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Edith Johnson

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Comfort and Pain Management

Objectives

Define pain.

Describe the neural mechanisms of pain and pain modulation.

Differentiate between nociceptive and neuropathic types of pain.

Explain the physical and psychologic effects of unrelieved pain.

Interpret the subjective and objective data that are obtained from a comprehensive pain assessment.

Describe effective multidisciplinary pain management techniques.

Describe drug and nondrug methods of pain relief.

Explain your role and responsibility in pain management.

Describe characteristics of pain.

Describe different types of pain; referred, breakthrough, visceral pain acute vs. chronic pain

Introduction

One major reason people seek health care

Nurses have a central role in assessment and management.

Can reduce quality of life

Pain is a complex, multidimensional experience.

For many people, it is a major problem that causes suffering and reduces quality of life.

Nursing Roles

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.

Magnitude of Pain Problem

25 million people experience acute pain from injury or surgery.

116 million people have back pain, arthritis, and migraine headaches.

70% of cancer patients experience significant pain.

The financial impact of pain is staggering.

In the United States, unrelieved and inadequately managed pain costs an estimated $560-635 billion each year in direct medical treatment costs and lost work productivity.

Magnitude of Pain Problem

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

1/3 of hospice patients report pain at their last visit.

For example, approximately one-third of patients enrolled in hospice reported pain at their last hospice visit.

Cancer pain is often undertreated.

Magnitude of Pain Problem

Consequences of untreated pain

Unnecessary suffering

Physical and psychosocial dysfunction

Sleep disturbances

Immunosuppression

Definition of Pain

“Whatever the person experiencing pain says it is, existing whenever the person says it does.” Margo McCaffery RN (1968)

“Unpleasant sensory and emotional experience associated with actual or potential tissue damage.” International Assoc. for the study of pain (IASP)

Pain was originally defined in 1968 by Margo McCaffery, a nurse and pioneer in pain management.

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Note that these definitions emphasize the subjective nature of pain, in which the patient’s self-report is the most valid means of assessment.

Description of Pain

Subjective: Patient’s experience and self-report are essential.

Can be problematic when dealing with special populations (coma or dementia)

Nonverbal information such as behaviors aids the assessment of pain.

Patients who are comatose or who suffer from dementia, patients who are mentally disabled, and patients with expressive aphasia possess varying ability to report pain.

In these instances, you must incorporate nonverbal information such as behaviors into your pain assessment.

Types of Pain

Nociceptive Pain: Injury to tissues

Neuropathic Pain: Injury to peripheral nerves

It develops when the nociceptive nerve fibers are triggered by inflammation, chemicals, or physical events, such as stubbing a toe on a piece of furniture

Pain Mechanisms

Nociception: Physiologic process that communicates tissue damage to the CNS

Involves four processes:

Transduction

Transmission

Perception

Modulation

https://www.youtube.com/watch?v=uOaiaYDoUnA

Mechanism of Pain Perception

Nociception is the physiologic process by which information about tissue damage is communicated to the central nervous system (CNS).

It involves four processes: (1) transduction, (2) transmission, (3) perception, and (4) modulation.

Pain Mechanisms Transduction

Noxious stimuli causes tissue damage and begins the neuronal action potential

Occurs at the nociceptors

The noxious stimuli causes tissue damage, and the CNS converts the stimulus into an electrical signal called an action potential.

Pain Mechanisms Transduction

Noxious stimuli cause release of a of chemicals into the damaged tissues.

These substances activate nociceptors and move the pain along the spinal pathway

Prostaglandins, Substance P and Bradykinin

Noxious (tissue-damaging) stimuli, including thermal (e.g., sunburn), mechanical (e.g., surgical incision), and chemical stimuli (e.g., toxic substances), cause the release of numerous chemicals such as hydrogen ions, substance P, and adenosine triphosphate (ATP) into the damaged tissues.

Other chemicals are released from mast cells (e.g., serotonin, histamine, bradykinin, prostaglandins) and macrophages (e.g., interleukins, tumor necrosis factor [TNF]).

