NU 231 Chapter 44- Pain Management

Pain
Most common cause why people seek health care; yet often unrecognized, misunderstood and inadequately treated.
“an unpleasant, SUBJECTIVE sensory and emotional experience associate with actual or potential tissue damage, or described in terms of such damage.”
Mcaffery’s classic definition of pain
“Pain is whatever the experiencing person says it is, existing whenever he says it does.”
Effective Pain management
-improves quality of life
-reduces physical discomfort
-promotes earlier mobilization
-return to previous baseline functional activity levels
-fewer hospital and clinic visits
-lower health care costs
Nature of pain
It has physical, emotional and cognitive components. It is subjective and highly individualized. It depletes a person’s energy–chronic fatigue. Interferes with interpersonal relationships and influences the meaning of life.
Physiology of pain
There are four physiological processes of normal pain; transduction, transmission, perception and modulation. A patient cannot discriminate among the processes.
Transduction
Thermal, chemical, or mechanical stimuli usually cause pain.
Transduction covers energy produced by these stimuli into electrical energy.
Begins in periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential.
Transmission
Cellular damage caused by chemical, thermal or mechanical stimuli results in release of excitatory neurotransmitters such as
-prostaglandins, bradykin, substance P, and histamine.
These either excite transmission or inhibit during modulation.
Excitatory neurotransmitters
send electrical impulses across the synaptic cleft between two nerve fibers, enhancing transmission of the pain impulse. These pain-sensitizing substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response.
Pain sitmulus enters spinal cord via dorsal honr and travels one of several routes until ending within the gray matter.
What happens at dorsal horn?
Substance P is released, causing a synaptic transmission from the afferent (sensory) peripheral nerve to spinothalmic tract nerves, which cross to the opposite side
Two types of peripheral nerve fibers that conduct painful stimuli
Fast, myelinated A-delta fibers: send sharp localized & distinct sensations that specify the source of pain and detect its intensity.

very small, slow,unmyelinated C fibers: relay impulses that are poorly localized, visceral, and persistent.

