Comfort and Pain Management Chapter 35 exam 3

Nursing diagnoses related to pain can classify it as either the

problem or the etiology.

What are endorphins?

"morphine within"—natural, opiate-like neurotransmitters linked to pain control and to pleasure.

The primary purposes of using a guide to assess pain are to:

(1) eliminate guesswork and biases when dealing with the patient's pain; (2) understand what the person is experiencing; (3) analyze findings that will help prepare an appropriate nursing response to the patient's pain; and (4) facilitate improved outcomes, such as fewer complications, shorter hospital stays, and improved quality of life.

Adult Nonverbal Pain Scale (NVPS)

Adults who are sedated and nonresponsive

Epidural analgesia

Analgesia injected into the epidural space outside the dura mater to relieve pain. can be used to provide pain relief during the immediate postoperative phase (particularly after thoracic, abdominal, orthopedic, and vascular surgery) and for chronic pain situations. Epidural pain management is also being used for children with terminal cancer and for children undergoing hip, spinal, or lower extremity surgery -pain relief is achieved with smaller doses and less severe side effects. -The epidural analgesia can be administered as a bolus dose (either one time or intermittent) via a continuous infusion pump or by means of a patient-controlled epidural analgesia (PCEA) pump -Nursing responsibilities vary among institutions but must include careful monitoring of vital signs, laboratory values, pain intensity, motor and sensory function, the insert site, the delivery system, urinary output, and side effects related to surgery and opioid use (decreased gastric mobility, nausea, vomiting, pruritus, and headache;

Local Anesthesia

Anesthetic agents may be applied topically to the skin or mucous membranes or injected into the body to produce a temporary loss of sensation and motor and autonomic function in a localized area. The agents work by chemically blocking the nerve pathways involved in pain sensation and response, and are sometimes called nerve blocks. Many people have experienced nerve blocks during dental work, when having a wound sutured, during delivery of a newborn, or for some minor surgical procedures.

The HEAL Initiative is an aggressive, trans-agency effort in response to the national opioid public health crisis designed to:

Build on existing research related to the science of pain and addiction, treatment models, behavioral interventions (medication-assisted treatment; MAT), and pharmacological/nonpharmacological interventions. Prevent addiction through enhanced pain management research on the development of chronic pain and biomarkers for pain, and the development of a clinical trials network for testing new pain theories. Improve treatments for opioid misuse disorder and addiction through research that will help people with opioid use disorders (OUDs) achieve and sustain recovery.

Faces Pain Scale—Revised (FPS-R)

Children (4-16) in parallel with numerical self-rating scales (0-10); patients choose the depiction of a facial expression that best corresponds with their pain

____ and _____ measures can be integrated with conventional medical pain treatments and practiced in all health care settings.

Complementary health approaches, integrated health pain relief

PCA has many advantages:

Consistent analgesic blood level is maintained rather than the inconsistent analgesia obtained with periodic injections, which results in sharp rises and falls of serum opioid levels. The analgesic is delivered intravenously or epidurally so that absorption is faster and more predictable than with the intramuscular route. The patient is in charge of the pain management program. The patient tends to use less medication because it is self-administered before the pain becomes too severe. The patient is able to ambulate earlier, which causes fewer pulmonary complications. The patient is more satisfied and has improved pain relief.

factors affecting pain experience

Culture Ethnic variables Family, gender, and age variables Religious beliefs Environment and support people Anxiety and other stressors Past pain experience

______necessitates the nurse's ongoing attention to the patient's pain experience and the continual modification of pain therapies as needed.

Evaluation of the care plan

WHO three-step analgesic ladder

Focuses on aligning the proper analgesic with the intensity of pain. This has eveolved into "rational polypharmacy." Demands health professionals be aware of all ingrediants of meds that alleviate pain. Combo's reduce need for high doses of any one med, thus maximizing pain control while minimizing side effects or toxicity. For mild pain (1-3 on a 0-10 scale), step 1 of the analgesic ladder, nonopiod analgesics For mild pain that persists or if pain is moderate (4-6 pn a 0-10 scale), then step 2, an opioid for moderate pain or combo of opiod and nonopioid med is provided with or without coanalgesic meds. For moderate pain that persists or increases or if pain is severe (7-10) then step 3, an opioid for severe pain is administered and titrated in ATC and scheduled doses until the pain is relieved.

