group c (pain management)

8/7/2019 GROUP C (PAIN MANAGEMENT)

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UNIVERSITY OF SAN JOSE- RECOLETOS

COLLEGE OF NURSING

IN PARTIAL FULLFILMENT IN

SKILLS LABORATORY REQUIREMENTS

PAIN MANAGEMENT, NON PHARMACOLOGIC PAIN MANAGEMENT,

AND INFECTION CONTROL

TITLE PROCEDURE

PREPARED BY:

Simacon, Peps Iriel

Tabaag, Donnabelle

Tagadiad, Leah

Tan, Danielle Therese

Tangog, Charmy Fe

Turtoga, Jonessa

Ungod, Jean Rose

Taer,Godfrey Bryan

BSN-III BLOCK 4

PAIN MANAGEMENT


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I. BASIC PRINCIPLES

All patients have the right to have their pain relieved as much as

possible.

The patient's age; gender; race or ethnic background; religiousbeliefs; lifestyle choices; stage of illness; underlying diagnoses;and/or history of substance abuse do not change this right.

Some groups, including children, the elderly, the mentally orphysically disabled, and those with a history of addictions needto have special care to be sure their pain is well-treated.

Because pain is such a personal experience, the patient's report ofpain is the "gold standard", and all treatment is based on that report.

The goal of treatment is to relieve as much of the patient's pain as ispossible.

Sometimes, it may not be possible to relieve the entire patient'spain. If this is the case, the goal should be to reduce the pain tothe level that the patient says is his/her goal.

For the best pain relief, doctors, nurses, and other professionalsmust watch out for side effects and their treatment; the goal isto achieve the best pain relief with the least side effects.

A complete review of the patient's pain should be done at the start oftreatment, and pain should be reviewed each time the patient is seenby a health care professional after that.

Pain should be considered the fifth vital sign, along with pulse,breathing rate, blood pressure, and temperature.

The review of the patient's pain should include a review of howmuch pain the patient has; what the pain feels like; side effectsof the pain and medicines for it; mood; and how the pain affectsthe patient in all areas of his/her life.

NURSING PRINCIPLES FOR ADMINISTERING ANALGESICS


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1. Know the clients previous response to analgesics.

Determine whether relief was obtained.

Ask whether a nonnarcotic was as effective as a narcotic.

Identify previous doses and routes of administration to avoidundertreatment.

Determine whether the client has allergies.

2. Select proper medications when more than one is ordered.

Use nonnarcotic analgesics or milder narcotics for mild to moderatepain.

Know that nonnarcotics can be alternated with narcotics.

In older adults, avoid combinations of narcotics.

Remember that morphine and hydromorphone are the narcotics ofchoice for long-term management of sever pain.

Know that injectable medications act quicker and can relieve severe,acute pain within 1 hour and that oral medication may take as long as2 hours to relieve pain.

Use a narcotic with a nonnarcotic analgesic for severe pain becausesuch combinations treat pain peripherally and centrally.

3. Know the accurate dosage.

Remember that doses at the upper end of normal are generally neededfor severe pain.

Adjust doses, as appropriate, for children and older clients.

4. Assess the right time and interval for administration.

Administer analgesics as soon as pain occurs and before it increases inseverity.

Do not give analgesics only by ordered schedules. Remember that anaround-the-clock (ATC) administration schedule is usually best.

Give analgesics before pain-producing procedures or activities.

Know the average duration of action for a drug and the time ofadministration so that the peak effect occurs when the pain is mostintense.

II. PAIN ASSESSMENT


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Although pain is referred to us the fifth vital sign, pain is a symptom.Subjective in nature, pain is whatever the person says it is whenever he orshe says it does (McCaffery, 1999). Pain has also been defined as anunpleasant sensory and emotional experience associated with actual orpotential tissue damage (International Association for the Study of Pain,2006)

PURPOSE:

Accurate assessment of pain in the first step in developing andeffective treatment plan to deal with pain. The strategy of linking painassessment to routine vital sign assessment and documentation represents apush to make pain assessment a routine aspect of care for all clients. Giventhe highly subjective and individually unique nature of pain, a comprehensiveassessment of the pain experience (physiologic, psychologic, behavioral,emotional, and sociocultural) provides the necessary foundation for optimalpain control.

EQUIPMENTS/MATERIALS NEEDED:Pain Assessment has various instruments. Consider the patients age

and developmental status along with his or her cultural background whenselecting a pain scale.

