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7/27/2019 Pain Lecture 2
1/23
Chapter 13
Pain Management
Significance of PainSubjective response: only felt by the person
Negative: discomfort
Protective role: warning of potential threat to health
sometimes a life!threatening condition"# prompt for
person to see$ medical attention
Pain
! %n unpleasant sensory and emotional e&perience withactual or potential tissue damage'
! (he most common reason for see$ing health care'
! )(he fifth vital sign* by the %merican Pain Society
+,,3"
! -C%./ +,,0" standards state that )pain is assessed
in all patients* and that )patients have the right to
appropriate assessment and management of pain'*! )Pain is whatever a person says it is e&isting whenever
the e&periencing person says it does* McCaffery 2
Pasero 1"'
! Pain is categori4ed according to its duration location
and etiology'
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(ypes of Pain
%cute pain can be described as lasting from seconds to 5months
Chronic persistent" pain is constant or intermittent
pain that persists beyond the e&pected healing time and
that can seldom be attributed to a specific cause or
injury'
Cancer!related pain
%ccording to 6ocation
eg pelvic pain headache chest pain"' (his type of
categori4ation aids in communication about and
treatment of the pain'
%ccording to 7tiology
8urn pain and postherpetic neuralgia are e&les of
pain described
Classifications of Pain and 9efinitions
%' %cute: sudden onset usually sharp and
locali4ed# less than 5 months# significant of
actual or potential injury to tissues# initiates
flight or fight stress response
1' Somatic: arises from s$in close to surface of
body# sharp or dull# often with nausea and
vomiting
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+' isceral: arises from body organs# dull and
poorly locali4ed# with nausea and vomiting#
may radiate or is referred
3' ;eferred: pain perceived in area distantfrom stimuli
8' Chronic: prolonged pain# more than 5 months#
often dull aching diffuse# not always associated
with specific cause often unresponsive to
conventional treatment# most common is lower
bac$ pain
1' ;ecurrent acute pain
+' /ngoing time!limited pain3' Chronic nonmalignant pain
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=actors %ffecting ;esponse to Pain
%'Pain threshold: Point at which a stimulus is
e&perienced as pain# same for all persons but
individuals have different perceptions andreactions to pain
8'Pain tolerance: amount of pain a person can
endure before outwardly responding to it
1' 9ecreased by repeated pain episodes
fatigue anger an&iety sleep deprivation
+' >ncreased by alcohol hypnosis warmth
distraction spiritual practices
C'%ge9'Sociocultural influences
1' =amily beliefs e'g' males don?t cry
+' Cultural: some persons of ethnic groups
handle pain in similar manner
7'7motional status e'g' an&iety
1' =atigue and@or lac$ of sleep
+' 9epression: decreased amount of serotonina neurotransmitter thus increased amount
of pain sensation
=' Past e&periences with pain
A' Source and meaning
.' Bnowledge about pain
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./ %pproach to Cancer Pain
7ffects of Pain
Sleep deprivation %cute pain
Can affect respiratory cardiovascular endocrine
and immune systems'
Stress response increases metabolic rate and
cardiac output and increases ris$ for physiologic
disorders'
Chronic pain 9epression
>ncreased disability
Suppression of immune function
Pathophysiology of Pain
involve the peripheral and central nervous systems'
Nociceptors pain receptors" are free nerve endings in
the s$in that respond only to intense potentially
damaging stimuli' Such stimuli may be mechanical
thermal or chemical in nature' (he joints s$eletal
muscle fascia tendons and cornea also have
nociceptors that have the potential to transmit stimuli
that produce pain'
(ransmission of pain nociception"
Chemical substances
Prostaglandins increase sensitivity of pain
receptors" chemical substances that increase the
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sensitivity of pain receptors by enhancing the pain!
