Download مفاهيم في التمريض4- أ. هناء أبو سنينة مع أستاذ عبد الباسط الحليقاوي

Kingdom of Saudi Arabia
Ministry of Higher Education
Al-Jouf University
Collage of Applied Medical Sciences
Department of Nursing
Subject: concept of nursing (123 nur)
Pain
Outline:
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Definition of pain.
Causes.
Classification of pain.
Pain pathways.
Pain management.
Nonpharmacological pain.
Pharmacologic pain.
Definition:
Pain can be described as "an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage".
Causes:
It may be caused by disease, trauma, or certain therapeutic procedures or have no
identifiable cause.
Classification of pain:
Pain is classified as acute or chronic.
 Acute pain is protective, has a sudden onset, an identifiable cause, and an anticipated
duration. It may progress to chronic pain if not successfully treated.
 Chronic pain is a continuous or recurring pain that usually lasts longer than is
typically expected or predicted. It may be associated with prolonged healing of an
acute injury or disease; however, it may not have an identifiable pathologic cause.
Chronic pain may be continuous or intermittent.
Pain Pathways:
Pain due to injury begins at special pain receptors scattered throughout the body. These
pain receptors transmit messages or signals as electrical impulses along nerves to the spinal
cord and then upward to the brain. Sometimes the signal evokes a reflex response. When
the signal reaches the spinal cord, a signal is immediately sent back along motor nerves to
the original site of the pain, triggering the muscles to contract without involving the brain.
For example, when people inadvertently touch something very hot, they immediately pull
away. This reflex reaction helps prevent permanent damage. The pain signal is also sent to
the brain. Only when the brain processes the signal and interprets it as pain do people
become conscious of the pain.
Pain receptors and their nerve pathways differ in different parts of the body. For this
reason, pain sensation varies with the type and location of injury. For example, pain
receptors in the skin are plentiful and capable of transmitting precise information,
including where an injury is located and whether the source was sharp, such as a knife
wound, or dull, such as pressure, heat, or cold. In contrast, pain receptors in the intestine
are limited and imprecise. The intestine can be pinched, cut, or burned without generating a
pain signal. However, stretching and pressure can cause severe intestinal pain, even from
something as relatively harmless as a trapped gas bubble. The brain cannot identify the
precise source of intestinal pain; the pain is difficult to locate and is likely to be felt over a
large area.
Pain management:
The nurse promotes, advocates for and strives to protect the health, safety and rights of the
patient. "this statement ethically obligates the nurse to provide clients with adequate pain
management".
Pain management includes:
 Nonpharmacological pain.
 Pharmacologic pain
Nonpharmacological Pain Managemen t:
Controlling pain and promoting comfort are two of the most important goals of nursing
practice. In 1965 Melzack and Wall proposed the gate control theory of pain. They
suggested that pain transmission could be increased or decreased by opening or closing a
gating mechanism in the central nervous system (CNS). In addition, it was the first theory to
suggest that pain sensation has both physical and psychological components.
Thus the nurse should use pharmacological and non pharmacological interventions to
manage both components of pain. Nonpharmacological strategies are varied physical
(progressive muscle relaxation, massage, transculanous electrical nerve stimulation "TENS"
heat/cold application), or psychological/cognitive (music, biofeedback, imagery, education)
and should be used in conjunction with and not instead of pharmacological interventions,
and vice versa. If a pain management plan is to be successful, pain must continually be
assessed, treated, and interventions evaluated to determine if a client is achieving comfort.
ASSESSMENT
1-Identify possible factors for the discomfort/pain. Alterations in comfort may be acute
(postoperative, associated with labor of childbirth, traumatic wounds burns) or chronic
(associated with cancer, migraine headaches, low back pain, joint pain).
Rationale: Causative factors influence the choice of interventions most likely to be successful .
2-Assess factors that influence perception of pain (e.g., past pain history, depression, fatigue,
loneliness, anxiety, helplessness, fear).
Rationale: These factors significantly reduce clients' ability to cope with pain.
