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Nursing considerations for pain
- Pain is a protective mechanism
- -Can continue long after the tissue damage is repaired
- -Serves no useful purpose
- -Can result in chronic pain BUT if no mechanism in place to identify pain then (ie pain has no obvious cause), if left uninvestigated it can lead to...
- --extensive tissue damage
- --more disability, morbidity and mortality
Things to know about Pain Threshold
Varies from one individual to another related to physiologic and psychosocial factors
- Psychosocial factors
- cultural background, values, environment, past pain experiences, support persons, anxiety/stress,locus of control
- Physiologic factors
- age, gender, intactness of the CNS, physical pain stimulus itself, fatigue
Reactions to pain
- Physiologic Response
- Involuntary responses: withdraw from source of pain, fetal position, pressure on site (gate control)
- Sympathetic response comes first, but as pain continues the parasympathetic predominates
- May actually precipitate a shock-like state
- Behavioral Response
- Related to pain tolerance
- Clenching teeth, holding painful part, bending over, grimacing, tensing muscles, crying, moaning, calling nurse often
Principles of Pain Assessment
- ASK about pain
- Patient’s self report is primary source (even for cognitively impaired)
- Use rating scales
- -Document at regular intervals and with changes in symptoms and interventions
- -Teach patients and families to use
- -Be sure to ask what the acceptable level of discomfort is
ABC's of Pain
- Ask. Every 2 hrs with documentation
- Chose appriopriate pain control option
- Deliver in timely fashion
- Empower pts and their families.
- Enable pts to control their course to the greatest extent possible.
- Medication used primarily for other indications--but also produce pain relief
- Can be used in conjunction with opioids, or as primary therapy
- Especially helpful for neuropathic and bone pain, ie NSAIDS, antidepressants, anticonvulsants, benzodiazapenes, muscle relaxants, local anesthetics
- In many ways, adjuvants are the ideal Rx for analgesia.
Pt controled analgesics (PCA pumps)
- Less fluctuations in analgesia level
- Less total drug requirements
- Less sedation and nausea due to less opioid
- Improved post-op pulmonary function --> decreased chance of postop pneumonia.
- Earlier ambulation
- Patient control of analgesia with less anxiety
- Patient preference over IM injections
- Less nocturnal awakening
- Less cost
- Increased patient satisfaction
- Reduced hospitalization
- Patient Controlled Analgesia
- Refers to a process
- Uses a computerized pump connected to IV to administer Rx. Has cap on times/hr can be activated.
Important points concering PCA
- Prescribed dose (Demand bolus)
- Dose interval (usually 6-8 minutes)
- Lockout interval (1 hour or 4 hours)
- If attempts to activate are 2x # of doses prescribed –need to request an increase in dose.
- Two RN’s verify PCA settings when working with narcatics.
- Initial PCA set-up
- -At the beginning of each shift
- -Upon transfer
- -Change of order (rate, mode, lockout or medication)
Pt teaching points with PCAs
- Discuss pain experience with patient
- Demonstrate PCA pump usage
- Describe safety features of PCA
- Discuss potential for adverse effects
- NO ONE other than the patient should activate the PCA pump
- Encourage communication about pain
Stuff nurses should know about PCAs
- Monitor and document respirations, sedation scale and pain intensity q 1 hour x 4, then q 2h x 4, then q 4h
- Initiate the “stir-up regimen” (shake'em'n'wake'em) if R (respirations) are 6-8/minute and/or sedation scale is 2
- Administer Narcan (opiod antidote) if R < 6 --> to neutrilization of opiod and pt will be in lots of pain.
- If pulse ox < 89, administer oxygen
PCA pt selection
- Must be able to understand concept and physically able and willing to follow instructions
- Infants and young children: must be assessed for ability to operate and understanding.
- Confused older adults: ditto
- Obesity: unpredictable metabolism of narcotics
- Asthma: Opiods disrupt sleep, so no.
