305- Ch. 44- Pain Management
Describe the physiology of pain.
Identify components of the pain experience.
Explain how the physiology of pain relates to selecting interventions for pain relief.
Describe the components of pain assessment.
Explain how cultural factors influence the pain experience.
Explain various pharmacological and non-pharmacological approaches to treating pain.
Discuss nursing implications for administering analgesics.
Discuss barriers to effective pain management.
Evaluate a patient’s response to pain interventions
It is purely subjective.
Providing pain relief is a basic human right (Pain Care Bill of Rights, APF, 2007).
Nurses are legally and ethically responsible for managing pain and relieving suffering.
Remember – A patient’s pain level is whatever the person experiencing it states it is.-everyone’s pain is DIFFERENT
Reduces physical discomfort.
Promotes earlier mobilization and return to previous activity levels.
Results in fewer hospital and clinic visits.
Decreases hospital lengths of stay resulting in lower health care costs.
A Nurses role in management is:
A Nurses role in management is:
Promoting empowerment and health literacy
Treating patients with compassion and respect
Transduction: Begins in the periphery with a pain-producing stimulus.
Transmission: Cellular damage results in release of neurotransmitters (bradykinin, histamine) spreading the pain “message” and creating an inflammatory response.
Two Types of nerve peripheral nerve fibers:
Fast myelinated (A-delta): Sharp, localized and distinct
Slow unmyelinated (C fibers): Poorly localized, burning, persistent
Perception: Aware of pain. Processed from past experience knowledge, and cultural associations in the perception of pain.
Modulation: Inhibition of the pain process by the release of inhibitory neurotransmitters (endogenous opioids, serotonin, norepinephrine). Helps to produce an analgesic effect.
Afferent (sensory) nerve fibers
Sense pain impulse
Efferent (motor) nerve fibers
Sends impulse to withdraw from stimulus back to source
Stimulated by pain of low to moderate intensity
Stimulated by continuous, severe, or deep pain ( involving the visceral organs such as MI or colic from the gallbladder)
Most people adapt to pain; ultimately VS return to normal:
Look to other problems if changes in VS persist.
Threatens physical and psychological well-being.
Do not let personal bias dictate your nursing care:
Labeling patients as “drug seekers”
“Complainers” (patients with low pain tolerance)
Prevention is easier than treatment:
Encourage patients to seek relief before pain occurs.
Watch for patients who choose not to report pain:
Sign of weakness, loss of control, cultural considerations
Encourage patients to accept pain relieving measures:
Helps to maintain ADL’s
Chronic pain leads to psychological depression and even suicide. Major cause of:
Inability to perform simple ADL’s
Sickle cell disease
70% to 90% of cancer patients experience pain
60% report moderate to severe pain (Maxwell, et al., 2005; Potter & Perry, 8th ed.).
Nurses assessment of pain intensity underestimates patients’ pain reports
Patient variables such as culture, gender, age, education, patient diagnosis contribute to nurses differences in pain ratings
Nurses vary pain medication administration according to patient affect (smiling, grimacing)
Nurses use their judgment to decide if the patient is ‘really in pain’
Nurses must accept the patient’s report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and EB research findings (Pasero & McCaffery, 2011 as cited in P & P, 9th ed)
Older Adults development of pathological conditions leading to impairment of function leading to: T. 44-4 p. 1020
Decreased mobility, ADL’s, social activity, and activity tolerance.
Multiple diseases may affect similar parts of the body (vague symptoms)
Fatigue: Heightens perception of pain. Decreases coping abilities.
Genes: Genetic information possibly increases or decreases sensitivity to pain/pain tolerance.
Neurological Functions: Any factor that interrupts or influences normal pain reception or perception
Previous Experience: Learning from painful experiences: experienced relief or no relief. Anticipatory Pain: explain procedures to the patient be clear on what to expect.
Family & Social Support: Can make experience less stressful especially parents in the presence of children.
Spiritual Factors: Punishment, lessons from God etc…
Anxiolytic medications are not a replacement for analgesia
Coping Style: Internal loci vs. External loci
Cultural Factors: Individual learn what is expected and accepted by their culture. Demonstrative vs. Introverted.
What level will allow your patient to function?
Treat pain assessment like a 6th vital sign.
Determine your patients health literacy.
Higher vocabulary allows patients to better describe their pain
Utilize an assessment tool to allow for a more accurate measure.
Assess previous pain experience and effective home interventions.
During an episode of acute pain assess:
Believe patient stated pain level
Choose appropriate options
Deliver interventions both timely and logically
Empower patient to take control of pain management
Use an individualized approach for assessment. Specific populations often require special considerations:
Mental health populations
Critically ill (artificial airways, NGT’s)
Location: Use anatomical landmarks and descriptive terminology (superficial, cutaneous, deep or visceral, referred or radiating (Table 43-5, p. 973).
Severity: Use pain scales F.’s 44-5-7 p. 1026
Quality: Aching, throbbing, sharp, dull (nociceptive); burning, shooting or electric-like (neuropathic)
Aggravating/Precipitation Factors: Events or conditions that precipitate or aggravate pain.
Relief Measures: What works? (changing positions, heat, cold).
Contributing Symptoms: Depression, anxiety, anorexia, sleep disturbances.
Used for infants; possibly for mentally or neurologically impaired.
