Download Comfort and Pain

Chapter 34
Comfort and Pain Management
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Categories of Pain
• Duration
– Acute
– Chronic
• Location or source
• Mode of transmission
• Etiology
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Sources of Pain
• Nociceptive
• Cutaneous
• Somatic
• Visceral
• Neuropathic
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Question
A patient who has bone cancer is most likely
experiencing which of the following types of pain?
A. Cutaneous
B. Somatic
C. Visceral
D. Referred
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Answer
Answer: B. Somatic
Rationale: Deep somatic pain is diffuse or scattered and
originates in tendons, ligaments, bones, blood vessels,
and nerves. Cutaneous pain usually involves the skin or
subcutaneous tissue. Visceral pain is poorly localized and
originates in body organs. Referred pain is pain that
originates in one part of the body and is perceived in an
area distant to that part.
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Origin of Pain
• Physical: cause of pain can be identified
• Psychogenic: cause of pain cannot be identified
• Referred: pain is perceived in an area distant from its
point of origin
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The Pain Process
• Transduction: activation of pain receptors
• Transmission: conduction along pathways (A-delta and
C-delta fibers)
• Perception of pain: awareness of the characteristics of
pain
• Modulation: inhibition or modification of pain
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Stimulator of Nociceptors or
Pain Receptors
• Bradykinin: a powerful vasodilator that increases
capillary permeability and constricts smooth muscle
• Prostaglandins: important hormone-like substances that
send additional pain stimuli to the CNS
• Substance P: sensitizes receptors on nerves to feel pain
and also increases the rate of firing of nerves
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Gate Control Theory of Pain
• Describes the transmission of painful stimuli and
recognizes a relationship between pain and emotions
• Small- and large-diameter nerve fibers conduct and
inhibit pain stimuli toward the brain.
• Gating mechanism determines the impulses that reach
the brain.
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Perception of Pain
• Pain threshold
• Adaptation
• Modulation of pain
– Neuromodulators
– Endorphins, dynorphins, enkephalins
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Question
Which modulator of pain is thought to reduce pain
sensation by inhibiting the release of substance P from
the terminals of afferent neurons?
A. Endorphins
B. Dynorphins
C. Enkephalins
D. Nociceptors
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Answer
Answer: C. Enkephalins
Rationale: Enkephalins are thought to reduce pain by
inhibiting the release of substance P from the terminals
of afferent neurons. Endorphins and dynorphins are
released when certain measures are used to relieve pain.
Nociceptors are the peripheral nerve fibers that transmit
pain.
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Pain Sensation and Relief
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Common Responses to Pain
• Physiologic
• Behavioral
• Affective
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Duration of Pain
• Acute
– Rapid in onset, varies in intensity and duration
– Protective in nature
• Chronic
– May be limited, intermittent, or persistent
– Lasts beyond the normal healing period
– Periods of remission or exacerbation are common
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Factors Affecting Pain Experience
• Culture
• Ethnic variables
• Family, gender, and age variables
• Religious beliefs
• Environment and support people
• Anxiety and other stressors
• Past pain experience
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Assessment Parameters for Pain
• Psychological
• Emotional
• Sociologic
• Physiologic
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General Assessments of Pain
• Patient’s verbalization and description of pain
• Duration of pain
• Location of pain
• Quantity and intensity of pain
• Quality of pain
• Chronology of pain
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General Assessments of Pain (cont.)
• Aggravating and alleviating factors
• Physiologic indicators of pain
• Behavioral responses
• Effect of pain on activities and lifestyle
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Question
Tell whether the following statement is true or false.
The best judge of the existence and severity of a
patient’s pain is the physician or nurse caring for the
patient.
A. True
B. False
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Answer
Answer: B. False
Rationale: The best judge of the existence and severity
of a patient’s pain is the patient.
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Basic Methods of Assessing Pain (Pasero
and McCaffery (20ll)
• Patient self-report
• Report of family member, other person close to the
patient or caregiver familiar with the person
• Nonverbal behaviors: restlessness, grimacing, crying,
clenching fists, protecting the painful area
• Physiologic measures: increased blood pressure and
pulse
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Pain Assessment Tools
• Wong-Baker FACES
• Beyer Oucher pain scale
• CRIES pain scale
• FLACC scale
• COMFORT scale
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Question
Which following pain assessment tool is recommended
for use with neonates ages 0 to 6 months?
A. Oucher pain scale
B. Wong-Baker FACES
C. FLACC pain scale
D. CRIES pain scale
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Answer
Answer: D. CRIES pain scale
Rationale: The CRIES Pain Scale is a tool intended for
use with neonates and infants from 0 to 6 months.
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FLACC Pain Scale
• F - Faces
• L - Legs
• A - Activity
• C - Cry
• C - Consolability
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Diagnosing Pain
• Type of pain
• Etiologic factors
• Behavioral, physiologic, affective response
• Other factors affecting pain process
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Nursing Interventions for Pain
• Establishing trusting nurse–patient relationship
• Manipulating factors affecting pain experience
• Initiating nonpharmacologic pain relief measures
• Managing pharmacologic interventions
• Reviewing additional pain control measures, including
complementary and alternative relief measures
• Considering ethical and legal responsibility to relieve pain
• Teaching patient about pain
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Manipulating Pain Experience Factors
• Remove or alter cause of pain.
• Alter factors affecting pain tolerance.
• Initiate nonpharmacologic relief measures.
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Nonpharmacologic Pain Relief Measures
• Distraction
• Humor
• Music
• Imagery
• Relaxation
• Cutaneous stimulation
• Acupuncture
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Nonpharmacologic Pain Relief Measures
(cont.)
• Hypnosis
• Biofeedback
• Therapeutic touch
• Animal-facilitated therapy
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Pharmacologic Pain Relief Measures
• Analgesic administration
• Nonopioid analgesics
• Opioids or narcotic analgesics
• Adjuvant drugs
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The WHO 3-Step Analgesic Ladder
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Question
A sedated patient is frequently drowsy and drifts off
during his conversation with the nurse. What number on
the sedation scale best describes this patient?
A. 1
B. 2
C. 3
D. 4
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Answer
Answer: D. 3
Rationale: 3 denotes that the patient is frequently
drowsy and hard to awake. 1 means the patient is awake
and alert. 2 denotes the patient is occasionally drowsy,
but easy to arouse. At 4, the patient is somnolent, with
minimal or no response to stimuli.
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Numeric Sedation Scale
• S: sleep, easy to arouse: no action necessary
• 1: awake and alert; no action necessary
• 2: occasionally drowsy, but easy to arouse; no action
necessary
• 3: frequently drowsy, drifts off to sleep during
conversation; reduce dosage
• 4: somnolent with minimal or no response to stimuli;
discontinue opioid, consider use of naloxone
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Pain Management Regimens
for Cancer or Chronic Pain
• Give medications orally if possible.
• Administer medications ATC rather than PRN.
• Adjust the dose to achieve maximum benefit with
minimum side effects.
• Allow patients as much control as possible over the
regimen.
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Additional Methods for
Administering Analgesics
• Patient-controlled analgesia
• Epidural analgesia
• Local anesthesia
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Placement of an Epidural Catheter
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