Nursing 1: Theory Exam 4: Unit 12: Sleep and Pain: Part B: Pain Management

Epidurals

As a precaution, have naloxone (Narcan), sodium chloride 0.9% diluent, and injection equipment on hand for each client receiving an opioid-containing epidural infusion Nursing Interventions Maintain client safety > Label the tubing, the infusion bag, and the front of the pump with tape marked EPIDURAL to prevent confusion with similar-looking IV lines. (Most epidural tubings are yellow for this reason.) Post sign above client's bed indicating epidural is in place. Secure all connections with tape. If there is no continuous infusion, apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter. Do not use alcohol in any care of catheter or insertion site because it can be neurotoxic. Ensure that any solution injected or infused intraspinally is sterile, preservative free, and safe for intraspinal administration. Maintain catheter placement > Secure temporary catheters with tape. When bolus doses are used, gently aspirate prior to medication administration to determine catheter has not migrated into the subarachnoid space. (Expect <1 mL of fluid return in syringe.) Assist client in repositioning or moving out of bed. Teach client to avoid tugging on the catheter. Assess insertion site for leakage with each bolus dose or at least every 8-12 hr Prevent infection > Use strict aseptic techniques with all epidural-related procedures. Maintain sterile occlusive dressing over insertion site. Assess insertion site for signs of infection. Maintain urinary and bowel function. > Monitor intake and output. Assess for bowel and bladder distention Prevent respiratory depression. > Assess sedation level and respiratory status q1h for the first 24 h and q4h thereafter. Do not administer other opioids or CNS depressants unless ordered. Keep an ampule of naloxone hydrochloride (0.4 mg) available. Notify the clinician in charge if the respiratory rate falls below 8/min or if the client is difficult to rouse.

sympathectomy

Excision of a portion of the sympathetic division of the autonomic nervous system, used, e.g., to treat hyperhydrosis (refractory sweating of the palms or feet) or Raynaud's phenomenon. It may include a nerve, plexus, ganglion, or a series of ganglia of the sympathetic trunk

The following concepts are important reasons to prevent pain or treat it as soon as possible to prevent the amplification, spread, and persistence of pain:

Sensitization: An increased sensitivity of a receptor after repeated activation by noxious stimuli. Windup: Progressive increase in excitability and sensitivity of spinal cord neurons, leading to persistent, increased pain.

cordotomy

Spinal cord section of lateral pathways to relieve intractable pain.

rhizotomy

Surgical section of a nerve root (e.g., the root of a spinal or dental nerve) to relieve pain or reduce spasticity.

pain sensation

The acknowledgement of pain, often known as pain threshold.

preemptive analgesia

The administration of anesthetic before surgery in order to abort postoperative pain and disability.

pain tolerance

The degree of pain an individual can withstand.

Transcutaneous Electrical Nerve Stimulation (TENS)

a battery-powered device delivers stimulation to nerves to relieve acute and chronic pain

agonist-antagonist analgesic

a drug that can act like opioids and relieve pain (agonist effect) when given to a client who has not taken any pure opioids

nociceptors

a pain receptor A free nerve ending that is a receptor for painful stimuli.

Analgesics based on Pain Intensity

*NONOPIOID ANALGESICS/NSAIDS FOR MILD PAIN* - Acetaminophen (Tylenol, Datril) - Acetylsalicylic acid (aspirin) - Choline magnesium trisalicylate (Trilisate) - Ibuprofen (Motrin, Advil) - Indomethacin sodium trihydrate (Indocin) - Naproxen (Naprosyn), naproxen sodium (Anaprox) - Ketorolac (Toradol) - Piroxicam (Feldene) - Meloxicam (Mobic) - Celecoxib (Celebrex) Cox II NSAID *OPIOID ANALGESICS FOR MODERATE PAIN* - Hydrocodone (Lortab, Vicodin) - Codeine (Tylenol No. 3) - Tramadol (Ultram, Ultracet) - Pentazocine (Talwin) *OPIOID ANALGESICS FOR SEVERE PAIN* - Fentanyl citrate (Sublimaze, transdermal patches, Actiq lozenges) - Hydromorphone hydrochloride (Dilaudid) - Oxycodone (OxyContin) - Morphine sulfate (morphine) - Oxymorphone (Opana) - Methadone (Dolophine) *COANALGESICS* - Tricyclic antidepressants (nortriptyline, amitriptyline) - Anticonvulsants (gabapentin, pregabalin) - Topical local anesthetic (Lidoderm)

Objective 5: Identify subjective and objective data to collect and analyze when assessing pain

- (Subjective) Pain history - (Objective)Direct observation of behaviors, physical signs of tissue damage, secondary physiological responses ↓ -> Nonverbal responses to pain --> Facial expression --> Vocalizations like moaning and groaning or crying and screaming --> Immobilization of the body or body part --> Purposeless body movements --> Behavioral changes such as confusion and restlessness --> Rhythmic body movements or rubbing - Nurse focus for acute pain -> Previous pain treatment & effectiveness -> Analgesics & other medications being taken -> Allergies to medications - Nurse focus for chronic pain -> Coping mechanisms -> Effectiveness of current pain management -> Ways pain has affected client

Objective 6: Identify examples of nursing diagnoses for clients with pain

- Acute Pain - Chronic Pain - Labor Pain - Chronic Pain syndrome Pain as etiology of other nursing diagnoses: -> Ineffective Airway Clearance -> Hopelessness -> Anxiety -> Ineffective Coping -> Ineffective Health Maintenance -> Self-Care Deficit (specify) -> Deficient Knowledge related to pain control measures -> Impaired Physical Mobility -> Insomnia

Objective 8: Identify barriers to effective pain management

- Lack of knowledge of adverse effects of pain - Misinformation about use of analgesics - Misconceptions about pain - Client not reporting pain - Fear of becoming addicted, especially with long term opioid use

Why Might Clients be Unwilling to Report Pain?

