Exam 13 - Managing the Patient with Pain

The Nature of Pain

• Pain is a complex and personal experience; subjective experience.
• Pain is an unpleasant sensation caused by noxious stimulation of the sensory nerve endings.
• Pain serves as a warning to the body of actual or potential tissue damage.
• Pain is a cardinal sign of inflammation and is valuable in diagnosing many disorders and conditions.
• Pain can occur even without tissue damage, such as the pain of grief or migraine headaches.
• The interpretation and significance of pain depend on the individual's learned experiences, including psychosocial and cultural factors.
• Only the person experiencing pain is the expert on their own pain, not the healthcare provider.
• Patients with pain may not always know how to report pain to healthcare professionals.
• Nurses play a vital role in empowering patients to be active partners in reporting pain information.

How Pain is Perceived

• Pain is recognized in the brain, not in the body area where it originates.
• When a body part is injured, nerve endings at the point of injury transmit electrical impulses along nerves to the spinal cord.
• At the spinal cord, the signal is transferred to special pain nerve tracts and travels up the spinal cord to the brain.
• Pain is perceived only in the brain.
• Any interference with the transmission of the pain signal from the point of injury to the brain can alter pain perception.
• Severed spinal cord nerve tracts prevent pain impulses from being transmitted.
• Damage to the area of the brain responsible for interpreting pain prevents pain perception.
• Anxiety, depression, fatigue, and chronic diseases can increase pain perception.

Theories of Pain Transmission

• Gate Control Theory:
  • Pain impulses can be regulated or blocked by gating mechanisms located in the central nervous system, particularly in the dorsal horn of the spinal cord.
  • Pain and other sensations travel the same pathways through large nerves in the spinal cord.
  • Cutaneous stimuli other than pain can temporarily block the "gate" for pain impulses.
  • The brain focuses on other stimuli, blocking pain perception.
  • Sensory bombardment (pressure, heat, cold) can close the gate to painful stimuli.
  • Distraction can help make pain more tolerable.
  • Gating mechanisms can be influenced by thoughts, feelings, and memories.
• Endorphins:
  • The body produces morphine-like substances called endorphins.
  • Stress and pain activate endorphin release.
  • Endorphins attach to opioid receptor sites in the brain, preventing the release of neurotransmitters and inhibiting pain transmission.
  • Individuals with higher endorphin levels experience less pain from similar injuries.
  • Pain relief measures like TENS, acupuncture, and placebos are believed to trigger endorphin release.

Classification of Pain

• Acute Pain:
  • Intense and short-duration pain.
  • Usually lasts less than 6 months.
  • Serves as a warning sign of tissue damage.
  • Triggers a sympathetic nervous system response, releasing epinephrine ("fight or flight").
  • Associated with anxiety.
  • Often treated with opioids and other analgesics.
  • Examples: post-surgical pain, traumatic injury, bone fracture, infection.
• Chronic Pain:
  • Pain lasting longer than 6 months.
  • Can be continuous or intermittent and may be as intense as acute pain.
  • Not a warning sign of tissue damage; may be due to past damage.
  • Associated with conditions like arthritis, back injuries, neurologic conditions, and accidents.
  • Can lead to low self-esteem, social identity changes, fatigue, sleep disturbance, and depression.
• Continuous Pain: Always present, but may vary in intensity (e.g., sciatica).
• Intermittent Pain: Comes and goes (e.g., abdominal cramping, intestinal irritation).
• Nociceptive Pain: Localized pain described as aching or throbbing (e.g., arthritis, cuts, fractures).
• Visceral Pain: Difficult to pinpoint, may be referred to distant sites, described as continual aching (e.g., shoulder pain with gallstones).
• Neuropathic Pain: Sharp, shooting, stabbing, or burning sensations (e.g., diabetic neuropathy, shingles).
• Cancer Pain: Complex and multifaceted, often involving multiple pain types and requiring multiple pain management approaches.

Joint Commission Standards for Pain Control

• Healthcare providers are expected to be knowledgeable about pain assessment and management.
• Facilities must develop policies and procedures supporting the use of analgesics and other pain management therapies.
• Key Concepts:
  • Patients have the right to appropriate pain assessment.
  • Patients will be treated for pain or referred for treatment.
  • Pain will be assessed and regularly reassessed.
  • Patients will be educated about effective pain management.
  • Patients will be involved in making care decisions.
  • Routine and PRN analgesics will be administered as ordered.
  • Discharge planning includes continuing pain management based on individual needs.

