Potter Perry Chapter 44 – Pain Management

Transduction
the energy of thermal, chemical, or mechanical stimuli is converted to electrical energy
nociceptor
sensory peripheral pain nerve fiber
substance P
cause vasodilation and edema
Serotonin
inhibits pain transmission
prostaglandins
increases sensitivity to pain
bradykinin
binds to receptors on peripheral nerves, increasing pain stimuli
neuromodulators
body natural supply of morphinelike substances
Perception
the point at which a person is aware of pain
modulation
inhibition of the pain impulse of the nociceptive process
Pain threshold
the point at which a person feels pain
Pain tolerance
level of pain a person is willing to put up with
acute pain
is protective, has a cause, is of short duration, and has limited tissue damage and emotional response
chronic pain
is chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
Nociceptive pain
Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids and/or opioids.
Somatic
comes from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well-localized.
Visceral pain
Arises from visceral organs, such as the gastrointestinal tract and pancreas.
Neuropathic pain
Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant analgesics.
Deafferentation pain
Injury to either the peripheral or central nervous system. Examples: Phantom pain reflects injury to the peripheral nervous system; burning pain below the level of a spinal cord lesion reflects injury to the central nervous system.
Sympathetically maintained pain
Associated with dysregulation of the autonomic nervous system. Examples: pain associated with reflex sympathetic dystrophy/causalgia (complex regional pain syndrome, type I, type II).
Polyneuropathies
Client feels pain along the distribution of many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barré syndrome.
Mononeuropathies
Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve entrapment, trigeminal neuralgia.
Identify the physiological factors that influences pain
a. age
b. fatigue
c. genes
d. neurological function
Identify the social factors that can influence pain
a. attention
b. previous experience
c. family and social support.
Identify the spiritual factors that can influence pain
Active searching for meaning, concerns of loss of independence and becoming a burden to the family
Identify the psychological factors that can influence pain
a. anxiety
b. coping styles
Identify the cultural factors that can influence pain
a. meaning of the pain
b. ethnicity
Nursing process: Assessment

Identify the ABCDE clinical approach to pain assessment and management

A

A: Ask about pain regularly. Assess pain systematically.
Nursing process: Assessment

Identify the ABCDE clinical approach to pain assessment and management

B

B: Believe the client and family in their report of pain and what relieves it.
Nursing process: Assessment

Identify the ABCDE clinical approach to pain assessment and management

C

C: Choose pain-control options appropriate for the client, family, and setting.
Nursing process: Assessment

Identify the ABCDE clinical approach to pain assessment and management

D

D: Deliver interventions in a timely, logical, and coordinated fashion.
Nursing process: Assessment

