1. Chapter 43 Pain Management
Pain is purely subjective. No two individuals experience pain to the same degree. Each patient has physiological, sociocultural, spiritual, and psychological factors that influence reactions to discomfort and pain. Therefore, students need to practice effective pain management techniques in an effort to improve quality of life, to reduce physical discomfort, to promote early mobilization, and to return to normal activities of life.

2. Nature of Pain Involves physical, emotional, and cognitive components
Results from physical and/or mental stimulus
Reduces quality of life
Not measurable objectively
Subjective and highly individualized component
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 to identify patients who may not be able to express pain? Answers may include aphasic, cognitively impaired, intubated, mentally impaired, or pediatric patients.]

3. Transmission of Pain Impulse
Chemical synapses involve transmitter chemicals (neurotransmitters) that signal postsynaptic cells.
[Shown is Figure 43-1 from text p. 963.]

4. Physiology of Pain
Cellular damage by thermal, mechanical, or chemical stimuli causes release of neurotransmitters.
Prostaglandins, bradykinin, potassium, histamine, substance P
Neurotransmitters surround the pain fibers, spreading the pain message and causing an inflammatory response.
Nerve impulse travel along afferent (sensory) nerve fibers to the spinal cord.
When cellular damage occurs by thermal, mechanical, or chemical stimuli, neurotransmitters such as prostaglandin, bradykinin, potassium, histamine, and substance P are released.
These substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response.
[See also Box 43-1 on text p. 963 Neurophysiology of Pain: Neuroregulators.]

5. Physiology of Pain (cont’d)
Pain impulses ascend the spinal cord to the thalamus, which transmits information to higher brain centers that perceive pain.
Two types of sensory nerve fibers:
Fast myelinated A-delta fibers: send sharp, localized, distinct sensations
Slow, small, unmyelinated C fibers: send poorly localized, burning, persistent pain
There is a physical reason why some pain is perceived as sharp and other pain as more general.
[See also Figure 43-2 Spinothalamic pathway that conducts pain stimuli to the brain.]

6. Physiology of Pain (cont’d)
Transduction Conversion of stimulus into electrical energy
Transmission
Sending of impulse across a sensory pain nerve fiber (nociceptor)
Perception
The patient’s experience of pain
Modulation
Inhibition of pain/ release of inhibitory neurotransmitters
•A patient who is experiencing pain cannot discriminate between these four factors.
•Energy of these pain stimuli is converted to electrical energy. This energy conversion is transduction (phase 1). During transduction, the pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), beginning the transmission of pain (phase 2).
•Perception is the point at which the patient experiences pain—when it is received in the brain. Psychological and cognitive factors interact with neurophysiological ones in the perception of pain. Recall that no single pain center exists (phase 3). Once perception occurs, inhibitory neurotransmitters are released, which is described as modulation.
•Inhibition of the pain impulse is known as modulation (phase 4).
•Physiological response occurs when pain impulses ascend the spinal cord toward the brainstem and thalamus. The autonomic nervous system (ANS) becomes stimulated. Pain thus triggers the fight-or-flight reaction of the general adaptation syndrome (GAS). Stimulation of the sympathetic branch of the ANS results in a physiological response.

7. Physiology of Pain (cont’d)
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.
•The gates can be physiological, emotional, or cognitive processes. You gain a useful conceptual framework for pain management by understanding the physiological, emotional, and cognitive influences on the gates.
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 each individual, the response to pain varies.

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.
[Consider options available to Mrs. Ellis for pain control.]

9. Protective Reflex to Pain Stimulus
A protective reflex response also occurs with pain reception. A-delta fibers send sensory impulses to the spinal cord, where they synapse with spinal motor neurons. 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 protective withdrawal from the source of pain. For example, when you accidentally touch a hot iron, you feel a burning sensation, but your hand also reflexively withdraws from the surface of the iron.
[Shown is Figure 43-3 from text p. 964.]

10. Inferred pathological
Types of Pain
Acute/transient pain
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
Inferred pathological
Musculoskeletal, visceral, or neuropathic
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.
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. This type of pain is non–life threatening.
Chronic pain lasts longer than 6 months and is constant or recurring with mild to severe intensity.
Differences between acute and chronic pain include the concept of harm (acute pain is protective, preventing harm; chronic pain is no longer protective) and the duration (acute pain lasts for a shorter time than chronic).
Often a person with chronic pain who consults with numerous health care providers is labeled a drug seeker, when he or she is actually seeking adequate pain relief. This situation is called pseudoaddiction.
[See also Table 43-2 Classification of Pain by Inferred Pathology on text p. 966.]