Pain as a Vital Sign

• Treating pain as a vital sign, alongside pulse, temperature, blood pressure, and respirations, ensures regular monitoring.
• Using a pain rating scale (0-10, 0 being no pain and 10 being the worst imaginable) helps patients clearly articulate their pain and receive appropriate treatment.
• Effective pain management leads to quicker recoveries, shorter hospital stays, fewer readmissions, and improved quality of life.
• Unrelieved pain has harmful physical and psychological effects, including increased oxygen demand, respiratory dysfunction, decreased GI motility, confusion, and a weakened immune system.

Pain Assessment Guideline (HILDA)

• Characteristics of Pain: How does your pain feel? (e.g., aching, throbbing, shooting)
• Intensity: What is your pain level now? In the past 24 hours? (0-10 scale or other appropriate scale)
• Location: Where is your pain?
• Duration: Is the pain constant, intermittent, or associated with activity?
• Aggravating/Alleviating Factors: What makes the pain better or worse?
• Other Assessments:
  • How does the pain affect sleep, energy, relationships?
  • Are there any accompanying symptoms (e.g., nausea, vomiting, itching)?
• To Check:
  • Vital signs
  • Past medical history
  • Patient's understanding of pain
  • Use of non-invasive techniques

Nursing Assessment of Pain

• Subjective Data: Nurses should be skilled in pain assessment, as it is a subjective experience.
  • Characteristics to note: site, severity, duration, location.
  • Sociocultural information is beneficial. Understanding cultural backgrounds helps ensure accurate assessment.
  • Pain rating scales aid in measuring pain levels.
  • Scales should be easy to use, understandable, and consistent for the same patient.
  • The 0-10 scale is common.
  • Visual scales combine descriptions and facial expressions with assigned numbers.
  • Specific scales are available for children.
• Objective Data:
  • Tachycardia
  • Increased respiratory rate and depth
  • Diaphoresis, pallor
  • Increased blood pressure
  • Increased muscle tension in the face and body
  • Behavioral signs (rigid body posture, restlessness, frowning, clenching teeth, crying, moaning).
  • Some patients may report pain without outward signs.

Nursing Interventions for Pain

• Non-Pharmacological Interventions:
  • Tighten wrinkled linens.
  • Reposition drainage tubes or other objects.
  • Provide warm blankets if cold.
  • Loosen constricting bandages.
  • Change moist dressings.
  • Position patient in proper alignment.
  • Check the temperature of hot or cold applications.
  • Lift (don't pull) the patient up in bed.
  • Position the patient on a bedpan correctly.
  • Prevent skin or mucous membrane irritation.
  • Prevent urinary retention and constipation.

Guidelines for Individualized Pain Therapy

• Begin pain intervention immediately when the patient reports pain.
• Reduce the patient's anxiety by acknowledging their pain and offering support.
• Clarify concerns, answer questions, and provide information for informed decision-making.
• Be an effective advocate for the patient:
  • Believe the patient is in pain and build trust.
  • Discuss the plan of care and expectations for the patient and family.
  • Respect the patient's right to express pain.
  • Encourage effective coping techniques from the past.
  • Provide reassurance and distraction as needed.
• Fundamental Principle: "The failure to treat pain is inhumane and constitutes professional negligence."
• Ultimate Goals of Pain Management:
  • Provide pain relief through immediate intervention.
  • Enable the patient to resume activities of daily living with minimal pain.
  • Enhance self-esteem.
  • Improve sleep quality.
• Use Multiple Pain Relief Measures:
  • Combining therapies can have an additive effect in pain reduction.
  • The character of pain changes throughout the day, requiring multiple approaches.
• Provide Pain Relief Before Pain Becomes Severe:
  • Preventing severe pain is easier than relieving it.
  • Administer medications before painful procedures.
  • Use PRN medications regularly to control moderate to severe pain.
• Use Measures That the Patient Believes Are Effective:
  • The patient is the expert on their own pain and has valuable insight into what works best.
• Consider the Patient's Ability and Willingness to Participate:
  • Some patients may not be able to actively participate due to fatigue, sedation, or altered consciousness.
  • Do not force unwilling patients into therapy.
• Choose Appropriate Pain Relief Measures Based on Pain Severity:
  • Avoid using potent opioids for mild pain.
  • Assess the patient's self-reported pain levels to guide therapy selection.
• Encourage Persistence with Therapy:
  • Reassure patients that even if a therapy is initially ineffective, it may become effective with continued use.
  • Anxiety, doubt, or the need for adjustment can sometimes hinder the effectiveness of certain therapies.
• Maintain an Open Mind:
  • New pain control methods are continually emerging, and much about pain remains to be discovered..
• Never Give Up:
  • It can be frustrating when pain relief efforts fail.
  • If pain persists, reassess the situation and explore alternative therapies.
• Prioritize Patient Safety:
  • All pain relief measures have potential side effects.
  • Strive to relieve pain without disabling the patient mentally, emotionally, or physically.
  • Ensure patient and environmental safety.

