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Chapter 43

Chapter 43. Pain Management. Importance. Pain management is a primary nursing responsibility Nurse have a legal and ethical duty to control/relieve pain Pain relief is a basic human right Patients need to know we CAN and WILL relieve their pain. Why?. Effective pain management :

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Chapter 43

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  1. Chapter 43 Pain Management NRS_105/320_Collings

  2. Importance • Pain management is a primary nursing responsibility • Nurse have a legal and ethical duty to control/relieve pain • Pain relief is a basic human right • Patients need to know we CAN and WILL relieve their pain NRS_105/320_Collings

  3. Why? • Effective pain management: • Improves quality of life • Reduces disability • Promotes early mobility and return to work • Results in less hospital / office visits • Reduces length of stay, complications • Reduces health care cost • Improves patient satisfaction NRS_105/320_Collings

  4. Nature of Pain • Physical • Emotional • Cognitive • Subjective NRS_105/320_Collings

  5. Physiology of Pain • Transduction • Thermal,chemical,mechanical stimulation • → electrical impulse in nerve fiber • Transmission • A fibers: sharp, localized, distinct sensation • C fibers: generalized, persistent sensation • E.g. Burn finger – spot pain → ache • Peripheral → spinal → brain NRS_105/320_Collings

  6. Physiology of Pain • Perception • Brain interprets impulse, perceives as pain • Experience, memory, context, knowledge • Ascribes meaning to sensation • Modulation • Body response • Endogenous opiods, serotonin, norepinephrine, GABA • ↓ transmission of impulse, analgesic effect • These deplete over time with continued pain NRS_105/320_Collings

  7. Gate-Control Theory of Pain • Gating mechanisms along the CNS • Can block transmission of impulses • Pain relief measures to close the gate • Light touch [effleurage] • Pain threshold • Level at which you feel pain • Genetic, learned, • Runner’s high, endogenous opiods • Individual – not transferrable! NRS_105/320_Collings

  8. Physiological Response to Pain • Mild – moderate pain [1-6] superficial → autonomic response [sympathetic]; • fight or flight, general adaptation • ↑HR, RR, B/P, BG, diaphoresis, peripheral vasoconstriction • Severe or deep [7-10], visceral pain → parasympathetic response • ↓ HR, B/P, muscle tension, immobility, irreg resp • may cause harm • Physiologic response [VS] is short-term; • VS are not reliable pain indicators over time NRS_105/320_Collings

  9. Behavioral responsesto Pain • Dependent on context, meaning, culture, pain tolerance • It is supposed to hurt • Men don’t cry • I don’t want to be a complainer, bother • Nonverbal indicators • Body movements; restless or still, holding, guarding • Facial expression; grimace, frown, clenched teeth, posture, • Lack of expression of pain does not mean it isn’t there! NRS_105/320_Collings

  10. Types of Pain • Acute pain • Protective, identifiable cause, short duration, limited tissue damage, ↓ emotional response • Causes harm by ↓ mobility, energy Goal is to control pain so patient can participate in recovery ↓ Pain → ↑Mobility → decreased complications, decreased length of stay NRS_105/320_Collings

  11. Types of Pain • Chronic pain • Serves no purpose [not protective] • Lasts longer than anticipated • May or may not have an identifiable cause • Impacts every part of patient’s life • Depression, Suicide • Disability, isolation, energy drain, ADL’s • Pseudoaddiction: seeking pain relief • not drug-seeking NRS_105/320_Collings

  12. Types of Pain • Cancer pain • May be acute or chronic, constant or episodic, mild to severe • Up to 90% of Ca pts have pain • Pain by inferred pathology • Known cause = characteristic pain [neuropathic] • Idiopathic pain • No known cause BUT still pain • “Excessive” pain for a condition NRS_105/320_Collings

  13. Knowledge, Attitudes, and Beliefs • Subjective nature of pain • Pain is what the patient says it is, not what the nurse thinks it should be • Same procedure, different pain • Expectations, context, culture affect perception and expression of pain NRS_105/320_Collings

  14. Knowledge, Attitudes, and Beliefs • Nurse’s Response to Pain • Bias • ‘I go to work with 5/10 pain every day’ • ‘Its only a minor surgery’ • ‘I had three kids and didn’t scream’ • Fallacies • Infants don’t feel pain like we do • Regular pain med use causes addiction • Older people all are in pain NRS_105/320_Collings

