Pain Lecture

Acute pain-Pain directly related to tissue injury. Resolves

when tissue heals
Chronic pain-Pain that persists beyond 6 months secondary
to chronic disorders or nerve malfunctions that produce
ongoing pain after healing is complete
Intractable pain-A pain state (generally severe) for which
there is no cure possible. Treatment turns from cure to
reduction of pain
Neuropathic pain-Pain that is related to damaged or
malfunctioning nervous tissue in the PNS or CNS
Nociceptive pain-Pain that is directly related to tissue
damage. May be somatic or visceral
Pain threshold-Process of recognizing, defining, and
responding to pain
Pain tolerance-The most pain an individual is willing or able
to tolerate before taking evasive actions

Pain-“pain is whatever the experiencing person says it is,

existing whenever he (she) says it does” McCaffery
• Even after minor surgery, patients can experience
intense pain
• The person who experiences the pain is the only
authority about its existence and nature
• Patients are unlikely to become addicted to an
analgesic provided to treat pain
• Pain is a subjective experience and the intensity and
duration of pain vary considerably among individuals
• Even w/severe pain, periods of physiologic and
behavioral adaptation can occur
• Considered the 5th VS
• Tricyclic antidepressants delay uptake of pain. Often
used with patients in chronic pain
Nociception: (pain receptors)
• The receptors that transmit pain sensation

4 Processes in Nociception:
• Transduction-1st process of nociception
 o Injury is the trigger
 Biochemical mediators sensitize nociceptors
o Pain medications work during this phase by:
 Blocking the production of prostaglandin (ex.
ibuprofen blocks prostaglandin)
 Decreasing the movement of ions across the
cell membrane (ex. local anesthetic); stops
the transmission of pain
• Transmission-2nd process in Nociception
o Pain impulse travels from peripheral nerve fibers
to spinal cord
 Substance P-Neurotransmitter that enhances
movement of the pain impulse
 C-fibers (unmyelinated):
• Chronic pain
• Transmit dull, achy pain.
• Small fibers take longer to transmit
• Burning, aching, throbbing, nauseous
 A-Delta fibers (myelinated):
• Acute Pain
• Transmit sharp localized pain
• Large fibers
• Sharp, pricking, electric
o Transmission from the spinal cord & ascension, via
spinothalamic tracts to the brain stem and
thalamus
o Transmission of signals between the thalamus to
the somatic sensory cortex where pain perception
occurs.
• Modulation –(3rd process)-Neurons in brain stem send
signals back down to the dorsal horn of the spinal cord
o Descending fibers release substances such as
endogenous opiods(endorphins), serotonin, and
norepinephrine, which can inhibit the ascending
noxious (painful) impulses in the dorsal horn
• Perception-The client becomes conscious of the pain
 Acute vs. Chronic Pain
Acute Pain Chronic Pain
Mild to severe Mild to severe
SNS response: PNS response:
• > pulse rate • VS normal
• >respiratory rate
• ^ BP
• Diaphoresis (perspiration)
• Dilated pupils
Related to tissue injury; Dry, warm skin
• Resolves with healing Pupils normal or dilated
Continues beyond healing
Clients appear restless/anxious Client appears depressed and
withdrawn
Client reports pain Client does not mention pain
unless asked
Client exhibits behavior indicative Pain behavior often absent
of pain, crying, rubbing/holding
area

Stimulus Type Physiologic Basis of Pain

Mechanical:
• Trauma to body tissue (ex. Tissue damage; direct irritation of
surgery the pain receptors; inflammation
• Alterations in body tissues Pressure on pain receptors
(ex. edema)
• Blockage of a body duct Distention of the lumen of duct
• Tumor Pressure on pain receptors;
irritation of nerve endings
Stimulation of pain receptors
• Muscle spasm
Thermal
• Extreme heat or cold (ex. Tissue destruction; stimulation of
burns) thermosensitive pain receptors
Chemical
• Tissue ischemia (ex. blocked Stimulation of pain receptors d/t
coronary artery) accumulated lactic acid (and other
chemicals, such as bradykinin &
enzymes) in tissues
 • Muscle spasm Tissue ischemia secondary to
mechanical stimulation

