1. Introduction to Adult Health Chapter 13 Pain Management Dr
Introduction to Adult Health Chapter 13 Pain Management Dr. Ahmad Aqel 2014

2. pain
Pain: an unpleasant sensory and emotional experience resulting from actual or potential tissue damage
In 1968, McCaffery defined pain as “whatever the experiencing person says it is, existing whenever she/he says it does”.
pain is a subjective experience.
Pain management is considered as “the fifth vital sign” to emphasize its significance and to increase the awareness among health care professionals of the importance of effective pain management

3. Types of pain 1. Acute pain
Recent onset and associated with a specific injury,
Indicates that damage or injury has occurred.
Decreases as healing occurs.
Acute pain can last from seconds to 6 months.
2. Chronic pain
Constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury.
Poorly defined onset
Difficult to treat because the cause or origin may be unclear.
Lasts for 6 months or longer

4. Types of pain 3. Cancer-related pain
Pain associated with cancer may be acute or chronic.
Pain in patients with cancer can be associated with the cancer (e.g., bony infiltration with tumor cells or nerve compression), a result of cancer treatment (e.g., surgery or radiation), or not associated with the cancer (e.g., trauma).

5. Classification of pain
Pain Classified by Location
(e.g., pelvic pain, headache, chest pain). This classification may help in diagnosis and treatment of the pain.
Pain Classified by Etiology
Burn pain and post therapeutic neuralgia are examples of pain described in terms of their cause.

6. Harmful Effects of Pain
Sleep deprivation (hyposomnia (little sleep)
Fatigue
Depression
Less effective analgesia if patients experience sleep deprivation.

7. Effects of Acute Pain
Affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems.
The stress response (“neuroendocrine response to stress”) that occurs with trauma also occurs with other causes of severe pain.
The widespread endocrine, immunologic, and inflammatory changes that occur with stress can have significant negative effects.
This is particularly harmful in patients whose health is already compromised by age, illness, or injury.

8. The stress response:
Increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids.
Increase the risk of physiologic disorders (e.g., myocardial infarction, pulmonary infection, venous thromboembolism, prolonged paralytic ileus).
Unable to take deep breaths, increased fatigue and decreased mobility.

9. Effects of Chronic Pain
Suppression of the immune function
Promote tumor growth.
Depression, anger, fatigue and disability.
Required high dosages of opioid medications to relieve chronic pain

10. Pathophysiology of Pain
The sensory experience of pain depends on the interaction between the nervous system and the environment.
The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous systems.
Nociceptors
Nociception: Neurologic transmission of pain

11. Pathophysiology of Pain
Nociceptors are neuronal receptors involved in the transmission of pain perceptions to and from the brain that respond to biochemical mediators or noxious stimuli.
They are free nerve endings in the skin that respond only to intense, potentially damaging stimuli.
Such stimuli may be mechanical, thermal, or chemical in nature.
The joints, skeletal muscle, fascia, tendons, and cornea also have nociceptors with the potential to transmit stimuli that produce pain.

12. Pathophysiology of Pain
The large internal organs (viscera) do not contain nerve endings that respond only to painful stimuli.
Pain originating in these organs results from intense stimulation of receptors that have other purposes. For example, inflammation, stretching, ischemia, dilation, and spasm of the internal organs all cause an intense response in these multipurpose fibers and can cause severe pain.
Nociceptors are part of complex multidirectional path-ways. These nerve fibers branch very near their origin in the skin and send fibers to local blood vessels, mast cells, hair follicles, and sweat glands.
When these fibers are stimulated, histamine is released from mast cells, causing vasodilation. Nociceptors respond to high-intensity mechanical, thermal, and chemical stimuli.

13. Gate Control Theory
stimulation of the skin evokes nervous impulses then transmitted by three systems located in the spinal cord.
The sub stantiagelatinosa in the dorsal horn, the dorsal column fibers, and the central transmission cells act to influence nociceptive impulses.
The noxious impulses are influenced by a “gating mechanism.” Stimulation of the large-diameter fibers inhibits the transmission of pain, thus “closing the gate.” Conversely, when smaller fibers are stimulated, the gate is opened.
The gating mechanism is influenced by nerve impulses that descend from the brain.
This theory proposes a specialized system of large-diameter fibers that activate selective cognitive processes via the modulating properties of the spinal gate.