PROCEDURE/STEPS:

1. PQRST Tool

Precipitating / palliative / provocative

What were you doing when the pain started?

Does anything make it better, such as medication or a certain position?

Does anything make it worst, such as movement or breathing?

Quality / quantity

What does it feel like?

a. Superficial somatic pain is sharp, pricking, or burning

b. Deep somatic pain is dull or aching.

c. Visceral pain is dull, aching, or cramping

d. Neuropathic pain is burning, shocklike, jabbing, squeezing, oraching.

How often are you experiencing it?

To what degree is the pain affecting your ability to perform your usual

daily activities?


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Region / radiation / related symptoms

Can you point to where it hurts?

Does the pain occur or spread anywhere?

a. Localized pain confined to the sight of origin, such as cutaneous

pain.

b. Referred pain is referred to a distant structure, such as shoulder

pain with acute cholecyctitis or jaw pain associated with angina.

c. Projected pain is transmitted along a nerve, such as with herpes

zoster or trigeminal neuralgia.

d. Dermatomal pattern is as with peripheral neuropathic pain.

e. Nondermatomal pattern is as with central neurophatic pain.

Severity

Use appropriate pain scale.

Timing

When did the pain begin?

How did it last?

a. Brief flash: Quick pain as with needle stick.

b. Rhythmic pulsation: pulsating as with migraine or toothache

c. Long duration rhythmic: as with intestinal colic

d. Plateau pain: pain that rises the plateaus such as angina

e. Paroxysmal pain: such as neuropathic pain

How often does it occur?

a. Continuous fluctuating pain: as with musculoskeletal pain.

Do you have times when you are pain free?


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2. OLDCART

O Onset: When did the pain begin?

L - Location: Where does it hurt? Can you point to where it hurts?

D - Duration: How long does it last?C - Characteristics: What does it feels like?

A - Aggravating factors: Does anything make it worse?

R - Radiation: Does the pain go anywhere else?

T - Treatment: Did anything make it better? (Pain medication, ice,heat?)

PAIN SCALE FOR ADULTS

1. Numeric Rating Scale

The Numeric Rating Scale rates pain on a scale of 0 (no pain) to either5 or 10 (worst pain) by asking the patient to rate her or his current pain level.

2. Visual Analogue Scale

The Visual Analogue Scale utilizes a vertical or horizontal 10-cm linewith anchors. One end of the line is labeled No Pain and the opposite end ofthe line is labeled Worst Pain. The patient marks his or her current painlevel on the line.

[______________________________________]

0 cm 10 cm

(no pain) (worst pain)

3. Categorical Scales

Categorical Scales use verbal or visual descriptors to identify painintensity. The patient selects the descriptor that she or he feels bestrepresents the current pain level. Verbal descriptors include:

Mild, discomforting, distressing, horrible, excruciating. No pain, mild pain, moderate pain, severe pain, very severe pain,

worst possible pain.


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Visual descriptors include the Faces Pain Scale for Adults and Children

(FPS), which utilized illustrated faces with facial expressions ranging fromhappy (no pain) to sad and crying (worst pain). The FPS has eight faces toselect current pain level. The patient is asked to select the face that bestrepresents his or her current pain level.

4. Multidimensional Pain Scales

These scales assess pain characteristics and its effects on patientsactivities of daily living and include such scales as the Initial Pain AssessmentInventory (IPAI), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ),and the Neuropathic Pain Scale.

5. Initial Pain Assessment Inventory

The IPAI is used for initial assessment of pain. It assessescharacteristics of pain; effects of pain on the patients life, such as dailyactivities, sleep, appetite, relationships, and emotions; and the patientsexpression of pain. This assessment tool includes a diagram to not painlocation, a scale to rate pain intensity, and space to document additionalcomments and the treatment plan.

6. Brief Pain Inventory

The BPI is used to quantify pain intensity and associated disability. Itassesses pain intensity, location, effects on life, type, and effectiveness of

treatment over the last 24 hours. Benefits of the BPI include that it is quickand easy to use and available in multiple languages.

7. McGill Pain Questionnaire

The MPQ uses descriptive words to assess pain on three levels;sensory, affective, and evaluative. It can be used with other tools and isavailable in short and long forms.

8. Neuropathic Pain Scale

The Neuropathic Pain Scale assesses the type and degree ofsensations associated with neuropathic pain. The patient rates eight commonqualities of neuropathic pain (sharp, dull, hot, cold, sensitive, itchy, deep, orsurface pain) on a scale of 0 (no pain) to 10 (worst pain). This scale is still inthe developmental stages, but early testing holds diagnostic and therapeuticpromise.


