Exam 4 3040 Comfort and Pain Management

Adjuvant Analgesics

Adjuvant drugs are typically used for other purposes, but are also used to enhance the effect of opioids by providing additional pain relief. They may also reduce side effects from prescribed opioids or lessen anxiety about the pain experience. Adjuvant analgesics include antidepressants, anticonvulsants, corticosteroids, and biophosphonates. They may be used to treat acute pain resulting from surgery, burns, or trauma but are also effective for persistent neuropathic pain syndromes such as fibromyalgia, diabetic neuropathy, and postherpetic neuralgia

OLDER ADULTS

Adults over the age of 65 experience pain more frequently than do younger adults Pain negatively impacts the emotional well-being, functional ability, sleep, coping, and resources of older adults. Although pain is not a normal part of aging, pain occurs secondary to many chronic illnesses that are present in older adults. Risk factors associated with chronic pain include advancing age, female sex, low/lower socioeconomic status and education level, obesity, use of tobacco, history of injury or a physically strenuous job, childhood trauma, and depression and/or anxiety Many older adults view pain as a forecast of serious illness or death and thus are reluctant to admit its occurrence or report it. Boredom, loneliness, and depression may affect an older adult's perception and report of pain. Experts agree that pain is best assessed using a comprehensive pain assessment that includes using a standardized tool, determining the impact of chronic pain on functioning, identifying attitudes and beliefs, including family members and caregivers in the data-gathering phase, identifying resources, and reviewing comorbidities and medications. Although the Numeric Rating Scale is the most commonly used standardized tool, the Wong-Baker FACES Pain Rating Scale or Faces Pain Scale-Revised (FPS-R) may also be effective for this age group. Some research has indicated that older adults prefer a vertical pain scale such as the Iowa Pain Thermometer (IPT) or Revised Iowa Pain Thermometer (IPT-R) rather than the horizontal numeric pain scales

EMPLOYING BIOFEEDBACK

Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the patient's skin. The feedback signal or unit transforms the physiologic data into a visual display of their rate and depth of respirations, muscle tension, sweat response, and/or heart rate (Simons & Basch, 2016). Upon seeing pain-related responses, such as increased muscle tension or elevated blood pressure, the patient is taught to regulate this physiologic response and control pain by practicing techniques such as deep-breathing exercises, progressive relaxation exercises, or visual imagery. Biofeedback decreases the person's pain by reducing the anxiety associated with lack of control over bodily functions, directing the person's attention away from the pain to the person's inner state and the feedback signal, and reducing the cause of the pain. Limitations of this method include the high degree of motivation needed and difficulty of maintaining control after the training program.

USING HYPNOSIS

Hypnosis, a technique that produces a subconscious state accomplished by suggestions made by a hypnotist, has been used successfully in many instances to control pain. The person's state of consciousness is altered by suggestions so that pain is not perceived as it normally would be. According to many hypnotists, it also alters the physical signs of pain. Many people can be taught autohypnosis, that is, self-induced hypnosis, for the control of pain. It is generally believed that a successful response to hypnosis is related to the person's openness to suggestion, belief that hypnosis will work, and emotional readiness.

Routine Pain Assessment

In an effort to improve patients' quality of life and make pain management a priority, the American Pain Society (1995) encouraged caregivers to include assessment for pain as the fifth vital sign. Routine measurement of vital signs accompanied by a pain assessment was thought to raise awareness of the existence of pain, place additional emphasis on optimizing pain relief, and move patients more quickly toward comfort and recovery. Realistic pain management goals need to be set with each patient.

Affective (Psychological) Responses

Exaggerated weeping and restlessness Withdrawal Stoicism Anxiety Depression Fear Anger Anorexia Fatigue Hopelessness Powerlessness

Religious Beliefs

In some religions, people view pain and suffering as a lack of goodness in themselves. Thus, pain and suffering are viewed as a means of purification or of making up for individual and community sin. This meaning helps the person to cope with pain, thus becoming a source of strength. Patients with this belief may refuse analgesics and other pain relief measures, feeling that this lessens their suffering. On the other hand, illness and pain may also be viewed as punishment from a vengeful God. People may find their faith shaken and question the existence of a loving God. How can belief in a loving God be compatible with their present experience of pain? Anger, resentment, and depression may compound the pain experience. Patients may find it helpful to confer with a spiritual adviser about their pain experience.

Acute Pain

generally rapid in onset and varies in intensity from mild to severe. It is protective in nature. In other words, acute pain warns the person of tissue damage or organic disease and triggers autonomic responses such as increased heart rate, the fight-or-flight response, and increased blood pressure. stops after injury heals. After its underlying cause is resolved, acute pain disappears. It should end once healing occurs. Causes of acute pain include a pricked finger, sore throat, or surgery.

Key indicators of addiction

include a profound craving for the drug, erosion of the inhibitory mechanisms that control efforts to refrain from drug use, and compulsive drug taking. Addiction is associated with long-term opioid use, but surveillance with short-term use is also beneficial. Primary clinical efforts to prevent addiction include performing an assessment of addition risks before prescribing opioids, regular monitoring, referral to addiction treatment as needed, and prescription of amounts that minimize the risk of diversion

Perception of Pain

involves the sensory process that occurs when a stimulus for pain is present. It includes the person's interpretation of the pain. The pain threshold is the "minimum intensity of a stimulus that is perceived as painful" Adaptation may affect this perception of pain. For example, when a person's hand is immersed in warm water, a sensation of pain eventually occurs as the water is heated. However, the person can tolerate a higher temperature as water is gradually heated to the pain level than if the hand had been plunged into hot water without any preparation.

Tolerance

occurs when the body becomes accustomed to the opioid and needs a larger dose (up to 10 times the original dose) for pain relief. Physical dependence and tolerance are different from addiction primarily because physical dependence and tolerance are expected responses; addiction is not a typical or predictable result of opioid use

EMPLOYING HUMOR

Humor can be an effective distraction, can help a person cope with pain, and may even have a positive effect on the immune system. It has been proven beneficial in relieving acute painful procedural pain in children. Many pain, cancer, and ambulatory care centers encourage patients to view humorous videos before a painful, tedious procedure Remember to use humor only with patients who are responsive to its use and wish to use it. Humor should not be used with patients in moderate to severe pain, nor should it be a replacement for pharmacologic analgesia. In addition, humor must be patient specific. Let the patient select the humorous materials, and when possible, incorporate strategies that include the patient's family and friends.

protective pain reflex

responsible for withdrawal of an endangered tissue from a damaging stimulus. Sensory impulses travel over A-fibers through the dorsal root ganglion to the dorsal horn of the spinal cord. At this point, the sensory nerve impulse synapses with a motor neuron, and the impulse is carried along efferent nerve pathways back to the site of the painful stimulus in a reflex arc. This results in an immediate muscle contraction intended to withdraw/remove the injured body part from the source of the pain.

Neurotransmitters

substances that either excite or inhibit target nerve cells. Receptors in the skin and superficial organs are incapable of responding selectively. However, mechanical, thermal, chemical, and electrical agents may stimulate them. Friction from bed linens and pressure from a cast are mechanical stimulants. Sunburn and cold water on a tooth with caries are thermal stimulants. An acid burn is the result of a chemical stimulant. The jolt of a static charge is an electrical stimulant

Chronology

How does the pain develop and progress? Has the pain changed since it first began? If so, how? If pattern can be identified, interventions early in a pain sequence will often be far more effective than those used after the pain is well established.

Duration

How long have you been experiencing pain? How long does a pain episode last? How often does a pain episode occur?

Endorphins

"morphine within"--natural, opiatelike neurotransmitters linked to pain control and to pleasure. produced at neural synapses at various points along the CNS pathway. powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. endorphins may be released when certain measures are used to relieve pain, such as skin stimulation and relaxation techniques, and when certain pain-relieving drugs are used.

