Basic Human Needs Comfort and Pain Management

1. Basic Human NeedsComfort and Pain Management

2. Pain Unpleasant, subjective sensory and emotional experience associated with an actual or potential tissue damage Can be a factor inhibiting the ability and willingness to recover from illness Subjective experience

3. Comfort Concept central to the art of nursing Through comfort measures nurses provide strength, hope, solace, support, encouragement, and assistance As subjective as pain

4. Pain McCaffery on Pain-Pain is whatever the experiencing person says it is, existing whenever the person says it does. (Margo McCaffery, 1979) Pain relief is a basic legal right (American Bar Association, 2000) Nurses are ethically and legally responsible for managing pain and relieving suffering.

5. Pain Management Effective pain management reduces physical discomfort Promotes earlier mobilization and return to work Shortens hospital stay and reduces health care costs

6. Pain Management

7. Nature of Pain Subjective, highly individualized Stimulus can be physical and/or mental in nature Pain is tiring, places demands on person’s energy Can interfere with relationships and influence the meaning of life

8. Nature of Pain Cannot be objectively measured Certain types of pain produce predictable symptoms Pain Assessment-nurse relies on clients words and behaviors Protective physiologic mechanism, changes behavior

9. Physiology of PainCategories Acute Chronic Idiopathic Pain Cancer pain Pain by Inferred Pathology/Nociceptive & Neuropathic Pain as a result of a Metabolic Need/Ischemic Pain

10. Nociceptive Pain Normal processing of stimuli that damages normal tissue or has the potential to do so if prolonged Usually responsive to nonopioids or opioids Somatic or visceral

11. Somatic Pain Arises from bone, joint, muscle, skin or connective tissue Usually aching, throbbing, well-localized pain Responds to traditional analgesia

12. Visceral Pain Arises from visceral organs such as the GI tract, heart, and pancreas. Can be subdivided further: 1. Tumor involvement of organ 2. Obstruction of hollow viscus

13. Neuropathic Pain Abnormal processing of sensory input by the peripheral or CNS Treatment usually with tricyclic antidepressants, SSRI’s, anticonvulsants Centrally generated pain Peripherally generated pain

14. Idiopathic Pain • Chronic pain in the absence of an identifiable cause • Complex Regional Pain Syndrome

15. Ischemic Pain • Pain as a result of the metabolic need for oxygen • Warning sign of tissue damage • Cardiac pain (angina, MI) • Vascular pain- Peripheral vascular disease, intermittent claudication

16. Nociceptive Pain Transduction Transmission Perception Modulation

17. Gate Control Theory of Pain Pain impulses can be regulated or even blocked by gating mechanism along CNS Theory suggests that pain impulses pass when gate is open and blocked when gate is closed Closing the gate is basis for pain relief interventions

18. Gate Control Theory of Pain Involves the addition of mechanoreceptors (A-beta neurons), which releases inhibiting neurotransmitter (Serotonin) If dominant input is from A-beta fibers, gating mechanism will close, pain reduced, due to release of Serotonin (Back rub) If dominant input from A-delta fiber, gate will be open and pain perceived Release of endorphins also close gate

20. Physiological Response to Pain ANS stimulated as pain impulses ascend the spinal cord Pain of low to moderate intensity and superficial pain elicit the “fight or flight” reaction Sympathetic stimulation results in physiologic responses (Increased heart rate, peripheral vasoconstriction, dilatation of bronchial tubes, increased blood sugar)

21. Physiological Response to Pain Continuous pain or severe, deep pain (visceral) involving organs puts the parasympathetic system into effect Parasympathetic stimulation results in pallor, muscle tension, decreased heart rate and BP, N/V, weakness, exhaustion

22. Behavioral Responses to Pain Pain threatens physical & psychological well-being Some people choose not to express pain (belief, value, cultural influences) Typical body movements that indicate pain: clenching teeth, grimace, holding area, bent posture

23. Acute Pain Follows acute injury, disease, surgical intervention Rapid onset Varies in intensity (mild-severe) Lasts a brief period of time (less than 6 months)

24. Chronic Pain Prolonged Varies in intensity Lasts longer than 6 months Also known as chronic non-malignant pain Arthritis, headache, myofascial pain, low back pain

26. Cancer Pain Pain that is due to tumor progression Related to pathology, invasive procedures, infection, toxicities of Rx Can be acute or chronic, nociceptive or neuropathic At the actual site or distant to the site (Referred pain)

27. Factors Influencing Pain Age Gender Culture Meaning of pain Attention Anxiety Fatigue Previous Experience Coping Style Family & Social Support

28. Nursing ProcessAssessment AHCPR guidelines for assessing pain Clients expression of pain Characteristics of pain Onset & duration Location Intensity (Pain scales-numerical, FACES)

31. Assessment Quality Pain pattern Concomitant Symptoms Effect of pain on client (physical, behavioral, effect on ADL) Cultural Considerations

32. Nursing ProcessNursing Diagnosis Anxiety Alteration in Comfort Self-care Deficit Sleep Pattern Dysfunction Sexual Dysfunction

33. Nursing ProcessImplementation Non-Pharmacological and pharmacological Methods Non-pharmacologic methods-lessen pain, can be used at home or in hospital Utilize cognitive-behavioral & physical approaches Allow patients some control

34. Non-pharmacological Methods Acupuncture Relaxation Guided Imagery Distraction Music Biofeedback Self-Hypnosis Reducing Pain Perception Cutaneous Stimulation (Heat or Cold application, massage, TENS unit)

39. Pharmacologic Methods Require a physicians order Guidelines set by regulatory agencies Analgesics most common method Tendency to under treat with pain meds

40. Analgesics Non-opioid or non-narcotic agents & non-steroidal anti-inflammatory agents (NSAIDS) Narcotics, Opioids Adjuvants, Co-analgesics

41. NSAIDS Relief of mild to moderate pain Believed to inhibit prostaglandins & inhibits cellular response during inflammation Acts on peripheral nerve receptors to reduce the transmission & reception of pain Does not cause sedation or respiratory depression or interfere with bowel/bladder function Avoid prolonged or overuse in elderly

42. NSAIDS Used in arthritic pain, minor surgical, dental procedures, low back pain, should be initially used in mild-moderate post-op pain Motrin, Naprosyn, Indocin, Toradol

43. Opioids Moderate to severe pain Act on CNS, act on higher brain centers & spinal cord binding with opiate receptors to modify perception of or reaction to pain Risk for depression of vital nervous system functions

44. Opioids If pain is anticipated for longer than 12-24 hours, ATC timing should be used instead of PRN timing Opioids can be used effectively with elderly, START LOW & GO SLOW Morphine, Demerol, Codeine, Percocet, Fentanyl, Hydromorphone Opioid antagonist- NARCAN-reverses effect

45. Adjuvant Therapy Sedatives, anti-anxiety, & muscle relaxants Enhance pain control or relieve symptoms associated with pain Vistaril, Elavil, Thorazine, Valium, Ativan, Xanax

47. Patient-Controlled Analgesia PCA Drug delivery system Patients have control over pain therapy Safe method for post-op, traumatic, or cancer pain Self-administration without risk of overdose IV administration

49. PCA Prescription Loading Dose Basal (Continuous rate) On demand dose Hourly maximum amounts can be prescribed

50. Local & Regional Anesthetics Wound suturing Delivery of baby Performing simple surgery Epidural Analgesia for post-op pain management, L&D pain, chronic cancer pain On-Q Pain Pump