1. Pain Assessment Subjective Data
Comprehensive pain history includes COLDERR
Character
Onset
Location
Duration
Exacerbation
Relief
Radiation

2. Additional Data to Obtain
Associated symptoms
Effect on ADLs
Past pain experiences
Meaning of the pain to the person
Coping resources
Affective response

3. Nursing Process for Clients with Pain
Figure 9–11 Examples of commonly used pain scales.

4. Pain Assessment Objective Data
Nonverbal responses to pain
Facial expression
Vocalizations like moaning and groaning or crying and screaming
Immobilization of the body or body part
Purposeless body movements
Behavioral changes such as confusion and restlessness
Rhythmic body movements or rubbing
Figure 46-6 An 11-point pain intensity scale with word modifiers.

5. Pain Assessment Objective Data
Early physiologic responses
Increases BP, HR, RR
Pallor
Diaphoresis
Pupil dilation
May be absent in people with chronic pain
Pain diary

6. NANDA Nursing Diagnoses
Acute Pain and Chronic Pain
Specify the location
Related factors, when known, can include physiologic and psychologic factors
Pain may be etiology of other nursing diagnoses

7. NANDA Nursing Diagnoses
Pain as etiology of other nursing diagnoses
Ineffective Airway Clearance
Hopelessness
Anxiety
Ineffective Coping
Ineffective Health Maintenance
Self-Care Deficit (Specify)
Deficient Knowledge (Pain Control Measures)
Disturbed Sleep Patterns

8. Nursing Process for Clients with Pain
Assess the client’s pain level
Establish a nursing diagnosis
Plan and implement a care plan
Educate the client
Evaluate the patient’s response to the care plan

9. Treatment Plan
Goals vary according to the diagnosis and its defining characteristics
Select pain relief measures appropriate for the client, based on assessment data and input from the client or support persons

10. Practice Guidelines Establish a trusting relationship
Consider client’s ability and willingness to participate
Use a variety of pain relief measures
Provide pain relief before pain is severe
Use pain relief measures the client believe are effective
Align pain relief measures with report of pain severity

11. Practice Guidelines
Encourage client to try ineffective measures again before abandoning
Maintain unbiased attitude about what may relieve pain
Keep trying
Prevent harm
Educate client and caregiver about pain

12. Pain Treatment Plan
Include variety of pharmacologic and nonpharmacologic interventions
Plan with wide range of strategies
Document plan in client record and for home care
Involve client and support persons

13. Barriers to Effective Pain Management
Lack of knowledge of the adverse effects of pain
Misinformation regarding the use of analgesics
Misconceptions about pain
May not report pain
Fear of becoming addicted

14. Addiction Primary, chronic, neurobiologic disease
Genetic, psychosocial, and environment are influential factors
Behaviors can include:
Impaired control over drug use
Compulsive use
Craving
Continued use despite harm

15. Dependence State of adaptation Manifested by withdrawal syndrome
Produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist

16. Tolerance State of adaptation Exposure to a drug induces changes
Result in a diminution of one or more of the drug’s effects over time

17. Pharmacologic Interventions for Pain
Opioids (narcotics)
Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS)
Co-analgesic drugs

18. Opioids (Narcotics) Full agonists No ceiling on analgesia
Dosage can be steadily increased to relieve pain
E.g., morphine, oxycodone, hydromorphone

19. Opioids (Narcotics) Mixed agonist-antagonists Partial agonist
Act like opioids and relieve pain
Can block or inactivate other opioid analgesics
E.g. dezocine, petazocine hydrochloride, butorphanol tartrate, nalbuphine hydrochloride
Partial agonist
Have a ceiling effect
E.g., buprenorphine

20. Nonopioids/NSAIDS
Vary little in analgesic potency but do vary in anti-inflammatory effects, metabolism, excretions, and side effects
Have a ceiling effect
Narrow therapeutic index
E.g. acetaminophen, ibuprofen, aspirin

21. Coanalgesic Drugs Antidepressants Anticonvulsants Local anesthetics
Others

22. WHO Ladder Step Approach for Cancer Pain Control
Figure 46-9 The WHO three-step analgesic ladder. (From Cancer Pain Relief, 2nd ed. WHO 1996 Geneva).

23. WHO Ladder Step Approach for Cancer Pain Control
For clients with mild pain (1-3 on a 0-10 scale)
Use of nonopioid analgesics (with or without a coanalgesic)

24. WHO Ladder Step Approach
Client has mild pain that persists or increases
Pain is moderate (4-6 on a 0-10 scale)
Use of a weak opioid (e.g. Codeine, tramadol, pentazocine) or a combination of opioid and nonopioid medicine (oxycodone with acetaminophen, hydrocodone with ibuprofen)

25. WHO Ladder Step Approach
Client has moderate pain that persists or increases
Pain is severe (7-10 on a 0-10 scale)
Strong opioids (e.g. Morphine, hydromorphone, fentanyl)

