Pain Management

C. Calzolari

2014

What is Pain?

Why Do We Experience Pain?

It is protective. How?

It is a signal. What?

Cause of Pain

Nociceptive pain(pain receptors) – most common. Respond to stimulation.Visceral – organs , linings of cavitiesSomatic – Skin, muscles, bones, connective

tissue

Neuropathic pain – complex and often chronic.

Classification of Pain

AcuteCan Identify CauseTemporaryActivates SNS - BP, HR, RR, more blood to brain, dilates pupils

Classification of Pain

ChronicLonger Duration – lasts beyond healing phaseInterferes with ADLsRemissions & exacerbationsStimulates PNS - or normal Vital SignsAffective Responses

Classification of Pain

IntractableChronic

Resistant to pain relief

Multi-Disciplinary Approach

Descriptions of Pain

Based on site, cause, duration and quality.

Site of Pain

Cutaneous or superficial pain

Visceral pain

Deep somatic pain

Radiating pain

Referred pain

Phantom pain

Psychogenic pain

Take the Vocabulary Quiz

Application

How would you classify the pain that the following patients are experiencing?

● A patient with metastatic cancer

A patient with back pain that was the result of an automobile injury a year ago

A patient with a broken leg

Quality of Pain

Only the patient can describe the quality of their pain. They may use words such as:

Sharp Dull Throbbing Stabbing Burning Ripping Tingling Intermittent Constant Mild Intense Severe

Factors Which Influence Pain

EmotionsDevelopmental StageCommunication ImpairmentsPain ThresholdCulture

Factors Which Influence Pain

Emotions: Anxiety Fear Guilt Anger Helplessness Exhaustion Irritability Depression

Factors Which Influence Pain

Developmental Stage:Infants and childrenAdultsOlder Adults

Factors Which Influence Pain

Communication Impairment: Those who have had a CVA, speak another language

or are cognitively impaired. You will need to observe nonverbal cues for pain.

Facial expressions Vocalizations Changes in physical activity Change in vital signs Change in routines Mental status changes

Factors Which Influence Pain

Culture:Involves the patient’s expression of pain,

the family’s response to the situation and the nurse’s attitude.

William & Hopper: Box 10.2 – page 143-144

Factors Which Influence Pain

Pain Threshold: The point at which the receptors in the frontal

cortex recognizes and defines a stimulus as pain.

Varies from person to person.

Pain Tolerance: The duration or intensity of pain that a person

is willing to endure.

Pharmacological Pain Relief Measures

Analgesics Nonopioids – acetaminophen, salicylates,

NSAIDS and COX -2 inhibitors

Opioids - morphine, codeine, hydromorphone, methadone, meperdine, oxycodone, sublimaze patch

Analgesics

Routes of Administration

Oral – preferred routeNasalTransdermalRectalSubcutaneousIntramuscular – least preferredIntravenousPCA – patient controlled analgesiaIntraspinal analgesics

Adverse Affects of Pain Medications

Nonopioids – GIB, inhibition of platelet aggregation, renal insufficiency, hypersensitive reactions in persons with asthma, liver necrosis with OD of Tylenol.

Opioids – respiratory depression, hypotension, drowsiness, constipation, nausea, vomiting, constricted pupils.

Analgesic Adjuvants

These medications may potentiate the effects of opioids or nonopioids.

Examples: steroids, benzodiazepines, tricyclic antidepressants, and anticonvulsants.

Able to use less opioid doses when used with these adjuvants.

Antidote

Narcan (naloxone)- counteracts the effect of opioids.

Interpreting MD Orders

Morphine Sulfate 2 mg. IM q 4 hours prn for surgical pain.

Percocet one tab po q 6 hours prn for foot pain

Duragesic patch 25mcg/hr transdermal q 72 hours at 0800.

Oxycontin 20 mg. po BIDOxyIR 5 mg. po q 6 hours prn for

breakthrough pain

Evaluation

Always re-assess your patient after administering pain medications.

At what time interval?

Special Considerations

The Elderly

The Person with Substance Abuse or Addiction

Unrelieved Pain

Nonpharmacological Pain Relief Measures

Cutaneous StimulationTENS – Trancutaneous Electrical Nerve

StimulatorAcupunctureAcupressureMassageHot and Cold TX

Transelectrical Nerve Stimulation

TENS

Acupuncture

Acupressure

Based on the same principles as acupuncture, (but using pressure instead of needles), acupressure works by stimulating specific reflex points located along the lines of energy which run through the body, called meridians.

Massage

Hot & Cold Therapies

Nonpharmacological Pain Relief Measures

Surgery

Immobilization Splints, slings, braces

Cognitive-Behavioral Interventions Distraction Relaxation Techniques Guided Imagery Hypnosis Therapeutic Touch Humor

Guided Imagery

start the day meditation - guided imagery – YouTube

Guided Imagery - Bubble Release - YouTube

REIKI

Biofeedback

Biofeedback Session Demo – YouTube

http://www.youtube.com/watch?v=a53LA7aL2Og

The Nursing Process

Lets Start With You, as a student nurse and health care providers.

The HCW’s Perception of Pain

What are some myths associated with pain management that you have witnessed in the healthcare setting?

Nursing Process: Collect Data

The fifth vital sign.Accept the patient’s report of pain.Obtain a pain history.Perform a physical assessment.Observe for nonverbal indicators of pain.Use WHAT”S UP format and pain

scales.

WHAT”S UP?

W here is the pain? H ow does the pain feel? A ggravating & alleviating factors. T iming. S everity. U seful other data. P erception.

Pain Scales

Visual Analog Scale

Numerical Rating Scale

The Wong-Baker FACES pain Rating Scale

Analgesic Administration

Use resources to check on purposes and actions of pharmacological agents

Reconcile & maintain MAR +/or Patient’s list of medications.

Identify patient’s allergies and intervene as appropriate.

Identify a contraindication to administration of a prescribed medication.

Acetaminophen Caution and Guidance

Planning

Use data collected to plan action with patient’s input.

Teach patient to use pain scales.Set goals for acceptable pain levels.Example: you will ask your patient who is in

pain, “What is an acceptable level of pain for you after we have helped you relieve your pain?”

“What has helped in the past to relieve your pain?”

Drug Calculations

Nursing Diagnoses

Nursing Diagnosis: Pain, acute or chronic,

Impaired Comfort

Others: Self-Care Deficit, Impaired Mobility, Sleep Deprivation, Ineffective Airway Clearance, Ineffective Coping.

Interventions

Apply therapies for comfort.Use alternative/complementary therapies for pain

management.Administer pain medication as prescribed.Identify patient expected response to pain

medication. Reinforce client teaching on possible effects of

medication.

Follow rights of medication administration.

Maintain medication safety practice. Follow protocol for handling controlled

substances.Monitor patient use of medication over

time.Maintain pain control devices.

Evaluation

Monitor and document patient’s response to pharmacological and non – pharmacological interventions.

Notify primary healthcare provider of actual/potential adverse effects of pain medications.

Explain the protocol for withholding pain medication if patient experiences an adverse reaction.

Discuss actions used in the event of adverse reactions with the use of opioids.

Role Playing & Case Scenarios

Utilize your Medication Research cards and The Joint Commission Handout, “SpeakUP” to perform these excercises.