Pain Management

1. Pain Management P. Maloney MSN/Ed,RN Nursing 101

2. Pain • Pain is a complex, subjective phenomenon that involves biological, cultural, and social factors. • “Pain is whatever the patient says it is and occurs whenever the patient says it does.” • Serves as a warning sign indicating that actual damage has occurred or that the potential exists for damage of tissue.

3. Effects of pain on normal life Pain can make it difficult to: • Perform activities of daily living • Rest & experience restorative sleep • Eat • Perform normal body movements & exercise • Maintain family relationships • Work or maintain a job • Have a social life • Maintain cognitive abilities • Focus on spiritual beliefs

4. Understanding Pain • As a nurse, you must develop an understanding of pain and how you can assist you patient cope with pain. • Holistically-taking into consideration the physical, mental, social, and spiritual aspects of the patient. Look at the whole being. • This prepares you to meet the needs of the patient on an individual basis.

5. Gate Control Pain Theory • Researchers in the 1960’s proposed this theory. The theory proposes that the transmission of pain impulses to the central nervous system is controlled by a “gate”. • The gate must be open for the pain impulse to be transmitted to the brain & transmitted as pain. • When the gate is closed, the nerve impulse for pain is blocked from transmission.

6. Gate Control Theory Open gate causes: • Stress & anxiety • Stimulation of narrow nerve fibers • Injury or tissue damage stimulates narrow nerve fibers Closed gate causes: • Decreased stress & anxiety • Exercise, heat, cold, massage, • Endorphins-natural body chemicals produced by pleasant thoughts or feelings

7. Classifications of Pain • Acute Pain-pain that has a short duration, usually 6 months or less. • Chronic Pain-pain that lasts longer than 6 months. • Intermittent pain-pain that comes & goes at intervals.

8. Classifications of Pain • Intractable pain-pain that cannot be relieved, pain that is incurable or resistant to treatment. Ex. Cancer pain • Referred pain-pain that is felt in an area other than where the pain is produced. Ex. Pain that is felt in jaw or arm during a MI due to lack of O2 supply. • Radiating pain-pain that begins at a specific site & shoots or extends to a larger area.

9. Nociceptive Pain Pain is derived in two way: • From the stimulation of nerve pain receptors, called nociceptors. • From damage to the nerves themselves. Nociceptors are randomly dispersed throughout the skin, subcutaneous tissue, & muscular tissue.

10. Nociceptors Nociceptors can be stimulated by temperature change, tissue damage & certain chemicals. Two of the chemicals that can stimulate nerve pain receptors are substance P and prostoglandins. Substance P-elicits localized tissue reactions similar to inflammation. Prostoglandins are hormones that act in the immediate area and initiate inflammation.

12. Types of Nociceptive Pain • Cutaneous-pain that is more superficial or on the surface of the skin. Ex. Paper cut • Visceral –pain experienced from stimulation of deep internal pain receptors. Ex. Traumatic injury or surgery • Deep, somatic pain-pain in bone, ligament or tendon. May be diffuse with longer duration than cutaneous pain. Ex. Fractures, arthritis

13. Neuropathic Pain Pain that occurs due to injury or destruction of peripheral nerves or the central nervous system itself. Pain may extend beyond the local region to encompass a broadening area of discomfort that follows along the pathway of the damaged nerves.

14. Neuropathic Pain Neuropathic pain is described as burning, stabbing or a deep ache. Nerve destruction can cause sharp, jagged, knife-like pain or numbness. Ex. Diabetic neuropathy

15. Phantom Limb Pain Type of neuropathic pain where patient feels pain from an area that has been amputated. Ex. Complaint of foot pain after the lower leg and foot have been surgically amputated.

19. Pain Pain is the fifth vital sign. Nurse must assess: Temperature Blood Pressure Pulse Respirations Level of pain

20. Pain Assessment Assessment of pain must be made before pain can be treated effectively: • Measure level or extent of pain-use of pain scale such as 0 to 10 scale with 0 being none and 10 being the worst. • Assess the site of pain-be specific. • Characteristics of pain-dull, sharp, aching? • Is pain acute or chronic? • What causes the pain?

21. Pain Assessment Scale

22. Factors Affecting Pain • Ethnic and cultural beliefs • Developmental stage • Individual values • Previous pain experiences • Personal support system • Emotions • Fatigue

24. Responses to Pain The body responds to pain: physiologically phychologically behaviorally Sympathetic Nervous System responds: increased pulse increased resp rate increased BP pupils dilate

25. Acute and Chronic Pain Acute Pain Chronic Pain Onset longer than 6 months Pupils may constrict Vital signs may not change Depression, fatigue, anger Sudden onset, lasts less than 6 months Fight /flight response occurs As pain worsens, BP drops, diaphoresis, syncope, pupils constrict Fear and anxiety

26. Pain Assessment Nurse needs to evaluate and assess patient before pain can be treated effectively. Assessment: • Level or extent of pain, use of pain scale • Site of pain and any radiation of pain • Characteristics of pain, ex. Sharp, dull, burning • Is pain acute or chronic? • What elicits pain? • Patient desires in relation to pain?

