Chapter 8: Pain

What are the different types of neuropathic pain?

1. Central Pain 2. Peripheral Neuropathies 3. Deafferentation Pain 4. Sympathetically Maintained Pain

Most common side effect of opioid use:

Constipation *Left untreated, constipation may increase the individual's pain and can lead to fecal impaction and paralytic ileus. Because tolerance to opioid-induced constipation does not develop, a bowel regimen should be initiated at the beginning of opioid therapy and continued for as long as the person takes opioids.

Possible gastrointestinal consequences due to unrelieved acute pain:

Constipation Anorexia Paralytic ileus

Central Pain

Caused by primary lesion or dysfunction in the CNS Examples: poststroke pain, pain associated with multiple sclerosis

Possible neurologic consequences due to unrelieved acute pain:

Confusion Impaired ability to think, reason, and make decisions

Possible renal and urologic consequences due to unrelieved acute pain:

Fluid imbalance Electrolyte disturbance

Providing opioids to a dying patient who is experiencing moderate to severe pain a. may cause addiction. b. will probably be ineffective. c. is an appropriate nursing action. d. will likely hasten the person's death.

c. is an appropriate nursing action.

How can nociceptive pain be treated?

Usually responsive to nonopioid and/or opioid drugs

Possible endocrine and metabolic consequences due to unrelieved acute pain:

Weight loss (from ↑ catabolism) ↑ Respiratory rate ↑ Heart rate Shock Glucose intolerance Hyperglycemia Fluid overload Hypertension Urinary retention, ↓ urine output

Drug Alert: Fentanyl Patches

• Fentanyl patches (Duragesic) may cause death from overdose. • Signs of overdose include trouble breathing or shallow respirations; tiredness, extreme sleepiness, or sedation; inability to think, talk, or walk normally; and faintness, dizziness, or confusion.

Physiologic

• Genetic, anatomic, and physical determinants of pain influence how painful stimuli are processed, recognized, and described.

Gastrointestinal response to pain

↓ Gastric and intestinal motility

Immunologic response to pain

↓ Immune response - Unrelieved acute pain can put patient at risk for infection

Respiratory response to pain:

↓ Tidal volume (normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied.) Hypoxemia ↓ Cough, sputum retention

Renal and urologic responses to pain:

↓ Urine output Urinary retention

Pain is best described as a. a creation of a person's imagination. b. an unpleasant, subjective experience. c. a maladaptive response to a stimulus. d. a neurologic event resulting from activation of nociceptors.

b. an unpleasant, subjective experience.

6. An example of distraction to provide pain relief is a. TENS. b. music. c. exercise. d. biofeedback.

b. music.

An important nursing responsibility related to pain is to a. leave the patient alone to rest. b. help the patient appear to not be in pain. c. believe what the patient says about the pain. d. assume responsibility for eliminating the patient's pain.

c. believe what the patient says about the pain.

5. A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is a. probably exaggerating his pain. b. best treated by referral for surgical treatment of his pain. c. best treated by receiving a long-acting and a short-acting opioid. d. best treated by regularly scheduled short-acting opioids plus acetaminophen.

c. best treated by receiving a long-acting and a short-acting opioid.

A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/minute. The most appropriate nursing action in this situation is to a. stop the PCA infusion. b. obtain an oxygen saturation level. c. continue to closely monitor the patient. d. administer naloxone and contact the physician.

c. continue to closely monitor the patient.

Unrelieved pain is a. expected after major surgery. b. expected in a person with cancer. c. dangerous and can lead to many physical and psychologic complications. d. an annoying sensation, but it is not as important as other physical care needs.

c. dangerous and can lead to many physical and psychologic complications.

Which words are most likely to be used to describe neuropathic pain (select all that apply)? a. Dull b. Mild c. Burning d. Shooting e. Shock-like

c. Burning d. Shooting e. Shock-like

Barriers to pain management:

- Fear of addiction - Fear of tolerance - Concerns about side effects - Ineffective meds - Trying to be a "good patient" - Fear of injections - Desire to be stoic - Forgetting to take analgesic - Concern that pain indicates disease progression - Sense of fatalism

Common side effects of opioids:

- Constipation - Nausea and vomiting - Sedation - Respiratory depression - Pruritus. *With continued use, many side effects diminish; the exception is constipation.

