1. Nursing Care of Clients Experiencing Pain

2. Pain Pathway A-delta fibers: transmit pain quickly, associated with acute pain C-fibers: transmit pain more slowly, diffuse burning pain and chronic pain Inhibitory mechanisms: the analgesia system stimulates a pain inhibitory center in the dorsal horns of the spinal cord (the exact mechanism is unknown) Endorphins: naturally occurring opioid peptides present in the neurons in the brain

3. Pain Pathway

5. Four Processes Involved in Nociception Transduction Transmission Perception Modulation

6. Transmission of Pain

7. Gate Control Theory Small diameter (a-delta or C) peripheral nerve fibers carry signals of noxious stimuli to the dorsal horn Signals are modified when they are exposed to the substantia gelatinosa Ion channels on the pre- and postsynaptic membranes serve as gates When open, permit positively charged ions to rush into the second order neurons, sparking an electrical impulse and sending signals of pain to the thalamus Large diameter (A-delta) fibers have inhibitor effect May activate descending mechanism that can inhibit transmission of pain

8. Gate Control Theory

9. Clinical Application of Gate Control Theory Stop nociceptor firing Apply topical therapies Address client’s mood Address client’s goals

10. Acute, Chronic, Central, Phantom, and Psychogenic Pain Acute Pain – Somatic Pain May be sharp or diffused May be accompanied by nausea and vomiting – Visceral Pain Arises from the body organs Usually dull and poorly localized May be referred or may radiate – Referred Pain Perceived in an area distant from the site of the stimuli

11. Acute, Chronic, Central, Phantom, and Psychogenic Pain

12. Chronic Pain – Recurrent Acute Pain Well-defined episodes of pain Migraine headaches, sickle cell crisis – Ongoing Time-limited Pain Persists for a definite time period Ends with control of the disease, rehabilitation, or death

13. Acute, Chronic, Central, Phantom, and Psychogenic Pain Chronic Pain – Chronic Nonmalignant Pain Not life-threatening but persists past expected time for healing – Chronic Intractable Nonmalignant Pain Syndrome Client unable to cope well with the pain Pain may be mild to severe The pain itself becomes the pathologic process

14. Acute, Chronic, Central, Phantom, and Psychogenic Pain Central Pain – May be caused by a vascular lesion, tumor, or inflammation Phantom Pain – Thought to be due to stimulation of severed nerves at the amputation site Psychogenic Pain – Involves a long history of severe pain – The pain is real and can lead to physiologic changes

15. Factors Affecting Pain Response Age Sociocultural influences Emotional status Past experiences with pain Meaning associated with the pain Lack of knowledge

16. Myths and Misconceptions Concerning Pain Pain is a result, not a cause Chronic pain is really a masked form of depression Narcotic medication is too risky to be used for chronic pain It is best to wait until a client has pain before giving medication Many client’s lie about the existence or severity of pain Pain relief interferes with diagnosis

17. Pain Assessment Subjective Data Comprehensive pain history includes COLDERR – Character – Onset – Location – Duration – Exacerbation – Relief – Radiation

18. Additional Data to Obtain Associated symptoms Effect on ADLs Past pain experiences Meaning of the pain to the person Coping resources Affective response

19. Nursing Process for Clients with Pain

20. Pain Assessment Objective Data Nonverbal responses to pain – Facial expression – Vocalizations like moaning and groaning or crying and screaming – Immobilization of the body or body part – Purposeless body movements – Behavioral changes such as confusion and restlessness – Rhythmic body movements or rubbing

21. Pain Assessment Objective Data Early physiologic responses – Increases BP, HR, RR – Pallor – Diaphoresis – Pupil dilation – May be absent in people with chronic pain Pain diary

22. NANDA Nursing Diagnoses Acute Pain and Chronic Pain Specify the location Related factors, when known, can include physiologic and psychologic factors Pain may be etiology of other nursing diagnoses

