305- Ch. 44- Pain Management

Nursing Diagnosis

Accurate identification of related factors is necessary in choosing appropriate nursing interventions. Applicable dx include: Self-care deficit Activity intolerance Ineffective coping Impaired social interaction Spiritual distress Powerlessness Acute pain r/t- Fear Hopelessness

Factors Influencing Pain: Physiological Factors

Age: Children have difficulty understanding and expressing pain. Lack of experience, vocabulary, cognitive development. Older Adults development of pathological conditions leading to impairment of function leading to: T. 44-4 p. 1020 Decreased mobility, ADL's, social activity, and activity tolerance. Multiple diseases may affect similar parts of the body (vague symptoms) Fatigue: Heightens perception of pain. Decreases coping abilities. Genes: Genetic information possibly increases or decreases sensitivity to pain/pain tolerance. Neurological Functions: Any factor that interrupts or influences normal pain reception or perception

Pharmacological Pain-Relief Interventions

Analgesics: Most common and effective Three types: Nonopioids: Acetaminophen (hepatotoxicity/ Mucomyst) Nonsteroidal anti-inflammatories (GI bleeding/renal insufficiency) Opioids: narcotics (sedation/respiratory depression/ Narcan; N/V, constipation [ongoing], itching, urinary retention, AMS) Adjuvants: enhance analgesic properties: steroids, anticonvulsants, antidepressants. May contribute to respiratory depression.

Factors Influencing Pain: Psychological Factors

Anxiety: Anxiety increases feelings of pain and pain causes anxiety. Loss of control over environment increases anxiety. Anxiolytic medications are not a replacement for analgesia Coping Style: Internal loci vs. External loci Cultural Factors: Individual learn what is expected and accepted by their culture. Demonstrative vs. Introverted.

ABCDE's of Pain Assessment

Ask about pain Believe patient stated pain level Choose appropriate options Deliver interventions both timely and logically Empower patient to take control of pain management

Factors Influencing Pain: Social Factors

Attention: Increased attention to pain causes increased pain, whereas distraction is associated with diminished pain response (relaxation, guided imagery). The reticular activating system-inhibits painful stimuli if sensory input sufficiently stimulated; person ignores or becomes unaware of pain. Previous Experience: Learning from painful experiences: experienced relief or no relief. Anticipatory Pain: explain procedures to the patient be clear on what to expect. Family & Social Support: Can make experience less stressful especially parents in the presence of children. Spiritual Factors: Punishment, lessons from God etc...

Effects of Pain on the Patient

Behavioral Effects B. 44-9 p. 1027 Assess verbalizations, vocal responses, facial and body movements, social interaction Influence on ADLs Assess for physical deconditioning, sleep patterns, self-care deficits, sexual dysfunctions related to pain, social activities Concomitant Symptoms HA, nausea, dizziness, constipation, depression

Chronic Episodic Pain:

Chronic Episodic Pain: Lasting hours days or weeks: Migraine HA Sickle cell disease

Chronic/Persistent Non-cancer Pain:

Chronic/Persistent Non-cancer Pain: Pain lasting longer than 6 mo. Or "pain that extends beyond the expected period of healing" (Arthritis, low back pain, peripheral neuropathy). Chronic pain leads to psychological depression and even suicide. Major cause of: Job loss Inability to perform simple ADL's Sexual dysfunction Social isolation

Environmental Control

Clean wrinkle-free sheets Repositioning Proper fitting bandages/devices Proper patient lifting/moving Clean dry skin Foley catheter protocol Prevent constipation

Objectives

Discuss common misconceptions about pain. Describe the physiology of pain. Identify components of the pain experience. Explain how the physiology of pain relates to selecting interventions for pain relief. Describe the components of pain assessment. Explain how cultural factors influence the pain experience. Explain various pharmacological and non-pharmacological approaches to treating pain. Discuss nursing implications for administering analgesics. Discuss barriers to effective pain management. Evaluate a patient's response to pain interventions

