Transcript Pain Management - Wilkes-Barre Area Career & Technical

Ruth Weiscarger, BSN, RN
Pain is a complex, subjective phenomenon that
involves biological, cultural, and social factors.
“Pain is whatever the patient says it is and
occurs whenever the patient says it does.”
Serves as a warning sign indicating that actual
damage has occurred or that the potential exists
for damage of tissue.
Pain can make it difficult to:
• Perform activities of daily living
• Rest & experience restorative sleep
• Eat
• Perform normal body movements & exercise
Maintain family relationships
Work or maintain a job
Have a social life
Maintain cognitive abilities
Focus on spiritual beliefs
As a nurse, you must develop an understanding
of pain and how you can assist your patient to
cope with pain.
Holistically-taking into consideration the
physical, mental, social, and spiritual aspects of
the patient. Look at the whole being.
This prepares you to meet the needs of the
patient on an individual basis.
It is thought that the thalamus can open and
close the gate in relationship to stress and
anxiety
Researchers in the 1960’s proposed this theory.
The theory proposes that the transmission of
pain impulses to the central nervous system is
controlled by a “gate”.
• The gate must be open for the pain impulse to
be transmitted to the brain & transmitted as
pain.
• When the gate is closed, the nerve impulse for
pain is blocked from transmission.
Open gate causes:
Stress & anxiety
Stimulation of narrow
nerve fibers
Injury or tissue damage
stimulates narrow nerve
fibers
Closed gate causes:
• Decreased stress &
anxiety
• Exercise, heat, cold,
massage,
• Endorphins-natural body
chemicals produced by
pleasant thoughts or
feelings
Acute Pain-pain that comes on suddenly and has
a short duration, usually 6 months or less.
Chronic Pain Is -pain that lasts longer than 6
months.
Intermittent pain-pain that comes & goes at
intervals.
Intractable pain-pain that cannot be relieved,
pain that is incurable or resistant to treatment.
Ex. Cancer pain
Referred pain-pain that is felt in an area other
than where the pain is produced. Ex. Pain that
is felt in jaw or arm during a MI due to lack of
O2 supply.
Radiating pain-pain that begins at a specific site
& shoots or extends to a larger area.
Pain is derived in two ways:
1. From the stimulation of nerve pain receptors,
called nociceptors.
2. From damage to the nerves themselves.
Nociceptors are randomly dispersed throughout
the skin, subcutaneous tissue, & muscular
tissue.
• Nociceptors can be stimulated by temperature
change, tissue damage & certain chemicals.
• Two of the chemicals that can stimulate nerve
pain receptors are substance P and
prostoglandins which are released during injury
and damage to the tissue.
.
•Substance P-elicits localized
tissue reactions similar to
inflammation
•Prostoglandins are hormones
that act in the immediate area
and initiate inflammation
1. Cutaneous-pain that is more superficial or on
the surface of the skin. Ex. Paper cut
2. Visceral –pain experienced from stimulation of
deep internal pain receptors. Ex. Traumatic
injury or surgery
3. Deep, somatic pain-pain in bone, ligament or
tendon. May be diffuse with longer duration
than cutaneous pain. Ex. Fractures, arthritis
• Is pain that is usually burning, stabbing, or
sometimes a deep ache.
Example: Compression fractures of the spine,
• Pain that occurs due to injury or destruction of
peripheral nerves or the central nervous system
itself. Example: Diabetic neuropathy.
• Pain may extend beyond the local region to
encompass a broadening area of discomfort
that follows along the pathway of the damaged
nerves.
Type of neuropathic pain where patient feels pain
from an area that has been amputated.
Ex. Complaint of foot pain after the lower leg and
foot have been surgically amputated.
Pain is considered the fifth vital sign.
Nurse must assess: Temperature
Blood Pressure
Pulse
Respirations
Level of pain
Assessment of pain must be made before pain can
be treated effectively:
• Measure level or extent of pain-use of pain scale
such as 0 to 10 scale with 0 being none and 10
being the worst.
• Assess the site of pain-be specific. For example:
Abdominal pain (lower) upper outer quadrant).
• Characteristics of pain-dull, sharp, aching,
burning, pressure?
• Is pain acute or chronic? When did it begin?
• What causes the pain? Breathing, coughing,
with movement, activity?