Example of pain stimuli and nerve fibers
You step on a nail, you feel a sharp, localized pain (A-fiber transmission/1st pain). Then the whole foot aches from C-fiber transmission or 2nd pain.
Prostaglandins
Generated from breakdown of phospholipids in cell membranes; thought to increase sensitivity to pain
Bradykinin
released from plasma that leaks from surrounding blood vessels at site of tissue injury.
-Binds to receptors on peripheral nerves, increasing pain stimuli
-Binds to cells that cause the chain reaction producing prostaglandins.
Substance P
found in pain neurons of dorsal horn (excitatory peptide)
-needed to transmit pain impulses from periphery to higher brain centers
-causes vasodilation and edema
Histamine
Produced by mast cells causing capillary dilation and increased capillary permeability
Neuromodulators (inhibitory)
-natural supply of morphinelike substances in the body
-activated by stress and pain
-located within brain, spinal cord and GI tract
-cause analgesia when they attach to opiate receptors in the brain
-present in higher levels in people who have less pain than others with a similar injury
Perception
Pain stimulus reaches cerebral cortex, brain interprets quality of pain and processes info from past experience, knowledge and cultural associations in the perception of the pain
Definition of perception
Point at which a person is aware of pain. Somatosensory cortex identifies location and intensity of pain.
Association cortex (primarily limbic system) determines how a person feels about it.
*No single pain center
Reaction to pain
includes physiological and behavioral responses
Modulation
once brain perceives pain, release of inhibitory neurotransmitters (endorphins, serotonin, norepi, and GABA)- hinder transmission of pain and help produce analgesic effect.
Inhibition of pain impulse is last phase of normal pain process= modulation
Protective reflex response
A-delta fibers send sensory impulses to spinal cord, where they synapse with spinal motor neurons. Motor impulses travel via reflex arc along efferent (motor) nerve fibers back to a peripheral muscle near the site of stimulation, thus bypassing brain.
Contraction of muscle leads to a protective withdrawal from source of pain
Gate Control Theory of Pain
Gating mechanisms located along the central nervous system regulate or block pain impulses. Pain impulses pass thru when a gate is open & are blocked when the date is closed. Closing the gate is the basis for non pharmacological pain-relief interventions.
ex: Factors such as stress and exercise increase the release of endorphins, often raising a person’s pain threshold.
*This theory suggest that pain has emotional & cognitive components in addition to physical sensations.
Physiological Responses
Stimulation of sympathetic branch of ANS results in physiological responses.
Continous severe or deep pain typically involving visceral organs activates parasympathetic nervous system.
Behavioral Responses
Clenching teeth, facial grimacing, holding or guarding the painful part, and bent posture are common indications of acute pain.
Chronic pain affects a patient’s activity (eating, sleeping, socialization), thinking (confusion, forgetfulness), or emotions (anger, depression, irritability) and quality of life and productivity.
pain tolerance
level of pain a person is willing to accept.
Sometimes patients with low pain tolerance are inaccurately perceived as complainers.
Acute pain
protective, usually has an identifiable cause, is of short duration & has limited tissue damage & emotional response.
Acute pain warns people of injury or disease, thus is protective.
Eventually resolves with or without treatment after an injured area heals.
Self limiting; patient knows an end is in sight
Primary nursing goal with acute pain
provide pain relief that allows patients to participate in their recovery, prevent complications, and improve functional status.
Chronic Pain
not protective- no purpose BUT has dramatic effect on a person’s quality of life. Chronic non cancer pain is prolonged, varies in intensity, & lasts longer than expected. (at least 6 months)
Ex: arthritis, low back pain, headche, fibromyalgia, peripheral neuropathy.
Can be viwed as disease- bc it has a distinct pathology that causes changes throughout the nervous system that may worsen over time.
