Effective Pain Management

Pain Management Overview

• Effective pain management uses both pharmacological and nonpharmacological therapies.
• Nerve ablation is an invasive therapy that can be used for intractable cancer-related pain.
• Clients have the right to pain assessment and management.
• Nurses should advocate for and educate clients about effective pain management.
• Nurses should continually assess the client's pain level and provide individualized interventions.
• Pain reassessment may be required 10-60 minutes after administering medication, depending on the setting and route.
• Assessment can be more challenging for clients with cognitive impairment, language differences, or those requiring mechanical ventilation.
• Undertreatment can lead to physiological and psychological issues and poorly managed acute pain may lead to chronic pain syndrome.
• Acute or chronic pain may cause anxiety, fear, and depression.

Pain Categories

• Pain is categorized by duration (acute or chronic) or origin (nociceptive or neuropathic).

Acute Pain

• Acute pain is protective, temporary, and self-limiting with a direct cause, resolving with tissue healing.
• Fight-or-flight responses are physiological responses which include tachycardia, hypertension, anxiety, diaphoresis, and muscle tension.
• Behavioral responses include grimacing, moaning, flinching, and guarding.
• Treatment of the underlying problem is important.
• Unrelieved acute pain can lead to chronic pain.

Chronic Pain

• Chronic pain is not protective, is ongoing, recurs frequently, persists beyond 6 months and past tissue healing.
• Depression, fatigue, and decreased functioning are potential physiological responses; it is often not life-threatening.
• Psychosocial implications can lead to disability.
• Management focuses on symptomatic relief, however, pain may not always respond to interventions.
• Chronic pain is categorized as either cancer pain or noncancer pain.
• Idiopathic pain is chronic pain without a known cause or pain exceeding typical levels for the client.
• Strategies for relieving chronic pain include administering long-acting opioid analgesics (including transdermal) and administering analgesics around the clock rather than PRN.

Nociceptive Pain

• Nociceptive pain comes from tissue damage or inflammation, which is a noxious stimulus to pain receptors called nociceptors.
• The pain is usually throbbing, aching and localized, responding to opioids and non-opioid medications.
• Somatic nociceptive pain affects bones, joints, muscles, skin, or connective tissues.
• Visceral nociceptive pain affects internal organs (stomach or intestines) and can cause referred painseparate from the stimulus.

Neuropathic Pain

• Neuropathic pain comes from abnormal or damaged nerves.
• Phantom limb pain, pain below a spinal cord injury, and diabetic neuropathy are included.
• The pain is often intense, shooting, burning, or described as "pins and needles".
• Adjuvant medications (antidepressants, antispasmodics, skeletal muscle relaxants) and topical medications are useful for peripheral neuropathic pain.

Physiology of Nociceptive Pain

• Transduction: Painful stimuli become electrical impulses via peripheral nerve fibers (nociceptors).
• Transmission: Electrical impulses travel along nerve fibers, regulated by neurotransmitters.
• Pain threshold is the point at which pain is felt.
• Pain tolerance is the amount of pain a person will bear.
• Perception is awareness of pain in the brain, influenced by thoughts and emotions.
• Modulation occurs in the spinal cord, causing reflexive muscle contractions to move away from stimuli.

Substances that Increase Pain Transmission and Cause Inflammation

• Substance P
• Prostaglandins
• Bradykinin
• Histamine

Substances that Decrease Pain Transmission and Produce Analgesia

• Serotonin
• Endorphins

Pain Assessment/Data Collection

• Pain is subjective and exists whenever the client says it does and the client's report is the most reliable measure.
• Standardized pain scales that incorporate images, numbers, words, or other intensity markers are useful for clients over 7 years old.
• Specialized pain scales are available for use with younger children or individuals who have trouble communicating verbally.
• Pain should be assessed and documented frequently as the fifth vital sign and a symptom analysis is useful for obtaining subjective data.
• Use anatomical terminology and landmarks to describe pain location (superficial, deep, referred, or radiating).
• Quality refers to how the pain feels which may be sharp, dull, aching, burning, stabbing, pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying, torturing, nagging, annoying, intense, or unbearable.
• Intensity, strength, and severity are “measures” of the pain and a pain intensity scale is used to measure pain, monitor pain, and evaluate the effectiveness of interventions.
• Onset, duration, and frequency are important related to timing.
• Daily life activities can be affected by pain.
• Fatigue, depression, nausea, and anxiety are associated findings.
• Cultural/societal attitudes, lack of knowledge, fear of addiction and exaggerated fear of respiratory depression are risk factors for undertreatment of pain.
• Populations at risk for undertreatment are infants, children, older adults, and clients who have a substance use disorder.
• Factors that affect the pain experience are trauma, surgery, cancer, arthritis, fibromyalgia, neuropathy, and diagnostic or treatment procedures.
• Infants cannot verbalize or understand their pain and older adult clients can have multiple pathologies that cause pain.
• Fatigue can increase sensitivity to pain and genetic sensitivity can increase or decrease pain tolerance.
• The cognitive function of a client can impact the pain report and prior experiences can increase or decrease sensitivity depending on whether clients obtained adequate relief.
• Anxiety and fear can increase sensitivity to pain, while support systems and coping styles can decrease sensitivity to pain.
• Culture can influence how clients express their pain.
• Behaviors that complement a self-report can assist with the pain assessment of nonverbal clients.
• Facial expressions, body movements, moaning, crying, and decreased attention span are examples of complementing behaviors.
• Blood pressure, pulse, and respiratory rate increase temporarily with acute pain then physiological indicators might not be an accurate measure after vital signs stabilize.
• Hyperalgesia (a heightened sense of pain) and allodynia are conditions that can occur.

