1. Chapter 15
Pain Management

2. Learning Objectives Define pain.
Explain the physiologic basis for pain.
Identify situations in which patients are likely to experience pain.
Explain the relationships between past pain experiences, anticipation, culture, anxiety, or activity and a patient’s response to pain.
Identify differences in the duration of pain and patient responses to acute and chronic pain.

3. Learning Objectives
Explain the special needs of the older adult patient with pain.
List the data to be collected in assessing pain.
Describe interventions used in the management of pain.
Describe the nursing care of patients receiving opioid and nonopioid analgesics for pain.
List the factors that should be considered when pain is not relieved with analgesic medications.

4. Definition of Pain
International Association for the Study of Pain defines it as an unpleasant sensory and emotional experience associated with actual or potential tissue damage
McCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses: “Pain is whatever the person experiencing it says it is and exists whenever he says it does”

5. Definition of Pain
International Association for the Study of Pain defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”
McCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses: “Pain is whatever the person experiencing it says it is and exists whenever he says it does”

6. Physiology of Pain
Sensory experiences: time/space, emotions, cognition
Afferent pathways
Nerves that carry messages to the brain for interpretation
Efferent (or descending) pathways
Carry messages away from the brain via spinal cord
Nociceptors
Receptors that activate the afferent pathways
Unevenly distributed in muscles, tendons, subcutaneous tissue, and the skin
Why are parts of the body are more sensitive to pain than other parts?

7. Physiology of Pain
Pain receptors are sensitive to chemical changes, temperature, mechanical stimuli, and tissue damage
Pain receptors are unable to adapt to repeated stimuli and thus continue to react until stimuli are removed
When pain receptors are stimulated, impulses are transmitted to the spinal cord

8. Physiology of Pain
Impulses then travel up the spinal cord to the brain
In the brain, the cortex interprets the impulses as pain and identifies the location and qualities of the pain
Endorphins and enkephalins, natural opioid-like substances: block transmission of painful impulses to the brain
Once pain is transmitted to the spinal cord and brain, the descending pathway is activated and several substances such as endorphins, serotonin, norepinephrine, gamma-aminobutyric acid (GABA), and enkephalins are released to inhibit pain transmission to the spinal cord.
Why do some people experience more pain than others?

9. Gate-Control Theory Pain reflects physical and psychosocial factors
Painful impulses are transmitted to the spinal cord through small-diameter nerve fibers in the afferent pathway
When these fibers are stimulated, the gating mechanism opens in the spinal cord, which permits the transmission of impulses from the spinal cord to the brain
Many theories have been proposed to explain pain, but none fully describe the pain experience.
Who are Melzack and Wall?

10. Gate-Control Theory
Factors that cause the gate to open include tissue damage, a monotonous environment, and fear of pain
Stimulation of large-diameter fibers can close the gate and interfere with impulse transmission between spinal cord and the brain, causing diminished pain perception
Large-diameter nerve fibers are stimulated by cutaneous (skin) stimulation through massage, position change, and heat or cold applications.
What types of sensory input may close the gate?

11. Figure 15-1

12. Factors Influencing Response to Pain
Although people may have the same injury or insult, they may respond differently because many physical and psychosocial factors affect the response to pain
Important for health professionals to be nonjudgmental and to avoid comparing one individual in pain with another

13. Physical Factors Pain threshold Pain tolerance Age
Point at which stimulus causes sensation of pain
Pain tolerance
Intensity of pain that a person will endure
Age
Physical activity and nervous system integrity
Surgery and anesthesia
Type of surgery performed and the type of anesthesia used can influence the response to pain
Anger, fatigue, anxiety, insomnia, depression, and uncontrolled pain all lower the pain threshold.
Increasing or prolonged pain may lower the pain tolerance because the patient fears the pain will not be relieved.
Pain is not a normal part of aging, but older adults often suffer from chronic conditions such as arthritis, cancer, and bone fractures that are associated with pain.
How can physical activity affect pain?
Some anesthetic agents injected at the operative site may prolong analgesia for 12 to 24 hours after surgery.