These chemicals activate nociceptors, which are specialized receptors or free nerve endings that respond to painful stimuli. Activation of nociceptors results in an action potential that is carried from the nociceptors to the spinal cord primarily via small, rapidly conducting, myelinated A-delta fibers and slowly conducting, unmyelinated C fibers.

Pain Mechanisms Transmission

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

Primary afferent fibers

A-delta fibers (acute localized pain) “fast sharp pain”

C fibers (diffuse visceral pain Burning or aching) “slower dull pain” (THINK C=CHRONIC)

Nerves that carry pain impulses from the periphery to the spinal cord are called primary afferent fibers that include A-delta and C fibers, each of which is responsible for a different pain sensation.

As was previously mentioned, A-delta fibers are small, myelinated fibers that conduct pain rapidly and are responsible for the initial, sharp pain that accompanies tissue injury.

C fibers are small, unmyelinated fibers that transmit painful stimuli more slowly and produce pain that is typically aching or throbbing in quality. Primary afferent fibers terminate in the dorsal horn of the spinal cord, which contains the cell bodies for afferent nerve fibers. Activity in the dorsal horn integrates and modulates pain inputs from the periphery.

Pain Mechanisms Transmission

Three segments are involved:

Transmission along the peripheral nerve fibers to the spinal cord

Dorsal horn processing

Transmission to the thalamus and the cerebral cortex: Opioid analgesics work here

Pain Mechanisms Modulation

Process by which the sensation of pain is inhibited or modified by neuromodulators.

Endorphins : endogenous opioids compounds. Can be released with skin stimulation or relaxation techniques

Descending modulatory fibers release chemicals such as serotonin, norepinephrine, γ-aminobutyric acid (GABA), and endogenous opioids that can inhibit pain transmission.

Several antidepressants exert their effects through the modulatory systems. For example, amitriptyline (Elavil), venlafaxine (Effexor), and duloxetine (Cymbalta) are used in the management of chronic nonmalignant and cancer pain.

Pain Mechanisms Perception

Occurs when pain is recognized, defined, and assigned meaning

Nociceptive input is perceived as pain in the brain.

There is no precise, known location where pain perception occurs.

There is no single, precise location where pain perception occurs. Instead, pain perception involves several brain structures. For example, it is believed that the reticular activating system (RAS) is responsible for warning the individual to attend to the pain stimulus.

Cortical structures also are thought to be crucial to constructing the meaning of the pain. Therefore, behavioral strategies such as distraction and relaxation strategies are effective pain-reducing therapies for many people. By directing attention away from the pain sensation, patients can reduce the sensory and affective components of pain.

Opioids and other classes of analgesics such as some types of anti-seizure drugs and antidepressants modify pain perception.

Following an injury, pain signals are transmitted to the spinal cord and then up to the brain

Before the information is transmitted to the brain, the pain messages encounter "nerve gates" that control whether these signals are allowed to pass through to the brain.

Gate Control Theory

Classification of Pain

By underlying pathology

Nociceptive

Neuropathic: Injury to peripheral nerves

Neuropathic Pain

Injury/ Damage to peripheral nerve or CNS

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

Sudden, intense, short-lived, or lingering

Common causes of neuropathic pain include trauma, inflammation, metabolic disease such as diabetes mellitus, infections of the nervous system, tumors, toxins, and neurologic disease such as multiple sclerosis.

Neuropathic pain often is not well controlled by opioid analgesics alone. Treatment is typically augmented with adjuvant therapies, including tricyclic antidepressants (e.g., amitriptyline [Elavil], nortriptyline [Pamelor], desipramine [Norpramin]), serotonin norepinephrine reuptake inhibitors (e.g., venlafaxine [Effexor], duloxetine [Cymbalta], bupropion [Wellbutrin and Zyban]), anti-seizure drugs (e.g., gabapentin [Neurontin], pregabalin [Lyrica]), and α2-adrenergic agonists (e.g., clonidine [Catapres]).

More recently, NMDA receptor antagonists such as ketamine have shown promise in alleviating neuropathic pain refractory to other classes of antineuropathic pain drugs.

Neuropathic Pain

Can be of short duration but frequently chronic

Allodynia (is the experience of pain from stimuli that isn't normally painful) characteristic of neuropathy pain.

