Lecture 2 Part 2 - Comfort and Pain Management

‭Categories of Pain: Location‬ ‭●‬ ‭Cutaneous‬ ‭●‬ ‭Visceral/Splanchnic‬ ‭●‬ ‭Deep somatic‬ ‭●‬ ‭Referred‬ ‭ uestion:‬‭A patient who has bone cancer is most likely‬‭experiencing which of the following‬ Q ‭types of pain?‬ ‭a.‬ ‭Cutaneous‬ ‭b.‬ ‭Somatic‬ ‭c.‬ ‭Visceral‬ ‭d.‬ ‭Referred‬ ‭The Pain Process‬ ‭●‬ ‭Four physiologic processes of nociception‬ ‭●‬ ‭Transduction: Initial recognition of pain via pain receptors‬ ‭○‬ ‭Nociceptors‬ ‭○‬ ‭Convergences of stimulus to electrical signals‬ ‭●‬ ‭Transmission: Pathway of pain electrical signals to the brain‬ ‭○‬ ‭Afferent pathways‬ ‭○‬ ‭A-delta fibers‬ ‭○‬ ‭C fibers‬ ‭●‬ ‭Perception: Sensory process of how a person interprets pain‬ ‭○‬ ‭Pain characteristics‬ ‭○‬ ‭Pain threshold‬ ‭■‬ ‭High vs. low‬ ‭■‬ ‭Influences‬ ‭●‬ ‭Modulation: How a pain sensation is inhibited or modified‬ ‭○‬ ‭Endorphins‬ ‭○‬ ‭Neuromodulators‬ ‭●‬ ‭Stimulator of nociceptors or pain receptors‬ ‭○‬ ‭Bradykinin (vasodilator)‬ ‭○‬ ‭Prostaglandins‬ ‭○‬ ‭Substance P‬ ‭●‬ ‭Pain modulator (neuromodulators)‬ ‭○‬ ‭Endorphins‬ ‭○‬ ‭Dynorphins‬ ‭○‬ ‭Enkephalins‬ ‭Gate Control Theory of Pain‬ ‭ ‬ ‭TENS: Transcutaneous Electrical Nerve‬ ● ‭ timulation‬ S ‭ uestion:‬‭A client comes to the emergency department‬‭complaining of a shooting pain in his‬ Q ‭chest. When assessing the client’s pain, what behavioral response would the nurse expect to find?‬ ‭a.‬ ‭Decreased heart rate‬ ‭b.‬ ‭Guarding of the chest area‬ ‭c.‬ ‭Increased respiratory rate‬ ‭d.‬ ‭High blood pressure‬ ‭Common Pain Responses‬ ‭●‬ ‭Characterized by the duration and severity of pain‬ ‭●‬ ‭Behavioral responses visually communicate the pain experience‬ ‭●‬ ‭Affective responses demonstrate how the pain psychologically impacts the patient‬ ‭○‬ ‭Observed through actions, words, demeanor, and overall appearance‬ ‭○‬ ‭Crucial to evaluate mood and affect with each interaction‬ ‭Physiologic Responses to Pain‬ ‭●‬ ‭Sympathetic response to moderate and superficial pain‬ ‭○‬ ‭Increased BP, pulse, and respirations‬ ‭○‬ ‭Pupil dilation‬ ‭○‬ ‭Muscle tension and rigidity‬ ‭○‬ ‭Pallor‬ ‭ ‬ ‭Increased glucose‬ ○ ‭ ‬ ‭Parasympathetic responses to severe and deep pain‬ ● ‭○‬ ‭N/V‬ ‭○‬ ‭Decreased BP‬ ‭○‬ ‭Decreased pulse‬ ‭○‬ ‭Rapid and irregular breathing‬ ‭○‬ ‭Fainting and unconsciousness‬ ‭●‬ ‭Behavioral response (voluntary) reflected in body movements‬ ‭○‬ ‭Posture: Protecting the painful area and refusing to move‬ ‭○‬ ‭Gross motor activities: Moving away from painful stimuli, restlessness‬ ‭○‬ ‭Facial features: Grimacing‬ ‭○‬ ‭Verbal expression: Moaning, crying, voicing pain‬ ‭●‬ ‭Affective response (psychological) reflected in mood and emotions‬ ‭○‬ ‭Anxiety, depression, insomnia‬ ‭○‬ ‭Hopelessness, fear, anger‬ ‭○‬ ‭Fatigue, withdrawal from others‬ ‭○‬ ‭Anorexia‬ ‭Factors Affecting Pain Experience‬ ‭●‬ ‭Culture‬ ‭○‬ ‭Enduring pain stoically, sign of strength‬ ‭●‬ ‭Ethnic variables: Ancestry, nationality, language, and set of beliefs/values held by a group‬ ‭of people that are passed down from one generation to the next‬ ‭○‬ ‭Miscommunication (understanding of the nurse’s meaning of pain → discomfort,‬ ‭ache, etc.)