Chapter 35 - Pain Management
Intraspinal routes include
intrathecal and epidural
Nursing Goal:
Maintain acceptable level of comfort
Non Opioids
Not effective for neuropathic pain
Pain assessment should include: Aggravating and alleviating factors
What makes the pain better or worse?
The pain process is not only electrical. When you get injured -- say with a sprain -- the damaged tissue releases chemicals called
prostaglandins, which are like hormones. These prostaglandins cause the tissue to swell. They also amplify the electrical signal coming from the nerves. Basically, they increase the pain you feel.
Common assessment findings that are present when a client is in pain include
restlessness, grimacing, crying, clenching fists, guarding of the painful area, increased blood pressure and pulse, and reported pain.
Naloxone (antagonist) is used to
reverse the effects of oversedation and respiratory depression related to opioids in excess.
How can electricity decrease my pain? (TENS)
"The mild electrical impulses block the pain signal before it can reach the brain."
(Non Opioids) APAP:
Always check 24hr totals when APAP is an element in combination drugs
Cutaneous Stimulation
involves stimulation of the skin and underlying tissue, this technique is thought to interrupt transmission of the pain signal
The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:
1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.
Implementation
A Ask regularly, assess systematically B Believe patient's self-report C Choose treatment options based on comprehensive assessment D Deliver interventions in a coordinated way E Evaluate treatment effectiveness by reassessment
Epidural Catheter considerations:
A peripheral IV line should already be in place.
biofeedback:
A technique in which the patient learns voluntary control over autonomic functions
visceral pain:
A type of nociceptive pain that originates internally and is the result of stretching, distention, inflammation, or damage to the hollow and solid organs. associated with disease or injury. It is sometimes poorly localized as it is not experienced in the exact site where an organ is located.
Nonopoids
Acetaminophen (APAP)-antipyretic, analgesic NSAIDs-antipyretic, analgesic, anti- inflammatory
Outcome Planning and Identification
Active participation from patient in pain self-reporting
Outcome Planning and Identification
Active participation from patient in pain self-reporting Assist in establishing realistic comfort goals to maximize function Verbalizing the purpose for pain-relieving medications and side effects to report Utilize nonpharmacological pain-relieving interventions as appropriate
Gate-Control Theory.
Administering a backrub
Identify factors that may affect an individual's pain experience.
Affective- emotional response associated with increased pain Behavioral- activities that cause pain or increase pain Cognitive- meanings associated with a disease and pain, along with beliefs, attitudes, and expectations Physiological/Sensory- client exhibits physiological and behavioral responses
Implementation: A
Ask regularly, assess systematically
Pattern Theory
Asking the client how sensory stimuli produces pain
Most NSAIDs block both Cox-1 and Cox-2 enzymes. They include the over-the-counter drugs:
Aspirin (Bufferin, Bayer, and Excedrin) Ibuprofen (Advil, Motrin, Nuprin) Ketoprofen (Actron, Orudis) Naproxen (Aleve)
Outcome Planning and Identification
Assist in establishing realistic comfort goals to maximize function
Nonpharmacological Pain Management
Basic comfort measures are routinely offered by nurses to promote comfort and help diminish pain
Manifestations of pain:
Behavioral Responses Verbal vs Nonverbal
Cognitive
Beliefs, attitudes, meanings of pain and disease, memory of past pain (include aspects that are cultural in origin)
Implementation: B
Believe patient's self-report
Pain assessment should include: Intensity
Can you rate your pain on a scale of 0 to 10? Zero is no pain and 10 is the worst pain you can image
Pain assessment should include: Location
Can you tell me where it hurts, does the pain move or radiate?
Identify nursing diagnoses that relate to pain problems.