Identify the ABCDE clinical approach to pain assessment and management

E

E: Empower clients and their families. Enable them to control their course to the greatest extent possible.
Identify the common characteristics of pain that the nurse would assess.
a. onset and duration
b. location
c. intensity
d. quality
e. pain pattern
f. relief measures
g. contributing symptoms
h. effects of pain on the client
i. behavioral effects
j. influence on activities of daily living
Nursing Diagnosis
List potential or actual nursing diagnosis related to a client in pain
-anxiety
-fatigue
-hopelessness
-impaired physical mobility
-imbalanced nutrition: less than
-powerlessness
-chronic low self-esteem
-disturbed sleep pattern
-impaired social interaction
-spiritual distress
Planning
List the client outcomes appropriate for the client experiencing pain.
-Reports that pain is a 3 or less on a scale of 0-10, does not interfere with ADLs, or personal pain intensity goal attained
-Identifies factors that intensify pain and modifies behavior accordingly
-Uses pain-relief measures safely
Implementation
35. The agency for healthcare research and quality (AHRQ) guidelines for acute pain management cite non pharmacological interventions appropriate for clients who meet certain criteria. List those criteria.
a. find such interventions appealing
b. express anxiety or fear
c. will possibly benefit from avoiding or reducing drug therapy d. are likely to experience and need to cope with a prolonged interval of postoperative pain e. have incomplete pain relief after use of pharmacological interventions
Relaxation for Pain
is mental and physical freedom from tension or stress that provides individuals with a sense of self-control
Distraction for Pain
directs a client’s attention to something other than pain and thus reduces the awareness of pain
Music for Pain
diverts the person’s attention away from the pain and creates a relaxation response
Cutaneous Stimulation for Pain
a massage, warm bath, ice bag, and TENS stimulates the skin to reduce pain perception by the release of endorphins, which block the transmission of painful stimuli
Herbals for Pain
not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements
Reducing pain perception
One simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback
Three types of analgesics used for pain relief
a. nonopioids
b. opioids
c. adjuvants/coanalgesics
adjuvants/coanalgesics
variety of medications that enhance analgesics or have analgesic properties that were originally unknown
Benefits of patient-controlled analgesia (PCA):
• allows clients to self-administer opioids with minimal risk of overdose
• the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing
Explain the purpose of perineural local anesthetic infusion
manage pain from a variety of surgical procedures with a pump that is set as a demand or continuous mode and left in place for 48 hours
explain the purpose of topical analgesics
EMLA via a disc or thick cream to the skin for 30 to 60 minutes before minor procedures
Local anesthesia
local infiltration of an anesthetic medication to induce loss of sensation to a body part
Regional anesthesia
is the injection of a local anesthetic to block a group of sensory nerve fibers
epidural anesthesia
permits control or reduction of severe pain and reduces the client’s overall opioid requirement; can be short- or long-term
Complications of opioid analgesia are:
• nausea and vomiting
• urinary retention
• Constipation
• respiratory depression
• pruritus
List the goals for the care of a client with epidural infusions. Describe one action for each goal.
a. Prevent catheter displacement: Secure catheter (if not connected to implanted reservoir) carefully to outside skin.
b. Maintain catheter function: Check external dressing around catheter site for dampness or discharge. (Leak of cerebrospinal fluid may develop.)
c. Prevent infection: Use strict aseptic technique when caring for catheter (see Chapter 33).
d. Monitor for respiratory depression: Monitor vital signs, especially respirations, per policy.
e. Prevent undesirable complications: Assess for pruritus (itching) and nausea and vomiting.
f. Maintain urinary and bowel function: Monitor intake and output.
transdermal fentanyl
100 times more potent than morphine in predetermined doses that provide analgesic for 48-72 hours; useful when unable to take oral medications
transmucosal fentanyl
to treat breakthrough pain in opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed
Incident pain
Pain that is predictable and elicited by specific behaviors such as physical therapy or wound-dressing changes
End-of-dose failure pain
Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic
Spontaneous pain
Pain that is unpredictable and not associated with any activity or event
examples of barriers to effective pain management

Client

Fear of addiction, Worry about side effects, Fear of tolerance (won’t be there when I need it), Take too many pills already, Fear of injections, Concern about not being a “good” client, Don’t want to worry family and friends, May need more tests, Need to suffer to be cured, Pain is for past indiscretions, Inadequate education, Reluctance to discuss pain, Pain is inevitable, Pain is part of aging, Fear of disease progression, Primary health care providers and nurses are doing all that they can, Just forget to take analgesics, Fear of distracting primary health care providers from treating illness, Primary health care providers have more important or ill clients to see, Suffering in silence is noble and expected
examples of barriers to effective pain management

Health Care Provider

Inadequate pain assessment, Concern with addiction, Opiophobia (fear of opioids), Fear of legal repercussions, No visible cause of pain, Clients must learn to live with pain, Reluctance to deal with side effects of analgesics, Fear of giving a dose that will kill the client, Not believing the client’s report of pain, Primary health care provider time constraints, Inadequate reimbursement, Belief that opioids “mask” symptoms, Belief that pain is part of aging, Overestimation of rates of respiratory depression
examples of barriers to effective pain management