Physiology of Pain: (patient cannot discriminate among

these)
• Reception-Initial receiving. Nerve
• receptors in skin & tissue respond to stimuli resulting
from actual or potential tissue damage
o Pain threshold-Amount of pain stimulation a
person requires to feel pain (can change)
o Pain tolerance-Max. amount and duration of pain
that an individual is willing to endure
 Varies from individual to individual
 Decreased pain relief despite increase in
dosage
• Perception-Point at which person is conscious of the
pain; experience of pain; process by which stimulus is
received
• Reaction-Physiological or behavioral responses after
pain is received
o Coping methods:
 Voluntary
 Involuntary
 Emotional
Gate Control Theory:
• Suggests transmission of pain impulses may be
modified, or even blocked by gating mechanisms along
the CNS
o Gate open=Pain impulses flow freely
o Gate closed=Pain impulses blocked
o Gates can be partially open
• Explains how external measure can override sensory
input and block pain transmission at the gate (closes
gate)
o Massage
o Relaxation breathing
o Imagery
o Distraction
How does the Gate theory work?
Pain results from stimulation of C-fibers (slow, small fibers)
• When sensory stimulation (pain) reaches a critical level;
gate opens allowing pain message access to the brain
Pain is inhibited by the A-delta fibers (fast, large fibers)
• Stimulating these opposes C-fibers input and causes
the gate to close
Pain Scales
• Verbal Descriptions Scale
o Word
o Descriptors
o Numbers
• Visual Analog-consists of straight line continuum
o May be more sensitive measure of pain severity
because clients mark at any point on continuum
rather than being forced to use one word
Wong-Baker FACES is universal to all ages
Flacc scale good for infants/children who lack language

Subjective & Objective Data to correct and analyze

when assessing pain:
QUEST (children) OLDCART PQRST
• Question child • Onset • Provoking
• Use rating • Location • Quality
scale • Character • Region
• Evaluate • Aggravating • Severity
• Secure (fear) factors • Timing
• Think about • Radiation
pathology • Treatment

Pain Pattern:
• Helps assess specific events/conditions that
precipitates or aggravates pain
• Ask patient to demonstrate actions that elicit painful
responses-coughing or ambulation
• Precipitating factors-Body functions or movement may
cause variation in character of pain.
• Alleviating factors:
 o Patient may have own way of relieving pain
 Change position
 Eating
 Applying heat to site
o Patient’s methods often work best for nurse as
well
o Patients with chronic pain are more likely to try
alternative healthcare methods
Nursing Diagnosis:
• Ineffective coping related to prolonged continuous back
pain
• Ineffective pain management
• Inadequate support systems
• Disturbed sleep pattern related to increased pain
perception at night
• Deficient knowledge (pain control measures) related to
lack of exposure to information resources
ADL’s
• Inability to participate in routine activities
o Assess extent of disability and needed
adjustments to help patient participate in self care
o Help patient select ways of minimizing or
controlling pain so they remain productive
Sleep Hygiene Sexual activity
Ability to work Homemaker Social activities
• Assess if necessary for patient to temporarily stop or
modify activity d/t pain
Implementation:
• Nature of pain & extent to which it affects physical and
psychosocial well being-determine choice of pain relief
therapy
• Witt describes following characteristics of ideal nursing
interventions for chronic pain management
o Interventions should be within the scope of the
average nurses qualifications to use them
effectively
o There should be no need for special equipment
that may not be unavailable in the HC setting
 o Therapies should not interfere w/the patients
medical treatments
o Nursing interventions should not be subject to a
physician’s approval or supervision and should not
require the client’s consent
Non-Pharmacologic Pain Control Interventions
Massag Breathing techniques Relaxation Education
e
Imager Relaxation Rest/sleep Dim lights
y
Tens Cutaneous Hot/cold Distraction
stimulation
hypnosi Anticipatory Acupuncture biofeedback
s guidance

