1. Chapter 44 Pain Management
Pain is purely subjective. No two people experience pain in the same way, and no two painful events create identical responses or feelings in a person.
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
The 2010 Patient Protection and Affordable Care Act required the Department of Health and Human Services to obtain the support of the Institute of Medicine (IOM) in conducting an extensive examination of pain as a public health problem. The results of the IOM study were released in the 2011 report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” This report acknowledges the tragic epidemic of pain in the United States and calls for major coordinated efforts to develop safe effective preventive and management strategies.
The IASP, in the “Declaration of Montreal,” declared that access to pain management is a fundamental human right (IASP, 2015). Nurses are legally and ethically responsible for managing pain and relieving suffering.
Pain management should be patient centered, with nurses practicing patient advocacy, patient empowerment, compassion, and respect. Caring for patients in pain requires recognition that pain can and should be relieved.
Effective communication among the patient, family, and professional caregivers is essential to achieve adequate pain management. Recognition of the subjective nature of pain and respect for the patient in pain is demonstrated when a nurse accepts McCaffery’s classic definition: “Pain is whatever the experiencing person says it is, existing whenever he says it does.”
Effective pain management improves quality of life; reduces physical discomfort; promotes earlier mobilization and return to previous baseline functional activity levels; results in fewer hospital and clinic visits; and decreases hospital lengths of stay, resulting in lower health care costs.
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2. Nature of Pain Involves physical, emotional, and cognitive components
Pain is subjective and individualized
Reduces quality of life
Not measurable objectively
May lead to serious physical, psychological, social, and financial consequences
Always remember that the patient is the one who is experiencing pain. Therefore, pain is whatever the patient states it is. It is not the responsibility of patients to prove that they are in pain; it is a nurse’s responsibility to accept their report.
If patients are having difficulty expressing pain, this does not mean that they are not in pain.
The Joint Commission pain standard requires health care providers to assess all patients for pain on a regular basis. Many health care institutions have added pain as the fifth vital sign.
[Ask students: Can you identify patients who may not be able to express pain? Discuss: Answers may include aphasic, cognitively impaired, intubated, mentally impaired, or pediatric patients.]
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3. Physiology of Pain Transduction
Converts energy produced by these stimuli into electrical energy.
Begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential.
Once transduction is complete, transmission of the pain impulse begins.
There are four physiological processes of normal pain: transduction, transmission, perception, and modulation. A patient who is experiencing pain cannot discriminate between these four factors. Understanding each process helps you recognize factors that cause pain, symptoms that accompany it, and the rationale for selected therapies.
Transduction begins in the periphery when a pain-producing stimulus (e.g., exposure to pressure or a hot surface) sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. Once transduction is complete, transmission of the pain impulse begins.
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4. Physiology of Pain (Cont.)
Transmission
Sending of impulse across a sensory pain nerve fiber (nociceptor)
Nerve impulses
Pain impulses
[Review Box 44-1, Neurophysiology of Pain: Neuroregulators, with students.]
The neurotransmitters affect the sending of nerve stimuli. They either excite during transmission or inhibit during modulation. Excitatory neurotransmitters send electrical impulses across the synaptic cleft between two nerve fibers, enhancing transmission of the pain impulse. These pain-sensitizing substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response.
[More information about transmission is on the following slide.]
Once a pain stimulus reaches the cerebral cortex, the brain interprets the quality of the pain and processes information from past experience, knowledge, and cultural associations in the perception of the pain. Perception is the point at which a person is aware of pain. The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex, primarily the limbic system, determines how a person feels about it. There is no single pain center.
As a person becomes aware of pain, a complex reaction occurs. Psychological and cognitive factors interact with neurophysiological ones. Perception gives awareness and meaning to pain, resulting in a reaction. The reaction to pain includes the physiological and behavioral responses that occur after an individual perceives pain.
Nerve impulses resulting from the painful stimulus travel along afferent (sensory) peripheral nerve fibers. Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C fibers. The A fibers send sharp, localized, and distinct sensations that specify the source of the pain and detect its intensity. The C fibers relay impulses that are poorly localized, visceral, and persistent. For example, after stepping on a nail, a person initially feels a sharp, localized pain, which is a result of A-fiber transmission, or first pain. Within a few seconds the whole foot aches from C-fiber transmission, or second pain.
[Shown are Figures 44-1: Chemical synapses involve transmitter chemicals (neurotransmitters) that signal postsynaptic cells; and 44-2: Spinothalamic pathway that conducts pain stimuli to the brain.]
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5. Physiology of Pain (Cont.)
Perception
The point at which a person is aware of pain.
The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex, primarily the limbic system, determines how a person feels about it. There is no single pain center.
Once a pain stimulus reaches the cerebral cortex, the brain interprets the quality of the pain and processes information from past experience, knowledge, and cultural associations in the perception of the pain.
As a person becomes aware of pain, a complex reaction occurs. Psychological and cognitive factors interact with neurophysiological ones. Perception gives awareness and meaning to pain, resulting in a reaction. The reaction to pain includes the physiological and behavioral responses that occur after an individual perceives pain.
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6. Physiology of Pain (Cont.)
Modulation
Inhibits pain impulse
A protective reflex response occurs with pain reception
Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endorphins (endogenous opioids), serotonin, norepinephrine, and gamma-aminobutyric acid (GABA), which hinder the transmission of pain and help produce an analgesic effect.
A-delta fibers send sensory impulses to the spinal cord, where they synapse with spinal motor neurons. The motor impulses travel via a reflex arc along efferent (motor) nerve fibers back to a peripheral muscle near the site of stimulation, thus bypassing the brain. Contraction of the muscle leads to a protective withdrawal from the source of pain.
Pain processes require an intact nervous system and spinal cord. Common factors that disrupt the pain process includes trauma, drugs, tumor growth, and metabolic disorders.
[Shown is Figure 44-3: Protective reflex to pain stimulus.]
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7. Physiology of Pain (Cont.)
Gate-control theory of pain (Melzack and Wall)
Pain has emotional and cognitive components, in addition to a physical sensation.
Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses.
Pain impulses pass through when a gate is open and are blocked when a gate is closed.