- Sleep apnea: ditto
- Taking other drugs that would potentiate opioids, ie muscle relaxants, antiemetics, sleeping meds
University of Michigan Sedation Scale
- 0 Awake and alert
- 1 Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound
- 2 Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation or simple verbal command
- 3 Deep sedation: deep sleep, arousable only with deep or significant physical simulation
- 4 Unarousable
- 5 Patient is sleeping. If you're there to assess, you MUST assess. Can still assess respiration, HR, rousability (have to know if they can be roused).
Epidural Pain Control
- Catheter placed in the epidural (in spine) space in which either bolus or continuous medications may be administered for pain control. Blocks pain from that point down.
- Nurse must:
- Monitor site
- Check infusion rate
- Monitor for desired effect
- Monitor for potential complications, ie epidural analgesia. Expect pt to have loss of sensation everywhere distal to site of infusion
Potential complications with epidural analgesia
- Urine Retention:
- -Monitor I and O
- -Palpate for bladder distention, just above pubis.
- -Provide for privacy
- -Use nursing measures as appropriate, ie peppermint oil relaxes sphincter muscles, move to urination position over bed pan.
- Be alert for S and S (signs and symptoms)
- Use comfort measures like:
- -soft linen cool, light clothing
- -Assess for potential allergic reaction
- -Increased temp, dyspnea, edema, itching
Potential complications with epidural analgesia and
- Possible causes:
- Insufficient dose of analgesia
- Displaced catheter
- Kinked or disconnected tubing
- Catheter placement below site of pain innervation
- Increase in patient’s activity
- Assessment Criteria
What is the epidural pain assessment?
- Pain level?
- Note site and quality of pain
- Check for leakage at insertion site --> severe HA.
- Look for any obvious breaks, knots or kinks
Epidural complications, Spinal HA
- Increase fluid intake
- Keep flat for 12-14 hours
- Anesthesiologist may do “autologous blood patch.” Small amount of blood taken from pt and inserted through epidural. to plug leak.
What is the main benefit of using opioid analgesics?
Relieves pain without loss of consciousness
What is an opioid?
- Derived from opium
- similar to morhphine
- Mu: Mediates central analgesia, euphoria, respiratory depression, and physical dependence (primary site of stimulation with opioids)
- Kappa: Mediate spinal analgesia, miosis, sedation, disorientation and appetite regulation
- Delta: Both spinal and in brain structure; primary receptors for endogenous endorphins
SnSs of Opioid Physical Dependence
- Abstinence syndrome occurs if drug abruptly stopped
- Abstinence syndrome is dependent on
- -Half-life of drug
- -Degree of physical dependence
- Adverse Effects
- "feeling sick"
- can actually reach shock-like state.
- Classic triad (toxic levels will depend on how naive/wise pt is to Rx)
- -Respiratory depression
- -Pinpoint pupils
- Ventilatory support when R depression gets too low.
- Opioid antagonists like
- -Naloxone (Narcan)
- -Nalmefene (Revex)
IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:
- D/C the PCA – or other dose forms of Opioid
- D/C all other infusions that could be contributing to sedation
- Maintain IV site
- Attempt to rouse the patient
- Call Rapid Response Team (group of nurses, ER Dr., respiritory therapist, to advise or assist with pt.)
- If apneic: administer bag & mask ventilation with 100% oxygen
- Capnography is used in many facilities
- -Co2 levels > 45% cause for concernIf breathing: maintain airway, monitor oxygen saturations and capnography and administer oxygen via face mask at 8 L/min
- Check circulation. If pulseless: commence chest compressions
- Be prepared to administer naloxone if opioid toxicity is suspected
5 must do steps for IV Narcotis
- 1. obtain an accurate Hx of all medicaiton taken in the last 6 months
- -Time for alst doses of Rx in the last 24 hrs.
- 2. Use smaller amount and titrate for effect instead of giving a rapid bolus of the total amount the physician will allow to be given.
- 3. Know which pt are at high risk for problems
- -pt with allergies
- -Hx of prior use
- -hypotensivion, dehydration, liver and kidney disease (all because narcs will not circulate well.)
- 4. Prevent falls.
- 5. Have analgesic reversal Rx readily available. (look for narcan)