Pain Management

LEARNING OBJECTIVES

  • Identify types and categories of pain

  • Differentiate between pain tolerance, dependence, and addiction

  • Describe both pharmacologic and non-pharmacologic pain relief interventions

  • Identify factors that may affect an individual’s pain experience

  • Identify subjective and objective assessment data for pain

  • Identify barriers to effective pain management

  • Explain an appropriate pain assessment using interviewing and physical assessment skills

  • Explain proper pain documentation and reassessment

DEFINITION OF PAIN

  • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage” – International Association for the Study of Pain

  • Pain is a defensive mechanism of the body.

Subjective vs. Objective

  • Pain is primarily subjective:

    • "Pain is whatever the person says it is, and exists whenever s/he says it does" — Margo McCaffery (1979)

  • Pain can significantly impact physiological and psychological health.

THE PHYSIOLOGY OF PAIN

Four Parts

  1. Transduction: Activation of pain receptors.

  2. Transmission: Pain impulse travels to the brain.

  3. Perception: Individual becomes aware of the pain.

  4. Modulation: Inhibition or modification of the painful sensation.

GATE CONTROL THEORY

  • The gate opens when a painful impulse is sensed in the thalamus.

  • The gate closes when a treatment or analgesic activity is performed.

  • Gate opening & closing is affected by several factors:

    • Personal experiences

    • Mood

    • Beliefs regarding pain

    • Fear, Anxiety, Anger

    • Distraction, Focus

PAIN THRESHOLD VS. TOLERANCE

  • Pain Threshold: The minimum intensity of a stimulus that is perceived as painful.

  • Pain Tolerance: The point beyond which a person is no longer willing to endure pain.

    • Aspect may vary in duration or intensity.

CLASSIFYING PAIN

By Duration

  • Acute Pain

    • Rapid in onset

    • Can be mild or severe

    • Protective in nature

    • Triggers autonomic responses

    • Usually ends when healing occurs

  • Chronic Pain

    • Pain lasts beyond the normal healing period

    • Presentation can vary widely

    • Is not protective

    • Psychological impacts are common

    • Interferes with normal functioning

    • Providers may dismiss the pain

Classification Details

Description

Cause

Duration

Treatment

Quality of Life

Acute

Normal response to injury or medical condition

Short term

Often responds to traditional treatment

Does not affect long-term quality

Chronic

Often unknown or unrelated to medical findings

Longer than 3 months

Minimal or no response to treatment

Often interferes with quality of life

Types of Pain based on Location

  • Cutaneous Pain:

    • Superficial; involves skin or subcutaneous tissue (e.g., paper cut).

  • Somatic Pain:

    • Diffuse; usually involves tendons, ligaments, bones, blood vessels, nerves (e.g., ankle sprain).

  • Visceral Pain:

    • Poorly localized; originates in body organs of the thorax, abdomen, and head (e.g., angina, IBS, labor).

Referred Pain Mapping

  • Referred Pain Locations

    • Heart, Lung and diaphragm, Liver, Stomach, Pancreas, Small intestine, Kidney, Ovary, Appendix, Colon, Bladder, Ureters

ETIOLOGY OF PAIN

  • The cause of pain can vary greatly.

  1. Nociceptive Pain: Actual or perceived damage to peripheral tissue; the “normal” pain process.

  2. Neuropathic Pain: Caused by disease or damage to a nerve, can be peripheral or central; characterized by sensations such as burning, tingling, or stabbing.

  3. Intractable Pain: Pain that is not relieved by various interventions.

  4. Phantom Pain: Perceived pain in a body part that is missing.

  5. Psychogenic Pain: Physical cause of pain that cannot be identified.

RESPONSES TO PAIN

  1. Physiological Responses:

    • Involuntary body responses (e.g., changes in vital signs, fainting, pupil dilation).

  2. Behavioral Responses:

    • Reflect body movements (e.g., crying, grimacing, restlessness, moving away from painful stimuli).

  3. Affective Responses:

    • Reflect mood and emotions (e.g., depression, anxiety, exhaustion, hopelessness).

  • Lack of an obvious response to pain does not imply absence of pain; careful assessment is vital.

