1 Pain

pain

"unpleasant sensory or emotional experience associated with actual or potential tissue damage..." (APS, 1994)

pain prevents injury

(such as when a person instantly withdraws a hand after touching a hot surface) and results from injury in other cases (such as the pain of a fractured hip from a fall).

factors affecting pain experience

- Culture - Ethnic variables - Family, gender, and age variables - Religious beliefs - Environment and support people. Hosptial pt loss of control and lack of sleep - Anxiety and other stressors. Increased perceived intensity of pain, threat of unknown (pre-op teaching) - Previous pain experience. Acute fear/despair if have severe unlabored pain. - Emotions - Developmental stage - Communication & cognitive impairments

assessing pain in Verbal older adults

- Determine patients reliability, ability and willingness to self report - Ask the patient if he or she is experiencing pain, hurting or in discomfort right now (use plain words) - Measure pain intensity using a valid and reliable pain intensity scale preferred by the patient. - Assess the tolerability of pain. - Assess the impact of pain on sleep and mood - Mutually develop a pain management plan with comfort-function-mood goals. We have to use a variety of modalities We need to see if what is ordered correlated with the pain that they are experiencing

inadequate pain management may lead to

- Impaired recovery and progression to chronic pain. - Inability to get adequate rest and sleep, leading to a diminished quality of life - Work absenteeism and potential underemployment or loss of employment. - Difficulty accessing disability compensation. - Compromised ability to carry out activities of daily life. - Significant suffering, with increasing anxiety, depression, fear, and anger. - Increased health care costs.

the concept of pain

- Pain has physical and emotional aspects. - Pain is whatever the person with the pain says it is and that it exists whenever the person says it does. - Pain may prevent injury or results from injury. - Pain is the most subjective of all symptoms that patients experience. - Cognitive, affective, behavioral, and sensory factors can influence pain.

patient education

- Teach patients to keep a journal of the type, onset, and intensity of pain; activity related to the pain; and measures used to relieve pain. - Teach patients methods of nonpharmacologic treatment to relieve pain, such as massage, guided imagery, and muscle relaxation. - Instruct patients to consult with their primary care provider before using herbal remedies. - Teach patients to take pain medication before the pain becomes severe or occurs around the clock. - Instruct patients about when to contact their primary care provider or pain specialist, and stress the importance of doing so in the event that the pain control measures used are ineffective. - Offer information on community agencies or resources and support groups that provide information and educational materials. - When educating the patient about medication administration, turn off the television and any handheld devices to minimize interruptions.

duration of pain

- acute - chronic - intractable

There are a lot of things play into addiction:

- it is very important to monitor the amount of opioid/medication a patient is receiving to try and regulate/prevent narcotic addiction -We have tried by using best practice routes such as giving oral medications, administering a break, adjusting a dose with minimum side effects

Special nursing considerations

- managing pain in the elderly - managing pain in clients with addictions - use of placebos

pharmacologic pain management

Adjuvant or coanalgesic medications •Antiemetics •Laxatives •Ketorolac •Caffeine

intractable pain

Chornic Poorly localized Difficult to describe Debilative and destructive Persistent pain Resistant to relief Can be very frustrating for pt and healthcare provider. Must be approached with multiple methods. These pt are sometimes called drug seekers, hypochonriacs Treatment for each type of pain is different, as is each patient's response to the various types of pain.

alterations in pain pathways

Damage and hypersensitivity anywhere along the pain pathway—in pain receptors, the spinal cord, or cerebral cortex—can alter a patient's perception of pain •Neurologic injuries that result in permanent damage to the spinal cord, such as paraplegia or quadriplegia, prevent a person from feeling pain in areas below the level at which the spinal cord was injured or severed. •Neurologic damage resulting from disease processes such as peripheral neuropathy due to diabetes mellitus alters pain perception. •Psychological dysfunction may result from or lead to altered pain perception.

gastrointestinal

Delayed gastric emptying; decreased intestinal motility; constipation; anorexia; weight loss

T/F: •Pain is the most subjective of all symptoms that patients experience, and it is felt the same by each individual.

False it is felt differently by each person

evaluation

Medical intervention: •Documents the time the medication was given, the time of postintervention reassessment, and the duration of acceptable pain relief post intervention •Document the pain scale on every shift •Provide patient education about medications at discharge •Document teaching •If pain relief goals are unmet, collaborate with other health care team members and the patient to determine other options for treatment

Determine patients reliability, ability and willingness to self report

Note coherence or incoherence in communication and thought patterns Assess mental status Note any diagnosis of cognitive impairment (patients with mild to moderate dementia can reliably self report pain Assess comprehension by ask patient to show were no pain or severe pain is on a pain scale Sensory impairments can also affect the pt ability to self report

assess the tolerability of pain

Pain tolerability involves assessing how bearable or disabling the pain is in relation to functional ability

mind and body medicine

Practices that focus on the interaction among the brain, mind, body & behavior with the intent to use the mind to affect physical functioning & promote health. meditation, deep breathing, acupuncture, guided imagery; hypnotherapy; progressive relaxation; tai chi

Nursing interventions for pain cont.

Pt must believe that you care - will suffer loss Select pain relief measures appropriate for the client based on assessment data and input from the client or support persons. Include a variety of pharmacological and non pharmacological interventions. Involved pt and support persons Establish a trusting nurse-patient relationship As a bedside nurse, we are not there to ask the patient questions if that's really the pain they are experiencing. Don't forget that narcotics are sedating and cause respiratory depression so it is important to keep an eye on these patients

meditation

Specific postures, focused attention or distraction Uses: increase calmness/relaxation; improve psychological balance, cope with illness

pain assessment tools

Standardized forms more useful for chronic pain conditions or complex acute pain problems •Initial pain assessment; The Brief Pain Inventory; McGill Pain Questionnaire Pain rating scales •One-dimensional •Reflect pain intensity •Purpose: indicate a baseline intensity, identify changes and evaluate treatment

T/F:

Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.

