Foundations Chap 41 Pain Management PDF

CHAPTER 41 UNIT 4 PHYSIOLOGICAL INTEGRITY PAIN CATEGORIES SECTION: BASIC CARE AND COMFORT Pain is categorized by duration (acute or chronic) or by P...

CHAPTER 41 UNIT 4 PHYSIOLOGICAL INTEGRITY PAIN CATEGORIES SECTION: BASIC CARE AND COMFORT Pain is categorized by duration (acute or chronic) or by Pain Management origin (nociceptive or neuropathic). CHAPTER 41 Acute pain Acute pain is protective, temporary, usually self‑limiting, Effective pain management includes the use has a direct cause, and resolves with tissue healing. of pharmacological and nonpharmacological Physiological responses (sympathetic nervous system) are fight‑or‑flight responses (tachycardia, hypertension, pain management therapies. Invasive therapies anxiety, diaphoresis, muscle tension). (nerve ablation) can be appropriate for Behavioral responses include grimacing, moaning, flinching, and guarding. intractable cancer‑related pain. Interventions include treatment of the underlying problem. Clients have a right to adequate assessment and Can lead to chronic pain if unrelieved. management of pain. Nurses are accountable Chronic pain for the assessment of pain. The nurse’s role is Chronic pain is not protective. It is ongoing or recurs that of an advocate and educator for effective frequently, lasting longer than 6 months and persisting pain management. beyond tissue healing. Physiological responses do not usually alter vital signs, Nurses have a priority responsibility to measure but clients can have depression, fatigue, and a decreased level of functioning. It is not usually life‑threatening. the client’s pain level on a continual basis and to Psychosocial implications can lead to disability. provide individualized interventions. Depending on Management aims at symptomatic relief. Pain does not always respond to interventions. the setting and route of analgesia administration, Chronic pain can be categorized as either cancer pain or the nurse might be required to reassess pain 10 to noncancer pain. Idiopathic pain is a form of chronic pain without a 60 min after administering medication. known cause, or pain that exceeds typical pain levels associated with the client’s condition. Assessment challenges can occur with clients Strategies specific for relieving chronic pain include the who have cognitive impairment, who speak following. a different language than the nurse, or who Administering long‑acting or controlled‑release opioid analgesics (including the transdermal route). receive prescribed mechanical ventilation. Administering analgesics around the clock rather than PRN. Undertreatment of pain is a serious health care problem. Consequences of undertreatment of pain include physiological and psychological 41.1 Comparative pain scale components. Acute/chronic pain can cause anxiety, fear, and depression. Poorly managed acute pain can lead to chronic pain syndrome. FUNDAMENTALS FOR NURSING CHAPTER 41 Pain Management 235  Nociceptive pain PHYSIOLOGY OF NOCICEPTIVE PAIN Nociceptive pain arises from damage to or inflammation Transduction is the conversion of painful stimuli to of tissue, which is a noxious stimulus that triggers the an electrical impulse through peripheral nerve fibers pain receptors called nociceptors and causes pain. (nociceptors). It is usually throbbing, aching, and localized. Transmission occurs as the electrical impulse travels This pain typically responds to opioids and along the nerve fibers, where neurotransmitters non-opioid medications. regulate it. TYPES OF NOCICEPTIVE PAIN Pain threshold is the point at which a person feels pain. Somatic: In bones, joints, muscles, skin, or connective tissues. Pain tolerance is the amount of pain a person is Visceral: In internal organs (the stomach or intestines). willing to bear. It can cause referred pain in other body locations Perception or awareness of pain occurs in various separate from the stimulus. areas of the brain, with influences from thought and Cutaneous: In the skin or subcutaneous tissue. emotional processes. Neuropathic pain Modulation occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from Neuropathic pain arises from abnormal or damaged painful stimuli. pain nerves. It includes phantom limb pain, pain below the level of a SUBSTANCES THAT INCREASE PAIN TRANSMISSION AND spinal cord injury, and diabetic neuropathy. CAUSE AN INFLAMMATORY RESPONSE Neuropathic pain is usually intense, shooting, burning, Substance P or described as “pins and needles.” Prostaglandins This pain typically responds to adjuvant medications Bradykinin (antidepressants, antispasmodic