ComfortComfort

Ch 41Ch 41

PainPain

• Considered the 5Considered the 5thth Vital Sign Vital Sign

• IsIs what the patient says it is what the patient says it is

Pain BasicsPain Basics

• SourceSource– Nociceptive – sensoryNociceptive – sensory– Neuropathic – from nervesNeuropathic – from nerves– Psychogenic – mental Psychogenic – mental

• Area to which it is referredArea to which it is referred• DurationDuration

– AcuteAcute– ChronicChronic

Sources of PainSources of Pain

• NociceptiveNociceptive– CutaneousCutaneous

– SomaticSomatic– VisceralVisceral

• NeuropathicNeuropathic

Types of PainTypes of Pain

• Physical cause — cause of pain can Physical cause — cause of pain can be identifiedbe identified

• Psychogenic — cause of pain cannot Psychogenic — cause of pain cannot be identifiedbe identified

• Referred — pain is perceived in an Referred — pain is perceived in an area distant from its point of originarea distant from its point of origin

Duration of PainDuration of Pain

• Acute Acute – Rapid in onset, varies in intensity and durationRapid in onset, varies in intensity and duration– Protective in natureProtective in nature

• ChronicChronic– May be limited, intermittent, or persistentMay be limited, intermittent, or persistent– Lasts for 6 months or longerLasts for 6 months or longer– Periods of remission or exacerbation are Periods of remission or exacerbation are

commoncommon

Pain ProcessPain Process

• Transduction — activation of pain Transduction — activation of pain receptorsreceptors

• Transmission — conduction along Transmission — conduction along pathways (A-delta and C-delta fibers)pathways (A-delta and C-delta fibers)

• Modulation — initiation of the Modulation — initiation of the protective reflex responseprotective reflex response

• Perception of pain — awareness of Perception of pain — awareness of the characteristics of painthe characteristics of pain

Chemicals of PainChemicals of Pain

• Bradykinin Bradykinin – Powerful vasodilatorPowerful vasodilator– Constricts smooth muscleConstricts smooth muscle– Involved in pain awarenessInvolved in pain awareness

• Prostaglandins – send stimuli to CNSProstaglandins – send stimuli to CNS• Substance PSubstance P

– Sensitizes nerve receptorsSensitizes nerve receptors– Increases rate of firingIncreases rate of firing

Gate Control TheoryGate Control Theory

• Relationship between pain and Relationship between pain and emotionsemotions

• Small and large diameter nerve Small and large diameter nerve fibers conduct and inhibit pain stimulifibers conduct and inhibit pain stimuli

• Gating mechanisms determine Gating mechanisms determine impulses that reach the brainimpulses that reach the brain

Pain PerceptionsPain Perceptions

• Pain threshold – lowest intensity at which Pain threshold – lowest intensity at which pain is perceivedpain is perceived

• AdaptationAdaptation

• Modulation of pain – regulation or modified Modulation of pain – regulation or modified by:by:– Neuromodulators- natural, resemble morphineNeuromodulators- natural, resemble morphine– Endorphins – pain blockers, prolonged effect Endorphins – pain blockers, prolonged effect – Dynorphins – most potent Dynorphins – most potent – Enkephalins – less potent, inhibit release of sub.PEnkephalins – less potent, inhibit release of sub.P

Pain ResponsesPain Responses

• Physiologic – automatic (involuntary) Physiologic – automatic (involuntary) responsesresponses

• Behavioral – change in behaviorBehavioral – change in behavior

• Affective – emotional responseAffective – emotional response

• Box 41-1, p 1203Box 41-1, p 1203

Factors in PainFactors in Pain

• CultureCulture

• Ethnic variablesEthnic variables

• Family, gender, and age variablesFamily, gender, and age variables

• Religious beliefsReligious beliefs

• Environment and support peopleEnvironment and support people

• Anxiety and other stressorsAnxiety and other stressors

• Past pain experiencePast pain experience

Assessing PainAssessing Pain

• PsychologicalPsychological

• EmotionalEmotional

• SociologicSociologic

• PhysiologicPhysiologic

Assessing Pain, cont’dAssessing Pain, cont’d

• Patient’s verbalization and Patient’s verbalization and description of paindescription of pain