Closing the gate is the basis for nonpharmacological pain relief interventions.
You gain a useful conceptual framework for pain management by understanding the physiological, emotional, and cognitive influences on the gates. For example, factors such as stress and exercise increase the release of endorphins, often raising an individual’s pain threshold (the point at which a person feels pain). Because the amount of circulating substances varies with every individual, the response to pain varies.
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8. Case Study
Mrs. Ellis is a 70-year-old African-American woman with hypertension, diabetes, and rheumatoid arthritis. Her current health priority is the discomfort and disability associated with her rheumatoid arthritis.
Arthritis has severely deformed her hands and feet. The pain in her feet is so severe that she often walks only short distances. The pain interferes with sleep and reduces her energy both physically and emotionally. As a result, she does not leave home often.
[Ask students: What options may be available to Mrs. Ellis for pain control? Discuss.]
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9. Physiological Responses
As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system (ANS)
Fight or flight
Continuous, severe, or deep pain typically involving the visceral organs activates the parasympathetic nervous system
Stimulation of the sympathetic branch of the autonomic nervous system (ANS) results in physiological responses.
[Review Table 44-1, Physiological Reactions to Pain, with students.]
Sustained physiological responses to pain sometimes seriously harm individuals. Except in cases of severe traumatic pain, which causes a person to go into shock, most people adapt to their pain reflexively, and their physical signs return to normal baseline. Note that normal is not the same for each individual. Thus patients in pain do not always have changes in their vital signs. Changes in vital signs more often indicate problems other than pain.
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10. Behavioral Responses
Clenching the teeth, facial grimacing, holding or guarding the painful part, and bent posture are common indications of acute pain.
Chronic pain affects a patient’s activity.
Lack of pain expression does not indicate that a patient is not experiencing pain.
Some patients choose not to report pain if they believe that it inconveniences others or if it signals loss of self-control. Others endure severe pain without asking for assistance.
Be familiar with behavioral responses to pain.
Clenching the teeth, facial grimacing, holding or guarding the painful part, and bent posture are common indications of acute pain.
Chronic pain affects a patient’s activity (eating, sleeping, socialization), thinking (confusion, forgetfulness), or emotions (anger, depression, irritability) and quality of life and productivity.
Recognizing a patient’s unique response to pain is important in assessing success of pain management therapies.
Encourage your patients to accept pain-relieving measures so they remain active and continue to maintain daily activities.
A patient’s ability to tolerate pain significantly influences your perceptions of the degree of the patient’s discomfort. Patients who have a low pain tolerance (level of pain a person is willing to accept) are sometimes inaccurately perceived as complainers.
Teach patients the importance of reporting their pain sooner rather than later to facilitate better control and optimal functional status.
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11. Types of Pain Acute/transient pain Chronic/persistent noncancer
Protective, identifiable, short duration; limited emotional response
Chronic/persistent noncancer
Is not protective, has no purpose, may or may not have an identifiable cause
Chronic episodic
Occurs sporadically over an extended duration
Cancer
Can be acute or chronic
Idiopathic
Chronic pain without identifiable
physical or psychological cause
Pain can be categorized by duration (chronic or acute) or pathology (cancer or neuropathic).
Acute pain can threaten a patient’s recovery by resulting in prolonged hospitalization, complications from immobility, or delayed rehabilitation. Note that unrelieved acute pain can progress to chronic pain.
Acute pain seriously threatens a patient’s recovery by hampering the patient’s ability to become active and involved in self-care.
Physical and psychological progress is delayed as long as acute pain persists because a patient focuses all energy on pain relief.
A primary nursing goal is to provide pain relief that allows patients to participate in their recovery, prevent complications, and improve functional status.
Chronic pain lasts longer than anticipated pain and can be cancerous or noncancerous. Chronic noncancerous pain may include arthritis, headache, low back pain, or peripheral neuropathy.
Chronic noncancer pain may be viewed as a disease since it has a distinct pathology that causes changes throughout the nervous system which may worsen over time.
The possible unknown cause of chronic pain frequently leads to psychological depression, and even suicide.
The goal of chronic noncancer pain is to improve functional status with a multimodality plan.
Cancer pain is normal (nociceptive), resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damaged pain nerves.
A patient senses pain at the actual site of the tumor or distant to the site, called referred pain. Always completely assess reports of new pain by a patient with existing pain.
[Review Table 44-2, Classification of Pain by Inferred Pathology, with students.]
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12. Nursing Knowledge Base
Knowledge, attitudes, and beliefs
Attitude of health care providers
Malingerer or complainer
Assumptions about patients in pain
Biases based on culture, education, experiences
Acknowledge pain through patient’s experiences
Limit your ability to help the patient
When there is no obvious source of pain (e.g., the patient with chronic low back pain or neuropathies), health care providers sometimes stereotype pain sufferers as malingerers, complainers, or difficult patients.
Studies of nurses’ attitudes regarding pain management show that a nurse’s personal opinion about a patient’s report of pain affects pain assessment and titration of opioid doses.
The amount of analgesia administered may vary based on whether a patient is grimacing or smiling during the nurse’s assessment.
Nurses’ assumptions about patients in pain seriously limit their ability to offer pain relief. Biases based on culture, education, and experience influence everyone. Too often nurses allow misconceptions about pain to affect their willingness to intervene.
[Review Box 44-2, Common Biases and Misconceptions About Pain, with students.]
A nurse must accept a patient’s report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and evidence-based research findings.
To help a patient gain pain relief, it is important to view the experience through the patient’s eyes. Acknowledging personal prejudices or misconceptions help to address patient problems more professionally.
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13. Factors Influencing Pain
Physiological
Age, fatigue, genes, neurological function
Fatigue increases the perception of pain and can cause problems with sleep and rest
Social
Attention, previous experiences, family and social support, spiritual
Spirituality includes active searching for meaning in situations, with questions such as “Why am I suffering?”
Pain is complex and a holistic approach may help to meet the needs of your patient.
Pain is not an inevitable part of aging. Likewise, pain perception does not decrease with age.