23. NANDA Nursing Diagnoses Pain as etiology of other nursing diagnoses – Ineffective Airway Clearance – Hopelessness – Anxiety – Ineffective Coping – Ineffective Health Maintenance – Self-Care Deficit (Specify) – Deficient Knowledge (Pain Control Measures) – Disturbed Sleep Patterns

24. Nursing Process for Clients with Pain Assess the client’s pain level Establish a nursing diagnosis Plan and implement a care plan Educate the client Evaluate the patient’s response to the care plan

25. Treatment Plan Goals vary according to the diagnosis and its defining characteristics Select pain relief measures appropriate for the client, based on assessment data and input from the client or support persons

26. Practice Guidelines Establish a trusting relationship Consider client’s ability and willingness to participate Use a variety of pain relief measures Provide pain relief before pain is severe Use pain relief measures the client believe are effective Align pain relief measures with report of pain severity

27. Practice Guidelines Encourage client to try ineffective measures again before abandoning Maintain unbiased attitude about what may relieve pain Keep trying Prevent harm Educate client and caregiver about pain

28. Pain Treatment Plan Include variety of pharmacologic and nonpharmacologic interventions Plan with wide range of strategies Document plan in client record and for home care Involve client and support persons

29. Barriers to Effective Pain Management Lack of knowledge of the adverse effects of pain Misinformation regarding the use of analgesics Misconceptions about pain May not report pain Fear of becoming addicted

30. Addiction Primary, chronic, neurobiologic disease Genetic, psychosocial, and environment are influential factors Behaviors can include: – Impaired control over drug use – Compulsive use – Craving – Continued use despite harm

31. Dependence State of adaptation Manifested by withdrawal syndrome Produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist

32. Tolerance State of adaptation Exposure to a drug induces changes Result in a diminution of one or more of the drug’s effects over time

33. Pharmacologic Interventions for Pain Opioids (narcotics) Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS) Co-analgesic drugs

34. Opioids (Narcotics) Full agonists – No ceiling on analgesia – Dosage can be steadily increased to relieve pain – E.g., morphine, oxycodone, hydromorphone

35. Opioids (Narcotics) Mixed agonist-antagonists – Act like opioids and relieve pain – Can block or inactivate other opioid analgesics – E.g. dezocine, petazocine hydrochloride, butorphanol tartrate, nalbuphine hydrochloride Partial agonist – Have a ceiling effect – E.g., buprenorphine

36. Nonopioids/NSAIDS Vary little in analgesic potency but do vary in anti-inflammatory effects, metabolism, excretions, and side effects Have a ceiling effect Narrow therapeutic index E.g. acetaminophen, ibuprofen, aspirin

37. Coanalgesic Drugs Antidepressants Anticonvulsants Local anesthetics Others

38. WHO Ladder Step Approach for Cancer Pain Control

39. Step 1 – For clients with mild pain (1-3 on a 0-10 scale) – Use of nonopioid analgesics (with or without a coanalgesic)

40. WHO Ladder Step Approach Step 2 – Client has mild pain that persists or increases – Pain is moderate (4-6 on a 0-10 scale) – Use of a weak opioid (e.g. Codeine, tramadol, pentazocine) or a combination of opioid and nonopioid medicine (oxycodone with acetaminophen, hydrocodone with ibuprofen)

41. WHO Ladder Step Approach Step 3 – Client has moderate pain that persists or increases – Pain is severe (7-10 on a 0-10 scale) – Strong opioids (e.g. Morphine, hydromorphone, fentanyl)

42. Rational Polypharmacy Evolved from WHO three step approach Demands health professionals be aware of all ingredients of medications that alleviate pain Use combinations to reduce the need for high doses of any one medication Maximize pain control with a minimum of side effects or toxicity Combined with multimodal therapy (e.g. nondrug approaches)

