MANAGEMENT PAIN NUR 317 Dr. Isabelita Pandaan

Objectives At the end of an evocative lecture discussion, the learners will be able to acquire the necessary knowledge essential in the care of clients with pain. Specifically, the learners will be able to: 1. Define pain. 2. Identify the basic categories of pain. 3. Describe the pathophysiology of pain. 4. Recognize factors influencing pain responses. 5. Demonstrate appropriate use of pain measurement instruments. 6. Compare pharmacologic, non pharmacologic and neurological methods of pain control. 7. Utilize the nursing process as a framework in the care of patients with pain.

What is Pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is the most common reason for seeking health care. “The fifth vital sign” Joint Commission (2005) standards: “pain is assessed in all patients,” “patients have the right to appropriate assessment and management of pain.”

3 Basic Categories of Pain I. Acute Pain II. Chronic Pain (nonmalignant) III. Cancer related Pain

I. Acute Pain This is usually recent onset and commonly associated with a specific injury. It indicates that damage or injury has occurred. If no lasting damage occurs, it usually decreases along with healing. It can be described as lasting from seconds to 6 months.

II. Chronic (Nonmalignant) Pain Is constant or intermittent that persists beyond the expected healing time and can seldom be attributed to a specific cause or injury. It may have a poorly defined onset and often difficult to treat. This type of pain lasts for 6 months and is usually accompanied by problems related to the pain itself.

III. Cancer-related Pain This type of pain is associated with cancer. It may be acute or chronic. This is the second most common fear of newly diagnosed cancer patients. Pain in the patient suffering from cancer can be directly associated with the cancer (nerve compression), a result of cancer treatment (surgery or radiation) , or not associated with cancer ( trauma)

EFFECTS OF PAIN Impairs the patient’s ability to sleep. Acute Pain effects: Endocrine, immunologic and inflammatory changes as a response to stress which includes increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids. Unrelieved acute pain may affect the pulmonary, cardiovascular, gastrointestinal, endocrine and immune system Chronic Pain effects: Adverse effects of chronic pain includes the suppression of the immune function which may promote tumor growth. It can also results in depression and disability.

Pain Syndromes Complex regional pain syndrome Postmastectomy pain syndrome Fibromyalgia Hemiplegia associated shoulder pain Pain associated with sickle cell disease AIDS-related pain Burn pain Guillain-Barré syndrome, pain Opioid tolerance

Physiology of pain

Pain Transmission Nerve mechanisms and structures involved in the transmission of pain perception to and from the area of the brain: A. Nociceptors B. Pain Receptors C. Chemical Mediators

Pathophysiology of Pain Pain begins in the presence of an intense and potentially damaging stimuli. Stimuli can be mechanical, thermal, or chemical in nature. This triggers a response from the Nociceptors (free nerve endings in the skin). Nociceptors’ nerve fibers branch very near to the origin and sends fibers to the local blood vessels, mast cells, hair follicles and sweat glands. When fibers are stimulated, histamine is released from the mast cells causing vasodilation.

Chemical Substances Algogenic ( pain – causing) substances affect sensitivity of nociceptors released from the extracellular tissue because of tissue damage. Prostaglandin - increases the sensitivity of pain receptors by enhancing the pain provoking effect of bradykinin. Endorphins, enkephalins (suppress pain reception) - reduce or inhibit the transmission or perception of pain.

Descending and Ascending control system

Gate control System Theory

Factors that Influence Pain Response Past experience Anxiety Depression Culture Age Gender ****These factors may increase or decrease the person’s perception of pain, increase or decrease tolerance for pain, and affect the responses to pain. ****

Nursing Assessment of Pain

CHARACTERISTICS OF PAIN Intensity Timing Location Quality Personal Meaning Aggravating and Alleviating Factors Pain Behaviors

Instruments used for Assessing the Patient’s Perception of Pain Visual Analogue Scales Faces Pain Scale, Revised

Pharmacologic Interventions Opioid analgesics act on CNS to inhibit activity of ascending nocioceptive pathways NSAIDS decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin) Local anesthetics block nerve conduction when applied to nerve fibers

Pharmacological Pain relief Interventions Balanced anesthesia “PRN” medications Routine administration: around the clock (ATC) or preventive approach PCA: patient-controlled analgesia Local anesthetics Topicals, patches Intraspinal administration

Non - pharmacological Interventions 1. Cutaneous stimulation, massage Promotes comfort as it produces muscle relaxation 2. Thermal therapies ( heat and cold application) Ice and heat stimulate the non-pain receptors in the same receptor field as the injury. 3. Transcutaneous electrical nerve stimulation (TENS) This uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain. Decreases pain by stimulating the non-pain receptors in the same area as the fibers that transmit the pain.

Non-pharmacological interventions 4. Distraction Involves focusing the patient’s attention on something other than the pain, may be the mechanism responsible for other effective cognitive techniques. Perception of pain is reduced by stimulating the descending control system, resulting in fewer painful stimuli being transmitted to the brain. 5. Relaxation techniques Relaxing tense muscles reduces pain through abdominal breathing at a slow, rhythmic rate. 6. Guided imagery – consists of combining slow, rhythmic breathing with a mental image of relaxation and comfort.

Non-pharmacological interventions 7. Hypnosis Usually, hypnosis must be induced by a specially skilled person (a psychologist or a nurse with specialized training in hypnosis). Its effectiveness depends on the hypnotic susceptibility of the individual.

Neurologic and Neurosurgical Methods for Pain Control A. Stimulation procedures a. Electrical stimulation – a method of suppressing pain by applying a controlled low voltage electrical pulses to different parts of the nervous system b. Spinal cord stimulation – a technique used for relief of chronic, intractable pain, ischemic pain and pain from angina through a surgically implanted device. c. Deep brain stimulation – performed for special pain problems when the patient does not respond to the usual techniques of pain control of pain pathways. B. Interruption Cordotomy - Rhizotomy

Nurses Role in Pain Management I. Help relieve pain by administering pain-relieving interventions ( both pharmacologic and nonpharmacologic approaches). II. Assess effectiveness of interventions. III. Monitoring of adverse effects. IV. Educate the patient and family to enable them to manage the prescribed intervention themselves when appropriate.

Nursing Diagnosis Acute Pain related to physical injury, reduction of blood supply, process of giving birth Chronic Pain related to the malignancy Anxiety related to pain that is felt Ineffective individual coping related to chronic pain Impaired physical mobility related to musculoskeletal pain Risk for injury related to lack of perception of pain

Nursing Process Framework for Pain Management Identify goals for pain management Establish nurse-patient relationship, teaching Provide physical care Manage anxiety related to pain Evaluate pain-management strategies Reference: Brunner and Suddarth’s Textbook of Medical Surgical Nursing 12th Edition.