*Chronic pain is a major cause of psychological depression & even suicide.
Associated symptoms of Chronic Pain
fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, depression and anger.
Chronic episodic pain
pain that occurs sporadically over an extended period of time is episodic.
Pain episodes last for hours, days or weeks.
ex: migrane headache that occurs up to 14 days per month compared to chronic migraine that occurs more than 15 days per month.
Cancer Pain
Some patients with cancer experience acute and/or chronic pain. The pain is moral, resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damage pain nerves.
Cancer pain is usually caused by tumor progression & related pathologic processes, invasive procedures, chemo, infection and physical limitations.
referred pain
A patient senses pain at the actual site of tumor or distant to the site
Idiopathic pain
chronic pain in the absence of an identifiable physical or psychological cause.
ex: complex regional pain syndrome (CRPS)
Common Biases & misconceptions about pain
*Patients who abuse substances overreact to discomforts.
*Patiens with minor illnesses have less pain than those with severe physical alteration.
*Administering analgesis regular leads to drug addiction
*Amount of tissue damage in an injury accurately indicates pain intensity
*Psychogenic pain is not real
*Chronic pain is psychological
*Patiens who are hospitalized experience pain
*Patients who cannot speak do not feel pain
Age
Age influences pain experience.
ex: pain for a teenager may prevent them from engaging socially with friends
Important to recognize how developmental difference affect how infants and older adults react to pain.
ex: infants don’t realize what pain is & have difficulty describing it
*older adults- serious impairment of functional often accompanies pain. requires aggressive assessment, diagnosis, and management
Fatigue
heightens perception of pain & decreases coping abilities.
not enough sleep= usually greater perception of pain
Genes
Genetic influences have been shown to play a role in sensitivity, perception and expression of pain.
Neurological function
Any factor that interrupts or influences normal pain reception or perception (ex: spinal cord injury, peripheral neuropathy, or neurological disease) impacts a patient’s awareness of and response to pain.
Social factors: Attention
Increased attention is associated with increased pain. Distraction is associated with diminishing pain. Nurses can use this ex: guided imagery, massage.
Social factors: Previous experience
-Previous experience to pain does not mean that a person will accept pain more easily.
-When a patient has no pain experience, first perception of pain often impairs ability to cope
Social Factors: Family and Social Support
Presence of family and friends can often make the experience less stressful. Conversations with family are a useful distraction
Social factors: Spiritual factors
Spiritual beliefs affect how a person views or copes with pain.
Psychological factors: Anxiety
A person perceives pain differently if it suggests a threat, loss, punishment or challenge.
Anxiety often increases the perception of pain, and pain causes feelings of anxiety.
Critically ill or injured patients who perceive a lack of control over their environments & care have high anxiety levels.
Psychological Factors: Coping style
Pain is a lonely experience that often causes patients to feel a loss of control.
People with internal loci of control- perceive themselves as having control over events in life and outcomes such as pain. They ask questions & make choices about treatment.
People with external loci of control- perceive that other factors in their life such as nurses are responsible for the outcome of events
Cultural Factors
Different meanings and attitudes are associated with pain across various cultural groups. Culture affects pain expression. Some cultures believe that it natural to be demonstrative about pain where others tend to be more introverted.
PQRRSTU
P- Provokes; what causes pain? What makes it better?
Q-Qualtiy; What does pain feel like?
R-Radiates; Where does the pain go or does it stay in one place?
S-Severity; Scale of 0-10
T-Time; When pain startes? How long does it last?

