Sean Whitfield - NURS 3000 - Module 6 Pain Assessment & Management PDF

NURS 3000 -Professional Nursing Comfort Needs Comfort Needs Harding University - Active Learning Guide, Module 6 Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client sc...

NURS 3000 -Professional Nursing Comfort Needs Comfort Needs Harding University - Active Learning Guide, Module 6 Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers; or you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Pain Assessment and Management: Chapter 30 1. What is pain? Pg 625 An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage 2. Types of pain:  Location: Classifications of pain based on location (e.g., head, back, chest) may be problematic. o Referred; Radiating: Complicating the categorization of pain by location is the fact that some pains radiate (spread or extend) to other areas (e.g., low back to legs).  Duration: When pain lasts only through the expected recovery period of less than 3 months, it is described as acute pain, whether it has a sudden or slow onset, regardless of its intensity. o Acute vs Chronic (See Table 30.1): NURS 3000 -Professional Nursing Comfort Needs   Intensity: Most practitioners classify intensity of pain by using a numeric scale: 0 (no pain) to 10 (worst pain imaginable). Linking the rating to health and functioning scores, pain in the 1 to 3 range is considered mild pain, a rating of 4 to 6 is moderate pain, and pain reaching 7 to 10 is viewed as severe pain and is associated with the worst outcomes. Etiology: the cause, set of causes, or manner of causation of a disease or condition. o Nociceptive: is experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care. o Somatic: originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain. o Neuropathic: is associated with damaged or malfunctioning nerves due to illness (e.g., post-herpetic neuralgia, diabetic peripheral neuropathy), injury (e.g., phantom limb pain, spinal cord injury pain), or undetermined reasons. Neuropathic pain is typically chronic; it is often described as burning, “electricshock,” or tingling, painful numbness, dull, and aching. Episodes of sharp, shooting pain can also be experienced. Neuropathic pain tends to be difficult to treat. 3. Common Chronic Pain Syndromes (See Box 30.1) NURS 3000 -Professional Nursing Comfort Needs 4. What is the difference between pain threshold and pain tolerance? Pain threshold: is the least amount of stimuli that is needed for someone to label a sensation as pain. It may vary slightly from individual to individual, and may be related to age, gender, or race, but it changes little in the same individual over time. Pain tolerance: is the maximum amount of painful stimuli that an individual is willing to withstand without seeking avoidance of the pain or relief. Pain tolerance varies significantly among individuals, even within the same individual at different times and in different circumstances. 5. Concepts Associated with Pain (See Box 30.2) 6. What are the four processes involved in nociception?  Transduction: During the transduction phase, harmful stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, which sensitize nociceptors. Painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications can work during this phase by blocking the production of prostaglandin (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]) or by decreasing the movement of ions across the cell membrane (e.g., topical local anesthetic). Another example is NURS 3000 -Professional Nursing Comfort Needs the topical analgesic capsaicin, which depletes the accumulation of substance P and blocks transduction.  Transmission: During the first segment of transmission, the pain impulses travel from the peripheral nerve fibers to the spinal cord. Substance P serves as a neurotransmitter, enhancing the movement of impulses across the nerve synapse from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal cord. Two types of nociceptor fibers cause this transmission to the dorsal horn of the spinal cord: unmyelinated C fibers, which transmit dull, aching pain, and thin Adelta fibers, which transmit sharp, localized pain. The second segment is transmission of the pain signal through an ascending pathway in the spinal cord to the brain. The third segment involves transmission of information to the brain where pain perception occurs. Only microseconds are required for the signal to be conducted from the site of injury (transduction process) to the brain, where pain is perceived (perception process).  Perception: The third process, perception, is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system (CNS) that may shape the character and intensity of pain perceived (e.g., sharp, burning, pressure) and give meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows. Nonpharmacologic interventions such as distraction, imagery, massage, and acupuncture have been used to influence pain perception.  Modulation: Often described as the “descending system,” this final process occurs when neurons in the brain send signals back down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opioids, serotonin, and norepinephrine, which can inhibit or reduce the ascending painful impulses in the dorsal horn. In contrast, excitatory amino acids (e.g., glutamate, N-methyl-d-aspartate [NMDA]) can increase these pain signals. The effects of excitatory amino acids tend to continue, while the effects of the inhibitory neurotransmitters (endogenous opioids, serotonin, and norepinephrine) tend to be short lived because they are reabsorbed into the nerves. Tricyclic antidepressants can relieve pain by blocking the resorption of norepinephrine and serotonin, making them more available to fight pain; or NMDA-receptor antagonists (e.g., ketamine, dextromethorphan) or opioids may be used to help diminish the pain signals. 