Pain sensation and relief

(1) Pain's path begins as a message and is received by nerve endings in a burned finger. (2) The pain signal from the burned finger travels as an electrochemical impulse along the length of the nerve to the dorsal horn on the spinal cord, a region that runs the length of the spine and receives signals from all over the body. (3) The message is relayed to the thalamus, a sensory center in the brain where sensations such as heat, cold, pain, and touch first become conscious. (4) It then travels on to the cortex, where the intensity and location of pain are perceived. (5) Pain relief begins as a signal from the brain and descends by way of the spinal cord. (6) In the dorsal horn, chemicals such as endorphins are released to diminish the pain message from the injured finger.

primary purposes of using a guide to assess pain

(1) eliminate guesswork and biases when dealing with the patient's pain; (2) understand what the person is experiencing; (3) analyze findings that will help prepare an appropriate nursing response to the patient's pain; and (4) facilitate improved outcomes, such as fewer complications, shorter hospital stays, and improved quality of life. For continued assessment of pain and evaluation of pain control measures, a pain scale allows the patient to rate pain experienced on a continual basis. A numerical pain scale that is currently the national standard is best for use with verbally communicative patients. Assessment of pain requires information from a variety of sources. However, patients are the experts on their pain, and their ratings and descriptions of the pain are most important.

Components of a Pain Assessment

A comprehensive pain assessment must also include discussion of the patient's expectations for pain relief. The patient and health care team need to set a realistic goal or a number on the pain scale that is acceptable and satisfactory, and that facilitates recovery. For example, it may not be possible to have a pain rating of zero after a surgical procedure when the movement required to prevent complications naturally causes some pain or discomfort. Having this conversation and setting a realistic goal facilitate the patient's recognition and report of pain that is unacceptable, and also allow caregivers to evaluate the effectiveness of their pain management techniques. Treatment goals for pain (as well as agitation and delirium) need to take into consideration possibly conflicting goals related to cardiopulmonary stability and promoting organ function

Environment and Support People

A person's environment and the presence or absence of caring support people may also influence the experience of pain. Many people find that the strangeness of the health care environment, especially the lights, noise, lack of sleep, and constant activity of a critical care unit, compounds the experience of pain. The sense of powerlessness that accompanies admission to a health care facility may decrease the person's ability to cope with pain. Depersonalization or separation from a favorite pillow, pet, or source of music may further decrease the person's sense of comfort. For some, the presence of a loved family member or friend is essential to their sense of well-being. Others prefer to be alone when in pain and may become agitated in the presence of a family member. Some patients may use their pain to acquire secondary gains, such as special attention and services from their families. If unchecked, this tendency may lead to resentment and anger in family members and their eventual avoidance of the patient.

Family, Sex, Gender, and Age Variables

A person's response to pain or symptoms may be affected or influenced by the response of family members. Spouses also may reinforce pain behavior in their partners. Children growing up in different families may learn to be brave and ignore pain or to use the pain experience to secure attention and service from family members. Family size and birth order do not appear to be significant in distinguishing chronic pain sufferers. Similarly, children may learn that there are gender differences in pain expression. Adult men and women may hold on to gender expectations regarding pain communication and incorrectly interpret the presence or absence of pain expressions in others. Women are more comfortable communicating the discomfort associated with pain, but this ability to verbalize may cause some to view the pain as emotionally or psychologically based. Data suggest that there may be a biological component to pain responses as well. In addition, different age groups have different beliefs and norms regarding pain sensation and response. An older adult not reporting pain may indicate that the person fears the treatment for the pain, the pain is dulled based on processes inherent in normal aging or chronic disease progression, or the older adult simply refuses to give in to the pain. For many older adults, pain has become accepted as a daily occurrence and is regarded as part of the normal aging process.

USING ACUPUNCTURE

Acupuncture is a technique that uses thin needles of various lengths inserted through the skin at specific locations to produce insensitivity to pain. It has gained acceptance in the Western world as a CHA to help control discomfort from disorders such as headaches, low back pain, neck pain, osteoarthritis or knee pain, and cancer This therapy is considered safe when a licensed, experienced practitioner who uses sterile acupuncture needles performs it. Repeated treatments are often needed.

Outcome Identification and Planning

After the diagnosis of a pain problem is made, developing and implementing a care plan that demonstrates nursing's commitment to assist the patient in developing effective pain management strategies is crucial.

Initiating Complementary Health Approaches and Integrative Health Care

Although analgesics are usually the primary treatment measure for pain, a growing trend is seen involving integration of complementary health approaches (CHA) and integrative health care (IH) concepts.

ADMINISTERING ANALGESICS

An analgesic is a pharmaceutical agent that relieves pain. Analgesics function to reduce the person's perception of pain and to alter the person's responses to discomfort. There are three general classes of drugs used for pain relief: Opioid analgesics (all controlled substances; e.g., morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) Nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDs]) Adjuvant analgesics (anticonvulsants, antidepressants, multipurpose drugs) The nurse administering analgesics needs to combine a healthy respect for the drug being administered with a thorough knowledge of its mechanism of action, side effects, and administration guidelines. This combination of knowledge of and respect for the drug should result in analgesics being used wisely to produce their desired effect. Nurses must employ best practices that consider evidence-based guidelines, position statements from associations, and consensus reports from expert panels to prevent the transition of acute pain to chronic pain

Affective responses

Anxiety Do you feel anxious? Are you afraid? If so, how bad are these feelings? Depression Do you feel depressed, down, or low? If so, how bad are these feelings? Are your feelings about yourself mostly good or bad? Do you have feelings of failure? Do you see yourself or your illness as a burden to those you care about? Interactions with others How does the patient act when in pain in the presence of others? How does the patient respond to others when not in pain? How do significant others and caregivers respond to the patient when the patient is in pain? When the patient is not in pain? Degree to which pain interferes with patient's life (use past performance as baseline) Does the pain interfere with sleep? If so, to what extent? Is fatigue a major factor in the pain experience? Is the conduct of intimate or peer relationships affected by the pain? Is work function affected? Participation in recreational-diversional activities? An activity diary is often helpful—sometimes crucial. One to several weeks of hourly activity recorded by the patient may be necessary. Levels of pain, intake of food, and sleep-rest periods are noted along with activities performed. Separate diaries for inpatient and outpatient episodes may be necessary because hospitalization markedly affects the nature and type of activities performed. Perception of pain and meaning to patient Are you worried about your illness? Do you see any connection between your pain and the nature or course of illness? If so, how do you see them as related? Do you find any meaning in your pain? If so, is this beneficial or detrimental to you? Are you struggling to find some meaning for your pain? Adaptive mechanisms used to cope with pain What do you usually do to relieve stress? How well do these things work? What techniques do you use at home to help cope with the pain? How well have they worked? Do you use these in the hospital? If not, why not? Outcomes What would you like to be doing right now, this week, this month, if the pain were better controlled? How much would the pain have to decrease (on the 0-10 scale) for you to begin to accomplish these goals? What is your pain goal (on the 0-10 scale)? Keep in mind that NO pain may not be an option for some patients. Helping them to identify a realistic goal promotes effective pain management.

Anxiety and Other Stressors

Anxiety, which is almost always present when pain is anticipated or being experienced, tends to increase the perceived intensity of pain. it is best to assume that pain is the underlying cause when anxiety or depression is also present Although a cause-and-effect relationship has not clearly been verified, pain may be aggravated with anxiety, muscular tension, and fatigue. The rested and relaxed person can often cope with more discomfort than someone who is suffering from a lack of sleep. A person who is greatly fatigued and who has no competing demands requiring attention may experience pain more acutely. For example, many people have discovered that the pain of a foot ache or an ingrown toenail that was only mildly annoying during the day's work becomes unbearable at night when there is nothing else to distract the mind from the pain.

