Pain Management and Legal/Ethical Responsibilities

Pain Management

• The Nurse Practice Act (1997) emphasizes the RN's role in ensuring patient comfort and managing pain as a nursing function.
• The BRN (Board of Registered Nursing) adopted a pain management policy for RN practice and curriculum guidelines for nursing programs.

Joint Commission Pain Standards

• Identify pain assessment and management as an organizational priority.
• Conduct quality improvement projects.

Pain Definition

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
• It is a personal and subjective experience, with the patient's report being the most reliable indicator of pain.
• Pain is a common reason for seeking healthcare.

Harmful Effects of Unrelieved Pain

• Endocrine: Increased cortisol, ADH, and epinephrine.
• Metabolic: Hyperglycemia, insulin resistance.
• Cardiovascular: Increased heart rate, blood pressure, and cardiac workload.
• Respiratory: Atelectasis, hypoxia, decreased cough.
• GU: Decreased urine output, fluid overload, hypokalemia.
• GI: Decreased gastric and bowel motility (constipation).
• Musculoskeletal: Muscle spasm, fatigue.
• Cognitive: Decreased cognition, mental confusion.
• Immune: Depression of immune response.
• Developmental: Increased behavioral and physiologic response to pain, addictive behavior.
• Future pain: Debilitating chronic pain syndrome, phantom pain.
• Quality of life: Sleeplessness, anxiety, fear, hopelessness, increased thoughts of suicide.

Types of Pain (Duration)

• Acute pain: Short duration, resulting from tissue damage (surgery, trauma, burns).
• Chronic pain: Persistent pain that can last a lifetime, continuous or intermittent.
• Breakthrough pain: Chronic pain with intense acute exacerbations.

Categories of Pain (Pathology)

• Nociceptive pain: Caused by tissue injury.
• Neuropathic pain: Caused by damage to the peripheral or central nervous system.
• Mixed pain: Combination of nociceptive and neuropathic pain.

Nociception Process

• Transduction: Involves nociceptors, releasing prostaglandins, enhancing pain signals.
• Transmission: Glutamate carries pain signals to the spinal cord and brain.
• Perception: The brain processes and interprets pain signals.
• Modulation: Neurochemicals in the spinal cord and brain regulate pain signals.

Transduction and Analgesic Agents

• Acetaminophen, ibuprofen, local anesthetics, and anticonvulsants are examples of analgesic agents.

Transmission

• A-delta fibers: Responsible for detecting thermal and mechanical injuries, quickly transmitting pain signals.
• C fibers: Slower in conducting impulses, responding to mechanical, thermal, and chemical stimuli.

Perception

• Involves higher brain structures, associated with awareness, emotions, and drives.
• Nonpharmacologic therapies and distraction can help alleviate pain.

Modulation

• Pain modulation occurs throughout the body, involving the use of different chemicals to control pain information.
• Includes serotonin, norepinephrine, and other neurochemicals.

Neuropathic Pain

• Caused by a problem with the nerves that sense touch and pain.
• Can occur without physical injury or inflammation.
• Involves peripheral and central mechanisms.

Gate Control Theory of Pain

• Explains how pain signals are processed by the nervous system.
• Involves two types of nerve fibers: small and large.
• Large nerve fibers act as a "gate" to regulate pain signal transmission.

Factors Affecting the Pain Experience

• Cultural and ethnicity variables.
• Family, biological sex, gender, and age.
• Religious beliefs and spirituality.
• Environment and support people.
• Anxiety and other stressors.
• Past pain experience.

Components of Pain Assessment

• Self-report: Most reliable measure of pain.
• SOCRATES (site, onset, character, radiates, associated system, time/duration, exacerbating, severity).

Assessing Intensity

• Pain scales: Numeric Rating Scale (NRS), Wong-Baker FACES Pain Rating Scale, Faces Pain Scale–Revised (FPS-R), Verbal Descriptor Scale (VDS), and Visual Analog Scale (VAS).

Hierarchy of Pain Measures

• Attempt to obtain self-report.
• Consider the patient's condition.
• Observe behaviors.
• Evaluate physiologic indicators.
• Conduct an analgesic trial.

Pain Management in Specific Populations

• Nonverbal patients: Use the Hierarchy of Pain Measures.
• Young children or individuals who are unable to communicate: Use FLACC.
• Patients with advanced dementia: Use PAINAD.
• Patients in critical care units: Use CPOT.

Reassessing Pain

• Regularly reassess pain to evaluate treatment effectiveness.
• Depends on the stability of the patient and timing of peak effect of medication.
• Titration (adjusting) medication.

Pharmacological Management

• PCA: Patient Controlled Analgesia, an interactive method of pain management.
• Closely monitor sedation and respiratory status.

Analgesic Medications

• Nonopioids: Decrease pain by inhibiting cyclo-oxygenase.
• Opioids: Act on the CNS to inhibit activity of ascending nociceptive pathways.
• Local anesthetics: Block nerve conduction.

Opioid Analgesic Agents

• Mu agonists: Directly activate the mu receptors in the brain and spinal cord.
• Agonist-antagonists: Partially activate certain opioid receptors while blocking others.
• Antagonists: Block the effects of other opioids.

Safe Use of Opioids

• Individualized treatment plan.
• Route of administration.
• Titration (adjusting the dose).
• Equianalgesia (comparing the strength of different opioids).
• Physical dependence and tolerance.
• Withdrawal symptoms.

Substance Use Disorder (SUD)

• Chronic and treatable neurological disease.
• Impaired control over substance use.
• Compulsive use.
• Continued use despite harm.
• Craving for the substance.

Opioid-Induced Hyperalgesia (OIH)

• Increasing doses of an opioid result in increasing sensitivity to pain.

Co-analgesic Agents

• Local anesthetics.
• Anticonvulsants.
• Antidepressants.
• Ketamine.

Nursing Implementations

• Distraction.
• Humor.
• Music.
• Mindfulness practice.
• Cutaneous stimulation.
• Acupuncture and dry needling.
• Hypnosis.
• Biofeedback.
• Healing/therapeutic touch.
• Animal-assisted intervention.

Pain Management in the Elderly

• Use acetaminophen for mild to moderate pain.
• Use NSAIDs when other treatments have failed.
• Progress to opioids for severe pain.
• Consider adjuvants that address depression and neuropathic pain.
• Consider the use of legal cannabis.
• Sensitive to agents that produce sedation and CNS effects.
• Initiate with low dose and titrate slowly.
• Increased risk for NSAID-induced GI toxicity.
• Acetaminophen preferred for mild pain.
• Opioid dose should be reduced 25% to 50%.