Transcript Pain Management: Acute and Chronic Pain

Pain is misunderstood
 Describe an experience with pain-either yourself or
someone close to you.
 Pain is subjective.
Nature of Pain
Involves physical, emotional, and cognitive
components
Results from physical and/or mental stimulus
Reduces quality of life
Not measurable objectively
Subjective and highly individualized component
Pain
 The International Association for the Study of Pain
defined pain as
 “an unpleasant, subjective sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage.”
 So physical pain can cause psychological pain and vise
versa.
Congressional Actions:
 Declared 2000 through 2010 the Decade of Pain
Control and Research, yet pain continues to be a
leading public health problem in the United States
(American Pain Foundation, 2005).
 Providing pain relief is a basic human right and is in
the Pain Care Bill of Rights (American Pain
Foundation, 2001).
 The American Bar Association (2000) declared pain
relief a basic legal right.
 Nurses are legally and ethically responsible for
managing pain and relieving suffering.
Physiology of Pain
 Cellular damage by thermal, mechanical, or
chemical stimuli causes release of
neurotransmitters.
 Prostaglandins, bradykinin, potassium, histamine,
substance P
 Neurotransmitters surround the pain fibers,
spreading the pain message and causing an
inflammatory response.
 Nerve impulse travel along afferent (sensory) nerve
fibers to the spinal cord.
Physiology of Pain (cont’d)
 Pain impulses ascend the spinal cord to the
thalamus, which transmits information to higher
brain centers that perceive pain.
 Two types of sensory nerve fibers:
 Fast myelinated A-delta fibers: send sharp, localized,
distinct sensations
 Slow, small, unmyelinated C fibers: send poorly
localized, burning, persistent pain
Physiology of Pain (cont’d)
Transduction
Conversion of
stimulus into
electrical energy
Transmission
Sending of impulse
across a sensory pain
nerve fiber
(nociceptor)
Perception
The patient’s
experience of pain
Modulation
Inhibition of pain/
release of inhibitory
neurotransmitters
Physiology of Pain (cont’d)
 Gate-control theory of pain (Melzack and Wall)
 Pain has emotional and cognitive components, in
addition to a physical sensation.
 Gating mechanisms in the central nervous system
(CNS) regulate or block pain impulses.
 Pain impulses pass through when a gate is open and
are blocked when a gate is closed.
 Closing the gate is the basis for nonpharmacological
pain relief interventions.
Transmission of Pain Impulse
Pain Threshold
 The threshold of pain is the point at which pain
begins to be felt. It is an entirely subjective
phenomenon
Pain Tolerance
 Pain tolerance is the maximum level of pain that a
person is able to tolerate
Case Study
 Mrs. Ellis is a 70-year-old African American woman
with hypertension, diabetes, and rheumatoid
arthritis. Her current health priority is the
discomfort and disability associated with her
rheumatoid arthritis.
 Arthritis has severely deformed her hands and feet.
The pain in her feet is so severe that she often walks
only short distances. The pain interferes with sleep
and reduces her energy both physically and
emotionally. As a result, she does not leave home
often.
Protective Reflex to Pain Stimulus
Types of Pain
Acute/transient pain
Protective, identifiable,
short duration; limited
emotional response
Chronic/persistent
noncancer
Is not protective, has no
purpose, may or may not have
an identifiable cause
Chronic episodic
Cancer
Occurs sporadically over
an extended duration
Can be acute or chronic
Inferred pathological
Idiopathic
Musculoskeletal,
visceral, or neuropathic
Chronic pain without identifiable
physical or psychological cause
Acute Pain
 Is protective, has a cause, is of short duration, and has
limited tissue damage and emotional response
Acute Pain
 http://www.youtube.com/watch?v=EpcDZbXslfw
Chronic Pain
 Lasts longer than anticipated, does not always have a
cause, and leads to great personal suffering.
