1. Chapter 43
Pain Management
NRS_105/320_Collings

2. Importance Pain management is a primary nursing responsibility
Nurse have a legal and ethical duty to control/relieve pain
Pain relief is a basic human right
Patients need to know we CAN and WILL relieve their pain
NRS_105/320_Collings

3. Why? Effective pain management: Improves quality of life
Reduces disability
Promotes early mobility and return to work
Results in less hospital / office visits
Reduces length of stay, complications
Reduces health care cost
Improves patient satisfaction
NRS_105/320_Collings

4. Nature of Pain Physical Emotional Cognitive Subjective
NRS_105/320_Collings

5. Physiology of Pain Transduction Transmission
Thermal,chemical,mechanical stimulation
→ electrical impulse in nerve fiber
Transmission
A fibers: sharp, localized, distinct sensation
C fibers: generalized, persistent sensation
E.g. Burn finger – spot pain → ache
Peripheral → spinal → brain
NRS_105/320_Collings

6. Physiology of Pain Perception Modulation
Brain interprets impulse, perceives as pain
Experience, memory, context, knowledge
Ascribes meaning to sensation
Modulation
Body response
Endogenous opiods, serotonin, norepinephrine, GABA
↓ transmission of impulse, analgesic effect
These deplete over time with continued pain
NRS_105/320_Collings

7. Gate-Control Theory of Pain
Gating mechanisms along the CNS
Can block transmission of impulses
Pain relief measures to close the gate
Light touch [effleurage]
Pain threshold
Level at which you feel pain
Genetic, learned,
Runner’s high, endogenous opiods
Individual – not transferrable!
NRS_105/320_Collings

8. Physiological Response to Pain
Mild – moderate pain [1-6] superficial
→ autonomic response [sympathetic];
fight or flight, general adaptation
↑HR, RR, B/P, BG, diaphoresis, peripheral vasoconstriction
Severe or deep [7-10], visceral pain
→ parasympathetic response
↓ HR, B/P, muscle tension, immobility, irreg resp
may cause harm
Physiologic response [VS] is short-term;
VS are not reliable pain indicators over time
NRS_105/320_Collings

9. Behavioral responses to Pain
Dependent on context, meaning, culture, pain tolerance
It is supposed to hurt
Men don’t cry
I don’t want to be a complainer, bother
Nonverbal indicators
Body movements; restless or still, holding, guarding
Facial expression; grimace, frown, clenched teeth, posture,
Lack of expression of pain does not mean it isn’t there!
NRS_105/320_Collings

10. Goal is to control pain so patient can participate in recovery
Types of Pain
Acute pain
Protective, identifiable cause, short duration, limited tissue damage, ↓ emotional response
Causes harm by ↓ mobility, energy
Goal is to control pain so patient can participate in recovery
↓ Pain → ↑Mobility → decreased complications, decreased length of stay
NRS_105/320_Collings

11. Types of Pain Chronic pain Pseudoaddiction: seeking pain relief
Serves no purpose [not protective]
Lasts longer than anticipated
May or may not have an identifiable cause
Impacts every part of patient’s life
Depression, Suicide
Disability, isolation, energy drain, ADL’s
Pseudoaddiction: seeking pain relief
not drug-seeking
NRS_105/320_Collings

12. Types of Pain Cancer pain Pain by inferred pathology Idiopathic pain
May be acute or chronic, constant or episodic, mild to severe
Up to 90% of Ca pts have pain
Pain by inferred pathology
Known cause = characteristic pain [neuropathic]
Idiopathic pain
No known cause BUT still pain
“Excessive” pain for a condition
NRS_105/320_Collings

13. Knowledge, Attitudes, and Beliefs
Subjective nature of pain
Pain is what the patient says it is, not what the nurse thinks it should be
Same procedure, different pain
Expectations, context, culture affect perception and expression of pain
NRS_105/320_Collings

14. Knowledge, Attitudes, and Beliefs
Nurse’s Response to Pain
Bias
‘I go to work with 5/10 pain every day’
‘Its only a minor surgery’
‘I had three kids and didn’t scream’
Fallacies
Infants don’t feel pain like we do
Regular pain med use causes addiction
Older people all are in pain
NRS_105/320_Collings

15. Factors Influencing Pain
Physiological
Age – interpretation/communication
Fatigue
increases pain,
sleep not sign pain is relieved
Genes
Pain threshold
Neurological function
Interpretation, communication, reflex
NRS_105/320_Collings