Age-related changes and increased frailty may lead to a less predictable response to analgesics, increased sensitivity to medications, and potential harmful drug effects. The presence of pain in an older adult requires aggressive assessment, diagnosis, and management.
[Review Box 44-3, Focus on Older Adults: Factors Influencing Pain in Older Adults, with students.]
It is necessary to address misconceptions about pain management in the very young and in older adults before intervening for a patient.
[Review Tables 44-3, Pain in Infants; and 44-4, Misconceptions About Pain in Older Adults, with students.]
Genetic makeup may possibly affect a person’s pain threshold or pain tolerance.
Any factor that interrupts or influences normal pain reception or perception (spinal cord injury, peripheral neuropathy, neurological disease) can affect the patient’s response to pain.
A patient’s attention to pain, previous experiences, and social support systems will affect pain experiences. Repeated pain experiences may help the patient deal with the present pain experience. When in pain, a patient may rely heavily on others for assistance.
Increased attention is associated with increased pain, whereas distraction is associated with a diminished pain response.
Each person learns from painful experiences. Prior experience does not mean that a person accepts pain more easily in the future.
It is crucial to remember that spirituality stretches beyond religion. When experiencing pain, a patient may ask, “Why has God done this to me?”
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14. Factors Influencing Pain (Cont.)
Psychological
Anxiety
Coping style
Pain tolerance
The level of pain a person is willing to accept
Cultural
Meaning of pain
Ethnicity
Anxiety often increases the perception of pain, and pain causes feelings of anxiety. It is difficult to separate the two sensations.
Pharmacological and nonpharmacological approaches to the management of anxiety are appropriate; however, anxiolytic medications are not a substitute for analgesia.
Pain is a lonely experience that often causes patients to feel a loss of control. Coping style influences the ability to deal with pain.
Persons with internal loci of control perceive themselves as having control over events in their life and the outcomes such as pain; persons with external loci of control perceive that other factors in their life, such as nurses, are responsible for the outcome of events.
The meaning that a person associates with pain affects the experience of pain and how one adapts to it.
This is often closely associated with a person’s cultural background, including age, ethnicity, education, race, and familial factors.
Cultural beliefs and values affect how individuals cope with pain. Individuals learn what is expected and accepted by their culture, including how to react to pain.
Health care providers often mis­takenly assume that everyone responds to pain in the same way. Different meanings and attitudes are associated with pain across various cultural groups.
An understanding of the cultural meaning of pain helps you design culturally sensitive care for people with pain.
As a nurse, explore the impact of cultural differences on a patient’s pain experience and make adjustments to the plan of care.
[Review Box 44-4, Cultural Aspects of Care: Assessing Pain in Culturally Diverse Patients, with students.]
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15. Critical Thinking
Knowledge of pain physiology and the many factors that influence pain help you manage a patient’s pain.
Critical thinking attitudes and intellectual standards ensure the aggressive assessment, creative planning, and thorough evaluation needed to obtain an acceptable level of patient pain relief, while balancing treatment benefits with treatment associated risks.
Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards.
To make clinical judgments, you anticipate the information you need, analyze the data, and make decisions regarding patient care.
A patient’s condition or situation is always changing. During assessment consider all critical thinking elements that lead to appropriate nursing diagnoses.
Successful pain management does not necessarily mean pain elimination but rather attainment of a mutually agreed-on pain-relief goal that allows patients to control their pain instead of the pain controlling them.
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16. Nursing Process and Pain
Pain management needs to be systematic.
Pain management needs to consider the patient’s quality of life.
Clinical guidelines are available to manage pain:
American Pain Society
Sigma Theta Tau
National Guidelines Clearinghouse
Nurses approach pain management systematically to understand and treat a patient’s pain.
Successful management of pain depends on establishing a relationship of trust among health care providers, patient, and family.
Pain management extends beyond pain relief, encompassing the patient’s quality of life and ability to work productively, enjoy recreation, and function normally in the family and society.
The American Nurses Association (ANA, 2005) upholds that pain assessment and management is within the scope of every nurse’s practice.
Guidelines are available through the American Pain Society (APS) on the management of pain in the primary care setting; sickle cell pain; cancer pain in adults and children; and pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis.
Sigma Theta Tau International offers guidelines for the older adult on their website (
The National Guidelines Clearinghouse ( posts a variety of pain-management guidelines.
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17. Assessment Through the patient’s eyes
Ask the patient’s pain level
Use ABCs of pain management
Pain is not a number
In selecting a tool to be used with a patient, be aware of the clinical usefulness, reliability, and validity of the tool in that specific patient population.
Be aware of possible errors in pain assessment.
It is important to learn what are a patient’s own values and beliefs about the management of pain and recognize that patient expectations will influence your ability to achieve outcomes in pain management.
Asking a patient about his or her tolerable pain level is a first step in helping a patient regain control. Assessing previous pain experiences and effective home interventions provides a foundation on which you can build. Patients expect nurses to accept their reports of pain and be prompt in meeting their pain needs.
When assessing pain, be sensitive to the level of discomfort and determine what level will allow your patient to function.
Determine the patient’s health literacy.
During an episode of acute pain, streamline your assessment and assess its location, severity, and quality. Collect a more detailed acute pain assessment when the patient is more comfortable.
[Review Box 44-5, Nursing Assessment Questions, with students.]
Using the ABCs of pain management is an effective way to manage pain.
[Review Box 44-6, Routine Clinical Approach to Pain Assessment and Management: ABCDE, with students.]
Because pain is not static but dynamic, accurate assessment requires you to monitor pain on a regular basis along with other vital signs. Some institutions treat pain as the fifth vital sign. Pain assessment is not simply a number. Relying solely on a number fails to capture the multidimensionality of pain and may be unsafe, particularly when the number fails to reflect the entire pain experience, or when the patient does not understand the use of the selected pain rating scale.
[Review Box 44-7, Possible Sources for Error in Pain Assessment, with students.]
Using the right tools and methods helps to avoid errors and ensures the selection of the right pain interventions. Failure of clinicians to accurately assess a patient’s pain, accept the findings, and treat the report of pain is a common cause of unrelieved pain and suffering.
[Review Figure 44-4, Critical thinking model for pain assessment, with students.]
