Pain

1. Pain Lisa B. Flatt, RN, MSN, CHPN

2. Definition • Complex • Subjective • Psychological • Biological • Cultural • Social factors • WHAT THE PATIENT SAYS IT IS!!!!!

3. Types of Pain • Acute • Chronic • Intermittent • Intractable • Malignant • Neuropathic • Phantom • Radiating • Remittent • Episodic

4. Acute Pain • Follows injury and goes away when it heals • May be associated with autonomic nervous stimulation: TC, HTN, diaphoresis (sweat not to be confuse with sweet ), pallor, dryness • Confirm pain prior to medicated

5. Chronic Pain • Prolonged disease/dysfunction • Intermittent, limited, persistent (>6mo) • Influences: environment, emotional

6. Three categories of chronic pain • Chronic nonmalignant -– non-progressive or healed tissue • Chronic malignant --- cancer or progressive disease • Chronic intractable pain --- ability to cope with chronic pain deteriorates

7. Areas of ‘suffering’ • Physical • Social • Spiritual • HOLISTIC CARE • Environmental • Psychosocial • Physical • Spiritual

8. Acute Pain Trauma Surgery Fracture Chronic inflammation, bruising Procedural Phantom Chronic Pain Marriage lol Arthritis Malignancy/tumor back-chronic Non-malignant Neuropathy Phantom Acute vs. Chronic Pain

9. ACUTE Mild to severe Sympathetic Nervous System responses Increased: HR, RR, BP, diaphoretic, dilated pupils Subjective r/t tissue injury Resolves with healing Crying, rubbing area, holding area CHRONIC Mild to severe Parasympathetic Nervous System Normal VS Dry warm skin Pupils normal or dilated Does not always mention pain unless asked Appears withdrawn and depressed Pain behavior often absent Pain and comparison

10. Physiology Descriptors/Categories • Intractable; resistant to analgesia, advanced tumors • Neuropathic; peripheral or CNS, may be tissue related • Phantom; missing limb, spinal cord injury (some)

11. More categories • Cutaneous – skin or SC tissue • Deep somatic – tendon/blood vessels, nerves • Visceral – internal organs

12. Radiation and Referred • Radiating – extends from area of insult/injury outwards – UTI, kidney/back/urethra – chest pain/jaw/arm • Referred pain – felt in an area that is actually not the source – chest pain (arteries/blood vessels/muscle); earache (right ear hurts, left ear has infection)

13. Stimulus Type Mechanical – trauma, tissue, blockage duct, tumor, spasms Thermal – heat and/or cold Chemical – tissue ischemia ( blocked artery) – muscle spasm Physiologic basis of pain Tissue damage – direct irritation of receptors (inflammation) – distention of duct – irritation on nerve endings – chemical stimuli – tissue destruction – thermosensititive – chemical (lactic acid, K, Mg, Na) Pain Stimuli

14. Gate Control Theory • Nerve fibers carrying painful stimuli to spinal cord. • Input can be modified at spinal cord level prior to going to the brain. Stops the sense of pain before it goes to the brain to be processed. • Limited amount of pain stimuli the brain can handle at one time. • Small fibers carry pain stimuli. Large fibers stimulate a non-noxious stimuli going through same gate (ice pack, pain meds) this inhibits and blocks the gate.

15. 4 points to be modulated/reduced • Peripheral site • Spinal cord • Brain stem • Cerebral cortex

16. Shut out pain (neuromodulators) • Mechanoreceptors -stimulation of fibers • Endogenous opiods • Electrical stimulation • Opiods and morphine • Normal and excessive sensory stimuli • Cerebral cortex and thalamic inhibition

17. Pain in the… • Threshold -Differing perceptions of pain, fairly uniform (sprain less painful than gall bladder attack) • Tolerance – how much you can handle • Neuromodulators (endorphin and enkephalin) – produced in brain, act like an opiate, bind to opiate receptor sites, increases pain threshold **released with fight or flight and excessive exercise**

18. Pain is…Psychological and Physical • Cognitive • Toddler- dramatic, carry on – perception, frustrated, intolerant, fearful • Childbirth – acute, varies, helpless • Emotional- anxiety, depression, stress, frustration, length of time/perceived time • Myths- not always drug-seeking, aging means pain, pt not complaining they don’t have, admitting pain is a sign of weakness, unavoidable, deserved = bad person = sinned, resistant to med’s • Suffering – physical, psychological, emotional or distress- chronic pain and never fully relieved ----alternative holistic methods

