Pain Management

Priority Concepts and Objectives

Priority Concept: Adult Pain Management

Interrelated Concepts: Comfort, cognition, sensory perception

Examplars: Acute & Chronic Pain

Unit Objectives:

1. Use knowledge of anatomy and physiology to perform an evidence-based assessment for a patient with pain.

   • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

   • Pain is whatever the patient says it is, and exists whenever the patient says it does. Self-report is always the most reliable indication of pain.

2. Use clinical judgment to plan evidence-based nursing care to promote comfort and prevent complications in patients with pain.

3. Teach the patient and caregivers about drug therapy and complementary and integrative therapies for pain management.

Types of Pain

• Referred Pain: Occurs in one area but hurts in another area.

• Radiating Pain: Extends to another area of the body.

  • Example: Someone having a heart attack with pain radiating to the arm.

• Uncontrolled Pain: Inadequate pain management may lead to:

  • Impaired recovery

  • Inability to perform Activities of Daily Living (ADLs)

  • Poor sleep

  • Unnecessary suffering

  • Increased health care costs

  • Progression from acute to chronic pain

Acute Pain

• Acts as a warning sign.

• Activation of the sympathetic nervous system.

• "Fight or Flight" reactions, such as pulling back from a hot stove.

• Vital signs elevate.

• Protects self from body (e.g., guarding an injured area).

Persistent (Chronic) Pain

• Normal pain processing that continues beyond the expected healing time.

• Nociceptive Pain: Caused by damage to somatic or visceral tissue.

  • Somatic Pain: Involves tissues, bones, joints, muscles, or skin.

    • Example: A cut, burn, surgical incision, or broken bone.

  • Visceral Pain: Arises from internal organs (e.g., gallbladder rupture, intestinal damage).

• Neuropathic Pain: Caused by nerve injury; pain continues even after the painful stimuli are gone. Often described as burning, tingling, or shooting pain. Hard to explain because the initial cause may be gone.

  • Example: Neuropathy in diabetics due to high blood glucose levels causing nerve damage.

Nursing Care: Assessing Pain

• A patient's self-report is the "gold standard" for pain assessment.

• Assess pain during all assessments and vital sign checks, even if the patient does not verbally report pain.

• Use a full pain assessment every time to gather comprehensive information:

  • Onset (When did it start?)

  • Location (Where is the pain?)

  • Duration (How long does it last? Is it constant or intermittent?)

  • Characteristics (What does it feel like? e.g., sharp, dull, throbbing, burning)

  • Aggravating Factors (What makes the pain worse?)

  • Relieving Factors (What makes the pain better?)

  • Time (Any specific time of day it's worse?)

  • Severity (Rate on a scale of $1$ to $10$)

Pain Scales for Adults

• Numeric Rating Scale: $1$-$10$ scale, with $0$ being no pain and $10$ being the worst possible pain.

  • Mild Pain: $1$-3

  • Moderate Pain: $4$-7

  • Severe Pain: $8$-10

• Wong-Baker FACES Pain Rating Scale: Useful for cognitively impaired, special needs, or nonverbal patients.

Pharmacologic Interventions

Mild to Moderate Pain

• Nonopioid Analgesics:

  • Acetaminophen (Tylenol):

    • Never exceed $3$-$4 gm in $24$ hours.

    • Not addictive and is antipyretic (anti-fever).

    • Monitor liver function, as it is metabolized through the liver.

    • Caution for patients with: Liver disease or alcoholism.

  • Nonsteroidal Anti-inflammatory Drugs (NSAIDs):

    • Examples: Ibuprofen, aspirin, ketorolac.

    • Anti-inflammatory and analgesic effects.

    • Metabolized through the kidneys; monitor kidney function.

    • Caution for patients with: Chronic Kidney Disease (CKD) or those on dialysis.

    • Can cause GI ulcers; Example: A patient chronically using ibuprofen who presents with bloody stools may have a GI ulcer.

Moderate to Severe Pain

• Opioid Analgesics: Highly effective but carry risks.

  • Examples (PO): Oxycodone & hydrocodone (Often combined with acetaminophen, e.g., Percocet, Norco, Vicodin).

  • Examples (IV): Morphine & hydromorphone.

  • Risks & Side Effects: Respiratory depression, constipation, bowel obstruction.

    • If the patient is NPO, IV pain medications will be necessary.

Drug Formulation Terminology

• Short-acting, fast-acting, immediate release (IR), normal release: Typically kick in around $30$ minutes but do not last long, requiring another dose in $3$ to $4$ hours.

• Modified-release, extended release (ER), coated release, sustained release (SR), controlled release (CR): Do not have a strong immediate effect but last longer. Crucially, patients cannot crush, chew, or break these because they are designed for slow absorption through the GI tract at different pH levels, allowing layers to dissolve gradually.

