Pain Management

Cancer Pain

Can be acute or chronic Cancer pain is normal (nociceptive), resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damaged pain nerves. A patient senses pain at the actual site of the tumor or distant to the site, called referred pain. Always completely assess reports of new pain by a patient with existing pain.

Concomitant Symptoms

Caused by pain: nausea, dizziness, depression, constipation, urge to urinate, restlessness

Idiopathic pain

Chronic pain without identifiable physical or psychological cause

evaluation of pain management

How is patient tolerating pain? Is treatment plan working? Do we need to change plan of care? Through the patient's eyes: • Patients help decide the best times to attempt pain treatments • They are the best judge of whether a pain-relief intervention works Patient outcomes: • Evaluate for change in the severity and quality of the pain

Long- Acting pain meds

Long-acting or controlled-release medications may provide relief for all types of chronic pain, including cancer pain. These controlled-release medications (e.g., morphine [MS Contin, Roxanol SR], and oxycodone [OxyContin]) relieve pain for 8 to 12 hours. Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn or "as needed."

Key points: _________________ commonly underreport pain and believe that it is unacceptable to show/express pain

Older Adults

Implementation: Health Promotion

Maintaining wellness: • Help patient understand • Health literacy (affects a patient's pain experience and understanding of pain management strategies.) • Patients actively participate in their own well-being whenever possible

Acute/transient pain

Protective, identifiable, short duration; limited emotional response

Commonly Used topical agents:

NSAID products (ketoprofen patch) and capsaicin. ** ex: The Lidoderm patch is a topical analgesic effective for cutaneous neuropathic pain, such as postherpetic neuralgia, in adults. Place three patches, cut to size, on and around the pain site using a 12-hour on, 12-hour off schedule.

Radiating Pain

Sensation of pain extending from initial site of injury to another body part. Pain feels like it travels along or down a body part. It is intermittent or constant. Examples of Causes: Low back pain from ruptured intervertebral disk, accompanied by pain radiating down leg from sciatic nerve irritation.

Administering Nalaxone

Nalaxone (narcan) 0.4mg diluted with 9mL saline IV push at a rate of 0.5mL every 2 min until respiratory rate is greater than 8 breaths/min with good depth. -Administering any faster can cause sever pain and serious complications, like hypotension, hypertension, cardiac arrhythmia, dyspnea and pulmonary edema. - Evaluate patients every 15 min for 2 hrs following a drug administration because its duration may be less than that of the opioid and respiratory depression can return.

Visual Analog Scale (VAS) for Pain

consists of a straight line without labeled subdivisions. The strait line shows a continuum of intensity was has labeled end points. The patient indicates pain by marking the appropriate point on the line.

Key Points: A persons _______________ influences the meaning of pain and how it is expressed

cultural background

Nonopioids

include acetaminophen and NSAIDs. Acetaminophen has no anti-inflammatory or antiplatelet effects. NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli. Long-term use is associated with gastrointestinal (GI)bleeding and renal insufficiency.

ISAP "Declaration of Montreal"

declared that access to pain management is a fundamental human right (IASP, 2015). Nurses are legally and ethically responsible for managing pain and relieving suffering.

Key Points: Misconceptions about pain often result in _______ and degree of the patients suffering and unwillingness to provide relief

doubt

Nursing implications for administering ___________________ analgesia include preventing infection, assessing sensation, and motor function, and monitoring closely for respiratory depression.

epidural

Incident Pain

occurs predictably after specific movements

Key Points: pain is purely a ____________ physical and psychosocial experience

subjective

WHO Analgesic Ladder

three step approach in treating cancer pain 1= Nonopoid ± adjuvant (pain persisting or increasing) 2= Opoid for mild to moderate pain ± Nonopioid ± Adjuvant (pain persisting or increasing) 3= Opioid for moderate to sever pain ± Nonopioid ± Adjuvant (Freedom from Cancer pain)

Oucher Pain Scale

Facial pictures for kids.

