Angelite Nurses

Pain is an unpleasant sensation, entirely subjective, that produces discomfort, distress, or suffering.

Gate Control Theory

1. Substantia gelatinosa in the dorsal horn of the spinal cord acts as a gate mechanism that can close to keep pain impulses from reaching the brain, or can open to allow pain impulses to ascend to the brain.
2. Most pain impulses are conducted over small-diameter nerve fibers; if predominant nerve message is pain, the gate opens and allows pain impulses to reach the brain.
3. The gate can be closed by conflicting impulses from the skin conducted over large-diameter nerve fibers, by impulses from the reticular formation in the brainstem, or by impulses from the entire cerebral cortex or thalamus.

Acute Pain and Chronic Pain

1. Acute pain
1. Short duration; may last from split second to about six months.
2. Serves the purpose of warning the client that damage or injury has occurred in the body that requires treatment.
3. Subsides as healing occurs.
4. Usually associated with autonomic nervous system symptoms, e.g., increased pulse and blood pressure, sweating, pallor.
2. Chronic pain
1. Prolonged duration; lasts for six months or longer.
2. Serves no useful purpose.
3. Persists long after injury has healed.
4. Rarely accompanied by autonomic nervous system activity.

Assessment of Pain
See Table 4.4.

TABLE 4.4 Pain Assessment

General Nursing Interventions

1. Establish nurse-client relationship.
1. Let the client know that you believe that his pain is real.
2. Respect the client's attitudes and behavioral responses to his pain.
2. Assess characteristics of pain and evaluate client's response to interventions.
3. Promote rest and relaxation.
1. Prevent fatigue.
2. Teach relaxation techniques, e.g., slow, rhythmic breathing, guided imagery.
4. Institute comfort measures.
1. Positioning: support body parts.
2. Decrease noxious stimuli such as noise or bright lights.
5. Provide cutaneous stimulation: massage, pressure, baths, vibration, heat, cold packs; increased input of large-diameter fibers closes gate.
6. Relieve anxiety and fears.
1. Spend time with client.
2. Offer reassurance, explanations.
7. Provide distraction and diversion, e.g., music, puzzles.
8. Administer pain medication as needed.
1. Administer pain medication in early stages before pain becomes severe.
2. If pain is present most of the day, a preventative approach may be used, e.g., an around-the-clock schedule may be ordered in place of a prn schedule.
9. Teach client about pain and pain control measures, e.g., relaxation techniques, cutaneous stimulation.

Specific Medical and Surgical Therapies for Pain

1. Case Study
   Mrs. Linda Boyd, age 48, is admitted to the local hospital for an abdominal hysterectomy. Postoperatively she is placed on meperidine (Demerol) 100 mg IM every 4 hours prn.
2. Prototype--Morphine Sulfate
1. Action. Acts on opioid receptors in CNS and induces sedation, analgesia, and euphoria.
2. Use. Relief of moderate to severe pain, preoperative medication, pain relief in MI, relief of dyspnea occurring in pulmonary edema or acute left ventricular failure.
3. Adverse Effects. Sedation, confusion, euphoria, impaired coordination, dizziness; urinary retention; hyperglycemia; respiratory depression; hypotension, tachycardia, bradycardia; nausea, vomiting, constipation; decreased uterine contractility; allergic reactions; tolerance, physical and psychological dependence; pupil constriction.
4. Nursing Implications
1. Assess client's pain before giving medication.
2. Evaluate effectiveness of analgesic including onset and duration of response to medication.
3. Observe for signs of tolerance with prolonged use.
1. Tolerance means that a larger dose of narcotic analgesic is required to produce the original effect.
2. The first sign of tolerance is usually a decreased duration of effect of the analgesic.
4. Monitor respiratory rate and depth before giving drug, and periodically thereafter.
5. Encourage sighing, coughing, and deep breathing.
6. Warn ambulatory clients to avoid activities that require alertness.
7. Advise client to change position slowly.
8. Check for signs of urinary retention.
9. Keep stool record and institute measures to prevent constipation; e.g., fluids, foods high in fiber, and activity as tolerated; administer stool softeners and laxatives as ordered.
10. Have narcotic antagonist (naloxone [Narcan]) available for reversal of effects if necessary.
11. Teach client not to drink alcoholic beverages while taking narcotics.
12. Monitor for withdrawal symptoms and decrease dose slowly since these drugs may produce physical dependence.
13. Use special caution with clients with increased intracranial pressure, chronic obstructive pulmonary disease (COPD), alcoholism, severe hepatic or renal disease, and in elderly or debilitated clients who may not metabolize the drug efficiently.
5. Discharge Teaching
1. Take before pain intensifies to receive fullest analgesic effect.
2. No alcohol or CNS depressants should be taken.
3. No smoking or ambulating alone after drug has been taken.
4. Avoid activities requiring alertness.
3. Related Drugs. See Table 2.6.
4. Narcotic Agonists/Antagonists
1. Examples: pentazocine (Talwin), nalbuphine (Nubain), butorphanol (Stadol), buprenorphone (Buprenex)
2. Mechanism of action
1. Term "agonist" refers to the fact that they bind to opioid receptors to produce analgesia.
2. Term "antagonist" refers to the fact that they counteract the effects of the pure narcotic agonists (i.e., morphine, meperidine [Demerol]).
3. Use. Relief of moderate to severe pain; may be used for clients who cannot tolerate pure narcotic agonists. Caution: May produce withdrawal in a client who has been taking pure narcotic agonists for a week or more.
4. Adverse Effects. Drowsiness, nausea, psychotomimetic effects, e.g., hallucinations; respiratory depression and constipation but less of a risk than with pure narcotic agonists such as butorphanol (Stadol), nalbuphine (Nubain), pentazocine (Talwin)
5. Combination Drugs
1. Some narcotics can be combined with other drugs.
2. Examples of this would be codeine combined with Empirin, Fiorinal, or Tylenol.