provo$ing effect of brady$inin
7ndorphins and en$ephalins suppress pain
reception" morphine!li$e substances produced by thebody' Primarily found in the central nervous system
they have the potential to reduce pain'
Nociception System Showing %scending and 9escending
Pathways of the 9orsal .orn
Aate Control System (heory
=actors (hat >nfluence Pain ;esponse
Past e&perience
%n&iety
9epression
Culture
Aender Aenetics
Aerontologic considerations
7&pectations
(he )Placebo 7ffect*
% physiologic response that results from an
e&pectation that a treatment will wor$'
%merican Society of Pain Management Nurses
+,,0" contends that placebos should not be used to
assess or manage pain'
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Chart 13!3: 7thics and ;elated >ssues
%ssessment of Pain
%ssessment: the patient?s pain goal or e&pectationsof comfort and pain relief
Meaning of pain for the patient
Chart 13!0: Common Concerns and Misconceptions
%bout Pain and %nalgesia
8ehaviors associated with the pain
% patient may grimace cry rub the affected area guard
the affected area or immobili4e it' /thers may moan
groan grunt or sigh' Not all patients e&hibit the same
behaviors and there may be different meanings
associated with the same behavior'
Physiologic responses to the pain
Physiologic responses to pain such as tachycardia
hypertension tachypnea pallor diaphoresis mydriasis
hypervigilance and increased muscle tone are related
to stimulation of the autonomic nervous system'
Characteristics: >ntensity (iming 6ocation
Duality
>ntensity of pain ranges from none to mild discomfort to
e&cruciating' (here is no correlation between reported
intensity and the stimulus that produced it' (he
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reported intensity is influenced by the personEs pain
threshold and pain tolerance'
(iming ! patient is as$ed if the pain began suddenly or
increased gradually'
6ocation of pain is best determined by having the
patient point to the area of the body involved'
! especially helpful if the pain radiates referred pain"
Duality ! nurse as$s the patient to describe the pain in
his or her own words without offering clues'! nurse can suggest words such as burning aching
throbbing or stabbing'
%ggravating or alleviating factors
! nurse as$s the patient what if anything ma$es the
pain worse and what ma$es it better and as$s
specifically about the relationship between activity and
pain'
Pain >ntensity Scales
%S are useful in assessing the intensity of pain' /ne
version of the scale includes a hori4ontal 1,!cm line
with anchors ends" indicating the e&tremes of pain' (he
patient is as$ed to place a mar$ indicating where thecurrent pain lies on the line'
=aces Pain ScaleF;evised
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(his instrument has si& faces depicting e&pressions that
range from contented to obvious distress' (he patient is
as$ed to point to the face that most closely resembles
the intensity of his or her pain'
Pain >ntensity Scale
=aces Pain Scale
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Auidelines for %ssessing Pain in Patients ith
9isabilities
%lternative forms of communication may be necessary
for people with sensory impairments or other
disabilities'
=or people who are blind and who $now how to
read 8raille pain assessment instruments can be
obtained in 8raille' >n addition there is now
computer software that allows written documents
to be scanned and converted into 8raille' >f these
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programs are not available agencies that provide
services for people who are blind may be able to
assist in developing 8raille versions'
=or people who are deaf or hard of hearing outsideinterpreters ie not family members" should be
used' /ther useful communication strategies may
include sign language written notes or pictures'
hen writing notes on a )magic slate* or ma$ing
written notes it is necessary to ma$e every effort to
guard the patientEs privacy and confidentiality'
=or people with disabilities that result in
communication impairment computer!generatedspeech may be useful'
(he NurseEs ;ole in Pain Management
- nurse helps relieve pain by administering pain!
relieving interventions including both
pharmacologic and nonpharmacologicapproaches" assessing the effectiveness of those
interventions monitoring for adverse effects and
serving as an advocate for the patient when the
prescribed intervention is ineffective in relieving
pain'
Aoals for pain management
-complete elimination of the pain
- decrease in the intensity duration or freGuency of
pain and a decrease in the negative effects of the
pain
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7stablishing the NurseFPatient ;elationship and
(eaching
% positive nurseFpatient relationship and teaching
are $ey to managing analgesia in patients with painbecause open communication and patient cooperation
are essential to success
(he patient should be informed that pain should be
reported in the early stages' hen the patient waits
too long to report pain sensiti4ation may occur and
the pain may be so intense that it is difficult to relieve
Providing Physical Care
Patients are usually more comfortable when physical
and self!care needs have been met and efforts have
been made to ensure as comfortable a position as
possible
Managing %n&iety ;elated to Pain
(eaching the patient about the nature of the
impending painful e&perience and the ways to reduce
pain often decreases an&iety
6earning about measures to relieve pain may lessen
the threat of pain and give the patient a sense of
control'
Pain Management Strategies
Pharmacologic >nterventions
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Pharmacologic management of pain is accomplished in
collaboration with physicians patients and often
families'
Premedication %ssessment
8efore administering any medication the nurse should
as$ the patient about allergies to medications and the
nature of any previous allergic responses
! nurse obtains the patientEs medication history
Aerontologic Considerations
Physiologic changes in older adults reGuire thatanalgesic agents be administered with caution' 9rug
interactions are more li$ely to occur in older adults
because of the higher incidence of chronic illness and
the increased use of prescription and /(C medications
Aerontologic Considerations
More li$ely to have adverse drug effects and drug
interactions >ncreased li$elihood of chronic illness
May need to have more time between doses of
medication due to decreased e&cretion and metabolism
related to aging changes
(%867 13!+ %dverse >nteractions of .erbal Substances
or =oods ith %nalgesics
%nalgesic .erb or =ood 7ffect
NS%>9s Ain$go garlic
ginger bilberry
dongGuai feverfew
ginseng turmeric
7nhanced ris$ of
bleeding
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meadowsweet
willow
%cetaminophen Ain$go and
possibly some ofthe above!