Examples of Opioids

- Morphine (IV/PO) - Hydromorphone (Dilaudid) (IV/PO) - Oxymorphone - Butorphanol - Hydrocodone (PO) -Oxycodone (PO) - Fentanyl - Etorphine - Buprenorphine - Pentazocine - Methadone - Codeine - Tramadol - Diphenoxlate, Loperamide, Apomorphone Most are available in a short-acting form, which provides relief for about 4 hours; some are also available in longer-acting preparations (oral morphine, oxycodone, hydromorphone, and a transdermal fentanyl patch). (Potter 1035)

Opioid Effects

- Numerous side effects - Except for constipation and CNS changes - Patients usually become tolerant to many of them -Effects Associated with Long Term Use: - Depression - Impaired Sleep patterns - Endocrine effects (decreased testosterone levels, decreased libido) - Immune system supression To reduce side effects: - Patients should take lowest dose of an opioid needed to manage pain - If reducing a dose does not relieve a side effect, ask prescriber about a change in the type of opioid - If side effects persist, it may be necessary to prevent or treat them by administering other medications (antihistamines, antiemetics, stimulants)

Assessment Questions for Pain

- Onset - Duration - Quality - Severity *Palliative or Provocative factors:* What makes your pain worse? What makes it better? *Quality:* How do you describe your pain? *Relief measures:* What do you take at home to gain pain relief? *Region (location)*: Show me where you hurt. *Severity*: On a scale of 0 to 10, how bad is your pain now? • What is the worst pain you have had in the past 24 hours? • What is the average pain you have had in the past 24 hours? *Timing:* Is your pain constant, intermittent, or both? *U:* Effect of pain: What are you not able to do because of your pain? • With whom do you live, and how do they help you when you have pain? (Potter 1023)

A patient's___________ to pain, ______________________, and _________________________ will affect pain experiences. Repeated pain experiences may help the patient deal with the present pain experience. When in pain, a patient may rely heavily on others for assistance.

1. Attention 2. Previous Experience 3. Support Systems

Persons with __________ loci of control perceive themselves as having control over events in their life and the outcomes such as pain; persons with ____________ loci of control perceive that other factors in their life, such as nurses, are responsible for the outcome of events.

1. Internal 2. External

Two types of peripheral nerve fibers conduct painful stimuli:

1. The fast, myelinated A fibers send sharp, localized and distinct sensations that specify the source of the pain, and detect its intensity. 2. The C fibers relay impulses that are poorly localized, visceral and persistent. For example, after stepping on a nail, a person initially feels a sharp, localized pain, which is a result of A-fiber transmission, or first pain. Within a few seconds the whole foot aches from C-fiber transmission, or second pain.

transdermal fentanyl

100 times more potent than morphine, available for opioid tolerant patients with cancer or chronic pain. Delivers predetermined doses that provide analgesia for up to 72 hrs. -Good for patients who cannot take PO meds - Not for adult patients who weigh less than 100 lbs (to little subcutaneous tissue for absorption) or who are hyperthermic (increases drug absorption) - Do NOT place heating pads over a patch, and never cut it. - To dispose of a patch, fold it in half, adhesive side onto itself, and flush down the toilet.

Accurate Dosage

4g max in 24 hrs for Acetamionphen and Acetylsalicylic Acid 3200 mg for ibuprofen Large doses of opioids are acceptable in opioid tolerant patients but not in opioid naive patients.

Assessment Questions for Pain

> When a patient is in pain, conduct a focused physical and neurological examination and observe for nonverbal responses to pain. Examine the painful area to see if palpation or manipulation of the site increases pain. > Ask questions to determine the onset, duration, and time sequence of pain. Ask a patient to describe or point to all areas of discomfort in order to assess pain location. To localize the pain specifically, have the patient trace the area from the most severe point outward.

Gate-control theory of pain (Melzack and Wall)

>> Pain has emotional and cognitive components, in addition to a physical sensation. >> Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses. >> Pain impulses pass through when a gate is open and are blocked when a gate is closed. >> Closing the gate is the basis for nonpharmacological pain relief interventions.

