Chapter 12: Pain Management

Front 1

Pain

Back 1

- most common reason for seeking health care

- the 5th vital sign

- Most used definition: "Pain is whatever a person says it is, existing whenever the experiencing person says it does"

Front 2

Acute Pain:

Back 2

Usually short duration (less than 6 months)

Will resolve with normal healing

Front 3

Chronic Pain:

Back 3

Sub-categorized as being of cancer or non-cancer origin

Can be time limited or persist throughout the course of a person's life

1. Peripheral neuropathy (tingling and burning) from diabetes

2. Back or neck pain (neuropathy)

3. Osteoarthritis (bone on bone and meds cannot get there)

Front 4

Cancer-related Pain:

Back 4

Need to know how cancer pain is treated -

Front 5

The time frame of pain that can be classified as chronic:

Back 5

longer than 6 months (Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Chronic pain may be defined as pain that lasts for 6 months or longer, although 6 months is an arbitrary period for differentiating between acute and chronic pain.)

Front 6

Nociceptors (pain receptors)

Back 6

Considered to be normal functioning of physiological systems that lead to the perception of noxious stimuli (tissue injury) as being painful.

Front 7

Neuropathic (pathophysiologic) pain

Back 7

is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the peripheral or central nervous system or both.

Front 8

Transmission of pain

Back 8

nociception

Front 9

Chemical substances

Back 9

Prostaglandins (increase sensitivity of pain receptors)

Endorphins, enkephalins (suppress pain reception)

Front 10

Physiological Processes

Back 10

normal processing of stimuli that damages tissues or has the potential to do so if prolonged; can be somatic or visceral

Front 11

Somatic Pain:

Back 11

Arises from bone joint, muscle, skin or connective tissue.

It is usually described as aching or throbbing in quality and is well located.

Front 12

Visceral Pain:

Back 12

Arises from visceral organs, such as the GI tract and pancreas.

Maybe be subdivided: tumor involvement or obstruction

Front 13

Abnormal processing of sensory input by the peripheral or central nervous system or both (NERVE RELATED)

Back 13

1. Centrally Generated Pain

2. Peripherally Generated Pain

Front 14

Pharmacologic Treatment

Back 14

Adjuvant analgesic agents, such as antidepressants, anticonvulsants, and local anesthetics, but there is a wide variability in terms of efficacy and adverse-effect profiles.

Front 15

Endorphins do not represent the same mechanism of pain relief as nonnarcotic analgesics.

Back 15

Endorphins release inhibits the transmission of painful impulses.

They are endogenous neurotransmitters structurally similar to opioids.

They are found in heavy concentration in the central nervous system.

Front 16

Opioid tolerance

Back 16

(need more meds to get relief):

Front 17

Factors that influence pain response:

Back 17

1. past experience - determines how they rate their pain

2. anxiety

3. depression

4. culture - some cultures are taught to control severe pain differently

5. age

6. gender - men don't like being told what to do; tell them you're there to work with them to control pain

Front 18

Effects of Pain:

Back 18

1. Sleep deprivation

2. Acute pain

- Can affect respiratory, cardiovascular, endocrine, immune systems

- When would a nurse provide teaching for a patient who was going for a lobectomy? Before; so they know what to expect when they come back; take deep breaths beforehand and reassess after

- Stress response increases metabolic rate, cardiac output, risk for physiologic disorders

- If you have a patient stressed preop- what can the nurse do to help decrease pain with a patient who is stressed?

3. Chronic Pain

- depression (not everyone has an emotional disorder, but everyone does have emotional distress)

- increased disability

- suppression of immune function

- How would immune function be affected by pain? -lowers immune function

Front 19

Location:

Back 19

"state" or point to area(s) of pain

Front 20

Intensity:

Back 20

rate on a valid pain assessment tool

(know tools available)

Front 21

Quality:

Back 21

descriptors such as "sharp, shooting, burning" describes feeling of pain

Front 22

Onset and Duration:

Back 22

when pain starts and if constant or intermittent

Front 23

Aggravating/alleviating factors:

Back 23

ask patient what makes pain worse and/or better

Front 24

Effects of pain on function and quality of life:

Back 24

ask patient how pain affects their life if pain persists past acute pain timeframe

Front 25

Comfort-Function:

Back 25

(pain intensity goals):

Acute pain - short term functional goal

Chronic pain - perform ADLs with reasonable ease

Front 26

Personal meaning

Back 26

patients interpretation

Front 27

Pain behaviors:

Back 27

grimacing, moaning, slow movement, refusal to move, crying

Front 28

Patients who are unable to report their pain:

Back 28

are at a higher risk for under-treated pain than those who can report

(This includes: cognitively impaired, critically ill, comatose or imminently dying.

