NRS_105/320_Collings Chapter 43 Pain Management. NRS_105/320_Collings Importance Pain management is...

NRS_105/320_Collings

Chapter 43

Pain Management


Importance

• Pain management is a primary nursing responsibility

• Nurse have a legal and ethical duty to control/relieve pain

• Pain relief is a basic human right

• Patients need to know we CAN and WILL relieve their pain


Why?

• Effective pain management:– Improves quality of life– Reduces disability– Promotes early mobility and return to work– Results in less hospital / office visits– Reduces length of stay, complications– Reduces health care cost– Improves patient satisfaction


Nature of Pain

• Physical

• Emotional

• Cognitive

• Subjective


Physiology of Pain• Transduction

• Thermal,chemical,mechanical stimulation• → electrical impulse in nerve fiber

• Transmission• A fibers: sharp, localized, distinct sensation• C fibers: generalized, persistent sensation

– E.g. Burn finger – spot pain → ache• Peripheral → spinal → brain


Physiology of Pain

• Perception– Brain interprets impulse, perceives as pain– Experience, memory, context, knowledge– Ascribes meaning to sensation

• Modulation– Body response

• Endogenous opiods, serotonin, norepinephrine, GABA• ↓ transmission of impulse, analgesic effect

– These deplete over time with continued pain


Gate-Control Theory of Pain

• Gating mechanisms along the CNS– Can block transmission of impulses

• Pain relief measures to close the gate– Light touch [effleurage]

• Pain threshold– Level at which you feel pain

• Genetic, learned, • Runner’s high, endogenous opiods• Individual – not transferrable!


Physiological Response to Pain

• Mild – moderate pain [1-6] superficial → autonomic response [sympathetic];

• fight or flight, general adaptation• ↑HR, RR, B/P, BG, diaphoresis, peripheral

vasoconstriction

• Severe or deep [7-10], visceral pain→ parasympathetic response

• ↓ HR, B/P, muscle tension, immobility, irreg resp• may cause harm

– Physiologic response [VS] is short-term; – VS are not reliable pain indicators over time


Behavioral responsesto Pain

• Dependent on context, meaning, culture, pain tolerance– It is supposed to hurt– Men don’t cry– I don’t want to be a complainer, bother

• Nonverbal indicators– Body movements; restless or still, holding, guarding– Facial expression; grimace, frown, clenched teeth, posture,

• Lack of expression of pain does not mean it isn’t there!


Types of Pain

• Acute pain– Protective, identifiable cause, short

duration, limited tissue damage, ↓ emotional response

– Causes harm by ↓ mobility, energy

Goal is to control pain so patient can participate in recovery

↓ Pain → ↑Mobility → decreased complications, decreased length of stay


Types of Pain• Chronic pain

– Serves no purpose [not protective]– Lasts longer than anticipated – May or may not have an identifiable cause– Impacts every part of patient’s life– Depression, Suicide– Disability, isolation, energy drain, ADL’s

• Pseudoaddiction: seeking pain relief– not drug-seeking


Types of Pain

• Cancer pain– May be acute or chronic, constant or episodic,

mild to severe– Up to 90% of Ca pts have pain

• Pain by inferred pathology– Known cause = characteristic pain [neuropathic]

• Idiopathic pain– No known cause BUT still pain– “Excessive” pain for a condition


Knowledge, Attitudes, and Beliefs

• Subjective nature of pain– Pain is what the patient says it is, not

what the nurse thinks it should be– Same procedure, different pain– Expectations, context, culture affect

perception and expression of pain


Knowledge, Attitudes, and Beliefs• Nurse’s Response to Pain• Bias

– ‘I go to work with 5/10 pain every day’– ‘Its only a minor surgery’– ‘I had three kids and didn’t scream’

• Fallacies– Infants don’t feel pain like we do– Regular pain med use causes addiction– Older people all are in pain


