PAIN: NURSING IMPLICATIONS
Prepared by: Shalini Joy. MSN, Manipal College
of Nursing, Manipal University
Last updated on
23-10-08
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Outline
INTRODUCTION
Everyone has
experienced some type or degree of pain. It is the most common reason why
people seek healthcare. Despite being one of the most commonly occurring
symptoms in the medical world, pain is one of the least understood. A person
in pain feels distress or suffering and seeks relief. However, the nurse
cannot see or feel the client’s pain. Pain is subjective. Now, pain is
considered to be a separate disease.
Definition
*Pain is defined as
an unpleasant, subjective sensory and emotional experience associated with
actual or potential issue ,damage or described in terms of such damage.
(IASP,1979)
*McCaffery and
Pasero (1999)say it best by defining pain as “whatever the person
experiencing it says it is, existing whenever (he/she) says it does”
*The American pain
society also stresses the importance of self-report. Pain is always
subjective…the clinician must accept the patient’s report of pain”(1999)
*Agency for
healthcare research and quality (AHRQ) from the guideline for cancer pain
states, health professionals should ask about pain and the patients self
report should be the primary source of assessment.
NATURE OF PAIN.
Pain is much more than a physical sensation caused by a specific
stimulus. The pain experience is complex, involving physical, emotional and
cognitive components. Pain is subjective and highly individualized. Pain
cannot be objectively measured; only the client knows whether pain is
present and what the experience is like.
TYPES OF PAIN
Pain can be described by its origin or cause and by its nature or
description.
*On the basis of
origin, the pain can be classified as:
CUTANEOUS PAIN.
This is caused by stimulating the cutaneous nerve endings
in the skin and results in a well organized “burning” or “prickling”
sensation. Eg: Tangled hair that is pulled during combing causes pain
SOMATIC OR DEEP PAIN
This is
non localized and originates in supporting structures such as
tendons, ligaments and nerves. Pain in somatic structures is a complicated
phenomenon. Deep pain is poorly localized, may produce nausea and is
frequently associated with sweating and changes in blood pressure. Deep
somatic pain is generally diffuse, less localizable than cutaneous
pain. Also pain from deep structures frequently radiates from primary
sites. Eg: pain from lumbar disc is felt along the sciatic nerve.
VISCERAL OR SPLANCHNIC PAIN
Visceral pain is a discomfort in the internal organs, is less localized and
more slowly transmitted than cutaneous pain. Usually autonomic
manifestations accompany (diarrhea, cramps..).Visceral pain is transmitted
through sympathetic and parasympathetic fibers of ANS with the pain often
referred to the body surface, often in sites at a
distance.
On the basis of nature of pain, it is
divided into two:
ACUTE PAIN
Acute pain has a sudden onset, relatively short
duration, mild to severe intensity, with a steady decrease in intensity over
a period of days to weeks. Once the noxious stimuli is resolved, the pain
usually disappears. It is usually associated with a specific
condition, injury or tissue damage caused by disease. As healing
occurs, acute pain should diminish. Eg: toothaches, headaches, needle sticks.
The client
will exhibit elevated heart rate, respiratory rate and blood pressure; and
may become diaphoretic and have dilated pupils. These signs resemble
anxiety, which often accompanies anxiety.
RECURRENT ACUTE PAIN
is repetitive painful episodes
that recur over a prolonged period or throughout the client’s
lifetime. Pain intervals alternate with painful episodes.
CHRONIC PAIN
Chronic pain is defined as long term, persistent, nearly constant or recurrent pain producing significant
changes in the client’s life. Chronic pain may last long after the
pathology is resolved.