Chronic Pain
 http://www.youtube.com/watch?v=87v_unEkh3c
Nursing Knowledge Base
 Attitude of health care providers
 Malingerer or complainer
 Assumptions about patients in pain
 Biases based on culture, education, experiences
 Acknowledge pain through patient’s experiences
 Limit your ability to help the patient
Factors Influencing Pain
 Physiological
 Age, fatigue, genes, neurological function
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Fatigue increases the perception of pain and can cause
problems with sleep and rest.
 Social
 Attention, previous experiences, family and support
groups, spiritual
 Spirituality includes active searching for meaning in
situations, with questions such as “Why am I
suffering?”
Factors Influencing Pain (cont’d)
 Psychological
 Anxiety
 Coping style
 Pain tolerance
 The level of pain a person is willing to accept
 Cultural
 Meaning of pain
 Ethnicity
Nursing Process and Pain
 Pain management needs to be systematic.
 Pain management needs to consider the patient’s
quality of life.
 Clinical guidelines are available to manage pain:
 American Pain Society
 National Guideline Clearing House
(www.guideline.gov)
 Agency for Healthcare Research and Quality
(AHRQ)
Assessment
 Patient’s expression of pain
 Characteristics of pain
 Onset and duration
 Location
 Intensity
 Quality
 Pattern
 Relief measures
 Contributing symptoms
 Effects of pain on the patient
Sample Pain Scales
Wong-Baker FACES Scale
Assessment
 Effects of pain on the patient
 Behavioral effects
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Assess verbalization, vocal response, facial and body
movements, and social interaction.
For patients unable to communicate pain, it is vital for
you to be alert for indicative behaviors.
 Influence on activities of daily living
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Physical deconditioning
Sleep disturbances
Sexual relationships
Ability to work (outside of and in the home)
Common Characteristics of Pain
that should be assessed:
 a. onset and duration
 b. location –Superficial/cutaneous, deep/visceral, referred,
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radiating
c. intensity –pain scale
d. quality –”Tell me what your pain feels like”
e. pain pattern –what initiates it, how long does it last
f. relief measures
g. contributing symptoms
h. effects of pain on the client
i. behavioral effects
j. influence on activities of daily living
Pain Assessment and Management:
 A: Ask about pain regularly. Assess pain systematically.
 B: Believe the patient and family in their report of pain
and what relieves it.
 C: Choose pain control options appropriate for the
patient, family, and setting.
 D: Deliver interventions in a timely, logical, and
coordinated fashion.
 E: Empower patients and their families. Enable them to
control their course to the greatest extent possible.
Case Study (cont’d)
 Jim is a 26-year-old nursing student assigned to do
home visits with the community health nurse. Jim
knows that Mrs. Ellis has lived alone since her
husband’s death 6 years ago.
 Jim conducts assessments, performs procedures,
and teaches health promotion to a variety of
patients. This is Jim's first experience caring for a
patient with severe chronic pain.
Quick Quiz!
1. When a smiling and cooperative patient complains of
discomfort, nurses caring for this patient often harbor
misconceptions about the patient's pain. Which of the
following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judges of their pain.
C. Regular use of narcotic analgesics leads to drug
addiction.
D. Amount of pain is reflective of actual tissue damage.
Case Study (cont’d)
 When Jim enters Mrs. Ellis’ four-room apartment, he
finds the home in disarray. Mrs. Ellis is sitting in a
recliner in her living room, with clothing on the floor
and soiled dished on a nearby table. She reports that
the pain she has been experiencing has made it very
difficult to use her hands and walk between rooms. She
is able to get to the bathroom, but it causes her to
become fatigued.
 Her pain is constant and is localized in the joints of her
hands and knees.
Nursing Diagnosis
Activity
intolerance
Anxiety
Ineffective
coping
Hopelessness
Insomnia
Fear
Powerlessness
Fatigue
Impaired
physical
mobility
Spiritual
distress
Chronic
Impaired
low selfsocial
esteem
interaction
Imbalanced nutrition: less than body requirements
Case Study (cont’d)
 Mrs. Ellis’ responses lead Jim to this nursing
diagnosis: chronic pain related to joint
inflammation.
 Mrs. Ellis has rated the pain as a 3 on a FACES Pain
Scale of 0 to 10, with her most severe pain as a 4.
