Comfort

COMFORT I.

PAIN EXPERIENCE

- pain is an elusive and complex phenomenon - one of the human body’s defense mechanisms that indicates the person is experiencing a problem - pain is whatever the experiencing person says it is, existing whenever he/she says it does A.

ORIGINS OF PAIN 1. nociceptive – pain that is usually acute and transmitted after normal processing of noxious stimuli - may be categorized as cutaneous, deep somatic, or visceral in nature a. cutaneous (or superficial) pain – involves the skin or subcutaneous tissue ex. paper cut that produces sharp pain with a burning sensation b. deep somatic – diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves ex. strong pressure on a bone or damage to tissue that occurs with a sprain c. visceral – poorly localized and originates in body organs in the thorax, cranium, and abdomen - occurs as organs stretch abnormally and become distended, ischemic or inflamed 2. neuropathic pain – results from injury to or abnormal functioning of peripheral nerves or the CNS - exact cause is unknown - can occur in many forms - can be of short duration or lingering - often described as burning or stabbing a. allodynia – pain that occurs after a normally weak or nonpainful stimuli, such as a light touch or cold drink 3.

psychogenic pain – physical cause for pain cannot be identified - pain that results from a mental event can be just as intense as pain that results from a physical event 4. origin

referred pain – pain that is perceived in an area distant from its point of

- transmitted to a cutaneous (skin) site different from where it originated - can travel to other areas of body innervated by affected nerve root ex. pain associated with MI is frequently referred to the neck, shoulders, or arms (often the left) B.

PAIN SYNDROMES - capable of causing severe pain - treatment is often delayed as a result of misdiagnosis

1. Complex regional pain syndrome (causalgia) – occurs in area of partially injured peripheral nerve (brachial plexus or median or sciatic nerve) - described as burning, severe, diffuse, and persistent - elicited by minimal movement or touch of affected area 2.

Postherpetic neuralgia – follows acute CNS infection - severity may be mild to severe - intractable pain may persist for months to years

3. Phantom limb pain – may occur in person who has had a body part amputated either surgically or traumatically - pain varies and may be severe, burning, fiery sensation; crushing; cramping; sense that limb is edematous; sensation that limb is being twisted and distorted - may be triggered by sensation of touching the stump, occurrence of another illness, fatigue, atmospheric changes, and emotional stress 4. Trigeminal neuralgia – paroxysms of lightening-like stabs of intense pain in distribution of one or more divisions of the trigeminal nerve (5th cranial) - experienced in the mouth, gums, lips, nose, cheek, chin, and surface of the head - may be triggered by everyday activities like talking, eating, shaving, or brushing one’s teeth 5. Diabetic neuropathy – metabolic and vascular changes result in damage to peripheral and autonomic nerves - sensory loss can result and eventually leads to injury progressing to infection and gangrene - symptoms include sensations of numbness, prickling, or tingling (paresthesias)

C.

TRANSMISSION OF PAIN STIMULI - no specific pain organs or cells exist in the body - interlacing network of undifferentiated free nerve endings receive painful stimuli - include afferent (fibers carrying impulses from pain receptors toward the brain) fastconducting A-delta-fibers and the slow-conducting C-fibers - A-delta-fibers transmit acute, well-localized pain - C-fibers convey diffuse, visceral pain often described as burning and aching - stimulation of sensory receptors and intactness of nerve supply are neither necessary nor sufficient conditions for pain - receptor for pain and nerve route that eventually carries impulse to brain are necessary (but not always) phantom pain – without demonstrated physiologic or pathologic substance - sensory misrepresentation from missing limb may still remain in brain causing this pain 1. Gate Control Theory – describes transmission of painful stimuli and recognizes relation between pain and emotions - certain nerve fibers (small diameter) conduct excitatory pain stimuli toward the brain, but nerve fibers of large diameter appear to inhibit transmission of pain impulses from spinal cord to the brain - exciting and inhibiting signals at the gate in spinal cord determine impulses that eventually reach the brain - appears to be influenced by amount of activity in large and small afferent fibers in addition to nerve impulses that descent from the brain D.

