1. Chapter 13 NUR 299 C 1&2 (Adapted from LLW 2010)
Pain Management
Chapter 13
NUR 299 C 1&2
(Adapted from LLW 2010)

2. Pain
Unpleasant sensory, emotional experience with actual or potential tissue damage
Most common reason for seeking health care
“The fifth vital sign”
Joint Commission (2005) standards: “pain is assessed in all patients,” “patients have the right to appropriate assessment and management of pain.”
“Pain is whatever a person says it is, existing whenever the experiencing person says it does.” (McCaffery & Pasero, 1999)

3. Role of the Nurse
Collaborate
Evaluate effectiveness
Advocate
Educate

4. Nursing Assessment Assess for: Duration – how long Location - where
Etiology – cause may be a predictor so a plan can be put into effect [Cancer, Burns]

5. Types of Pain Acute pain Chronic pain Cancer-related pain
May be classified by location or etiology

6. Effects of Pain Sleep deprivation Acute pain Chronic pain
Can affect respiratory, cardiovascular, endocrine, immune systems, gastrointestinal
Stress response increases metabolic rate, cardiac output, risk for physiologic disorders
Chronic pain
Depression
Increased disability
Suppression of immune function

7. Pathophysiology of Pain
Nociceptors (pain receptors) transmission of pain perception to & from the brain
Non-Nociceptor- does not transmit pain. Ie: pressure or temperature
Neurologic Transmission of pain (nocicetion) by nerves
Chemical substances
Prostaglandins (increase sensitivity of pain receptors)
Endorphins, enkephalins (suppress pain reception)

8. Nociception System Showing Ascending & Descending Pathways of the Dorasal Horn

9. Gate Control Theory

10. Factors that Influence Pain Response
Past experience
Anxiety
Depression
Culture
Age
Gender
Expectations

11. Characteristics of Pain
Intensity
Timing
Location
Quality
Personal meaning
Aggravating/ Alleviating factors
Pain behaviors- eyes shut, rubbing, fists, jaw clenched

12. Pain Intensity Scales

13. Faces Pain Scale

14. Physiologic Basis for Relief Pharmacologic Interventions
Opioid analgesics act on CNS to inhibit activity of ascending nocioceptive pathways
NSAIDS decrease pain by inhibiting cyclo- oxygenase (enzyme involved in production of prostaglandin) Aleve, Motrin, Advil
NSAIDS can be given in combination with narcotics to relieve pain using less narcotics.
Local anesthetics block nerve conduction when applied to nerve fibers

15. Gerontologic Considerations
More likely to have adverse drug effects, drug interactions
Increased likelihood of chronic illness
May need to have more time between doses of medication due to decreased excretion, metabolism related to aging changes

16. Opioid Tolerance and Addicition
Maximum safe opioid dosage must be individually assessed
Tolerance develops in all patients who take opioids for prolonged periods
With tolerance, increased usage needed to effect pain relief

17. Opiod Tolerance and Addiction (cont’d)
Dependence occurs with tolerance, physical symptoms occur when opioid is discontinued
Addiction: behavioral pattern characterized by need to take drug for psychic effects
Addiction from therapeutic use of opioid is negligible

18. Pain Relief Interventions-Pharmacologic
Balanced anesthesia
“PRN” medications
Routine administration: around the clock (ATC) or preventive approach
PCA: patient-controlled analgesia
Local anesthetics
Topicals, patches
Intraspinal a

20. PCA - Patient Controlled Analgesia
Two Types
Continuous – delivers set amount per hour AND Pt can request additional doses up to pre set maximum as needed.
On Demand – only delivers when medication is requested by patient.

21. PCA Physician’s Order for PCA shall include: Type of analgesic Rate
Loading/bolus dose
PCA dosage with mg/minutes lock out interval
Four hour dose
Basal rate
Medication concentration

22. PCA cont’d Parameters should include:
Loading dose- A bolus dose given prior to initiating PCA therapy
usually higher than a bolus dose given during PCA therapy.
Bolus dose- Equivalent to a loading dose –
administered during the course of PCA therapy.
Lockout Interval – Predetermined period during which the patient cannot initiate doses.
PCA dose – Amount administered each time the PT activates pump.
Four hour limit – Predetermined maximum drug volume, which can be delivered during any 4 hour period.
Basal Rate- Amount administered continuously.

23. PCA Nursing Considerations
Notify MD of the following so that orders may be obtained for continuing, slowing or stopping the infusion when one or more of the following exists:
Diastolic B/P drops more than 20% from baseline
Respiratory rate of less than 10/min(hold < 8)
Significantly altered mental status
Pain Score of 5 or greater &/or pain that is not decreasing

24. Nonpharmacologic Interventions
Cutaneous stimulation, massage
Thermal therapies
Transcutaneous electrical nerve stimulation (TENS)
Distraction
Relaxation techniques

25. Nonphamacologic Interventions
Guided imagery
Hypnosis
Music therapy
Alternative therapies

26. Neurologic & Neurosurgical Methods for Pain Control
Intrathecal catheters- spinal, meds to spinal cord
Epidural catheters- epidural space in spinal cord
Stimulation procedures - TENS
Interruption of pain pathways
Cordotomy- division of spinal cord tracts(neck). Destroys pain, not sensation.
Rhizotomy- Sensory nerve root is destroyed. Ie: chest pain /lung CA. May be done surgically, percutaneously or chemically.

27. Intrathecal & Epidural Catheters

28. Cordotomy

29. Rhizotomy

30. Adverse Effects of Analgesic Agents
Respiratory depression
Sedation
Nausea, vomiting
Constipation
Pruritis

31. Nursing Process Framework for Pain Management
Identify goals for pain management
Establish nurse-patient relationship, teaching
Provide physical care
Manage anxiety related to pain
Evaluate pain-management strategies

32. NCLEX Review Tell whether the following statement is true or false:
Endorphins represent the same mechanism of pain relief as nonnarcotic analgesics.

33. Answer
False.
Rationale: Endorphins do not represent the same mechanism of pain relief as nonnarcotic analgesics. Endorphins release inhibits the transmission of painful impulses. They are endogenous neurotransmitters structurally similar to opioids. They are found in heavy concentration in the central nervous system.

34. NCLEX Review
The RN asks a patient to describe the quality of pain. Which of the following is a descriptive term for the quality of pain?
Burning
Chronic
Intermittent
Severe

35. Answer
A. Burning
Rationale: A descriptive term for the quality of pain is burning. Chronic and intermittent pain are examples of types of pain. Severe is a descriptive term for the intensity of pain.