2. Pain Management
• Analgesics relieve pain without producing loss of
consciousness or reflex activity
• Should be potent
• Should not cause dependence
• Should exhibit little adverse effects: constipation,
hallucinations, respiratory depression, N/V
• Should not cause tolerance
• Should act promptly 7 over a long period w/little
amount of sedation
4. Pain Actions
• Pathways to pain tranasmission from the site
of injury to the brain for processing & reflexive
action
• First step:
• Nociceptors
– Transduction
– Transmission
– Perception
– modulation
5. Pain Action
• Nociceptor
– Stimulation of receptors at nerve endings (skin,
blood vessel, joints, SQ, periosteum, viscera)
– Classified—thermal, chemical, mechanical-
thermal based on type of sensation they transmit
6. Pain Actions
• Important to Nociceptors is the transduction
phase for meds to causing their effects
• Transduction
– 1. noxious stimuli causes cell damage with release of
sensitizing chemicals
• Prostaglandins
• Bradykinin
• Serotonin
• Substance P
• Histamine
– 2. these substances activate nociception and lead to
generation of action potential
8. Pain Actions
• In the CNS there are 4 pain-transmitting
pathways to various areas of the brain for
response—opiate receptors
– Mu—induce central analgesia, euphoria, dependence,
miosis, resp. depression
– Delta—limbic for euphoria
– Kappa—responsible for analgesia, sedation, dysphoria
– Epsilon-
– Sigma (opioid & partial agonists)—autonomic
stimulation, hallucinations, sysphoria
11. Pain Stepwise Approach
1. Non-opioid +/- Adjuvant—pain persisting or
increasing
2. Opioid for mild to moderate pain—pain
persisting or increasing
+/- Non-opioid
+/-Adjuvant
3. Opioid for moderate to severe pain
Non-opioid
+/- Adjuvant
12. Pain Recommendations
• Mild acute pain—ASA, NSAIDs, or Tylenol
• Inflammatory pain—NSAIDs
• Unrelieved moderate pain—moderate potency—
codeine or oxycodone often combination
w/Tylenol or ASA
• Severe acute pain—opioid agonist-Morphine,
hydromorphone, levophanol
• Severe chronic pain—Morphine sulfate
• Other adjunctive—antidepressants or
anticonvulsants—depending on pain cause!
13. Joint Commission Standards
• Primary therapeutic outcomes:
• Relief of pain intensity and duration of pain complaint
• Prevention of the conversion of persistent pain to
chronic pain
• Prevention of suffering and disability associated with
pain
• Prevention of psychological & socioeconomic
consequences associated with inadequate pain
management
• Control of adverse effects
• Optimization of the ability to perform ADL’s
• Placebo therapy should never be used with pain
management
14. Nursing Process: Pain Management
• Pain is 5th Vital Sign
• Assessed every time VS are taken & recorded
• Pain flow sheets
• Evaluate pain immediately before and after
administration at 1, 2, and 3 hour intervals PO
• At 15-30 min intervals after parenteral administration
• Data Sheets:
• Rating before and after
• Nonpharmacologic measures initiated
• Patient teaching performed
• Breakthrough pain measures implemented
15. Nursing Process: PM
• Believe patients report
• Consider past history, subjective experiences, feelings
• Consider psychological, physical and environmental factors—rest, low lighting,
quiet, hydration, back rub, repositioning, hot or cold applications, relaxation
techniques, diversion activities
• Be consistent
• Tools:
• Riley for Infants—face, legs, activity, cry consolability FLACC Scale nonverbal client
• Pain Observation Scale—young children 1-4 yrs. POCIS
• Modified Objective Pain Score MOPS—children 1-4 yrs. after ENT surgery
• Toddler-Preschooler Postop Pain Scale TPPPS—following medical or surgical
procedures
• Postop Pain Score POPS—infants surgical procedures
• Neonatal Infant Pain Scale NIPS—preterm and full-term neonates painful
procedures
• Wong-Baker– 3 yrs. And older as well as adults with language barriers, who don’t
read, select faces
17. Nursing Process: PM
• How does your pain change with time?