PERCEPTION OF PAIN - involves sensory process that occurs when stimulus for pain is present - includes person’s interpretation of pain pain threshold – lowest intensity of stimulus that causes subject to recognize

pain - can be changed within a certain range ex. adaptation can be demonstrated when a person’s hand is immersed in warm water - sensation of pain eventually occurs as water is heated; however, the person can

tolerate higher temps as water is gradually heated to the pain level that if the hand had been plunged into hot water without any preparation E.

SEVERITY, QUALITY AND PERIODICITY OF PAIN 1. Severity – depends on patient’s interpretation of pain - behavioral and physiological signs help assess severity a. Severe or Excruciating – on a scale of 1 to 10, between 8 and 10 b. Moderate – on a scale of 1 to 10, between 4 and 7 c. Slight or Mild – on a scale of 1 to 10, between 1 and 3 2.

Quality a. Sharp – pain that is sticking in nature and is intense b. Dull – pain that is not as intense or acute as sharp - possibly more annoying than painful - usually more diffuse than sharp c. Diffuse – pain that covers a large area - usually, patient is unable to point to a specific area without moving the hand over a large surface, such as the entire abdomen d. Shifting – pain that moves from one area to another, such as from lower abdomen to area over stomach Other terms used to describe quality include sore, stinging, pinching, cramping, gnawing, cutting, throbbing, shooting, viselike pressure 3.

F.

Periodicity a. Continuous – pain that does not stop b. Intermittent – pain that stops and starts again c. Brief or Transient – pain that passes quickly

RESPONSES TO PAIN - severity and duration affect responses 1.

Types a. Behavioral (Voluntary) – moving away from painful stimuli; grimacing, moaning, and crying; protecting painful area and refusing to move b. Physiologic (Involuntary) – moderate / superficial: increased blood pressure, pulse and respirations; pupil dilation; muscle tension and rigidity; pallor (peripheral vasoconstriction); increased adrenalin output; increased blood pressure severe / deep: nausea and vomiting; fainting or unconsciousness; decreased blood pressure and pulse; prostration; rapid and irregular breathing

c. Affective (Psychological) – exaggerated weeping and restlessness; stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness - mild pain experienced briefly may produce little or no behavioral response, whereas intense pain experienced briefly usually results in reflex action to escape the cause - pain that continues for relatively short periods, such as for a few days or a week, is often accepted by the patient without it being all consuming - patient expects relief and believes the cause is self-limiting; however, anxiety is ordinarily present - chronic pain tends to consume the entire person - demand total attention - leaves limited resources for patient to handle ADL - physically and emotionally exhausting - - tends to result in depression and irritability

II.

ACUTE / CHRONIC

A.

ACUTE PAIN - generally rapid in onset - varies in intensity from mild to severe - may last from a brief period to any period less than 6 months - protective in nature - warns patient of tissue damage or organic disease - after underlying cause is resolved, acute pain disappears - causes include a pricked finger, sore throat, or surgery

PAIN

B.

CHRONIC PAIN - pain that may be limited, intermittent, or persistent but that lasts for 6 months or longer and interferes with normal functioning - patients have difficulty describing chronic pain because it may be poorly localized - healthcare personnel have difficulty assessing chronic pain accurately because of the unique responses of individual patients to persistent pain - often perceived as meaningless and may lead to withdrawal, depression, anger, frustration, and dependency - patients may be viewed in general by healthcare personnel as hysterical personalities, malingerers, or hypochondriacs remission – disease is present but the person does not experience symptoms

exacerbation – symptoms reappear chronic malignant pain – pain associated with cancer or other progressive disorders chronic nonmalignant pain – pain in people whose tissue injury is nonprogressive or healed intractable – when pain is resistant to therapy and persists despite a variety of interventions

III.

FACTORS AFFECTING

THE PAIN

EXPERIENCE

A.

