AD

Chapter 9: Pain Management

Pain Concept

  • Definition: pain is the “unpleasant sensory, emotional experience with actual or potential tissue damage.”
  • It is a personal and subjective experience.
  • The patient is the most reliable indicator of pain and an essential component of pain assessment.
  • Pain is the most common reason for seeking health care.

Effects of Pain

  • Affects multiple determinants: Age, Sex, Race, Gender, Socioeconomic class.
  • Pain affects every body system.

Types of Pain

  • Acute pain: result of tissue damage; associated with surgery or trauma.
  • Chronic pain: can be time-limited or last a lifetime; includes cancer and noncancer pain.
  • Breakthrough pain: transient spikes in pain despite ongoing treatment.

Nociceptive vs Neuropathic Pain

  • Nociceptive pain:
    • Somatic
    • Visceral
  • Neuropathic pain:
    • Centrally generated pain
    • Peripherally generated pain

Components of Pain Assessment

  • Self-report
  • Location
  • Intensity
  • Quality
  • Onset and duration
  • Aggravating and relieving factors
  • Effects on function and quality of life
  • Comfort–function goal

Assessing Intensity—Pain Scales

  • Numeric Rating Scale (NRS)
  • Wong–Baker FACES Pain Rating Scale
  • Faces Pain Scale—Revised (FPS-R)
  • Verbal descriptor scale (VDS)
  • Visual Analog Scale (VAS)

Assessing Pain for Specific Populations

  • The Hierarchy of Pain Measures—nonverbal patient
  • FLACC—young children
  • PAINAD—patients with advanced dementia
  • CPOT—patients in critical care units

Pain Management

  • Goals: effective and safe analgesia; optimal relief; comfort function goal.
  • Responsibility of all members of the health care team.
  • Pharmacologic: multimodal approaches.

Analgesic Medications (Overview)

  • Categorized into 3 major groups:
    1) Nonopioid agents
    2) Opioid agents
    3) Co-analgesic agents

Analgesic Agents: Nonopioid

  • Acetaminophen:
    • Adverse effects: Hepatotoxicity.
    • Limit alcohol intake; limit use with warfarin.
  • NSAIDs:
    • Decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin).
    • Examples: ibuprofen, naproxen, celecoxib.
    • Adverse effects: Gastric effects, cardiovascular effects, renal impact.

Analgesic Agents: Opioid

  • Opioids act on the central nervous system to inhibit activity of ascending nociceptive pathways.
  • Mu agonists: Morphine, hydromorphone, fentanyl, oxycodone.
  • Agonist–antagonist: buprenorphine, nalbuphine, butorphanol.
    • Can antagonize the effects of other opioid agents, so should be avoided in concomitant pain regimens.
  • Antagonists: Naloxone, naltrexone (primarily used as reversal agents).

Analgesic Agents: Co-Analgesic Agents

  • Local anesthetics: block nerve conduction when applied to nerve fibers.
    • Example: Lidocaine patch 5%.
  • Anticonvulsants: Gabapentin, pregabalin.
  • Antidepressants:
    • Tricyclic antidepressants (TCAs): desipramine, nortriptyline.
    • Serotonin–norepinephrine reuptake inhibitors (SNRIs): duloxetine, venlafaxine.
  • Ketamine

Opioid Physical Dependence and Tolerance

  • Physical dependence:
    • Normal physiological response with opioid use of 2 weeks or more.
    • Manifested by withdrawal symptoms.
  • Tolerance:
    • Normal response with regular opioid use.
    • Decrease in one or more of the effects; increased usage needed to achieve the same pain relief.

Withdrawal

  • Occurs when a medication or substance to which the body has become dependent is abruptly reduced or discontinued.
  • Occurs with opioid use.
  • Unpleasant for the patient: Symptoms include: (not specified in the transcript).

Substance Use Disorder

  • Also known as/previously named addiction; impairment in use of a substance despite major problems.
  • Impaired control over use; continued use despite harm; craving for the substance.
  • Use of opioids for nontherapeutic reasons; independent of pain relief.
  • Influenced by genetic, psychosocial, and environmental factors.

Gerontologic Considerations

  • Older adults are sensitive to agents that produce sedation and CNS effects.
  • Initiate treatment with a low dose and titrate slowly.
  • Increased risk for NSAID-induced GI toxicity.
  • Acetaminophen is preferred for mild pain.
  • Opioid dose should be reduced by 25% to 50% in older adults.

Nonpharmacologic Methods

  • Natural products: herbs, botanicals, vitamins, probiotics.
  • Mind and body practices: acupuncture, chiropractic manipulation, massage therapy, yoga, tai chi.
  • Refer to Table 9-5 (table referenced in the source).

Nursing Process Framework for Pain Management

  • Identify goals for pain management.
  • Establish nurse–patient relationship and provide teaching.
  • Provide physical care.
  • Manage anxiety related to pain.
  • Evaluate pain management strategies.

Adverse Effects of Analgesic Agents

  • Respiratory depression.
  • Sedation.
  • Nausea and vomiting.
  • Constipation.
  • Pruritis.

Care of Patients with Pain

  • Requires a collaborative approach.
  • Must be evidence-based and comprehensive.