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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Coanalgesic Drugs Antidepressants Anticonvulsants Local anesthetics Others

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).

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)

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)

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)

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)

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

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

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

Subcutaneous Infusion Placement Figure 46-10 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, 1999. St. Louis, MO.)

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

Medication Administration Intraspinal Provides superior analgesia with less medication used Figure 46-11 Placement of intraspinal catheter in the epidural space. Copyright 2008 by Pearson Education, Inc.

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 46-13 The older child is able to regulate a PCA pump.

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

Physical Modalities Cutaneous stimulation Immobilization or therapeutic exercises Transcutaneous electrical nerve stimulation (TENS) Figure 46-14 A transcutaneous electric nerve stimulator.

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

Lifestyle Management Stress management Exercise, nutrition Pacing activities Disability management

Spiritual Feel part of a community Bond with universe Religious activities

Nonpharmacologic Invasive Techniques Cordotomy Rhizotomy Neurotomy Sympathectomy Spinal cord stimulation

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

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.

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

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

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

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

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

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

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

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

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