Pain that occurs after a weak or non painful stimuli.

Neuropathic Pain Treatment

Multimodal approach (PT/OT)

Opioid analgesics

Adjuvant analgesics

Tricyclic antidepressants

Serotonin norepinephrine reuptake inhibitors (SNRIs)

Antiseizure drugs

Psychologic Support

, and α2-adrenergic agonists

Neuropathic pain often is not well controlled by opioid analgesics alone.

Treatment frequently necessitates a multimodal approach combing various adjuvant analgesics including tricyclic antidepressants (e.g., nortriptyline [Pamelor], desipramine [Norpramin]), serotonin norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine [Effexor], duloxetine [Cymbalta], bupropion [Wellbutrin, Zyban]), antiseizure drugs (e.g., gabapentin [Neurontin], pregabalin [Lyrica]), transdermal lidocaine, and α2-adrenergic agonists (e.g., clonidine [Catapres]).

NMDA receptor antagonists such as ketamine have shown promise in alleviating neuropathic pain refractory to other drugs.

Neuropathy

https://www.youtube.com/watch?v=Tt3J0flYZt8&app=desktop

Acute Pain and Chronic Pain

Differences based on

Cause

Course

Manifestation

Treatment

Acute Pain

Sudden onset

Less than 3 months time for normal healing to occur

Mild to severe

Generally a precipitating event or illness can be identified.

Examples of acute pain include postoperative pain, labor pain, and pain from trauma (e.g., lacerations, fractures, sprains), infection (e.g., dysuria from cystitis), and acute ischemia.

For acute pain, treatment includes analgesics for symptom control and treatment of the underlying cause (e.g., splinting for a fracture, antibiotic therapy for an infection). Normally, acute pain diminishes over time as healing occurs.

However, acute pain that persists can ultimately lead to disabling chronic pain states. For example, pain associated with herpes zoster (shingles) subsides as the acute infection resolves, usually within a month. However, sometimes the pain persists and develops into a chronic pain state called postherpetic neuralgia.

Acute Pain

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

Scheduled pain medications 3-4 hours o more frequently.

Acute Pain

Manifestations reflect sympathetic nervous system activation:

Increased heart rate

Increased respiratory rate

Increased blood pressure

Chronic Pain

Persistent pain

Gradual or sudden onset

3-month duration or longer; may start acute but continues past normal recovery time

Cause may be unknown.

The severity and functional impact of chronic pain often are disproportionate to objective findings due to changes in the nervous system not detectable with standard tests. Whereas acute pain functions as a signal, warning the person of potential or actual tissue damage, chronic pain does not appear to have an adaptive role.

As previously discussed, untreated acute pain leads to chronic pain through central sensitization and neuroplasticity. Consequently, it is imperative to treat acute pain aggressively and effectively to help prevent chronic pain.

Chronic Pain

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

Behavioral manifestations

Decreased physical movement/activity

Fatigue

Withdrawal from others and social interaction

Chronic Pain

Can be disabling and accompanied by anxiety and depression

Treatment goals

Control to the extent possible

Focus on enhancing function and quality of life

Pain Mechanisms Transmission

Neuroplasticity refers to the brain forming and reorganizing synaptic connections, especially following an injury

Neuroplasticity contributes to adaptive mechanisms for reducing pain but also can result in maladaptive mechanisms that enhance pain.

the ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury

Genetic variability among individuals may play important roles in affecting the plasticity of the CNS.

Understanding this phenomenon helps to explain individual differences in responses to pain and why some patients develop chronic pain conditions while others do not.

Pain Assessment 5th Vital Sign

Nurse is often responsible to

Gather and document data.

Make collaborative decisions with patient and other health care providers.

Regularly screen all patients for pain.

Assessment is an essential, although often overlooked, step in pain management.

Regularly screen all patients for pain and, when present, perform a more thorough pain assessment.

See Table 9-5.

Pain Assessment

Goals

Describe experience to treat.

Identify goal for therapy and resources for self-management.

Pain Assessment

Elements (multidimensional)

Direct interview

Observation

Diagnostic studies

Physical examination

Before beginning any assessment, the nurse needs to recognize that patients may use words other than “pain.”