CULTURE - avoid stereotyping responses to pain because the nurse frequently encounters patients who are in pain or anticipating that it will develop - a form of pain expression that is frowned on in one culture may be desirable in another cultural group B.

ETHNIC VARIABLES - today the ethnic heritage of many people is mixed, thereby making it more difficult to anticipate individual responses to pain C.

FAMILY, GENDER, AND AGE VARIABLES - individual response may be affected or influenced by the response of family members - spouses may reinforce pain behavior - children may learn to “be brave” and ignore pain or to use the pain experience to secure attention and service from family members - it may be acceptable for a little girl to run home crying with a scraped knee, but a little boy may be told that he should be brave and not cry - women are more comfortable communicating the discomfort associated with pain, but this ability to verbalize may cause some to view the pain as emotionally or psychologically based - infants and small children are sensitive to and experience pain - among older people, pain has often been viewed as a natural component of aging process, being ignored or undertreated by healthcare providers - conditions normally painful in young adults may result in minimal pain complaints in older people - that older person does not complain of pain may indicate that he/she fears treatment or just refuses to give in to the pain

- for many older people, pain has become accepted as a daily occurrence and is regarded as part of the normal aging process D.

RELIGION - in some religions, individuals view pain and suffering as a “lack of goodness” in themselves - viewed as a means of purification or of making up for individual and community sin - helps individual cope with pain and becomes a source of strength - patients may refuse analgesics and other pain relief measures - illness and pain may also be viewed as punishment from a vengeful God - anger, resentment, and depression may compound the pain experience E.

ENVIRONMENT / SUPPORT PERSONS - many find the strangeness of the healthcare environment, especially the lights, noise, lack of sleep, and constant activity of C.C.U., compounds the experience of pain - sense of powerlessness that accompanies admission to an institution may decrease the individuals’ ability to cope with pain - depersonalization or separation from a favorite pillow, pet, or source of music may further decrease the person’s sense of comfort - others prefer to be alone when in pain and may become agitated in the presence of family members - some may use their pain to acquire secondary gains, such as special attention and services from their families - if unchecked, leads to resentment and anger in family members and their eventual avoidance of the patient F.

ANXIETY AND OTHER STRESSORS - anxiety is always present when pain is anticipated or being experienced - tends to increase perceived intensity - threat of unknown is ordinarily more devastating and anxiety producing - pain is aggravated with anxiety, muscular tension, and fatigue - when pain interferes with rest and relaxation, and tension and fatigue almost always aggravate the discomfort - rested and relaxed patients can often cope with more discomfort than someone suffering from lack of sleep - greatly fatigued individual who has no competing demands requiring attention may experience pain acutely G.

PAST PAIN EXPERIENCE - experience of pain in the past and the qualities of that experience profoundly affect new experiences

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IV.

some have never known severe pain and have no fear of it, not realizing how intense it can be some have experienced severe acute or chronic pain but received immediate and adequate relief - generally unafraid of pain and initiate appropriate requests for assistance some have known severe pain in the past and were unable to secure relief - - even the suggestion of new pain can lead to acute feelings of fear, despair, and hopelessness those whose past pain experience led to correction of unhealthy behavior and produced a greater sense of health and well-being may respect and value pain and consider the meaning and significance of a new pain carefully in general, those who have experienced more pain than usual in their lifetime tend to anticipate more pain and exhibit increased sensitivity to pain some pain memories are virtually inerasable; new contact with conditions similar to those that caused the earlier pain can provoke a violent response

APPLICATION

OF THE

NURSING PROCESS

TO

COMFORT

A.

ASSESSING THE PAIN EXPERIENCE - pain experience is unique to each individual - assessing all factors that affect the experience - - psychological, emotional, sociocultural, physiologic - - is essential - caregivers should include assessment of vitals accompanied by a pain assessment raises awareness of the existence of pain, places additional emphasis on optimizing pain relief, and moves patients more quickly toward comfort and recovery 1.