Barriers to Effective Pain Management

Do not label patients as "drug seeking". Pseudoaddiction: looks like addiction but it is not addiction. In cases of pseudoaddiction, the drug-seeking behaviors cease once the pain is properly controlled, thereby confirming the absence of true addiction. Understand personal biases. Placebos: Discouraged May be considered unethical and deceitful Differentiate: B. 44-19, p. 1044 Physical Dependence Addiction Drug Tolerance

Herbals

Don't negate the patients use/belief in herbal remedies. May interact with prescribed analgesics. Ask patients to report all substances they take.

Nursing Implications: Regional

Explain insertion technique to patient. Add medications administered via drug pump Drugs must be free of preservatives and additives (Duramorph-morphine/ Sublimaze-fentanyl). Assist the patient the first time up out of bed. Surgical asepsis to prevent serious/fatal infection. Observe for S&S of complications such as N/V, urinary retention, constipation, respiratory depression (Narcan for RR <8), pruritus. Monitoring may be as often as every 15 minutes.

FLACC Pain Scale

Face, Legs, Activity, Cry, Consolability Used for infants; possibly for mentally or neurologically impaired.

Numeric Pain Scale

For patients who can easily communicate and understand its usage.

Physiology of Pain

Four physiological processes of normal (nociceptive: thermal, mechanic, or chemical) pain: Transduction: Begins in the periphery with a pain-producing stimulus. Transmission: Cellular damage results in release of neurotransmitters (bradykinin, histamine) spreading the pain "message" and creating an inflammatory response. Two Types of nerve peripheral nerve fibers: Fast myelinated (A-delta): Sharp, localized and distinct Slow unmyelinated (C fibers): Poorly localized, burning, persistent Perception: Aware of pain. Processed from past experience knowledge, and cultural associations in the perception of pain. Modulation: Inhibition of the pain process by the release of inhibitory neurotransmitters (endogenous opioids, serotonin, norepinephrine). Helps to produce an analgesic effect.

Implementation

Health Promotion: Patients are better prepared to handle almost any situation when they understand it. Provide an individualized approach Understand your patient's health literacy Common Holistic Health Approaches include: Wellness education Regular exercise Rest Attention to good hygiene practices Nutrition management Management of interpersonal relationships

Acute/transient Pain:

Identifiable cause; short duration generally less than 6 mo (traditionally). May interfere with recovery, increases risk of complications from resulting immobility.

Effective Pain Management does what for a patient?

Improves quality of life. Reduces physical discomfort. Promotes earlier mobilization and return to previous activity levels. Results in fewer hospital and clinic visits. Decreases hospital lengths of stay resulting in lower health care costs.

Invasive Pain Management Interventions

Intrathecal implantable pumps or injections Spinal cord stimulators Deep brain stimulation Neruoablative procedures (cordotomy: a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature sensation). Trigger point injections Refer patients with pain unresponsive to medication to a pain expert. It is unacceptable to tell a patient "there is nothing more we can do for you".

Cutaneous Stimulation

May cause release of endorphins, thus blocking the transmission of painful stimuli (Gate Control Theory). Massage-Physical and mental relaxation B. 44-11 p. 1034. Warm Bath-Relieves tension Ice Packs- Reduces acute pain from inflamed joints/tissues

Cancer and Chronic Non-Cancer/Cancer Pain Management

May develop opioid tolerance. Pain management best when administered ATC and not PRN. Patients usually become tolerant to side effects (except constipation) so respiratory depression less of a problem. Transdermal fentanyl: 100 times more potent than morphine. Hydromorphone (Dilaudid): 10 times more potent than morphine Consider the use of the WHO three-step analgesic ladder F. 44-14 p. 1042 Breakthrough Pain: Pain that "breaks through" a scheduled regimen of pain treatment B. 44-17 p. 1042.

