Download Chronic pain

Chapter 43
Pain Management
NRS_105/320_Collings
Importance
• Pain management is a primary nursing
responsibility
• Nurse have a legal and ethical duty to
control/relieve pain
• Pain relief is a basic human right
• Patients need to know we CAN and WILL
relieve their pain
NRS_105/320_Collings
Why?
• Effective pain management:
–
–
–
–
–
–
–
Improves quality of life
Reduces disability
Promotes early mobility and return to work
Results in less hospital / office visits
Reduces length of stay, complications
Reduces health care cost
Improves patient satisfaction
NRS_105/320_Collings
Nature of Pain
•
•
•
•
Physical
Emotional
Cognitive
Subjective
NRS_105/320_Collings
Physiology of Pain
• Transduction
• Thermal,chemical,mechanical stimulation
• → electrical impulse in nerve fiber
• Transmission
• A fibers: sharp, localized, distinct sensation
• C fibers: generalized, persistent sensation
– E.g. Burn finger – spot pain → ache
• Peripheral → spinal → brain
NRS_105/320_Collings
Physiology of Pain
• Perception
– Brain interprets impulse, perceives as pain
– Experience, memory, context, knowledge
– Ascribes meaning to sensation
• Modulation
– Body response
• Endogenous opiods, serotonin, norepinephrine, GABA
• ↓ transmission of impulse, analgesic effect
– These deplete over time with continued pain
NRS_105/320_Collings
Gate-Control Theory of Pain
• Gating mechanisms along the CNS
– Can block transmission of impulses
• Pain relief measures to close the gate
– Light touch [effleurage]
• Pain threshold
– Level at which you feel pain
• Genetic, learned,
• Runner’s high, endogenous opiods
• Individual – not transferrable!
NRS_105/320_Collings
Physiological Response to Pain
• Mild – moderate pain [1-6] superficial
→ autonomic response [sympathetic];
• fight or flight, general adaptation
• ↑HR, RR, B/P, BG, diaphoresis, peripheral
vasoconstriction
• Severe or deep [7-10], visceral pain
→ parasympathetic response
• ↓ HR, B/P, muscle tension, immobility, irreg resp
• may cause harm
– Physiologic response [VS] is short-term;
– VS are not reliable pain indicators over time
NRS_105/320_Collings
Behavioral responses
to Pain
• Dependent on context, meaning, culture, pain
tolerance
– It is supposed to hurt
– Men don’t cry
– I don’t want to be a complainer, bother
• Nonverbal indicators
– Body movements; restless or still, holding, guarding
– Facial expression; grimace, frown, clenched teeth, posture,
• Lack of expression of pain does not mean it
isn’t there!
NRS_105/320_Collings
Types of Pain
• Acute pain
– Protective, identifiable cause, short
duration, limited tissue damage, ↓
emotional response
– Causes harm by ↓ mobility, energy
Goal is to control pain so patient can
participate in recovery
↓ Pain → ↑Mobility → decreased
complications, decreased length of stay
NRS_105/320_Collings
Types of Pain
• Chronic pain
– Serves no purpose [not protective]
– Lasts longer than anticipated
– May or may not have an identifiable cause
– Impacts every part of patient’s life
– Depression, Suicide
– Disability, isolation, energy drain, ADL’s
• Pseudoaddiction: seeking pain relief
– not drug-seeking
NRS_105/320_Collings
Types of Pain
• Cancer pain
– May be acute or chronic, constant or episodic,
mild to severe
– Up to 90% of Ca pts have pain
• Pain by inferred pathology
– Known cause = characteristic pain [neuropathic]
• Idiopathic pain
– No known cause BUT still pain
– “Excessive” pain for a condition
NRS_105/320_Collings
Knowledge, Attitudes, and Beliefs
• Subjective nature of pain
– Pain is what the patient says it is, not
what the nurse thinks it should be
– Same procedure, different pain
– Expectations, context, culture affect
perception and expression of pain
NRS_105/320_Collings
Knowledge, Attitudes, and Beliefs
• Nurse’s Response to Pain
• Bias
– ‘I go to work with 5/10 pain every day’
– ‘Its only a minor surgery’
– ‘I had three kids and didn’t scream’
• Fallacies
– Infants don’t feel pain like we do
– Regular pain med use causes addiction
– Older people all are in pain
NRS_105/320_Collings
Factors Influencing Pain
• Physiological
– Age – interpretation/communication
– Fatigue
• increases pain,
• sleep not sign pain is relieved
– Genes
• Pain threshold
– Neurological function
• Interpretation, communication, reflex
NRS_105/320_Collings
Factors Influencing Pain
• Social
– Attention/ distraction
– Previous experience
• May increase or decrease tolerance
– Family and social support
• Spiritual
– Meaning of pain, suffering
– Support system
NRS_105/320_Collings
Factors Influencing Pain
• Psychological
– Anxiety
– Coping style
• Control [PCA]
• Cultural
–
–
–
–
Meaning of pain
Expression of pain
Role in Family
Ethnicity
NRS_105/320_Collings
Assessment of Pain
• Client’s expression of pain
– Description is most valid indicator
• Characteristics of pain
– Onset and duration
– Location
– Intensity
– Quality
– Pattern
NRS_105/320_Collings
Assessment of Pain
• Characteristics of pain (cont'd)
–
–
–
–
Relief measures
Contributing symptoms
Behavioral effects on the client
Influences on ADLs
• Client expectations
– What pain level would allow you to function
well?