11. Nursing Knowledge Base
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
Unfortunately, if patients do not have objective signs of pain, some health care providers do not believe the patient is experiencing pain. This can be in part a result of the “medical model” of pain, which indicates that pain is due to an organ dysfunction.
It will be important that the nurse’s and the patient’s perceptions of the patient’s pain are congruent, so the patient can experience pain relief.
Note that a patient in pain will not always experience a change in vital signs!
Behavioral responses to pain will vary. If pain is untreated, the patient’s life will be altered. Pain threatens a patient’s physiological and psychological well-being.
Often, nurses will allow their misconceptions about pain and pain management to interfere with their ability to treat their patients. Box 43-2 on text page 966 presents common biases and misconceptions regarding pain. Misconceptions about pain often result in doubt about the degree of the patient’s suffering and unwillingness to provide relief.
It is important to understand that cultural background influences the meaning and expression of pain. In addition, older persons may not report pain, and those in chronic pain are unlikely to show behavioral changes.

12. 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 support groups, 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.
Age will influence the pain experience, especially in the young and the very old. These two groups may not be able to adequately express their needs.
[Table 43-3 on test page 967 presents information regarding pain in infants, Box 43-3 on text page 967 focuses on pain in the elderly, and Table 43-4 on text p. 968 reviews misconceptions about pain in older adults.]
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.
It is crucial to remember that spirituality stretches beyond religion. When experiencing pain, a patient may ask, “Why has God done this to me?”
[For more information, refer to Chapters 11: Developmental Theories; 12: Conception Through Adolescence; 14: Older Adult; 35: Spiritual Health; and 37: Stress and Coping.]

13. Factors Influencing Pain (cont’d)
Psychological
Anxiety
Coping style
Pain tolerance
The level of pain a person is willing to accept
Cultural
Meaning of pain
Ethnicity
The degree and quality of pain a patient experiences are related to the meaning of pain. It is difficult to separate pain from anxiety sensations.
Critically ill and injured patients often perceive lack of control over their environment and experience anxiety.
Coping styles influence a patient’s ability to handle pain. For example, allowing the patient to self-medicate using patient-controlled analgesia (PCA) can help the patient control the pain experience.
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 are sometimes inaccurately perceived as complainers. Teach patients the importance of reporting their pain sooner rather than later.
Recognize variations in subjective responses to pain. Some patients are stoic and less expressive, whereas others are emotive and more likely to verbalize pain.
The meaning of pain may be closely related to culture and ethnicity.
[Box 43-4 on text page 969 presents cultural aspects of care. Also refer back to Chapters 9: Culture and Ethnicity, and 37: Stress and Coping.]

14. 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
National Guideline Clearing House (
Agency for Healthcare Research and Quality (AHRQ)
Successful pain management will depend on establishing a relationship of trust between the patient, the family, and health care providers.
The goal of pain management is to anticipate and prevent pain rather than treat it.
The American Nurses Association believes that pain assessment and management is within the scope of every nurse’s practice. This is why pain is now known as the fifth vital sign.
The Agency for Healthcare Research and Quality (AHRQ) has established specific guidelines for assessing patients with acute and cancer pain. The focus is on planning successful pain management interventions before a patient has pain. Because it involves a collaborative approach, the AHRQ pain treatment flow chart offers a useful conceptual approach to the control of acute pain.
[See also Figure 43-5 Pain treatment flow chart: preoperative and intraoperative phases.]

15. Assessment Patient’s expression of pain Characteristics of pain
Onset and duration
Location
Intensity
Quality
Pattern
Relief measures
Contributing symptoms
Effects of pain on the patient
It is vital that you ascertain the level of pain the patient is experiencing. It will also be important to encourage the patient to express pain or discomfort. It is the nurse’s duty to constantly assess the patient’s pain.
Box 43-8 on text page 972 presents pain assessment in the nonverbal patient. Body movements and facial expressions indicating pain include clenched teeth, holding the painful area, bent posture, and grimacing. Some patients cry or moan, are restless, or make frequent requests of a nurse. You soon learn to recognize patterns of behavior that reflect pain. This becomes especially important in patients who are unable to report their pain, such as the cognitively impaired. However, lack of pain expression does not indicate that the patient is not experiencing pain.
[See also Box 43-5 on text p. 970 Nursing Assessment Questions and Box 43-7 on text p. 970 Possible Sources for Error in Pain Assessment.]
Do not collect an in-depth pain history when the patient is experiencing severe discomfort. Note that pain causes physical signs and symptoms similar to those of other diseases.
[Review Table 43-5 Classification of Pain by Location.]
(Effects of pain on the patient are discussed on the next slide.)

