Chapter 35 Study Guide PDF

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Chapter 35 THE PAIN PROCESS:

Transduction: activation of pain receptors

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

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Perception of pain: awareness of the characteristics of pain 

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Modulation: inhibition or modification of pain

GATE CONTROL THEORY OF PAIN: o Describes the transmission of painful stimuli and recognizes a relationship between pain and emotions. o Small- and large-diameter nerve fibers conduct and inhibit pain stimuli toward the brain. o Gating mechanism determines the impulses that reach the brain. CATAGORIES OF PAIN: o Duration  Acute: sudden onset  Chronic: lasting longer than 3 months o Localization/location  Cutaneous: Usually involves the skin or SubQ tissue  Somatic: diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves.  Visceral: is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed  Referred: Pain that originate in one part of the body but be perceived in an area distant from its point of origin.

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ADDITIONAL TERMS USED TO DECRIBE PAIN:

Quality

Severity

Periodicity

Sharp Dull Diffuse Shifting

Severe/excruciating Moderate Slight or mild

Continuous Intermittent Brief or transient

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FACTORS EFFECTING PAIN EXPERIENCE: o Culture o Ethnic variables o Family, gender, and age variables o Religious beliefs o Environment and support people o Anxiety and other stressors o Past pain experience THE FIFTH VITAL SIGN: o In 1995, the American Pain society encouraged caregivers to include assessment of pain as the 5th vital sign. o Required to assess pain and to assess the response to pain treatment. o Each patient's pain experience is unique. Nurses must assess all factors that effect the pain experience – psychological, emotional, and sociocultural, as well as physiologic.

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Basic Methods of Assessing Pain (Pasero and McCaffery 20ll) o Patient self-report

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o Identify pathologic conditions or procedures that may be causing pain; consider physiologic measures (increased blood pressure and pulse) o Report of family member, other person close to the patient or caregiver familiar with the person o Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, protecting the painful area o Physiologic measures: increased blood pressure and pulse o Attempt an analgesic trial and monitor the results PAIN ASSESSMENT TOOLS: o Wong-Baker FACES: Adults and children (>3 years old) in all patient care settings o Beyer Oucher pain scale: Young children who can point to a face to indicate their level of pain o CRIES pain scale: Neonates (ages 0–6 months) o FLACC scale: Infants and children (2 months–7 years) who are unable to validate the presence of or quantify the severity of pain. o COMFORT scale: Infants, children, adults who are unable to use the numeric rating scale or Wong–Baker FACES pain rating scale. o Numeric: Adults and children (>9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain Managing Pain in Patients With Cognitive Impairment o Common behaviors that may indicate pain in this population o History of pain, observation of pain by families & caregivers, and medical dx associated with pain o Assessment tools for patients with dementia include: o Pain Assessment in Advanced Dementia o The Iowa Pain Thermometer Nursing diagnosis related to pain: o Should include type of pain, etiologic factors, patient’s behavioral, physiologic and affective response, & other factors affecting pain stimulus, transmission, perception, and response o Acute pain -acute pain r/t recent surgery aeb facial grimacing, elevated bp, report of pain of a 7/10 o Chronic pain – chronic pain r/t history of migraines for 5 years aeb anorexia, alteration is sleep pattern and report of pain as 10/10 at its worst o Labor pain – labor pain r/t prolonged labor and commitment to natural childbirth aeb moaning and verbalizing pain, focused breathing, and frequent repositioning o Pain may also be the etiology for other nursing diagnoses –hopelessness r/t belief that present pain means imminent death, constipation r/t chronic use of narcotic analgesics Outcome identification and planning: o Outcomes could include reduction or eradication of pain, demonstration of execution of a pain management strategy, or contacting an outpatient center for pain management.

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o The client will report pain reduction to no more than a 3, 30 minutes after receiving pain medication. o The client will verbalize 2 nonpharmalogic pain interventions to reduce pain immediately after teaching. Nursing interventions for pain: o Establishing trusting nurse–patient relationship o Manipulating factors affecting pain experience o Initiating nonpharmacologic pain relief measures o Managing pharmacologic interventions o Reviewing additional pain control measures, including complementary and alternative relief measures o Considering ethical and legal responsibility to relieve pain o Teaching patient about pain Nursing Interventions for Pain: Manipulating Pain Experience Factors o Remove or alter cause of pain. o Alter factors affecting pain tolerance. o Initiate nonpharmacologic relief measures

Nursing Interventions for Pain: Pharmacologic Pain Relief Measures o Analgesic administration  Nonopioid analgesics (acetaminophen, NSAIDS)  Opioids or narcotic analgesics – controlled substances (morphine, codeine, oxycodone, meperidine, hydromophone, methadone)  PCA  Local  Epidural o Adjuvant drugs

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Anticonvulsants (Tegretol, Neurontin) Antidepressants (Elavil, trazadone, Paxil, Prozac) Corticosteroids (Prednisone, dexamethasone)

Nursing Interventions for Controlling Pain: Additional Methods for Administering Analgesics o Patient-controlled analgesia o Local anesthesia o Epidural analgesia

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The Role of the Nurse in Interpreting and Implementing PRN or Titrated Pain Meds o Basing decisions on a complete pain assessment including (at least) pain intensity, temporal characteristics, and patient’s previous response to this or other analgesics o Using valid and reliable tools that are consistent and individualized to the patient o Considering the pharmacokinetics of the opioid

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o Avoiding administration issues such as giving partial doses more frequently or making patient wait the full-time interval after a partial dose o Waiting until the peak effect of the first dose is reached before giving a subsequent dose o Verifying the patient’s allergies o Teaching the patient the name of the drug, the dose administered, the monitoring process, and potential side effects to report o Evaluating the patient’s response o Ensuring complete documentation and communication o Assisting with the development of policies that ensure patient comfort and safety o (The American Society of Pain Management Nurses & American Pain Society joint statement) Nursing Interventions for Controlling Pain: Patient Education o Give information about the nature and cause of the pain o Preventing and controlling pain is an important aspect of treatment o Interventions to manage pain (pharmacologic and nonpharmacologic) o Side effects of opioids can be managed. o The risk of addiction when using opioids to manage acute pain is relatively low o It is the patient's responsibility to alert practitioners about pain and when the nature or level of pain changes. o Complete pain relief is usually not achievable – decreasing pain to a level that is tolerable is the goal. ******** o Explain the pain scale o Safety concerns o Don’t take oral pain meds on empty stomach

Nursing Interventions for Controlling Pain: Pain Management Regimens for Cancer or Chronic Pain

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o Give medications orally if possible. o Administer medications ATC rather than PRN. o Adjust the dose to achieve maximum benefit with minimum side effects. o Allow patients as much control as possible over the regimen. WHO 3 STEP ANALGESIC LADDER. 

Nursing Considerations for the Older Adult o Observe for behavioral manifestation or indications of pain o Monitor for behavior changes and confusion after giving pain meds o Clarify terms used to describe pain o Teach pain is not a normal part of aging o Be aware of dosage and frequency to avoid over-sedation and toxicity o Monitor for over sedation and respiratory depression

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o Caution about use of etoh with analgesics o Caution about driving or operating machinery when taking analgesics Ethical and Legal Responsibilities Related to Pain Management o Patients have the right to have their pain accepted and treated o Patients have the right to have their pain treated effectively o Patients have the right to have nurses who treat them with respect o Placebo...