Basic Human NeedsBasic Human Needs

Comfort and Pain Comfort and Pain ManagementManagement

Donna M Penn RN MSN CNE

PainPain

• 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

ComfortComfort

• Concept central to the art of nursing

• Through comfort measures nurses provide strength, hope, solace, support, encouragement, and assistance

• As subjective as pain

PainPain

• 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.

Pain ManagementPain Management

• Effective pain management reduces physical discomfort

• Promotes earlier mobilization and return to work

• Shortens hospital stay and reduces health care costs

Pain Management

Nature of PainNature 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

Nature of PainNature 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

Physiology of PainPhysiology of PainCategoriesCategories

• Acute

• Chronic

• Idiopathic Pain

• Cancer pain

• Pain by Inferred Pathology/Nociceptive & Neuropathic

• Pain as a result of a Metabolic Need/Ischemic Pain

Nociceptive PainNociceptive 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

Somatic PainSomatic Pain

• Arises from bone, joint, muscle, skin or connective tissue

• Usually aching, throbbing, well-localized pain

• Responds to traditional analgesia

Visceral PainVisceral 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

Neuropathic PainNeuropathic 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

Idiopathic Pain

• Chronic pain in the absence of an identifiable cause

• Complex Regional Pain Syndrome

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

Nociceptive PainNociceptive Pain

• Transduction

• Transmission

• Perception

• Modulation

TransductionTransduction

• 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

TransductionTransduction

• 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

TransductionTransduction

• 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

TransmissionTransmission

• 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

TransmissionTransmission

• Neurotransmitters

1. Substance P

2. Serotonin

3. Prostaglandins

• Neuromodulators

1. Endorphins

2. Bradykinin

Gate Control Theory of Gate Control Theory of PainPain

• 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

Gate Control Theory of Gate Control Theory of PainPain

• 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

PerceptionPerception

• 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

PerceptionPerception

• Limbic system-controls emotion, anxiety, & emotional reaction to pain

• Responses to pain can be physiological and behavioral

Physiological Response to Physiological Response to PainPain

• 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)

Physiological Response to Physiological Response to PainPain

• 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

Behavioral Responses to Behavioral Responses to PainPain

• 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

ModulationModulation

• 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

Acute PainAcute Pain

• Follows acute injury, disease, surgical intervention

• Rapid onset

• Varies in intensity (mild-severe)

• Lasts a brief period of time (less than 6 months)

Chronic PainChronic Pain

• Prolonged

• Varies in intensity

• Lasts longer than 6 months

• Also known as chronic non-malignant pain

• Arthritis, headache, myofascial pain, low back pain

Cancer PainCancer 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)

Factors Influencing PainFactors Influencing Pain

• Age• Gender• Culture• Meaning of pain• Attention• Anxiety• Fatigue• Previous Experience• Coping Style• Family & Social Support

Nursing ProcessNursing ProcessAssessmentAssessment

• AHCPR guidelines for assessing pain• Clients expression of pain• Characteristics of pain• Onset & duration• Location• Intensity (Pain scales-numerical,

FACES)

AssessmentAssessment

• Quality

• Pain pattern

• Concomitant Symptoms

• Effect of pain on client (physical, behavioral, effect on ADL)

Nursing ProcessNursing ProcessNursing DiagnosisNursing Diagnosis

• Anxiety

• Alteration in Comfort

• Self-care Deficit

• Sleep Pattern Dysfunction

• Sexual Dysfunction

Nursing ProcessNursing ProcessImplementationImplementation

• 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

Non-pharmacological Non-pharmacological MethodsMethods

Acupuncture• Relaxation• Guided Imagery• Distraction• Music• Biofeedback• Self-Hypnosis• Reducing Pain Perception• Cutaneous Stimulation (Heat or Cold

application, massage, TENS unit)

Pharmacologic MethodsPharmacologic Methods

• Require a physicians order

• Guidelines set by regulatory agencies

• Analgesics most common method

• Tendency to under treat with pain meds

AnalgesicsAnalgesics

• Non-opioid or non-narcotic agents & non-steroidal anti-inflammatory agents (NSAIDS)

• Narcotics, Opioids

• Adjuvants, Co-analgesics

NSAIDSNSAIDS

• 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

NSAIDSNSAIDS

• 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

OpioidsOpioids

• 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

OpioidsOpioids

• 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

Adjuvant TherapyAdjuvant Therapy

• Sedatives, anti-anxiety, & muscle relaxants

• Enhance pain control or relieve symptoms associated with pain

• Vistaril, Elavil, Thorazine, Valium, Ativan, Xanax

Patient-Controlled Patient-Controlled Analgesia PCAAnalgesia 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

PCA PrescriptionPCA Prescription

• Loading Dose

• Basal (Continuous rate)

• On demand dose

• Hourly maximum amounts can be prescribed

Local & Regional Local & Regional AnestheticsAnesthetics

• Wound suturing

• Delivery of baby

• Performing simple surgery

• Epidural Analgesia for post-op pain management, L&D pain, chronic cancer pain

Epidural Pain ManagementEpidural Pain Management

• Short or long term

• Administered into spinal epidural space

• Catheter is left in place, secured with tape and dressing

• Can be continuous infusion or daily injection

Epidural Pain ManagementEpidural Pain Management

• Monitor hourly for:

1. Catheter Displacement

2. Catheter Function

3. Respiratory Depression

4. Side effects: N/V, itching, urinary retention, constipation

5. Pain effect

Cancer Pain ManagementCancer Pain Management

• Long acting preparations, sustained release

• Drug dependence low in cancer related pain

• Can develop tolerance, requiring higher doses

• Goal is to minimize pain, rather than cure it

Clicker Question

• 1. When a smiling and cooperative client complains of discomfort, nurses caring for this client often harbor misconceptions about the client’s pain. To properly care for clients in pain, nurses need to remember that:

• A. Chronic pain is psychological in nature.• B. Clients are the best judges of their pain.• C. Regular use of narcotic analgesics leads to drug addiction.• D. The amount of pain is reflective of actual tissue damage.

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Clicker Question

• 2. Established pain management guidelines direct nurses to frequently assess the client’s pain. The most appropriate action for the nurse to take when assessing the client’s reaction to pain is to:

• A. Ask what precipitates pain. • B. Question the client about the location of pain.• C. Offer the client a pain scale to objectively identify the

pain.• D. Use open-ended questions to find out about the client’s

pain.

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Clicker Question

• 3. A client has just undergone abdominal surgery. When discussing with the client several pain relief interventions, the most appropriate recommendation would be:

• A. Adjunctive therapy• B. Nonopioids• C. NSAIDs• D. PCA pain management

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