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

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2

One major reason people seek health care.

Nurses have a central role in assessment and management.


3

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.


4

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.


5

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


6

Consequences of untreated pain Unnecessary suffering Physical and psychosocial dysfunction

Impaired recovery from acute illness and surgery

Immunosuppression Sleep disturbances


7

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


8

Whatever the person experiencing pain says it is

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


9

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.


10

Multidimensional experience Physiologic Affective Cognitive Behavioral Sociocultural


11

Affective (emotions, suffering)

Behavioral (behavioral responses)

Cognitive (beliefs, attitudes, evaluations, goals)

Physiologic (transmission of nociceptive stimuli)

Sensory (pain perception)

PAINPAIN


12

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


13

Emotional response to pain experience Anger Fear Depression Anxiety


14

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


15

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


16

Observable actions used to express or control pain Facial expressions Socially withdrawn Less physically active Using relaxation Taking medication


17

Beliefs, attitudes, memories, and meaning attributed to pain

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


18

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

Must be assessed without stereotyping


19

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


20Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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.

21

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


22

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.


23

Inflammation increases the likelihood of transduction. Peripheral sensitization


24

Two types of pain Nociceptive•Activation of peripheral nociceptors

Neuropathic•Abnormal processing of stimuli by the nervous system


25

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


26

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


27

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

Dorsal horn processing Transmission to thalamus and cerebral cortex


28

See Notes.


29

Spinal Dermatomes


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

30

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.


31

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


32

By underlying pathology Nociceptive Neuropathic

By duration Acute Chronic


33

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


34

Superficial or deepLocalizedArises from bone, joint,

muscle, skin, or connective tissue


35

Tumor involvement or obstruction

Arises from internal organs such as the intestine and bladder


36

Damage to peripheral nerve or CNS

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

Sudden, intense, short-lived, or lingering


37

Deafferentation Injury to the peripheral or central nervous system

Sympathetically maintained Dysregulation of the autonomic nervous system


38

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

Complex regional pain syndromeCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

39

Differences based on Cause Course Manifestation Treatment


40

Sudden onsetLess than 3 months time for

normal healing to occurMild to severe Generally a precipitating

event or illness can be identified


41

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


42

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


43

Gradual or sudden onsetLess than 3 month duration;

may start acute but continues past normal recovery time

Cause may be unknown.


44

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

Behavioral manifestations Decreased physical movement/activity

Fatigue Withdrawal from others and social interaction


45

Can be disabling and accompanied by anxiety and depression

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


46

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.”


47

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


48

Elements (multidimensional) Direct interview Observation Diagnostic studies Physical examination


49

OnsetDurationAssociated

symptomsFactors

increasing or relieving pain

PatternLocation IntensityQuality


50

Pain Assessment: Pain Pattern

Pain onset May be unidentifiable

Pain durationPain may be constant or

intermittent.Incident pain


51

Pain Assessment: Characteristics

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


52

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.

54

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.

56

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


57

Associated symptoms Can worsen pain•Anxiety•Fatigue•Depression


58

Management Inquire about strategies used. •Effective and ineffective


59

• Follow principles of assessment.

• Every patient deserves adequate pain management.

• Treatment based on patient’s goals

• Use drug and nondrug therapies.


60

• Use a multimodal approach.• Use a multidisciplinary

approach.• Evaluate effectiveness.• Prevent or manage side

effects.• Involve patient and family

teaching through assessment and treatment.


61

Three categories of medications Nonopioid Opioid Co-analgesic or adjuvant


62

Analgesic ceiling Increasing dose above upper limit produces no greater analgesia

Do not produce tolerance or addiction

Many are OTC


63

Aspirin and other salicylatesAcetaminophenNSAIDs


64

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.

66

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

Altered limbic activity Activation of descending inhibitory pathways


67

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


68

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


69

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


70

See Notes.


71

Used in conjunction with opioids and nonopioids

Generally developed for other purposes, but also effective for pain


72

CorticosteroidsAntidepressantsAntiseizure drugsGABA receptor agonists


73

Adjunct Therapy

α2-Adrenergic agonistsLocal anestheticsMixed mu agonist opioid and

NE/5-HT reuptake inhibitors Cannabinoids


74

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


75

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


76

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.


77

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


78

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

Avoid certain side effects Provide analgesia when patients cannot swallow


79

Oral Route of choice with functioning GI tract

Sublingual and buccal Exempts drug from first-pass effect

IntranasalRectal


80

See Notes.


81

Transdermal Parenteral routes

IM, SC, and IV Intraspinal delivery

Highly potent (smaller doses necessary)

Implantable pumpsPatient-controlled analgesia

(PCA)Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

82

See Notes.


83

See Notes.


84

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.

85

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

Used during and after surgery to manage pain


86

Neuroablative techniques For severe pain unresponsive to other therapy

Destroy nerves to stop transmission



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

88

Neuroaugmentation Electrical stimulation of brain and spinal cord

Commonly used for chronic back pain


89

Reduces dose of analgesic required and minimizes side effects

Possibly alters ascending nociceptive input or stimulates descending pain modulation mechanisms


90

MassageExerciseTENS or PENSAcupunctureHeat or cold therapy


91

See Notes.


92

TENS Treatment


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

93

Cognitive therapies Distraction Hypnosis Imagery Relaxation


94

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.


95

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


96

Common concerns Tolerance Physical dependence Addiction


97

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.


98

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.


99

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.


100

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

Not a priority in clinical education


101

Fear of hastening death by administering analgesics

Requests for assisted suicideUse of placebo in pain

assessment and treatment


102

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.


103

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


104

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

Physical and social role dysfunction


105

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


106

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


107

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


108

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


109

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.


110

Comprehensive pain assessment Detailed history Physical examination Psychosocial assessment Diagnostic workup


111

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

Usually require a multidisciplinary team approach


113

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.


116

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

She is prescribed hydrocodone and is referred for physical therapy.


117

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


118

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

3. What patient teaching is important for her?


Author

Please review Note below for response to Question 3, and revise or correct as needed.

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

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