• Duration of painDuration of pain

• Location of painLocation of pain

• Quantity and intensity of painQuantity and intensity of pain

• Quality of painQuality of pain

• Chronology of painChronology of pain

Assessing Pain, cont’dAssessing Pain, cont’d

• Patient’s verbalization and Patient’s verbalization and description of paindescription of pain

• Duration of painDuration of pain

• Location of painLocation of pain

• Quantity and intensity of painQuantity and intensity of pain

• Quality of painQuality of pain

• Chronology of painChronology of pain

More AssessingMore Assessing

• Aggravating and alleviating factorsAggravating and alleviating factors

• Physiologic indicators of painPhysiologic indicators of pain

• Behavioral responsesBehavioral responses

• Effect of pain on activities and Effect of pain on activities and lifestylelifestyle

Assessment ToolsAssessment Tools

• McGill-Melzack pain questionnaireMcGill-Melzack pain questionnaire

• Pain scale Pain scale – 0 to 100 to 10– FacesFaces

• McCaggery methodMcCaggery method

• WILDA pain measurement scaleWILDA pain measurement scale

WILDA ScaleWILDA Scale

• WWords that describe the painords that describe the pain

• IIntensity of painntensity of pain

• LLocation of painocation of pain

• DDuration of painuration of pain

• AAggravating or alleviating factorsggravating or alleviating factors

Diagnosing PainDiagnosing Pain

• Type of painType of pain

• Etiologic factorsEtiologic factors

• Behavioral, physiological, affective Behavioral, physiological, affective responseresponse

• Other factors affecting pain processOther factors affecting pain process

Nursing InterventionsNursing Interventions

• Establishing trusting nurse-patient Establishing trusting nurse-patient relationshiprelationship

• Initiating non-pharmacologic pain Initiating non-pharmacologic pain relief measuresrelief measures

• Considering ethical and legal Considering ethical and legal responsibility to relieve painresponsibility to relieve pain

• Teaching patient about painTeaching patient about pain

Nursing Plan Nursing Plan

• Remove or alter cause of painRemove or alter cause of pain

• Alter factors affecting pain toleranceAlter factors affecting pain tolerance

• Initiate non-pharmacologic relief Initiate non-pharmacologic relief measuresmeasures

Non-Drug Comfort MeasuresNon-Drug Comfort Measures

• DistractionDistraction

• HumorHumor

• MusicMusic

• ImageryImagery

• RelaxationRelaxation

• Cutaneous Cutaneous stimulationstimulation

• AcupunctureAcupuncture

• HypnosisHypnosis

• BiofeedbackBiofeedback

• Therapeutic touchTherapeutic touch

Drug-Related TreatmentsDrug-Related Treatments

• Analgesic administrationAnalgesic administration– Non-opioid analgesicsNon-opioid analgesics– Opioids or narcotic analgesicsOpioids or narcotic analgesics

• Adjuvant drugsAdjuvant drugs

Administering AnalgesicsAdministering Analgesics

• Patient controlled analgesiaPatient controlled analgesia

• Epidural analgesiaEpidural analgesia

• Local anesthesiaLocal anesthesia

Sedation ScaleSedation Scale

• 1 — awake and alert, no action 1 — awake and alert, no action necessarynecessary

• 2 — occasionally drowsy, but easy to 2 — occasionally drowsy, but easy to arouse, no action necessaryarouse, no action necessary

• 3 — frequently drowsy, drifts off to sleep 3 — frequently drowsy, drifts off to sleep during conversation, reduce dosageduring conversation, reduce dosage

• 4 — somnolent with minimal or no 4 — somnolent with minimal or no response to stimuli, discontinue opiod, response to stimuli, discontinue opiod, consider use of naloxone (Narcan)consider use of naloxone (Narcan)

Managing Chronic PainManaging Chronic Pain

• Give medications Give medications orally orally if possible.if possible.

• Administer medications ATC (around-Administer medications ATC (around-the-clock) rather than prn.the-clock) rather than prn.

• Adjust the dose to achieve Adjust the dose to achieve maximummaximum benefit with benefit with minimumminimum side effects. side effects.

• Allow patients as much control as Allow patients as much control as possible over the regimen.possible over the regimen.