Comfort and Pain

Effective Pain Management: Effective pain management can increase socialization, quality of life, appetite, and it can decrease sleep disturbances. It can also promote earlier mobilization, result in fewer clinic visits, shorten hospital stays and decrease health care costs1.

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Barriers to Cancer Pain Management: This specific topic is not discussed in the sources. However, it is noted that pain in cancer patients can be related to tumor progression, operations and other procedures, toxicity of chemo or radiation, infection or limited physical activity .

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Undertreatment of Pain: Research indicates that nurses fail to assess pain, tend to under medicate, and have inadequate knowledge about pain relief measures2.

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Patients at Risk of Undertreatment of Pain:

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Infants and children3

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Those who speak a different language3

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Those whose cultural background differs from the clinician3

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Developmentally delayed, cognitively impaired, or severely emotionally disturbed individuals3

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Types of Pain:

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Acute4...

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Chronic4...

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Intractable4...

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Nociceptive8...

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Neuropathic8...

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Cutaneous8...

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Deep Somatic8...

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Visceral8...

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Phantom8...

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Psychogenic8...

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Radiating16

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Referred16

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Definition of Pain: Pain is whatever the client says it is and exists whenever the client says it does1.

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Misconceptions of Pain: This specific topic is not discussed in the sources, but it does mention to decrease misconceptions about pain through therapeutic communication . Also, patients may not "look like" they are in pain, especially those with chronic pain

Nervous System Review: The sources describe the process of pain conduction, involving the nervous system1.

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The afferent nerve pathway (sensory) transmits impulses from pain receptors to the brain2.

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The efferent nerve pathway (motor) transmits impulses from the brain to the site, resulting in withdrawal from the painful stimulus or muscle contraction3.

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Pain Experience Physiology:

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Transduction occurs when nociceptors are activated by various stimuli, such as thermal, mechanical, chemical, or electrical stimuli4.... Cellular damage during transduction leads to the release of biochemicals like bradykinin, prostaglandins, and substance P6.

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Transmission involves the impulse traveling via nerve fibers to the spinal cord2. A-delta fibers carry fast, sharp, shooting sensations associated with acute, well-localized pain, while C-fibers carry dull, aching, burning, diffuse, chronic pain3.

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Perception is when the thalamus directs impulses to the somatosensory cortex (perceives and interprets physical sensations), the limbic system (emotional reactions to stimuli), and the frontal cortex (involved in thought and reason), resulting in the patient perceiving pain7.... The pain threshold is the amount of pain stimulation needed for a patient to feel pain and is similar for everyone8.

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Modulation is the process where pain signals can be either facilitated or inhibited9.

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Neuro-regulators of Pain:

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Endorphins are produced in the CNS and cause prolonged analgesia and euphoria9....

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Enkephalins inhibit substance P, which decreases the pain impulse9....

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Substance P is a neurotransmitter that increases the firing of nerve impulses6.

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Prostaglandins are hormones that send additional stimuli to the CNS

Acute pain: Acute pain has a rapid onset and can range from mild to severe1. It serves a protective function by warning of tissue damage or disease1. It generally represents a symptom of a disease or a temporary aspect of treatment, and it resolves once the underlying cause is addressed1.... Patients typically expect quick relief from acute pain2.

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Chronic pain: Chronic pain lasts beyond the normal healing period, often defined as longer than 3-6 months3. It is characterized by periods of remission and exacerbation and can lead to weight gain, fatigue, immobility, depression, and even suicide3. Chronic pain may be associated with progressive disorders or non-healing tissue injury and can become a constant part of a client's life3.... Describing chronic pain can be difficult because it is sometimes hard to localize3.

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Other types of pain:

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Intractable pain is highly resistant to relief and may persist until death, often associated with conditions like cancer or advanced malignancy5.

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Nociceptive pain is the most common type of pain, occurring when nociceptors respond to potentially damaging stimuli5....

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Neuropathic pain is complex and often chronic, arising from injury to one or more nerves, resulting in repeated pain signals even without painful stimuli5.... It can result from conditions like poorly controlled diabetes mellitus, stroke, tumors, viral infections, or medication side effects8.

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Cutaneous pain originates in the skin or subcutaneous tissue, resulting in sharp or burning pain5.... Examples include paper cuts, road rash, and superficial burns9.

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Deep somatic pain arises from ligaments, tendons, nerves, blood vessels, and bones, often due to an inflammatory process5.... It can cause muscle spasms and is aggravated by coughing, sneezing, movement, or palpation8.... Examples include sprains, soreness after strenuous activity, bone fractures, or cancer11.

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Visceral pain is caused by the stimulation of deep internal pain receptors in the abdominal cavity, cranium, or thorax5.... It can vary from local, achy discomfort to widespread, intermittent, and "crampy" pain11. It may occur with trauma, menstrual cramps, GI infections, bowel disorders, and organ cancers11.

