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Pain Management Chapter 13 NUR 299 C 1&2 (Adapted from LLW 2010) Pain Unpleasant sensory, emotional experience with actual or potential tissue damage Most common reason for seeking health care “The fifth vital sign” Joint Commission (2005) standards: “pain is assessed in all patients,” “patients have the right to appropriate assessment and management of pain.” “Pain is whatever a person says it is, existing whenever the experiencing person says it does.” (McCaffery & Pasero, 1999) Role of the Nurse Collaborate Evaluate effectiveness Advocate Educate Nursing Assessment Assess for: ◦ Duration – how long ◦ Location - where ◦ Etiology – cause may be a predictor so a plan can be put into effect [Cancer, Burns] Types of Pain Acute pain Chronic pain Cancer-related pain May be classified by location or etiology Effects of Pain Sleep deprivation Acute pain ◦ Can affect respiratory, cardiovascular, endocrine, immune systems, gastrointestinal ◦ Stress response increases metabolic rate, cardiac output, risk for physiologic disorders Chronic pain ◦ Depression ◦ Increased disability ◦ Suppression of immune function Pathophysiology of Pain Nociceptors (pain receptors) transmission of pain perception to & from the brain Non-Nociceptor- does not transmit pain. Ie: pressure or temperature Neurologic Transmission of pain (nocicetion) by nerves Chemical substances ◦ Prostaglandins (increase sensitivity of pain receptors) ◦ Endorphins, enkephalins (suppress pain reception) Nociception System Showing Ascending & Descending Pathways of the Dorasal Horn Gate Control Theory Factors that Influence Pain Response Past experience Anxiety Depression Culture Age Gender Expectations Characteristics of Pain Intensity Timing Location Quality Personal meaning Aggravating/ Alleviating factors Pain behaviors- eyes shut, rubbing, fists, jaw clenched Pain Intensity Scales Faces Pain Scale Physiologic Basis for Relief Pharmacologic Interventions • Opioid analgesics act on CNS to inhibit activity of ascending nocioceptive pathways • NSAIDS decrease pain by inhibiting cyclooxygenase (enzyme involved in production of prostaglandin) Aleve, Motrin, Advil • NSAIDS can be given in combination with narcotics to relieve pain using less narcotics. • Local anesthetics block nerve conduction when applied to nerve fibers Gerontologic Considerations •More likely to have adverse drug effects, drug interactions •Increased likelihood of chronic illness •May need to have more time between doses of medication due to decreased excretion, metabolism related to aging changes Opioid Tolerance and Addicition Maximum safe opioid dosage must be individually assessed Tolerance develops in all patients who take opioids for prolonged periods With tolerance, increased usage needed to effect pain relief Opiod Tolerance and Addiction (cont’d) Dependence occurs with tolerance, physical symptoms occur when opioid is discontinued Addiction: behavioral pattern characterized by need to take drug for psychic effects Addiction from therapeutic use of opioid is negligible Pain Relief InterventionsPharmacologic Balanced anesthesia “PRN” medications Routine administration: around the clock (ATC) or preventive approach PCA: patient-controlled analgesia Local anesthetics Topicals, patches Intraspinal a PCA - Patient Controlled Analgesia Two Types Continuous – delivers set amount per hour AND Pt can request additional doses up to pre set maximum as needed. On Demand – only delivers when medication is requested by patient. PCA Physician’s Order for PCA shall include: ◦ ◦ ◦ ◦ Type of analgesic Rate Loading/bolus dose PCA dosage with mg/minutes lock out interval ◦ Four hour dose ◦ Basal rate ◦ Medication concentration PCA cont’d Parameters should include: Loading dose- A bolus dose given prior to initiating PCA therapy ◦ usually higher than a bolus dose given during PCA therapy. Bolus dose- Equivalent to a loading dose – ◦ administered during the course of PCA therapy. Lockout Interval – Predetermined period during which the patient cannot initiate doses. PCA dose – Amount administered each time the PT activates pump. Four hour limit – Predetermined maximum drug volume, which can be delivered during any 4 hour period. Basal Rate- Amount administered continuously. PCA Nursing Considerations Notify MD of the following so that orders may be obtained for continuing, slowing or stopping the infusion when one or more of the following exists: Diastolic B/P drops more than 20% from baseline Respiratory rate of less than 10/min(hold < 8) Significantly altered mental status Pain Score of 5 or greater &/or pain that is not decreasing Nonpharmacologic Interventions Cutaneous stimulation, massage Thermal therapies Transcutaneous electrical nerve stimulation (TENS) Distraction Relaxation techniques Nonphamacologic Interventions Guided imagery Hypnosis Music therapy Alternative therapies Neurologic & Neurosurgical Methods for Pain Control Intrathecal catheters- spinal, meds to spinal cord Epidural catheters- epidural space in spinal cord Stimulation procedures - TENS Interruption of pain pathways ◦ Cordotomy- division of spinal cord tracts(neck). Destroys pain, not sensation. ◦ Rhizotomy- Sensory nerve root is destroyed. Ie: chest pain /lung CA. May be done surgically, percutaneously or chemically. Intrathecal & Epidural Catheters Cordotomy Rhizotomy Adverse Effects of Analgesic Agents Respiratory depression Sedation Nausea, vomiting Constipation Pruritis Nursing Process Framework for Pain Management Identify goals for pain management Establish nurse-patient relationship, teaching Provide physical care Manage anxiety related to pain Evaluate pain-management strategies NCLEX Review Tell whether the following statement is true or false: Endorphins represent the same mechanism of pain relief as nonnarcotic analgesics. Answer False. Rationale: Endorphins do not represent the same mechanism of pain relief as nonnarcotic analgesics. Endorphins release inhibits the transmission of painful impulses. They are endogenous neurotransmitters structurally similar to opioids. They are found in heavy concentration in the central nervous system. NCLEX Review The RN asks a patient to describe the quality of pain. Which of the following is a descriptive term for the quality of pain? A. Burning B. Chronic C. Intermittent D. Severe Answer A. Burning Rationale: A descriptive term for the quality of pain is burning. Chronic and intermittent pain are examples of types of pain. Severe is a descriptive term for the intensity of pain.