T/F: nurses should try and start with the non-opioid and then the opioid so we can try and control their pain without too strong or too many opioids

T

pain is what the patient says it is

The patient is the authority on their pain***it is not the nurses job to tell the patient that they aren't in pain (if the patient says they are in pain, we must treat them as if they are)

The timing of pain medication administration can be critical in providing adequate relief

There is strong support for providing around-the-clock (ATC) dosing of analgesia to prevent pain levels from getting too high. Consistent analgesia helps to maintain medication blood levels and prevent pain recurrence. If a patient delays asking for pain medication until the pain is severe, the nurse may need to administer higher doses of analgesia or stronger medications to initially get the patient's pain under control. Relief from pain may take longer. In light of this, nurses should administer or encourage patients to take (or request) pain medicine on a scheduled basis, especially when patients are recovering from surgical or diagnostic procedures known to cause moderate to severe pain or when they are experiencing chronic pain.

Time intervals for reassessment after treatment

Time intervals for reassessment are patient-specific and depend on the route of administration: •Non-pharmacologic techniques: check back 30 to 60 minutes post-intervention •IM, SC, or PO administration: 30 to 60 minutes post-intervention •Transdermal administration: 12 to 16 hours post-intervention •IV or sublingual administration: 15 to 30 minutes post-intervention

T.F: •The evaluation of treatment interventions for patients with pain is according to the attainment of goals and is an ongoing process.

True

T/F: Adjust the dose to achieve maximum benefit with minimum side effects Allow patients as much control as possible over the regimen

True

T/F: If medication intervention is required for pain management, the pain is reassessed and documented

True

T/F: Initial time intervals for reassessment are patient specific and depend on the route of administration

True

T/F: Pain should be assessed and documented to provide comfort at a level acceptable to each patient

True

T/F: Supplements are used a lot in the community, its not very regulated. Sometimes you have to help patients understand what they are taking. They can be good but we must be able to tell patients what works together and what doesn't

True

T/F: When discharging a patient, the nurse is responsible for educating the patient, family, and support persons about the proper administration of medications. Patient education must be documented in the nurse's notes and on the patient education sheet. The patient is given a copy of the education sheet, which explains the medication, its intended purpose, how to take it, and side effects

True

T/F: in most health care settings, only advanced practice nurses and physicians can prescribe medications for pain relief. To understand how a patient perceives pain, the nurse must understand the physiology of pain.

True

T/F: instruct patients about what to expect

True

T/F: visual cues help patients to more accurately understand the pain scale

True

T/F: •Health care providers may have barriers as well. Adequate pain relief for patients may be compromised by poor pain assessment skills, inaccurate beliefs, or prejudicial attitudes on the part of health care team members about the experience of pain. Sometimes pain relief medication cannot be prescribed until after the patient has been diagnosed, which can cause pain levels to increase so significantly that they become very difficult to get under control.

True

T/F: •Nurses who work with addicted individuals collaborate with PCPs to closely monitor prescription control, document the patient's complaints of pain, and report the effectiveness of prescribed medication.

True

T/F: •Patients are not the only ones affected. Relationships with family and friends may be stressed and strained. It is the nurse's responsibility to provide every patient with adequate pain management to ensure maximum relief with the fewest side effects that leads to the highest quality of life possible.

True

T/F: •The nurse documents the time the medication is given, the time of postintervention reassessment, and the duration of acceptable pain relief post intervention. The nurse is required to document the pain scale on every shift, whether the patient is having pain or is pain free.

True

T/F: •There are many barriers to adequate pain management, including a patient's personal barriers. Fear of addiction or tolerance to the drug may cause an individual to refuse medication for pain. The cost of medication and no access to health care may be factors. Some people think that pain is inevitable and should be tolerated, believing that "good" patients do not complain about pain.

True

The general rule with complementary and alternative medicine is that if the patients aren't getting harmed from it and are enjoying it, then we can continue to allow/encourage it but make sure their healthcare professional is aware

True

T/F: The barriers to adequate pain management are especially high within the health care system

True •Pain is often not a high priority for treatment. Systematic pain management approaches and pain management teams may not be in place. There may be inadequate reimbursement for pain medications, and regulations may restrict access to medications.

hyperalgesia

excessive sensitivity

endocrine

fever; shock

hyperpathia

greatly exaggerated pain reaction to stimuli

at the site of a tissue injury...

nociceptors detect pain stimuli and convert (transduce) this electrochemical response into an electrical impulse (signal). This process is called transduction. Tissue injury initiates the release of neurotransmitters, chemicals that transmit signals across synapses from one neuron to another. This release of neurotransmitters is part of the inflammatory response. The inflammatory process may be the most significant cause of generalized pain.

phantom pain

occurs when the brain continues to receive messages from the area of an amputation. Over time, the brain adapts to the loss of the limb, and the pain stops. This adaption is called plasticity. Can be difficult to treat because its neurologic/neuropathic pain that does not respond to opioids

adjuvent medications

or coanalgesic medications, work synergistically with standard pain medications to enhance pain relief and to treat side effects of the medication. •Antiemetics are often administered with opioid analgesics to counteract the nausea and vomiting. •Laxatives or stool softeners (e.g., senna and docusate) are prescribed to prevent constipation, and antihistamines (e.g., diphenhydramine) are given to decrease the itching side effect of morphine. •Ketorolac (Toradol) is an NSAID used along with opioid analgesics to enhance pain relief. Caffeine is used with analgesics to treat migraine headaches

allodynia

pain from non-injury stimuli

Mutually develop a pain management plan with comfort-function-mood goals.

patient and family and develop plan using pharmacological and non-pharmacological treatments. Remind patient and family that complete pain elimination isn't always a realistic goal but reductions are attainable.

