1. Comfort Ch 41

2. Pain Considered the 5 th Vital Sign Considered the 5 th Vital Sign Is what the patient says it is Is what the patient says it is

3. Pain Basics Source Source –Nociceptive – sensory –Neuropathic – from nerves –Psychogenic – mental Area to which it is referred Area to which it is referred Duration Duration –Acute –Chronic

4. Sources of Pain Sources of Pain Nociceptive Nociceptive –Cutaneous –Somatic –Visceral Neuropathic Neuropathic

5. Types of Pain Physical cause — cause of pain can be identified Physical cause — cause of pain can be identified Psychogenic — cause of pain cannot be identified Psychogenic — cause of pain cannot be identified Referred — pain is perceived in an area distant from its point of origin Referred — pain is perceived in an area distant from its point of origin

6. Duration of Pain Acute Acute –Rapid in onset, varies in intensity and duration –Protective in nature Chronic Chronic –May be limited, intermittent, or persistent –Lasts for 6 months or longer –Periods of remission or exacerbation are common

7. Pain Process Transduction — activation of pain receptors Transduction — activation of pain receptors Transmission — conduction along pathways (A-delta and C-delta fibers) Transmission — conduction along pathways (A-delta and C-delta fibers) Modulation — initiation of the protective reflex response Modulation — initiation of the protective reflex response Perception of pain — awareness of the characteristics of pain Perception of pain — awareness of the characteristics of pain

8. Chemicals of Pain Bradykinin Bradykinin –Powerful vasodilator –Constricts smooth muscle –Involved in pain awareness Prostaglandins – send stimuli to CNS Prostaglandins – send stimuli to CNS Substance P Substance P –Sensitizes nerve receptors –Increases rate of firing

9. Gate Control Theory Relationship between pain and emotions Relationship between pain and emotions Small and large diameter nerve fibers conduct and inhibit pain stimuli Small and large diameter nerve fibers conduct and inhibit pain stimuli Gating mechanisms determine impulses that reach the brain Gating mechanisms determine impulses that reach the brain

10. Pain Perceptions Pain threshold – lowest intensity at which pain is perceived Pain threshold – lowest intensity at which pain is perceived Adaptation Adaptation Modulation of pain – regulation or modified by: Modulation of pain – regulation or modified by: –Neuromodulators- natural, resemble morphine –Endorphins – pain blockers, prolonged effect –Dynorphins – most potent –Enkephalins – less potent, inhibit release of sub.P

11. Pain Responses Physiologic – automatic (involuntary) responses Physiologic – automatic (involuntary) responses Behavioral – change in behavior Behavioral – change in behavior Affective – emotional response Affective – emotional response Box 41-1, p 1203 Box 41-1, p 1203

12. Factors in Pain Culture Culture Ethnic variables Ethnic variables Family, gender, and age variables Family, gender, and age variables Religious beliefs Religious beliefs Environment and support people Environment and support people Anxiety and other stressors Anxiety and other stressors Past pain experience Past pain experience

13. Assessing Pain Psychological Psychological Emotional Emotional Sociologic Sociologic Physiologic Physiologic

14. Assessing Pain, cont’d Patient’s verbalization and description of pain Patient’s verbalization and description of pain Duration of pain Duration of pain Location of pain Location of pain Quantity and intensity of pain Quantity and intensity of pain Quality of pain Quality of pain Chronology of pain Chronology of pain

15. Assessing Pain, cont’d Patient’s verbalization and description of pain Patient’s verbalization and description of pain Duration of pain Duration of pain Location of pain Location of pain Quantity and intensity of pain Quantity and intensity of pain Quality of pain Quality of pain Chronology of pain Chronology of pain

16. More Assessing Aggravating and alleviating factors Aggravating and alleviating factors Physiologic indicators of pain Physiologic indicators of pain Behavioral responses Behavioral responses Effect of pain on activities and lifestyle Effect of pain on activities and lifestyle

17. Assessment Tools McGill-Melzack pain questionnaire McGill-Melzack pain questionnaire Pain scale Pain scale –0 to 10 –Faces McCaggery method McCaggery method WILDA pain measurement scale WILDA pain measurement scale

18. WILDA Scale Words that describe the pain Words that describe the pain Intensity of pain Intensity of pain Location of pain Location of pain Duration of pain Duration of pain Aggravating or alleviating factors Aggravating or alleviating factors

19. Diagnosing Pain Type of pain Type of pain Etiologic factors Etiologic factors Behavioral, physiological, affective response Behavioral, physiological, affective response Other factors affecting pain process Other factors affecting pain process

20. Nursing Interventions Establishing trusting nurse-patient relationship Establishing trusting nurse-patient relationship Initiating non-pharmacologic pain relief measures Initiating non-pharmacologic pain relief measures Considering ethical and legal responsibility to relieve pain Considering ethical and legal responsibility to relieve pain Teaching patient about pain Teaching patient about pain

21. Nursing Plan Remove or alter cause of pain Remove or alter cause of pain Alter factors affecting pain tolerance Alter factors affecting pain tolerance Initiate non-pharmacologic relief measures Initiate non-pharmacologic relief measures

22. Non-Drug Comfort Measures Distraction Distraction Humor Humor Music Music Imagery Imagery Relaxation Relaxation Cutaneous stimulation Cutaneous stimulation Acupuncture Acupuncture Hypnosis Hypnosis Biofeedback Biofeedback Therapeutic touch Therapeutic touch

23. Drug-Related Treatments Analgesic administration Analgesic administration –Non-opioid analgesics –Opioids or narcotic analgesics Adjuvant drugs Adjuvant drugs

24. Administering Analgesics Patient controlled analgesia Patient controlled analgesia Epidural analgesia Epidural analgesia Local anesthesia Local anesthesia

25. Sedation Scale 1 — awake and alert, no action necessary 1 — awake and alert, no action necessary 2 — occasionally drowsy, but easy to arouse, no action necessary 2 — occasionally drowsy, but easy to arouse, no action necessary 3 — frequently drowsy, drifts off to sleep during conversation, reduce dosage 3 — frequently drowsy, drifts off to sleep during conversation, reduce dosage 4 — somnolent with minimal or no response to stimuli, discontinue opiod, consider use of naloxone (Narcan) 4 — somnolent with minimal or no response to stimuli, discontinue opiod, consider use of naloxone (Narcan)

26. Managing Chronic Pain Give medications orally if possible. Give medications orally if possible. Administer medications ATC (around-the- clock) rather than prn. Administer medications ATC (around-the- clock) rather than prn. Adjust the dose to achieve maximum benefit with minimum side effects. Adjust the dose to achieve maximum benefit with minimum side effects. Allow patients as much control as possible over the regimen. Allow patients as much control as possible over the regimen.