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Phantom pain is felt in a nonexistent body part that has been amputated2.... It is thought to result from the stimulation of severed nerve fibers and is often described as burning, itching, or deep pain2.

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Psychogenic pain is pain for which a physical cause cannot be identified, and it results from mental or emotional events2....

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Radiating pain is perceived at the source of pain and extends to nearby tissues12. Sciatic nerve pain is an example12.

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Referred pain is felt in a part of the body that is considerably removed from the tissues causing the pain12. Neck pain during a heart attack is an example

Age:

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Infants may experience widespread inadequate relief of pain2. It should never be assumed that a non-verbal child is not in pain2.

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Young children may have difficulty understanding pain and procedures that may cause pain, and they may lack the vocabulary to describe it2....

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Older adults may have an increased probability of having a pathological condition that causes pain3.... They may also present atypical symptoms, not report pain, be afraid of addiction, believe it's unacceptable to show pain, or use different terminology to describe pain4.

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Gender: Research indicates that women report higher levels of pain or have less tolerance of painful stimuli, possibly linked to mechanisms of excitatory and inhibitory control4.... Pain symptoms can also differ between genders, especially in coronary artery disease, IBS, appendicitis, and cancer5.

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Culture: Culture greatly influences a client's response to pain5. Lower-income and minority patients are less likely to receive recommended pain management treatment1....

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Personal Significance: The meaning of pain and individual coping styles influence the experience of pain1.

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Emotions: Previous experiences, chronic pain, depression, anxiety, fatigue, and fear can all affect pain1.

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Family and Social Support: Social support systems can play a role in how a client perceives pain1.

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Environment: A distracting environment versus an environment that increases stress can influence a client's pain

Assessment/Recognizing and Analyzing Cues: During assessment, it's important to avoid personal bias that could prejudice pain assessment1.... The client must report pain so the healthcare team can manage it2.

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Expression of pain: Pain expression is unique to each patient3. Many patients are unaware that they can speak out when they have pain or discomfort3.

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Characteristics of pain: Thoroughly question all pain4. Use the PQRST method to gather information about the pain:

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Provoking/Precipitating factors: Determine what makes the pain worse, such as movement, urination, coughing, swallowing, or lifting, and what makes it better, such as changing positions, applying heat/cold, medications, movement, or prayer5....

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Quality: Ask the patient to describe how the pain feels, avoiding leading them with specific words7. Examples include crushing, sharp, stabbing, aching, dull, tight, burning, heavy, gnawing, throbbing, or tender8.

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Radiation: Ask the patient to point to the areas of discomfort and whether the pain radiates9. Understand the difference between radiating pain, which extends to nearby tissue, and referred pain, which is felt in a different part of the body10.

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Severity: Use verbal descriptor scales, numerical rating scales, or visual analog scales to decrease clinician bias in pain management11. Pain scales can help measure the severity of pain12. There are also pain scales for specific populations such as the CRIES Pain Scale for neonates 0-6 months, FLACC Scale for children 2 months-7 years, and the PAINAD scale for adults with dementia who cannot self-report13....

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Timing: Determine the onset, duration, and frequency of the pain17.

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Common responses to pain: Examine the site of pain for heat, redness, swelling, tenderness, or abnormal positioning17.... Keep in mind that patients with chronic pain may not "look like" they are in pain19.

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Nursing Diagnosis/Prioritizing Hypotheses: Use a multidisciplinary approach20. The diagnostic statement and plan of care should identify the type of pain, etiologic factors, client responses, and factors affecting pain

C. Planning/Generating Solutions:

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Always include the patient when generating solutions1.

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Goals include obtaining a manageable level of pain, achieving a sense of well-being and comfort, and the ability to perform ADLs, and using therapies safely at home1.

D. Implementation/Taking Action:

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Non-pharmacologic Pain Relief Measures:

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Be open-minded about what may relieve pain2.

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Consider support groups or counseling2.

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Reposition the patient2.

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Maintain quiet environments2.

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Provide back or feet massages2....

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Use distraction techniques to reduce the awareness of pain and increase tolerance, which is especially helpful with pediatrics2.... This can include visual distractions, auditory distractions, tactile-kinesthetic distractions, project distractions or getting the patient out of their room4.

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Suggest the patient use imagery by creating an image in their mind that involves one or all of the senses4.

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Teach relaxation techniques to decrease skeletal muscle tension and anxiety, potentially helping patients sleep4. Examples include meditation, yoga, and progressive relaxation4.

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Encourage exercise (if appropriate) to strengthen weak muscles, mobilize stiff joints, restore coordination and balance, enhance comfort, provide cardiovascular conditioning, and release endorphins3.