Non-Pharmacological Pain Control

• Pain control without medication.
• Can be helpful even when used alongside medication.
• Aims to decrease pain perception and improve the patient's sense of control.

Types of Non-Pharmacological Pain Control

• Physical Interventions:
  • Deep Tissue Massage: Reduces muscle tension and spasms; effective for mild to moderate discomfort.
  • Exercise: Strengthens core muscles and stabilizes the spine to reduce discomfort.
  • Transcutaneous Electrical Nerve Stimulation (TENS): Stimulates the skin with mild electric current, reducing mild to moderate pain; believed to release endorphins and block pain impulses; requires specialized equipment.
  • Heat or Cold Application:
    • Moist heat relieves stiffness in arthritis and relaxes muscles.
    • Cold application reduces acute pain associated with inflammation.
  • Flotation Therapy: Involves floating in a chamber of water with magnesium sulfate; reduces musculoskeletal pain due to near-zero gravity and magnesium absorption.
  • Acupuncture: Inserts fine needles into the skin; believed to balance the body's energy flow; requires professional administration.
• Psychological and Cognitive Interventions:
  • Music: Simple relaxation and anxiety reduction; studies show it can reduce postoperative pain by 50%.
  • Biofeedback: Reduces mild to moderate pain and muscle tension; requires high cognitive function, skilled personnel, and specialized equipment.
  • Imagery: Reduces mild to moderate pain; encourages focusing on a pleasant image to divert attention from pain; may require assistance to relax and focus.
  • Humor: Reduces mild to moderate pain; laughter and humor increase oxygenation and circulation, improving rest and sleep.
  • Education: Effective for all types of pain; should include sensory and procedural information to reduce activity-related pain.

Opioid Analgesic Agents

• Include morphine, codeine, heroin, and synthetic medications like hydromorphone, hydrocodone, fentanyl, and oxycodone.
• Potential for Abuse:
  • Strong opioids like hydromorphone and fentanyl require lower doses for the same effect as weaker opioids.
  • Morphine and strong opioids are used for severe pain in hospitals and hospice settings.
  • Codeine, hydrocodone, and oxycodone are weaker and often combined with acetaminophen for outpatient use.
• Tolerance and Dependence:
  • Signs of tolerance and dependence occur after 1-4 weeks of regular opioid therapy.
  • Tolerance: The body gradually increases the rate of drug breakdown and elimination, requiring higher doses for pain control.
  • Dependence: Withdrawal symptoms (nausea, anxiety) occur after stopping or reducing the medication.
  • Tapering off the medication slowly can minimize withdrawal symptoms.
• Psychological Dependence (Addiction):
  • An intense craving for and use of the drug for non-medical reasons.
  • Difficulty controlling drug craving and use.
• Pain Relief Not Denied Due to Addiction Fears: Patients in pain should not be denied opioid medication solely because of addiction concerns.

Opioids

• Opioids bind to Mu, Kappa, and Delta receptors, primarily acting on Mu receptors.
• Mu receptor activation results in pain relief, respiratory depression, sedation, decreased intestinal motility, pupil constriction, lower blood pressure, and euphoria.
• Opioids change the perception of pain, not the source of the pain.
• Opioids can be combined with acetaminophen, aspirin, caffeine, and barbital for enhanced effects.
• Expected side effects include sedation, constipation, bradycardia, hypotension, decreased respirations, dry mouth, and euphoria.
• Serious adverse reactions and overdose symptoms require immediate medical attention, including respirations of 8 breaths per minute or less, very low blood pressure, excessive sedation or coma, and below-normal body temperature.
• Naloxone (Narcan) or naltrexone (Revia) can reverse opioid effects by blocking the Mu receptors.
• Opioids have depressive effects on the CNS, so avoid substances like alcohol, antianxiety drugs, muscle relaxants, barbiturates, and psychiatric drugs.

