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NSG 3008A: PROFESSIONALNURSING TRANSITION

PAIN MANAGEMENT: STRESSADAPTATION; CULTURAL DIVERSITY;

SUBSTANCE ABUSE AND ETHICALISSUES

Objectives1. Describe the physiology of pain and relatedtheories of pain management, including substanceabuse2. Compare individual factors that influenceperception and responses to pain, including culturaldiversity.3. Differentiate between acute and chronic pain,including stress adaptation4. Describe pharmacologic and nonpharmacologicapproaches to pain management5. Describe the nursing management of the patientexperiencing pain, including ethical issues.

NATURE OF PAIN

Pain is key to the survival of anorganism

Pain is a conscious perception thatresults from environmental stress.

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NATURE OF PAIN

DefinitionsMedical- “ that sensory experience evokedby stimuli that injures or threatens todestroy tissue, defined introspectively byevery man as that which hurts.”

NATURE OF PAIN

Definitions (continued)Psychological- an abstract concept whichrefers to: a) a personal, private sensationof hurt; b) a harmful stimulus that signalscurrent or pending tissue damage; c) apattern of responses to protect theorganism from pain.

NATURE OF PAIN

Definitions (continued)Nursing- “ whatever the experiencingperson says it is and existing whenever theperson says it does” ( McCaffery, RN1966).

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Physiology of pain

Pain receptors are found in all parts ofthe body.They are called nociceptors.

Nociceptors

Physiology of pain

Types of nociceptorsThermalChemicalMechanical

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Physiology of pain

Types of fibers and their functionsA-delta receptors- small, myelinatedfibers,transmit acute, sharp pain signalsfrom peripheral nerves to spinal cord.C receptors have larger, unmyelinatedfibers that transmit pain at a slower rate,transmit long lasting, burning painsensation.

Physiology of pain

A-beta receptors respond to non-painfultouch, such as gentle rub or pressure.

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Physiology of pain

Pain producing substances- releasedinto tissues after tissue damage

BradykininSerotoninHistamineProstaglandinsLeukotrienesSubstance P

NATURE OF PAIN

Transmission of pain

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Pain Transmission

Pain Transmission

When a toe is stubbed, cells called nociceptorssense damage (1) and send an impulse via a sensorynerve (2) to the dorsal horn (3) region of the spinalcord. This processes the signal, and sends anothersignal down the leg via a motor nerve (4) causing legmuscles (5) to pull away from the source of injury (6).The dorsal horn sends a second impulse to the brain,reaching nerve endings (7). These releaseneurotransmitters to further carry the message. Thebrain processes the impulse as an unpleasantsensation (8). © Microsoft Corporation. All RightsReserved.

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Gate Theory of Pain

Neurons not involved directly involvedin the afferent pain transmission arestimulated and help to regulatetransmission of nociceptor transmission.The non-nociceptor sensory receptorsfor vibration are used in the TENS unit

NATURE OF PAIN

BARRIERS TO PAIN CONTROL

Healthcare Professionals- Inadequateknowledge of pain managementPoor assessment of painConcern about regulation of controlledsubstancesFear of client addictionConcern about side effects of analgesics

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BARRIERS TO PAIN CONTROL

Clients- Reluctance to report painConcern about distracting MDs fromtreatment of underlying diseaseConcern about not being a good clientReluctance to take pain medicationFear of addictionConcern about becoming tolerant

BARRIERS TO PAIN CONTROL

Health care system- Low priority givento cancer pain treatmentInadequate reimbursementRestrictive regulation of controlledsubstancesProblems of availability of treatment oraccess to it

Perception of pain-conscious

Fast pain- precise localization on thebodySlow pain- much less precise, may bereferred from C fibers of the samedermatome.

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Perception of pain

Interpretation is individualizedDoes not depend solely on the degreeof physical damage Pain tolerance- amount of pain aperson is willing to endurePain threshold- lowest intensity of apainful stimulus that is perceived by aperson as pain.

Perception of pain

Person’s past history of pain

Multiple factors-anxiety, experience,attention, expectation, and meaning ofthe situation

Perception of pain

Sympathetic autonomic response-“flight or fight response”Increased pulseIncreased respiratory rate

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Misconceptions & MythsMyths

Addiction occurs w/prolonged useNurse is best judgeWait for pain beforemedicatingReal pain has causeSleeping person has nopainSame stimulus-same pain

FactsIncidence of addiction is<0.1%Only client can judgeUnrelieved pain createsproblemsPain of psychologicalorigin is just as realSleep can be escapemechanismIntensity, duration,distress vary

Addiction

Addiction- a behavioral pattern of druguse

obsessive use and securing supply of drug tendency to relapse after withdrawal actual opioid addiction occurs less than0.1%

Dependence

Psychological dependence- is a pattern of continual craving for opioiddrugs when not experiencing pain.

Physical dependence- is seen when a client is abruptly taken off

of opioids. The client has anxiety, chillsalternating with hot flashes, irritability,vomiting, abdominal cramps and insomnia.

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Negative effects of pain

Unrelieved pain- affects major organsGI, pulmonary, CV, immune, endocrine

Increased costs due to prolonged staysPrevent ambulation- DVT, PERelease of catecholamines, stresshormonesDecrease immune system

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Standards and guidelines

Agency for Health Care Policy andResearch

Help individual and professional worktogether to relieve pain

American Pain SocietySet the standard for pain management

JCAHOStandards for organizations

Types of painAcute pain-less than 6 months duration,reversible, predictable durationChronic pain- long period of time, hard totreat, defined in vague terms

Chronic nonmalignant – continuous, has noforeseeable end, hard to determine causeChronic malignant- has qualities of both of acuteand chronic, neuropathic, visceral, and bone pain.Chronic intermittent- recurrence of chroniccondition, pain occurs at specific times.

