Chapter 41: Pain Management for Medical Procedures

Pain Management

• Medicating clients prior to painful procedures can prevent or minimize pain.

Factors Affecting the Pain Experience

• Age:
  • Infants cannot verbalize or understand their pain.
  • Older adult clients can have multiple pathologies, causing pain and limiting function.
• Fatigue: Increases sensitivity to pain.
• Genetic sensitivity: Can increase or decrease pain tolerance.
• Cognitive function: Clients with cognitive impairment might not report pain or report it accurately.
• Prior experiences: Can increase or decrease sensitivity depending on whether clients obtained adequate relief.
• Anxiety and fear: Increase sensitivity to pain.
• Support systems and coping styles: Presence can decrease sensitivity to pain.
• Culture: Influences how clients express pain or the meaning they give to pain.

Undertreatment of Pain

• Causes:
  • Cultural and societal attitudes
  • Lack of knowledge
  • Fear of addiction
  • Exaggerated fear of respiratory depression
• Populations at risk: Infants, children, older adults, and clients with substance use disorder.

Nursing Care

• Schedule pain interventions around the clock to keep pain at a tolerable level.
• Include PRN dosing to manage pain exacerbations.
• Review provider prescriptions for analgesia, noting mild, moderate, or severe pain.
• Use nursing judgment to determine the prescription to administer based on client data.
• Take a proactive approach by giving analgesics before pain becomes severe.

Causes of Acute and Chronic Pain

• Trauma
• Surgery
• Cancer (tumor invasion, nerve compression, bone metastases, associated infections, immobility)
• Arthritis
• Fibromyalgia
• Neuropathy
• Diagnostic or treatment procedures (injection, etc.)

Pain-Relief Measures

• Cognitive-behavioral measures: Changing the way clients perceive pain.
• Physical approaches to improve comfort:
  • Cutaneous (skin) stimulation: transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, and massage.
  • Cold for inflammation.
  • Heat to increase blood flow and reduce stiffness.
  • Distraction: Decreased attention to the presence of pain can decrease perceived pain level.

Opioid Analgesics

• Used for treating moderate to severe pain (postoperative pain, myocardial infarction pain, cancer pain).
• Essential to monitor and intervene for adverse effects of opioid use:
  • Sedation: Monitor level of consciousness and take safety precautions.
  • Respiratory depression: Monitor respiratory rate prior to and following administration of opioids.

Pain Management

• Undertreatment of pain is a serious healthcare problem, leading to physiological and psychological consequences, including anxiety, fear, and depression.

Types of Pain

• Nociceptive pain:
  • Arises from damage or inflammation of tissue, triggering pain receptors (nociceptors)
  • Typical characteristics: throbbing, aching, localized, and responds to opioids and non-opioid medications
  • Subtypes:
    • Somatic: in bones, joints, muscles, skin, or connective tissues
    • Visceral: in internal organs (e.g., stomach or intestines)
    • Cutaneous: in the skin or subcutaneous tissue
• Neuropathic pain:
  • Arises from abnormal or damaged pain nerves
  • Typical characteristics: intense, shooting, burning, or "pins and needles"
  • Responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants) and topical medications

Physiology of Pain

• Transduction: conversion of painful stimuli to an electrical impulse through peripheral nerve fibers
• Transmission: electrical impulse travels along nerve fibers, regulated by neurotransmitters
• Pain threshold: point at which a person feels pain
• Pain tolerance: amount of pain a person is willing to bear
• Modulation: occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli
• Perception or awareness of pain: occurs in various areas of the brain, influenced by thought and emotional processes

Substances Affecting Pain Transmission

• Substances that increase pain transmission and cause an inflammatory response:
  • Substance P
  • Prostaglandins
  • Bradykinin
  • Histamine
• Substances that decrease pain transmission and produce analgesia:
  • Serotonin
  • Endorphins

Pain Assessment

• Use anatomical terminology and landmarks to describe location (superficial, deep, referred, or radiating)
• Intensity, strength, and severity are "measures" of the pain
• Setting: how the pain affects daily life or activities of daily living

Pain Categories

• Categorized by duration: acute or chronic
• Categorized by origin: nociceptive or neuropathic
• Acute pain:
  • Protective, temporary, usually self-limiting, with a direct cause, and resolves with tissue healing
  • Physiological responses: fight-or-flight responses (e.g., tachycardia, hypertension, anxiety, diaphoresis, muscle tension)
  • Behavioral responses: grimacing, moaning, flinching, and guarding
• Chronic pain:
  • Not protective, can lead to chronic pain syndrome if unrelieved
  • Can be managed with pharmacological and non-pharmacological therapies, including invasive therapies (nerve ablation) for intractable cancer-related pain