Unit 12 Pain

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Whatever the person experiencing it says it is » Can be different to treat their pain

Pain Physiology

Experienced when an intact, properly functioning nervous system signals that tissues are damaged, requiring attention and proper care

Transient

Comes and goes

Persistent

(Continuous » prolonged)

Subcategories to Pain

Somatic (system wide), Visceral (organs), Neuropathic (nerve pain)

Somatic (system wide)

Skin, muscle, bones

Visceral (organs)

Hard to describe » pain radiates to another body part from within (cavities)

Neuropathic (nerve pain)

• This is treated differently, to stop nerve transmission

• Pain in lower extremities (diabetes)

• Hitting the sciatic nerve

• Phantom pain (limb)

Nociception

• Transduction » Stimuli

• Transmission » Pain travels

• Perception » Conscious of pain

• Modulation » Natural mechanics within the body that modifies pain

Transduction

Stimuli

Transmission

Pain travels

Perception

Conscious of pain

Modulation

Natural mechanics within the body that modifies pain

Gate Control Theory » Most common theory on how we interrupt pain

• Nerves must be functioning to feel pain

• A way to moderate the pain within the brain and its neurotransmitters

• Stimuli » along the nerve pathway » spinal cord » Brain

Contributing Factors

Chemical, Developmental, Physical, Physiological, Psychosociocultural, Iatrogenic

Chemical

• Ex; medication

  • Aspirin can cause irratation and bleeding in the stomach

  • Steroids, iron supplements

Developmental

• Ex; age

• Their understanding of pain changes with age

• Older adults » expect pain therefore don’t seek help

• Preschool aged children may associate pain with punishment » pain may not understand if pain goes away

Physical

• Ex; radiation, pressure, trauma, heat/burns, temp, and surgeries

Physiological

Ex; inflammation, diabetes, renal calculi, arthritis

Psychosociocultural

• Your previous experiences with pain and how you handle it

• How culture affects how you experience pain

• Gender- woman can tolerate more pain because of menstrual cycle

  • Men aren’t as readily verbal about their pain — comes off as non-masculine

Iatrogenic

Physician induced » any procedure that causes pain

• Ex; Foley catheter causing a painful UTI

• Ex; IV’s, drawing blood, injections

Acute Pain

• Sympathetic nervous system

• Duration is less than 3 months

• Severity can range from slight to extreme

• Vitals usually increase – increase BP, RR, HR, temp (GAS)

• Skin may be flushed / red

• Pupils generally dilated

• Behavioral changes

  • Irritable

  • Guarding the area that is painful » “don’t touch me”

  • Crying

  • Wincing

  • Anxiety

  • Restlessness

  • Diaphoresis

Chronic Pain » prolonged/usually cyclical and irreversible

• Parasympathetic nervous system

• Duration persists more than 3 months

• Severity can range

• Vital signs are not always elevated – have become somewhat tolerable to the pain » adapts to pain

• Behavioral changes:

  • Depression

  • No Guarding

  • Some older adults don’t mention pain considering they are used to it

  • Dry/warm skin

  • Pupils constrict

Pain Threshold

• How much stimulus does it take for the person to feel pain » varies slightly but not too much

• Entryway

Pain Tolerance

• Maximum amount of pain that a person is willing to withstand before seeking relief

• How much pain an individual can handle » varies person to person

Pain Pattern

Onset, duration, consistency, reoccurrences, intervals of pain

Precipitating Factors

What aggravates the pain » Stressors that preceded or worsens pain

Alleviating Factors

What helps the pain? » Interventions which decreases pain

Intractable Pain

• Pain that does not go away even with treatment

• Cannot be managed even with treatment

  • Ex; cancer

Associated Symptoms

Vomiting, nausea, headache, anorexia, and insomnia

Location (subcategories)

• Localized

• Radiates

• Referred

• Diffuses

Localized

Pertains to a specific area

Radiates

Travels to surrounding body parts » happens with visceral pain

Referred

• Pain experienced in another area are not close to the site of injury

  • Ex; heart attack felt in the jaw, or the shoulder

Diffuse

Spreads to be all over (Kidney pain)

Quality or character

• Ex; describe your pain

  • Achy, dull, sharp, pins, throbbing, burning, stabbing

Affective Responses

• Emotional responses

  • Does it give you suicidal thoughts?

