2What is Pain? Pain is subjective. Pain is a multidimensional experiencePain 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
3Why Do We Experience Pain? It is protective. How?It is a signal. What?
4Cause of PainNociceptive pain(pain receptors) – most common. Respond to stimulation.Visceral – organs , linings of cavitiesSomatic – Skin, muscles, bones, connective tissueNeuropathic 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.skip
5Classification of Pain AcuteCan Identify CauseTemporaryActivates SNS BP, HR, RR, more blood to brain, dilates pupilsAcute pain – short duration, rapid onset. May last up to 6 mos.Mostly associated with injury or surgery.IT IS PROTECTIVE in nature
6Classification of Pain ChronicLonger Duration – lasts beyond healing phaseInterferes with ADLsRemissions & exacerbationsStimulates PNS or normal Vital SignsAffective ResponsesLasts 6 mos or longerCan be related to progressive or chronic disorders.Neuropathic pain is an example.Affective Responses – anxiety, depression, anger, fear, exhaustion, hopelessness, irritabilityWhy? Lack of purpose of pain and uncertainty of duration
7Classification of Pain IntractableChronicResistant to pain reliefMulti-Disciplinary Approach
8Descriptions of PainBased on site, cause, duration and quality.
9Site of Pain Cutaneous or superficial pain Visceral pain Deep somatic painRadiating painReferred painPhantom painPsychogenic painCutaneous 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.
10Duration 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
12ApplicationHow would you classify the pain that the following patients are experiencing?● A patient with metastatic cancerAnswer:Chronic pain
13A patient with back pain that was the result of an automobile injury a year ago Answer:Chronic pain, potentially neuropathic pain
14A patient with a broken leg Answer:Acute deep somatic pain
15Quality of PainOnly the patient can describe the quality of their pain.They may use words such as:SharpDullThrobbingStabbingBurningRippingTinglingIntermittentConstantMildIntenseSevereSharp-Dull- mild, difficult to describeThrobbing-Stabbing-Burning-Ripping-Tingling-
16Factors Which Influence Pain EmotionsDevelopmental StageCommunication ImpairmentsPain ThresholdCulture
17Factors Which Influence Pain Emotions:AnxietyFearGuiltAngerHelplessnessExhaustionIrritabilityDepressionA 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.
18Factors Which Influence Pain Developmental Stage:Infants and childrenAdultsOlder Adults
19Factors 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 expressionsVocalizationsChanges in physical activityChange in vital signsChange in routinesMental status changes
20Factors 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
21Factors 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.
23AnalgesicsAt 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
24Routes of Administration Oral – preferred routeNasalTransdermalRectalSubcutaneousIntramuscular – least preferredIntravenousPCA – patient controlled analgesiaIntraspinal analgesics
25Adverse 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.
26Analgesic AdjuvantsThese 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.
27AntidoteNarcan (naloxone)- counteracts the effect of opioids.
28Interpreting MD Orders Morphine Sulfate 2 mg. IM q 4 hours prn for surgical pain.Percocet one tab po q 6 hours prn for foot painDuragesic patch 25mcg/hr transdermal q 72 hours at 0800.Oxycontin 20 mg. po BIDOxyIR 5 mg. po q 6 hours prn for breakthrough pain
29EvaluationAlways re-assess your patient after administering pain medications.At what time interval?
30Special Considerations The ElderlyThe Person with Substance Abuse or AddictionUnrelieved Pain
35AcupressureBased 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.
42The Nursing ProcessLets Start With You, as a student nurse and health care providers.
43The 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
44Nursing 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.
45WHAT”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.
46Pain Scales Visual Analog Scale Numerical Rating Scale The Wong-Baker FACES pain Rating Scale
47Analgesic Administration Use resources to check on purposes and actions of pharmacological agentsReconcile & maintain MAR +/or Patient’s list of medications.Identify patient’s allergies and intervene as appropriate.
48Identify a contraindication to administration of a prescribed medication. Acetaminophen Caution and Guidance
49Case Study: Mr. LewisAnswer ONLY these questions for Now:1.2.4.
50Planning 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?”
53Interventions 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.
54Follow 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.
55EvaluationMonitor and document patient’s response to pharmacological and non – pharmacological interventions.Notify primary healthcare provider of actual/potential adverse effects of pain medications.
56Explain 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.
57What Happens When Someone Has Pain? Transduction -Stimuli: mechanical, thermal, chemicalTransmission-A-Delta Fibers & C FibersPain Perception-Cerebral Cortex & Limbic SystemPain Modulation-Endogenous opioids, neurotransmitters
58Case study: Mr. LewisFinish the case study with your partner(s)
59Role Playing & Case Scenarios Utilize your Medication Research cards and The Joint Commission Handout, “SpeakUP” to perform these excercises.