PAIN

Nursing Ethos and Dedication

Motto on Page 1: "PURE CALLING PURE DEDICATION PURE EXCELLENCE PURE COMPASSION" (repeated; emphasizes core nursing values)
Theme: Pure calling, pure dedication, pure excellence, pure compassion, pure nursing dedication

Pain: Definition, Perception, and Transmission

Pain is described as Pain & Discomfort: a feeling of distress and discomfort that affects or interferes with normal activity
There is no completely accurate objective measurement of pain; it is sometimes referred to as the “fifth vital sign”
Pain is a subjective experience requiring assessment in all patients

Pain Standards and Assessment (Joint Commission)

The Joint Commission: Pain Control Standards
Key elements:
- Appropriate assessment and management of pain
- Pain is assessed in all patients
- Education about pain management is provided
- Pain is included in the discharge process

What Is Pain?

Pain is a feeling of distress or suffering
It serves as a warning of possible tissue damage
It is transmitted through the nervous system

Pain Transmission and Brain Pathway

Transmission pathway includes: Brain → Sensory neuron → Spinal cord → Pain-producing neurotransmitters
Example: Noxious stimulus such as a hot pan triggers a sensory impulse to the brain
End result: Perception of pain
Diagrammatically: Hot pan (noxious stimulus) → sensory impulse → spinal cord → brain → pain perception

Endorphins and Pain Modulation

Endorphins are naturally occurring substances that modify the perception of pain
Both physiologic and psychological stressors can trigger the release of endorphins

Types of Pain

Acute
Chronic
Nociceptive
Neuropathic
Phantom

Acute Pain

Causes: injury, medical condition, or surgical procedure
Characteristics: short duration; described as aching or throbbing; patient may be restless or agitated; may be accompanied by vital sign changes
Treatment: usually controlled with analgesics

Chronic Pain

Cause: ongoing conditions; persists for months or years
Characteristics: may be dull, constant, shooting, tingling, or burning; psychosocial effects
Treatment/Interventions: often includes non-pharmacologic interventions; treatment overall aims to improve function and quality of life

Nociceptive Pain

Cause: injury to tissue where nociceptors are located
Characteristics: sharp, aching, throbbing
Interventions: non-pharmacologic approaches and pharmacologic treatments as appropriate

Neuropathic Pain

Cause: dysfunction of the nervous system
Characteristics: burning, tingling, shooting, numbness
Treatment: often involves anticonvulsants; may include other neuropathic pain strategies

Phantom Pain

Cause: amputation
Symptoms: felt in the amputated extremity; shooting, burning, cold, stabbing sensations
Treatment: same approaches as neuropathic pain; electrical stimulation in the thalamus can be used

Objective Data in Pain Assessment and the Nursing Process

Objective data and subjective data are used in the nursing process (Assessment focus)
Assessment involves:
- Subjective data (descriptions from the patient)
- Objective data (observations, measurements)
Considerations: cultural influences, age-related influences

Pain Assessment: History and Contributing Factors

Pain history elements: hx of pain, medications, verbal indicators, nonverbal indicators, social/psychological factors, treatments used, contributing factors

Pain Assessment: Severity of Pain and Scales

Severity assessment options:
- Numerical rating scale (NRS) / numeric pain scale
- Picture scale
- Neonatal Infant Pain Scale (NIPS) for neonates
These are referred to as pain scales used to quantify pain intensity

Pain Number Rating Scale (Numerical Scale)

Process: Ask patient to rate pain on a scale from $0$ to $10$ , where 0 = no pain and 10 = worst pain imaginable
Example scale depiction: 0 1 2 3 4 5 6 7 8 9 10

Wong-Baker FACES Pain Rating Scale

Visual scale using faces to represent pain intensity; commonly used in pediatrics
Scale ranges from 0 to 10 corresponding to:
- 0: No hurt
- 1-3: Hurts a little bit
- 4-6: Hurts even more
- 7-10: Hurts worst; whole lot of pain
References: Hockenberry & Wilson pediatric nursing texts; adapted scales with permission

