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Pain managment

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Pain managment

  1. 1. Dr. Naglaa Youssef Medical-Surgical Nursing Dep. Faculty of Nursing Cairo University
  2. 2. Content outlines  Definition of pain  Components of pain  Types of pain  Physiology of pain  Management of pain  Assessment of pain  Nursing diagnosis of patient with pain  Nursing care for patient with pain
  3. 3. Pain definition  Pain has been defined as an „‟unpleasant sensation usually associated with disease or injury‟‟ (Timby 2009).  It causes physical discomfort that is a companied by suffering, which is the emotional component of pain.  the American Pain Society coined the phrase “Pain: The 5th Vital Sign”
  4. 4.  Pain is „‟whatever the person says it is, and existing whenever the person says it does‟‟ (Margo McCaffery 1998).  “It is not the responsibility of clients to prove that they are in pain; it is the nurses‟ responsibility to believe them.” (Crisp & Taylor, 2005).
  5. 5. Components of pain Experience of pain includes: Sensory Affective Cognitive Behavioural Physiological Perception of pain characteristics: intensity, quality, location Negative emotion: anxiety, fear, unpleasant sensation Interpretation of pain Coping strategy used to express, avoid, or control pain Nociceptive and stress response
  6. 6. Types of pain  Types of pain can be described/classified according to: Typesofpain Source Cutaneous Somatic Visceral NeuropathicAetiology Duration Acute Chronic Nociceptive pain
  7. 7. Cutaneous pain  Discomfort feeling originates at the skin level, e.g. trauma.
  8. 8. Nociceptive pain Somatic Involves superficial tissue: skin, muscles, joints, bones Location is well defined Sensation is described as Tender, Burning, Shooting, Throbbing e.g. cut skin, stretch a muscle too far or exercise for a long period of time. Visceral  Involves organs: heart, stomach, liver..etc.  Location: Diffuse  Sensation is described as: aching, cramping
  9. 9. Visceral pain  Discomfort arising from internal organs.  Is associated with injury or disease.  It is sometimes referred (referred pain) or poorly localized.  Referred pain is a discomfort or pain perceived in a general area of the body, usually away from the site of stimulation. E.g., cardiac pain may be felt in the shoulder or left arm, with or without chest pain.
  10. 10. Areas of referred pain
  11. 11.  Radiating pain  Perceived in the source of pain and extended to nearby tissue.
  12. 12. Neuropathic Pain  Is pain that experienced days, weeks, or longer after the cause of pain has been treated.  Is called functional pain.  Is due to dysfunction of the nervous system.  E.g. phantom pain limb pain/sensation.  a person with an amputated limb perceives that the limb still exists and feels burning, itching, deep pain in tissues that have been surgically removed.
  13. 13. Acute and chronic pain Acute • Recent/rapid onset • Specific, localized • Severity associated with the acuity of disease • Good response to medication therapy • Requires less drug therapy • Suffering is decreased • Associated with sympathetic nervous system responses: hypertension, tachycardia, restlessness & anxiety. Chronic • Prolonged onset • Nonspecific, generalized • Severity out of promotion to the disease • Poor response to medication therapy • Requires more drug therapy • Suffering is intensified • Absence of autonomic nervous system responses • Psychological suffering: depression & irritability.
  14. 14. Physiology of Pain Specialized pain receptors or nociceptors can be excited by mechanical, thermal, or chemical stimuli. Nociceptors Central Nervous System
  15. 15.  What is nociceptor?  Is a type of sensory nerve (free nerve endings in the skin) that sensitive to a noxious stimulus. Nociceptors are also called pain receptors, but the former term is preferred.  Where does it locate?  It locates in the:  Skin, bones, joints, muscles & internal organs.
  16. 16. Physiology of pain It is the process by which the person experiences pain occurs in four phases: Transduction Transmission Perception Modulation
  17. 17. First phase: Transduction  Chemicals substances such as  substance p, histamine & prostaglandins Injured cells release chemicals excite nociceptors Pain medications can work during this phase by blocking the production of prostaglandin (e.g., ibuprofen or aspirin) or by decreasing the movement of ions across the cell membrane (e.g., local-anesthetic).
