Ch 46 Pain

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Ch 46 Pain
2011-09-16 21:14:14

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  1. Pain: Description
    • -Subjective: whatever patient reports
    • -Can’t measure objectively
    • -Unpleasant sensory/emotional experience
    • -Actual or potential tissue damage
    • -Can warn of potential injury
    • -Pain has protective effect
    • -Can have destructive effects
    • -Sleep loss, irritability, immobility, job performance,
    • social relationships
  2. Pain Classifications: By Origin
    -By origin

    • 1) Superficial
    • a) Skin or subcutaneous tissue
    • b) Ex. hot object, paper cut

    • 2) Visceral
    • a) Deep pain in abdomen, cranium, thorax
    • b) Varies from local, achy discomfort to widespread intense pain
    • c) Ex. Menstrual cramps, labor & cancer pain

    • 3) Somatic
    • a) Ligaments, tendons, nerves, blood vessels, bones b) Diffuse; lasts longer than superficial pain
    • c) Ex: fracture, sprain, arthritis, bone cancer

    • 4) Radiating
    • a) Radiates outward from source to other sites
    • b) Ex: GERD: sternum to entire thorax; MI: substernal to neck, jaw, L shoulder, or L arm

    • 5) Referred
    • a) Pain felt at site distant from origin
    • b) Ex: MI: no substernal pain or chest pain, instead
    • pain in jaw, back, or L arm

    • 6) Psychogenic
    • a) No physical cause identified

    • 7) Phantom
    • a) Felt in area surgically removed
    • b) Ex: amputated limb
    • c) C/o burning, itching, or deep pain
  3. Pain Classifications: By quality
    • Descriptors: sharp, dull, aching, boring,
    • throbbing, stabbing, burning, ripping, searing, tingling

    By periodicity: episodic, intermittent, constant

    • By intensity: 0 (no pain)- 10 (worst)
    • 1-3- mild, 4-6- moderate, 7-10-severe
    • (know those numbers)
  4. Pain Classification: By Duration
    • 1) Acute
    • a) Short duration, rapid onset, variable intensity, lasts up to 6 months
    • b) Causes: injury or surgery
    • c) Protective: actual/potential tissue damage
    • d) Disappears with tissue healing

    • Acute pain initiates the “fight or flight” responses of the autonomic nervous system and is characterized by the following symptoms:
    • Tachycardia
    • Rapid, shallow resp.
    • Increased B/P
    • Sweating
    • Pallor
    • Dilated pupils
    • Fear and anxiety

    • 2) Chronic
    • a) Lasts longer than 6 months
    • b) Interferes with daily functioning
    • c) Causes: progressive disorder or neuropathic pain; possible exacerbation or remission
    • d) Parasympathetic response -Normal VS, warm
    • dry skin, normal pupils
    • e) Emotional responses: withdrawal, depression, anger, frustration, dependence

    • 3) Malignant Pain
    • Chronic pain can be nonmalignant
    • Chronic pain can be malignant (cancer)
    • Related to tumor progression and its related pathology and treatments
    • Continual, progressive tissue damage
    • Continues to be under managed
  5. Physiology of pain- Nociception
    Nociceptors (pain receptors) are excited by mechanical, chemical, or thermal stimuli

    • This triggers release of chemicals (histamine,
    • prostaglandins, etc)

    • Pain transmitted from peripheral nerve fibers to spinal
    • cord to brain stem to cortex (where pain is perceived)

    • Small diameter fibers in spinal cord carry signals
    • C fibers: dull achy pain
    • A fibers: sharp localized pain

    • -Brain stem sends signals back down spinal cord where inhibiting substances are released to decrease pain
    • -Perception- client becomes conscious of the pain. The perception is the sum of the activity in the
    • central nervous system & psychological context (meaning of pain to client, past experiences)

    -Medications work at various points along these processes
  6. Gate Control Theory
    -Can regulate pain impulses by gating mechanism in the dorsal horn of spinal cord keeping impulses from reaching brain