16. Sample Pain Scales
Pain scales are one way for the patient to communicate the intensity of pain.
The sample pain scales shown here are as follows: A, Numerical; B, Verbal descriptive; and C, Visual analogue.
[Shown is Figure 43-6 from text p. 973.]
[See also is Figure 43-7 Asian girl version of the Oucher pain scale.]

17. Wong-Baker FACES Scale
With the Wong-Baker FACES Pain Rating Scale, first point to each face using words to describe pain intensity. Then, ask the child to choose the face that best describes his/her own pain; record the appropriate number.
[Shown is Figure 43-8 from text p. 974.]

18. Assessment Effects of pain on the patient Behavioral effects
Assess verbalization, vocal response, facial and body movements, and social interaction.
For patients unable to communicate pain, it is vital for you to be alert for indicative behaviors.
Influence on activities of daily living
Physical deconditioning
Sleep disturbances
Sexual relationships
Ability to work (outside of and in the home)
Pain alters a person’s lifestyle and affects psychological well-being. Chronic/persistent pain causes suffering, loss of control, loneliness, disabilities, exhaustion, and impaired quality of life.
[See also Box 43-9 Behavioral Indicators of Effects of Pain; and Figure 43-4 Critical thinking model for pain assessment.]

19. Case Study (cont’d)
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 the class: 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.]

20. Pain Assessment and Management:
A: Ask about pain regularly. Assess pain systematically.
B: Believe the patient and family in their report of pain and what relieves it.
C: Choose pain control options appropriate for the patient, family, and setting.
D: Deliver interventions in a timely, logical, and coordinated fashion.
E: Empower patients and their families. Enable them to control their course to the greatest extent possible.
[This information is from Box 43-6 on text p. 970 Routine Clinical Approach to Pain Assessment and Management: ABCDE.]

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

22. Case Study (cont’d)
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 dished 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 the class: 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.]

23. Nursing Diagnosis Activity intolerance Anxiety Ineffective coping
Fatigue
Hopelessness
Insomnia
Fear
Impaired physical mobility
Powerlessness
Chronic low self-esteem
Impaired social interaction
Spiritual distress
Imbalanced nutrition: less than body requirements
Often the diagnosis will be acute pain or chronic pain; the extent to which pain affects a patient’s function and general state of health determines whether other nursing diagnoses are relevant, such as those shown on the slide.
The diagnosis focuses on the specific nature of pain.
[See also Box on text p. 975 Nursing Diagnostic Process: Chronic Pain; and Figure Concept map on text p. 979.]

24. Case Study (cont’d)
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 the class: 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.]

25. Planning
Determine with the patient what the pain has prevented the patient from doing.
Then agree on an acceptable level of pain that allows return of function.
For example, for the goal, “The patient will achieve a satisfactory level of pain relief within 24 hours,” possible outcomes are as follows:
Reports that pain is a 3 or less on a scale of 0 to 10
Identifies factors that intensify pain
Uses pain relief measures safely
Level of discomfort does not interfere with activities of daily living (ADLs).
When managing pain, goals of care promote a patient’s optimal function.
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.
[Review Figure 43-9 on text p. 978 Critical thinking model for pain management planning; and Nursing Care Plan: Acute Pain on text pp ]

26. Implementation: Health Promotion
Nonpharmacological pain relief interventions
Relaxation, guided imagery
Biofeedback
Distraction, music
Cutaneous stimulation
Massage, transcutaneous electrical nerve stimulation (TENS), heat, cold, acupressure
Herbals
Reducing pain perception
Pain therapy requires an individualized approach. It is significant to make sure patients understand their pain. However, patients with moderate to severe pain are not always able to participate in the decision-making process until pain is controlled at an acceptable level.
Each one of these techniques can be used in combinations. Nonpharmacological methods are to be used with pharmacological ones.
Not all therapies will be beneficial or liked by all patients. Patients will need to be able to participate in relaxation, guided imagery, distraction, and music therapy.
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. Evidence shows that music decreases the use of analgesics in some postoperative patients.
The gate control theory suggests that cutaneous stimulation activates larger, faster-transmitting A-beta sensory nerve fibers. This closes the gate, thus decreasing pain transmission through small-diameter C fibers.
One form of cutaneous stimulation is transcutaneous electrical nerve stimulation (TENS), involving stimulation of the skin with a mild electrical current passed through external electrodes. [See also Box Procedural Guidelines: Massage on text p. 980.]
Herbals often interact with prescribed analgesics; thus ask patients to report all substances they take to relieve pain.
Remember that at times the simplest act can reduce pain, such as smoothing a wrinkled sheet, repositioning, or positioning tubing away from body surfaces.
[See also Box on text p. 981 Controlling Painful Stimuli in the Patient’s Environment.]

