2Learning Objectives Define pain. Explain the physiologic basis for pain.Identify situations in which patients are likely to experience pain.Explain the relationships between past pain experiences, anticipation, culture, anxiety, or activity and a patient’s response to pain.Identify differences in the duration of pain and patient responses to acute and chronic pain.
3Learning ObjectivesExplain the special needs of the older adult patient with pain.List the data to be collected in assessing pain.Describe interventions used in the management of pain.Describe the nursing care of patients receiving opioid and nonopioid analgesics for pain.List the factors that should be considered when pain is not relieved with analgesic medications.
4Definition of PainInternational Association for the Study of Pain defines it as an unpleasant sensory and emotional experience associated with actual or potential tissue damageMcCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses: “Pain is whatever the person experiencing it says it is and exists whenever he says it does”
5Definition of PainInternational Association for the Study of Pain defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”McCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses: “Pain is whatever the person experiencing it says it is and exists whenever he says it does”
6Physiology of PainSensory experiences: time/space, emotions, cognitionAfferent pathwaysNerves that carry messages to the brain for interpretationEfferent (or descending) pathwaysCarry messages away from the brain via spinal cordNociceptorsReceptors that activate the afferent pathwaysUnevenly distributed in muscles, tendons, subcutaneous tissue, and the skinWhy are parts of the body are more sensitive to pain than other parts?
7Physiology of PainPain receptors are sensitive to chemical changes, temperature, mechanical stimuli, and tissue damagePain receptors are unable to adapt to repeated stimuli and thus continue to react until stimuli are removedWhen pain receptors are stimulated, impulses are transmitted to the spinal cord
8Physiology of PainImpulses then travel up the spinal cord to the brainIn the brain, the cortex interprets the impulses as pain and identifies the location and qualities of the painEndorphins and enkephalins, natural opioid-like substances: block transmission of painful impulses to the brainOnce pain is transmitted to the spinal cord and brain, the descending pathway is activated and several substances such as endorphins, serotonin, norepinephrine, gamma-aminobutyric acid (GABA), and enkephalins are released to inhibit pain transmission to the spinal cord.Why do some people experience more pain than others?
9Gate-Control Theory Pain reflects physical and psychosocial factors Painful impulses are transmitted to the spinal cord through small-diameter nerve fibers in the afferent pathwayWhen these fibers are stimulated, the gating mechanism opens in the spinal cord, which permits the transmission of impulses from the spinal cord to the brainMany theories have been proposed to explain pain, but none fully describe the pain experience.Who are Melzack and Wall?
10Gate-Control TheoryFactors that cause the gate to open include tissue damage, a monotonous environment, and fear of painStimulation of large-diameter fibers can close the gate and interfere with impulse transmission between spinal cord and the brain, causing diminished pain perceptionLarge-diameter nerve fibers are stimulated by cutaneous (skin) stimulation through massage, position change, and heat or cold applications.What types of sensory input may close the gate?
12Factors Influencing Response to Pain Although people may have the same injury or insult, they may respond differently because many physical and psychosocial factors affect the response to painImportant for health professionals to be nonjudgmental and to avoid comparing one individual in pain with another
13Physical Factors Pain threshold Pain tolerance Age Point at which stimulus causes sensation of painPain toleranceIntensity of pain that a person will endureAgePhysical activity and nervous system integritySurgery and anesthesiaType of surgery performed and the type of anesthesia used can influence the response to painAnger, fatigue, anxiety, insomnia, depression, and uncontrolled pain all lower the pain threshold.Increasing or prolonged pain may lower the pain tolerance because the patient fears the pain will not be relieved.Pain is not a normal part of aging, but older adults often suffer from chronic conditions such as arthritis, cancer, and bone fractures that are associated with pain.How can physical activity affect pain?Some anesthetic agents injected at the operative site may prolong analgesia for 12 to 24 hours after surgery.
14Psychological Factors Culture and ethnicityDifferent ways of expressing/responding to painReligious beliefsSome patients may pray and believe that divine intervention will help them to endure the painOthers may view pain as a punishment for sinsSome believe that suffering is required before pain reliefIt is critical to avoid making judgments based on how you think a person should react or behave.What reactions may patients have to pain?
15Psychological Factors Past experiences and anxietyMay have developed positive coping strategies to deal with previous painful experiencesIf strategies were unsuccessful, may be very anxious and overwhelmed by another painful experienceSituational factorsIf pain associated with a serious illness, it may have a greater effect on mood and activity than if the pain were associated with a less serious condition
16Autonomic Nervous System Activates the fight-or-flight response; certain physiologic responses initiatedThe nervous system responses measured by increased heart rate, respiratory rate, and blood pressureAcute and chronic pain elicit different kinds of responsesThe pain signal is interpreted by the brain as a stressor.What behaviors may the patient exhibit in response to pain?
17Acute PainFollows the normal pathway for pain from nociceptor activation to the brain and may be called nociceptive painCause is known and treatableIt serves as a warning of tissue damage and subsides when healing takes placeBehavioral and physiologic signs: when patient guards or rubs a body part, wrinkles the brow, bites the lip, and has changes in the heart rate, blood pressure, and respiratory rate
18Chronic Pain Persists/recurs for >6 months; may last a lifetime Most chronic pain is neuropathic pain because it follows an abnormal pathway for painResults from nerve damage from anatomic and physiologic conditions and underlying diseasesIncludes unusual sensations such as burning, shooting pain, and abnormal sensations that occur when there is no painful stimulus presentSee Table 15-2, p. 206Treatment may or may not be helpful in relieving the pain.Chronic pain is associated with a variety of diagnoses, including cancer, arthritis, peripheral vascular diseases, and traumatic injuries.What is chronic nonmalignant or benign pain?