Individualizing Care For Clients With Pain:

• Trusting relationship, convey concern & acknowledge
pain
• Consider Pt’s ability & willingness to participate actively
in pain relief measures
• Use variety of pain relief measures
• Relieve pain before it becomes severe-educate patient
to ask for meds
o Use pain relief methods that the patient believes
are effective
o Pt. reports on pain/effectiveness
o Encourage different attempts if innefective
• Maintain unbiased attitude
• Keep trying. Do not ignore
• Prevent harm; therapy should not increase discomfort
• Educate patient and caregivers

Education:
• Better able to handle when they understand it
• Teaching about pain experience reduces anxiety &
helps patient achieve a sense of control
• Fear if friends had unpleasant experience in similar
circumstances
 o Fear increases perception of painful stimuli
• Teach during “anticipatory phase” (recognizing
symptoms)
• Anxious patient/fearful patient
• Relevant play-child (dolls, toys, pictures..etc)
Barriers to effective Pain Management:
• Misconceptions and biases
• Knowledge deficits
• Patient may not report because they think nothing can
be done
• Fear of addiction
• Cultural issues
Measures That Alter Pain Reception:
• Promote comfort & protect from harm by removing or
preventing painful stimuli
• Controlling painful stimuli in patient’s environment
• Avoid pain by maintaining normal body function
• Anticipate and prevent pain (procedures or activities)
• Knowledge of precipitating or aggravating factors may
help prevent or minimize the patient’s discomfort
Cutaneous Stimulation-Stimulation of a person’s skin to
relieve pain
• Used to prevent or reduce pain reception
• Do not use on sensitive skin areas
• Can be used in home
• Gives patients/families some control over pain
symptoms & treatment
Massage Warm baths Liniments Hot/cold
TENS Therapeutic reiki
touch

Patients With Intractable Pain

• Can’t be permanently relieved; intense pain/unbearable
• Patient assumes a dependent role due to debilitating
pain
• Encompasses Patients total existence
• Patient will do anything for relief even though it may
not be obtained
 • 1 in 3 metastatic cancer patient’s have this
• Analgesic treatment is different for patients who can’t
control the spread of their cancer
• WHO recommends 3 step approach to manage cancer
pain
• When patient w/cancer, first experiences pain, best to
begin w/a higher dose of meds than needed for relief
• Opiates are often under-prescribed; MD’s fear
depression of CNS
Pain Clinics: (experts in field)
• Inpatient/outpatient
• Coordination of members of health disciplines
• Diversity of therapy/new treatments
• Syndrome-oriented
• Modality-oriented
Hospice:
• Help terminally ill to live at home in comfort & privacy
w/help of hospice HC team
• Pain control experts
• Educate family
• Option to be hospitalized if needed
Pharmacological Pain Therapy:
• Requires MD orders
• Nurses judgment in the use & management of meds
helps to insure best pain relief possible
• Administering analgesics:
o Most common method of pain relief
o Nurses & MD’s have misconceptions about
dangers & effects of analgesics
o Opioids generally prescribed for severe pain ex.
malignant
o Adjuvants
 May create analgesic (lack of pain)
 Relieve other S/S associated w/pain ex.
nausea, depression

Types of Analgesics
  Nonopioid Analgesics/NSAIDS
Acetaminophen acetylsalicylic acid Choline
(Tylenol, Datril) (ASA) magnesium
trisalicylate
(trilisate)
Diclofenac sodium Ibuprofen (Motrin, Indomethacin
(Voltaren) Advil) sodium trihydrate
(Indocin)
Naproxen Celecoxib Piroxicam
(naprosin) (Celebrex) (Feldene)

 Mixed or weak Opioid Analgesics

Butorphanol Hydrocodone Codeine (Tylenol
(Stadol) (Lortab, Vicodin) #3, Empirin #3)
Tramadol (Ultram, Propoxyphene
Ultracet) napsylate (Darvon-
N)

 Strong Opioid Analgesics

Fentanyl citrate Hydromorphone Meperidine
(Sublimaze, hydrochloride hydrochlorid
transdermal patches (Dilaudid) e (Demerol)
Morphine sulfate Methadone
(Dolophine)