  18. 18. Phase 2: Transmission (spread)  Is the phase where stimuli moves from the peripheral nervous system toward the brain.  Types of nerve fibers A-delta fibers Smaller, myelinated fibers, Carry impulses rapidly Smaller, myelinated Aδ (A delta) fibers transmit nociception rapidly, which produces the initial “fast pain Result in: Sharp, localized pain, acute initial sensation. e.g. touching a hot iron then withdraw from pain provoking stimulus C-fibers Larger, unmyelinated fibers. Carry impulses at a slow rate. E.g. dull, aching, burning sensation.
  19. 19.  Pain impulses move to higher level in the brain such as: thalamus, cerebral cortex and limbic system by assistance of substance P.  Prostaglandin is a chemical that released from injured cells speeds the pain transmission. Opioids (narcotic analgesics) block the release of neurotransmitters, particularly substance P, which stops the pain at the spinal level.
  20. 20. Phase 3: Perception  What does perception mean?  Is the person‟s „‟conscious experience of discomfort „‟(Timby 2009).  When does perception occur?  It occurs when the pain threshold (‫األلم‬ ‫)عتبة‬ is reached.
  21. 21. What is pain threshold?  „‟Point at which sufficient pain-transmitting stimuli reach the brain‟‟ (Timby 2009).  The point at which a stimulus is perceived as painful.  What is pain tolerance?  Is the maximum amount (intensity) or duration of pain that person can endure or tolerate.
  22. 22. Phase 4: Modulation or descending ( ‫تعديل‬‫المسار‬ )  Is the last phase of pain impulse transmission where the brain interacts with the spinal nerves in a downward way to alter the pain experience.  Release of pain inhibiting neurochemicals that can reduce the pain, such as:  Endogenous opioids  Gamma-aminobutyric acid
  23. 23. Gate control theory (Melzack and Wall, 1965) Protective pain reflex. Discomfort stimulus from skin travel along sensory neuron to dorsal horn of spinal cord, synapses with motor neuron, travels along spinal nerve to skeletal muscle, causing withdrawal from pain stimulus.
  24. 24. Physiological response to pain  Pain produces a physiological stress response that includes increased heart and breathing rates to facilitate the increasing demands of oxygen and other nutrients to vital organs. Failure to relieve pain produces a prolonged stress state, which can result in harmful multisystem effects (Middleton, 2003).  Incase of sever traumatic pain may place client into shock.
  25. 25. Vocalization Moaning, crying & gasping ‫والبكاء‬ ‫الشكوى‬ ‫ويلهث‬ Facial expression Grimace, clenched teeth, tightly closed eye & lip biting & wrinkle forehead Body movement Immobilization ,restlessness & muscle tension Social interaction Avoid the conversation or social contacts Behavioral response
  26. 26. Impact of pain on patient daily life  Fatigue  Sleeping disturbance  Loss of appetite  Social withdraw  Disturb family life  Tense muscles  Impair immune system….poor healing, infection, ulcers.  Stop activity…..complications of immobility such as muscle atrophy, cardiovascular complications
  27. 27. Factors influencing pain perception Factors influence pain Age Gender Culture Environ ment Meaning of pain Anxiety Fatigue Previous experience Family support e.g. keep a stiff upper lip e.g. Money reward
  28. 28. • Assessment • Nursing diagnosis • Intervention • Evaluation Nursing process Caring for patient with pain
  29. 29.  Pain is the fifth vital signs that should be assessed during assessment stage (the American Pain Association). Pain assessment
  30. 30. Method of assessing pain: A. Taking history B. Physical examination of pain
  31. 31. Pain Scales  There are different pain intensity scales: 1. Word scales 2. Numeric scales 0 Mild pain Moderate pain Sever pain Very sever pain Worst possible painNo pain 7 85 6 92 3 41 No pain 10 Worst possible pain Moderate pain
  32. 32. 3. Linear (visual analogy) scale/VAS 4. Rating scale No pain Pain as bad as it could possible be
  33. 33. Components of pain assessment: COLDERR Focus of assessmentComponents Describe pain sensation (e.g. sharp, aching, burning)Character When it started, sudden, gradually.Onset Where it hurts, mark on a diagramLocation Constant versus intermittent in nature, how longDuration Factors that make it worseExacerbation Factors that make it betterRelief Pattern of shooting/spreading/location of pain away from its origin. Radiation