Nursing Implications for Opioids

• Assess pain using appropriate tools and vital signs, specifically respiratory rate and SpO2.
• Administer opioids before pain becomes severe.
• Double-check the medication name and dosage, ensuring accuracy.
• Ensure patient safety due to drowsiness and dizziness.
• Monitor pain relief and respiratory changes every hour.
• Patient teaching includes taking medication as prescribed, avoiding alcohol, changing positions slowly to prevent dizziness, and managing constipation with fluids, fiber, and laxatives.

Administration Routes for Opioids

• IV route is ideal for rapid pain relief after major surgery.
• IM administration is less effective and potentially dangerous due to variable absorption.
• Oral route is often optimal for chronic pain treatment due to convenience, flexibility, and steady blood levels.
• Patient-controlled analgesia (PCA) allows patients to self-administer analgesics as needed.
• Epidural analgesia delivers opioids directly to the epidural space for greater effects with lower doses.
• Elastomeric pumps (Pain Balls) administer local anesthetics through a catheter beneath the skin for up to 2-5 days.

Acetaminophen

• Acetaminophen reduces pain and fever by inhibiting prostaglandin production in the brain.
• It does not act on the site of injury and lacks anti-inflammatory properties.
• Usual adult dosage is 325-650mg every 4 hours, not exceeding 4 grams per day to prevent liver disease.
• Common side effects are nausea and skin rash.
• Liver toxicity is possible with high doses or prolonged use.
• Many OTC medications contain acetaminophen, so consider total daily intake when administering.

Nursing Implications for Acetaminophen

• Assess patient’s pain and inquire about OTC medications.
• Ensure accurate calculations when administering liquid formulations.
• Reassess pain level 1 hour after administration.
• Patient teaching includes taking medication as prescribed, avoiding alcohol, and staying aware of the amount of acetaminophen in other OTC medications.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• NSAIDs work at the site of injury by inhibiting inflammatory mediators (COX-1 and COX-2), resulting in analgesic, anti-inflammatory, anti-platelet, and antipyretic effects.
• COX-1 protects the stomach lining, decreases fever, and promotes platelet aggregation.
• COX-2 triggers pain and inflammation.
• Non-selective NSAIDs block both COX-1 and COX-2, while selective COX-2 inhibitors target only COX-2, resulting in fewer side effects.
• NSAIDs are used for pain in muscles, nerves, joints, headaches, dysmenorrhea, and various forms of arthritis.
• Common side effects include heartburn, nausea, vomiting, dizziness, headache, and increased bleeding risk.
• All NSAIDs except aspirin can cause fluid retention, edema, and increased blood pressure, so they should be avoided by patients with hypertension, heart failure, or renal failure.

Nursing Implications for NSAIDs

• Assess for allergies to aspirin, asthma, bleeding disorders, GI problems, liver or renal disease.
• Administer NSAIDs with a full glass of water or with food to minimize GI upset.
• Monitor for pain relief, signs of bleeding, bruising, and vital signs.
• Patient teaching includes taking the medication with water or food, reporting abnormal bleeding or bruising, avoiding alcohol and anticoagulants, staying hydrated, taking the medication regularly for maximum effect, and avoiding OTC medications containing aspirin or other NSAIDs.

Fatigue, Sleep Disturbances, and Depression

• Fatigue, sleep disturbance, and depression can work synergistically to worsen pain perception.

Rest and Sleep

• Rest is crucial for healing physical and psychological illnesses.
• Bedrest reduces physical and psychological demands on the body.
• Sleep provides sustained rest, repair, and recovery for body systems.
• Sleep-wake cycle regulates body functions and behavioral responses.
• Disrupted sleep-wake cycles can negatively affect other physiological functions.

Stages of Sleep

• Sleep consists of two phases: Rapid eye movement (REM) and non-rapid eye movement (NREM).
• NREM progresses through four stages:
  • Stage 1: Lightest sleep, brief duration, easily aroused.
  • Stage 2: Sound sleep, longer duration, easily aroused.
  • Stage 3: Deep sleep, longer duration, difficult to arouse, hormonal release.
  • Stage 4: Deepest sleep, longer duration, very difficult to arouse, significant vital sign reductions.
• REM sleep is characterized by rapid eye movement, fluctuating blood pressure, and skeletal muscle relaxation.

Sleep Deprivation

• Sleep deprivation affects the amount, quality, and consistency of sleep, disrupting sleep cycles and stages.
• Physiological changes include hand tremors, decreased reflexes, slowed response time, reduced memory, decreased reasoning and judgment.
• Psychological changes include mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperexcitability.