FACTORS AFFECTING THE PAIN EXPERIENCE

Cultural & Ethnic Variables

  • Cultural Norms: Dictate behavior, attitude, and values.

  • Ethnicity: Provides identity rooted in ancestry.

  • Other Factors: Family, gender, age, religion, socioeconomic status can influence how pain is expressed and the behaviors demonstrated.

Environmental Factors

  • Influence of the physical environment: noise, light, sleep, distractions.

  • Isolation and loneliness can exacerbate pain.

  • Strangeness of the hospital environment (e.g., absence of home, pets, familiar items).

Background & Past Experience

  • Patients with various pain experiences will react differently:

    • No previous experience with pain.

    • Extensive pain experience.

    • Past severe pain without relief.

    • Unhealthy behavior from prior pain experiences.

Psychological Factors

  • Anxiety, Fear, Sleep, Tension, Sense of Control can all affect pain perception.

PAIN ASSESSMENT

  • Considered the 5th Vital Sign:

    • Self-reported by patients.

    • Verbal children are primary sources; must be routine in assessments and documented.

COMPONENTS OF A PAIN ASSESSMENT

  1. Duration

  2. Location

  3. Intensity

  4. Quality

  5. Chronology

  6. Aggravating Factors

  7. Alleviating Factors

  8. Effect on Activities of Daily Living (ADLs) and lifestyle

PAIN SCALES

The 10 Point Scale

  • Used for adults and children (>9 years) who can rate pain.

  • Scale: 0 (no pain) to 10 (worst pain imaginable).

    • 0-1: no pain

    • 1-3: mild pain

    • 4-6: moderate pain

    • 7-10: severe pain

The FACES Scale

  • For children who cannot use the numeric scale, also for nonverbal patients.

The FLACC Scale

  • For infants and children unable to validate or quantify pain severity.

SPECIAL CONSIDERATIONS IN PAIN POPULATIONS

Children

  • Self-reporting is the most reliable source of pain.

  • Inadequate pain control during infancy can change pain responses in adulthood.

  • Observe indicators: restlessness, crying, grimacing, grabbing affected areas.

  • Caregiver assessments are important.

Cognitively Impaired Patients

  • Challenges in assessment; observe facial expressions, body movements, activity pattern changes.

  • Use the PAINAD tool for non-verbal patients encompassing breathing, vocalization, facial expression, body language, and consolability.

Older Adults

  • Adults >65 years frequently experience more pain than younger adults.

  • Consider impairments in vision, hearing, and risks associated with polypharmacy.

  • Reluctance to admit pain due to established attitudes towards suffering and emotional burden.

PHYSICAL EXAMINATION

  • Involves nurse’s observations and vital signs as baseline measurements prior to medication administration.

  • Observations include physiological, behavioral, and affective responses.

NURSING DIAGNOSES RELATED TO PAIN

  • Examples:

    • Acute Pain related to recent surgery

    • Chronic Pain related to rheumatoid arthritis

    • Labor Pain related to prolonged labor

    • Ineffective Airway Clearance related to weak cough post-abdominal surgery

    • Anxiety related to past poor pain control

    • Impaired Physical Mobility related to pain in right knee from arthritis

OUTCOME IDENTIFICATION & PLANNING

  • Goal: Relieve pain and help the patient achieve the highest functioning level possible.

    • Acute pain: Aim for relief.

    • Chronic pain: May require referral to a pain clinic, hospice, or other resources.

    • Involvement of the patient and family is essential.

    • Building a trusting relationship is key.

    • Both pharmacologic and non-pharmacologic interventions should be considered.

INTERVENTIONS

  • A balance between pharmacologic and non-pharmacologic methods is important.

  • May require multiple analgesics with different mechanisms for effective pain control.

PHARMACOLOGIC INTERVENTIONS

  1. Non-opioid Analgesics

  2. Opioid Analgesics

  3. Adjuvant Medications

Opioid Analgesics

  • Formerly known as narcotics, used for moderate to severe pain.

Common Adverse Effects:

  • Sedation

  • Respiratory Depression: if unable to arouse, administer naloxone (Narcan).

