Pain Management PDF

PAIN MANAGEMENT LEARNING Define pain. OBJECTIVES Describe the role of the nurse in pain management. Explain the physiology of pain and its perception. Articulate factors that influence pain perception and response. De...

PAIN MANAGEMENT LEARNING Define pain. OBJECTIVES Describe the role of the nurse in pain management. Explain the physiology of pain and its perception. Articulate factors that influence pain perception and response. Determine individual physiologic, behavioral, and psychosocial responses to pain during patient assessment. Identify nursing diagnoses for patients experiencing pain. Generate nursing care goals and outcome criteria for patients experiencing pain. Plan pain management care that includes implementation and evaluation of pharmacologic and nonpharmacologic interventions for pain. 2 THE CONCEPT Pain has physical and emotional aspects Pain is whatever the person with the pain says it is OF PAIN and it exists whenever the person says it does Pain may prevent injury or results from injury Pain is the most subjective of all symptoms that patients experience Cognitive, affective, behavioral, and sensory factors can influence pain NURSING AND PAIN MANAGEMENT Pain should be assessed and documented to provide comfort In addition to assessing for pain, the nurse: Monitors for pain management Evaluates the level of pain relief Advocates for the patient Educates the patient about treatment options for pain management 4 NORMAL STRUCTURE AND FUNCTION: NOCICEPTION Transduction At the site of tissue injury, nociceptors detect pain stimuli and convert (transduce) this electrochemical response into an electrical impulse (signal) Transmission The action potential, or electrical signal, is transmitted through an afferent nerve to the spinal cord and brain NORMAL STRUCTURE AND FUNCTION: NOCICEPTION Perception Perception (recognition) of pain occurs when the brain translates the afferent nerve signals as pain. Pain threshold is the lowest intensity at which the brain recognizes the stimulus as pain Pain tolerance is the intensity or duration of pain that a patient is able or willing to endure NORMAL STRUCTURE AND FUNCTION: NOCICEPTION Modulation Once pain is recognized, the brain can change the perception of it by sending inhibitory input to the spinal cord to impede the transmission NORMAL STRUCTURE AND FUNCTION: PAIN THEORIES Specificity Theory Von Frey identified four somatosensory modalities—touch, cold, heat, and pain—that he believed were the origin of all skin sensations. He identified pressure points on the skin’s surface associated with specific nerve endings Provided a foundation for later research that identified the existence of pain receptors and peripheral pathways Sensory Interaction Theory Noordenbos proposed that when an injury occurs, a signal is carried along large-diameter nerve fibers (touch fibers) that may inhibit a signal carried by thin fibers (pain fibers) Provided a foundation for the gate control theory NORMAL STRUCTURE AND FUNCTION: PAIN THEORIES Gate Control Theory According to the theory, the interplay of signals from different nerve fibers at a gating mechanism in the dorsal horn of the spinal cord determines whether painful stimuli are stopped or go on to the brain Neuromatrix Theory Suggests that pain is a multidimensional experience controlled by a body-self neuromatrix Proposes that each person has a unique genetically controlled network of neurons NORMAL STRUCTURE AND FUNCTION: TYPES OF PAIN Acute pain: _____ Chronic pain: _____ Nociceptive pain Visceral: arises from the organs of the body Somatic: injury to skin, muscles, bones, and joints Referred: originates in one area but hurts in another area Radiating: extends from the source to an adjacent area of the body NORMAL STRUCTURE AND FUNCTION: TYPES OF PAIN Neuropathic pain: results from nerve injury, and the pain continues even after the painful stimuli are gone Dysesthesia: _____ Allodynia: _____ Hyperalgesia: _____ Hyperpathia: _____ Phantom pain: brain continues to receive messages from the area of an amputation Plasticity: brain adapts to the loss of the limb and the pain stops Psychogenic pain: perceived by an individual but has no physical cause ALTERED STRUCTURE AND FUNCTION Alterations in pain pathways Damage and hypersensitivity anywhere along the pain pathway can alter a patient’s perception of pain Physiologic alterations caused by pain Acute injury triggers physiologic stress responses; these responses may have adverse effects for the patient if pain is left untreated Factors influencing pain Age, gender, morphology, disabilities, culture, ethnicity, and religion play a role in the behavioral reaction to pain and in the perception of pain ASSESSMENT: PAIN HISTORY AND ASSESSMENT SOCRATES S = site O = onset C = character R = radiation A = associations T = time course E = exacerbating/relieving factors S = severity 13 ASSESSMENT How will you assess pain in patients who are unable to communicate with you? Pain assessment tools Vital signs 14 ASSESSMENT Physiologic responses to pain Chronic or prolonged pain Decrease in the systolic blood pressure and a decrease in the pulse rate below the patient’s normal baseline Behavioral