n325 pain

definition of pain

• whatever the person experiencing the pain says it is, existing when they say it does

• an unpleasant sensory and emotional experience associated with acute or potential tissue damage or described in terms of such damage

pain is a multidimensional experience

• #1 reason people seek healthcare

• unpleasant both physiologic and psychological dimensions

• causes suffering

• decreased QOL

gender differences

• men

  • less likely to report pain than women

  • report more control over pain

  • less likely to use alternative treatments for pain

• women

  • more likely to have migraines, back pain, arthritis, fibromyalgia, neuropathic pain, abdominal pain, and foot ache

  • more likely to be diagnosed with a nonspecific, somatic disorder

  • less likely to receive analgesics for chest and abdominal pain

aging considerations

• more likely to experience pain from a chronic condition

• may expect pain as a part of aging and fail to report it

• may have cognitive problems that limit the ability to describe pain

• often manifested by depression and increased social withdrawal

physiological responses to ACUTE pain

• cardiovascular

  • increased BP and HR → enhanced alertness to threats

• neurological

  • increased pupil diameter → visual perception of threat

• skin integrity

  • increased perspiration → removal of excess body heat

• musculoskeletal

  • increased muscle tension and activity → body ready for rapid motor activity

• psychosocial

  • increased apprehension, irritability, anxiety → enhanced mental alertness

classification of pain: duration

• acute

  • onset: sudden

  • duration: usually under 3 months

  • severity: mild to severe

  • cause: can usually ID

  • course: decreases over time

  • goals: pain control, resume activities, minimize SEs

• chronic

  • onset: sudden or gradual

  • duration: usually over 3 months

  • severity: mild to severe

  • cause: may be unknown

  • course: persists, ebb & flow

  • goals: pain control, improve QOL

classification of pain: source

• nociceptive

• neuropathic

• ischemic

• referred

nociceptive pain

• normal processing of stimulus that either damages or has potential to damage tissue

• superficial somatic: arising from skin, mucous membranes, subcutaneous tissue. localized

• deep somatic: arising from muscles, fasciae, bones, tendons. localized or diffuse/radiating

• visceral: arising from visceral organs, such as gallbladder of pancreas, usually referred to cutaneous sites

  • think abominal organs when hear visceral

• functional: pain and disability without a clear etiology involving persistent and complex physical symptoms

  • wide range of diff types of pain

neuropathic pain

• damage to peripheral nerves or to structures within the CNS

• traditional pain meds not rly effective for treating neuropathic pain

• causes:

  • hereditary

  • metabolic

  • infectious

  • inflammatory

  • toxic

  • traumatic

• examples:

  • diabetes

  • alcoholism (ETOH)

  • shingles

  • amputation

  • chemotherapy

  • nerve compression

• description of pain:

  • shooting

  • burning

  • stabbing

  • electric

  • numbness

  • paresthesia

ischemic pain

• caused by tissue hypoxia (lack of oxygen)

• ex) heart attack → loss of blood to heart and feel pain

referred pain

• pain perceived in an area other than the site of origin

• different from radiating pain

• result of interconnected sensory nerves

• somatic mapping helps practitioners pinpoint the problem

• ketamine can block referred pain

• ex) appendix pain is one of the most common

nociception: physiology of pain

• nociception: physiological process by which our body communicates painful stimuli up to the CNS

• involves 4 processes:

  • transduction

  • transmission

  • perception

  • modulation

transduction

• conversion of painful stimuli (usually tissue damaging) into an electrical signal that travels to the brain

• ex) burn

• local damage to cells → release of chemokines like histamines and prostaglandins → localized inflammation

• activation of nociceptors → generates electrical signals (action potentials) that send signals to the spinal cord

• have nociceptors all thru our body

transmission

• conduction of action potential from site of injury to spinal cord

• nerve endings enter spinal cord at very specific areas

perception

• conscious awareness of pain

• ouch that hurt!