Addiction

A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations

Drug tolerance

A state of adaptation in which exposure to a drug induces changes that result in a reduction of one or more effects of the drug over time

physical dependence

A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist

How Pain Affects Quality of Life

ADL interference Anxiety Depression Hopelessness Fear Anger Sleeplessness Impairs relationships-family, Work, social life

Prescribing analgesics on a PRN basis for chronic pain is ineffective and causes more suffering; thus patients with chronic pain need to take analgesics ______ even when their pain subsides.

ATC= around the clock

Implementation: Acute Care Pharmacological Pain Therapies

Analgesics: • Nonopiods • Opioids • Adjuvants/co-analgesics

________________ pain is challenging aspect of cancer because it can impact the quality of life of patients and family caregivers; thus it requires a holistic approach to treatment.

Breakthrough pain

Common Opioid Side Effects

Central Nervous System (CNS) Toxicity • Drowsiness • Cognitive impairment • Confusion • Hallucinations • Myoclonic jerks • Euphoria • Sedation • Sleep disturbances • Dizziness Ocular • Pupil constriction Respiratory • Bradypnea • Hypoventilation Cardiac • Hypotension • Bradycardia • Peripheral edema Gastrointestinal • Constipation • Nausea • Vomiting • Delayed gastric emptying Genitourinary • Urinary retention Endocrine • Hormonal and sexual dysfunction Skin • Pruritus Immunological • Immune system impairment possible with chronic use Tolerance • Over time, increased doses needed to obtain analgesic effect Withdrawal Syndrome • Rapid or sudden cessation or marked dose reduction may cause rhinitis, chills, pupil dilatation, diarrhea, "gooseflesh"

Referred Pain

Common in visceral pain because many organs themselves have no pain receptors (the sensory neurons from the affected organ travel into the spinal cord segment, as neurons from areas where the person feels pain causes the perception of pain in unaffected areas) Pain is in part of the body, separate from source of pain and assumes any characteristic Examples of Cause: MI, which causes referred pain to the jaw, left arm, and left shoulder, kidney stones, which refer pain to the groin.

Visual Descriptive Scale (VDS) for pain

Consists of a line with 3-6 word descriptors equally spaced along the line. Show a patient eh scale and ask him or her to choose the descriptor that best represents the severity of pain.

Parasympathetic Nervous System Reaction to pain

Continous, severe or deep pain typically involving the visceral organs (ex: with a myocardial infarction or colic from gallbladder or renal stones) activates the parasympathetic nervous system. Responses: • Pallor= causes blood supply to shift away from periphery • Nausea and Vomiting: vagus nerve sends impulses to chemoreceptor trigger zone in the brain • Decreased HR & BP= results from vagal stimulation • Rapid, irregular breathing= causes body defenses to fail under prolonged stress of pain

Chronic/persistent noncancer pain

Is not protective, has no purpose, may or may not have an identifiable cause •Chronic noncancerous pain may include arthritis, headache, low back pain, or peripheral neuropathy. • The goal of chronic noncancer pain is to improve functional status with a multimodality plan. • Chronic noncancer pain may be viewed as a disease since it has a distinct pathology that causes changes throughout the nervous system which may worsen over time.

chronic episodic pain

Occurs sporadically over an extended duration

Restorative and Continuing Care for Pain:

Pain clinics, palliative care, and hospices Pain centers treat patients on an inpatient or outpatient basis. The goal of palliative care is to learn how to live life fully with an incurable condition. Hospices are programs for end-of-life care. The American Nurses Association (ANA) supports aggressive treatment of pain and suffering, even if it hastens a patient's death.

Nursing Process and Pain

Pain management needs to be systematic. Pain management needs to consider the patient's quality of life. > Clinical guidelines are available to manage pain: American Pain Society Sigma Theta Tau National Guidelines Clearinghouse

Deep or Visceral

Pain resulting from stimulation of internal organs Pain is diffuse, and radiates in several directions. Duration varies, but it usually lasts longer than superficial pain. Pain is sharp, dull, or unique to organ involved. Example of Causes: Crushing sensation, like angina. Burning sensation, like a gastric ulcer.

