Ati Chapter 4: Pain Management

Front 1

Overview

Back 1

1. Effective pain management includes the use of pharmacological and nonpharmacological pain management therapies. Invasive therapies such as nerve ablation may be appropriate for intractable cancer-related pain.

2. Clients have a right to adequate assessment and management of pain. Nurses are accountable for the assessment of pain. The nurse's role is that of an advocate and educator for effective pain management.

3. Nurses have a priority responsibility for the continual assessment of the client's pain level and to provide individualized interventions. They should assess the effectiveness of the interventions 30 to 60 min after implementation.

4. Assessment challenges may occur with clients who are cognitively impaired or on a ventilator.

5. Undertreatment of pain is a serious health care problem. Consequences of undertreatment of pain include physiological and psychological components.

- Acute/chronic pain can cause anxiety, fear, and depression.

- Poorly managed acute pain may lead to chronic pain syndrome.

Front 2

Physiology of Pain

Back 2

1. Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers.

2. Transmission occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it.

3. The pain threshold is the point at which a person feels pain.

4. Pain tolerance is the amount of pain a person is willing to bear.

5. Perception or awareness of pain occurs in various areas of the brain, with influences from though and emotional processes.

6. Modulation occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.

Front 3

Substances that increase pain transmission and cause an inflammatory response:

Back 3

1. Substance P

2. Prostaglandins

3. Bradykinin

4. Histamine

Front 4

Substances that decrease pain transmission and produce analgesia:

Back 4

1. Serotonin

2. Endorphins

Front 5

Pain Categories:

Back 5

1. Acute Pain

2. Chronic Pain

3. Nociceptive Pain

4. Neuropathic Pain

Front 6

Acute Pain:

Back 6

1. Acute pain is protective, temporary, usually self-limiting, and resolves with tissue healing.

2. Physiological responses (sympathetic nervous system) are fight-or-flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tone).

3. Behavioral responses include grimacing, moaning, flinching, and guarding.

4. Interventions include treatment of the underlying problem.

Front 7

Chronic Pain:

Back 7

1. Chronic pain is not protective. It is ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing.

2. Physiological responses do not usually alter vital signs, but clients may have depression, fatigue, and a decreased level of functioning.

3. Psychosocial implications may lead to disability.

4. Chronic pain may not have a known cause, and it may not respond to interventions.

5. Management aims at symptomatic relief.

6. Chronic pain can be malignant or nonmalignant.

Front 8

Nociceptive Pain:

Back 8

1. Nociceptive pain arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems.

2. It is usually throbbing, aching, and localized.

3. This pain typically responds to opioids adn nonopioid medications.

4. Types of nociceptive pain include:

- Somatic: in bones, joints, muscles, skin, or connective tissues.

- Visceral: in internal organs such as the stomach or intestines. It can cause referred pain in other body locations separate from the stimulus.

- Cutaneous: in the skin or subcutaneous tissue.

Front 9

Neuropathic Pain:

Back 9

1. Neuropathic pain arises form abnormal or damaged pain nerves.

2. It includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.

3. Neuropathic pain is usually intense, shooting, burning, or described as "pins and needles."

4. This pain typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).

Front 10

Risk factors for undertreatment of pain include the following:

Back 10

1. Cultural and societal attitudes

2. Lack of knowledge

3. Fear of addiction

4. Exaggerated fear of respiratory depression

Front 11

Populations at risk for undertreatment of pain include the following:

Back 11

1. Infants

2. Children

3. Older adults

4. Clients who have substance use disorder

Front 12

Causes of acute and chronic pain include the following:

Back 12

1. Trauma

2. Surgery

3. Cancer

4. Arthritis

5. Fibromyalgia

6. Neuropathy

7. Diagnostic or treatment procedures (injection, intubation, radiation)

Front 13

Factors that affect the pain experience include the following:

Back 13

1. Age

- Infants cannot verbalize or understand their pain.

- Older adult clients may have multiple pathologies that cause pain and limit function.

2. Fatigue, which can increase sensitivity to pain.

3. Genetic sensitivity, which can increase or decrease pain tolerance.

4. Cognitive function.

- Clients who are cognitively impaired may not be able to report pain or report it accurately.