Associated phenomena

Are there any other factors that seem to relate consistently to your pain? Any other symptoms that occur just before, during, or after your pain?

Quantity

Ask the patient to indicate the degree (amount) of pain currently experienced on the following scale: Note that it is important to give patients zero/no pain as an option. It is also helpful to ask how much pain the patient has (on the same scale) when the pain is at its least and at its worst: Least ____________ Worst ____________

Assessing

Assessing all factors that affect the pain experience—psychological, emotional, and sociocultural, as well as physiologic—is essential. Pain is complex and difficult to interpret and requires a reliable assessment tool.

Nurse's role in interpreting and implementing as needed/PRN or titrated pain medications. The role of nurses in this process includes:

Basing decisions on a complete pain assessment including (at least) pain intensity, temporal characteristics, and patient's previous response to this or other analgesics Using valid and reliable tools that are consistent and individualized to the patient Considering the pharmacokinetics of the opioid Avoiding administration issues such as giving partial doses more frequently or making a patient wait the full time interval after a partial dose Waiting until the peak effect of the first dose is reached before giving a subsequent dose Verifying the patient's allergies Teaching the patient the name of the drug, the dose administered, the monitoring process, and potential side effects to report Evaluating the patient's response Ensuring complete documentation and communication Assisting with the development of policies that ensure patient comfort and safety Prescribers should provide a fixed time interval (every 3 hours), but may provide a dosage range for a PRN opioid (20 to 30 mg). Prescribing dosages based solely on a 0 to 10 numeric value reported by the patient does not consider other factors that the nurse considers when determining the appropriate dose for an individual patient. A registered nurse who is competent in pain assessment and medication administration can manage the pain management regimen using a correctly written prescription/order set

Pain or Chronic Pain as the Etiology

Because the experience of pain affects so many other aspects of human functioning, pain may be the etiology of numerous other nursing diagnosis statements, including but not limited to: Ineffective Airway Clearance related to unwillingness to ambulate secondary to postoperative incisional pain Anxiety related to pain anticipation and inadequate pain management in the past Constipation related to chronic use of narcotic analgesics Ineffective Health Maintenance related to loss of will to live secondary to prolonged chronic pain Hopelessness related to belief that present pain means imminent death Risk for Injury related to decreased pain sensation Fatigue related to lack of relief from chronic pain Fear related to possible significance of pain Disturbed Sleep Pattern from inability to fall asleep related to pain's worsening at night Risk for Spiritual Distress related to belief that God is unfairly causing this pain as some sort of undeserved punishment Risk for Self-Directed Violence related to loss of will to live with unrelieved chronic pain

Management of Breakthrough Pain

Breakthrough pain (BTP), or breakthrough cancer pain (BTcP), is a temporary flare-up of moderate to severe pain that occurs even when the patient is taking around-the-clock (ATC) medication for persistent pain and has had well-controlled background pain. As many as 40% to 80% of patients with cancer experience breakthrough pain, with the frequency higher in late- and end-stage cancer This pain is often not diagnosed correctly and is frequently undertreated. Breakthrough pain can be classified as incident pain (e.g., pain caused by movement), or idiopathic (spontaneous pain due to an unknown cause), and should be differentiated from end-of-dose pain, which is when the pain occurs before the next dose of analgesic is due. Incident and idiopathic BTcP is treated more effectively with supplemental doses of a short-acting opioid taken on a PRN basis, rather than with an increase in the dose of the ATC medication or shortening of the interval between doses, which typically is more effective with end-of-dose pain. Effective management of BTcP requires use of rapid-onset opioids (ROOs) administered via the oral, buccal, intranasal, or sublingual route.

USING DISTRACTION

Conscious attention often appears to be necessary to experience pain, whereas preoccupation with other things has been observed to distract the patient from pain. Distraction requires the patient to focus attention on something other than the pain. It is not entirely clear whether distraction raises the threshold of pain or increases pain tolerance. Many patients whose pain is relieved by distraction report being able to place pain in the periphery of awareness. This is compatible with the theory that if the reticular formation in the brainstem receives sufficient sensory input, it can ignore or block out select sensations such as pain. The Lamaze method of childbirth is one common example involving the use of distraction. Distraction alone may relieve mild pain. However, it is most effective when used before pain begins or soon thereafter. It has also been proven effective when used with analgesics for treatment of a brief episode of severe pain Distraction may also be used successfully with children.

Additional Terms used to Describe Pain- Periodicity

Continuous Intermittent Brief or transient Pain does not stop. Pain stops and starts again. Pain passes quickly.

CHILDREN

Current thinking is that inadequately controlled pain during infancy and childhood may alter a person's response to pain in adulthood. Children who learn unhealthy responses to chronic pain are more likely to become adults with chronic pain Pain is frustrating for children because they are unable to understand the concept or cause of pain and may have difficulty describing it. Depending on age, children may see the pain as a form of punishment for something they have done. Therefore, assessment and management of pain in children is critical. A pain history provides information about the language the child uses to indicate pain, how and to whom this pain is usually reported, and indications of previous pain experiences and coping strategies. Self-report by the child is usually the most reliable account of pain. Communication with parents, guardians, or other important family members is also vital for accurate pediatric pain assessment and management. In addition, the following observations may provide an indication of the presence and severity of pain in a child: Irritability and restlessness Crying, screaming, or other verbal expression of pain Grimacing, grinding of teeth, or clenching fists Touching or grabbing of painful body part Kicking, thrashing, or attempting to move away from a painful stimulus the Wong-Baker FACES Pain Rating Scale (Fig. 35-4), asks children to compare their pain to a series of faces ranging from a broad smile to a tearful grimace. The Oucher Pain Scale, developed by Beyer and colleagues (1992) for use in young patients, combines a 0-to-100 scale with six photographic images of children in pain. This scale is helpful for use with older children. Adaptations of the Oucher pain scale are also available for various ethnic groups. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC Scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability), designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain, rates each of the five categories on a 0-to-2 scale. Additionally, children may be asked to record their pain experiences in a daily diary. Detecting and accurately assessing pediatric pain have resulted in new and innovative approaches toward pain control in children.

Components of a Pain Assessment

Do not overlook pain in patients who have difficulty with communication. Their pain requires adequate treatment. Examples of pain rating scales that can be used with patients who are nonverbal or have difficulty communicating verbally include the Behavioral Pain Scale (BPS) for use with critically ill patients who are intubated and the Face Legs Activity Cry and Consolability (FLACC) pain scale for use with infants and young children (from ages 2 months to 7 years) and with older adults who can't speak.

PROVIDING ANIMAL-FACILITATED THERAPY

Either a patient's own pet or an animal with an experienced handler can be used as complementary therapy to help relieve pain and provide a degree of comfort to people in various health care settings. AAT has been used to relieve pain in children in acute care settings.