Patient-Centered Care - Nursing Care

• Schedule pain interventions around the clock to keep pain at a more tolerable level with PRN dosing for managing pain exacerbations when pain is persistent.
• Review provider prescriptions for analgesia, noting prescriptions may be different depending on pain level.
• Older adults are at an increased risk for undertreatment of pain, as well as adverse events following analgesia administration and take a proactive approach by giving analgesics before pain becomes too severe.
• Clients should report developing or recurrent pain and not wait until pain is severe (for PRN pain medication).
• Help to explain misconceptions about pain, reduce fear/anxiety and create a treatment plan that includes both nonpharmacological and pharmacological pain-relief measures.
• Ensure bed linens are clean and smooth, and that the client is not lying on tubing or other equipment that could cause discomfort.
• Gentle positioning techniques and repositioning can minimize discomfort and instruct clients on strategies to reduce pain.
• Cognitive-behavioral measures are used to change the way a client perceives pain and physical approaches, such as cutaneous (skin) stimulation using TENS, heat, cold, therapeutic touch, and massage, can improve client comfort.
• Distractions using ambulation, deep breathing, visitors, television, games, prayer, and music can help to decrease attention to the presence of pain which can decrease perceived pain level.
• Relaxation includes meditation, yoga, and progressive muscle relaxation and focusing on a pleasant thought for imagery requires an ability to concentrate.
• Acupuncture and acupressure can be used to stimulate subcutaneous tissues at specific points using needles or digits and reduction of pain stimuli in the environment and elevation of edematous extremities can reduce swelling.

Pharmacological Interventions

• Analgesics are the mainstay for relieving pain.
• Non-opioids, opioids, and adjuvants are the three classes of analgesics.
• The parenteral route is best for immediate, short-term relief of acute pain.
• The oral route is better for chronic, non-fluctuating pain.
• Non-opioid analgesics (acetaminophen, NSAIDs, including salicylates) treat mild to moderate pain.
• Be aware of the hepatotoxic effects of acetaminophen and clients who have a healthy liver should take no more than 4 g/day and be aware of opioids that contain acetaminophen.
• Monitor for salicylism (tinnitus, vertigo, and decreased hearing acuity), prevent gastric upset, and monitor for bleeding.
• Opioid analgesics (morphine sulfate, fentanyl, and codeine) treat moderate to severe pain and monitor and intervene for adverse effects of opioid use.
• Monitor level of consciousness and take safety precautions for sedation (which usually precedes respiratory depression).
• For respiratory depression, monitor respiratory rate prior to and following administration of opioids, especially for clients who have little previous exposure.
• Initial treatment of respiratory depression and sedation is generally a reduction in opioid dose and if necessary, slowly administer diluted naloxone to reverse opioid effects.
• Advise clients to sit or lie down if lightheadedness or dizziness occur and avoid sudden changes in position and provide assistance with ambulation to prevent orthostatic hypotension.
• Monitor I&O, assess for distention, administer bethanechol, and catheterize for urinary retention and administer antiemetics, advise clients to lie still and move slowly, and eliminate odors for nausea/vomiting.
• Use a preventative approach (monitoring of bowel movements, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas) for constipation.
• Adjuvant analgesics enhance the effects of non-opioids, help alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are helpful for treating neuropathic pain.
• Anticonvulsants, antianxiety agents, tricyclic antidepressants, anesthetics, antihistamines, glucocorticoids, antiemetics, bisphosphonates, and calcitonin are examples.

Patient-Controlled Analgesia (PCA)

• Allows clients to self-administer safe doses of opioids and small, frequent dosing ensures consistent plasma levels.
• Clients have less lag time between identified need and delivery which increases their sense of control and can decrease the amount of medication they need.
• Morphine, hydromorphone, and fentanyl are typical opioids for PCA delivery and let the nurse know if using the pump does not control the pain.
• Only the client should push the PCA button to prevent inadvertent overdosing.
• Additional pharmacological pain interventions include local and regional anesthesia and topical analgesia.
• Undertreatment of pain is a serious complication that can lead to increased anxiety with acute pain and depression with chronic pain, so assess clients frequently and intervene.
• Sedation, respiratory depression, and coma can occur as a result of overdosing and sedation always precedes respiratory depression.
• Identify high-risk clients (older adult clients, clients who are opioid-naïve), carefully titrate dose while closely monitoring respiratory status.
• If respiratory rate is below 8/min and shallow, or the client is difficult to arouse, stop the opioid and give the antagonist naloxone and identify the cause of sedation.