Pain Management.pdf

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Chapter 12

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Pain

• Unpleasant sensory, emotional experience with actual or potential tissue damage

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Pathophysiology of Pain

• Nociceptors (pain receptors)

• Transmission of pain (nocicetion)

– Acute pain travels via A-delta fibers

– Chronic pain travels via C fibers

• Nociceptors most abundant receptors

– Mechanical stimuli

– Chemical stimuli

– Thermal stimuli

• Chemical substances

– Prostaglandins (increase sensitivity of pain receptors)

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Factors That Influence Pain Response

• Past experience • Anxiety

• Depression • Culture

• Age

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Types of Pain

• Acute pain • Chronic pain

• Cancer-related pain

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Pain Syndromes

• Complex regional pain syndrome • Postmastectomy pain syndrome • Fibromyalgia

• Hemiplegia associated shoulder pain • Pain associated with sickle cell disease • AIDS-related pain

• Burn pain

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Effects of Pain

• Sleep deprivation • Acute pain

– Can affect respiratory, cardiovascular, endocrine, immune systems

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Effects of Pain (cont’d)

• Chronic pain – Depression

– Increased disability

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Question

What is the time frame for pain that can be classified as chronic?

A. 1 month

B. 2 to 3 months C. 4 to 5 months

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Answer

D. Longer than 6 months

Rationale: Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can

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Subjective Assessment Tools

• Characteristics of pain

–

Precipitating cause

–

Severity

–

Location and radiation

–

Duration

–

Alleviating or aggravating factors

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Subjective PQRST

Chest pain characteristics

P = provocation or position

Q= quality

R = radiation

S = severity or associated symptoms

T

= timing or triggers

COLDERA

COLDSPA

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Subjective Assessment Tools

• Pain score, 0 to 10 rating scale

–

0 = No pain

–

10 = Worst pain imaginable

• FACES scale, series of faces from happy to

distressed

• Visual analog scale (VAS)

–

Patient points to a level of pain severity on a

10-cm line

–

Can also be done with pencil to mark severity

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Objective Assessment Tools

• For patients who cannot communicate, no

objective tool completely reflects patients’

pain level

• Examples

–

Behavioral Pain Scale

–

Critical-Care Pain Observation Tool

–

Checklist of Nonverbal Pain Indicators

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Behavioral Pain Scale

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Characteristics of Pain

• Intensity • Timing • Location • Quality

• Personal meaning

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Question

The RN asks a patient to describe the quality of pain. Which of the following is a descriptive term for the

quality of pain? A. Burning

B. Chronic

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Answer

A. Burning

Rationale: A descriptive term for the quality of pain is burning. Chronic and intermittent pain are examples of

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Nonpharmacologic Interventions

• Cutaneous stimulation, massage • Thermal therapies

• Distraction

• Relaxation techniques

• Environmental manipulation • Aromatherapy

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Nonpharmacologic Interventions (cont’d)

• Guided imagery • Hypnosis

• Music therapy

• Alternative therapies • PMR

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Pharmacological management

• NSAIDs ie. Brufen and acetaminophen • Opioids ie. Morphine

• Non Opioids ie fentanyl

• Anesthetics ie local (lidocain) and general (propfol) • Sedatives ie benzodiazepines

• Muscle Relaxants

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Physiologic Basis for Pain Relief

Pharmacologic Interventions

• Opioid analgesics act on the CNS to inhibit activity of ascending nociceptive pathways

• NSAIDS decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)

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Opioid Tolerance and Addiction

• Maximum safe opioid dosage must be individually assessed

• Tolerance develops in all patients who take opioids for prolonged periods

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Opioid Tolerance and Addiction (cont’d)

• Dependence occurs with tolerance, physical symptoms occur when opioid is discontinued

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Adverse Effects of Analgesic Agents

• Respiratory depression • Sedation

• Nausea, vomiting • Constipation

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Opioids

• Concerns

–

Respiratory depression

–

Hypotension

–

CNS depression

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Hallucinations

–

Constipation (gastric ileus and retention)

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Management—NSAIDs and

Acetaminophen

• NSAIDs may decrease need of opioid

• Risks of GI bleeding and renal (ibuprofen)

or liver (acetaminophen) insufficiency

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Analgesics

• Acetaminophen for mild to moderate pain

• Used in combination with opioids

• Concern for hepatic function with use of

acetaminophen

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Question

The RN is reviewing a postoperative patient’s orders for opioid analgesia. What pharmacologic intervention should

the RN ensure is ordered to prevent a common complication with opioid analgesia?

A. Benzodiazepine antagonist B. Stool softener

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Answer

B. Stool softener

Rationale: The most common complication with opioid analgesia is constipation. Patients receiving opioids should have stool softeners ordered at the same time that the opioid is initiated to prevent this complication.

An opioid antagonist (Narcan, naloxone), not a