- Unwillingness to trouble staff who are perceived as busy - Do not want to be labeled as a "complainer" or "bad" - Fear of the injectable route of analgesic administration— especially children - Belief that unrelieved pain is an expected, normal part of recovery or aging - Belief that others will think they are weak if they express pain - Difficulty or inability to communicate their discomfort - Concern about risks associated with opioid drugs (e.g., addiction) - Concern about unwanted side effects, especially of opioid drugs - Concern that use of drugs now will render the drug inefficient later in life - Fear that reporting pain will lead to further tests and expenses - Belief that nothing can be done to control pain - Belief that enduring pain and suffering may lead to spiritual enlightenment - Culture affects behavioral responses to pain and treatment preferences (e.g., some cultures are comfortable expressing pain while others are stoic and are not comfortable expressing or reporting pain)

Objective 4: Describe the gate control theory and its application to nursing care

-> Melzack & Wall's gate control theory (1965), (A-delta or C) peripheral nerve fibers carry signals of noxious (painful) stimuli to the dorsal horn, where these signals are modified when they are exposed to the substantia gelatinosa. -> Ion channels on the pre- and postsynaptic membranes serve as gates that, when open, permit positively charged ions to rush into the second order neurons, sparking an electrical impulse and sending signals of pain to the thalamus. -> Peripherally, large-diameter (A-delta) nerve fibers -> Send messages of touch, warm, or cold temperatures -> Inhibitory effect on the substantia gelatinosa. -> May activate the descending mechanism that can lessen the intensity of pain perceived or inhibit the transmission of those pain impulses—that is, close the (ion) gates. -> Nurses can use this model to: - Stop nociceptor firing by treating the cause of pain (treat the underlying cause) - Apply topical therapies (heat, ice, electrical stimulation (TENS), or massage) - Address client's mood (reduce fear, anxiety, anger) - Address client's goals (client education, anticipatory guidance)

Patient-controlled analgesia (PCA): Risk Factors for Adverse Outcomes

1. Inadequate patient assessment: a. Has the patient taken opiates previously, or is the patient opiate-naive? Naive patients have lower tolerance for adverse effects from narcotics. b. Does the patient have risk factors for respiratory depression with treatment, e.g., advanced age, morbid obesity, liver failure, or renal failure? 2. Have patients and caregivers been advised about warning signs of narcotic overdose, e.g., excessive sedation? 3. Is the patient adequately monitored? 4. Have the prescribed doses of medication been checked and verified by the prescriber, the pharmacist, and the nurse?

Patient-Controlled Analgesia (PCA)

A method of administering drugs that permits the patient to control the rate of drug delivery for the control of pain. It is usually performed with an infusion pump. An adult or child who is cognitively and physically able to use the equipment and who understands that pressing a button can result in pain relief is an appropriate candidate to administer his or her own pain medications when they are needed. Health care professionals should advise patients, family members, and other visitors that the PCA should be used only by the patient.

Culture and Pain

AFRICAN AMERICANS - Some believe pain and suffering is a part of life and is to be endured. - Some may deny or avoid dealing with pain until it becomes unbearable. - Some believe that prayer and laying on of hands will free a person from suffering and pain. HISPANIC/LATINO - Mexican Americans may tend to view pain as a part of life and as an indicator of the seriousness of an illness. - Some believe that enduring pain is a sign of strength. - Puerto Ricans may tend to be loud and outspoken in their expressions of pain. This is a socially learned way to cope and it is important for the nurse to not judge or disapprove. ASIANS AMERICANS - Chinese culture values silence. As a result, some clients may be quiet when in pain because they do not want to cause dishonor to themselves and their family. Therefore, offer pain medications frequently because they generally agree to the use of pain medications, but may be afraid to ask for them. - Japanese may have a stoic (minimal verbal and nonverbal expressions) response to pain. They may even refuse pain medication. Bearing pain is considered a virtue and a matter of family honor. - Filipino clients may believe that pain is "God's will" and therefore to be endured, not expressed. Some older Filipino clients may refuse pain medication. - If the client is a Buddhist, remaining calm when in pain is viewed as bringing oneself to a higher state of being. NATIVE AMERICANS - In general, Native Americans are quiet, less expressive verbally and nonverbally, and may tolerate a high level of pain. They tend to not request pain medication and may tolerate pain until they are physically disabled. ARAB AMERICANS - Pain is regarded as unpleasant and they anticipate immediate relief from their symptoms. Expressive emotional and vocal responses to pain are reserved for immediate family, not for health professionals. As a result, this may lead to conflicting perceptions among the family members and the nurse regarding the effectiveness of the client's pain relief. For example, the nurse may believe the client has adequate pain management, whereas the family is requesting additional pain medication for their family member.

Acute vs Chronic Pain (Table 46-1)

Acute Pain > Mild to severe > Sympathetic nervous system responses: - Increased pulse rate - Increased respiratory rate - Elevated blood pressure - Diaphoresis - Dilated pupils > Related to tissue injury; resolves with healing > Client may be restless and anxious > Client reports pain > Client may exhibit behavior indicative of pain: crying, rubbing area, holding area Chronic Pain > Mild to severe > Parasympathetic nervous system responses: - Vital signs normal - Dry, warm skin - Pupils normal or dilated > Continues beyond healing > Client is usually depressed and withdrawn > Client often does not mention pain unless asked > Pain behavior often absent

Age Variations in Pain

Adult Pain Perception/Behavior: - Behaviors exhibited when experiencing pain may be gender-based behaviors learned as a child. - May ignore pain because to admit it is perceived as a sign of weakness or failure. - Fear of what pain means may prevent some adults from taking action. Nursing Interventions: - Deal with any misconceptions about pain. - Focus on the client's control in dealing with the pain. - Allay fears and anxiety when possible. Older Adult Pain Perception/Behavior: - May have multiple conditions presenting with vague symptoms. - May perceive pain as part of the aging process. - May have decreased sensations or perceptions of the pain. - Lethargy, anorexia, and fatigue may be indicators of pain. - May withhold statements of pain because of fear of the treatment, of any lifestyle changes that may be involved, or of becoming dependent. - May describe pain differently, that is, as "ache," "hurt," or "discomfort." - May consider it unacceptable to admit or show pain. Nursing Interventions: - Take a thorough history and assessment. - Spend time with the client and listen carefully. - Clarify misconceptions. - Encourage independence whenever possible.