People with cancer sometimes suffer needlessly from pain. The major principles that guide treatment for cancer or chronic pain include:

Giving medications orally, if possible, for ease and convenience of administration Administering medication ATC rather than on a PRN basis Adjusting the dose to achieve maximum benefits with minimal side effects Allowing patients as much control as possible over their medication regimen

The positive effects of relaxation for the person with pain include the following

Improved quality of sleep Distraction from the pain Decreased fatigue Increased confidence and sense of self-control in coping with pain Lessening of the detrimental physiologic effects of continued or repeated stress from pain Increased effectiveness of other pain relief measures Improved ability to tolerate pain Decreased distress or fear during anticipation of pain Reassurance that the nurse is aware of the person's problem and wants to help

FLACC Behavioral Scale

Infants and children (2 months-7 years) who are unable to validate the presence of or quantify the severity of pain

COMFORT Behavior Scale

Infants, children, adults who are unable to use the numeric rating scale or Wong-Baker FACES pain rating scale

Some forms of cutaneous stimulation include the following:

Massage (with or without analgesic ointments or liniments containing menthol); see Skill 35-1 (on pages 1271-1274) Application of heat or cold, or both intermittently (see detailed discussion in Chapter 32) Acupressure Transcutaneous electrical nerve stimulation (TENS)

CRIES Instrument

Neonates (ages 0-6 months)

two options that exist to deliver opioids and improve pain management.

Patient-controlled analgesia (PCA) and epidural analgesia

a commonly feared adverse effect of opioid use

Respiratory depression

Recommendations for analgesic administration for older adults include the following :

Use acetaminophen for older adults with mild to moderate pain. Use NSAIDs (oral or topical) when other treatments have failed; use for shortest period of time possible. Progress to opioids for moderate to severe pain when other treatments have been unsuccessful and the pain is impacting on quality of life and functional issues. Consider adjuvants that address depression and neuropathic pain.

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. The most frequently prescribed drugs for PCA administration are morphine, fentanyl, and hydromorphone.

placebo

any sham medication or procedure that is designed and known to not be of any therapeutic clinical value. The person receiving the placebo treatment, unaware of the placebo's properties, may find it to be effective for the relief of pain because of the perception that it will provide comfort and because of belief in the person administering it. -The nurse has firm legal and ethical grounds for refusing to administer a placebo.

Expected patient outcomes regarding pain are directed toward

eliminating or reducing the pain and, if possible, facilitating the patient's management of pain relief strategies that will allow them to resume their normal lifestyle pattern.

Massage only the hands, feet, or scalp of patients with sepsis

fever over 100°F, sickle cell or HIV crisis, thrombocytopenia or meningitis (Westman & Blaisdell, 2016).

physical dependence

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

Morphine is considered the prototype opioid because

it is available in multiple dosage forms, has a fairly predictable action, and is relatively inexpensive.

Opioid receptor sites are further classified as

mu, delta, and kappa types.

Pain is classified by cause as either

nociceptive pain or neuropathic pain.

Analgesics are medications that relieve pain. The three types are

opioids, nonopioid analgesics, and adjuvant analgesics.

a universal human experience, yet each person's experience and response to pain is unique.

pain

The three-step analgesic ladder devised by the World Health Organization recommends

the appropriate progression of drugs and dosages to manage chronic pain effectively.

what is exacerbation?

the symptoms reappear

The pain processes involved in nociceptive pain are

transduction, transmission, perception, and modulation of pain.