  15. Factors Influencing Pain • Physiological • Age – interpretation/communication • Fatigue • increases pain, • sleep not sign pain is relieved • Genes • Pain threshold • Neurological function • Interpretation, communication, reflex NRS_105/320_Collings

  16. Factors Influencing Pain • Social • Attention/ distraction • Previous experience • May increase or decrease tolerance • Family and social support • Spiritual • Meaning of pain, suffering • Support system NRS_105/320_Collings

  17. Factors Influencing Pain • Psychological • Anxiety • Coping style • Control [PCA] • Cultural • Meaning of pain • Expression of pain • Role in Family • Ethnicity NRS_105/320_Collings

  18. Assessment of Pain • Client’s expression of pain • Description is most valid indicator • Characteristics of pain • Onset and duration • Location • Intensity • Quality • Pattern NRS_105/320_Collings

  19. Assessment of Pain • Characteristics of pain (cont'd) • Relief measures • Contributing symptoms • Behavioral effects on the client • Influences on ADLs • Client expectations • What pain level would allow you to function well? • [walk the hall, do ADL’s, resume job…] NRS_105/320_Collings

  20. Assessment • Can we do a full assessment of pain when the client is in severe pain? • No! • Alleviate severe [7-10] pain before talking it to death • Pain rated >7 needs immediate attention NRS_105/320_Collings

  21. Nursing Diagnoses • Anxiety • Ineffective coping • Fatigue • Acute pain • Chronic pain • Ineffective role performance • Disturbed sleep pattern NRS_105/320_Collings

  22. Planning • Goals and outcomes • Client is using pain relief measures safely • Pain level reported at </=___ and congruent nonverbal behaviors seen • Demonstrate understanding of need to premedicate before activity • Splint abdomen with cough • Setting priorities • What is important for the client? What does he need to do? • Control pain enough to eat, sleep? Be mobile to prevent complications? Work? PT? Maintain dignity, relationships while dying? • Maslow: Pain relief is basic need NRS_105/320_Collings

  23. Implementation: Health Promotion • Client education • Expectations, when to seek treatment • Preparation before pain • Holistic care • Whole self; physical, emotional, spiritual • Education, rest, exercise, nutrition, relationships NRS_105/320_Collings

  24. Nonpharmacological Pain Relief • Relaxation and guided imagery • Distraction • Biofeedback • Cutaneous stimulation—massage, application of hot/cold, TENS • Herbals • Reducing painful stimuli and perception NRS_105/320_Collings

  25. Controlling Painful Stimuli • Managing the client’s environment—bed, linens, temperature • Positioning • Changing wet clothes and dressings • Monitoring equipment, bandages, hot and cold applications • Preventing urinary retention and constipation NRS_105/320_Collings

  26. Implementation Pain Management • Pharmacological pain relief • … Administer analgesics as ordered/ reassess pain in 30 minutes and hourly • Analgesics: NSAIDs and nonopioids, opioids, adjuvants • Patient-controlled analgesia (PCA) • Local analgesic infusion pump • Topical analgesics and anesthetics • Local and regional anesthetics NRS_105/320_Collings

  27. ImplementationPain Management • Surgical interventions • Procedural pain management • Chronic and cancer pain management NRS_105/320_Collings

  28. Implementation Pain Management • Barriers to effective pain management [pts, nurses, doctors, system…] • Fear of addiction - #1 barrier • Terms: • Dependence: physical adaptation resulting in withdrawal symptoms • tolerance: physical adaptation resulting in diminished drug effect over time • Addiction: impaired control over use, use despite harm • pseudoaddiction: drug seeking behavior to relieve undertreated pain NRS_105/320_Collings

  29. Implementation Pain Management • Nursing implications for pain management • Accurate safe medication administration • Assess effectiveness and side effects • Patient education [families too] • Use the appropriate drug when given a choice • Treat pain before it gets severe NRS_105/320_Collings

  30. Implementation: Restorative Care • Pain clinics • Palliative care • Hospices NRS_105/320_Collings

  31. Evaluation • Effectiveness • Assess at peak of drug effect • [30 minutes IV, 1 hour PO] • Add complementary therapies for partial effect • Talk with M.D. about options if approach is consistently ineffective • Side effects • Document and communicate • Most effective relief NRS_105/320_Collings

  32. Evaluation • Client expectations • Validate experience • Relieve the pain • Show you care • Did client achieve goal? • Walk hall w/o pain? • Pain < 3/10 all day [except with PT] • Able to return to work, enjoy visit, T,C,&DB? • Pain report congruent with nonverbal? NRS_105/320_Collings

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