    -Large diameter A fibers send messages of touch, warm, cold

    -Pain impulses pass when a gate is open, and are blocked when a gate is closed

    • -Therapeutic touch and massage can stimulate large A fiber impulses and close the gate
    • Massage
    • Accupressure
    • Warm water shower
  7. Factors Affecting Perception of Pain
    • -Ethnic and cultural values
    • -Developmental stage
    • -Environment and support people
    • -Past pain experiences
    • -Meaning of pain
    • -Spiritual
    • -Social
  8. Pain Threshold
    Pain Tolerance
    • Pain threshold – the amount of pain stimulation that is required for a person to feel pain - Differs person to
    • person

    • Pain tolerance – the maximum amount of pain (quantity & duration) that a person is willing to endure
    • -How much pain before treatment is needed
  9. Pain Assessment: Objective Data
    • onverbal responses to pain
    • Facial expression
    • Vocalizations like moaning and groaning or crying and
    • screaming
    • Immobilization of the body or body part
    • Purposeless body movements
    • Behavioral changes such as confusion and restlessnessRhythmic body movements or rubbing

    • If Cognitive impairment
    • Facial expression: sad/frightened; rapid eye blinking
    • Vocalizations: moaning, groaning, profanity, abusive language
    • Change in activity: fidgeting, pacing/rocking, disruptive behavior
    • Change in mentation: increased confusion
  10. Assessment of Pain: When
    • 1) 5th vital sign: rate intensity with each VS check
    • 2) On admission
    • 3) Before/after each painful procedure/tx
    • 4) At rest, with activity
    • 5) Before pain intervention, 30 mins after
    • 6) When c/o pain
  11. Assessment of Pain: How
    • 1)Ask about pain regularly
    • 2)Assess pain systematically
    • 3)Believe patient and family
    • 4)Choose appropriate pain interventions
    • 5)Deliver pain intervention in timely way
    • 6)Empower patient and family (control over pain experience as much as possible)
  12. Pain Scales
    • Pain scales: consider
    • 1) Level of education
    • 2) Language skills
    • 3) Eyesight
    • 4) Developmental level

    Visual Analogue Scale (VAS)-10 cm horizontal line

    • Numeric Rating Scale (NRS)- A line numbered from 0-10. Zero = no pain and 10 is the worst possible pain
    • -To use this scale the pt. must be able to count.

    Simple descriptor scale- Mild, moderate, severe

    11 point pain intensity scale

    • Wong-Baker Faces Pain Rating Scale-No
    • numerical or reading skill needed. Children >3 & adults with communication & cognitive impairments

    FLACC scale- for non-verbal clients unable to report pain
  13. Stratigies in Pain Management
    • Remove barriers to pain managementFear of becoming addicted
    • Nurses need to acknowledge & accept client’s pain
    • Assist support persons to deal with pain
    • Reduce fear & anxiety to decreases pain intensity
    • Prevent pain- ATC & supplemental meds
    • Esp during the first 24 hours after surgery
  14. Nursing Interventions: Nonpharmacological
    • Physical therapy
    • Cutaneous stimulation- Gate control theory
    • -Heat/cold
    • -Massage
    • -Accupressure
    • -Contralateral stimulation- stim skin opposite
    • painful site
    • -Transcutaneous Electrical Nerve Stimulation (TENS)

    • Cognitive Behavioral Therapies
    • Relaxation
    • Guided imagery
    • Distraction
    • Reading, TV (visual), humor, music (Auditiory), Breathing, massage, pets (tactile)
    • Puzzles, cards, hobbies (Intellectual distraction)

    • OTHER
    • Repositioning
    • Immobilization: splint, remove to exercise
    • Dark, quiet room
    • Bed linens: clean and straight
    • Soft music
  15. Pharmacologic Pain Management
    • Involves use of:
    • Opioids: Codeine, Demerol, morphine

