CHAPTER 20

Clients with Pain

Nhelia B. Perez RN, MSN

Northeastern College – Nursing Department

Santiago City, Philippines

THE PHYSIOLOGY OF PAIN

• Nociceptor Activation* Bradykinin* prostaglandin* substance P* Histamine * Serotonin* leukotrienes* nerve growth factor

• Fast Pain

• Slow pain

Spinal Cord

• Dorsal horn

• Spinal cord

• Spinothalamic tract

• Thalamus

• C fiber – substantia gelatinosa

• Synapse on interneurons

• Thru neurotransmitters

• Sensory cortex

• Brain – limbic system

• Brain stem

Brain• Nociceptive Sensory info• Multiple ascending pathways• Spinothalamic tracts• Spinoreticular tract• Thalamus• Cerebral cortex and limbic system• Amygdala via the spinomesencephalic tract• Pain elicits an autonomic response directly

via the spinohypothalamic tract.

Conscious Perception of Pain

Hyperalgesia

PAIN SUPPRESSION APPROACHES• Nociceptor

• Synaptic Interruption

• Gate Theory

• Brain Chemicals and Analgesics

The Fifth Vital Sign

• Acute pain• Chronic (malignant)pain• Cancer-related pain• Pain classified by location• Pain classified by etiology

Chronic Pain

• Chronic Persisten Pain

• Chronic Intermittent Pain

• Chronic Malignant Pain

SOURCES OF PAIN

• Cutaneous Pain• Somatic Pain• Visceral Pain• Referred Pain• Neuropathic Pain• Breaktrhough pain• Phantom limb sensation• Psychogenic Pain

FACTORS AFFECTING PAIN

• Perception of Pain

• Socio Cultural Factors

• Age

• Gender

• Meaning of Pain

• Anxiety

• Past experience with Pain

Medications to Control Pain

• Local Anesthetic Agent• Nerve blocks• Topical Local Anesthesia• Analgesics

* Non-opioid Analgesicse.g. aspirin

Salycylate SaltsAcetaminophenNSAID’s

• Opioid Analgesics

e.g. Opioid agonist

Opioid antagonist

Opioid Agonist – Antagonist

Methadone

• Adjuvant Medications

* Antidepressants

* Anti-Anxiety Agents

* Anticonvulsants

* Corticosteroids

* Miscellaneous Agents

ORAL POTENCY

• Ceiling Effect

• Tolerance

• Dependence

• Production of Metabolites

NURSING MGT

• Misconception and Myths

• Assessment

• Diagnosis, Outcomes and Interventions

Numeric Rating Scale Ask the patient to rate their pain

intensity on a scale of 0 (no pain) to 10 (the worst pain imaginable). Some patients are unable to do this with only verbal instructions,

but may be able to look at a number scale and point to the

number that describes the intensity of their pain.

• Color Scale • This scale is a colored stripe in which

color gradually changes from white (no pain) through shades of pink to dark red (worst possible pain). Ask the patient to point to the area on the scale that shows their level of pain. To obtain a number for documentation use the scale parallel to the color stripe to find the number corresponding to the area where the patient points.

• Word Graphic Scale • This scale can be used with patient as young

as 6 years of age. It uses a line with words to describe pain intensity from "no pain" to "worst possible pain". Show and explain the scale to the patient and then ask him or her to point (or mark) anywhere along the line that shows how much pain they have. To find a number for documentation count the black dots, starting with zero at the far left, to the area where the patient points, up to ten at the far right.

Wong-Baker FACES Pain Rating Scale

• This scale can be used with young children (sometimes as young as 3 years of age). It also works well for many older children and adults as well as for those who speak a different language. Explain that each face represents a person who may have no pain, some pain, or as much pain as imaginable. Point to the appropriate face and say:

• (0) "This face is happy and does not hurt at all." (2) "This face hurts just a little bit." (4) "This face hurts a little more." (6) "This face hurts even more." (8) "This face hurts a whole lot." (10) "This face hurts as much as you can imagine, but you don't have to be crying to feel this bad."

FLACC Scale

This is a behavior scale that has been tested with children age 3 months to 7 years. Each of the five categories (Faces, Legs, Activity, Cry, Consolability) is scored from 0-2 and the scores are added to get a total from 0-10. Behavioral pain scores need to be considered within the context of the child's psychological status, anxiety and other environment factors.

Face

0No particular expression or

smile

1Occasional grimace or

frown, withdrawn disinterested

2Frequent to

constant frown, clenched jaw, quivering chin

Legs0

Normal position or relaxed

1Uneasy, restless, tense

2Kicking, or legs

drawn up

Activity

0Lying quietly,

normal position, moves easily

1Squirming, shifting back

and forth, tense

2Arched, rigid, or

jerking

Cry0

No cry (awake or asleep)

1Moans or whimpers, occasional complaint

2Crying steadily,

screams or sobs, frequent complaints

Consolability

0Content, relaxed

1Reassured by

occasional touching, hugging or "talking to,

distractible

2Difficult to console

or comfort

INTERVENTIONSLicensed Nurse Role: Knowledge

Based Practice

A) Knowledge of Self

B) Knowledge of Pain

C) Knowledge of the Standard of Care

The standard of care is effective ongoing pain assessment and pain management. This includes but is not limited to:

1. Acknowledging and accepting the patient’s pain

2. Identifying the most likely source of thepatient’s pain;3. Assessing pain at regular intervals,

witheach new report of pain or when pain isexpected to occur or reoccur. Assessment includes but is not limitedto:a) The patient’s level of pain utilizing apain assessment tool;

b) Barriers to effective pain management,

which may include personal, cultural and

Institutional barriers. Sources of these

barriers may include but are not limited to

patient, family, significant other, physician,

nurse and institutional constraints;

4. Reporting the patient’s level of pain;

5. Developing the patient’s plan of care that includes an interdisciplinary plan for effective pain management involving the patient, family and significant other;

6. Implementing pain management strategies and indicated nursing interventions including: a) Aggressive treatment of side effects (i.e. nausea, vomiting, constipation, pruritus etc),b. Educating the patient, family and significant other(s) regarding, (i) Their role in pain management,(ii) The detrimental effects of unrelieved pain,(iii) Overcoming barriers to effective pain

management,(iv) The pain management plan and expected outcome of the plan;.

7. Evaluating the effectiveness of the

strategies and the nursing interventions;

8. Documenting and reporting the interventions, patient’s response, outcomes; and

9. Advocating for the patient and family for effective pain management.

Non-Pharmacologic ApproachesTo Pain A. Non-pharmacologic interventions should routinely be used. Although these strategies alone are frequently insufficient for moderate to severe pain, they are usually helpful in conjunction with pharmacological therapy. Such strategies may include:

B. Cognitive-behavioralEducationRelaxation, imageryPsychotherapy, counselingHypnosisBiofeedbackMusic, literature, art, playPrayer, meditation

C. PhysicalMassageAcupuncture, acupressureApplication of heat or coldTENSImmobilization, graded mobilizationTherapeutic exercise

D. Nonpharmacologic interventions may be provided, based on training, by:PhysiciansNursesPhysical, occupational, recreation, art, music, child-life or other therapistsSocial workersReligious or spiritual leadersClinical psychologistsOthers

EVALUATION AND DOCUMENTATION