PROVIDING HEALING/THERAPEUTIC TOUCH

Healing Touch (HT) is an energy therapy that has proved valuable as an adjunct to traditional medicine. Studies have indicated that it has been effective in reducing pain and anxiety in hospitalized patients and is recognized as an alternative therapy in end-of-life care for both adults and children. It requires no equipment, uses light touch, and is appropriate for every level of care. Therapeutic Touch (TT) historically is focused more on the universal field and directing life energy to patients. Patients who have received TT state that it helps with feelings of comfort, calmness, and well-being. It is derived from the ancient practice of laying on of hands, but nurses skilled in TT never actually touch their patients when using this technique. Nurses caring for patients with terminal diseases relate that TT complements their efforts to alleviate suffering and can be used to promote comfort during the final stages of life Both HT and TT were developed by nurses, do not require a provider's prescription

Cultural and Ethnicity Variables

Intentionally involve your patient in the pain assessment, taking time to appreciate the potential effects of culture and ethnicity, without making assumptions or generalizations about the patient's individual pain experience. Communication is the cornerstone of a nurse's subjective assessment and associated teaching. Perceived and actual barriers to verbal and written communication should be considered and directly addressed with appropriate tools and resources. including information sheets in different languages and the use of medical interpreters. It is important to remember that the greater the language differences or barriers, the poorer a patient's pain is controlled A cultural accommodation such as transposing a horizontal numeric pain rating scale to a vertical presentation may simplify pain assessment for a patient who speaks only Chinese, since this is the format in which the Chinese language is read Initiatives to address treatment disparities and advance health equity begin at the local or community level, where assessments and interventions have a direct impact on the health-related social, policy, and economic needs of these vulnerable populations

Trigeminal neuralgia

characterized by severe lightning-like pain due to an inflammation of the fifth cranial nerve Paroxysms of lightning-like stabs of intense pain in the distribution of one or more divisions of the trigeminal nerve, the fifth cranial nerve. Pain is usually experienced in the mouth, gums, lips, nose, cheek, chin, and surface of the head and may be triggered by everyday activities like talking, eating, shaving, or brushing one's teeth.

Ongoing Assessment

Just as the pain experience of each patient is unique, so too is the response of each patient to a prescribed analgesic. The nurse needs to continuously evaluate whether the medication is producing the desired analgesic effect; identify changes in the patient's condition (correction or worsening of pathology, increased drug tolerance) that necessitate changes in the analgesic agent, dose, or route of administration; and identify the development of side effects of the analgesic that may warrant its discontinuance. As long as the patient's pain exists, ongoing assessment and documentation of pain control is imperative. Timing is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense. For example, an analgesic would be offered before ambulating a patient postoperatively. A PRN (as needed) drug regimen has not been proven effective for people experiencing acute pain. In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient. Later, however, in the postoperative course, a PRN schedule may be acceptable to relieve occasional pain episodes. Continuous intravenous infusion has proved effective for the relief of acute postoperative pain. Nonpharmacologic and nonopioid pharmacologic therapies are the preferred choices for chronic pain that is not related to active cancer, palliative care, or end-of-life care. If progression to opioids becomes necessary, the lowest effective dose of an immediate-release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the prescription of opioids for the management of chronic pain. Long-acting, controlled-release oral morphine or oxycodone or use of a fentanyl patch may be used in pain associated with cancer. intended for use in patients who are opioid-tolerant and have chronic pain; it should not be used to treat acute pain.

Therapeutic Effects of Laughter

Laughter causes the following physiologic and psychological effects: Increases the pain threshold Reduces arterial wall stiffness and improves endothelial function Reduces the risk of myocardial infarction (MI); reduces recurrence after MI in diabetes Improves lung function in patients with chronic obstructive pulmonary disease (COPD) Improves glycemic control; impacts on obesity Improves the success rate of in vitro fertilization Associated with satisfaction and an increased quality of life

LISTENING TO MUSIC

Listening to music can relax, soothe, decrease pain, and provide distraction. Music affects various neurotransmitters (such as epinephrine and norepinephrine), hormones (particularly cortisol), components of the immune system (especially with the cytokine interleukin-6), the autonomic nervous system (sympathetic and parasympathetic components), and psychological responses Recent studies have confirmed that perioperative music therapy resulted in a decrease in postoperative pain, anxiety, and pain medication use, and improved reported patient satisfaction. Acute pain guidelines recommend music and relaxation as interventions that, in combination with opioids, help to relieve moderate postoperative pain. Music therapy is a readily accessible therapy that is not associated with significant adverse effects. It should be considered a viable, potential treatment for many patients, including those in pain

addiction

compulsive drug craving and use, despite adverse consequences is a "chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences"

Common Misconceptions

Many patient misconceptions interfere with the patient's ability to communicate pain. Some of these instances can lead to undertreatment of pain. It is important to assess for the following common patient beliefs related to pain and communicating it: The doctor has prescribed pain-relieving medication for me, which I will be given routinely. If I ask for something for my pain, I will immediately become addicted to the medication. Sometimes it is better to put up with the pain than to deal with the side effects of the pain medication. I should somehow be able to control my pain. It is immature to talk about pain. It is better to wait until the pain gets really bad before asking for help. If I take the medication now for moderate pain, it won't relieve severe pain later on. I don't want to bother anyone—I know how busy everyone is. It's natural for me to have excruciating pain after surgery. After a few days, I should notice it lessening.

Establishing a Trusting Nurse-Patient Relationship

Measures that help strengthen the nurse-patient relationship and promote pain relief include discussing pain with the patient, allowing the patient to help choose a method of pain relief, and visiting and staying with the patient in pain. These measures promote a collaborative relationship in which the patient's pain is treated with respect

DRUG SAFETY

Methadone is a mu-receptor agonist and an N-methyl-D-aspartate (NMDA) receptor antagonist that must be used cautiously because it has a rapid onset of action and a long half-life. The most common side effects associated with opioid use are sedation, nausea, and constipation. Most side effects disappear with prolonged use, but if constipation persists, it usually responds to treatment with increased fluids and fiber and use of a mild laxative or stool softener. An opioid-naïve person can experience the side effects, but has not taken opioids with enough frequency to become tolerant. This contrasts with an opioid-tolerant person who has taken opioids long enough and at sufficient levels to develop tolerance to the analgesic effect of the opioid and most of the side effects, except constipation. Respiratory depression is a commonly feared adverse effect of opioid use. In reality, it is an uncommon occurrence in long-term therapy because patients have usually developed a tolerance to the drug and its respiratory-depressant effects. However, with these CNS depressants, respiratory depression is often the root cause of opioid-related death and is typically related to an overdose (Burchum & Rosenthal, 2016). Nursing assessment using the numeric sedation scale can determine those patients at risk for respiratory depression more so than assessing the respiratory rate. The Pasero Opioid-Induced Sedation Scale can be used to assess respiratory depression in adult and pediatric populations S = sleep, easy to arouse: no action necessary 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 If respiratory depression is suspected and the opioid dose is withheld, the patient may be physically stimulated by shaking or using a loud sound, along with reminders every few minutes to breathe deeply. If this is ineffective, naloxone, an opioid antagonist that reverses the respiratory-depressant effect of an opioid, can be used. Naloxone is administered intravenously in the hospital setting, but a new nasal form may be used in other settings Within 1 to 2 minutes, the patient usually opens the eyes and is able to respond to the nurse. When the patient is alert again and the respiratory rate is greater than 9 breaths/min, the opioid may be resumed. However, the half-life (time required for the concentration to decrease by half; duration of action) of naloxone is very short, so re-sedation may occur and subsequent doses of naloxone may be required (every 5 minutes). Keep in mind that the naloxone works by blocking the action of the opioid, so if naloxone is required and/or the opioid cannot be resumed in a reasonable amount of time, the nurse must ensure another method of pain relief is administered. There is a difference between opioid use short term (<3 weeks) for acute pain and long-term (>3 months) management of chronic pain with opioids. Patient education often needs to include a review of these key terms in order to allay fears and collaboratively develop a plan for pain management. Physical dependence and tolerance are frequently confused with addiction.

