Transcript Chapter_015_LO

Chapter 15
Pain Management
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Learning Objectives
• Define pain.
• Explain the physiologic basis for pain.
• Identify situations in which patients are likely to
experience pain.
• Explain the relationships between past pain experiences,
anticipation, culture, anxiety, or activity and a patient’s
response to pain.
• Identify differences in the duration of pain and patient
responses to acute and chronic pain.
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Learning Objectives
• Explain the special needs of the older adult patient with
pain.
• List the data to be collected in assessing pain.
• Describe interventions used in the management of pain.
• Describe the nursing care of patients receiving opioid
and nonopioid analgesics for pain.
• List the factors that should be considered when pain is
not relieved with analgesic medications.
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Definition of Pain
• International Association for the Study of Pain
defines it as an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage
• McCaffery, a nurse and leader in the pain
management field, has a more useful definition
for nurses: “Pain is whatever the person
experiencing it says it is and exists whenever he
says it does”
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Definition of Pain
• International Association for the Study of Pain
defines it as “an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage”
• McCaffery, a nurse and leader in the pain
management field, has a more useful definition
for nurses: “Pain is whatever the person
experiencing it says it is and exists whenever
he says it does”
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Physiology of Pain
• Sensory experiences: time/space, emotions,
cognition
• Afferent pathways
• Nerves that carry messages to the brain for
interpretation
• Efferent (or descending) pathways
• Carry messages away from the brain via spinal cord
• Nociceptors
• Receptors that activate the afferent pathways
• Unevenly distributed in muscles, tendons,
subcutaneous tissue, and the skin
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Physiology of Pain
• Pain receptors are sensitive to chemical
changes, temperature, mechanical stimuli, and
tissue damage
• Pain receptors are unable to adapt to repeated
stimuli and thus continue to react until stimuli
are removed
• When pain receptors are stimulated, impulses
are transmitted to the spinal cord
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Physiology of Pain
• Impulses then travel up the spinal cord to the
brain
• In the brain, the cortex interprets the impulses
as pain and identifies the location and qualities
of the pain
• Endorphins and enkephalins, natural opioidlike substances: block transmission of painful
impulses to the brain
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Gate-Control Theory
• Pain reflects physical and psychosocial factors
• Painful impulses are transmitted to the spinal
cord through small-diameter nerve fibers in the
afferent pathway
• When these fibers are stimulated, the gating
mechanism opens in the spinal cord, which
permits the transmission of impulses from the
spinal cord to the brain
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Gate-Control Theory
• Factors that cause the gate to open include
tissue damage, a monotonous environment,
and fear of pain
• Stimulation of large-diameter fibers can close
the gate and interfere with impulse
transmission between spinal cord and the
brain, causing diminished pain perception
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Figure 15-1
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Factors Influencing Response to
Pain
• Although people may have the same injury or
insult, they may respond differently because
many physical and psychosocial factors affect
the response to pain
• Important for health professionals to be
nonjudgmental and to avoid comparing one
individual in pain with another
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Physical Factors
• Pain threshold
• Point at which stimulus causes sensation of pain
• Pain tolerance
• Intensity of pain that a person will endure
• Age
• Physical activity and nervous system integrity
• Surgery and anesthesia
• Type of surgery performed and the type of
anesthesia used can influence the response to pain
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Psychological Factors
• Culture and ethnicity
• Different ways of expressing/responding to pain
• Religious beliefs
• Some patients may pray and believe that divine
intervention will help them to endure the pain
• Others may view pain as a punishment for sins
• Some believe that suffering is required before pain
relief
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Psychological Factors
• Past experiences and anxiety
• May have developed positive coping strategies to
deal with previous painful experiences
• If strategies were unsuccessful, may be very
anxious and overwhelmed by another painful
experience
• Situational factors
• If pain associated with a serious illness, it may have
a greater effect on mood and activity than if the pain
were associated with a less serious condition
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Autonomic Nervous System
• Activates the fight-or-flight response; certain
physiologic responses initiated
• The nervous system responses measured by
increased heart rate, respiratory rate, and
blood pressure
• Acute and chronic pain elicit different kinds of
responses
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Acute Pain
• Follows the normal pathway for pain from
nociceptor activation to the brain and may be
called nociceptive pain
• Cause is known and treatable
• It serves as a warning of tissue damage and
subsides when healing takes place