accidental ingestion

patient education is so important! •In addition to individuals dying from accidental overdose and substance use disorder, children are in danger of accidental ingestion when narcotics are not kept secure and out of reach. Nurses can be instrumental in reducing accidental overdose by minors by educating patients, family members, and care providers of prevention strategies. Research findings indicate that twice as many parents with no PCP discussion kept leftover pain medication at home, vulnerable to child access. •Review Box 36.12, Home Care Considerations: Protecting Children from Accidental Ingestion of Medication, in the textbook.

two types of symptoms are related to pain

referred and radiating pain

transduction

transduction •At the site of tissue injury, nociceptors detect pain stimuli and convert (transduce) this electrochemical response into an electrical impulse (signal). Shown is Figure 36.1 from the textbook: Four physiologic processes conduct pain from injured tissue to the peripheral and central nervous systems

•Multiple systems of the body may be affected by pain, depending on its severity and duration. With chronic or prolonged pain, the parasympathetic nervous system responds with a decrease in the systolic blood pressure and a decrease in the pulse rate below the patient's normal baseline.

true Review Table 36.4, Clinical Manifestations of Pain, in the textbook

You should regularly assess for pain and accept the patient's report of pain

true, Increased pain may indicate a change in condition or need for more aggressive pain management

dysesthesia

unpleasant and abnormal sensation

the meaning of pain

varies among individuals. Current pain is influenced by an individual's previous experiences with pain. Just as the meaning of pain and the perception of pain are individualized responses, the response to drugs is influenced by each person's genetic makeup

Complementary and alternative medicine

•""A group of diverse medical & health care systems, practices & products that are not presently considered to be part of conventional medicine." (NCCAM, 2013) •Complementary Medicine is Non mainstream therapy used together with conventional medicine •Alternative Medicine is a non mainstream therapy used in the place of conventional medicine •Integrative Medicine - combining complementary therapies and conventional medicine in a coordinated manner •Boundaries between CAM & conventional medicine is not absolute

common nursing diagnoses directly associated with pain

•Acute pain •Chronic pain •Ineffective coping •Anxiety •Disturbed sleep pattern •Readiness for enhanced comfort •Examples of nursing diagnostic statements: •Acute pain related to long-bone fracture as evidenced by reported pain of 10 out of 10, pain with movement, and request for pain medication. •Chronic pain related to deformity of joints as evidenced by limited mobility, inability to manage activities of daily living, and feelings of helplessness. •Ineffective coping related to severe pain as evidenced by inability to ask for help, lack of appetite, and poor concentration. Acute and chronic pain- specify location related factors when known can include physciologic and psycohologic factors Pain as etiology of other nursing diagnosis-

acute pain

•Acute pain most frequently is defined as pain lasting less than 3 to 6 months. Usually associated with injury, recent onset duration less than 6 months •warns of tissue damage or organic disease •after underlining cause is resolved it goes away •Rapid in onset, varies in intensity and duration Protective in nature (it's letting you know something is wrong

•The American Society for Pain Management Nursing (ASPMN) and the American Society of Addiction Medicine (ASAM) provide guidelines for pain management in patients with substance use disorders.

•Addicted patients are different from opioid-dependent patients who rely on analgesia for treatment of chronic conditions. Whereas addicted patients exhibit a lack of control and a compulsive need for medication, dependent patients experience an improved quality of life and increased level of function with treatment

Pain management for addicted patients

•American Society for Pain Management Nursing (ASPMN) and the American Society of Addiction Medicine (ASAM) guidelines for pain management

alexander technique

•An Alexander Technique teacher helps you see what in your movement style contributes to your recurring difficulties -- whether it's a bad back, neck and shoulder pain, restricted breathing, perpetual exhaustion or limitations in performing a task or sport. Analyzing your whole movement pattern -- not just your symptom -- the teacher alerts you to habits of compression in your characteristic way of sitting, standing and walking. He or she then guides you -- with words and a gentle, encouraging touch -- to move in a freer, more integrated way.

Cognitive, affective, behavioral, and sensory factors can influence pain

•An alert, oriented patient knows what pain is, can verbalize what it is, knows what it feels like, and can perform behaviors to prevent or alleviate it.

If pain occurs, there should be prompt oral administration of drugs (f able to take oral drugs) in the following order

•Analgesic administration reduced the person's perception of pain •Non-opioid analgesics: (aspirin and acetaminophen, NSAIDS) •Opioids or narcotic analgesics: (all controlled substances) as necessary, start with mild opioids; •Then stronger opioids, until the patient is free of pain. •Morphine, codeine, meperidine, hydromorphone, methadone •Adjuvant (go with) drugs used to calm fears and anxiety, additional drugs. Potentiates the effect of analgesics --Anticonvulsants, antidepressants, multipurpose drugs

palliative nursing care

•Another option for pain relief is palliative nursing care. The goal of palliative care is to help relieve pain caused by serious illness, regardless of the patient's prognosis. Palliative care is appropriate for patients of any age and for any stage of serious illness. Typically, a group of physicians, nurses, and social workers work as a team to provide the appropriate treatment for the patient. Palliative care improves the quality of life of patients and families who face a life-threatening illness by providing pain and symptom relief and supplying spiritual and psychosocial support from diagnosis to the end of life and bereavement.

practical knowledge about pain

•Ask about pain; Assess pain systematically (regular basis, consistently, often) •Believe the patient & family report of pain & what relieves it •Choose pain control options appropriately for the patient, family & setting (am I giving the patient the appropriate medication?) •Deliver interventions in a timely, logical & coordination •Empower the patient & their families •Enable patients to control the course of their care as much as possible

multidisciplinary approach

•Because various members of the health care team specialize in different ways of accomplishing pain relief, a multidisciplinary approach is often needed to achieve pain relief goals. The multidisciplinary team collaborates to develop a plan of care for the patient's pain management. While maintaining ultimate responsibility for overseeing the implementation and proper completion of duties, the nurse may delegate appropriate duties to unlicensed assistive personnel (UAP). •Review Box 36.4, Interprofessional Collaboration and Delegation: Complementary Pain Therapy, in the textbook. •Review Box 36.5, Ethical, Legal, and Professional Practice: Meeting Pain Management Standards, in the textbook.