The other letters
R- Relief (what do you take at home to make it better?)
U- Effect of pain (What are you not able to do because of the pain?)

Routine Clinical Approach to Pain Assessment and Management
A: Ask about pain regular. Assess pain systematically
B: Believe patient and family in there report of pain and what relieves it
C: Choose pain control options appropriate for the patient, family & 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 extent possible
Superficial or cutaneous
Pain resulting from stimulation of skin
– pain is of short duration and localized. (Sharp sensation)
Ex of causes: needlestick, small cut or laceration
Deep or visceral
Pain resulting from stimulation of internal organs
-pain is diffuse and radiates in several directions. Duration varies, but usually lasts longer than superficial pain. Pain is sharp, dull or unique to organ involved.
Ex: crushing sensation (angina) or burning sensation (gastric ulcer)
Referred pain
Common in visceral pain because many organs themselves have no pain receptors.
Pain is in part of body separate from source of pain and assumes any characteristic.
ex: Myocardial infarction- causes referred pain to jaw, left arm, left shoulder, kidney stones
Radiating
sensation of pain extending from initial site of injury to another body part.
-pain feels as though it travels down or along body part. intermittent or constant
-low back pain from ruptured intraverterbral dis accompanied by pain radiating down left from sciatic nerve irritation
Characteristics of pain: Timing (onset, duration and pattern)
When did it begin? How long has it lasted? Does it occur at the same time each day? Is it intermittent, constant or a combination? How often does it occur?
Characteristics of pain: Location
Ask patient to describe or point to all areas of discomfort to asses pain locator.
Characteristics of pain: Severity
Pain scales- use appropriate ones based on patient’s age and mental status.
For kids- grimacing face scale (Oucher)
NRS- On a scale of 0-10
VDS- a line with 3 or 6 words to describe pain
VAS- consists of straight line shows a continuum of intensity and labeled end points
Aggravating and precipitating factors
Ask the patient to describe activities that cause or aggravate pains such as physical movement, positions, drinking coffee or alcohol, urination, swallowing ,eating or psychological stress.
Relief Measures
Useful to know whether patient has an effective way of relieving pain such as chaining position, using ritualistic behavior, eating, mediating, praying or applying heat or cold to the painful site.
Behavioral indicators of effects of pain: Vocalizing
-Moaning
-Crying
-Gasping
-Grunting
Behavioral indicators of effects of pain: Facial Expressions
-Grimace
-Clenched teeth
-wrinkled forehead
-tightly closed or widely opened eyes or mouth
-lip biting
Behavioral indicators of effects of pain: Body Movement
-Restlessness
-Immobilization
-Muscle tension
-Increased hand & finger movements
-pacing activities
-rhythmic or rubbing motions
-protective movement of body parts
-grabbing or holding a body part
Behavioral indicators of effects of pain: Social Interaction
-Avoidance of conversation
-focus only on activities for pain relief
-avoidance of social contacts
-reduced attention span
-reduced interaction with environment
Influence on activités of daily living
Patients who live with daily pain or have prolonged pain during a hospitalization are less able to participate in routine activities, which results in physical deconditioning.
Primary goal of nurse- improve patient function
Ask pt whether pain interfere with sleep.
Pain sometimes impairs the ability to maintain normal sexual relations. Desire for sex can decrease due to fatigue or pain.
Pain threatens a person’a ability to work- job loss
Concomitant Symptoms
Nausea, headache, dizziness, urge to urinate, constipation, depression, restlessness occur with pain and usually increase a patient’s pain severity.
Examples of Nursing Diagnoses for pain
-Activity intolerance
-Anxiety
-Bathing self care deficit
-Ineffective coping
-Fatigue
-Impaired physical mobility
-Insomnia
Impaired social interaction
Health Promotion
When providing pain-relief measures, choose therapies suited to a patient’s unique pain experience.
-Use different types of pain-relief measures
-Use measures that patient believes are effective
-Keep an open mind about ways to relieve pain
-Keep trying. Don’t abandon patient
Maintaining wellness
Health literacy affects a patient’s pain experience. Low health literacy poses significant barriers to optimal pain management
Nonpharamxological pain-releif interventions
They include: cognitive behavioral and physical approaches.
Cognitive behavioral interventions- change person’s perception of pain, alter pain behavior and provide greater sense of control. Ex: distractions, prayers, relaxation, guided imagery, music and biofeedback.

