Basic Human Needs Comfort and Pain Management

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Basic Human NeedsComfort and Pain Management
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Pain

• Unpleasant, subjective sensory and emotional
  experience associated with an actual or potential
  tissue damage
• Can be a factor inhibiting the ability and
  willingness to recover from illness
• Subjective experience

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Comfort

• Concept central to the art of nursing
• Through comfort measures nurses provide strength,
  hope, solace, support, encouragement, and
  assistance
• As subjective as pain

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Pain

• McCaffery on Pain-Pain is whatever the
  experiencing person says it is, existing whenever
  the person says it does. (Margo McCaffery, 1979)
• Pain relief is a basic legal right (American Bar
  Association, 2000)
• Nurses are ethically and legally responsible for
  managing pain and relieving suffering.

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Pain Management

• Effective pain management reduces physical
  discomfort
• Promotes earlier mobilization and return to work
• Shortens hospital stay and reduces health care
  costs

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Pain Management
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Nature of Pain

• Subjective, highly individualized
• Stimulus can be physical and/or mental in nature
• Pain is tiring, places demands on persons energy
• Can interfere with relationships and influence
  the meaning of life

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Nature of Pain

• Cannot be objectively measured
• Certain types of pain produce predictable
  symptoms
• Pain Assessment-nurse relies on clients words and
  behaviors
• Protective physiologic mechanism, changes behavior

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Physiology of PainCategories

• Acute
• Chronic
• Idiopathic Pain
• Cancer pain
• Pain by Inferred Pathology/Nociceptive
  Neuropathic
• Pain as a result of a Metabolic Need/Ischemic
  Pain

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Nociceptive Pain

• Normal processing of stimuli that damages normal
  tissue or has the potential to do so if prolonged
• Usually responsive to nonopioids or opioids
• Somatic or visceral

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Somatic Pain

• Arises from bone, joint, muscle, skin or
  connective tissue
• Usually aching, throbbing, well-localized pain
• Responds to traditional analgesia

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Visceral Pain

• Arises from visceral organs such as the GI tract,
  heart, and pancreas.
• Can be subdivided further
• 1. Tumor involvement of organ
• 2. Obstruction of hollow viscus
  

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Neuropathic Pain

• Abnormal processing of sensory input by the
  peripheral or CNS
• Treatment usually with tricyclic antidepressants,
  SSRIs, anticonvulsants
• Centrally generated pain
• Peripherally generated pain

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Idiopathic Pain

• Chronic pain in the absence of an identifiable
  cause
• Complex Regional Pain Syndrome

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Ischemic Pain

• Pain as a result of the metabolic need for oxygen
• Warning sign of tissue damage
• Cardiac pain (angina, MI)
• Vascular pain- Peripheral vascular disease,
  intermittent claudication

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Nociceptive Pain

• Transduction
• Transmission
• Perception
• Modulation

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Gate Control Theory of Pain

• Pain impulses can be regulated or even blocked by
  gating mechanism along CNS
• Theory suggests that pain impulses pass when gate
  is open and blocked when gate is closed
• Closing the gate is basis for pain relief
  interventions

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Gate Control Theory of Pain

• Involves the addition of mechanoreceptors (A-beta
  neurons), which releases inhibiting
  neurotransmitter (Serotonin)
• If dominant input is from A-beta fibers, gating
  mechanism will close, pain reduced, due to
  release of Serotonin (Back rub)
• If dominant input from A-delta fiber, gate will
  be open and pain perceived
• Release of endorphins also close gate

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Physiological Response to Pain

• ANS stimulated as pain impulses ascend the spinal
  cord
• Pain of low to moderate intensity and superficial
  pain elicit the fight or flight reaction
• Sympathetic stimulation results in physiologic
  responses (Increased heart rate, peripheral
  vasoconstriction, dilatation of bronchial tubes,
  increased blood sugar)

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Physiological Response to Pain

• Continuous pain or severe, deep pain (visceral)
  involving organs puts the parasympathetic system
  into effect
• Parasympathetic stimulation results in pallor,
  muscle tension, decreased heart rate and BP, N/V,
  weakness, exhaustion

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Behavioral Responses to Pain

• Pain threatens physical psychological
  well-being
• Some people choose not to express pain (belief,
  value, cultural influences)
• Typical body movements that indicate pain
  clenching teeth, grimace, holding area, bent
  posture

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Acute Pain

• Follows acute injury, disease, surgical
  intervention
• Rapid onset
• Varies in intensity (mild-severe)
• Lasts a brief period of time (less than 6 months)

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Chronic Pain

• Prolonged
• Varies in intensity
• Lasts longer than 6 months
• Also known as chronic non-malignant pain
• Arthritis, headache, myofascial pain, low back
  pain

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Cancer Pain

• Pain that is due to tumor progression
• Related to pathology, invasive procedures,
  infection, toxicities of Rx
• Can be acute or chronic, nociceptive or
  neuropathic
• At the actual site or distant to the site
  (Referred pain)

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Factors Influencing Pain

• Age
• Gender
• Culture
• Meaning of pain
• Attention
• Anxiety
• Fatigue
• Previous Experience
• Coping Style
• Family Social Support