Superficial or Cutaneous Pain

Pain resulting from stimulation of skin Pain is short, and localized. It is usually a sharp sensation. Example of Causes: needle stick; small cut or laceration

Breakthrough Pain

Pain that occurs between doses of pain medication **A patient can be given a total of 2 units of transmucosal fentanyl per episode of breakthrough pain.

End-of-dose failure pain

Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic

Somatic Pain

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

Characteristics of Pain

Quality Aggravating and precipitating factors Relief measures

Epidural analgesia

Regional Administered into epidural space treats: acute postoperative pain, rib fracture pain, labor and delivery pain, and chronic cancer pain. The health care provider administers epidural analgesia into the spinal epidural space by inserting a blunt-tip needle into the level of the vertebral interspace nearest to the area requiring analgesia. The health care provider advances the catheter into the epidural space, removes the needle, and secures the remainder of the catheter with a dressing while ensuring the catheter is taped securely.

Faces Pain Scale - Revised (FPS-R)

Self-report pain analog measure that uses pictures of facial expressions across a rating scale, primarily designed for children ages 4 - 16 years

Numeric Rating Pain Scale (NRS)

Self-report pain measure where a client verbalizes a number to correspond with a perceived level of pain from no pain to most severe pain 0= relaxed and comfortable without any pain. 1-3= mild pain. 4-6= moderate pain. 7-10= severe pain.

Sympathetic Nervous System Response to Pain

Stimulation of the sympathetic branch of the ANS results in physiological responses. Response: • Dilation of bronchial tubes and increased RR= provides increased O2 intake • Increased HR: provides increased o2 transport • Peripheral Vasoconstriction (pallor, elevation in BP)=provides additional energy • Increased Cortisol Level (short term)=Heightened memory functions, a burst of increased immunity, and lower sensitivity to pain • Diaphoresis= Controls body temp during stress • Increased Muscle tension= prepares muscles for action • Dilation of pupils= affords better vision • Decreased GI motility= frees energy for more immediate activity

Pain tolerance

The level of pain a person is willing to accept

Safety Guidelines:

The patient is the only person who should press the button to administer the pain medication when PCA is used. Monitor the patient for signs and symptoms of oversedation and respiratory depression. Monitor for potential side effects of opioid analgesics.

Assessment for Pain

Through the patient's eyes: >>Ask the patient's pain level >>Use ABCs of pain management >>Pain is not a number • In selecting a tool to be used with a patient, be aware of the clinical usefulness, reliability, and validity of the tool in that specific patient population. • Be aware of possible errors in pain assessment.

Types of Pharmacological Pain Therapies

Topical analgesics: >>Creams, ointments, patches Local anesthesia: >>Local infiltration of an anesthetic medication to induce loss of sensation to a body part >>Regional anesthesia >> Perineural local anesthetic infusion >> Epidural analgesia

If patient outcomes are not met, ask the patient:

What is your current pain level? How far away is your pain level from your goal? What side effects are you experiencing from your pain medication? What have you done to help manage your pain? Describe limitations in function you are experiencing related to uncontrolled pain. How is your pain limiting or altering your rest and sleep?

Patient-controlled analgesia (PCA)

a drug delivery system that uses a computerized pump with a button the patient can press to deliver a dose of an analgesic through an intravenous catheter Maintains a constant plasma level of analgesic

Wong-Baker FACES scale

a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain

perineural local anesthetic infusion

a surgeon places the tip of an unsutured catheter near a nerve or groups of nerves and the catheter exits from the surgical wound.

local anesthesia

anesthesia used to numb a specific area without causing loss of consciousness Health care providers often use local anesthesia during brief surgical procedures such as removal of a skin lesion or suturing a wound by applying local anesthetics topically on skin and mucous membranes or by injecting them subcutaneously or intradermally to anesthetize a body part.

Adjuvants and co-analgesics

are drugs used to treat other conditions, but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).