27. Implementation: Health Promotion (cont’d)
Pharmacological pain relief
Acute pain management
Analgesics
Nonopioids
Opioids
Adjuvants/co-analgesics
Delivery systems
Patient-controlled analgesia (PCA)
Local/regional anesthesia
Topical agents
The Agency for Health Care Policy and Research (AHCPR) established a pain treatment flow chart in 1992 that is still used today for treatment of postoperative pain and pain from medical procedures and trauma. This systematic approach ensures quick caregiver response to patient discomfort.
[See Figure on text p. 982 for a postoperative pain management algorithm.]
One way to maximize pain relief while potentially decreasing drug use is to administer analgesics on an around-the-clock (ATC) rather than prn basis.
Analgesics are the most common and effective method of pain relief.
Nonopioids include acetaminophen and nonsteroidal anti-inflammatories (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 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.
[Box on text p. 983 presents information regarding Nursing Principles for Administering Analgesics.]
Adjuvants and co-analgesics are drugs used to treat other conditions, but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).
A drug delivery system called patient-controlled analgesia (PCA) is a safe method of pain management that many patients prefer; PCA allows patients to help manage their pain. However, patients must be able to participate in this type of intervention. The goal is to maintain a constant plasma level of analgesic to avoid problems of as needed dosing. It gives patients pain control with low risk of overdose.
The most common types of drugs used in PCA are morphine, hydromorphone, and fentanyl.
Local and regional anesthesias are used in a variety of conditions, including labor and delivery, chronic cancer pain, and selected postoperative procedures. Local anesthesia is local infiltration of an anesthetic to induce loss of sensation to a body part. Regional anesthesia is the injection of local anesthetic to block a group of sensory nerve fibers. Epidural anesthesia is common for acute postoperative pain, labor and delivery, and chronic cancer pain. When caring for a patient who receives local anesthesia, protect him or her from injury.
Topical agents such as EMLA and lidocaine are administered via patches or discs. They produce anesthesia to soft tissue.

28. Case Study (cont’d)
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 anti-inflammatory 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 the class: What is the rationale for using more than one type of pain medication? Discuss that different medications are used to control the pain and symptoms of rheumatoid arthritis.]
[Ask the class: What is the rationale for having Mrs. Ellis take the analgesics ahead of activities? Discuss that 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.]

29. Patient-Controlled Analgesia
Shown is a patient-controlled analgesia (PCA) pump with cassette.
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, the patient pushes a button attached to the PCA device.
Systems are designed to deliver a specified number of doses every 1 to 4 hours (depending on the pump settings) given every 5 to 15 minutes (programmable) to avoid overdoses. Most pumps have locked safety systems that prevent tampering by patients or family members and are generally safe to be managed in the home.
For patients with cancer pain, a low-dose continuous infusion (basal rate) of 0.5 to 1 mg/hr is sometimes programmed to deliver a steady dose of continuous medication.{AU: Please confirm dosage here. TK: Confirmed.}
[See also Box on text p. 984 Patient Teaching: Patient-Controlled Analgesia.]
[Shown is Figure from text p. 984.]

30. Epidural Space
Shown is an anatomical drawing of the epidural space (Fig from text p. 985).
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.
Ensure that the catheter is taped securely along the back of the patient. If the catheter is temporary, it is connected to tubing positioned along the spine and over the patient’s shoulder. The end of the catheter is then placed on the patient’s chest for the nurse’s access.
Nurse anesthetists, anesthesiologists, and nurses control epidural analgesia, depending on agency policy.
[See also Table 43-6 Nursing Care for Patients with Epidural Infusions.]

31. Case Study (cont’d) 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 3 times a day.
Referral to a physical therapist to determine possible use of a walker or other assistive device
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.]