Assess verbalizations, vocal responses, facial and body movements, social interaction
Influence on ADLs
Assess for physical deconditioning, sleep patterns, self-care deficits, sexual dysfunctions related to pain, social activities
HA, nausea, dizziness, constipation, depression
Applicable dx include:
Impaired social interaction
Acute pain r/t-
Determine with the patient the expected pain goals and outcomes.
Teamwork and Collaboration
Use available resources for pain control including:
Advanced Practice Nurses
PT and Occupational therapists
Clinical Pain Specialists.
Provide an individualized approach
Understand your patient’s health literacy
Common Holistic Health Approaches include:
Attention to good hygiene practices
Management of interpersonal relationships
Cognitive-behavioral- Changing patients’ perceptions of pain, alter pain behavior, provide patients with a greater sense of control. Includes:
Prayer, relaxation, guided imagery, music and biofeedback.
Physical Approaches: Provide pain relief, correct physical dysfunction, alter physiological responses and reduce fears associated with pain related therapy. Includes:
Chiropractic therapy, acupuncture/acupressure therapy
Decreased blood pressure
Decreased respiratory rate
Decreased oxygen consumption
Decreased muscle tension
Decreased metabolic rate
Massage-Physical and mental relaxation B. 44-11 p. 1034.
Warm Bath-Relieves tension
Ice Packs- Reduces acute pain from inflamed joints/tissues
Battery powered transmitter with electrodes placed on or near the pain. Creates a buzzing/tingling sensation. Adjustable by the user.
-won’t really see in hospital but pt. might talk about
May interact with prescribed analgesics.
Ask patients to report all substances they take.
Proper fitting bandages/devices
Proper patient lifting/moving
Clean dry skin
Foley catheter protocol
Nonopioids: Acetaminophen (hepatotoxicity/ Mucomyst) Nonsteroidal anti-inflammatories (GI bleeding/renal insufficiency)
Opioids: narcotics (sedation/respiratory depression/ Narcan; N/V, constipation [ongoing], itching, urinary retention, AMS)
Adjuvants: enhance analgesic properties: steroids, anticonvulsants, antidepressants. May contribute to respiratory depression.
The Joint Commission requires range-order policies to be in place, utilized, and well documented.
Many institutions have strict guidelines on the use (or non-use) of range-orders. May be considered “prescribing”
Allows patients to self-administer opioids with minimal risk of overdose**
Goal: to maintain a constant plasma level of analgesia.
IV or subcutaneous administration.
Patients must be physically able to press the button to deliver the dose. Caution families not to medicate their loved one.
System designed to deliver a specified number of doses every hour (for example every 10 to 15 minutes).
Patient gains control over pain
Access to medication when the patient needs it.
Decreases anxiety and leads to decreased medication use
Stabilized serum drug levels by delivering small doses at short intervals.
MD orders too strong a dose of morphine/dilaudid
Nurse programs the machine wrong
Injury and death can occur even with no errors with the pump
Patient is monitored with oximetry alone
Need for continuous oximetry and capnography
Topical Analgesics: EMLA (lidocaine/prilocaine cream) or LET (lidocaine, epinephrine, tetracaine), Lidoderm patch.
Regional Anesthesia: nerve blocks, spinal anesthesia, epidural Analgesia: childbirth, chronic pain.
Reduces a patient’s overall opioid requirement.
Add medications administered via drug pump
Drugs must be free of preservatives and additives (Duramorph-morphine/ Sublimaze-fentanyl).
Assist the patient the first time up out of bed.
Surgical asepsis to prevent serious/fatal infection.
Observe for S&S of complications such as N/V, urinary retention, constipation, respiratory depression (Narcan for RR <8), pruritus. Monitoring may be as often as every 15 minutes.
Spinal cord stimulators
Deep brain stimulation
Neruoablative procedures (cordotomy: a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature sensation).
Trigger point injections
Refer patients with pain unresponsive to medication to a pain expert. It is unacceptable to tell a patient “there is nothing more we can do for you”.
Pain management best when administered ATC and not PRN.
Patients usually become tolerant to side effects (except constipation) so respiratory depression less of a problem.
Transdermal fentanyl: 100 times more potent than morphine.
Hydromorphone (Dilaudid): 10 times more potent than morphine
Consider the use of the WHO three-step analgesic ladder F. 44-14 p. 1042
Breakthrough Pain: Pain that “breaks through” a scheduled regimen of pain treatment B. 44-17 p. 1042.
Pseudoaddiction: looks like addiction but it is not addiction. In cases of pseudoaddiction, the drug-seeking behaviors cease once the pain is properly controlled, thereby confirming the absence of true addiction.
Understand personal biases.
May be considered unethical and deceitful
Differentiate: B. 44-19, p. 1044
Palliative Care: Learning to live life fully with an incurable condition.
Hospices: Care for patients at end of life. Emphasis on quality of life not quantity.
Reassess after each intervention at the appropriate time.
Document patient response to therapy.
Document any unexpected outcomes.
The pain threshold varies between patients
Remember a number of factors influence a persons response to pain including their cultural background, developmental stage, environment, personal experience with pain, and emotional status
Assessment is the key to providing a correct care plan for a patient’s pain
There are two types of interventions for pain: nonpharmacological and pharmacological
Always follow policy and procedure for pain management
Patients should always be the center of their care plan and include their preferences