  • Does it make you fearful

Pain Assessment Mneumonic (Subjective Data)

COLDERR, PQRST, OLDCARTS

COLDERR

• Character/quality- stabbing, throbbing, burning

• Onset- when it starts

• Location- where

• Duration- how long does it last

• Exacerbation- what makes it worse

• Relief

• Radiation- does it spread

C (COLDERR*)

Character

O (COLDERR*)

Onset (COLDERR*)

L (COLDERR*)

Location

D (COLDERR*)

Duration

E (COLDERR*)

Exacerbation

R (COLDERR*)

Relief

R* (COLDERR*)

Radiation

PQRST

• Provoked (what brought the pain on)

• Quality- stabbing, throbbing, burning

• Region/Radiation- where it’s localized/does it spread

• Severity- intensity

• Timing- when does it happen

P (PQRST)

Provoke

Q (PQRST)

Quality (pain description)

R (PQRST)

Regional (where is it located, does it spread- radiation)

S (PQRST)

Severity (On a scale of 0-10)

T (PQRST)

Timing

OLDCARTS

• Onset- when it starts

• Location- where it’s localized

• Duration- how long does it last

• Characteristics- stabbing, throbbing, burning

• Aggravating Factors- stressors that precedes or worsens pain

• Radiating (reffered, region, location)

• Treatment (has anything worked to alleviate the pain)

• Severity- intensity

O (OLDCARTS)

Onset

L (OLDCARTS)

Location

D (OLDCARTS)

Duration

C (OLDCARTS)

Characteristics

A (OLDCARTS)

Aggravating Factors

R (OLDCARTS)

Radiating (referred, region, location)

T (OLDCARTS)

Treatments (what has alleviated the pain vs what hasn’t)

S (OLDCARTS)

Severity (intensity)

Severity Pain Scale

0 (no pain) » 1-3 (mild pain) » 4-5 (moderate pain) » 5-7 (severe pain) » 8-9 (severe pain) 10 (worse pain possible)

0

No pain

1-3

Mild pain

4-5

Moderate pain

5-7

Severe pain

8-9

More severe pain

10

Worse pain possible

Pediatric Pain Scale

• Wong Baker/Faces

• FLACC Scale

Wong Baker/Faces

Comes in different languages for non-English patient’s

FLACC Scale

Babies, non-verbal patient’s, and patient’swith dementia

Objective Data

• Behavioral responses to pain

  • Grimacing, sweating, moaning, guarding, restless, altered LOC, thrashing, obscene language

• Physiologic changes

  • Vital signs » unless it’s chronic pain » vital signs sometimes don’t change

    • Increased respiratory, heart rate, blood pressure

• Skin changes

• Pupillary changes

F (FLACC*)

Facial expression

L (FLACC*)

Leg movement

A (FLACC*)

Activity

C (FLACC*)

Crying

C* (FLACC*)

Consolability

Additional Pain Data

• Associated symptoms

• Effects on ADLs

  • Are you still able to perform daily task

• Past pain experiences

• Meaning of pain to a person

• Coping resources

  • Meditation, relaxation, guided imagery, distraction

  • Educate the patient about pain

• Affective responses

Nursing Interventions

• Establish a trusting relationship – take their word for it

• Consider patient’s ability and willingness to participate – motivation, have to believe it’s going to work

• Use a variety of pain relief measures: pharmacologic and non-pharmacologic (do first before administrating medication)