There are various factors that affect pain and its
expression:
• Ethnic and cultural beliefs
• Developmental stage
• Individual values
• Previous pain experiences
• Personal support system
• Emotions
• Fatigue
The body responds to pain: physiologically
phychologically
behaviorally
Sympathetic Nervous System responds:
increased pulse
increased resp rate
increased BP
pupils dilate
Acute Pain
Chronic Pain
Sudden onset, lasts less than 6
months
Fight /flight response occurs
Initially pulse rate, BP, and
respirations are elevated. Pupils
dilate.
As pain worsens, BP drops,
diaphoresis, syncope, pupils
constrict
Fear and anxiety
Onset longer than 6 months
Pupils may constrict
Vital signs may not change
May have impaired mobility
Sleep disturbance
Depression, fatigue, anger
Nurse needs to evaluate and assess patient before
pain can be treated effectively.
Assessment:
• Level or extent of pain, use of pain scale
• Site of pain and any radiation of pain
• Characteristics of pain, ex. Sharp, dull, burning
• Is pain acute or chronic?
• What elicits pain?
• Patient desires in relation to pain?
• Nurse must not be judgmental
• Nurse must let patient know that you believe
that they are in pain
• Evaluate patient’s pain
• Let patient know what you are going to do to
help relieve their pain
Nonpharmaceutical Methods:
The Agency for Healthcare Research and Quality
(AHRQ) has printed guidelines encouraging
healthcare providers to incorporate
nonpharmaceutical methods of pain relief to
help relieve pain and decrease the need for
medication.
Adjuvant therapy-a means to assist or aid another
treatment, therefore increasing the
effectiveness.
Heat and cold therapy are
both effective for relief of
musculoskeletal pain and
discomfort.
In acute setting, need a
physicians order.
Massage can be effective
for some painful
conditions, used to relax
muscles and relieve
tension.
Effleurage-repetitive, gentle,
gliding of your fingertips
over the surface of the
skin.
Transcutaneous Electrical
Nerve Stimulation:
Battery-powered device
with lead wires and
electrode pads which are
applied to the skin over
the painful area to deliver
electrical stimulation to
nerve fibers.
Acupressure involves
applying fingertip
pressure.
Acupuncture involves the
insertion of ultrafine
needles into specific body
areas.
Both are thought to
stimulate endorphins.
Progressive relaxationsystematic process using
the mind to relax the
patient’s muscles from
the top of the head to the
toes.
Patient lays in bed with eyes
closed. Therapist directs
the patient to focus on
certain muscles, tensing
and then relaxing.
Guided Imagery- using the
mind to guide the patient
to a more relaxed state.
Done verbally or by using
tapes to direct the patient
to thoughts of a
comfortable place.
Distraction-used to try to
take the patient’s mind
off of pain. Does not
always work.
Decreases the conscious
awareness of pain.
Use of different senses.
Visual distraction-television,
reading
Auditory distractionlistening to music or
someone reading aloud
Tactile distraction-back rub,
rocking, receiving hugs,
rocking, holding
Intellectual distractionconversing with others,
puzzles, card games
Classifications of medications:
• Non-steroidal anti-inflammatory drugs (NSAID’s)
• Non-opioids
• Opioid narcotics
• Adjuvant drugs
Non-narcotic pain relievers
used for mild to moderate
pain.
Ex. Acetaminophen-has
both analgesic and antipyretic effects.
Maximum dose is 3-4 gms
or 3000mg – 4000 mg q
4 hrs.
Side effect-hepatotoxicity
Non-steroidal antiinflammatory drugs
reduce inflammation and
pain at the site of the
injury.
Over-the-counter
Most common are:
ibuprofen, naproxen, and
aspirin.
Aspirin:
• Anti-inflammatory
• Analgesic
• Anti-pyretic
• Usual adult dose-6001,000mg q 4hrs.
• Anti-platelet effect
(decreases platelet
clumping)
• Usual dose for antiplatelet is 81-300mg daily
•
•
•
•
•
May cause gastric irritation and bleeding.
Do not exceed recommended dosage.
Administer medication with food.
Instruct patient to take with food at home.
Instruct patient to notify MD immediately of any
GI bleeding.
Opiate/Opioid
Analgesics:
Used when non-opoid
medications are
ineffective in relieving
moderate to severe pain.
Usually effective in
relieving visceral pain and
deep somatic pain.
Work by binding with
opiate receptors and
stimulate the brain’s
production of betaendorphins that decrease
pain perception.
