1. PROFESSOR HILL, RN, MN, MSG NURSING 102 PAIN

2. OBJECTIVES Define pain. Discuss the physiology of pain. Differentiate between acute and chronic pain. Name the types of pain. Discuss pharmacological treatment of pain. Discuss Pain Case Study in Clinical Groups 2

3. PAIN DEFINITION An unpleasant sensory & emotional experience associated with actual or potential tissue damage (Iggy, 2013) Pain is whatever the experiencing person says it is & exists whenever he or she says it does (McCaffery & Pasero, 1999) Pain is whatever the pt thinks it is at the present time 3

4. PHYSIOLOGY OF PAIN Cellular damage by thermal, mechanical, or chemical stimuli causes release of neurotransmitters. Prostaglandins, bradykinin, potassium, histamine, substance P Neurotransmitters surround the pain fibers, spreading the pain message and causing an inflammatory response. Nerve impulse travel along afferent (sensory) nerve fibers to the spinal cord.

5. TRANSMISSION OF PAIN IMPULSE

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7. PHYSIOLOGY OF PAIN (cont’d) Pain impulses ascend the spinal cord to the thalamus, which transmits information to higher brain centers that perceive pain. Two types of sensory nerve fibers: Fast myelinated A-delta fibers: send sharp, localized, distinct sensations Slow, small, unmyelinated C fibers: send poorly localized, burning, persistent pain

8. PHYSIOLOGY OF PAIN (cont’d)

9. Gate-control theory of pain (Melzack and Wall) Pain has emotional and cognitive components, in addition to a physical sensation. Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed. Closing the gate is the basis for nonpharmacological pain relief interventions.

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11. PAIN CLASSIFICATION 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

12. PROTECTIVE REFLEX TO PAIN STIMULUS

13. ACUTE VS CHRONIC PAIN Acute Pain Chronic Pain Results from noxious stimulus that activates nociceptors neuron It accompanies surgery, traumatic injury, tissue damage, and inflammatory processes Self-limited, resolves over days to wks, can last 3 mos Tx is short term & curative Results from nociceptors, visceral, or somatic It accompanies chronic dz, untreated condition Last longer than 3 mos Unresolved as long as underlying cause is present Tx is goal-oriented 13

14. 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

15. 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?” 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?”

16. FACTORS INFLUENCING PAIN (cont’d)

17. 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)www.guideline.gov Agency for Healthcare Research and Quality (AHRQ)

18. PAIN MNEMONIC P: Precipitating or palliative Q: Quality or quantity R: Region or radiation S: Severity scale T: Timing 18

19. 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)

20. SAMPLE PAIN SCALES

21. WONG-BAKER FACES SCALE

22. 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.

23. QUICK QUIZ! 1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.

24. NURSING DIAGNOSIS Activity intoleranceAnxiety Ineffective copingFatigue HopelessnessInsomniaFear Impaired physical mobility PowerlessnessChronic low self- esteem Impaired social interaction Spiritual distress Imbalanced nutrition: less than body requirements

25. 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).

26. 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

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28. IMPLEMENTATION: HEALTH PROMOTION Pharmacological pain relief Acute pain management Analgesics Nonopioids Opioids Adjuvants/co-analgesics Delivery systems Patient-controlled analgesia (PCA) Local/regional anesthesia Topical agents

29. Patient-Controlled Analgesia

30. 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.

31. 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.

32. EPIDURAL SPACE

33. QUICK QUIZ! 2. A patient has just undergone an appendectomy. When discussing with the patient several pain relief interventions, the most appropriate recommendation would be A. Adjunctive therapy. B. Nonopioids. C. NSAIDs. D. PCA pain management.

34. CHRONIC NON-CANCER AND CANCER PAIN MANAGEMENT Cancer pain may be chronic or acute. Breakthrough pain = A transient flare of moderate to severe pain superimposed on continuous or persistent pain. Transdermal pain patches may be used.

35. WHO ANALGESIC LADDER WHO, World Health Organization.

36. 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

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38. RESTORATIVE AND CONTINUING CARE Pain centers, palliative care, and hospices Pain centers treat patients on an inpatient or outpatient basis. The goal of palliative care is to learn how to live life fully with an incurable condition. Hospices are programs for end-of-life care. The American Nurses Association (ANA) supports aggressive treatment of pain and suffering even if it hastens a patient’s death.

39. QUICK QUIZ! A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when A. You compare assessed pain w/baseline pain. B. Body language is incongruent with reports of pain relief. C. Family members report that pain has subsided. D. Vital signs have returned to baseline.

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42. 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.

43. CONCLUSION Frequency & routes of adm analgesic is imp Physiological & psychological consequences if not managed effectively Nurses must learn how to properly assess pain 43