modulation

• automatic

• release of inhibitory or affect on pain transmission

• involves signals from the brain going to spinal cord to help stop the pain signals

• body alters/modifies pain signals

• chronic pain → modulation system becomes less effective → increased pain sensitivity and reduced pain inhibition

  • bc turned on so long

• ex) hit knee on something and start rubbing it

dermatones

• can help identify spine, spinal cord, or spinal nerve injury

• for those sections of body, those nerves innervate to that area

what pain management actually is (for nurses)

• planning, educating, advocating, interpreting, supporting

• assessment

  • verbal

  • nonverbal

• intervention

  • pharmacological

  • nonpharmacological

• monitor/evaluate

• educate patients/families

core principles of pain assessment

• everyone has a right to assessment/treatment of pain

• pain is subjective

• physiological/behavioral signs of pain are not always reliable

• pain is unpleasant

• assessment must be appropriate for each patient

• pain can exist without physical etiology

• pain perception is individual

• chronic pain sufferers may be more sensitive to stimuli

• unrelieved pain has physiologic consequences

assessment

• regularly screen ALL patients for pain

• when pain is present, perform a more thorough assessment

• goals:

  • describe the patient’s pain experience to design pain management techniques

  • identify goals for therapy and resources for self-management

  • ensure realistic goals (pain 0/10 is not always a reasonable goal)

• elements (multidimensional):

  • interview

  • observation

  • diagnostics

  • physical exam

assessment: interview tools

• P: palliative/provoking

• Q: quality

• R: radiation

• S: severity

• T: temporal factors

describe pain

• palliative/provoking

  • what makes it better/worse?

• quality

  • sharp? dull? burning? aching?

• radiating

  • pain travels and is felt along pathway (usually neuropathic)

• temporal

  • when does it hurt? always?

• visceral

  • internal organ pain (diffuse)

• somatic

  • pain of skin & deep tissues (musculoskeletal)

• referred

  • perceived at location other than site of stimulus

• BTP (breakthrough pain)

  • occurs when pt is already medicated

• immediate

  • BTP that is associated with a specific activity

assessment: pain severity

• rate 0-10 → 0 = no pain, 10 = the worst pain

• get a baseline and then after an intervention → reassess -? how well did the intervention work?

• faces more appropriate for children

• pain assessment in non-verbal pain scale

assessment part 1: observation

• what are their facial expressions?

  • look between eyebrows → eyebrows furred = experiencing pain

• body movements?

assessment part 2: physical exam

• general observations

• mental status exam

• inspection, palpation, percussion

• strength

• sensation

• reflexes

• vital signs

assessment: diagnostics

• donut of truth (CT)

• MRI

• nerve blocks

• myelogram

• bone scan

• ultrasound

• labs

interventions

• assess routinely (this is an intervention only in the broadest sense)

• explore patient beliefs, expectations, and goals

• teach about pain and its relief

• administer meds and explain them

• explain/demonstrate non-pharmacological management strategies

  • back rub, ice packs, elevate an extremity

• cluster care

• monitor for SEs

evaluation

• ALWAYS follow up and evaluate treatment

gate control theory of pain

• non-painful sensations can override and reduce painful sensations

• mon-painful sensory input (e.g., rubbing) can close this gate, while pain signals (e.g., injury) open it, either blocking or allowing signals to reach the brain based on nerve fiber activity and descending brain signals

complementary interventions for pain

• benefits

  • reduced dose of analgesic needed

  • minimizes side effects

  • Rx not usually necessary

  • cost effective

• examples

  • massage

  • exercise

  • transcutaneous electrical nerve stimulation (TENS)

  • acupuncture/acupressure

  • heat/cold therapy

  • cognitive therapies (relaxation, distraction, hypnosis, music)

  • immobilization

treatment principles

• thorough assessment

  • remember: PQRST. objective & subjective data

• holistic approach

  • pain affects all areas of life

• base treatment on pt goals

  • what is realistic for pt? what are their functional goals?