physical approaches aim to provide pain relief, correct physical dysfunction, alter physiological responses, and reduce fears associated with pain-related immobility.

Complementary and alternative medicine (CAM) therapies- such as therapeutic touch, mindfulness mediations help to alleviate pain in some patients.

Can be used alone or in combo with pharmacological interventions. However, for acute pain they should never be used in place of pharmacological therapies.

Relaxation
is mental and physical freedom from tension or stress that provides individuals a sense of self-control.
Relaxation techniques include- mediation, yoga, sen, guided imagery and progressive relaxation exercises.
Distraction
Reticular activating system inhibits painful stimuli if a person receives sufficient or excessive sensory input. With sufficient sensory stimuli, a person ignores or becomes unaware of pain.
Distraction works best for short, intense pain lasting a few minutes.
Cutaneous Stimulation
stimulation of the skin through a massage, warm bath, cold application, and transcutaneous electrical nerve stimulation (TENS) may be helpful in reducing pain perception.

Cold therapies are particularly effective for acute pain relief.

Accupressure
Cold is effective for tooth or mouth pain when you place the ice on the web of the hand between the thumb and index finger. This point on the hand is an acupressure point that influences nerve pathways to the face and head.
Heat application
More affection for some patients, especially those with chronic pain.
TENS
stimulation of the skin with a mild electrical current passed through external electrodes. Can work both peripherally and centrally
Herbals
Many patients use herbal and dietary supplements such as echinacea, ginseng, gingko blob, and garlic despite conflicting research. Herbal supplements may interact with prescribe analgesics.
Reducing pain perception and reception
Simple way to promote comfort is to remove or prevent painful stimuli.
ex: patient becomes constipated and has abdominal distention and cramping- should intervene to ensure normal elimination process continues
Analgesics
most common and effective method of pain relief.
Types
1. nonopioids (acetaminophen and nonsterioidal anti-inflammatory drugs (NSAIDs)
2. Opioids (narcotics)
3. Adjuvants or co-analgesics
Acetaminophen (Tylenol)
considered one of the most tolerated and safest analgesics available. Direct effect on CNS, no anti-inflammatory effects. IV acetaminophen is an effective analgesic agent because ti crosses the blood brain barrier rapidly- thus providing nonopiod analgesia for postoperative patients. can be combined with an opioid.
Major adverse effect: hepatotoxicity and because the drug is widely used. FDA altered the dosage
Nonselective NSAIDs
ex: aspirin, ibuprofen and naproxen
relieve midl to moderate actue intermittent pain like headache or muscle strain.
NSAIDs inhibit synthesis of prostaglandins. Do not repress the CNS and do not interfere with bowel or bladder functions.
Not recommended for use in older adults bc of worsened adverse effects for them such as GI bleeding and renal insufficiency)
Opioids
prescribed for moderate to severe pain. They act on higher centers of the brain and spinal cord by binding with opiate receptors to modify perceptions of pain.
ex: morphine, codeine, hydromorphone, fentanyl, oxycodone, and hydrocodone,.
Numerous side effects can occur.
Long-term use side effects- depression, impaired sleep patterns, endocrine effects, and immune system suppression.
Constipation is always anticipated and can be prevented thru diet, hydration and stool softness.
Opioid side effect for naive patients
people who have never used opioids around the clock before experience respiratory depression.
Closely monitor for sedation in opioid-naive patients.
If pt experiences respiratory depression- administer naloxone (Narcan).
Multi-modal analgesia
combines drugs with a t least two different mechanisms of action so pain control can optimized. Main benefit- use of different agents allows for lower than usual doses of each medication, there for lowering the risk of side effects.
Nursing principles for administering analgesics
-Know patient’s previous response to analgesics
-Select proper medication when more than one in ordered
-Know accurate dosage
-Assess right time and interval for administration
Co-adjuvants
these are drugs originally developed to treat conditions tother than pain abut also analgesic properties.
ex: Corticosteroids- relief pain from inflammation and bone metastasis
Patient controlled analgesia (PCA)
Drug delivery system method for pain management that many patients prefer. Allows patients to self-administer pious with minimal risk of overdose. Goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing.
PCA infusion pumps are portable and computerized and contain a chamber for a syringe or bag that delivers a small, preset dose of opioid. The PCA gives a specific dose which is available at a specific time.
Need proper education for patients
Topical Analgesics
Include prescription and OTC creams, ointments and patches that are applied to a painful area. Commonly used topical agents include NSAID products.
Local Anesthesia
local infiltration of an anesthetic medication to induce loss of sensation to a body part.
ex: removing a skin lesion or suturing a wound by applying local anesthetics topically on skin & mucous membranes.
Block motor and autonomic functions
Regional Anesthesia
is the injection or infusion of local anesthetic to block a group of sensory nerve fibers.
Perineural local anesthetic infusion
A type of regional anesthesia is the use of perineurial injection and infusions of local anesthetic agents to relieve pain.
A surgeon places the tip of unstirred catheter bear a nerve or groups of nerves, and the catheter exits from the surgical wound.
Epidural Analgesia
Pain therapy-a form of regional anesthesia. Preservative-free opioids are often administered as single agents or in combination with local anesthetics into a patient’s epidural space.
effective for: postoperative pain, rib fracture pain, labor and delivery pain and chronic cancer pain.
Blunt tip needle is used, catheter into epidural space
Risks: bleeding, subsequent hematoma formation near the injection/insertion site.
Invasive interventions for Pain relief
When severe pain persists despite medical treatments you can give:
-intrathecal implantable pumps or injections, cry oblation, spinal cord and deep brain stimulation, neuroblative procedures, and intraspinal medications.
Common pharmacological agents for managing procedural comfort
local anesthetics, NSAIDs, acetaminophen, opioids, anxiolytics and sedatives.
Cancer pain and chronic non cancer pain management
I need to figure out how to summarize those paragraphs on this. sorry, coming soon!
Barriers to effective pain management
-lack of knowledge
-misconceptions about pain
Patient Barriers:
-fear of addiction
-worry about side effects
-takes too many pills already
-pain inevitable
-pain part of aging
Health Care provider: barriers:
-inadequate pain-assessment skills
-no visible cause of pain
-not believing patient’s report of pain
Health Care system barriers:
-concern with creating “addicts”
-poor understanding of economic impact of unrelieved pain
-lack of money
Physical Dependence
A state of adaption 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. Common symptoms of opioid withdrawal include shaking, chills, abdominal cramps, excessive yawning and join pain.
Addiction
A primary, chronic neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.
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.
Placebos
pharmacologically inactive preparations or procedures that produce no beneficial or therapeutic effect.