Chapter 46 Pain Management Nursing Skills Types of Pain: 1.

Location where it is may be useful in determining the clients underlying problems or needs. a. If knee surgery and client reports chest pain this is immediate concern. b. Some pain radiate. Referred appear to arise in different areas. Referred to other body parts. Cardiac pain may be felt in shoulder of left arm with or without chest pain c. Visceral pain arising from organs or hollow viscera. Feel in an area remote from the organ causing the pain. 2. Duration Acute sudden or slow onset and intensity doesnt matter. It should only last through the expected recovery period. a. Chronic over 6 months. Chronic Pain according to NANDA mild to severe, constant or recurring, without an anticipated or predictable end and a duration greater than 6 months. b. Chronic cancer (malignant) vs. Chronic nonmalignant pain categorizing has been difficult. Cancer pain may result from direct effects of disease and its treatment. Or may be unrelated to disease and its treatment. i. Malignant HIV/AIDS, burn pains because tend to be treated more aggressively than nonmalignant pain 3. Intensity Mild, moderate, or severe or underlying physiology (somatic, visceral, neuropathic) a. 1-3 mild b. 4-6 moderate c. 7-10 severe 4. Etiology a. Physiologic pain experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care. Cut or broken bone. i. Transient pain meaning once healed it goes away. ii. Persistent pain iii. Somatic Pain skin, muscles, bone or connective tissue iv. Visceral pain activation of pain receptors in organs or hollow viscera. Tends to be poorly located and may have a cramping, throbbing, pressing or aching quality. Feeling sick-nausea, vomiting, or labor pain, angina pectoris or irritable bowel. b. Neuropathic pain damaged or malfunctioning nerves. Typically chronic i. Peripheral neuropathic pain damage or sensitization of peripheral nerves (carpal tunnel syndrome, phantom limb pain) ii. Central neuropathic pain malfunctioning nerves in CNS (spinal cord injury, post stroke)

iii. Sympathetically maintained pain abnormal connections between pain fibers and the sympathetic NS perpetuate problems with both the pain and sympathetically controlled functions. (temp, edema, and blood flow regulation) 5. Concepts associated with Pain a. Pain threshold-least amount of pain needed to label it as pain. b. Pain tolerance- max amount of painful stimuli person is willing to withstand. c. If these are caught early, they may be reversed. These are development of neuropathic processes d. Hyperalgesia-Hyperpathia-heightened response to pain stimuli e. Allodynia-nonpainful stimuli produce pain f. Dysesthesia-unpleasant abnormal sensation. Imitates pathology of a central neuropathic pain disorder, such as the pain that follows a stroke or spinal cord injury. 6. Pain Assessment a. The fifth vital sign b. Comprehensive assessment physiologic, psychologic, behavioral, emotional, and sociocultural c. Acute, severe pain focus on location, quality and severity provide intervention to control pain before conducting a more detailed evaluation. d. Pain should be screened every time vital signs are evaluated. are you experiencing any discomfort right now During initial postoperative period vitals are taken every 15 minutes, screening for pain this frequently is justifiable as there is a high incidence of pain in perioperative period. e. Major barriers inadequate assessment of pain and fear of treatment related problems. Pain assessments must be initiated by the nurse most patients wont express pain unless asked. Ask do you have discomforts to report? Not do you have any complaints of pain? f. Consist of two major components i. A pain history to obtain facts from the client ii. Direct observation of behaviors, physical signs of tissue damage and secondary physiologic responses. iii. Goal is to gain objective understanding of a subjective experience. g. COLDERR i. Character: describe sensation (sharp, aching, burning) ii. Onset: when it started, how it has changed iii. Location: where it hurts iv. Duration: constant vs. intermittent v. Exacerbation: factors that make it worse vi. Relief: factors that make it better vii. Radiation: pattern of shooting/spreading/location of pain away from its origin. 7. Pain History a. Each persons pain is unique and the client is best interpreter of the pain experience. b. Previous pain treatment and effectiveness

When and what analgesics were last taken Other medications being taken Allergies to meds Chronic pain focus on clients coping mechanisms, effectiveness of current pain management, and ways in which pain has affected clients body, thoughts and feelings, activities and relationships. g. Data needed COLDERR, effect on ADLs, past pain experiences, meaning of the pain to the person, coping resources, and affective responses. 8. Pain intensity or Rating scales a. 0-10 b. 0= no pain, 2=awareness of pain only when paying attention to it, 4= can ignore pain and do things, 6=cant ignore pain, interferes with functioning, 8=impairs ability to function or concentrate, and 10=intense incapacitating pain. c. Perception of intensity is affected by: i. Amount of distraction or clients concentration on another event ii. The clients state of consciousness iii. The level of activity iv. Clients expectations d. Preverbal children, elderly clients with impairments in cognition or communication, people who do not speak English. i. Wong-Baker FACES rating scale may be easier. e. For clients who cannot verbalize their pain due to age, mental capacity, medical interventions, nurse must rely on observation of behavior. f. Use of pain rating scale and pain flow sheet effective in improving pain management. Pain Management 9. Acknowledge and accept clients pain a. Pharmacologic Pain Management i. NSAIDS aspirin and ibuprofen. analgesic and anti-inflammatory, and antipyretic effects. ii. Acetaminophen has only analgesic and antipyretic effects. iii. Opioids relieve moderate to severe pain. Reduce perception of pain, produce sedation, decrease emotional stress of pain. 1. Assess pain prior to and 60 minutes after administration 2. Assess bowel function to prevent constipation 3. Keep track of total amount of acetaminophen or aspirin the client is receiving. 4. Take with food, avoid alcohol, meds may cause dizziness, b. Patient Controlled Analgesia i. Interactive method of pain management that permits clients to treat their pain by self administering doses of analgesics.

c. d. e. f.

ii. Oral route most common, but subcutaneous, intravenous and epidural routes. iii. Minimizes the roller coaster effect of peaks of sedation and valleys of pain that occur with traditional method of prn dosing. iv. Effective for clients with acute pain related to a surgical incision, traumatic injury or labor and delivery and for chronic pain as with cancer. v. PCA by proxy used even if client is unable to initiate dose as long as caregiver is willing to accept the responsibility. This practice should be avoided. 10. Nonpharmacologic Pain Management a. Cutaneous stimulation b. Ice or heat c. Immobilization or therapeutic exercises d. Transcutaneous electrical nerve stimulation (TENS) e. Acupuncture f. Mind body interventions distracting activities, relaxation techniques, imagery, meditation, biofeedback, hypnosis, cognitive-reframing, emotional counseling, and spiritually directed approaches such as therapeutic touch or Reiki. g. Lifestyle management stress management, exercise, nutrition, pacing activities, disability management, and other approaches needed by many clients with persistent pain that has drastically changed their life.