Unit 8: Promoting Comfort and Managing Pain

Unit 8: Promoting Comfort and Managing Pain

Objectives

  • Discuss the care of a client with altered comfort level, specifically pain.
  • Describe the assessment tools and techniques for pain.
  • Describe the factors that impact a client's pain status.
  • Describe the principles of pain management.
  • Describe strategies to maintain a safe environment for a client with sensory deficits.

Pain

  • The primary purpose of pain is not explicitly stated but implied to be a protective mechanism.
  • Pain perception is individualized and can be culturally influenced; it is affected by endorphins.
  • Pain tolerance is the level of pain a person is willing to tolerate without experiencing discomfort. It's the degree to which pain is endured (duration and intensity) before initiating a response.
  • Pain threshold is the point at which a person experiences or demonstrates pain, which is the level to activate the nerve ending to perceive pain. The associated nerve fibers then transmit the pain signal to the spinal cord and brain.
  • Pain pathway involves a basic mechanism of signal production at the cellular level.

Pain Threshold

  • Mild pain may manifest as irritation, sting, or itch.
  • The action taken in response to pain can range from ignoring it to acting upon it.

Transmission of Painful Stimulus

  • Transmission begins when the pain threshold is surpassed in specialized nerve endings of sensory nerves, known as nociceptors.
  • Pain stimuli are transmitted by afferent neurons to the dorsal horn of the spinal cord.
  • Peripheral nerve afferent pain fibers (A delta fibers or C fibers) transmit the pain impulse to the dorsal root ganglia in the spinal cord.
  • Pain information is filtered and modified before being sent to the brain.

Pain Message

  • The pain message is sent through the spinothalamic tract to the reticular activating system (RAS) in the pons and medulla oblongata.
  • Arousal of the RAS influences the brain’s awareness of incoming pain stimuli.
  • Pain impulse reaches higher levels of the brain:
    • Thalamus: Sensory relay center
    • Limbic system: Emotional response to pain
    • Hypothalamus: Stress response to pain

Classification & Types of Pain

  • Classifications:
    • Nociceptive:
      • Somatic
      • Visceral
    • Neuropathic: Involves the central nervous system (CNS) and/or peripheral nervous system (PNS)
  • Types:
    • Acute pain
    • Chronic pain
    • Cancer pain

Quick Quiz 1

  • Question: On initial assessment, a patient complains of pain but was laughing and talking with family before the assessment. What must the nurse remember during a pain assessment?
  • Answer: B. Patients are the best judges of their pain.

Factors Influencing Pain

  • Physiological
    • Age
    • Fatigue
  • Social
    • Attention
    • Previous experience
    • Family/social support
  • Spiritual
  • Psychological
    • Anxiety
    • Coping style
    • Meaning of pain
  • Cultural

Quick Quiz 2

  • Question: Established pain management guidelines direct nurses to frequently assess the patient’s pain. What is the most appropriate action for the nurse to take when assessing the patient’s pain?
  • Answer: D. Use open-ended questions to find out about the patient’s pain.

Pain Assessment

  • Includes:
    • Characteristics
    • Expressions

Pain Assessment Mnemonic: OPQRSTU

  • Onset: When did it begin? How long does it last (duration)? How often does it occur (time)? What were you doing when the pain started?
  • Provoking or Palliating Factors: What brings it on? What makes it better? What makes it worse?
  • Quality: What does it feel like? Can you describe it (throbbing, stabbing, dull, etc.)?
  • Region & Radiation: Does your pain radiate? Where does it spread? Point to where it hurts the most. Where does your pain go from there?
  • Severity: What is the intensity (pain scale of 1-10, visual scales) of the symptom? Right now? At worst?
  • Time & Treatment: When did the symptoms first begin? What medications are you currently taking for this? How effective are these? Side effects?
  • Understanding & Impact: What do you believe is causing this? How is this affecting your ADLs, you and/or your family? Do you have any other concerns?

Behavioral Indicators of Pain

  • How might the client vocalize pain?
  • What might you observe on their face?
  • How might pain be expressed in body movements?
  • What about the client’s social interaction?

Pain Scale

  • Numerical Pain Scale: 0-10
    • 0 = no pain
    • 10 = severe pain

FLACC Scale

  • Used as a pain assessment tool, especially for patients who cannot self-report.
  • Components include: Face, Legs, Activity, Cry, Consolability.
  • Each component is scored from 0-2, with a total score ranging from 0-10.