• Behavioral and physiologic signs: when patient
guards or rubs a body part, wrinkles the brow,
bites the lip, and has changes in the heart rate,
blood pressure, and respiratory rate
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Chronic Pain
• Persists/recurs for >6 months; may last a
lifetime
• Most chronic pain is neuropathic pain because
it follows an abnormal pathway for pain
• Results from nerve damage from anatomic and
physiologic conditions and underlying diseases
• Includes unusual sensations such as burning,
shooting pain, and abnormal sensations that
occur when there is no painful stimulus present
• See Table 15-2, p. 206
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Comparison of Acute and Chronic
Pain
• Chronic pain serves no useful purpose; acute
warns of tissue damage and trauma
• Nursing assessment to identify
• Type and amount of pain
• Chronic or acute
• If acute and chronic pain at the same time
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Figure 15-2
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Nursing Care of the Patient in Pain
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Assessment
• Should be done on admission and on a regular
basis
• Assessment of vital signs is called the fifth vital
sign
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Assessment
• Six steps
• Accept the patient’s report
• Determine the status of the pain
• Describe the pain
• Location, quality, intensity, aggravating and alleviating
factors
• Examine the site of the pain
• Identify coping methods
• Document assessment findings and evaluate
interventions
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Figure 15-5
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Nonpharmacologic Interventions
• Those that do not employ drugs
• Physical interventions
•
•
•
•
•
Physical comfort measures
Environmental control
Stimulation techniques
Anxiety reduction
Distraction
• Psychological interventions
• Relaxation
• Imagery
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Pharmacologic Interventions
• Nonopioid analgesics
• Aspirin, acetaminophen, and nonsteroidal
anti-inflammmatory drugs (NSAIDs) such as
ibuprofen
• Generally initial treatment choice for mild
pain
• Act mostly on the peripheral nervous system
• Antipyretic (fever-reducing), analgesic (painreducing), and/or anti-inflammatory
(inflammation-reducing) properties
• See Table 15-4, p. 216
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Pharmacologic Interventions:
Opioid Analgesics
• For moderate to severe acute pain, chronic
cancer pain, and some other types of pain
• Opioids: potency/duration of action vary
• Opioid agonists
• Examples: codeine, methadone (Dolophine),
hydromorphone (Dilaudid), meperidine (Demerol),
morphine, and fentanyl
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Pharmacologic Interventions:
Opioid Analgesics
• Opioid agonist-antagonists
• Examples: buprenorphine (Buprenex), nalbuphine
(Nubain), butorphanol (Stadol), and pentazocine
(Talwin)
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Pharmacologic Interventions:
Opioid Analgesic Misconceptions
• Patients, families, nurses, and physicians have
misconceptions about addiction; therefore, the
term must be defined and differentiated from
the terms tolerance and physical dependence
• Tolerance and physical dependence are
normal responses to continued opioid
administration for pain relief; they do not lead
to a craving for the drug for its mind-altering
effects
• Fear of addiction greatly exaggerated; rare
(<1%) in patients taking opioids for pain relief
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Pharmacologic Interventions:
Opioid Analgesics
• Routes of administration
•
•
•
•
Oral
Intramuscular
Sublingually
Intravenously: intermittent bolus injections,
continuous infusions, or patient-controlled
analgesia (PCA)
• Epidural or intrathecal route
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Pharmacologic Interventions:
Opioid Analgesics
• Side effects
•
•
•
•
•
•
•
•
Constipation
Nausea, with or without vomiting
Sedation
Respiratory depression
Confusion
Hypotension (especially orthostatic)
Dizziness
Urinary retention
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Pharmacologic Interventions:
Placebos
• Inactive substances (e.g., saline) used in
research or clinical practice to determine the
effects of a legitimate drug or treatment
• Appropriately used in studies in which patients
consent to participate
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Pharmacologic Interventions:
Placebos
• Many health care organizations take the
position that placebos should not be used to
assess or manage pain
• Nurses have ethical obligation to ensure that
patients are not deceived and that institutional
policies related to placebos are followed
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Pharmacologic Interventions:
Adjuvant Analgesics and
Medications
• Drugs not usually classified as analgesics may
relieve pain in certain situations
• A patient who has undergone back surgery
may complain more about muscle spasms than
incisional pain
• A muscle relaxant may be more effective in relieving
pain than an opioid alone
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Pharmacologic Interventions:
Adjuvant Analgesics and
Medications
• Specific pain syndromes, especially
neuropathic, may be controlled with drugs
other than the commonly known analgesics
• See Table 15-6, p. 219
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Problem Solving with Pain
Medication
• Patients whose prescribed analgesic drugs do
not relieve pain
• Ask questions about the analgesic drug and
the “five rights” (right dose, right patient, right
time, right route, right analgesic) to determine
why the patient is not getting adequate pain
relief
• See Box 15-8, p. 221
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