chronic pain duration

•Chronic pain is identified as persisting longer than 3 months postoperatively, longer than 6 months, or beyond a normal healing period. •It may limited, intermitten, persisitent , or constant •It may have periods of remission or exacerbation •May be limited, intermittent, or persistent •Lasts beyond the normal healing period •Periods of remission or exacerbation are common

whole medicine systems

•Complete systems of theory & practice evolved overtime in different cultures apart from conventional or western medicine Ex: •Traditional Chinese Medicine •Homeopathy •Originated in Europe •Stimulates the body's ability to heal self •Gives very small, highly diluted substances that in larger amounts would cause symptoms

genitourinary

•Decreased urine output; urinary retention; fluid overload; hypokalemia

Pain should be assessed and documented to provide comfort. In addition to assessing for pain, the nurse:

•Diagnoses pain. •Monitors for pain management. •Evaluates the level of pain relief. •Advocates for the patient. Educates the patient about treatment options for pain management

factors influencing pain

•Differences in individual characteristics—age, gender, morphology, disabilities, culture, ethnicity, and religion—play a role in the behavioral reaction to pain and in the perception of pain. Reactions to pain and perceptions of pain vary among individuals, even within the same culture. When providing culturally sensitive nursing care, the nurse adjusts the plan of care to incorporate the patient's needs.

Nonpharmacologic measures

•Distraction •Humor •Music •Imagery •Relaxation •Cutaneous stimulation- hot/cold •Acupuncture •Hypnosis •Biofeedback Therapeutic Touch (massage) want to use these measures of relief as much as possible

manipulative body-based practices

•Focus on structure & system •Spinal manipulation •Apply controlled pressure on a joint •Most common treatment for low back pain •Massage therapy •Press, rub/manipulate muscles & soft tissues •Uses: relieve pain, rehab sports injury, decrease stress, increase relaxation, address anxiety/depression

Palliative care (end of life care)

•For patients of any age/any stage of serious illness •Improves quality of life

palliative pain nursing care cont.

•Goal is to help relieve pain caused by serious illness, regardless of the patient's prognosis •Appropriate for patients of any age and for any stage of serious illness •Team approach to provide treatment for the patient •The nurse makes the therapeutic decision as to the best treatment for individual patients based on knowledge of pain relief techniques and the primary care provider's orders WHO pain relief ladder - Pain management is at the core of palliative care (no questions on this about the exam) - Goal is to keep them comfortable and have a high quality of life until the end

more on healing touch

•Healing Touch is an energy therapy in which practitioners consciously use their hands in a heart-centered and intentional way to support and facilitate physical, emotional, mental and spiritual health. •Healing Touch is a biofield (magnetic field around the body) therapy that is an energy-based approach to health and healing. •Healing Touch uses the gift of touch to influence the human energy system, specifically the energy field that surrounds the body, and the energy centers that control the flow from the energy field to the physical body. •These non-invasive techniques employ the hands to clear, energize, and balance the human and environmental energy fields, thus affecting physical, mental, emotional and spiritual health. It is based on a heart-centered, caring relationship in which the practitioner and client come together energetically to facilitate the client's health and healing. •The goal of Healing Touch is to restore balance and harmonies in the energy system, placing the client in a position to self heal.

Natural Products

•Herbal medicines (botanicals) •Vitamins/minerals •Sold as dietary supplements •Ex:Probiotics

Patients have a right to pain relief. Inadequate pain management may lead to detrimental outcomes such as:

•Impaired recovery and progression to chronic pain •Compromised ability to carry out ADLs •Inability to get adequate rest and sleep, leading to a diminished quality of life •Significant suffering, with increasing anxiety, depression, fear, and anger •Work absenteeism and potential underemployment or loss of employment •Increased health care costs •Difficulty accessing disability compensation

manipulation of energy fields

•Magnetic therapy is an alternative medical practice that uses static (i.e. unmoving) magnets to alleviate pain and other health concerns. So-called therapeutic magnets are typically integrated into bracelets, rings, or shoe inserts, though therapeutic magnetic mattresses and clothing are also on the market. •Light therapy is a way to treat seasonal affective disorder (SAD) and certain other conditions by exposure to artificial light. SAD is a type of depression that occurs at a certain time each year, usually in the fall or winter. During light therapy, you sit or work near a device called a light therapy box.

traditional healers

•Methods based on indigenous theories, beliefs, experiences handed down over centuries

pain step stool

•Non opiod - nsaids, Tylenol •Opiod or narcotic analgesics - morphine / dilaudid •Adjuvant drugs- meidaction s that help pain meds work better, antidepressants as example or anticonvulsants • •Opiods •Tolerance-larger doses needed. •Addiction - compulsive use •<1% pt become addicted • • •When given early and on schedule, non-narcotic analgesics can be very effective •Can give all three which gets better pain control At the end of the day, narcotics aren't the best way to manage chronic/long term pain

barriers within the healthcare system

•Pain not a priority, systematic pain management approaches and pain management teams not in place, inadequate reimbursement for pain medications, regulations may restrict access to medications •Patients have a right to pain relief. •Inadequate pain management may lead to detrimental outcomes.

barriers to adequate management

•Patient barriers: fear of addiction, cost of medication, and no access to health care •Health care provider barriers: poor pain assessment skills, inaccurate beliefs, prejudicial attitudes, delayed diagnosis

pilates

•Pilates is a method of exercise that consists of low-impact flexibility and muscular strength and endurance movements. Pilates emphasizes proper postural alignment, core strength and muscle balance. Pilates is named for its creator, Joseph Pilates, who developed the exercises in the 1920s.

acupuncture

•Procedure that stimulates specific points in the body (needles/pressure points) •Oldest healing practice in the world •Key component of traditional Chinese Medicine •Based on concept that disease results from disturbance of body's energy flow

Reiki

•Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by "laying on hands" and is based on the idea that an unseen "life force energy" flows through us and is what causes us to be alive. If one's "life force energy" is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy.

