1. Pain Management
C. Calzolari
2014

2. What is Pain? Pain is subjective.
Pain is a multidimensional experience
Pain is whatever the patient says it is.
Nurses most forego their own values and experience of pain and focus on the patient’s experience of pain

3. Why Do We Experience Pain?
It is protective. How?
It is a signal. What?

4. Cause of Pain
Nociceptive pain(pain receptors) – most common. Respond to stimulation.
Visceral – organs , linings of cavities
Somatic – Skin, muscles, bones, connective tissue
Neuropathic pain – complex and often chronic.
Nociceptive pain may occur due to trauma, surgery or inflammation.
Neuropathic pain – nerve injury from DM, CVA, tumor, viral infection, meds such as chemotherapy.
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5. Classification of Pain
Acute
Can Identify Cause
Temporary
Activates SNS BP, HR, RR, more blood to brain, dilates pupils
Acute pain – short duration, rapid onset. May last up to 6 mos.
Mostly associated with injury or surgery.
IT IS PROTECTIVE in nature

6. Classification of Pain
Chronic
Longer Duration – lasts beyond healing phase
Interferes with ADLs
Remissions & exacerbations
Stimulates PNS or normal Vital Signs
Affective Responses
Lasts 6 mos or longer
Can be related to progressive or chronic disorders.
Neuropathic pain is an example.
Affective Responses – anxiety, depression, anger, fear, exhaustion, hopelessness, irritability
Why? Lack of purpose of pain and uncertainty of duration

7. Classification of Pain
Intractable
Chronic
Resistant to pain relief
Multi-Disciplinary Approach

8. Descriptions of Pain
Based on site, cause, duration and quality.

9. Site of Pain Cutaneous or superficial pain Visceral pain
Deep somatic pain
Radiating pain
Referred pain
Phantom pain
Psychogenic pain
Cutaneous or superficial pain- arises in the skin or subq tissue example touch something hot and feel pain.
Visceral pain – stimulation of deep internal pain receptors – abdominal cavity, cranium, thorax. Example – menstrual cramps, labor pain, gi disorders.
Deep somatic pain- originates in the ligaments, tendons, nerves, blood vessels, bones. . Examples: fractures, arthritis. More diffuse lasts longer.
Radiating pain – extends to other areas – sore throat pain may expand to hands and ears.
Referred pain – occurs in area distant from original site.. Chest pain may be felt in right or left hand, or jaw.
Phantom pain – pain from site that was surgically removed. Person may perceive burning, itching, deep pain in that area.
Psychogenic pain – arises from mind – no physical cause can be identified.

10. Duration of Pain Acute Chronic Intractable
Acute pain – short duration, rapid onset. May last up to 6 mos.
Most ly associated with injury or surgery.
IT IS PROTECTIVE in nature.
Chronic pain – lasts 6 mos or longer. Interferes with daily activities.
Can be related to progressive disorder, or

11. Take the Vocabulary Quiz

12. Application
How would you classify the pain that the following patients are experiencing?
● A patient with metastatic cancer
Answer:
Chronic pain

13. A patient with back pain that was the result of an automobile injury a year ago
Answer:
Chronic pain, potentially neuropathic pain

14. A patient with a broken leg
Answer:
Acute deep somatic pain

15. Quality of Pain
Only the patient can describe the quality of their pain.
They may use words such as:
Sharp
Dull
Throbbing
Stabbing
Burning
Ripping
Tingling
Intermittent
Constant
Mild
Intense
Severe
Sharp-
Dull- mild, difficult to describe
Throbbing-
Stabbing-
Burning-
Ripping-
Tingling-

16. Factors Which Influence Pain
Emotions
Developmental Stage
Communication Impairments
Pain Threshold
Culture

17. Factors Which Influence Pain
Emotions:
Anxiety
Fear
Guilt
Anger
Helplessness
Exhaustion
Irritability
Depression
A person’s emotional response to pain is affected by previous pain experiences. Think of a child who received a shot at a MD’s office.

18. Factors Which Influence Pain
Developmental Stage:
Infants and children
Adults
Older Adults

19. Factors Which Influence Pain
Communication Impairment:
Those who have had a CVA, speak another language or are cognitively impaired.
You will need to observe nonverbal cues for pain.
Facial expressions
Vocalizations
Changes in physical activity
Change in vital signs
Change in routines
Mental status changes

20. Factors Which Influence Pain
Culture:
Involves the patient’s expression of pain, the family’s response to the situation and the nurse’s attitude.
William & Hopper: Box 10.2 – page

21. Factors Which Influence Pain
Pain Threshold:
The point at which the receptors in the frontal cortex recognizes and defines a stimulus as pain.
Varies from person to person.
Pain Tolerance:
The duration or intensity of pain that a person is willing to endure.