• pharm & non-pharm options

  • drugs are mainstay, but complementary treatments can work wonders

• multimodal plan

  • when one med isn’t enough, patient may need two or more classes of analgesics

• awareness of bias

  • all patients deserve to have their pain tested

• collaboration

  • anesthesia, pharmacy, nursing, PT, OT, palliative care specialists

• evaluate effectiveness

  • trial and error may be needed and may be necessary, re-assess, adjust, re-assess

• manage side effects

  • CNS depression, constipation, n/v, dry mouth, tinnitus, itching, rash, etc

• patient teaching

  • what can/can’t they do? how to manage side effects? when to call?

• understand policy

  • what are the laws in texas? institutional policies? what are your responsibilities?

pharmaceutical management

• pain management principles

  • less medication is required to prevent pain than relieve it

    • try to proactively manage pain

  • opiate naive patients need a lower dosage than opioid tolerant patients

  • preventative analgesia can be utilized (be sure to document)

  • good pain control increases functional outcomes and participation in care

  • untreated acute pain can lead to chronic pain

  • chronic pain can be complex and hard to manage

medications

• non-opioids

  • ASA (aspirin)

  • APAP (acetaminophen)

  • NSAIDs

• opioids

  • schedule 2

  • schedule 3

  • schedule 4

• adjuvants

  • antidepressants

  • anticonvulsants

  • corticosteroids

  • GABA receptor agonists

  • anesthetics

NSAIDs examples

• ibuprofen

• naproxen

• ketorlac

• diclofenac

• meloxicam

• indomethacin

schedule 2 medication examples

• morphine

• hydromorphone (Dilaudid)

• hydrocodone/APAP (Norco, Lortab, Vicodin)

• oxycodone (Percocet)

• fentanyl

schedule 3 medication examples

• APAP with codeine

schedule 4 medication examples

• tramadol

adjuvant medication examples

• antidepressants

  • amitriptyline (elavil)

  • nortriptyline (norventyl)

  • duloxetine (cymbalta)

• anticonvulsants

  • gabapentin (neurontin)

  • pregabalin (lyrica)

• corticosteroids

• GABA receptor agonists

• anesthetics

medications for mild to moderate pain

• acetaminophen

• NSAIDs

acetaminophen (Tylenol)

• Class: analgesic

• Indications: analgesia, antipyretic

• Mechanism of Action: not fully understood;

• Side Effects/Adverse Effects: generally well-tolerated.

• Cautions: in many OTC products, check labels; risk of hepatotoxicity in high doses; limit to no more than 4g/day in healthy adults

• Dosage: 325-650mg PO/PR q 4-6 hrs [max 4000mg]

• Pregnancy and Lactation: Not associated with increased risk of miscarriage or stillbirth

• Special considerations:

  • Maximum daily dose: 4000mg (in some hospitals ↓ 3000 mg)

  • 3000mg in chronic users (healthy adults)

  • 2400mg in elderly patients or those with liver, renal, or cardiac impairment

  • It’s in practically everything OTC

NSAIDs

• Ibuprofen, Naproxen, Aspirin, Ketoralac (IV, only NSAID that we can give IV)

• Class: Indications: pain (anti-inflammatory)

• Mechanism of Action: inhibits prostaglandin synthesis

• Side Effects/Adverse Effects: increased risk of GI bleed, perforation;

  • Stool will come out black and tarry if GI bleed occurs…

  • Educate pt to watch out for dark/tarry stools

• Cautions: Risk of bleeding, kidney dysfunction

• Dosage: 200 – 800 mg/ 4-6 hrs

• Pregnancy and Lactation: caution after 20 weeks gestation, discuss with provider

• Take with food

medications for moderate to severe pain relief

• opioids

  • bind with receptors in CNS

  • inhibit nociceptive input from periphery to spine

  • alter limbic activity

  • activation of inhibitory pathways that modulate transmission in the spinal cord