Rolfing/Structural Integration

•Rolfing Structural Integration has the ability to dramatically alter a person's posture and structure. Rolfing SI can potentially resolve discomfort, release tension and alleviate pain. Rolfing SI aims to restore flexibility, revitalize your energy and leave you feeling more comfortable in your body. •Uses deep fascia tissue manipulation & movement education •Goal to bring body into proper realignment with gravity

visceral pain

•Visceral pain arises from the organs of the body. Poorly localized Originates in organs in the thorax, cranium, abdomen Pain caused by organ stretch/distended/ischemic/inflamed Guarding occurs as protective mechanism Appendicitis, pancreatitis, inflammatory bowel disease, bladder distention, cancer

To determine if pain relief measures are effective:

•the nurse evaluates the patient's level of pain relief and documents the results in the patient's chart. The World Health Organization's (2017) pain relief ladder to treat cancer pain is a tool that helps health care providers determine which pain medication and adjuvant therapy may be most effective on the basis of the intensity of the reported pain. •To maintain freedom from pain, drugs should be given "by the clock", that is every 3-6 hours, rather than "on demand" This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective.

To provide appropriate nursing care for a patient in pain:

•the nurse must have an understanding of the pathophysiology of pain, types of pain, physiologic alterations caused by pain, and factors influencing pain. With this knowledge, the nurse can apply the nursing process to develop a patient-centered plan of care, incorporating nonpharmacologic and pharmacologic treatments, and educating the patient and caregivers about the treatment methods. If pain relief goals are unmet, the nurse needs to collaborate with other health care team members and the patient to determine other options for treatment. Nurses must advocate for the most effective pain management regimen possible for every patient.

COLDSPA

**important** •C=character= Describe the sign or symptom, feeling, appearance, sound, smell, taste. What does it feel like? •O=onset= when did it begin, when did it happen, is it better, worse or the same since it began •L=location= where is it at, does it radiate, does in occur anywhere else this may be a not applicable •D=duration= how long does it last, does it reoccur, intermittent, constant •S=severity= how bad is it, how much does it bother you •P=pattern= what makes it better or worse •A=associated factors= what other symptoms occur with it, how does it affect you, what do you think caused it to start, will you be able to continue doing your work or other activities (Leisure or exercise)

what to do when your patient is in pain

- Discuss changes in the patients behavior, mood, and daily functional patterns that may indicate pain with all caregivers. - Ask family members for additional details. Consulting with those who know the patients normal behavior to determine if pain is triggering behavior changes - If pain is suspected initiate an analgesic trial if: •Pathological conditions likely to cause pain exist •Procedures likely to cause pain are scheduled and performed •behaviors suggest pain based on score of an observational pain behavior tool •Pain behaviors continue after attention to potential causes of pain •Pain behaviors continue after attention to basic needs and comfort measures •Pain behaviors don't respond to non-drug interventions. •Proxy (family or caregivers) report previous chronic pain, behaviors indicative of pain, or changed in function.

general assessment of pain cont.

- Duration - acute chronic intractable - Location- where-- where they perceive it is. Radiating, referred, phantom (feel amputated extremitiy) Location actual cutaneous - skin or subq - sunburn. Visceral- poorly localized originates in organs- abdominal cavity- distended, ischemic, inflammed. Thorax, cranium, deep somatic pain- ligaments tendons bones, blodd vessles, nerves, diffuse - Nociceptive- body tissue- burn/twist ankle, stub toe, can be temporary or chronic transmitted by perofpheral nerve fibers. Referred pain- originates in 1 area and felt in another- chest pain appendisitis - Quantity and intensity of pain - Quality of pain throbbing, burning stabbing achy - Chronology of pain- when did it start - Aggravating and alleviating factors- what makes it worse what helps Physiological indictors of pain- actual cause - body reactions increased hr, rr, bp - Behavioral response - non verbal behaviors pt may exhibit, restlessness, grimacing, crying, moaning - Effect of pain on activities and lifestyle- adls - precipatting factors- associated symptoms

documentation example

7/8/2019 2030. Started about 2 hours ago when I was walking my pet turtle down the street. Patient reports increased pain in right hand since first started. Denies radiation. But wrists also hurt. Constant pain since I picked that snapping turtle up, it has not let up at all. Patient rates pain 9/10 with a goal of 0/10. It bothers me so much that I cannot use the call button for help. It was better when the snapping turtle left go for a minute . It started when the turtle snapped onto my fingers. Once we get that turtle off I will be able to go about cooking it up for turtle stew. ---------------------------------------------- N Hill R

somatic pain

Diffuse or scattered Originates in tendons, ligaments, bones, blood vessels, nerves the pt who has bone cancer is likely to experiencing which of the following types of pain conditions such as sinburn, lacerations fractures, sprains, arthritis

the international association for the study of pain (2014)

In 1979, the International Association for the Study of Pain (2014) defined pain as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." This is the most widely used definition today. It can be all consuming and their only thought is relief It is tangible sometimes difficult to evaluate Research shows 30% of hospitalized pt do not receive adequate pain relief

cardiovascular system

Increased heart rate and force of contraction in acute pain; increased systolic blood pressure in acute pain; decreased systolic blood pressure in prolonged pain or chronic pain; decreased pulse in prolonged pain or chronic pain; increased myocardial oxygen demand; increased vascular resistance; hypercoagulation; chest pain

respiratory

Increased respiratory rate; increased bronchospasms; pneumonia; atelectasis

assessment of pain in nonverbal patients

Nonverbal patients are at risk for not being treated for pain correctly Important to look for physical and nonverbal cues •Facilitate self report in patients who can reliably communicate non-verbally •Observe coherency in communication patterns and thought processed •Patients may not use expected descriptors - patient may not report pain or location of pain but may ask for help. •Intubated but not heavily sedated patients can squeeze hands, raise a finger, blink eyes, or nod head. •Use a visual self report pain scale for patients limited by aphasia or dysphasia, (faces pain scale revised), to assess location use a simple body map or ask patients to point to the location on their body •Note if healthcare provider has diagnosed a cognitive impairment. •Determine any sensory impairments (vision or hearing) that might impact reliability. •Identify potential causes or sources of pain- pathological, procedural, pharmacologic •Close observation during care activities often reveals pain cues, which can be subtle or obvious- followed by focused nursing assessments and •Review of medical record to help determine underlying cause •Observe for indicators or behaviors suggesting pain

perception

Perception (recognition) of pain occurs when the brain translates the afferent nerve signals as pain. The thalamus sends the impulse to the somatosensory cortex, which perceives physical sensations about the location, intensity, and quality of pain; to the limbic system, which controls emotional reactions to stimuli; and to the frontal cortex of the brain, which is involved in thought and reason. The stimulation of these areas allows a person to perceive pain