22. Pharmacological Pain Relief Measures
Analgesics
Nonopioids – acetaminophen, salicylates, NSAIDS and COX -2 inhibitors
Opioids - morphine, codeine, hydromorphone, methadone, meperdine, oxycodone, sublimaze patch

23. Analgesics
At the site of an injury, the body produces prostaglandins, which increase pain sensitivity. Aspirin prevents the production of prostaglandins. Acetaminophen is believed to block pain impulses in the brain itself. Local anesthetics intercept pain signals traveling up the nerve. Opiate drugs, which act primarily in the central nervous system, block the transfer of pain signals from the spinal cord to the brain.
Illustration by Lydia V. Kibiuk, Baltimore, MD

24. Routes of Administration
Oral – preferred route
Nasal
Transdermal
Rectal
Subcutaneous
Intramuscular – least preferred
Intravenous
PCA – patient controlled analgesia
Intraspinal analgesics

25. Adverse Affects of Pain Medications
Nonopioids – GIB, inhibition of platelet aggregation, renal insufficiency, hypersensitive reactions in persons with asthma, liver necrosis with OD of Tylenol.
Opioids – respiratory depression, hypotension, drowsiness, constipation, nausea, vomiting, constricted pupils.

26. Analgesic Adjuvants
These medications may potentiate the effects of opioids or nonopioids.
Examples: steroids, benzodiazepines, tricyclic antidepressants, and anticonvulsants.
Able to use less opioid doses when used with these adjuvants.

27. Antidote
Narcan (naloxone)- counteracts the effect of opioids.

28. Interpreting MD Orders
Morphine Sulfate 2 mg. IM q 4 hours prn for surgical pain.
Percocet one tab po q 6 hours prn for foot pain
Duragesic patch 25mcg/hr transdermal q 72 hours at 0800.
Oxycontin 20 mg. po BID
OxyIR 5 mg. po q 6 hours prn for breakthrough pain

29. Evaluation
Always re-assess your patient after administering pain medications.
At what time interval?

30. Special Considerations
The Elderly
The Person with Substance Abuse or Addiction
Unrelieved Pain

31. Nonpharmacological Pain Relief Measures
Cutaneous Stimulation
TENS – Trancutaneous Electrical Nerve Stimulator
Acupuncture
Acupressure
Massage
Hot and Cold TX

32. Transelectrical Nerve Stimulation

33. TENS

34. Acupuncture

35. Acupressure
Based on the same principles as acupuncture, (but using pressure instead of needles), acupressure works by stimulating specific reflex points located along the lines of energy which run through the body, called meridians.

36. Massage

37. Hot & Cold Therapies

38. Nonpharmacological Pain Relief Measures
Surgery
Immobilization
Splints, slings, braces
Cognitive-Behavioral Interventions
Distraction
Relaxation Techniques
Guided Imagery
Hypnosis
Therapeutic Touch
Humor

39. Guided Imagery start the day meditation - guided imagery – YouTube
Guided Imagery - Bubble Release - YouTube

40. REIKI

41. Biofeedback Biofeedback Session Demo – YouTube

42. The Nursing Process
Lets Start With You, as a student nurse and health care providers.

43. The HCW’s Perception of Pain
What are some myths associated with pain management that you have witnessed in the healthcare setting?
W&H p 145

44. Nursing Process: Collect Data
The fifth vital sign.
Accept the patient’s report of pain.
Obtain a pain history.
Perform a physical assessment.
Observe for nonverbal indicators of pain.
Use WHAT”S UP format and pain scales.

45. WHAT”S UP? W here is the pain? H ow does the pain feel?
A ggravating & alleviating factors.
T iming.
S everity.
U seful other data.
P erception.

46. Pain Scales Visual Analog Scale Numerical Rating Scale
The Wong-Baker FACES pain Rating Scale

47. Analgesic Administration
Use resources to check on purposes and actions of pharmacological agents
Reconcile & maintain MAR +/or Patient’s list of medications.
Identify patient’s allergies and intervene as appropriate.

48. Identify a contraindication to administration of a prescribed medication.
Acetaminophen Caution and Guidance

49. Case Study: Mr. Lewis
Answer ONLY these questions for Now: 1. 2. 4.

50. Planning Use data collected to plan action with patient’s input.
Teach patient to use pain scales.
Set goals for acceptable pain levels.
Example: you will ask your patient who is in pain, “What is an acceptable level of pain for you after we have helped you relieve your pain?”
“What has helped in the past to relieve your pain?”

51. Drug Calculations

52. Nursing Diagnoses Nursing Diagnosis: Impaired Comfort
Pain, acute or chronic,
Impaired Comfort
Others: Self-Care Deficit, Impaired Mobility, Sleep Deprivation, Ineffective Airway Clearance, Ineffective Coping.

53. Interventions Apply therapies for comfort.
Use alternative/complementary therapies for pain management.
Administer pain medication as prescribed.
Identify patient expected response to pain medication.
Reinforce client teaching on possible effects of medication.

54. Follow rights of medication administration.
Maintain medication safety practice.
Follow protocol for handling controlled substances.
Monitor patient use of medication over time.
Maintain pain control devices.

55. Evaluation
Monitor and document patient’s response to pharmacological and non – pharmacological interventions.
Notify primary healthcare provider of actual/potential adverse effects of pain medications.

56. Explain the protocol for withholding pain medication if patient experiences an adverse reaction.
Discuss actions used in the event of adverse reactions with the use of opioids.

57. What Happens When Someone Has Pain?
Transduction -
Stimuli: mechanical, thermal, chemical
Transmission-
A-Delta Fibers & C Fibers
Pain Perception-
Cerebral Cortex & Limbic System
Pain Modulation-
Endogenous opioids, neurotransmitters

58. Case study: Mr. Lewis
Finish the case study with your partner(s)

59. Role Playing & Case Scenarios
Utilize your Medication Research cards and The Joint Commission Handout, “SpeakUP” to perform these excercises.