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18. Assessment (Cont.) Patient’s expression of pain
Pain is individualistic
Characteristics of pain
Timing
Location
Severity
A patient’s self-report of pain is the single most reliable indicator of its existence and intensity.
If patients sense that you doubt that pain exists, they share little information about their pain experience or minimize their report.
Patients unable to communicate effectively often require special attention during assessment.
Although no one tool had sufficient reliability and validity, there are clinical practice recommendations.
[Review Box 44-8, Evidence-Based Practice: Pain Assessment in the Nonverbal Patient, with students.]
Patients with cognitive impairments often require insightful assessment approaches involving close observation of vocal response, facial movements (e.g. grimacing, clenched teeth) and body movements (e.g., restlessness, pacing). Also assess social interaction, does the patient avoid conversation? Patients who are critically ill and have a clouded sensorium or the presence of nasogastric tubes or artificial airways require specific questions that they can answer with a nod of the head or by writing out a response. If the patient speaks a different language, pain assessment is difficult. A professional interpreter is often necessary.
When a patient is in pain, conduct a focused physical and neurological examination and observe for nonverbal responses to pain. Examine the painful area to see if palpation or manipulation of the site increases pain.
Ask questions to determine the onset, duration, and time sequence of pain.
Ask a patient to describe or point to all areas of discomfort in order to assess pain location. To localize the pain specifically, have the patient trace the area from the most severe point outward.
[Review Table 44-5, Classification of Pain by Location, with students.]
One of the most subjective and therefore most useful characteristics for reporting pain is its severity.
The purpose of using a pain scale is to identify pain intensity over time so that the effectiveness of pain interventions can be evaluated.
[Shown are Figures 44-5, Sample pain scales. A, Numerical. B, Verbal descriptive. C, Visual analog; 44-6: Asian girl version of the Oucher pain scale; and 44-7: Wong-Baker FACES pain-rating scale.]
[Review Figure 44-8, Faces Pain Scale-Revised (FPS-R), with students.]
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19. Assessment (Cont.) Characteristics of pain (Cont.)
Quality
Aggravating and precipitating factors
Relief measures
Effects of pain on the patient
Behavioral effects
Influence on activities of daily living (ADLs)
Concomitant symptoms
Usually increases pain severity
There is no common or specific pain vocabulary in general use. Patients describe pain in their own way. Assess the terms that patients use to describe their discomfort and then always use these words consistently to obtain an accurate report.
Ask a patient to describe activities that cause or aggravate pain such as physical movement, positions, drinking coffee or alcohol, urination, swallowing, eating food, or psychological stress. Also ask patients to demonstrate actions that cause a painful response such as coughing or turning a certain way. Some symptoms (depression, anxiety, fatigue, sedation, anorexia, sleep disruption, spiritual distress, and guilt) cause worsening of pain or may be aggravated by pain.
It is useful to know whether a patient has an effective way of relieving pain, such as changing position, using ritualistic behavior (pacing, rocking, or rubbing), eating, meditating, praying, or applying heat or cold to the painful site. Assessment of relieving factors also includes identifi­cation of all the patient’s health care providers.
To understand a patient’s pain experience, ask the patient what the pain prevents him or her from doing.
When a patient has pain, assess verbalization, vocal response, facial and body movements, and social interaction. A verbal report of pain is a vital part of assessment. You need to be willing to listen and understand. When a patient is unable to communicate pain, it is especially important for you to be alert for behaviors that indicate pain.
[Review Box 44-9, Behavioral Indicators of Effects of Pain, with students.]
Patients who live with daily pain or who have prolonged pain during a hospitalization are less able to participate in routine activities, which results in physical deconditioning. Ask a patient whether pain interferes with sleep. Pain may impair the ability to maintain normal sexual relations, threatens a person’s ability to work, performing various activities.
Include an assessment of the effect of pain on social activities. Some pain is so debilitating that the patient becomes too exhausted to socialize. Identify a patient’s normal social activities, the extent to which activities have been disrupted, and the desire to participate in these activities.
Concomitant symptoms include nausea, headache, dizziness, urge to urinate, constipation, depression and restlessness. Certain types of pain have predictable concomitant symptoms.
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20. Case Study (Cont.)
Jim is a 26-year-old nursing student assigned to do home visits with the community health nurse. Jim knows that Mrs. Ellis has lived alone since her husband’s death 6 years ago.
Jim conducts assessments, performs procedures, and teaches health promotion to a variety of patients. This is Jim's first experience caring for a patient with severe chronic pain.
[Ask students: In preparing for the visit, what does Jim need to do? Discuss:
Review pain physiology of rheumatoid arthritis.
Prepare to conduct pain assessment.
Draw upon previous experiences and interventions to relieve pain.
Consider professional guidelines for chronic pain management.
Learn about support systems.
Respect personal and cultural meanings of pain.]
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21. Quick Quiz!
1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.
Answer B
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22. Case Study (Cont.)
When Jim enters Mrs. Ellis’ four-room apartment, he finds the home in disarray. Mrs. Ellis is sitting in a recliner in her living room, with clothing on the floor and soiled dishes on a nearby table. She reports that the pain she has been experiencing has made it very difficult to use her hands and walk between rooms. She is able to get to the bathroom, but it causes her to become fatigued.
Her pain is constant and is localized in the joints of her hands and knees.
[Ask students: What assessment activities would you perform if you were Jim? Discuss:
Ask Mrs. Ellis to select a pain scale that she prefers and to rate her current pain intensity.
Ask Mrs. Ellis to rate her pain intensity when it is most severe.
Ask Mrs. Ellis what she does to control her pain.
Ask Mrs. Ellis whether the pain medication is causing any side effects.
Observe Mrs. Ellis standing and walking to the kitchen.
Ask Mrs. Ellis if she has friends or neighbors to assist her.]
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23. Nursing Diagnosis Activity intolerance Anxiety Fatigue Insomnia
Impaired social interaction
Ineffective coping
Impaired physical mobility
An accurate nursing diagnosis may be made only after you perform a complete assessment. The development of accurate nursing diagnoses for a patient in pain results from thorough data collection and analysis.
