Basic Human Needs Comfort and Pain Management

1. Basic Human NeedsComfort and Pain Management Donna M Penn RN MSN CNE

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. 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. Transduction Begins in periphery Pain producing stimuli sends impulse to nerve fiber Pain fiber enter spinal tract Pain message is prevented from reaching brain or enters cerebral cortex Once in cerebral cortex pain perception interpreted causing a response

18. Transduction All cellular damage caused by thermal, mechanical, or chemical stimuli result in the release of pain producing substances Bradykinin, Histamine, Substance P These pain producing substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing the inflammatory response

19. Transduction Nerve impulses resulting from the painful stimulus travel along peripheral nerve fibers Two types of peripheral nerve fibers conduct pain 1. Fast, myelinated A-delta 2. Slow, unmyelinated C

23. Transmission Neuroregulators affect the transmission of nerve stimuli Substances are found at the site of a nociceptor at nerve terminals within the dorsal horn of the spinal tract and at receptor sites within the spinothalmic tract

24. Transmission Neurotransmitters 1. Substance P 2. Serotonin 3. Prostaglandins Neuromodulators 1. Endorphins 2. Bradykinin

26. 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

27. 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

29. Perception Point at which person is aware of pain Pain stimuli are transmitted up spinal cord to thalamus and midbrain From thalamus, fibers transmit pain message to cortex, frontal lobe, & limbic system Somatosensory cortex-identifies location & intensity of pain Association cortex- how we feel pain

30. Perception Limbic system-controls emotion, anxiety, & emotional reaction to pain Responses to pain can be physiological and behavioral

31. 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)

32. 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

33. 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

34. Modulation Process of inhibiting or changing pain impulse Final process in nociception Involves release of serotonin and endorphins Work to inhibit pain or provide an analgesic effect Release of endorphins can raise an individuals pain threshold

35. 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)

36. 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

38. 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)

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

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

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

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

45. 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

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