16. Factors Influencing Pain
Social
Attention/ distraction
Previous experience
May increase or decrease tolerance
Family and social support
Spiritual
Meaning of pain, suffering
Support system
NRS_105/320_Collings

17. Factors Influencing Pain
Psychological
Anxiety
Coping style
Control [PCA]
Cultural
Meaning of pain
Expression of pain
Role in Family
Ethnicity
NRS_105/320_Collings

18. Assessment of Pain Client’s expression of pain Characteristics of pain
Description is most valid indicator
Characteristics of pain
Onset and duration
Location
Intensity
Quality
Pattern
NRS_105/320_Collings

19. Assessment of Pain Characteristics of pain (cont'd)
Relief measures
Contributing symptoms
Behavioral effects on the client
Influences on ADLs
Client expectations
What pain level would allow you to function well?
[walk the hall, do ADL’s, resume job…]
NRS_105/320_Collings

20. Assessment
Can we do a full assessment of pain when the client is in severe pain?
No!
Alleviate severe [7-10] pain before talking it to death
Pain rated >7 needs immediate attention
NRS_105/320_Collings

21. Nursing Diagnoses Anxiety Ineffective coping Fatigue Acute pain
Chronic pain
Ineffective role performance
Disturbed sleep pattern
NRS_105/320_Collings

22. Planning Goals and outcomes Setting priorities
Client is using pain relief measures safely
Pain level reported at </=___ and congruent nonverbal behaviors seen
Demonstrate understanding of need to premedicate before activity
Splint abdomen with cough
Setting priorities
What is important for the client? What does he need to do?
Control pain enough to eat, sleep? Be mobile to prevent complications? Work? PT? Maintain dignity, relationships while dying?
Maslow: Pain relief is basic need
NRS_105/320_Collings

23. Implementation: Health Promotion
Client education
Expectations, when to seek treatment
Preparation before pain
Holistic care
Whole self; physical, emotional, spiritual
Education, rest, exercise, nutrition, relationships
NRS_105/320_Collings

24. Nonpharmacological Pain Relief
Relaxation and guided imagery
Distraction
Biofeedback
Cutaneous stimulation—massage, application of hot/cold, TENS
Herbals
Reducing painful stimuli and perception
NRS_105/320_Collings

25. Controlling Painful Stimuli
Managing the client’s environment—bed, linens, temperature
Positioning
Changing wet clothes and dressings
Monitoring equipment, bandages, hot and cold applications
Preventing urinary retention and constipation
NRS_105/320_Collings

26. Implementation Pain Management
Pharmacological pain relief
… Administer analgesics as ordered/ reassess pain in 30 minutes and hourly
Analgesics: NSAIDs and nonopioids, opioids, adjuvants
Patient-controlled analgesia (PCA)
Local analgesic infusion pump
Topical analgesics and anesthetics
Local and regional anesthetics
NRS_105/320_Collings

27. Implementation Pain Management
Surgical interventions
Procedural pain management
Chronic and cancer pain management
NRS_105/320_Collings

28. Implementation Pain Management
Barriers to effective pain management [pts, nurses, doctors, system…]
Fear of addiction - #1 barrier
Terms:
Dependence: physical adaptation resulting in withdrawal symptoms
tolerance: physical adaptation resulting in diminished drug effect over time
Addiction: impaired control over use, use despite harm
pseudoaddiction: drug seeking behavior to relieve undertreated pain
NRS_105/320_Collings

29. Implementation Pain Management
Nursing implications for pain management
Accurate safe medication administration
Assess effectiveness and side effects
Patient education [families too]
Use the appropriate drug when given a choice
Treat pain before it gets severe
NRS_105/320_Collings

30. Implementation: Restorative Care
Pain clinics
Palliative care
Hospices
NRS_105/320_Collings

31. Evaluation Effectiveness Side effects Document and communicate
Assess at peak of drug effect
[30 minutes IV, 1 hour PO]
Add complementary therapies for partial effect
Talk with M.D. about options if approach is consistently ineffective
Side effects
Document and communicate
Most effective relief
NRS_105/320_Collings

32. Evaluation Client expectations Did client achieve goal?
Validate experience
Relieve the pain
Show you care
Did client achieve goal?
Walk hall w/o pain?
Pain < 3/10 all day [except with PT]
Able to return to work, enjoy visit, T,C,&DB?
Pain report congruent with nonverbal?
NRS_105/320_Collings