 She has been taking aspirin, but the pain prevents
her from falling asleep; if she does sleep, she often
reawakens.
 She has difficulty standing and an unsteady gait.
Planning
 Determine with the patient what the pain has
prevented the patient from doing.
 Then agree on an acceptable level of pain that allows
return of function.
 For example, for the goal, “The patient will achieve a
satisfactory level of pain relief within 24 hours,”
possible outcomes are as follows:
 Reports that pain is a 3 or less on a scale of 0 to 10
 Identifies factors that intensify pain
 Uses pain relief measures safely
 Level of discomfort does not interfere with activities of daily
living (ADLs).
Implementation: Health Promotion
 Nonpharmacological pain relief interventions
 Relaxation, guided imagery
 Biofeedback
 Distraction, music
 Cutaneous stimulation
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Massage, transcutaneous electrical nerve stimulation
(TENS), heat, cold, acupressure
 Herbals
 Reducing pain perception
Implementation: Health Promotion (cont’d)
 Pharmacological pain relief
 Acute pain management
 Analgesics
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Nonopioids
Opioids
Adjuvants/co-analgesics
 Delivery systems
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Patient-controlled analgesia (PCA)
Local/regional anesthesia
Topical agents
Case Study (cont’d)
 Jim discussed with Mrs. Ellis’ primary health care
provider the possibility of starting a disease-modifying
antirheumatic drug (DMARD), a biological response
modifier, a nonsteroidal anti-inflammatory drug
(NSAID), or an analgesic.
 Jim had Mrs. Ellis take analgesics approximately 30
minutes before ambulating, performing self-care
activities, or going to sleep. He instructed her to take
medication with a light snack or meal and a full glass of
water. During instruction, he explained that the drug
will relieve the pain.
Patient-Controlled Analgesia
Safety Guidelines
 The patient is the only person who should press
the button to administer the pain medication when
PCA is used.
 Monitor the patient for signs and symptoms of
oversedation and respiratory depression.
Epidural Space
Case Study (cont’d)
 Jim also suggested the following to Mrs. Ellis:
 Place a sturdy stool in the shower stall and run warm
water continuously over joints of the hands and feet.
 Apply moist, warm compresses to the joints of the
hands 3 times a day.
 Referral to a physical therapist to determine possible
use of a walker or other assistive device
 What are the rationales for these additional
measures?
Implementation
 Nursing implications
 You maintain responsibility for providing emotional
support to patients receiving local or regional
anesthesia.
 After administration of a local anesthetic, protect the
patient from injury until full sensory and motor
function return.
 Nursing implications for managing epidural
analgesia are numerous.
 Nurses monitor IV sites, lines, and controllers.
Nursing Process: Planning
 Outcome Examples: (also include time measure)
 _Patient_______ reports that pain is a 3 or less on a scale
of 0-10 by________,
 __Patient_____ is able to perform ADLs by________,
 __Patient_____identifies factors that intensify pain and
modifies behavior accordingly by__________
Quick Quiz!
2. A patient has just undergone an appendectomy.
When discussing with the patient several pain relief
interventions, the most appropriate
recommendation would be
A. Adjunctive therapy.
B. Nonopioids.
C. NSAIDs.
D. PCA pain management.
Chronic Noncancer and Cancer Pain
Management
 Cancer pain may be chronic or acute.
 Breakthrough pain = A transient flare of moderate
to severe pain superimposed on continuous or
persistent pain.
 Transdermal pain patches may be used.
WHO Analgesic Ladder
WHO, World Health Organization.
Barriers to Effective Pain Management
 Physical dependence: A state of adaptation that is manifested by
a drug class–specific withdrawal syndrome produced by abrupt
cessation, rapid dose reduction, decreasing blood level of the drug,
and/or administration of an antagonist
 Addiction: A primary, chronic, neurobiological disease with
genetic, psychosocial, and environmental factors influencing its
development and manifestations
 Drug tolerance: A state of adaptation in which exposure to a drug
induces changes that result in a diminution of one or more effects
of the drug over time
 Placebos
Quick Quiz!
