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Transcript of Pain Management HC
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A. Concepts
Definitions of Pain
1. Pain is an unpleasant sensory and emotional experience with actual or potential
tissue damage. (Merskey and Bogduk, 1994)
2. Pain is whatever the person says it is, existing whenever the experiencing person
says it does. (McCaffery and Beebe, 1989)
Types of Pain
1. ACUTE PAIN - usually ofrecent onset and commonly associated with a specific injury
- lasting from seconds to 6 months.
2. CHRONIC PAIN constant or intermittent pain that persists beyond theexpected
healing time that can be seldom be attributed to specificcause or
injury.
- lasts for6 months or longer
3. CANCER-RELATED PAIN - associated with thecancer, cancertreatment ornot
associated with cancer.
4. PAIN CLASSIFIED BY LOCATION pelvic pain, head pain, chest pain
5. PAIN CLASSIFIED BY ETIOLOGY burn pain and postherpetic neuralgia are
examples of pain described by theiretiology.
HARMFUL EFFECTS OF PAIN
1. Effects of Acute Pain - Affect pulmonary, cardiovascular, gastrointestinal, endocrine and
immune system
increased metabolicrate and cardiac output
impaired insulin response
increased production ofcortisol
increased retention of fluids
2. Effects ofChronic Pain Suppression of the Immune Function may promote tumor
growth
- Depression, Disability, Anger, Fatigue
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Mechanism of Pain
Diagram 1.1
PATHOPHYSIOLOGY OF PAIN
PAIN TRANSMISSION
NOCICEPTORS free nerve endings in the skin that respond only to intense, potentially
damaging stimuli.
Mechanic
Thermal
Chemical
ALGOGENIC SUBSTANCES - (Pain Causing) substances that affect the sensitivity of
nociceptors
Ex. Histamine, Bradykinin, Acetylcholine, Serotonin and Substance P
NOCICEPTION pain transmission
PROSTAGLANDINS - chemical substances thought to increase sensitivity of pain receptors by
enhancing the pain provoking effect ofbradykinin.
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Effects of Chemical Mediators
- Vasodilation, Increased vascularpermeability, redness, warmth and swelling of the
injured area.
FIRSTORDER NEURON travels from the periphery (skin, cornea, visceral organs) to the
spinal cord via theDORSALHORN
Two Types of Fibers
1. A DELTA FIBERS smaller, myelinated fibers transmit nociception rapidly
- produces the initial FAST PAIN
2. TYPEC FIBERS largerunmyelinated fibers that transmit what is called second pain
- dull, aching, burning qualities that last longer than initial fast pain
ENDORPHINS & ENKEPHALINS chemicals that reduce or inhibit the transmission of pain
- morphine like neurotransmitters areendogenous
LAIMANE II Substancia gelatinosa
DESCENDINGCONTROL SYSTEM system of fibers that originate in the lower and mid-
portion of thebrain and terminate on the inhibitory interneuronal fibers in the dorsal horn of the
spinal cord
INHIBITORY INTERNEURAL FIBERS the interconnections between the descending neuronal
system and the ascending sensory tract
CLASSICGATE CONTROL THEORY OF PAIN (Melzack and Wall, 1965) proposes that
stimulation of the skin evokes nervous impulses that are transmitted by three systems located in
the spinal cord.
- substancia gelatinosa in the dorsal horn, the dorsal column fibers and central
transmission cells act to influence nociceptive impulses.
LARGEDIAMETERS FIBERS inhibits the transmission of pain, thus closing the gate.
SMALLER FIBERS gate is opened
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Illustration 1.1
FACTORS INFLUENCING THE PAIN RESPONSE
PASTEXPERIENCE
The way a person responds to pain is a result of many separate painful events during a lifetime.For some, past pain may havebeen constant and unrelenting, as in prolonged orchronic and
persistent pain. The individual who has pain for months or years may become irritable,
withdrawn, and depressed.
Once a person experiences severe pain, that person knows just how severe it can be.
Conversely, someone who has neverhad severe pain may have no fearof such pain.
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ANXIETY ANDDEPRESSION
Although it is commonlybelieved that anxiety will increase pain, this is not necessarily true.