CHRONIC ACUTE PAIN occurs almost daily over a long period, months or years, and may never
stop. Eg: Cancer pain
CHRONIC NON MALIGNANT PAIN is also called chronic
benign pain, occurs almost daily and lasts for at least 6 months, ranging
from mild to severe intensity. Three critical characteristics of chronic
non malignant pain is identified by McCaffery and Pasero (1999):
a) caused by non-life
threatening causes
b) not responsive to currently available pain relief
methods
c) may continue for the rest of the client’s life
Eg: Rheumatoid arthritis
-
The body
cannot tolerate the sympathetic nervous symptoms for long and therefore, adapts.
Vital signs will often be normal with no accompanying
pupil dilatation or perspiration. The client often describes exhaustion and
fatigue. Behaviors include no complaint of pain unless asked and physical
inactivity or immobility leading to functional disability.
OTHER CLASSIFICATIONS
*Psychogenic
pain
*Idiopathic
pain
*Nociceptive
pain
*Neuropathic
pain
*Deafferentiation
pain
PURPOSES OF PAIN
DIMENSIONS OF PAIN AND PAIN
PROCESS
As a multidimensional
phenomenon, pain consists of 5 dimensions.
1.
PHYSIOLOGIC
2.
BEHAVIORAL
3.
SENSORY
4.
COGNITIVE
5.
AFFECTIVE
1.
PHYSIOLOGIC DIMENSION OF PAIN
The opioid system and the non
opioid system are the two known endogenous
analgesia systems in humans. The best known is the opioid system. It is
mediated by endorphins. The nonopioid system is mediated by monoamine
substances such as norepinephrine and serotonin.
The neural mechanism by
which pain is perceived consists of four major steps:
TRANSDUCTION
- is the conversion of a
mechanical, thermal or chemical stimulus into a neuronal action potential
- noxious stimuli causes cell
damage with the release of sensitizing chemicals like
prostaglandins, bradykinin, serotonin, substance P, histamine
- these substances activate
nociceptors and lead to generation of action potential
TRANSMISSION
-is the movement
of pain impulses from the site of transduction to the brain
-
Action potential continues from :
*site of injury to spinal cord
*spinal cord to brain stem and
thalamus
*thalamus to cortex for
processing
PERCEPTION
-occurs when
pain is recognized, defined and responded to by the individual experiencing
the pain.
-is the
conscious experience of the pain
MODULATION
-
involves the activation of descending
pathways that exert inhibitory or facilitatory effects on the transmission
of pain
-
neurons originating in the brainstem
descend to the spinal cord and release substances that inhibit nociceptive
impulses.
-
Modulation of pain signals can occur at
the level of the periphery, spinal cord, brainstem, and cerebral cortex.
-
Descending modulatory fibers release
chemicals such as serotonin, norepinephrine, GABA and endogenous opioids
that can inhibit pain transmission
2.SENSORY, AFFECTIVE, BEHAVIORAL,
COGNITIVE AND SOCIOCULTURAL DIMENSIONS OF PAIN
-
The sensory component of pain is the recognition of the
sensation as painful. Sensory – pain elements include
Pattern, Area, Intensity and Nature.
-
The affective component of pain refers to the emotional
responses to the pain experience. These affective responses include
anger, fear, depression and anxiety. Negative emotions can impair the
patient’s quality of life.
-
The behavioral component of pain refers to the observable
actions used to express or control pain. For example, facial expressions
such as grimacing may reflect pain or discomfort. Posturing may be used to
decrease pain associated with specific movements.
-
The cognitive component of pain refers to beliefs, attitudes, memories, and meaning attributed to pain. The meaning of
the pain to patient can be particularly important.
-
The
sociocultural dimension of pain encompasses factors such as demographics (eg: age, gender,;
education..),support systems, social roles and culture.
THEORIES OF PAIN
THE
SPECIFICITY THEORY
This
theory was based on the assumption that pain was perceived following
injury because there was a single, dedicated, hard wired system of afferent
nerves which carried messages from specific pain receptors in the
periphery to a pain centre in the brain. The simple idea proposed that
specific nerve endings in the skin and other tissues respond exclusively
to nociceptive stimuli; that afferent nerves carry this information to
specialized parts of the dorsal horn of the spinal cord, and thence via the
anterolateral spinothalamic tract to the thalamus or pain centre in the
brain and to the relevant part of the sensory cortex.
