307: chapter 44: Pain

Nature of pain
involves, physical, emotion, and cognitive components.
physiology of pain
cellular damage by thermal, mechanical, or chemical stimuli causes release of neurotransmitters.
Transduction
conversion of stimulus into electrical energy
Transmission
sending of impulse across a sensory plan nerve fiber (noiciceptor)
Perception
the patient’s experience of pain. when it is experienced in the brain.
Modulation
inhibition of pain/release of inhibitory neurotransmitters
gate control theory of pain
invented by Melzack and Wall. Pain has emotion and cognitive components, in addition to a physical sensation.
Gating mechanisms in CNS regulate or block pain impulses.
closing the gate is basis for non-pharmacological pain relief interventions.
Acute/ transient pain:
protective, identifiable, short duration; limited emotional response. Can progress to chronic pain if not treated.
Chronic/ persistent non-cancer
not protective. no purpose. may or may not have an identifiable cause. Lasts more than 6 months. examples: arthritis, headache, low back pain, peripheral neuropathy. Can be cancerous or noncancerous. May include arthritis, headache, low back pain, or peripheral neuropathy (nonthreatening)
Cancer
can be acute or chronic
Chronic episodic
occurs sporadically over an extended duration
Interred pathological
musculoskeletal, visceral, or neuropathic.
Idiopathic
Chronic pain without identifiable physical or psychological cause.
Factors influencing pain
1) physiological (age, fatigue, genes, neurological function);
2) social (attention, previous experiences, family and support groups, spiritual)
3) psychological (anxiety, coping style);
4)pain tolerance (lvl of pain patient is willing to accept);
5) cultural (meaning of pain, ethnicity),
others: support system, attention to pain, previous experiences, genetic makeup, damage to spinal cord, peripheral neuropathy, neurological disease.
characteristics of pain
onset and duration, location, intensity, quality, pattern, relief measures, contributing symptoms, effects of pain on patient.
Effects of pain on patient
Behavioral effects, influence on daily living, lifestyle, psychological well-being. long term/chronic, causes suffering, loss of control, loneliness, disabilities, exhaustion, and impaired QOL.
ABCDE of Pain assessment + management
A: ask: about pain regularly, assess pain systematically
B) Believe: the patient and family in their report of pain and what relieves it.
C) choose pain control options appropriate for the patient, family and setting.
D)Deliver interventions in a timely, logical, and coordinated fashion
E)Empower patients and their families. Enable them to control their course to the greatest extend possible.
exapmles of non-pharmacological pain relief interventions
relaxation, guided imagery, biofeedback, distraction, music, cutaneous stimulation (massage, TENS, heat), Herbs, reducing pain preception.
Nonopiods
anti-inflammatory
Opiods
narcotics. Prescribed for moderate to severe pain. Associated with respiratory depression and adverse effects of nausea, vomitting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opiods that always precedes respiratory depression.
delivery systems of pain medications
patient-controlled analgesia (PCA), local/regional anesthesia, topical agents.
Breakthrough pain
A transient flare of moderate to severe pain superimposed on continuous or persistent pain.
Barriers to effective pain management
Physical dependence, addiction, drug tolerance, placebos
Pseudoaddiction
person with chronic pain who consults with numerous health care providers is labeled a drug seeker, when he or she is actually seeking adequate pain relief.
disadvantages of Attitude of Health Care Providers regarding pain perception in their patients.
Malingerer or complainer, assumptions about patient’s in pain, biases based on culture, education, experiences.
These limit ability to help patient. instead acknowledge pain through patient’s experiences.
nursing goal of pain management?
to anticipate it, and prevent pain instead of treating it.
what’s the 5th vital sign?
Pain
Influence of pain on daily living activities
physical de-conditioning, sleep disturbances, sexual relationships, ability to work (outside and in home), altered lifestyle and psychological well-being.
what can Chronic/persistent pain cause in patient?
suffering, loss of control, loneliness, disabilities, exhaustion, and impaired Quality of life.
Relaxation and guided imagery
allows patients to alter affective-motivational and cognitive pain perception. relaxation is mental and physical freedom from tension or stress that provides individuals a sense of self-control.
Distraction
directs a patient’s attention to something other than pain and thus reduces awareness of it. Evidence shows that music decreased the use of analgesics in some postoperative patients
gate control
The gate control theory suggests that cutaneous stimulation activates larger, faster-transmitting A-beta sensory nerve fibers. This closes the gate, thus decreasing pain transmission through small-diameter C fibers.
TENS. Transcutaneous electrical nerve stimulation
stimulation of the skin with a mild electrical current passed through external electrodes.
Herbals
can interact with prescribed analgesics;ask patient to report all substances they take to relieve pain
benefits of Around The Clock analgesics
maximizes pain relief while potentially decreasing drug use. used rather than prn basis.
Analgesics
Types of Pharmacological Pain Relief
nonopiods (anti-inflammatory), Adjuvants/co-analgesics, Opiods (narcotics, affect alertness, addiction, tolerance, dependence, constipation [increase fiber and water]),
Delivery systems
Patient-controlled analgesia (PCA), Local/regional anesthesia, topical agents,
Non-opiods
acetaminophen and nonsteriodal anti-inflammatories (NSAIDs).
Acetaminophen
Has no anti-inflammatory or anti-platelet effects.