Research has demonstrated no consistent relationship between anxiety and pain, nor has
research shown that preoperative stress reduction training reduces postoperative pain (Keogh,
Ellery, Hunt et al., 2001; Rhudy & Meagher, 2000).
Just as anxiety is associated with pain because of concerns and fears about the underlying
disease, depression is associated with chronic pain and unrelieved cancerpain.
CULTURE
Beliefs about pain and how to respond to it differ from oneculture to the next. Cultural factors
must be taken into account to effectively manage pain. Inconsistent results, methodologic
weakness or flaws (Lasch, 2000), and failure of many researchers to carefully distinguish
ethnicity, culture and race make it difficult to interpret the findings of many of these studies.
Factors that help to explain differences in a cultural group include age, gender, education level,
and income.
Recognizing the values of ones own culture and learning how these values differ from those of
othercultures help to avoid evaluating the patients behavioron thebasis of ones own cultural
expectations and values
Regardless of the patients culture, nurses need to learn about that particularculture and be
aware of powerand communication issues that will affect care outcomes.
AGE
Age has long been the focus ofresearch on pain perception and pain tolerance, and again the
results havebeen inconsistent. Although someresearchers have found that olderadults require
a higher intensity of noxious stimuli than do youngeradults before theyreport pain (Washington,
Gibson & Helme, 2000), others have found no differences in responses ofyounger and older
adults (Edwards & Fillingim, 2000).
GENDER
Researchers have studied gender differences in pain levels and in response to pain, and the
results havebeen still inconsistent.
In a study ofresponses of men and women to chronic pain and anxiety, Edwards, Auguston and
Fillingim (2000) noted no differencebetween genders regarding pain and depression. Therewas, however, a difference in anxiety and gender, with men being more anxious about their
pain.
PLACEBOEFFECT
A placebo effect occurs when a person responds to the medication orother treatment because
of an expectation that the treatment will work ratherthan because it actually does so.
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A patients positive expectations about treatment may increase the effectiveness of a
medication or other intervention. Often the more cues the patient receives about the
interventions effectiveness, the more effective it will be. A person who is informed that a
medication is expected to relieve pain is more likely to experience pain relief than one who is
told that a medication is unlikely to have anyeffect.
B. Nursing Assessment of Pain
1. Characteristics of Pain
INTENSITY from non to mild discomfort to excruciating
PAIN THRESHOLD smallest stimulus forwhich a person reports pain
PAIN TOLERANCE maximum amount of pain a person can tolerate
TIMING onset, duration, relationship between time and intensity, and whetherthere
arechanges in rhythmic patterns
LOCATION best determined by having the patient point to the area of thebody
involved. This is especially helpful if the pain radiates (referred pain)
QUALITY if quality of pain cannot be described, words such as burning, aching,
throbbing orstabbing can be offered
PERSONALMEANING Patients experience pain differently, and the pain experience
can mean many different things. The meaning attached to the pain experience helps thenurse understand how the patient is affected and assists in planning treatment.
AGGRAVATING AND ALLEVIATING FACTORS - what makes pain worse and what
makes it better, and asks specifically about the relationship between activity and pain.
Knowledge of alleviating factors assists the nurse in developing a treatment plan.
PAIN BEHAVIORS not all patients exhibit the same behaviors, and there may be
different meanings associated with the samebehavior.