Knowledge, Attitudes, and Beliefs

Nurses personal attitudes affects pain titration Nurses assessment of pain intensity underestimates patients' pain reports Patient variables such as culture, gender, age, education, patient diagnosis contribute to nurses differences in pain ratings Nurses vary pain medication administration according to patient affect (smiling, grimacing) Nurses use their judgment to decide if the patient is 'really in pain' Nurses must accept the patient's report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and EB research findings (Pasero & McCaffery, 2011 as cited in P & P, 9th ed)

Transcutaneous Electrical Nerve Stimulation (TENS)

OTC devices are now available Battery powered transmitter with electrodes placed on or near the pain. Creates a buzzing/tingling sensation. Adjustable by the user. -won't really see in hospital but pt. might talk about

Assessment

Obtain a mutually agreed upon pain relief goal. What level will allow your patient to function? Treat pain assessment like a 6th vital sign. Determine your patients health literacy. Higher vocabulary allows patients to better describe their pain Utilize an assessment tool to allow for a more accurate measure. 0-10 scale Wong/Baker Faces Assess previous pain experience and effective home interventions. During an episode of acute pain assess: Location Severity Quality

Protective reflex response:

Pain stimulus bypasses the brain and causes muscle contractions to withdraw from the pain source Afferent (sensory) nerve fibers Sense pain impulse Efferent (motor) nerve fibers Sends impulse to withdraw from stimulus back to source

Assessment-Characteristics of Pain

Onset & Duration: When did it begin? How long has it lasted? Location: Use anatomical landmarks and descriptive terminology (superficial, cutaneous, deep or visceral, referred or radiating (Table 43-5, p. 973). Severity: Use pain scales F.'s 44-5-7 p. 1026 Quality: Aching, throbbing, sharp, dull (nociceptive); burning, shooting or electric-like (neuropathic) Aggravating/Precipitation Factors: Events or conditions that precipitate or aggravate pain. Relief Measures: What works? (changing positions, heat, cold). Contributing Symptoms: Depression, anxiety, anorexia, sleep disturbances.

Restorative and Continuing Care

Pain Clinics: Work with patients to find the most effective pain-relief measures. Palliative Care: Learning to live life fully with an incurable condition. Hospices: Care for patients at end of life. Emphasis on quality of life not quantity.

Gate-Control Theory of Pain

Pain has emotional and cognitive components in addition to physical sensation. "Pain Threshold" is increased [endorphins], for example, through stress and exercise

Pain management is A Nurses role in management is:

Pain management is patient-centered A Nurses role in management is: Patient advocacy Promoting empowerment and health literacy Treating patients with compassion and respect

Behavioral Responses to Pain

Pain significantly alters quality of life if left untreated. Threatens physical and psychological well-being. Do not let personal bias dictate your nursing care: Labeling patients as "drug seekers" "Complainers" (patients with low pain tolerance) Prevention is easier than treatment: Encourage patients to seek relief before pain occurs. Watch for patients who choose not to report pain: Sign of weakness, loss of control, cultural considerations Encourage patients to accept pain relieving measures: Helps to maintain ADL's

Patient-Controlled Analgesia (PCA)

Places the patient in control of analgesia. Allows patients to self-administer opioids with minimal risk of overdose** Goal: to maintain a constant plasma level of analgesia. IV or subcutaneous administration. Patients must be physically able to press the button to deliver the dose. Caution families not to medicate their loved one. System designed to deliver a specified number of doses every hour (for example every 10 to 15 minutes). Benefits include: Patient gains control over pain Access to medication when the patient needs it. Decreases anxiety and leads to decreased medication use Stabilized serum drug levels by delivering small doses at short intervals.

Local and Regional Anesthetics

Perineural Infusion pumps: Unsutured catheter coming from an incisional site infusing local anesthetic. Very short term (1-2 days). Topical Analgesics: EMLA (lidocaine/prilocaine cream) or LET (lidocaine, epinephrine, tetracaine), Lidoderm patch. Regional Anesthesia: nerve blocks, spinal anesthesia, epidural Analgesia: childbirth, chronic pain. Reduces a patient's overall opioid requirement.

