Pain Management

Kim L. Paxton MSN, ANP, APRN-BC

Bro. Jim O’Brien, OFM, Conv. R.N., M.S.N., O.C.N.
The International Association for the Study of
Pain defines Pain as:

“an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or
described in terms of such damage or both.”
McCaffery, 1979
Regardless of the definition, most will agree that pain
has both Sensory & Behavioral components and is
strongly influenced by:

Physiologic
Psychologic
Sociologic factors.
 Types of Pain
Acute Radiating
Chronic Referred
Cutaneous Intractable
Somatic Phantom
Visceral
Neuropathic
 Characteristics of Acute Pain

Acute Pain serves a biologic purpose

It acts as a “warning signal” because it can

activate the sympathetic nervous system causing
various physiologic responses, similar to “fight or
flight”
Characteristics of Acute Pain
Has a short duration
Usually has a well-defined cause
Decreases with healing
Is reversible
Ranges for mild to severe
May be accompanied by anxiety and restlessness
 Physiologic & Behavioral Responses to Acute Pain

Physiologic Response Behavioral Response

Acute Pain: Acute Pain:

Increased BP initially Restlessness

Increased pulse rate Inability to concentrate
Increased respirations Apprehension
Dilated pupils Distress
Perspiration
AcutePain:
Post-op pain is the most common example of Acute
Pain
The severity of postoperative pain may
be a predictor of long-term pain
Trauma
Burns
Procedural
Obstetric
PAIN’S VARIABLE FACE
Post-op pain management:
The use of “pre-emptive” analgesia is a “new”
technique

Pre-emptive analgesia includes administering

local anesthetics, opioids, & NSAIDs in pre-op,
intra-op, & post-op
Characteristics of Chronic Pain

Lasts more than 3 or > months

May or may not have well defined cause
Begins gradually and persists
Is exhausting and useless
Ranges from mild to severe
May be accompanied by depression, fatigue and
 functional ability
 Physiologic and Behavioral Responses to Chronic Pain

Physiologic Response Behavioral Response

Chronic Pain: Chronic Pain:

Normal BP Immobility or physical

Normal pulse rate inactivity
Normal respirations Withdrawal
Normal pupils Despair
Dry skin
Chronic Pain:

Often associated with non-cancer entities:

diabetic neuropathy
“phantom limb pain”
 low back pain
 no identifiable cause
Chronic Pain:

May have remissions and exacerbations

Oftentimes leads to depression & anger

Is not as readily treated as Acute Pain is by health care

workers
Chronic Pain Cancer

Cancer pains is caused by a the disease itself:

Nerve compression
Invasion of tissue
Bone metastasis
The cells of the substantia Gate Control Theory
gelatinosa
Can either inhibit or
facilitate the pain
impulses through the
trigger cells (T cells)
The T-cell acts as the
gate
If the gate is closed
there is less
probability of a
impulse being
transmitted to the
pain to illicit a pain
response
 Sources of pain

Somatic pain

Cutaneous or superficial
Originates in skin or subcutaneous tissue
Has an abrupt onset, with a sharp, stinging
quality i.e., a paper cut
Deep, Somatic Pain:

Originates in the
bone, muscle, blood
vessels, connective
tissue
Has a slower onset, a
burning quality, &
lasts longer than
cutaneous pain i.e., a
sprained ankle
Somatic pain

Acute post-op Chronic

Incisional pain Bony mets
IV’s, catheters, drains Lumbar back pain
Skeletal muscle spasms PVD
Ortho procedures fibromyalgia
Arthritis
Osteo
Rhematoid
Visceral Pain:

Originates from the organs and linings of the body

cavity
Stimulation of pain receptors in the:
Abdominal cavity
Thorax
Characteristics of Visceral Pain:
Poor localization
Diffuse,
Deep cramping, aching, feeling of pressure

Examples include: chest tube, pancreatitis, bowel

obstruction
Visceral Pain

Post op acute Chronic

Chest tubes Pancraetitis
Drains Liver mets
Bladder distention Appendicitis
Bowel distention Cholecystitis
etc.
Neuropathic Pain:

Chronic

Diabetic neuropathies
Postherpetic neuralgia
Nerve compression: back injury
Neuropathic Pain:

Results from current or past damage to the nerve

fibers, spinal cord, central nervous system
Neuropathic Pain:

Characteristics include: long-lasting, poorly

localized, shooting, burning, sharp, numb, shock-
like

Examples: chemotherapy-induced neuropathies,

diabetic neuropathy
“Phantom Pain:”

Considered acute form

Usually pain that follows a limb amputation, although
the term can be applied to mastectomy & tooth
extractions

A type of neuropathic pain

Phantom Pain:”

Specific cause is unknown, but research suggests that is a

somatosensory “memory” that does not reside in a specific
region of the CNS, but may involve complex interactions
of neural networks in the brain
 Asessment of Pain
Location
Character and quality – ask the patient to describe the
pain without suggesting words, unless he’s having
difficulty
Pattern – rarely the same at all times
Duration – how long does it last
Intensity – Use scale of “0 to “10”
Aggravating & alleviating factors
Types of pain
Localized pain:
Pain confined to the site of origin

Projected pain:
Pain along a specific nerve or nerve root
Types of pain
Radiating:
Perceived at the source of pain and extends into
nearby tissues
An example being: Cardiac pain that radiates down
the left shoulder and arm

Referred Pain:
Perceived in an area distant from the site of painful
stimuli
Ex. Right shoulder pain referred from gallbladder
Pain
Assessment
O - Onset
L - Location
D - Duration

C - Character
A - Associated/aggravating symptoms
R - Relieving factors / exacerbating
factors
T - Types of treatments patient has tried
Pain
Assessment