19. Pain Management Principles • Acknowledge – accept-educate-medicate- • Pharmacological and non-pharm • Different types of med’s: NSAID’s, ASA, Opiods, etc.. • Treat the pain before it becomes severe • 0-10 – treat when? 4-5 – pt perception

20. Factors Influencing Pain • Age • Gender • Culture • Religion • Physical condition at start • Support • Social • Environment • Financial

21. Assessment Methods to measure/describe pain • Wong/Baker Faces • Numeric • WILDA • OPQRST • COLDERRA

22. Wong-Baker Scales • Happy face to sad face with sweat/tears and blood • Adult patient 0-10 • Child faces 0-5

23. WILDA • W=word describes pain (sharp, stabbing, throbbing, aching) • Intensity – 0-10 or faces • Location – where is it • Duration- how long does it last • Aggravating and alleviating factors – what makes it worse or better

24. OPQRST • Other s/s • Provocative/palliative – what makes it worse or better • Quality – description • Region of pain • Severityof pain • Temporal/timing

25. COLDERRA • Character- sharp, burning • Onset – when did it start • Location – where it is • Duration • Exacerbation – makes it worse • Relief • Radiation • Associated s/s

26. Assess those things we always talk about • Age • Sex • Emotional • Blah • Blah • blah

27. Assess Physical Side • Facial expression • VS • Positioning • Guarding • Striking at nurse if she touches area that hurts • Diaphoresis • Labs

28. Analyze • Synthesis of the assessment • Collaborative approach to other disciplines findings • Determine a nursing diagnosis • Acute vs. chronic

29. Planning • Determine desired outcomes • Step by step goal strategy • Patient centered • Realistic

30. SMART ER • Specific • Measurable • Attainable and action based • Realistic • Timebound • Evaluation • Reassessment

31. WHO (world health organization) • 3 – step analgesic ladder approach • Nursing intervention – backrubs, massage, lotion, ice and heat, distraction, (hammer…ignoring) • Environmental – noise • Listening • ******Patient Bill of Rights******* • Treat pain to the best of our ability and right to treatment, refuse treatment, pt centered decision making, confidentiality

32. Implementation • Initiate and complete plan • Work toward goal • Nursing measures/massages • Pain society usage and guidelines • CDC and NIH website on pain

33. Physical modifications • Accupressure – Chinese healing system, finger pressure at certain points, ointments, linaments, massaging • TENS, transcutaneous electrical nerve stimulation – prickling sensation small stimulation ( Gate control theory)

34. Environmental Modification • Stairs • Room temp • Ventilation • Fans • Assistive devices

35. Psychological Modifications • Cognitive behavioral therapies – model desired behaviors, learning theories • Biofeedback theory – teach to relax, calm, reproduce condition of happiness • Meditation – ‘getting out of oneself’ • This is not prayer.

36. WHO 3 step Ladder • Non-opiod analygesics +/- an adjuvant. Moderate ain persists go to • Opioid admin +/- non-opioid +/- adjuvant • Opioid for moderate to severe pain +/- non opioid +/- adjuvant. Used for the relief of cancer pain. • Adjuvants med’s – enhance analgesia of opioids, treat symptoms that exacerbate pain/provide independent analgesia for types of pain. Corticosteroids, antidepressants, hypnotics.

37. Medications/Sedatives • NSAIDS – naproxen, motrin, advil, indomethacin, ASA, Acetaminophen • Opioids agonists – morphine, codeine, hydromorphone, oxycodone, oxymorphine, meperidine, fentanyl, methadone. Produce analgesia by binding to opioid receptors. • Opioids antagonist – naloxone, reverses depressant effect of opioids, treatm opioid OD • Opioid agonist-antagonists – pentazocine, nalphybine, butorphanol, dezocine, bind only to certain sites • Topical drugs localized pain

38. PCA • Patient controlled analgesia • Beneficial psychologically • Decreases dependency • Decreases anxiety • Patient part of their treatment plan

39. Evaluation • Assess verbal and nonverbal response • Response to pain reduction methods • VS • Pain scale

40. MYTHS per the book • Expected with age • Chronic pain = hypochondriac • Infants feel no pain • No complaining no pain • Pain is unavoidable part of recovery • Admission is a sign of weakness • Drug addiction • Using drug at the start of pain will make it not work as good later • Severe pain is only seen in people who are melodramatic and/or hysterical