For example, older adults may deny that they have pain but may respond positively when asked if they have soreness or aching.

Document the specific words that the patient uses to describe pain. Then consistently ask the patient about pain using those words.

Assessing Pain

O nset

L ocation

D uration

C haracteristics

A ggregating factors

R elieving factors

T reatment

P inpoint

Q uality

R adiating

S everity

T reatment

Pain Assessment

Location of pain “P” pinpoint

Location assists in identifying cause and treatment. (Localized/Generalized)

Visceral: arises from internal organs such as the intestine, bladder and heart

Referred or radiated from origin to different site

For example, pain from liver disease is frequently located in the right upper abdominal quadrant but can also be referred to the anterior and posterior neck region and to a posterior flank area.

If referred pain is not considered when evaluating a pain location report, diagnostic tests and therapy could be misdirected.

T1-T4 Myocardium

Pain Assessment Pain Pattern

Pain onset

May be unidentifiable

Pain duration

Pain may be constant or intermittent.

Incident pain

Pain onset involves determining when the pain started. Patients with acute pain resulting from injury, acute illness, or treatment (e.g., surgery) typically will know exactly when their pain began. Those with chronic pain may be less able to identify when the pain started.

Establish the duration of the pain (how long it has lasted). This information will help to determine if the pain is acute or chronic and will assist in identifying the origin of the pain. For example, a patient with advanced cancer who also has chronic low back pain from spinal stenosis reports a sudden, severe pain in the back that began 2 days ago.

Many types of chronic pain (e.g., arthritis pain) increase and decrease over time. A patient may have pain all the time (constant, around-the-clock pain), as well as discrete periods of intermittent pain.

Episodic, procedural, or incident pain is a transient increase in pain that is caused by a specific activity or event that precipitates the pain. Examples include dressing changes, movement, eating, position changes, and procedures such as catheterization.

Pain Assessment Location

Location of pain

Location assists in identifying cause and treatment.

Localized

All over

Referred or radiated from origin to different site

Pain may radiate from its origin to another site. For example, angina pectoris is known to radiate from the chest to the jaw or down the left arm. Sciatica is pain that follows the course of the sciatic nerve. It may originate from joints or muscles around the back or from compression or damage to the sciatic nerve.

Typically, information about the location of pain is elicited by asking the patient to (1) describe the site(s) of pain, (2) point to painful areas on the body, or (3) mark painful areas on a pain map.

Because many patients have more than one site of pain, it is important to make certain that the patient describes every location.

Visceral Pain

Arises from internal organs such as the intestine, bladder and heart

Tumor involvement or obstruction

“What happens during a heart attack?”

https ://www.youtube.com/watch?v=H_VsHmoRQKk

Visceral pain comes from the activation of nociceptors in the internal organs and lining of the body cavities such as the thoracic and abdominal cavities.

Visceral nociceptors respond to inflammation, stretching, and ischemia.

Stretching of hollow viscera in the intestines and bladder that occurs from tumor involvement or obstruction can produce intense cramping pain.

Dermatomes

Areas of skin that send their sensory information into specific spinal cord segments

Visceral structures share these sensory afferents with skin areas

Maximal intensity of the visceral pain is in the retrosternal area/precordial area, up the neck, down the inner arm

Spleen pain radiates to shoulder

The dermatome chart

Pain Mechanisms

Referred pain may occur with injury or disease involving visceral organs.

Referred or radiated pain from origin to different site

The location of a stimulus may be distant from the pain location reported by the patient.

For example, pain from liver disease is frequently located in the right upper abdominal quadrant but can also be referred to the anterior and posterior neck region and to a posterior flank area.

If referred pain is not considered when evaluating a pain location report, diagnostic tests and therapy could be misdirected.

Pain Assessment Intensity

Intensity of pain

Reliable measure for determining treatment

Rated using scales

0 to 10

Use observational skills for nonverbal patients.

Most adults can rate the intensity of their pain using numeric scales (e.g., 0 = no pain and 10 = the worst pain) or verbal descriptor scales (e.g., none, a little, moderate, and severe).

These tools sometimes are easier for patients to use if they are oriented vertically or include a visual component.

