1. 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 15 Pain Management

2. 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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”

3. 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

4. 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

5. 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

6. 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

7. 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

8. 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 15-1

9. 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

10. 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Factors  Pain threshold ◦ 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

11. 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

12. 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

13. 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

14. 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

15. 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

16. 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

17. 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 15-2

18. 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care of the Patient in Pain

19. 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment  Should be done on admission and on a regular basis  Assessment of vital signs is called the fifth vital sign

20. 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

21. 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 15-5

22. 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nonpharmacologic Interventions  Those that do not employ drugs  Physical interventions ◦ Physical comfort measures ◦ Environmental control ◦ Stimulation techniques ◦ Anxiety reduction ◦ Distraction  Psychological interventions ◦ Relaxation ◦ Imagery

23. 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

24. 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

25. 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharmacologic Interventions: Opioid Analgesics  Opioid agonist-antagonists ◦ Examples: buprenorphine (Buprenex), nalbuphine (Nubain), butorphanol (Stadol), and pentazocine (Talwin)

26. 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

27. 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

28. 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharmacologic Interventions: Opioid Analgesics  Side effects ◦ Constipation ◦ Nausea, with or without vomiting ◦ Sedation ◦ Respiratory depression ◦ Confusion ◦ Hypotension (especially orthostatic) ◦ Dizziness ◦ Urinary retention

29. 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

30. 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

31. 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

32. 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

33. 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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