Chapter 43 Pain Management NRS_105/320_Collings

Importance Pain management is a primary nursing responsibility Nurse have a legal and ethical duty to control/relieve pain Pain relief is a basic human right Patients need to know we CAN and WILL relieve their pain NRS_105/320_Collings

Why? Effective pain management: Improves quality of life Reduces disability Promotes early mobility and return to work Results in less hospital / office visits Reduces length of stay, complications Reduces health care cost Improves patient satisfaction NRS_105/320_Collings

Nature of Pain Physical Emotional Cognitive Subjective NRS_105/320_Collings

Physiology of Pain Transduction Transmission Thermal,chemical,mechanical stimulation → electrical impulse in nerve fiber Transmission A fibers: sharp, localized, distinct sensation C fibers: generalized, persistent sensation E.g. Burn finger – spot pain → ache Peripheral → spinal → brain NRS_105/320_Collings

Physiology of Pain Perception Modulation Brain interprets impulse, perceives as pain Experience, memory, context, knowledge Ascribes meaning to sensation Modulation Body response Endogenous opiods, serotonin, norepinephrine, GABA ↓ transmission of impulse, analgesic effect These deplete over time with continued pain NRS_105/320_Collings

Gate-Control Theory of Pain Gating mechanisms along the CNS Can block transmission of impulses Pain relief measures to close the gate Light touch [effleurage] Pain threshold Level at which you feel pain Genetic, learned, Runner’s high, endogenous opiods Individual – not transferrable! NRS_105/320_Collings

Physiological Response to Pain Mild – moderate pain [1-6] superficial → autonomic response [sympathetic]; fight or flight, general adaptation ↑HR, RR, B/P, BG, diaphoresis, peripheral vasoconstriction Severe or deep [7-10], visceral pain → parasympathetic response ↓ HR, B/P, muscle tension, immobility, irreg resp may cause harm Physiologic response [VS] is short-term; VS are not reliable pain indicators over time NRS_105/320_Collings

Behavioral responses to Pain Dependent on context, meaning, culture, pain tolerance It is supposed to hurt Men don’t cry I don’t want to be a complainer, bother Nonverbal indicators Body movements; restless or still, holding, guarding Facial expression; grimace, frown, clenched teeth, posture, Lack of expression of pain does not mean it isn’t there! NRS_105/320_Collings

Goal is to control pain so patient can participate in recovery Types of Pain Acute pain Protective, identifiable cause, short duration, limited tissue damage, ↓ emotional response Causes harm by ↓ mobility, energy Goal is to control pain so patient can participate in recovery ↓ Pain → ↑Mobility → decreased complications, decreased length of stay NRS_105/320_Collings

Types of Pain Chronic pain Pseudoaddiction: seeking pain relief Serves no purpose [not protective] Lasts longer than anticipated May or may not have an identifiable cause Impacts every part of patient’s life Depression, Suicide Disability, isolation, energy drain, ADL’s Pseudoaddiction: seeking pain relief not drug-seeking NRS_105/320_Collings

Types of Pain Cancer pain Pain by inferred pathology Idiopathic pain May be acute or chronic, constant or episodic, mild to severe Up to 90% of Ca pts have pain Pain by inferred pathology Known cause = characteristic pain [neuropathic] Idiopathic pain No known cause BUT still pain “Excessive” pain for a condition NRS_105/320_Collings

Knowledge, Attitudes, and Beliefs Subjective nature of pain Pain is what the patient says it is, not what the nurse thinks it should be Same procedure, different pain Expectations, context, culture affect perception and expression of pain NRS_105/320_Collings

Knowledge, Attitudes, and Beliefs Nurse’s Response to Pain Bias ‘I go to work with 5/10 pain every day’ ‘Its only a minor surgery’ ‘I had three kids and didn’t scream’ Fallacies Infants don’t feel pain like we do Regular pain med use causes addiction Older people all are in pain NRS_105/320_Collings

Factors Influencing Pain Physiological Age – interpretation/communication Fatigue increases pain, sleep not sign pain is relieved Genes Pain threshold Neurological function Interpretation, communication, reflex NRS_105/320_Collings