TABLE 2.6 Narcotic Analgesics

Nonnarcotic Analgesics

1. Salicylates
1. Examples: Acetylsalicylic acid (ASA, aspirin (Ecotrin), choline magnesium trisalicylate (Trilisate), diflunisal (Dolobid), salsalate (Disalcid)
2. Mechanism of action
1. Analgesic action: produced by action on the hypothalamus and inhibition of prostaglandin synthesis
2. Antipyretic action: acts on hypothalamus to produce peripheral vasodilation, which causes sweating and heat loss (diflunisal [Dolobid] has minimal antipyretic effect)
3. Anti-inflammatory action: caused by inhibition of prostaglandin formation
4. Antiplatelet activity: inhibits platelet aggregation (Trilisate, Dolobid, and Disalcid have no effect on platelet aggregation)
3. Uses
1. Relief of mild to moderate pain
2. Reduction of elevated body temperature
3. Symptomatic treatment of numerous inflammatory disorders
4. Side effects
1. Allergic reaction: varies from rash to anaphylaxis
2. Anemia, decreased platelet aggregation, prolonged bleeding time (not with Trilisate, Dolobid, or Disalcid)
3. Nausea, vomiting, gastritis, occult GI bleeding
4. Renal failure with high doses
5. Toxicity: tinnitus, visual changes, alterations in mental status
5. Nursing interventions
1. Give with food, milk, or antacid to decrease GI irritation; contraindicated in clients with ulcer disease.
2. Check auditory and visual status periodically.
3. Instruct client to watch for any signs of bleeding.
4. Monitor renal function tests in clients receiving high doses or those in ASA toxicity.
2. Acetaminophen (Datril, Tylenol) (see Unit 2).
3. Nonsteroidal anti-inflammatory drugs (NSAIDs: ibuprofen [Motrin], indomethacin [Indocin], piroxicam [Feldene])
1. Nursing interventions
1. Administer with food or milk to prevent GI upset.
2. Teach client to observe for and report signs of bleeding.
3. Caution client that drowsiness and dizziness may occur and may impair ability to perform mechanical tasks.