[Review Box 44-10, Nursing Diagnostic Process: Chronic Pain, with students.]
The nursing diagnosis focuses on the specific nature of a patient’s pain to identify the most useful types of interventions for alleviating it and improving the patient’s function.
Accurate identification of related factors is necessary in choosing appropriate nursing interventions.
The extent to which pain affects a patient’s function and general state of health determines whether other nursing diagnoses are relevant.
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24. Case Study (Cont.)
Mrs. Ellis’ responses lead Jim to this nursing diagnosis: chronic pain related to joint inflammation.
Mrs. Ellis has rated the pain as a 3 on a FACES Pain Scale of 0 to 10, with her most severe pain as a 4.
She has been taking aspirin, but the pain prevents her from falling asleep; if she does sleep, she often reawakens.
She has difficulty standing and an unsteady gait.
As far as people to assist Mrs. Ellis, she replied, “I hate to be a bother, although my next-door neighbor has offered to help in the past.”
[Ask students: What are possible goals and expected outcomes? Discuss:
Goals:
Mrs. Ellis will achieve a sense of pain relief within 1 week; she will ambulate with less discomfort on self-report within 14 days and will perform activities of daily living with less discomfort within 14 days.
Expected outcomes:
Mrs. Ellis will report pain at 2 on a FACES Scale of 0 to 10 following relaxation therapy and heat application.
Mrs. Ellis will demonstrate the ability to rise to a standing position without assistance within 1 week.
She will demonstrate the ability to walk from room to room using a walker with steady gait in 2 weeks.
She will be able to perform dishwashing and house cleaning in 2 weeks.]
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25. Planning Analyze information from multiple sources.
Apply critical thinking
Adhere to professional standards
Use a concept map
Goals and outcomes
Setting priorities
Teamwork and collaboration
Professional standards of care regarding pain management are available as agency policies or through professional organizations such as the American Society for Pain Management Nursing (ASPMN).
Another strategy for planning care is using a concept map. Patients who are in pain frequently have interrelated problems. As one problem gets worse, other aspects of a patient’s level of health also change. A concept map helps you determine how the nursing diagnoses are interrelated with one another and linked to the patient’s medical diagnosis.
A successful plan of care requires a therapeutic relationship with a patient.
When managing pain, goals of care promote a patient’s optimal function. Determine, along with the patient, what are the realistic expectations for pain relief.
Helping patients learn how to manage their pain is always a goal of care.
When setting priorities in pain management, consider the type of pain the patient is experiencing and the effect that it has on various body functions. Work with the patient to select interventions that are appropriate.
A comprehensive plan includes a variety of resources from the healthcare team such as advanced practice nurses, doctors of pharmacology (PharmDs), physical therapists, occupational therapists, physicians, social workers, psychologists, and clergy.
[Review Figure 44-9, Critical thinking model for pain management planning, with students.]
[Review Figure 44-10, Concept map for Mrs. Mays, with students.]
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26. Implementation: Health Promotion
Maintaining wellness
Help patient understand
Health literacy
Patients actively participate in their own well-being whenever possible
Pain therapy requires an individualized approach
You are responsible for administering and monitoring therapies ordered by health care providers for pain relief and independently providing pain-relief measures that complement those prescribed.
Generally try the least invasive or safest therapy first, along with previously used successful patient remedies. If you question a medical therapy, consult with the health care provider.
Apply guidelines for individualizing pain therapy, including:
Use different types of pain-relief measures.
Use measures that patient believes are effective.
Keep an open mind about ways to relieve pain.
Keep trying. When efforts at pain relief fail, do not abandon the patient but reassess the situation.
Health literacy significantly affects a patient’s pain experience and understanding of pain management strategies.
Common holistic health approaches include wellness education, regular exercise, rest, attention to good hygiene practices and nutrition, and management of interpersonal relationships.
In the case of acute pain, nonpharmacologic measures should never be used in place of pharmacologic therapies.
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27. Implementation: Health Promotion (Cont.)
Nonpharmacological pain-relief interventions
Cognitive and behavioral approach
Relaxation and guided imagery
Distraction
Music
Cutaneous stimulation
Cold and heat application
Transcutaneous electrical nerve stimulator (TENS)
Herbals
Reducing pain perception and reception
An evidence-based practice protocol for pain management in older adults recommends these guidelines for nonpharmacological therapies:
Tailor nonpharmacological techniques to the individual.
Cognitive behavioral strategies may not be appropriate for the cognitively impaired.
Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain and are generally safe and effective.
Relaxation and guided imagery allow patients to alter affective-motivational and cognitive pain perception. Relaxation is mental and physical freedom from tension or stress that provides individuals a sense of self-control.
Distraction directs a patient’s attention to something other than pain and thus reduces awareness of it.
Music therapy may be useful in treating acute or chronic pain, stress, anxiety, and depression.
Stimulation of the skin through a massage, warm bath, cold application, and TENS may be helpful in reducing pain perception.
[Review Box 44-11, Procedural Guidelines: Massage, with students.]
Cold and heat applications relieve pain and promote healing.
Another form of cutaneous stimulation is transcutaneous electrical nerve stimulation (TENS), involving stimulation of the skin with a mild electrical current passed through external electrodes.
Many patients use herbals and dietary supplements such as echinacea, ginseng, ginkgo biloba, and garlic despite conflicting research evidence supporting their use in pain relief.
One simple way to promote comfort is to remove or prevent painful stimuli.
[Review Box 44-12, Controlling Painful Stimuli in the Patient’s Environment, with students.]
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28. Implementation: Health Promotion (Cont.)
Acute care: pharmacological pain therapies
Analgesics
Nonopioids
Opioids
Adjuvants/co-analgesics
Analgesics are the most common and effective method of pain relief. There are three types of analgesics: (1) nonopioids, includ­ing acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs); (2) opioids (traditionally called narcotics); and (3) co-analgesics or adjuvants, a variety of medications that enhance analgesics or have analgesic properties that were originally unknown.
Nonopioids include acetaminophen and NSAIDs. Acetaminophen has no anti-inflammatory or antiplatelet effects. NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli. Long-term use is associated with gastrointestinal (GI)bleeding and renal insufficiency.
