Pain

Lisa B. Flatt, RN, MSN, CHPN

Definition

Complex

Subjective

Psychological

Biological

Cultural

Social factors

WHAT THE PATIENT SAYS IT IS!!!!!

Types of Pain

AcuteChronicIntermittentIntractableMalignantNeuropathicPhantomRadiatingRemittentEpisodic

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

Chronic Pain

Prolonged disease/dysfunction

Intermittent, limited, persistent (>6mo)

Influences: environment, emotional

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

Areas of ‘suffering’

PhysicalSocialSpiritual

HOLISTIC CAREEnvironmentalPsychosocialPhysicalSpiritual

Acute vs. Chronic Pain

Acute PainTrauma

Surgery

Fracture

Chronic inflammation, bruising

Procedural

Phantom

Chronic PainMarriage lol

Arthritis

Malignancy/tumor

back-chronic

Non-malignant

Neuropathy

Phantom

Pain and comparison

ACUTEMild to severeSympathetic Nervous System responsesIncreased: HR, RR, BP, diaphoretic, dilated pupilsSubjectiver/t tissue injury Resolves with healingCrying, rubbing area, holding area

CHRONICMild to severeParasympathetic Nervous SystemNormal VSDry warm skinPupils normal or dilatedDoes not always mention pain unless askedAppears withdrawn and depressedPain behavior often absent

Physiology Descriptors/Categories

Intractable; resistant to analgesia, advanced tumors

Neuropathic; peripheral or CNS, may be tissue related

Phantom; missing limb, spinal cord injury (some)

More categories

Cutaneous – skin or SC tissue

Deep somatic – tendon/blood vessels, nerves

Visceral – internal organs

Radiation and Referred

Radiating – extends from area of insult/injury outwards – UTI, kidney/back/urethra – chest pain/jaw/armReferred 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)

Pain Stimuli

Stimulus TypeMechanical – 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)

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.

4 points to be modulated/reduced

Peripheral site

Spinal cord

Brain stem

Cerebral cortex

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

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**

Pain is…Psychological and Physical

CognitiveToddler- dramatic, carry on – perception, frustrated, intolerant, fearfulChildbirth – acute, varies, helpless

Emotional- anxiety, depression, stress, frustration, length of time/perceived timeMyths- 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’sSuffering – physical, psychological, emotional or distress- chronic pain and never fully relieved ----alternative holistic methods

Pain Management Principles

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

Factors Influencing Pain

AgeGenderCultureReligionPhysical condition at startSupportSocialEnvironmentFinancial

Assessment Methods to measure/describe pain

Wong/Baker Faces

Numeric

WILDA

OPQRST

COLDERRA

Wong-Baker Scales

Happy face to sad face with sweat/tears and blood

Adult patient 0-10

Child faces 0-5

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

OPQRST

Other s/s

Provocative/palliative – what makes it worse or better

Quality – description

Region of pain

Severityof pain

Temporal/timing

COLDERRA

Character- sharp, burningOnset – when did it startLocation – where it isDurationExacerbation – makes it worseReliefRadiationAssociated s/s

Assess those things we always talk about

Age

Sex

Emotional

Blah

Blah

blah

Assess Physical Side

Facial expressionVSPositioningGuardingStriking at nurse if she touches area that hurtsDiaphoresisLabs

Analyze

Synthesis of the assessment

Collaborative approach to other disciplines findings

Determine a nursing diagnosis

Acute vs. chronic

Planning

Determine desired outcomes

Step by step goal strategy

Patient centered

Realistic

SMART ER

Specific

Measurable

Attainable and action based

Realistic

Timebound

Evaluation

Reassessment

WHO (world health organization)

3 – step analgesic ladder approachNursing intervention – backrubs, massage, lotion, ice and heat, distraction, (hammer…ignoring)Environmental – noiseListening******Patient Bill of Rights*******

Treat pain to the best of our ability and right to treatment, refuse treatment, pt centered decision making, confidentiality

Implementation

Initiate and complete plan

Work toward goal

Nursing measures/massages

Pain society usage and guidelines

CDC and NIH website on pain

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)

Environmental Modification

Stairs

Room temp

Ventilation

Fans

Assistive devices

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.

WHO 3 step Ladder

Non-opiod analygesics +/- an adjuvant. Moderate ain persists go toOpioid admin +/- non-opioid +/- adjuvantOpioid 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.

Medications/Sedatives

NSAIDS – naproxen, motrin, advil, indomethacin, ASA, AcetaminophenOpioids 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 ODOpioid agonist-antagonists – pentazocine, nalphybine, butorphanol, dezocine, bind only to certain sitesTopical drugs localized pain

PCA

Patient controlled analgesiaBeneficial psychologically

Decreases dependency

Decreases anxiety

Patient part of their treatment plan

Evaluation

Assess verbal and nonverbal response

Response to pain reduction methods

VS

Pain scale

MYTHS per the book

Expected with ageChronic pain = hypochondriacInfants feel no painNo complaining no painPain is unavoidable part of recoveryAdmission is a sign of weaknessDrug addictionUsing drug at the start of pain will make it not work as good laterSevere pain is only seen in people who are melodramatic and/or hysterical