Factors Affecting Sleep

• Healthcare facility routines can disrupt sleep habits.
• Physical illness: pain, discomfort, altered positions, fear of sleep, nocturia, restless legs syndrome, and altered CNS can disrupt sleep.
• Anxiety and depression: increased anxiety and depression lead to sleep deprivation, which further exacerbates anxiety and depression.
• Drugs and substances: hypnotics, medications, and other substances can affect sleep patterns and quality.
• Lifestyle: work shifts, heavy work, late-night activities, and changing mealtimes can disrupt sleep.
• Sleep patterns: starting time, duration, and sleep abnormalities can affect future sleep attempts.
• Stress: tension, fear, and hormonal release associated with stress can lead to sleeplessness.
• Environment: ventilation, lighting, bed type, sound level, presence of a bed partner, and hospital-related noises can affect sleep.
• Exercise and fatigue: moderate exercise can improve sleep, while excess fatigue can make falling asleep difficult.
• Nutrition: weight gain can lengthen sleep periods, while weight loss can lead to shorter, broken sleep.

Promoting Rest and Sleep Interventions

• Determine the patient’s usual sleep patterns and adequacy.
• Develop a plan to improve rest:
  • Minimize nighttime interruptions.
  • Provide a quiet environment with a comfortable temperature.
  • Limit visitors and visit duration.
• Prepare for sleep:
  • Wash the patient’s back.
  • Give a backrub.
  • Change linens.
  • Ensure warmth.
  • Offer a warm beverage.
  • Change soiled dressings.
  • Assist with urination.
• Decrease environmental stimuli: dim lights, reduce noise.
• Administer sleep medication or analgesics as ordered.
• Implement safety precautions: nightlight, lower bed.

The Nature of Pain

• Pain is a complex, personal, and subjective experience.
• Pain is an unpleasant sensation caused by stimulation of sensory nerve endings.
• Pain serves as a warning sign to the body, often indicating actual or potential tissue damage.
• Pain may be a significant symptom of inflammation.
• Some pain can occur without tissue damage, such as the pain of grief or migraine headaches.
• The interpretation and significance of pain are influenced by individual experiences, psychosocial factors, and cultural perspectives.
• Only the individual experiencing the pain is the expert on their pain.
• People experiencing pain may not always know how to effectively communicate it to healthcare providers.
• Nurses play a crucial role in assessing and understanding patient pain, empowering them to actively participate in reporting their pain experience.

How Pain is Perceived

• Pain is perceived in the brain, not in the injured body part.
• When an injury occurs, pain nerve endings send electrical impulses through nerves to the spinal cord.
• In the spinal cord, these impulses are transferred to pain pathways and travel to the brain where the point of injury is perceived.
• Anything interfering with the transmission of these impulses can affect pain perception.
• Severed spinal cord nerve tracts can block pain perception, even in the presence of severe injury.
• Injury to the brain area responsible for pain interpretation can prevent pain from being perceived.
• Factors like anxiety, depression, fatigue, and chronic diseases can amplify the perception of pain.

Theories of Pain Transmission

• **Gate Control Theory:**Suggests pain impulses can be regulated or blocked by gating mechanisms within the central nervous system.
  • These gates are located in the dorsal horn of the spinal cord.
  • Pain and other sensations travel through the same pathways in the spinal cord.
  • Non-painful stimuli can temporarily block the "gate" for pain impulses.
  • This allows the brain to focus on other sensory information, potentially reducing pain perception.
  • Distraction techniques, like pressure, heat, cold, or auditory/visual stimuli, can close the pain gate.
  • Thoughts, feelings, and memories can also influence these gating mechanisms, highlighting the role of conscious control in pain perception.
• Endorphins:
  • The body contains natural morphine-like substances called endorphins.
  • Stress and pain trigger endorphin release.
  • Endorphins attach to opioid receptor sites in the brain, preventing the release of neurotransmitters and inhibiting pain transmission.
  • Individuals with higher endorphin levels may experience less pain from similar injuries.
  • Pain relief measures like transcutaneous electric nerve stimulation (TENS), acupuncture, and placebos are believed to trigger endorphin release.

