305- Ch. 44- Pain Management

Objectives
Discuss common misconceptions about pain.
Describe the physiology of pain.
Identify components of the pain experience.
Explain how the physiology of pain relates to selecting interventions for pain relief.
Describe the components of pain assessment.
Explain how cultural factors influence the pain experience.
Explain various pharmacological and non-pharmacological approaches to treating pain.
Discuss nursing implications for administering analgesics.
Discuss barriers to effective pain management.
Evaluate a patient’s response to pain interventions
Pain
The most common reason people seek health care.

It is purely subjective.

Providing pain relief is a basic human right (Pain Care Bill of Rights, APF, 2007).

Nurses are legally and ethically responsible for managing pain and relieving suffering.

Remember – A patient’s pain level is whatever the person experiencing it states it is.-everyone’s pain is DIFFERENT

Effective Pain Management does what for a patient?
Improves quality of life.

Reduces physical discomfort.

Promotes earlier mobilization and return to previous activity levels.

Results in fewer hospital and clinic visits.

Decreases hospital lengths of stay resulting in lower health care costs.

Pain management is

A Nurses role in management is:

Pain management is patient-centered

A Nurses role in management is:
Patient advocacy
Promoting empowerment and health literacy
Treating patients with compassion and respect

Physiology of Pain
Four physiological processes of normal (nociceptive: thermal, mechanic, or chemical) pain:
Transduction: Begins in the periphery with a pain-producing stimulus.

Transmission: Cellular damage results in release of neurotransmitters (bradykinin, histamine) spreading the pain “message” and creating an inflammatory response.
Two Types of nerve peripheral nerve fibers:
Fast myelinated (A-delta): Sharp, localized and distinct
Slow unmyelinated (C fibers): Poorly localized, burning, persistent

Perception: Aware of pain. Processed from past experience knowledge, and cultural associations in the perception of pain.

Modulation: Inhibition of the pain process by the release of inhibitory neurotransmitters (endogenous opioids, serotonin, norepinephrine). Helps to produce an analgesic effect.

Protective reflex response:
Pain stimulus bypasses the brain and causes muscle contractions to withdraw from the pain source

Afferent (sensory) nerve fibers
Sense pain impulse
Efferent (motor) nerve fibers
Sends impulse to withdraw from stimulus back to source

Gate-Control Theory of Pain
Pain has emotional and cognitive components in addition to physical sensation. “Pain Threshold” is increased [endorphins], for example, through stress and exercise
Physiological Responses to Pain
Sympathetic branch of the ANS- “Fight or Flight” reaction:
Stimulated by pain of low to moderate intensity

Parasympathetic branch:
Stimulated by continuous, severe, or deep pain ( involving the visceral organs such as MI or colic from the gallbladder)

Most people adapt to pain; ultimately VS return to normal:
Look to other problems if changes in VS persist.

Behavioral Responses to Pain
Pain significantly alters quality of life if left untreated.

Threatens physical and psychological well-being.

Do not let personal bias dictate your nursing care:
Labeling patients as “drug seekers”
“Complainers” (patients with low pain tolerance)

Prevention is easier than treatment:
Encourage patients to seek relief before pain occurs.
Watch for patients who choose not to report pain:
Sign of weakness, loss of control, cultural considerations
Encourage patients to accept pain relieving measures:
Helps to maintain ADL’s

Acute/transient Pain:
Identifiable cause; short duration generally less than 6 mo (traditionally). May interfere with recovery, increases risk of complications from resulting immobility.
Chronic/Persistent Non-cancer Pain:
Chronic/Persistent Non-cancer Pain: Pain lasting longer than 6 mo. Or “pain that extends beyond the expected period of healing” (Arthritis, low back pain, peripheral neuropathy).
Chronic pain leads to psychological depression and even suicide. Major cause of:
Job loss
Inability to perform simple ADL’s
Sexual dysfunction
Social isolation
Chronic Episodic Pain:
Chronic Episodic Pain: Lasting hours days or weeks:
Migraine HA
Sickle cell disease
Cancer Pain: Nociceptive (somatic) and/or neuropathic:
Tumor progression, invasive treatments, infection, physical limitations. Visceral pain (from internal organs) often referred pain.
70% to 90% of cancer patients experience pain
60% report moderate to severe pain (Maxwell, et al., 2005; Potter & Perry, 8th ed.).
Idiopathic Pain
[Psychogenic]Chronic pain in the absence of an identifiable cause or too excessive for a pathological condition.
Knowledge, Attitudes, and Beliefs
Nurses personal attitudes affects pain titration

