(relates to chapter 10, “pain,” in the textbook) copyright © 2011, 2007 by mosby, inc., an...

(Relates to Chapter 10, “Pain,” in the textbook)

One major reason people seek health care.

Nurses have a central role in assessment and management.

Assess pain and communicate with other health care providers.

Ensure initiation of adequate pain relief measures.

Evaluate effectiveness of interventions.

Advocate for those in pain.

25 million people experience acute pain from injury or surgery.

50 million people have back pain, arthritis, and migraine headaches.

75% of cancer patients experience significant pain.

Despite the prevalence of pain, many studies document inadequate pain management across care settings and patient populations.

Consequences of untreated pain Unnecessary suffering Physical and psychosocial dysfunction

Impaired recovery from acute illness and surgery

Immunosuppression Sleep disturbances

Why pain is undertreated Inadequate skills to assess and treat pain

Unwillingness to believe patient reports

Lack of time, expertise, and perceived importance of pain assessments

False concepts of addiction and tolerance

Whatever the person experiencing pain says it is

Unpleasant sensory and emotional experience associated with actual or potential tissue damage

Subjective: Patient’s experience and self-report are essential. Can be problematic when dealing with special populations (coma or dementia)

Nonverbal information such as on behaviors aids the assessment of pain.

Multidimensional experience Physiologic Affective Cognitive Behavioral Sociocultural

Affective (emotions, suffering)

Behavioral (behavioral responses)

Cognitive (beliefs, attitudes, evaluations, goals)

Physiologic (transmission of nociceptive stimuli)

Sensory (pain perception)

PAINPAIN

Genetic, anatomic, and physical determinants Influence how stimuli are recognized and described

Emotional response to pain experience Anger Fear Depression Anxiety

Suffering: State of severe distress associated with loss Eased by pain relief Influenced by spirituality

Studies demonstrate a link between depression and pain. Treating one can relieve the symptoms of the other.

Observable actions used to express or control pain Facial expressions Socially withdrawn Less physically active Using relaxation Taking medication

Beliefs, attitudes, memories, and meaning attributed to pain

Influence response to pain and must be incorporated into the comprehensive treatment plan

Include demographics, support systems, social roles, and culture Age, gender, and education influence beliefs and coping strategies.

Must be assessed without stereotyping

Nociception: Physiologic process that communicates tissue damage to the CNS Involves four processes•Transduction•Transmission•Perception•Modulation

Fig. 10-1. Nocioceptive pain originates when the tissue is injured. 1, Transduction occurs when there isrelease of chemical mediators. 2, Transmission involves the conduct of the action potential from theperiphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3,Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going backdown the spinal cord to modify incoming impulses.

Conversion of a mechanical, thermal, or chemical stimulus into a neuronal action potential Occurs at the nociceptors

Noxious stimuli cause release of a “biologic soup” of chemicals. These substances activate nociceptors and lead to generation of an action potential carried to the spinal cord.

Inflammation increases the likelihood of transduction. Peripheral sensitization

Two types of pain Nociceptive•Activation of peripheral nociceptors

Neuropathic•Abnormal processing of stimuli by the nervous system

Therapy alters local environment or sensitivity of peripheral nociceptors. Prevents transduction and initiation of an action potential

Process by which pain signals are relayed from the periphery to the spinal cord and then to the brain

Three segments are involved: Transmission along peripheral nerve fibers to spinal cord

Dorsal horn processing Transmission to thalamus and cerebral cortex

See Notes.

Spinal Dermatomes

eFig. 10-1. Spinal dermatomes representing organized sensory input carried via specific spinal nerveroots. C, Cervical; L, lumbar; S, sacral; T, thoracic.

Occurs when pain is recognized, defined, and responded to

Nociceptive input is perceived as pain in the brain.

There is no precise, known location where pain perception occurs.

Activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain

Can occur at periphery, spinal cord, brainstem, and cerebral cortex

By underlying pathology Nociceptive Neuropathic

By duration Acute Chronic

Damage to somatic or visceral tissue Surgical incision, broken bone, or arthritis•Usually responsive to opioids and nonopioid medications

Superficial or deepLocalizedArises from bone, joint,

muscle, skin, or connective tissue

Tumor involvement or obstruction

Arises from internal organs such as the intestine and bladder

Damage to peripheral nerve or CNS

Numbing, hot-burning, shooting, stabbing, or electrical in nature

Sudden, intense, short-lived, or lingering

Deafferentation Injury to the peripheral or central nervous system

Sympathetically maintained Dysregulation of the autonomic nervous system

Painful polyneuropathies Felt along distribution of many peripheral nerves

Painful mononeuropathies Associated with a known peripheral nerve injury and felt along distribution of damaged nerve

Differences based on Cause Course Manifestation Treatment

Sudden onsetLess than 3 months time for

normal healing to occurMild to severe Generally a precipitating

event or illness can be identified

Course of pain decreases over time and goes away as recovery occurs

Includes postoperative, labor, and trauma pain

Treatment goal Pain control with eventual elimination

Manifestations reflect sympathetic nervous system activation: Increased heart rate Increased respiratory rate Increased blood pressure

Gradual or sudden onsetLess than 3 month duration;

may start acute but continues past normal recovery time

Cause may be unknown.