agents, skeletal Histamine muscle relaxants). Topical medications can provide SUBSTANCES THAT DECREASE PAIN TRANSMISSION AND relief for peripheral neuropathic pain. PRODUCE ANALGESIA Serotonin Endorphins 41.2 Focused pain assessment Use anatomical terminology and Intensity, strength, and severity are Setting: how the pain affects landmarks to describe location “measures” of the pain. Use a pain daily life or how activities of daily (superficial deep, referred, or radiating). intensity scale (visual analog, description, living (ADLs) affect the pain or number rating scales) to measure QUESTIONS pain, monitor pain, and evaluate the QUESTIONS “Where is your pain? Does it effectiveness of interventions. “Where are you when the radiate anywhere else?” symptoms occur?” QUESTIONS Ask clients to point to the location. “What are you doing when “How much pain do you have now?” the symptoms occur?” “What is the worst/best “How does the pain affect your sleep?” Quality refers to how the pain feels: the pain has been?” sharp, dull, aching, burning, stabbing, “How does the pain affect your ability “Rate your pain on a scale of 0 to 10.” to work or interact with others?” pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying, torturing, nagging, Timing: onset, duration, frequency annoying, intense, or unbearable. Associated findings: fatigue, QUESTIONS depression, nausea, anxiety. QUESTIONS “When did it start?” QUESTIONS “What does the pain feel like?” “How long does it last?” “What other symptoms do you have Give more than two choices: “Is the pain when you are feeling pain?” throbbing, burning, or stabbing?” “How often does it occur?” “Is it constant or intermittent?” Aggravating/relieving factors QUESTIONS “What makes the pain better?” “What makes the pain worse?” “Are you currently taking any prescription, herbal, or over‑the‑counter medications?” 236 CHAPTER 41 Pain Management CONTENT MASTERY SERIES  Online Video: Pain Assessment ASSESSMENT/DATA COLLECTION EXPECTED FINDINGS Noted pain experts agree that pain is whatever the Behaviors complement self‑report and assist in pain person experiencing it says it is, and it exists whenever assessment of nonverbal clients. the person says it does. The client’s report of pain is the ◯ Facial expressions (grimacing, wrinkled forehead), most reliable diagnostic measure of pain. body movements (restlessness, pacing, guarding) Self‑report using standardized pain scales is useful for ◯ Moaning, crying clients over the age of 7 years. Pain scales can include ◯ Decreased attention span images, numbers, words, or other intensity markers that Blood pressure, pulse, and respiratory rate increase allow the client to select a pain level. temporarily with acute pain. Eventually, increases Specialized pain scales are available for use with in vital signs will stabilize despite the persistence of younger children or individuals who have difficulty pain. Therefore, physiologic indicators might not be an communicating verbally. accurate measure of pain over time. Assess and document pain (the fifth vital sign) frequently. Clients might experience hyperalgesia (a heightened Use a symptom analysis to obtain subjective data. (41.2) sense of pain). Allodynia is a condition in which the client experiences pain following experiences that are not usually painful RISK FACTORS (when wearing clothes or feeling the wind blow). UNDERTREATMENT OF PAIN Cultural and societal attitudes Lack of knowledge PATIENT‑CENTERED CARE Fear of addiction Exaggerated fear of respiratory depression NURSING CARE POPULATIONS AT RISK FOR UNDERTREATMENT OF PAIN When pain is persistent, schedule pain interventions Infants around the clock to keep pain at a more tolerable Children level. Including PRN dosing is helpful for managing Older adults pain exacerbations. Clients who have substance use disorder Review provider prescriptions for analgesia, noting CAUSES OF ACUTE AND CHRONIC PAIN that some might be for mild, moderate, or severe pain. Trauma Use nursing judgment to determine the prescription to Surgery administer based on client data. Cancer (tumor invasion, nerve compression, bone Older adults are at an increased risk for undertreatment metastases, associated infections, immobility) of pain, as well as increased risk for adverse events Arthritis following analgesia administration. Fibromyalgia Take a proactive approach by giving analgesics before Neuropathy pain becomes too severe. It takes less medication Diagnostic or treatment procedures (injection, to prevent pain than to treat pain. Medicating the intubation, radiation) client prior to painful procedures