Components of Pain Assessment - primary purpose of using a guide to assess pain is to eliminate guesswork and biases when dealing with the patient’s pain, to understand what the person is experiencing, to analyze findings that will help prepare an appropriate nursing response to patient’s pain, and to facilitate improved outcomes a.

Characteristics Assessed Onset Location of pain (hurts worse/feels better Duration of pain

Characteristics Aggravating and alleviating factors when ___)

Radiating Treatment (what’s been done and did it work) Physiologic indicators of pain Behavioral responses Effects of pain experience on activities and lifestyle - must also include discussion of patient’s expectations for pain relief b.

Basic Methods - patient’s self-report - report of family member, other person close who is familiar

with patient - behaviors (restlessness, grimacing, crying, protecting painful area) - physiologic measures (increased BP and pulse) B.

ANALYSIS / DIAGNOSING - data collected during comprehensive pain assessment benefit patient most when shared with physicians and other members of the healthcare team - attempting to intervene before an accurate assessment has been completed may mask the real cause of the pain and lead to false assumptions and even further progression of symptoms and the disease process - plan of care should identify: type of pain etiologic factors, to the extent that they are known and understood patient’s behavioral, physiologic, and affective responses other factors affecting pain stimulus, transmission, perception and response C.

PLANNING: CLIENT GOALS - developing a plan of care that, when implemented, demonstrates nursing’s commitment to assist patient to develop effective pain management strategies is crucial - nursing measures are directed toward achievement of the following patient outcomes for individuals whose pain is acute: - describe gradual reduction of pain, using scale of 0 (no pain) to 10 (pain is as bad as it can be) - demonstrate competent execution of successful pain management program - chronic pain outcomes may be contacting a hospice or pain clinic

- hospice care addresses physical, spiritual, social, and economic needs of terminally ill and their families - pain relief is a priority in this setting - out-patient centers support patients with chronic pain and improve their pain management through a variety of approaches - physicians, nurses, and other members of the healthcare collaborate to develop the optimal pain treatment plan for each patient D.

IMPLEMENTING 1. Establish a Trusting Nurse-Client Relationship – most patients with pain feel better, suffer less, and experience less anxiety when they believe that a competent nurse cares about their experience of pain and is available for help and support - measures include discussing pain with the patient, allowing the patient to help choose a method of pain relief, and visiting and remaining with the patient in pain - these measures promote a collaborative relationship in which the patient’s pain is treated with respect 2. Teaching the Client about pain – patient and family need information about nature and causes of pain, explanation about pain scale that can be used easily, practice with this assessment tool, and assistance to set goals for comfort and either optimal function or recovery 3.

Manipulating Factors Affecting the Pain Experience a. Removing or Altering the Cause of Pain – possible measures include removing or loosening a tight binder, if permissible; seeing to it that a distended bladder is emptied; taking steps to relieve constipation and flatus; changing body positions and ensuring correct body alignment; changing soiled linens and dressings that may be irritating the skin - a hungry or thirsty patient may need a snack or drink - certain drugs are useful for removing or altering the intensity b.

Altering Factors Affecting Pain Tolerance pain tolerance – point beyond which a person is no longer willing to endure pain

- factors should be alleviated whenever possible - nursing measures include communication to patient that responses to pain are acceptable and education of patient’s family - fatigue tends to increase pain - - promoting rest is helpful - ensure environment is quiet and restful - although removing unnecessary noise and bright lights are usually indicated, it is rarely helpful to leave the patient alone in an environment with little sensory input - - patient is more likely to focus on self and discomfort - common fears include a loss of control and embarrassment by being unable to deal with pain maturely, fear of taking pain relief medication, view the need for medication as a sign of weakness or may fear addiction or loss of the effectiveness at a later date 4. Initiating Nonpharmacologic (Complimentary and Alternative) Relief Measures a. Distraction – conscious attention often appears to be necessary to experience pain, whereas preoccupation with other things has been observed to distract the patient from pain - distraction requires the patient to focus on something other than the pain - Lamaze method of childbirth is one common example of distraction - distraction alone may relieve mild pain - most effective when used before pain begins or soon there after - effective when used with analgesics for treatment of a brief episode of severe pain - successful with children Techniques: visual – counting objects, reading, watching TV auditory – listening to music tactile kinesthetic – holding or stroking a loved person, pet, or toy; rocking; slow rhythmic breathing project – playing a challenging game, performing meaningful play or work b. Humor – can be an effective distraction, can help an individual cope with pain, and may even have a positive effect on the immune system