Numerous misconceptions about pain by both the patient and health care professional can influence the pain experience and result in?

underassessment and failure to relieve the pain adequately

Nurses and other health care providers must be attuned to the public health epidemic of opioid abuse and engage in

vigilant assessment, prescription, administration, and reassessment practices that promote effective pain management, while monitoring for potential and actual issues related to abuse.

Unlike acute pain, chronic pain is often perceived as meaningless and may lead to

withdrawal, depression, anger, frustration, and dependency.

Nursing Interventions for Controlling Pain: Patient Education

•Give information about the nature and cause of the pain •Preventing and controlling pain is an important aspect of treatment •Interventions to manage pain (pharmacologic and nonpharmacologic) •Side effects of opioids can be managed. •The risk of addiction when using opioids to manage acute pain is relatively low •It is the patient's responsibility to alert practitioners about pain and when the nature or level of pain changes. •Complete pain relief is usually not achievable - decreasing pain to a level that is tolerable is the goal. ******** •Explain the pain scale •Safety concerns

Nursing Considerations for the Older Adult

•Observe for behavioral manifestation or indications of pain •Monitor for behavior changes and confusion after giving pain meds •Clarify terms used to describe pain •Teach pain is not a normal part of aging •Be aware of dosage and frequency to avoid over-sedation and toxicity •Monitor for over sedation and respiratory depression •Caution about use of etoh with analgesics •Caution about driving or operating machinery when taking analgesics

Ethical and Legal Responsibilities Related to Pain Management

•Patients have the right to have their pain accepted and treated •Patients have the right to have their pain treated effectively •Patients have the right to have nurses who treat them with respect •Placebo Patients have the right to be treated with dignity and to be involved in developing their pain management plan of care.

Pain Assessment Tools

•Wong-Baker FACES •Beyer Oucher pain scale •CRIES pain scale •FLACC scale •COMFORT scale •Numeric

Iowa Pain Thermometer (IPT) & Revised Iowa Pain Thermometer (IPT-R)

Older adults with cognitive impairment

PDMP

Prescription Drug Monitoring Program. database that allows prescribers to access prescription and dispensing data on prescription drugs for individual patients from multiple institutions within a geographic area

adjuvant analgesics

include antidepressants, anticonvulsants, corticosteroids, and biophosphonates. They may be used to treat acute pain resulting from surgery, burns, or trauma but are also effective for persistent neuropathic pain syndromes such as fibromyalgia, diabetic neuropathy, and postherpetic neuralgia

somatic

diffuse or scattered - originates in tendons, ligaments, bones, blood vessels, and nerves

What is remission?

disease is present, but the person does not experience pain

Pain may be classified according to its?

duration, its localization/location, or its etiology.

Opioids

formerly called narcotic analgesics, are generally considered the major class of analgesics used in the management of moderate to severe pain because of their effectiveness -Opioids produce analgesia by attaching to opioid receptors in the brain, similar to how a key fits a lock

Duration of pain: Acute

generally rapid in onset and varies in intensity from mild to severe. It is protective in nature. In other words, acute pain warns the person of tissue damage or organic disease and triggers autonomic responses such as increased heart rate, the fight-or-flight response, and increased blood pressure

Tolerance

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

phantom pain

occurs with amputated limbs where receptors and nerves are absent, but pain is real for patient

Breakthrough pain (BTP)

or breakthrough cancer pain (BTcP), is a temporary flare-up of moderate to severe pain that occurs even when the patient is taking around-the-clock (ATC) medication for persistent pain and has had well-controlled background pain. As many as 40% to 80% of patients with cancer experience breakthrough pain, with the frequency higher in late- and end-stage cancer

visceral

poorly localized - originates in body organs in thorax, cranium, and abdomen

What are neurotransmitters?

substances that either excite or inhibit target nerve cells. -Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters.

Nonopioid analgesics

such as acetaminophen and NSAIDs, are usually the drugs of choice for both acute and persistent moderate chronic pain. The simplest dosage schedules and least invasive pain management modalities should be used first. Many times, these drugs alone can provide adequate pain relief.

cutaenous

superficial - usually involves skin or subcutaneous tissue

What is pain threshold?

the "minimum intensity of a stimulus that is perceived as painful" example: when a person's hand is immersed in warm water, a sensation of pain eventually occurs as the water is heated. However, the person can tolerate a higher temperature as water is gradually heated to the pain level than if the hand had been plunged into hot water without any preparation.