What are dermatomes?

Areas on the skin that are innervated primarily by a single spinal cord segment.

Possible respiratory consequences due to unrelieved acute pain:

Atelectasis Pneumonia

What is nociception?

The physiologic process by which information about tissue damage is communicated to the central nervous system (CNS).

Cognitive

• Beliefs, attitudes, memories, and meaning attributed to pain influence the ways in which a person responds to pain.

Side effects of drugs can be managed in one or more of the following methods:

• Decreasing the dose of analgesic by 10% to 15% • Changing to a different medication in the same class • Adding a drug to counteract the adverse effect of the analgesic (e.g., using a stool softener for patients experiencing opioid-induced constipation) • Using an administration route that minimizes drug concentrations (e.g., intraspinal administration of opioids used to minimize high drug levels that produce sedation, nausea, and vomiting)

Behavioral

• Observable actions (e.g., grimacing, irritability, coping skills) are used to express or control pain. • People unable to communicate may have behavioral changes (e.g., agitation, combativeness).

Women and pain:

• Women more frequently experience migraine headache, back pain, arthritis, fibromyalgia, irritable bowel syndrome, neuropathic pain, abdominal pain, and foot ache. • Women are more likely to be diagnosed with a nonspecific, somatic disorder and less likely to receive analgesics for symptoms of chest and abdominal pain.

Endocrine and metabolic responses to pain:

↑ Adrenocorticotropic hormone (ACTH) ↑ Cortisol ↑ Antidiuretic hormone (ADH) ↑ Epinephrine and norepinephrine ↑ Renin, ↑ aldosterone ↓ Insulin Gluconeogenesis Glycogenolysis Muscle protein catabolism

Cardiovascular response to pain:

↑ Heart rate ↑ Cardiac output ↑ Peripheral vascular resistance ↑ Myocardial oxygen consumption ↑ Coagulation

Nonopioid analgesics include

- Acetaminophen - Aspirin and other salicylates - NSAIDs *Nonopioids are effective for mild to moderate pain. They are often used in conjunction with opioids because they allow for effective pain relief using lower opioid doses (thereby causing fewer opioid side effects). This phenomenon is called the opioid-sparing effect.

Negative consequences of unrelieved acute pain can have effects on which systems?

- Endocrine and Metabolic - Cardiovascular - Respiratory - Renal and Urologic - Gastrointestinal - Musculoskeletal - Neurologic - Immunologic

Elements of a Pain Assessment

- Most components of a pain assessment involve direct interview or observation of the patient. - Diagnostic studies and physical examination findings complete the initial assessment. - Although the assessment differs according to the clinical setting, patient population, and point of care (i.e., whether the assessment is part of an initial workup or a reassessment of pain following therapy), the evaluation of pain should always be multidimensional

Pain medications generally are divided into three categories:

- Nonopioids - mild pain often can be relieved using nonopioids alone. - Opioids - moderate to sever pain - Adjuvant drugs - certain types of pain, such as neuropathic pain, typically require adjuvant drug therapy alone or in combination with an opioid or another class of analgesics

What are some of the consequences of untreated pain?

- Unnecessary suffering - Physical and psychosocial dysfunction - Immunosuppression - Sleep disturbances

Less common side effects of opioids:

- Urinary retention - Myoclonus - Dizziness - Confusion - Hallucinations

All pain treatment plans are based on the following 10 principles and practice standards:

1. Follow the principles of pain assessment. Remember that pain is a subjective experience. The patient is not only the best judge of his or her own pain but also the expert on the effectiveness of each pain treatment. 2. Use a holistic approach to pain management. 3. Every patient deserves adequate pain management. 4. Base the treatment plan on the patient's goals. 5. Use both drug and nondrug therapies. 6. When appropriate, use a multimodal approach to analgesic therapy. Multimodal analgesia employs the use of two or more classes of analgesic agents to take advantage of the various mechanisms of action. 7. Address pain using an interprofessional approach. 8. Evaluate the effectiveness of all therapies to ensure that they are meeting the patient's goals. 9. Prevent and/or manage medication side effects. 10. Incorporate patient and caregiver teaching throughout assessment and treatment.

