Pain Lisa B Flatt RN MSN CHPN Definition

Pain Lisa B. Flatt, RN, MSN, CHPN

Definition Complex Subjective Psychological Biological Cultural Social factors WHAT THE PATIENT SAYS IT IS!!!!!

Types of Pain Acute Chronic Intermittent Intractable Malignant Neuropathic Phantom Radiating Remittent Episodic

Acute Pain Follows injury and goes away when it heals May be associated with autonomic nervous stimulation: TC, HTN, diaphoresis (sweat not to be confuse with sweet ), pallor, dryness Confirm pain prior to medicated

Chronic Pain Prolonged disease/dysfunction Intermittent, limited, persistent (>6 mo) Influences: environment, emotional

Three categories of chronic pain Chronic nonmalignant -– nonprogressive or healed tissue Chronic malignant --- cancer or progressive disease Chronic intractable pain --- ability to cope with chronic pain deteriorates

Areas of ‘suffering’ Physical Social Spiritual HOLISTIC CARE Environmental Psychosocial Physical Spiritual

Acute vs. Chronic Pain Acute Pain Trauma Surgery Fracture Chronic inflammation, bruising Procedural Phantom Chronic Pain Marriage lol Arthritis Malignancy/tumor back-chronic Non-malignant Neuropathy Phantom

Pain and comparison ACUTE Mild to severe Sympathetic Nervous System responses Increased: HR, RR, BP, diaphoretic, dilated pupils Subjective r/t tissue injury Resolves with healing Crying, rubbing area, holding area CHRONIC Mild to severe Parasympathetic Nervous System Normal VS Dry warm skin Pupils normal or dilated Does not always mention pain unless asked Appears withdrawn and depressed Pain behavior often absent

Physiology Descriptors/Categories Intractable; resistant to analgesia, advanced tumors Neuropathic; peripheral or CNS, may be tissue related Phantom; missing limb, spinal cord injury (some)

More categories Cutaneous – skin or SC tissue Deep somatic – tendon/blood vessels, nerves Visceral – internal organs

Radiation and Referred Radiating – extends from area of insult/injury outwards – UTI, kidney/back/urethra – chest pain/jaw/arm Referred pain – felt in an area that is actually not the source – chest pain (arteries/blood vessels/muscle); earache (right ear hurts, left ear has infection)

Pain Stimuli Stimulus Type Mechanical – trauma, tissue, blockage duct, tumor, spasms Thermal – heat and/or cold Chemical – tissue ischemia ( blocked artery) – muscle spasm Physiologic basis of pain Tissue damage – direct irritation of receptors (inflammation) – distention of duct – irritation on nerve endings – chemical stimuli – tissue destruction – thermosensititive – chemical (lactic acid, K, Mg, Na)

Gate Control Theory Nerve fibers carrying painful stimuli to spinal cord. Input can be modified at spinal cord level prior to going to the brain. Stops the sense of pain before it goes to the brain to be processed. Limited amount of pain stimuli the brain can handle at one time. Small fibers carry pain stimuli. Large fibers stimulate a non-noxious stimuli going through same gate (ice pack, pain meds) this inhibits and blocks the gate.

4 points to be modulated/reduced Peripheral site Spinal cord Brain stem Cerebral cortex

Shut out pain (neuromodulators) Mechanoreceptors -stimulation of fibers Endogenous opiods Electrical stimulation Opiods and morphine Normal and excessive sensory stimuli Cerebral cortex and thalamic inhibition

Pain in the… Threshold -Differing perceptions of pain, fairly uniform (sprain less painful than gall bladder attack) Tolerance – how much you can handle Neuromodulators (endorphin and enkephalin) – produced in brain, act like an opiate, bind to opiate receptor sites, increases pain threshold **released with fight or flight and excessive exercise**

Pain is…Psychological and Physical Cognitive Toddler- dramatic, carry on – perception, frustrated, intolerant, fearful Childbirth – acute, varies, helpless Emotional- anxiety, depression, stress, frustration, length of time/perceived time Myths- not always drug-seeking, aging means pain, pt not complaining they don’t have, admitting pain is a sign of weakness, unavoidable, deserved = bad person = sinned, resistant to med’s Suffering – physical, psychological, emotional or distress- chronic pain and never fully relieved ---alternative holistic methods