Impaired Comfort Acute Pain Chronic Pain Labor Pain Chronic Pain Syndrome
Implementation: C
Choose treatment options based on comprehensive assessment
Opioids
Come in many forms, routes, and doses
Other NSAIDs are available by prescription. They include:
Daypro Indocin Lodine Naprosyn Relafen Vimovo Voltaren
Inadequate pain management may lead to:
Decreased quality of life Depression, suicidal ideations Isolation / decreased socialization Decreased appetite Increased healthcare costs
Osteoarthritis
Degeneration of the articular surface of weight-bearing joints
Implementation: D
Deliver interventions in a coordinated way
Opioids
Drug of choice for moderate and severe pain Used for persistent pain in select patients Effective for both nociceptive and neuropathic pain Comes in many forms, routes, and doses Works peripherally and centrally along the pain pathway No analgesic ceiling (useful for upward dose titration if pain worsens) Respiratory depression is a life-threatening side effect due to the drug's actions on the CNS
Adjuvant Analgesics
Drugs with primary indication other than pain (antidepressants,antiepileptics)
Adjuvants
Drugs without analgesic properties that can be critical to pain management and treatment of related symptoms that may exacerbate pain (muscle relaxants, sleep medications, anxiolytics)
Non Opioids
Effective against nociceptive pain
Non Opioids
Effective against nociceptive pain Not effective for neuropathic pain APAP: metabolized in the liver, may cause toxicity. Always check 24hr totals when APAP is an element in combination drugs NSAIDs: used for both acute and persistent pain. Inhibits prostaglandin production, which protects the stomach and kidneys. Inhibits platelet aggregation
Opioids are:
Effective for both nociceptive and neuropathic pain
Pain perception is subjective and can be perceived by
Emotional, social, cultural, behavioral components, past experiences, Anxiety, fear, decreased pain tolerance
Implementation: E
Evaluate treatment effectiveness by reassessment
Opioids
Full agonist-morphine, hydromorphone, oxycodone, methadone, fentanyl Antagonist-naloxone
NSAID side effects include
GI irritation, renal toxicity, and bleeding. Use with caution in patients with GI disorders, kidney disease, and patients with bleeding risk
NSAID side effects include:
GI irritation, renal toxicity, and bleeding. Use with caution in patients with GI disorders, kidney disease, and patients with bleeding risk
Adjuvant Analgesics
Have pain relieving properties
Endogenous opioid theory
Having the healthcare provide order the client's opioid medication
Adjuvant Analgesics
Helpful in treating neuropathic and persistent pain
Pain assessment should include: Impact pain has on ability to function and quality of life
How does pain affect your sleep, activity, appetite, relationship, work, quality of life
Pain assessment should include: Quality
How would you describe your pain? Nociceptive pain? Neuropathic pain?
Manifestations of Pain - Physiologic Responses
Increased Blood Pressure Increased Heart Rate Increased Respiratory Rate Neuroendocrine and Metabolic Responses (stress response)
NSAIDs (Non Opioids):
Inhibits platelet aggregation (blood clotting)
NSAIDs (Non Opioids):
Inhibits prostaglandin production, which protects the stomach and kidneys.
Nursing Interventions for pain
Instruct patient to report pain often Educate regarding pain medication and side effects Utilize the ABC of pain management guide Utilize pharmacological and non-pharmacological methods of pain management Constantly reevaluate pain management plan Use careful communication and positive encouragement
Pain assessment should include: Duration
Is your pain constant or intermittent?
Behavioral
Many behaviors are associated with pain; some aggravate it and others alleviate it. How pain is expressed impacts pain intensity, tolerance, and adherence to analgesic therapy.
Other Adjuvants
May compound sedative effects when used in combination with opioids
Identify nursing interventions which may be appropriate to delegate to other members of the healthcare team to promote sleep and comfort.
