Chapter 34 Comfort and Pain Management

1. Chapter 34Comfort and Pain Management

2. Categories of Pain • Duration • Acute • Chronic • Location or source • Mode of transmission • Etiology

3. Sources of Pain • Nociceptive • Cutaneous • Somatic • Visceral • Neuropathic

4. Question A patient who has bone cancer is most likely experiencing which of the following types of pain? A. Cutaneous B. Somatic C. Visceral D. Referred

5. Answer Answer: B. Somatic Rationale: Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissue. Visceral pain is poorly localized and originates in body organs. Referred pain is pain that originates in one part of the body and is perceived in an area distant to that part.

6. Origin of Pain • Physical: cause of pain can be identified • Psychogenic: cause of pain cannot be identified • Referred: pain is perceived in an area distant from its point of origin

7. The Pain Process • Transduction: activation of pain receptors • Transmission: conduction along pathways (A-delta and C-delta fibers) • Perception of pain: awareness of the characteristics of pain • Modulation: inhibition or modification of pain

8. Stimulator of Nociceptors or Pain Receptors • Bradykinin: a powerful vasodilator that increases capillary permeability and constricts smooth muscle • Prostaglandins: important hormone-like substances that send additional pain stimuli to the CNS • Substance P: sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves

9. Gate Control Theory of Pain • Describes the transmission of painful stimuli and recognizes a relationship between pain and emotions • Small- and large-diameter nerve fibers conduct and inhibit pain stimuli toward the brain. • Gating mechanism determines the impulses that reach the brain.

10. Perception of Pain • Pain threshold • Adaptation • Modulation of pain • Neuromodulators • Endorphins, dynorphins, enkephalins

11. Question Which modulator of pain is thought to reduce pain sensation by inhibiting the release of substance P from the terminals of afferent neurons? A. Endorphins B. Dynorphins C. Enkephalins D. Nociceptors

12. Answer Answer: C. Enkephalins Rationale: Enkephalins are thought to reduce pain by inhibiting the release of substance P from the terminals of afferent neurons. Endorphins and dynorphins are released when certain measures are used to relieve pain. Nociceptors are the peripheral nerve fibers that transmit pain.

13. Pain Sensation and Relief

14. Common Responses to Pain • Physiologic • Behavioral • Affective

15. Duration of Pain • Acute • Rapid in onset, varies in intensity and duration • Protective in nature • Chronic • May be limited, intermittent, or persistent • Lasts beyond the normal healing period • Periods of remission or exacerbation are common

16. Factors Affecting Pain Experience • Culture • Ethnic variables • Family, gender, and age variables • Religious beliefs • Environment and support people • Anxiety and other stressors • Past pain experience

17. Assessment Parameters for Pain • Psychological • Emotional • Sociologic • Physiologic

18. General Assessments of Pain • Patient’s verbalization and description of pain • Duration of pain • Location of pain • Quantity and intensity of pain • Quality of pain • Chronology of pain

19. General Assessments of Pain (cont.) • Aggravating and alleviating factors • Physiologic indicators of pain • Behavioral responses • Effect of pain on activities and lifestyle

20. Question Tell whether the following statement is true or false. The best judge of the existence and severity of a patient’s pain is the physician or nurse caring for the patient. A. True B. False

21. Answer Answer: B. False Rationale: The best judge of the existence and severity of a patient’s pain is the patient.

22. Basic Methods of Assessing Pain (Pasero and McCaffery (20ll) • Patient self-report • Report of family member, other person close to the patient or caregiver familiar with the person • Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, protecting the painful area • Physiologic measures: increased blood pressure and pulse

23. Pain Assessment Tools • Wong-Baker FACES • Beyer Oucher pain scale • CRIES pain scale • FLACC scale • COMFORT scale

24. Question Which following pain assessment tool is recommended for use with neonates ages 0 to 6 months? A. Oucher pain scale B. Wong-Baker FACES C. FLACC pain scale D. CRIES pain scale

25. Answer Answer: D. CRIES pain scale Rationale: The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months.

26. FLACC Pain Scale • F - Faces • L - Legs • A - Activity • C - Cry • C - Consolability

27. Diagnosing Pain • Type of pain • Etiologic factors • Behavioral, physiologic, affective response • Other factors affecting pain process

28. Nursing Interventions for Pain • Establishing trusting nurse–patient relationship • Manipulating factors affecting pain experience • Initiating nonpharmacologic pain relief measures • Managing pharmacologic interventions • Reviewing additional pain control measures, including complementary and alternative relief measures • Considering ethical and legal responsibility to relieve pain • Teaching patient about pain

29. Manipulating Pain Experience Factors • Remove or alter cause of pain. • Alter factors affecting pain tolerance. • Initiate nonpharmacologic relief measures.

30. Nonpharmacologic Pain Relief Measures • Distraction • Humor • Music • Imagery • Relaxation • Cutaneous stimulation • Acupuncture

31. Nonpharmacologic Pain Relief Measures (cont.) • Hypnosis • Biofeedback • Therapeutic touch • Animal-facilitated therapy

32. Pharmacologic Pain Relief Measures • Analgesic administration • Nonopioid analgesics • Opioids or narcotic analgesics • Adjuvant drugs

33. The WHO 3-Step Analgesic Ladder

34. Question A sedated patient is frequently drowsy and drifts off during his conversation with the nurse. What number on the sedation scale best describes this patient? A. 1 B. 2 C. 3 D. 4

35. Answer Answer: D. 3 Rationale: 3 denotes that the patient is frequently drowsy and hard to awake. 1 means the patient is awake and alert. 2 denotes the patient is occasionally drowsy, but easy to arouse. At 4, the patient is somnolent, with minimal or no response to stimuli.

36. Numeric Sedation Scale • S: sleep, easy to arouse: no action necessary • 1: awake and alert; no action necessary • 2: occasionally drowsy, but easy to arouse; no action necessary • 3: frequently drowsy, drifts off to sleep during conversation; reduce dosage • 4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

37. Pain Management Regimens for Cancer or Chronic Pain • Give medications orally if possible. • Administer medications ATC rather than PRN. • Adjust the dose to achieve maximum benefit with minimum side effects. • Allow patients as much control as possible over the regimen.

38. Additional Methods for Administering Analgesics • Patient-controlled analgesia • Epidural analgesia • Local anesthesia

39. Placement of an Epidural Catheter