14. Psychological Factors
Culture and ethnicity
Different ways of expressing/responding to pain
Religious beliefs
Some patients may pray and believe that divine intervention will help them to endure the pain
Others may view pain as a punishment for sins
Some believe that suffering is required before pain relief
It is critical to avoid making judgments based on how you think a person should react or behave.
What reactions may patients have to pain?

15. Psychological Factors
Past experiences and anxiety
May have developed positive coping strategies to deal with previous painful experiences
If strategies were unsuccessful, may be very anxious and overwhelmed by another painful experience
Situational factors
If pain associated with a serious illness, it may have a greater effect on mood and activity than if the pain were associated with a less serious condition

16. Autonomic Nervous System
Activates the fight-or-flight response; certain physiologic responses initiated
The nervous system responses measured by increased heart rate, respiratory rate, and blood pressure
Acute and chronic pain elicit different kinds of responses
The pain signal is interpreted by the brain as a stressor.
What behaviors may the patient exhibit in response to pain?

17. Acute Pain
Follows the normal pathway for pain from nociceptor activation to the brain and may be called nociceptive pain
Cause is known and treatable
It serves as a warning of tissue damage and subsides when healing takes place
Behavioral and physiologic signs: when patient guards or rubs a body part, wrinkles the brow, bites the lip, and has changes in the heart rate, blood pressure, and respiratory rate

18. Chronic Pain Persists/recurs for >6 months; may last a lifetime
Most chronic pain is neuropathic pain because it follows an abnormal pathway for pain
Results from nerve damage from anatomic and physiologic conditions and underlying diseases
Includes unusual sensations such as burning, shooting pain, and abnormal sensations that occur when there is no painful stimulus present
See Table 15-2, p. 206
Treatment may or may not be helpful in relieving the pain.
Chronic pain is associated with a variety of diagnoses, including cancer, arthritis, peripheral vascular diseases, and traumatic injuries.
What is chronic nonmalignant or benign pain?

19. Comparison of Acute and Chronic Pain
Chronic pain serves no useful purpose; acute warns of tissue damage and trauma
Nursing assessment to identify
Type and amount of pain
Chronic or acute
If acute and chronic pain at the same time
Chronic pain can lead to depression, marital difficulties, loss of self-esteem, immobility, and isolation.
When the patient reports pain but shows no physical symptoms, this does not mean there is no pain.

20. Figure 15-2

21. Nursing Care of the Patient in Pain

22. Assessment Should be done on admission and on a regular basis
Assessment of vital signs is called the fifth vital sign
Assessment is the first step in pain management.
Pain should be anticipated as a result of what situations?
Visual, speech, hearing, and motor impairments may limit the ability of older patients to communicate pain or to use scales to rate pain.
When the patient cannot report pain, the nurse may need to perform a different assessment, which includes observing for usual or unusual behaviors that may indicate pain.

23. Assessment Six steps Accept the patient’s report
Determine the status of the pain
Describe the pain
Location, quality, intensity, aggravating and alleviating factors
Examine the site of the pain
Identify coping methods
Document assessment findings and evaluate interventions
Obtain specific details about the pain, and respond positively that action will be taken to relieve the pain.
Ask the patient if he or she has had this pain before and whether it was diagnosed by a physician.
Assess the area for heat, redness, swelling, tenderness, abnormal position, or other factors that may be causing local irritation.
What are some coping methods patients may use?
Record the location, quality, and intensity of the pain, related factors, and how the patient copes with pain.

24. Figure 15-5

25. Nonpharmacologic Interventions
Those that do not employ drugs
Physical interventions
Physical comfort measures
Environmental control
Stimulation techniques
Anxiety reduction
Distraction
Psychological interventions
Relaxation
Imagery
Comfort may increase pain tolerance, and the patient may experience less pain.
Stimulation of the skin and underlying tissues relieves pain.
What types of skin or cutaneous stimulation can be applied to relieve pain?
Anxiety, fear of the unknown, and feelings of loss of control may be directly related to the level of pain experienced.
Distraction refers to focusing on stimuli other than pain.