Key Principles of Opioid Administration

• Know signs and symptoms of side effects/adverse reactions and what to do:

  • If narcotic causes constipation, a stool softener can be given.

  • If causes nausea, an anti-emetic can be given.

  • If causes respiratory depression ($8$ bpm or less in an adult), naloxone (Narcan) can be administered.

Opioid Epidemic Terminology

• Physical Dependence: A normal physiologic response to chronic opioid use, characterized by withdrawal symptoms if the drug is suddenly stopped or reduced.

• Tolerance: A normal physiologic response where a patient requires a higher dose of opioid to achieve the same analgesic effect.

• Opioid Addiction: A chronic neurologic and biologic disease characterized by impaired control over drug use, compulsive use, craving, and continued use despite harm.

Patient-Controlled Analgesia (PCA)

• Allows the patient to self-administer pain medication, but only the patient can press the button (not nurses or family members).

• Uses more frequent but smaller doses of medication (e.g., $0.2$ mg every $10$ minutes).

• Restricted to certain parameters as prescribed by the healthcare provider to prevent overdose.

• If a patient is cognitively impaired and cannot understand how to use the PCA, it should not be used, and the nurse will administer pain medication per physician orders.

Nonpharmacologic Interventions

• Appropriate for mild and some moderate-intensity pain, but not severe pain.

• Should complement, not replace, pharmacologic therapies for more severe pain.

• Physical Modalities: Acupuncture, aquatherapy, physical therapy, occupational therapy, yoga, cutaneous stimulation (e.g., Transcutaneous Electrical Nerve Stimulation - TENS), massage, repositioning, warm blankets, application of heat/cold.

• Cognitive/Behavioral Strategies: Prayer, relaxation breathing, mindfulness, meditation, guided imagery, distraction.

Care Coordination

• Health Care Resources:

  • Palliative Care: A team-based approach to providing care for a patient based on prognosis and diagnosis, focusing on symptom relief and optimizing quality of life. Anyone with a serious illness can receive palliative care, regardless of life expectancy. It is not the same as hospice.

  • Hospice Care: Specifically for individuals with a prognosis of $6$ months or less, focusing on comfort at the end of life.

• Realistic Plans of Care: Consider patient circumstances during discharge planning:

  • Can they afford their medications?

  • Do they have transportation to appointments?

  • Do they have assisted devices at home if needed?

Clinical Case Studies

Case Study 1: Acute Post-Operative Pain Management

• A $68$-year-old male is $2$ days post-op from a total knee replacement. He reports his pain as $8/10$ and describes it as a sharp, throbbing ache in his operative knee, radiating down his shin. His vital signs are: BP $150/90$ mmHg, HR $105$ bpm, RR $20$ bpm. He is due for his an oral opioid analgesic.

  1. Question: Based on his self-report, what is the most appropriate initial nursing action?

     • Answer: Administer the prescribed opioid analgesic and reassess his pain level within $30$-60 minutes.

  2. Question: What potential adverse effect should the nurse monitor for closely after administering an opioid, and what intervention should be ready?

     • Answer: Respiratory depression. The nurse should be prepared to administer naloxone (Narcan) if his respiratory rate falls below $8$-10 bpm and he shows signs of distress.

Case Study 2: Chronic Pain and NSAID Use

• A $55$-year-old female presents to the clinic with chronic lower back pain, which she rates $6/10$. She has been taking over-the-counter ibuprofen ($800$ mg, three times daily) for the past $6$ months. She reports recent black, tarry stools and occasional stomach discomfort.

  1. Question: What is the most likely cause of her black, tarry stools given her medication regimen?

     • Answer: Prolonged high-dose NSAID use can cause gastrointestinal ulcers and bleeding.

  2. Question: What vital sign and laboratory value should the nurse prioritize monitoring due to these symptoms?

     • Answer: Hemoglobin and hematocrit levels (for bleeding/anemia) and blood pressure (hypotension could indicate significant blood loss). Also, monitor kidney function (BUN, creatinine) due to chronic NSAID use.

Case Study 3: Pain Assessment in a Nonverbal Patient

• A $78$-year-old patient with advanced dementia is admitted to the hospital with a urinary tract infection. The patient is nonverbal but is observed grimacing, guarding her abdomen, and intermittently moaning. Her last documented pain score was from a previous shift using a numeric scale, which she could not consistently respond to.

  1. Question: Which pain assessment tool would be most appropriate for this patient?

     • Answer: The Wong-Baker FACES Pain Rating Scale or a behavioral pain scale (e.g., PAINAD Scale) would be appropriate, as it relies on visual cues and observable behaviors rather than verbal self-report.

  2. Question: Beyond administering analgesia, what nonpharmacologic interventions could the nurse implement to improve her comfort?

     • Answer: Repositioning, gentle massage, ensuring a calm and quiet environment, using warm blankets, and addressing the underlying cause of pain (treating the UTI).