PCA Risks

Potential for receiving too much medication may occur MD orders too strong a dose of morphine/dilaudid Nurse programs the machine wrong Injury and death can occur even with no errors with the pump Respiratory depression Patient is monitored with oximetry alone Need for continuous oximetry and capnography

Range Orders

Range-orders are medication orders in which the dose varies over a prescribed range depending on the situation or the patient's status. Example: Morphine 2-4 mg IV every 4 hours for pain. The Joint Commission requires range-order policies to be in place, utilized, and well documented. Many institutions have strict guidelines on the use (or non-use) of range-orders. May be considered "prescribing"

Complimentary & Alternative Medicine

Relaxation and Guided Imagery such as meditation, yoga. benefits include: Decreased pulse Decreased blood pressure Decreased respiratory rate Decreased oxygen consumption Decreased muscle tension Decreased metabolic rate

How we provide effective pain management to our patients?

Remember pain is subjective and it is what the patient states it is. The pain threshold varies between patients Remember a number of factors influence a persons response to pain including their cultural background, developmental stage, environment, personal experience with pain, and emotional status Assessment is the key to providing a correct care plan for a patient's pain There are two types of interventions for pain: nonpharmacological and pharmacological Always follow policy and procedure for pain management Patients should always be the center of their care plan and include their preferences

Patient's Expression of Pain

Single most reliable indicator of its existence and intensity. Use an individualized approach for assessment. Specific populations often require special considerations: Children Developmentally delayed Mental health populations Critically ill (artificial airways, NGT's) Dementia Non-English speaking

Physiological Responses to Pain

Sympathetic branch of the ANS- "Fight or Flight" reaction: Stimulated by pain of low to moderate intensity Parasympathetic branch: Stimulated by continuous, severe, or deep pain ( involving the visceral organs such as MI or colic from the gallbladder) Most people adapt to pain; ultimately VS return to normal: Look to other problems if changes in VS persist.

Pain

The most common reason people seek health care. It is purely subjective. Providing pain relief is a basic human right (Pain Care Bill of Rights, APF, 2007). Nurses are legally and ethically responsible for managing pain and relieving suffering. Remember - A patient's pain level is whatever the person experiencing it states it is.-everyone's pain is DIFFERENT

Nonpharmacological Pain-Relief Interventions

To be used WITH and not IN PLACE of pharmacological measures. Includes: Cognitive-behavioral- Changing patients' perceptions of pain, alter pain behavior, provide patients with a greater sense of control. Includes: Prayer, relaxation, guided imagery, music and biofeedback. Physical Approaches: Provide pain relief, correct physical dysfunction, alter physiological responses and reduce fears associated with pain related therapy. Includes: Chiropractic therapy, acupuncture/acupressure therapy

Cancer Pain: Nociceptive (somatic) and/or neuropathic:

Tumor progression, invasive treatments, infection, physical limitations. Visceral pain (from internal organs) often referred pain. 70% to 90% of cancer patients experience pain 60% report moderate to severe pain (Maxwell, et al., 2005; Potter & Perry, 8th ed.).

Evaluation

Understand peak effects of analgesics. Reassess after each intervention at the appropriate time. Document patient response to therapy. Document any unexpected outcomes.

Wong Baker FACES

Used for children 3 years and up (assess understanding) and for non-English speaking patients. Oucher scale is the face of a child (CH Yeh, 2003).

Planning

Utilize professional standards of care including agency policies or through professional organizations when planning interventions. Determine with the patient the expected pain goals and outcomes. Set Priorities Teamwork and Collaboration Use available resources for pain control including: Advanced Practice Nurses Pharmacists PT and Occupational therapists Clergy Clinical Pain Specialists.

Idiopathic Pain

[Psychogenic]Chronic pain in the absence of an identifiable cause or too excessive for a pathological condition.