14. gate control system

15. Factors Influencing Pain Response
Past experience with pain
People who have had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have had little experience with pain.
Anxiety and Depression
Anxiety related to the pain may increase the patient’s perception of pain. Eg, the patient who was treated 2 years ago for breast cancer and now has hip pain may fear that the pain indicates metastasis

16. Factors Influencing Pain Response
Depression is associated with chronic pain
Culture
avoiding exaggerated expressions of pain, such as excessive crying and moaning; seeking immediate relief from pain; and giving complete descriptions of the pain
Gerontologic Considerations
The decrease in myelinated fibers is partly responsible for causing a decrease in expression of the major myelin proteins.
elderly people have a slower metabolism and a greater ratio of body fat to muscle mass compared to younger people, small doses of analgesic agents maybe sufficient to relieve pain, and these doses may be effective longer.

17. Factors Influencing Pain Response
Gender
Men and women are thought to be socialized to respond differently and differ in their expectations about pain.

18. Characteristics of Pain
Assess posture and presence or absence of pain behaviors.
Ask the patient to describe, in his or her own words, the specifics of the pain.
The factors to consider in a complete pain assessment are the intensity, timing, location ,quality, personal meaning of pain; aggravating and alleviating factors; and pain behaviors.

19. Instruments for Assessing the Perception of Pain

20. Factors Influencing Pain Response
Word Graphic Scale

21. Arabic version of pain rating scale
Pain Scale
مقياس الألم المرئي |__________________________________________________________________|
لا يوجد ألم
 أشد ألم ممكن
مقياس الألم الرقمي | | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10
لا يوجد ألم
خفيف
معتدل
شديد
أشد ألم ممكن
Arabic version of pain rating scale

22. Pain Scales

23. Faces Pain Scale–Revised
This instrument has six faces depicting expressions that range from contented to obvious distress
The patient is asked to point to the face that most closely resembles the intensity of his or her pain.

24. Pain management
Reducing pain to a “tolerable” level was once considered the goal of pain management.
any intervention is most successful if it is initiated before pain sensitization occurs, and the greatest success is usually achieved if several interventions are applied simultaneously.

25. Pain Management Strategies
Include both pharmacologic and non pharmacologic approaches.
PHARMACOLOGIC INTERVENTIONS
it is the nurse who maintains the analgesia, assesses its effectiveness, and reports whether the intervention is ineffective or produces side effects.

26. Agents Used to Treat Pain
Three general categories of analgesic agents are used:
opioids
NSAIDs
local anesthetics.

27. Physiologic Basis for Pain Relief Pharmacologic Interventions
Opioid analgesics act on CNS to inhibit activity of ascending nocioceptive pathways
NSAIDS decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)
Local anesthetics block nerve conduction when applied to nerve fibers

28. Opioid Analgesic Agents
The goal of administering opioids is to relieve pain and improve quality of life.
Factors that are considered in determining the route, dose, and frequency of medication include:
the characteristics of the pain (eg, its expected duration and severity)
The overall status of the patient
the patient’s response to analgesic medications
the patient’s report of pain.

29. Opioid Tolerance and Addiction
Tolerance (the need for increasing doses of opioids to achieve the same therapeutic effect).
Maximum safe opioid dosage must be individually assessed
Tolerance develops in all patients who take opioids for prolonged periods
With tolerance, increased usage needed to effect pain relief

30. Tolerance and Addiction
Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance (drug or alcohol) primarily to experience its psychic effects. (The opioids should be tapered slowly to prevent withdrawal symptoms).

31. Nonsteroidal Anti-inflammatory Drugs
decrease pain by inhibiting cyclooxygenase (COX), the enzyme involved in the production of prostaglandin from traumatized or inflamed tissues.
Check kidney function

32. Local Anesthetic Agents
Local anesthetics work by blocking nerve conduction when applied directly to the nerve fibers.
Topical Application
Intraspinal Administration

33. Pre medication Assessment
Before administering any medication
ask about allergies to medications and the nature of any previous allergic responses.
the nurse often learns that the extent of the allergy is “itching” or “nausea and vomiting.” These responses are not allergies; rather, they are side effects that can be managed.
document responses or reactions and report
Obtain the patient’s medication history (eg, current, usual, or recent use of prescription or OTC medications or herbal agents).

