Download Pain Management

JUDITH M. WILKINSON LESLIE S. TREAS
KAREN BARNETT MABLE H. SMITH
FUNDAMENTALS OF
NURSING
Chapter 31:
Pain
Copyright © 2016 F.A. Davis Company
What Is Pain?
• Unpleasant sensory/emotional experience
• Can have destructive effects
• Can warn of potential injury
• A multidimensional experience
• Whatever person experiencing it says it is; exists
whenever person says it does
• Self-report always most reliable indication of pain
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Classification of Pain
• By origin
• Superficial
• Visceral
• Somatic
• Radiating/referred
• Phantom
• Psychogenic
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Classification of Pain (cont’d)
• By cause
• Nociceptive
• Neuropathic
• By quality
• By duration
• Acute
• Chronic
• Intractable
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Acute Pain
•Major distinction from chronic pain
is the effect on biologic responses
•Acts as warning sign
•Activation of sympathetic nervous
system
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Acute Pain Responses
•Increased heart rate
•Increased blood pressure
•Increased respiratory rate
•Dilated pupils
•Sweating
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Chronic Pain
• Persists or recurs for indefinite period
(more than 3 months)
• Onset is gradual
• Poorly localized (hard to pinpoint)
• Often accompanied by depression
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Physiology of Pain
• Transduction: activation of nociceptors by stimuli
• Transmission: conduction of pain message to
spinal cord
• Pain perception: recognizing and defining pain
in cortex
• Pain modulation: changing pain perception
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Chapter 3
Pain: The Fifth Vital Sign
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Pain Transmission
• Painful stimuli often originate in extremities
• If pain not transmitted to the brain, person feels
no pain
• Mu receptors otherwise activate
• Two specific fibers transmit periphery pain:
– A delta fibers
– C fibers
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Pain Transmission (cont’d)
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Factors That Influence Pain
• Past experience
with pain
• Emotions
• Developmental stage
• Sociocultural factors
• Communication skills
• Cognitive impairments
• Other illnesses
contributing to pain
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Attitudes & Practices Related to Pain
• Health care provider and nurse
attitudes affect interaction with
patients experiencing pain
• Many patients reluctant to report pain
–Desire to be “good” patient
–Fear of addiction
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Considerations for Older Adults
•Greater risk for undertreated pain
•Undertreatment of cancer pain due
to inappropriate beliefs about pain
sensitivity, tolerance, and ability to
take opioids
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Psychosocial Assessment
• All pain holds significant meaning for the
person experiencing it
• Remain objective; advocate for proper pain
control
• Unresolved pain leads to distrust
– aberrant behaviors manifest
– then withdrawal from routine activities
– then depression sets in
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Assessing Pain
Includes
• Obtaining a complete pain history
(e.g., onset, location, aggravating/alleviating factors)
• Nonverbal signs of pain
• Elevated pulse/blood pressure
• Crying, moaning
• Grimacing
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PQRST for Pain Assessment
•P: Precipitating or palliative
•Q: Quality or quantity
•R: Region or radiation
•S: Severity scale
•T: Timing
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Assessing Pain (cont’d)
Pain scales
• Visual Analogue
Scale (VAS)
• Numeric Rating
Scale (NRS)
• Simple descriptor scale
• Wong-Baker Faces Pain
Rating Scale
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Pain Management
Nonpharmacological measures
• Cutaneous stimulation
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Based on “gate control” theory
Transcutaneous electrical nerve stimulation (TENS)
Percutaneous electrical nerve stimulation (PENS)
Acupuncture
Acupressure
Massage
Use of heat and cold
Contralateral stimulation
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Pain Management (cont’d)
Nonpharmacological measures (cont’d)
 Immobilization and rest
 Cognitive-behavioral interventions
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Distraction
Progressive muscle relaxation
Guided imagery
Hypnosis
Therapeutic touch
Humor
Journaling
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Nonpharmacologic Interventions
•Used alone or with drug therapy
•Physical measures
•Physical and occupational therapy
•Cognitive/behavioral measures
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Physical Interventions
• Complementary and alternative therapies
• Cutaneous stimulation
– Application of heat, cold, pressure
– Therapeutic touch
– Massage
– Vibration
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Physical Interventions - TENS
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Cognitive/Behavioral Measures
• Strategies used to relieve pain as adjuncts to drug
therapy:
– Distraction
– Imagery
– Relaxation techniques
– Hypnosis
– Acupuncture
– Glucosamine
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Invasive Techniques for Chronic Pain
• Used when drugs/other methods ineffective
– Nerve blocks (temporary/permanent)
– Spinal cord stimulation
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Drug Therapy
• When nonpharmacologic methods are not
helpful
• Administer before procedures (e.g., surgical
debridement, complex dressing change)
• Three drug groups:
– Non-opioids
– Opioids
– Adjuvants
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Pain Management (cont’d)
Pharmacological measures
• Nonopioid analgesics
• NSAIDs
• Acetaminophen
• Opioid analgesics
• Includes IV, transdermal, and epidural forms
• Client-controlled analgesia pumps
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Analgesics by Classification:
Non-Opioids
• Acetaminophen (Tylenol)
• NSAIDs (nonselective)
– Aspirin, ibuprofen (Motrin), naproxen
(Naprosyn, Alleve)
• NSAIDs (selective)
– Celecoxib (Celebrex)
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Analgesics by Classification:
Opioids
• Pure agonists
– Morphine long acting - MS Contin
short acting – MSIR or instant release
– Oxycodone long acting – OxyContin
short acting – Oxycodone, OxyIR, “oxy”
– Methadone
– Codeine
– Cocaine in terminaly ill
– Fentanyl
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Pain Pharmacologic Therapy—
Opioid Analgesics
• Block release of neurotransmitters in spinal
cord
• Suppress mu receptor activation
• Can be administered by every route
• PRN range orders
• Patient-controlled analgesia (PCA)
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Side Effects of Opioids
•Nausea/vomiting
•Constipation
•Sedation
•Respiratory depression – late
sign
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Analgesics by Classification:
Adjuvants
• SSRIs
• Anti-epileptic drugs (AEDs)
• Muscle relaxants/antispasmotic drugs
• Alpha-2 adrenergics
• Local anesthetics/analgesics
• NMDA antagonists
• Cannabinoids (cannabis extracts)
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Considerations for Older Adults: Opioids
• “Start low and go slow”; initially use no
more than half of recommended dose
• Evaluate patient response and drug
effectiveness
• Older adults feel moderate and severe pain
as much as younger adults
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Community-Based Care
• Home care management
• Teaching self-management
• Health care resources
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Special Nursing Considerations
• Managing pain in the elderly
• Managing pain in clients with addictions
• Use of placebos
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Think Like a Nurse
• Which groups of patients are most at risk for inadequate
pain management?
• What can you do to assist each group?
• How do past pain experiences affect present
pain experience?
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