Care of the Patient With Pain Chapter 7 Care of the Patient With Pain

Theory objectives Demonstrate an understanding of the current view of pain as a specific entity requiring appropriate intervention Review the gate control theory of pain and its relationship to nursing care Compare nociceptive and neuropathic pain and the nursing care for each Explain how pain perception is affected by personal situations and cultural backgrounds Describe the false perception that underlies many current ideas about pain and pain management List different pharmacologic approaches to pain management Analyze the differences between acute and chronic pain

Clinical Practice Objectives Effectively utilize the nursing process for pain management Use appropriate pain evaluation tools for a variety of patients Recognize common side effects of analgesics Employ non-pharmacologic approaches to pain maanagement

Theories of Pain Pain can be defined as an neurologic response to an unpleasant stimuli Pain receptors are abundant throughout the skin and in many deeper structures throughout the body Pain results from a release of chemicals from damaged cells Gate Control Theory-when the gate is opened the pain sensation is allowed through, when the gate is closed pain sensations are blocked-extreme pain sensations can still pass through

Theories of Pain Gate Control Theory and the Nursing Practice 2 types of nerve fibers carry pain stimuli-small and large diameter Activity in small diameter nerve fibers seems to open the gate, and activity in larger diameter fibers close the gate. Massage and vibrations cause activity in the large diameter fibers High levels of sensory input create brain stem impulses that close the gate-distraction activities Increase anxiety opens gate and decreased anxiety closes it

Theories of Pain Endorphins-produced by the body (endogenous morphine) that can attach to a pain receptor and block pain sensations.

Classification of Pain Two physiologic classifications of pain Nociceptive-associated with pain stimuli from either (somatic)body tissue or organs (visceral) Pain arises from injury to tissues where pain receptors are located (skin, bones, joints, muscles) 4 phases of pain associated with nociceptive pain Transduction Transmission Perception Modulation

Four Phases of Nociceptive Pain Transduction-tissue damage causes the release of substances that stimulate the nociceptors and initiate the sensation of pain Transmission-involves movement od the pain sensation to the spinal cord Perception-occurs when impulses reach the brain and the pain is recognized Modulation-occurs when neurons in the brain send signals back down the spinal cord by release of neurotransmitters

Nursing Implication of Nociceptive Pain Directed at one of the four phases NSAIDS and antiinflammatories block the production of substances that trigger the nociceptors with the transmission phase Opioids interfere with the transmission phase Drugs that block the neurotransmitter uptake work on the modulation stage Non- pharmacologic treatments-work on th perception phase

Neuropathic Pain Associated with a dysfunction of the nervous system that involves an abnormality in the processing of sensations These dysfunctions in the nervous system are often associated with medical conditions rather than tissue damage Neuropathic pain may be a result of damage to nerve roots such as compression or entrapment The pain signal that would normally move away from the periphery towards the brain reverses and the signal is sent in the opposite directions-phantom pains/amputation

Neuropathic Pain Nursing Implications Analgesics and opioids do not relieve neuropathic pain Adjunct medications such as NDAIDS, tricyclic, antidepressants, anticonvulsants, and corticosteroids relieve neuropathic pain

Pain Threshold Point at which pain is perceived Relaxation and distraction can alter the perception of pain

Pain Tolerance The length of time or the intensity of pain a person will endure before outwardly responding to it Tolerance varies among people and is influenced by culture, pain experience, expectations, and role behavior

Physiologic Response to pain Can cause a variety of physiologic responses including: Increased RR, pulse, BP Muscle tension Sweating Flushing or pallor Frowning, grimacing, or groaning NB: Note abscence of these symptoms does not indicate absence of pain

Cultural Considerations to Pain Cultural background influences feeling about pain Role-western societies male-high pain threshold Some cultures promote enduring pain is honorable or natural Acceptance without judgment

Acute Versus Chronic Pain Acute pain: Duration-hours to days Relief-good, responds to analgesics Causes-relatively easy to identify Psychosocial effects-transient, temp disrupt activities Effects of therapy-meds usually beneficial Chronic pain: Months to years Poor unless complicating factors remove Can be complex or undetermined Can affect ADL Meds may help, but patients may become dependent/surgery

Elder Considerations Pain perception does not diminish with age Elderly have chronic pain Common conditions causing pain-osteoarthritis, back pain, joint pain More accurate assessment of pain is obtained when several pain scales are used Reduced tolerance for medications Diminished muscle and fatty tissue for IM injections Stroke patients and diabetic patients have areas of lost or diminished sensation

Assessment Appearance Behavior Activity level Verbalization Physiologic clues

Pain Scales

Pain Scales

Barriers to Collecting Pain Information Language Cultural considerations Hearing loss Speech

Planning Goal-relief of pain Actions that promote pain relief and promote comfort Team approach Pharmacologic and non-pharmacologic approaches Pain management need-family, situation, cultural considerations, financial constraints, nature of pain acute or chronic

Implementation Reassess Appropriate interventions Adjunct measures Teaching Prevent complications of treatment- document allergies, known reactions, accurate recording of interventions and responses Patient teaching education Monitor effects/side effects

Evaluation Assess before and after interventions Oral medications-take up to one hour to have effect IM-45-60 minutes IV- effective within 15-30 minutes Documentation: Initial assessment Location Duration Method (scale) Aggravating factors Alleviating factors Interventions Evaluation of effectiveness

Advances in Pain Management Surgically implanted medication pumps and nerve stimulators Dorsal column stimulators Epidural injections

Nursing Responsibilities 6 RIGHTS/safe administration and monitoring of medication Monitoring side effects Accurate documentation Community care Extended care

Non-pharmacologic and Complimentary Approaches Non-pharmacologic-sleep, heat/cold, relaxation, distraction, guided imagery, massage, acupuncture Complimentary-relaxation, aromatherapy, massage, yoga, hypnosis, meditation

References deWit, S. (2013). Medical-surgical nursing: Concepts & practice. 2nd ed. St Louis: Saunders Elsevier