T/F: •After vital sign and pain scale assessments are completed, the nurse determines what level of intervention the patient needs.

True

T/F: •The nurse evaluating and administering care to the patient makes the therapeutic decision about best treatment according to knowledge of pain relief techniques and the primary care provider (PCP) orders.

True

T/F: When the PCP has ordered a range of pain medication for a patient, the nurse can titrate the dose on the basis of the patient's pain assessment.

True •If the pain is severe, the nurse may begin with a higher dose or stronger opioid to obtain pain relief. •If the patient complains of moderate pain, the nurse may try giving a nonopioid pain medication, such as acetaminophen or ibuprofen. •For mild pain, the nurse may try nonpharmacologic interventions before administering a nonopioid pain medication if ordered.

T/F: Vital signs may vary according to how the patient perceives pain.

True •Elevated pulse and blood pressure values may indicate acute pain and a need for pain medication. •A decrease in blood pressure and pulse rate may indicate chronic pain. •While taking vital signs, the nurse may ask the patient what his or her pain level is or, for the non-verbal patient, determines the pain level on a noncognitive pain scale. •The nurse can perform measures such as repositioning the patient or therapeutically touching the patient in an effort to decrease the pain level before administering pain medication.

T/F: When the pain assessment has been completed and the plan of care has been formulated with nursing diagnoses and goals appropriate for the patient, implementation of the plan of care begins.

True •Review Table 36.5, Care Planning, in the textbook.

addiction

substance use disorder is in patients and nurses Addiction is a psychological or emotional dependence on a prescribed medication or illicit drug. •Substance use disorder occurs when a person's repeated use of alcohol and/or drugs causes significant impairment such as disability, inability to fulfill work, home, or school responsibilities, or health problems. Drug overdose is the leading cause of accidental death in the U.S., with estimates of over 52,000 overdose deaths in 2015. Many special facility treatment centers are available to treat individuals suffering from substance use disorder. First responders and in some cases, family members of persons who are addicted, are being trained to recognize opioid overdose and administer supplied naloxone. •Nurses with substance use disorder pose a threat to both patient and colleague safety. Some studies suggest that the prevalence of substance use disorder among nurses may be similar to the general population. Nurses who suspect substance abuse by a co-worker need to address their concerns with a supervisor, so that treatment can be initiated. The National Council of State Boards of Nursing stresses the importance of early recognition, reporting, and intervention to patient safety and nurse recovery.

pain management and pain relief

•essential elements of nursing practice. In addition to assessing pain, the nurse monitors pain management, evaluates the level of pain relief, advocates for the patient, and educates the patient about treatment options for pain management.

pain has physical and emotional aspects

•. It is what the person feels and how the person perceives how it feels. Margo McCaffery, a pain management nurse expert, developed a definition of pain in 1968 that has served as a practical guide for health care providers for many years. McCaffery maintains that pain is whatever the person with the pain says it is and that it exists whenever the person says it does, even when no specific cause of the pain can be found. leaving pain open to interpretation (Pasero and McCaffery, 2011).

physiologic alterations caused by pain

•Acute injury or tissue damage triggers physiologic stress responses, which are attempts by the body to protect itself. These responses may have adverse effects for the patient if pain is left untreated. The sympathetic nervous system is stimulated first, and if the pain is not relieved, the parasympathetic nervous system is stimulated. Each body system has its specific response to pain.

universal pain assessment tool

•Although there are no laboratory or diagnostic studies that assess for pain level, many types of pain assessment tools have been developed to assist patients of all ages. •Many types of pain assessment tools are available, including cognitive and noncognitive scales. •The basic pain assessment tool is the 0-10 numeric pain scale, which allows patients to verbally report their pain level. •Descriptors of pain are denoted verbally in the verbal descriptor scale and the Wong-Baker Facial Grimace scale. •The Neonatal Infant Pain Scale (NIPS) that is recommended for use with children younger than 1 year of age. •Cries pain scale- is tool recommended for use with neonates 0-6 •Shown is Figure 36.4 from the textbook: Visual cues, descriptive terms, and activity levels can be useful in helping patients identify their level of pain if they are unable to relate to the numeric scale.

pain assessment tools and vital signs

•Although there are no laboratory or diagnostic studies that assess for pain level, many types of pain assessment tools have been developed to assist patients of all ages. •Many types of pain assessment tools are available, including cognitive and noncognitive scales. •The basic pain assessment tool is the 0-10 numeric pain scale, which allows patients to verbally report their pain level. •Descriptors of pain are denoted verbally in the verbal descriptor scale and the Wong-Baker Facial Grimace scale. •The Neonatal Infant Pain Scale (NIPS) that is recommended for use with children younger than 1 year of age. •Review Table 36.3, Neonatal Infant Pain Scale, in the textbook.

neuropathic pain

•Dysesthesia •Allodynia •Hyperalgesia •Hyperpathia •Phantom pain (Plasticity) •Neuropathic pain results from nerve injury, and the pain continues even after the painful stimuli are gone. Sometimes referred to as pathologic pain, neuropathic pain may stem from injury to nerves in the central or peripheral nervous system. Burning, aching, crushing, stabbing, shooting, tingling, numbing. Causes neuropathies, tumore, infection, chemo, caused by medical diagnosis of dm, cva, infection, carpal tunnel syndrome, phantom lim pain