- particularly effective before painful procedures, and many pain, cancer, and ambulatory care centers encourage patients to view humorous videos before painful, tedious procedures - use only with patients who are responsive to its use and wish to use it - should not be used with patients in moderate to severe pain, nor as a replacement for pharmacologic analgesia c. Imagery – to decrease pain sensations, imagine something that involves one or all of the senses, concentrate on that image, and gradually become less aware of the pain - think of “happy things” - recreate a favorite place and then experience the healing presence or touch of a loved person or the healing energies of nature in that setting - used to create an image in which the cause of pain is visualized and then overcome or counteracted by some powerful image - more effective for patients with chronic pain than patients with acute, severe pain - if patient becomes restless or upset, experience is terminated and attempted later Techniques: - help patient identify the problem or goal - suggest that patient begin imagery with several minutes of focused breathing, relaxation, or meditation - help patient develop images of problem, as well as personal internal resources and external healing therapies - encourage images of desired state of well-being at end of session d.

Relaxation – techniques reduce skeletal muscle tension and lessen

anxiety - nurse acknowledges patient’s pain and expresses a willingness to help patient relieve distress caused by pain - most effective as pain alleviator when combined with slow, deep, easy breathing from the abdomen or diaphragm, with patient’s eyelids closed or with the individual focusing on real or imagined fixed spot

Positive Effects: - improved quality of sleep - distraction from pain - decreased fatigue - increased confidence and sense of self-control in coping - lessening of detrimental physiologic effects of continued or repeated stress - increased effectiveness of other pain relief measures - decreased distress or fear during anticipation of pain - reassurance that nurse is aware of patient’s problem and wants to help 5.

Cutaneous Stimulation – techniques that stimulate the skin’s surface - when skin is stimulated, pain Is believed to be controlled by closing gating mechanism in spinal cord - decreases number of pain impulses that reach the brain for perception - can be used in all healthcare settings to supplement a pain control regimen a.

Forms: i. massage – with or without analgesic ointments or liniments containing menthol ii. application of heat or cold intermittently iii. acupressure – involves use of fingertips to create gentle but firm pressure to usual acupuncture sites - has calming effect, most likely related to body’s release of endorphins and enkephalins

V.

COLLABORATIVE PRACTICE

A.

ANALGESIC ADMINISTRATION analgesic – pharmaceutical agent that relieves pain - function to reduce person’s perception of pain and to alter person’s responses to discomfort - nurse administering analgesics needs to combine a healthy respect for the drug being administered with a thorough knowledge of its mechanism of action, side effects, and administration guidelines - respect should result in analgesics being used wisely to produce desired effect - knowledge enables the nurse to tailor patient’s regimen and communicate professionally with physicians about a patient - nurses should not refrain from using analgesics or reduce their doses because of an unrealistic fear

of their potency and side effects 1.

Classes of Analgesics a. Nonopioid – acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) - usually the drugs of choice for mild to moderate pain - simplest dosage schedule and least invasive pain management modalities should be used first - NSAIDs also have anti-inflammatory effect - many are OTC, some are available by prescription only - can cause gastric side effects, but symptoms may be preventable if drug is taken with food or antacids - individual responses vary, but are contraindicated in patients with bleeding disorders or probable infections (signs of infections may be masked) - combination of nonopioids and opioids provide more analgesia than either drug taken alone b. Opioids or Narcotic – all controlled substances, eg. morphine, codeine, meperidine, methadone - considered the major class of analgesics used in management of moderate to severe pain because of effectiveness - capable of relieving pain of virtually every nature opioid – produce analygesia by attaching to opioid receptors in the brain Common Side Effects: sedation, nausea, constipation - most disappear with prolonged use, but if constipation persists, it usually responds to treatment with increased fluids and fiber and use of a mild laxative - respiratory depression is a commonly feared side effect, but in reality it is uncommon because patient’s develop tolerance to the drugs - if respiratory depression is suspected, it’s usually preceded by sedation Sedation Scale:

1 = awake and alert, no action necessary

2 = occasionally drowsy but easy to arouse; no action required 3 = frequently drowsy and drifts off to sleep during conversation; decrease opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue opioid and consider use of naloxone (Narcan) - if respiratory depression is suspected and opioid is withheld, patient may be physically stimulated by shaking or using a loud sound, along with reminders every few minutes to breathe deeply - naloxone (Narcan) is an opioid antagonist that reverses respiratory depressant effects - administered intravenously very slowly - within 1 – 2 minutes, patient usually responds - when respirations are greater than 9/min, opioids may be resumed c. Adjuvant Drugs – corticosteroids, anticonvulsants, antidepressants, multipurpose drugs - used to enhance effect of opioids by providing additional pain relief - reduce side effects from prescribed opioids or lessen anxiety 2. General Principles for Administration - first assess patient’s pain and understand patient’s goals for pain relief - review pain scale of choice thoroughly - discuss benefits of using pain scale - try various pain control measures - use pain control measures before pain increases in severity - ask patient what has proved effective for pain relief in the past - select and modify pain control measures based on patient’s response - encourage patient to try pain treatment several times before labeling it ineffective - be open-minded about alternative pain relief strategies - be persistent - be a safe practitioner - in home, oral morphine is still the drug of choice to control chronic pain and to moderate severe acute pain - this method is less expensive and easy to administer but requires patient’s ability to

swallow and retain food and fluids - accurate documentation is imperative to determine effectiveness or the need to change control measures - effective patient and family teaching is the cornerstone for this therapy 3. Ongoing Assessment – nurse continually needs to evaluate whether medication is producing desired analgesic effect; identify changes in patient’s condition (correction, worsening, building of tolerance) that necessitate changes in agent, dose, or route of administration; and identify development of side effects that may warrant discontinuance - knowledge of basic actions, doses, routes of administration, side effects, and administration guidelines is fundamental - timing is an important consideration when administering - p.r.n. (as needed) regimen has not been proven effective for acute pain - continuous intravenous infusion has proved effective for relief of acute postoperative pain - totally inadequate for chronic pain - regular administration or around-the-clock (ATC) administration has shown to offer superior pain management - long-acting controlled-release oral morphine or use of fentanyl patch have been proven effective breakthrough pain – temporary flare-up of moderate to severe pain that occurs even when patient is taking ATC medication - treated more effectively with supplemental doses of opioid taken on p.r.n. basis rather than an increase in dose of ATC medication - frequent need for rescue pain medication may necessitate an increase in ATC dose - best if rescue or breakthrough drug is the same as ATC - usually calculated as 10 – 15% of total daily ATC dose - classified as incident pain (caused by movement) or end-of-dose pain (occurs before next dose is due) B. HYPNOSIS - produces subconscious state accomplished by suggestions made by a hypnotist - used successfully in many instances to control pain - state of consciousness is altered by suggestions so that pain is not perceived as it normally would be - alters physical signs of pain