The following states indicate abnormal nerve functioning, and the associated cause needs to be identified/treated (as soon as possible) before irreversible damage occurs:

Allodynia: Sensation of pain from a stimulus that normally does not produce pain (e.g., light touch). Dysesthesia: An unpleasant abnormal sensation that can be either spontaneous or evoked. Hyperalgesia: Increased sensation of pain in response to a normally painful stimulus.

Objective 13: Describe nonpharmacological pain control interventions

Alter physiologic responses to reduce pain perception > Distract client from painful sensations > Stimulate A-beta nerve fibers > Activate mechanisms that reduce pain intensity, activate endorphins, > Diminish conscious awareness of pain; > Optimize functioning > Reduce pain triggers > Promote comfort > Holistic nonpharmacologic interventions

visceral hypersensitivity

An abnormally low tolerance for painful stimuli in the internal organs. It is seen, e.g., in patients with irritable bowel syndrome.

adjuvant analgesic

An analgesic that augments the effect of another pain reliever even though it is not primarily indicated for the relief of pain when used alone

hyperalgesia

An excessive sensitivity to pain; the opposite of hypalgesia

placebo

An inactive substance or treatment given instead of one that has a proven effect. A drug or treatment used as a nonspecific or inactive control in a test of a therapy that is suspected of being useful for a particular disease or condition. The placebo is given to one group of patients, and the drug being tested is given to a similar group; then the results obtained in the two groups are compared. Placebos often elicit a response, possibly because of patient expectations that they will produce a cure or prove harmful

Nonpharmacologic Interventions for Pain Control

Body: Reducing pain triggers, promoting comfort Massage Applying heat or ice Electrical stimulation (TENS) Positioning, bracing (selective immobilization) Acupressure Diet, nutritional supplements Exercise, pacing activities Invasive interventions (e.g., blocks) Sleep hygiene Mind: Relaxation, imagery Self-hypnosis Pain diary, journal writing Distracting attention Repatterning thinking Attitude adjustment Reducing fear, anxiety, stress Reducing sadness, helplessness Information about pain Music therapy Spirit: Prayer, meditation Self-reflection regarding life and pain Meaningful rituals Energy work (e.g., therapeutic touch, Reiki) Spiritual healing Social interactions: Functional restoration Improved communication Pet therapy Family therapy Problem solving Vocational training Volunteering Support groups Types of Distraction VISUAL DISTRACTION - Reading or watching television - Video and computer games (also tactile) - Watching a baseball game - Guided imagery AUDITORY DISTRACTION - Humor - Music TACTILE DISTRACTION - Slow, rhythmic breathing - Massage - Holding or stroking a pet or toy INTELLECTUAL DISTRACTION - Crossword puzzles, Sudoku number puzzles - Card games - Hobbies > Effleurage is a type of massage consisting of long, slow, gliding strokes. Research demonstrates that back massage can enhance client comfort, relaxation, and sleep.

Narcotic Analgesic oxycodone (OxyContin), oxycodone/acetaminophen (Percocet), oxycodone/aspirin (Percodan)

CLIENT WITH PAIN Opioids relieve moderate to severe pain by inhibiting the release of substance P in both central and peripheral nerves, reducing the perception of pain, producing sedation, and decreasing the emotional stress of pain. Oxycodone is a semisynthetic derivative of codeine and a Schedule II controlled substance. It is often administered as a combination drug with acetaminophen (Percocet, Tylox) or aspirin (Percodan). It is also available as a single-agent, controlled-release medication (OxyContin). NURSING RESPONSIBILITIES - Assess pain prior to and 60 minutes after administration. - Assess bowel function to prevent constipation. - Keep track of the total amount of acetaminophen or aspirin the client is receiving when taking a combination drug. The maximum daily dose of acetaminophen is 4,000 mg unless the client is at risk for liver problems (e.g., older adult, malnourished, or hepatic problems). For these clients, the maximum amount is lowered to 2,000 mg/day (Arnstein, 2010; D'Arcy, 2011). CLIENT AND FAMILY TEACHING - Take with food to decrease GI upset. - Avoid crushing or chewing long-acting tablets (e.g., OxyContin). - Avoid alcohol or other CNS depressants. - Explain that the medication may cause dizziness, and instruct to make position changes slowly. - Instruct that constipation is a common side effect. Discuss preventive measures. - Take only as prescribed.