Opioids are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opioids that always precedes respiratory depression. One way to maximize pain relief while potentially decreasing opioid use is to administer analgesics around the clock (ATC) rather than on a prn basis.
Opioids can cause numerous, but common, side effects.
[Review Box 44-13, Common Opioids Side Effects, with students.]
Careful assessment and critical thinking is required to safely administer analgesics.
[Review Box 44-14, Nursing Principles for Administering Analgesics, with students.]
When you convert a patient from an intravenous (IV) to an oral form of the same opioid, understand that the dose of the oral opioid is usually much higher than the IV dose because of the first-pass effect.
Opioids are usually necessary and effective for acute pain and cancer pain of moderate or severe intensity.
Many patients are at higher risk for opioid-related adverse drug events.
[Review Box 44-15, Patient Characteristics Associated with Higher Risk for Opioid-Related Adverse Drug Events, with students.]
The Joint Commission requires health care agencies, where permissible, to have range-order policies in place to guide nurses in selecting the most appropriate dose of a medication.
Follow these guidelines from the American Society for Pain Management Nurses:
Avoid administration of partial doses at more frequent intervals so as to not underdose a patient with small, frequent, ineffective doses from within a range (e.g., giving oxycodone 10 mg q 2 hours when the order reads oxycodone 10 to 20 mg q 3 hours PRN).
Avoid making a patient wait a full time interval after giving a partial dose within the allowed range.
Wait until peak effect of the first dose has been reached before giving a subsequent dose.
Adjuvants and co-analgesics are drugs used to treat other conditions, but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).
[Shown is Figure 44-11: Multimodal analgesia sites of action. © Elsevier Collections.]
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29. Case Study (Cont.)
Jim discussed with Mrs. Ellis’ primary health care provider the possibility of starting a disease-modifying antirheumatic drug (DMARD), a biological response modifier, a nonsteroidal antiinflammatory drug (NSAID), or an analgesic.
Jim had Mrs. Ellis take analgesics approximately 30 minutes before ambulating, performing self-care activities, or going to sleep. He instructed her to take medication with a light snack or meal and a full glass of water. During instruction, he explained that the drug will relieve the pain.
[Ask students: What is the rationale for using more than one type of pain medication? Discuss: Different medications are used to control the pain and symptoms of rheumatoid arthritis.]
[Ask students: What is the rationale for having Mrs. Ellis take the analgesics ahead of activities? Discuss: Medication will exert peak effect when the patient begins activities. Administration with food and water reduces the chances of gastrointestinal upset. An added positive effect occurs when the patient understands the action and purpose of the analgesic and believes the medication will relieve pain.]
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30. Patient-Controlled Analgesia
Allows patient to self-administer with minimal risk of overdose
Maintains a constant plasma level of analgesic
[Review Skill 44-1: Patient-Controlled Analgesia, with students.]
Systemic patient-controlled analgesia (PCA) traditionally involves IV or subcutaneous drug administration. However, a controlled analgesia device for oral medications is available. This device allows patients access to their own oral prn mediations, including opioids and other analgesics, antiemetics, and anxiolytics, at the bedside.
PCA infusion pumps are portable and computerized and contain a chamber for a syringe or bag that delivers a small, preset dose of opioid. To receive a demand dose, a patient pushes a button attached to the PCA device. The PCA infusion pumps are designed to deliver a specific dose, which is programmed to be available at specific time intervals (usually in the range of 8 to 15 minutes) when the patient activates the delivery button.
There are many benefits to PCA use. The patient gains control over pain, and pain relief does not depend on nurse availability. Patients also have access to medication when they need it. This decreases anxiety and leads to decreased medication use. Small doses of medications are delivered at short intervals, stabilizing serum drug concentrations for sustained pain relief.
Patient preparation and teaching is critical to the safe and effective use of PCA devices.
[Review Box 44-16, Patient Teaching: Patient-Controlled Analgesia, with students.]
An established and properly functioning intravenous catheter is needed for intravenous PCA. Check the IV line and PCA device per institutional policy to ensure proper functioning.
[Shown is Figure 44-12: Patient-controlled analgesia pump with cassette.]
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31. Pharmacological Pain Therapies
Topical analgesics
Creams, ointments, patches
Local anesthesia
Local infiltration of an anesthetic medication to induce loss of sensation to a body part
Regional anesthesia
Perineural local anesthetic infusion
Commonly used topical agents include NSAID products (ketoprofen patch) and capsaicin.
Do not place eutectic mixture of local anesthetics (EMLA) around the eyes, the tympanic membrane, or over large skin surfaces. The Lidoderm patch is a topical analgesic effective for cutaneous neuropathic pain, such as postherpetic neuralgia, in adults. Place three patches, cut to size, on and around the pain site using a 12-hour on, 12-hour off schedule.
Health care providers often use local anesthesia during brief surgical procedures such as removal of a skin lesion or suturing a wound by applying local anesthetics topically on skin and mucous membranes or by injecting them subcutaneously or intradermally to anesthetize a body part.
Regional anesthesia is the injection or infusion of local anesthetics to block a group of sensory nerve fibers.
For perineural local anesthetic infusion, a surgeon places the tip of an unsutured catheter near a nerve or groups of nerves and the catheter exits from the surgical wound.
Local anesthetics cause side effects, depending on their absorption into the circulation. Pruritus or burning of the skin or a localized rash is common after topical applications. Application to vascular mucous membranes increases the chance of systemic effects such as a change in heart rate. The use of local anesthetics in peripheral nerve and epidural infusions (see below) may block motor nerves as well as sensory nerves.
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32. Pharmacological Pain Therapies (Cont.)
Epidural analgesia
Regional
Administered into epidural space
Epidural analgesia effectively treats acute postoperative pain, rib fracture pain, labor and delivery pain, and chronic cancer pain.
Epidural analgesia controls or reduces severe pain and reduces a patient’s overall opioid requirement, thus minimizing adverse effects. Epidural analgesia is short or long term, depending on a patient’s condition and life expectancy.
