Module 5: Comfort and Pain Management Notes

Sensory Systems and Receptors

• The sensory experience is comprised of components that allow individuals to interact with and interpret their environment.
• There are five primary sensory systems:
  • Vision
  • Hearing
  • Taste
  • Smell
  • Touch/Tactile

Factors Affecting Sensory Stimulation

• Age: Sensory stimulation requirements and responses change from the newborn stage through the older adult stage.
  • In the older adult, there is a decrease in the number of nerve conduction fibers.
  • This physiological change results in slower reflexes and a delayed response to stimuli.
• Culture: Cultural factors influence sensory perception through norms regarding eye contact, personal space, and physical touch.
• Medications: Certain pharmacological agents can alter or damage sensory function.
  • Aspirin and Lasix are classified as ototoxic, meaning they can cause damage to the ear or hearing.
  • Opioids and sedatives lead to decreased perception of stimuli.
• Stress: High levels of stress can impact how sensory information is processed.
• Illness: Pathological conditions can interfere with sensory organs or the nervous system's ability to transmit signals.
• Personality and Lifestyle: Individual traits and daily habits influence the amount and type of stimulation a person seeks or encounters.

Sensory Alterations and Deficits

• Sensory Overload: Occurs when an individual receives more stimuli than their nervous system can process.
• Sensory Deprivation: Occurs when there is an insufficient level of sensory input to remain functional.
• Impaired Tactile Perception: A specific alteration in the ability to sense touch or physical environment.
• Sensory Deficits: These are specific impairments in the primary senses, including:
  • Vision deficits.
  • Hearing deficits.
  • Taste deficits.
  • Smell deficits.
• Clinical Recognition: Nurses must recognize behavioral and physiological cues to determine if a client is experiencing a sensory alteration and implement interventions to minimize the impact of these alterations.

Fundamental Concepts of Pain

• Pain is defined subjectively: it is whatever the person experiencing it says it is and exists whenever they say it does.
• The client's self-report of pain is the most reliable diagnostic measure available to healthcare providers.
• Pain is considered the 5th vital sign and must be assessed alongside pulse, blood pressure, temperature, and respirations.
• Standardized pain scales are utilized for self-reporting to maintain consistency in assessment.

Pain Intensity Scales

• Verbal Pain Intensity Scale: Clients describe pain levels using words ranging from No Pain, Mild Pain, Moderate Pain, Severe Pain, Very Severe Pain, to Worst Possible Pain.
• $0$-$10$ Numeric Pain Intensity Scale: A scale where $0$ represents "No Pain" and $10$ represents the "Worst Possible Pain."
• Visual Analogue Scale: A linear scale where the client marks a point representing their pain level between "No Pain" and "Worst Possible Pain."
• Wong-Baker FACES Pain Rating Scale: Often used for children or those with communication barriers, utilizing facial expressions to represent pain levels:
  • $0$: No hurt.
  • $2$: Hurts little bit.
  • $4$: Hurts little more.
  • $6$: Hurts even more.
  • $8$: Hurts whole lot.
  • $10$: Hurts worst.

PAINAD Scale for Dementia

• The Pain Assessment in Advanced Dementia (PAINAD) scale evaluates pain based on observable behaviors, independent of vocalization.
• Breathing:
  • Score $0$: Normal.
  • Score $1$: Occasional labored breathing; short period of hyperventilation.
  • Score $2$: Noisy labored breathing; long period of hyperventilation; Cheyne-Stokes respirations.
• Negative Vocalization:
  • Score $0$: None.
  • Score $1$: Occasional moan or groan; low-level speech with a negative or disapproving quality.
  • Score $2$: Repeated troubled calling out; loud moaning or groaning; crying.
• Facial Expression:
  • Score $0$: Smiling or inexpressive.
  • Score $1$: Sad; frightened; frown.
  • Score $2$: Facial grimacing.
• Body Language:
  • Score $0$: Relaxed.
  • Score $1$: Tense; distressed pacing; fidgeting.
  • Score $2$: Rigid; fists clenched; knees pulled up; pulling or pushing away; striking out.
• Consolability:
  • Score $0$: No need to console.
  • Score $1$: Distracted or reassured by voice or touch.
  • Score $2$: Unable to console, distract, or reassure.