Sources of pain

Cutaneous pain- abrupt onset, sharp,stinging quality.

Easily localized by dermatome.Each dermatome is served by one spinalnerve

Deep somatic pain- poorly localized,may produce nausea, sweating, BPchanges.

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Sources of pain

Visceral pain- coming from body organsDiffuse, poorly localized, vague dull pain.Nerve fibers innervating body organsfollow the sympathetic nerves to the spinalcord. Autonomic manifestations- diarrhea,cramps, sweating, hypertension.

Sources of pain

Referred pain-Felt in an area distant from the site of thestimulus

InflammationAssociated with stressors, such as heat,cold, trauma. Symptoms such as redness,swelling, heat, and pain.

Sources of pain

Neuropathic pain- caused by damage tothe nerve fibers in the periphery or CNS

Felt as numbness, burning, stabbing,“needles”, allodyniaDifficult to manage. No obvious injury,problem can be at the spinal cord level.

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Sources of pain

Phantom limb sensationsNerve fibers extend to the periphery,ending at the incision site. They continueto mediate sensations associated with theiroriginal location. These are perceived aspresence of the missing limb.Sensations can be itching, pressure,numbness, painful

Sources of pain

Headache- most common type. Mostlyintracranial and extra cranial structures.Malignancy- occurs 40-70% of peoplewith solid tumors. 90% of cancer paincan be controlled with oral medicationHIV- GI, abd. Pain, peripheralneuropathy, pleuritic pain,oropharyngeal pain,

Assessment of pain

Data collectionMcGill-Melzack Pain Questionnaire

Visual Analog Scale

Faces Pain Rating Scale

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Documentation of pain

Intensity- use of scaleLocation- verbal or marking a drawingof the body.Quality – descriptive adjectivesDuration- time of onset, duration,interval, pattern, constant, steady,intermittent, briefDistress- psychological reaction

Medications to control pain

Anesthetic agents- abolishes pain butalso causes loss of feeling andsensation

Local anesthesia- us a restricted part ofbodyGeneral anesthesia- loss of consciousnessand reflexes along with amnesia

Analgesics- diminish or eliminate painwithout producing unconsciousness

Analgesics

Pain ladder- Fig. 22-10-Used in care of patients with acute painnot just in cancer pain.

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Step one

Non-opioid drugsSalicylatesNSAIDSAcetaminophenAdjuvant drugs

Step two

Opioid- agonist drugs- moderate or mildpersistent

CodieneOxycodonePropoxypheneHydrocodoneMeperidine (low doses)Pentazocine HCL (Talwin)-opioid agonist-antagonist

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Step three

Opioid for moderate to severe pain+/- Non-opioid+/- Adjuvant Oral continuous release Fentanyl patch Hydromorphone Morphine IVMethadone

Pharmaceutical considerations

Ceiling effect- maximum effective dose;increasing dose cannot increase painrelief but may increase side effects.Pure opiates DO NOT have a ceilingeffectTolerance- can be managed by addingnon-opioid to the dose or switching toalternate opioid.

Pharmaceutical considerations

Dependence- symptoms associated withtermination of medication includeanxiety, irritability, chills, lacrimation,rhinorrhea, nausea and vomiting, andabdominal cramps.

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Adverse effects

Constipation- number one problemNausea and vomitingRespiratory depressionCirculatory depressionUrinary retention

Adjuvant medications

Tricyclic antidepressantsAntidepressantsAnti-anxiety agentsAnticonvulsantsCorticosteroidsLocal anesthetic agents

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Principles of pain management

Use adequate dosesPreventionTotal pain relief is primary goal, thentreat side effectsDo not use placebosBelieve the clientOnly the client can determine theamount of pain experienced

Methods of administration

Nurse-administered Analgesia- DemandPatient-controlled analgesiaOral routeIM routeIV routeRectal routeTransdermal/transmucosal route

Titration

Titrate up after 24 hours if pt. needsmore than 3 break through dosesAdd all break through doses in 24 hourperiod and divide by 2 and then addthat to the 12 hour med. Dose.

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Addictive potential

Clients with addictive disease have theright to receive quality painmanagementInvolve patient in making painmanagement plan and in makinginformed choices about medicationsTaper slowly when pain decreasing

Nonpharmacologicmanagement

Cutaneous stimulation- activates large-diameter (A-beta)fibers.TENS- Transcutaneous electrical nervestimulation- electrical bursts throughthe skin to superficial and deep nerves.Massage- cutaneous stimulationHeat/cold application- Activate A-betafibers.

Nonpharmacologicmanagement

Acupuncture- practiced for centuries inthe Asian cultures.AcupressureMusicProgressive relaxation trainingDeep breathing for relaxationGuided imagery

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Nonpharmacologicmanagement

Rhythmic breathingMeditationHypnosisHumorBiofeedbackTherapeutic touchDistraction

Evaluation

Evaluation- is best when it is unifiedthroughout a healthcare agency.Key items-

Client satisfaction- with pain management and itsimpact on quality of lifeResponsible party for pain mgmt.Systematic assessment of painEffectiveness of pain mgmt optionsPrevalence and severity of side effects

Evaluation continued

Evaluation of the process of pain mgmtas well as the outcome should be done

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Documentation

Flow sheet works best to allowvisualization of client’s pain experiencePain diary

DiscussionAn 80 year old client, Mrs. Parker, isterminally ill with cancer. An opiate analgesichas been prescribed for her pain. She isbeing cared for at home by family memberswho are concerned about pain control fortheir loved one. What should the client andfamily be taught about complicationsassociated with use of opiate analgesia? Whowould be the ideal person to assess andcoordinate the client’s response to dosing ofmed or combination of med?