- success response to hypnosis is related to individual’s openness to suggestion, belief that hypnosis will work, and emotional readiness C. ACUPUNCTURE - uses needles of various lengths inserted into specific parts of the body to produce insensitivity to pain - alternative intervention to help control discomfort from disorders such as headaches, menstrual cramps, postoperative dental pain, low back pain, and carpal tunnel syndrome D. BIOFEEDBACK – uses a machine to monitor physiologic responses through electrode sensors on patient’s skin - patient is taught to regulate physiologic responses (increased muscle tension or elevated blood pressure) by practicing deep-breathing exercises, progressive relaxation exercises, or visual imagery - decreases individual’s pain by reducing anxiety associated with lack of control over bodily functions, distracts person’s attention from pain to concentration on person’s inner state and feedback signal, and reduces cause of pain - limitation of this method include the high degree of motivation needed and difficulty of maintaining control after training program E. PATIENT-CONTROLLED ANALGESIA – (PCA) used to manage acute and chronic pain in healthcare facility or home - effectively relieves pain associated with operative procedures, labor and delivery, trauma situations and cancer - used to deliver analgesics intravenously, but subcutaneous route is also an option - frequently prescribed drug is morphine - consists of portable infusion pump containing reservoir or chamber for a syringe that is prefilled with prescribed opioid - when sensation of pain recurs, patient pushes a button that activates PCA device to deliver small preset bolus dose of analgesic - lockout interval is programmed into unit to prevent reactivation of pump and administration of another dose during a specific period of time - limits possibility of overmedicating Advantages: consistent analgesic blood level is maintained analgesic is delivered intravenously for faster absorption patient is in charge of pain management

patient tends to use less medication patient is more satisfied and has improved pain relief F. EPIDURAL ANALGESIA – used more commonly to provide pain relief during immediate postoperative phase and for chronic pain situations - used for children with terminal cancer and children undergoing hip, spinal, or lower extremity surgery - anesthesiologist inserts catheter in midlumbar region into epidural space of spinal cord - for temporary therapy, catheter exits directly over the spine, tubing is positioned over patient’s shoulder, with catheter taped to patient’s chest - for long-term therapy, catheter is tunneled subcutaneously and exits on side of body or abdomen - narcotic or opioid acts directly on opiate receptors in spinal cord and pain relief is achieved with smaller doses and less severe side effects - can administer bolus dose via continuous infusion pump, or by means of patient-controlled epidural pump - drug of choice is usually preservative-free morphine or fentanyl - rapid onset of action, but short duration of action - typically removed between 36 and 73 hours after surgery, when oral medication can be substituted - nursing responsibilities include careful monitoring patient’s response to therapy with particular attention to respiratory rate and pattern - potential side effects include hypertension, pruritus, urinary retention, nausea and vomiting, and infection or contamination G. LOCAL ANALGESIA – applied topically to skin or mucous membranes or injected into body to produce temporary loss of sensation and motor and autonomic function in a localized area - agents work by chemically blocking nerve pathways involved in pain sensation and response (nerve blocks) - used during dental work, having a wound sutured, delivery of a newborn, or for some minor surgical procedures - nursing measures include noting any allergic responses (past or present), alerting patient to pain associated with initial injection, offering emotional support during procedure, observing for any untoward effects and protecting patient from injury until sensory and motor functions return - prescribed by physician and must be covered by occlusive dressing for at least 1 hour before procedure to provide local pain relief

H.

ELECTRICAL NERVE STIMULATION 1. Transcutaneous electrical nerve stimulation (TENS)- noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful impulses carried over small diameter fibers - consists battery-powered portable unit, lead wires, and cutaneous electrode pads that are applied to painful area - requires physician’s order - effective in reducing post-operative pain and improving mobility after surgery - used as adjunct with physical therapy and for patients with low back pain - may be applied intermittently throughout day or worn for extended periods of time 2. Percutaneous electrical nerve stimulation (PENS) – combines advantages of both electroacupuncture and TENS - consists of needle probes being placed into soft tissue to stimulate peripheral sensory nerves that relate to area of injury or pain - electrical stimulus bypasses skin barrier and goes directly to involved nerve - effective when dealing with chronic low back pain as well as diabetic neuropathy pain

VI.

EVALUATION

- as soon as pain is identified and a treatment plan developed and implemented, evaluation becomes ongoing - directed toward the changing nature of pain experience, treatment modalities, and patient’s and family’s response to plan of care