1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 15 Pain Management.

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 15

Pain Management

2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Learning Objectives

• Define pain.• Explain the physiologic basis for pain.• Identify situations in which patients are likely to

experience pain.• Explain the relationships between past pain experiences,

anticipation, culture, anxiety, or activity and a patient’s response to pain.

• Identify differences in the duration of pain and patient responses to acute and chronic pain.

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Learning Objectives

• Explain the special needs of the older adult patient with pain.

• List the data to be collected in assessing pain.• Describe interventions used in the management of pain.• Describe the nursing care of patients receiving opioid

and nonopioid analgesics for pain.• List the factors that should be considered when pain is

not relieved with analgesic medications.

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Definition of Pain

• International Association for the Study of Pain defines it as an unpleasant sensory and emotional experience associated with actual or potential tissue damage

• McCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses: “Pain is whatever the person experiencing it says it is and exists whenever he says it does”

5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Definition of Pain

• International Association for the Study of Pain defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”

• McCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses: “Pain is whatever the person experiencing it says it is and exists whenever he says it does”

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Physiology of Pain

• Sensory experiences: time/space, emotions, cognition

• Afferent pathways• Nerves that carry messages to the brain for

interpretation

• Efferent (or descending) pathways • Carry messages away from the brain via spinal cord

• Nociceptors • Receptors that activate the afferent pathways • Unevenly distributed in muscles, tendons,

subcutaneous tissue, and the skin

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Physiology of Pain

• Pain receptors are sensitive to chemical changes, temperature, mechanical stimuli, and tissue damage

• Pain receptors are unable to adapt to repeated stimuli and thus continue to react until stimuli are removed

• When pain receptors are stimulated, impulses are transmitted to the spinal cord

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Physiology of Pain

• Impulses then travel up the spinal cord to the brain

• In the brain, the cortex interprets the impulses as pain and identifies the location and qualities of the pain

• Endorphins and enkephalins, natural opioid-like substances: block transmission of painful impulses to the brain

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Gate-Control Theory

• Pain reflects physical and psychosocial factors• Painful impulses are transmitted to the spinal

cord through small-diameter nerve fibers in the afferent pathway

• When these fibers are stimulated, the gating mechanism opens in the spinal cord, which permits the transmission of impulses from the spinal cord to the brain

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Gate-Control Theory

• Factors that cause the gate to open include tissue damage, a monotonous environment, and fear of pain

• Stimulation of large-diameter fibers can close the gate and interfere with impulse transmission between spinal cord and the brain, causing diminished pain perception

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Figure 15-1

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Factors Influencing Response to Pain

• Although people may have the same injury or insult, they may respond differently because many physical and psychosocial factors affect the response to pain

• Important for health professionals to be nonjudgmental and to avoid comparing one individual in pain with another

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Physical Factors

• Pain threshold

• Point at which stimulus causes sensation of pain

• Pain tolerance

• Intensity of pain that a person will endure

• Age• Physical activity and nervous system integrity• Surgery and anesthesia

• Type of surgery performed and the type of anesthesia used can influence the response to pain

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Psychological Factors

• Culture and ethnicity • Different ways of expressing/responding to pain

• Religious beliefs • Some patients may pray and believe that divine

intervention will help them to endure the pain • Others may view pain as a punishment for sins • Some believe that suffering is required before pain

relief

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Psychological Factors

• Past experiences and anxiety

• May have developed positive coping strategies to deal with previous painful experiences

• If strategies were unsuccessful, may be very anxious and overwhelmed by another painful experience

• Situational factors

• If pain associated with a serious illness, it may have a greater effect on mood and activity than if the pain were associated with a less serious condition

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Autonomic Nervous System

• Activates the fight-or-flight response; certain physiologic responses initiated

• The nervous system responses measured by increased heart rate, respiratory rate, and blood pressure

• Acute and chronic pain elicit different kinds of responses

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Acute Pain

• Follows the normal pathway for pain from nociceptor activation to the brain and may be called nociceptive pain

• Cause is known and treatable • It serves as a warning of tissue damage and

subsides when healing takes place• Behavioral and physiologic signs: when patient

guards or rubs a body part, wrinkles the brow, bites the lip, and has changes in the heart rate, blood pressure, and respiratory rate

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Chronic Pain

• Persists/recurs for >6 months; may last a lifetime

• Most chronic pain is neuropathic pain because it follows an abnormal pathway for pain

