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Nurse Caring Concepts 1A

PAIN

"Pain is whatever the patient says it is, existing whenever he says it does" (McCaffery, 1979)

Week 9 October 13, 2003

Pain Definitions

· Unrelieved pain: potentially dangerous to wellbeing; affects every body system negatively · Acute Pain: mild to severe pain with sudden onset for < 6months; cause usually known; decreases & goes away over time · Chronic Pain: mild to severe pain with gradual or sudden onset for > 6 months; cause may not be known; pain waxes & wanes; does not usually go away

Nursing and Pain Assessment

· Silent suffering is a highly valued response to pain · Expect clients to be objective about pain · Reduction rather than elimination of pain is often the goal · Ethnic background of nurse and client frequently determine the degree of pain assessed and amount of analgesia given · Essential to identify own attitudes about pain to be truly empathic

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Nursing Pain Responsibilities

· Help patient obtain pain relief · Help patient cope with any unrelieved pain · Establish effective relationship with patient experiencing pain: ­ Believe patient ­ Clarify responsibilities in pain relief ­ Respect patient's response to pain ­ Be with patient often

ABCs of Pain

· Perception of pain results from complex interactions among these dimensions: ­ Affective: emotional factors that can affect the experience of pain ­ Behavioral: actions taken to express or control pain ­ Cognitive: meaning, beliefs and attitudes about pain

P.A.I.N. Assessment

· Pattern: onset and duration of pain · Area: location; may be referred or be in multiple sites · Intensity: level of pain on rating scale · Nature: how pain feels to patient; descriptive words If your patient is unable to verbalize, use behavioral indicators to rate pain; assume they have pain if you think you would have pain under the same circumstances

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Pain in Special Populations

· Infants: must use behavioral indicators · Older adults: pain is not a normal part of aging · Communication barriers: neonates, infants, limited language skills, different language, emotionally disturbed, cognitively impaired, altered LOC, intubated · Those at risk for addiction: history of alcohol or other drug-lrelated problems

Nocioceptive Pain

· `Normal' pain caused by stimulation of nocioceptors (free sensory nerve endings in tissue that are receptors for noxious stimuli) ­ Found in skin, blood vessels, muscle, viscera, joints, subcutaneous tissue etc ­ Noxious stimuli: heat, chemical or pressure · May be described as aching or throbbing · Usually responds to nonopiod & opiod analgesics

Neuropathic Pain

· `Abnormal' pain caused by damage to nerve cells or changes in spinal cord processing of sensory impulse · May be described as: ­ Burning, shooting, stabbing or electrical ­ Sudden, intense, short-lived or lingering · Does not respond well to opiod analgesics; adjuvant analgesics usually required (e.g., corticosteroids, tricyclic antidepressants, antihistamines, caffeine)

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Physiology of Pain

· Transduction: noxious stimulus creates action potential & release of neurotransmitters (e.g,. substance P, bradykinin, histamine & prostaglandins) that convert stimulus to electrical impulse · Transmission: impulse relayed to CNS (synapse in dorsal horn of spinal cord) & is processed by neurotransmitters (e.g., substance P), sent to thalamus, then relayed to cerebral cortex

Physiology of Pain continued

· Perception: input perceived as pain by person · Modulation: activated neurons descending from brainstem to dorsal horn & release biochemicals that enhance or inhibit pain impulse transmission ­ Enhancement: chemical substance increases activation of nerve fiber & pain perceived ­ Inhibition: biochemical blocks release of neurotransmitters or binds with receptor site, slowing or preventing relay of impulse

How Meds Interrupt Pain Pathway

· Transduction: ­ NSAIDs block prostaglandin production ­ Local anesthetics, antiseizure agents & corticosteroids block action potential · Transmission: opiods block substance P release · Perception: opiods decrease conscious experience of pain · Modulation: tricyclic antidepressants interfere with reuptake of serotonin & norepinephrine

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Nocioceptor Characteristics

· · · A-alpha fibers: large, myelinated nerve fibers; conduct muscle sensory impulses rapidly A-beta fibers: large, myelinated nerve fibers; conduct skin sensory impulses rapidly A-delta fibers: small myelinated nerve fibers; conduct impulses med slow; associated with sharp, well-localized, pain of short-duration C-fibers: smallest; unmyelinated; slow conduction rate; associated with dull, aching, burning pain with slow onset & longer duration

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Gate Control Theory

· Theory of pain modulation that provides support for pain relief therapies acting on different parts of nervous system · Spinal cord dorsal horn cells act as gate, able to open to allow or close to prevent nocioceptive impulses reaching brain · Opening of gate influenced by A-delta & Cfibers · Closing of gate is influenced A-alpha and Abeta fibers (& other neuro structures)

Pharmacologic Pain Relief

· Nonopioids: mild to moderate pain (ASA, NSAIDS, acetaminophen) · Opiods: mild to moderate pain (codiene, oxycodone) a& moderate to severe pain (hydromorphine, morphine) · Routes: PO, PR, Transdermal, IM, IV Is more effective if pain meds are scheduled rather than PRN while pain expected to last

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Nonpharmacologic Pain Relief

· Positioning: ROM, exercise, body alignment · Pressure/Acupressure: pressure applied to area or trigger points · Acupuncture: needles inserted into body Massage: rubbing painful area · TENS unit: electric current applied to skin · Heat/cold therapy: dry or moist heat to skin

Nonpharmacologic Pain Relief

· Relaxation: consciously reducing muscle tension · Distraction: refocusing pt's attention on

something other than pain

· Imagery: sensory images to substitute for pain · Hypnosis: sensory images substitute for pain · Therapeutic Touch: "laying on" of hands · Chiropractic therapy: vertebral manipulation

Alternative Therapies

· Biofeedback: provides client with info about bodily changes · Herbal remedies: medicinal plants · Homeopathy: based on belief that balance can be restored by facilitating individual's healing therapy

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Identifying Pain Nursing Dx Goals

· Patient will report: ­ Absence of pain ­ Reduction of pain to a tolerable level (must specify level e.g., 3/10) ­ Increase in ability to perform daily activities ­ Others validate that their pain exists · Patient will practice noninvasive pain relief measures to manage pain

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