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PAIN SCALE FOR CHILDREN

1. Faces Pain Rating Scale

The FACES Pain Scale assesses pain for children ages 3 years and up.

The Wong-Baker has five faces from which the child can select her or hiscurrent pain level.

2. Oucher

The Oucher scale assesses pain for children ages 3 to 13 years withphotos or a numeric scale. The photographic scale uses six photographs ofchildren ranging from a child with no hurt to a child with a lot of hurt. Thephotographs are arranged vertically from 0 to 5, with 0 (no hurt) on thebottom and 5 (lot of hurt) on the top. This scale also has photographs of blackand Hispanic children available.

Explain to the person that each face is for a person who feels happybecause he has no pain (hurt) or sad because he has some or a lot of pain.Face 0 is very happy because he doesnt hurt at all. Face 2 hurts a littlemore. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as muchas you can imagine, although you do not have to be crying to feel this bad.Ask the person to choose the face that best describes how he is feeling.Rating scale is recommended for persons age 3 and older.

3. Numeric Scale


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The numeric scale ranges vertically from 0 to 100, with 0 being nohurt and 100 being biggest hurt.

0 = no hurt 1-29 = little hurt 30-69 = middle hurt 70-99 = big hurt 100 = biggest hurt

4. Poker Chip Tool

The Poker Chip Tool assesses pain in children 4 years of age and up.The nurse places red poker chips horizontally in front of the child, with thepoker chips denoting pieces of hurt. She then asks the child to select howmany pieces of hurt he or she has.

5. Word-Graphic Rating Scale

The Word-Graphic Rating Scale assesses pain in children ages 4 to 17years. It uses words on a horizontal linear scale to assess pain. The child isasked to identify her or his current pain level on the scale.

[__________________________________________________]

No Little Medium Large Worst

Pain Pain Pain Pain Pain

6. Numeric Scale

The Numeric Scale assesses pain for children ages 5 years and older. Ituses a horizontal linear scale with numbers from 0 to 5 or 10, with 0 beingno pain and 5 or 10 being worst pain. The child is asked to identify his orher current pain level on the scale. Although similar to a scale used foradults, this provides the child with a visual to help assess his or her pain.

No pain Worst pain

[_________________________________________________]

0 1 2 3 4 5

7. Visual Analogue Scale


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The Visual Analogue Scale, which assesses pain in children age 4 and older, is similar to that used for adults. The child is asked to identify heror his pain level by marking the line in the area that represents her or hislevel of pain.

8. Color Tool

The Color Tool assesses pain for children as young as 4 years byhaving the child create a body outline using colored markers or crayons. Thechild selects four colors. The first color represents most hurt, the secondrepresents little hurt, the third represents least hurt, and the lastrepresents no hurts. Using all four colors, the child identifies areas anddegree of hurt on the body outline.

SOURCE: Dillon, Patricia M. Nursing Health Assessment. A Critical ThinkingCase Studies Approach. Edition 2. pp 97-100

Fundamentals of Nursing, Potter and Perry, 5th Edition, Vol. 2, pp1311.

III. GENERAL PAIN MANAGEMENT STRATEGIES

1. Acknowledging and Accepting Clients Pain.

According to the professional standards of conduct, nurses have a duty

to ask clients about their pain and to believe their reports of discomfort.Challenging the clients report of discomfort undermines the environment oftrust that is an essential component in the therapeutic relationship. Considerthese four ways of communicating this belief:

a.) Acknowledge the possibility of the.

Example: Many people with your condition are bothered by leg pain.Are you experiencing any leg discomfort? What does it feel like? Howconcerned/upset are you about it?

b.) Listen attentively to what the client says about the pain, restatingyour understanding of the reported discomfort.

Example: Adding an empathetic statement like, Im sorry you arehurting, it must be very upsetting. I want to help you feel better lets theclient know you believe the pain is real and intend to help.

c.) Convey that you need to ask about the pain because, despite somesimilarities, everybodys experience is unique.


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Example: Many people with you condition report having somediscomforts. Do you have any pain or other discomforts now?

d.) Attend to the clients needs promptly. It is unconscionable tobelieve the clients report of pain and then do nothing. After determiningthe client has pain, discuss options and plan actions for providing relief.

Example: Now that you have stated the site of pain and the intensityof pain, we are now going to intervene you as much as we could.