Principles of pain assessment:

1. Patients have the right to appropriate assessment and management of pain. 2. Pain is always subjective. 3. Physiologic and behavioral signs of pain (e.g., tachycardia, grimacing) are not reliable or specific for pain. 4. Pain is an unpleasant sensory and emotional experience. 5. Assessment approaches, including tools, must be appropriate for the patient population. 6. Pain can exist even when no physical cause can be found. 7. Different patients experience different levels of pain in response to comparable stimuli. 8. Patients with chronic pain may be more sensitive to pain and other stimuli. 9. Unrelieved pain has adverse consequences. Acute pain that is not adequately controlled can result in physiologic changes that increase the likelihood of developing persistent pain.

What are the types of nociceptive pain?

1. Superficial Somatic Pain 2. Deep Somatic Pain 3. Visceral Pain

What are the 3 segments involved in the transmission of pain?

1. Transmission along the peripheral nerve fibers to the spinal cord 2. Dorsal horn processing 3. Transmission to the thalamus and the cerebral cortex

___________ people experience acute pain form injury or surgery

25 million

______% of cancer patients experience significant pain

60

What is pain?

A complex, multidimensional experience that can cause suffering and decreased quality of life. - Pain is one of the major reasons that people seek health care. - To effectively assess and manage patients with pain, you need to understand the physiologic and psychosocial dimensions of pain.

What is Episodic, procedural, or incident pain?

A transient increase in pain that is caused by a specific activity or event that precipitates pain. Examples include dressing changes, movement, position changes, and procedures such as catheterization.

What is neuropathic pain?

Abnormal processing of sensory input by the peripheral or central nervous - Typically described as numbing, hot, burning, shooting, stabbing, sharp, or electric shock-like, neuropathic pain can be sudden, intense, short lived, or lingering. **Note: Some types of neuropathic pain (e.g., postherpetic neuralgia) are caused by more than one neuropathologic mechanism.**

What are opioid agonists used for?

Acute and chronic pain. - Although nociceptive pain appears to be more responsive to opioids than neuropathic pain, opioids may be used to treat both types of pain. - In the treatment of neuropathic pain, antineuropathic pain drugs such as antidepressants and antiseizure drugs are recommended as first-line agents. Pure opioid agonists include morphine, oxycodone (OxyContin), hydrocodone, codeine, methadone, hydromorphone (Dilaudid), oxymorphone (Opana), and levorphanol (Levo-Dromoran). These drugs are effective for moderate to severe pain because they are potent, theoretically have no analgesic ceiling, and can be administered via several routes. - When opioids are prescribed for moderate pain, they are usually combined with a nonopioid analgesic such as acetaminophen (e.g., codeine plus acetaminophen [Tylenol #3], or hydrocodone plus acetaminophen or ibuprofen [Vicoprofen]). - Addition of acetaminophen or NSAIDs limits the total daily dose that can be given.

What is hyperalgesia?

An exaggerated or increased pain response to noxious stimuli.

Which part of the nursing process does the following describe? * Post-Op Colon resection (24 hrs) with mid-line lower abdominal incision, * Report pain level of 8 on 0-10 scale; non compliant with TCDB, incentive spirometer & Ambulation

Assessment

Which part of the nursing process does the following describe? *Pt will experience decreased pain within 48 hours * < Pain level report will decrease to 3 on 0-10 scale * Ambulatory in hall 4 times / day Incentive Spirometer 8-10 times / hour while awake

Goals/Outcome

Possible cardiovascular consequences due to unrelieved acute pain:

Hypertension Unstable angina Myocardial infarction Deep vein thrombosis

Possible musculoskeletal consequences due to unrelieved acute pain:

Immobility Weakness and fatigue

Neurologic response to pain:

Impaired cognitive function

Which part of the nursing process does the following describe? * Assess Pain Q4H; Administer Dilaudid IV Q4H PRN; Assist to ambulate & perform IS; Cough 30 minutes after pain med administered.