mentioned herbs
7nhanced ris$ of
bleeding
7chinacea $ava
willow
meadowsweet
>ncreased potential
for hepatoto&icity
and nephroto&icity
/pioids alerian $ava
chamomile
>ncreased central
nervous system
depressionAinseng >nhibits analgesic
effects
%lfentanil
fentanyl
sufentanil
Arapefruit juice >nhibits the
cytochrome P
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Preventive %pproach ;(C or %(C
administering analgesic agents
Hse of )%s Needed* ;ange /rders for /pioid
%nalgesics
>ndividuali4ed 9osage
(he dosage and the interval between doses should be
based on the patientEs reGuirements rather than on an
infle&ible standard or routine
! fear of promoting addiction or causing respiratorydepression health care providers tend to prescribe and
administer inadeGuate dosages of opioid agents to treat
acute pain or persistent pain particularly in terminally
ill patients
Patient!Controlled %nalgesia
Hsed to manage postoperative pain as well as persistentpain patient!controlled analgesia PC%" allows patients
to control the administration of their own medication
within predetermined safety limits'
6ocal %nesthetic %gents
(opical %pplication
>ntraspinal %dministration
/pioid %nalgesic %gents
%dverse 7ffects:
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- ;espiratory depression is the most serious adverse
effect of opioid analgesic agents administered by
> subcutaneous or epidural routes
-
Sedation- Nausea and omiting
- Constipation
- >nadeGuate Pain ;elief
(%867 13!3 Selected /pioid %nalgesics Commonly
Hsed for Moderate and Severe Pain in %dults
Name
Starting 9ose
milligrams"
Comments
Precautions
andContraindicati
ons
Modera
te Pain
Severe
Pain
Morphine I 3,F5,
oral"
1,
parenter
al"
%cts as an
agonist at
specific opioid
receptors in the
CNS to produce
analgesiaeuphoria and
sedation'
Hse with
caution
especially in
elderly
patients very
ill patients andthose with
respiratory
impairment'
Major ris$s
include
respiratory
depression
apneacirculatory
depression and
respiratory
arrest shoc$
and cardiac
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arrest' /btain
history of
hypersensitivit
y to opioids'
Monitorpatient closely'
>f prescribed in
correct dose
oral
preparations
MS Contin"
are effective in
treatingmoderate and
severe pain'
Codeine 10F3,
oral"
5, oral"
up to
35,@+< hr
%cts as an
agonist at
specific opioid
receptors in the
CNS to produce
analgesiaeuphoria and
sedation' >s also
an antitussive'
1,J of people
lac$ the en4yme
needed to ma$e
codeine active'
Codeine may
cause more
nausea and
constipation per
unit of
analgesia than
other mu
Many
preparations of
codeine and the
other opioids in
this table are
combinationswith nonopioid
analgesics'
Caution must
be used in
patients with
impaired
ventilation
bronchial
asthma
increased
intracranial
pressure or
impaired liver
function and in
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agonist opioids' elderly and
very ill
patients'
/&ycodone
/&yContin"
0 oral" 1,F+,
oral"
%cts as an
agonist atspecific opioid
receptors in the
CNS to produce
analgesia
euphoria and
sedation'
Caution must
be used inpatients with
impaired
ventilation
bronchial
asthma
increased
intracranial
pressure orimpaired liver
function and in
elderly and
very ill
patients'
Meperidine
9emerol"
0,
oral"
3,, oral"
K0
parenteral"
%cts as an
agonist at
specific opioidreceptors in the
CNS to produce
analgesia
euphoria and
sedation'
Shorter acting
than morphine'
Meperidine is
biotransformed
to
normeperidine
a to&ic
metabolite'
Normeperidine
a to&ic
metabolic ofmeperidine
accumulates
with repetitive
dosing causing
CNS e&citation'
.igh ris$ for
sei4ures'
Should be
avoided in
patients with
impaired renal
function who
are receiving
M%/