Nurses assessment of pain intensity underestimates patients’ pain reports

Patient variables such as culture, gender, age, education, patient diagnosis contribute to nurses differences in pain ratings

Nurses vary pain medication administration according to patient affect (smiling, grimacing)

Nurses use their judgment to decide if the patient is ‘really in pain’

Nurses must accept the patient’s report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and EB research findings (Pasero & McCaffery, 2011 as cited in P & P, 9th ed)

Factors Influencing Pain: Physiological Factors
Age: Children have difficulty understanding and expressing pain. Lack of experience, vocabulary, cognitive development.

Older Adults development of pathological conditions leading to impairment of function leading to: T. 44-4 p. 1020
Decreased mobility, ADL’s, social activity, and activity tolerance.
Multiple diseases may affect similar parts of the body (vague symptoms)

Fatigue: Heightens perception of pain. Decreases coping abilities.

Genes: Genetic information possibly increases or decreases sensitivity to pain/pain tolerance.

Neurological Functions: Any factor that interrupts or influences normal pain reception or perception

Factors Influencing Pain: Social Factors
Attention: Increased attention to pain causes increased pain, whereas distraction is associated with diminished pain response (relaxation, guided imagery). The reticular activating system-inhibits painful stimuli if sensory input sufficiently stimulated; person ignores or becomes unaware of pain.

Previous Experience: Learning from painful experiences: experienced relief or no relief. Anticipatory Pain: explain procedures to the patient be clear on what to expect.

Family & Social Support: Can make experience less stressful especially parents in the presence of children.

Spiritual Factors: Punishment, lessons from God etc…

Factors Influencing Pain: Psychological Factors
Anxiety: Anxiety increases feelings of pain and pain causes anxiety. Loss of control over environment increases anxiety.
Anxiolytic medications are not a replacement for analgesia

Coping Style: Internal loci vs. External loci

Cultural Factors: Individual learn what is expected and accepted by their culture. Demonstrative vs. Introverted.

Assessment
Obtain a mutually agreed upon pain relief goal.
What level will allow your patient to function?

Treat pain assessment like a 6th vital sign.

Determine your patients health literacy.
Higher vocabulary allows patients to better describe their pain
Utilize an assessment tool to allow for a more accurate measure.
0-10 scale
Wong/Baker Faces

Assess previous pain experience and effective home interventions.

During an episode of acute pain assess:
Location
Severity
Quality

ABCDE’s of Pain Assessment
Ask about pain
Believe patient stated pain level
Choose appropriate options
Deliver interventions both timely and logically
Empower patient to take control of pain management
Patient’s Expression of Pain
Single most reliable indicator of its existence and intensity.

Use an individualized approach for assessment. Specific populations often require special considerations:
Children
Developmentally delayed
Mental health populations
Critically ill (artificial airways, NGT’s)
Dementia
Non-English speaking

Assessment-Characteristics of Pain
Onset & Duration: When did it begin? How long has it lasted?

Location: Use anatomical landmarks and descriptive terminology (superficial, cutaneous, deep or visceral, referred or radiating (Table 43-5, p. 973).

Severity: Use pain scales F.’s 44-5-7 p. 1026

Quality: Aching, throbbing, sharp, dull (nociceptive); burning, shooting or electric-like (neuropathic)

Aggravating/Precipitation Factors: Events or conditions that precipitate or aggravate pain.

Relief Measures: What works? (changing positions, heat, cold).

Contributing Symptoms: Depression, anxiety, anorexia, sleep disturbances.