2. Assisting support persons.

Support persons often need assistance to respond in a helpful mannerto the person experiencing pain. Nurses can help by giving them accurateinformation about the pain and providing opportunities for them to discusstheir emotional reactions, which may include anger, fear, frustration, andfeelings of inadequacy. Support persons also may need the nursesunderstanding, reassurance, and perhaps access to resources that will helpthem cope as they add the caregiver role to an already stressful lifecircumstance.

3. Reducing Misconceptions about pain.

Reducing a clients misconceptions about the pain and its treatmentwill remove one of the barriers to optimal pain relief. The nurse shouldexplain to the client that pain is a highly individual experience and that it isonly the client who really experiences the pain, although others canunderstand and empathize.

4. Reducing fear and anxiety.

It is important to help relieve strong emotions capable of amplifyingpain (e.g., anxiety, anger, and fear). When clients have no opportunity to talkabout their pain and associated fears, their perceptions and reactions to thepain can be intensified. Often, these emotions are related to uncertaintyabout the future, feeling mistreated in the past, or having unmetexpectations.

5. Preventing pain.

A preventive approach to pain management involves the provision ofmeasures to treat the pain before it occurs or before it becomes severe. Thisstrategy prevents the windup and sensitization described earlier thatspreads, intensifies, and prolongs pain.

SOURCE: Kozier and Erbs Fundamentals of Nursing. Eight Edition. Vol. 2.pp.1206-1208.


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1V. POST OPERATIVE PAIN

Pain Management in patient post operatively

Although pain is a sensory and emotional experience that serves toalert us to harm and initiate responses to avoid or minimize harm, pain in thesurgical client has little protective value.

Pain is usually greatest 12 to 36 hours after surgery, decreasing afterthe second or third postoperative day. During the initial postoperative period,patient-controlled analgesia (PCA) or continuous analgesic administrationthrough an intravenous or epidural catheter is often prescribed. The nursemonitors the infusion or amount of analgesic administered by PCA, assessesthe clients pain relief, and notifies the primary care provider if the client isexperiencing unacceptable side effects or inadequate pain relief.

An anti-inflammatroy agent such as ibuprofen or ketorolac (Toradol) isoften administered in conjunction with a narcotic analgesic to enhance painrelief. Clients need to be reminded that analgesics are most effective whentaken on a regular basis or before pain becomes severe. Because muscletension increases pain perception and responses, nurses need to usenonpharmacologic measures in addition to prescribed analgesia. Theseinclude ensuring that the client is warm and providing back rubs, positionchanges, diversional activities, and adjunctive measures such as imagery.

Types of Pain-Control Treatments:

1. Patient-Controlled Analgesia (PCA)

It is an interactive method of pain management that permits clients totreat their pain by self-administering doses of analgesics. The oral route forPCA is most common, but the subQ, IV, and epidural routes are increasinglybeing used. PCA pumps are designed with built-in safety mechanisms toprevent client overdosage, abusive use, and narcotic theft.

Patient-controlled analgesia (PCA) is a computerized pump that safelypermits you to push a button and deliver small amounts of pain medicine intoyour intravenous (IV) line, usually in your arm. There is no injection ofneedles into your muscle. PCA provides stable pain relief in most situations.Many patients like the sense of control they have over their painmanagement.


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2. Patient-Controlled Epidural Analgesia

In epidural analgesia, pain medications are injected through a long,thin tube (catheter) inserted into the epidural space within your spinal canalbut outside your spinal fluid. An epidural catheter is often used for labor anddelivery, and sometimes before a major operation such as joint replacementor lung surgery. The epidural catheter can be left in place for several days ifneeded to control postoperative pain. A continuous infusion of pain relievers including numbing medications (local anesthetics) and opioid medications,

such as morphine or fentanyl can be delivered through the catheter tocontrol pain.

3. Spinal anesthesia

Some surgeries can be done with spinal anesthesia. Unlike epiduralanalgesia, this form of pain relief involves medications injected directly intothe spinal fluid. Spinal anesthesia is easier and faster than epidural analgesia,but it doesn't last as long because there is no catheter to allow theadministration of additional medication. Your doctor can add a long-actingopioid to the spinal medication that can relieve post-surgical pain for up to 24hours.

4. Nerve block

A nerve block provides targeted pain relief to an area of your bodysuch as an arm or leg. It prevents pain messages from traveling up the nervepathway to your brain. If you need only a few hours of pain relief, youranesthesiologist may use a single injection of local anesthetic around theappropriate nerves related to your surgery. For longer pain relief, your


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anesthesiologist may place a catheter into that area to deliver a continuousinfusion of pain medications.