2. Instruments forAssessing Perception of Pain
Purposes:
a. to document the need for intervention
b. to evaluate the effectiveness of the intervention
c. to identify the need for alternative or additional interventions if the initial
intervention is ineffective in relieving the pain
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C.R.I.E.S Neonatal Post-operative Pain Measurement Scale
Crying, Requires O2 saturation >95%, Increased vital signs, Expressions, and
Sleepiness
FLACC Pain Assessment Tool
- suitable for children less than 3 years of age or unable to communicate
FLACC Pain Assessment Tool Table 1.1
0 1 2
Face No particular
expression
Occasional grimace orfrown, withdrawn,
disinterested
Frequent toconstant quivering
of chin, clenched
jaw
Leg Normal position,
relaxed
Uneasy, restless, tense Kicking, or legs
drawn up
Activity Lying quietly,normal position,
moves easily
Squirming, shifting backand forth
Arched, rigid, orjerking
Cry No cry Moans or whimpers,
complains occasionally
Cries steadily,
screams or sobs,
complains
frequently
Consolability Content, relaxed Reassured by constanthugging, orbeing talked to,
can be distracted
Difficult to consoleorcomfort
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Poker Chip Tool
- suitable for children over 3 years of age
- uses 4 poker chips in determining level of pain
Wong-Baker FACES Pain Rating Scale
- can be used with young children as young as 3 7 years old
- faces are pattern from Smiley
Oucher Pain Scale- similarto the Wong-BakerPain Rating Scalebut uses real-life pictures
Word Graphic Scale
- can be used with patient as young as 6 years old
- Uses a line with words to describe pain intensity from no pain to worst pain.
Word Graphic Pain Rating Scale Illustration 1.2
Numerical or Visual Analog Scale
- can be used by school agechildren who understand proportionality of numbers
- uses a line to describe pain intensity from no pain to worst possible pain
Pain Logs and Diaries
- Keeping of pain record
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Pain Logs and Diaries Table 1.2
Date Describe
Pain
Describe
Situation or
Activity
Physical
Pain
Sensation
(1 10)
Describe
Sensation
Emotional
Distress
(1-9)
Describe
Distress
Actions
taken
Guidelines for Using Pain AssessmentScales
1. Use appropriate pain assessment tool.
2. Use pain assessment tools consistently.
3. When a person with pain is cared forat homeby familycaregivers, teach the patient and the
familycaregivers to use a pain assessment scale to assess and manage pain.
4. Terms and language use must be understandable to patients.
Pediatric Pain Assessment
The QUEST Principles of Pediatric Pain Assessment
Q Question thechild.
U Use pain rating scales.
E Evaluatebehaviorand physiological changes.
S Secure parents involvement.
T Takecause of pain into account.
Take action and evaluateresults
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Adult Pain Assessment
Mnemonics forAdult Pain Assessment
OLDCART PQRST
O Onset P Provoked
L Location Q Quality
D Duration R Region orradiation
C Characteristics S Severity
A Aggravating Factors T Timing
R Relieving Factors
T Treatment
C. Nursing Care of a Client Experiencing Pain
Analysis
Potential Nursing Diagnoses
1. Acute pain
2. Chronic pain
3. Impaired physical mobility
4. Activity intolerance
5. Altered nutrition: less than bodyrequirements
6. Impaired social interaction
Planning/Implementation
Nurses Role in Pain Management
IDENTIFYING GOALS FOR PAIN MANAGEMENT
The nurse helps relieve pain by
1. Administering pain relieving interventions (pharmacologic and nonpharmacologic)
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2. Assessing theEffectiveness of these interventions
3. Monitoring forAdverseEffects
4. Serving as Advocate for the Patient when the prescribed intervention is ineffective in
relieving pain
5. Serves as an Educator to the patient and family
Factors to be considered
1. Severity of Pain as judged by patient
2. Anticipated Harmful Effects of Pain
3. Anticipated Duration of Pain
The goals for the patient maybe accomplished by pharmacologic ornonpharmacologic means,
but most success will be achieved with a combination ofboth.
ESTABLISHING THE NURSE-PATIENT RELATIONSHIP AND TEACHING
A positive nurse-patient relationship and teaching are keys to managing analgesia in the patient
with pain because open communication and patient cooperation areessential to success, and it
is essentiallycharacterized by trust.
- Byconveying to the patient thebelief that he or she has pain, the nurse often helps
reduce the patients anxiety.
- Teaching patients about pain and strategies to relieve it mayreduce pain in the absence
of other pain relief measures and may enhance the effectiveness of the pain reliefmeasures used.
PROVIDING PHYSICAL CARE
The patient in pain may be unable to participate in the usual activities of daily living or to
perform usual self-care and may need assistance to carry out these activities.