‬ ‭●‬ ‭Family, gender, and age variables‬ ‭○‬ ‭Feeling the need to be brave and ignore pain‬ ‭○‬ ‭Seeing pain as a way to get people’s attention‬ ‭○‬ ‭Gender expectations‬ ‭○‬ ‭Accepting the aging process (belief that it’s supposed to come with pain)‬ ‭●‬ ‭Religious beliefs‬ ‭○‬ ‭Pain and suffering equates to not being a good person‬ ‭■‬ ‭Purification‬ ‭■‬ ‭Punishment (shaken faith)‬ ‭●‬ ‭Environment and supportive circle‬ ‭○‬ ‭Low-income → experience pain for a lengthy period before seeking treatment‬ ‭○‬ ‭Rural vs. urban; limited travel and resources‬ ‭○‬ ‭Hospital is a foreign environment (unfamiliar → greater pain)‬ ‭○‬ ‭Prefer to have a comfort family member or to be alone‬ ‭●‬ ‭Anxiety and other stressors‬ ‭ ‬ ‭Threat of the unknown → increased pain‬ ○ ‭○‬ ‭Not rested or relaxed‬ ‭ ‬ ‭Past pain experience‬ ● ‭○‬ ‭Experienced prejudice‬ ‭○‬ ‭Never known severe pain‬ ‭○‬ ‭Had good or bad experiences → carries into the present‬ ‭How Nurses Help the Pain Experience‬ ‭●‬ ‭Using pain assessment tools: Standardized, translated into multiple languages, and‬ ‭adapted for use across races/ethnicities‬ ‭○‬ ‭Eliminating guesswork and bias‬ ‭○‬ ‭Acknowledging what a person is experiencing‬ ‭●‬ ‭Connecting patients with resoruces like spiritual advisors to navigate their pain‬ ‭ uestion:‬‭The best judge of the existence and severity‬‭of a patient’s pain is the physician or‬ Q ‭nurse caring for the patient.‬ ‭a.‬ ‭True‬ ‭b.‬ ‭False‬ ‭Pain Assessment Tools‬ ‭●‬ ‭CRIES pain scale‬ ‭●‬ ‭FLACC scale‬ ‭●‬ ‭Wong-Baker FACES‬ ‭CRIES Pain Scale‬ ‭‬ B ● ‭ eyer Oucher pain scale‬ ‭●‬ ‭PAINAD scale‬ ‭●‬ ‭COMFORT scale‬ ‭FLACC Scale‬ ‭Oucher Pain Scale‬ ‭Comfort Scale‬ ‭●‬ ‭Used in unconscious and ventilated infants, children, and‬ ‭adolescents; has eight indicators:‬ ‭○‬ ‭Alertness‬ ‭○‬ ‭Calmness/agitation‬ ‭○‬ ‭Respiratory response‬ ‭○‬ ‭Physical movement‬ ‭○‬ ‭Blood pressure‬ ‭○‬ ‭Heart rate‬ ‭○‬ ‭Muscle tone‬ ‭○‬ ‭Facial tension‬ ‭PAINAD Scale‬ ‭●‬ ‭Breathing (normal to noisy labored breathing)‬ ‭●‬ ‭Negative vocalization (moan, groan)‬ ‭●‬ ‭Facial expression (inexpressive, frown)‬ ‭●‬ ‭Body language (relaxed, tense, rigid)‬ ‭●‬ ‭Consolability (no need to console, unable to console)‬ ‭ uestion:‬‭Which of the following pain assessment tools‬‭is recommended for use with neonates‬ Q ‭0-6 months?‬ ‭a.‬ ‭Voucher pain scale‬ ‭b.‬ ‭Wong-Baker FACES‬ ‭c.‬ ‭PAINAD scale‬ ‭d.‬ ‭CRIES pain scale‬ ‭Assessment Parameters for Pain‬ ‭Nursing Interventions for Pain‬ ‭●‬ ‭Establishing a trusting nurse-patient relationship‬ ‭○‬ ‭Nurses provide comfort and support‬ ‭○‬ ‭Discussing pain and setting goals‬ ‭●‬ ‭Manipulating factors‬ ‭○‬ ‭Altering the cause of pain‬ ‭○‬ ‭Altering pain tolerance‬ ‭●‬ ‭Additional pain control‬ ‭○‬ ‭Nonpharmacologic interventions‬ ‭●‬ ‭Initiating nonpharmacologic and pharmacologic pain relief measures‬ ‭○‬ ‭Holistic routes: Music, imagery, and humor‬ ‭○‬ ‭Pharmacologic is more complex and needs to be monitored‬ ‭●‬ ‭Teaching patients about pain‬ ‭○‬ ‭Include caregivers and family members‬ ‭○‬ ‭Well-informed patients can cope‬ ‭●‬ ‭Ethical and legal responsibility‬ ‭○‬ ‭Patients have the right to be involved in their pain management‬ ‭○‬ ‭Nurse needs to inform patient‬ ‭Nonpharmacologic Pain Relief Measures‬ ‭●‬ ‭Music‬ ‭●‬ ‭Humor‬ ‭●‬ ‭Acupuncture‬ ‭●‬ ‭Imagery‬ ‭●‬ ‭Therapeutic touch‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ iofeedback‬ B ‭Hypnosis‬ ‭Distraction‬ ‭Relaxation‬ ‭Cutaneous stimulation (TENS)‬ ‭Pharmacologic