  • Constipation

  • Orthostatic Hypotension

  • Nausea and Vomiting

  • Pruritus

  • Urinary Retention

Common Opioids

  • Morphine sulfate

  • Hydrocodone

  • Hydromorphone (Dilaudid)

  • Tramadol (Ultram)

Combination Drugs

  • Codeine/Acetaminophen (Tylenol 3)

  • Hydrocodone/Acetaminophen (Lortab or Vicodin)

  • Oxycodone/Acetaminophen (Percocet)

  • Oxycodone/Aspirin (Percodan)

DRUG DEPENDENCE, TOLERANCE, & ADDICTION

  • Dependence: The body becomes accustomed to the opioid and experiences withdrawal symptoms.

  • Tolerance: The body becomes accustomed to the opioid and needs larger doses to achieve the same analgesic effect.

  • Addiction: A chronic, relapsing brain disease characterized by drug-seeking behavior and use, despite harmful consequences.

Indicators of Addiction

  • Craving for the drug

  • Compulsive drug use

  • Continued use despite harm

  • Impaired control over drug use

THE NURSE’S ROLE IN PAIN MANAGEMENT

  • Conduct thorough pain assessments.

  • Understand pharmacokinetics of opioids.

  • Avoid administration issues; know the medication and potential side effects.

  • Ensure full understanding of each patient’s pain experience and response to community medication.

  • Patient education is essential.

  • Continuously assess and evaluate pain management strategies.

  • Accurate documentation of pain management interventions is critical.

  • Involvement in policy development to enhance patient comfort and safety.

NON-OPIOID ANALGESICS

  • Effective for acute and persistent moderate pain.

  • Simple and least invasive strategies should be prioritized.

  • Many non-opioid medications are available over the counter (OTC) or through prescriptions.

  • They can be combined with opioids for enhanced effects.

  • Acetaminophen: Analgesic and antipyretic; risk for hepatotoxicity.

  • NSAIDs: e.g., ibuprofen, aspirin, naproxen; analgesic, antipyretic, and anti-inflammatory properties; risks include GI irritation, renal toxicity, and bleeding.

ADJUVANT ANALGESICS

  • Typically used off-label.

  • Examples include:

    • Antidepressants

    • Anticonvulsants

    • Corticosteroids

    • Anti-anxiety medications

    • Muscle relaxants

  • Effective for treating: burns, trauma, neuropathic pain syndromes such as fibromyalgia and diabetic neuropathy.

PRN (AS NEEDED) PAIN MEDICATION

  • Assess pain intensity, characteristics, and prior responses to medications.

  • Consider developmental factors, especially in children and elderly patients:

    • Time of onset

    • Time to peak effect

    • Duration of action

    • Side effects

PCA PUMPS

  • PCA system includes a computerized, portable infusion pump with a syringe containing prescribed opioid analgesics.

  • Only the patient should operate the device (push the button for dosage).

Parameters for PCA Pumps

  • Loading Dose: Initial dose given.

  • PCA Dose: Amount of medication delivered upon button press.

  • Continuous Infusion: Variable continuous dose delivery.

  • Lockout Interval: Prevents overdose by limiting frequency of dose delivery.

Documentation Considerations for PCA

  • Document pain level, respiratory rate, level of consciousness, vital signs, orientation every 2 hours.

Advantages of PCA Pumps

  • Maintained consistent analgesic blood levels.

  • Faster absorption with IV and Epidural routes.

  • Empowers patients over their pain management.

  • Patients generally use less medication.

  • Enhanced patient satisfaction regarding pain management.

USE OF PLACEBOS

  • Defined as a treatment that appears real but has no therapeutic effect.

  • Ethical considerations: must ensure “do no harm” and avoid deceiving patients.

  • Inadequate pain treatment can create additional harm.

  • Legal and ethical usage requires informed consent from patients involved in placebo studies.

DOCUMENTATION OF PAIN MANAGEMENT

  • Document whether pain management was achieved, including both subjective and objective data.

  • Record pharmacologic and non-pharmacologic interventions.

  • Include vital signs during interventions and peak effectiveness evaluations.

  • Assess and document effectiveness 30-60 minutes after intervention initiation.

  • Document any adverse reactions and the interventions initiated in response.