3. A postoperative patient is using PCA. You will
evaluate the effectiveness of the medication when
A. You compare assessed pain w/baseline pain.
B. Body language is incongruent with reports of pain
relief.
C. Family members report that pain has subsided.
D. Vital signs have returned to baseline.
Checklist for
Communication with Colleagues
 What is the pain rating now? Over the past period
of time?
 Which pain rating is acceptable to the patient?
 How do you recommend that the patient’s
treatment be changed to reduce the pain rating?
 Which professional reference can be used, if
needed, to support this recommendation?
Case Study (cont’d)
 When Jim observed Mrs. Ellis’ ability to stand and
walk from the living room to the kitchen, she was
able to ambulate with the walker; her gait was slow
but steady.
 Mrs. Ellis reports that she has less discomfort from
bathing after using warm water over her joints,
although dressing is still causing some discomfort
when manipulating buttons.
 Mrs. Ellis rates her pain at a 2 after taking the
analgesic.
Evaluation
 Evaluation of pain is one of many nursing
responsibilities that require effective critical
thinking.
 The patient’s response to pain may not be obvious.
 Evaluating the appropriateness of pain medication
will require nurses to evaluate patients’ responses
after administration.
Case Study (cont’d)
 Two weeks after his last visit, Jim returns to
evaluate Mrs. Ellis’ progress. She has gone to see a
nurse practitioner, who prescribed an NSAID for
her arthritic pain. She has not filled the
prescription and is still taking her aspirin, but
continues to have some gastrointestinal irritation.
Jim gets the chance to observe Mrs. Ellis using a
warm compress on her hands and notes that her
gait is steadier.
 Mrs. Ellis has spoken with her neighbor, who has
offered to help with shopping.
Practice NCLEX Questions:
 Which of the following is most appropriate when the
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nurse assesses the intensity of the client’s pain?
1.Ask about what precipitates the pain.
2.Question the client about the location of the pain.
3.Offer the client a pain scale to objectify the
information.
4.Use open-ended questions to find out about the
sensation.
 ANS:
3
 Descriptive scales are a more objective means of
measuring pain intensity. Asking the client what
precipitates the pain does not assess intensity, but
rather it is an assessment of the pain pattern. Asking
the client about the location of pain does not assess
the intensity of the client’s pain. To determine the
quality of the client’s pain, the nurse may ask openended questions to find out about the sensation
experienced.
Practice NCLEX Questions:
 Nurses working with clients in pain need to recognize
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and avoid common misconceptions and myths about
pain. In regard to the pain experience, which of the
following is correct?
1.The client is the best authority on the pain
experience.
2.Chronic pain is mostly psychological in nature.
3.Regular use of analgesics leads to drug addiction.
4.The amount of tissue damage is accurately reflected
in the degree of pain perceived.
 ANS:
1
 A client’s self-report of pain is the single most reliable
indicator of the existence and intensity of pain and any
related discomfort. Pain is individualistic. A
misconception about pain is that chronic pain is
psychological. The belief that administering analgesics
regularly will lead to drug addiction is a
misconception. Another misconception about pain is
that the amount of tissue damage is accurately
reflected in the degree of pain perceived.
Practice NCLEX Questions:
 Which of the following statements made by a nurse
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requires follow-up with additional instruction regarding
the personal nature of pain?
1.“I have experienced pain before, and so I have great
compassion for anyone dealing with pain.”
2.“My postsurgical clients get the prescribed pain
medications on schedule with no diversion from that
schedule.”
3.“If I were experiencing severe pain, I certainly would want
someone to devote their time to managing for me.”
4.“Clients don’t always request pain medication, and so I
always ask them if they want it according to the schedule.”
 ANS:
2
 The nurse cannot see or feel the client’s pain. Pain is
purely subjective; no two persons experience pain in
the same way, and no two painful events create
identical responses or feelings in a person. Flexibility is
a necessary component in pain management. The
remaining options do not require follow-up because
they do not express any attitudes that are not
compatible with good nursing care of the client in
pain.