Pain Relief Measures‬ ‭●‬ ‭Nonopioid analgesics‬ ‭○‬ ‭Examples: Acetaminophen, NSAIDs‬ ‭○‬ ‭Mechanism: Reduce inflammation and pain by inhibiting the cyclooxygenase‬ ‭(COX) enzymes, which are involved in the production of prostaglandins‬ ‭○‬ ‭Considerations: Lower risk of addiction but potential for gastrointestinal issues‬ ‭with prolonged use‬ ‭●‬ ‭Opioid analgesics‬ ‭○‬ ‭Examples: Morphine, codeine‬ ‭○‬ ‭Mechanism: Bind to opioid receptors in the CNS to block pain signals‬ ‭○‬ ‭Considerations: Effective for severe pain but carries risks of addiction, tolerance,‬ ‭and respiratory depression‬ ‭●‬ ‭Adjuvant drugs‬ ‭○‬ ‭Anticonvulsants: Stabilize nerve cell membranes to reduce neuropathic pain‬ ‭○‬ ‭Antidepressants: Enhance serotonin and norepinephrine levels in the brain, which‬ ‭can modulate pain perception‬ ‭○‬ ‭Corticosteroids: Reduce inflammation by suppressing the immune response,‬ ‭leading to pain relief‬ ‭●‬ ‭Analgesic administration routes‬ ‭○‬ ‭Oral: Common for mild to moderate pain; convenient but with slower onset‬ ‭○‬ ‭IV: Used for severe pain or when rapid relief is needed; offers quick onset but‬ ‭requires monitoring‬ ‭○‬ ‭Transdermal: Provides steady pain relief over time; ideal for chronic pain‬ ‭management‬ ‭○‬ ‭Intramuscular and subcutaneous: Alternative for patients who can’t take oral‬ ‭medications; quicker onset but less convenient‬ ‭The WHO 3-Step Analgesic Ladder‬ ‭Side Effects of Opioid Use‬ ‭●‬ ‭Sedation: Generally given prior‬ ‭to a procedure; decreases anxiety‬ ‭●‬ ‭Nausea: Decrease in the function‬ ‭of the GI system‬ ‭●‬ ‭Constipation: When a stool‬ ‭cannot pass through normally‬ ‭●‬ ‭Physical dependence: Physical‬ ‭dependence on a substance that results‬ ‭in withdrawal symptoms when a drug is‬ ‭stopped or decreased in dosage‬ ‭‬ T ● ‭ olerance: The need to receive a larger dose in order to abate pain‬ ‭●‬ ‭Addiction: An uncontrollable search for drugs and desire to take them even after there‬ ‭have been bad outcomes‬ ‭ uestion:‬‭A sedated patient is frequently drowsy and‬‭drifts off during his conversation with the‬ Q ‭nurse. What number on the sedation scale best describes this patient?‬ ‭a.‬ ‭1‬ ‭b.‬ ‭2‬ ‭c.‬ ‭3‬ ‭d.‬ ‭4‬ ‭Numeric Sedation Scale‬ ‭a.‬ ‭1: Awake and alert; no action necessary‬ ‭b.‬ ‭2: Occasionally drowsy, but easy to arouse; no action necessary‬ ‭c.‬ ‭3: Frequently drowsy and drifts off to sleep during conversation; reduce dosage‬ ‭d.‬ ‭4: Somnolent with minimal or no response to stimuli; discontinue opioid and consider use‬ ‭of naloxone‬ ‭Pain Management Regimens for Cancer/Chronic Pain‬ ‭●‬ ‭Allow as much control as possible‬ ‭●‬ ‭ATC (not PRN)‬ ‭●‬ ‭Oral medication‬ ‭●‬ ‭Opioids vs. non-opioids‬ ‭●‬ ‭Adjust dose‬ ‭Additional Methods for Administering Analgesics‬ ‭●‬ ‭Patient-controlled analgesia (PCA)‬ ‭●‬ ‭Intravenously or via epidural route‬ ‭●‬ ‭Morphine, fentanyl, and hydropmorphone‬ ‭Placement of an Epidural Catheter‬ ‭Hot vs. Cold Therapy‬ ‭●‬ ‭Cold therapy‬ ‭○‬ ‭Reduces swelling and inflammation‬ ‭○‬ ‭Relieves pain‬ ‭○‬ ‭Used immediately after an injury‬ ‭○‬ ‭May continue to use for 3-5 days‬ ‭●‬ ‭Hot therapy‬ ‭○‬ ‭Increases blood circulation‬ ‭○‬ ‭Promotes healing process‬ ‭○‬ ‭Relaxes stiff muscles/joints‬ ‭○‬ ‭Increases ROM‬ ‭○‬ ‭Soothes sore muscles‬ ‭●‬ ‭Don’t apply cold/heat for longer than 20 minutes‬