PATTERN THEORIES
This
relate the perception of pain to patterns of impulses in the nervous
system rather than to impulses in the nervous system rather than to
impulses in dedicated pain pathways. The patterns may be temporal (in time)
or spatial (in space). Pattern theories may explain some chronic or
recurrent pains which occur when there are nerve lesions.
THE
GATE CONTROL THEORY;
In 1965,Melzack and wall proposed the gate control pain theory, which was the first one recognizing the psychological aspects of
pain are as important as physiological aspects. The gate control theory
combined cognitive, sensory, and emotional components – in addition to the
physiological aspects- and proposed that they can act on a gate control
system to block the individual’s perception of pain. The basic premise is
that transmission of potentially painful nerve impulses to the cortex is
modulated by a spinal cord gating mechanism and by CNS activity. As a
result, the level of conscious awareness of painful sensation is altered.
The theory suggests that nerve fibers that contribute to pain
transmission converge at a site in the dorsal horn of the spinal cord. This
site is thought to act as a gating mechanism that determines which
impulses will be blocked and which will be transmitted to the thalamus. The
image of gate is useful in teaching clients and their families about pain
relief measures. If the gate is closed, the signal is stopped before it
reaches the brain, where perception of pain occurs. If the gate is open, the
signal will continue on through the spinothalamic tract to the cortex and
the client will feel the pain. Whether the gate is opened or closed is
influenced by impulses from peripheral nerves and nerve signals that
descend from the brain.
If a person is anxious, the gate can be opened by signals sent
from the room down to the mechanism in the dorsal horn of the spinal
cord. On the other hand, if the person has had positive experiences with
pain control in the past, the cognitive influence can send signals down to
the gating mechanism and close it. The gate theory offered a great benefit
by suggesting new approaches to relieving both acute and chronic pain. Pain
could be relieved by blocking the transmission of pain impulses to the
brain by both physical modalities and by altering the individual’s thought
processes, emotions or other behaviors.
FACTORS AFFECTING THE PAIN
EXPERIENCE
PHASES OF PAIN EXPERIENCE
MANAGEMENT OF
PAIN
DRUG THERAPY
EQUIANALGESIC
DOSE – refers to a dose of one analgesic that is equivalent in pain
relieving effects compared with another analgesic. This equivalence permits
substitution of analgesics in the event that a particular drug is
ineffective or causes intolerable side effects. Generally, equianalgesic
doses are provided for opioids and are important because there is no upper
dosage limit for many of these drugs.
SCHEDULING ANALGESICS
–Appropriate analgesic scheduling should
focus on preventive or ongoing control of pain rather than providing
analgesics only after the patient’s pain has become severe.
Analgesic titration
is dose adjustment based on assessment of the adequacy of analgesic effect
versus the side effects produced. An analgesic can be titrated upwards or
downwards, depending on the situation. For eg; in a post operative patient
the dose of analgesic generally decreases over time as the acute pain
resolves. On the other hand, opiods for chronic, severe cancer pain can be
titrated upward many times over the course of therapy to maintain adequate
pain control. The goal of titration is to use the smallest dose of
analgesic that provides affective pain control with fewest side effects.
Analgesic ladder-The
WHO treatment plan calls for concurrent treatment of the cause of the pain
when possible and use of a three ladder approach. Step 1 drugs are used for
mild pain, and step 2 for mild to moderate pain, and step 3 for moderate to
severe pain. If pain persists or increases or increases, drugs from the next
higher step are used to control pain.
DRUG THERAPY FOR MILD PAIN
When pain is
mild, nonopioid analgesics and other NSAIDs are used. These agents are
characterized by the following :
1.There is
a ceiling effect to their analgesic properties; that is, increasing the dose
beyond an upper limit provides no greater analgesia.
