1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Chapter 11:
Pain Management

2. FACT OR FICTION????
Visceral pain is pain that is processed abnormally by the nervous system
Despite the fact that the client is the only reliable source for quantifying pain, nurses are not consistent in responding to the client’s description of pain intensity with pain-relieving interventions
There are 5 components of a pain assessment: onset, quality, intensity, location & magnitude

3. Pain
Pain is a privately experienced, unpleasant sensation usually associated with disease or injury.
It also has an emotional component known as “suffering”.

4. Types of Pain Introduction Classification
Source-nocicepetive, neuropathic
Onset, intensity, and duration –
Acute or chronic
Nociceptive Pain
Noxious stimuli transmitted from point of cellular injury through pathways to the cerebral cortex of the brain
Subdivided into somatic and visceral

5. Types of Pain Nociceptive Pain Somatic pain
Causes: Mechanical, chemical, thermal, or electrical injuries or disorders
Affects bones, joints, muscles, skin, or other structures composed of connective tissue
Types: Superficial somatic pain, also known as cutaneous pain; deeper somatic pain from trauma

6. Types of Pain Nociceptive Pain Visceral pain
Diseased or injured heart, kidneys, and intestine
Causes: Ischemia, organ compression, intestinal distention with gas or contraction
Referred pain
Discomfort perceived in a general area of the body

7. Figure 11-2 Common areas of referred pain, pg 99
Types of Pain
Figure 11-2 Common areas of referred pain, pg 99

8. Types of Pain Neuropathic Pain Damaged
Pain pathways in peripheral nerves
Pain processing centers in the brain
Cause of nerve damage: Drugs or radiation used to treat cancerous tumor
Acute Pain
Discomfort that has a short duration
Tissue trauma
Physical and emotional distress

9. Types of Pain Chronic Pain
Discomfort that lasts longer than six months
Longer pain periods: More far-reaching effects on the sufferer - breakthrough pain
Negative reactions of others to chronic pain sufferer
Characteristics of Acute and Chronic Pain, Table 11- 1, pg 99

10. Question
Is the following statement true or false?
Pain is always located in the organ of the body in which it is generated.

11. Answer
False.
Referred pain is discomfort that is perceived in a general area of the body but not in the exact site where an organ is located.

12. Pain Transmission Four Phases Transduction
Chemical information in the cellular environment is converted to electrical impulses that move toward the spinal cord; release of chemical mediators
Chemicals that are released by the damaged cells stimulate nociceptors
Impulses transmitted by the fast pain pathway (A-delta); person withdraws from the pain-provoking stimulus

13. Pain Transmission Four Phases, con’t Transmission
Peripheral nerve fibers form synapses with neurons in the spinal cord
Pain impulses move from spinal cord to brain; impulses ascend finally to the cerebral cortex
Perception
Phase of impulse transmission: brain experiences pain at a conscious level; brain structures in the pain pathway

14. Pain Transmission Four Phases, con’t Perception (cont’d)
Pain perception: Conscious experience of discomfort
Pain threshold: Point at which pain- transmitting neurochemicals reach the brain, causing conscious awareness
Pain tolerance: Amount of pain a person endures once the threshold has been reached; influenced by gender, age, and culture

15. Pain Transmission Four Phases, con’t Modulation
Phase during which the brain interacts with the spinal nerves to alter the pain
Pain sensation reduced
Release of pain- inhibiting neurochemicals
Figure 11-3, pg 100 The phases of pain transmission

16. Pain Assessment Introduction
Client’s description of pain onset, quality, intensity, location, and duration (Table 11-2 pg 101)
Assessment for accompanying symptoms
Should be treated as the fifth vital sign
Assessment biases
Client: Only reliable source for quantifying pain
Nurses: Not consistent in responding to the client’s description of pain intensity

17. Pain Assessment Assessment biases (cont’d)
Pain undertreated if the client’s expressions are incongruent with the nurse’s expectations
Assessment Tools
Numeric scale, word scale, and linear scale
Wong–Baker FACES scale: Best for pediatric, culturally diverse, and mentally challenged clients

18. Question
Is the following statement true or false?
Pain is exactly as the client describes it.

19. Answer
True.
Margo McCaffery, a nursing expert on pain, states, “Pain is whatever the person says it is, and exists whenever the person says it does” (McCaffery & Beebe, 1989).