Implementation/Intervention

Modulation

Involves signals from the brain going back down the spinal cord to modify incoming impulses. - Neurons originating in the brainstem descend to the spinal cord and release substances (e.g., endogenous opioids) that inhibit nociceptive impulses

Transmission:

Involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex for processing. *Drugs that stabilize the neuronal membrane act on peripheral sodium channels to inhibit propagation of nerve impulses. These medications include local anesthetics (e.g., injectable or topical lidocaine, bupivacaine [Sensorcaine]) and antiseizure drugs (e.g., gabapentin [Neurontin]).*

Typical physical and behavioral manifestations of acute pain:

Manifestations vary but can reflect sympathetic nervous system activation: • ↑ Heart rate, respiratory rate, BP • Diaphoresis, pallor • Anxiety, agitation, confusion • Urine retention

Musculoskeletal responses to pain

Muscle spasm Impaired muscle function

What is nociceptive pain?

Normal processing of stimulus that damages normal tissue or has the potential to do so if prolonged

Which part of the nursing process does the following describe? * Altered comfort, Pain, R/T abdominal surgical incision

Nursing Diagnosis

Transduction:

Occurs when there is release of chemical mediators. 1. Noxious stimuli cause cell damage with the release of sensitizing chemicals: prostaglandins, bradykinin, serotonin, substance P, histamine 2. These substances activate nociceptors and lead to generation of action potential *Therapies that alter either the local environment or sensitivity of the peripheral nociceptors can prevent transduction and initiation of an action potential. Decreasing the effects of chemicals released at the periphery is the basis of several drug approaches to pain relief. For example, nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (Advil), exert their analgesic effects by blocking the action of COX*

Therapeutic approaches that target pain transmission include:

Opioid analgesics that bind to opioid receptors on primary afferent and dorsal horn neurons. - These agents mimic the inhibitory effects of endogenous opioids. - Another medication, baclofen (Lioresal), inhibits pain transmission by binding to GABA receptors, thus mimicking the inhibitory effects of GABA.

Deep Somatic Pain

Pain arising from muscles, fasciae, bones, tendons. Localized or diffuse and radiating - Often characterized as aching or throbbing and originates in bone, joint, muscle, or connective tissue. Examples: arthritis, tendonitis, myofascial pain

Superficial Somatic Pain

Pain arising from skin, mucous membranes, subcutaneous tissue. Tends to be well localized - It is often described as sharp, burning, or prickly. Examples: sunburn, skin contusions

Visceral Pain

Pain arising from visceral organs, such as the GI tract and bladder. Well or poorly localized. Often referred to cutaneous sites - May be describes as cramping pain Examples: appendicitis, pancreatitis, cancer affecting internal organs, irritable bowel and bladder syndromes

Usual goals of treatment of chronic pain:

Pain control to the extent possible. Focus on enhancing function and quality of life.

Usual goals of treatment of acute pain:

Pain control with ability to participate in recovery activities Minimize side effects of treatment

Peripheral Neuropathies

Pain felt along the distribution of one or many peripheral nerves caused by damage to the nerve Examples: diabetic neuropathy, alcohol-nutritional neuropathy, trigeminal neuralgia, postherpetic neuralgia

What is allodynia?

Pain from a stimulus that is not typically painful.

Deafferentation Pain

Pain resulting from a loss of or altered afferent input Examples: phantom limb pain, postmastectomy pain, spinal cord injury pain

What is End-of-dose failure?

Pain that occurs before the expected duration of a specific analgesic. - It should not be confused with BTP. - Pain that occurs at the end of the duration of an analgesic often leads to a prolonged increase in the baseline persistent pain. - For example, in a patient on transdermal fentanyl (Duragesic patches) the typical duration of action is 72 hours. An increase in pain after 48 hours on the drug would be characterized as end-of-dose failure. - End-of-dose failure signals the need for changes in the dose or scheduling of the analgesic.

Sympathetically Maintained Pain

Pain that persists secondary to sympathetic nervous system activity Examples: phantom limb pain, complex regional pain syndrome

Even though patient's self-report is said to be the most valid means of assessment, what are some limitations of this?

Patients who are comatose or who suffer from dementia, patients who are mentally disabled or challenged, and patients with expressive aphasia have varying abilities to report pain. - In these instances, you must incorporate nonverbal information such as observed behaviors into your pain assessment. - Perceptions can also influence the ways in which a person responds to pain and must be incorporated into a comprehensive treatment plan. - People who believe that their pain is uncontrollable and overwhelming are more likely to have poor outcomes.

