Concepts of PainYisehak Tura, RN, OCN

Pain

• What is pain? • The American Pain Society (APS) defines pain as “an

unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (APS, 2008, p. 1)

• Pain is a highly personal and subjective experience: “Pain is whatever the experiencing person says it is, existing whenever he says it does.” (McCaffery, 1968, p.8)

Pain

• How do you actually feel pain?• (6 min video by Khan Academy)

Classifications of pain

• How is pain classified by its inferred pathology?• Nociceptive pain• Neuropathic pain• What are some examples of nociceptive (normal pain),

neuropathic pain or combination of the two?

Categories of pain• What are the categories of pain based on duration?• Acute pain: • What are some examples of acute pain?• (1) somatic (superficial), (2) visceral (internal), or (3) referred (present in

an area distant from its origin). • Chronic pain (persistent):• What are some examples of chronic pain?• Can patients experience both acute and chronic pain at the same time?

Risk factors

• What age group (s) are at a higher risk of pain?• How about the non verbal who can not report their pain?

Physiologic processes of pain

(Adapted from Pasero C, McCaffery M, editors: Pain assessment and pharmacologic management, St Louis, 2011, Mosby/Elsevier.)

Small group discussion:

How does unrelieved pain affects each of these physiologic processes?

Physiologic processes of unrelieved pain

• How does unrelieved pain prolong stress response?• Unrelieved pain can prolong the stress response and produce a cascade of

harmful effects in all body systems • The stress response causes the endocrine system to release excessive

amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease.

• Increased endocrine activity in turn initiates a number of metabolic processes, in particular accelerated carbohydrate, protein, and fat destruction (catabolism), which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death.

Physiologic processes of unrelieved pain

• How does unrelieved pain affects cardiovascular status? (in relation to cardiovascular instability)

• Through sympathetic stimulation, pain may increase arterial blood pressure and hence surgical blood losses

• A patient experiencing pain might contract the moving leg and raise the venous blood pressure of that limb and increase its blood loss that way (Guay, 2006).

Physiologic processes of unrelieved pain

• How does unrelieved pain affects respiratory status? (in relation to respiratory dysfunction).

• Unrelieved pain impacts the respiratory system, causing small tidal volumes and decreases in functional lung capacity.

• which can lead to pneumonia, atelectasis, and an increased need for mechanical ventilation.

• What do you do as a nurse to prevent this complication?

Physiologic processes of unrelieved pain

• How does unrelieved pain affects the immune system? • The immune system is also affected by pain as

demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth.

Pain assessment

• The gold standard of pain assessment: • the patient's report of the pain experience.• What is the best way to do a comprehensive pain

assessment? • Location(s) of pain:• Intensity: Numeric Rating Scale (NRS), Faces Pain Scale-

Revised (FPS-R) & Wong-Baker FACES Pain Rating Scale

Pain assessment

• Quality:• Onset and duration: • Alleviating and relieving factors:• Effect of pain on function and quality of life:• Comfort-function (pain) goal:• Other information:

Breakthrough pain

• What is the importance of pain assessment?• to determine whether the patient is experiencing

breakthrough pain and if its treatment is effective.• How do we treat breakthrough pain?• A fast-onset, short-acting formulation of a first-line

analgesic, such as morphine, oxycodone, hydromorphone, or fentanyl, is used to manage breakthrough pain.

Reassessment of pain

• When do we reassess patient’s pain?• At a minimum, pain should be reassessed with each new

report of pain,• Before and after the administration of analgesics.• How frequently do you want to assess patient’s pain?

Challenges of assessment in the nonverbal patient

• How do you assess and determine pain management in the nonverbal patient? such as the critically ill (intubated, unresponsive)

• Use key components of hierarchy of importance of pain measures:• (1) attempt to obtain self-report; • (2) consider underlying pathology or conditions and procedures that

might be painful (e.g., surgery); • (3) observe behaviors; • (4) evaluate physiologic indicators; and • (5) conduct an analgesic trial

Pharmacologic management of pain

Routes of administration

• Oral• Intravenous (IV)• Patient Controlled Analgesia (PCA)• Intraspinal analgesia and continuous peripheral nerve

block infusions• Transdermal (Patches for long term pain control)

Watch out for the side effects…

• Nurse monitoring of side effects is essential to ensure patient safety during analgesic administration.

• Opioid-induced respiratory depression• Systematic assessment of patients’ sedation level• Pasero Opioid-Induced Sedation Scale (POSS) with

interventions (Pasero, 1994).• What other common side effects are associated with opioids?

PASERO OPIOID-INDUCED SEDATION SCALE (POSS) WITH INTERVENTIONS

• S = Sleep easy to arouse Acceptable;• 1 = Awake and alert Acceptable;• 2 = Slightly drowsy, easily aroused Acceptable; • 3 = Frequently drowsy, arousable, drifts off to

sleep during conversation Unacceptable; • 4 = Somnolent, minimal or no response to

verbal and physical stimulation Unacceptable. • Copyright 1994, Chris Pasero.

Non pharmacologic strategies

• Body-based (physical) modalities, • Biologically-based therapies,• Energy therapies• Nonpharmacological methods may be effective alone for

mild to some moderate-intensity pain and are used to complement, but not replace, pharmacologic therapies for more severe pain.

Interrelated concepts: causes and effects of pain

Case study• J. A. is a 38-year-old otherwise healthy female who has been admitted directly to

the ICU after an automobile accident and emergency abdominal surgery. In addition to surgery, she has deep face, neck, and chest lacerations and contusions. J. is on a ventilator and somewhat disoriented and restless with elevated blood pressure and heart rate. She is unable to provide a report of pain.

• How would you assess her pain?• What are the challenges of assessing her pain?• Give indicators of components of the hierarchy of pain measures. (self report,

underlying pathology, behaviors, physiologic indicators and pain management regimen you would trial or ask her medical team)

References• American Pain Society (APS): Principles of analgesic use in the treatment of acute and cancer pain.

ed 6, 2008, Author, Glenview, Ill.• American Geriatrics Society (AGS): Pharmacological management of persistent pain in older

persons. J Am Geriatr Soc. 57, 2009, 1331–1346.• Guay, J. (2006). Postoperative Pain Significantly Influences Postoperative Blood Loss in Patients

Undergoing Total Knee Replacement. Pain Medicine, 7(6), 476-482.• K. Herr: Pain in older adult: an imperative across all health care settings. Pain Manag Nurs. 11(2),

2010, S1–S10.• M. McCaffery: Nursing practice theories related to cognition, bodily pain, and man-environment

interactions. 1968, University of California, Los Angeles.• C. Pasero, R.K. Portenoy: Neurophysiology of pain and analgesia and the pathophysiology of

neuropathic pain. In C. Pasero, M. McCaffery (Eds.): Pain assessment and pharmacologic management. 2011, Mosby/Elsevier, St Louis, 1–12.

References

• C. Pasero: Postoperative pain management in the older adult. In S.J. Gibson, D.K. Weiner (Eds.): Pain in older persons. 2005, International Association for the Study of Pain (IASP), Seattle, 377–401.

• M.G. Titler, K. Herr, M.L. Schilling, et al.: Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers. Appl Nurs Res. 16(4), 2003, 211–227.