- A fresh gown and change and bed linens, along with theefforts to make the patient feel
refreshed (e.g. brushing of teeth, combing of hair)
- Gives the opportunity to perform a complete assessment and identify problems that may
contribute to the patients discomfort and pain.
- Appropriate gentle and physical touch
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MANAGING ANXIETY RELATED TO PAIN
The patient who anticipates pain maybecome increasingly anxious. Teaching the patient about
the nature of the impending painful experience and the ways to reduce pain often decreases
anxiety.
Anxietyresulting from anticipation of pain or the pain experience itself may often be managed
effectivelybyestablishing a relationship with the patient and by patient teaching.
A patient who is anxious about pain maybe less tolerant of the pain, which in turn may increase
the anxiety level. To prevent the pain and anxiety from escalating, the anxiety-producing cycle
must be interrupted.
NONPHARMACOLOGIC INTERVENTIONS
Although pain medication is the most powerful pain relief tool available to nurses, it is not theonly one. Nonpharmacological nursing activities can assist in relieving pain with usually low risk
to the patient. Although such measures are not a substitute formedication, they maybe all that
is necessary orappropriate to relieveepisodes of pain lasting only seconds orminutes.
1. Physiatric Approaches
a. Therapeutic Exercise
a.1 Strengthens weak muscles
a.2 Mobilizes stiff joints
a.3 Decrease anxiety and stress
b. Heat Therapy
b.1 Increase blood flow to the skin
b.2 Dilate blood vessels, increasing oxygen and nutrients to local tissues
b.3 Decrease joint stiffness by increasing muscle elasticity
c. Cold Therapy
c.1. Reduces pain and tension of muscles through constriction of blood vessel
c.2. Reduces swelling if applied soon after injury
- Ice and heat therapies maybeeffective pain relief strategies in somecircumstances; however,
theireffectiveness and mechanism of action need furtherstudy. Proponents believe that ice and
heat stimulate the non-pain receptors in the samereceptorfield as the injury.
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2. Non-Invasive Stimulatory Approaches
a. Transcutaneous Electrical Nerve Stimulation (TENS)
- a method of applying a gentle electric current to the skin to relieve pain.
- It has been used in both acute and chronic pain relief and is thought to decrease pain by
stimulating the non-pain receptors in the same area as the fibers that transmit the pain. This
mechanism is consistent with the gatecontrol theory of pain and explains theeffectiveness of
cutaneous stimulation when applied in the same area as an injury.
3. Psychoeducational Approaches
Cognitive Behavioral Techniques
- are used to reduce thebodys unproductiveresponses to stress, helping to relieve pain
or improve the ability to tolerate it.
DEEP BREATHING AND PROGRESSIVE MUSCLE RELAXATION
Skeletal musclerelaxation is believed to reduce pain byrelaxing tense muscles that contribute
to pain.
A simple relaxation technique consists of abdominal breathing at a slow, rhythmic rate. A
constant rhythm can be maintained bycounting silently and slowly with each inhalation (in, two,
three) and exhalation (out, two, three).
NURSING CONSIDERATION
When teaching this technique, the nurse may count out loud with the patient at first.
Slow, rhythmicbreathing may also be used as a distraction technique.
GUIDED IMAGERY
Guided imagery is using ones imagination in a special way to achieve a specific positiveeffect.
If guided imagery is to beeffective, it requires a considerable amount of time to explain the
technique and time forthe patient to practice.
NURSING CONSIDERATION
The nurse instructs the patient to close theeyes and breathe slowly in and out.
With each slowly exhaled breath, the patient imagines muscle tension and discomfort being
breathed out, carrying away pain and tension and leaving behind a relaxed comfortablebody.
With each inhaled breath, the patient imagines healing energy flowing to the are of discomfort.
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YOGA AND MEDITATION
The word yoga, derived from the Sanskrit root yugmeaning to bind or to yoke, is the uniting
of all the powers of thebody, mind, and spirit. Yoga is an approach to living a balanced life
based on ancient teaching found in Hindu spiritual treatises (theUpanishads) written in 800-400
BC. On the other hand, meditation is a technique used to quiet the mind and focus it in the
present and to release fears, worries, anxieties, and doubts concerning the past and the future.