7. Types of Pain Stimuli (See Box 30.2) See #5 8. How does the body respond to painful stimuli? NURS 3000 -Professional Nursing Comfort Needs Our sensory receptors that respond to pain, send a signal along the sensory neurons to the spinal cord, where the signal is transmitted to the brain for interpretation. The brain then sends a signal back to the site of pain via motor neurons, causing the body to respond to the painful stimuli. 9. Factors Which Affect the Pain Experience: List and describe.  Ethnic/Cultural Factors Ethnic background and cultural heritage are factors that can influence both an individual’s reaction to pain and the expression of that pain. Behavior related to pain is a part of the socialization process. For example, individuals in one culture may learn to be expressive about pain, whereas individuals from another culture may have learned to keep those feelings to themselves.  Developmental Stage The age and developmental stage of a client is an important variable that will influence both the reaction to and the expression of pain.  Environment A strange environment such as a hospital, with its noises, lights, and activity, can compound pain. In addition, the lonely client who is without a support network may perceive pain as severe, whereas the client who has supportive people around may perceive less pain. Some clients prefer to withdraw when they are in pain, whereas others prefer the distraction of people and activity around them.  Support System Family caregivers can provide significant support to a client in pain. With the increase in outpatient and home care, families are assuming an increased responsibility for the management of pain. Education related to the assessment and management of pain can positively affect the perceived quality of life for both clients and their caregivers.  Previous Pain Experiences Previous pain experiences alter a client’s sensitivity to pain. Clients who have personally experienced pain or who have been exposed to the suffering of someone close to them are often more threatened by anticipated pain than those without a pain experience. In addition, the success or lack of success of pain relief measures influences a client’s expectations for relief and future response to interventions.  Meaning of Pain Some clients may accept pain more readily than others, depending on the circumstances and the client’s interpretation of its significance. A client who associates the pain with a positive outcome may withstand the pain amazingly well. For example, a woman giving birth to a child or an athlete undergoing knee surgery to prolong her career may tolerate pain better because of the benefit associated with it. These clients may view the pain as a temporary inconvenience rather than a potential threat or disruption to daily life.  Emotional State/Coping ability Anxiety often accompanies pain. Prolonged anxiety associated with pain can lead to other emotional disturbances, such as depression or NURS 3000 -Professional Nursing Comfort Needs difficulty coping. Fear of the unknown and the inability to control the pain or the events surrounding it often raises pain perception. When clients are experiencing pain, they often become fatigued. Fatigue reduces a client’s ability to cope, thereby increasing pain perception. With anxiety, depression, and fatigue, sleep disturbances can occur. When pain interferes with sleep, fatigue and muscle tension often result and increase the pain; thus, a cycle of pain, fatigue, and increased pain develops. Assessing clients with chronic pain for the presence of insomnia, major depression, and suicide potential is vitally important. 10.Assessment of Pain: What questions should the nurse ask? What objective assessments should the nurse make? 11.Clinical Alert: p. 636 Client’s perception of pain - Why is that important? Perception is reality. The client’s self-report of pain is what must be used to determine pain intensity. The nurse is obligated to record the pain intensity as reported by the client. By challenging the believability of the client’s report, the nurse is undermining the therapeutic relationship and preventing the fulfillment of advocacy and helping clients with pain. 12.What is important to consider regarding the client’s nonverbal behaviors and their relation to pain the client may be experiencing? When clients are unable to verbalize their pain due to age, being nonverbal or cognitively impaired, medical interventions, or other reasons, nurses need to accurately assess the intensity of their pain and the effectiveness of the pain management interventions. For these clients, the nurse must rely on observation of behavior. For example, the Neonatal Infant Pain Scale (NIPS) NURS 3000 -Professional Nursing Comfort Needs can be used for premature infants to 3 months of age. The FLACC scale has been validated in children 2 months up to adolescence and rates pain behaviors as manifested by Facial expressions, Leg movement, Activity, Cry, and Consolability measures that yield a score of 0 to 10. The Wong-Baker FACES scale can also be used for clients ranging in age from 3 months to adults. It includes a number scale along with an illustrated facial expression so that the pain intensity can be documented. When using the FACES rating scale, it is important to remember that the client’s facial expression does not need to match the picture. 