Pain Lecture 2

7/27/2019 Pain Lecture 2

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Chapter 13

Pain Management

Significance of PainSubjective response: only felt by the person

Negative: discomfort

Protective role: warning of potential threat to health

sometimes a life!threatening condition"# prompt for

person to see$ medical attention

Pain

! %n unpleasant sensory and emotional e&perience withactual or potential tissue damage'

! (he most common reason for see$ing health care'

! )(he fifth vital sign* by the %merican Pain Society

+,,3"

! -C%./ +,,0" standards state that )pain is assessed

in all patients* and that )patients have the right to

appropriate assessment and management of pain'*! )Pain is whatever a person says it is e&isting whenever

the e&periencing person says it does* McCaffery 2

Pasero 1"'

! Pain is categori4ed according to its duration location

and etiology'


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(ypes of Pain

%cute pain can be described as lasting from seconds to 5months

Chronic persistent" pain is constant or intermittent

pain that persists beyond the e&pected healing time and

that can seldom be attributed to a specific cause or

injury'

Cancer!related pain

%ccording to 6ocation

eg pelvic pain headache chest pain"' (his type of

categori4ation aids in communication about and

treatment of the pain'

%ccording to 7tiology

8urn pain and postherpetic neuralgia are e&amples of

pain described

Classifications of Pain and 9efinitions

%' %cute: sudden onset usually sharp and

locali4ed# less than 5 months# significant of

actual or potential injury to tissues# initiates

flight or fight stress response

1' Somatic: arises from s$in close to surface of

body# sharp or dull# often with nausea and

vomiting


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+' isceral: arises from body organs# dull and

poorly locali4ed# with nausea and vomiting#

may radiate or is referred

3' ;eferred: pain perceived in area distantfrom stimuli

8' Chronic: prolonged pain# more than 5 months#

often dull aching diffuse# not always associated

with specific cause often unresponsive to

conventional treatment# most common is lower

bac$ pain

1' ;ecurrent acute pain

+' /ngoing time!limited pain3' Chronic nonmalignant pain


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=actors %ffecting ;esponse to Pain

%'Pain threshold: Point at which a stimulus is

e&perienced as pain# same for all persons but

individuals have different perceptions andreactions to pain

8'Pain tolerance: amount of pain a person can

endure before outwardly responding to it

1' 9ecreased by repeated pain episodes

fatigue anger an&iety sleep deprivation

+' >ncreased by alcohol hypnosis warmth

distraction spiritual practices

C'%ge9'Sociocultural influences

1' =amily beliefs e'g' males don?t cry

+' Cultural: some persons of ethnic groups

handle pain in similar manner

7'7motional status e'g' an&iety

1' =atigue and@or lac$ of sleep

+' 9epression: decreased amount of serotonina neurotransmitter thus increased amount

of pain sensation

=' Past e&periences with pain

A' Source and meaning

.' Bnowledge about pain


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./ %pproach to Cancer Pain

7ffects of Pain

Sleep deprivation %cute pain

Can affect respiratory cardiovascular endocrine

and immune systems'

Stress response increases metabolic rate and

cardiac output and increases ris$ for physiologic

disorders'

Chronic pain 9epression

>ncreased disability

Suppression of immune function

Pathophysiology of Pain

involve the peripheral and central nervous systems'

Nociceptors pain receptors" are free nerve endings in

the s$in that respond only to intense potentially

damaging stimuli' Such stimuli may be mechanical

thermal or chemical in nature' (he joints s$eletal

muscle fascia tendons and cornea also have

nociceptors that have the potential to transmit stimuli

that produce pain'

(ransmission of pain nociception"

Chemical substances

Prostaglandins increase sensitivity of pain

receptors" chemical substances that increase the


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sensitivity of pain receptors by enhancing the pain!

provo$ing effect of brady$inin

7ndorphins and en$ephalins suppress pain

reception" morphine!li$e substances produced by thebody' Primarily found in the central nervous system

they have the potential to reduce pain'

Nociception System Showing %scending and 9escending

Pathways of the 9orsal .orn

Aate Control System (heory

=actors (hat >nfluence Pain ;esponse

Past e&perience

%n&iety

9epression

Culture

Aender Aenetics

Aerontologic considerations

7&pectations

(he )Placebo 7ffect*

% physiologic response that results from an

e&pectation that a treatment will wor$'