Behavioral (Voluntary) Responses

Moving away from painful stimuli Grimacing, moaning, and crying Restlessness Protecting the painful area and refusing to move

Typical Parasympathetic Responses When Pain is Severe and Deep

Nausea and vomiting Fainting or unconsciousness Decreased blood pressure Decreased pulse rate Prostration Rapid and irregular breathing

Nonopioid Analgesics

Nonopioid analgesics, such as acetaminophen and NSAIDs, are usually the drugs of choice for both acute and persistent moderate chronic pain. The simplest dosage schedules and least invasive pain management modalities should be used first. Many times, these drugs alone can provide adequate pain relief. Many of these medications are over-the-counter (OTC) products, whereas some are available by prescription only. Some can cause gastric side effects, but these symptoms may be preventable if the drug is taken with food or antacids. Acetaminophen has long been viewed as one of the safest and best-tolerated analgesics. It has proven to be an effective drug for acute pain treatment and is the most commonly used analgesic in the United States. It has a low incidence of adverse effects, but the risk of hepatotoxicity must be considered when acetaminophen is used for a lengthy period or at larger than the recommended dose (maximum of 4 grams/day). If pain is not controlled using the recommended dose of acetaminophen, NSAIDs or an opioid analgesic may be required to achieve pain relief. NSAIDs also have an anti-inflammatory effect. Individual responses to NSAIDs vary, but these agents are contraindicated in patients with bleeding disorders (their action may interfere with platelet function) or probable infections (NSAIDs can mask the signs of an infection). potential for GI bleeding and skin reactions associated with all NSAIDs, and a warning that all NSAIDs, except for aspirin, increase the risk of myocardial infarction (heart attack) or stroke. The combination of nonopioid analgesics and opioids provides more analgesia than either drug taken alone. Multimodal analgesic therapy is a relatively recent approach to pain management. It combines two or more classes of analgesics that target different sites in the peripheral and central nervous systems to maximize pain relief with fewer adverse effects. The most common multimodal approach is a combination of nonopioid, opioid, and adjuvant analgesics The patient and family will require an explanation regarding why multiple medications have been prescribed and how they work to relieve pain. Although often considered in relation to chronic pain, multimodal analgesia is also a valid approach to the management of acute pain. The pain associated with the postoperative period and trauma are positively impacted by the synergistic effect of multimodal analgesia, which maximizes pain relief at lower doses, thus reducing the risk of adverse effects of specific drugs The COX-2 inhibitors, a class of NSAIDs, have a lower risk of GI bleeding but are thought to significantly increase cardiovascular risks. Two of the COX-2 inhibitors, rofecoxib and valdecoxib, have been withdrawn from the market because of increased evidence of adverse cardiac events. Celecoxib, another COX-2 inhibitor, is available in the United States and used for treatment of osteoarthritis and rheumatoid arthritis NSAIDs appear to be safe in low doses for short periods of time

Implementing

Nursing interventions described in this chapter include establishing a trusting nurse-patient relationship, manipulating factors that affect the pain experience, initiating nonpharmacologic pain relief measures, managing pharmacologic interventions, reviewing additional pain control measures, ensuring ethical and legal responsibility to relieve pain, and teaching the patient about pain.

When assessing a person's pain, discuss these basic methods:

Obtain the patient's self-report of pain. Identify pathologic conditions or procedures that may be causing pain; consider physiologic measures (increased blood pressure and pulse). However, most research verifies that reliance on vital signs to indicate the presence of pain should be minimized. The absence of an increase in vital signs does not mean that pain is not present. Consider patient behaviors that may indicate pain such as nonverbal behaviors (restlessness, grimacing, crying, clenching fists, protecting the painful area). Take into account the report of a family member, another person close to the patient, or a caregiver who is familiar with the patient. Attempt an analgesic trial and monitor the results.

Opioid Analgesics

Opioids, formerly called narcotic analgesics, are generally considered the major class of analgesics used in the management of moderate to severe pain because of their effectiveness. Drugs derived directly from the opium poppy are technically called opiates, with partially or fully synthetic derivatives called opioids (we will generally refer to both classes of drugs as opioids). In sufficient dosage, opioids are considered effective in relieving pain that is peripheral/nociceptive in nature, such as acute pain due to injury, pain associated with rheumatoid arthritis, or cancer pain Opioids produce analgesia by attaching to opioid receptors in the brain, similar to how a key fits a lock. New research on opioid analgesics also indicates that opioid receptors are present on peripheral terminals of sensory nerves and cells of the immune system Opioid receptor sites are further classified as mu, delta, and kappa types. Opioids that produce analgesia (agonists) can compete for binding sites on the receptors with opioids that do not produce analgesia (antagonists). An opioid agonist such as morphine binds to the mu site and produces analgesia that is also associated with unwanted side effects (Porth, 2015). An opioid antagonist such as naloxone also competes for binding on the mu site, but it blocks the analgesic effect of morphine as well as its side effects. Most of the opioid analgesics commonly used in a clinical setting bind primarily to mu-receptor sites. Patients also differ in their sensitivity to morphine because of genetic variability of the mu-receptor site. There are many opioid analgesics that range from weak (codeine or tramadol) to strong (morphine, oxycodone, or hydromorphone). Health care providers individualize the choice of medication based on the disease process, level/type of pain, and other assessment factors. Morphine, the prototype opioid, is often the opioid of choice because providers are familiar with it, it is readily available in multiple forms, and is relatively inexpensive. Fentanyl, a synthetic opioid that is 50 to 100 times stronger than morphine, is available in a variety of forms that range from rapid-acting to long-acting Methadone is most commonly used to treat cancer pain and to manage detoxification in people with opioid dependence/addiction. Meperidine was used extensively in the past, but its use is now discouraged because its half-life is short, it interacts with many drugs, and significant accumulation of a toxic metabolite from the breakdown of meperidine can lead to altered mental status, delirium, seizures, and psychosis. When used, it is primarily for prevention and treatment of postoperative shivering and in short-term pain management in patients who cannot tolerate other opioids If patients have continued uncontrolled pain, unmanageable side/adverse effects, a change in status that requires a change in route of administration, or develop toxicity, an opioid rotation (switch to another medication) may be initiated

Etiology

Pain also is classified by its cause, which can be highly varied. Nociceptive pain is initiated by nociceptors that are activated by actual or threatened damage to the peripheral tissue and is representative of the normal pain process. Nociceptors are the peripheral somatosensory nerve fibers that transduce and encode noxious stimuli. Nociceptive pain is different from neuropathic pain, which is pain caused by a lesion or disease of the peripheral or central nerves. exact cause of neuropathic pain is unknown but it can originate either peripherally (e.g., phantom leg pain) or centrally (e.g., pain from spinal cord injury). Neuropathic pain can be of short duration but frequently is chronic. It is often described as burning, electric, tingling, or stabbing. Allodynia, a characteristic feature of neuropathic pain, is an unexpected pain response that occurs after the introduction of a stimulus that is not normally known to provoke pain. Other characteristics of this pain include hyperalgesia where there is an increased pain response to a normally painful stimulus, and hyperesthesia where there is an increase in the level of sensitivity to a stimulus. When pain is resistant to therapy and persists despite a variety of interventions, it is referred to as intractable.

Localization/Location of Pain

Pain can also be categorized according to whether it is generalized or localized. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. A person automatically tenses the abdomen when an acute abdominal pain condition is present. This prevents underlying tissues and organs from being palpated or touched. Pain can originate in one part of the body but be perceived in an area distant from its point of origin. This is known as referred pain. For example, pain associated with a myocardial infarction (heart attack) is frequently referred to the neck, shoulder, chest, or arms (often the left arm). Referred pain is transmitted and perceived at a site different from the originating location, but is referred to a place innervated by the same spinal segment.

Phantom limb pain

Pain in a limb that no longer exists. Pain that may occur in any person who has had a body part amputated either surgically or traumatically. Pain varies and may be a severe, burning, fiery sensation; crushing; cramping; a sense that the limb is edematous; or a sensation that the limb is being twisted and distorted. It may be triggered by the sensation of touching the stump, the occurrence of another illness, fatigue, atmospheric changes, and emotional stress.

