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Pain Management chapter. Spring semester., Lecture notes of Nursing

Nashville State Community CollegeNursing
Prof. Linda Morrow

Explains how pain management is in the nursing field.

Typology: Lecture notes

2022/2023

Available from 03/04/2023

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Chapter 34 Pain Management
- Scientific Knowledge Base: Nature of Pain
Pain
oSubjective and highly individualized
oProtects a person from a harmful stimulus
oExists when the patient says it exists
oInability to express pain doesn’t mean the patient is pain free
oCareful assessment is critical
- Physiology of Pain
- Physiology of Pain
Transduction
oConverts energy produced by stimuli into electrical energy
Transmission
oCellular damage from injury results in the release of excitatory neurotransmitters
- Physiology of Pain
Transmission
oThe pain stimulus enters the spinal cord
oNerve impulses travel along afferent peripheral nerve fibers
Fast myelinated A-delta fibers
Slow unmyelinated C fibers
- Physiology of Pain
Perception
oCNS extracts information from the pain impulse
oBrain interprets information
Modulation
oNeurotransmitters
- Physiology of Pain (Cont.)
Gate-control theory of pain (Melzack and Wall)
Pain has emotional and cognitive components, in addition to a physical sensation.
Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses.
Pain impulses pass through when a gate is open and are blocked when a gate is closed.
Closing the gate is the basis for nonpharmacological pain relief interventions
- Physiology of Pain (Cont.)
Physiological responses
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Chapter 34 Pain Management

  • Scientific Knowledge Base: Nature of Pain  Pain o Subjective and highly individualized o Protects a person from a harmful stimulus o Exists when the patient says it exists o Inability to express pain doesn’t mean the patient is pain free o Careful assessment is critical
  • Physiology of Pain
  • Physiology of Pain  Transduction o Converts energy produced by stimuli into electrical energy  Transmission o Cellular damage from injury results in the release of excitatory neurotransmitters
  • Physiology of Pain  Transmission o The pain stimulus enters the spinal cord o Nerve impulses travel along afferent peripheral nerve fibers  Fast myelinated A-delta fibers  Slow unmyelinated C fibers
  • Physiology of Pain  Perception o CNS extracts information from the pain impulse o Brain interprets information  Modulation o Neurotransmitters
  • Physiology of Pain (Cont.)  Gate-control theory of pain (Melzack and Wall)  Pain has emotional and cognitive components, in addition to a physical sensation.  Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses.  Pain impulses pass through when a gate is open and are blocked when a gate is closed.  Closing the gate is the basis for nonpharmacological pain relief interventions
  • Physiology of Pain (Cont.)  Physiological responses

o Low to moderate intensity pain; superficial pain  Sympathetic stimulation  Severe or deep pain o Parasympathetic stimulation o If untreated, can progress to chronic pain  Chronic pain o Unrelieved pain can cause permanent neuroplastic changes  Behavioral responses

  • Acute and Chronic Pain
  • Cognitive and Cultural Influences on Pain Perception  Perception of pain is influenced by cognitive and cultural factors: o Patient’s previous experiences with pain and current physical and mental status affect pain perception and response.  Cognitive factors: o Attention people give to the pain. o Expectation or anticipation of pain. o Appraisal or expression of pain.  Cultural factors: o Cultural influences may affect how pain is communicated.
  • Types of Pain  Pain is categorized in several ways, but clear distinctions among types may not be possible.  Acute pain has recent onset and results from tissue damage, is usually self-limiting, and ends when tissue heals. o May cause physiologic signs associated with pain.  Persistent (chronic) pain may be intermittent or continuous pain lasting more than 6 months. o Clinical manifestations of chronic pain are not those of physiologic stress because patient adapts to pain, but often reports symptoms of irritability, depression, withdrawal, or insomnia.
  • Inferred Pain Pathology  Nociceptive pain: o Arises from somatic structures such as bone, joint, or muscle. o Results from activation of normal neural systems.  Neuropathic pain: o Occurs because of abnormal processing of sensory input.

 School-age children better understand pain and are able to describe pain location.

  • Age-Related Variations: Older Adults  Although transmission and perception of pain may have slowed down in older person, pain is felt no differently than by any other adult.  Many older adults have a lifetime of experience in coping with pain, but pain is not an expected part of aging.
  • Nursing Process: Assessment  Determine which level of pain will allow your patient to function.  When the patient is in acute pain, assess location, severity, and quality.  When the patient is more comfortable, collect a more detailed assessment. o PQRSTU  Pain is always changing; monitor it on a regular basis along with other vital signs.
  • Nursing Process: Assessment (Cont.)  Patient’s expression of pain o Patients may not volunteer pain status; always ask o Recognize nonverbal expressions of pain  Patients unable to self-report pain o Infants and children o Patients who are critically ill and/or unconscious o Patients with dementia o Patients who are mute or aphasic o Patients with an intellectual disability o Patients at the end of life
  • Nursing Process: Assessment (Cont.)  Characteristics of pain o Timing (onset, duration, pattern) o Precipitating factors o Quality o Relief measures o Region/location o Severity o Effect of pain on patient
  • Problem-Based History  Pain is a complex, multidimensional, subjective experience  Collect data from patients using a symptom analysis applying the mnemonic OLD CARTS o O = Onset o L = Location o D = Duration o C = Characteristics o A = Aggravating factors o R = Related symptoms o T = Treatment by the patient o S = Severity
  • Assessing Pain in Children
  • Nursing Process: Assessment (Cont.)  Concomitant symptoms o Occur with pain and usually increase pain intensity  Patient expectations o Recognition and relief of pain o Prompt response  Documentation o Report of pain o Effectiveness of interventions o Always use the same assessment tool to reassess the patient’s pain.
  • Pain Reassessment  After taking the medication, how would rate your pain now? o 30 minutes after parenteral administration. o 60 minutes after oral administration.  Assessing those who cannot communicate: o Attempt self-report. o Search for potential causes of pain. o Observe for behavioral changes. o Question caregivers about patient’s usual response to pain. o Attempt analgesic trial and observe behavior.
  • Examination  Observe patient for posture and behavior that helps relieve pain.  Observe facial expressions.  Listen for sounds made by patient.  Inspect skin for color, temperature, moisture.  Measure blood pressure and pulse.  Assess respiratory rate and pattern.  Observe pupillary size and reaction to light.
  • Nursing Process: Diagnosis  Risk for Caregiver Role Strain  Ineffective Coping  Fatigue  Impaired Physical Mobility
  • Nursing Process: Implementation (Cont.)  Restorative and continuing care o Opioid infusions o Failure of pain control medications with chronic pain o Palliative care o Hospice
  • Evaluation  Patient care o The patient is the source for evaluating outcomes. o Compare actual outcomes with expected outcomes.  Patient expectations o Assess patient behaviors. o Ask the patient if expectations have been met. o Use open-ended assessment questions.
  • Safety Guidelines  Be vigilant during the entire process of medication administration.  Take care of yourself. You think as clearly and critically as possible if you are healthy.  Set up and prepare medications in distraction-free areas.