1. Caring for Clients in Pain8
Caring for Clients in Pain

2. Learning Outcomes Describe the physiology of pain.
Identify the characteristics of acute, chronic, cancer, neuropathic, and psychogenic pain.
Identify factors that may affect a client’s response to pain.

3. Learning Outcomes
Discuss the interdisciplinary care for the client in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies.
Describe nonpharmacologic interventions clients may use in reducing or relieving pain.

4. Learning Outcomes
Describe pain rating scales and their use in assessing pain.
Use the nursing process in care of clients experiencing pain.
Explain the nurse’s role in administering medications to reduce or relieve pain.

5. Pain
“Whatever the person experiencing it says it is, and existing whenever the person says it does.”
All pain should be considered real
A subjective response to physical and psychologic stressors
Affected by biologic, psychologic, cognitive, social, cultural, and spiritual factors
Most common reason for seeking health care

6. Factors Affecting Pain Perception and Management
Lack of understanding about pain management
Fear of addiction
Positive or negative bias by nurse
Subjective response that may impair judgment

7. Pain as Fifth Vital Sign
Pain should be routinely assessed (American Pain Society)
Standards for pain management developed by
Agency for Health Care Policy and Research
The Joint Commission for the Accreditation of Healthcare Organizations

8. Physiology of Pain Tissue damage → inflammation ↓ bradykinin and
prostaglandins → nociceptors
Nociceptors are nerve endings that are activated by painful stimuli

10. Figure 8-1 Pain conduction
Figure Pain conduction. (A) Transduction: Cutaneous nociceptors send impulses to spinal cord. (B) Transmission: Impulses synapse in the substantia gelatinosa. (C) Perception: Pain impulses processed in the thalamus and cerebral cortex. (D) Modulation: Along efferent fibers from cerebral cortex to substantia gelatinosa, pain may be inhibited or modulated.

11. Pain Conduction Transduction
Change of noxious stimulus into electrical action potential stimulus
Sends impulses transmitted by afferent A-delta fibers and small C nerve fibers throughout central nervous system
A fibers rapid, defined pain sensations (acute pain)
C fibers slow, diffuse, dull, aching pain (chronic pain)
Transmission
Sending impulses from afferent neurons to spinal cord
Substance-P sends impulse across synapse to travel to brain

12. Pain Conduction Perception
Processing of pain impulse in thalamus and cerebral cortex
Pain threshold—point at which pain is recognized
Pain tolerance—amount and duration of pain person can stand before seeking relief
Modulation
Body attempts to decrease perception of pain
Endorphins bind with opiate receptors and inhibit release of substance-P

13. Gate-Control Theory Pain impulse travels from skin to spinal cord
Stimulation of large and small nerve fibers can open or block the pain transmission to the brain

14. Acute Pain Types of Acute Pain Temporary, lasts less than 6 months
Sudden, localized - has an identified cause, caused by tissue injury
Has physical responses
Types of Acute Pain
Cutaneous pain
Injury to skin or superficial tissue
Sharp, burning, cutting, well localized
Deep Somatic pain
Injury to deep body structures
Dull, diffuse
Visceral pain
Injury to body organs
Deep, dull, poorly localized

15. Types of Acute Pain Referred pain
Starts at one site but is perceived in another site

16. Chronic Pain Neuropathic Pain: Psychogenic Pain:
Prolonged, lasts more than 6 months
May not have identifiable cause; unresponsive to conventional medical treatment; malignant or nonmalignant
Has psychologic responses – depression, withdrawal, irritable
Neuropathic Pain:
Caused by damage to central nervous system or peripheral nerves; burning or tingling sensation
Allodynia - results from stimulus usually not causing pain
Phantom pain - Itching, tingling, pressure, or burning, stabbing sensations in absent limb
Psychogenic Pain:
Emotional rather than physical causes

18. Factors Affecting Client Response to Pain
Age – older clients generally have one chronic disease
Sociocultural factors
Emotional status – relaxation, guided imagery
Past perception with pain – anxiety ↑ pain
Meaning of pain – etiology, prognosis, 2nd pain
Knowledge deficit – process and plan of care

19. Medications Used in Pain Management
Analgesics
Opioids – agonists, agonist-antagonists
Nonopioids – Tylenol and NSAIDS
Adjuvant Analgesics
Anticonvulsants – Neurontin, Tegretol
Antidepressants – Elavil, Senequan
Systemic anesthetics - Bupivicain
Corticosteroids - Decadron
Psychostimulants - Ritalin

20. Routes of Medication Administration
Oral
Rectal
Transdermal
Intramuscular
Intravenous
Subcutaneous
Intraspinal (intrathecal)
Nerve block

22. TABLE 8-4 (continued) Equianalgesic Dosage Chart.

23. Pain Relief Surgeries Cordotomy – abdominal, leg pain, CA Neurectomy
Sympathectomy – lumbar, cervical
Rhizotomy – head, neck, lungs

24. Alternative Pain Relief
Transcutaneous Electrical Nerve Stimulation (TENS)

25. Complementary Therapies for Pain Relief
Acupuncture
Biofeedback
Relaxation – diaphragmatic breathing, progressive relaxation, guided imagery, meditation
Distraction
Hypnotism
Cutaneous stimulation – massage, heat and cold (Table 8-5)

27. Nursing Process in Pain Management
Assessment of pain and client’s perception of pain
Use pain-rating scale (next slide)
Diagnosing, planning, and implementing
Explore misconceptions
Consider priorities of care
Prevent side effects – NSAIDS v. Narcotics

28. Pain Rating Scales Color scales Numeric scales from 0 to 10
Word descriptor scale
Wong-Baker Faces Pain Rating Scale

29. Responses to Pain Physiologic (p. 161) Behavioral
Sympathetic nervous system responses
Muscle tension, ↑ HR, ↑ BP, shallow RR, sweating, pallor, dilated pupils
Behavioral
May result from cultural factors, coping skills, fear, denial
May use relaxation or distraction
Addiction, physical dependence
*Interdisciplinary – medications, complementary, hospice, surgery,

30. Misconceptions About Pain Management
People who frequently ask for opioid pain medications are addicted.
It is best to wait until a client has pain before giving medication.
Postoperative pain is best treated with intramuscular injections.

31. Misconceptions About Pain Management
It is dangerous to give an opioid and a NSAID at the same time.
Opioid medication is too risky to be used in chronic pain.

33. BOX 8-2 (continued) ASSESSMENT

34. Nursing Process in Pain Management
Evaluating
Determine effectiveness of pain management strategies
Give teaching points in writing to client
Make referrals as needed