Fundamental to ongoing assessment is the knowledge of

the basic action, doses, and routes of administration; side effects; and administration guidelines of the analgesic being administered.

Acetaminophen

(Tylenol) has long been viewed as one of the safest and best-tolerated analgesics. It has proven to be an effective drug for acute pain treatment and is the most commonly used analgesic in the United States

neuropathic pain

- caused by a lesion or ds of the peripheral or central nervous system

There are three general classes of drugs used for pain relief:

-Opioid analgesics (all controlled substances; e.g., morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) -Nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDs]) -Adjuvant analgesics (anticonvulsants, antidepressants, multipurpose drugs)

Methadone

-is most commonly used to treat cancer pain (PDQ Supportive and Palliative Care Editorial Board, 2017) and to manage detoxification in people with opioid dependence/addiction. -Methadone is a mu-receptor agonist and an N-methyl-D-aspartate (NMDA) receptor antagonist that must be used cautiously because it has a rapid onset of action and a long half-life.

Wong-Baker FACES Pain Rating Scale

Adults and children (>3 years old) in all patient care settings

0-10 Numeric Rating Scale

Adults and children (>9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain

Critical-Care Pain Observation Tool (CPOT)

Adults who are sedated and nonresponsive

Checklist of Nonverbal Indicators

Adults who are unable to validate the presence of or quantify the severity of pain using either the Numeric Rating Scale or Wong-Baker FACES pain rating scale

Animal-facilitated therapy

Either a patient's own pet or an animal with an experienced handler can be used as complementary therapy to help relieve pain and provide a degree of comfort to people in various health care settings. -Animals that visit patients include dogs, rabbits, guinea pigs, birds, cats, and even llamas

The U.S. Food and Drug Administration (FDA) requires that NSAID labels contain information about the potential for

GI bleeding and skin reactions associated with all NSAIDs, and a warning that all NSAIDs, except for aspirin, increase the risk of myocardial infarction (heart attack) or stroke

General techniques for successfully guiding a patient to use imagery include the following:

Help the patient to identify the problem or goal. Suggest that the patient begin the imagery with several minutes of focused breathing, relaxation, or meditation. Help the patient to develop images of the problem, as well as personal internal resources (e.g., coping strategies) and external healing therapies (e.g., medications, treatments). Encourage images of the desired state of well-being at the end of the session.

he following observations may provide an indication of the presence and severity of pain in a child:

Irritability and restlessness Crying, screaming, or other verbal expression of pain Grimacing, grinding of teeth, or clenching fists Touching or grabbing of painful body part Kicking, thrashing, or attempting to move away from a painful stimulus

Multimodal analgesic therapy

It combines two or more classes of analgesics that target different sites in the peripheral and central nervous systems to maximize pain relief with fewer adverse effects. The most common multimodal approach is a combination of nonopioid, opioid, and adjuvant analgesics

Therapeutic affects of laughter

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

The nurse will generally assess the following characteristics of pain:

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

Pain Assessment in Advanced Dementia Scale (PAINAD)

Patients whose dementia is so advanced that they cannot verbally communicate

The following guidelines are recommended for effective, individualized pain management in any setting:

Review the pain scale of choice thoroughly. Discuss the benefits of using a pain scale. Try various pain control measures. Use pain control measures before pain increases in severity. Ask the patient what has been effective for pain relief in the past. Select and modify pain control measures based on the patient's response. Encourage the patient to try the pain treatment several times before labeling it ineffective. Be open-minded about alternative, nonpharmacologic pain relief strategies. Be persistent. Be a safe practitioner.

The Pasero Opioid-Induced Sedation Scale can be used to assess respiratory depression in adult and pediatric populations:

S = sleep, easy to arouse: no action necessary 1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone

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

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

What is transduction?

