Pain Management

PAIN MANAGEMENT

Overview

  • Course: NUR 155/156

  • Units: 9/10

  • Institution: Galen College of NursingⓇ

The Concept Of Pain

  • Pain encompasses both physical and emotional dimensions.

  • Definition of Pain:

    • "Pain is whatever the person with the pain says it is and it exists whenever the person says it does."

  • Functions of Pain:

    • Preventive Role: It may prevent injury.

    • Response Role: It may result from an injury.

  • Subjectivity:

    • Pain is the most subjective of all symptoms that patients experience.

  • Influencing Factors:

    • Cognitive, affective, behavioral, and sensory factors can influence the experience of pain.

Nursing and Pain Management

  • Importance of Assessment:

    • Pain must be assessed and documented to aid in providing comfort.

  • Nurse's Role:

    • Monitor for effective pain management.

    • Evaluate the level of pain relief provided.

    • Advocate for the patient regarding pain management options.

    • Educate the patient about treatment options for pain management.

Normal Structure and Function: Nociception

  • Transduction:

    • Occurs at the site of tissue injury where nociceptors detect pain stimuli and convert it into an electrical impulse (signal).

  • Transmission:

    • The action potential, or electrical signal, is transmitted through an afferent nerve to the spinal cord and brain.

  • Perception:

    • Pain perception occurs when the brain translates afferent nerve signals into the sensation of pain.

    • Pain Threshold: The lowest intensity at which the brain recognizes a stimulus as pain.

    • Pain Tolerance: The maximum intensity or duration of pain that an individual can endure.

  • Modulation:

    • After recognition, the brain can alter pain perception by sending inhibitory input to the spinal cord, impeding the transmission.

Normal Structure and Function: Pain Theories

  • Specificity Theory:

    • This theory laid the foundation for later research identifying pain receptors and peripheral pathways.

  • Sensory Interaction Theory:

    • This theory provided a basis for the gate control theory.

  • Gate Control Theory:

    • It posits that the interaction of signals from different nerve fibers at a gating mechanism in the dorsal horn of the spinal cord determines whether painful stimuli are transmitted to the brain.

  • Neuromatrix Theory:

    • This theory suggests that pain is a multidimensional experience controlled by a body-self neuromatrix, with each person having a unique, genetically controlled network of neurons.

Types of Pain

  • Acute Pain: Typically short-term pain that arises suddenly.

  • Chronic Pain: Long-term pain that persists beyond the typical recovery period.

  • Nociceptive Pain:

    • Visceral Pain: Pain originating from internal organs.

    • Somatic Pain: Pain originating from muscle, bone, and other soft tissues.

    • Referred Pain: Pain perceived at a location different from its source.

    • Radiating Pain: Pain that spreads from the origin.

Nociceptive Pain Examples:

  • Liver and gallbladder.

  • Lung and diaphragm.

  • Heart.

  • Stomach.

  • Pancreas.

  • Ovary.

  • Small intestine.

  • Colon.

  • Appendix.

  • Kidney.

  • Ureter.

  • Urinary bladder.

  • Neuropathic Pain: Pain resulting from damage to the nervous system, exemplified by types such as:

    • Dysesthesia: Abnormal sensation.

    • Allodynia: Pain from stimuli that do not normally provoke pain.

    • Hyperalgesia: Increased sensitivity to pain.

    • Hyperpathia: A condition of exaggerated response to painful stimuli.

    • Phantom Pain: Pain felt in an area where a limb has been amputated.

    • Plasticity: Changes in the nervous system that affect pain perception.

    • Psychogenic Pain: Pain that is primarily related to psychological factors.

Altered Structure and Function

  • Alterations in Pain Pathways:

    • Physiological alterations caused by pain can change how pain is perceived.

  • Factors Influencing Pain:

    • Age, gender, and damage anywhere along the pain pathway can alter a patient's perception of pain.

    • Physiologic stress responses triggered by acute injury may result in negative outcomes if left untreated.

    • Morphology, disabilities, culture, ethnicity, and religion impact behavioral reactions to pain and perceptions of pain.

Assessment

  • Pain History and Assessment:

    • Utilizes the SOCRATES acronym:

    • S = Site

    • O = Onset

    • C = Character

    • R = Radiation

    • A = Associations

    • T = Time course

    • E = Exacerbating/relieving factors

    • S = Severity

Assessment Tools:

  • 0 to 10 Scale: Numeric pain rating from no pain (0) to worst pain possible (10).

  • Verbal Descriptor Scale: Ranges from "NO PAIN" to "WORST PAIN POSSIBLE."

  • Wong-Baker FACES Pain Rating Scale: Uses faces to quantify pain experienced.

