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Ruth Weiscarger, BSN, RN Pain is a complex, subjective phenomenon that involves biological, cultural, and social factors. “Pain is whatever the patient says it is and occurs whenever the patient says it does.” Serves as a warning sign indicating that actual damage has occurred or that the potential exists for damage of tissue. Pain can make it difficult to: • Perform activities of daily living • Rest & experience restorative sleep • Eat • Perform normal body movements & exercise Maintain family relationships Work or maintain a job Have a social life Maintain cognitive abilities Focus on spiritual beliefs As a nurse, you must develop an understanding of pain and how you can assist your patient to cope with pain. Holistically-taking into consideration the physical, mental, social, and spiritual aspects of the patient. Look at the whole being. This prepares you to meet the needs of the patient on an individual basis. It is thought that the thalamus can open and close the gate in relationship to stress and anxiety Researchers in the 1960’s proposed this theory. The theory proposes that the transmission of pain impulses to the central nervous system is controlled by a “gate”. • The gate must be open for the pain impulse to be transmitted to the brain & transmitted as pain. • When the gate is closed, the nerve impulse for pain is blocked from transmission. Open gate causes: Stress & anxiety Stimulation of narrow nerve fibers Injury or tissue damage stimulates narrow nerve fibers Closed gate causes: • Decreased stress & anxiety • Exercise, heat, cold, massage, • Endorphins-natural body chemicals produced by pleasant thoughts or feelings Acute Pain-pain that comes on suddenly and has a short duration, usually 6 months or less. Chronic Pain Is -pain that lasts longer than 6 months. Intermittent pain-pain that comes & goes at intervals. Intractable pain-pain that cannot be relieved, pain that is incurable or resistant to treatment. Ex. Cancer pain Referred pain-pain that is felt in an area other than where the pain is produced. Ex. Pain that is felt in jaw or arm during a MI due to lack of O2 supply. Radiating pain-pain that begins at a specific site & shoots or extends to a larger area. Pain is derived in two ways: 1. From the stimulation of nerve pain receptors, called nociceptors. 2. From damage to the nerves themselves. Nociceptors are randomly dispersed throughout the skin, subcutaneous tissue, & muscular tissue. • Nociceptors can be stimulated by temperature change, tissue damage & certain chemicals. • Two of the chemicals that can stimulate nerve pain receptors are substance P and prostoglandins which are released during injury and damage to the tissue. . •Substance P-elicits localized tissue reactions similar to inflammation •Prostoglandins are hormones that act in the immediate area and initiate inflammation 1. Cutaneous-pain that is more superficial or on the surface of the skin. Ex. Paper cut 2. Visceral –pain experienced from stimulation of deep internal pain receptors. Ex. Traumatic injury or surgery 3. Deep, somatic pain-pain in bone, ligament or tendon. May be diffuse with longer duration than cutaneous pain. Ex. Fractures, arthritis • Is pain that is usually burning, stabbing, or sometimes a deep ache. Example: Compression fractures of the spine, • Pain that occurs due to injury or destruction of peripheral nerves or the central nervous system itself. Example: Diabetic neuropathy. • Pain may extend beyond the local region to encompass a broadening area of discomfort that follows along the pathway of the damaged nerves. Type of neuropathic pain where patient feels pain from an area that has been amputated. Ex. Complaint of foot pain after the lower leg and foot have been surgically amputated. Pain is considered the fifth vital sign. Nurse must assess: Temperature Blood Pressure Pulse Respirations Level of pain Assessment of pain must be made before pain can be treated effectively: • Measure level or extent of pain-use of pain scale such as 0 to 10 scale with 0 being none and 10 being the worst. • Assess the site of pain-be specific. For example: Abdominal pain (lower) upper outer quadrant). • Characteristics of pain-dull, sharp, aching, burning, pressure? • Is pain acute or chronic? When did it begin? • What causes the