Does not go away; characterized by periods of waxing and waning

Behavioral manifestations Decreased physical movement/activity

Fatigue Withdrawal from others and social interaction

Can be disabling and accompanied by anxiety and depression

Treatment goals Control to the extent possible Focus on enhancing function and quality of life

Nurse is often responsible to Gather and document data Make collaborative decisions with patient and other health care providers

Consider pain the “fifth vital sign.”

Goals Describe experience to treat. Identify goal for therapy and resources for self-management.

Elements (multidimensional) Direct interview Observation Diagnostic studies Physical examination

OnsetDurationAssociated

symptomsFactors

increasing or relieving pain

PatternLocation IntensityQuality

Pain Assessment: Pain Pattern

Pain onset May be unidentifiable

Pain durationPain may be constant or

intermittent.Incident pain

Pain Assessment: Characteristics

Breakthrough pain Transient, moderate to severe Occurs beyond treated pain Usually rapid onset and brief duration with variable frequency and intensity

Pain Assessment: Location

Area of pain Location assists in identifying cause and treatment.•Localized•All over•Referred or radiated from origin to different site

Fig. 10-2. Typical areas of referred pain.

Pain Assessment: Intensity

Intensity of pain Reliable measure for determining treatment

Rated using scales •0 to 10•Use observational skills for nonverbal patients.

Fig. 10-3. Pain thermometer scale. The patient is asked to circle words next to the thermometeror to mark the area on the thermometer to indicate the intensity of pain.

Pain quality Nature or characteristics•Sharp, aching, burning, numbing, stabbing, electric shock–like, throbbing

Associated symptoms Can worsen pain•Anxiety•Fatigue•Depression

Management Inquire about strategies used. •Effective and ineffective

• Follow principles of assessment.

• Every patient deserves adequate pain management.

• Treatment based on patient’s goals

• Use drug and nondrug therapies.

• Use a multimodal approach.• Use a multidisciplinary

approach.• Evaluate effectiveness.• Prevent or manage side

effects.• Involve patient and family

teaching through assessment and treatment.

Three categories of medications Nonopioid Opioid Co-analgesic or adjuvant

Analgesic ceiling Increasing dose above upper limit produces no greater analgesia

Do not produce tolerance or addiction

Many are OTC

Aspirin and other salicylatesAcetaminophenNSAIDs

See Notes.

Fig. 10-4. Arachidonic acid is oxidized by two different pathways: lipoxygenase and cyclooxygenase. Thecyclooxygenase pathway leads to two forms of the enzyme cyclooxygenase: COX-1 and COX-2. COX-1 is knownas “constitutive” (always present) and COX-2 is known as “inducible” (meaning its expression varies markedlydepending on the stimulus). NSAIDs differ in their actions, with some having more effects on COX-1 and othersmore on COX-2. Indomethacin acts primarily on COX-1, whereas ibuprofen is equipotent on COX-1 and COX-2.Celecoxib primarily inhibits COX-2.

Bind to receptors in the CNS Inhibition of transmission of nociceptive input

Altered limbic activity Activation of descending inhibitory pathways

Pure agonists Morphine, oxycodone, and codeine•Potent, no analgesic ceiling, and have several routes for administration

•Often combined with nonopioid analgesic for relief of moderate pain

Mixed agonists-antagonists Nalbuphine, pentazocine, butorphanol•Less respiratory depression •More dysphoria and agitation•Have an analgesic ceiling •Can precipitate withdrawal

Common side effects Constipation (most common) Nausea/vomiting Sedation Respiratory depression Pruritus

See Notes.

Used in conjunction with opioids and nonopioids

Generally developed for other purposes, but also effective for pain

CorticosteroidsAntidepressantsAntiseizure drugsGABA receptor agonists

Adjunct Therapy

α2-Adrenergic agonistsLocal anestheticsMixed mu agonist opioid and

NE/5-HT reuptake inhibitors Cannabinoids

A patient who has been treated with morphine by patient-controlled analgesia (PCA) is discharged from the hospital with instructions that all of the following medications may be used for pain. Which medication will the nurse instruct the patient to use first?

1. Aspirin 2. Ibuprofen (Motrin, Advil)3. Acetaminophen (Tylenol)4. Oxycodone/acetaminophen (Percocet)

Audience Response Question

Scheduling Focus on prevention or control. Do not wait for severe pain. Constant pain requires around-the-clock administration (not PRN).

Fast-acting drugs for breakthrough

Titration Dose adjustment based on assessment of analgesic effect versus side effects

Use the smallest dose to provide effective pain control with fewest side effects.

Administration

Equianalgesic dosing Dose of one analgesic that is equivalent in pain-relieving effects compared with another analgesic

Permits substitution of analgesics in the event that a particular drug is ineffective or causes intolerable side effects

Benefits of variable routes Target a particular source Achieve therapeutic blood levels rapidly

Avoid certain side effects Provide analgesia when patients cannot swallow

Oral Route of choice with functioning GI tract

Sublingual and buccal Exempts drug from first-pass effect

IntranasalRectal

See Notes.