Nursing Diagnoses Related to Pain (Nursing Process)

Possible diagnoses include:
- Anxiety
- Acute pain
- Chronic pain
- Deficient knowledge
- Readiness for enhanced comfort

Nursing Goals for Pain Management

Goal example: Will have a decrease in pain by discharge
Criteria (AEB, as evidenced by):
- Will report a pain level of less than $3$ on the $0-10$ scale by discharge
- VS within normal limits (WNL)
- No nonverbal indicators of pain

Nursing Process: Implementation for Pain Management

Implementation components:
- Assess for pain
- Administer medications as ordered
- Implement non-pharmacological interventions
- Reposition the patient as needed
- (The slide emphasizes a comprehensive approach combining pharmacologic and nonpharmacologic strategies)

Pain Control: Nonpharmacological (Nonmedicinal) Methods

Transcutaneous Electrical Nerve Stimulation (TENS)
Percutaneous Electrical Nerve Stimulation (PENS)
Binders & braces
Application of heat and cold
Relaxation techniques
Acupuncture
Biofeedback
Distraction and guided imagery
Meditation
Music
Hypnosis
Massage

Pain Control: Pharmacological (Medicinal) Pain Control

Analgesic medications include nonopioid options such as NSAIDs:
- Aspirin
- Acetaminophen
- Ibuprofen
- Naproxen
COX-2 inhibitors: Celecoxib (Celebrex)
Narcotics/Opioids: Morphine, oxycodone, hydrocodone, meperidine
Adjuvant analgesics: Phenergan (promethazine), antidepressants, muscle relaxants

Analgesic Routes and Delivery Methods

Analgesic medications can be delivered via multiple routes:
- Oral
- Topical
- Injected
- Intravenous
Advanced delivery systems include:
- Patient-Controlled Analgesia (PCA)
- Epidural analgesia
- Implantable pumps
Nursing considerations include monitoring for efficacy and adverse effects, ensuring proper administration, and adjusting plans as needed

Nursing Process: Evaluation of Pain Management

Continuous evaluation is required with frequent revisions in pain control after each pain intervention

Sleep: Functions and Importance

Sleep supports general health and recovery from illness
Sleep increases pain tolerance and improves response to analgesia

Stages of Sleep

There are stages characterized by dreaming, high brain activity, and vital signs that resemble wakefulness during REM sleep
REM sleep: body receives a high level of rest; HR, BP, and respiration decline
Non-rapid eye movement (NREM) sleep is a separate stage

Normal Sleep Requirements by Age

Newborns: at least 16 hours of sleep per day
Age 1: 12-14 hours per day
Preschool: 11-13 hours per day
School-age: 10-11 hours per night
Adolescents: 9-10 hours per night
Adults: about 7 hours per night

Factors Affecting Sleep

Work schedules: night or evening shifts, shift changes
Travel and jet lag; exposure to sunlight
Snoring
Substances: caffeine, nicotine, alcohol
Exercise and naps
Stress, illness, fatigue, discomfort
Environmental factors: heat, cold, light, noise

Sleep Disorders: Insomnia and Sleep Apnea

Insomnia:
- Difficulty falling or staying asleep
- Transient insomnia (short-term) vs chronic insomnia (long-term)
- Causes: chronic underlying problems or stress
- Treatments depend on cause and may involve specialists
Sleep Apnea:
- No breathing for brief periods during sleep
- Causes: usually obstruction; may be signaling issues
- Treatments: CPAP (continuous positive airway pressure)

Sleep Disorders (Cont.): Snoring and Narcolepsy

Snoring:
- Harsh sounds due to vibration/obstruction of airway
- Causes: poor muscle tone, excessive tissue, structural deformities (e.g., deviated septum)
- Represents partial airway blockage; management includes sleeping on the side or weight loss
Narcolepsy:
- Sudden, recurrent, uncontrollable brief episodes of sleep during wakefulness
- May occur at any time; episodes last from a few seconds to 30 minutes
- Usually begins around age 25
- No known cure