Numeric Pain Scale
For patients who can easily communicate and understand its usage.
Wong Baker FACES
Used for children 3 years and up (assess understanding) and for non-English speaking patients. Oucher scale is the face of a child (CH Yeh, 2003).
FLACC Pain Scale
Face, Legs, Activity, Cry, Consolability
Used for infants; possibly for mentally or neurologically impaired.
Effects of Pain on the Patient
Behavioral Effects B. 44-9 p. 1027
Assess verbalizations, vocal responses, facial and body movements, social interaction

Influence on ADLs
Assess for physical deconditioning, sleep patterns, self-care deficits, sexual dysfunctions related to pain, social activities

Concomitant Symptoms
HA, nausea, dizziness, constipation, depression

Nursing Diagnosis
Accurate identification of related factors is necessary in choosing appropriate nursing interventions.

Applicable dx include:
Self-care deficit
Activity intolerance
Ineffective coping
Impaired social interaction
Spiritual distress
Powerlessness
Acute pain r/t-
Fear
Hopelessness

Planning
Utilize professional standards of care including agency policies or through professional organizations when planning interventions.

Determine with the patient the expected pain goals and outcomes.

Set Priorities

Teamwork and Collaboration
Use available resources for pain control including:
Advanced Practice Nurses
Pharmacists
PT and Occupational therapists
Clergy
Clinical Pain Specialists.

Implementation
Health Promotion: Patients are better prepared to handle almost any situation when they understand it.

Provide an individualized approach
Understand your patient’s health literacy

Common Holistic Health Approaches include:
Wellness education
Regular exercise
Rest
Attention to good hygiene practices
Nutrition management
Management of interpersonal relationships

Nonpharmacological Pain-Relief Interventions
To be used WITH and not IN PLACE of pharmacological measures.

Includes:
Cognitive-behavioral- Changing patients’ perceptions of pain, alter pain behavior, provide patients with a greater sense of control. Includes:
Prayer, relaxation, guided imagery, music and biofeedback.

Physical Approaches: Provide pain relief, correct physical dysfunction, alter physiological responses and reduce fears associated with pain related therapy. Includes:
Chiropractic therapy, acupuncture/acupressure therapy

Complimentary & Alternative Medicine
Relaxation and Guided Imagery such as meditation, yoga. benefits include:

Decreased pulse
Decreased blood pressure
Decreased respiratory rate
Decreased oxygen consumption
Decreased muscle tension
Decreased metabolic rate

Cutaneous Stimulation
May cause release of endorphins, thus blocking the transmission of painful stimuli (Gate Control Theory).

Massage-Physical and mental relaxation B. 44-11 p. 1034.
Warm Bath-Relieves tension
Ice Packs- Reduces acute pain from inflamed joints/tissues

Transcutaneous Electrical Nerve Stimulation (TENS)
OTC devices are now available
Battery powered transmitter with electrodes placed on or near the pain. Creates a buzzing/tingling sensation. Adjustable by the user.
-won’t really see in hospital but pt. might talk about
Herbals
Don’t negate the patients use/belief in herbal remedies.

May interact with prescribed analgesics.

Ask patients to report all substances they take.

Environmental Control
Clean wrinkle-free sheets
Repositioning
Proper fitting bandages/devices
Proper patient lifting/moving
Clean dry skin
Foley catheter protocol
Prevent constipation
Pharmacological Pain-Relief Interventions
Analgesics: Most common and effective Three types:

Nonopioids: Acetaminophen (hepatotoxicity/ Mucomyst) Nonsteroidal anti-inflammatories (GI bleeding/renal insufficiency)

Opioids: narcotics (sedation/respiratory depression/ Narcan; N/V, constipation [ongoing], itching, urinary retention, AMS)

Adjuvants: enhance analgesic properties: steroids, anticonvulsants, antidepressants. May contribute to respiratory depression.

Range Orders
Range-orders are medication orders in which the dose varies over a prescribed range depending on the situation or the patient’s status. Example: Morphine 2-4 mg IV every 4 hours for pain.

The Joint Commission requires range-order policies to be in place, utilized, and well documented.