Common Opioid Side Effects and Treatment Measures

CONSTIPATION - Increase fluid intake (e.g., 6 to 8 glasses daily). - Increase fiber and bulk-forming agents to the diet (e.g., fresh fruits and vegetables). Increasing exercise is often ineffective in controlling this type of constipation. - Administer daily stool softeners combined with a mild laxative (e.g., Senokot-S) as a first line of prevention against constipation for clients on opioid maintenance therapy. - Stimulants (bisacodyl), osmotic laxatives (lactulose, sorbitol, and polyethylene glycol), enemas (tap water and sodium phosphate), and even prokinetic agents (metoclopramide) may be needed for refractory cases of constipation. - A new medication has been approved for opioid-induced constipation in end-of-life care, Relistor (methylnaltrexone bromide). It is to be given subcutaneously, when other methods prove ineffective (D'Arcy, 2011). NAUSEA AND VOMITING - Inform client that tolerance to this emetic effect generally develops after several days of opioid therapy. - Provide an antiemetic: the 5HT antagonist ondansetron ( Zofran), phenothiazines (Compazine, Phenergan), or the GI stimulant metoclopramide (Reglan). - Change the dose or analgesic agent as indicated. SEDATION - Inform client that tolerance usually develops over 3 to 5 days. - Consider the administration of a stimulant in the morning (e.g., caffeine, Dexedrine, or Ritalin for adult clients) or an alternative route of administration (e.g., epidural) to counteract sedation. - Observe client for evidence of respiratory depression that may occur with sedation. RESPIRATORY DEPRESSION - Administer an opioid antagonist, such as naloxone hydrochloride (Narcan), cautiously by diluting 1 ampule in 10 mL of saline and then administering 1 mL/min until the respirations are equal to or more than 10/min. Make provisions for repeat administration, continuous infusion, or a longer acting version of a reversal agent because the half-life of naloxone is considerably shorter than that of most opioids being reversed. - Remember to titrate naloxone to prevent seizures, arrhythmias, and returning pain. - Attempt to stimulate the client to take deep breaths every 15 to 30 minutes. Stop, change, or slow the administration of opioids until respirations are restored. - Be aware of the CNS depression risks of other medications such as hypnotics, benzodiazepines, and sedatives, especially in the opioid-naÏve client. PRURITUS - Apply cool packs, lotion, and diversional activity. - Administer an antihistamine, for example, diphenhydramine hydrochloride (Benadryl). Instruct client about sedation effects. - Inform the client that tolerance also develops to pruritus within a few days; otherwise, as with other unresolved side effects, switching to another opioid may prove beneficial. URINARY RETENTION - May need to catheterize client, or change or lower the analgesic dose. >>Assessing for sedation and respiratory status is critical during the first 12 to 24 hours after starting opioid therapy. The most critical period is during the peak effect of the first dose (15 minutes if administered IV; first hour after IM, oral, or rectal route). An exception is with opioids administered via the spinal route. Respiratory depression may increase over time with epidural infusions and with intrathecal analgesia; respiratory depression may manifest 24 hours after the spinal injection even after the analgesic effect has worn off. In general, the longer the client receives opioids, the wider the safety margin as the client develops a tolerance to the sedative and respiratory depressive effects of the drug.

Clinical Alert for Opioid Usage

Constipation is an almost universal adverse effect of opioid use. All clients should receive prophylactic stimulant laxative therapy, unless contraindicated. Stool softeners are not useful alone, but are a good choice when combined with a stimulant laxative (e.g., Senokot-S). If those products are ineffective, a regimen of cathartic laxatives (e.g., bisacodyl), followed by more aggressive forms of treatment (e.g., osmotic laxatives, enema, manual disimpaction) may be necessary.

Pain Descriptors

Descriptive adjectives help people communicate the quality of pain. The astute clinician can collect subtle clinical clues from the quality of the pain described; thus it is important to record the description verbatim. Note that the term "unbearable" is listed as an affective term and "piercing" is a sensory term. Both pains are real physical conditions signaling an underlying condition, but the affective description "unbearable" suggests that there is a coexisting emotional distress that needs to be addressed as well. Pain described as burning or shock-like tends to be neuropathic in origin and may be responsive to anticonvulsants (e.g., gabapentin or pregabalin), with or without an opioid (e.g., morphine, fentanyl, hydromorphone). **Pain** *Sensory Words* Searing Scalding Sharp Piercing Drilling Wrenching Shooting Burning Crushing Penetrating *Affective Words* Unbearable Killing Intense Torturing Agonizing Terrifying Exhausting Suffocating Frightful Punishing Miserable **Hurt** *Sensory Words* Hurting Pricking Pressing Tender *Affective Words* Heavy Throbbing **Ache** *Sensory Words* Numb Cold Flickering Radiating Dull Sore Aching Cramping *Affective Words* Annoying Nagging Tiring Troublesome Gnawing Uncomfortable Sickening Tender

WHO Analgesic Ladder

For clients with mild pain (1 to 3 on a 0-to-10 scale), step 1 of the analgesic ladder, nonopioid analgesics (with or without a coanalgesic), is the appropriate starting point. If the client has mild pain that persists or increases despite using full doses of step 1 medications, or if the pain is moderate (4 to 6 on a 0-to-10 scale), then a step 2 routine is appropriate. At the second step, an opioid for moderate pain (e.g., codeine, tramadol) or a combination of opioid and nonopioid medicine (e.g., oxycodone with acetaminophen, hydrocodone with ibuprofen) is provided with or without coanalgesic medications. If the client has moderate pain that persists or increases despite using full doses of step 2 medications, or if the pain is severe (7 to 10 on a 0-to-10 scale), then a step 3 schedule is medically indicated. At the third step, an opioid for severe pain (e.g., morphine, hydromorphone, fentanyl) is administered and titrated in ATC scheduled doses until the pain is relieved > Combining opioid and nonopioid analgesics is a useful way to manage pain, and is frequently overlooked. Each has different mechanisms of action, side effects, and toxicity profiles. Alternating the two or giving them at the same time creates no danger and often produces a synergistic rather than merely additive effect. By combining nonopioids and opioids, pain management can be enhanced, reducing doses of analgesics and decreasing the risks of side effects for both. This practice is sometimes referred to as multimodal therapy.