34. Barriers to Pain Management
Lack of Education
Accessibility of Opioids
Addiction Fears

35. Routes of Administration
parenteral,
oral,
rectal,
transdermal,
transmucosal,
intraspinal, or epidural routes. (subarachnoid [intrathecal space or spinal canal]or dura space).

36. Intrathecal and Epidural Catheter Placement

37. Placebo Effect (occurs when a person responds to the medication or other treatment because of an expectation that the treatment will work rather than because it should work).

38. Gerontologic Considerations
More likely to have adverse drug effects, drug interactions
Increased likelihood of chronic illness
May need to have more time between doses of medication due to decreased excretion, metabolism related to aging changes

39. Adverse Effects of Opioid
Respiratory Depression and Sedation.
Nausea and Vomiting.
Adequate hydration and the administration of antiemetic agents may also decrease the incidence of nausea.
Constipation.
Mild laxatives and a high intake of fluid and fiber may be effective in managing mild constipation.
Severe constipation often requires bisacodyl (Dulcolax).
Pruritus.
(itching) is a frequent side effect of opioids administered by any route, but it is not an allergic reaction. It can be relieved by administering prescribed antihistamines.

40. Local Anesthetic Agents
blocking nerve conduction when applied directly to the nerve fibers.
anesthetic spray
injection.
epidural catheter.
Topical Application
EMLA cream (lumbar puncture or the insertion of IV lines. To be effective, EMLA must be applied to the site 60 to 90 minutes before the procedure.

41. Intra spinal Administration
Intermittent or continuous administration of local anesthetic agents through an epidural catheter during surgery.
Administration of local anesthetic agents in the spinal canal is still largely confined to acute pain, such as postoperative pain and pain associated with labor and delivery.
A local anesthetic agent administered through an epidural catheter is applied directly to the nerve root.

42. Approaches for using analgesic agents
Balanced analgesia
refers to the use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects.
Pro Re Nata:(PRN), or “as needed.”
Preventive Approach
Administering analgesic medication on a timed basis, rather than on the basis of a patient’s report of pain, prevents the serum drug level from falling to sub therapeutic levels.

43. Patient-Controlled Analgesia (PCA)
(PCA) allows patients to control the administration of their own medication within predetermined safety limits.
The PCA pump permits the patient to self-administer continuous infusions of medication (basal rates) safely and to administer extra medication (bolus doses) with episodes of increased pain or painful activities.

44. NONPHARMACOLOGIC INTERVENTIONS
Massage
Massage also promotes comfort because it produces muscle relaxation.
Thermal Therapies
Application of heat increases blood flow to an area and contributes to pain reduction by speeding healing and provide some analgesia,
Transcutaneous Electrical Nerve Stimulation
(TENS) uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain.

45. NONPHARMACOLOGIC INTERVENTIONS
Distraction
focusing the patient’s attention on something other than the pain, to reduce the perception of pain
Relaxation Techniques
abdominal breathing at a slow, rhythmic rate. The patient may close both eyes and breathe slowly and comfortably.

46. NONPHARMACOLOGIC INTERVENTIONS
Guided Imagery
The nurse instructs the patient to close both eyes and breathe slowly in and out. With each slowly exhaled breath, the patient imagines muscle tension and discomfort being breathed out, carrying away pain
Hypnosis
Music Therapy

47. Surgical Intervention
Cordotomy
the division of certain tracts of the spinal cord
It may be performed percutaneously, by the open method after laminectomy, or by other techniques.
Cordotomy is performed to interrupt the transmission of pain.
Rhizotomy
Sensory nerve roots are destroyed where they enter the spinalcord. A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input. With the advent of microsurgical techniques, the complications are few, with mild sensory deficits and mild weakness.