Factors Influencing Pain

• Physiological– Age – interpretation/communication– Fatigue

• increases pain, • sleep not sign pain is relieved

– Genes• Pain threshold

– Neurological function• Interpretation, communication, reflex



• Social– Attention/ distraction– Previous experience

• May increase or decrease tolerance

– Family and social support

• Spiritual– Meaning of pain, suffering– Support system



• Psychological– Anxiety– Coping style

• Control [PCA]

• Cultural– Meaning of pain– Expression of pain– Role in Family– Ethnicity


Assessment of Pain

• Client’s expression of pain– Description is most valid indicator

• Characteristics of pain– Onset and duration– Location– Intensity– Quality– Pattern


Assessment of Pain

• Characteristics of pain (cont'd)– Relief measures– Contributing symptoms– Behavioral effects on the client– Influences on ADLs

• Client expectations– What pain level would allow you to function

well? • [walk the hall, do ADL’s, resume job…]


Assessment

• Can we do a full assessment of pain when the client is in severe pain?

• No!

• Alleviate severe [7-10] pain before talking it to death

• Pain rated >7 needs immediate attention


Nursing Diagnoses

• Anxiety

• Ineffective coping

• Fatigue

• Acute pain

• Chronic pain

• Ineffective role performance

• Disturbed sleep pattern


Planning• Goals and outcomes

– Client is using pain relief measures safely– Pain level reported at </=___ and congruent

nonverbal behaviors seen– Demonstrate understanding of need to

premedicate before activity– Splint abdomen with cough

• Setting priorities– What is important for the client? What does he

need to do? • Control pain enough to eat, sleep? Be mobile to

prevent complications? Work? PT? Maintain dignity, relationships while dying?

– Maslow: Pain relief is basic need


Implementation: Health Promotion

• Client education– Expectations, when to seek treatment– Preparation before pain

• Holistic care– Whole self; physical, emotional, spiritual– Education, rest, exercise, nutrition,

relationships


Nonpharmacological Pain Relief

• Relaxation and guided imagery• Distraction • Biofeedback• Cutaneous stimulation—massage,

application of hot/cold, TENS• Herbals• Reducing painful stimuli and

perception


Controlling Painful Stimuli

• Managing the client’s environment—bed, linens, temperature

• Positioning• Changing wet clothes and dressings• Monitoring equipment, bandages, hot

and cold applications• Preventing urinary retention and

constipation


Implementation Pain Management

• Pharmacological pain relief • … Administer analgesics as ordered/

reassess pain in 30 minutes and hourly– Analgesics: NSAIDs and nonopioids, opioids,

adjuvants– Patient-controlled analgesia (PCA)– Local analgesic infusion pump– Topical analgesics and anesthetics– Local and regional anesthetics


ImplementationPain Management

• Surgical interventions

• Procedural pain management

• Chronic and cancer pain management



• Barriers to effective pain management [pts, nurses, doctors, system…]– Fear of addiction - #1 barrier– Terms:

• Dependence: physical adaptation resulting in withdrawal symptoms

• tolerance: physical adaptation resulting in diminished drug effect over time

• Addiction: impaired control over use, use despite harm

• pseudoaddiction: drug seeking behavior to relieve undertreated pain



• Nursing implications for pain management– Accurate safe medication administration– Assess effectiveness and side effects– Patient education [families too]– Use the appropriate drug when given a

choice– Treat pain before it gets severe


Implementation: Restorative Care

• Pain clinics

• Palliative care

• Hospices


Evaluation• Effectiveness

– Assess at peak of drug effect• [30 minutes IV, 1 hour PO]

– Add complementary therapies for partial effect– Talk with M.D. about options if approach is

consistently ineffective

• Side effects• Document and communicate

– Most effective relief


Evaluation

• Client expectations– Validate experience– Relieve the pain– Show you care

• Did client achieve goal?– Walk hall w/o pain?– Pain < 3/10 all day [except with PT]– Able to return to work, enjoy visit, T,C,&DB?

• Pain report congruent with nonverbal?

NRS_105/320_Collings Chapter 43 Pain Management. NRS_105/320_Collings Importance Pain management is...

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