  34. 34. Components of pain assessment Focus of assessmentComponents Rating for present pain severity using a pain scale. Intensity Description own client‟s own words (like knife).Quality prayer or other religious practices, withdrawalCoping resources Pain characteristics that change.Variations Repetitive or not.Patterns Sleep, appetite, concentration, school, work, driving, walking, slef-care. Effects on ADL’S N/V, dizziness, diarrheaAssociated Symptoms
  35. 35. Focus of assessmentComponents Approaches used to control the pain and results and effectiveness. Current pain treatment Past medications or interventions and the response, manner of expressing pain, personal cultural, spiritual, or ethnic believes that can affect pain management. Pain treatment history Level of tolerance, expectation for level of pain relief ability to restore function. Person’s goal for pain control
  36. 36. Nursing diagnoses  Ineffective airway clearance related to weak cough secondary to incision abdominal pain  Activity intolerance related to pain (specify location as left ankle pain)  Immobilization related to pain (specify )  Sleep disturbance related to pain (specify)  Self care deficit (specify) related to poor pain control  Ineffective coping related to ineffective pain management (specify location as left ankle pain)  Depression & anxiety related to pain (specify)  Deficient knowledge (specify pain medication) related to lack of exposure to information resources
  37. 37. Planning (goals)  After 2 hours the patient:  Will report pain control or relief of pain  Will express satisfaction with pain control  Will states pain is 2/10  Will reported decrease in intensity of pain  Willing to try relaxation technique  Increases interactions with family and friends  Demonstrates use of new strategies to relieve pain
  38. 38. Interventions 1. Monitoring 2. Actions / interventions 3. Teaching
  39. 39. Monitoring  Use pain assessment scale to identify intensity of pain.  Assess and record pain and its characteristics: location, quality, frequency, and duration.  Assess vital signs every 30 minutes
  40. 40. Actions / interventions  Aim of pain management to preventing, reducing, relieving pain, such as: Non-pharmacologic interventions Pharmacologic management Health teaching
  41. 41. Non-pharmacologic interventions  Relaxation techniques = releasing tension  Education = support & coping methods  Imagery = using mind to visualize an experience=daydreaming  Distraction=switch from unpleasant sensory experience to one more pleasant  Acupuncture= thin needles are inserted into the skin  Acupressure = tissue compression  Meditation = concentrating on a spiritual word or idea  Heat & cold = thermal therapy = swelling & vasodilatation
  42. 42. Types of distraction Visual distraction Tactile distraction Auditory distraction TalkingOder Intellectual distraction Reading, watching T.V Listen to music Message, deep breathing Hobbies, writing cross word puzzle
  43. 43. Pharmacologic Analgesia = relief of pain. Gk an- without + algesis-sense of pain.  Oral medications  Patient – Controlled Analgesia (PCA)  Epidural analgesia  Injection in the lumber region at the L2/3 or L3/4 space
  44. 44. Health teaching  Teach patient additional strategies to relieve pain and discomfort: distraction, relaxation, cutaneous stimulation, etc.  Instruct patient and family about potential side effects of analgesics and their prevention and management.
  45. 45. Approaches to pain management ExamplesInterventionApproach Aspirin, ibuprofen,Local anaesthetics, anti- inflammatory medications Interrupting pain transmitting chemicals at the site of injury Epidural, rhizotomy, sympathectomy Intra spinal anaesthesia and analgesia or neurosurgery Altering the transmission at the spinal cord Massage, acupuncture, acupressure, heat, cold electrical stimulation Cutaneous stimuliUsing gate closing mechanism Morphine, imagery, distraction, hypnosis Narcotics, non- pharmacological techniques Blocking brain perception
  46. 46. Evaluation  Report pain level  Respiratory rate  Amount of medication, frequency use  Side effect of medication