Typical physical and behavioral manifestations of chronic pain:

Predominantly behavioral manifestations: • Flat affect • ↓ Physical activity • Fatigue • Withdrawal from social interaction

How do opioids work?

Produce their effects by binding to receptors in the CNS. This results in: (1) inhibition of the transmission of nociceptive input from the periphery to the spinal cord (2) altered limbic system activity (3) activation of the descending inhibitory pathways that modulate transmission in the spinal cord. *Thus opioids act on several nociceptive processes.

What must be considered when interpreting the location of pain reported by the person with an injury or a disease involving visceral organs?

Referred pain - The location of a stimulus may be distant from the pain location reported by the patient. - For example, pain from liver disease is frequently located in the right upper abdominal quadrant but can also be referred to the anterior and posterior neck region, shoulder area, and posterior flank area. - If referred pain is not considered when evaluating a pain location report, diagnostic tests and therapy could be misdirected.

__________ is usually seen in opioid-naive patients being treated for acute pain.

Sedation *Resolves with the development of tolerance.

What are some drugs the work during the modulation process?

Several antidepressants exert their effects through the modulatory systems. For example, tricyclic antidepressants (e.g., amitriptyline [Elavil]) and serotonin norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine [Effexor]) are used in the management of chronic noncancer and cancer pain. These agents interfere with the reuptake of serotonin and norepinephrine, thereby increasing their availability to inhibit noxious stimuli.

Why should some opioids be avoided for pain relief and which ones?

Some opioids should be avoided for pain relief because of limited efficacy and/or toxicities. - Meperidine (Demerol) or pethidine is associated with neurotoxicity (e.g., seizures) caused by accumulation of its metabolite, normeperidine. - Its use is limited for very short-term (i.e., less than 48 hours) treatment of acute pain when other opioid agonists are contraindicated.

Drug Alert: Meperidine (Demerol)

The American Pain Society does not recommend the use of meperidine as an analgesic.

What is Breakthrough pain (BTP)?

Transient, moderate to severe pain that occurs in patients whose baseline persistent pain is otherwise mild to moderate and fairly well controlled. The average peak of BTP can be 3 to 5 minutes and can last up to 30 minutes or even longer. BTP can be either predictable or unpredictable, and patients can have one to many episodes per day. Several transmucosal fentanyl products are used specifically to treat BTP.

How is neuropathic pain treated?

Treatment usually includes adjuvant analgesics. - Neuropathic pain often is not well controlled by opioid analgesics alone. - Treatment frequently necessitates a multimodal approach combining various adjuvant analgesics from different drug classes, including tricyclic antidepressants (e.g., amitriptyline [Elavil]), SNRIs (e.g., bupropion [Wellbutrin, Zyban]), antiseizure drugs (e.g., pregabalin [Lyrica]), transdermal lidocaine, and α2-adrenergic agonists (e.g., clonidine [Catapres]). - NMDA receptor antagonists such as ketamine have shown promise in alleviating neuropathic pain refractory to other drugs.

Because of the connection between inadequately treated _________ _________and _________ _________, it is important to treat acute pain aggressively.

acute pain; chronic pain

The ___________ model of pain includes the physiologic, affective, cognitive, behavioral, and sociocultural dimensions of pain.

biopsychosocial

It is important for you to understand that acute, unrelieved pain leads to ___________ __________ through __________ __________.

chronic pain; central sensitization *Even brief intervals of acute pain are capable of inducing long-term neuronal remodeling and sensitization (plasticity), chronic pain, and lasting psychologic distress.

One particularly debilitating type of neuropathic pain is known as:

complex regional pain syndrome (CRPS) - Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. - CRPS type I is frequently triggered by tissue injury, surgery, or a vascular event such as stroke. - CRPS type II includes all these features in addition to a peripheral nerve lesion.

For patients who are excessively sedated or unresponsive, ___________, an opioid antagonist that rapidly reverses the effects of opioids, can be administered.

naloxone

The most commonly administered subclass of opioids is the ______________.

pure opioid agonists, or morphine-like opioids, which bind to mu receptors.