3- Assess clients' culturally determined beliefs about pain.
Rationale: Culture influences the meaning pain holds for a client and how a client reacts toward discomfort .
4- Assess client's sensation of pain (PQRST assessment):
a.P: Precipitating factors: position, movement, edema, constricting dressings, tubes or drains,
invasive procedures, distended bladder.
Rationale: Assists in determining factors to avoid.
b.Q; Quality: sharp, dull, burning, nagging, stabbing, aching, throbbing, shooting, or crushing.
Rationale: Helps determine type of pain (somatic, visceral, neuropathic).
Characteristics of Pain
Quality ( Characteristics)
 Somatic (myofascial/joints):( Aching, deep, throbbing, sharp, stabbing, constant,
increases with movement, well localized)
 Visceral (organ-related, smooth muscle): ( Cramping, squeezing, pressure-like, poorly
localized, constant or intermittent, associated
with symptoms of visceral
discomfort )
 Neuropathic : (Burning, searing, shooting, electric-like, numbing, radiating, stabbing,
tingling, touch sensitive)
c.R: Region: localized, radiating, or generalized. Have client point to area of body affected.
Rationale: Assists in identifying cause of pain.
d.S: Severity: have client rate pain both at rest and with activity using an appropriate pain scale
Different scales may be used with different clients; however, the same scale must be used
consistently with each client.
Rationale: Provides a measurable means to determine if client's pain improves or worsens over time.
WONG-BAKER FACES: PAIN RATING SCALE FOR USE WITH CHILDREN 3 YEARSOLD AND
OLDER.
e-T: Timing/Duration: onset: sudden or gradual; constant or intermittent or both; procedural
or nonprocedural.
Rationale: Assists in determining if
pain is acute (a new pain or pain due to a complication) or
chronic (same pain
or escalating pain.)
5.Perform physical assessment of site of pain.
Rationale: This may reveal the nature of the pain and appropriate interventions.
6.Assess physiological and psychological responses to pain.
Rationale: Physiological signs may assist in the etiology. However, due to physiological adaptation,
overt and persistent physical responses (vital signs) to pain rarely occur, whereas lasting psychological
distress is often evident.
7.Assess behavioral responses to pain.
Rationale: Nonverbal responses to pain may be especially useful in assessing pain in clients who are
cognitively impaired or nonverbal.
Behavioral Indicators of Pain
 Facial expression: grimace, frowning, crying
 Vocalizations: moaning, groaning
 Posture: bent, leaning, guarding
 Gait: favors one side, uneven
 Activity level: increased, decreased, restless Muscle: tense, guarded
 Behavior: change in usual activities Emotions: irritable, withdrawn
 Change in ADLs: eating, sleeping, dressing, conversing
8. In cognitively impaired clients, obtain a proxy pain intensity rating
caregiver. (e.g., family member or friend).
Rationale: Proxy ratings may closely approximate the client's pain intensity
from the primary
9.Assess environment for factors such as noise or bright lights that may aggravate the
client's perception or tolerance of pain.
Rationale: Environmental factors may intensify perception of discomfort
10.Determine what does or may relieve the client's pain. Consider client's experience with
over-the counter drugs (including herbals and topicals) that have helped to reduce pain in
the past
Consider physician's orders regarding activity, oral intake, and prescribed medication..
IMPLEMENTATION FOR NON PHARMACOLOGICAL PAIN
MANAGEMENT:
1-Follow Standard Protocol.
2- Teach client how to use pain intensity scale.
Rationale Accurate reporting by client improves pain assessment.
3-Set pain-intensity goal with client.
Rationale Pain is unique to each individual. When able, client should set goal for tolerable pain
severity.
4- Remove or reduce painful stimuli.
a- Reposition using pillows as needed for support and to prevent pressure areas.
Rationale Repositioning reduces' stimulation of pain and pressure receptors.
b- Reapply dressings if wet or constricting.
Rationale Clean, dry dressings minimize irritation to surrounding tissues.