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Apply cutaneous stimulation techniques to stimulate the skin’s surface nerve fibers, potentially closing the gate to pain3. Massage decreases muscle tension and anxiety, but should not be used on burns, bruises, rashes, or fractures3.

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Apply heat to increase blood flow, decrease joint stiffness, and relax smooth muscles3....

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Apply cold to decrease inflammation and prevent bleeding and edema, especially after oral or orthopedic surgery5.

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Consider acupuncture, acupressure, transcutaneous electrical nerve stimulation (TENS), hypnosis, biofeedback, or therapeutic touch5....

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Pharmacologic Pain Therapy:

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Pharmacological intervention is the primary treatment for pain management in all age groups8.

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Assess and record the effectiveness of analgesics by asking the patient for a pain rating before and after intervention8.

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Administer analgesics to prevent or minimize pain, giving opioids on a regular schedule for some types of pain8.

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Instruct patients to ask for pain medication if needed and determine patients at high risk for developing pain and assess them frequently8....

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Non-steroidal anti-inflammatory drugs (NSAIDs) are used for mild to moderate pain, both acute and chronic9. Many are available over the counter, do not cause sedation or respiratory depression, do not interfere with bowel/bladder function, have no tolerance, or cause physical or psychological dependence and are antipyretic9....

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Opioid analgesics are used for moderate to severe pain, relieving pain and providing euphoria by binding to opiate receptors and activating endogenous pain suppression in the CNS10.

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Adjuvant drugs are medications developed for uses other than analgesia but found to reduce certain types of pain11. They can enhance the effects of opioids and decrease their side effects and decrease anxiety about the pain experience11....

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Patient-controlled analgesia (PCA) allows the client to administer pain medications when they want them12.

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Epidural analgesia involves an anesthesiologist inserting a catheter in the mid-lumbar region, usually removed 36 to 72 hours after surgery13.... It provides pain relief in smaller doses with fewer side effects14.

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Local anesthetics cause loss of sensation to a localized body part, and can be applied topically or injected15.

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Nerve blocks involve chemical interruption of a nerve pathway by injecting a local anesthetic into a nerve15....

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Invasive interventions include radiation therapy and surgery16....

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For management of cancer pain, the oral method is the method of choice and should be used as long as possible17....

E. Evaluation/Evaluating Outcomes:

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Tolerance to therapy & overall relief obtained19

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The client is the best resource to evaluate the effectiveness of pain relief measures19. Use the appropriate pain scale19.

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Look for reports of pain relief and expressions of reasonable comfort19.

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Evaluate behavioral responses and observe the patient19.

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Determine if adequate analgesic has been given and if appropriate instructions and adequate support have been provided19.

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Assess for the absence of nonverbal responses to pain, increased mobility, and uninterrupted sleep19....

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Check for decreased side effects to pain medications and reduction or elimination of factors that precipitate or intensify pain20.

F. Community Resources:

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Hospice programs provide care for terminally ill clients, helping them live at home with pain control as a priority21.

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Pain clinics specialize in pain treatment21.

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Organizations:

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American Chronic Pain Association (ACPA) [None]

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National Chronic Pain Outreach Association (NCPOA) [None]

VI. Nursing Process: Alterations in Sleep

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A. Assessment/Recognizing and Analyzing Cues

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Sleep History: Assessments include the time the patient retires, the time the patient tries to fall asleep, the approximate time the patient falls asleep, the time of any awakenings during the night and resumption of sleep, the presence of any stressors affecting sleep, and whether the patient is a shift worker22. Also, keep a record of food, drink, or medication affecting sleep, record physical and mental activities, record activities performed 2 to 3 hours before bedtimes, and note the presence of worries and anxieties affecting sleep22....

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B. Nursing Diagnosis/Prioritizing Hypothesis

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Disturbed Sleep Pattern23

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C. Planning/Generating Solutions23

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D. Implementation/Taking Action

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Non-pharmacologic Sleep Measures:

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Avoid naps23.

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Eat a light carb/PRO snack before bed23.

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Keep bedroom distraction free – no TV23. Remember the bedroom is for sleeping and sex only23.

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Avoid ETOH and Caffeine before bed23.

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Decrease fluids in the evening to decrease waking during the night23.

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Take a warm bath before bedtime23.

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Sleep in a cool, dark room23.

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Sleep in another room if the issue is a partner (i.e., snoring)23.

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Keep regular sleep/wake times, even on weekends23....

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Medications to Promote Sleep:

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Sedative/hypnotic: Zaleplon (Sonata), Zolpidem (Ambien), Eszopiclone (Lunesta), Ramelteon (Rozerem)25

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Others: Trazadone, Diphenhydramine (Benadryl