Three Primary Types of Opiods

Full agonists. These pure opioid drugs bind tightly to mu receptor sites, producing maximum pain inhibition, an agonist effect. A full agonist analgesic includes morphine, the gold standard opioid. Other full agonists include oxycodone (e.g., Percocet, OxyContin), hydromorphone (e.g., Dilaudid), and fentanyl (Duragesic, Actiq). There is no ceiling on the level of analgesia from these drugs; their dose can be steadily increased to relieve pain. There is also no maximum daily dose limit unless they are in compound with a nonopioid analgesic drug. Mixed agonists-antagonists. Agonist-antagonist analgesic drugs can act like opioids and relieve pain (agonist effect) when given to a client who has not taken any pure opioids. However, they can block or inactivate other opioid analgesics when given to a client who has been taking pure opioids (antagonist effect). These drugs include dezocine (Dalgan), pentazocine hydrochloride (Talwin), butorphanol tartrate (Stadol), and nalbuphine hydrochloride (Nubain). They block the mu receptor site and activate a kappa receptor site. If a client has been receiving a mu agonist (e.g., morphine, Percocet, or Vicodin for pain) daily for more than a couple of weeks, the administration of a mixed agonist-antagonist may result in an immediate and severe withdrawal reaction. These drugs also have a ceiling effect that limits the dose. They are not recommended for use with clients who are terminally ill. In the opioid-naÏve client (individual who has not taken opioids for a week or longer) with acute pain (e.g., migraine headache), these agents have success and few side effects. Partial agonists. Partial agonists have a ceiling effect in contrast to a full agonist. These drugs such as buprenorphine (Buprenex) block the mu receptors or are neutral at that receptor but bind at a kappa receptor site. Buprenorphine has good analgesic potency and is emerging as an alternative to methadone for opioid maintenance and narcotic treatment programs. The safety and favorable side effect profile make it an increasingly popular choice.

Objective 1: Identify types and categories of pain according to location, etiology, and duration

Location: - Localized - Radiating - Referred pain: -> Appear to arise in different areas to other parts of the body -> Ex- Cardiac pain may be felt in the shoulder or left arm, with or without chest pain. - Visceral pain: -> Pain arising from organs or hollow viscera Duration: - Acute pain: -> Pain that lasts only through the expected recovery period -> Sudden or slow onset - Chronic pain: -> Persistent pain -> Recurring or lasting 3 months or longer -> Interferes with function Etiology: - Nociceptive pain -> Experienced when an intact, properly functioning nervous system signals that tissues are damaged, requiring attention and proper care -> Transient or persistent -> 2 subcategories: >> Somatic (Skin, muscles, bone, connective tissue) >> Visceral (organ) cramping, aching, labor pain, IBS, angina pectoris - Neuropathic pain -> Experienced by people who have damaged or malfunctioning nerves -> Typically, chronic; usually described as burning, "electric-shock", and/or tingling, dull, and aching. -> Difficult to treat -> Subcategories: >> Peripheral neuropathic pain --> Phantom limb pain, post-herpetic neuralgia, carpal tunnel syndrome >> Central neuropathic pain --> Spinal cord injury, post CVA, MS >> Sympathetically maintained pain --> Edema, temp, blood flow regulation

Pain History Assessment

Location: - Where is your discomfort? Quality: - Tell me what your discomfort feels like. Intensity: - On a scale of 0 to 10, with "0" representing no pain (substitute the term client uses, e.g., "no burning") and "10" representing the worst possible pain (e.g., "burning sensation"), how would you rate the degree of discomfort you are having right now? Pattern a. Time of onset: - When did or does the pain start? b. Duration: - How long have you had it, or how long does it usually last? c. Constancy: - Do you have pain-free periods? When? And for how long? Precipitating factors: - What triggers the pain or makes it worse? • Alleviating factors: - What measures or methods have you found helpful in reducing or relieving the pain? - What pain medications do you use? Associated symptoms: - Do you have any other symptoms (e.g., nausea, dizziness, blurred vision, shortness of breath) before, during, or after your pain? Effects on ADLs: - How does the pain affect your daily life (e.g., eating, working, sleeping, and social and recreational activities)? Past pain experiences: - Tell me about past pain experiences you have had and what was done to relieve the pain. Meaning of pain: - What does having this pain mean to you? - Does it signal something about the future or past? - What worries or scares you the most about your pain? Coping resources: - What do you usually do to help you deal with pain? Affective response: - How does the pain make you feel? - Anxious? - Depressed? - Frightened? - Tired? - Burdensome?

Types of Painful Stimuli

Mechanical > trauma to body tissues - tissue damage, direct irritation of pain receptors, inflammation > alterations in body tissues - pressure on pain receptors > blockage of a body duct - distention of the lumen of the duct > tumor - pressure on pain receptors, irritation of nerve endings > muscle spasm - stimulation of pain receptors Thermal > extreme heat or cold - tissue destruction; stimulation of thermosensitive pain receptors Chemical > tissue ischemia - stimulation of pain receptors because of accumulated lactic acid and other chemicals and enzymes in tissues > muscle spasm - tissue ischemia secondary to mechanical stimulation

Misconceptions About Nonopioids

Misconception: Regular daily use of NSAIDs is much safer than taking opioids Correction >> Side effects from long-term use of NSAIDs are considerably more severe and life threatening than the side effects from daily doses of opioids. The most common side effect from long-term use of opioids is constipation, whereas NSAIDs can cause gastric ulcers, increased bleeding time, and renal insufficiency. Acetaminophen can cause hepatotoxicity. Misconception: A nonopioid should not be given at the same time as an opioid Correction >> It is safe to administer a nonopioid and opioid at the same time. Giving a dose of nonopioid at the same time as a dose of opioid poses no more danger than giving the doses at different times. In fact, many opioids are compounded with a nonopioid (e.g., Percocet [oxycodone and acetaminophen]). Misconception: Administering antacids with NSAIDs is an effective method of reducing gastric distress. Correction >> Administering antacids with NSAIDs can lessen distress but may be counterproductive. Antacids reduce the absorption and therefore the effectiveness of the NSAID by releasing the drug in the stomach rather than in the small intestine where absorption occurs Misconception : Nonopioids are not useful analgesics for severe pain. Correction >> Nonopioids alone are rarely sufficient to relieve severe pain, but they are an important part in the total analgesic plan. One of the basic principles of analgesic therapy is: Whenever pain is severe enough to require an opioid, adding a nonopioid should be considered. Misconception: Gastric distress (e.g., abdominal pain) is indicative of NSAID induced gastric ulceration. Correction >> Most clients with gastric lesions have no symptoms until bleeding or perforation occurs.

