Pain ManagementChapter 13NUR 299 C 1&2(Adapted from LLW 2010)

PainUnpleasant sensory, emotional experience

with actual or potential tissue damageMost 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

CollaborateEvaluate effectivenessAdvocateEducate

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 PainAcute painChronic painCancer-related painMay be classified by location or

etiology

Effects of PainSleep deprivationAcute 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 PainNociceptors (pain receptors) transmission

of pain perception to & from the brainNon-Nociceptor- does not transmit pain.

Ie: pressure or temperatureNeurologic Transmission of pain

(nocicetion) by nervesChemical 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 ResponsePast experienceAnxietyDepressionCultureAgeGenderExpectations

Characteristics of PainIntensityTiming LocationQualityPersonal meaningAggravating/ Alleviating factorsPain 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 cyclo-oxygenase (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 Interventions-PharmacologicBalanced anesthesia“PRN” medicationsRoutine administration: around

the clock (ATC) or preventive approach

PCA: patient-controlled analgesiaLocal anestheticsTopicals, patchesIntraspinal a

PCA - Patient Controlled Analgesia Two TypesContinuous – 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.

PCAPhysician’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’dParameters 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 statusPain Score of 5 or greater &/or pain that is

not decreasing

Nonpharmacologic InterventionsCutaneous stimulation, massageThermal therapiesTranscutaneous electrical nerve

stimulation (TENS)DistractionRelaxation techniques

Nonphamacologic Interventions

Guided imageryHypnosisMusic therapyAlternative therapies

Neurologic & Neurosurgical Methods for Pain Control

Intrathecal catheters- spinal, meds to spinal cord

Epidural catheters- epidural space in spinal cord

Stimulation procedures - TENSInterruption 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 depressionSedationNausea, vomitingConstipationPruritis

Nursing Process Framework for Pain Management

Identify goals for pain management

Establish nurse-patient relationship, teaching

Provide physical careManage anxiety related to painEvaluate 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.

AnswerFalse.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 ReviewThe RN asks a patient to describe

the quality of pain. Which of the following is a descriptive term for the quality of pain?

A. BurningB. ChronicC. IntermittentD. Severe

AnswerA. BurningRationale: 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.