1. Chapter 55:
Pain Management

2. Pain It is a subjective symptom; only the client can describe it
It is the body’s signal of distress
It is a warning that tissues are being damaged
McCaffrey states “Pain is whatever the experiencing person says it is, existing whenever he says it does.”

3. Causes of Pain
Mechanical stress of trauma, surgical incision, or tumor growth
Physical causes include mechanical stressors
1. trauma
2. MI
Excesses in pressure, heat and cold
Chemical substances released when tissues are damaged or destroyed
Lack of oxygen to tissues
Muscle spasms

4. The Pain Cycle

5. Pain Transmission and Interpretation: Nociception
Transduction: The nervous system changes painful stimuli in nerve endings to impulses.
Transmission: The impulses travel from their original site to the brain.
Perception: The brain recognizes, defines, and responds to pain.
Modulation: The body activates needed inhibitory responses to the effects of pain.

6. The International Association for the Study of Pain (IASP): Types of Pain
*Acute pain or nociceptive pain
After the underlying cause is identified and successfully treated, acute pain disappears
*Referred pain
Cancer pain
*Chronic pain or neuropathic pain
Limited, intermittent, or persistent
Neuropathic
*Intractable pain
*phantom limb pain
*psychogenic pain
*monitor body cues for pain

7. Results of the Chronic Pain Experience
Loss of control
Decreased self-esteem and communication
Inappropriate life goals
Change in relationships, lack of sexual activity, role changes within family
Anger of family and friends over need to do client’s work or “take care of ” client
Depression, symptoms include
1. fatigue
2. sleeping too much
3. lack of interest in surroundings
4. sexual impotence

8. *Factors Affecting Pain Perception
Pain threshold
Lowest intensity of a stimulus that causes the subject to recognize pain
Pain tolerance
The point at which a person can no longer endure pain

9. Factors affecting pain perception
Endorphins
Naturally occurring substances produced by the central nervous system to relieve pain
Intake of certain chemicals alter endorphin production
1. caffeine
2. nicotine
3. alcohol
4. sugar

10. Collection of Client Data About Pain
The fifth vital sign
Document
Level of pain
Description of pain
Action taken
Results

11. Joint Commission Accreditation Standards: Pain
1. Patients have the right to appropriate evaluation and management of pain.
2. On-going data collection should include the nature and intensity of pain.
3. Responses to evaluation of pain should be recorded so regular reassessment and follow-up occurs.
4. Staff must be oriented and competent in gathering data and pain management.

12. Joint Commission Accreditation Standards: Pain (cont.)
Policies and procedures supporting ordering of pain medications must be in place.
(Clients) and families require education about effective pain management.
Discharge planning should address the (client’s) needs for pain management.

13. Pain Rating Scales 1. Pain Intensity Scale or Pain Distress Scale
Reserved children older than 7
2. McGill–Melzack Pain Questionnaire
Wong–Baker Faces Pain Scale
Can be used for adults who have difficulty expressing themselves or people who do not speak the prevailing language at the facility
FLACC
NIPS
PAINAD
DMC Pain Assessment Behavioral Scale
3. Numeric
0-10 scale

14. Documentation of Pain Level of pain Description of pain Action taken
Response to interventions

15. Description of Pain *Character Duration
Occasional, intermittent, spasmodic, or constant
Severity
Mild, slight, moderate, severe, or excruciating
Associated factors

16. COLDSPA Memory Guide
Character: Describe the pain. How does it feel? Be specific. Is it constant, occasional, or recurring?
Onset: When did the pain start? How long have you had it?
Location: Where is the pain? Internal or external? Does it radiate? Where does it start and where does it radiate to? Is it always in the same place?
Duration: How long does the pain last? Does it come back? How often?

17. COLDSPA Memory Guide (cont.)
Severity: How bad is the pain? (Use an appropriate rating scale.)
Pattern: Does anything relieve the pain? What? Does anything make it worse? Does anything specific seem to cause the pain?
Associated Factors or Related Occurrences: Are other symptoms associated with the pain (headache, visual difficulties, sensitivity to light, nausea)?

18. Teaching Client to Manage Chronic Pain
Medications
Exercise
Nutrition
Recreation
Relaxation
Support
Hobbies
Rest/sleep
*alternative/complementary therapy

19. Route of Administration/Analgesics
IM injections
Epidural medications delivered by infusion catheter
Continuous and perfusion to surgical site
Perineural administration
*PCA pump
CCA pump
NCA pump

20. Pharmacologic Therapy
Analgesics provide pain relief by altering the body’s sodium and potassium levels thus slowing or halting pain transmission.
Nonopioid nonsteroidal anti-inflammatory drugs (NSAIDs)*
Mild to moderate pain
Opioids/narcotic analgesics
Morphine
Used to manage pain in clients with moderate to severe pain*
Adjuvant drugs
Anticonvulsants and antidepressants
Ointments and liniments

21. Surgical Intervention
Surgery may be necessary to alleviate certain types of chronic pain
Herniated disk
Tumors causing pressure
Pinched nerves
Ablation surgery
Cut the nerves transmitting the pain sensation

22. Nursing Interventions
Independent comfort measures
Diversion, changing position, bathing, massage hands, giving a back rub*
Encourage nutritious diet and adequate fluids
Assist with elimination
Monitor voiding and bowel patterns
Offer ordered medications to prevent constipation and diarrhea

23. Nursing Interventions
Physical measures
Physical stimulus (cutaneous stimulation) TENS
Allows client to wear an electronic device and trigger and electrical stimulation when he or she feels pain*
Heat and cold application (vasodilate and vasoconstrict)
*need MD order
Exercise

24. Nursing Interventions
Cognitive–behavioral measures
Distraction and diversion
Deep relaxation and guided imagery
*Support groups and stress management
Gives client an opportunity to express feelings and talk about pain with others who can relate

25. Alternative Techniques
*Chiropractic care
*Acupuncture or acupressure
*Hypnosis
*Biofeedback
*therapeutic massage
Homeopathy
Use of flower essences and aromatic oils
Herbal remedies

26. The Nursing Process Data gathering Possible nursing diagnoses Planning
Implementation
Evaluation