Nursing interventions for pain

•Establish trusting nurse-patient relationship •Manipulating factors affecting pain experience •Reviewing additional pain control measures •Initiating non-pharmacologic and pharmacologic pain relief measures •Considering ethical and legal responsibility to relieve pain •Teaching patient about pain •Remove or alter cause of pain. •Alter factors affecting pain tolerance

immune

•Impaired immune function; puts patient at risk for infection

chronic pain

•Long-term disability is most commonly the result of chronic pain (NIH, 2013). As the population ages, the number of people who need pain management for back disorders, degenerative joint diseases, rheumatologic conditions, visceral diseases, and cancer is expected to rise.

musculoskeletal system

•Muscle spasms; increased muscle tension; impaired mobility; weakness; fatigue

how nurses assess pain

•Nurses assess pain using various pain assessment tools or strategies, perform a comprehensive pain assessment, and document the patient's response following assessment, before and after pain control interventions, or if, analgesic (pain-reducing) medication is administered.

modulation

•Once pain is recognized, the brain can change the perception of it by sending inhibitory input to the spinal cord to impede the transmission.

radiating pain

•Originates in one part of body but perceived in another part •Transmitted to a different cutaneous (skin) site •Possible b/c pain travels to other areas affected by same nerve root - it extends from the source of pain to an adjacent area of the body

psychogenic pain

•Pain that is perceived by an individual but has no physical cause is called psychogenic pain. It may be caused, increased, or prolonged by mental, emotional, or behavioral factors. Some patients may report headaches, back pain, or stomach pain that is psychogenic pain. Although there is not a physical cause, the pain is treated through a variety of interventions to alleviate the patient's distress. •Review Table 36.2, Types of Pain, in the textbook. No physical cause can be found Can be just as intense as physical pain Appropriate treatment would be therapy

pain tolerance

•Pain tolerance is the intensity or duration of pain that a patient is able or willing to endure. Tolerance varies from person to person and from one injury to another. People who have a decreased or lack the ability to sense pain, such as the elderly or diabetic patients with neuropathy, are at risk for tissue injury because tissue damage may occur before the individual is aware of any problems.

sensory

•Pallor; diaphoresis (excessive sweating); dilated pupils in acute pain; constricted pupils in deep or prolonged pain; rapid speech in acute pain; slow speech in deep or prolonged pain

planning: goals and outcome statement examples

•Patient will report a steady decrease in pain level to 4-5/10 within 5 postoperative days. •Patient will perform activities of daily living each day, reporting chronic pain at a level of 3 or less within 1 week of starting on newly prescribed pain medication. •Patient will report increased ability to concentrate on routine activities within 2 hours of receiving the prescribed dose of analgesia. •Patient will state being able to sleep for 6 to 8 hours each night within 3 days of hospitalization.

general assessment of pain

•Patient's verbalization and description of pain •Duration of pain •Location of pain •Quantity and intensity of pain •Quality of pain •Chronology of pain •Aggravating and alleviating factors •Physiologic indicators of pain •Behavioral responses •Effect of pain on activities and lifestyle

how some patients exhibit pain

•Patients may exhibit psychological responses to pain, including anxiety, fear, depression, anger, irritability, helplessness, and hopelessness. When a patient is anxious, fearful, or angry, the nurse addresses the patient's physical needs first. The nurse provides a comfortable environment and privacy for the patient. Then the nurse communicates with clear, simple validating statements to relieve the stress of the situation and to develop a trusting relationship with the patient. The nurse needs to allow time for the patient to verbalize feelings and concerns regarding pain relief to assess the patient's coping abilities. The nurse acknowledges the patient's pain experience and expresses acceptance of the patient's response to pain. After pain has been assessed, the nurse uses nursing diagnoses to develop a plan of care for the patient. Change in vs-- increase heart rate, increased respiratory rate, irregular shallow respirations, increased bp Chornic pain bracing Rubbing Decreased activity Sighing Change in appetite withdrawn

assessing pain as the fifth vital sign

•Raises awareness of pain •Emphasizes pain relief •Ask pain to rate their pain intensity whenever taking full set of VS •Perform pain assessment routinely including but not limited to... •On admission •Before & after painful procedures or treatments •At rest and during activity •Before & after implementing pain management interventions •When patient complains of pain The opioid epidemic has a lot that goes into it, overprescribing pain medication can be a problem but it's not the whole/main thing - Important to assess pain before you give meds and after

Nurses roles in pain management

•Recognize the right of patients to have appropriate assessment and management of their pain. •Identify patients with pain in an initial screening assessment. •Perform a more comprehensive pain assessment when pain is identified. •Record the results of the assessment in a way that facilitates regular reassessment and follow-up. •Educate relevant providers in pain assessment and management. •Determine and ensure staff competency in pain assessment and management. •Policies and procedures that support appropriate prescribing and ordering of effective pain medications

how to use pain scales

•Select a pain scale considering •Patient age •Level of education •Language skills •Eyesight •Development level •Once chosen, use the same pain scale consistently

transmission

•The action potential, or electrical signal, is transmitted through an afferent nerve to the spinal cord and brain.

the nervous system and pain

•The nature of pain is complex and poorly understood. Pain may arise from many factors. •The peripheral and central nervous systems are involved in processing painful stimuli. Various structures and mechanisms in the nervous system are part of pain transmission, including nociceptors. Nociceptors are the free endings of afferent nerve fibers, which are sensory neurons that are sensitive to noxious thermal, mechanical, or chemical stimuli. These pain receptors are distributed throughout the body, with the highest density found in the skin, making the skin extremely sensitive to pain. Although the joints, tissues, and organs have nociceptors, the internal organs have the lowest density of receptors that respond only to painful stimuli. •Nociception is the process by which the sensation of tissue injury is conducted from the peripheral to the central nervous system.

pain threshold

•The pain threshold is the lowest intensity at which the brain recognizes the stimulus as pain. This threshold varies from person to person.

