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This chapter provides an overview of pain management, including the nature of pain, its classification, and its underlying physiological processes. It also explores the impact of pain on various body systems and the importance of effective pain management.
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Introduction to Adult HealthChapter 13Pain ManagementDr. Ahmad Aqel2014
Pain: an unpleasant sensory and emotional experience resulting from actual or potential tissue damage • In 1968, McCaffery defined pain as “whatever the experiencing person says it is, existing whenever she/he says it does”. • pain is a subjective experience. • Pain management is considered as “the fifth vital sign” to emphasize its significance and to increase the awareness among health care professionals of the importance of effective pain management
1. Acute pain • Recent onset and associated with a specific injury, • Indicates that damage or injury has occurred. • Decreases as healing occurs. • Acute pain can last from seconds to 6 months. 2. Chronic pain • Constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. • Poorly defined onset • Difficult to treat because the cause or origin may be unclear. • Lasts for 6 months or longer
3. Cancer-related pain • Pain associated with cancer may be acute or chronic. • Pain in patients with cancer can be associated with the cancer (e.g., bony infiltration with tumor cells or nerve compression), a result of cancer treatment (e.g., surgery or radiation), or not associated with the cancer (e.g., trauma).
Pain Classified by Location • (e.g., pelvic pain, headache, chest pain). This classification may help in diagnosis and treatment of the pain. • Pain Classified by Etiology • Burn pain and post therapeutic neuralgia are examples of pain described in terms of their cause.
Sleep deprivation (hyposomnia (little sleep) • Fatigue • Depression • Less effective analgesia if patients experience sleep deprivation.
Affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems. • The stress response (“neuroendocrine response to stress”) that occurs with trauma also occurs with other causes of severe pain. • The widespread endocrine, immunologic, and inflammatory changes that occur with stress can have significant negative effects. • This is particularly harmful in patients whose health is already compromised by age, illness, or injury.
Increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids. • Increase the risk of physiologic disorders (e.g., myocardial infarction, pulmonary infection, venous thromboembolism, prolonged paralytic ileus). • Unable to take deep breaths, increased fatigue and decreased mobility.
Suppression of the immune function • Promote tumor growth. • Depression, anger, fatigue and disability. • Required high dosages of opioid medications to relieve chronic pain
The sensory experience of pain depends on the interaction between the nervous system and the environment. • The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous systems. • Nociceptors • Nociception: Neurologic transmission of pain
Nociceptors are neuronal receptors involved in the transmission of pain perceptions to and from the brain that respond to biochemical mediators or noxious stimuli. • They are free nerve endings in the skin that respond only to intense, potentially damaging stimuli. • Such stimuli may be mechanical, thermal, or chemical in nature. • The joints, skeletal muscle, fascia, tendons, and cornea also have nociceptors with the potential to transmit stimuli that produce pain.
Pathophysiology of Pain • The large internal organs (viscera) do not contain nerve endings that respond only to painful stimuli. • Pain originating in these organs results from intense stimulation of receptors that have other purposes. For example, inflammation, stretching, ischemia, dilation, and spasm of the internal organs all cause an intense response in these multipurpose fibers and can cause severe pain. • Nociceptors are part of complex multidirectional path-ways. These nerve fibers branch very near their origin in the skin and send fibers to local blood vessels, mast cells, hair follicles, and sweat glands. • When these fibers are stimulated, histamine is released from mast cells, causing vasodilation. Nociceptors respond to high-intensity mechanical, thermal, and chemical stimuli.
stimulation of the skin evokes nervous impulses then transmitted by three systems located in the spinal cord. • The sub stantiagelatinosa in the dorsal horn, the dorsal column fibers, and the central transmission cells act to influence nociceptive impulses. • The noxious impulses are influenced by a “gating mechanism.” Stimulation of the large-diameter fibers inhibits the transmission of pain, thus “closing the gate.” Conversely, when smaller fibers are stimulated, the gate is opened. • The gating mechanism is influenced by nerve impulses that descend from the brain. • This theory proposes a specialized system of large-diameter fibers that activate selective cognitive processes via the modulating properties of the spinal gate.