Classification of Pain

• Acute Pain:
  • Intense and short-lived, typically lasting less than 6 months.
  • Often serves as a warning signal of tissue damage.
  • Triggers the body's "fight or flight" response, releasing epinephrine.
  • Usually accompanied by anxiety.
  • Opioids and other analgesics are commonly prescribed.
  • Examples: post-surgical pain, traumatic injury, bone fractures, infections.
• Chronic Pain:
  • Pain lasting longer than 6 months.
  • Can be continuous or intermittent, with potential for intense pain like acute pain.
  • May not indicate tissue damage, often related to pre-existing conditions like arthritis, back injuries, neurologic issues, or accidents.
  • Associated with negative effects like low self-esteem, social isolation, fatigue, sleep disturbance, and depression.
• Continuous Pain: Always present but may vary in intensity. Associated with conditions like sciatica (back pain).
• Intermittent Pain: Comes and goes. Associated with conditions like abdominal cramping or intestinal irritation.
• Nociceptive Pain: Specific to a particular body part, described as aching or throbbing. Associated with conditions like arthritis, cuts, and fractures.
• Visceral Pain: Difficult to pinpoint, may be felt in distant areas. Described as constant aching. Associated with conditions like right shoulder pain with gallstone disease.
• Neuropathic Pain: Sharp, shooting, stabbing, or burning sensations. Associated with conditions like diabetic neuropathy or shingles.
• Cancer Pain: Often encompasses multiple types of pain due to various causes. Requires complex pain management strategies.

Joint Commission Standards for Pain Management

• Healthcare providers are expected to be proficient in pain assessment and management.
• Facilities must establish policies and procedures supporting appropriate use of analgesics and other pain-control therapies.
• Key Joint Commission Principles:
  • Patients have the right to pain assessment and appropriate treatment.
  • Unrelieved pain needs medical intervention or referral.
  • Pain requires regular assessments and reassessments.
  • Patients should be educated about effective pain management.
  • Pain management is considered a vital part of treatment plans.
  • Patients should be involved in decision-making about their care.
  • Analgesics are administered routinely and as needed.
  • Discharge planning includes instruction for ongoing pain management.
• Making pain a vital sign, alongside pulse, temperature, blood pressure, and respirations, ensures consistent monitoring.
• Pain rating scales help patients articulate their pain level and promote proper treatment.
• Effective pain management leads to quicker recoveries, shorter hospital stays, fewer readmissions, and improved quality of life.
• Unrelieved pain can have harmful physical and psychological effects, including increased oxygen needs, respiratory issues, digestive problems, confusion, and weakened immunity.

Pain Assessment Guideline (HILDA)

• How does your pain feel? (Characteristics: aching, throbbing, shooting, etc.)
• Intensity (0-10 scale, or other appropriate scale: What is your pain level now? In the past 24 hours?)
• Location (Where is your pain located?)
• Duration (Constant, intermittent, with activity, etc.)
• Aggravating and Alleviating Factors (What makes your pain better or worse?)
• Other Assessments:
  • How does the pain affect sleep, energy, relationships, etc.?
  • Are you experiencing any other symptoms? (Nausea, vomiting, itching, etc.)
• Things to Check:
  • Vital Signs
  • Past Medical History
  • Knowledge of Pain
  • Use of Non-Invasive Techniques