Many institutions have strict guidelines on the use (or non-use) of range-orders. May be considered “prescribing”

Patient-Controlled Analgesia (PCA)
Places the patient in control of analgesia.

Allows patients to self-administer opioids with minimal risk of overdose**

Goal: to maintain a constant plasma level of analgesia.

IV or subcutaneous administration.

Patients must be physically able to press the button to deliver the dose. Caution families not to medicate their loved one.

System designed to deliver a specified number of doses every hour (for example every 10 to 15 minutes).

Benefits include:

Patient gains control over pain
Access to medication when the patient needs it.
Decreases anxiety and leads to decreased medication use
Stabilized serum drug levels by delivering small doses at short intervals.

PCA Risks
Potential for receiving too much medication may occur
MD orders too strong a dose of morphine/dilaudid
Nurse programs the machine wrong

Injury and death can occur even with no errors with the pump
Respiratory depression

Patient is monitored with oximetry alone
Need for continuous oximetry and capnography

Local and Regional Anesthetics
Perineural Infusion pumps: Unsutured catheter coming from an incisional site infusing local anesthetic. Very short term (1-2 days).

Topical Analgesics: EMLA (lidocaine/prilocaine cream) or LET (lidocaine, epinephrine, tetracaine), Lidoderm patch.

Regional Anesthesia: nerve blocks, spinal anesthesia, epidural Analgesia: childbirth, chronic pain.
Reduces a patient’s overall opioid requirement.

Nursing Implications: Regional
Explain insertion technique to patient.

Add medications administered via drug pump

Drugs must be free of preservatives and additives (Duramorph-morphine/ Sublimaze-fentanyl).

Assist the patient the first time up out of bed.

Surgical asepsis to prevent serious/fatal infection.

Observe for S&S of complications such as N/V, urinary retention, constipation, respiratory depression (Narcan for RR <8), pruritus. Monitoring may be as often as every 15 minutes.

Invasive Pain Management Interventions
Intrathecal implantable pumps or injections
Spinal cord stimulators
Deep brain stimulation
Neruoablative procedures (cordotomy: a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature sensation).
Trigger point injections

Refer patients with pain unresponsive to medication to a pain expert. It is unacceptable to tell a patient “there is nothing more we can do for you”.

Cancer and Chronic Non-Cancer/Cancer Pain Management
May develop opioid tolerance.

Pain management best when administered ATC and not PRN.

Patients usually become tolerant to side effects (except constipation) so respiratory depression less of a problem.
Transdermal fentanyl: 100 times more potent than morphine.
Hydromorphone (Dilaudid): 10 times more potent than morphine

Consider the use of the WHO three-step analgesic ladder F. 44-14 p. 1042

Breakthrough Pain: Pain that “breaks through” a scheduled regimen of pain treatment B. 44-17 p. 1042.

Barriers to Effective Pain Management
Do not label patients as “drug seeking”.

Pseudoaddiction: looks like addiction but it is not addiction. In cases of pseudoaddiction, the drug-seeking behaviors cease once the pain is properly controlled, thereby confirming the absence of true addiction.

Understand personal biases.

Placebos: Discouraged
May be considered unethical and deceitful

Differentiate: B. 44-19, p. 1044
Physical Dependence
Addiction
Drug Tolerance

Restorative and Continuing Care
Pain Clinics: Work with patients to find the most effective pain-relief measures.

Palliative Care: Learning to live life fully with an incurable condition.

Hospices: Care for patients at end of life. Emphasis on quality of life not quantity.

Evaluation
Understand peak effects of analgesics.

Reassess after each intervention at the appropriate time.

Document patient response to therapy.

Document any unexpected outcomes.

How we provide effective pain management to our patients?
Remember pain is subjective and it is what the patient states it is.
The pain threshold varies between patients
Remember a number of factors influence a persons response to pain including their cultural background, developmental stage, environment, personal experience with pain, and emotional status
Assessment is the key to providing a correct care plan for a patient’s pain
There are two types of interventions for pain: nonpharmacological and pharmacological
Always follow policy and procedure for pain management
Patients should always be the center of their care plan and include their preferences