Past experience with pain • People who have had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have had little experience with pain. • Anxiety and Depression • Anxiety related to the pain may increase the patient’s perception of pain. Eg, the patient who was treated 2 years ago for breast cancer and now has hip pain may fear that the pain indicates metastasis
Depression is associated with chronic pain • Culture • avoiding exaggerated expressions of pain, such as excessive crying and moaning; seeking immediate relief from pain; and giving complete descriptions of the pain • Gerontologic Considerations • The decrease in myelinated fibers is partly responsible for causing a decrease in expression of the major myelin proteins. • elderly people have a slower metabolism and a greater ratio of body fat to muscle mass compared to younger people, small doses of analgesic agents maybe sufficient to relieve pain, and these doses may be effective longer.
Gender • Men and women are thought to be socialized to respond differently and differ in their expectations about pain.
Assess posture and presence or absence of pain behaviors. • Ask the patient to describe, in his or her own words, the specifics of the pain. • The factors to consider in a complete pain assessment are the intensity, timing, location ,quality, personal meaning of pain; aggravating and alleviating factors; and pain behaviors.
مقياس الألم المرئي|__________________________________________________________________| مقياس الألم الرقمي|---------|---------|----------|---------|---------|---------|---------|---------|---------|---------| Arabic version of pain rating scale
This instrument has six faces depicting expressions that range from contented to obvious distress • The patient is asked to point to the face that most closely resembles the intensity of his or her pain.
Pain management • Reducing pain to a “tolerable” level was once considered the goal of pain management. • any intervention is most successful if it is initiated before pain sensitization occurs, and the greatest success is usually achieved if several interventions are applied simultaneously.
Include both pharmacologic and non pharmacologic approaches. • PHARMACOLOGIC INTERVENTIONS • it is the nurse who maintains the analgesia, assesses its effectiveness, and reports whether the intervention is ineffective or produces side effects.
Agents Used to Treat Pain • Three general categories of analgesic agents are used: • opioids • NSAIDs • local anesthetics.
Physiologic Basis for Pain Relief Pharmacologic Interventions • Opioid analgesics act on CNS to inhibit activity of ascending nocioceptive pathways • NSAIDS decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin) • Local anesthetics block nerve conduction when applied to nerve fibers
Opioid Analgesic Agents • The goal of administering opioids is to relieve pain and improve quality of life. • Factors that are considered in determining the route, dose, and frequency of medication include: • the characteristics of the pain (eg, its expected duration and severity) • The overall status of the patient • the patient’s response to analgesic medications • the patient’s report of pain.
Opioid Tolerance and Addiction • Tolerance (the need for increasing doses of opioids to achieve the same therapeutic effect). • Maximum safe opioid dosage must be individually assessed • Tolerance develops in all patients who take opioids for prolonged periods • With tolerance, increased usage needed to effect pain relief
Tolerance and Addiction • Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance (drug or alcohol) primarily to experience its psychic effects. (The opioids should be tapered slowly to prevent withdrawal symptoms).
Nonsteroidal Anti-inflammatory Drugs • decrease pain by inhibiting cyclooxygenase (COX), the enzyme involved in the production of prostaglandin from traumatized or inflamed tissues. • Check kidney function
Local Anesthetic Agents • Local anesthetics work by blocking nerve conduction when applied directly to the nerve fibers. • Topical Application • Intraspinal Administration
Before administering any medication • ask about allergies to medications and the nature of any previous allergic responses. • the nurse often learns that the extent of the allergy is “itching” or “nausea and vomiting.” These responses are not allergies; rather, they are side effects that can be managed. • document responses or reactions and report • Obtain the patient’s medication history (eg, current, usual, or recent use of prescription or OTC medications or herbal agents).
Lack of Education • Accessibility of Opioids • Addiction Fears
Routes of Administration • parenteral, • oral, • rectal, • transdermal, • transmucosal, • intraspinal, or epidural routes. (subarachnoid [intrathecal space or spinal canal]or dura space).
Placebo Effect (occurs when a person responds to the medication or other treatment because of an expectation that the treatment will work rather than because it should work).