 Coanalgesics
Tricyclic antidepressants Anticonvulsants (gabpentin)
(nortiptyline)
Topical local anesthetic Hydroxyzine (Vistaril)
(Lidoderm)

Nurses principles for administering meds:

 Careful assessment-Know patient’s previous response
to analgesics
 Application of pharmacological principles-Select proper
meds when more than on is ordered
 Common sense-mild narcotic could be more potent for
some
  Know accurate dosage
 Asses right time & interval for administration
Nurses Responsibility to a Client in Pain:
 Educate about:
o Facilities pain management policy
o Pain assessment process
o Ways of providing pain relief
 Identify level of pain
 Include pain management in plan of care
 Document patient’s response to meds/treatment
 Evaluate effectiveness of plan of care & modify
 Notify PCP if pain continues unabated
WHO 3-step Analgesic Ladder
 Step 1-nonopioid; +/- adjuvant
o Pain persisting or increasing, go to:
 Step 2 opioid for mild to moderate pain; +/-
nonopioid/adjuvant
o Pain persisting or increasing, go to:
 Step 3 opioid for moderate to severe pain; +/-
nonopiod/adjuvant
o Freedom from cancer pain
Placebo-An inert substance that is “used in research or
clinical practice to determine effects attributable to the
administration of the placebo rather than the pharmacologic
properties of a legitimate drug or treatment.
 Prescribed by MD, prepared by pharmacy
 Ethics-Pt needs to be informed
 Action-30% effective
 American Pain society adamantly opposes without
consent
Nursing Interventions for Clients receiving Analgesics
through an Epidural Catheter
 Safety-label tubing, infusion bag, pump marked
“epidural”
 Prevent infection-aseptic
 Maintain urinary & bowel function-monitor I&O/assess
distention
  Monitor for & manage narcotic-related S/E & catheter
related complications
 Monitor effectiveness of pain control
PCA—Patient Controlled Analgesia
 Patient benefits from having control over pain therapy
 Portable (usually computerized) pump containing
chamber for syringe
 Educate about use: how it works, when to use,
 Assess ability
 Monitor pain level, VS, LOC, mental status, sedation
level q 2 hr
 Evaluate IV patency
 Verify pump settings by 2 nurses q time the syringe is
changed, parameters are changed and shift change (at
least q 8 hr)
 Lock machine (machine has lock-out; limit)
 Usually morphine, hydromorphone
 May have basal rate-small amount given automatically
but patient can push button prn
Local Anesthesia Techniques
Type Area of injection Area Indications for
anesthetized use
Infiltration Superficial area under Sm. Peripheral Sm. Incision of
skin or mucous nerves to area skin, insertion of
membrane infiltrated sutures to close
cuts or wounds,
minor dental
repairs
Peripheral Area surrounding lg. Wide area than Major dental
nerve peripheral nerve at with infiltration, repairs,
block point above numbing entire manipulation or
bifurcation of nerve body part (hand, reduction of
upper gums, foot) extremity
fractures, minor
hand & foot
surgery
Epidural or Lumbosacral region of Lower trunk & Delivery of
peridural spinal cord, around extremities newborn, major
nerve major nerve roots surgery to lower
block exiting base of spinal trunk & extremities
cord at site outside (hemorrhoidectom
dura mater y, appendectomy,
vascular repair
Spinal Around major nerve Lower trunk & Major surgery to
nerve root within extremities lower trunk &
block subarachnoid space extremities,
of spinal cord patients at risk
w/general
anesthesia

Evaluation of Pain Relief Measures

 Patient is best resource for evaluation of effectiveness
of pain relief measures
 Nurse must continually determine
 Family is another valuable source, esp. w/CA pts not
able to express discomfort during the latter stages of
terminal illness
 Nurse uses evaluation criteria in determining the
outcome of pain relief therapies
 Therapy not working; change or try a different one
 Nurse evaluates patient’s perception of effectiveness of
therapy