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inhibitors' >s
irritating to
tissues with
repeated
intramuscularinjections'
Chronic use
should be
avoided'
Should not be
used for more
than 1 or +
days'Propo&yphe
ne 9arvon"
50F13,
oral"
I ea$ analgesic#
acts as an
agonist at
specific opioid
receptors in the
CNS to produce
analgesia
euphoria andsedation' Many
preparations
include
nonopioid
analgesics#
biotransformed
to potentially
to&ic metabolite
norpropo&phe
ne"'
%ccumulation
of
propo&yphene
and to&ic
metabolites
occurs with
repetitive
dosing'/verdose is
complicated by
sei4ures'
Propo&yphene
is not
recommended
for older adults
or patients with
renal
impairment'
.ydrocodon
e icodin"
0F1,
oral"
I I Most
preparations
are combined
with nonopioid
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analgesics'
(ramadol
Hltram"
0,F1,,
oral"
I HniGue
mechanism#
analgesia
results from thesynergy of two
mechanisms'
Ma&imum dose
is 9s decrease pain by inhibiting cyclo!
o&ygenase which is the en4yme involved in the
production of prostaglandin'
6ocal anesthetics bloc$ nerve conduction whenapplied to the nerve fibers'
/pioid (olerance and %ddiction
Ma&imum safe opioid dosage must be individually
assessed'
(olerance develops in all patients who ta$e opioids
for prolonged periods'
ith tolerance increased usage is needed to effect
pain relief'
9ependence occurs with tolerance and physical
symptoms occur when the opioid is discontinued'
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%ddiction is a behavioral pattern characteri4ed by
the need to ta$e the drug for its psychic effects'
%ddiction from therapeutic use of opioids is negligible
Nonpharmacologic >nterventions
Cutaneous stimulation massage and use of hot
and cold may be e&plained by the gateway theory'
Hse of heat and cold changes blood flow to the
areas and promotes healing'
Hse of distraction rela&ation and guided imagery
may redirect attention promote muscle rela&ation and
affect perception or reception of pain stimulus in thebrain'
%dministration ;outes for %nalgesics
(%867 13!< %dministration ;outes for %nalgesics
;elationship of Mode of %nalgesia to Serum 6evel
Currently a preventive approach to relieving pain by
administering analgesic agents is considered the most
effective strategy because a therapeutic serum level of
medication is maintained' ith the preventive
approach analgesic agents are administered at set
intervals so that the medication acts before the pain
becomes severe and before the serum opioid level
decreases to a subtherapeutic level'
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Neurologic and Neurosurgical Methods for Pain
Control
>ntrathecal and epidural catheters
(7NS units
(ranscutaneous electrical nerve stimulation (7NS"
uses a battery!operated unit with electrodes applied to
the s$in to produce a tingling vibrating or bu44ing
sensation in the area of pain
>nterruption of pain pathways
Cordotomy ! the division of certain tracts of the spinalcord =ig' 13!1,"' >t may be performed percutaneously
by the open method after laminectomy or by other
techniGues' Cordotomy is performed to interrupt the
transmission of pain' Care must be ta$en to destroy
only the sensation of pain leaving motor functions
intact'
;hi4otomy ! Sensory nerve roots are destroyed where
they enter the spinal cord' % lesion is made in the dorsal
root to destroy neuronal dysfunction and reduce
nociceptive input' ith the advent of microsurgical
techniGues the complications are few with mild sensory
deficits and mild wea$ness =ig' 13!11"'
%dverse 7ffects of %nalgesic %gents
;espiratory depression
Sedation
Nausea and vomiting
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Constipation
Pruritus