responses to pain Facial grimaces, clenched teeth, rubbing or guarding of the painful area, agitation, restlessness, and withdrawal from painful stimuli How will you assess pain in patients who are unable to Psychological responses to pain communicate with you? Anxiety, fear, depression, anger, irritability, helplessness, and hopelessness 15 PRIORITY PROBLEMS (NURSING DIAGNOSIS) “The patient reports pain 10 of 10” (NANDA-I: Acute pain) Supporting data: Red and edematous areas on face, chest, arms, and hands from burned skin, reports pain of 10 of 10, requests pain medication “Patient states, ‘I wake up every morning with aching in my joints’” (NANDA-I: Chronic pain) Supporting data: Edema of joints, painful mobility, inability to manage activities of daily living, feelings of helplessness “The patient reports inability to sleep because of pain” (NANDA-I: Difficulty coping) Supporting data: Severe pain, inability to ask for help, lack of appetite, poor concentration PLANNING Patient will report a steady decrease in pain level to 4 or 5/10 within 5 postadmission days. Patient will perform activities of daily living each day, reporting chronic pain at a level of 3 or less within 1 week of starting on newly prescribed pain medication. Patient will report increased ability to concentrate on routine activities within 2 hours of receiving the prescribed dose of analgesic medication. How will you know your patient-centered goals are SMART? IMPLEMENTATION AND EVALUATION Multimodal pain management Combines a variety of treatments Nonpharmacologic pain management and complementary and alternative therapies Positioning, splinting, massage, progressive relaxation techniques, guided imagery, meditation Distraction (television, music, and conversation) Spiritual support (prayer and meditation) Neurologic and neurosurgical pain therapies How will you educate your patients about the safe use of complementary and alternative pain therapies? IMPLEMENTATION AND EVALUATION Pharmacologic pain management Multimodal analgesia Pre-emptive analgesia Non-opioid analgesics Acetaminophen Nonsteroidal anti-inflammatory drugs (NSAIDs) How will you educate your patients about safe pharmacological pain management? IMPLEMENTATION AND EVALUATION Pharmacologic pain management Opioid analgesics Agonist analgesics Agonist-antagonist analgesic Antagonist analgesics Patient-controlled analgesia (PCA) Additional opioid delivery methods On-Q infusion pump: _____ Transdermal administration: _____ Intrathecal injection: _____ Epidural analgesia: _____ Nerve block: _____ How will you educate your patients about safe pharmacological pain management? IMPLEMENTATION AND EVALUATION Addiction: psychological or emotional dependence on a prescribed medication or illicit drug U.S. in 2020: 70,200 died from drug overdoses; 47,600 drug overdoses involved opioids ~10% of nurses will abuse drugs or alcohol during their career Accidental ingestion: patient education is key ~50,000 young children per year Medical marijuana: Schedule 1 drug of the Controlled Substance Act Approved for use in more than 30 states and in Washington, DC IMPLEMENTATION AND EVALUATION Adjuvant or coanalgesic medications: work synergistically with standard pain medications to enhance pain relief and to treat side effects of the medication Antiemetics Laxatives Ketorolac Caffeine Palliative care: help relieve pain caused by serious illness, regardless of the patient’s prognosis How will you educate your patients about safe adjuvant/coanalgesic or pallative pain management? IMPLEMENTATION AND EVALUATION Therapeutic decision making Titrating doses Around-the-clock dosing World Health Organization’s pain relief ladder As a nurse, what assessment findings and priority problems will you use to inform your decision-making regarding pain management? IMPLEMENTATION AND EVALUATION Barriers to adequate management Patient barriers: fear of addiction, cost of medication, and no access to health care Health care provider barriers: poor pain assessment skills, inaccurate beliefs, prejudicial attitudes Pain management for addicted patients American Society for Pain Management Nursing (ASPMN) and the American Society of Addiction Medicine (ASAM) guidelines for pain management As a nurse, how will advocate for overcoming these barriers?  IMPLEMENTATION AND EVALUATION Barriers within the health care system Pain not considered a priority Systematic pain management approaches and pain management teams not in place Inadequate reimbursement for pain medications Regulations may restrict access to medications Patients have a right to pain relief Inadequate pain management may lead to detrimental outcomes As a nurse, how will advocate for overcoming these barriers? IMPLEMENTATION AND EVALUATION Evaluation: Medication Document the time the medication was given, the time of postintervention reassessment, and the duration of acceptable pain relief post intervention Document the pain scale on every shift Provide patient education about medications at discharge Document teaching If pain relief goals are unmet, collaborate with other health care team members and the patient to determine other options for treatment How will you know if the interventions were effective?