PAIN MEDICATIONS TAKEN BY MOUTH

1. Opioids (Narcotics) after surgery (medications such as morphine,fentanyl, hydromorphone):

Indication: Strong pain relievers. Many options are available if one iscausing significant side effects.

Contraindication: May cause nausea, vomiting, itching, drowsiness,and constipation. The risk of becoming addicted is extremely rare.

2. Opioids (Narcotics) at home (Percocet, Vicodin, Darvocet, Tylenol)

Indication: Effective for moderate to severe pain. Many optionsavailable.

Contraindication: Nausea, vomiting, itching, drowsiness,constipation. Stomach upset can be lessened if the drug is taken withfood. Should not drive or operate machinery while taking these


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medications. Note: These medications often contain acetaminophen(Tylenol). Make sure that other medications that you are taking do notcontain acetaminophen, as too much of it may damage your liver.

Be sure to tell your doctor about all medications (prescribed and over-the- counter), vitamins and herbal supplements you are taking. This mayaffect which drugs are prescribed for your pain control.

3. Non-Opioid (Non-narcotic) Analgesics (Tylenol, Feverall)

Indication: Effective for mild to moderate pain. They have very fewside effects and are safe for most patients. They often decrease the

requirement for stronger medications, which may reduce the incidenceof side effects.

Contraindication: Liver damage may result if more than therecommended daily dose is used. Patients with pre-existing liver

disease or those who drink significant quantities of alcohol may be atincreased risk.

4. Nonsteroidal Anti-inflammatory Drugs (NSAIDS) ibuprofen (Advil),naproxen sodium (Aleve), celecoxib (Celebrex)

Indication: These drugs reduce swelling and inflammation and relieve

mild to moderate pain. Ibuprofen and naproxen sodium are availablewithout a prescription, but you should ask your doctor about takingthem. They may reduce the amount of opioid analgesic you need, possiblyreducing side effects such as nausea, vomiting, and drowsiness. If takenalone, there are no restrictions on driving or operating machinery.

Contraindication: The most common side effects of nonsteroidal anti-inflammatory medication (NSAIDS) are stomach upset and

dizziness. You should not take these drugs without your doctor'sapproval if you have kidney problems, a history of stomach ulcers, heartfailure or are on "blood thinner" medications such as Coumadin

(warfarin), Lovenox injections, or Plavix.

SOURCE:

Kozier & Erbs Fundamentals of Nursing. Concepts, Process, andPractice. Eight Edition. Volume 2. pp. 962,1216


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http://www.riversideonline .com/health_reference/Nervous-System/PN00060.cfm

V. PAIN MANAGEMENT FOR ELDERLY

MISCONCEPTIONS CORRECTIONS

1. Pain is a natural outcome ofgrowing old.

It is true that older adults are atgreater risk (as much as twofold)than younger adults for many painfulconditions; however, pain is not aninevitable result of aging.

2. Pain perception, or sensitivity,

decreases with age.

This assumption is unsafe. Although

there is evidence that emotionalsuffering specifically related to painmay be less in older than in youngerclients, no scientific basis exists forthe assertion that a decrease inperception of pain occurs with age orthat age dulls sensitivity to pain.Assessment and intervention for painin older adults should begin with theassumption that allneurophysiological processesinvolved in nociception are unaltered

by age.

3. If the older client does not reportpain, he or she does not have pain.

Older clients commonly underreportpain. Reasons include expecting tohave pain with increasing age; notwanting to alarm loved ones; beingfearful of losing their independence;not wanting to distract, anger, orbother caregivers; and believingcaregivers know they have pain andare doing all that can be done torelieve it. The absence of a report of

pain does not mean the absence ofpain.

4. If an older client appears to beoccupied, asleep, or otherwisedistracted from pain he or she doesnot have pain.

Older clients often believe it isunacceptable to show pain and havelearned to use a variety of ways tocope with it. Sleeping may be acoping strategy or indicate
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exhaustion, not pain relief.

5. The potential side effects ofopioids make them too dangerous touse to relieve pain in older adults.

Opioids may be used safely olderadults. Although the opioid-naveolder adult may be more sensitive toopioids, this does not justify

withholding the use of them in themanagement of pain in thispopulation. The key to use of opioidsin older adults is to start low and goslow. Potentially dangerous opioid-induced side effects can beprevented with slow titration; regular,frequent monitoring and assessmentof the clients response; andadjustment of dose and intervalbetween doses when side effects aredetected. If necessary, clinically

significant respiratory depression canbe reversed by an opioid antagonistdrug.

