Chapter 55: Pain Management

Pain It is a subjective symptom; only the client can describe it It is the body’s signal of distress It is a warning that tissues are being damaged McCaffrey states “Pain is whatever the experiencing person says it is, existing whenever he says it does.”

Causes of Pain Mechanical stress of trauma, surgical incision, or tumor growth Physical causes include mechanical stressors 1. trauma 2. MI Excesses in pressure, heat and cold Chemical substances released when tissues are damaged or destroyed Lack of oxygen to tissues Muscle spasms

The Pain Cycle

Pain Transmission and Interpretation: Nociception Transduction: The nervous system changes painful stimuli in nerve endings to impulses. Transmission: The impulses travel from their original site to the brain. Perception: The brain recognizes, defines, and responds to pain. Modulation: The body activates needed inhibitory responses to the effects of pain.

The International Association for the Study of Pain (IASP): Types of Pain *Acute pain or nociceptive pain After the underlying cause is identified and successfully treated, acute pain disappears *Referred pain Cancer pain *Chronic pain or neuropathic pain Limited, intermittent, or persistent Neuropathic *Intractable pain *phantom limb pain *psychogenic pain *monitor body cues for pain

Results of the Chronic Pain Experience Loss of control Decreased self-esteem and communication Inappropriate life goals Change in relationships, lack of sexual activity, role changes within family Anger of family and friends over need to do client’s work or “take care of ” client Depression, symptoms include 1. fatigue 2. sleeping too much 3. lack of interest in surroundings 4. sexual impotence

*Factors Affecting Pain Perception Pain threshold Lowest intensity of a stimulus that causes the subject to recognize pain Pain tolerance The point at which a person can no longer endure pain

Factors affecting pain perception Endorphins Naturally occurring substances produced by the central nervous system to relieve pain Intake of certain chemicals alter endorphin production 1. caffeine 2. nicotine 3. alcohol 4. sugar

Collection of Client Data About Pain The fifth vital sign Document Level of pain Description of pain Action taken Results

Joint Commission Accreditation Standards: Pain 1. Patients have the right to appropriate evaluation and management of pain. 2. On-going data collection should include the nature and intensity of pain. 3. Responses to evaluation of pain should be recorded so regular reassessment and follow-up occurs. 4. Staff must be oriented and competent in gathering data and pain management.

Joint Commission Accreditation Standards: Pain (cont.) Policies and procedures supporting ordering of pain medications must be in place. (Clients) and families require education about effective pain management. Discharge planning should address the (client’s) needs for pain management.

Pain Rating Scales 1. Pain Intensity Scale or Pain Distress Scale Reserved children older than 7 2. McGill–Melzack Pain Questionnaire Wong–Baker Faces Pain Scale Can be used for adults who have difficulty expressing themselves or people who do not speak the prevailing language at the facility FLACC NIPS PAINAD DMC Pain Assessment Behavioral Scale 3. Numeric 0-10 scale

Documentation of Pain Level of pain Description of pain Action taken Response to interventions

Description of Pain *Character Duration Occasional, intermittent, spasmodic, or constant Severity Mild, slight, moderate, severe, or excruciating Associated factors

COLDSPA Memory Guide Character: Describe the pain. How does it feel? Be specific. Is it constant, occasional, or recurring? Onset: When did the pain start? How long have you had it? Location: Where is the pain? Internal or external? Does it radiate? Where does it start and where does it radiate to? Is it always in the same place? Duration: How long does the pain last? Does it come back? How often?

COLDSPA Memory Guide (cont.) Severity: How bad is the pain? (Use an appropriate rating scale.) Pattern: Does anything relieve the pain? What? Does anything make it worse? Does anything specific seem to cause the pain? Associated Factors or Related Occurrences: Are other symptoms associated with the pain (headache, visual difficulties, sensitivity to light, nausea)?

Teaching Client to Manage Chronic Pain Medications Exercise Nutrition Recreation Relaxation Support Hobbies Rest/sleep *alternative/complementary therapy

Route of Administration/Analgesics IM injections Epidural medications delivered by infusion catheter Continuous and perfusion to surgical site Perineural administration *PCA pump CCA pump NCA pump

Pharmacologic Therapy Analgesics provide pain relief by altering the body’s sodium and potassium levels thus slowing or halting pain transmission. Nonopioid nonsteroidal anti-inflammatory drugs (NSAIDs)* Mild to moderate pain Opioids/narcotic analgesics Morphine Used to manage pain in clients with moderate to severe pain* Adjuvant drugs Anticonvulsants and antidepressants Ointments and liniments

Surgical Intervention Surgery may be necessary to alleviate certain types of chronic pain Herniated disk Tumors causing pressure Pinched nerves Ablation surgery Cut the nerves transmitting the pain sensation

Nursing Interventions Independent comfort measures Diversion, changing position, bathing, massage hands, giving a back rub* Encourage nutritious diet and adequate fluids Assist with elimination Monitor voiding and bowel patterns Offer ordered medications to prevent constipation and diarrhea

Nursing Interventions Physical measures Physical stimulus (cutaneous stimulation) TENS Allows client to wear an electronic device and trigger and electrical stimulation when he or she feels pain* Heat and cold application (vasodilate and vasoconstrict) *need MD order Exercise

Nursing Interventions Cognitive–behavioral measures Distraction and diversion Deep relaxation and guided imagery *Support groups and stress management Gives client an opportunity to express feelings and talk about pain with others who can relate

Alternative Techniques *Chiropractic care *Acupuncture or acupressure *Hypnosis *Biofeedback *therapeutic massage Homeopathy Use of flower essences and aromatic oils Herbal remedies

The Nursing Process Data gathering Possible nursing diagnoses Planning Implementation Evaluation