BIOFEEDBACK THERAPY
It is a technique that teaches various forms of relaxation by providing a response from
physiologic processes, and it is often described as a technique to bring bodily processes under
conscious control. Specifically, biofeedback teaches clients to achieve a generalized state of
relaxation characterized by parasympathetic dominance and to reduce the pattern of physiologic
arousal manifested in stress related disorders.
DISTRACTION
Distraction helps relieveboth acute and chronic pain (Johnson & Petrie, 1997). Distraction is
thought to reduce the perception of pain by stimulating the descending control system, resulting
in fewerpain stimuli being transmitted to thebrain. Theeffectiveness of distraction depends on
the patients ability to receive and create sensory input other than pain. It may range from
simple activities, such as watching TV or listening to music, to highly complex physical and
mental exercises.
HYPNOSIS
Hypnosis, which has been effective in relieving pain or decreasing the amount of analgesic
agents required in patients with acute and chronic pain, may promote pain relief in particularlydifficult situations (e.g. burns). The mechanism by which hypnosis acts is unclear. Its
effectiveness depends on the hypnotic susceptibility of the individual (Farthing, Venturino,
Brown et al., 1997).
THOUGHT-STOPPING and REFRAMING
ALTERNATIVE THERAPIES
People suffering chronic, debilitating pain are often desperate. Often they will try anything,
recommended by anyone, at any price. Information about an array of potential therapies can be
found on the Internet and in the self-help section of the bookstore. Therapies specifically
recommended for pain from these sources includebut are not limited to chelation, therapeutic
touch, music therapy, herbal therapy, reflexology, magnetic therapy, electrotherapy, polarity
therapy, acupressure, emu oil, pectin therapy, aromatherapy, homeopathy, and macrobiotic
dieting. Many of these therapies (with theexception of macrobiotic dieting) are probably not
harmful. However, they haveyet to be proven effectiveby the standards used to evaluate the
effectiveness of medical and nursing interventions.
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Despite the lack of scientificevidence that these therapies areeffective, a patient may find any
one of them helpful via the placebo response.
NURSING CONSIDERATION
The nurses role is to help the patient and family understands scientific research and
how that differs from anecdotal evidence. Without diminishing the placebo effects the
patient mayreceive, the nurseencourages the patient to assess theeffectiveness of the
therapycontinually using standard pain assessment techniques. In addition, the nurse
encourages the patient using alternative therapies to combine them with conventional
therapies and to discuss this use with the physician.
a. Acupuncture
b. Massage
c. Crystal and Gemstones Therapy
d. Magnet Therapy
e. Essential Oils/Aromatherapy
f. Herbal Therapy
NURSING CONSIDERATION
- Help the patient and family understand scientific research and how that differs from
anecdotal evidence
- Encourage the patient to assess the effectiveness of the therapy continually using
standard pain assessment techniques.
- Encourage patient using alternative therapies to combine them with conventional
therapies and to discuss this use with the physician.
Crystals and Gemstones
y Amethyst - headaches, hangover
y aquamarine, turquoise - neck and throat pain
y rose quartz - forheartaches, chest pains
y amber, topaz - epigastric painy moonstone - dysmenorrhea
y jasper, garnet, and ruby - pain of the genitals
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Herbal Medicine
y ginger - insect bites, joint pain
y eucalyptus - muscle and joint pain
y fresh papaya juice - heartburn, ulcers, back pain
y aloe vera - burns, cut
PHARMACOLOGIC INTERVENTIONS
Managing a patients pain pharmacologically is accomplished in collaboration with the physician
orotherprimarycare provider, the patient, and often the family.
The pharmacologic management of pain requires close collaboration and effective
communication among health care providers.
Premedication Assessment
a. Check forallergies to medications and nature of previous allergies.
b. Obtain medication history. (current, usual, orrecent use of prescription orOTC
drugs orherbal agents.
c. Obtain health history.
d. Assess patients pain status.
APPROACHES FOR USING ANALGESIC AGENTS
Medications are most effective when the dose and interval between doses are individualized to
meet the patients needs. The only safe and effective way to administeranalgesic medications
is by asking the patient to rate the pain and by observing theresponse to medications.
