1. Care of the Patient With Pain
Chapter 7
Care of the Patient With Pain

2. Theory objectives
Demonstrate an understanding of the current view of pain as a specific entity requiring appropriate intervention
Review the gate control theory of pain and its relationship to nursing care
Compare nociceptive and neuropathic pain and the nursing care for each
Explain how pain perception is affected by personal situations and cultural backgrounds
Describe the false perception that underlies many current ideas about pain and pain management
List different pharmacologic approaches to pain management
Analyze the differences between acute and chronic pain

3. Clinical Practice Objectives
Effectively utilize the nursing process for pain management
Use appropriate pain evaluation tools for a variety of patients
Recognize common side effects of analgesics
Employ non-pharmacologic approaches to pain maanagement

4. Theories of Pain
Pain can be defined as an neurologic response to an unpleasant stimuli
Pain receptors are abundant throughout the skin and in many deeper structures throughout the body
Pain results from a release of chemicals from damaged cells
Gate Control Theory-when the gate is opened the pain sensation is allowed through, when the gate is closed pain sensations are blocked-extreme pain sensations can still pass through

5. Theories of Pain Gate Control Theory and the Nursing Practice
2 types of nerve fibers carry pain stimuli-small and large diameter
Activity in small diameter nerve fibers seems to open the gate, and activity in larger diameter fibers close the gate. Massage and vibrations cause activity in the large diameter fibers
High levels of sensory input create brain stem impulses that close the gate-distraction activities
Increase anxiety opens gate and decreased anxiety closes it

6. Theories of Pain
Endorphins-produced by the body (endogenous morphine) that can attach to a pain receptor and block pain sensations.

7. Classification of Pain
Two physiologic classifications of pain
Nociceptive-associated with pain stimuli from either (somatic)body tissue or organs (visceral)
Pain arises from injury to tissues where pain receptors are located (skin, bones, joints, muscles)
4 phases of pain associated with nociceptive pain
Transduction
Transmission
Perception
Modulation

8. Four Phases of Nociceptive Pain
Transduction-tissue damage causes the release of substances that stimulate the nociceptors and initiate the sensation of pain
Transmission-involves movement od the pain sensation to the spinal cord
Perception-occurs when impulses reach the brain and the pain is recognized
Modulation-occurs when neurons in the brain send signals back down the spinal cord by release of neurotransmitters

9. Nursing Implication of Nociceptive Pain
Directed at one of the four phases
NSAIDS and antiinflammatories block the production of substances that trigger the nociceptors with the transmission phase
Opioids interfere with the transmission phase
Drugs that block the neurotransmitter uptake work on the modulation stage
Non- pharmacologic treatments-work on th perception phase

10. Neuropathic Pain
Associated with a dysfunction of the nervous system that involves an abnormality in the processing of sensations
These dysfunctions in the nervous system are often associated with medical conditions rather than tissue damage
Neuropathic pain may be a result of damage to nerve roots such as compression or entrapment
The pain signal that would normally move away from the periphery towards the brain reverses and the signal is sent in the opposite directions-phantom pains/amputation

11. Neuropathic Pain Nursing Implications
Analgesics and opioids do not relieve neuropathic pain
Adjunct medications such as NDAIDS, tricyclic, antidepressants, anticonvulsants, and corticosteroids relieve neuropathic pain

12. Pain Threshold Point at which pain is perceived
Relaxation and distraction can alter the perception of pain

13. Pain Tolerance
The length of time or the intensity of pain a person will endure before outwardly responding to it
Tolerance varies among people and is influenced by culture, pain experience, expectations, and role behavior

14. Physiologic Response to pain
Can cause a variety of physiologic responses including:
Increased RR, pulse, BP
Muscle tension
Sweating
Flushing or pallor
Frowning, grimacing, or groaning
NB: Note abscence of these symptoms does not indicate absence of pain

15. Cultural Considerations to Pain
Cultural background influences feeling about pain
Role-western societies male-high pain threshold
Some cultures promote enduring pain is honorable or natural
Acceptance without judgment

16. Acute Versus Chronic Pain
Acute pain: Duration-hours to days Relief-good, responds to analgesics Causes-relatively easy to identify Psychosocial effects-transient, temp disrupt activities Effects of therapy-meds usually beneficial Chronic pain: Months to years Poor unless complicating factors remove Can be complex or undetermined Can affect ADL Meds may help, but patients may become dependent/surgery

17. Elder Considerations Pain perception does not diminish with age
Elderly have chronic pain
Common conditions causing pain-osteoarthritis, back pain, joint pain
More accurate assessment of pain is obtained when several pain scales are used
Reduced tolerance for medications
Diminished muscle and fatty tissue for IM injections
Stroke patients and diabetic patients have areas of lost or diminished sensation

18. Assessment Appearance Behavior Activity level Verbalization
Physiologic clues

19. Pain Scales

20. Pain Scales

21. Barriers to Collecting Pain Information
Language
Cultural considerations
Hearing loss
Speech

22. Planning Goal-relief of pain
Actions that promote pain relief and promote comfort
Team approach
Pharmacologic and non-pharmacologic approaches
Pain management need-family, situation, cultural considerations, financial constraints, nature of pain acute or chronic

23. Implementation Reassess Appropriate interventions Adjunct measures
Teaching
Prevent complications of treatment- document allergies, known reactions, accurate recording of interventions and responses
Patient teaching education
Monitor effects/side effects

24. Evaluation Assess before and after interventions
Oral medications-take up to one hour to have effect
IM minutes
IV- effective within minutes
Documentation:
Initial assessment
Location
Duration
Method (scale)
Aggravating factors
Alleviating factors
Interventions
Evaluation of effectiveness

25. Advances in Pain Management
Surgically implanted medication pumps and nerve stimulators
Dorsal column stimulators
Epidural injections

26. Nursing Responsibilities
6 RIGHTS/safe administration and monitoring of medication
Monitoring side effects
Accurate documentation
Community care
Extended care

27. Non-pharmacologic and Complimentary Approaches
Non-pharmacologic-sleep, heat/cold, relaxation, distraction, guided imagery, massage, acupuncture Complimentary-relaxation, aromatherapy, massage, yoga, hypnosis, meditation

28. References
deWit, S. (2013). Medical-surgical nursing: Concepts & practice. 2nd ed. St Louis: Saunders Elsevier