The activation of pain receptors. •Nociceptors -peripheral receptors •Neurotransmitters - substances that either excite or inhibit target nerve cells

What is modulation?

The process by which the sensation of pain is inhibited or modified. The sensation of pain appears to be regulated or modified by substances called neuromodulators.

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

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

Behavioral Pain Scale (BPS)

Useful with intubated, critically ill patients; measurement of bodily indicators of pain; and tolerance of intubation

Types of distractions

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

Oucher Pain Scale

Young children who can point to a face to indicate their level of pain

Addiction

a "chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences" (National Institute on Drug Abuse, 2014, p. 5). If people are not misusing the prescribed drug(s), addiction occurs over time and in a small percentage of patients exposed to opioids, even if they have pre-existing vulnerabilities such as long-term opioid use, a history of depression, or an existing substance-use disorder.

Acupressure

a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care.

What is TENS?

a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful impulses carried over small-diameter fibers. The TENS unit consists of a battery-powered portable unit, lead wires, and cutaneous electrode pads that are applied to the painful area (Fig. 35-6). The use of TENS requires a health care provider's prescription. TENS therapy has reportedly been effective in reducing postoperative pain and improving mobility after surgery. Positive results have also been noted when it is used as an adjunct to physical therapy and for patients with low back pain.

analgesic

a pharmaceutical agent that relieves pain. Analgesics function to reduce the person's perception of pain and to alter the person's responses to discomfort.

Bradykinin

a powerful vasodilator that increases capillary permeability and constricts smooth muscle, plays an important role in the chemistry of pain at the site of an injury even before the pain message gets to the brain. It also triggers the release of histamine and, in combination with it, produces the redness, swelling, and pain typically observed when an inflammation is present.

Key indicators of addiction include

a profound craving for the drug, erosion of the inhibitory mechanisms that control efforts to refrain from drug use, and compulsive drug taking. Addiction is associated with long-term opioid use, but surveillance with short-term use is also beneficial.

Fentanyl

a synthetic opioid that is 50 to 100 times stronger than morphine, is available in a variety of forms that range from rapid-acting to long-acting

Hypnosis

a technique that produces a subconscious state accomplished by suggestions made by a hypnotist, has been used successfully in many instances to control pain. The person's state of consciousness is altered by suggestions so that pain is not perceived as it normally would be. -It is generally believed that a successful response to hypnosis is related to the person's openness to suggestion, belief that hypnosis will work, and emotional readiness.

Biofeedback

a technique that uses a machine to monitor physiologic responses through electrode sensors on the patient's skin. The feedback signal or unit transforms the physiologic data into a visual display of their rate and depth of respirations, muscle tension, sweat response, and/or heart rate -Biofeedback decreases the person's pain by reducing the anxiety associated with lack of control over bodily functions, directing the person's attention away from the pain to the person's inner state and the feedback signal, and reducing the cause of the pain.

Acupuncture

a technique that uses thin needles of various lengths inserted through the skin at specific locations to produce insensitivity to pain. It has gained acceptance in the Western world as a CHA to help control discomfort from disorders such as headaches, low back pain, neck pain, osteoarthritis or knee pain, and cancer

Healing Touch (HT)

an energy therapy that has proved valuable as an adjunct to traditional medicine. Studies have indicated that it has been effective in reducing pain and anxiety in hospitalized patients and is recognized as an alternative therapy in end-of-life care for both adults and children (Weaver, 2017). It requires no equipment, uses light touch, and is appropriate for every level of care.

naloxone

an opioid antagonist that reverses the respiratory-depressant effect of an opioid

Pain is defined as

an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

diversion

any act that results in a drug not reaching the person who was originally prescribed the drug

Prostaglandins

are important hormone-like substances that send additional pain stimuli to the CNS.

Transmission

conduction along pathways (A-delta and C-delta fibers)

What are neuromodulators?

endogenous opioid compounds, meaning they are naturally present, morphine-like chemical regulators in the spinal cord and brain.