Pain Management Principles Acknowledge – accept-educatemedicate. Pharmacological and non-pharm Different types of med’s: NSAID’s, ASA, Opiods, etc. . Treat the pain before it becomes severe 0 -10 – treat when? 4 -5 – pt perception

Factors Influencing Pain Age Gender Culture Religion Physical condition at start Support Social Environment Financial

Assessment Methods to measure/describe pain Wong/Baker Faces Numeric WILDA OPQRST COLDERRA

Wong-Baker Scales Happy face to sad face with sweat/tears and blood Adult patient 0 -10 Child faces 0 -5

WILDA W=word describes pain (sharp, stabbing, throbbing, aching) Intensity – 0 -10 or faces Location – where is it Duration- how long does it last Aggravating and alleviating factors – what makes it worse or better

OPQRST Other s/s Provocative/palliative – what makes it worse or better Quality – description Region of pain Severityof pain Temporal/timing

COLDERRA Character- sharp, burning Onset – when did it start Location – where it is Duration Exacerbation – makes it worse Relief Radiation Associated s/s

Assess those things we always talk about Age Sex Emotional Blah blah

Assess Physical Side Facial expression VS Positioning Guarding Striking at nurse if she touches area that hurts Diaphoresis Labs

Analyze Synthesis of the assessment Collaborative approach to other disciplines findings Determine a nursing diagnosis Acute vs. chronic

Planning Determine desired outcomes Step by step goal strategy Patient centered Realistic

SMART ER Specific Measurable Attainable and action based Realistic Timebound Evaluation Reassessment

WHO (world health organization) 3 – step analgesic ladder approach Nursing intervention – backrubs, massage, lotion, ice and heat, distraction, (hammer…ignoring) Environmental – noise Listening ******Patient Bill of Rights******* Treat pain to the best of our ability and right to treatment, refuse treatment, pt centered decision making, confidentiality

Implementation Initiate and complete plan Work toward goal Nursing measures/massages Pain society usage and guidelines CDC and NIH website on pain

Physical modifications Accupressure – Chinese healing system, finger pressure at certain points, ointments, linaments, massaging TENS, transcutaneous electrical nerve stimulation – prickling sensation small stimulation ( Gate control theory)

Environmental Modification Stairs Room temp Ventilation Fans Assistive devices

Psychological Modifications Cognitive behavioral therapies – model desired behaviors, learning theories Biofeedback theory – teach to relax, calm, reproduce condition of happiness Meditation – ‘getting out of oneself’ This is not prayer.

WHO 3 step Ladder Non-opiod analygesics +/- an adjuvant. Moderate ain persists go to Opioid admin +/- non-opioid +/- adjuvant Opioid for moderate to severe pain +/- non opioid +/- adjuvant. Used for the relief of cancer pain. Adjuvants med’s – enhance analgesia of opioids, treat symptoms that exacerbate pain/provide independent analgesia for types of pain. Corticosteroids, antidepressants, hypnotics.

Medications/Sedatives NSAIDS – naproxen, motrin, advil, indomethacin, ASA, Acetaminophen Opioids agonists – morphine, codeine, hydromorphone, oxycodone, oxymorphine, meperidine, fentanyl, methadone. Produce analgesia by binding to opioid receptors. Opioids antagonist – naloxone, reverses depressant effect of opioids, treatm opioid OD Opioid agonist-antagonists – pentazocine, nalphybine, butorphanol, dezocine, bind only to certain sites Topical drugs localized pain

PCA Patient controlled analgesia Beneficial psychologically Decreases dependency Decreases anxiety Patient part of their treatment plan

Evaluation Assess verbal and nonverbal response Response to pain reduction methods VS Pain scale

MYTHS per the book Expected with age Chronic pain = hypochondriac Infants feel no pain No complaining no pain Pain is unavoidable part of recovery Admission is a sign of weakness Drug addiction Using drug at the start of pain will make it not work as good later Severe pain is only seen in people who are melodramatic and/or hysterical