• 1. Continuous
• Steady
• Constant
• 2. Rhythmic
• Periodic
• Intermittent
• 3. Brief
• Momentary
• Transient
• What kinds of things relieve your pain?
• What kinds of things increase your pain?
18. Nursing Process: PM
Lifespan Considerations:
Maintain steady blood level of analgesic—best control
ADME are affected by age
Dosages & frequency increased in children, especially
teenager (metabolism)
Older Adults smaller dosages (slow metabolism &
excretion)
Make regular assessments on pain level
Contact provider for adjustments in dose & frequency
based on responses
Before initiating pain assessment: assess hearing & visual
impairment
19. Nursing Process: PM Assessment
• Medication history
– What meds
– How effective
– Adverse effects
• Patient’s perception—causes
• Believe pain experience
• Onset—when pain was 1st noticed, abrupt, occur with
eating food
• Location--exactly where is your pain
• Depth—does sensation spreading out or diffusing, localized
• Quality—actual sensation felt like dull, sharp stabbing
• Duration—continuous or intermittent, how often
• Severity—rate your pain using pain methodology
20. Nursing Process: PM Assessment
• Nonverbal Observations—body position, facial
grimace, immobility of particular part, holding
extremity, think about developmental differences--
clingy to parents, irritable baby, teens deny pain in
front of peers
• Pain relief—specific measure, measure tried, beneficial
• Physical Data—always examine affected part for
alterations in appearance, sensational changes,
limitation or ROM
• Behavioral Responses—coping mechanisms, manages,
crying, anger, withdrawal, depression, anxiety, fear,
ADL’s
21. Nursing Diagnoses
• Acute Pain
• Chronic Pain
• Urinary Retention
• Impaired Gas Exchange
• Risk for Constipation
22. Nursing Process: PM Planning
• History of Pain Experience
– Evaluate pain location, depth, quality, duration and severity
– Perform baseline VS at least Qshift or more by condition and type of meds
• Pain Relief
– Goal of treatment established when initiating regimen, prevention, reduction or elimination,
capacity, QOL, and ability to retain independence
• Pain at rest < 3
• Pain with movement < 5
• At least 6 hrs. of sleep uninterrupted by pain
• Able to work at hobby
• Update care plan
• Implement nonpharmacologic & pharmacology
• During 1st 24 hours reassess often evaluate degree of pain relief provide reassurance
• Environmental Control of quiet, little distraction of rest, modify schedules, schedule
diversional activities
• Psychological Interventions get staff involve in rest, understanding, providing
diversional activities
• Med Administration
– Check degree of pain relief
– Keep adequate supply
23. Nursing Process: PM Implementing
• Comfort Measures
– Basic hygiene
– Back rubs, massage, hot/cold application
– Support affected part, give med in advance
• Exercise and Activity
– Moderate if not contraindicated
• Non-pharmacologic Approaches
– Relaxation
– Visualization
– Meditation
– Biofeedback
– TENS
• Medication
– Request pain meds
– Encourage open communication
– PCA
• Pain Control
– Anticipate their need
• Nutritional Aspects
– Eat well balanced diet high in B-complex, vitamins, limit or eliminate sugar,
nicotine, caffeine, alcohol, 8 glass of water daily
24. Education and Health Promotion
• Orient client, family & significant others to benefits of adequate
pain control
• Work with them to determine perception of pain management, use
of drug & non-pharmacologic approaches
• Stress addiction is not a major factor with short-term use
• With long term use is to obtain sufficient pain control to ensure
comfort
• Teach what meds are available
• Teach how and when to request them
• Discuss patient expectations
• Ask what level of exercise is attainable without severe pain
• Assess changes in expectations
• Constantly report duration and intensity to provider
• Assist with effective coping
• Teach self-administration
• Make sure family understand how to obtain assistance