Therapeutic Touch (TT)

historically is focused more on the universal field and directing life energy to patients. Patients who have received TT state that it helps with feelings of comfort, calmness, and well-being. It is derived from the ancient practice of laying on of hands, but nurses skilled in TT never actually touch their patients when using this technique. Nurses caring for patients with terminal diseases relate that TT complements their efforts to alleviate suffering and can be used to promote comfort during the final stages of life

NSAIDs

nonsteroidal anti-inflammatory drugs. (ibuprofen) have an anti-inflammatory effect. Individual responses to NSAIDs vary, but these agents are contraindicated in patients with bleeding disorders (their action may interfere with platelet function) or probable infections (NSAIDs can mask the signs of an infection)

nociceptive pain

pain from a normal process that results in noxious stimuli being perceived as painful. (peripheral)

intractable pain

pain that is resistant to therapy and persists despite interventions

duration of pain: chronic

pain that lasts beyond the normal healing period. In clinical practice, the time frame associated with defining pain as chronic varies based on the cause and may be anywhere between 1 and 6 months, with 3 months commonly used in practice and 6 months used in research. May be limited, intermittent, or persistent Periods of remission or exacerbation are common

referred pain

pain which originates in one part of the body but is perceived in an area distant from its point of origin. For example, pain associated with a myocardial infarction (heart attack) is frequently referred to the neck, shoulder, chest, or arms (often the left arm)

Primary clinical efforts to prevent addiction include

performing an assessment of addition risks before prescribing opioids, regular monitoring, referral to addiction treatment as needed, and prescription of amounts that minimize the risk of diversion

Psychogenic pain

physical cause for pain can't be identified

The most common side effects associated with opioid use are

sedation, nausea, and constipation. Most side effects disappear with prolonged use, but if constipation persists, it usually responds to treatment with increased fluids and fiber and use of a mild laxative or stool softener.

Substance P

sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves.

The perception of pain involves

the sensory process that occurs when a stimulus for pain is present. It includes the person's interpretation of the pain. (awareness of the characteristics of pain)

What is the gate control theory?

the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain. •Small- and large-diameter nerve fibers conduct and inhibit pain stimuli toward the brain. •Gating mechanism determines the impulses that reach the brain. •Past experiences, the cultural and social environment, personal expectations, beliefs about pain, the emphasis placed on pain, and emotions all effect the opening and closing of the gate.

The four specific physiologic processes involved in nociception (the ability to feel painful stimuli) include:

transduction, transmission, perception, and modulation of pain

There are many opioid analgesics that range from

weak (codeine or tramadol) to strong (morphine, oxycodone, or hydromorphone). Health care providers individualize the choice of medication based on the disease process, level/type of pain, and other assessment factors.

Nursing Diagnoses Related to Pain

•Acute pain -acute pain r/t recent surgery aeb facial grimacing, elevated bp, report of pain of a 7/10 • •Chronic pain - chronic pain r/t history of migraines for 5 years aeb anorexia, alteration is sleep pattern and report of pain as 10/10 at its worst •Labor pain - labor pain r/t prolonged labor and commitment to natural childbirth aeb moaning and verbalizing pain, focused breathing, and frequent repositioning •Pain may also be the etiology for other nursing diagnoses -hopelessness r/t belief that present pain means imminent death, constipation r/t chronic use of narcotic analgesics

Nursing Interventions for Pain: Pharmacologic Pain Relief Measures

•Analgesic administration •Nonopioid analgesics (acetaminophen, NSAIDS) •Opioids or narcotic analgesics - controlled substances (morphine, codeine, oxycodone, meperidine, hydromophone, methadone) •PCA •Local •Epidural •Adjuvant drugs •Anticonvulsants (Tegretol, Neurontin) •Antidepressants (Elavil, trazadone, Paxil, Prozac) •Corticosteroids (Prednisone, dexamethasone) •

