Pain And Comfort Chp 41 Blackboard

Pain and Comfort Chapter 41

Pain and Comfort • Pain – Is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. It is one of the body’s defense mechanisms that indicates the person is experiencing a problem. “Pain is whatever the experiencing person says it is.”

• Comfort – Through comfort and comfort measures . . . Nurses provide strength, hope, solace, support, encouragement, and assistance. A variety of nursing theorists refer to comfort as a basic client need for which nursing care is delivered

Categories of Pain • • • •

Duration Source Mode of Transmission Etiology

Three Types of Pain • There are three types of pain: • acute pain – Rapid in onset then disappears

• chronic pain – Limited, intermittent, or persistent lasts beyond the normal healing period.

• cancer pain or chronic malignant pain

Source of Pain • Cutaneous (superficial) – Involves the skin or subcutaneous tissue – Ex: a paper cut

• Somatic (deep) – Is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves

• Visceral – Poorly localized and originates in body organs in the thorax, cranium, and abdomen. Pain occurs as organs stretch abnormally

Mode of Transmission • Referred Pain – Pain can originate in one part of the body but be perceived in an area distant from its point of origin. – Ex: Pain associated with Myocardial Infarction (MI) or heart attack, pain may be referred to neck, shoulder, or arms.

Etiology of Pain • Neuropathic pain – Results from injury to or abnormal functioning of Peripheral nerves or CNS. Described as burning or stabbing

• Intractable pain – Pain is persistent to therapy and persists despite a variety of interventions

• Phantom pain – Without demonstrated physiologic or pathologic substance – Ex: Amputated leg

Physiology of Pain • “Pain” – Physiological Mechanism of Pain – It is helpful for the nurse to understand the physiological effect of pain therapy on the human body. – The pain experience is a four stage process: transduction, transmission, perception, and modulation.

The Pain Process • Transduction—activation of pain receptors • Transmission—conduction along pathways (A-delta and C-delta fibers) • Modulation—initiation of the protective reflex response • Perception of pain—awareness of the characteristics of pain

Transduction • For pain to be perceived nociceptors must be stimulated • These pain receptors can be stimulated by – Serotonin – Histamine ( a damaged cell releases) – Prostaglandins – Substance P

Transduction • 3 types of stimuli can stimulate pain receptors – Mechanical – Thermal – Chemical

Transduction (cont’d) • Mechanical stimulus – Friction from bed linens – Pressure from a case

• Thermal stimulus – Sunburn, cold water on a tooth with caries

• Chemical stimulus – Acid burn

Pain Sensation and Relief

Transmission of Pain Stimuli • 2 separate pathways that transmit pain impulses to the brain – Type A – delta fibers (fast conducting) • Fast, sharp, and acute pain

– Type C fibers • Diffuse, visceral that burns or aches

OBJECTIVE Describe the gate control theory of pain.

Gate Control Theory of Pain • Pain impulses can be regulated or even blocked by gating mechanisms located along the central nervous system. The theory suggests that pain impulses pass through when a gate is open and are blocked when the gate is closed. • Large diameter cutaneous pain fibers can be stimulated (rubbing like a massage) and may inhibit smaller diameter fibers to prevent transmission of the impulse (closing the gate) • Using pain relief measures to close the gate like massage, or warm compress

Gate Control Theory of Pain • Gate Control Theory – Relationship between pain and emotion – If cutaneous stimuli other than pain are transmitted, the “gate” is temporarily blocked by the stimuli. – The brain cannot acknowledge the pain while it is interpreting the other stimuli.

Gate Control Theory of Pain •

Small-diameter nerve fibers carry the pain stimuli through the same gate

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Large diameter fibers that carry the non-pain impulses go through the same gate and inhibit the transmission of those pain impulses – close the gate.

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Only a limited amount of sensory info can be processed by the nervous system at one time centain cells interrupt the signal and close the gate

Gate Control Theory of Pain – A bombardment of sensory impulses will close the gates to painful stimuli. – Some patients can be distracted from pain – Gating mechanisms can also be altered by thoughts, feelings, and memories.

Perception of Pain • Pain threshold – The perception of pain – Lowest intensity of a stimulus that causes the subject to recognize pain.

• Adaptation – The pain threshold can be changed within a certain range. – Example: hand immersed in warm water then water is gradually heated. Person will tolerate longer than if had immersed in hot water.

Modulation of Pain • Modulation of pain Sensation of pain is inhibited or modified – Neuromodulators • Release endogenous opioids include enkephalins, endorphins and dynorphins which are morphine like. • Have analgesic activity and alter perception of pain • Bind to specific opioid receptors throughout CNS clocking the release of pain-transmitting substances

– Released when skin stimulation and relaxation techniques along with certain

OBJECTIVE Discuss techniques and rationales that assist clients with pain.