2.They do
not produce tolerance or physical; and
3.Many are
available without a prescription.
A number of nonopioid analgesics such as
acetylsalicylic acid and NSAIDs inhibit the
chemicals that activate the PAN. Thus when these agents agents are used, the
PAN is transduced less often or a larger stimulus is needed to produce
transduction.
DRUG THERAPY FOR MILD TO MODERATE PAIN
When pain is
moderate in intensity(4 to 6 on a scale of 0 to 10) or mild but persistent
despite nonopioid therapy, step 2 drugs are
indicated. eg: codeine, oxycodone). These drugs usually are prescribed in
combining an opioid with a non opioid analgesic.
DRUG THERAPY FOR MODERATE
TO SEVERE PAIN
Step 3 drugs
are recommended for moderate to severe pain (7 to 10 on a scale of 0 to10)
or when step two drugs are providing no relief. These drugs are effective
for moderate to severe pain because they are potent, have no analgesic
ceiling and can be delivered via many routes of
administration. E.g: Morphine, morphine like agonists-hydromorphone, methadone, Mixed
Agonist-Antagonists-Pentazocine
ADJUVANT DRUGS USED FOR
PAIN MANAGEMENT
Corticosteroids, Antideprassants, Antiseizure, Muscle relaxants, Anesthetics.
ROUTES OF ADMINISTRATION
-
Oral
-
Sublingual
and buccal
-
Intranasl
-
Rectal
-
Transdermal
-
Parentral
routes
-
Intraspinal
deliver
PATIENT CONTROLLED
ANALGESIA
A specific
type of SC, IV or intraspinal delivery system is PCA or demand
analgesia. With PCA, a dose of opioid is delivered when the patient
decides
a dose is needed. PCA uses an infusion system in which the patient pushes a
button to receive a bolus infusion of an analgesic. PCA is widely used for
the management of acute pain ,including post operative pain and cancer
pain.
Use of
PCA begins with patient teaching. The patient needs to understand the
mechanics of getting a drug dose and how to titrate the drug to achieve
good pain relief. The patient should be encouraged to self-administer the
analgesic before pain intensity goal. The patient also needs to be assured
that he or she cannot “over dose” because the pump is programmed to
deliver a maximum number of doses per hour.
SURGICAL
THERAPY
Nerve Blocks
Nerve blocks are used to
reduce pain by temporarily or permanently interrupting transmission of
nociceptive input by application of local anesthetics or nerurolytic
agents.
Neuroablative techniques.
This technique destroy nerves, thereby interrupting pain transmission. Those destroying the sensory
division of a peripheral or spinal nerve are classified as
neurectomies, rhizotomies and sympathectomies.
Neuroaugmentation
involves
electrical stimulation of the brain and the spinal cord.
NON PHARMACOLOGIC THERAPY
FOR PAIN
COGNITIVE
THERAPIES:
-
Distraction
-
Hypnosis
-
Relaxation
NURSING MANAGEMENT OF PAIN
NURSE ROLES IN CARING
FOR PEOPLE IN PAIN
1. In relation to the person in pain:
-Assessor
-Preventor
-Stregth lender and
validator
-Supporter of patient’s
methods of control
-Teacher of coping
strategies
-Provider of specific
pain therapies
2. In
relationship to other carers:
-Advocate and evaluator
-Team member
-Team coordinator
3. In
relationship to the environment:
-Planner, provider or
controller of ambient temperature, noise etc.
ASSESSMENT
-Be
aware of your own values and expectations about pain behaviours.
-Pain
assessment tools are the most effective method to identify the presence
and intensity of pain in clients. These tools must be used and the results
must be accepted.
-The JCAHO
now considers pain as the fifth vital sign. It is to be assessed and
recorded along with the client’s TPR and blood pressure.
a) subjective data
-
A
client’s pain threshold and pain tolerance level should be assessed.