• Provide pain relief before pain is severe

• Use pain relief measures the patient believe are effective

• Align pain relief measures with report of pain severity

• Encourage patient to try ineffective measures again before abandoning

• Maintain unbiased attitude about what may relieve pain

• Keep trying

• Prevent harm

• Educate patient, family and caregivers about pain

Opioids

• Examples – morphine, dilaudid

• No ceiling on analgesia » taking more has an affect and can even kill you

  • Depends on a person’s tolerance and patient’s history and situation

  • There is no max of dose

• Make sure it’s not leaking

• Concerns

  • Addiction » keep taking medication when not needed

  • Dependence

  • Tolerance

Side effects to Opioids

• Depresses respiratory rate

• Urinary retention, constipation, and nausea

Opioid Routes

All routes, any site

Antidote to opioids

Narcan

Opioid Dependence

Decreases blood levels of the drug » manifested by withdrawal syndrome

Opioid Tolerance

• Adaptation to a drug » varies greatly » build a tolerance overtime

• Increased tolerance

• The effectiveness of a drug decreases if you’re on it for a prolonged period

Nonopiods/NSAIDS- Intake through GI tract (given with food considering it’s irritating in the GI tract

• Vary little in analgesic potency but do vary in anti-inflammatory effects, metabolism, excretions, and side effects

• Have a ceiling effect » you can only go so high » very short ½ life, taking more does not help

• Narrow therapeutic index

  Ex) Acetaminophen, ibuprofen, aspirin (ASA)

Co-Analgesics/Adjuvant Medications

• Antidepressants

• Anticonvulsants

• Local anesthetics

• Placebos

• Use Nonopioids/NSAIDS with co-analgesics

Medications which are not specifically designed to relieve pain, but which can help improve pain either alone or in combination with medications

Oral Routes

• Preferred because of ease of administration

• Duration of action is often only 4 to 8 hours

• Must awaken during the night for medication

• Long-acting preparations developed

• May need rescue dose of immediate-release medication

PCA (Patient Controlled Analgesic)

• Gives patient control of pain medications – IV pump machine

• Must be A&Ox4, always need a witness

• Not used frequently due to the opioid crisis

Other Routes

• Transmucosa and transnasal

• Transdermal (lidocaine patch)

• Rectal

• Continuous subcutaneous infusion

• Intramuscular

• Intravenous

Intraspinal

Epidermal for pain management

Other ways to treat pain

• Physical Modalities » Transmission of energy to or through the patient

  • Cutaneous stimulation » massage, heat, cold, and therapeutic touch

  • Immobilization or therapeutic exercises » repositioning

  • Transcutaneous electrical nerve stimulation (TENS) » alters perception of patient’s pain » mild electric current to relieve pain » sending non-painful stimuli through injured tissues and into the nervous system

Cutaneous Stimulation

Massage, heat, cold, and therapeutic touch

Immobilization or therapeutic exercisee

Repositioning

Transcutaneous Electrical Nerve Stimulation (TENS)

• Alters perception of patient’s pain » mild electric current to relieve pain » sending non-painful stimuli through injured tissues and into the nervous system

Cognitive Behavior (Mind/Body)

• Providing comfort

• Distraction

• Eliciting relaxation response

• Re-pattern thinking

  • Change how you perceive pain (anticipatory pain)

• Facilitating coping with emotions

Cognitive Behavior Interventions

• Reducing pain triggers

• Massage

• Applying heat (dilates) or ice (constricts) » Icepack needs to be left 15-20 minutes » rebound phenomenon

• Electric stimulation (TENS)

• Positioning and bracing (selective immobilization)

• Acupressure

• Diet and nutritional supplements

• Exercise and pacing activities

• Invasive interventions

Invasive Interventions

• Surgical disruption of pain conduction

• Sympathectomy

• Spinal cord stimulation

Beneficial for cognitive (mind/body)

Lifestyle Management

• Stress management

  • Deep breathing

• Exercise, nutrition

  • Release of endorphins

• Pacing activities

• Disability management

Lifestyle Interventions

• Relaxation and imagery

• Self-hypnosis

• Pain diary and journal writing

• Distracting attention

• Re-pattern thinking

• Attitude adjustment

• Reducing fear, anxiety, stress, sadness, and helplessness

• Providing information about pain » Educate