The Pain Thermometer Scale is an example of this type of scale (next slide).

Although intensity is an important factor in determining analgesic approaches, do not dose patients with opioids solely based on reported pain scores.

Opioid “dosing by numbers” without taking into account a patient’s sedation level and respiratory status can lead to unsafe practices and serious adverse events.

Safer analgesic administration can be achieved by balancing an amount of pain relief with analgesic side effects.

Pain Thermometer

Fig. 9-3. 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.

Wong-Baker FACES

Pain Assessment Characteristics

Breakthrough pain

Transient, moderate to severe

Occurs beyond treated pain

Usually rapid onset and brief duration with variable frequency and intensity

End-of-dose failure

End-of-dose failure is breakthrough pain that occurs before the duration of pain relief that is expected with a specific analgesic.

For example, in a patient on transdermal fentanyl (Duragesic patches), the typical duration of action is 72 hours.

An increase in pain after 48 hours on the medicine would be characterized as end-of-dose failure.

End-of-dose failure signals the need for changes in the dose or scheduling of the analgesic.

Pain Assessment Quality

Pain quality

Nature or characteristics

Sharp, aching, burning, numbing, stabbing, electric shock–like, throbbing

Patients typically describe neuropathic pain as a burning, numbing, shooting, stabbing, or itchy sensation.

Nociceptive pain may be described as sharp, aching, throbbing, and cramping.

Since the quality of pain relates to some degree to the classification of pain (e.g., neuropathic, nociceptive, or visceral), these descriptors can help to guide treatment options that best address the specific mechanism of pain.

Pain Assessment

Associated symptoms

Ask about activities and situations that increase or alleviate pain.

For example, musculoskeletal pain may be increased or decreased with movement and ambulation.

Resting or immobilizing a painful body part can decrease pain.

Pain Management

Management

Inquire about strategies used.

Effective and ineffective

Strategies include prescription and nonprescription drugs, nondrug therapies such as hot and cold applications, and complementary and alternative therapies (e.g., herbal products, acupuncture), and relaxation strategies (e.g., imagery).

It is important to document both those that work and those that are ineffective.

Pain Treatment Principles

Follow principles of assessment.

Every patient deserves adequate pain management.

Treatment based on patient’s goals

Use drug and nondrug therapies.

Documentation is critical to ensure effective communication pain assessment tools.

Patient and family beliefs, attitudes, and expectations influence responses to pain and pain treatment.

Assess for attitudes and beliefs that may hinder effective treatment (e.g., the belief that opioid use will result in addiction).

Ask about expectations and goals for pain management.

Pain Reassessment

Critical to reassess at appropriate intervals, guided by

Pain severity

Physical and psychosocial condition

Type of intervention

Risks of adverse effects

Institutional policy***

For example, reassessment for a postoperative patient is done within 30 minutes of an intravenous dose of an analgesic.

In a long-term care facility, residents with chronic pain are reassessed at least quarterly or with a change in condition or functional status.

Pain Treatment Principles

Follow the principles of pain assessment.

Use a holistic approach.

Every patient deserves adequate pain management.

Base treatment plan on patient’s goals.

Follow the principles of pain assessment (Table 9-5). Remember that pain is a subjective experience. The patient is not only the best judge of his or her own pain but also is the expert on the effectiveness of each pain treatment.

Utilize a holistic approach to pain management. The experience of pain impacts all aspects of a person’s life.

Every patient deserves adequate pain management.

Many patient populations, including ethnic minorities, older adults, and people with past or current substance abuse, are at risk for inadequate pain management.

Base the treatment plan on the patient’s goals. Discuss with the patient realistic goals for pain relief during the initial pain assessment.

Pain Treatment Principles

Prevent and/or manage medication side effects.

Incorporate patient and caregiver teaching throughout.

Prevent and/or manage medication side effects. Side effects are a major reason for treatment failure and nonadherence. Side effects are managed in one of several ways, as described in Table 9-7. You play a key role in monitoring for and treating side effects and in teaching patients and caregivers how to minimize these effects.

Incorporate patient and caregiver teaching throughout assessment and treatment. Content should include information about the cause(s) of the pain, pain assessment methods, treatment goals and options, expectations of pain management, proper use of drugs, side effect management, and nondrug and self-help pain relief measures.