Transmission of Pain Stimuli

Pain sensations from the site of an injury or inflammation are conducted along pathways to the spinal cord and then on to higher centers. No specific pain organs or cells exist in the body. Rather, an interlacing network of undifferentiated free nerve endings receives painful stimuli. Free nerve-ending pain receptors include the afferent (those fibers carrying impulses from the pain receptors toward the brain) fast-conducting A-delta-fibers and the slow-conducting C-fibers. The larger A-delta-fibers transmit acute, well-localized pain that is typically elicited by mechanical or thermal stimuli. The smaller C-fibers convey diffuse, longer-lasting pain that is triggered by chemical stimuli or persistent mechanical or thermal stimuli

Postherpetic neuralgia

Pain that lasts longer than a month after a shingles infection and is caused by damage to the nerve; the pain may last for months or years. Pain syndrome follows an acute central nervous system infection, such as herpes zoster (shingles). The herpes syndrome is characterized by a vesicular eruption and neuralgic pain, which is usually unilateral and encircles the body in band-like clusters. The severity of the pain may be mild to severe. Intractable pain may persist for months to years.

ALTERING FACTORS AFFECTING PAIN TOLERANCE

Pain tolerance level is the maximum intensity of a stimulus that produces pain a person is willing to accept in a given situation. Alleviate these factors whenever possible. For example, patients whose families have never acknowledged their pain and who have repeatedly been told that their pain is all in their head may experience a greater ability to deal with their pain when someone finally takes the pain seriously. Nursing measures include communicating to the patient that responses to pain are acceptable and providing education to the patient's family. A discussion of goals and expectations regarding pain also increases the amount of control the person feels and can impact on his or her ability to tolerate a certain level of pain at a given moment in time. Fatigue tends to increase pain, so promoting rest is helpful. The patient in pain usually feels more comfortable when the environment is quiet and restful. Although sensory restrictions—such as eliminating unnecessary noise and bright lights—are usually indicated, it is rarely helpful to leave the patient alone in an environment with little sensory input. The patient is then more likely to focus on self and the discomfort. Lack of knowledge, finding no meaning in the pain, being pessimistic about its relief, and fear may also interfere with the patient's ability to deal with pain. Common fears include a loss of control and embarrassment by being unable to deal with the pain maturely. Another fear may be a fear of taking pain relief medication. The patient may view the need for medication as a sign of weakness or may fear addiction or loss of the effectiveness at a later date. Older adults, in particular, are frequently frustrated by similar concerns about pain management.

USING IMAGERY

Patients who use imagery (an example of mind-body interaction) to decrease pain sensation imagine something that involves one or all of the senses, concentrate on that image, and gradually become less aware of the pain. Imagery may be as simple as a child thinking of happy things (a beloved pet, lollipops, Christmas morning, Grandma's lap) or as involved as an adult recreating a favorite place and then experiencing the healing presence, or touch of a loved person, or the healing energies of nature in that setting. The imagery technique has also been used to create an image in which the cause of the pain is visualized and then overcome or counteracted by some more powerful image. Imagery has been found to be more effective for patients with chronic pain than for patients with acute, severe pain. General techniques for successfully guiding a patient to use imagery include the following: Help the patient to identify the problem or goal. Suggest that the patient begin the imagery with several minutes of focused breathing, relaxation, or meditation. Help the patient to develop images of the problem, as well as personal internal resources (e.g., coping strategies) and external healing therapies (e.g., medications, treatments). Encourage images of the desired state of well-being at the end of the session. If the patient becomes restless or upset, the imagery experience is terminated and attempted later when the patient seems better disposed.

Acute Pain

Possible Related/Risk Factors (R/T) • Physical injury agent: recent surgery (cholecystectomy) Sample Defining Characteristics/As Evidenced By (AEB): • Facial expression of pain; face is pale and drawn • Change in physiologic parameter: vital signs elevated from baseline • Self-report of pain characteristics using standardized pain instrument and pain scale: "sharp pain when I move" and "7/10"

Chronic Pain

Possible Related/Risk Factors (R/T): • Injury agent: Reports history of migraine headaches for past 5 years • Emotional distress: belief that the patient deserves this pain Sample Defining Characteristics/As Evidenced By (AEB): • Self-focused: reports never seeking pain relief assistance; expresses fear of taking medications due to the risk of addiction (at-risk population d/t history of substance misuse) • Alteration in sleep pattern • Anorexia • Self-report of pain characteristics using standardized pain instrument and pain scale: "pain so intense at times - sharp and aching at the same time" and "10/10 when it's at its worst"

Labor Pain

Possible Related/Risk Factors (R/T): • Prolonged labor (dystocia) and commitment to natural childbirth • Admitted to labor unit 18 hours ago with moderate contractions 2 minutes apart • Strength of contractions weakening; progress of dilation and effacement slow; failure to progress • "I'll feel like a failure if I take anything for pain. I want to 'go natural.' I know I can do it. Besides, the drugs would only hurt my baby." Sample Defining Characteristics/As Evidenced By (AEB): • Expressive behavior: moaning, yelling, verbalizing pain • Alteration in blood pressure, heart rate, muscle tension, respiratory rate • Positioning to ease pain: frequent ambulation, moving in bed • Vomiting • Narrowed focus: focused breathing, all verbalizations related to labor pain

Behavioral responses

Posture, gross motor activities Does patient rub or support a particular area? Make frequent position changes? Walk, pace, kneel, or assume a rolled-up position? Does patient rest a particular body part? Protect an area from stimulation? Lie quietly? In acute pain, postural and gross motor activities are often altered; in chronic pain, the only signs of change may be postures characteristic of withdrawal. Facial features Does the patient have a pinched look? Are there facial grimaces? Knotted brow? Overall taut, anxious appearance? A look of fatigue is more characteristic of chronic pain. Verbal expressions Does the patient sigh, moan, scream, cry

EMPLOYING RELAXATION

Relaxation techniques reduce skeletal muscle tension and lessen anxiety. By assisting the patient with relaxation techniques, the nurse acknowledges the patient's pain and expresses a willingness to help the patient relieve the distress caused by that pain. The positive effects of relaxation for the person with pain include the following: Improved quality of sleep Distraction from the pain Decreased fatigue Increased confidence and sense of self-control in coping with pain Lessening of the detrimental physiologic effects of continued or repeated stress from pain Increased effectiveness of other pain relief measures Improved ability to tolerate pain Decreased distress or fear during anticipation of pain Reassurance that the nurse is aware of the person's problem and wants to help Relaxation is most effective as a pain relief measure when combined with slow, deep, easy breathing from the abdomen or diaphragm, with the patient's eyelids closed or with the person focusing on a real or imagined fixed spot. Progressive muscle relaxation seems to have a positive effect on arthritis pain.

REMOVING OR ALTERING THE CAUSE OF PAIN

Removing or altering the cause of the pain is ideal and sometimes possible. Possible measures that promote comfort and help in pain relief include removing or loosening a tight binder, if permissible; seeing to it that a distended bladder is emptied; taking steps to relieve constipation and flatus; changing body positions and ensuring correct body alignment; and changing soiled linens and dressings that may be irritating the skin. A hungry or thirsty patient may need a snack or a drink to feel more comfortable. Certain drugs are useful for removing or altering the intensity of painful stimuli. For example, drugs that decrease smooth-muscle spasms in the GI tract and those that decrease contractions of skeletal muscles reduce discomfort.

The checklist for prescribing opioids for chronic pain includes the following actions:

Set realistic goals for pain and function based on the diagnosis. Verify that nonopioid therapies have been tried and optimized. Discuss the benefits and risks of opioid therapy. Evaluate the risk of harm or misuse, specifically considering risk factors, drug monitoring program, and urine drug screen. Set criteria for discontinuing or continuing opioids. Assess baseline pain and functional ability. Schedule a follow-up reassessment within 1 to 4 weeks. Prescribe short-acting opioids at the lowest dose, ensuring the amount dispensed matches the scheduled reassessment.