The health care provider administers epidural analgesia into the spinal epidural space by inserting a blunt-tip needle into the level of the vertebral interspace nearest to the area requiring analgesia. The health care provider advances the catheter into the epidural space, removes the needle, and secures the remainder of the catheter with a dressing while ensuring the catheter is taped securely.
One of the concerns related to the use of peripheral and epidural anesthetic techniques is the risk of bleeding and subsequent hematoma formation near the injection/insertion site.
Safe placement or removal of these injections and catheters is based on knowledge of the patients’ coagulation status as well as the timing of administration of anticoagulant or antiplatelet medications.
Because the epidural space is a highly vascular area, patients with epidural catheters are at risk for the development of epidural hematomas, which may lead to ischemia of the spinal cord, and if unaddressed, serious neurological complications.
[Shown is Figure 44-13: Anatomical drawing of epidural space.]
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33. Case Study (Cont.) Jim also suggested the following to Mrs. Ellis:
Place a sturdy stool in the shower stall and run warm water continuously over joints of the hands and feet.
Apply moist, warm compresses to the joints of the hands three times a day.
Referral to a physical therapist to determine possible use of a walker or other assistive device.
[Ask students: What are the rationales for these additional measures? Discuss. Heat reduces pain of chronic arthritis by improving blood flow and reducing stiffness of inflamed tissues. Cutaneous stimulation activates mechanoreceptor A-beta fibers, thus inhibiting transmission of pain by releasing inhibitory neurotransmitters. Physical therapists teach effective exercise and ambulation techniques to reduce pain and conserve energy.]
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34. Implementation (Cont.)
Nursing implications
You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia.
After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return.
Nursing implications for managing epidural analgesia are numerous.
Patient education.
Provide emotional support to patients receiving local or regional anesthesia by explaining the insertion technique and warning patients that they will temporarily lose sensory function within minutes of injection. Motor and autonomic (bowel and bladder control) function may also be quickly lost, depending on the area anesthetized.
After administration of a local or regional anesthetic, protect the patient from injury until full sensory and motor function return.
When managing epidural infusions, if agency policy allows, connect the catheter to an infusion pump, a port, or reservoir, or cap it off for bolus injections. To reduce the risk of accidental epidural injection of drugs intended for IV use, clearly label the catheter epidural catheter.
[Review Table 44-6, Nursing Care for Patients with Epidural Infusions, with students.]
Do not administer supplemental doses of opioids or sedative/hypnotics because of possible additive central nervous system adverse effects.
To minimize bleeding risks and the potential for hematoma formation, anticoagulant and antiplatelet medications should not be administered until safe use can be verified with a pain specialist.
The patient needs to receive thorough education about epidural analgesia in terms of the action of the medication and its advantages and disadvantages.
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35. Implementation (Cont.)
Nursing implications for local and regional anesthesia
Provide emotional support
Protect patient from injury
Patient education
Invasive interventions for pain relief
Procedure pain management
Cancer pain and chronic noncancer pain management
Provide emotional support to patients receiving local or regional anesthesia by explaining the insertion technique and warning patients that they will temporarily lose sensory function within minutes of injection.
After administration of a local or regional anesthetic, protect the patient from injury until full sensory and motor function return. Patients are at risk for injuring an anesthetized body part without knowing it.
When managing epidural infusions, if agency policy allows, connect the catheter to an infusion pump, a port, or reservoir, or cap it off for bolus injections. To reduce the risk of accidental epidural injection of drugs intended for IV use, clearly label the catheter epidural catheter.
Nursing implications for managing epidural analgesia are numerous.
Do not administer supplemental doses of opioids or sedative/hypnotics because of possible additive central nervous system adverse effects.
When patients receive epidural analgesia, initially monitor them as often as every 15 minutes, including assessment of vital signs, respiratory effort, and skin color. Once stabilized, monitoring occurs every hour in the first 12 to 24 hours and then with less frequency if the patient is stable.
To minimize bleeding risks and the potential for hematoma formation, anticoagulant and antiplatelet medications should not be administered until safe use can be verified with a pain specialist.
The patient needs to receive thorough education about epidural analgesia in terms of the action of the medication and its advantages and disadvantages. Instruct patients about the potential for side effects and to notify their health care provider if side effects develop.
When severe pain persists despite medical treatment, available invasive interventions include intrathecal implantable pumps or injections, spinal cord and deep brain stimulation, neuroablative procedures (cordotomy, rhizotomy), trigger point injections, cryoablation, and intraspinal medications.
Diagnostic and treatment procedures potentially produce pain and anxiety, both of which should be assessed and treated before a procedure begins.
Cancer pain is either chronic or acute. The prevalence of pain varies amongst cancer patients. A review of research spanning 40 years shows the prevalence ranging from 64% in patients with metastatic, advanced or terminal phases of the disease, 59% in patients on anticancer treatment, and 33% in patients after curative treatment.
Many patients with cancer experience breakthrough cancer pain (BTCP), a transient worsening of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain.
[Review Box 44-17, Types of Breakthrough Pain and Treatment, with students.]
The American Pain Society reports that the primary goal in treating chronic noncancer pain with opioids is to increase patients’ level of function rather than just to provide pain relief.
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36. Quick Quiz!
2. A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: A. adjunctive therapy. B. nonopioids. C. NSAIDs. D. PCA pain management.
Answer: D
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37. WHO Analgesic Ladder WHO, World Health Organization.
The World Health Organization (WHO) recommends a three-step approach, the “analgesic ladder” to the management of cancer pain.
Treatment begins with NSAIDs and/or adjuvants and progresses to opioids.
This three-step approach has been used worldwide and has been praised for its simplicity and ease of use. However, the ladder has been the object of criticism.
[Shown are Figures 44-14: WHO analgesic ladder is a three-step approach in treating cancer pain, and 44-15: Adaptation of the analgesic ladder. (From Vargas-Schaffer G: Is the WHO analgesic ladder still valid?: Twenty-four years of experience, Can Fam Physician 56:514, 2010.)]
A bidirectional approach has been suggested in which, in addition to the original step up approach, a step-down approach would be used for patients with intense acute pain, uncontrolled cancer pain, and breakthrough pain.