Pain Intensity

Most practitioners classify intensity of pain by using a standard scale: 0 (no pain) to 10 (worst possible pain) scale. Linking the rating to health and functioning scores, pain in the *1 to 3* range is deemed *mild* pain, a rating of *4 to 6* is *moderate* pain, and pain reaching *7 to 10* is deemed *severe* pain and is associated with the worst outcomes.

Objective 3: Describe the four processes involved in nociception and how pain interventions can work during each process.

Nociception: The physiological processes related to pain perception 4 processes: Transduction -> Harmful stimuli trigger release of biochemical mediators which sensitize nociceptors (prostaglandins, bradykinin, serotonin, histamine, substance P) -> Painful stimulation also causes movement of ions across cell membranes which excites nociceptors -> Aspirin or ibuprofen block the production of prostaglandin -> Local anesthetics decrease movement of ions across cell membranes -> Capsaicin (Zostrix) depletes accumulation of substance P and blocks transduction Transmission -> Includes 3 segments: > First segment -> Pain impulse from peripheral nerve to spinal cord -> Two types of fibers cause this transmission to dorsal horn: --> A-delta fibers (sharp, localized pain) --> C fibers (dull, aching pain) > Second segment -> Transmission of the pain signal through an ascending pathway in the spinal cord to the brain > Third segment -> Transmission of information to the brain where pain perception occurs. Perception > Client conscious of pain -> Assesses intensity & character -> Assigns meaning Modulation > Descending system > Neurons in the brain send signals back down to the dorsal horn of the spinal cord. > These descending fibers release endogenous opioids; serotonin, norepinephrine reabsorbed quickly, which can inhibit or reduce the ascending painful impulses in the dorsal horn. > In contrast, amino acids can increase pain signals. > Tricyclic antidepressants block resorption of norepinephrine & serotonin

NSAIDs

Nonopioids include acetaminophen and nonsteroidal anti- inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. All are useful for the management of acute and chronic pain. Aspirin is the most common NSAID and is available over the counter (OTC). Because it can prolong bleeding time, clients should stop taking it 1 week prior to any surgical procedure. Aspirin should never be given to children under 12 years of age due to the possibility of Reye's syndrome. The nurse must also be aware that aspirin can cause excessive anticoagulation if a client is taking the anticoagulant warfarin. Acetaminophen (Tylenol) does not affect platelet function and rarely causes gastrointestinal (GI) distress. It does, however, have serious side effects such as hepatotoxicity and possible renal toxicity, especially with high doses or with long-term use. Studies show that even with recommended doses up to 4 grams per day, some clients may be at an increased risk for liver toxicity (Pasero & McCaffery, 2011). The U.S. Food and Drug Administration (FDA) currently require warnings against taking alcohol with acetaminophen. It is recommended that otherwise young and healthy people limit their acetaminophen consumption to less than 3 grams per day, with susceptible individuals (e.g., older adults, those with a history of alcoholism, dehydration, or liver disease) limiting their consumption to less than 2 grams per day (Arnstein, 2010; D'Arcy, 2011). Given that acetaminophen is so well tolerated, it is often an ingredient in OTC remedies (e.g., pain, fever, allergy, cough and cold preparations), so clients must be instructed to read the ingredient list of all OTC medicines they take. Box 46-6 lists common prescription medications that contain acetaminophen. Common Prescription Pain Medications Containing Acetaminophen: - Tylenol No. 3 (325 mg acetaminophen/30 mg codeine) - Percocet (325 mg acetaminophen/5 mg oxycodone) - Lortab (500 mg acetaminophen/5, 7.5, or 10 mg hydrocodone) - Vicodin (500 mg acetaminophen/5 mg hydrocodone) - Tylox (500 mg acetaminophen/5 mg oxycodone) - Darvocet-N 100 (650 mg acetaminophen/100 mg propoxyphene) - Vicodin ES (750 mg acetaminophen/7.5 mg hydrocodone)

Pain Management in Older Adults

OLDER ADULTS - Promote clients' use of pain control measures that have worked in the past for them. - Spend time with clients and listen carefully. - Clarify misconceptions. Encourage independence whenever possible. - Carefully review the treatment plan to avoid drug-drug, food- drug, or disease-drug interactions. - Physicians and nurse practitioners with advanced certification in hospice and palliative medicine (HPM) are often members of the intraprofessional team that works with the client and family to provide the best possible hospice care.

Pain in Older Adults

OLDER ADULTS The presentation of pain may vary in older adults for a variety of reasons. Changes in nerve structure and functioning or vascular changes with aging may cause a variation in the pain sensation. Sometimes the pain is heightened in those whose nervous systems have been sensitized from previous unresolved pain, whereas at other times significant tissue damage (e.g., silent heart attack) may occur without pain being experienced. In some situations, pain presents itself with atypical symptoms, such as confusion, restlessness, or irritability. This is especially true in clients with dementia who have a difficult time understanding and verbalizing what they are feeling. Maintaining optimal function is especially crucial for a high quality of life in older clients. If pain is not effectively controlled, the following areas are often affected in their daily lives: • Activity tolerance • Mobility • Ability to socialize • Sleep disturbance • Ability to perform ADLs • Ability to remain as independent as possible. All efforts, pharmacologic and nonpharmacologic, should be used to help provide pain reduction, while maintaining or enhancing functional ability. Involvement of the client and family is important when working with the primary care provider, pharmacist, and nurse to plan which treatment is most appropriate and most acceptable to the client. *The principle "start low and go slow" is especially important when ordering dosages and pain medications for older adults.* Typically, the starting dose of medicines for older adults is reduced by 25% to 50%, and then titrated for effect. Decreased renal and liver function may prolong the duration of action, but it also increases the risk of toxicity from pain medications in older clients. In particular, risk of silent gastrointestinal bleeding and renal damage from nonsteroidal anti-inflammatory drugs (NSAIDs) increases, so dosages and lab work need to be carefully monitored related to hematocrit and renal function (liver function is monitored with acetaminophen). Comorbid conditions may also affect medication selection in older adults; for example, clients with gastric ulcers, hypertension, or the combination of asthma and nasal polyps should not receive NSAIDs. Older adults with chronic obstructive pulmonary disease (COPD) must have their respiratory rate carefully monitored when placed on an opioid pain reliever, especially at night when respirations slow and the risk of oxygen desaturation is high.