The Join Commission (TJC) developed a standard of pain management for the care of hospitalized patients in 1999

•This standard resulted from the undertreatment of pain. Since 2009, TJC has stressed that each health care facility is responsible for determining the frequency of pain assessment and treatment modality based on individual patient needs. •TJC standards require that patients be assessed for pain, while not requiring the use of medication for pain management (Baker, 2016).

•Once pain is recognized, the brain can change the perception of it by sending inhibitory input to the spinal cord to impede the transmission through a process called modulation. The brainstem activates descending nerve fibers to send the signal back to the spinal cord.

•This triggers the release of natural analgesic neurotransmitters called endogenous opioids (i.e., enkephalins, beta-endorphins, and dynorphins). •Enkephalins influence the perception of pain and the associated emotional aspects. •Beta-endorphins act on the central and peripheral nervous systems to reduce pain. •Dynorphins are modulators of pain that may stimulate pain or reduce it, depending on which receptors are activated. •These three types of neurotransmitters inhibit the transmission of pain impulses and the release of substance P by binding to opiate receptor sites in the central and peripheral nervous systems.

Therapeutic decision making (to control a patient's pain)

•Titrating doses •Around-the-clock (ATC) dosing rather than prn •World Health Organization's (2017) pain relief ladder •Give medications orally if possible •Administer break-through medications as necessary •Adjust the dose to achieve maximum benefit with minimum side effects (if a patient has a 5 out of 10 pain with two narcotics ordered, start by giving one and see what happens. If they need more, give the second one. But it is important to start out low, so we don't over give medication to increase risk of addiction) •Allow patients as much control as possible over the regimen (write, for example, on a white board when the patient is due for their next dose so they are aware)

Medical Marijuana

•Used to treat neuropathic pain and spasms of multiple sclerosis, pain and/or nausea from cancer and its treatment, and pain from HIV and AIDS •A newer form of pain management is the use of medical marijuana. Medical marijuana is the use of the marijuana plant (Cannabis sativa) or its extracts to treat symptoms of disease processes, such as neuropathic pain and spasms of multiple sclerosis, pain and/or nausea from cancer and its treatment, and pain from HIV and AIDS. Delivery can be through an inhaler spray or smoked to produce a "high reaction" within minutes. It can be eaten, or taken in liquid form, which works within one hour. It is a Schedule 1 drug of the Controlled Substance Act. •Medical marijuana is approved for use in 29 states and in Washington DC. Its legislative use varies by state. It has not been approved by the FDA due to lack of large scale clinical trials to determine if benefits outweigh the risks for use. Can be good in treating neurologic pain and can be good for some patients •Research studies have demonstrated that smoking medical marijuana leads to the development of lung disease. Some short-term effects of marijuana use include a negative impact on memory, learning, the ability to think and problem solve, coordination, and aggravation of depression and psychoses. Research into its efficacy is ongoing.

nociceptive pain

•Visceral •Somatic •Referred •Radiating •Treatment for each type of pain is different, as is each patient's response to the various types of pain. •Nociceptive pain is the most common type of pain. This type of physiologic (physical) pain occurs when nociceptors are stimulated in response to trauma, inflammation, or tissue damage from surgery. Sharp, burning, cramping, stabbing Nociceptive pain originates in visceral and somatic locations.

assessing a patient in pain

•While assessing the patient, the nurse may notice behaviors that the patient is exhibiting in response to pain, including facial grimaces, clenched teeth, rubbing or guarding of the painful area, agitation, restlessness, and withdrawal from painful stimuli. A patient in labor may use effleurage (rhythmic massaging of the abdomen with her hands) and immobilization to help deal with uterine contraction pain. Vocalizations of pain may be expressed as crying, moaning, or screaming. •Gaurding - protecting the area •stillness- fear if they move they will hurt

unrelieved pain

•can result from the health care professional's failure to assess pain, failure to accept a patient's reported pain, and failure to initiate pain relief. Nurses must be aware of their own attitudes and expectations regarding pain. Awareness allows the nurse to focus on the patient's experience of reported pain. All patients have a right to effective management of pain. •

reviewing data collected during the assessment phase of the nursing process helps the nurse to:

•identify and prioritize nursing diagnoses and set realistic outcome criteria according to a patient's condition and capabilities. Goals and expected outcomes must consider the economic, psychosocial, physical, and other resources available in individual situations. Goals will vary according to diagnosis and its defining characterisitics

referred pain

•originates in one area but hurts in another area, such as pain from a myocardial infarction. Pain due to lack of o2 in heart muscle but felt in jaw or left arm

after transduction takes place,

•the action potential, or electrical signal, is transmitted through an afferent nerve to the spinal cord and brain. This process is called transmission. Substance P, which transmits the pain impulses in nerve fibers, is one of the most important neurotransmitters in the transmission process. •Signals from the nociceptors travel along two types of afferent (sensory) nerve fibers: A-delta fibers, which are large-diameter, myelinated fibers with rapid conduction of signals that are translated as sharp, acute pain, and C fibers, which are smaller, unmyelinated fibers with slow conduction of signals that are translated as diffuse, dull, and longer-lasting pain. The signals are transmitted by the spinothalamic pain transmission route. •Shown is Figure 36.2 from the textbook: Spinothalamic tract through which pain sensation is conducted to the brain, from the textbook. •A-delta and C fibers in the peripheral tissues carry impulses to the dorsal root ganglia and then on to the spinal dorsal horn, the spinothalamic tract, the brainstem, the thalamus, and the cerebral cortex. In addition to the signals traveling along the sensory transmission pathways, motor reflexes, when intact, are initiated as a protective mechanism that causes withdrawal from a pain source, as occurs when a person touches a hot item. The action potential, or electrical impulse, is propagated along nerve fibers, causing contraction of the muscle and withdrawal from the heat source