Administration

Scheduling

Focus on prevention or control.

Do not wait for severe pain.

Constant pain requires around-the-clock administration (not PRN).

Who would get PRN pain meds?

Fast-acting drugs for breakthrough

A patient should be premedicated before painful procedures and activities that are expected to produce pain. Similarly, a patient with constant pain should receive analgesics around the clock rather than on an “as needed” (PRN) basis.

Administration Routes

Transdermal

Parenteral routes

IM, SC, and IV

Intraspinal delivery

Highly potent (smaller doses necessary)

Implantable pumps

Patient-controlled analgesia (PCA)

Transdermal. Fentanyl (Duragesic) is available as a transdermal patch system for application to nonhairy skin. This delivery system is useful for the patient who cannot tolerate oral analgesic drugs. Absorption from the patch is slow, and it takes 12 to 17 hours to reach full effect with the first application. Therefore, transdermal fentanyl is not suitable for rapid dose titration but can be effective if the patient’s pain is stable and the dose required to control it is known. Patches may need to be changed every 48 hours rather than the recommended 72 hours based on individual patient responses.

A 5% lidocaine impregnated transdermal patch (Lidoderm patch) is used for postherpetic neuralgia. The patch, placed directly on the intact skin in the area of postherpetic pain, is left in place for up to 12 hours.

Currently, creams and lotions containing 10% trolamine salicylate (Aspercreme, Myoflex cream) are available for joint and muscle pain. This aspirin-like substance is absorbed locally. This route of administration avoids gastric irritation, but the other side effects of high-dose salicylate are not prevented.

Parenteral Routes. The parenteral route includes subcutaneous, (IM), and (IV) administration. Single, repeated, or continuous dosing (subcutaneous or IV) is possible via parenteral routes. Although it is frequently used, the IM route is not recommended because injections cause significant pain and result in unreliable absorption. With chronic use, IM injections can result in abscesses and fibrosis. Onset of analgesia following subcutaneous administration is slow, and thus the subcutaneous route rarely is used for acute pain management. However, continuous subcutaneous infusions are effective for pain management at the end of life. This route is especially helpful for people with abnormal GI function and limited venous access.

Administration Routes

Implantable pumps

Intraspinal catheters may be surgically placed for long-term pain relief.

The catheter is connected to a subcutaneous pump with reservoir.

Implantable Pumps. Intraspinal catheters can be surgically implanted for long-term pain relief. The surgical placement of an intrathecal catheter to a subcutaneously placed pump and reservoir allows for the delivery of drugs directly into the intrathecal space. The pump, which is normally placed in a pocket made in the subcutaneous tissue of the abdomen, may be programmable or fixed. Changes are made by reprogramming the pump or by changing the mixture or concentration of drug in the reservoir.

Administration Routes

Patient-controlled analgesia (PCA)

A dose of opioid is delivered when the patient decides a dose is needed.

Patient pushes a button to deliver a bolus dose of opioid IV.

Teach patient that they cannot “overdose.”

Patient-Controlled Analgesia. With PCA, a dose of opioid is delivered when the patient decides a dose is needed. PCA uses an infusion system in which the patient pushes a button to receive a bolus infusion of an analgesic. PCA is used widely for the management of acute pain, including postoperative pain and cancer pain.

Opioids such as morphine and hydromorphone are commonly administered for IV PCA therapy for acute and chronic pain management. Fentanyl is less often used for acute pain. Sometimes IV PCA is administered with a continuous or background infusion called a basal rate, depending on the patient’s opioid requirement.

Use of PCA begins with patient teaching. Help the patient understand the mechanics of getting a drug dose and how to titrate the drug to achieve good pain relief. Teach the patient to self-administer the analgesic before pain intensity is greater than the patient’s desired pain intensity goal. Assure the patient that he or she cannot “overdose” because the pump is programmed to deliver a maximum number of doses per hour. Pressing the button after the maximum dose is administered will not result in additional analgesic. If the maximum doses are inadequate to relieve pain, the pump can be reprogrammed to increase the amount or frequency of dosing.