Controlled substance
Require a prescription
Controlled or scheduled
drugs due to greater
capacity for addiction.
Regulated by federal law.
• Opiates come from opium and it’s derivatives
known as opioids.
• Opioids –synthetic form.
• Opiates and opioids can be administered:
• Orally
• Rectally
• Subcutaneously (Sq)
• Intramuscular (IM)
• Intravenous (IV)
Nausea
Vomiting
Constipation
Itching
Sedation
Respiratory distress
Pupil constriction
** Narcan is a medication used to counteract the
effects of opiates if patient should become
unresponsive or in case of overdose.**
Computerized IV infusion
device consisting of a
pump, a large syringe
containing the analgesic,
IV tubing, push button
that the patient pushes
for delivery of analgesic.
Physician orders maximum
dose and nurse or
pharmacist calibrates the
pump.
Initially, the nurse will
deliver a loading dose or
bolus to get the patient
started to get the pain
under control.
The patient will then be set
up to push the button to
self-administer a dose
whenever they have pain.
The patient will only be able
to receive the set dose no
matter how many times
they push the button.
Provides the patient with control over their pain
relief.
Avoids repeated injections.
Provides rapid relief via IV route.
Reduces the anxiety and fear that pain will get
out of control.
Allows for smaller dosing, ultimately resulting in
the use of less medication.
Reduces waiting for nurse response.
Enables patient to achieve more comfortable
ambulation, reducing complications
Classes of medication that produces pain relief
through a mechanism different than traditional
analgesics, or by potentiating or increasing the
effects of opiates, opioids, and non-opioid
drugs.
Ex. Anticonvulsants and antidepressants. Some of
these drugs may help to treat nerve pain.
Ex. Skeletal muscle relaxants may be helpful to
reduce muscle spasms.
Restorative sleep is that
which allows an individual
to awaken feeling rested,
refreshed, rejuvenated,
and energized.
Resting may or may not
involve sleep but it is a
time when the patient
should feel relaxed and
free from anxiety.
Circadian Rhythm-24-hr cyclical pattern during
which the body metabolism and functions
increase and decrease in rhythmic patterns.
2 cycles of sleep are (NREM)-non-rapid eye
movement sleep and (REM)-rapid eye
movement sleep.
Stage I-relaxation begins, lightest sleep, easy to
arouse.
Stage II-relaxation deepens, begin to experience
sound sleep but still relatively easy to arouse.
Usually last about 15-20mins.
Stage III-lasts about 15-30mins, body rests and
restores during this sleep.
Stage IV-becomes difficult to arouse, this is the
deepest sleep, body rests and is restored.
REM Sleep occurs at the end of each NREM cycle.
Rapid eye movement begins
Vital signs fluctuate
Vivid dreaming
REM sleep is not as restful as NREM sleep
• Newborns: 16 to 18 hrs per day
• Infants up to 2yrs: 12 to 14 hrs a day including
naps
• Children 3 to 6: 12 hrs per day including naps
• Children 7 to 12: 10 hrs per night
• Adolescents: 8.5 to 9.5 hrs per night
• Young adults: 7.5 to 8 hrs per night
• Older adults: gradually decreases to 5.5 or 6 hrs
per night, may begin to nap
• Lifestyle-caffeine, nicotine, alcohol, and sleep
inducing medications can impair the body’s
ability to get adequate sleep.
• Stress and Anxiety-worries at night can effect
falling asleep.
• Environmental-temp. too hot or too cold,
uncomfortable bed.
• Illness and health problems-pain, itching, SOB.
• Sleep disorders
Bruxism-grinding of teeth during sleep.
Insomnia-chronic inability to fall asleep or stay
asleep.
Narcolepsy-uncontrollable, recurrent daytime
episodes of sleepiness. Hinders driving or
operating dangerous equipment.
Restless leg syndrome-intolerable crawling
sensation in legs that results in an irrestible urge
to move legs.
Sleep apnea-inability to maintain breathing
while sleeping. Patient usually snores,
accompanied by periods of apnea. Can be life
threatening.
Somnambulism- sleepwalking
Sundowning-confusion or disorientation in
elderly patients occurring in the evening hours.
Prepare the environment-room temp, adjust
pillows, turn and reposition, lighting.
Relaxation-offer back rub, wash face and hands.
Pain relief-administer pain med as ordered.
Sleep medications-administer sleeping
medication if ordered, if needed.