Nursing Assessment of Pain

• Subjective Data:
  • Pain is subjective, requiring skilled nursing assessment.
  • Important characteristics include site, severity, duration, and location of pain.
  • Understanding cultural backgrounds and personal characteristics improves pain assessment accuracy.
  • Pain rating scales are useful for measuring pain intensity.
  • A good pain rating scale is easy to understand and use.
  • Consistent use of the same scale for a patient is recommended.
  • Examples of pain scales: 0-10 scale, visual scale with numeric and facial expressions, FACES pain rating scale for children.
• Objective Data:
  • Tachycardia (elevated heart rate).
  • Increased rate and depth of respirations.
  • Diaphoresis (sweating).
  • Pallor (pale skin).
  • Elevated blood pressure.
  • Increased muscle tension in the face and body.
  • Behavioral signs: rigid body posture, restlessness, frowning, teeth clenching, crying, moaning.
• Nursing Interventions:
  • Tighten loose bed linens.
  • Reposition drainage tubes or other objects that may be causing discomfort.
  • Provide warm blankets if the patient is cold.
  • Loosen constricting bandages.
  • Change moist dressings.
  • Position the patient anatomically to ensure comfort.
  • Monitor the temperature of hot or cold applications.
  • Assist the patient in getting out of bed by lifting, not pulling.
  • Position the patient correctly on a bedpan.
  • Avoid exposing skin or mucous membranes to irritants.
  • Prevent urinary retention and constipation.
• Guidelines for Individualizing Pain Therapy:
  • Begin immediate pain intervention when the patient reports pain.
  • Reduce patient anxiety by validating their pain and assuring them of assistance.
  • Provide timely pain relief measures.
  • Address patient concerns, answer questions, and ensure informed decision-making.
  • Effective patient advocacy involves:
    • Believing the patient's pain and gaining their trust.
    • Discussing treatment strategies and expectations with the patient and family.
    • Respecting the patient's right to express their pain.
    • Encouraging the use of past coping techniques.
    • Providing reassurance and distraction when needed.
  • Failing to treat pain is considered inhumane and professionally negligent.
  • Ultimate Pain Management Goals:
    • Provide pain relief through prompt interventions.
    • Enable the patient to resume activities of daily living with minimal pain.
    • Enhance patient self-esteem through effective pain management.
    • Improve sleep quality through pain control.
  • Pain Management Strategies:
    • Using multiple therapy approaches can have an additive effect.
    • Pain characteristics may change throughout the day, necessitating the use of different interventions.
    • Administer pain relief measures before pain becomes severe, as it is easier to prevent severe pain than to relieve it.
    • Provide PRN medication round-the-clock to manage moderate to severe pain.
    • Choose measures that the patient believes are effective, as they are the experts on their own pain.
    • Consider the patient's ability and willingness to participate in pain management.
    • Select interventions appropriate to the severity of the pain.
    • Encourage the patient to re-try a therapy if it was initially ineffective, as anxiety or doubt can hinder its effectiveness.
    • Maintain an open mind about potential pain relief measures, acknowledging that new approaches are continually being developed.
    • Persist in finding effective pain relief methods.
    • Protect the patient by minimizing the risk of side effects and ensuring patient and environmental safety.

Non-Pharmacological Pain Control

• Control pain without medication.
• Aim to reduce pain perception and enhance the patient's sense of control.
• Two types of non-pharmacological interventions: Physical Interventions and Physiological/Cognitive Interventions.
• Physical Interventions:
  • Deep Tissue Massage: Reduces muscle tension and spasms, effective for mild to moderate discomfort.
  • Exercise: Strengthens core muscles and stabilizes the spine to alleviate pain.
  • Transcutaneous Electric Nerve Stimulation (TENS): Reduces mild to moderate pain by stimulating the skin with mild electric current. Electrodes are placed near the pain site. Believed to trigger endorphin release and block pain impulses. Requires specialized equipment.
  • Heat or Cold Application:
    • Moist heat relieves stiffness from arthritis and relaxes muscles.
    • Cold application reduces acute pain associated with inflammation from arthritis or injury.
  • Flotation Therapy: Involves floating in a magnesium sulfate solution, promoting relaxation and reducing musculoskeletal pain.
  • Acupuncture: Involves the insertion of fine needles into the skin. Believed to balance energy flow in the body. Requires a trained professional.
• Physiological and Cognitive Interventions:
  • Music: Provides relaxation and reduces anxiety. Music can significantly reduce postoperative pain.
  • Biofeedback: Reduces mild to moderate pain and muscle tension. Requires a patient with good cognitive function and specialized equipment.
  • Imagery: Reduces mild to moderate pain. Encourage the patient to focus on a pleasant image to distract from pain. May require assistance for relaxation and focus.
  • Humor: Reduces mild to moderate pain. Laughter increases oxygenation and circulation, improving rest and sleep.
  • Education: Effective for all types of pain. Provides sensory, procedural information, and instruction to minimize activity-related pain.

Opioid Analgesic Agents

• Opioids include compounds like morphine, codeine, and heroin.
• Synthetic opioid medications include hydromorphone, hydrocodone, fentanyl, and oxycodone.
• Opioids have a high potential for abuse.
  • Strong opioids, like hydromorphone and fentanyl, require lower doses for pain relief compared to weaker opioids.
  • Morphine and other strong opioids are used in hospital and hospice settings for severe pain.
  • Codeine, hydrocodone, and oxycodone are weaker than morphine and commonly used in outpatient settings combined with acetaminophen.
• Physical tolerance and physical dependence can occur after 1-4 weeks of regular opioid use. These are not abnormal and should not be confused with addiction.
  • Tolerance develops as the body degrades and eliminates the drug more quickly, requiring higher doses for pain control.
  • Dependence refers to withdrawal symptoms occurring when the drug is stopped or reversed.
  • Withdrawal symptoms include physical and mental changes like nausea or anxiety.
  • Gradually tapering off the medication can reduce withdrawal symptoms.
• Substance use disorder or psychological dependence is a distinct issue, characterized by a compelling need for non-medical drug use with limited control.
• Individuals experiencing pain should not be denied pain relief due to the fear of addiction.