Health care system barriers

Concern with creating “addicts,”, Ability to fill prescriptions, Absolute dollar restriction on amount reimbursed for prescriptions, Mail order pharmacy restrictions, Nurse practitioners and physician assistants not used efficiently, Extensive documentation requirements, Poor pain policies and procedures regarding pain management, Lack of money, Inadequate access to pain clinics, Poor understanding of economic impact of unrelieved pain
Type of dependence:

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.
Type of dependence:

drug tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.
Type of dependence:

Addiction

A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Type of dependence:

Pseudoaddiction

Client behaviors (drug seeking) that occur when pain is undertreated.
Type of dependence:

Pseudotolerance

Need to increase opioid dose for reasons other than opioid tolerance: progression of disease, onset of new disorder, increased physical activity, lack of adherence, change in opioid formulation, drug-drug interaction, drug-food interaction.
Define placebo
a medication or procedure that produces positive or negative effects in clients that are not related to the placebo’s specific physical or chemical properties
Pain clinics
treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain-relief measures
Palliative care
the goal is to live life fully with an incurable condition
Hospice
care of clients at the end of life, this emphasizes quality of life over quantity
Evaluation
identify some principles to evaluate related to pain management.
-evaluate the client for the effectiveness of the pain management after an appropriate period of time
-entertain new approaches if no relief
-evaluate the client’s perception of pain
Review questions
Pain is a protective mechanism warning of tissue injury and largely a (an):
1. Objective experience
2. Subjective experience
3. Acute symptom of short duration
4. Symptom of a severe illness or disease
Answer is: 2.
Rationale: Only the client knows whether pain is present and what the experience is like.
Review questions
A substance that can cause analgesia when it attaches to opiate receptors in the brain is:
1. Endorphin
2. Bradykinin
3. Substance P
4. Prostaglandin
Answer is: 1.
Rationale: Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids (e.g., endorphins) which hinder the transmission of pain and help produce an analgesic effect.
Review questions

To adequately assess the quality of a client’s pain, which question would be appropriate?
1. “Is it a sharp or a dull pain?”
2. “Tell me what your pain feels like.”
3. “Is your pain a crushing sensation?”
4. “How long have you had this pain?”

Answer is: 2.
Rationale: A client’s self-report of pain is the single most reliable indicator of the existence and intensity of pain.
Review questions
The use of client distraction in pain control is based on the principle that:
1. Small C fibers transmit impulses via the spinothalamic tract
2. The reticular formation can send inhibitory signals to gating mechanisms
3. large A fibers compete with pain impulses to close gates to painful stimuli
4. Transmission of pain impulses from the spinal cord to the cerebral cortex can inhibited
Answer is: 2.
Rationale: The reticular activating system inhibits painful stimuli if a person receives sufficient or excessive sensory input; with sufficient sensory stimulation a person is able to ignore or become unaware of pain.
Review questions
Teaching a child about painful procedures is best achieved by:
1. Early warnings of the anticipated pain
2. Storytelling about the upcoming procedure
3. Relevant play directed toward procedure activities
4. Avoiding explanations until the pain is experienced
Answer is: 3.
Rationale: Developmental differences are found between age groups; therefore, the nurse needs to adapt approaches for assessing a child’s pain and how to prepare a child for a painful procedure.
Activity tolerance
The type or exercise or work that a person is able to perform w/o undue exertion or possible injury
when A person begins to walk monitor for
dyspnea,chest pain or fatigue
serotonin
released from the brain stem and dorsal horn to inhibit pain transmission
Diaphoresis
Physiological reactions to pain
controls body temp during stress
Pallor
Parasympathetic stimulation
cause blood supply to shift away from periphery
Respiratory depression is an adverse effect of ?
opioids
When a patient with chronic pain seeks pain medication from multiple primary health care providers, the patient is called a drug seeker but not an illicit drug abuser.this called of addiction is called ?
pseudoaddiction.