Another modification includes the addition of a fourth step which recommends neurosurgical and other invasive procedures and also includes management of pediatric pain and acute pain in emergency departments and in postoperative situations.
All patients on chronic opioid therapy require monitoring and follow-up.
Many patients, family members, and health care providers have concerns about the risks of addiction associated with opioid use. Estimates of addiction in patients with chronic persistent pain range from 6% to 10%.
Administer analgesics rectally when patients are unable to swallow, have nausea or vomiting, or are near death.
When a patient first receives continuous-drip opioids, the IV access needs to be patent and without complications.
WHO, World Health Organization.
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38. Implementation (Cont.)
Physical dependence: A state of adaptation that is manifested by a drug class–specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time
Placebos
[Review Box 44-18, Barriers to Effective Pain Management, with students.]
Lack of knowledge and misconceptions about pain and appropriate pain management present significant barriers.
Patients and health care providers often do not understand the differences between physical dependence, addiction, and drug tolerance.
[Review Box 44-19, Definitions Related to the Use of Opioids in Pain Treatment, with students.]
Experiencing a physical dependency does not imply addiction, and drug tolerance in and of itself is not the same as addiction.
There are many different definitions and interpretations of the terms placebo and placebo effect. It is generally accepted that placebos are pharmacologically inactive preparations or procedures that produce no beneficial or therapeutic effect. Professional organizations discourage the use of placebos to treat pain. It is considered unethical and deceitful to administer them. Placebo use jeopardizes the trust between patients and their caregivers. If a placebo is ordered, question the order. Many health care agencies have policies that limit the use of placebos to research only.
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39. Restorative and Continuing Care
Pain clinics, palliative care, and hospices
Pain centers treat patients on an inpatient or outpatient basis.
The goal of palliative care is to learn how to live life fully with an incurable condition.
Hospices are programs for end-of-life care.
The American Nurses Association (ANA) supports aggressive treatment of pain and suffering, even if it hastens a patient’s death.
A comprehensive pain center treats persons on an inpatient or outpatient basis. Staff members representing all health care disciplines (e.g., nursing, medicine, physical therapy, pastoral care, dietetics) work with patients to find the most effective pain-relief measures. A comprehensive clinic provides not only diverse therapy but also research into new treatments and training for professionals.
Many hospitals have palliative care departments to help patients and their family members successfully manage disease. The goal of palliative care is to learn to live life fully with an incurable condition.
Hospice helps terminally ill patients continue to live at home or in a health care setting in comfort and privacy. Pain control is a priority for hospices. Under the guidance of hospice nurses, families learn to monitor patients’ symptoms and become the primary caregivers.
Hospice programs help nurses overcome their fears of contributing to a patient’s death when administering large doses of opioids. Recent research suggests that moderate opioid dose increases in patients who are terminally ill do not hasten death. The disease, not the opioid, is killing the patient.
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40. Quick Quiz!
3. A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when:
A. you compare assessed pain w/baseline pain.
B. body language is incongruent with reports of pain relief.
C. family members report that pain has subsided.
D. vital signs have returned to baseline.
Answer: A
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41. Case Study (Cont.)
When Jim observed Mrs. Ellis’ ability to stand and walk from the living room to the kitchen, she was able to ambulate with the walker; her gait was slow but steady.
Mrs. Ellis reports that she has less discomfort from bathing after using warm water over her joints, although dressing is still causing some discomfort when manipulating buttons.
Mrs. Ellis rates her pain at a 2 after taking the analgesic.
Jim considers referring Mrs. Ellis to an occupational therapist to adapt clothes fasteners requiring less hand mobility. He is pleased that her discomfort level has diminished.
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42. Evaluation Through the patient’s eyes Patient outcomes
Patients help decide the best times to attempt pain treatments
They are the best judge of whether a pain-relief intervention works
Patient outcomes
Evaluate for change in the severity and quality of the pain
For patients with chronic pain, the effect of the pain intervention on the patient’s function should be considered when evaluating the patient’s perception of his or her response to treatment.
If patients state that an intervention is not helpful or even aggravates the discomfort, stop it immediately and seek an alternative. Time and patience are necessary to maximize the effectiveness of pain management. Educate patients about what to expect. For a patient in acute pain, reassure that you will check back frequently to assess for changes in pain level. Continually assess if the character of the patient’s pain changes and whether individual interventions are effective.
A patient’s behavioral responses to pain-relief interventions are not always obvious.
Evaluating the effectiveness of a pain intervention requires you to evaluate for change in the severity and quality of the pain. Also be sure to evaluate after an appropriate period of time.
Ask a patient if a medication alleviates the pain when it is peaking. Do not expect the patient to volunteer the information.
If patient outcomes are not met, ask the patient:
What is your current pain level?
How far away is your pain level from your goal?
What side effects are you experiencing from your pain medication?
What have you done to help manage your pain?
Describe limitations in function you are experiencing related to uncontrolled pain.
How is your pain limiting or altering your rest and sleep?
Effective communication of the assessment of a patient’s pain and the response to intervention is facilitated by accurate and thorough documentation.
[Review Box 44-20, Checklist for Communicating Patients’ Unrelieved Pain to Colleagues, with students.]
[Review Figure 44-16, Critical thinking model for pain-management evaluation, with students.]
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43. Safety Guidelines
The patient is the only person who should press the button to administer the pain medication when PCA is used.
Monitor the patient for signs and symptoms of oversedation and respiratory depression.
Monitor for potential side effects of opioid analgesics.
Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care.
When performing the skills in this chapter, remember these points to ensure safe, individualized patient care.
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44. Case Study (Cont.)
Two weeks after his last visit, Jim returns to evaluate Mrs. Ellis’ progress. She has gone to see a nurse practitioner, who prescribed an NSAID for her arthritic pain. She has not filled the prescription and is still taking her aspirin, but continues to have some gastrointestinal irritation. Jim gets the chance to observe Mrs. Ellis using a warm compress on her hands and notes that her gait is steadier.
Mrs. Ellis has spoken with her neighbor, who has offered to help with shopping.
[Ask students: What are the important elements a documentation note would contain? Discuss:
Steadier gait
Proper warm compress application
Less fatigued
Replaced aspirin with NSAID]
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