Transdermal Parenteral routes

IM, SC, and IV Intraspinal delivery

Highly potent (smaller doses necessary)

Implantable pumpsPatient-controlled analgesia

See Notes.

Spinal Anatomy

Fig. 10-5. Spinal anatomy. The spinal cord extends from the foramen magnum to the first or second lumbarvertebral space. The subarachnoid space (intrathecal space) is filled with cerebrospinal fluid that continuallycirculates and bathes the spinal cord. The epidural space is a potential space filled with blood vessels, fat, and anetwork of nerve extensions.

Nerve blocks Interrupt all afferent and efferent transmission, not only nociceptive input

Used during and after surgery to manage pain

Neuroablative techniques For severe pain unresponsive to other therapy

Destroy nerves to stop transmission

Fig. 10-6. Sites of neurosurgical procedures for pain relief.

Neuroaugmentation Electrical stimulation of brain and spinal cord

Commonly used for chronic back pain

Reduces dose of analgesic required and minimizes side effects

Possibly alters ascending nociceptive input or stimulates descending pain modulation mechanisms

MassageExerciseTENS or PENSAcupunctureHeat or cold therapy

See Notes.

TENS Treatment

Fig. 10-7. Initial TENS treatment being given by a physical therapist to assessvalue in pain relief.

Cognitive therapies Distraction Hypnosis Imagery Relaxation

Effective communication Patient’s report of pain is believed, is not perceived as “complaining.”

The nurse communicates concern and affirms her commitment to the patient.

The nurse’s role in analgesic titration for a postoperative patient is:1. Monitoring the effects of continuous infusion of opioid analgesics.2. Determining with the patient the dosage of analgesic required for pain relief. 3. Teaching the patient to try to increase the time between doses of pain medication.4. Assisting the patient to plan the distribution of a specific total dose of analgesic over a 24-hour period.

Audience Response Question

Common concerns Tolerance Physical dependence Addiction

Tolerance Need for increased dose to maintain same degree of pain control

Not as common as was once thought

Rotate drug if tolerance develops, as increasing dose could contribute to hyperalgesia.

Physical dependence Expected response to ongoing exposure to pharmacologic agents manifested by withdrawal syndrome when blood levels drop abruptly

To avoid withdrawal, drug should be tapered.

Addiction Neurobiologic condition with drive to obtain and take substances for other than prescribed therapeutic value

Tolerance and physical dependence are not indicators of addiction.

Inadequate health care provider education Curriculum does not include education on pain.

Not a priority in clinical education

Fear of hastening death by administering analgesics

Requests for assisted suicideUse of placebo in pain

assessment and treatment

Chronic pain is a problem associated with physical disability and psychosocial problems.

50% to 80% of older adults are estimated to have chronic pain problems.

Most common painful conditions Musculoskeletal •Osteoarthritis •Low back pain•Previous fracture sites

Chronic pain often results in Depression Sleep disturbance Decreased mobility Decreased health care utilization

Physical and social role dysfunction

Barriers Belief that pain is inevitable for aging

Greater fear of using opioids Use words like aching, soreness, or discomfort instead of pain

High prevalence of cognitive, sensory-perceptual, and motor problems

Treatment cautions Metabolize drugs more slowly Risk of GI bleeding with NSAIDs Multiple drug use (interactions) Cognitive impairment, ataxia can be exacerbated by analgesics

When planning care for a 76-year-old patient with chronic low back pain and severe cervical arthritis, the nurse recognizes that chronic pain in the older adult:1. Is better tolerated than in younger patients.2. Is often seen as an inevitable part of aging.3. Does not require the use of opioids for pain control. 4. Is poorly tolerated because of past experiences with pain.

Audience Response Questions

Behavioral and physiologic changes may be indicators of pain.

Scales to assess pain in cognitively impaired are based on common behavioral indicators: Facial expressions Breathing Body movement or tension

Assessing and providing relief with a dual diagnosis of pain and substance abuse is challenging. These patients still have a right to receive effective pain management.

Comprehensive pain assessment Detailed history Physical examination Psychosocial assessment Diagnostic workup

Establish a treatment plan that will relieve pain and minimize withdrawal symptoms.

Usually require a multidisciplinary team approach

52-year-old woman is experiencing chronic lumbar pain.

Pain began 2 years ago and has gradually increased.

She has been using acupuncture for pain management, and it is no longer effective.

She uses a heating pad at night, which provides some relief.

She is a recovering substance abuser who has been sober for 30 years. Because of her history, she has avoided using medication unless absolutely necessary.

Imaging studies show degenerative disk disease between L1-L2 and L2-L3.

She is prescribed hydrocodone and is referred for physical therapy.

1. She is concerned about taking hydrocodone because of her history of substance abuse. What should you say to her?

2. Other than medication and physical therapy, what pain relief options might be discussed?

3. What patient teaching is important for her?

(relates to chapter 10, “pain,” in the textbook) copyright © 2011, 2007 by mosby, inc., an...

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