Additional Terms used to Describe Pain- Severity

Severe or excruciating Moderate Slight or mild These terms depend on the patient's interpretation of pain. Behavioral and physiologic signs help assess the severity of pain. On a scale of 0-10, slight pain could be described as being between 1 and 3; moderate pain, between 4 and 7; and severe pain, between 8 and 10.

Additional Terms used to Describe Pain - Quality

Sharp Pain is sticking in nature and that is intense. Dull Pain is not as intense or acute as sharp pain, possibly more annoying than painful. It is usually more diffuse than sharp pain. Diffuse Pain covers a large area. Usually, the patient is unable to point to a specific area without moving the hand over a large surface, such as the entire abdomen. Shifting Pain moves from one area to another, such as from the lower abdomen to the area over the stomach. Other terms used to describe the quality of pain include sore, stinging, pinching, cramping, gnawing, cutting, throbbing, shooting, and vise-like pressure.

PATIENTS WITH COGNITIVE IMPAIRMENT

Some common behaviors that can be assessed for indicators of pain in this population include: Facial expressions Verbalizations and vocalizations Body movements Changes in interpersonal interactions Changes in activity patterns or routines Changes in mental status, such as agitation and aggression Wong-Baker FACES pain rating scale. Instructions: Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to have this worst pain. Ask the person to choose the face that best describes how much pain he or she has. Rating scale is recommended for people aged 3 years and older. The combination of a history of pain, observations of a patient's pain by families and caregivers, and the presence of medical diagnoses associated with pain also facilitates pain assessment in this population. The Pain Assessment in Advanced Dementia (PAINAD) Scale has been developed to assess pain in this population. It relies on observation of five specific items: breathing, vocalization, facial expression, body language, and consolability

Past Pain Experience

Some patients have never known severe pain and have no fear of pain, not realizing how intense the sensation can be. Some patients have experienced severe acute or chronic pain in the past but received immediate and adequate pain relief. These patients are generally unafraid of pain and initiate appropriate requests for assistance. Some patients have known severe pain in the past and were unable to secure relief. Even the suggestion of new pain can lead to acute feelings of fear, despair, and hopelessness. A person whose past pain experience led to correction of unhealthy behavior and produced a greater sense of health and well-being, may respect and value pain and consider the meaning and significance of new pain carefully. In general, people who have experienced more pain than usual in their lifetimes tend to anticipate more pain and exhibit increased sensitivity to pain. Some pain memories are virtually unforgettable. New contact with conditions similar to those that caused the earlier pain can provoke a violent response.

The Pain Process

The four specific physiologic processes involved in nociception (the ability to feel painful stimuli) include transduction, transmission, perception, and modulation of pain. Nociceptive pain is initiated by nociceptors that are activated by injury to the peripheral tissue and is representative of the normal pain process

Components of a Pain Assessment

The nurse will generally assess the following characteristics of pain: Patient's verbalization and description of the pain Duration of the pain Location of the pain Quantity and intensity of the pain Quality of the pain Chronology of the pain Aggravating factors Alleviating factors Physiologic indicators of the pain Behavioral responses Effect of the pain experience on activities and lifestyle

Nursing measures are directed toward the achievement of the following patient outcomes for people whose pain is acute in nature (i.e., it is expected that with healing the pain will subside and eventually disappear)

The patient will: Describe a gradual reduction of pain, using a scale ranging from 0 (no pain) to 10 (pain as bad as it can be), clearly identifying numeric pain goals Demonstrate competent execution of successful pain management program (specify) When pain or chronic pain is the etiology in nursing diagnosis statements, outcomes will be specific to the underlying interference with health that is associated with the pain. For patients whose pain is chronic in nature, an expected outcome may be contacting a hospice or a pain clinic. Hospice care (also mentioned in Chapters 8 and 9) addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families in either the home or a hospice center. Pain relief is a priority in this setting. Numerous outpatient centers are also available to support patients with chronic pain and to improve their pain management through a variety of approaches.

USING CUTANEOUS STIMULATION

The success of cutaneous stimulation (techniques that stimulate the skin's surface) in relieving pain is often explained using the gate control theory. The gate control theory of pain involves cutaneous nerve fibers, which are large-diameter fibers carrying impulses to the CNS. When the skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decreases the number of pain impulses that reach the brain for perception. These techniques can be used in all health care settings to supplement a pain-control regimen. Some forms of cutaneous stimulation include the following: Massage (with or without analgesic ointments or liniments containing menthol); see Skill 35-1 (on pages 1271-1274) Application of heat or cold, or both intermittently (see detailed discussion in Chapter 32) Acupressure Transcutaneous electrical nerve stimulation (TENS) Acupressure, a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care. TENS is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful impulses carried over small-diameter fibers. The TENS unit consists of a battery-powered portable unit, lead wires, and cutaneous electrode pads that are applied to the painful area (Fig. 35-6). The use of TENS requires a health care provider's prescription. TENS therapy has reportedly been effective in reducing postoperative pain and improving mobility after surgery. Positive results have also been noted when it is used as an adjunct to physical therapy and for patients with low back pain. The TENS unit may be applied intermittently throughout the day or worn for extended periods of time, depending on the provider's order. Use of cutaneous stimulation is limited because the pain must be localized. Otherwise, it is most likely too diffuse to be effective. In addition, most people cannot tolerate stimulation of the painful area; however, they may be helped by stimulation of the surrounding or contralateral area.

The Gate Control Theory of Pain

The theory that pain is a product of both physiological and psychological factors that cause spinal gates to open and relay patterns of intense stimulation to the brain, which perceives them as pain. describes the transmission of painful stimuli and recognizes a relation between pain and the projection of pain information to the brain theory states that small nerve fibers conduct excitatory pain stimuli toward the brain, exaggerating the effect of the arriving impulses through a positive feedback mechanism. Large nerve fibers appear to inhibit the transmission of pain impulses from the spinal cord to the brain through a negative feedback system. transmission mechanism that is believed by some to be located in substantia gelatinosa cells in the dorsal horn of the spinal cord. This serves as the gate. Only a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells in the spinal column interrupt the signal as if closing a gate when a person rubs the site of an injury that has just occurred. This stimulation of the large fibers, which are largely inactive when the small-fiber activity is increased, can decrease the level of pain experienced by the person Other factors thought to have an impact on the opening and closing of this gate are past experiences, the cultural and social environment, personal expectations, beliefs about pain, the emphasis placed on pain, and emotions. For example, a positive mood, distraction, or relaxation can work to close the gate; fear and anxiety have been shown to open the gate, thus increasing the pain experienced. Understanding gate theory can positively impact on a patient's development of skills that help in their self-management of chronic pain explains why mechanical and electrical interventions or heat and pressure may provide effective pain relief. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Teaching self-management techniques that activate closing the gate may also minimize the experience of pain for patients

Manipulating Factors Affecting the Pain Experience

There are many ways to manage pain. In addition to pharmacologic and nonpharmacologic measures, simple nursing interventions can positively alter patients' pain experience and speed their recovery.

When a nursing diagnosis of acute or chronic pain is developed, the diagnostic statement and care plan should identify the following:

Type of pain Etiologic factors, to the extent that they are known and understood Patient's behavioral, physiologic, and affective responses Other factors affecting pain stimulus, transmission, perception, and response

Physiologic (Involuntary) Responses

Typical Sympathetic Responses When Pain is Moderate and Superficial Increased blood pressurea Increased pulse and respiratory ratesa Pupil dilation Muscle tension and rigidity Pallor (peripheral vasoconstriction) Increased adrenaline output Increased blood glucose

Transduction

activation of pain receptors. involves conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn. The nociceptors, or peripheral receptors, respond selectively to mechanical, thermal, and chemical stimuli that are noxious The nociceptors, or peripheral receptors, respond selectively to mechanical, thermal, and chemical stimuli that are noxious when there is injured tissue, it is believed that the injured tissue releases chemicals that excite or activate nerve endings. even harmless stimuli can trigger pain; pain signals are faster and feel more intense.