%merican Society of Pain Management Nurses

+,,0" contends that placebos should not be used to

assess or manage pain'


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Chart 13!3: 7thics and ;elated >ssues

%ssessment of Pain

%ssessment: the patient?s pain goal or e&pectationsof comfort and pain relief

Meaning of pain for the patient

Chart 13!0: Common Concerns and Misconceptions

%bout Pain and %nalgesia

8ehaviors associated with the pain

% patient may grimace cry rub the affected area guard

the affected area or immobili4e it' /thers may moan

groan grunt or sigh' Not all patients e&hibit the same

behaviors and there may be different meanings

associated with the same behavior'

Physiologic responses to the pain

Physiologic responses to pain such as tachycardia

hypertension tachypnea pallor diaphoresis mydriasis

hypervigilance and increased muscle tone are related

to stimulation of the autonomic nervous system'

Characteristics: >ntensity (iming 6ocation

Duality

>ntensity of pain ranges from none to mild discomfort to

e&cruciating' (here is no correlation between reported

intensity and the stimulus that produced it' (he


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reported intensity is influenced by the personEs pain

threshold and pain tolerance'

(iming ! patient is as$ed if the pain began suddenly or

increased gradually'

6ocation of pain is best determined by having the

patient point to the area of the body involved'

! especially helpful if the pain radiates referred pain"

Duality ! nurse as$s the patient to describe the pain in

his or her own words without offering clues'! nurse can suggest words such as burning aching

throbbing or stabbing'

%ggravating or alleviating factors

! nurse as$s the patient what if anything ma$es the

pain worse and what ma$es it better and as$s

specifically about the relationship between activity and

pain'

Pain >ntensity Scales

%S are useful in assessing the intensity of pain' /ne

version of the scale includes a hori4ontal 1,!cm line

with anchors ends" indicating the e&tremes of pain' (he

patient is as$ed to place a mar$ indicating where thecurrent pain lies on the line'

=aces Pain ScaleF;evised


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(his instrument has si& faces depicting e&pressions that

range from contented to obvious distress' (he patient is

as$ed to point to the face that most closely resembles

the intensity of his or her pain'

Pain >ntensity Scale

=aces Pain Scale


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Auidelines for %ssessing Pain in Patients ith

9isabilities

%lternative forms of communication may be necessary

for people with sensory impairments or other

disabilities'

=or people who are blind and who $now how to

read 8raille pain assessment instruments can be

obtained in 8raille' >n addition there is now

computer software that allows written documents

to be scanned and converted into 8raille' >f these


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programs are not available agencies that provide

services for people who are blind may be able to

assist in developing 8raille versions'

=or people who are deaf or hard of hearing outsideinterpreters ie not family members" should be

used' /ther useful communication strategies may

include sign language written notes or pictures'

hen writing notes on a )magic slate* or ma$ing

written notes it is necessary to ma$e every effort to

guard the patientEs privacy and confidentiality'

=or people with disabilities that result in

communication impairment computer!generatedspeech may be useful'

(he NurseEs ;ole in Pain Management

- nurse helps relieve pain by administering pain!

relieving interventions including both

pharmacologic and nonpharmacologicapproaches" assessing the effectiveness of those

interventions monitoring for adverse effects and

serving as an advocate for the patient when the

prescribed intervention is ineffective in relieving

pain'

Aoals for pain management

-complete elimination of the pain

- decrease in the intensity duration or freGuency of

pain and a decrease in the negative effects of the

pain


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7stablishing the NurseFPatient ;elationship and

(eaching

% positive nurseFpatient relationship and teaching

are $ey to managing analgesia in patients with painbecause open communication and patient cooperation

are essential to success

(he patient should be informed that pain should be

reported in the early stages' hen the patient waits

too long to report pain sensiti4ation may occur and

the pain may be so intense that it is difficult to relieve

Providing Physical Care

Patients are usually more comfortable when physical

and self!care needs have been met and efforts have

been made to ensure as comfortable a position as

possible

Managing %n&iety ;elated to Pain

(eaching the patient about the nature of the

impending painful e&perience and the ways to reduce

pain often decreases an&iety

6earning about measures to relieve pain may lessen

the threat of pain and give the patient a sense of

control'

