Pain Management: Legal and Ethical Responsibilities for Nurses

Pain Management and Legal/Ethical Responsibilities

• RNs should ensure patient comfort and manage pain as part of their role as patient advocates.
• The BRN adopted a pain management policy for RN practice and curriculum guidelines for nursing programs.
• Healthcare facilities should educate staff on pain management, and nursing programs should integrate pain as a 5th vital sign into their curriculum.

Joint Commission Pain Standards

• Identify pain assessment and management, including safe opioid prescribing, as an organizational priority.
• Quality improvement projects should prioritize pain management.

Pain Definition and Assessment

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
• Patient self-report is the most reliable indicator of pain and essential for pain assessment.
• Pain is the most common reason for seeking healthcare.

Harmful Effects of Unrelieved Pain

• Endocrine:
  • Increased cortisol, ADH, epinephrine
• Metabolic:
  • Hyperglycemia, insulin resistance
• Cardiovascular:
  • Increased heart rate, blood pressure, 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

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

Categories of Pain (Pathology)

• Nociceptive Pain:
  • Physiologic pain caused by tissue injury
  • Somatic pain: originating from the skin, muscles, or bones
  • Visceral pain: originating from internal organs
• Neuropathic Pain:
  • Pathophysiologic pain caused by damage to the peripheral or central nervous system or both
  • Centrally generated pain: caused by dysfunction in the central nervous system
  • Peripherally generated pain: caused by dysfunction in the peripheral nervous system
• Mixed Pain:
  • Combination of nociceptive and neuropathic pain
  • Example: Fibromyalgia (widespread pain and tenderness throughout the body)

Nociception Process

• Transduction:
  • Involves nociceptors detecting noxious stimuli
  • Prostaglandins released during tissue injury enhance pain signals
• Transmission:
  • Glutamate, a neurotransmitter, carries pain signals from nociceptors to the spinal cord and brain
• Perception:
  • The brain processes and interprets pain signals, leading to the conscious experience of pain
• Modulation:
  • Neurochemicals in the spinal cord and brain amplify or suppress pain signals, affecting pain perception and intensity

Transduction and Analgesic Agents

• Transduction is the process where harmful stimuli activate nociceptors, releasing substances like serotonin, histamine, and prostaglandin.
• Examples of analgesic agents:
  • Acetaminophen
  • Ibuprofen
  • Local anesthetic
  • Anticonvulsants (e.g., gabapentin for pain relief)