1. Balanced Anesthesia refers to use of more than one form of analgesia concurrently to
obtain more pain relief with fewersideeffects.
2. Pro Re Nata as needed, the past standard method used by most nurses and physicians in
administering analgesia
- the standard practice was for the nurse to wait forthe patient to complain of
pain then administeranalgesia
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3. Preventive Approach with the preventive approach, analgesic agents are administered at
set intervals so that the medication acts before the pain becomes severe and before the serum
opioid level falls to a sub-therapeutic level.
4. Individualized Dosage the dosage and the interval between doses should bebased on the
patients requirements rather than on an inflexible standard ofroutine.
5. Patient-Controlled Analgesia (PCA) used to manage postoperative pain as well as chronic
pain. It allows patients to control the administration of theirown medication within predetermined
safety limits.
3 GENERAL CATEGORIES OF ANALGESICS
LOCAL ANESTHETICS
- Work byblocking nerveconduction when applied directly to the nerve fibers. Theycan
be applied directly to the site of injury (e.g. topical anesthetic spray for sunburn) or
directly to nerve fibers by injection or at the time of surgery. They can also beadministered through an epidural catheter.
- Topical Application ex. Emulsion ofLocal Anesthetics (EMLA cream); to beeffective, it
must be applied to the site 60 to 90 minutes before the procedure
- Intraspinal Administration the anesthetic agent can be administered continuously in
low doses, intermittently on a schedule, oron demand as the patient requires it, and is
often combined with theepidural administration of opioids. Surgical patients treated with
this combination experience fewer complications after surgery, ambulate sooner, and
have shorter hospital stays than patients receiving standard therapy (Correll, Viscusi,
Grunwald et al., 2001).
OPIOIDS
The goal of administering opioids is to relieve pain and improve quality life; therefore, theroute
of administration, dose, and frequency are determined on an individual basis.
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
- Are thought to decrease pain by inhibiting cyclo-oxygenase (COX), the rate-limiting
enzyme involved in the production of prostaglandin from traumatized or inflamed tissues.
Two types ofCOX
1. COX-1 : is involved with mediating prostaglandin formation involved in the maintenance of
physiologic functions.
2. COX-2 : mediates prostaglandin formation that results in symptoms of pain, inflammation,
and fever.
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ROUTES OF ADMINISTRATION
1. PARENTERAL produces effects morerapidly than oral administration, but theseeffects
are of shorter duration. (Indicated in patients who are not permitted oral intake or is
vomiting)
a. Intramuscular
b. Intravenous
c. Subcutaneous
2. ORALROUTE preferred over parenteral administration because it is easy, non-
invasive, and not painful
3. RECTALROUTE indicated in patients who cannot take medications by any other
route or with bleeding problems such as hemophilia. The onset of action of opioids
administered is unclear but is delayed compared with other routes of administration.
Similarly, the duration of action is prolonged.
4. TRANSDERMALROUTE has been used to achieve a consistent opioid serum level
through absorption of the medication via the skin. This route is most often used for
cancerpatients who are at home or in hospicecare and who havebeen receiving oralsustained-release morphine.
5. TRANSMUCOSALROUTE used in periods called breakthrough pain, an oral dose
of a short-acting transmucosal opioid that has a rapid onset of action.
6. INTRASPINAL & EPIDURAL ROUTES used for effective control of pain in
postoperative patients and those with chronic pain unrelieved by othermethods.
NEUROLOGIC AND NEUROSURGICAL APPROACHES
- In some situations, especially with long-term and severe intractable pain, usual
pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those
situations, neurologic and neurosurgical approaches to pain management may be
considered. Intractable pain refers to pain that cannot be relieved satisfactorilyby the
usual approaches, including medications. Such pain usually is theresult of malignancy
(especially of thecervix, bladder, prostate, and lowerbowel), but it may occur in other
conditions, such as postherpetic neuralgia, trigeminal neuralgia, spinal cord
arachnoiditis, and uncontrollable ischemia and otherforms of tissue destruction.