pain? Breathing, coughing, with movement, activity? There are various factors that affect pain and its expression: • Ethnic and cultural beliefs • Developmental stage • Individual values • Previous pain experiences • Personal support system • Emotions • Fatigue The body responds to pain: physiologically phychologically behaviorally Sympathetic Nervous System responds: increased pulse increased resp rate increased BP pupils dilate Acute Pain Chronic Pain Sudden onset, lasts less than 6 months Fight /flight response occurs Initially pulse rate, BP, and respirations are elevated. Pupils dilate. As pain worsens, BP drops, diaphoresis, syncope, pupils constrict Fear and anxiety Onset longer than 6 months Pupils may constrict Vital signs may not change May have impaired mobility Sleep disturbance Depression, fatigue, anger Nurse needs to evaluate and assess patient before pain can be treated effectively. Assessment: • Level or extent of pain, use of pain scale • Site of pain and any radiation of pain • Characteristics of pain, ex. Sharp, dull, burning • Is pain acute or chronic? • What elicits pain? • Patient desires in relation to pain? • Nurse must not be judgmental • Nurse must let patient know that you believe that they are in pain • Evaluate patient’s pain • Let patient know what you are going to do to help relieve their pain Nonpharmaceutical Methods: The Agency for Healthcare Research and Quality (AHRQ) has printed guidelines encouraging healthcare providers to incorporate nonpharmaceutical methods of pain relief to help relieve pain and decrease the need for medication. Adjuvant therapy-a means to assist or aid another treatment, therefore increasing the effectiveness. Heat and cold therapy are both effective for relief of musculoskeletal pain and discomfort. In acute setting, need a physicians order. Massage can be effective for some painful conditions, used to relax muscles and relieve tension. Effleurage-repetitive, gentle, gliding of your fingertips over the surface of the skin. Transcutaneous Electrical Nerve Stimulation: Battery-powered device with lead wires and electrode pads which are applied to the skin over the painful area to deliver electrical stimulation to nerve fibers. Acupressure involves applying fingertip pressure. Acupuncture involves the insertion of ultrafine needles into specific body areas. Both are thought to stimulate endorphins. Progressive relaxationsystematic process using the mind to relax the patient’s muscles from the top of the head to the toes. Patient lays in bed with eyes closed. Therapist directs the patient to focus on certain muscles, tensing and then relaxing. Guided Imagery- using the mind to guide the patient to a more relaxed state. Done verbally or by using tapes to direct the patient to thoughts of a comfortable place. Distraction-used to try to take the patient’s mind off of pain. Does not always work. Decreases the conscious awareness of pain. Use of different senses. Visual distraction-television, reading Auditory distractionlistening to music or someone reading aloud Tactile distraction-back rub, rocking, receiving hugs, rocking, holding Intellectual distractionconversing with others, puzzles, card games Classifications of medications: • Non-steroidal anti-inflammatory drugs (NSAID’s) • Non-opioids • Opioid narcotics • Adjuvant drugs Non-narcotic pain relievers used for mild to moderate pain. Ex. Acetaminophen-has both analgesic and antipyretic effects. Maximum dose is 3-4 gms or 3000mg – 4000 mg q 4 hrs. Side effect-hepatotoxicity Non-steroidal antiinflammatory drugs reduce inflammation and pain at the site of the injury. Over-the-counter Most common are: ibuprofen, naproxen, and aspirin. Aspirin: • Anti-inflammatory • Analgesic • Anti-pyretic • Usual adult dose-6001,000mg q 4hrs. • Anti-platelet effect (decreases platelet clumping) • Usual dose for antiplatelet is 81-300mg daily • • • • • May cause gastric irritation and bleeding. Do not exceed recommended dosage. Administer medication with food. Instruct patient to take with food at home. Instruct patient to notify MD immediately of any GI bleeding. Opiate/Opioid Analgesics: Used when non-opoid medications are ineffective in relieving moderate to severe pain. Usually effective in relieving visceral pain and deep somatic pain. Work by binding with opiate receptors and stimulate the brain’s production of betaendorphins that decrease pain perception. Controlled substance Require a prescription Controlled or scheduled drugs due to greater capacity for addiction. Regulated by federal law. • Opiates come from opium and it’s derivatives known as opioids. • Opioids –synthetic form. • Opiates and opioids can be administered: • Orally • Rectally • Subcutaneously (Sq) • Intramuscular (IM) • Intravenous (IV) Nausea Vomiting Constipation Itching Sedation Respiratory distress Pupil constriction ** Narcan is a medication used to counteract the effects of opiates if patient should become unresponsive or in case of overdose.