  • categorized by action (agonist, antagonist) and which receptors they bind to (mu, kappa, delta)

  • most used are pure agonist (morphine, hydrocodone, oxycodone, hydromorphone)

• opioid medications

  • morphine

  • hydromorphone

  • hydrocodone & oxycodone

• antidepressants

  • duloxetine

• anticonvulsants

  • gabapentin

opioid side effects

• respiratory depression

  • opioids depress autonomic breathing processes

• constipation

  • ask patient if they are experiencing constipation

  • give stool softeners

  • be proactive in offering stool softeners

• poor concentration

• N/V

  • give anti-emetic

• urinary retention

  • suppressing autonomic nervous functioning

  • use catheter or find another way to manage pain

• sedation: POSS scale

  • scale 1-4

    • 1 = awake and alert

    • 2 = slightly drowsy, easily aroused

    • 3 = frequently drowsy, arousable, drifts off to sleep during concentration

    • 4 = somnolent, minimal or no response to verbal and physical stimulation

  • 1-2 is expected effects

  • 3-4 is over-sedation symptoms

• itching

• increased pain

morphine

• Class: opioid analgesic

• Indications: acute pain, chronic severe pain

• Mechanism of Action: opiate receptor agonist; inhibits ascending pain pathways

• Side Effects/Adverse Effects: respiratory depression, constipation, CNS depression, hypotension, nausea, vomiting.

  • Causes vasodilation -> if pt is already hypotensive -> don’t give morphine unless EOL patient

  • Vasodilation -> BP drops

  • Pts at most risk for hypotension is those who are already compromised -> blood loss, other meds that decr BP

  • Before giving, assess BP, pulse, O2 sat

• Cautions: CNS depression, elderly, allergies, kidney dysfunction

• Dosage: Depends on route

hydromorphone (Dilaudid)

• Class: Opioid analgesic

• Indications: acute pain, chronic severe pain

  • Much more potent than morphine.. Generally give 1 or the other.. Never both morphine/dilaudid

  • Depends on tolerance/what they’re being treated for

• Mechanism of Action: Same

• Side Effects/Adverse Effects: Same – more potent!

• Cautions: opioid naïve, elderly, low BMI, cognitive impaired

  • Try to look for something less potent for elderly and opioid naive.. Unless they already been taking it before and tolerating okay

• Dosage: 1.5 mg hydromorphine = 10 mg morphine

  • Don’t get doses mixed up! Super different in dosing and potency

• Usual dosages are 0.5 mg – 2 mg IV

hydrocodone & oxycodone

• Class: Opioid analgesic

• Indications: acute pain, chronic pain

• Mechanism of Action: same but PO administration (not IV)

• Side Effects/Adverse Effects: same

  • Can have oversedation, constipation, and respiratory depression

  • The body builds tolerance to opioids.. If pt takes opioids at home, they’re gonna need greater doses

  • When we can, we need to use other meds -> if only take opioids, it’s not gonna be so effective anymore

• Cautions: Same but may be mixed with acetaminophen

  • Important to know.. So don’t have pt taking too much tylenol

• Dosage: 5mg (naïve) to 20mg tolerate every 4-6 hours.

duloxetine

• Class: antidepressant, SNRI

• Indications: depression, peripheral neuropathic pain, generalized anxiety disorder, fibromyalgia, chronic musculoskeletal pain

• Mechanism of Action: inhibits reuptake of serotonin and norepinephrine

  • Helps modulate pain receptors.. Change neuropathic pain reception.. Opioids don’t work well for neuropathic pain

• Side Effects/Adverse Effects: nausea, dry mouth, headache, fatigue, sleepiness

• Cautions: can increase suicidal thoughts; risk of hepatotoxicity; risk for skin reactions, risk for othostatic hypotension, risk of cognitive/motor function impairment