May delegate non-pharmacological activities of pain management to other members of the healthcare team
WHO - Step 1
Mild Pain - (1-3) Treated with around the clock NSAID or acetiminophen
WHO - Step 2
Moderate pain (4-6) addition of oral opioid analgesics or low dose IV
Other Adjuvants
Monitor sedation levels for safety when used in combination with opioids
Opioids have:
No analgesic ceiling (useful for upward dose titration if pain worsens)
Epidural Catheter considerations:
No other medications should be administered
Other Adjuvants
No pain-relieving properties
Other Adjuvants
No pain-relieving properties Used to treat associated symptoms that can exacerbate pain (insomnia, anxiety, muscle spasm) May compound sedative effects when used in combination with opioids Monitor sedation levels for safety
NSAID is an abbreviation of:
Nonsteroidal Antiinflammatory Drugs
Opioids are:
Often used in surgery patients, trauma, procedures and cancer patients
What Is Pain?
On a basic level, pain is the result of an electrical signal being sent from your nerves to your brain.
Pain assessment should include:
Onset Location Duration Quality Intensity Aggravating and alleviating factors Impact pain has on ability to function and quality of life Pain care goal Medications and treatments (concerns or worries)
Describe the types of analgesics.
Opioids. Nonopoids, Adjuvant Analgesics, Adjuvants, Patient-Controlled Analgesia (PCA), intrathecal and epidural
Older adults often suffer from chronic pain
Osteoarthritis Neuropathies Central/Neuropathic pain following CVA Postherpatic neuralgia Phantom limb pain
Affective:
Pain and suffering are not synonymous. The emotions associated with pain such as fear, anxiety, depression, anger.
neuropathic pain:
Pain caused by nerve damage - experienced days, weeks, or even months after the source of the pain has been treated and resolved.
somatic pain:
Pain that originates in bone, skin, and soft tissue and is often well localized
Adjuvant Analgesics
Primary use for reasons other than pain management Have pain relieving properties Helpful in treating neuropathic and persistent pain
Adjuvant Analgesics
Primary use for reasons other than pain management
Nonpharmacological Pain Management Nursing Implications
Proper positioning Therapeutic environment Appropriate lighting Low noise levels Comfortable temperature Wrinkle-free sheets Nonconstrictive gowns or devices Cutaneous Stimulation Heat (hot water bottles, electric heating pads, warm damp towels, warm bath or shower) Cold (ice packs, refrigerated gel pack, a frozen damp towel or towel dipped in ice water) Massage Transcutaneous Electrical Nerve Stimulation (TENS) is a palm-sized light weight, battery operated stimulator that generates a mild electrical impulse Distraction Relaxation Imagery Biofeedback
Neuromatrix Theory
Removing items that remind the client of a former spouse
Epidural Catheter considerations:
Resistance should not be felt when removing an epidural catheter.
Opioids can cause:
Respiratory depression is a life-threatening side effect due to the drug's actions on the CNS
Adverse effects of opioids:
Sedation and Respiratory DepressionOpioid-naïve pts Pts receiving other sedative meds Elderly pts Pts with obstructive sleep apnea (OSA)
WHO - Step 3
Severe pain (7-10) addition of higher dose opioid opioids, more frequently
WHO (World Health Organization) Analgesic Ladder
Stepwise approach to pharmacologic pain management Multimodal approach
Epidural Catheter considerations:
The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache.
TENS is used as an adjunct in the overall management of acute and chronic pain.
The voltage intensity, frequency, and duration of treatment are prescribed by the MD.
Physiological/sensory
These responses are considered indicators of pain. Ethics and culture affect aspects of pain
Risk Identification
Tolerance, physical dependence, addiction
Kidney/liver issues + pain meds =
Toxicity
This is known as the stress response -
Unrelieved pain causes stored energy to be consumed in order to provide energy to vital organs and injured tissue.
Opioids are:
Used for persistent pain in select patients
Opioids
Used for persistent pain in select patients. Drug of choice for moderate and severe pain Effective for both nociceptive and neuropathic pain Comes in many forms, routes, and doses Works peripherally and centrally along the pain pathway No analgesic ceiling (useful for upward dose titration if pain worsens) Respiratory depression is a life-threatening side effect due to the drug's actions on the CNS
Other Adjuvants
Used to treat associated symptoms that can exacerbate pain (insomnia, anxiety, muscle spasm)
Outcome Planning and Identification
Utilize nonpharmacological pain-relieving interventions as appropriate
Outcome Planning and Identification
Verbalizing the purpose for pain-relieving medications and side effects to report
Pain assessment should include: Pain care goal
What level of pain on the pain scale would let you participate fully in your life?