Classification of Pain: Acute vs. Chronic

Acute Pain

• Duration: Temporary and resolves as tissue healing occurs.
• Purpose: Generally protective, signaling tissue damage.
• Physiological Responses: Tachycardia (increased heart rate), hypertension (increased blood pressure), anxiety, diaphoresis (sweating), and muscle tension.
• Behavioral Responses: Grimacing, moaning, flinching, and guarding the affected area.
• Treatment Goal: Aimed at relieving the underlying cause of the pain.

Chronic Pain

• Duration: Ongoing or recurs frequently, lasting longer than $6\,\text{months}$.
• Persistence: Continues even after tissue healing is complete.
• Physiological Responses: Vital signs do not usually alter (the body adapts), but the client may experience depression, fatigue, and a decreased level of functioning.
• Treatment Goal: Aimed at symptomatic relief.

Classifying Pain by Origin

Pain can be categorized based on its source or the nature of the sensation:

• Visceral Pain: Pain originating from internal organs.
• Radiating Pain: Pain that starts in one area and spreads to others.
• Referred Pain: Pain felt in a part of the body other than its actual source.
• Phantom Pain: Pain felt in a limb or organ that is no longer there (e.g., post-amputation).
• Psychogenic Pain: Pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors.
• Neuropathic Pain: Pain caused by damage or disease affecting the somatosensory nervous system.

Influencing Factors and Expected Findings

Factors Influencing Pain Perception

• Age: Older adult clients may have multiple pathologies that both cause pain and limit their functional capacity.
• Fatigue: Can heighten the perception of pain.
• Prior Experiences: Past encounters with pain can shape current expectations and tolerance.
• Anxiety and Fear: Emotional distress can exacerbate the sensation of pain.
• Support Systems and Coping Styles: The availability of social support and how an individual manages stress impacts pain experience.
• Culture: Influences how pain is expressed and interpreted.
• Cognitive Function: May affect the ability to report or describe pain accurately.

Expected Findings (Nonverbal Indicators)

• Facial expressions (grimacing).
• Body movements such as restlessness, pacing, or guarding the painful area.
• Vocalizations such as moaning or crying.
• A decreased attention span.
• Changes in vital signs (typically in acute pain).

Pain Assessment (OPQRST)

Nurses use the OPQRST mnemonic to conduct a comprehensive pain assessment:

• Onset: When did the pain start?
• Palliative/Provoking: What makes the pain better or worse?
• Quality: What does the pain feel like (e.g., sharp, dull, burning)?
• Radiation and Region: Where is the pain, and does it travel anywhere else?
• Severity: How bad is the pain on a scale of $0$-$10$?
• Time: How long does the pain last, and is it constant or intermittent?

Nursing Interventions for Management

• Assessment and Monitoring:
  • Perform a comprehensive OPQRST assessment.
  • Monitor pain using tools appropriate for the patient's age and communication ability.
  • Assess for pain frequently and document all findings.
  • Accountability: Nurses are held accountable for the assessment and management of pain as a fundamental client right.
• Care Planning:
  • Explore client beliefs and knowledge about pain, specifically considering cultural influences.
  • Help the client reduce fear and anxiety.
  • Include both pharmacological and nonpharmacological measures.
• Pharmacological Strategy:
  • Schedule pain interventions "round the clock" for persistent pain rather than waiting for pain to return.
  • Administer analgesics before pain becomes severe.
  • Administer analgesics before pain-inducing activities (e.g., physical therapy, wound care).
  • Instruct the client to report developing or recurrent pain (PRN/as-needed medications).
  • Use nursing judgment to determine which prescription to administer based on the severity of pain (mild, moderate, or severe).
• Older Adult Considerations:
  • Increase monitoring for under-treatment of pain.
  • Higher risk for adverse events following the administration of analgesia.
• Risks of Undertreatment:
  • Can lead to increased anxiety in cases of acute pain.
  • Can lead to depression in cases of chronic pain.

Nonpharmacological Pain Measures

• Environmental Comfort: Ensure bed linens are clean and smooth. Ensure the client is not lying on medical tubing or equipment that causes discomfort.
• Positioning: Assist the client into an anatomic position. Elevate edematous (swollen) extremities.
• Physical Modalities: Use of heat, cold, or massage.
• Alternative Therapies: Acupuncture.
• Cognitive-Behavioral Strategies:
  • Distraction: Ambulation, deep breathing, visitors, television, prayer, or music.
  • Relaxation: Meditation and yoga.
  • Imagery: Focusing on pleasant thoughts to divert focus; this requires the client to have the ability to concentrate.