43. Oral Administration Preferred because of ease of administration Duration of action is often only 4 to 8 hours Must awaken during night for medication Long-acting preparations developed May need rescue dose of immediate-release medication

44. Transmucosa/Transnasal and Transdermal Administration Transmucosa and Transnasal – Enters blood immediately – Onset of action is rapid Transdermal – Delivers relatively stable plasma drug level – Noninvasive

45. Medication Administration Rectal – Useful for clients with dysphagia or nausea/vomiting Continuous subcutaneous infusion – Used for pain poorly controlled by oral medications

46. Subcutaneous Infusion Placement

47. Medication Administration Intramuscular – Should be avoided – Variable absorption – Unpredictable onset of action and peak effect – Tissue damage Intravenous – Provides rapid and effective relief with few side effects

48. Copyright 2008 by Pearson Education, Inc. Medication Administration Intraspinal – Provides superior analgesia with less medication used

49. Benefits/Risk Routes and Technology Patient-controlled analgesia – Minimizes peaks of sedation and valleys of pain that occur with prn dosing – Electronic infusion pump – Safety mechanisms

50. Nonpharmacologic Pain Control Interventions Consists of variety of pain management strategies – Physical – Cognitive-behavioral – Lifestyle pain management Target body, mind, spirit, and social interactions

51. Physical Modalities Cutaneous stimulation Immobilization or therapeutic exercises Transcutaneous electrical nerve stimulation (TENS)

52. Cognitive-Behavioral (Mind-Body) Providing comfort Eliciting relaxation response Repatterning thinking Facilitating coping with emotions

53. Lifestyle Management Stress management Exercise, nutrition Pacing activities Disability management

54. Spiritual Feel part of a community Bond with universe Religious activities

55. Nonpharmacologic Invasive Techniques Cordotomy Rhizotomy Neurotomy Sympathectomy Spinal cord stimulation

56. Collaborative Care for Pain Surgery – Cordotomy: an incision into the anterolateral tracts of the spinal cord to interrupt the transmission of pain – Neurectomy: removal of part of the nerve – Sympathectomy: destruction of the ganglia by incision or injection – Rhizotomy: surgical severing of the dorsal spinal roots – Transcutaneous electrical nerve stimulation (TENS): electrodes stimulate the A-beta touch fibers to close the “pain” gate

57. Collaborative Care for Pain

58. Body Interventions Reducing pain triggers Massage Applying heat or ice Electric stimulation (TENS) Positioning and bracing (selective immobilization) Acupressure Diet and nutritional supplements Exercise and pacing activities Invasive interventions (e.g. blocks) Sleep hygiene

59. Mind Interventions Relaxation and imagery Self-hypnosis Pain diary and journal writing Distracting attention Re-pattern thinking Attitude adjustment Reducing fear, anxiety, stress, sadness, and helplessness Providing information about pain

60. Spirit Interventions Prayer Meditation Self-reflection Meaningful rituals Energy work (therapeutic touch, Reiki) Spiritual healing

61. Social Interaction Functional restoration Improved communication Family therapy Problem-solving Vocational training Volunteering Support groups

62. Collaborative Care for Pain Medications – NSAIDs: analgesic, antipyretic, and anti- inflammatory action – Narcotics: opioids – Antidepressants: act on the retention of serotonin, thus inhibiting the pain sensation – Anticonvulsants: used for headache and neuropathic pain – Local anesthetics: blocks the transmission of nerve impulses, therefore blocking pain

63. Collaborative Care for Pain

64. Complementary Therapies – Acupuncture – Biofeedback – Hypnotism – Relaxation – Distraction – Cutaneous stimulation

65. Neuropathic Pain Experienced by people who have damaged or malfunctioning nerves Types – Peripheral – Central – Sympathetically maintained

66. Physiologic Pain Experienced when an intact, properly functioning nervous system signals that tissues are damaged, requiring attention and proper care Transient Persistent Subcategories – Somatic – Visceral