Nursing Care of Patients with Pain PDF

Nursing Care of Patients with Pain Chapter 10 What is pain?  Pain is a symptom of a disease or injury  Often serves a protective mechanism or warning  Think broken bone – pain helps you know that something is wrong  It is among the most common reasons patients seek...

Nursing Care of Patients with Pain Chapter 10 What is pain?  Pain is a symptom of a disease or injury  Often serves a protective mechanism or warning  Think broken bone – pain helps you know that something is wrong  It is among the most common reasons patients seek medical help  Pain is a personal experience shaped by events over one’s life course  Pain can negatively affect a person physically, emotionally, socially, spiritually, and financially What is pain? Pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” International Association for the Study of Pain, 2020 What is pain? “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.” Margo McCaffery, 1968  Thepatient’s self-report of pain is the gold standard in pain assessment Acute vs. Chronic Pain  Acute  Prompts an inflammatory response  Short term  Generally lasts less than 3 months but may last up to 6 months or longer depending on the cause  Symptoms lessen over time  Signsand symptoms are short-term, objective, physical (e.g., increased heart rate and respiratory rate, elevated blood pressure) Acute vs. Chronic Pain  Chronic  Lastslonger than the anticipated time of healing Longer than 6 months  Signs and symptoms persistent  Patients may not always appear to be in pain  Can cause increase in depression or in negative behaviors in patients with dementia, autism, schizophrenia, or other psychiatric conditions Suffering  Occurs when pain is not treated effectively or lasts longer than anticipated  Feelings of continuous distress  Often associated with chronic pain  Can cause emotional and spiritual distress and decrease quality of life  May be relieved with belief that comfort can be achieved Suffering  Spiritual coping may be a source of comfort.  May engage in religious practices such as prayer or meditation  May be non-religious and include self- reflection or connecting socially with others to affirm meaning and purpose in life Pathophysiology of Pain  Transduction  Stimulus converts to an electrical impulse at time of injury  Chemical neurotransmitters released  Prostaglandins, bradykinin, serotonin, substance P  Transmission  Painful message sent from peripheral nerve endings to the spinal cord and brain  Perception  Hypothalamus activates - Controls emotional input and goal driven behavior- pull hand off the stove  Cerebral cortex receives pain message – PAIN IS FELT  Modulation  Body attempts to interrupt pain impulses by releasing endorphins (ex. Enkephalins) Mechanisms of Pain  Nociceptive pain  Tissue damage Somatic – muscles or bones (localized, throbbing, aching)  Ex. Cancer that metastasizes to bone Visceral – organ (not localized, cramping)  Ex. Bowel obstruction  Neuropathic pain  PNS or CNS damage (numbness, tingling, shooting pain)  Ex. Diabetic neuropathy, phantom limb Referred Pain  Paincan be felt in parts of the body away from the main pain source  Ex.Back and flank pain that accompanies bladder infections Pain Assessment – WHAT’S UP?  Where is the pain?  How does the pain feel?  Aggravating and alleviating factors?  Timing  Severity (on 0–10 scale)  Useful other data  Patient’s perception Numeric Pain Scale Faces Pain Scale (Revised) Pain Assessment in Advanced Dementia (PAINAD) Level of Sedation Scale Nonverbal indicators of pain  Increased blood pressure  Increased heart rate  Shallow respirations  Muscle tension  Grimace  Guarding  Dilated pupils Cultural Assessment Considerations  Identify key areas of cultural expression  Language  Family engagement  Spirituality  Treatment preferences  Cultural differences can affect responses to pain and expectations regarding treatment  Stoic and quiet vs. dramatic or emotional – pain looks different  Cultural differences can also affect how a nurse treats a patient in pain  Remember ethical principles Managing Pain  Patient is center of health-care team  Entire health-care team is responsible for pain management  Regulatory bodies review pain management practices  The Joint Commission  Centers for Medicare and Medicaid Services  State licensing bodies  Agency for Healthcare Research and Quality Pharmacologic Treatment  Analgesics  Opioids  Non-opioids  Adjuvant medications  Opioid antagonists  *often need multiple medications in combination to be effective Non-opioid analgesics  