Chapter 43 Pain Management NRS105320Collings Importance Pain management

Chapter 43 Pain Management NRS_105/320_Collings

Importance • Pain management is a primary nursing responsibility • Nurse have a legal and ethical duty to control/relieve pain • Pain relief is a basic human right • Patients need to know we CAN and WILL relieve their pain NRS_105/320_Collings

Why? • Effective pain management: – Improves quality of life – Reduces disability – Promotes early mobility and return to work – Results in less hospital / office visits – Reduces length of stay, complications – Reduces health care cost – Improves patient satisfaction NRS_105/320_Collings

Nature of Pain • • Physical Emotional Cognitive Subjective NRS_105/320_Collings

Physiology of Pain • Transduction • Thermal, chemical, mechanical stimulation • → electrical impulse in nerve fiber • Transmission • A fibers: sharp, localized, distinct sensation • C fibers: generalized, persistent sensation – E. g. Burn finger – spot pain → ache • Peripheral → spinal → brain NRS_105/320_Collings

Physiology of Pain • Perception – Brain interprets impulse, perceives as pain – Experience, memory, context, knowledge – Ascribes meaning to sensation • Modulation – Body response • Endogenous opiods, serotonin, norepinephrine, GABA • ↓ transmission of impulse, analgesic effect – These deplete over time with continued pain NRS_105/320_Collings

Gate-Control Theory of Pain • Gating mechanisms along the CNS – Can block transmission of impulses • Pain relief measures to close the gate – Light touch [effleurage] • Pain threshold – Level at which you feel pain • Genetic, learned, • Runner’s high, endogenous opiods • Individual – not transferrable! NRS_105/320_Collings

Physiological Response to Pain • Mild – moderate pain [1 -6] superficial → autonomic response [sympathetic]; • fight or flight, general adaptation • ↑HR, RR, B/P, BG, diaphoresis, peripheral vasoconstriction • Severe or deep [7 -10], visceral pain → parasympathetic response • ↓ HR, B/P, muscle tension, immobility, irreg resp • may cause harm – Physiologic response [VS] is short-term; – VS are not reliable pain indicators over time NRS_105/320_Collings

Behavioral responses to Pain • Dependent on context, meaning, culture, pain tolerance – It is supposed to hurt – Men don’t cry – I don’t want to be a complainer, bother • Nonverbal indicators – Body movements; restless or still, holding, guarding – Facial expression; grimace, frown, clenched teeth, posture, • Lack of expression of pain does not mean it isn’t there! NRS_105/320_Collings

Types of Pain • Acute pain – Protective, identifiable cause, short duration, limited tissue damage, ↓ emotional response – Causes harm by ↓ mobility, energy Goal is to control pain so patient can participate in recovery ↓ Pain → ↑Mobility → decreased complications, decreased length of stay NRS_105/320_Collings

Types of Pain • Chronic pain – Serves no purpose [not protective] – Lasts longer than anticipated – May or may not have an identifiable cause – Impacts every part of patient’s life – Depression, Suicide – Disability, isolation, energy drain, ADL’s • Pseudoaddiction: seeking pain relief – not drug-seeking NRS_105/320_Collings

Types of Pain • Cancer pain – May be acute or chronic, constant or episodic, mild to severe – Up to 90% of Ca pts have pain • Pain by inferred pathology – Known cause = characteristic pain [neuropathic] • Idiopathic pain – No known cause BUT still pain – “Excessive” pain for a condition NRS_105/320_Collings

Knowledge, Attitudes, and Beliefs • Subjective nature of pain – Pain is what the patient says it is, not what the nurse thinks it should be – Same procedure, different pain – Expectations, context, culture affect perception and expression of pain NRS_105/320_Collings

Knowledge, Attitudes, and Beliefs • Nurse’s Response to Pain • Bias – ‘I go to work with 5/10 pain every day’ – ‘Its only a minor surgery’ – ‘I had three kids and didn’t scream’ • Fallacies – Infants don’t feel pain like we do – Regular pain med use causes addiction – Older people all are in pain NRS_105/320_Collings

Factors Influencing Pain • Physiological – Age – interpretation/communication – Fatigue • increases pain, • sleep not sign pain is relieved – Genes • Pain threshold – Neurological function • Interpretation, communication, reflex NRS_105/320_Collings