26. Rational Polypharmacy
Evolved from WHO three step approach
Demands health professionals be aware of all ingredients of medications that alleviate pain
Use combinations to reduce the need for high doses of any one medication
Maximize pain control with a minimum of side effects or toxicity
Combined with multimodal therapy (e.g. nondrug approaches)

27. Oral Administration Preferred because of ease of administration
Duration of action is often only 4 to 8 hours
Must awaken during night for medication
Long-acting preparations developed
May need rescue dose of immediate-release medication

28. Transmucosa/Transnasal and Transdermal Administration
Transmucosa and Transnasal
Enters blood immediately
Onset of action is rapid
Transdermal
Delivers relatively stable plasma drug level
Noninvasive

29. Medication Administration
Rectal
Useful for clients with dysphagia or nausea/vomiting
Continuous subcutaneous infusion
Used for pain poorly controlled by oral medications

30. Subcutaneous Infusion Placement
Figure Subcutaneous infusion needle placement. Figure shows sites for SC infusion needle placement, which may be attached to an ambulatory infusion pump. Other sites to consider include upper arms and thighs. Sites should be rotated. (From Pain: Clinical Manual, 2nd edition by McCaffery, Pasero, St. Louis, MO.)

31. Medication Administration
Intramuscular
Should be avoided
Variable absorption
Unpredictable onset of action and peak effect
Tissue damage
Intravenous
Provides rapid and effective relief with few side effects

32. Medication Administration
Intraspinal
Provides superior analgesia with less medication used
Figure Placement of intraspinal catheter in the epidural space.
Copyright 2008 by Pearson Education, Inc.

33. Benefits/Risk Routes and Technology
Patient-controlled analgesia
Minimizes peaks of sedation and valleys of pain that occur with prn dosing
Electronic infusion pump
Safety mechanisms
Figure The older child is able to regulate a PCA pump.

34. Nonpharmacologic Pain Control Interventions
Consists of variety of pain management strategies
Physical
Cognitive-behavioral
Lifestyle pain management
Target body, mind, spirit, and social interactions

35. Physical Modalities Cutaneous stimulation
Immobilization or therapeutic exercises
Transcutaneous electrical nerve stimulation (TENS)
Figure A transcutaneous electric nerve stimulator.

36. Cognitive-Behavioral (Mind-Body)
Providing comfort
Eliciting relaxation response
Repatterning thinking
Facilitating coping with emotions
One suggested pattern for a back massage.

37. Lifestyle Management Stress management Exercise, nutrition
Pacing activities
Disability management

38. Spiritual Feel part of a community Bond with universe
Religious activities

39. Nonpharmacologic Invasive Techniques
Cordotomy
Rhizotomy
Neurotomy
Sympathectomy
Spinal cord stimulation

40. Collaborative Care for Pain
Surgery
Cordotomy: an incision into the anterolateral tracts of the spinal cord to interrupt the transmission of pain
Neurectomy: removal of part of the nerve
Sympathectomy: destruction of the ganglia by incision or injection
Rhizotomy: surgical severing of the dorsal spinal roots
Transcutaneous electrical nerve stimulation (TENS): electrodes stimulate the A-beta touch fibers to close the “pain” gate

41. Collaborative Care for Pain
Figure 9–8 Surgical procedures are used to treat severe pain that does not respond to other types of management. They include cordotomy, neurectomy, sympathectomy, and rhizotomy.

42. Body Interventions Reducing pain triggers Massage Applying heat or ice
Electric stimulation (TENS)
Positioning and bracing (selective immobilization)
Acupressure
Diet and nutritional supplements
Exercise and pacing activities
Invasive interventions (e.g. blocks)
Sleep hygiene

43. Mind Interventions Relaxation and imagery Self-hypnosis
Pain diary and journal writing
Distracting attention
Re-pattern thinking
Attitude adjustment
Reducing fear, anxiety, stress, sadness, and helplessness
Providing information about pain

44. Spirit Interventions Prayer Meditation Self-reflection
Meaningful rituals
Energy work (therapeutic touch, Reiki)
Spiritual healing

45. Social Interaction Functional restoration Improved communication
Family therapy
Problem-solving
Vocational training
Volunteering
Support groups

46. Collaborative Care for Pain
Medications
NSAIDs: analgesic, antipyretic, and anti-inflammatory action
Narcotics: opioids
Antidepressants: act on the retention of serotonin, thus inhibiting the pain sensation
Anticonvulsants: used for headache and neuropathic pain
Local anesthetics: blocks the transmission of nerve impulses, therefore blocking pain

47. Collaborative Care for Pain
Figure 9–6 The transdermal patch administers medication in predictable doses.

48. Collaborative Care for Pain
Complementary Therapies
Acupuncture
Biofeedback
Hypnotism
Relaxation
Distraction
Cutaneous stimulation

49. Neuropathic Pain
Experienced by people who have damaged or malfunctioning nerves
Types
Peripheral
Central
Sympathetically maintained

50. Physiologic Pain
Experienced when an intact, properly functioning nervous system signals that tissues are damaged, requiring attention and proper care
Transient
Persistent
Subcategories
Somatic
Visceral