-
Pain threshold is the intensity level where a person
feels pain. It varies with each individual and with each type of pain.
-
Pain tolerance is the intensity level or duration of pain the client is
able or willing to endure.
-
Asses location, onset and duration, quality and
intensity of pain.
-
Enquire about aggravating and alleviating factors and associated
manifestations.
b) objective data
The objective data often presents a different picture depending on the
type of pain the client is experiencing.
ONGOING
ASSESSMENT
The initial
assessment obtains a baseline of information about the client’s pain, while
subsequent assessments provide information regarding the effectiveness of
the interventions.
RECORDING PAIN ASSESSMENT FINDINGS
A flow
sheet provides one place to document most of the information used to
make pain management decisions including pain rating, vital signs, analgesic
administered and level of arousal. The clients report of pain must be
accepted and recorded with pain management decisions based on that report.
NURSING
DIAGNOSES.
The
two primary nursing diagnoses used to describe pain are ACUTE PAIN and
CHRONIC PAIN. Many diagnoses can be related to the client in pain depending
on the effects of pain:
-
Activity intolerance
-
Anxiety
-
Constipation
-
Deficient knowledge (specify)
-
Disturbed body image
-
Disturbed sleep pattern
-
Disturbed thought process
-
Fatigue
-
Fear
-
Hopelessness
-
Impaired social interaction
-
Ineffective breathing pattern
-
Ineffective individual coping
-
Ineffective role performance
-
Ineffective therapeutic regimen management
-
Powerlessness
PLANNING / OUTCOME
IDENTIFICATION
When planning care, mutual goal setting with the client experiencing pain
is utmost importance. The nurse and client work together to develop
realistic outcomes. The general principles of management include
INDIVIDUALIZATION
A variety of pain relief measures can be tried in many
combinations is found. It is important to include measures that the client
believes will be effective. The cognitive component of pain perception can
have a powerful influence on the effectiveness of interventions. This may
mean including folk remedies or non scientific relief measures.
USE A PREVENTIVE APPROACH
Pain is much easier to control if it is treated before it gets severe. Interventions should be implemented when pain is mild or when it is
anticipated. Eg: medicate a client before a painful dressing change or
treatment rather than waiting for the pain to occur.
USE A MULTIDISCIPLINARY APPROACH
Pain relief is a complex phenomenon requiring input from various members
of the health care team. The nurse’s role is pivotal in managing a client’s
pain. The physician also plays a key role, diagnosing and treating the
medical cause of pain, which includes prescribing appropriate
medications. In complex cases, other professionals, such as physical
therapists, psychologists, social workers, social workers or chaplains may be
needed.
OR
-
The patient
must always be believed.
-
Every
patient deserves adequate pain management
-
Treatment
must be based on the patients goals.
-
Treatment
plans should use a combination of drug and nondrug therapies.
-
Multidisciplinary approach will be necessary to address all dimensions of
pain.
-
All
therapies must be evaluated to ensure that they are meeting the patient’s
goals.
-
Drug side
effects must be prevented and/or managed.
-
Patient and
family teaching should be a cornerstone to the treatment plan.
CONCLUSION
Nurses
are often the first health care professionals to encounter the person in
pain. So the relationship of patients and nurses can have an important
part in the care of person with pain.
REFERENCES
-
Ball.W.J, Bindler.CR. Paediatric Nursing.3rd
edition; Pearson Ltd: page no 287-294
-
Lewis, Heitkemper, Dirksen. Medical
Surgical nursing.6th edition. Mosby. Page no 131-157
-
Ignatavicius, Workman. Critical thinking
Study.5th edition. Elsevier Saunders; India:Pp 21-39
-
BlackJM, HawksJH. Medical Surgical Nursing
clinical management for positive outcomes. Vol 1.7th
edition. Saunders; India 2005 Pp 461-500
-
Fordham M,Dunn V. Along side the person in
pain-Holistic care and Nursing Practice. Pp 15 -37,124-134.
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