6. Clients with Alzheimers diseaseand others with cognitive impairmentdo not feel pain, and their reports ofpain are most likely invalid.

No evidence exists that cognitivelyimpaired older adults experience lesspain or that their reports of pain areless valid than those of individualswith intact cognitive function. It isprobable that clients with dementia,progressive deficits of cognition,apraxias, and agnosia, particularly

those in long-term care facilities,suffer significant unrelieved pain anddiscomfort. Assessment of pain inthese clients is challenging butpossible. The best approach is toaccept the clients report of pain.

7. Older clients report more pain asthey age.

Even though older clients experiencea higher incidence of painfulconditions, such as arthritis,osteoporosis, peripheral vasculardisease, and cancer, than younger

clients, studies have shown that theyunderreport pain. Many elderly clientsgrew up valuing the ability to grinand bear it, and, unfortunately, havebeen heavily influenced by the JustSay No to drugs campaign.


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SOURCE: Fundamentals of Nursing, Potter and Perry, 5th Edition, Vol. 2,pp. 1292.

2.) NON-PHARMACOLOGIC PAIN MANAGEMENT

Definition:

Non-pharmacological or natural therapies are things you can do orthink about that help decrease your pain. These therapies do not involvetaking medicines, but work along with your medicines. People have used"natural" ways to help with pain and healing from the very beginning of time.

Indication:

A long time ago, the Chinese learned that putting special needles inareas of the body could decrease pain. Music has also a very important partof healing the sick over time. Scientists are learning that common things like

music, laughter, exercise and good smells cause our brains to make specialchemicals. These special chemicals may help us to feel less pain.

Contraindication:

Being tense and upset causes pain to become worse. When you aretense, your muscles get tight which decreases blood flow in your body. Yourheart beats faster and your blood pressure goes higher. Your breathing alsogets faster and shallower. Your brain begins to make chemicals, includingones that may cause pain. This stress and upset cycle causes you more pain.Certain ways to relax help loosen muscles. This breaks the whole cycle andmay decrease your pain.

The following are the common non pharmacologic managements:

1. PHYSICAL INTERNVENTIONS

The goals of physical intervention include providing comfort, alteringphysiologic responses to reduce pain perception, and optimizing functioning.

a.) Breathing exercises- are another physical way to help your body relax.Teaching your body to relax, helps make the pain less. Breathing in and outvery slowly is all you do. Women have used breathing exercise for manyyears to decrease the pain of childbirth.

2. CUTANEOUS STIMULATION this can be applied directly to the painfularea, proximal to the pain or distal to the pain (along the nerve path ordermatome), and contralateral (exact location, opposite side of the body), tothe pain.

Indication:

It can provide effective temporary pain relief.


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It distracts the client and focuses attention on the tactile stimuli, awayfrom the painful sensations, thus reducing pain perception.

It interferes with the transmission and perception of pain by stimulatingthe large-diameter A-beta sensory nerve fibers that activate thedescending mechanisms that can reduce the intensity of pain, activate

the endorphin system of pain control, and thus diminish consciousawareness of pain.

Contraindication:

In the areas of skin breakdown or impaired neurological functioning.

a.) Massage a nonpharmacologic management technique that usesointments or liniments that provide localized pain relief with joint or musclepain. Massage can involve the back and neck, hands and arms, or feet.

Indication:

It aids relaxation.

It decreases muscle tension.

It eases anxiety because the physical contact communicates caring.

It decreases pain intensity by increasing superficial circulation to thearea.

Contraindication:

In the areas of skin breakdown, suspected clots, or infections.

Equipments:

Ointments, liniments, extra towel, etc.

b.) Heat and Cold Application a warm bath, heating pads, ice bags, icemassage, hot or cold compresses, and warm or cold sitz baths in generalrelive pain and promote healing of injured tissues.

c.) Accupressure It was developed for the ancient Chinese healing system

of acupuncture. The therapist applies finger pressure to points thatcorrespond tomany of the points used in acupuncture.

d.) Contralateral Stimulation it can be accomplished by stimulating theskin in an area opposite to the painful area (e.g., stimulating the left knee ifthe pain is in the right knee). The contralateral area may be scratched foritching, massaged for cramps, or treated with cold packs or analgesicointments. This method is particularly useful when the painful area cannot be


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touched because it is hypersensitive, when it is inaccessible by a cast orbandages, or when the pain is felt in a missing part.