5. Prior experiences, which can increase or decrease sensitivity depending on whether clients obtained adequate relief.

6. Anxiety and fear, which can increase sensitivity to pain.

7. Support systems that are present and can decrease sensitivity to pain.

8. Culture, which may influence how clients express pain or the meaning they give to pain.

Front 14

Assessment/Data Collection:

Back 14

According to noted pain experts Margo McCaffery and Chris Pasero, pain is whatever the person experiencing it says it is, and it exists whenever the person says it does.

The client's report of pain is the most reliable diagnostic measure of pain.

Self-report using standardized pain scales is useful for clients over the age of 7 years.

Specialized pain scales are available for use with younger children.

Assess and document the pain (the 5th vital sign) frequently.

Use a symptom analysis to obtain subjective data.

Front 15

Factors to consider when assessing pain:

Back 15

1. Location

2. Quality - how it feels

3. Intensity, strength, and severity (pain scale now, worst, best, etc)

4.Timing - onset, duration, frequency

5. Setting - how it affects ADLs

6. Associated symptoms

7. Aggravating/relieving factors

Front 16

Objective data

Back 16

Behaviors complement self-report and assist in pain assessment or nonverbal clients.

- facial expression, body movements

- moaning, crying

- decreased attention span

Front 17

Cutaneous (skin) stimulation (Nonpharmacological Pain Management)

Back 17

transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, and massage

- interruption of pain pathways

- cold for inflammation

- heat to increase blood flow and to reduce stiffness

Front 18

Distraction(Nonpharmacological Pain Management)

Back 18

- ambulation

- deep breathing

- visitors

- television

- music

Front 19

Relaxation(Nonpharmacological Pain Management)

Back 19

- meditation

- yoga

- progressive muscle relaxation

Front 20

Imagery(Nonpharmacological Pain Management)

Back 20

- focusing on a pleasant thought to divert focus

- requires an ability to concentrate

Front 21

Acupuncture(Nonpharmacological Pain Management)

Back 21

vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points

Front 22

Reduction(Nonpharmacological Pain Management)

Back 22

Reduction of pain stimuli in the environment

Front 23

Elevation of edematous extremities(Nonpharmacological Pain Management)

Back 23

Elevation of edematous extremities to promote venous return and decrease swelling

Front 24

Analgesics (Pharmacological Interventions)

Back 24

the mainstay for relieving pain.

The three classes of analgesics are nonopioids, opioids, and adjuvants.

Front 25

Nonopioid analgesics

Back 25

are appropriate for treating mild to moderate pain (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs])

Front 26

Opioid analgesics

Back 26

are appropriate for treating moderate to severe pain (postoperative pain, MI pain, cancer pain)

Front 27

Adverse effects of opioid use:

Back 27

1. Constipation

2. Orthostatic hypotention

3. Urinary retention

4. Nausea/vomiting

5. Sedation

6. Respiratory depression

Front 28

Adjuvant analgesics

Back 28

enhance the effects of nonopioids, help alleviate other symptoms that aggravate pain (depression, seizure, inflammation), and are useful for treating neuropathic pain.

Front 29

Patient-controlled analgesia (PCA)

Back 29

a medication delivery system that allows clients to self-administer sage doses of opioids

Front 30

Other strategies for effective pain management include the following:

Back 30

1. Taking a proactive approach by giving analgesics before pain becomes too sever. It takes less medication to prevent pain than to treat pain

2. Instructing clients to report developing or recurrent pain and not wait until pain is severe (for PRN pain medication)

3. Explaining misconceptions about pain.

4. Helping clients reduce fear and anxiety.

5. Creating a treatment plan that includes both nonpharmacological and pharmacological pain-relief measures.

Front 31

Strategies specific for relieving chronic pain include the above interventions, plus:

Back 31

1. Administering long-acting or controlled-release opioid analgesics

2. Administering analgesics around the clock rather than PRN.

Front 32

Undertreatment of pain (Complication)

Back 32

a serious complication and may lead to increased anxiety with acute pain and depression with chronic pain.

Front 33

Sedation, respiratory depression and coma (Complication)

Back 33

can occur as a result of overdosing.

Sedation always precedes respiratory depression.