Post on 27-Dec-2015
Definition
Complex
Subjective
Psychological
Biological
Cultural
Social factors
WHAT THE PATIENT SAYS IT IS!!!!!
Types of Pain
AcuteChronicIntermittentIntractableMalignantNeuropathicPhantomRadiatingRemittentEpisodic
Acute Pain
Follows injury and goes away when it heals
May be associated with autonomic nervous stimulation: TC, HTN, diaphoresis (sweat not to be confuse with sweet ), pallor, dryness
Confirm pain prior to medicated
Chronic Pain
Prolonged disease/dysfunction
Intermittent, limited, persistent (>6mo)
Influences: environment, emotional
Three categories of chronic pain
Chronic nonmalignant -– non-progressive or healed tissue
Chronic malignant --- cancer or progressive disease
Chronic intractable pain --- ability to cope with chronic pain deteriorates
Areas of ‘suffering’
PhysicalSocialSpiritual
HOLISTIC CAREEnvironmentalPsychosocialPhysicalSpiritual
Acute vs. Chronic Pain
Acute PainTrauma
Surgery
Fracture
Chronic inflammation, bruising
Procedural
Phantom
Chronic PainMarriage lol
Arthritis
Malignancy/tumor
back-chronic
Non-malignant
Neuropathy
Phantom
Pain and comparison
ACUTEMild to severeSympathetic Nervous System responsesIncreased: HR, RR, BP, diaphoretic, dilated pupilsSubjectiver/t tissue injury Resolves with healingCrying, rubbing area, holding area
CHRONICMild to severeParasympathetic Nervous SystemNormal VSDry warm skinPupils normal or dilatedDoes not always mention pain unless askedAppears withdrawn and depressedPain behavior often absent
Physiology Descriptors/Categories
Intractable; resistant to analgesia, advanced tumors
Neuropathic; peripheral or CNS, may be tissue related
Phantom; missing limb, spinal cord injury (some)
More categories
Cutaneous – skin or SC tissue
Deep somatic – tendon/blood vessels, nerves
Visceral – internal organs
Radiation and Referred
Radiating – extends from area of insult/injury outwards – UTI, kidney/back/urethra – chest pain/jaw/armReferred pain – felt in an area that is actually not the source – chest pain (arteries/blood vessels/muscle); earache (right ear hurts, left ear has infection)
Pain Stimuli
Stimulus TypeMechanical – trauma, tissue, blockage duct, tumor, spasms
Thermal – heat and/or cold
Chemical – tissue ischemia ( blocked artery) – muscle spasm
Physiologic basis of pain
Tissue damage – direct irritation of receptors (inflammation) – distention of duct – irritation on nerve endings – chemical stimuli – tissue destruction – thermosensititive – chemical (lactic acid, K, Mg, Na)
Gate Control Theory
Nerve fibers carrying painful stimuli to spinal cord.Input can be modified at spinal cord level prior to going to the brain. Stops the sense of pain before it goes to the brain to be processed.Limited amount of pain stimuli the brain can handle at one time.Small fibers carry pain stimuli. Large fibers stimulate a non-noxious stimuli going through same gate (ice pack, pain meds) this inhibits and blocks the gate.