32. Implementation 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.
Nurses monitor IV sites, lines, and controllers.
When administering pain medications, you are responsible for monitoring the patient for effective pain relief, as well as potential adverse reactions. You should have on hand medications to reverse the effects of pain medications (Narcan). Also you will need to monitor IV insertion sites, lines, and controllers to ensure that the proper amount of medication is being delivered. When administering epidural analgesia, include preventing infection and monitoring closely for respiratory depression.
[See also Table 43-6 on text p. 986 Nursing Care for Patients with Epidural Infusions.]
Premedicating patients before painful procedures allows patients to cooperate more fully and reduces the experience of pain.
Always check with your health care facility for policies and procedures.

33. 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

34. Chronic Noncancer and Cancer Pain Management
Cancer pain may be chronic or acute.
Breakthrough pain = A transient flare of moderate to severe pain superimposed on continuous or persistent pain.
Transdermal pain patches may be used.
In 1994, the AHCPR published clinical practice guidelines for cancer pain management that support comprehensive and aggressive treatment of cancer pain, including many options for pain relief.
Estimates for addiction to pain medications range from 6% to 10%.
Long-acting or controlled-release medications are very successful in managing all types of chronic pain. You can manage most chronic pain by using oral or patch medications.
Patients with chronic pain need to be given medications on a regular around-the-clock basis.
Transdermal fentanyl is 100 times more potent than morphine and provides analgesia for 48 to 72 hours. This route is used when patients are unable to take oral medications. Transmucosal fentanyl is used for breakthrough pain. The fentanyl is swabbed into the mouth.
When severe pain persists despite medical treatment, many invasive interventions are available for consideration.
[See also Figure on text p. 987 Flow chart: continuing pain management in patients with cancer; and Box Types of Breakthrough Pain on text p. 986.]

35. WHO Analgesic Ladder
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.
[Shown is Figure on text page 988.]
WHO, World Health Organization.

36. Barriers to Effective Pain Management
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
[This information is derived from Box on text p. 989.]
At times, health care providers fear problems with addiction, which will alter the use of medication.
[Box on text page 988 presents information on barriers to effective pain management.]
Patients and health care providers often do not understand the differences between physical dependence, addiction, and drug tolerance.
Physical dependence does not imply addiction but rather is a state of adaptation manifested by a drug withdrawal syndrome.
Drug tolerance does not imply addiction either. Instead, tolerance is the diminution of one or more of a drug’s effects resulting from repeated use over time.
Addiction is a neurobiological disease. Addiction rarely occurs in patients who take opioids to relieve pain.
Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Placebos are medications or procedures that produce positive or negative effects in patients. These effects are not related to the specific physical or chemical properties of the placebo. Professional organizations discourage their use to treat pain. Placebo use jeopardizes the trust between patients and their caregivers. If a placebo is ordered, you must question the order.

37. Restorative and Continuing Care
Pain centers, 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.

38. 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

39. Checklist for Communication with Colleagues
What is the pain rating now? Over the past period of time?
Which pain rating is acceptable to the patient?
How do you recommend that the patient’s treatment be changed to reduce the pain rating?
Which professional reference can be used, if needed, to support this recommendation?
Effectively communicating with colleagues helps you achieve optimal pain relief for patients.
Effective communication of patient’s pain assessment and response to intervention is facilitated by accurate and thorough documentation. This communication needs to happen nurse to nurse, shift to shift, and nurse to other health care providers.
[This information is from Box on text p. 990 Checklist for Communicating Patients’ Unrelieved Pain to Colleagues.]

40. Case Study (cont’d)
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.

41. Evaluation
Evaluation of pain is one of many nursing responsibilities that require effective critical thinking.
The patient’s response to pain may not be obvious.
Evaluating the appropriateness of pain medication will require nurses to evaluate patients’ responses after administration.
Patients help decide the best times to attempt pain treatments. Ask patients about tolerance to therapy and the overall amount of relief obtained. If patients state that an intervention is not helpful or even aggravates the discomfort, stop it immediately and seek an alternative.
Pain evaluation includes measuring the changing character of pain, the patient’s response to interventions, and the patient’s perceptions of effectiveness of a therapy.
[Review Figure Critical thinking model for pain-management evaluation.]
[Ask the class: If patient outcomes are not met, what questions will you ask the patient? Discuss:
• 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?
• Describe limitations in function that you are experiencing related to uncontrolled pain.
• How is your pain limiting or altering your rest and sleep?]

42. 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.
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.

43. Case Study (cont’d)
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 the class to list the important elements a documentation note would contain:
Steadier gait
Proper warm compress application
Less fatigued
Replaced aspirin with NSAID]