Nursing and Collaborative Management

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.

You are an important member of the interdisciplinary pain management team. You provide input into the assessment and reassessment of pain. You help in planning and implementing treatments including education, advocacy, and support of the patient and family.

Together with the patient, develop a written agreement or treatment plan that describes the pain management. The plan should ensure that pain will be treated based on the patient’s perception and report of pain. In addition, the plan should clearly outline the gradual tapering of the analgesic dose, with eventual substitution of parenteral analgesics with long-acting oral preparations and possibly cessation of opioids.

Challenges to Effective Pain Management

Common concerns

Tolerance

Physical dependence

Addiction

Tolerance occurs with chronic exposure to a variety of drugs. In the case of opioids, tolerance to analgesia is characterized by the need for an increased opioid dose to maintain the same degree of analgesia.

Like tolerance, physical dependence is a normal physiologic response to ongoing exposure to pharmacologic agents that is manifested by a withdrawal syndrome when the drug is abruptly decreased.

Inadequate treatment of pain can lead to a phenomenon called pseudoaddiction. This occurs when patients exhibit behaviors commonly associated with addiction (frequent requests for analgesic refills and/or higher doses), but the behaviors resolve with adequate treatment of the patient’s pain. These patients are often labeled as drug-seeking, which can result in a crisis of mistrust between the patient and provider. This phenomenon can be avoided by effective communication strategies and optimal pain management.

Addiction is a complex neurobiologic condition characterized by aberrant behaviors arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value. Addiction rarely occurs in patients who receive opioids for pain control. If addiction is suspected, it needs to be investigated and diagnosed, if appropriate, and not implied without evidence because this interferes with pain management.

Barriers to Effective Pain Management

Tolerance

Need for increased dose to maintain same degree of pain control

Rotate drug if tolerance develops.

It is essential to assess for increased analgesic needs in patients on long-term therapy. The health care team needs to evaluate and rule out other causes of increased analgesic needs, such as disease progression or infection. If significant tolerance to opioids develops and it is believed that an opioid is losing its effectiveness, or if intolerable side effects are associated with escalation of dose, the practice of opioid rotation may be considered.

Barriers to Effective Pain Management

Addiction rarely occurs in patients who receive opioids for pain control

Neurobiological condition with drive to obtain and take substances for other than prescribed therapeutic value

Addiction rarely occurs in patients who receive opioids for pain control. If addiction is suspected, it needs to be investigated and diagnosed, if appropriate, and not implied without evidence because this interferes with pain management. The hallmarks of addiction include (1) compulsive use, (2) loss of control of use, and (3) continued use despite risk of harm.

The risk of developing addiction is associated with certain factors, including younger age, personal or family history of substance abuse, and mood disorders. However, the risk of addiction should not prevent health care providers from using opioids to treat moderate to severe acute and chronic pain. Professional organizations and government agencies have issued joint statements about the roles and responsibilities of health care professionals in the appropriate use of opioids for pain management.

Barriers to Effective Pain Management

Inadequate health care provider education

Curriculum does not include education on pain.

Not a priority in clinical education

Over the past decade, progress has been made in overcoming these barriers. Medical and nursing schools now devote more time to addressing pain. Numerous professional organizations have published evidence-based guidelines for assessing and managing pain in many patient populations and clinical settings.

Ethical Issues – Pain Management

Fear of hastening death by administering analgesics

Requests for assisted suicide

A common concern of health care professionals and caregivers is that providing sufficient drug to relieve pain will hasten or precipitate death of a terminally ill person. However, no scientific evidence that opioids can hasten death has been found, even among patients at the very end of life. Moreover, as a nurse, you have a moral obligation to provide comfort and pain relief at the end of life. The rule of double effect provides ethical justification for administering analgesics despite the possibility of hastening death. This rule states that if an unwanted consequence (i.e., hastened death) occurs as the result of an action taken to achieve a moral good (i.e., pain relief), the action is justified if the nurse’s intent is to relieve pain and not to hasten death.

Unrelieved pain is one of the reasons that patients make requests for assisted suicide. Aggressive and adequate pain management may decrease the number of such requests. Assisted suicide is a complex issue that extends beyond pain and pain management.

