1. Pain Management B260: Fundamentals of Nursing

2. Goals for This Concept Presentation 1.Define and describe the concept. 2.Notice risk factors for experiencing pain. 3.Recognize when an individual has pain. 4.Provide appropriate nursing and collaborative interventions to effectively manage pain.

3. Definition Pain is whatever the experiencing person says it is, existing whenever he says it does (McCaffery, 1968) The patient report is the most reliable indicator of pain

4. Types of Pain Acute/transient pain Protective, identifiable, short duration Chronic/persistent Is not productive and has no purpose or may not have identifiable cause Chronic episodic Occurs sporadically over an extended duration Cancer Can be acute or chronic Inferred physiological Musculoskeletal, visceral, or neuropathic Idiopathic Chronic pain without an identifiable physical or psychological cause

5. Individual Risk Factors Learning #1 Brainstorm and identify three to four of what you believe are the most painful examples of each category.  Chronic conditions  Acute or traumatic injury  Medical procedures

6. Factors Influencing Pain PhysiologicalPhysiological –Age, fatigue, genes, neurological function SocialSocial –Attention, previous experiences, family and support groups PsychologicalPsychological –Anxiety, coping style Cultural/SpiritualCultural/Spiritual –Meaning of pain, ethnicity 6

7. Consequences of Untreated Pain

8. Risk Factors: Population at Greatest Risk Learning #2 Think about the following:  As a population group, older adults are at greatest risk for pain. What factors contribute to this risk?  Individuals who are unable to communicate are at risk for experiencing pain and have poor pain management. Why is this?

9. Elements of Pain Assessment Patient self-report of pain Location Intensity Quality Onset and duration Alleviating or relieving factors Effect of pain on quality of life and functional status Comfort and function goal

10. Pain Scale 10

11. Behavioral Signs of Pain Facial expressions Restlessness Change in activity Crying

12. Pain Assessment Learning #3 Think about the following:  How does the nurse assess for breakthrough pain?  How/When does the nurse conduct a pain reassessment?  What are common challenges with pain assessment?

13. Pain Assessment Here is a good depiction of a pain history assessment and educating the patient on expectations. https://www.youtube.com/watch?v=kBzzvs Q_B7Mhttps://www.youtube.com/watch?v=kBzzvs Q_B7M

14. CLINICAL MANAGEMENT

15. Clinical Management: Hierarchy of Pain Measures  Obtain patient self-report  Consider patient condition or exposure to painful procedures  Observe for behavioral signs of pain  Evaluate psychological indicators

16. Pharmacological Pain Meds 16

17. Pharmacological Pain Relief AnalgesicsAnalgesics –Non-opioids –Opioids (Narcotics) –Adjuvants/co-analgesics Administration routesAdministration routes –PCA –Local/regional anesthesia –Topical agents

18. Pharmacological Pain Relief PCA (Patient Controlled Analgesia) –Patient determines amount needed up to a set amount –Teach Family NOT to push the button for the patient

19. Clinical Management: Nonpharmacologic Interventions Massage Distraction Music Positioning and body alignment Splinting Thermal interventions (heat and cold) Mind–body therapies –Relaxation and Guided Imagery

20. Clinical Management Implementing scheduled pain medicine around the clock to manage severe pain –Surgical Pain –Hospice –Acute Trauma

21. Case Study Mrs. Ellis is a 70-year-old African American woman with hypertension, diabetes, and rheumatoid arthritis. Her current health priority is the discomfort and disability associated with her rheumatoid arthritis. Arthritis has severely deformed her hands and feet. The pain in her feet is so severe that she often walks only short distances. The pain interferes with sleep and reduces her energy both physically and emotionally. As a result, she does not leave home often.

22. Case Study (cont’d) Jim is a 26-year-old nursing student assigned to do home visits with the community health nurse. Jim knows that Mrs. Ellis has lived alone since her husband’s death 6 years ago. Jim conducts assessments, performs procedures, and teaches health promotion to a variety of patients. This is Jim's first experience caring for a patient with severe chronic pain. In preparing for the visit, what does Jim need to do?

23. Case Study (cont’d) When Jim enters Mrs. Ellis’ four-room apartment, he finds the home in disarray. Mrs. Ellis is sitting in a recliner in her living room, with clothing on the floor and soiled dished on a nearby table. She reports that the pain she has been experiencing has made it very difficult to use her hands and walk between rooms. She is able to get to the bathroom, but it causes her to become fatigued. Her pain is constant and is localized in the joints of her hands and knees. What assessment activities would you perform if you were Jim?

24. Case Study (cont’d) Mrs. Ellis’ responses lead Jim to this nursing diagnosis: chronic pain related to joint inflammation. Mrs. Ellis has rated the pain as a 3 on a FACES Pain Scale of 0 to 10, with her most severe pain as a 4. She has been taking aspirin, but the pain prevents her from falling asleep; if she does sleep, she often reawakens. She has difficulty standing and an unsteady gait. What are possible goals and expected outcomes?

25. Case Study (cont’d) Jim discussed with Mrs. Ellis’ primary health care provider the possibility of starting a disease-modifying antirheumatic drug (DMARD), a biological response modifier, a nonsteroidal anti- inflammatory drug (NSAID), or an analgesic. Jim had Mrs. Ellis take analgesics approximately 30 minutes before ambulating, performing self-care activities, or going to sleep. He instructed her to take medication with a light snack or meal and a full glass of water. During instruction, he explained that the drug will relieve the pain. What is the rationale for using more than one type of pain medication? What is the rationale for having Mrs. Ellis take the analgesics ahead of activities?

26. Case Study (cont’d) Jim also suggested the following to Mrs. Ellis: –Place a sturdy stool in the shower stall and run warm water continuously over joints of the hands and feet. –Apply moist, warm compresses to the joints of the hands 3 times a day. –Referral to a physical therapist to determine possible use of a walker or other assistive device What are the rationales for these additional measures?

27. Case Study (cont’d) When Jim observed Mrs. Ellis’ ability to stand and walk from the living room to the kitchen, she was able to ambulate with the walker; her gait was slow but steady. Mrs. Ellis reports that she has less discomfort from bathing after using warm water over her joints, although dressing is still causing some discomfort when manipulating buttons. Mrs. Ellis rates her pain at a 2 after taking the analgesic.

28. Case Study (cont’d) Two weeks after his last visit, Jim returns to evaluate Mrs. Ellis’ progress. She has gone to see a nurse practitioner, who prescribed an NSAID for her arthritic pain. She has not filled the prescription and is still taking her aspirin, but continues to have some gastrointestinal irritation. Jim gets the chance to observe Mrs. Ellis using a warm compress on her hands and notes that her gait is steadier. Mrs. Ellis has spoken with her neighbor, who has offered to help with shopping.