Opioids

are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opioids that always happens before respiratory depression. One way to maximize pain relief while potentially decreasing opioid use is to administer analgesics around the clock (ATC) rather than on a prn basis.

key points: _______________ pain is still not adequately treated, despite clinical guidelines for the effective use of opioids and other pharmacological alternatives

cancer

Behavioral responses to pain

clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction Some patients choose not to report pain if they believe that it inconveniences others or if it signals loss of self-control. Others endure severe pain without asking for assistance

Multimodal Analgesia

combines drugs with at least two different mechanisms of action so pain control can be optimized - Benefit is that the use of different agents allows for the lower-than usual dosing of each medication, so it lowers the risk of side effects while providing pain relief that is as good or even better than could be obtained from each med alone.

the difference between acute and chronic pain involves the ___________ of harm. Acute pain is protective, thus preventing harm. Chronic pain is no longer protective and does not provide any benefit.

concept

Perception

is the point at which a person is aware of pain. Gives awareness, and meaning to pain, resulting in a reaction. Somatosensory cortex identifies the location and intensity of the pain. Association cortex (primarily limbic) determines how a person feels about it. There is no single pain center.

Neuropathic Pain

pain from damage to neurons of either the peripheral or central nervous system

Spontaneous Pain

pain in the absence of stimulation

Chronic Pain

pain that lasts for 3 months or longer; may be intermittent or continuous Chronic pain affects a patient's activity (eating, sleeping, socialization), thinking (confusion, forgetfulness), or emotions (anger, depression, irritability) and quality of life and productivity.

Addiction ________ occurs in patients who take opioids to relieve pain

rarely

One of the concerns related to the use of peripheral and epidural anesthetic techniques is the:

risk of bleeding and subsequent hematoma formation near the injection/insertion site. Safe placement or removal of these injections and catheters is based on knowledge of the patients' coagulation status as well as the timing of administration of anticoagulant or antiplatelet medications. Because the epidural space is a highly vascular area, patients with epidural catheters are at risk for the development of epidural hematomas, which may lead to ischemia of the spinal cord, and if unaddressed, serious neurological complications.

Pain management

should be patient centered, with nurses practicing patient advocacy, patient empowerment, compassion, and respect. Caring for patients in pain requires recognition that pain can and should be relieved.

regional anesthesia

the injection or infusion of local anesthetics to block a group of sensory nerve fibers.

transmucosal fentanyl

to treat breakthrough pain in opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed - Allow to absorb for over a 15 min period, delaying swallowing as long as possible. - Use no more than 2 units per breakthrough pain episode. - If the patients pain is not relieved after 2 units, call the health care provider.

Physiology of Pain

transduction, transmission, perception, modulation

Nursing Knowledge Base: Pain

• A nurse must accept a patient's report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and evidence-based research findings. • Nurses' assumptions about patients in pain seriously limit their ability to offer pain relief. Biases based on culture, education, and experience influence everyone. Too often nurses allow misconceptions about pain to affect their willingness to intervene

Nursing Diagnosis for Pain

• Activity intolerance • Anxiety • Fatigue • Insomnia • Impaired social interaction • Ineffective coping • Impaired physical mobility

Physiological Factors for Pain

• Age, fatigue, genes, neurological function • Fatigue increases the perception of pain and can cause problems with sleep and rest * pain is not an inevitable part of aging, likewise pain perception does not decrease with age. Age-related changes and increased frailty may lead to a less predictable response to analgesics, increased sensitivity to medications and potential harmful drug effects.

Psychological Factors for Pain

• Anxiety • Coping Style * Pain is a lonely experience that often causes patients to feel a loss of control. Coping style influences the ability to deal with pain.

ABCDE of Pain

• Ask about pain/assess • Believe pts • Choose pain control option • Deliver pain medication/interventions • Empower pt/family

Social Factors for Pain

• Attention, previous experiences, family and social support, spiritual • Spirituality includes active searching for meaning in situations, with questions such as "Why am I suffering?"