Common Chronic Pain Syndromes

Post-herpetic neuralgia: This condition, which currently affects 2 million Americans, occurs when a case of herpes zoster (shingles) typically erupts decades after a primary infection (chickenpox) during a period of stress or compromised immune functioning. After the painful unilateral vesicular rash fades, burning or electric-shock pain in the area may persist for months or years. Advancing age is a risk factor for persistent post-herpetic neuralgia. A vaccine has been approved and is recommended for all people over the age of 60 to prevent shingles and the possibility of post-herpetic neuralgia. Phantom pain: Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. For many, this sensation is painful and it may occur spontaneously, or is evoked (e.g., by a poor-fitting prosthesis). When the amputation involves a limb, it is termed phantom limb pain, whereas following breast surgery, it is called postmastectomy pain. If the limb was painful or mangled before the amputation, that is commonly the sensation that is experienced (unless the discomfort is completely relieved prior to surgery). It is important for the nurse to remember to explain the reasons for phantom limb pain, as clients may have difficulty understanding why they have pain when the limb is gone. They may start to question their sanity. Trigeminal neuralgia: This is an intense stablike pain that is distributed by one or more branches of the trigeminal nerve (fifth cranial). The pain is usually experienced on parts of the face and head. It is so severe that it produces facial muscle spasms. Headache: An estimated 40% of the worldwide population suffers at least one severe, disabling headache per year. This commonly occurring painful condition can be caused by either intracranial or extracranial problems, serious or benign conditions. To establish a plan to prevent or treat headache, the nurse needs to assess the quality, location, onset, duration, and frequency of the pain, as well as any signs and symptoms that precede the headache. There are many types of headaches, but the three most common include migraine, tension type, and cluster. Migraine and tension-type headaches are three times more common in women than in men, while cluster headaches occur primarily in men. Low back pain: Nearly everyone suffers from low back pain at some time during their lives. Most occurrences of low back pain go away within a few days. Chronic back pain persists for more than 3 months. It is often progressive and the cause can be difficult to determine. Fibromyalgia: An estimated 5 million Americans suffer from a condition known as fibromyalgia, a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple tender points. This disease is poorly understood and primarily occurs in women. "Tender points" refers to tenderness that occurs in precise, localized areas, particularly in the neck, spine, shoulders, and hips. People with this syndrome may also experience sleep disturbances, morning stiffness, irritable bowel syndrome, anxiety, and other symptoms. Although the symptoms present as muscle pain, stiffness, and weakness, it is considered by many to be a problem of abnormal CNS functioning, particularly as it relates to the way nerves process pain.

Objective 12: Identify rationales for using various analgesic delivery routes

Oral route - Preferred because of ease of administration - Duration of action is often only 4-8 hours. - Requires awakening during night for medication - Long-acting or sustained-action preparations developed - May need rescue dose of immediate-release medication Transnasal route - Enters blood immediately Transdermal route - Noninvasive - Delivers relatively stable plasma drug level Transmucosal route - Onset of action rapid Rectal route - Useful for clients with dysphagia or nausea/vomiting Topical route - Directed at the point of application Subcutaneous route - Continuous infusion - Used for pain poorly controlled by oral medications, clients with dysphagia or GI obstruction, or clients with need for prolonged use - Requires client or caregiver teaching about how to operate pump and care for injection site Intramuscular route - Should be avoided - Variable absorption - Unpredictable onset of action and peak effect - Tissue damage Intravenous route - Provides rapid and effective relief with few side effects - Respiratory depression can occur rapidly. Intraspinal route - Needs to be sterile - Must be preservative-free medication - Provides superior analgesia with less medication used - Can be administered by bolus, continuous pump infusion, or continuous pump infusion plus intermittent bolus Continuous local anesthetic - For administration into/near surgical site - Conduct pain assessment and document q 2-4 hours while client is awake - Check dressing every shift - Check the site of the catheter - Assess client for signs of local anesthetic toxicity - Notify primary care provider of signs of local anesthetic toxicity or neurologic defect Patient Controlled Analgesia (PCA) - Interactive method Allows clients to administer own doses of analgesics - Minimizes peaks of sedation and valleys of pain that occur with prn dosing - Electronic infusion pump - Safety mechanisms are crucial. Dose interval and lockout are established to prevent fatal overdosing.

cancer pain

Pain associated with the disease, treatment, or some other factor in individuals with cancer.

phantom pain

Pain felt in the nerve distribution of a body part that has been amputated. Phantom pain can lead to difficulties in prosthetic training. TREATMENT Phantom limb pain or nonpainful sensations are reported by most amputees. A multimodal or combination approach to management is appropriate. Drugs used to treat neuropathic pain may be helpful, including some anticonvulsant drugs, tricyclic antidepressants, selective serotonin inhibitors, and muscle relaxants. Nerve blockade and/or transcutaneous electrical stimulation may also be helpful. Health care professionals should encourage amputees to move the affected extremity, seek counseling or group therapy, engage in physical and occupational therapy, and use distraction techniques.