  • Activity Tolerance Scale: Ranges from "NO HURT" to "BEDREST REQUIRED."

  • Vital signs as a component of assessing pain status.

Physiological Responses to Pain

  • Chronic or Prolonged Pain:

    • May result in a decrease in systolic blood pressure and a decrease in the pulse rate below the patient's normal baseline.

  • Behavioral Responses to Pain:

    • Facial grimaces, clenched teeth, rubbing or guarding the painful area, agitation, restlessness, withdrawal from painful stimuli.

  • Psychological Responses to Pain:

    • Anxiety, fear, depression, anger, irritability, feelings of helplessness, and hopelessness.

Nursing Diagnosis

  • Acute Pain:

    • Supporting Data: Red and edematous areas on face, chest, arms, and hands from burns, reports pain of 10 out of 10, requests pain medication.

  • Chronic Pain:

    • Supporting Data: Edema of joints, painful mobility, inability to manage activities of daily living, feelings of helplessness.

  • Difficulty Coping:

    • Supporting Data: Severe pain, inability to ask for help, lack of appetite, poor concentration.

Planning

  • Goals and Outcome Statements:

    • Patient will report a steady decrease in pain level to 4 or 5/10 within 5 days post-admission.

    • Patient will perform daily activities with chronic pain reported at a level of 3 or less within 1 week of starting newly prescribed pain medication.

    • Patient will report increased concentration on routine activities within 2 hours of receiving a prescribed dose of analgesic medication.

Implementation and Evaluation

  • Multimodal Pain Management:

    • Combines various treatment modalities.

  • Non-Pharmacologic Management Techniques:

    • Positioning, splinting, massage, progressive relaxation, guided imagery, meditation, distraction techniques (media or conversation), and spiritual support (prayer and meditation).

  • Pharmacologic Pain Management:

    • Multimodal Analgesia: Using different types of analgesics together.

    • Pre-emptive Analgesia: Administering analgesics before anticipated pain occurs.

    • Non-Opioid Analgesics:

    • Examples: Acetaminophen, NSAIDs (Nonsteroidal Anti-Inflammatory Drugs).

Opioid Analgesics:

  • Types:

    • Agonist analgesics (activate opioid receptors).

    • Agonist-antagonist analgesics (partially activate different receptors).

    • Antagonist analgesics (block opioid receptors).

    • Patient-Controlled Analgesia (PCA): Positive empowerment for managing pain.

    • Additional Delivery Methods:

    • On-Q infusion pump, transdermal administration, intrathecal injection, and epidural analgesia, as well as nerve block techniques.

Health Considerations:

  • Addiction and Substance Use Disorder:

    • Considerations for clients and healthcare providers.

  • Accidental Ingestion:

    • Care in medication management to prevent unintended consumption.

  • Medical Marijuana:

    • Legal use in over 30 states and D.C.

Adjuvant or Co-analgesic Medications:**

  • Examples include antiemetics, laxatives, ketorolac, and caffeine.

  • Palliative Care:

    • Focused on relieving pain from serious illnesses, independent of prognosis.

  • Therapeutic Decision-Making Strategies:

    • Titrating doses, around-the-clock dosing to maintain consistency, and the World Health Organization’s pain relief ladder as framework for treatment.

Barriers to Adequate Pain Management

  • Patient Barriers:

    • Fear of addiction, cost of medication, lack of access to healthcare.

  • Healthcare Provider Barriers:

    • Inadequate pain assessment skills, misbeliefs, and prejudicial attitudes influencing care decisions.

  • System Barriers:

    • Pain not prioritized, lack of systematic management approaches, and reimbursement issues affecting medication access.

  • Patient Rights:

    • Patients possess a right to pain relief; inadequate management can lead to adverse outcomes.

Evaluation

  • Medication Evaluation:

    • Document the timing of medication, reassessment times, and duration of pain relief.

    • Record pain scale on each shift and patient education about medications at discharge, documenting that teaching.

    • If pain relief goals are not met, collaborate with healthcare team members and the patient to explore alternative treatment options.

Knowledge Checks

  • The nurse is conducting a pain assessment using the SOCRATES acronym, which components are included?

    • Correct Components: a. Site, b. Onset, c. Character, d. Radiation.

  • Match the supporting data with the nursing diagnosis:

    • Acute Pain: Red and edematous areas from burns, pain of 10/10.

    • Chronic Pain: Edema and painful mobility, ADL challenges.

    • Difficulty Coping: Severe pain and inability to ask for help.

  • For a patient with chronic pain and ineffective analgesia, prioritize:

    • Collaborating with the healthcare team to explore additional treatment options after medication administration.