13.Why is pain sometimes referred to as the “5 th Vital sign”? Because the presence of pain can affect so many aspects of a client’s functioning, pain may be the etiology of other nursing diagnoses. Descriptive adjectives help people communicate the quality of pain. A headache may be described as “unbearable” or an abdominal pain as “piercing like a knife.” The smart clinician can collect subtle clinical clues from the quality of the pain described; thus, it is important to record the description exactly as described by the client. 14.Practice Guidelines: Individualizing Care for Clients with Pain p. 641- Review these. NURS 3000 -Professional Nursing Comfort Needs 15.Table 30.5 Misconceptions About Pain - Review these. 16.Acknowledging and Accepting Clients’ Pain, p. 644 - Do you agree with these four strategies? I do. Patients are in a vulnerable position. As a nurse it is important for them to understand that you are there to assist them with their pain management. The less anxiety a patient has the better. They are better able to cope and adjust to their specific situation. 17.What is preemptive analgesia? Preemptive analgesia is the administration of analgesics before surgery to decrease or relieve pain after surgery and reduce the need for opioid pain control. Some authors, however, believe the term “preventive” analgesia better explains the assumption of the practice—that the only way to prevent central sensitization might be to block any pain and afferent signals from the surgical wound from the time of incision until final wound healing. Nurses can use a preemptive approach by providing an analgesic around the clock (ATC), and supplementing with as-needed (prn) doses after surgery or prior to painful procedures (e.g., dressing changes, physical therapy). This strategy prevents the windup and sensitization (described earlier in Box 30.2) that spreads, intensifies, and prolongs pain. 18.Multimodal Pain Management: Discuss an example in the client care setting Multimodal pain management incorporates both pharmacologic and nonpharmacologic approaches to achieve the best possible outcomes for the NURS 3000 -Professional Nursing Comfort Needs client. Multimodal analgesia combines analgesics from two or more drug classes and a variety of delivery approaches for the analgesics that result in reducing, and often eliminating, the need for opioids. This is also referred to as opioid-sparing therapy. Multimodal pain therapies include therapies that are independent of or in addition to pharmacologic therapy and include nonpharmacologic therapies such as yoga, massage, biofeedback, acupuncture, mind–body therapies, and physical therapies. Multimodal pain control is the use of multiple analgesic medication, NSAIDS, NMDA antagonists, serotonin inhibitors, non-pharmacologic and non-opioids as an intervention to reduce pain along the pathway. 19.Pharmacological Pain Management:  Non-opioids: Most common ones: Acetaminophen, Acetylsalicylic acid, Celecoxib, Ibuprofen, Ketorolac, Meloxicam, Naproxen, Piroxicam o Primary effects:All are useful for the management of acute and chronic pain. o Most common side effects:Increased risk of heart attack, stroke, Renal function impairment, Aplastic anemia.  Opioids: Most common ones: Hydrocodone, Codeine, Tramadol, Pentazocine. o Primary effects: An opioid analgesic is a natural or synthetic morphine-like substance responsible for reducing moderate to severe pain. o Most common side effects: When administering any analgesic, the nurse must review adverse effects. Adverse effects of the opioids typically include sedation, respiratory depression, nausea, vomiting, constipation, urinary retention, blurred vision, and sexual dysfunction. o Most concerning effect of opioids: The most concerning adverse effect of opioids is respiratory depression (e.g., 8 breaths per minute or less), which usually occurs early in therapy among opioidnaïve clients (individuals who have not taken opioids for 1 week or longer), with dose escalation, or in clients with drug–drug or drug– disease interactions. Clinically, the client will appear overly sedated, and respirations will be slow and deep with periods of apnea. The nurse should assess a client’s level of alertness and respiratory rate for baseline data before administering opioids. 20.What is Patient-Controlled Analgesia? Why has it been so effective in managing pain? Patient-controlled analgesia (PCA) is an interactive method of pain management that permits clients to treat their pain by self-administering doses of analgesics. The IV route is the most common in an acute care setting. Its use for postoperative pain has been well documented. It is also helpful when oral pain management is not possible. The PCA mode of therapy minimizes the roller-coaster effect of peaks of sedation and valleys of pain that occur with the traditional method of prn dosing. With the parenteral routes, the client administers a predetermined dose of an opioid by an electronic infusion pump. This allows the client to NURS 3000 -Professional Nursing Comfort Needs maintain a more constant level of relief yet requires less medication for pain relief. 21.What are some of the most common non-pharmacological pain management methods? Companionship, Exercise, Heat/cold application, Lotions/massage therapy, Meditation, Music, art, or drama therapy, Pastoral counseling and Positioning.