** Computerized IV infusion device consisting of a pump, a large syringe containing the analgesic, IV tubing, push button that the patient pushes for delivery of analgesic. Physician orders maximum dose and nurse or pharmacist calibrates the pump. Initially, the nurse will deliver a loading dose or bolus to get the patient started to get the pain under control. The patient will then be set up to push the button to self-administer a dose whenever they have pain. The patient will only be able to receive the set dose no matter how many times they push the button. Provides the patient with control over their pain relief. Avoids repeated injections. Provides rapid relief via IV route. Reduces the anxiety and fear that pain will get out of control. Allows for smaller dosing, ultimately resulting in the use of less medication. Reduces waiting for nurse response. Enables patient to achieve more comfortable ambulation, reducing complications Classes of medication that produces pain relief through a mechanism different than traditional analgesics, or by potentiating or increasing the effects of opiates, opioids, and non-opioid drugs. Ex. Anticonvulsants and antidepressants. Some of these drugs may help to treat nerve pain. Ex. Skeletal muscle relaxants may be helpful to reduce muscle spasms. Restorative sleep is that which allows an individual to awaken feeling rested, refreshed, rejuvenated, and energized. Resting may or may not involve sleep but it is a time when the patient should feel relaxed and free from anxiety. Circadian Rhythm-24-hr cyclical pattern during which the body metabolism and functions increase and decrease in rhythmic patterns. 2 cycles of sleep are (NREM)-non-rapid eye movement sleep and (REM)-rapid eye movement sleep. Stage I-relaxation begins, lightest sleep, easy to arouse. Stage II-relaxation deepens, begin to experience sound sleep but still relatively easy to arouse. Usually last about 15-20mins. Stage III-lasts about 15-30mins, body rests and restores during this sleep. Stage IV-becomes difficult to arouse, this is the deepest sleep, body rests and is restored. REM Sleep occurs at the end of each NREM cycle. Rapid eye movement begins Vital signs fluctuate Vivid dreaming REM sleep is not as restful as NREM sleep • Newborns: 16 to 18 hrs per day • Infants up to 2yrs: 12 to 14 hrs a day including naps • Children 3 to 6: 12 hrs per day including naps • Children 7 to 12: 10 hrs per night • Adolescents: 8.5 to 9.5 hrs per night • Young adults: 7.5 to 8 hrs per night • Older adults: gradually decreases to 5.5 or 6 hrs per night, may begin to nap • Lifestyle-caffeine, nicotine, alcohol, and sleep inducing medications can impair the body’s ability to get adequate sleep. • Stress and Anxiety-worries at night can effect falling asleep. • Environmental-temp. too hot or too cold, uncomfortable bed. • Illness and health problems-pain, itching, SOB. • Sleep disorders Bruxism-grinding of teeth during sleep. Insomnia-chronic inability to fall asleep or stay asleep. Narcolepsy-uncontrollable, recurrent daytime episodes of sleepiness. Hinders driving or operating dangerous equipment. Restless leg syndrome-intolerable crawling sensation in legs that results in an irrestible urge to move legs. Sleep apnea-inability to maintain breathing while sleeping. Patient usually snores, accompanied by periods of apnea. Can be life threatening. Somnambulism- sleepwalking Sundowning-confusion or disorientation in elderly patients occurring in the evening hours. Prepare the environment-room temp, adjust pillows, turn and reposition, lighting. Relaxation-offer back rub, wash face and hands. Pain relief-administer pain med as ordered. Sleep medications-administer sleeping medication if ordered, if needed.