Pain Management Strategies

Pharmacologic >nterventions


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Pharmacologic management of pain is accomplished in

collaboration with physicians patients and often

families'

Premedication %ssessment

8efore administering any medication the nurse should

as$ the patient about allergies to medications and the

nature of any previous allergic responses

! nurse obtains the patientEs medication history

Aerontologic Considerations

Physiologic changes in older adults reGuire thatanalgesic agents be administered with caution' 9rug

interactions are more li$ely to occur in older adults

because of the higher incidence of chronic illness and

the increased use of prescription and /(C medications

Aerontologic Considerations

More li$ely to have adverse drug effects and drug

interactions >ncreased li$elihood of chronic illness

May need to have more time between doses of

medication due to decreased e&cretion and metabolism

related to aging changes

(%867 13!+ %dverse >nteractions of .erbal Substances

or =oods ith %nalgesics

%nalgesic .erb or =ood 7ffect

NS%>9s Ain$go garlic

ginger bilberry

dongGuai feverfew

ginseng turmeric

7nhanced ris$ of

bleeding


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meadowsweet

willow

%cetaminophen Ain$go and

possibly some ofthe above!

mentioned herbs

7nhanced ris$ of

bleeding

7chinacea $ava

willow

meadowsweet

>ncreased potential

for hepatoto&icity

and nephroto&icity

/pioids alerian $ava

chamomile

>ncreased central

nervous system

depressionAinseng >nhibits analgesic

effects

%lfentanil

fentanyl

sufentanil

Arapefruit juice >nhibits the

cytochrome P


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Preventive %pproach ;(C or %(C

administering analgesic agents

Hse of )%s Needed* ;ange /rders for /pioid

%nalgesics

>ndividuali4ed 9osage

(he dosage and the interval between doses should be

based on the patientEs reGuirements rather than on an

infle&ible standard or routine

! fear of promoting addiction or causing respiratorydepression health care providers tend to prescribe and

administer inadeGuate dosages of opioid agents to treat

acute pain or persistent pain particularly in terminally

ill patients

Patient!Controlled %nalgesia

Hsed to manage postoperative pain as well as persistentpain patient!controlled analgesia PC%" allows patients

to control the administration of their own medication

within predetermined safety limits'

6ocal %nesthetic %gents

(opical %pplication

>ntraspinal %dministration

/pioid %nalgesic %gents

%dverse 7ffects:


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- ;espiratory depression is the most serious adverse

effect of opioid analgesic agents administered by

> subcutaneous or epidural routes

-

Sedation- Nausea and omiting

- Constipation

- >nadeGuate Pain ;elief

(%867 13!3 Selected /pioid %nalgesics Commonly

Hsed for Moderate and Severe Pain in %dults

Name

Starting 9ose

milligrams"

Comments

Precautions

andContraindicati

ons

Modera

te Pain

Severe

Pain

Morphine I 3,F5,

oral"

1,

parenter

al"

%cts as an

agonist at

specific opioid

receptors in the

CNS to produce

analgesiaeuphoria and

sedation'

Hse with

caution

especially in

elderly

patients very

ill patients andthose with

respiratory

impairment'

Major ris$s

include

respiratory

depression

apneacirculatory

depression and

respiratory

arrest shoc$

and cardiac


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arrest' /btain

history of

hypersensitivit

y to opioids'

Monitorpatient closely'

>f prescribed in

correct dose

oral

preparations

MS Contin"

are effective in

treatingmoderate and

severe pain'

Codeine 10F3,

oral"

5, oral"

up to

35,@+< hr

%cts as an

agonist at

specific opioid

receptors in the

CNS to produce

analgesiaeuphoria and

sedation' >s also

an antitussive'

1,J of people

lac$ the en4yme

needed to ma$e

codeine active'

Codeine may

cause more

nausea and

constipation per

unit of

analgesia than

other mu

Many

preparations of

codeine and the

other opioids in

this table are

combinationswith nonopioid

analgesics'

Caution must

be used in

patients with

impaired

ventilation

bronchial

asthma

increased

intracranial

pressure or

impaired liver

function and in


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agonist opioids' elderly and

very ill

patients'

/&ycodone

/&yContin"

0 oral" 1,F+,

oral"

%cts as an

agonist atspecific opioid

receptors in the

CNS to produce

analgesia

euphoria and

sedation'