Gerontologic Considerations • More likely to have adverse drug effects, drug interactions • Increased likelihood of chronic illness • May need to have more time between doses of medication due to decreased excretion, metabolism related to aging changes
Respiratory Depression and Sedation. • Nausea and Vomiting. • Adequate hydration and the administration of antiemetic agents may also decrease the incidence of nausea. • Constipation. • Mild laxatives and a high intake of fluid and fiber may be effective in managing mild constipation. • Severe constipation often requires bisacodyl (Dulcolax). • Pruritus. • (itching) is a frequent side effect of opioids administered by any route, but it is not an allergic reaction. It can be relieved by administering prescribed antihistamines.
blocking nerve conduction when applied directly to the nerve fibers. • anesthetic spray • injection. • epidural catheter. • Topical Application • EMLA cream (lumbar puncture or the insertion of IV lines. To be effective, EMLA must be applied to the site 60 to 90 minutes before the procedure.
Intermittent or continuous administration of local anesthetic agents through an epidural catheter during surgery. • Administration of local anesthetic agents in the spinal canal is still largely confined to acute pain, such as postoperative pain and pain associated with labor and delivery. • A local anesthetic agent administered through an epidural catheter is applied directly to the nerve root.
Balanced analgesia • refers to the use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects. • Pro Re Nata:(PRN), or “as needed.” • Preventive Approach • Administering analgesic medication on a timed basis, rather than on the basis of a patient’s report of pain, prevents the serum drug level from falling to sub therapeutic levels.
(PCA) allows patients to control the administration of their own medication within predetermined safety limits. • The PCA pump permits the patient to self-administer continuous infusions of medication (basal rates) safely and to administer extra medication (bolus doses) with episodes of increased pain or painful activities.
Massage • Massage also promotes comfort because it produces muscle relaxation. • Thermal Therapies • Application of heat increases blood flow to an area and contributes to pain reduction by speeding healing and provide some analgesia, • Transcutaneous Electrical Nerve Stimulation • (TENS) uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain.
Distraction • focusing the patient’s attention on something other than the pain, to reduce the perception of pain • Relaxation Techniques • abdominal breathing at a slow, rhythmic rate. The patient may close both eyes and breathe slowly and comfortably.
Guided Imagery • The nurse instructs the patient to close both eyes and breathe slowly in and out. With each slowly exhaled breath, the patient imagines muscle tension and discomfort being breathed out, carrying away pain • Hypnosis • Music Therapy
Cordotomy • the division of certain tracts of the spinal cord • It may be performed percutaneously, by the open method after laminectomy, or by other techniques. • Cordotomy is performed to interrupt the transmission of pain. • Rhizotomy • Sensory nerve roots are destroyed where they enter the spinalcord. A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input. With the advent of microsurgical techniques, the complications are few, with mild sensory deficits and mild weakness.
A nurse who suspects pain in a patient who denies it should explore with the patient the reason for suspecting pain, such as the fact that the disorder or procedure is usually painful or that the patient grimaces when moving or avoids movement. • the nurse would use the patient’s words rather than the word “pain.” • Pain assessment includes determining what level of pain relief the acutely ill patient believes is needed to recover quickly or improve function, or what level of relief the chronically or terminally ill patient requires to maintain comfort.
Intensity (none to mild discomfort to excruciating.) • Timing (the nurse inquires about the onset, duration, relationship between time and intensity (eg, at what time the pain is the worst), and changes in rhythmic patterns. • Location (referred pain) • Quality (The nurse asks the patient to describe the pain in his or her own words without offering clues [burning, aching, throbbing, or stabbing ). • Personal meaning (It is important to ask how the pain affects the person’s daily life.)
Aggravating, alleviating factors (what, if anything, makes the pain worse and what makes it better and asks specifically about the relationship between activity and pain. This helps detect factors associated with pain. • Pain behaviors (Nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence of or the severity of pain experienced). Physiologic responses (tachycardia, hypertension, tachypnea, pallor, diaphoresis, mydriasis, hypervigilance, and increased muscle tone, are related to stimulation of the autonomic nervous system).