25. Education and Health Promotion
• Fostering Health Maintenance
– Discuss med information
– How it will benefit
– Combination of meds & comfort measures, relaxation, meditation, stress
reduction, meeting total care needs to ensure ADL’s
– Provide important information
– Health teaching of adverse effects
– Seek cooperation & understanding of:
• Adherence
• Name of Meds
• Dosage
• Route
• Times
• Common & Serious Adverse effect
• Written Record
– Frequency of attack
– Activity performed
– When
– Techniques used for control
– Degree of relief
26. Drug Class: Opiate Agonist
• Opiate Agonists—naturally occurring semisynthetic and synthetic drugs
– Relieve severe pain without loss of consciousness
– Stimulate opiate receptor in CNS
– Produce physical dependence
– Prolonged use produce tolerance or psychological & physical dependence
(addiction)
• Uses: relieve acute or chronic moderate to severe pain…injury, postop,
renal or biliary, MI or cancer
• Perform neurologic assessment: orientation, alertness, hand grip, motor
function
• Take VS hold if RR < 12/min
• Check prior analgesics
• Check bowel sounds and consistency of stools
• Review voiding pattern & urine output
• CAE: lightheaded, dizziness, sedation, confusion, orthostatic hypotension,
N/V, constipation
• SAE: respiratory depression, urinary retention, abuse
• Interactions CNS, Dilantin, Tegretol, SSRI—tramadol, warfarin
27. Class: Opiate Partial Agonist
• Nubain, Talwin, Stadol…etc.
• Depends of previous agonist administration
• Potency 1st few weeks similar to Morphine
• Prolonged use tolerance
• Increasing dose doesn’t produce increase analgesia but increase adverse effects—
ceiling effect
• Will induce withdrawal in those addicted to agonist opioids
• Uses: short term relief up to 3 wks of moderate to severe pain in cancer, burns,
renal colic, preop, obstetric
• Outcomes: relief of intensity & duration, conversion of persistent pain, prevention
of suffering, control adverse effects, ADL’s
• Perform baseline neurocheck: orientation, mental alertness, hand grip, motor
functioning
• Take VS
• Check bowel sounds and prior opiate agonist use
• Review voiding pattern & urine output
• CAE: clamminess, sedation, sweating, dizziness, N/V/dry mouth, constipation
• SAE: confustion, disorientation, hallucination, respiratory depression, Abuse
28. Class: Opiate Antagonists
• Naloxone pure because it has no effect on its own other
than reverse CNS depressant
• Withdrawal in addicted clients of agonists
• Added to Talwin to reduce abuse by blocking euphoria
• Choice treatment for reversal of respiratory depression
• Neurocheck: orientation, LOC, hand grip, motor
functioning
• VS: BP, HR, RR at frequent intervals
• Check prior dependence of agonists
• Have supportive equipment available
• Check bowel sign. Review voiding & urine output
• CAE: apathy, N/V, anorexia, mental depression
29. Drug Class: Salicylates
• Most common used
• Relief of slight to moderate pain
• Analgesic, antipyretic, anti-inflammatory
• Inhibit formation, production of S/S of inflammation, synthesis &
release of prostaglandins
• Combination effects as choice drug for above
• Can be taken long term without dependence
• Inhibition of platelet aggregation by blocking thromboxane A2
• Enhances bleeding time
• Reduce risk of recurrent TIAs or stroke, MI with previous episodes
• Outcomes: reduced pain, inflammation, eliminate fever,
antiplatelet
31. Drug Class: Misc Analgesics
• Acetaminophen—Tylenol
• Synthetic non-opiate analgesic
• Works by prostaglandin inhibition in CNS
• Blocks generation of pain impulses in peripheral tissue
• Antipyresis by inhibiting heat regulating center in hypothalamus
• Used: discomfort associated with bacterial & viral infection,
headache, musculoskeletal pain
• Client who can’t take ASA products, anticoagulants, or possible
bleeding problems from Gastric or Duodenal Gastritis & Hiatus
Hernia
• Not effective in RA
• Outcome: Reduced pain & fever
• CAE: gastric irritation
• SAE: liver toxicity