NSAIDs
aspirin and ibuprofen, provide mild to moderate pain relief. Most work on peripheral nerve receptors to reduce transmission of pain stimuli. Long term use is associated with GI bleeding and renal insufficiency.
Adjuvants & co-analgesics
drugs used to treat other conditions, but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants
Patient controlled analgesia (PCA)
a safe method of pain management that many patients prefer; PCA allows patients to help manage their pain. However patients must be able to participate in this type of intervention. Portable and computerized and contain a chamber for a syringe or bag that delivers a small, preset dose of opioid. Designed to give specific number of doses every 1 to 4 hours, given every 5, to 15 minutes (programmable) to avoid overdoses. Most have locked safety system to prevent tampering. Cancer patients have a low dose continous infusion (basal rate) of 0.5 to 1 mg/hr.
Goal of PCA
to maintain a constant plasma level of analgesic to avoid problems of as needed dosing. Gives patients pain control with low risk of overdose.
most common drugs used in PCA?
morphine, hydromorphine, and fentanyl.
conditions that local/regional anesthesias are used?
labor and delivery, chronic cancer pain, and selected postoperative procedures.
Local anesthesia
local infiltration of an anesthetic to induce loss of sensation to a body part.
Regional anesthesia
the injection of local anesthetic to block a group of sensory nerve fibers.
Epidural anesthesia
common for postoperative pain, labor and delivery, and chronic cancer pain. When caring for these patients, protect them from injury.
Topical agents
such as EMLA and lidocaine are administered via patches or discs. They produce anesthesia to soft tissue.
Epidural space
administered epidural analgesia into the spinal epidural space by inserting a blunt-tip needle into the level of the vertebral interspace nearest to the area requiring analgesia. Advance catheter into the epidural space, remove needle, and secure remainder of catheter with dressing. Ensure it is taped securely to back of patient. • Nurse anesthetists and anesthesiologists control epidural analgesia and insert it.
implications for patients with epidural
nurse has responsibility for providing emotional supports to patients after receiving local or regional anesthesia. after administration of local, protect patient from injury until full sensory and motor function return. monitor IV sites, lines and controllers.
Responsibilities when administering pain medications
monitoring the patient for effective pain relief, as well as potential adverse reactions. have medications on hand to reverse the effects of pain medications (narcan). Monitor Iv sites, lines, and controllers. monitor closely for respiratory depression. Ensure proper amount of medication is being delivered. With epidural, prevent infection.
Transdermal fentanyl
analgesia given topically. 100times more potent than morphine and provides analgesia for 48 to 72 hours. This route is used when patients are unable to take oral meds.
Transmucosal fentanyl
used for breakthrough pain. swabbed into mouth.
(WHO) World health organizer
The World Health Organization (WHO) recommends a three-step approach, the “analgesic ladder” to the management of cancer pain.
Treatment begins with NSAIDs and/or adjuvants and progresses to opioids.
Physical Dependence
A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
Addiction
A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations . rarely occurs in patients taking opioids for pain.
Drug Tolerance
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time. Don’t confuse with addiction.
Placebo
Placebos are medications or procedures that produce positive or negative effects in patients. These effects are not related to the specific physical or chemical properties of the placebo. Professional organizations discourage their use to treat pain. Placebo use jeopardizes the trust between patients and their caregivers. If a placebo is ordered, you must question the order. illegal to give placebos and tell patient it’s pain medication.
addictive behaviors
includes one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Restorative and continuing care
pain center treat patients on an inpatient or outpatient basis.
Goal of palliative care
learn how to live life fully with an incurable condition.
pain management in palliative car
A comprehensive pain center treats persons on an inpatient or outpatient basis. Staff members representing all health care disciplines (e.g., nursing, medicine, physical therapy, pastoral care, dietetics) work with patients to find the most effective pain relief measures. A comprehensive clinic provides not only diverse therapy but also research into new treatments and training for professionals.
hospice
helps terminally ill patients continue to live at home or in a health care setting in comfort and privacy. Pain control is a priority for hospices. Under the guidance of hospice nurses, families learn to monitor patients’ symptoms and become the primary caregivers.
• Hospice programs help nurses overcome their fears of contributing to a patient’s death when administering large doses of opioids. Recent research suggests that moderate opioid dose increases in patients who are terminally ill do not hasten death. The disease, not the opioid, is killing the patient.
pain evaluation
includes measuring the changing character of pain, the patient’s response to interventions, and the patient’s perceptions of effectiveness of a therapy.
questions to ask patient for pain evaluation
What is your current pain level?
How far away is your pain level from your goal?
What side effects are you experiencing from your pain medication?
Describe limitations in function that you are experiencing related to uncontrolled .
How is your pain limiting or altering your rest and sleep?
Safety guidelines
The patient on PCA is only person who presses the button to administer pain medication.
Monitor patient for signs and symptoms of over sedation and respiratory depression.
Patient safety is an essential role of the professional nurse. Ensure patient safety by communicating clearly with members of the health care team, assessing ,incorporating patient’s priorities of care and preferences, and use best evidence when making decisions about patient’s care.
When performing the skills in this chapter, remember these points to ensure safe, individualized patient care.
Elderly patients are very sensitive to pain medications. Can become severely over sedated.