• [walk the hall, do ADL’s, resume job…]
NRS_105/320_Collings
Assessment
• Can we do a full assessment of pain when
the client is in severe pain?
• No!
• Alleviate severe [7-10] pain before talking
it to death
• Pain rated >7 needs immediate attention
NRS_105/320_Collings
Nursing Diagnoses
•
•
•
•
•
•
•
Anxiety
Ineffective coping
Fatigue
Acute pain
Chronic pain
Ineffective role performance
Disturbed sleep pattern
NRS_105/320_Collings
Planning
• Goals and outcomes
– Client is using pain relief measures safely
– Pain level reported at </=___ and congruent
nonverbal behaviors seen
– Demonstrate understanding of need to
premedicate before activity
– Splint abdomen with cough
• Setting priorities
– What is important for the client? What does he
need to do?
• Control pain enough to eat, sleep? Be mobile to
prevent complications? Work? PT? Maintain dignity,
relationships while dying?
– Maslow: Pain relief is basic need
NRS_105/320_Collings
Implementation:
Health Promotion
• Client education
– Expectations, when to seek treatment
– Preparation before pain
• Holistic care
– Whole self; physical, emotional, spiritual
– Education, rest, exercise, nutrition,
relationships
NRS_105/320_Collings
Nonpharmacological Pain Relief
•
•
•
•
Relaxation and guided imagery
Distraction
Biofeedback
Cutaneous stimulation—massage,
application of hot/cold, TENS
• Herbals
• Reducing painful stimuli and
perception
NRS_105/320_Collings
Controlling Painful Stimuli
• Managing the client’s environment—
bed, linens, temperature
• Positioning
• Changing wet clothes and dressings
• Monitoring equipment, bandages, hot
and cold applications
• Preventing urinary retention and
constipation
NRS_105/320_Collings
Implementation
Pain Management
• Pharmacological pain relief
• … Administer analgesics as ordered/
reassess pain in 30 minutes and hourly
– Analgesics: NSAIDs and nonopioids, opioids,
adjuvants
– Patient-controlled analgesia (PCA)
– Local analgesic infusion pump
– Topical analgesics and anesthetics
– Local and regional anesthetics
NRS_105/320_Collings
Implementation
Pain Management
• Surgical interventions
• Procedural pain management
• Chronic and cancer pain
management
NRS_105/320_Collings
Implementation Pain
Management
• Barriers to effective pain management
[pts, nurses, doctors, system…]
– Fear of addiction - #1 barrier
– Terms:
• Dependence: physical adaptation resulting in
withdrawal symptoms
• tolerance: physical adaptation resulting in
diminished drug effect over time
• Addiction: impaired control over use, use despite
harm
• pseudoaddiction: drug seeking behavior to relieve
undertreated pain
NRS_105/320_Collings
Implementation Pain
Management
• Nursing implications for pain management
– Accurate safe medication administration
– Assess effectiveness and side effects
– Patient education [families too]
– Use the appropriate drug when given a
choice
– Treat pain before it gets severe
NRS_105/320_Collings
Implementation: Restorative Care
• Pain clinics
• Palliative care
• Hospices
NRS_105/320_Collings
Evaluation
• Effectiveness
– Assess at peak of drug effect
• [30 minutes IV, 1 hour PO]
– Add complementary therapies for partial effect
– Talk with M.D. about options if approach is
consistently ineffective
• Side effects
• Document and communicate
– Most effective relief
NRS_105/320_Collings
Evaluation
• Client expectations
– Validate experience
– Relieve the pain
– Show you care
• Did client achieve goal?
– Walk hall w/o pain?
– Pain < 3/10 all day [except with PT]
– Able to return to work, enjoy visit, T,C,&DB?
• Pain report congruent with nonverbal?
NRS_105/320_Collings