can prevent or minimize pain. FACTORS THAT AFFECT THE PAIN EXPERIENCE Instruct clients to report developing or recurrent Age pain and not wait until pain is severe (for PRN ◯ Infants cannot verbalize or understand their pain. pain medication). ◯ Older adult clients can have multiple pathologies that Explain misconceptions about pain (medication cause pain and limit function. dependence, pain measurement and perception). Fatigue: Can increase sensitivity to pain. Help clients reduce fear and anxiety. Genetic sensitivity: Can increase or decrease Create a treatment plan that includes both pain tolerance. nonpharmacological and pharmacological Cognitive function: Clients who have cognitive pain‑relief measures. impairment might not be able to report pain or report it accurately. Prior experiences: Can increase or decrease sensitivity depending on whether clients obtained adequate relief. Anxiety and fear: Can increase sensitivity to pain. Support systems and coping styles: Presence of these can decrease sensitivity to pain. Culture: Can influence how clients express pain or the meaning they give to pain. FUNDAMENTALS FOR NURSING CHAPTER 41 Pain Management 237  NONPHARMACOLOGICAL PAIN Non-opioid analgesics MANAGEMENT STRATEGIES Non-opioid analgesics (acetaminophen, nonsteroidal The nurse should not require the client to use anti‑inflammatory drugs [NSAIDs], including salicylates) nonpharmacological strategies in place of pharmacological are appropriate for treating mild to moderate pain. pain measures, although the client has the right to choose Be aware of the hepatotoxic effects of acetaminophen. whether to use both types. Clients who have a healthy liver should take no more Ensure bed linens are clean and smooth, and that the than 4 g/day. Make sure clients are aware of opioids that client is not lying on tubing or other equipment that contain acetaminophen (hydrocodone bitartrate 5 mg/ could cause discomfort. acetaminophen 500 mg). Position the client in anatomic position, using gentle Monitor for salicylism (tinnitus, vertigo, decreased positioning techniques, and reposition frequently to hearing acuity). minimize discomfort. Prevent gastric upset by administering the medication Instruct clients on the use of strategies to reduce pain. with food or antacids. Monitor for bleeding with long‑term NSAID use. Cognitive‑behavioral measures: changing the way a client perceives pain, and physical approaches to Opioid analgesics improve comfort Opioid analgesics (morphine sulfate, fentanyl, and Cutaneous (skin) stimulation: transcutaneous electrical codeine) are appropriate for treating moderate to severe nerve stimulation (TENS), heat, cold, therapeutic touch, pain (postoperative pain, myocardial infarction pain, and massage cancer pain). Interruption of pain pathways It is essential to monitor and intervene for adverse Cold for inflammation effects of opioid use. Heat to increase blood flow and to reduce stiffness ◯ Sedation: Monitor level of consciousness and take Distraction safety precautions. Sedation usually precedes Includes ambulation, deep breathing, visitors, television, respiratory depression. games, prayer, and music ◯ Respiratory depression: Monitor respiratory rate prior Decreased attention to the presence of pain can decrease to and following administration of opioids (especially perceived pain level. for clients who have little previous exposure to opioid medications). Initial treatment of respiratory Relaxation: Includes meditation, yoga, and progressive depression and sedation is generally a reduction in muscle relaxation opioid dose. If necessary, slowly administer diluted Imagery naloxone to reverse opioid effects until the client can Focusing on a pleasant thought to divert focus deep breathe with a respiratory rate of at least 8/min. Requires an ability to concentrate ◯ Orthostatic hypotension: Advise clients to sit or lie down if lightheadedness or dizziness occur. Instruct Acupuncture and acupressure: Stimulating subcutaneous clients to avoid sudden changes in position by slowly tissues at specific points using needles (acupuncture) or moving from a lying to a sitting or standing position. the digits (acupressure) Provide assistance with ambulation. Reduction of pain stimuliin the environment ◯ Urinary retention: Monitor I&O, assess for distention, administer bethanechol, and catheterize. Elevation of edematous extremitiesto promote venous ◯ Nausea/vomiting: Administer antiemetics, return and decrease swelling advise clients to lie still and move slowly, and eliminate odors. PHARMACOLOGICAL INTERVENTIONS ◯ Constipation: Use a preventative