3. IMMOBILIZATION/BRACING immobilizing or restricting the movementof a painful body part (e.g., arthritic joint, traumatized limb). Splints orsupportive devices should hold joints in the positions of optimal function and

should be removed regularly in accordance with agency protocol to provideROM exercises. Therefore, clients should be encouraged to participate in self-care activities and remain as active as possible, with frequent ROM exercises.

Indication:

To help manage episodes of acute pain.

Contraindication:

Prolonged immobilization can result in joint contracture, muscleatrophy, and cardiovascular problems.

Equipments:

Splints, brace, tractor, etc.

4. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) is amethod of applying low-voltage electrical stimulation directly over identifiedpain areas, at an acupressure point, along peripheral nerve areas thatinnervate the pain area, or along the spinal column. The TENS unit consists ofa portable, battery operated device with lead wire and electrode pads thatare applied to the chosen area of skin.

Indication:

To activate large-diameter fibers that modulate the transmission ofthe nociceptive impulse n the peripheral and CNS (closing the paingate), resulting in pain relief.

It causes a release of endorphins from the CNS center.

Contraindication:

Contraindicated for clients with pacemakers or arrhythmias

In areas of skin breakdown.

It is generally not used on the head or over the chest.

5. COGNITIVE-BEHAVIORAL INTERVENTIONS

Indication:

It provides comfort.

It alters psychologic responses to reduce pain perception.


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To optimize functioning.

a.) Distraction this draws the persons attention away for the pain andlessens the perception of pain. In some instances, distraction can make aclient completely unaware of pain. Distraction makes the person unaware ofthe pian only for the amount of time and to the extent that the distracting

activity holds his or her undivided attention.

b.) Biofeedback - teaches your body to respond in a different way to thestress of being in pain. Teaching your body to relax, helps make the pain less.Caregivers may use a biofeedback machine so that you know right awaywhen your body is relaxed. But, often you may not need any machines. Learnto take your pulse. Then take it while making your mind think about "slowingdown" your pulse. This can work with breathing, temperature, and bloodpressure too.

c.) Guided imagery - teaches you to put pictures in your mind that willmake the pain less intense. With guided imagery, you learn how to changethe way your body senses and responds to pain. Imagine floating in theclouds or remembering favorite place. Guided imagery seems to help peoplewith chronic lower back pain.

d.) Self-hypnosis - is a way to change your level of awareness. This meansthat by focusing your attention you can move away from your pain. You makeyourself open to suggestions like ignoring the pain or seeing the pain in apositive way. It is not known exactly how hypnosis helps pain. But, hypnosiscan give long-lasting relief of pain without affecting your normal activities.

Self-hypnosis gives you better control of your body. You may feel lesshopeless and helpless because you are doing something to decrease thepain.

e.) Laughter - It has been said that "10 minutes of belly laughter gives 2hours of pain-free sleep! Laughter helps you breathe deeper and yourstomach digest (break down) food. It lowers blood pressure and may causeyour brain to make endorphins. Laughter can also help change your moods. Ithelps you relax and let go of stress, anger, fear, depression, andhopelessness. These are all parts of chronic pain.

f.) Music - it does not matter whether you listen to it, sing, hum or play aninstrument. Music increases blood flow to the brain and helps you take inmore air. Scientists are learning that it increases energy and helps changeyour mood. Music also may cause your brain to make special chemicals likeendorphins. Endorphins are a natural body chemical like morphine thatdecrease pain. People who use music often say it decreases their need ofmedicines for pain and anxiety.


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SOURCE: Kozier & Erbs Fundamentals of Nursing. Concepts, Process, andPractice. Eight Edition. Vol. 2pp. 1217-1221

3.) INFECTION CONTROL

- An infection is the entry and multiplication of an infection agent in thetissues of a host. If the infectious agent (pathogens) fails to causeinjury to cells or tissues, the infection is asymptomatic.

- If the pathogens multiply and cause clinical signs and symptoms, theinfection is symptomatic. If the infectious disease can be transmitteddirectly from one person to another, it is a communicable, orcontagious, disease

- Infection control refers to policies and procedures used to minimize therisk of spreading infections, especially in hospitals and health carefacilities.

Purpose:

-To reduce the occurrence of infectious diseases. These diseases areusually caused by bacteria or viruses and can be spread by human-to-human contact, animal-to-human contact, human contact with aninfected surface, airborne transmission through tiny droplets ofinfectious agents suspended in the air, and, finally, by a commonvehicle such as food or water.