• Dosage: 40-60mg QD PO

gabapentin

• Class: GABA analog

• Indications: seizures, NEUROPATHY, restless leg, insomnia, neuropathy, tremors

  • Go to med for neuropathic pain

  • Most likely take for pain.. Can be seizures, but mostly for pain

• Mechanism of Action: structurally related to neurotransmitter GABA, methods for analgesia unknown

• Side Effects/Adverse Effects: drowsiness

• Cautions: clients with CNS depression

• Dosage: 100 – 800 mg / day

adjuvant analgesic therapy

• add analgesic effects, esp with neuropathic pain

• adjuvant = in addition to

  • corticosteroids (anti-inflammatory)

  • antidepressants (modulate neurotransmitters)

  • anti-seizure drugs (calm nerve cells)

  • GABA receptor agonists (inhibit GABA)

  • alpha-adrenergic agonist (alter pain perception)

  • local anesthetics (inhibit nerve impulses)

  • cannabinoids (modulate pain)

medication routes

• IV

• IM

• PO

• SQ

• PT (per tube, e.g. dobhoff, PEG)

• PR (per rectum)

• transdermal

• epidural

• intranasal

• topical

• intraosseous (marrow cavity of a bone)

• sublingual

• buccal

• intrathecal

rule of thumb when giving meds for pain

• treat pt’s pain level with:

  • lowest starting dose

  • fewest potential SEs

  • least invasive route

    • IV works faster, but hold off as much as possible and use PO

    • transition to home management better

    • manage pain better by being proactive, not catching up to it

    • shouldn’t be waking a pt up to ask their pain level

    • if pt is presenting signs of over-sedation, need to use good clinical judgement.. look for diff ways to manage their pain

alternative types of medicine administration

• epidural/intrathecal

  • potent due to delivery close to receptors in the dorsal horn

  • smaller doses (1 mg = 300 mg PO)

    • requires way less dosing bc it is more potent, reaching the spinal cord closely

  • complications

    • catheter displacement/migration

    • infection

• implantable devices

  • pain pump (meds)

  • spinal cord stimulator (electrical)

• nerve blocks

• PCA

  • patient-controlled analgesia

patient-controlled analgesia (PCA)

• patients need to be an appropriate candidate for PCA

  • need to be able to hit the button

  • there are PCAs that will be able to provide continuous analgesia → but reserve for hospice

• pt can deliver dose to themselves instead of the nurse coming frequently

• dosing is smaller but pt can get them more frequently

  • morphine or dilaudid PCA

• proper patient-family education

  • ONLY PATIENT CAN PRESS BUTTON

  • family should never press button → risk of over-sedation

• continous bolus, bolus dose, PCA dose

• locked unit, two nurses to verify

• IV must be running for PCA to work

  • needs normal saline driver

    • saline at very small amt per hour to help push thru the very small volume of medication

pain is undertreated

• terminal pain: 24% of families stated their dying loved one had inadequate pain control

• cancer pain: fewer opioids being prescribed, more ED visits

• consequences:

  • increased suffering

  • physical/psychological dysfunction

  • impaired recovery

  • immunosuppression

  • sleep disturbance

challenges of pain management

• tolerance

  • a normal need for an increased opioid dose to maintain the same degree of analgesia

• pseudoaddiction

  • behaviors similar to those of addiction, because of inadequate treatment of pain

• dependence

  • a normal physiologic response to ongoing exposure to opioids, manifested by withdrawal

• addiction

  • compulsive use, loss of control of use, and continued use of medication despite risk of harm

naloxone

• narcan

• opioid antagonist

• suspected OD

  • pinpoint pupils, respiratory depression, unconsciousness

• precipitates complete withdrawal of opioids (endogenous and exogenous)

  • will cause S/Sx of withdrawal

    • N/V, diaphoresis, tachycardia, hypertension, yawning, tremors, abdominal cramping, etc

• follow institution protocol for administering prescribed opioids after a Narcan dose (usually 2-4 hrs post Narcan)