The Role of the Nurse in Interpreting and Implementing PRN or Titrated Pain Meds

•Basing decisions on a complete pain assessment including (at least) pain intensity, temporal characteristics, and patient's previous response to this or other analgesics •Using valid and reliable tools that are consistent and individualized to the patient •Considering the pharmacokinetics of the opioid •Avoiding administration issues such as giving partial doses more frequently or making patient wait the full-time interval after a partial dose •Waiting until the peak effect of the first dose is reached before giving a subsequent dose •Verifying the patient's allergies •Teaching the patient the name of the drug, the dose administered, the monitoring process, and potential side effects to report •Evaluating the patient's response •Ensuring complete documentation and communication •Assisting with the development of policies that ensure patient comfort and safety

Managing Pain in Patients With Cognitive Impairment

•Common behaviors that may indicate pain in this population: •Facial expressions •Verbalizations and vocalizations •Body movements •Changes in interpersonal interactions •Changes in activity patterns or routines •Changes in mental status (agitation and aggression) The combination of a history of pain, observations of a patient's pain by families and caregivers, and the presence of medical diagnoses associated with pain also facilitates pain assessment in this population. Moreover, special efforts are needed to identify accurate methods for assessing pain in this population •Assessment tools for patients with dementia include: Pain Assessment in Advanced Dementia The Iowa Pain Thermometer •

Nursing Interventions for Pain: Nonpharmacologic Pain Relief Measures

•Distraction •Prayer •Humor •Music •Imagery •Relaxation •Cutaneous stimulation •Acupuncture •Hypnosis •Biofeedback •Therapeutic touch •Animal-facilitated therapy

Nursing Interventions for Pain

•Establishing trusting nurse-patient relationship •Manipulating factors affecting pain experience •Initiating nonpharmacologic pain relief measures •Managing pharmacologic interventions •Reviewing additional pain control measures, including complementary and alternative relief measures •Considering ethical and legal responsibility to relieve pain •Teaching patient about pain

The Fifth Vital Sign

•In 1995, the American Pain society encouraged caregivers to include assessment of pain as the 5th vital sign. •Required to assess pain and to assess the response to pain treatment. •Each patient's pain experience is unique. Nurses must assess all factors that effect the pain experience - psychological, emotional, and sociocultural, as well as physiologic.

Outcome Identification and Planning

•Outcomes could include reduction or eradication of pain, demonstration of execution of a pain management strategy, or contacting an outpatient center for pain management. •The client will report pain reduction to no more than a 3, 30 minutes after receiving pain medication. •The client will verbalize 2 nonpharmalogic pain interventions to reduce pain immediately after teaching.

When assessing a person's pain, Pasero and McCaffery (2011) discuss these basic methods:

•Patient self-report •Identify pathologic conditions or procedures that may be causing pain; consider physiologic measures (increased blood pressure and pulse) •Report of family member, other person close to the patient or caregiver familiar with the person •Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, protecting the painful area •Physiologic measures: increased blood pressure and pulse •Attempt an analgesic trial and monitor the results

Nursing Interventions for Controlling Pain: Additional Methods for Administering Analgesics

•Patient-controlled analgesia •Epidural analgesia •Local anesthesia

Nursing Interventions for Pain: Manipulating Pain Experience Factors

•Remove or alter cause of pain: removing or loosening a tight binder, if permissible; seeing to it that a distended bladder is emptied; taking steps to relieve constipation and flatus; changing body positions and ensuring correct body alignment; and changing soiled linens and dressings that may be irritating the skin. A hungry or thirsty patient may need a snack or a drink to feel more comfortable. •Alter factors affecting pain tolerance: Fatigue tends to increase pain, so promoting rest is helpful. The patient in pain usually feels more comfortable when the environment is quiet and restful. Although sensory restrictions—such as eliminating unnecessary noise and bright lights—are usually indicated, it is rarely helpful to leave the patient alone in an environment with little sensory input. The patient is then more likely to focus on self and the discomfort. •Initiate nonpharmacologic relief measures.