Placebos are still sometimes used to assess and to treat pain. Using a placebo involves deceiving patients by making them believe that they are receiving an analgesic (usually an opioid) when in fact they are typically receiving an inert substance such as saline. The use of placebos to assess or treat pain is condemned by several professional organizations.

Gerontologic Considerations

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.

The prevalence of chronic pain among community-dwelling older adults exceeds 50% and among elderly nursing home patients is approximately 80%.

Gerontologic Considerations

Most common painful conditions

Musculoskeletal

Osteoarthritis

Low back pain

Previous fracture sites

Gerontologic Considerations

Chronic pain often results in

Depression

Sleep disturbance

Decreased mobility

Decreased health care utilization

Physical and social role dysfunction.

Gerontologic Considerations

Barriers

Belief that pain is inevitable for aging

Greater fear of using opioids; fear of addition

Use words like aching, soreness, or discomfort instead of pain

High prevalence of cognitive, sensory-perceptual, and motor problems

In older adults, the increased prevalence of cognitive, sensory-perceptual, and motor problems that interfere with a person’s ability to process information and to communicate has been noted. Examples of these problems include dementia and delirium, post-stroke aphasia and paraplegia, and language barriers. Hearing and vision deficits may complicate assessment. Therefore, pain assessment tools may have to be adapted for older adults.

Gerontologic Considerations

Treatment cautions

Metabolize drugs more slowly

Risk of GI bleeding with NSAIDs

Multiple drug use (interactions)

Cognitive impairment, can be exacerbated by analgesics.

Treatment regimens for older adults must incorporate nondrug modalities. Exercise and patient teaching are particularly important nondrug interventions for older adults with chronic pain. Also include family and paid caregivers in the treatment plan.

Complementary and Alternative Therapies

Include a broad domain of systems, practices, and products other than those of the dominant health system of a particular society or culture

This definition highlights that which might be considered “complementary and alternative” in one country or at one period of history might be considered “conventional” in another place or time.

Complementary and Alternative Therapies

Complementary therapies are therapies used in conjunction with conventional medicine.

Alternative therapies are therapies used in place of conventional medicine.

Complementary/Alternative Relief

Distraction

Humor

Music

Imagery

Relaxation

Acupuncture

Hypnosis

Healing Touch

Animal Therapy

March 23, 2021

Nondrug Therapy

Transcutaneous electrical nerve stimulation (TENS)

Delivery of an electrical current through electrodes on the skin

Acupuncture

Traditional Chinese medicine

Heat and cold therapy

Transcutaneous Electrical Nerve Stimulation. Transcutaneous electrical nerve stimulation (TENS) involves the delivery of an electrical current through electrodes applied to the skin surface over the painful region, at trigger points, or over a peripheral nerve. A TENS system consists of two or more electrodes connected by lead wires to a small, battery-operated stimulator. Usually, a physical therapist is responsible for administering TENS therapy, although nurses can be trained in the technique. TENS may be used for acute pain, including postoperative pain and pain associated with physical trauma.

Acupuncture. Acupuncture is a technique of traditional Chinese medicine in which very thin needles are inserted into the body at designated points. Acupuncture is used for many different kinds of pain. (Acupuncture is discussed in Chapter 7.)

Heat Therapy. Heat therapy is the application of moist or dry heat to the skin. Heat therapy can be superficial or deep. Superficial heat can be applied using an electric heating pad (dry or moist), a hot pack, hot moist compresses, warm wax (paraffin), or a hot water bottle. For exposure to large areas of the body, patients can immerse themselves in a hot bath, shower, or whirlpool.

Cold Therapy. Cold therapy involves the application of moist or dry cold to the skin. Dry cold can be applied by means of an ice bag, and moist cold by means of towels soaked in ice water, cold hydrocollator packs, or immersion in a bath or under running cold water. Icing with ice cubes or blocks of ice made to resemble Popsicles is another technique used for pain relief. Cold therapy is believed to be more effective than heat for a variety of painful conditions, including acute pain from trauma or surgery, acute flare-ups of arthritis, muscle spasms, and headache.

TENS Treatment

QUESTIONS??