48. The Nurse’s Role in Assessment and Care of Patients with Pain
A nurse who suspects pain in a patient who denies it should explore with the patient the reason for suspecting pain, such as the fact that the disorder or procedure is usually painful or that the patient grimaces when moving or avoids movement.
the nurse would use the patient’s words rather than the word “pain.”
Pain assessment includes determining what level of pain relief the acutely ill patient believes is needed to recover quickly or improve function, or what level of relief the chronically or terminally ill patient requires to maintain comfort.

49. Characteristics of Pain
Intensity (none to mild discomfort to excruciating.)
Timing (the nurse inquires about the onset, duration, relationship between time and intensity (eg, at what time the pain is the worst), and changes in rhythmic patterns.
Location (referred pain)
Quality (The nurse asks the patient to describe the pain in his or her own words without offering clues [burning, aching, throbbing, or stabbing ).
Personal meaning (It is important to ask how the pain affects the person’s daily life.)

50. Aggravating, alleviating factors (what, if anything, makes the pain worse and what makes it better and asks specifically about the relationship between activity and pain. This helps detect factors associated with pain.
Pain behaviors (Nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence of or the severity of pain experienced).
Physiologic responses (tachycardia, hypertension, tachypnea, pallor, diaphoresis, mydriasis, hypervigilance, and increased muscle tone, are related to stimulation of the autonomic nervous system).

51. Only the patient can accurately describe and assess his or her pain.
tools may be used
to document the need for intervention,
to evaluate the effectiveness of the intervention, and
to identify the need for alternative or additional interventions if the initial intervention is ineffective in relieving the pain.

52. Nursing care Perform pain assessment
identify goals for pain management
Provide patient teaching
perform physical care
help relieve pain by administering pain-relieving interventions (including both pharmacologic and nonpharmacologic approaches)
assess the effectiveness of those interventions
monitor for adverse effects
serve as an advocate

53. Identifying Goals for Pain Management
goals may include a decrease in the intensity, duration, or frequency of pain and a decrease in the negative effects of the pain.
as the patient progresses through the stages of recovery, increased patient use of self-management pain relief measures may be a goal.
a goal might be to decrease time lost from work, to increase the quality of interpersonal relationships, or to improve the quality of sleep.)

54. Factors affect our goal:
the severity of the pain.
the anticipated harmful effects of pain.
the anticipated duration of the pain.
The goals for the patient may be accomplished by pharmacologic or nonpharmacologic means, but most success is achieved with a combination of these methods.

55. Establishing the Nurse–Patient Relationship and Teaching
open communication and patient cooperation are essential to success.
the nurse often helps reduce the patient’s anxiety.
Teaching is equally important, because the patient or family may be responsible for managing the pain at home and preventing or managing side effects.
Teaching the patient about pain and strategies and provide information explaining how pain can be controlled (sensitization).

56. Providing Physical Care
Patients in pain may be unable to participate in the usual activities of daily living or to perform usual self-care and may need assistance to carry out these activities.
A fresh gown and change of bed linens, along with efforts to make the person feel refreshed (eg, brushing teeth, combing hair), often increase the level of comfort and improve the effectiveness of the pain relief measures.
to identify problems that may contribute to the patient’s discomfort and pain. Appropriate and gentle physical touch during care may be reassuring and comforting.
If topical treatments such as patches or intravenous (IV) are used, the skin around the patch or catheter should be assessed for integrity during physical care.

57. Managing Anxiety Related to Pain
A patient who is anxious about pain may be less tolerant of the pain, which in turn may increase his or her anxiety level.
Teaching the patient about the nature of the impending painful experience and the ways to reduce.
explain the degree of pain relief that can be expected from each measure.
Pain relief measures should be used before pain becomes severe.

58. Nursing Process Framework for Pain Management
Identify goals for pain management
Establish nurse-patient relationship, teaching
Provide physical care
Manage anxiety related to pain
Evaluate pain-management strategies

59. Relief of pain, evidenced when the patient
• Rates pain at a lower intensity (on a scale of 0 to 10) after intervention
• Rates pain at a lower intensity for longer periods
Minimal effects of pain and minimal side effects of interventions, evidenced when the patient:
• Participates in activities important to recovery (eg, drinking fluids, coughing, ambulating)
• Participates in activities important to self and to family (eg, family activities, interpersonal relationships, parenting, social interaction, recreation, work)
• Reports adequate sleep and absence of fatigue and constipation