Opioids

• Act by binding to mu receptors
• Reduce pain perception
• Do not address the source of pain
• Can be combined with other medications to manage pain
• Common side effects: sedation, constipation, bradycardia, hypotension, decreased respirations, dry mouth, euphoria
• Serious adverse reactions require immediate medical attention: respirations less than 8 breaths per minute, very low blood pressure, excessive sedation or coma, below-normal body temperature
• Contraindications: substances that have a depressive effect on the CNS, such as alcohol, antianxiety drugs, muscle relaxants, barbiturates, and psychiatric drugs
• Nursing implications: assess pain using HILDA and vital signs, give dose before pain becomes severe, ensure patient safety due to potential drowsiness and dizziness, monitor for pain relief and changes in respirations
• Patient teaching: take as prescribed, do not change dosage, keep record of times and amount of medication taken, avoid alcohol, change position slowly to prevent dizziness, increase fluid and fiber intake to prevent constipation
• IV route is best for administration after major surgery, IM administration is ineffective, oral route is optimal for chronic pain, patient-controlled analgesia (PCA) allows patients to self-administer analgesics, epidural analgesia delivers medication directly to the action site, elastomeric pumps provide local anesthetic medication via a catheter placed beneath the skin

Acetaminophen (APAP)

• Common drug for pain relief, available over-the-counter and in IV form
• Acts in the brain to reduce prostaglandin production, which reduces pain perception
• Does not work at the site of injury and has no anti-inflammatory effects
• Used for mild to moderate pain, and can be combined with other medications to manage severe pain
• Used to reduce fever in infants and children
• Common side effect: nausea and skin rash
• Adverse reaction: liver toxicity with large doses or long-term use
• Nursing implications: assess patient's pain, ask about OTC medications, ensure accurate calculations for liquid preparations
• Patient teaching: take as ordered, do not exceed 4 g/day, avoid alcohol

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Act in the tissue where pain starts, reducing inflammation
• Slow the production of inflammatory mediators (COX-1 and COX-2)
• Non-selective NSAIDs block both COX-1 and COX-2, leading to more side effects than selective COX-2 inhibitor NSAIDs
• Common side effects: heartburn, nausea, vomiting, dizziness, headache, increased risk of bleeding and bruising
• Adverse reactions: renal failure, upper or lower GI bleeding, blood disorders, increased risk of myocardial infarction and stroke
• Nursing implications: assess for allergies, bleeding disorders, GI problems, liver or renal disease, give with a full glass of water or with food, monitor for signs of bleeding and bruising
• Patient teaching: take with a full glass of water or food, report abnormal bleeding or bruising, avoid OTC medications containing aspirin or other NSAIDs, stay well hydrated

Rest and Sleep

• Fatigue, sleep disturbance, and depression can affect pain perception
• Rest is essential for physical and psychological healing
• Bedrest may not necessarily equal rest, as emotional or metabolic stressors can cause restlessness
• Sleep is a state of sustained rest, reducing consciousness for body repair and recovery
• Sleep-wake cycle is regulated by a circadian rhythm, influenced by light, temperature, and external factors
• Disruptions to the sleep-wake cycle can affect other physiological functions
• Infants require 16 hours of sleep, teens require 9 hours, and adults require 8 hours
• Sleep has two phases: rapid eye movement (REM) and non-rapid eye movement (NREM)
• NREM sleep progresses through four stages, each with decreasing physiological activity and increasing sleep depth
• REM sleep is associated with vivid dreams and plays a role in memory storage and learning
• Sleep deprivation causes physiological and psychological changes, including decreased reflexes, impaired memory, mood swings, and fatigue
• Factors affecting sleep include physical illness, anxiety, depression, drugs, lifestyle, sleep patterns, stress, and environmental factors
• Promoting rest and sleep interventions include establishing routines, providing a quiet environment, minimizing interruptions, preparing patients for sleep, decreasing environmental stimuli, administering medication as ordered, and implementing safety precautions

This quiz assesses your understanding of key concepts related to pain management in nursing. Test your knowledge on subjective data in pain assessment, pain rating scales, and the role of nurses in managing patient pain. Gain insight into the complexities of pain perception, including nociceptive and chronic pain.