3 Neurologic and Neurosurgical Methods forPain Relief
STIMULATION PROCEDURES- Electrical stimulation, orneuromodulation, is a method of suppressing pain by applying
controlled low-voltage electrical pulses to the different parts of the nervous system.
Electrical stimulation is thought to relieve pain by blocking painful stimuli (the gate
control theory).
ADMINISTRATION OF INTRASPINALOPIOIDS (see previous discussion)
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INTERRUPTION OF PAIN PATHWAYS
- A treatment that is considered permanent other than stimulation procedures which are
reversible.
y RHIZOTOMY sensory nerve roots are destroyed where theyenter the spinal
cord. A lesion is made in the dorsal root to destroy neuronal dysfunction and
reduce nociceptive input. With the advent of microsurgical techniques, thecomplications are few, with mild sensory deficits and mild weakness.
y NERVE BLOCK
A. Epidural Anesthesia blocks sensory, motor, and autonomic
functions, but it is differentiated from spinal anesthesia by the injection
site which is the spinal canal in the space surrounding the dura mater,
and the amount of anesthetic used.
B. Spinal Anesthesia is a type ofextensiveconduction nerveblock that
is produced when a local anesthetic is introduced into the
subarachnoid space at the lumbar level, usuallybetween L4 and L5.
y NEURECTOMY
y SYMPATHECTOMY
NURSING INTERVENTIONS
The specific nursing care of patients who undergo neurologic and neurosurgical procedures for
the relief of chronic pain depends on the type of procedure performed, its effectiveness in
relieving the pain, and thechanges in neurologic function that accompany the procedure. After
the procedure, the patients pain level and neurologic function are assessed. Other nursing
interventions that maybe indicated include positioning, turning and skin care, bowel and bladder
management, and interventions to promote safety. Pain management remains an important
aspect of nursing care with each of these procedures.
PROMOTING HOME AND COMMUNITY-BASED CARE
In preparing the patient and family to manage pain at home, the patient and family need
to be taught and guided about what type of pain or discomfort to expect, how long the
pain is expected to last, and when the pain indicates a problem that should bereported.
TEACHING PATIENTSSELF-CARE
y The patient and family need to understand the purposes of each medication, the
appropriate time to use it, the associated sideeffects, and strategies that can be used to
prevent these problems. The patient and family often need reassurance that pain can besuccessfully managed at home.
y Inadequatecontrol of pain at home is a common reason people seek health care orare
readmitted to the hospital.
y Opportunities are provided for the patient and family members to practice administering
the medication until they arecomfortable and confident with the procedure.
Education for patients and families must stress the need for keeping analgesic agents
away from children, who might mistake them forcandy.
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CONTINUING CARE
A referral to a homecare nurse is indicated to patients who arereceiving parenteral or
intraspinal analgesia at home. The homecare nurse makes a home visit to asses the
patient and to determine if the pain management program is being implemented and if
the technique for injecting or infusing the analgesic agent is being carried out safely and
effectively.
REASSESSMENTS
An important aspect of caring for the patient in pain is reassessing the pain after the
intervention has been implemented. The measures effectiveness is based on the
patients assessment of pain, as reflected in pain assessment tools. If the intervention
was ineffective, the pain relief goals need to be reassessed in collaboration with the
physician. The nurse serves as a patient advocate in obtaining additional pain relief.
EVALUATION
Expected Patient Outcomes
1. Achieves pain relief
2. Patient orfamily administers prescribed analgesic medications correctly
3. Uses nonpharmacologic pain strategies as recommended
4. Reports minimal effects of pain and minimal sideeffects of interventions
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REFERENCES:
Brunner & Suddarths (MEDICAL-SURGICAL NURSING) Vol. 1; 10th Edition pages 216-245By: SuzanneC. Smeltzerand Brenda G. Bare
Adele Pillitteri Maternal & Child Health Nursing (Care of the Childbearing &ChildrearingFamily) Vol. 2; 3rd Edition
FUNDAMENTALS OF NURSING (Concepts, Process, and Practice) 7th EditionBy: Barbara Kozier, Glenora Erb, Audrey Berman & Shirlee Snyder