Equipments:

Antimicrobial or regular soap

Clean orangewood sticks or toothpick (optional)

Paper towel or hand towel

Easy to reach sink with warm running water

Procedure: HANDWASHING


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PROCEDURES RATIONALE

1.1. Inspect surface of hands for breaksor cuts in skin or cuticles.

Open cuts or wounds can harbor highconcentration of microorganism

2. Open cuts or wounds can harborhigh concentration of microorganism

Nails should be short and filledbecause most microbes of handscame from beneath the fingernails

3. Remove wristwatch and avoidwearing rings

Provide complete access to fingers,hands, and wrist. Wearing of ringscan increase numbers ofmicroorganism and the hands

4.Stand in front of the sink, keepinghands and uniform away from thesink surface. (If hands touch sinkduring hand washing repeat.)

Provides complete access to fingers,hands, wrists. Wearing of ringsincreases number of microorganismson hands.

5. Turn on water. Turn faucet on orpush knee pedals laterally or presspedals with foot to regulate flow andtemperature.

To let the water flow over the handsand facilitate in washing.

6. Avoid splashing water againstuniform.

Microorganisms travel and grow inmoisture.


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7. Regulate flow of water so thattemperature is warm.

Warm water removes less of theprotective oils than hot water.

8. Wet hands and wrists thoroughly

under running water. Keep handsand forearms lower than elbowsduring washing.

Hands are the most contaminated

parts to be washed. Water flowsfrom least to most contaminatedarea, rinsing microorganisms intothe sink.

2. 9. Apply a small amount ofsoap or antiseptic, latheringthoroughly. Soap granules andleaflet preparations may be used.

Use of antiseptic exclusively can bedrying to hands and can cause skinirritations. The decision whether touse an antiseptic should depend onthe procedure to be performed andthe clients immune status.

10. Wash hands using plenty oflather and friction for at least 10 to15 seconds. Interlace fingers andrub palms and back of hands withcircular motion at least 5 timeseach. Keep fingertips down tofacilitate removal ofmicroorganisms.

Soap cleanses by emulsifying fatand oil and lowering surfacetension. Friction and rubbingmechanically loosen and removedirt and transient bacteria.Interlacing fingers and thumbsensures that all surfaces arecleansed.

11. Areas underlying fingernails are

often soiled. Clean them withfingernails of other hand andadditional soap or cleanorangewood stick.

Area under nails can be highly

contaminated, which will increasethe risk of infection for the nurse orthe client.

12. Rinse hands and wriststhoroughly, keeping hands downand elbows up.

Rinsing mechanically washes awaydirt and microorganisms.

13. Dry hands thoroughly fromfingers to wrists and forearms withpaper towel, single-se cloth, or warmair dryer

Drying from cleanest (fingertips) toleast clean (forearm) area avoidscontamination. Drying handsprevents chapping and roughenedskin.

14. If used, discard paper towel inproper receptacle.

Prevents transfer ofmicroorganisms.


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15. Turn off water with foot or kneepedals. To turn off hand faucet, useclean, dry paper towel; avoidtouching handles with hands.

Wet towel and hands allow transferof pathogens by capillary action.

16. If hands are dry or chapped, asmall amount of lotion or barriercream can be applied.

Use small, individual-use containerof lotion because large, refillablecontainers have been associatedwith nosocomial infections.

17. Inspects surfaces of hands forobvious signs of soil or othercontaminants.

Determines if hand washing isadequate.

18. Inspects hands for dermatitis or

cracked skin.

Indicates complications from

excessive hand washing.

Nursing Responsibility:

- Encourage hand washing before and after eating and going to thecomfort room

- Instruct clients about cleaning equipments using soap and water anddisinfecting with an appropriate disinfectants

- Demonstrate proper hand washing, explaining that it should be donebefore and after all treatments and when infected body fluids arecontacted.

- Instruct client about signs and symptoms of wound infection

- Instruct clients to place contaminated dressing and their disposableitems containing infectious body fluids in impervious plastic bags.

- Place needles in metal containers such as soda cans and tape theopening shuts.

- Clean noticeably solid linen separate from other laundry. Wash inwater that is as hot as the fabric will tolerate

Evaluation:

- As client or family member to describe techniques used to reducetransmission of infection.

- Have client demonstrate select techniques

- Ask client to explain risk for infection based on the condition.


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Source:

- Fundamentals of Nursing, Potter and Perry, 5th Edition, Vol. 2, pp 835-864

group c (pain management)

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