NURS 1067 Week 10

Understanding Pain

• Definition of Pain:

  • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (International Association for the Study of Pain [IASP], 2012a, as found in RNAO, 2013, p.17).

  • Complex Nature of Pain:

  • Perception influenced by affective, cognitive, behavioral, or sensory components.

  • Stimuli that can trigger pain includes physical (e.g., injury), psychological (e.g., stress), or both.

  • Pain perception is further shaped by past experiences, culture, and situational factors.

Importance of Pain Management

• Human Rights Perspective:

  • Pain management is recognized as a human right.

  • Unmanaged pain is prevalent across ages:

  • Neonatal populations

  • Surgical clients

  • A significant portion of older adults live with chronic pain.

  • Common myths about pain persist.

Reflective Exercise

• Explore the accuracy of common beliefs about pain in the follow-up slides.

Pain Misbeliefs about Infants and Children

Pain Misbeliefs about Adults and Older Persons

Physiology of Pain

• Types of Pain:

  • Nociceptive Pain:

  • Arises from actual or threatened damage to non-neural tissue; activates nociceptors.

  • Types:

    • Somatic Pain:

    • Originates from bones, joints, muscles, connective tissues, and skin.

    • Visceral Pain:

    • Originates from internal organs, possibly due to obstructions or tumors.

  • Neuropathic Pain:

  • Caused by lesions or diseases impacting the somatosensory nervous system and verified by diagnostics.

Classification of Pain

• **Types: **

  • Acute Pain:

  • Has an identifiable cause; resolves once the cause is treated or healed.

  • Duration typically less than 6 months.

  • Chronic Pain:

  • Can be intermittent or persistent; not necessarily linked to an identifiable cause.

  • Cancer Pain:

  • Can be a combination of acute, chronic, nociceptive, or neuropathic pain.

  • Breakthrough Pain:

  • Transient and intense pain episode that can be incident-related or idiopathic (no known cause).

Factors Influencing Pain

• Physiological Factors:

  • Includes age, fatigue, heredity, and neurological function.

• Social Factors:

  • Influence of attention, previous experiences, and family support.

• Spiritual Factors.

• Psychological Factors:

  • Anxiety, fear, and the meaning of pain can affect perception.

• Cultural Factors.

Pain Behavioural Responses

• Facial expressions: Grimacing, clenched teeth, lip biting, tightly closed eyes.

• Behavioral indicators: Rubbing, guarding, or immobilizing the painful area.

• Vocalizations: Moaning, groaning, sighing.

• Social withdrawal or despondency.

Physiological Responses to Pain

• Physiological changes may include increased heart rate (HR), blood pressure (BP), respiratory rate (RR), pallor, and diaphoresis.

• Caution: Physiological responses should not solely be used to assess or diagnose pain, as they may vary significantly among individuals.

Complications Related to Pain

• Development of anxiety, depression, and other mood disorders.

• Decreased overall quality of life.

• Increased difficulty with Activities of Daily Living (ADLs).

• Negative impacts on personal and social life, including loss of work and independence.

• Lengthened healing times and burden on healthcare systems.

Nursing Assessment of Pain

• Pain is referred to as the 5th vital sign.

• Importance of routine screening at:

  • Admission, changes in medical status, during and after procedures.

• Self-report of Pain:

  • Considered the “gold standard” for pain assessment (Potter et. al., 2014, p.1027).

  • Nurses must initiate assessment; reliance on clients to self-report is insufficient.

Key Considerations in Nursing Assessment

• Be conscious of personal beliefs and values when conducting assessments.

• Assess vital signs for physiological indicators.

• Evaluate behavioral manifestations of pain.

• Assess characteristics of pain using the OPQRSTUV assessment framework:

  • Onset

  • Provoke/Palliative

  • Quality

  • Region/Radiation

  • Severity

  • Timing/Treatment

  • Understanding/Impact

  • Values

OPQRSTUV Assessment Details

1. Onset:

   • When did the pain begin? How long does it last? How often occurs?

2. Provoking/Palliating Factors:

   • What brings it on? What alleviates it? What exacerbates it?

3. Quality:

   • How would the patient describe the pain?

4. Region/Radiation:

   • Where is the pain? Does it radiate anywhere?

5. Severity:

   • Rate the pain intensity on a scale of 0 (no pain) to 10 (worst pain). At best, worst, and on average.

6. Timing/Treatment:

   • Is the pain constant or intermittent? What treatments currently being used? How effective are they?

7. Understanding/Impact:

   • What do they believe is causing the pain? Any accompanying symptoms? Impact on themselves or family?

8. Values:

   • What goals do they have regarding pain management? What is an acceptable pain level for them?

Pain Assessment Tools

• Evidence-based tools improve reliability and validity in pain assessments.

• Non-Verbal Assessment Tools:

  • For those unable to communicate verbally about pain:

  • Infants/Children: FLACC scale

  • Older Adults with Cognitive Impairments: PAINAD

Types of Pain Assessment Tools

• Uni-dimensional Tools:

  • Assessing a single aspect, primarily pain intensity.

  • Examples: Numerical Rating Scale [NRS 0-10], categorical scale, Faces Pain Scale-Revised.

• Multidimensional Tools:

  • Assessing multiple aspects of pain.

