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Pain is misunderstood Describe an experience with pain-either yourself or someone close to you. Pain is subjective. Nature of Pain Involves physical, emotional, and cognitive components Results from physical and/or mental stimulus Reduces quality of life Not measurable objectively Subjective and highly individualized component Pain The International Association for the Study of Pain defined pain as “an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” So physical pain can cause psychological pain and vise versa. Congressional Actions: Declared 2000 through 2010 the Decade of Pain Control and Research, yet pain continues to be a leading public health problem in the United States (American Pain Foundation, 2005). Providing pain relief is a basic human right and is in the Pain Care Bill of Rights (American Pain Foundation, 2001). The American Bar Association (2000) declared pain relief a basic legal right. Nurses are legally and ethically responsible for managing pain and relieving suffering. 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. 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 Physiology of Pain (cont’d) Transduction Conversion of stimulus into electrical energy Transmission Sending of impulse across a sensory pain nerve fiber (nociceptor) Perception The patient’s experience of pain Modulation Inhibition of pain/ release of inhibitory neurotransmitters Physiology of Pain (cont’d) 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. Transmission of Pain Impulse Pain Threshold The threshold of pain is the point at which pain begins to be felt. It is an entirely subjective phenomenon Pain Tolerance Pain tolerance is the maximum level of pain that a person is able to tolerate Case Study Mrs. Ellis is a 70-year-old African American woman with hypertension, diabetes, and rheumatoid arthritis. Her current health priority is the discomfort and disability associated with her rheumatoid arthritis. Arthritis has severely deformed her hands and feet. The pain in her feet is so severe that she often walks only short distances. The pain interferes with sleep and reduces her energy both physically and emotionally. As a result, she does not leave home often. Protective Reflex to Pain Stimulus Types of Pain 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 Cancer Occurs sporadically over an extended duration Can be acute or chronic Inferred pathological Idiopathic Musculoskeletal, visceral, or neuropathic Chronic pain without identifiable physical or psychological cause Acute Pain Is protective, has a cause, is of short duration, and has limited tissue damage and emotional response Acute Pain http://www.youtube.com/watch?v=EpcDZbXslfw Chronic Pain Lasts longer than anticipated, does not always have a cause, and leads to great personal suffering. Chronic Pain http://www.youtube.com/watch?v=87v_unEkh3c 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 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?” Factors Influencing Pain (cont’d) Psychological Anxiety Coping style Pain tolerance The level of pain a person is willing to accept Cultural Meaning of pain Ethnicity 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) Agency for Healthcare Research and Quality (AHRQ) Assessment Patient’s expression of pain Characteristics of pain Onset and duration Location Intensity Quality Pattern Relief measures Contributing symptoms Effects of pain on the patient Sample Pain Scales Wong-Baker FACES Scale 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) Common Characteristics of Pain that should be assessed: a. onset and duration b. location –Superficial/cutaneous, deep/visceral, referred, radiating c. intensity –pain scale d. quality –”Tell me what your pain feels like” e. pain pattern –what initiates it, how long does it last f. relief measures g. contributing symptoms h. effects of pain on the client i. behavioral effects j. influence on activities of daily living 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. Case Study (cont’d) Jim is a 26-year-old nursing student assigned to do home visits with the community health nurse. Jim knows that Mrs. Ellis has lived alone since her husband’s death 6 years ago. Jim conducts assessments, performs procedures, and teaches health promotion to a variety of patients. This is Jim's first experience caring for a patient with severe chronic pain. 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. Case Study (cont’d) When Jim enters Mrs. Ellis’ four-room apartment, he finds the home in disarray. Mrs. Ellis is sitting in a recliner in her living room, with clothing on the floor and soiled dished on a nearby table. She reports that the pain she has been experiencing has made it very difficult to use her hands and walk between rooms. She is able to get to the bathroom, but it causes her to become fatigued. Her pain is constant and is localized in the joints of her hands and knees. Nursing Diagnosis Activity intolerance Anxiety Ineffective coping Hopelessness Insomnia Fear Powerlessness Fatigue Impaired physical mobility Spiritual distress Chronic Impaired low selfsocial esteem interaction Imbalanced nutrition: less than body requirements Case Study (cont’d) Mrs. Ellis’ responses lead Jim to this nursing diagnosis: chronic pain related to joint inflammation. Mrs. Ellis has rated the pain as a 3 on a FACES Pain Scale of 0 to 10, with her most severe pain as a 4. She has been taking aspirin, but the pain prevents her from falling asleep; if she does sleep, she often reawakens. She has difficulty standing and an unsteady gait. 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). 