage: Drugs or radiation used to treat cancerous tumor Acute Pain Discomfort that has a short duration Tissue trauma Physical and emotional distress

Types of Pain Chronic Pain Discomfort that lasts longer than six months Longer pain periods: More far-reaching effects on the sufferer - breakthrough pain Negative reactions of others to chronic pain sufferer Characteristics of Acute and Chronic Pain, Table 11- 1, pg 99

Question Is the following statement true or false? Pain is always located in the organ of the body in which it is generated.

Answer False. Referred pain is discomfort that is perceived in a general area of the body but not in the exact site where an organ is located.

Pain Transmission Four Phases Transduction Chemical information in the cellular environment is converted to electrical impulses that move toward the spinal cord; release of chemical mediators Chemicals that are released by the damaged cells stimulate nociceptors Impulses transmitted by the fast pain pathway (A-delta); person withdraws from the pain-provoking stimulus

Pain Transmission Four Phases, con’t Transmission Peripheral nerve fibers form synapses with neurons in the spinal cord Pain impulses move from spinal cord to brain; impulses ascend finally to the cerebral cortex Perception Phase of impulse transmission: brain experiences pain at a conscious level; brain structures in the pain pathway

Pain Transmission Four Phases, con’t Perception (cont’d) Pain perception: Conscious experience of discomfort Pain threshold: Point at which pain- transmitting neurochemicals reach the brain, causing conscious awareness Pain tolerance: Amount of pain a person endures once the threshold has been reached; influenced by gender, age, and culture

Pain Transmission Four Phases, con’t Modulation Phase during which the brain interacts with the spinal nerves to alter the pain Pain sensation reduced Release of pain- inhibiting neurochemicals Figure 11-3, pg 100 The phases of pain transmission

Pain Assessment Introduction Client’s description of pain onset, quality, intensity, location, and duration (Table 11-2 pg 101) Assessment for accompanying symptoms Should be treated as the fifth vital sign Assessment biases Client: Only reliable source for quantifying pain Nurses: Not consistent in responding to the client’s description of pain intensity

Pain Assessment Assessment biases (cont’d) Pain undertreated if the client’s expressions are incongruent with the nurse’s expectations Assessment Tools Numeric scale, word scale, and linear scale Wong–Baker FACES scale: Best for pediatric, culturally diverse, and mentally challenged clients

Question Is the following statement true or false? Pain is exactly as the client describes it.

Answer True. Margo McCaffery, a nursing expert on pain, states, “Pain is whatever the person says it is, and exists whenever the person says it does” (McCaffery & Beebe, 1989).

Pain Assessment Assessment Standards Joint Commission standards related to pain management Aspects incorporated in the Joint Commission standards REVIEW: Stop Think Respond, 11-1, pg 102 Figure 11-4, pg 102  Pain assessment tools: (A) Word scale, (B) Numeric scale, (C) Linear scale

Pain Management Introduction Techniques used to prevent, reduce, or relieve pain Five techniques for achieving pain management, Refer to Bullet points, pg 102 Drug Therapy WHO: Three-tiered approach Cancer pain: Analgesics administered intrathecally, and electrical stimulation in the spinal cord

Pain Management Drug Therapy Neurosurgical analgesic techniques Opioid and opiate analgesics Nonopioid analgesics REFER to: Drug Therapy Table, 11-1, pg 104 & 105 Figure 11-8, pg 103

Pain Management Drug Therapy Methods of administration Analgesic drugs: Oral, rectal, transdermal, or parenteral Equianalgesic dose: Change from a parenteral to an oral route Patient-controlled analgesia Self-administration of narcotic analgesic Intravenous pump system

Pain Management Drug Therapy Methods of administration (cont’d) Intraspinal analgesia Infusion of narcotic or local anesthetic into the subarachnoid or epidural space of the spinal cord Relieves pain with minimal systemic drug effects Nurses do not administer intraspinal analgesia

Pain Management Drug Therapy Addiction, tolerance, physical dependence Addiction: A repetitive pattern of drug use to satisfy a craving for a drug’s mind-altering or mood-altering effects; fear of addiction affects use of medication Tolerance: A condition in which a client needs larger doses of a drug to achieve the same effect

Pain Management Drug Therapy Physical dependence: Physical discomfort, withdrawal symptoms; experienced when drug taken routinely is discontinued abruptly Adjuvant drug therapy Medications ordinarily administered for reasons other than treating pain Effects of combining adjuvant drugs with opioid and nonopioid analgesics REFER to: Drug Therapy Table, 11-1, pg 104 & 105

Pain Management Nondrug Interventions Heat and cold applications, transcutaneous and percutaneous electrical nerve stimulation, acupuncture, and acupressure Used for clients with chronic pain Body releases neurotransmitters: Calm the body and promote emotional well-being- use up sensory signals Release of endogenous opiates: Help relieve pain Modulation of pain transmission

Pain Management Nondrug Interventions Heat and cold Reduces localized swelling; decreases vasodilation; used for minor or moderate pain Ice bag or chemical pack

Pain Management Nondrug Interventions Transcutaneous electrical nerve stimulation (TENS) Delivers bursts of electricity to the skin and underlying nerves Acute and chronic pain Change in placement sites Intensity of electrical current Rate of electrical bursts and duration according to the client’s response

Pain Management Nondrug Interventions Acupuncture and acupressure Temporary relief: Repeat treatments Long treatment: Thin needles are inserted into the skin Acupressure uses tissue compression, rather than needles, to reduce pain

Pain Management Nondrug Interventions Percutaneous electrical nerve stimulation Combines the use of acupuncture needles with TENS Administered for 30 minutes three times a week for a total of three weeks Successful in research trials on clients with low back pain, pain caused by the spread of cancer to bones, shingles, neuropathic pain, and migraine

Question Is the following statement true or false? A nurse has several nondrug pain management techniques available to make pain management more effective.

Answer True. Several nondrug interventions can be used to help manage pain. Some, such as applications of heat and cold, are independent nursing measures or may require collaboration with the client’s physician.

Pain Management Nondrug Interventions Other noninvasive techniques Imagery, biofeedback, humor, breathing exercises and progressive relaxation, distraction, and hypnosis Spinal Surgery Techniques Relieves intractable pain Rhizotomy Spinal surgery involves a laminectomy

Pain Management Spinal Surgery Techniques Rhizotomy (cont’d) Sectioning of the posterior nerve root Permanent loss of sensation Reserved for terminally ill clients Cordotomy Interruption of pain pathways in the spinal cord Percutaneous: Less risk; better tolerated by terminally ill clients

Pain Management Nursing Management (Nursing Care Plan, 11-1, pg 110) Collaboration with patient and physician Nursing interventions for pain management Monitor and manage drug side effects: Constipation, injury, nutrition, sleep Client teaching Available pain management techniques Self-administration of analgesics Prescribed analgesics Nutritional

NCLEX Q & A..