The risk of _______________ is also higher in opioid-naive, hospitalized patients who are treated for acute pain.

respiratory depression - Patients most at risk for respiratory depression include those who are age 65 or older, have a history of snoring or witnessed apneic episodes, report excessive daytime sleepiness, have underlying cardiac or lung disease, are obese (body mass index greater than 30 kg/m2), have a history of smoking (more than 20 pack-years), or are receiving other CNS depressants (e.g., sedatives, benzodiazepines, antihistamines). - For postoperative patients the greatest risk for opioid-related respiratory adverse events is within the first 24 hours after surgery. Clinically significant respiratory depression cannot occur in patients who are fully awake.

Sociocultural

• Age and gender influence nociceptive processes and responses to opioids. • Families and caregivers influence patient's response to pain through their beliefs, behaviors, and support. • Culture affects pain expression, medication use, and pain-related beliefs and coping methods.

Nursing Implications associated with principles of pain assessment

• Assess pain in all patients. • Patient's self-report of pain is the single most reliable indicator of pain. • Accept and respect this self-report unless there are clear reasons for doubt. • Do not rely primarily on observations and objective signs of pain unless the patient is unable to self-report pain. • Address physical and psychologic aspects of pain when assessing pain. • Special considerations are needed for assessing pain in patients with difficulty communicating. • Include family members in the assessment process (when appropriate). • Do not attribute pain that does not have an identifiable cause to psychologic causes. • A uniform pain threshold does not exist. • Pain tolerance varies among and within individuals depending on various factors (e.g., genetics, energy level, coping skills, prior experience with pain). • Encourage patients to report pain, especially patients who are reluctant to discuss pain, deny pain when it is probably present, or fail to follow through on prescribed treatments.

Affective

• Emotional responses to pain include anger, fear, depression, and anxiety. • Negative emotions impair patient's quality of life.

Safety Alert: Sedation and Respiratory Depression

• If the number of patient's respirations falls below 8 or 10 breaths/minute and the sedation level is 3 or greater, you should vigorously stimulate the patient and try to keep the patient awake. • If the patient becomes oversedated, administer oxygen. • In this situation, the opioid dose should be reduced.

Men and pain:

• Men are less likely to report pain than women. • Men report more control over pain. • Men are less likely than women to use alternative treatments for pain.

Drug Alert: Methadone (Dolophine)

• Methadone may cause respiratory depression. • Methadone can cause cardiac toxicity, specifically QT prolongation.

Drug Alert: Morphine

• Morphine may cause respiratory depression. • If respirations are 12 or less breaths per minute, withhold medication and contact the HCP.

Drug Alert for NSAIDS

• NSAIDs (except aspirin) have been linked to a higher risk for cardiovascular events such as myocardial infarction, stroke, and heart failure. • Patients who have just had heart surgery should not take NSAIDs.

What are the goals of a nursing pain assessment?

(1) describe the patient's pain experience to identify and implement appropriate pain management techniques (2) identify the patient's goal for therapy and resources for self-management.

What are the 4 processes of nociception?

(1) transduction (2) transmission (3) perception (4) modulation

Three segments are involved in nociceptive signal transmission:

(1) transmission along the peripheral nerve fibers to the spinal cord (2) dorsal horn processing (3) transmission to the thalamus and cerebral cortex.

More than __________ suffer from chronic conditions such as arthritis, migraine headaches, and back pain.

1 million

Nursing role in relation to pain:

- Assess & communicate with HCP's - Ensure initiation of adequate pain relief measures - Evaluate effectiveness of interventions - Advocate for those in pain

Nursing assessment of pain:

**Subjective Data** 1. Important Health Information - Health history: Pain history includes onset, location, intensity, quality, patterns, aggravating and alleviating factors, and expression of pain. Coping strategies. Past treatments and their effectiveness. Review of health care utilization related to the pain problem (e.g., emergency department visits, treatment at pain clinics, visits to primary HCPs and specialists) - Medications: Use of any prescription or over-the-counter, illicit, or herbal products for pain relief. Alcohol use - Nondrug measures: Use of therapies such as, but not limited to, massage, heat or ice, Reiki, aromatherapy, acupuncture, hypnosis, yoga, or meditation 2. Functional Health Patterns - Health perception-health management: Social and work history, mental health history, smoking history. Effects of pain on emotions, relationships, sleep, and activities. Interviews with family members. Records from psychologic/psychiatric treatment related to the pain - Elimination: Constipation related to opioid drug use, other medication use, or pain related to elimination - Activity-exercise: Fatigue, limitations in ability to perform ADLs (activities of daily living), IADLs (instrumental activities of daily living), and pain related to use of muscles - Sexuality-reproductive: Decreased libido - Coping-stress tolerance: Psychologic evaluation using standardized measures to examine coping style, depression, anxiety **Objective Data** - Physical examination, including evaluation of functional limitations - Psychosocial evaluation, including mood NOTE: Before beginning any assessment, recognize that patients may use words other than "pain." For example, older adults may deny that they have pain but respond positively when asked if they have soreness or aching. Document the specific words that the patient uses to describe pain. Then consistently ask the patient about pain using those words.

Definition of pain.

- "Whatever the client says" - Subjective info - Unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Patient-controlled analgesia (PCA)

- Administered via IV *Continuous *Patient controls Meds *Lock out periods *Can evaluate how often pt request meds - Monitor and Document Q4H - O2 Sats - CO2 Level, Resp Rate - Only Patient should push the button - Patient teaching important

Gerontological considerations in pain management:

- Belief that pain is inevitable for aging - Greater fear of using opioids - Use words like aching, soreness, or discomfort instead of pain - High prevalence of cognitive, sensory-perceptual, and motor problems - Metabolize drugs more slowly - Risk of GI bleeding with NSAIDs - Multiple drug use (interactions) - Cognitive impairment, ataxia can be exacerbated by analgesics

Strategies for effect pain management:

- Educate - patient about consequences of unresolved pain: anxiety, depression immune response, etc - Proactive - Administer meds before pain becomes severe Incorporate - Non-pharm interventions to manage pain Advocate - Speak up for patient / create environment of "trust" with patient Nursing Process - Pain management

Evaluation of pain:

- You MUST always follow-up intervention, especially pain treatment - Educate - potential side effects

Patient & Caregiver Teaching: Pain Management

Include the following information in the teaching plan for the patient with pain and caregiver. • Self-management techniques • Realistic goals for pain control • Negative consequences of unrelieved pain • Need to maintain a record of pain level and effectiveness of treatment • Treat pain with drugs and/or nondrug therapies before it becomes severe. • Medication may stop working after it is taken for a period of time, and dosages may have to be adjusted. • Potential side effects and complications associated with pain therapies can include nausea and vomiting, constipation, sedation and drowsiness, itching, urinary retention, and sweating. • Need to report when pain is not relieved to tolerable levels

Perception:

The conscious awareness of pain.

Assessing Pain in Nonverbal Patients

The following assessment techniques are recommended. • Obtain a self-report when possible. • Never assume a nonverbal person is unable to communicate pain in some manner as blinking, writing, hand gestures, or nodding can be ways to express pain or the absence of pain. • Investigate potential causes of pain. • Observe patient behaviors that indicate pain (e.g., grimacing, frowning, rubbing a painful area, groaning, restlessness). • Obtain surrogate reports of pain from professional and family caregivers. • Try to use analgesics and reassess the patient to observe for a decrease in pain-related behaviors.

A nurse believes that patients with the same type of tissue injury should have the same amount of pain. This statement reflects a. a belief that will contribute to appropriate pain management. b. an accurate statement about pain mechanisms and an expected goal of pain therapy. c. a belief that will have no effect on the type of care provided to people in pain. d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.

d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.

Nondrug Therapies for Pain: Physical Therapies

• Acupuncture • Application of heat and cold • Exercise • Massage • Transcutaneous electrical nerve stimulation (TENS): involves the delivery of an electric current through electrodes applied to the skin surface over the painful region, at trigger points, or over a peripheral nerve

Pain: Role of Nursing Personnel - Licensed Nursing Professional (LPN)

• Administer ordered pain medications (consider the state nurse practice act and agency policy, since LPNs may not be able to give medications by all routes). • Assess patient's pain.

Pain: Role of Nursing Personnel - Registered Nurse (RN)

• Assess pain characteristics (pattern and onset, area or location, intensity, quality, associated symptoms, and management strategies). • Develop treatment plan for patient's pain (including drug and nondrug therapies). • Evaluate whether current treatment plan is effective. • Teach patient and caregiver about treatment plan. • Implement discharge teaching about pain management.

