Week 13: Pain Management & Urinary Elimination

Student Learning Outcomes

• Explain how physiology of pain relates to selection of interventions for pain relief
• Describe guidelines for selecting and individualizing comfort and pain interventions
• Describe non-pharmacological measures for pain relief and supportive comfort measures
• Describe implications for opioid analgesics, nonopioids, and NSAIDS use
• Utilize nursing process in care of client experiencing discomfort or pain
• Explain how cultural factors influence the pain experience

Nursing Roles

• Assess pain and communicate with other healthcare providers
• Ensure initiation of adequate pain relief measures
• Evaluate effectiveness of interventions
• Advocate for those in pain

Magnitude of the Pain Problem

• Acute pain: most common reason for healthcare visits (25 million Americans)
• Chronic pain: 50 million Americans suffer from persistent pain, 25 million from migraine headaches
• Inadequate pain management across care settings and patient populations

Definition of Pain

• "Whatever the person experiencing pain says it is" - Margo McCaffery
• Unpleasant sensory and emotional experience associated with actual or potential tissue damage (Perry, Potter pg. 962)

Pain Mechanisms

• Nociception: physiologic process that communicates tissue damage to CNS
• Transduction: conversion of stimulus into electrical energy
• Transmission: sending of impulse across a sensory pain nerve fiber (nociceptor)
• Perception: patient's experience of pain
• Modulation: activation of descending pathways that exert inhibitory or facilitatory effects on transmission of pain

Categorizing Pain

• Acute vs. Chronic Pain
• Nociceptive vs. Neuropathic Pain
• Cancer Pain: related to tumor progression, invasive procedures, toxicity of treatment, infection, and physical limitation
• Somatic Pain (body pain): aching or throbbing, localized, arises from bone, joint, muscle, skin, or connective tissue
• Visceral Pain: tumor involvement or obstruction, arises from internal organs

Breakthrough Pain

• Transient, moderate to severe
• Occurs beyond treated pain
• Rapid onset and brief duration with variable frequency and intensity

Nature of Pain

• Involves physical, emotional, and cognitive components
• Physical and/or mental stimulus
• Exhausting and demands energy
• Interferes with relationships

Dimensions of Pain

• Physiologic: genetic, anatomic, and physical determinants
• Affective: emotional response to pain experience (anger, fear, depression, anxiety)
• Behavioral: observable actions used to express and control pain (facial expressions, socially withdrawn, less physically active, guarding, crying)
• Cognitive: beliefs, attitudes, memories, and meaning attributed to pain

Pain Assessment

• Gather and document data
• Make collaborative decisions with patient and other healthcare providers
• Onset and duration
• Location/distribution
• Quality
• Intensity
• Aggravating/relieving factors
• Associated features or secondary signs/symptoms
• Associated factors (mood/emotional distress, functional activities)
• Treatment response### Pain Management
• Student Learning Outcomes:
  • Explain the physiology of pain and its relation to intervention selection
  • Describe guidelines for selecting and individualizing comfort and pain interventions
  • Describe non-pharmacological measures for pain relief and supportive comfort measures
  • Describe the implications of opioid analgesics, non-opioids, and NSAIDs use

Nursing Roles

• Assess pain and communicate with other healthcare providers
• Ensure initiation of adequate pain relief measures
• Evaluate the effectiveness of interventions
• Advocate for those in pain

Magnitude of the Pain Problem

• Acute pain is the most common reason for healthcare visits
• 25 million Americans have acute pain caused by injury or surgery
• 50 million Americans suffer from persistent or chronic pain, such as arthritis
• Over 25 million suffer from migraine headaches
• Despite the prevalence of pain, many studies document inadequate pain management across care settings and patient populations

Consequences of Untreated Pain

• Unnecessary suffering
• Physical and psychosocial dysfunction
• Impaired recovery from acute illness and surgery
• Immunosuppression
• Sleep disturbances

Definition of Pain

• "Whatever the person experiencing pain says it is" - Margo McCaffery
• Unpleasant sensory and emotional experience associated with actual or potential tissue damage

Pain Mechanisms

• Nociception: physiologic process that communicates tissue damage to the CNS
  • Involves four processes:
    • Transduction: conversion of stimulus into electrical energy
    • Transmission: sending of impulse across a sensory pain nerve fiber
    • Perception: the patient's experience of pain
    • Modulation: activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain

Types of Pain

• Nociceptive pain: caused by activity in neural pathways in response to potentially tissue-damaging stimuli
• Neuropathic pain: caused by a lesion or dysfunction in the nervous system
• Somatic pain: aching or throbbing pain from bone, joint, muscle, skin, or connective tissue
• Visceral pain: pain from internal organs
• Breakthrough pain: transient, moderate to severe pain that occurs beyond treated pain
• Referred pain: pain that is felt at a site distant from the origin of the pain

Dimensions of Pain

• Physiologic: genetic, anatomic, and physical determinants of pain
• Affective: emotional response to pain experience
• Behavioral: observable actions used to express and control pain
• Cognitive: beliefs, attitudes, memories, and meaning attributed to pain

Assessing the Patient with Pain

• Onset and duration of pain
• Location and distribution of pain
• Quality of pain
• Intensity of pain
• Aggravating and relieving factors
• Associated features or secondary signs/symptoms
• Associated factors: mood, emotional distress, functional activities, treatment response### Radiologic Studies of Urinary System: CT and IVP
• Common GU conditions: incontinence, urinary retention, urinary retention with overflow, stress incontinence, and benign prostatic hypertrophy
• Incontinence types: transient, functional, associated with retention (overflow urinary incontinence), stress, urge, and reflex

Stress Incontinence

• Involuntary loss of urine during physical exertion or upon coughing, sneezing, or laughing
• Caused by pelvic floor weakness, detrusor overactivity, and estrogen depletion
• Not automatically due to aging

Urinary Retention

• Accumulation of urine due to the inability of the bladder to empty
• Suspected when patient has large amounts of voided cloudy urine, pain in the suprapubic region, spasms and difficulty during urination, or incontinence

Nursing Diagnoses

• Urinary incontinence (functional, reflex, stress, urge)
• Infection
• Self-care deficit, toileting
• Impaired skin integrity
• Urinary retention

Nursing Actions

• Bladder training
• Pelvic floor muscle exercises (teaching)
• Health promotion/teaching clients non-surgical options
• Importance of fluid intake
• Proper cleaning technique
• UTI prevention
• Bowel elimination measures
• Medication use
• Catheterization if necessary (including teaching)
• Pre and post-diagnostic exam care

Catheterization

• Insertion of sterile tube via sterile technique into the bladder
• Document cath size, amount obtained, and appearance
• Indwelling (foley) or straight catheter (one-time use)
• Catheter care at least once a shift

Nursing Measures (Lab)

• Promote fluid intake (2000 to 2500 mL per day)
• Foley bag must remain below the bladder/free of kinks
• Prevent infection
• Bag must not touch floor
• Keep system sterile
• Empty QS

Condom Catheters

• Change daily – q shift optimal
• Caution with kinks
• Do not use masking tape
• Caution with application – might cut off circulation

Urinary Diversion

• Temporarily or permanently bypasses the bladder and urethra
• The bladder is removed, and the outlets of the ureters are placed inserted into openings made in the abdominal wall

NANDAs for Clients with Urinary Diversions

• Risk for impaired skin integrity
• Disturbed body image
• Acute pain
• Risk for infection