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 Implementation: Health Promotion (cont’d) Pharmacological pain relief Acute pain management Analgesics Nonopioids Opioids Adjuvants/co-analgesics Delivery systems Patient-controlled analgesia (PCA) Local/regional anesthesia Topical agents Case Study (cont’d) Jim discussed with Mrs. Ellis’ primary health care provider the possibility of starting a disease-modifying antirheumatic drug (DMARD), a biological response modifier, a nonsteroidal anti-inflammatory drug (NSAID), or an analgesic. Jim had Mrs. Ellis take analgesics approximately 30 minutes before ambulating, performing self-care activities, or going to sleep. He instructed her to take medication with a light snack or meal and a full glass of water. During instruction, he explained that the drug will relieve the pain. Patient-Controlled Analgesia 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. Epidural Space Case Study (cont’d) Jim also suggested the following to Mrs. Ellis: Place a sturdy stool in the shower stall and run warm water continuously over joints of the hands and feet. Apply moist, warm compresses to the joints of the hands 3 times a day. Referral to a physical therapist to determine possible use of a walker or other assistive device What are the rationales for these additional measures? 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. Nursing Process: Planning Outcome Examples: (also include time measure) _Patient_______ reports that pain is a 3 or less on a scale of 0-10 by________, __Patient_____ is able to perform ADLs by________, __Patient_____identifies factors that intensify pain and modifies behavior accordingly by__________ 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. Chronic Noncancer 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. WHO Analgesic Ladder WHO, World Health Organization. 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 Quick Quiz! 3. 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. Checklist for Communication with Colleagues What is the pain rating now? Over the past period of time? Which pain rating is acceptable to the patient? How do you recommend that the patient’s treatment be changed to reduce the pain rating? Which professional reference can be used, if needed, to support this recommendation? Case Study (cont’d) When Jim observed Mrs. Ellis’ ability to stand and walk from the living room to the kitchen, she was able to ambulate with the walker; her gait was slow but steady. Mrs. Ellis reports that she has less discomfort from bathing after using warm water over her joints, although dressing is still causing some discomfort when manipulating buttons. Mrs. Ellis rates her pain at a 2 after taking the analgesic. 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. Case Study (cont’d) Two weeks after his last visit, Jim returns to evaluate Mrs. Ellis’ progress. She has gone to see a nurse practitioner, who prescribed an NSAID for her arthritic pain. She has not filled the prescription and is still taking her aspirin, but continues to have some gastrointestinal irritation. Jim gets the chance to observe Mrs. Ellis using a warm compress on her hands and notes that her gait is steadier. Mrs. Ellis has spoken with her neighbor, who has offered to help with shopping. Practice NCLEX Questions: Which of the following is most appropriate when the nurse assesses the intensity of the client’s pain? 1.Ask about what precipitates the pain. 2.Question the client about the location of the pain. 3.Offer the client a pain scale to objectify the information. 4.Use open-ended questions to find out about the sensation. ANS: 3 Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the client’s pain. To determine the quality of the client’s pain, the nurse may ask openended questions to find out about the sensation experienced. Practice NCLEX Questions: Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct? 1.The client is the best authority on the pain experience. 2.Chronic pain is mostly psychological in nature. 3.Regular use of analgesics leads to drug addiction. 4.The amount of tissue damage is accurately reflected in the degree of pain perceived. ANS: 1 A client’s self-report of pain is the single most reliable indicator of the existence and intensity of pain and any related discomfort. Pain is individualistic. A misconception about pain is that chronic pain is psychological. The belief that administering analgesics regularly will lead to drug addiction is a misconception. Another misconception about pain is that the amount of tissue damage is accurately reflected in the degree of pain perceived. Practice NCLEX Questions: Which of the following statements made by a nurse requires follow-up with additional instruction regarding the personal nature of pain? 1.“I have experienced pain before, and so I have great compassion for anyone dealing with pain.” 2.“My postsurgical clients get the prescribed pain medications on schedule with no diversion from that schedule.” 3.“If I were experiencing severe pain, I certainly would want someone to devote their time to managing for me.” 4.“Clients don’t always request pain medication, and so I always ask them if they want it according to the schedule.” ANS: 2 The nurse cannot see or feel the client’s pain. Pain is purely subjective; no two persons experience pain in the same way, and no two painful events create identical responses or feelings in a person. Flexibility is a necessary component in pain management. The remaining options do not require follow-up because they do not express any attitudes that are not compatible with good nursing care of the client in pain.