approach (monitoring of bowel movements, fluids, fiber intake, Analgesics are the mainstay for relieving pain. The exercise, stool softeners, stimulant laxatives, enemas). three classes of analgesics are non-opioids, opioids, and adjuvants. Adjuvant analgesics The parenteral route is best for immediate, short‑term relief of acute pain. The oral route is better for chronic, Adjuvant analgesics, or coanalgesics, enhance the effects non-fluctuating pain. of non-opioids, help alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain. Anticonvulsants: carbamazepine, gabapentin Antianxiety agents: diazepam, lorazepam Tricyclic antidepressants: amitriptyline, nortriptyline Anesthetics: infusional lidocaine Antihistamine: hydroxyzine Glucocorticoids: dexamethasone Antiemetics: ondansetron Bisphosphonates and calcitonin: for bone pain 238 CHAPTER 41 Pain Management CONTENT MASTERY SERIES  Patient‑controlled analgesia Application Exercises Patient‑controlled analgesia (PCA) is a medication delivery system that allows clients to self‑administer safe doses 1. A nurse at a clinic is collecting data about pain from of of opioids. a client who reports severe abdominal pain. The nurse Small, frequent dosing ensures consistent plasma levels. asks the client if there has been any accompanying Clients have less lag time between identified need and nausea and vomiting. Which of the following pain delivery of medication, which increases their sense characteristics is the nurse attempting to determine? of control and can decrease the amount of medication A. Presence of associated manifestations they need. B. Location of the pain Morphine, hydromorphone, and fentanyl are typical C. Pain quality opioids for PCA delivery. D. Aggravating and relieving factors Clients should let the nurse know if using the pump does not control the pain. 2. A nurse is collecting data from a client who is To prevent inadvertent overdosing, the client is the reporting pain despite taking analgesia. Which only person who should push the PCA button. of the following actions should the nurse take to determine the intensity of the client’s pain? Other interventions A. Ask the client what precipitates the pain. ADDITIONAL PHARMACOLOGICAL PAIN INTERVENTIONS: B. Question the client about the location of the pain. Local and regional anesthesia and topical analgesia C. Offer the client a pain scale to measure their pain. D. Use open‑ended questions to identify the client’s pain sensations. COMPLICATIONS AND NURSING IMPLICATIONS 3. A nurse is discussing the care of a group of Undertreatment of pain is a serious complication and can clients with a newly licensed nurse. Which of lead to increased anxiety with acute pain and depression the following clients should the newly licensed with chronic pain. Assess clients for pain frequently, and nurse identify as experiencing chronic pain? intervene as appropriate. A. A client who has a broken femur Sedation, respiratory depression, and coma can occur as and reports hip pain. a result of overdosing. Sedation always precedes B. A client who has incisional pain 72 hr respiratory depression. following pacemaker insertion. Identify high‑risk clients (older adult clients, clients C. A client who has food poisoning and who are opioid‑naïve). reports abdominal cramping. Carefully titrate client dose while closely monitoring D. A client who has episodic back pain respiratory status. following a fall 2 years ago. Stop the opioid and give the antagonist naloxone if respiratory rate is below 8/min and shallow, or the client is difficult to arouse. 4. A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of Identify the cause of sedation. the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) A. Urinary incontinence Active Learning Scenario B. Diarrhea A nurse on a medical‑surgical unit is reviewing with a C. Bradypnea group of newly licensed nurses the various types of pain D. Orthostatic hypotension the clients on the unit have. Use the ATI Active Learning E. Nausea Template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: List the four different 5. A nurse is caring for a client who is receiving types of pain, their definitions, and characteristics. morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. “I’ll wait to use the device until it’s absolutely necessary.” B. “I’ll be careful about pushing the button too much so I don’t get an overdose.” C. “I should tell the nurse if the pain doesn’t stop while I am using this device.” D. “I will ask my adult child to push the dose button when I am sleeping.” FUNDAMENTALS FOR NURSING CHAPTER 41 Pain Management 239