Assessment: Errors

• Bias • Vague or unclear assessment questions • Use of pain assessment tools that are not evidence based • Use of medical terms with patients with low health literacy • Patients do not always provide complete, relevant or accurate information • Cognitively impaired patients

Nonpharmacological pain-relief interventions

• Cognitive and behavioral approach • Relaxation and guided imagery • Distraction (directs a patient's attention to something other than pain and thus reduces awareness of it.) • Music (may be useful in treating acute or chronic pain, stress, anxiety, and depression.) • Cutaneous stimulation (Stimulation of the skin through a massage, warm bath, cold application, and TENS may be helpful in reducing pain perception.) • Cold and heat application (relieve pain and promote healing. ) • Transcutaneous electrical nerve stimulator (TENS) • Herbals (Many patients use herbals and dietary supplements such as echinacea, ginseng, ginkgo biloba, and garlic despite conflicting research evidence supporting their use in pain relief. ) • Reducing pain perception and reception

Transduction

• Converts energy produced by these stimuli into electrical energy. • Begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. • Once transduction is complete, transmission of the pain impulse begins.

Achieving Adequate Pain Management

• Effective communication among the patient, family, and professional caregivers is essential to achieve adequate pain management. • Recognition of the subjective nature of pain and respect for the patient in pain is demonstrated when a nurse accepts McCaffery's classic definition: "Pain is whatever the experiencing person says it is, existing whenever he says it does."

Pain in Infants

• Infants have the anatomical and functional requirements for pain processing by mid-to-late gestation • Term neonates have the same sensitivity to pain as older infants/children. Preterm neonates have a greater sensitivity to pain than term neonates or older children. • Pain requires no prior experience, infants do not need to learn it from earlier painful experience. It occurs within the first insult • You use behavioral cues (facial expression/body movements/cry) and physiological indicators of pain (changes in vital signs) to reliably assess pain in infants. • Infants are very sensitive to drugs, response to drugs is intense and prolonged. Absorption is faster than expected. Dosages of drugs excreted by the kidneys need to be reduced. Prescribers carefully select the medication, dosage, administration, route, and time. Nurses monitor frequently for desired and undesired effects. They also follow medication orders to titrate and wean medications to minimize adverse effects.

Modulation

• Inhibits pain impulse • A protective reflex response occurs with pain reception >>Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endorphins (endogenous opioids), serotonin, norepinephrine, and gamma-aminobutyric acid (GABA), which hinder the transmission of pain and help produce an analgesic effect.

Nature of Pain

• Involves physical, emotional, and cognitive components •Pain is subjective and individualized • Reduces quality of life • Not measurable objectively • May lead to serious physical, psychological, social, and financial consequences

Cultural Factors for Pain

• Meaning of pain: affects the experience of pain and how one adapts to it; associated with a person's cultural background, including age, ethnicity, education, race, and familial factors. • Ethnicity: Cultural beliefs and values affect how individuals cope with pain. Individuals learn what is expected and accepted by their culture, including how to react to pain. Health care providers often mistakenly assume that everyone responds to pain in the same way. Different meanings and attitudes are associated with pain across various cultural groups.

Pain in Older Adults

• Older adults are at greater risk (2x) than younger adults for many painful conditions • Pain is not an inevitable result of aging. • Older adults commonly underreport pain. Reasons include: expecting to have pain with increasing age, not wanting to alarm love ones, being fearful of losing their independence, believing caregivers know they have pain and are doing all they can to relieve it. The absence of a report of pain does not mean the absence of pain • Older patients often believe that it is unacceptable to show pain, and learned a variety of ways to cope with it. • Opoids are safe to use in older adults, except if they're opioid-naive they're more sensitive to opioids. Slow titration prevents potentially dangerous opioid-induced side effects.

Nursing implications for local and regional anesthesia

• Provide emotional support • Protect patient from injury • Patient education • Invasive interventions for pain relief • Procedure pain management • Cancer pain and chronic noncancer pain management

Transmission

• Sending of impulse across a sensory pain nerve fiber (nociceptor) • Nerve impulses • Pain impulses

Nursing Implications

• You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia. • After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return. • Nursing implications for managing epidural analgesia are numerous. • Patient education.

Pain

• is purely subjective. No two people experience pain in the same way, and no two painful events create identical responses or feelings in a person. • Nurses are legally and ethically responsible for managing pain and relieving suffering • Pain can be categorized by duration (chronic or acute) or pathology (cancer or neuropathic).