Factors affecting the Pain Experience • Culture – Attitudes, values

• Family – Response or expression influenced by

• Gender – Female more vocal – Men don’t cry

• Age – Pain is not part of normal aging process – Is disease related

• Religious Beliefs – Illness or pain viewed as punishment by God.

• Environment and Support people – Presence or absence of others caring, sense of powerlessness

• Anxiety/Stressors – Threat of the unknown

• Past Pain Experience

Clients at risk when assessing and treating pain • A client’s self-report is the single most reliable indicator of the intensity of pain and the evaluation of treatment. Many client’s fail to report or discuss pain/discomfort due to ineffective communication. Those at risk include: – – – – – –

Children Elderly Cognitively impaired/unconscious Non-English speaking Different cultures History of substance use

OBJECTIVE Discuss common misconceptions about pain.

Common Biases and Misconceptions of Pain • Pain is a subjective, highly individualized experience. • Pain is the leading cause of disability and source of frustration. • Myths that should be irradicated include: – The doctor has ordered pain-relieving medication for me, which I will be given routinely. – If I ask for something for my pain, I may become addicted to the medication.

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Common Biases and Misconceptions of Pain cont’dare false: The following statements – Sometimes it’s better to put up with the pain than to deal with the side effects of the pain medication. – I should somehow be able to control my pain. It is immature to talk about pain. – It is better to wait until the pain gets really bad before asking for help. If I take the medication now for moderate pain, it won’t relieve severe pain later on. – I don’t want to bother anyone – I know how busy they are. – It’s natural for me to have pain after surgery. After a few days, I should notice it lessening.

Pain scales • Pain is the “5th Vital Sign”

The Nursing Process and “Pain” Assessment • Nurse works closely with client explore signs and symptoms of pain with each client (cannot allow personal biases to prejudice their assessment of pain • Physical signs and symptoms – Interpret cues – facial expressions; look for verbal and nonverbal expressions, changing vital signs,BP, pulse and resp rate. – Young children may be asked to point to the area that hurts. – May have to ask specific questions if there is a problem with developmental or psychotic problems.

The Nursing Process and “Pain” Assessment (cont’d) • Explore client’s subjective report – Is the single most reliable indicator of pain – Ask questions regarding the severity, onset, durations, time most often happens – There are several instruments to assist – The nurse with assessing pain. For location the nurse may use a body diagram to have client draw the site of the pain; or a pain scale, maybe numbered 0-10 (no pain – severe) or descriptive from no pain, mild, mod, severe to unbearable. For children, there is the “Oucher” scale – which has faces of children from comfort to severe discomfort. – Quality of pain is described as throbbing, sharp,

The Nursing Process and “Pain” Assessment cont’d • Pain history – time/duration; precipitating events, aggravating factors; relieving factors; concomitant symptoms; past experiences with pain • Alterations in lifestyle – – – –

Pain may interfere with activities of daily living Cause sleep disturbances May restrict mobility Ability to work

Nursing Diagnoses • • • • • • • •

Anxiety Hopelessness Mobility, impaired physical Pain Pain, chronic Self-care deficit Sexual dysfunction Sleep pattern disturbance

Outcome Identification and Planning • The client will: – Describe a gradual reduction of pain, using a scale ranging from 0 (no pain) to 10 (pain as bad as it can be). – Demonstrate competent execution of successful pain management program (specify).

Nonpharmacologic Pain Relief • • • • •

Distraction Humor Music Imagery Relaxation

• Cutaneous stimulation • Acupuncture • Hypnosis • Biofeedback • Therapeutic touch

Pharmacologic Pain Relief Measures • • • •

Analgesic administration Nonopiod analgesics Opioids or narcotic analgesics Adjuvant drugs

Analgesic Administration • Analgesic – Pharmaceutical agent that relieves pain

• Nonopiod analgesics – Acetaminophen & NSAID’s

• Opioid analgesics – Controlled substances – Morphine, codeine, meperidine, hydromorphone, methadone

• Opioid (con’t) – Produce analgesiz by attaching to opioid receptors in the brain – s/e, respiratory depression, nausea, constipation

• Adjuvant drugs – Anticonvulsants, antidepressants, and multipurpose drugs

Additional Methods for Administering Analgesics • Patient-Controlled Analgesia – Provides effective individualized analgesia and comfort – Portable infusion pump that is prefilled most frequently with morphine, fentanyl, or hydromorphone

• Epidural Analgesia – Provides pain relief during the immediate postoperative phase – Catheter is inserted into epidural space

The WHO 3-Step Analgesic Ladder

Evaluation • Client is main resource • The family is another valuable resource • Evaluate the client’s perceptions of treatment effectiveness • Re-evaluate