19Comparison of Acute and Chronic Pain Chronic pain serves no useful purpose; acute warns of tissue damage and traumaNursing assessment to identifyType and amount of painChronic or acuteIf acute and chronic pain at the same timeChronic pain can lead to depression, marital difficulties, loss of self-esteem, immobility, and isolation.When the patient reports pain but shows no physical symptoms, this does not mean there is no pain.
22Assessment Should be done on admission and on a regular basis Assessment of vital signs is called the fifth vital signAssessment is the first step in pain management.Pain should be anticipated as a result of what situations?Visual, speech, hearing, and motor impairments may limit the ability of older patients to communicate pain or to use scales to rate pain.When the patient cannot report pain, the nurse may need to perform a different assessment, which includes observing for usual or unusual behaviors that may indicate pain.
23Assessment Six steps Accept the patient’s report Determine the status of the painDescribe the painLocation, quality, intensity, aggravating and alleviating factorsExamine the site of the painIdentify coping methodsDocument assessment findings and evaluate interventionsObtain specific details about the pain, and respond positively that action will be taken to relieve the pain.Ask the patient if he or she has had this pain before and whether it was diagnosed by a physician.Assess the area for heat, redness, swelling, tenderness, abnormal position, or other factors that may be causing local irritation.What are some coping methods patients may use?Record the location, quality, and intensity of the pain, related factors, and how the patient copes with pain.
25Nonpharmacologic Interventions Those that do not employ drugsPhysical interventionsPhysical comfort measuresEnvironmental controlStimulation techniquesAnxiety reductionDistractionPsychological interventionsRelaxationImageryComfort may increase pain tolerance, and the patient may experience less pain.Stimulation of the skin and underlying tissues relieves pain.What types of skin or cutaneous stimulation can be applied to relieve pain?Anxiety, fear of the unknown, and feelings of loss of control may be directly related to the level of pain experienced.Distraction refers to focusing on stimuli other than pain.
26Pharmacologic Interventions Nonopioid analgesicsAspirin, acetaminophen, and nonsteroidal anti-inflammmatory drugs (NSAIDs) such as ibuprofenGenerally initial treatment choice for mild painAct mostly on the peripheral nervous systemAntipyretic (fever-reducing), analgesic (pain-reducing), and/or anti-inflammatory (inflammation-reducing) propertiesSee Table 15-4, p. 216When administering analgesics, keep in mind that it is critical to use a preventive approach to pain management.Who is responsible for assessing the pain, deciding which analgesic and how much to administer, and evaluating the drug’s effectiveness?
27Pharmacologic Interventions: Opioid Analgesics For moderate to severe acute pain, chronic cancer pain, and some other types of painOpioids: potency/duration of action varyOpioid agonistsExamples: codeine, methadone (Dolophine), hydromorphone (Dilaudid), meperidine (Demerol), morphine, and fentanylBoth types of opioids relieve pain at the level of the central nervous system.Why are older adults generally more sensitive to the analgesic effects of opioids?
29Pharmacologic Interventions: Opioid Analgesic Misconceptions Patients, families, nurses, and physicians have misconceptions about addiction; therefore, the term must be defined and differentiated from the terms tolerance and physical dependenceTolerance and physical dependence are normal responses to continued opioid administration for pain relief; they do not lead to a craving for the drug for its mind-altering effectsFear of addiction greatly exaggerated; rare (<1%) in patients taking opioids for pain reliefThe patient who is tolerant requires higher doses of a drug to achieve an analgesic effect.The patient who is physically dependent on an opioid will experience unpleasant withdrawal symptoms when the opioid is stopped.
30Pharmacologic Interventions: Opioid Analgesics Routes of administrationOralIntramuscularSublinguallyIntravenously: intermittent bolus injections, continuous infusions, or patient-controlled analgesia (PCA)Epidural or intrathecal routeA limited number of opioids, such as morphine, hydromorphone, and oxymorphone, may be administered rectally.How is medication administered via a PCA pump?
31Pharmacologic Interventions: Opioid Analgesics Side effectsConstipationNausea, with or without vomitingSedationRespiratory depressionConfusionHypotension (especially orthostatic)DizzinessUrinary retention
32Pharmacologic Interventions: Placebos Inactive substances (e.g., saline) used in research or clinical practice to determine the effects of a legitimate drug or treatmentAppropriately used in studies in which patients consent to participate
33Pharmacologic Interventions: Placebos Many health care organizations take the position that placebos should not be used to assess or manage painNurses have ethical obligation to ensure that patients are not deceived and that institutional policies related to placebos are followed
34Pharmacologic Interventions: Adjuvant Analgesics and Medications Drugs not usually classified as analgesics may relieve pain in certain situationsA patient who has undergone back surgery may complain more about muscle spasms than incisional painA muscle relaxant may be more effective in relieving pain than an opioid alone
35Pharmacologic Interventions: Adjuvant Analgesics and Medications Specific pain syndromes, especially neuropathic, may be controlled with drugs other than the commonly known analgesicsSee Table 15-6, p. 219
36Problem Solving with Pain Medication Patients whose prescribed analgesic drugs do not relieve painAsk questions about the analgesic drug and the “five rights” (right dose, right patient, right time, right route, right analgesic) to determine why the patient is not getting adequate pain reliefSee Box 15-8, p. 221The administration of analgesics is simply one intervention in the nursing care of a patient in pain.What interventions other than analgesics should the nurse provide?