Common Nursing Diagnoses Related to Pain

  • Anxiety
  • Ineffective coping
  • Fatigue
  • Fear
  • Hopelessness
  • Impaired physical mobility
  • Acute pain
  • Chronic pain
  • Powerlessness
  • Ineffective role performance
  • Situational low self-esteem
  • Disturbed sleep pattern
  • Impaired social interaction

Nursing Interventions

  • Non-pharmacological:
    • Relaxation
    • Guided imagery
    • Distraction
    • Cutaneous stimulation
  • Pharmacological:
    • Nonopioid Analgesics:
      • Salicylates (aspirin)
      • Nonsalicylates (acetaminophen/Tylenol)
      • NSAIDs (ibuprofen)
    • Opioid Analgesics:
      • Codeine
      • Demerol/Morphine
      • OxyContin

Acute Pain Management

  • Patient-Controlled Analgesia (PCA)
  • Local & Regional Anesthesia
  • Epidural Analgesia
  • Local Agents/Topical Agents
  • Breakthrough Pain management

Quick Quiz 3

  • Question: A postoperative patient is using PCA. When will the nurse evaluate the effectiveness of the medication?
  • Answer: A. When the patient’s present pain is compared with the baseline pain.

Implementation of Comfort Measures

  • Surgical interventions
  • Procedure pain management
  • Chronic noncancer and cancer pain management

Barriers to Effective Pain Management

  • Patient-related, healthcare provider-related, and healthcare system-related barriers
  • Physical dependence, addiction, and drug tolerance
  • Placebos

Evaluation

  • Reassess signs & symptoms of client’s pain response
  • Observe client’s response to therapies
  • Consider psychological and physiological responses to pain

Principles of Pain Management

  • Always remember the concept of Total Pain
  • Include the person, the family, and the caregiver in the plan
  • Do a quick but thorough assessment of the pain
  • Initiate treatment as rapidly as possible
  • Untreated pain is a medical emergency
  • Use a stepped approach to analgesia use
  • Choose simplest to complex approach
  • Constant pain requires around the clock management
  • Ensure patient has control over management as possible
  • Anticipate and treat other symptoms aggressively
  • Never give up hope of achieving the patient’s desired level of pain control

Other Symptoms Associated with Pain

  • Nausea and Vomiting
  • Constipation
  • Dyspnea
  • Consider associated symptoms with specific types of pain (e.g., abdominal pain).

Summary

  • Pain assessment and tools to assess pain
  • Plan nursing interventions
  • Evaluate the care provided
  • Health teaching for the patient

Sensory Stimulation and Alterations

  • Consider a person experiencing sensory alterations while also having pain.

Sensory Stimulation

  • Sensation: Receiving of information; being able to register a sound before seeing the object (e.g., dog barking, phone ringing).
  • Perception: Conscious recognition of a sensory stimulus (e.g., fragrance of fruit, being able to identify which fruit without seeing it).
  • Sensory deficit: A loss in the normal function of sensory reception and perception.

Sensory System

  • Visual: sight
  • Auditory: hearing
  • Gustatory: taste
  • Olfactory: smell
  • Kinesthetic: awareness of position & body movement

Common Sensory Deficits

  • Impaired hearing, loss of sight, loss of taste, loss of smell, loss of position sense
  • Examples: Meniere’s disease, vertigo
  • Safety becomes a risk factor.

Alteration in Visual Field: Nursing Interventions

  • Acknowledge your presence and identify yourself by name.
  • Speak in a normal tone of voice.
  • Explain if you are going to touch them and why.
  • If they have reduced vision, stay in their field of vision.
  • When the conversation has ended, indicate you are leaving the room.
  • Orient to room and surroundings, including sounds in the environment.
  • Do not leave objects in their path.
  • Ensure call bell is within reach.
  • Ensure they wear glasses if they use them.

Hearing Impaired: Nursing Interventions

  • Use visual aids such as hands when you talk and gestures.
  • Use eye contact.
  • Orient person to your presence: being in the field of vision, using touch.
  • Decrease background noises so they are able to concentrate on the conversation.
  • If they wear hearing aids, ensure they are in place.
  • Use simple sentences, speak in your normal voice, speak slowly and clearly.
  • Do not chew gum, cover your mouth, or turn away while talking.
  • If one ear is better than the other, try to speak towards the good ear.
  • Write on paper to convey the message.
  • Watch body language.

Aphasia

  • Loss of speech production and/or comprehension.
    • Expressive
    • Receptive
    • Global

Terms Related to Aphasia

  • Expressive: words cannot be formed or expressed (Broca’s aphasia)
  • Receptive: language is not understood, difficulty interpreting auditory, visual input leads to faulty interpretation of stimuli. Speech may be intact but inappropriate.
  • Global: is a mixture of both expressive and receptive aphasia

Sensory Deprivation

  • Insufficient quantity or quality of stimuli.
  • Causes:
    • ↓ sensory input caused by a sensory deficit
    • No meaning/order to input
    • Restriction of the environment

Sensory Overload

  • Excessive stimuli which individual has little control.
  • Stimuli beyond the person’s ability to absorb, comprehend, or ignore.
  • Individualized.