REMEMBER: Cognitively impaired is NOT the same as NON-VERBAL.

Front 29

Pain Intensity Scales:

Back 29

Front 30

Opioid analgesics:

Back 30

act on the Central Nervous System to inhibit activity of ascending nociceptive pathways

Front 31

NSAIDS

Back 31

decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)

Front 32

Local anesthetics

Back 32

block nerve conduction when applied to nerve fibers

Front 33

Pain Relief Interventions - Pharmacologic

Back 33

1. balanced anesthesia

2. "PRN" medications

3. routine administration: around the clock (ATC) or preventive approach (need to know when to use)

4. PCA: patient-controlled analgesia (Know and understand patient teaching [morphine pump])

5. local anesthetics

6. topicals, patches (when would these be used?)

7. intraspinal administration

Front 34

Routes to administer pain medication:

Back 34

1. oral route is preferred route of analgesic administration and should be used whenever feasible because it is generally the least expensive, best tolerated, and easiest to administer

2. other routes: transdermal, rectal, subcutaneous, intravenous, intramuscular

3. intraspinal include epidural, intrathecal, and spinall

(You will be given questions regarding pain relief and will need to decide which route is best based upon the situation in the question)

Front 35

Nonopioid analgesic agents: acetaminophen and NSAIDS

Back 35

Used for mild-mod nociceptive pain. Unless contraindicated, all surgical patients should routinely be given scheduled throughout post-operative period.

Front 36

Opioid Analgesic Agents: Morphine, hydromorphone, fentanyl, and oxycodone

Back 36

Often combined with nonopioids, used for mild-mod acute pain.

Front 37

Adjuvant analgesic agents: (co-analgesic agents)

Back 37

Agents that would not be thought of as a first line for pain. Local anesthetics, some anticonvulsants and antidepressants.

Front 38

Maximum daily dose of acetaminophen allowed and why:

Back 38

3 grams

Front 39

1. Efficacy

2. Adverse Effects

(tell patient in this order)

Back 39

1. Efficacy - the extent to which a drug or another treatment "works" and can produce the effect in question - analgesia in this context

2. Adverse Effects - an undesired harmful effect resulting from a medication or other intervention such as surgery. An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect.

Front 40

Adverse Effects of Analgesic Agents:

Back 40

Respiratory depression - know minimal respirations and what to do if respiratory depression occurs. (minimum = 10 respirations)

Sedation - is sedation a "bad thing"? - NO

Nausea, vomiting - patients will say they are "allergic" when really a side effect

Constipation

Pruritis - Easiest way to stop itching is _____?

(KNOW HOW TO TREAT EACH OF THESE TO ENSURE EFFICACY OF MEDICATION AND MINIMIZATION OF ADVERSE EFFECTS. WHEN WOULD YOU NOT TITRATE ANALGESIC AGENT?)

Front 41

Opioid Tolerance and Addiction

Back 41

- maximum safe opioid dosage must be individually assessed

- tolerance develops in all patients who take opioids for prolonged periods

- with tolerance, increased usage needed to effect pain relief

- dependence occurs with tolerance, physical symptoms occur when opioid is discontinued

- addiction: behavioral patterns characterized by need to take drug for psychic effects

- addiction from therapeutic use of opioid is negligible

(KNOW THE DIFFERENCE BETWEEN DEPENDENCE, TOLERANCE, AND ADDICTION)

Front 42

Gerontologic Considerations

Back 42

- more likely to have adverse drug effects, drug interactions

- increased likelihood of chronic illness

- may need to have more time between doses of medication due to decreased excretion, metabolism related to aging changes

Front 43

Nonpharmacologic Interventions

Back 43

- cutaneous stimulation, massage

- thermal therapies (not used if patient has no feeling - can't tell if it's burning them)

- transcutaneous electrical nerve stimulation

- distraction

- relaxation techniques

- guided imagery

- hypnosis

- music therapy

- alternative therapies

(In what instances would these techniques be used and why?)

Front 44

Nursing Process Framework for Pain Management:

Back 44

- identify goals for pain management

- establish nurse-patient relationship, teaching

- provide physical care

- manage anxiety related to pain

- evaluate pain management strategies

- (REVIEW CAREPLANS)

Front 45

Nursing Implications of Pain Management:

Back 45

- requires collaboration

- share common goals

- share common knowledge base

- share common language with regard to the analgesics and non-pharmacologic methods used to manage pain

Front 46

Nursing Diagnosis: Pain

Back 46

- Goal (set with patient/family)

- Interventions

- Rationale

- Expected Outcomes

- Reevaluation

Goal should be realistic, patient centered and should be reevaluated after each intervention. This is the most important, most often used nursing diagnosis by all nursing students.