Factors Influencing Pain Social Attention/ distraction Previous experience May increase or decrease tolerance Family and social support Spiritual Meaning of pain, suffering Support system NRS_105/320_Collings

Factors Influencing Pain Psychological Anxiety Coping style Control [PCA] Cultural Meaning of pain Expression of pain Role in Family Ethnicity NRS_105/320_Collings

Assessment of Pain Client’s expression of pain Characteristics of pain Description is most valid indicator Characteristics of pain Onset and duration Location Intensity Quality Pattern NRS_105/320_Collings

Assessment of Pain Characteristics of pain (cont'd) Relief measures Contributing symptoms Behavioral effects on the client Influences on ADLs Client expectations What pain level would allow you to function well? [walk the hall, do ADL’s, resume job…] NRS_105/320_Collings

Assessment Can we do a full assessment of pain when the client is in severe pain? No! Alleviate severe [7-10] pain before talking it to death Pain rated >7 needs immediate attention NRS_105/320_Collings

Nursing Diagnoses Anxiety Ineffective coping Fatigue Acute pain Chronic pain Ineffective role performance Disturbed sleep pattern NRS_105/320_Collings

Planning Goals and outcomes Setting priorities Client is using pain relief measures safely Pain level reported at </=___ and congruent nonverbal behaviors seen Demonstrate understanding of need to premedicate before activity Splint abdomen with cough Setting priorities What is important for the client? What does he need to do? Control pain enough to eat, sleep? Be mobile to prevent complications? Work? PT? Maintain dignity, relationships while dying? Maslow: Pain relief is basic need NRS_105/320_Collings

Implementation: Health Promotion Client education Expectations, when to seek treatment Preparation before pain Holistic care Whole self; physical, emotional, spiritual Education, rest, exercise, nutrition, relationships NRS_105/320_Collings

Nonpharmacological Pain Relief Relaxation and guided imagery Distraction Biofeedback Cutaneous stimulation—massage, application of hot/cold, TENS Herbals Reducing painful stimuli and perception NRS_105/320_Collings

Controlling Painful Stimuli Managing the client’s environment—bed, linens, temperature Positioning Changing wet clothes and dressings Monitoring equipment, bandages, hot and cold applications Preventing urinary retention and constipation NRS_105/320_Collings

Implementation Pain Management Pharmacological pain relief … Administer analgesics as ordered/ reassess pain in 30 minutes and hourly Analgesics: NSAIDs and nonopioids, opioids, adjuvants Patient-controlled analgesia (PCA) Local analgesic infusion pump Topical analgesics and anesthetics Local and regional anesthetics NRS_105/320_Collings

Implementation Pain Management Surgical interventions Procedural pain management Chronic and cancer pain management NRS_105/320_Collings

Implementation Pain Management Barriers to effective pain management [pts, nurses, doctors, system…] Fear of addiction - #1 barrier Terms: Dependence: physical adaptation resulting in withdrawal symptoms tolerance: physical adaptation resulting in diminished drug effect over time Addiction: impaired control over use, use despite harm pseudoaddiction: drug seeking behavior to relieve undertreated pain NRS_105/320_Collings

Implementation Pain Management Nursing implications for pain management Accurate safe medication administration Assess effectiveness and side effects Patient education [families too] Use the appropriate drug when given a choice Treat pain before it gets severe NRS_105/320_Collings

Implementation: Restorative Care Pain clinics Palliative care Hospices NRS_105/320_Collings

Evaluation Effectiveness Side effects Document and communicate Assess at peak of drug effect [30 minutes IV, 1 hour PO] Add complementary therapies for partial effect Talk with M.D. about options if approach is consistently ineffective Side effects Document and communicate Most effective relief NRS_105/320_Collings

Evaluation Client expectations Did client achieve goal? Validate experience Relieve the pain Show you care Did client achieve goal? Walk hall w/o pain? Pain < 3/10 all day [except with PT] Able to return to work, enjoy visit, T,C,&DB? Pain report congruent with nonverbal? NRS_105/320_Collings