C- Reapply or adjust equipment as needed: blood pressure (BP) cuff, intravenous (IV) arm
board, Ace bandages, tubes, drains, or identification bands.
Rationale Constricting devices create discomfort.
5- Reduce or eliminate factors that increase the pain experience.
Rationale Fear or anxiety may cause muscle tension and vasoconstriction, which
Intensify he pain experience.
6- Assist client in splinting painful area using firm pressure over a bath blanket or pillow
during coughing, deep breathing, and turning.
Rationale Splinting reduces pain by minimizing muscle movement.
7-Massage painful area gently or firmly.
Rationale Cutaneous stimulation closes the "pain gate," thus reducing pain perception.
8- Encourage relaxation using non pharmacological strategies such as imagery, progressive
relaxation, or deep rhythmical breathing.
Rationale Encourages active client participation in pain plan, enhances analgesic effect,
reduces psychosocial aspect of pain.
9- Direct client's attention to something else that increases pain tolerance.
Possible distractions include:
a. Singing or music
b. Praying
c. Describing pictures
d. Discussing pleasant memories
Rationale The reticular activating system (RAS) in the brain, which is essential for
concentration, inhibits painful stimuli if a person receives sufficient or excessive sensory input. With meaningful sensory input a person can ignore the pain. Pleasurable stimuli also
increase endorphins, which relieve pain.
10.Following nonpharmacologic interventions, be sure client is positioned comfortably and
room is left clean and pleasant.
Rationale Promotes client's ability to rest and fall asleep.
Recording and Reporting
Pain documentation should be on a regular (every 4 to 12 hours) basis (agency
dependent).
Report significant changes in any of the PQRST parameters to physician.
 Record findings of ongoing assessment, interventions completed (including
notification of physician, if done), and client's response to interventions.
Sample pain scales for use with cognitively intact adult.
Numerical
0
1
Nopain
2
3
4
5
6
7
8
9
10
Severe pain
Descriptive
No pain
mild pain
moderate pain severe pain unbearable
pharmacological Pain Management
Analgesics are the most common treatment for pain. Analgesics are classified as nonopioid (e.g.,
acetaminophen), nonsteroidal antiinflammatory drugs (NSAIDs), opioids (e.g., morphine
sulfate, hydromorphone, oxycodone, and fentanyl), and adjuvant analgesics (e.g.,
anticonvulsants, antidepressants, muscle relaxants, and antiarrhythmics).
Transcutaneous Electrical nerve stimulator (TENS).
Equipment
 Prescribed medication
 Necessary administration device.
 Opioid/narcotic control sheet (for controlled substances only).
IMPLEMENTATION FOR PHARMACOLOGICAL PAIN MANAGEMENT
1.Follow Standard Protocol.
2.Review six rights for administration of medications.
Rationale Ensures safe and appropriate medication administration.
3.Administer analgesics. Consider NSAIDs, opioids, and adjuvants. R.Nonopioids may be
administered with opioids to improve opioid effectiveness. Adjuvants are more effective for
neuropathic pain than opioids.
a.As soon as pain occurs
Rationale Pain is eaiser to prevent than to treat.
b.Before pain increases in severity
Rationale Higher levels of pain may not respond to ordered analgesic.
c.Before pain-producing procedures or activities
Rationale Reduce or block pain transmission in the CNS
d. Routinely, ATC
Rationale Maintains analgesic within therapeutic range, reducing pain intensity and
minimizing side effects.
4.Include nonpharmacological pain control measures in addition to analgesics.
Rationale Increases effectiveness of pharmacological agents; treats non physiological aspects
of pain.
5.IdentifY expected time for peak effects and usual duration of action of analgesics.
Rationale Effects vary depending on the type of medication used; allows for anticipation of
next dose; permits evaluation of effectiveness of analgesic.
6.Coordinate nursing care measures to maximize effectiveness (i.e., encourage to turn,
cough, and deep breathe while medication effects are best).
Rationale Maximizes effectiveness of nursing measures to prevent complications.
8.Remove and dispose of gloves, if used.
9.See Completion Protocol (inside front cover).