Techniques that distract attention include the following

Visual distractions: counting objects, reading, or watching TV Auditory distractions: listening to music Tactile kinesthetic distractions: holding or stroking a loved person, pet, or toy; rocking; slow rhythmic breathing Interactive video games Project distractions: playing a challenging game, performing meaningful play or work

Physiologic responses

Vital signs (blood pressure, pulse, respirations) Skin color Perspiration Pupil size Nausea Signs of sympathetic stimulation may occur with acute pain but need not be present to verify the presence of pain. Signs of parasympathetic stimulation (decreased blood pressure and pulse, rapid and irregular respirations, pupil constriction, nausea and vomiting, and warm, dry skin) may occur, especially in prolonged, severe, visceral, or deep pain. Muscle tension Observe. Ask the patient whether he or she is aware of any tight, tense muscles. Anxiety Are signs of anxiety evident? May include decreased attention span or ability to follow directions, frequent asking of questions, shifting of topics of conversation, avoidance of discussion of feelings, acting out, somatizing.

Alleviating factors

What makes the pain go away or lessen? What methods of relief have you tried in the past? How long were they used? How effective were they? Pharmacologic and nonpharmacologic methods of relief currently in effect for hospitalized patients should be apparent from the chart. It is important to verify the use of current prescriptions and their effectiveness with the patient. Outpatients may need to be asked to record a medication profile, a thorough and accurate account of all medications they are taking.

Aggravating factors

What makes the pain occur or increase in intensity?

Quality

What words would you use to describe your pain?

APPLYING GENERAL PRINCIPLES FOR ANALGESIC ADMINISTRATION

When using medications for pain relief, the nurse must first assess the patient's pain and understand the patient's goals for pain relief. In the home as well as in acute care settings, nurses provide quality nursing care when they empower patients to take charge of their own pain relief measures. The following guidelines are recommended for effective, individualized pain management in any setting: Review the pain scale of choice thoroughly. Discuss the benefits of using a pain scale. Try various pain control measures. Use pain control measures before pain increases in severity. Ask the patient what has been effective for pain relief in the past. Select and modify pain control measures based on the patient's response. Encourage the patient to try the pain treatment several times before labeling it ineffective. Be open-minded about alternative, nonpharmacologic pain relief strategies. Be persistent. Be a safe practitioner. Accurate documentation is imperative to determine effectiveness of the current regimen or the need to change pain control measures if relief is not obtained. Pain diaries or flow sheets provide a method for people to document their particular pain experience, list medication or alternative therapies that were used to treat the pain, and record their effectiveness. Pain diaries can be used in a variety of settings and help improve the overall management of pain. Since more patients with acute and chronic pain are cared for in their home environment, effective patient and family teaching is the cornerstone of pain relief therapy.

Location

Where is your pain? Is it external or internal? Asking the patient with acute pain to point to the painful area with one finger may help to localize the pain. Patients with chronic pain may have difficulty trying to localize their pain.

Enkephalin

one of the endogenous opioids widespread throughout the brain and dorsal horn of the spinal cord, are considered less potent than endorphins. reduce pain sensation by inhibiting the release of substance P from the terminals of afferent neurons

Psychogenic Pain

pain for which no physical cause can be identified Pain may originate from physical causes, that is, a physical cause for the pain can be identified. Pain may also have a psychogenic origin it has been observed that a pure origin is probably rare, and pain usually has both physical and psychogenic components. Furthermore, pain that results from a mental event can be just as intense as pain that results from a physical event.

Complex regional pain syndrome (causalgia)

pain is out of proportion Pain occurs in the area of a partially injured peripheral nerve (the most common lesions are of the brachial plexus or median or sciatic nerve). The pain is described as burning, severe, diffuse, and persistent and is elicited by minimal movement or touch of the affected area. It increases with repeated stimulation and continues even after stimulation ceases.

Chronic Pain

pain that lasts beyond the normal healing period. In clinical practice, the time frame associated with defining pain as chronic varies based on the cause and may be anywhere between 1 and 6 months, with 3 months commonly used in practice and 6 months used in research. pain presentation varies greatly and can include pain that is unrelenting and severe, pain that is consistent with or without periods of remission (disease is present, but the person does not experience pain) and exacerbation (the symptoms reappear), or pain that is recurring and contains elements of both chronic and acute pain Some providers are transitioning to use of the word persistent to describe this type of pain. Patients have difficulty describing chronic pain because it may be poorly localized. chronic pain is often perceived as meaningless and may lead to withdrawal, depression, anger, frustration, and dependency. Nurses need an awareness of their own personal feelings toward pain (especially chronic pain) and the factors that affect pain if they are to assess and manage their patient's pain creatively and effectively

Phantom Pain

pain that often occurs with an amputated leg where receptors and nerves are clearly absent, is a real experience for the patient or phantom limb pain and is without demonstrated physiologic or pathologic substance. One theory suggests that sensory misrepresentations from the missing limb may remain in the brain, thereby causing phantom pain.

physical dependence

phenomenon in which the body physiologically becomes accustomed to opioid therapy and suffers withdrawal symptoms if the opioid is suddenly removed or the dose is rapidly decreased.

Responses to Pain

physiologic, behavioral, affective The severity of pain and its duration affect responses to pain. Increases in vital signs may occur briefly in acute pain and may be absent in chronic pain states Physiologic responses are involuntary body responses; behavioral responses reflect body movements; affective responses reflect mood and emotions. Mild pain experienced briefly may produce little or no behavioral response; intense pain experienced briefly usually results in reflex action to escape the cause. The patient is often able to accept pain that continues for a relatively short time, such as for a few days or a week, without it being all-consuming. The patient expects relief and believes the cause is self-limiting. However, anxiety is ordinarily present. On the other hand, chronic pain tends to consume the entire person. It demands total attention so that the patient has limited resources to take care of other matters of daily living. It is physically and emotionally exhausting and is associated with ongoing irritability, isolation, fatigue, fear, anger, feelings for helplessness, stress/anxiety, and depression. Lack of an obvious response to pain does not mean the patient is without pain. Careful assessment is especially important to understand what the patient is experiencing.

Modulation of Pain

process by which the sensation of pain is inhibited or modified. The sensation of pain appears to be regulated or modified by substances called neuromodulators. These neuromodulators are endogenous opioid compounds, meaning they are naturally present, morphine-like chemical regulators in the spinal cord and brain. They appear to have analgesic activity and alter the perception of pain. These endogenous opioid compounds are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the CNS, blocking the release or production of pain-transmitting substances. Both pain and stress appear capable of activating the endogenous opiate system.

Concern about Prescription Analgesic Abuse

the diversion (any act that results in a drug not reaching the person who was originally prescribed the drug) and substance abuse that subsequently occurred was an unintended consequence. Opioid abusers often capitalize on the well-intentioned desire of health care providers to sufficiently address pain. They visit multiple doctors and request opioid prescriptions for high daily doses. This group is at high risk for a drug overdose, and some may even distribute drugs to others who are using them without a prescription (diversion) One initiative is the creation of the Prescription Drug Monitoring Program (PDMP) database that allows prescribers to access prescription and dispensing data on prescription drugs for individual patients from multiple institutions within a geographic area. A multifaceted approach to pain management and opioid abuse issues should involve the individual patient, health care, law enforcement, and public health and safety facilities.

Dynophin

the endorphin having the most potent analgesic effect

Diabetic neuropathy

too much blood sugar can make neurons less/more sensitive to pain A common complication of long-term diabetes mellitus. Metabolic and vascular changes result in damage to peripheral and autonomic nerves. Sensory loss can result when peripheral nerves are involved and eventually lead to injury progressing to infection and gangrene. Symptoms include sensations of numbness, prickling, or tingling (paresthesias).