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Nursing ProcessAssessment

• AHCPR guidelines for assessing pain
• Clients expression of pain
• Characteristics of pain
• Onset duration
• Location
• Intensity (Pain scales-numerical, FACES)

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Assessment

• Quality
• Pain pattern
• Concomitant Symptoms
• Effect of pain on client (physical, behavioral,
  effect on ADL)
• Cultural Considerations

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Nursing ProcessNursing Diagnosis

• Anxiety
• Alteration in Comfort
• Self-care Deficit
• Sleep Pattern Dysfunction
• Sexual Dysfunction

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Nursing ProcessImplementation

• Non-Pharmacological and pharmacological Methods
• Non-pharmacologic methods-lessen pain, can be
  used at home or in hospital
• Utilize cognitive-behavioral physical
  approaches
• Allow patients some control

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Non-pharmacological Methods

• Acupuncture
• Relaxation
• Guided Imagery
• Distraction
• Music
• Biofeedback
• Self-Hypnosis
• Reducing Pain Perception
• Cutaneous Stimulation (Heat or Cold application,
  massage, TENS unit)

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Pharmacologic Methods

• Require a physicians order
• Guidelines set by regulatory agencies
• Analgesics most common method
• Tendency to under treat with pain meds

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Analgesics

• Non-opioid or non-narcotic agents non-steroidal
  anti-inflammatory agents (NSAIDS)
• Narcotics, Opioids
• Adjuvants, Co-analgesics

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NSAIDS

• Relief of mild to moderate pain
• Believed to inhibit prostaglandins inhibits
  cellular response during inflammation
• Acts on peripheral nerve receptors to reduce the
  transmission reception of pain
• Does not cause sedation or respiratory depression
  or interfere with bowel/bladder function
• Avoid prolonged or overuse in elderly

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NSAIDS

• Used in arthritic pain, minor surgical, dental
  procedures, low back pain, should be initially
  used in mild-moderate post-op pain
• Motrin, Naprosyn, Indocin, Toradol

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Opioids

• Moderate to severe pain
• Act on CNS, act on higher brain centers spinal
  cord binding with opiate receptors to modify
  perception of or reaction to pain
• Risk for depression of vital nervous system
  functions

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Opioids

• If pain is anticipated for longer than 12-24
  hours, ATC timing should be used instead of PRN
  timing
• Opioids can be used effectively with elderly,
  START LOW GO SLOW
• Morphine, Demerol, Codeine, Percocet, Fentanyl,
  Hydromorphone
• Opioid antagonist- NARCAN-reverses effect

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Adjuvant Therapy

• Sedatives, anti-anxiety, muscle relaxants
• Enhance pain control or relieve symptoms
  associated with pain
• Vistaril, Elavil, Thorazine, Valium, Ativan, Xanax

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Patient-Controlled Analgesia PCA

• Drug delivery system
• Patients have control over pain therapy
• Safe method for post-op, traumatic, or cancer
  pain
• Self-administration without risk of overdose
• IV administration

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PCA Prescription

• Loading Dose
• Basal (Continuous rate)
• On demand dose
• Hourly maximum amounts can be prescribed

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Local Regional Anesthetics

• Wound suturing
• Delivery of baby
• Performing simple surgery
• Epidural Analgesia for post-op pain management,
  LD pain, chronic cancer pain
• On-Q Pain Pump

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Epidural Pain Management

• Short or long term
• Administered into spinal epidural space
• Catheter is left in place, secured with tape and
  dressing
• Can be continuous infusion or daily injection

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Epidural Pain Management

• Monitor hourly for
• 1. Catheter Displacement
• 2. Catheter Function
• 3. Respiratory Depression
• 4. Side effects N/V, itching, urinary
  retention, constipation
• 5. Pain effect

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Cancer Pain Management

• Long acting preparations, sustained release
• Drug dependence low in cancer related pain
• Can develop tolerance, requiring higher doses
• Goal is to minimize pain, rather than cure it

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Clicker Question

• 1. When a smiling and cooperative client
  complains of discomfort, nurses caring for this
  client often harbor misconceptions about the
  clients pain. To properly care for clients in
  pain, nurses need to remember that
• A. Chronic pain is psychological in nature.
• B. Clients are the best judges of their pain.
• C. Regular use of narcotic analgesics leads to
  drug addiction.
• D. The amount of pain is reflective of actual
  tissue damage.

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Clicker Question

• 2. Established pain management guidelines direct
  nurses to frequently assess the clients pain.
  The most appropriate action for the nurse to take
  when assessing the clients reaction to pain is
  to
• A. Ask what precipitates pain.
• B. Question the client about the location of
  pain.
• C. Offer the client a pain scale to objectively
  identify the pain.
• D. Use open-ended questions to find out about
  the clients pain.

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Clicker Question

• 3. A client has just undergone abdominal
  surgery. When discussing with the client several
  pain relief interventions, the most appropriate
  recommendation would be
• A. Adjunctive therapy
• B. Nonopioids
• C. NSAIDs
• D. PCA pain management

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