Pain Management

Nature of Pain Involves physical, emotional, and cognitive components Results from physical and/or mental stimulus Reduces quality of life Not measurable objectively Subjective and highly individualized component

Inferred pathological Types of Pain Acute/transient pain Protective, identifiable, short duration; limited emotional response Chronic/persistent noncancer Is not protective, has no purpose, may or may not have an identifiable cause Chronic episodic Occurs sporadically over an extended duration Cancer Can be acute or chronic Inferred pathological Musculoskeletal, visceral, or neuropathic Idiopathic Chronic pain without identifiable physical or psychological cause

Nursing Knowledge Base Attitude of health care providers Malingerer or complainer Assumptions about patients in pain Biases based on culture, education, experiences Acknowledge pain through patient’s experiences Limit your ability to help the patient

Factors Influencing Pain Physiological Age, fatigue, genes, neurological function Fatigue increases the perception of pain and can cause problems with sleep and rest. Social Attention, previous experiences, family and support groups, spiritual Spirituality includes active searching for meaning in situations, with questions such as “Why am I suffering?”

Factors Influencing Pain (cont’d) Psychological Anxiety Coping style Pain tolerance The level of pain a person is willing to accept Cultural Meaning of pain Ethnicity

Nursing Process and Pain Pain management needs to be systematic. Pain management needs to consider the patient’s quality of life. Clinical guidelines are available to manage pain: American Pain Society National Guideline Clearing House (www.guideline.gov) Agency for Healthcare Research and Quality (AHRQ)

Assessment Patient’s expression of pain Characteristics of pain Onset and duration Location Intensity Quality Pattern Relief measures Contributing symptoms Effects of pain on the patient

Assessment Effects of pain on the patient Behavioral effects Assess verbalization, vocal response, facial and body movements, and social interaction. For patients unable to communicate pain, it is vital for you to be alert for indicative behaviors. Influence on activities of daily living Physical deconditioning Sleep disturbances Sexual relationships Ability to work (outside of and in the home)

Pain Assessment and Management: A: Ask about pain regularly. Assess pain systematically. B: Believe the patient and family in their report of pain and what relieves it. C: Choose pain control options appropriate for the patient, family, and setting. D: Deliver interventions in a timely, logical, and coordinated fashion. E: Empower patients and their families. Enable them to control their course to the greatest extent possible.

Nursing Diagnosis Acute Pain Chronic Pain Self care deficit: dressing/grooming r/t pain Impaired physical mobility r/t pain

Planning Determine with the patient what the pain has prevented the patient from doing. Then agree on an acceptable level of pain that allows return of function. For example, for the goal, “The patient will achieve a satisfactory level of pain relief within 24 hours,” possible outcomes are as follows: Reports that pain is a 3 or less on a scale of 0 to 10 Identifies factors that intensify pain Uses pain relief measures safely Level of discomfort does not interfere with activities of daily living (ADLs).

Implementation: Health Promotion Nonpharmacological pain relief interventions Relaxation, guided imagery Biofeedback Distraction, music Cutaneous stimulation Massage, transcutaneous electrical nerve stimulation (TENS), heat, cold, acupressure Herbals Reducing pain perception

Implementation: Health Promotion (cont’d) Pharmacological pain relief Acute pain management Analgesics Nonopioids Opioids Adjuvants/co-analgesics Delivery systems Patient-controlled analgesia (PCA) Local/regional anesthesia Topical agents

Patient-Controlled Analgesia

Implementation Nursing implications You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia. After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return. Nursing implications for managing epidural analgesia are numerous. Nurses monitor IV sites, lines, and controllers.

Barriers to Effective Pain Management Physical dependence: A state of adaptation that is manifested by a drug class–specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time Placebos

Checklist for Communication with Colleagues What is the pain rating now? Over the past period of time? Which pain rating is acceptable to the patient? How do you recommend that the patient’s treatment be changed to reduce the pain rating? Which professional reference can be used, if needed, to support this recommendation?

Evaluation Evaluation of pain is one of many nursing responsibilities that require effective critical thinking. The patient’s response to pain may not be obvious. Evaluating the appropriateness of pain medication will require nurses to evaluate patients’ responses after administration.

Safety Guidelines The patient is the only person who should press the button to administer the pain medication when PCA is used. Monitor the patient for signs and symptoms of oversedation and respiratory depression.

Study Guide for Pain Chapter Physiological Responses pg 964 Behavioral Responses Types of Pain Knowledge, Attitudes, and Belief pg 966 Factors influencing Pain Physiological Factors Psychological Factors

Study Guide for Pain Chapter Nursing Process Assessment Planning Implementation Not!: Nonpharmacological pain relief interventions or Cutaneous Stimulation, but massage and cold and heat applications; TENS Acute pain managaement Pharmacological pain-relief interventions PCA—Stop until Barriers to effective pain Management pg 988 Evaluation