    • Nonopioids/
    • Nonsteroidal anti-inflammatory drugs (NSAIDs): (Tylenol, Aspirin)
    • Coanalgesic drugs (adjuvant): Anticonvulsants, Antidepressants, Anti-anxiety, Muscle relaxants, Sleep
    • Aids
  16. WHO Ladder Step Approach
    • Step 1
    • For mild pain (1-3 on a 0-10 scale)
    • Use of nonopioid analgesics/NSAIDS
    • With or without a coanalgesic

    • Step 2
    • If mild pain persists or increases or
    • Pain is moderate (4-6 on a 0-10 scale)
    • Use of a weak opioid (e.g. Codeine, tramadol) or a combination of opioid and nonopioid medicine (oxycodone with acetaminophen, hydrocodone with ibuprofen)
    • With or without coanalgesic

    • Step 3
    • Moderate pain that persists or increases
    • Pain is severe (7-10 on a 0-10 scale)
    • Strong opioids (e.g. Morphine, hydromorphone, fentanyl)
    • With or without a nonopioid & coanalgesic
  17. Nursing Interventions: Pharmacological
    • Nonopioid analgesics
    • 1) NSAIDs
    • a) Mild to moderate pain
    • b) Decrease inflammation and fever (antipyretic)
    • c) Ibuprofen
    • (1) s/e gastric irritation
    • d) Aspirin: inhibits platelet aggregation
    • (1) MI, non-hem CVA, DVT
    • (2) S/e: ecchymosis, prolonged bleeding

    • Nonopioid analgesics
    • 2) Acetominophen
    • a) Little anti-inflammatory effect
    • b) Analgesic and antipyretic
    • c) Few s/e; safest
    • d) Possible hepatotoxicity in ETOH and liver disease

    • Opioid analgesics
    • 1) Used for severe pain
    • 2) Potential problems
    • a) Respiratory depression: tx Narcan
    • b) Drug tolerance: tx increase dose or change route
    • c) Physical dependence: withdrawal sx if drug d/c’d; tx slowly decrease dose
  18. Opioid Side Effects
    • Constipation (fluids, fiber, exercise, stool softeners)
    • N&V (anti-emetics, change analgesic if needed)
    • Sedation –(tolerance develops in 3-5 days)- use sedation scale
    • Respiratory Depression (Narcan [narcotic antagonist], decrease dose)
    • Pruritis (cool packs, Benedryl, tolerance may develop)

    Urinary Retention (catheter, Narcan)
  19. Opioid analgesics: routes
    1) Oral

    a) Safe, steady analgesic level

    b) Preferred, unless rapid onset desired

    c) Mild to moderate pain

    2) Nasal

    a) Rich blood supply, rapid absorption

    b) Possible burning, stinging

    c) ex. Stadol
  20. Routes for Opiate Delivery
    • —Transdermal- relatively stable
    • drug level

    • —Rectal- good if
    • client can’t swallow

    • —SQ- injection or via
    • catheter & infusion pump

    • —IM- not best route,
    • variable absorption

    • —IV- bolus or
    • continuous on pump

    • —Intra-spinal- uses
    • less med for analgesia, less risk of sedation

    —Epidural analgesia

    —Intrathecal (subarachnoid)- CSF
  21. Pain in the Elderly
    • 1) Polypharmacy: risk of drug interactions
    • 2) Decreased distribution: decreased perfusion
    • 3) Decreased treatment: fear of confusion,
    • sedation, respiratory depression
    • 4) Increased risk of overtreatment: higher
    • peak effect, longer duration (metabolism)
  22. Addiction
    • Addiction: psychological dependence
    • 1)Craving med, self-destructive behavior to obtain drug
    • 2)Repeated requests for opioid injections
    • 3)Refusal to try oral medication
  23. Pain Assessment Acronym
    • O– onset
    • L– location
    • D– duration
    • C– characteristic
    • A– aggravating factors
    • R– radiation
    • T– treatment (what worked & did not)