Caution must

be used inpatients with

impaired

ventilation

bronchial

asthma

increased

intracranial

pressure orimpaired liver

function and in

elderly and

very ill

patients'

Meperidine

9emerol"

0,

oral"

3,, oral"

K0

parenteral"

%cts as an

agonist at

specific opioidreceptors in the

CNS to produce

analgesia

euphoria and

sedation'

Shorter acting

than morphine'

Meperidine is

biotransformed

to

normeperidine

a to&ic

metabolite'

Normeperidine

a to&ic

metabolic ofmeperidine

accumulates

with repetitive

dosing causing

CNS e&citation'

.igh ris$ for

sei4ures'

Should be

avoided in

patients with

impaired renal

function who

are receiving

M%/


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inhibitors' >s

irritating to

tissues with

repeated

intramuscularinjections'

Chronic use

should be

avoided'

Should not be

used for more

than 1 or +

days'Propo&yphe

ne 9arvon"

50F13,

oral"

I ea$ analgesic#

acts as an

agonist at

specific opioid

receptors in the

CNS to produce

analgesia

euphoria andsedation' Many

preparations

include

nonopioid

analgesics#

biotransformed

to potentially

to&ic metabolite

norpropo&phe

ne"'

%ccumulation

of

propo&yphene

and to&ic

metabolites

occurs with

repetitive

dosing'/verdose is

complicated by

sei4ures'

Propo&yphene

is not

recommended

for older adults

or patients with

renal

impairment'

.ydrocodon

e icodin"

0F1,

oral"

I I Most

preparations

are combined

with nonopioid


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analgesics'

(ramadol

Hltram"

0,F1,,

oral"

I HniGue

mechanism#

analgesia

results from thesynergy of two

mechanisms'

Ma&imum dose

is 9s decrease pain by inhibiting cyclo!

o&ygenase which is the en4yme involved in the

production of prostaglandin'

6ocal anesthetics bloc$ nerve conduction whenapplied to the nerve fibers'

/pioid (olerance and %ddiction

Ma&imum safe opioid dosage must be individually

assessed'

(olerance develops in all patients who ta$e opioids

for prolonged periods'

ith tolerance increased usage is needed to effect

pain relief'

9ependence occurs with tolerance and physical

symptoms occur when the opioid is discontinued'


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%ddiction is a behavioral pattern characteri4ed by

the need to ta$e the drug for its psychic effects'

%ddiction from therapeutic use of opioids is negligible

Nonpharmacologic >nterventions

Cutaneous stimulation massage and use of hot

and cold may be e&plained by the gateway theory'

Hse of heat and cold changes blood flow to the

areas and promotes healing'

Hse of distraction rela&ation and guided imagery

may redirect attention promote muscle rela&ation and

affect perception or reception of pain stimulus in thebrain'

%dministration ;outes for %nalgesics

(%867 13!< %dministration ;outes for %nalgesics

;elationship of Mode of %nalgesia to Serum 6evel

Currently a preventive approach to relieving pain by

administering analgesic agents is considered the most

effective strategy because a therapeutic serum level of

medication is maintained' ith the preventive

approach analgesic agents are administered at set

intervals so that the medication acts before the pain

becomes severe and before the serum opioid level

decreases to a subtherapeutic level'


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Neurologic and Neurosurgical Methods for Pain

Control

>ntrathecal and epidural catheters

(7NS units

(ranscutaneous electrical nerve stimulation (7NS"

uses a battery!operated unit with electrodes applied to

the s$in to produce a tingling vibrating or bu44ing

sensation in the area of pain

>nterruption of pain pathways

Cordotomy ! the division of certain tracts of the spinalcord =ig' 13!1,"' >t may be performed percutaneously

by the open method after laminectomy or by other

techniGues' Cordotomy is performed to interrupt the

transmission of pain' Care must be ta$en to destroy

only the sensation of pain leaving motor functions

intact'

;hi4otomy ! Sensory nerve roots are destroyed where

they enter the spinal cord' % lesion is made in the dorsal

root to destroy neuronal dysfunction and reduce

nociceptive input' ith the advent of microsurgical

techniGues the complications are few with mild sensory

deficits and mild wea$ness =ig' 13!11"'

%dverse 7ffects of %nalgesic %gents

;espiratory depression

Sedation

Nausea and vomiting


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Constipation

Pruritus

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Pain Lecture 2