  • Examples: Brief Pain Inventory [BPI], McGill Pain Questionnaire – Short-Form [MPQ-SF].

Specific Pain Assessment Scales

• Faces Pain Scale-Revised:

  • Utilizes facial expressions to rate pain levels among children.

• Numerical Pain Rating Scale:

  • Scale of 0 (no pain) to 10 (severe pain).

• Descriptive Pain Scale:

  • Categories from no pain to unbearable pain.

Specific Tools for Assessment

• FLACC Pain Scale:

  • A pain assessment tool for non-verbal children. Categories scored from 0 to 2 on Face, Legs, Activity, Cry, and Consolability yielding a total score from 0 to 10.

  • Score Interpretation:

    • 0: Relaxed and comfortable

    • 1-3: Mild discomfort

    • 4-6: Moderate pain

    • 7-10: Severe discomfort or pain

Goals and Interventions for Pain Management

• Collaborative Approach in Pain Care:

  • Involvement of various health professionals: RN, RPN, PSW, Physiotherapist, Occupational Therapist, Psychologist, Child Life Specialist, etc.

Nursing Interventions for Pain Management

• Ongoing assessment and monitoring of pain status.

• Support for Activities of Daily Living (ADLs) and providing comfort in positioning.

• Anxiety support related to pain.

• Educate patients and families about pain management.

• Advocate for appropriate pain management for all clients.

• Consult with a designated pain management team when available.

Medical Management Strategies

• Timing for Medication:

  • Administer medications before pain escalates; assessment and education are vital.

  • Maintaining stable serum levels of medication enhances effectiveness.

• Medications Used:

  • Acetaminophen:

  • For mild to moderate pain, can be combined with opioids for severe pain. Monitoring for hepatotoxicity is important.

  • NSAIDs:

  • For mild to moderate pain. Can lead to GI issues if used chronically. Examples: Ibuprofen, Aspirin.

  • Adjuvant Therapy:

  • Augments the effect of primary medications (e.g., Tricyclic antidepressants, anticonvulsants).

  • Opioids (Narcotics):

  • Indicated for moderate to severe pain. Continuous monitoring for side effects is crucial, including sedation and respiratory depression.

Alternative Strategies for Pain Management

• Techniques such as relaxation and guided imagery, distraction, and biofeedback.

• Acupuncture and cutaneous stimulation (e.g., therapeutic touch, TENS).

• Cognitive Behavioral Therapy (CBT) as a feasible methodology.

Safety Considerations: Risk for Falls

• Definition of a Fall:

  • “An event that results in a person coming to rest inadvertently on the ground or floor or other lower level, with or without injury” (World Health Organization [WHO], 2016, as stated in RNAO, 2017, p. 22).

  • Negative consequences of falls can include declines in self-esteem, confidence, anxiety, social withdrawal, and loss of independence.

Statistics on Falls in Canada

• Leading cause of injury-related deaths, hospitalizations, and disabilities. (Parachute, 2015).

• Approximately 30% of individuals over 65 in the community experience falls annually; this rate jumps to 50% in those over 80 (National Institute for Health and Care Excellence [NICE], 2013).

• About 95% of hip fractures stem from falls, with 20% of these being fatal (PHAC, 2014).

Risk for Falls

• Many falls can be anticipated and prevented; however, some cannot, necessitating strategies to mitigate fall-related injuries.

• Fall prevention is a shared responsibility among healthcare professionals.

• Interventions must be tailored to each individual’s context.

Fall Prevention Recommendations

• Implement a flow chart for assessing fall risk and prevention strategies.

  • At minimum, screening and assessments should include previous fall history and mobility challenges.

  • Maintain universal falls precautions; rescreen if notable changes in health status occur.

Intervention Strategies

• Educate patients and families on fall prevention.

• Promote exercise and physical training.

• Review and modify medications associated with falling.

• Dietary recommendations to support bone health.

• Consider the use of hip protectors for fall prevention.

• If a fall occurs:

  • Follow agency protocols, assess for injuries, and monitor for complications.

Introduction to Restraints

• Definition of a Restraint:

  • “A restraint is a physical, chemical, or environmental means of controlling an individual’s behavior or actions” (Potter et. al., 2014, p. 812).

  • Types include:

    • Physical Restraints:

    • Limit a client's ability to move (e.g., bed rails, seat belts).

    • Environmental Restraints:

    • Control a client's access to different areas (e.g., secured units).

    • Chemical Restraints:

    • Psychoactive medications not used for therapeutic purposes but to control behavior.

Controversy Surrounding Restraint Use

• Restraints raise ethical concerns due to safety issues and adverse patient outcomes.

• A least-restraint approach is recommended.

• Careful review of agency policies on restraint use is crucial.

• Focus areas include:

  • Assessment, prevention, alternative approaches.

  • Interventions for de-escalation and crisis management.

Alternatives to Restraints

• Strategies may include enhanced supervision, trained sitters, and adjusted staffing.

• Use of distraction, diversional activities, and environmental adjustments to reduce agitation.

• Promote de-escalation using calm communication and simple statements.

• Evaluate and manage medications that may contribute to behavioral issues.

• Ensure comfort measures such as relaxation and pain management are prioritized.