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Chapter 5

Chapter 5. Pain: The Fifth Vital Sign. Definitions of Pain. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999).

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Chapter 5

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  1. Chapter 5 Pain: The Fifth Vital Sign

  2. Definitions of Pain • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. • Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999). • Self-report is always the most reliable indication of pain.

  3. Types of Pain • Types of pain: • Acute pain • Chronic pain: • Chronic cancer pain • Chronic non-cancer pain • Sources of pain: • Nociceptive pain types: • Somatic pain • Visceral pain • Neuropathic pain

  4. Pain Transmission

  5. Attitudes and Practices Related to Pain • Attitudes of health care providers and nurses affect interaction with patients experiencing pain. • Many patients are reluctant to report pain: • Desire to be a “good” patient • Fear of addiction

  6. Addiction, Pseudoaddiction, Tolerance, and Physical Dependence • Addiction—primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations • Pseudoaddiction—iatrogenic syndrome created by the undertreatment of pain • Tolerance—state of adaptation in which exposure to a drug results in a decrease in one or more the drug’s effects over time

  7. Addiction, Pseudoaddiction, Tolerance, and Physical Dependence (Cont’d) • Physical dependence—adaptation manifested by a drug-class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist • Withdrawal or abstinence syndrome—N&V, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions

  8. Collaborative Management • History • Physical assessment/clinical manifestations: • Location of pain: • Localized pain • Projected pain • Radiating pain • Referred pain

  9. Pain Pharmacologic Therapy—Non-Opioid Analgesics • Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) are most common • Most are NSAIDs, including aspirin: • Can cause GI disturbances • COX-2 inhibitors for long-term use

  10. Non-Opioid Analgesics (Cont’d) • Acetaminophen (Tylenol): • Available in liquid form; can be taken on empty stomach • Preferable for patients for whom GI bleeding is likely • Can cause renal or liver toxicity if used long-term

  11. Pain Pharmacologic Therapy—Opioid Analgesics • Block the release of neurotransmitters in the spinal cord • Drugs include codeine, oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone

  12. Side Effects of Opioids • Nausea and vomiting • Constipation • Sedation • Respiratory depression

  13. WHO Analgesic Ladder • World Health Organization’s recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain) • Level 1 pain (1-3 rating)—Use non-opioids • Level 2 pain (4-6 rating)—Use weak opioids alone or in combination with an adjuvant drug • Level 3 pain (7-10 rating)—Use strong opioids

  14. Pain Management in End of Life • Opioid regimen should stay consistent with dose in weeks before last weeks of life • Generally believed that patient still feels pain when unconscious • Does not hasten death unless the dose was not properly and gradually titrated

  15. Routes of Opioid Administration • Can be administered by every route used • PRN range orders • Patient-controlled analgesia (PCA)

  16. PCA Infusion Pump

  17. Spinal Analgesia • Epidural analgesia • Intrathecal (subarachnoid) analgesia

  18. Implantable Devices

  19. Adjuvant Analgesics • Antiepileptic drugs • Tricyclic antidepressants • Antianxiety agents • Local anesthetics • Dextromethorphan, ketamine • Local anesthesia infusion pumps • Topical medications

  20. Nonpharmacologic Interventions • Used alone or in combination with drug therapy • Physical measures • Physical and occupational therapy • Cognitive/behavioral measures

  21. Physical Interventions

  22. Cognitive/Behavioral Measures • Strategies that can be used to relieve pain as adjuncts to drug therapy: • Distraction • Imagery • Relaxation techniques • Hypnosis • Acupuncture • Glucosamine

  23. Invasive Techniques for Chronic Pain • Nerve blocks • Spinal cord stimulation • Surgical techniques: • Rhizotomy • Cordotomy

  24. Surgical Procedures for the Alleviation of Pain

  25. Community-Based Care • Home care management • Health teaching • Health care resources

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