Pain Management Overview

Pain Management

• Pain is a significant reason for seeking healthcare.
• Acute pain affects 25 million people, resulting from injury or surgery.
• Chronic pain impacts over a million American adults.
• 60% of cancer patients experience pain during treatment.

Definition of Pain

• Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. (IASP)
• The American Pain Society considers pain a fifth vital sign.

Pain Mechanisms

• Nociception is the physiological process communicating tissue damage to the central nervous system (CNS).
• Nociception involves four processes: transduction, transmission, perception, and modulation.

Classification of Pain Types

• Categorization by underlying pathology:
  • Nociceptive pain
  • Neuropathic pain
• Categorization by duration:
  • Acute pain
  • Chronic pain

Nociceptive Pain Types

• Superficial Somatic Pain: Originates from skin, mucous membranes, and subcutaneous tissue. Well-localized. Examples include sunburn, skin contusions.
• Deep Somatic Pain: Arises from muscles, fascia, bones, tendons, and joints. Can be localized or diffuse. Examples include arthritis, tendonitis.
• Visceral Pain: Originates from visceral organs (e.g., GI tract, bladder). Variable localization, often referred to cutaneous sites. Examples include appendicitis, pancreatitis.

Neuropathic Pain Types

• Central Pain: Caused by CNS lesions or dysfunction. Post-stroke pain, multiple sclerosis.
• Peripheral Neuropathies: Pain along nerve distribution due to nerve damage. Diabetic neuropathy, trigeminal neuralgia.
• Deafferentation Pain: Consequence of loss of afferent input. Examples include phantom limb pain.
• Sympathetically Maintained Pain: Pain persists due to ongoing sympathetic nervous system activity. Examples include phantom limb, complex regional pain syndrome.

Areas of Referred Pain

• Diagram of various internal organs and their associated referred pain locations. (Diagram presented in the slides)

Classification of Pain Types (Acute vs Chronic)

• Acute Pain:

  • Onset: Sudden or gradual, lasting less than 3 months.
  • Duration: Lasts as long as required for normal healing.
  • Severity: Mild to severe.
  • Cause: Typically has a clear cause, like injury, illness, surgery.
  • Course: Decreases over time as recovery occurs.
  • Manifestations: Can include heightened sympathetic nervous system (e.g., increased heart rate, respiratory rate).
  • Goals of Treatment: Pain management with goal of eventual elimination.

• Chronic Pain:

  • Onset: Gradual or sudden, lasting more than 3 months.
  • Duration: Persists beyond normal recovery time.
  • Severity: Mild to severe, sometimes intermittent.
  • Cause: May or may not be known.
  • Course: Characterized by periods of increasing and decreasing pain intensity.
  • Manifestations: Can result in behavioral changes, like flat affect, reduced activity, and social withdrawal.
  • Goals of Treatment: Pain control to extent possible, focusing on quality of life enhancement.

Pain Assessment

• Methods of Pain Assessment:
  • Health History (Direct Interview): Gathers information on pain characteristics (OLDCARTS, SOCRATES, PQRST).
  • Observation: Assessing pain using visual and behavioral cues.
  • Physical Examination: Hands-on evaluation of patient's physical condition.
  • Diagnostic Studies: Utilize imaging techniques or labs to identify or rule out underlying pain causes.

Pain Characteristics

• Includes: Onset, location, duration, quality/intensity, associated symptoms, alleviating/aggravating factors.

Example Case Study (B.H.)

• 52-year-old woman reporting lumbar back pain that started two months ago, gradually increasing in intensity. Radiates to her left leg and worsens with prolonged sitting.
• During examination noted to be sitting with a forward lean and frequently shifting position to relieve discomfort.
• Tenderness over lumbar spine, straight leg raise test exacerbates her leg pain, suggesting nerve involvement.
• MRI shows degenerative disc disease between L1-L2 and L2-L3.

Nursing Diagnoses

• List of potential nursing diagnoses for a patient with pain. Examples: Acute pain related to injury, chronic pain, impaired physical mobility.

Pain Management Strategies

• Drugs (Pharmacological): Nonopioids, opioids, and adjuvant analgesics.
• Nondrug Therapies (Non-pharmacological): Massage, exercise, TENS, acupuncture, heat/cold therapy, cognitive therapies (e.g., distraction, hypnosis, relaxation).

Drug Therapy (Categories)

• Nonopioids: Examples include acetaminophen, aspirin, NSAIDs. Used for mild to moderate pain.
• Opioids: Examples include morphine, codeine, tramadol. Used for severe pain.
• Adjuvant Analgesics: Examples include antidepressants, antiseizure drugs, corticosteroids, and local anesthetics. Used alone or with opioid/nonopioid medications for other purposes beside pain, but also effective for pain management .

Pain Intensity Scales

• Numeric Rating Scale (NRS): Use numbered 0-10 scale where patient rates pain
• Visual Analog Scale (VAS): Use a line with endpoints labelled "No pain" and "Worst pain imaginable".
• Wong-Baker FACES Pain Rating Scale: Utilize facial expressions to represent different pain levels, suitable for patients experiencing difficulty conveying pain verbally.

Nursing Considerations

• Include points for specific medications used in pain management.
• Non-opioids: Do not produce tolerance or addiction; are often over-the-counter (OTC); suitable for mild to moderate pain; potential side effects include nausea, vomiting, and increased bleeding tendencies.
• Opioids: Use for severe pain; may cause constipation, nausea/vomiting, sedation, and respiratory depression; potential for tolerance and addiction.
• Adjuvant analgesics: Long-term use may need to cautiously adjust dosages and monitor side effects.

Non-drug Therapies (Strategies)

• Physical: Massage, exercise.
• Other techniques: Includes TENS (transcutaneous electrical nerve stimulation), acupuncture, traditional Chinese medicine, heat/cold therapy, and cognitive therapies like distraction, hypnosis, relaxation.