• Results from nerve damage from anatomic and physiologic conditions and underlying diseases

• Includes unusual sensations such as burning, shooting pain, and abnormal sensations that occur when there is no painful stimulus present

• See Table 15-2, p. 206

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Comparison of Acute and Chronic Pain

• Chronic pain serves no useful purpose; acute warns of tissue damage and trauma

• Nursing assessment to identify• Type and amount of pain• Chronic or acute• If acute and chronic pain at the same time

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Figure 15-2

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Nursing Care of the Patient in Pain

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Assessment

• Should be done on admission and on a regular basis

• Assessment of vital signs is called the fifth vital sign

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Assessment

• Six steps• Accept the patient’s report • Determine the status of the pain• Describe the pain

• Location, quality, intensity, aggravating and alleviating factors

• Examine the site of the pain • Identify coping methods • Document assessment findings and evaluate

interventions

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Figure 15-5

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Nonpharmacologic Interventions

• Those that do not employ drugs• Physical interventions

• Physical comfort measures• Environmental control• Stimulation techniques• Anxiety reduction• Distraction

• Psychological interventions• Relaxation• Imagery

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Pharmacologic Interventions

• Nonopioid analgesics• Aspirin, acetaminophen, and nonsteroidal

anti-inflammmatory drugs (NSAIDs) such as ibuprofen

• Generally initial treatment choice for mild pain

• Act mostly on the peripheral nervous system• Antipyretic (fever-reducing), analgesic (pain-

reducing), and/or anti-inflammatory (inflammation-reducing) properties

• See Table 15-4, p. 216

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Pharmacologic Interventions: Opioid Analgesics

• For moderate to severe acute pain, chronic cancer pain, and some other types of pain

• Opioids: potency/duration of action vary• Opioid agonists

• Examples: codeine, methadone (Dolophine), hydromorphone (Dilaudid), meperidine (Demerol), morphine, and fentanyl

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Pharmacologic Interventions: Opioid Analgesics

• Opioid agonist-antagonists • Examples: buprenorphine (Buprenex), nalbuphine

(Nubain), butorphanol (Stadol), and pentazocine (Talwin)

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Pharmacologic Interventions: Opioid Analgesic Misconceptions

• Patients, families, nurses, and physicians have misconceptions about addiction; therefore, the term must be defined and differentiated from the terms tolerance and physical dependence

• Tolerance and physical dependence are normal responses to continued opioid administration for pain relief; they do not lead to a craving for the drug for its mind-altering effects

• Fear of addiction greatly exaggerated; rare (<1%) in patients taking opioids for pain relief

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Pharmacologic Interventions: Opioid Analgesics

• Routes of administration• Oral• Intramuscular• Sublingually• Intravenously: intermittent bolus injections,

continuous infusions, or patient-controlled analgesia (PCA)

• Epidural or intrathecal route

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Pharmacologic Interventions: Opioid Analgesics

• Side effects• Constipation• Nausea, with or without vomiting• Sedation • Respiratory depression • Confusion• Hypotension (especially orthostatic)• Dizziness• Urinary retention

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Pharmacologic Interventions: Placebos

• Inactive substances (e.g., saline) used in research or clinical practice to determine the effects of a legitimate drug or treatment

• Appropriately used in studies in which patients consent to participate

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Pharmacologic Interventions: Placebos

• Many health care organizations take the position that placebos should not be used to assess or manage pain

• Nurses have ethical obligation to ensure that patients are not deceived and that institutional policies related to placebos are followed

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Pharmacologic Interventions: Adjuvant Analgesics and

Medications • Drugs not usually classified as analgesics may

relieve pain in certain situations• A patient who has undergone back surgery

may complain more about muscle spasms than incisional pain • A muscle relaxant may be more effective in relieving

pain than an opioid alone

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Pharmacologic Interventions: Adjuvant Analgesics and

Medications• Specific pain syndromes, especially

neuropathic, may be controlled with drugs other than the commonly known analgesics

• See Table 15-6, p. 219

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Problem Solving with Pain Medication

• Patients whose prescribed analgesic drugs do not relieve pain

• Ask questions about the analgesic drug and the “five rights” (right dose, right patient, right time, right route, right analgesic) to determine why the patient is not getting adequate pain relief

• See Box 15-8, p. 221