referred pain

Pain that arises in one body part or location but is perceived in another. Pain caused by inflammation of the diaphragm is often felt in the shoulder; pain caused by myocardial ischemia may be referred to the neck or jaw; and pain caused by appendicitis may first be felt near the umbilicus rather than in the right lower quadrant, where the appendix lies

nocioceptive pain

Pain that is directly related to tissue damage. May be somatic (e.g., damage to skin, muscle, bone) or visceral (e.g., damage to organs).

somatic pain

Pain that originates from skeletal muscles, ligaments, or joints.

neuropathic pain

Pain that originates in peripheral nerves or the central nervous system rather than in other damaged organs or tissues. A hallmark of neuropathic pain is its localization to specific dermatomes or nerve distributions. Some examples of neuropathic pain are the pain of shingles (herpes zoster), diabetic neuropathy, radiculopathy, and phantom limb pain. TREATMENT Drugs such as gabapentin or pregabalin provide effective relief of neuropathic pain for some patients. Other treatments include regional nerve blocks, selective serotonin and norepinephrine reuptake inhibitors, psychological counseling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy.

Objective 2: Differentiate pain threshold from pain tolerance.

Pain threshold > Least amount of stimuli needed for a person to label a sensation as pain Pain tolerance > Maximum amount of painful stimuli a person is willing to withstand without seeking avoidance, pain relief.

Objective 11: Describe the World Health Organization Three-Step Analgesic Ladder for pain management.

STEP 1: - Mild pain (1-3); nonopioid analgesics (with or without a coanalgesic) is appropriate starting point STEP 2: - Client has mild pain that persists or increases despite full doses of step 1 - Pain is moderate (4-6 on a 0-10 scale) - Use a weak opioid (e.g., codeine, tramadol, pentazocine) or a combination of opioid ad nonopioid medicine (oxycodone with acetaminophen, hydrocodone with ibuprofen) - With or without a coanalgesic STEP 3: - Client has moderate pain that persists or increases - Pain severe (7-10) - Use strong opioids > (e.g. morphine, hydromorphone, fentanyl) and titrated in ATC (around the clock) scheduled doses until pain is relieved

pain threshold

The point at which a psychological or physiological effect begins to be produced.

Objective 10: Define tolerance, dependence, and addiction

Tolerance - Occurs when opioid dose over time, leads to a decreased sensitivity of the drugs' analgesic effect. Opioid dose increased to provide same level of pain relief - Physical dependence (physiological dependence) - Expected physical response with long term opioid therapy and has opioid significantly reduced or withdrawn. Manifested by withdrawal syndrome -N&V, chills, VS changes. Produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of antagonist Addiction (psychological dependence) - Primary, chronic, neurobiological disease - Genetics, psychosocial factors, and environment are influential - Behaviors can include: - Impaired control over drug use; - Compulsive use; Craving; - Continued use despite harm Pseudoaddiction - Undertreatment of pain - Focus on obtaining medications to the point of becoming demanding, angry

nerve block

chemical interruption of a nerve pathway effected by injecting a local anesthetic

deep somatic pain

comes from sources such as blood vessels, joints, tendons, muscles, and bone

nonsteroidal anti-inflammatory drugs (NSAIDs)

drugs such as aspirin and ibuprofen that have anti-inflammatory, analgesic, and antipyretic effects

spinal cord stimulation

implantation of a device into the epidural space to treat chronic neurologic pain by producing a tingling sensation that alters pain perception

visceral pain

pain originating in the internal organs in the thorax, cranium, or abdomen Visceral pain (pain arising from organs or hollow viscera) is often perceived in an area remote from the organ causing the pain.

intractable pain

pain that is resistant to cure or relief Chronic pain that is difficult or impossible to manage by usual means. Common causes include metastatic cancer, chronic pancreatitis, radiculopathy, spinal cord transection, or peripheral neuropathy. Intractable pain may also accompany somatoform disorders, depression, fibromyalgia, irritable bowel syndrome, and opiate dependence. Various therapies are used to treat intractable pain such as antidepressant medications, counseling, deep brain stimulation, injected anesthetics, narcotic analgesics, neurological surgery, and pain clinic consultations.

acute pain

pain that lasts only through the expected recovery period (as opposed to chronic); Pain that is directly related to tissue injury and resolves when tissue heals.

radiating pain

pain that spreads out from an area

fifth vital sign

pain, as viewed by many health facilities

chronic pain

prolonged pain, usually recurring or persisting over 6 months or longer, that interferes with functioning Pain that persists beyond 3 to 6 months secondary to chronic disorders or nerve malfunctions that produce ongoing pain after healing is complete.

agonist analgesic

pure opioid drugs that bind slightly to mu receptor sites, producing maximum pain inhibition (morphine, oxycodone, hydromorphone)

equianalgesia

refers to the relative potency of various opioid analgesics compared to a standard dose of parenteral morphine equianalgesic dose: A dose of one form of analgesic drug equivalent in pain-relieving effect to another analgesic. In pain control, this equivalence permits substitution of one analgesic to avoid undesired side effects from another

cutaneous pain

superficial pain usually involving the skin or subcutaneous tissue

neurectomy

surgery in which peripheral or cranial nerves are interrupted to alleviate localized pain

pain management

the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client

pain reaction

the autonomic nervous system and behavioral responses to pain

nociception

the physiological processes related to pain perception The stimulus-response process involving the stimulation of peripheral pain-carrying nerve fibers and the transmission of impulses along peripheral nerves to the central nervous system, where the stimulus is perceived as pain.

pain

whatever the experiencing person says it is, existing whenever he or she says it does Perception is reality. The client's self-report of pain is what must be used to determine pain intensity. The nurse is obligated to record the pain intensity as reported by the client. By challenging the believability of the client's report, the nurse is undermining the therapeutic relationship and preventing the fulfillment of advocacy and helping people with pain, which is called for in the ANA's Standards of Professional Performance for Pain Management Nursing.