Factors Influencing Pain • Social – Attention/ distraction – Previous experience • May increase or decrease tolerance – Family and social support • Spiritual – Meaning of pain, suffering – Support system NRS_105/320_Collings

Factors Influencing Pain • Psychological – Anxiety – Coping style • Control [PCA] • Cultural – – Meaning of pain Expression of pain Role in Family Ethnicity NRS_105/320_Collings

Assessment of Pain • Client’s expression of pain – Description is most valid indicator • Characteristics of pain – Onset and duration – Location – Intensity – Quality – Pattern NRS_105/320_Collings

Assessment of Pain • Characteristics of pain (cont'd) – – Relief measures Contributing symptoms Behavioral effects on the client Influences on ADLs • Client expectations – What pain level would allow you to function well? • [walk the hall, do ADL’s, resume job…] NRS_105/320_Collings

Assessment • Can we do a full assessment of pain when the client is in severe pain? • No! • Alleviate severe [7 -10] pain before talking it to death • Pain rated >7 needs immediate attention NRS_105/320_Collings

Nursing Diagnoses • • Anxiety Ineffective coping Fatigue Acute pain Chronic pain Ineffective role performance Disturbed sleep pattern NRS_105/320_Collings

Planning • Goals and outcomes – Client is using pain relief measures safely – Pain level reported at </=___ and congruent nonverbal behaviors seen – Demonstrate understanding of need to premedicate before activity – Splint abdomen with cough • Setting priorities – What is important for the client? What does he need to do? • Control pain enough to eat, sleep? Be mobile to prevent complications? Work? PT? Maintain dignity, relationships while dying? – Maslow: Pain relief is basic need NRS_105/320_Collings

Implementation: Health Promotion • Client education – Expectations, when to seek treatment – Preparation before pain • Holistic care – Whole self; physical, emotional, spiritual – Education, rest, exercise, nutrition, relationships NRS_105/320_Collings

Nonpharmacological Pain Relief • • Relaxation and guided imagery Distraction Biofeedback Cutaneous stimulation—massage, application of hot/cold, TENS • Herbals • Reducing painful stimuli and perception NRS_105/320_Collings

Controlling Painful Stimuli • Managing the client’s environment— bed, linens, temperature • Positioning • Changing wet clothes and dressings • Monitoring equipment, bandages, hot and cold applications • Preventing urinary retention and constipation NRS_105/320_Collings

Implementation Pain Management • Pharmacological pain relief • … Administer analgesics as ordered/ reassess pain in 30 minutes and hourly – Analgesics: NSAIDs and nonopioids, adjuvants – Patient-controlled analgesia (PCA) – Local analgesic infusion pump – Topical analgesics and anesthetics – Local and regional anesthetics NRS_105/320_Collings

Implementation Pain Management • Surgical interventions • Procedural pain management • Chronic and cancer pain management NRS_105/320_Collings

Implementation Pain Management • Barriers to effective pain management [pts, nurses, doctors, system…] – Fear of addiction - #1 barrier – Terms: • Dependence: physical adaptation resulting in withdrawal symptoms • tolerance: physical adaptation resulting in diminished drug effect over time • Addiction: impaired control over use, use despite harm • pseudoaddiction: drug seeking behavior to relieve undertreated pain NRS_105/320_Collings

Implementation Pain Management • Nursing implications for pain management – Accurate safe medication administration – Assess effectiveness and side effects – Patient education [families too] – Use the appropriate drug when given a choice – Treat pain before it gets severe NRS_105/320_Collings

Implementation: Restorative Care • Pain clinics • Palliative care • Hospices NRS_105/320_Collings

Evaluation • Effectiveness – Assess at peak of drug effect • [30 minutes IV, 1 hour PO] – Add complementary therapies for partial effect – Talk with M. D. about options if approach is consistently ineffective • Side effects • Document and communicate – Most effective relief NRS_105/320_Collings

Evaluation • Client expectations – Validate experience – Relieve the pain – Show you care • Did client achieve goal? – Walk hall w/o pain? – Pain < 3/10 all day [except with PT] – Able to return to work, enjoy visit, T, C, &DB? • Pain report congruent with nonverbal? NRS_105/320_Collings