26. Pharmacologic Interventions
Nonopioid analgesics
Aspirin, acetaminophen, and nonsteroidal anti-inflammmatory drugs (NSAIDs) such as ibuprofen
Generally initial treatment choice for mild pain
Act mostly on the peripheral nervous system
Antipyretic (fever-reducing), analgesic (pain-reducing), and/or anti-inflammatory (inflammation-reducing) properties
See Table 15-4, p. 216
When administering analgesics, keep in mind that it is critical to use a preventive approach to pain management.
Who is responsible for assessing the pain, deciding which analgesic and how much to administer, and evaluating the drug’s effectiveness?

27. Pharmacologic Interventions: Opioid Analgesics
For moderate to severe acute pain, chronic cancer pain, and some other types of pain
Opioids: potency/duration of action vary
Opioid agonists
Examples: codeine, methadone (Dolophine), hydromorphone (Dilaudid), meperidine (Demerol), morphine, and fentanyl
Both types of opioids relieve pain at the level of the central nervous system.
Why are older adults generally more sensitive to the analgesic effects of opioids?

28. Pharmacologic Interventions: Opioid Analgesics
Opioid agonist-antagonists
Examples: buprenorphine (Buprenex), nalbuphine (Nubain), butorphanol (Stadol), and pentazocine (Talwin)

29. Pharmacologic Interventions: Opioid Analgesic Misconceptions
Patients, families, nurses, and physicians have misconceptions about addiction; therefore, the term must be defined and differentiated from the terms tolerance and physical dependence
Tolerance and physical dependence are normal responses to continued opioid administration for pain relief; they do not lead to a craving for the drug for its mind-altering effects
Fear of addiction greatly exaggerated; rare (<1%) in patients taking opioids for pain relief
The patient who is tolerant requires higher doses of a drug to achieve an analgesic effect.
The patient who is physically dependent on an opioid will experience unpleasant withdrawal symptoms when the opioid is stopped.

30. Pharmacologic Interventions: Opioid Analgesics
Routes of administration
Oral
Intramuscular
Sublingually
Intravenously: intermittent bolus injections, continuous infusions, or patient-controlled analgesia (PCA)
Epidural or intrathecal route
A limited number of opioids, such as morphine, hydromorphone, and oxymorphone, may be administered rectally.
How is medication administered via a PCA pump?

31. Pharmacologic Interventions: Opioid Analgesics
Side effects
Constipation
Nausea, with or without vomiting
Sedation
Respiratory depression
Confusion
Hypotension (especially orthostatic)
Dizziness
Urinary retention

32. Pharmacologic Interventions: Placebos
Inactive substances (e.g., saline) used in research or clinical practice to determine the effects of a legitimate drug or treatment
Appropriately used in studies in which patients consent to participate

33. Pharmacologic Interventions: Placebos
Many health care organizations take the position that placebos should not be used to assess or manage pain
Nurses have ethical obligation to ensure that patients are not deceived and that institutional policies related to placebos are followed

34. Pharmacologic Interventions: Adjuvant Analgesics and Medications
Drugs not usually classified as analgesics may relieve pain in certain situations
A patient who has undergone back surgery may complain more about muscle spasms than incisional pain
A muscle relaxant may be more effective in relieving pain than an opioid alone

35. Pharmacologic Interventions: Adjuvant Analgesics and Medications
Specific pain syndromes, especially neuropathic, may be controlled with drugs other than the commonly known analgesics
See Table 15-6, p. 219

36. Problem Solving with Pain Medication
Patients whose prescribed analgesic drugs do not relieve pain
Ask questions about the analgesic drug and the “five rights” (right dose, right patient, right time, right route, right analgesic) to determine why the patient is not getting adequate pain relief
See Box 15-8, p. 221
The administration of analgesics is simply one intervention in the nursing care of a patient in pain.
What interventions other than analgesics should the nurse provide?