27. Acknowledgement • Nurse must not be judgmental • Nurse must let patient know that you believe that they are in pain • Evaluate patient’s pain • Let patient know what you are going to do to help relieve their pain

29. Management and Treatment Nonpharmaceutical Methods: The Agency for Healthcare Research and Quality (AHRQ) has printed guidelines encouraging healthcare providers to incorporate nonpharmaceutical methods of pain relief to help relieve pain and decrease the need for medication. Adjuvant therapy-a means to assist or aid another treatment, therefore increasing the effectiveness.

30. Heat and Cold Heat and cold therapy are both effective for relief of musculoskeletal pain and discomfort. In acute setting, need a physicians order.

31. Message and Effleurage Message can be effective for some painful conditions, used to relax muscles and relieve tension. Effleurage-repetitive, gentle, gliding of your fingertips over the surface of the skin.

32. TENS Unit Transcutaneous Electrical Nerve Stimulation: Battery-powered device with lead wires and electrode pads which are applied to the skin over the painful area to deliver electrical stimulation to nerve fibers.

33. Acupressure and Acupuncture Acupressure involves applying fingertip pressure. Acupuncture involves the insertion of ultrafine needles into specific body areas. Both are thought to stimulate endorphins.

34. Relaxation Progressive relaxation-systematic process using the mind to relax the patient’s muscles from the top of the head to the toes. Patient lays in bed with eyes closed. Therapist directs the patient to focus on certain muscles, tensing and then relaxing.

35. Guided Imagery Guided Imagery- using the mind to guide the patient to a more relaxed state. Done verbally or by using tapes to direct the patient to thoughts of a comfortable place.

36. Distraction Distraction-used to try to take the patient’s mind off of pain. Does not always work. Decreases the conscious awareness of pain. Use of different senses. Visual distraction-television, reading Auditory distraction-listening to music or someone reading aloud Tactile distraction-back rub, rocking, receiving hugs, rocking, holding Intellectual distraction-conversing with others, puzzles, card games

37. Pharmaceutical Methods Classifications of medications: • Non-steroidal anti-inflammatory drugs (NSAID’s) • Non-opioids • Opioid narcotics • Adjuvant drugs

38. Non-Opioid Analgesics Non-narcotic pain relievers used for mild to moderate pain. Ex. Acetaminophen-has both analgesic and anti-pyretic effects. Maximum dose is 4gms or 4000mg q 4 hrs. Side effect-hepatotoxicity

39. NSAIDs • Non-steroidal anti-inflammatory drugs reduce inflammation and pain at the site of the injury. • Over-the-counter • Most common are: ibuprofen, naproxen, and aspirin.

40. NSAIDs Aspirin: • Anti-inflammatory • Analgesic • Anti-pyretic • Usual adult dose-600-1,000mg q 4hrs. • Anti-platelet effect (decreases platelet clumping) • Usual dose for anti-platelet is 81-300mg daily

41. NSAIDs • May cause gastric irritation and bleeding. • Do not exceed recommended dosage. • Administer medication with food. • Instruct patient to take with food at home. • Instruct patient to notify MD immediately of any GI bleeding.

42. Narcotic Analgesics • Opiate/Opioid Analgesics: • Used when non-opoid medications are ineffective in relieving moderate to severe pain. • Usually effective in relieving visceral pain and deep somatic pain.

43. Narcotic Analgesics • Work by binding with opiate receptors and stimulate the brain’s production of beta-endorphins that decrease pain perception. • Controlled substance • Require a prescription • Controlled or scheduled drugs due to greater capacity for addiction. • Regulated by federal law.

44. Route of Administration • Opiates come from opium and it’s derivatives known as opioids. • Opioids –synthetic form. • Opiates and opioids can be administered: • Orally • Rectally • Subcutaneously (Sq) • Intramuscular (IM) • Intravenous (IV)

45. Side Effects • Nausea • Vomiting • Constipation • Itching • Sedation • Respiratory distress • Pupil constriction ** Narcan is a medication used to counteract the effects of opiates if patient should become unresponsive or in case of overdose.**

46. Patient-controlled analgesia (PCA) Computerized IV infusion device consisting of a pump, a large syringe containing the analgesic, IV tubing, push button that the patient pushes for delivery of analgesic. Physician orders maximum dose and nurse or pharmacist calibrates the pump.

47. PCA Pump Initially, the nurse will deliver a loading dose or bolus to get the patient started to get the pain under control. The patient will then be set up to push the button to self-administer a dose whenever they have pain. The patient will only be able to receive the set dose no matter how many times they push the button.

48. Advantages to PCA • Provides the patient with control over their pain relief. • Avoids repeated injections. • Provides rapid relief via IV route. • Reduces the anxiety and fear that pain will get out of control. • Allows for smaller dosing, ultimately resulting in the use of less medication. • Reduces waiting for nurse response. • Enables patient to achieve more comfortable ambulation, reducing complications

49. Adjuvant Analgesics Classes of medication that produces pain relief through a mechanism different than traditional analgesics, or by potentiating or increasing the effects of opiates, opioids, and non-opioid drugs. Ex. Anticonvulsants and antidepressants. Some of these drugs may help to treat nerve pain. Ex. Skeletal muscle relaxants may be helpful to reduce muscle spasms.

50. Rest and Restorative Sleep Restorative sleep is that which allows an individual to awaken feeling rested, refreshed, rejuvenated, and energized. Resting may or may not involve sleep but it is a time when the patient should feel relaxed and free from anxiety.