Pain: Role of Nursing Personnel - Unlicensed Assistive Personnel (UAP)

• Assist with screening for pain and notify RN if patient expresses pain. • Take and report vital signs before and after pain medications are given. • Note and report if patient is refusing to participate in ordered activities such as ambulation (since this may indicate inadequate pain management).

Patient & Caregiver Teaching: Cold therapy

• Cover the cold source with a cloth or towel before applying to the skin to prevent tissue damage. • Do not apply cold to areas that are being treated with radiation therapy, have open wounds, or have poor circulation. • If it is not possible to apply the cold directly to the painful site, try applying it right above or below the painful site or on the opposite side of the body on the corresponding site (e.g., left elbow if the right elbow hurts).

Nondrug Therapies for Pain: Cognitive Therapies

• Distraction • Hypnosis • Imagery • Relaxation strategies • Relaxation breathing • Imagery • Meditation • Art therapy • Music therapy

Patient & Caregiver Teaching: Heat therapy

• Do not use heat on an area that is being treated with radiation therapy, is bleeding, has decreased sensation, or has been injured in the past 24 hours. • Do not use any menthol-containing products (e.g., Ben-Gay, Vicks, Icy Hot) with heat applications because this may cause burns. • Cover the heat source with a towel or cloth before applying to the skin to prevent burns.

Nursing Consideration: Fear of addiction

• Explain that addiction is uncommon in patients taking opioids for pain.

Nursing consideration: Desire to be stoic

• Explain that although stoicism is a valued behavior in many cultures, failure to report pain can result in undertreatment and severe, unrelieved pain.

Nursing consideration: Concern that pain indicates disease progression

• Explain that increased pain or the need for analgesics may reflect tolerance. • Emphasize that new pain may come from a non-life-threatening source (e.g., muscle spasm, urinary tract infection). • Institute drug and nondrug strategies to reduce anxiety. • Ensure that patient and caregivers have current, accurate, comprehensive information about the disease and prognosis. • Provide psychologic support.

Nursing consideration: Fear of injections

• Explain that oral medicines are preferred. • Emphasize that even if oral route becomes unusable, transdermal or indwelling parenteral routes can be used rather than injections.

Nursing consideration: Sense of fatalism

• Explain that pain can be managed in most patients. • Explain that most therapies require a period of trial and error. • Emphasize that side effects can be managed.

Nursing consideration: Desire to be "good" patient

• Explain that patients are partners in their care and that partnership requires open communication by both patient and nurse. • Emphasize to patients that they have a responsibility to keep you informed about their pain.

Nursing consideration: Forgetting to take analgesic

• Provide and teach use of pill containers. • Provide methods of record keeping for drug use. • Recruit caregivers to assist with the analgesic regimen.

Nursing consideration: Concern about side effects

• Teach methods to prevent and to treat common side effects. • Emphasize that side effects such as sedation and nausea decrease with time. • Explain that different drugs have unique side effects, and other pain drugs can be tried to reduce the specific side effect.

Nursing considerations: Ineffective medication

• Teach that there are multiple options within each category of medication (e.g., opioids, NSAIDs), and another medication from the same category may provide better relief. • Emphasize that finding the best treatment regimen often requires trial and error. • Incorporate nondrug approaches in treatment plan.

Nursing Consideration: Fear of tolerance

• Teach that tolerance is a normal physiologic response to chronic opioid therapy. If tolerance does develop, the drug may have to be changed (e.g., morphine in place of oxycodone). • Teach that there is no absolute upper limit to pure opioid agonists (e.g., morphine). Dosages can be increased, and patient should not save drugs for when the pain is worse. • Teach that tolerance develops more slowly to analgesic effects of opioids than to side effects (e.g., sedation, respiratory depression). Tolerance does not develop to constipation. Thus a regular bowel program should be started early.

Safety Alert: Sustained- or Extended-Release Preparations

• These should not be crushed, broken, dissolved, or chewed. These drugs are meant to be swallowed whole. • If all of the medicine is released into a person at once, very serious side effects can occur, including death from overdose.