20. Pain Assessment Assessment Standards
Joint Commission standards related to pain management
Aspects incorporated in the Joint Commission standards
REVIEW: Stop Think Respond, 11-1, pg 102
Figure 11-4, pg 102  Pain assessment tools: (A) Word scale, (B) Numeric scale, (C) Linear scale

21. Pain Management Introduction
Techniques used to prevent, reduce, or relieve pain
Five techniques for achieving pain management, Refer to Bullet points, pg 102
Drug Therapy
WHO: Three-tiered approach
Cancer pain: Analgesics administered intrathecally, and electrical stimulation in the spinal cord

22. Pain Management Drug Therapy Neurosurgical analgesic techniques
Opioid and opiate analgesics
Nonopioid analgesics
REFER to: Drug Therapy Table, , pg 104 &
Figure 11-8, pg 103

23. Pain Management Drug Therapy Methods of administration
Analgesic drugs: Oral, rectal, transdermal, or parenteral
Equianalgesic dose: Change from a parenteral to an oral route
Patient-controlled analgesia
Self-administration of narcotic analgesic
Intravenous pump system

24. Pain Management Drug Therapy Methods of administration (cont’d)
Intraspinal analgesia
Infusion of narcotic or local anesthetic into the subarachnoid or epidural space of the spinal cord
Relieves pain with minimal systemic drug effects
Nurses do not administer intraspinal analgesia

25. Pain Management Drug Therapy Addiction, tolerance, physical dependence
Addiction: A repetitive pattern of drug use to satisfy a craving for a drug’s mind-altering or mood-altering effects; fear of addiction affects use of medication
Tolerance: A condition in which a client needs larger doses of a drug to achieve the same effect

26. Pain Management Drug Therapy
Physical dependence: Physical discomfort, withdrawal symptoms; experienced when drug taken routinely is discontinued abruptly
Adjuvant drug therapy
Medications ordinarily administered for reasons other than treating pain
Effects of combining adjuvant drugs with opioid and nonopioid analgesics
REFER to: Drug Therapy Table, 11-1, pg & 105

27. Pain Management Nondrug Interventions
Heat and cold applications, transcutaneous and percutaneous electrical nerve stimulation, acupuncture, and acupressure
Used for clients with chronic pain
Body releases neurotransmitters: Calm the body and promote emotional well-being- use up sensory signals
Release of endogenous opiates: Help relieve pain
Modulation of pain transmission

28. Pain Management Nondrug Interventions Heat and cold
Reduces localized swelling; decreases vasodilation; used for minor or moderate pain
Ice bag or chemical pack

29. Pain Management Nondrug Interventions
Transcutaneous electrical nerve stimulation (TENS)
Delivers bursts of electricity to the skin and underlying nerves
Acute and chronic pain
Change in placement sites
Intensity of electrical current
Rate of electrical bursts and duration according to the client’s response

30. Pain Management Nondrug Interventions Acupuncture and acupressure
Temporary relief: Repeat treatments
Long treatment: Thin needles are inserted into the skin
Acupressure uses tissue compression, rather than needles, to reduce pain

31. Pain Management Nondrug Interventions
Percutaneous electrical nerve stimulation
Combines the use of acupuncture needles with TENS
Administered for 30 minutes three times a week for a total of three weeks
Successful in research trials on clients with low back pain, pain caused by the spread of cancer to bones, shingles, neuropathic pain, and migraine

32. Question
Is the following statement true or false?
A nurse has several nondrug pain management techniques available to make pain management more effective.

33. Answer
True.
Several nondrug interventions can be used to help manage pain. Some, such as applications of heat and cold, are independent nursing measures or may require collaboration with the client’s physician.

34. Pain Management Nondrug Interventions Other noninvasive techniques
Imagery, biofeedback, humor, breathing exercises and progressive relaxation, distraction, and hypnosis
Spinal Surgery Techniques
Relieves intractable pain
Rhizotomy
Spinal surgery involves a laminectomy

35. Pain Management Spinal Surgery Techniques Rhizotomy (cont’d)
Sectioning of the posterior nerve root
Permanent loss of sensation
Reserved for terminally ill clients
Cordotomy
Interruption of pain pathways in the spinal cord
Percutaneous: Less risk; better tolerated by terminally ill clients

36. Pain Management Nursing Management (Nursing Care Plan, 11-1, pg 110)
Collaboration with patient and physician
Nursing interventions for pain management
Monitor and manage drug side effects: Constipation, injury, nutrition, sleep
Client teaching
Available pain management techniques
Self-administration of analgesics
Prescribed analgesics
Nutritional

37. NCLEX
Q & A..