Pain assessment should include: Medications and treatments (concerns or worries)
What medications are you currently taking for your pain, do you use any herbal medications, or other pain relief interventions?
Pain assessment should include: Onset
When did the pain begin?
Opioids
Work peripherally and centrally along the pain pathway
Commonly observed responses in acute pain are usually
absent in persistent or chronic pain
APAP is an abbreviation of:
acetyl-para-aminophenol - the chemical name of acetaminophen.
Nociceptive pain is
aching, sharp, deep, gnawing
Behavioral
activities that cause pain or increase pain
Patient-Controlled Analgesia (PCA)
allows the patient to self- administer drugs by various routes - IV administration is the most common
Increased respiratory rate is:
an effort to increase the amount of oxygen available to the heart and circulation.
APAP
antipyretic, analgesic
NSAIDS
antipyretic, analgesic, anti-antiinflammatory
Always consider
bowel management interventions when patient is prescribed opioids
Physiological/Sensory
client exhibits physiological and behavioral responses
Cold application
decreases sensitivity to pain and is useful for muscle spasms, back pain, arthritis, headache, trauma, and surgical incision pain. May act faster than that and may provide a greater duration of relief. * Introduce cold gradually
Heat application
decreases the sensitivity to pain and increases blood flow through local vasodilatation of vessels
Tolerance
develops to many side effects of opioid use over time except constipation
cutaneous pain
discomfort originates at the skin level and is a commonly experienced sensation resulting from some form of trauma.
Increased BP and increased the work of the heart are:
due to overactivity of the sympathetic nervous system.
Affective
emotional response associated with increased pain
Psychological responses would include
exaggerated weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, and powerlessness.
Pain management plans that include both pharmacologic and nonpharmacological strategies
improve pain control, decrease emotional distress, improve functional comfort, and in some cases reduce analgesic use
Physiologic (involuntary) responses would include
increased blood pressure, increased pulse and respiratory rates, pupil dilation, muscle tension and rigidity, pallor (due to peripheral vasoconstriction), increased adrenaline output, and increased blood glucose.
anxiolytics
is a medication or other intervention that inhibits anxiety.
Somatic pain
is diffused or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves.
Visceral pain
is poorly localized and originates in body organs.
Constipation
is the most common side effect of opioid use.
Gabapentin
is used to treat nerve pain.
PCA allows the client to
keep pain within a constant tolerable level; pain relief is rapid because the drug is delivered intravenously. Safe parameters for dosing are set by the care team.
Some forms of cutaneous stimulation include the following:
massage, application of heat or cold (or both intermittently), acupressure, transcutaneous electrical nerve stimulation (TENS)
Cognitive
meanings associated with a disease and pain, along with beliefs, attitudes, and expectations
(Non Opioids) APAP:
metabolized in the liver, may cause toxicity.
Behavioral (voluntary) responses would include
moving away from painful stimuli, grimacing, moaning, crying, restlessness, protecting the painful area, and refusing to move the limb.
Phantom limb pain
occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.
Neuropathies
or paralysis
Current pain perception may be influenced by
past experiences
Side effects of opioid use include:
sedation, nausea, vomiting, pruritus (itching), respiratory depression, constipation, and delirium.
Neuropathic pain is
shocklike, burning, tingling
Increased heart rate is:
the body's attempt to increase available oxygen and circulating volume.
The client's report of back pain would alert the nurse to
the possibility of an epidural hematoma.
NSAIDs (Non Opioids):
used for both acute and persistent pain.
Cutaneous pain
usually involves the skin or subcutaneous tissues.