Shut out pain (neuromodulators)
Mechanoreceptors -stimulation of fibers
Endogenous opiods
Electrical stimulation
Opiods and morphine
Normal and excessive sensory stimuli
Cerebral cortex and thalamic inhibition
Pain in the…
Threshold -Differing perceptions of pain, fairly uniform (sprain less painful than gall bladder attack)
Tolerance – how much you can handle
Neuromodulators (endorphin and enkephalin) – produced in brain, act like an opiate, bind to opiate receptor sites, increases pain threshold **released with fight or flight and excessive exercise**
Pain is…Psychological and Physical
CognitiveToddler- dramatic, carry on – perception, frustrated, intolerant, fearfulChildbirth – acute, varies, helpless
Emotional- anxiety, depression, stress, frustration, length of time/perceived timeMyths- not always drug-seeking, aging means pain, pt not complaining they don’t have, admitting pain is a sign of weakness, unavoidable, deserved = bad person = sinned, resistant to med’sSuffering – physical, psychological, emotional or distress- chronic pain and never fully relieved ----alternative holistic methods
Pain Management Principles
Acknowledge – accept-educate-medicate-Pharmacological and non-pharmDifferent types of med’s: NSAID’s, ASA, Opiods, etc..Treat the pain before it becomes severe 0-10 – treat when? 4-5 – pt perception
Factors Influencing Pain
AgeGenderCultureReligionPhysical condition at startSupportSocialEnvironmentFinancial
Wong-Baker Scales
Happy face to sad face with sweat/tears and blood
Adult patient 0-10
Child faces 0-5
WILDA
W=word describes pain (sharp, stabbing, throbbing, aching)
Intensity – 0-10 or faces
Location – where is it
Duration- how long does it last
Aggravating and alleviating factors – what makes it worse or better
OPQRST
Other s/s
Provocative/palliative – what makes it worse or better
Quality – description
Region of pain
Severityof pain
Temporal/timing
COLDERRA
Character- sharp, burningOnset – when did it startLocation – where it isDurationExacerbation – makes it worseReliefRadiationAssociated s/s
Assess Physical Side
Facial expressionVSPositioningGuardingStriking at nurse if she touches area that hurtsDiaphoresisLabs
Analyze
Synthesis of the assessment
Collaborative approach to other disciplines findings
Determine a nursing diagnosis
Acute vs. chronic
SMART ER
Specific
Measurable
Attainable and action based
Realistic
Timebound
Evaluation
Reassessment
WHO (world health organization)
3 – step analgesic ladder approachNursing intervention – backrubs, massage, lotion, ice and heat, distraction, (hammer…ignoring)Environmental – noiseListening******Patient Bill of Rights*******
Treat pain to the best of our ability and right to treatment, refuse treatment, pt centered decision making, confidentiality
Implementation
Initiate and complete plan
Work toward goal
Nursing measures/massages
Pain society usage and guidelines
CDC and NIH website on pain
Physical modifications
Accupressure – Chinese healing system, finger pressure at certain points, ointments, linaments, massaging
TENS, transcutaneous electrical nerve stimulation – prickling sensation small stimulation ( Gate control theory)
Psychological Modifications
Cognitive behavioral therapies – model desired behaviors, learning theories
Biofeedback theory – teach to relax, calm, reproduce condition of happiness
Meditation – ‘getting out of oneself’This is not prayer.
WHO 3 step Ladder
Non-opiod analygesics +/- an adjuvant. Moderate ain persists go toOpioid admin +/- non-opioid +/- adjuvantOpioid for moderate to severe pain +/- non opioid +/- adjuvant. Used for the relief of cancer pain.Adjuvants med’s – enhance analgesia of opioids, treat symptoms that exacerbate pain/provide independent analgesia for types of pain. Corticosteroids, antidepressants, hypnotics.
Medications/Sedatives
NSAIDS – naproxen, motrin, advil, indomethacin, ASA, AcetaminophenOpioids agonists – morphine, codeine, hydromorphone, oxycodone, oxymorphine, meperidine, fentanyl, methadone. Produce analgesia by binding to opioid receptors.Opioids antagonist – naloxone, reverses depressant effect of opioids, treatm opioid ODOpioid agonist-antagonists – pentazocine, nalphybine, butorphanol, dezocine, bind only to certain sitesTopical drugs localized pain
PCA
Patient controlled analgesiaBeneficial psychologically
Decreases dependency
Decreases anxiety
Patient part of their treatment plan
MYTHS per the book
Expected with ageChronic pain = hypochondriacInfants feel no painNo complaining no painPain is unavoidable part of recoveryAdmission is a sign of weaknessDrug addictionUsing drug at the start of pain will make it not work as good laterSevere pain is only seen in people who are melodramatic and/or hysterical