P – Provokes or Palliative
Q - Quality
R – Radiation
S – Severity
T – Time What were you doing when this started how
long have you had it.
Pain
The Assessment
A. - Mental status
- Pain scale
- VS
- Any other symptoms present
- Check your site prior to administration

B. - Follow the 6 rights

C. - Reassess in a timely manner

Intractable Pain:

Moderate to severe pain that cannot be relieved by

any known treatment, or pain that is highly resistant to
relief methods

Nurses are challenged to use a variety of

pharmacologic & non-pharmacologic methods of
relief

Example: Advanced Bone Cancer Pain

Pain and children
Pain Rating Scales for Children:

FACES Pain Rating Scale – shows a series of happy to

really hurting faces, and the child simply points
Oucher Scale
Poker Chip Scale – children under five use poker chips
that represent 1-4 pieces of “hurt” to show how much
they’re hurting
The “Pain Scale”
Assessing Pain in Children:

With Infants, observe for:

Tears
High-pitched sharp cry,
Stiff posture
Clenched fists
Inconsolable
FLACC Behavioral Pain Assessment Scale
Assessing Pain in Children:

With Toddlers, there’s a limited vocabulary, and difficulty

making comparisons. Observe for:
Crying
Rocking
Not wanting to be touched
Behavior changes
Assessing Pain in Children:
Preschoolers can describe pain, but have trouble
with intensity. Observe for:
Gritting teeth
Covering painful areas with
their hands
Unusual behavior
School-Age & Adolescent Children:

May continue having difficulty describing pain

Younger children may still struggle with their
understanding of increments of pain
Older children may fear looking like a “baby” if
they report pain
ShotBlocker

• The device is positioned

over the injection site
• The blunt contact points are
pressed firmly against the
skin.
• The shot is immediately
administered through the
opening.
• After the injection
the ShotBlocker is lifted
from the skin and discarded.
Non-Pharmacologic Pain Management

Ice Biofeedback requires the

Heat use of a special machine
Elevation that allows the patient to
Distraction see how his body reacts
to his efforts. When the
Imagery
patient is connected to
Relaxation the machine, he performs
Biofeedback a relaxation technique.
Music The machine responds
with tones, lights, or a
digital readout.
Pharmacologic Pain Management:

Non-Opioid Analgesics
NSAID’s
Opioid Analgesics
PCA’s
Epidurals
Adjuvant Drugs – enhance effects of opioids & lessen
anxiety i.e., antidepressants
PCA pump and
Patient
activation cord
PCA pump
Analgesics & Adjuvant* Therapy

Non-Opioids: ASA, Tylenol

NSAID’s: Ibuprofen, Celebrex, Toradol

Opioids: Morphine, MS-Contin, Dilaudid, Demerol, Fentanyl

Patch

Combination Opioid/NSAID’s: Tylenol #3, Lortab, Vicodin,

Percocet, Percodan

* Adjuvant Therapy: Tegretol, Dilantin, Neurontin, Elavil,

Zoloft, & Paxil
For a Narcotic OVERDOSE, we give:

NARCAN

An Opioid (Narcotic) antagonist

0.4mg – 2mg IVP
AKA: Naloxone Hydrochloride
Usually given IV SLOWLY! Too rapid administration
results in nausea, vomiting, tremors, sweating, increased
BP, & tachycardia.
Setting A Pain Goal
This is mutually agreed upon between the patient
and the Health Care Team!

Questions to consider:
What is realistic?
What is tolerable?
What are the patient’s life goals? i.e., would the
patient rather have more pain, but be more alert?
Addiction, Physical Dependence, and Tolerance:
Addiction: persistent craving for and abuse of a drug for
recreational reasons; it is a psychological phenomenon, not a
physical one.

Physical Dependence: a physiological adaptation of the body

tissues so that continued administration of the drug is required
for normal tissue function. Withdrawal is suffered if drug is
discontinued!

Tolerance: a common physiologic result of chronic opioid use;

larger doses of opioid are required to achieve the same level of
analgesia.
Surgical Interventions for Pain:

Neurectomy – resection or partial or total

excision of a spinal or cranial nerve.

Rhizotomy – cutting a nerve to relieve pain;

sensory nerve roots are destroyed where they
enter the spinal cord.
Surgical Interventions for Pain:

Cordotomy – the surgeon cuts the pain pathways at

the midline portion of the spinal cord – before
impulses ascend.

Nerve Blocks – localizing a nerve root and injecting

it with a local anesthetic or with a chemical agent to
achieve permanent neurolysis
What is a TENS Unit?

TENS stands for “transcutaneous electrical

nerve stimulation”
It relieves acute and chronic pain by using a
mild electrical current that stimulates nerve
fibers to block transmission of pain impulses to
the brain. It is delivered through the application
of electrodes placed on the skin at points related
to pain
The TENS Unit
Nursing Diagnoses related to Pain:

Fear related to pain

Powerlessness related to pain
Altered sexuality related to illness & pain
Activity intolerance related to pain
Sleep pattern disturbance related to pain
Self-Care deficit related to pain
A feeling of hopelessness related to pain
Evaluation: Outcomes for the Client with Pain:

Report that acute pain is relieved or reduced

Report that chronic pain is relieved, reduced, or NOT

worsened

Establish realistic goals given limitations imposed by

chronic pain

Perform activities of daily living

Patient and Family Education:

Teach the names of the medications

Promote adherence to the pain regime – medication on a
scheduled basis vs. prn
Don’t wait until the pain is unbearable
Keeping a “pain diary”
Mechanisms of action of the medications(s): long-acting
vs. short-acting
Review adjuvant therapy – i.e., anti-anxiety
Goal of Pain Management:
A HAPPY,
Comfortable Patient!