Common examples: acetaminophen, aspirin, NSAIDs like ibuprofen  First class of drugs for mild pain  Have a ceiling effect – there is a dose beyond which there is no improvement in analgesic effect but may be an increase in adverse effects  Also need to be aware of max safe doses (ex. Acetaminophen 4g/day – also present in things like cold medicines)  Work mainly peripherally at the site of injury  Opioid analgesics  Morphine is often the drug of choice for treating severe pain – it is the standard against which other analgesics are compared  Other examples include: codeine, fentanyl, hydromorphone, oxycodone, tramadol  Bind to opioid receptors in the brain, spinal cord, and other areas of the body to inhibit perception of pain  Can be long acting or short acting (often use both)  Side effects  Respiratory depression – monitor pulse ox with assessment  Constipation – place on a bowel regimen  Confusion  Fatigue  Nausea/vomiting  Reduction in blood pressure  Suppression of cough  Can also be effective in reducing anxiety associated with pain Opioid Antagonists  Naloxone (Narcan)  Reverses, or antagonizes, the effect of opioids (respiratory depression, sedation)  Used in cases of overdose  Pain will return Adjuvant medications  Notinitially developed for pain, but can be effective in pain control  Examples include corticosteroids, benzodiazepines, antidepressants, anticonvulsants  Education is important WHO pain ladder Placebos  Administer inactive substitutes for analgesics.  Not justified in the treatment of pain  Only used in research with informed consent Routes of Administration  Oral  Subcutaneous  Rectal  Intraspinal  IV  Inhalation IV push  Transdermal Patient-  Intramuscular controlled analgesia (PCA) PCAs  RN programs dose, LPN can maintain  Medication gets locked, dual RN check  Gives patient control over their pain management  Lockout to prevent overdose  Only the patient should hit the button, not family – provide education  Order will include basal dose, patient bolus, lockout intervals, loading dose and clinician bolus as applicable Non-Pharmacologic Treatment  Cognitive–  Physical agents behavioral  Heat  Cold  Education  Massage/vibration  Relaxation  Exercise  Guided Imagery  Immobilization  Distraction  Transcutaneous electrical nerve  Biofeedback stimulation (TENS) Terminology  Itis important to understand the difference between: Tolerance Physical dependence Addiction/psychological dependence Pseudo-addiction Risks of Uncontrolled Pain  Body produces a stress response that causes harmful substances to be released from injured tissue  Reactions  Breakdown of tissue  Increased metabolic rate  Impaired immune function  Negative emotions  Prevents patient from participating in self-care activities Uncontrolled Pain Example A patient who had surgery is instructed to cough, deep breathe, and ambulate to promote post-op healing  Thepatient’s pain is not well controlled, so when he attempts these things, it hurts  The patient stops trying to cough and deep breathe  Pulmonary secretions are retained resulting in pneumonia  The patient stops trying to ambulate  Bowel function does not return, and an ileus results LPN role in pain management  Evaluate pain using standardized rating scales.  Maintain pain control devices (e.g., epidural, PCA, peripheral nerve catheter).  Provide nonpharmacological measures for pain relief (e.g., imagery, massage, repositioning).  Evaluate client response to medication (e.g., adverse reactions, interactions, therapeutic effects). Patient Education  Presented at the patient’s level of understanding!  Analgesic side effects  Fatigue  Constipation  NSAIDs  Opioids  Adverse effects  Monitor vital signs, respiratory rate.  Monitor total acetaminophen doses  Pain diary Patient Education (continued)  Dose frequency and duration  Take medication on a schedule with chronic pain to improve mobility and function.  Pill boxes and pain diaries  Interactions  Becareful with pain medications and muscle relaxants.  Do not mix drugs or alcohol with pain Safety  All pain medications should be kept out of reach of children, locked  Opioids should be locked away or at least not easily accessed by other members of the household or visitors.  Ensure proper disposal when discontinued. Pain In older Adults  Pain meds in LTC scheduled around the clock  NSAIDS are often contraindicated  GI disturbances  Medication interactions  Opioid Analgesics should be decreased 25-50 % initially because they tend to work longer and stringer in older patients  Changes in behavior may be signs of pain