Adjuvants

1. Includes several classes of drugs that may either:
1. Potentiate the effects of narcotic or nonnarcotic analgesics, e.g., hydroxyzine (Vistaril, Atarax)
2. Have independent analgesic properties in certain situations, e.g., tricyclic antidepressants such as amitriptyline (Elavil) for neuropathic pain.
3. Help control signs and symptoms associated with pain, e.g., anxiety, depression, nausea, and insomnia

Patient-controlled Analgesia (PCA)

1. Type of intravenous pump that allows the client to administer his own narcotic analgesic (e.g., morphine) on demand within preset dose and frequency limits.
2. Goal is to achieve more constant level of analgesia as compared to prn IM injections; also, in general, causes less sedation and lower risk of pulmonary depression.
3. Used most often for postoperative pain management; also used for intractable pain in terminal illness.
4. PCA pump may be used solely on PCA mode or may be combined with a continuous basal mode where client is receiving continuous infusion of narcotic in addition to self-administered bolus injections.
5. The dose of the analgesic bolus and the time interval between boluses (lockout period) is preset on the pump by the RN according to physician's orders.
6. Nursing Interventions
1. Instruct client in use of PCA pump
1. Demonstrate how to push control button.
2. Explain concept of patient-controlled analgesia.
2. Assess client's level of consciousness, respiratory rate, and degree of pain relief frequently.

Intraspinal Narcotic Infusion

1. Involves intraspinal infusion of narcotics or local anesthetic agents for relief of acute or chronic pain.
2. Medication is infused through catheter placed in the subarachnoid (intrathecal) or epidural space in the thoracic or lumbar area.
3. Repeated injections of narcotics produce analgesia without many of the side effects associated with systemic narcotics, e.g., sedation.
4. Indications
1. Temporary intraspinal narcotic therapy is used most frequently for postoperative pain.
2. For chronic pain, e.g., chronic cancer pain, the catheter may be tunneled under the skin and implanted subcutaneously in the abdomen; an implantable infusion device may be used to provide continuous narcotic infusion.
5. Nursing Interventions
1. Monitor client closely for respiratory depression especially during initiation of treatment.
2. Assess for other side effects:
1. urinary retention: Foley catheter may be used in post-op client until infusion is discontinued
2. pruritus: may be reversed with naloxone (Narcan)
3. nausea and vomiting
3. Check insertion site frequently for signs of infection.

Electrical Stimulation Techniques for Pain Control

1. Transcutaneous electrical nerve stimulator (TENS)
1. Noninvasive alternative to traditional methods of pain relief
2. Used in treating acute pain (e.g., post-op pain) and chronic pain (e.g., chronic low back pain)
3. Consists of impulse generator connected by wires to electrodes on skin; produces tingling, buzzing sensation in the area.
4. Mechanism based on gate-control theory: electrical impulse stimulates large diameter nerve fibers to "close the gate."
5. Nursing responsibilities
1. Do not place electrodes over incision site, broken skin, carotid sinus, eyes, laryngeal or pharyngeal muscles.
2. Do not use in client with cardiac pacemaker.
3. Provide skin care.
1. remove electrodes once a day; wash area with soap and water and air dry.
2. wipe area with skin prep pad before reapplying electrode.
3. assess area for signs of redness; reposition electrodes if redness persists for more than 30 minutes.
2. Dorsal column stimulator
1. Used in selected clients for whom conventional methods of pain relief have not been effective
2. Electrode is surgically placed over the dorsal column of the spinal cord via laminectomy; connected by wires to a transmitter that may be worn externally or be implanted subcutaneously.

Neurosurgical Procedures for Pain Control

1. Performed for persistent intractable pain of high intensity
2. Involves surgical destruction of nerve pathways to block transmission of pain
3. Types
1. Neurectomy: interruption of cranial or peripheral nerves by incision or injection
2. Rhizotomy: interruption of posterior nerve root close to the spinal cord
1. Laminectomy is necessary.
2. Results in permanent loss of sensation and position sense in affected parts.
3. Chordotomy: interruption of pain-conducting pathways within the spinal cord
1. Laminectomy usually required.
2. May be done by percutaneous needle insertion.
3. Interrupts conduction of pain and temperature sense in affected parts.
4. Sympathectomy: interruption of afferent pathways in the sympathetic division of the autonomic nervous system; used to control pain from causalgia and peripheral vascular disease.
4. Nursing responsibilities
1. Provide pre- and post-op care for a laminectomy (see Discetomy).
2. Assess extremities for sensation (e.g., touch, pain, temperature, pressure, position sense) and movement.
3. Provide safety measures to protect client from injury and carefully monitor skin for signs of damage or pressure.
4. Teach client ways to compensate for loss of sensation in affected parts.
1. Visually inspect skin for signs of injury or pressure.
2. Check temperature of bath water.
3. Avoid use of hot water bottles, heating pads.
4. Avoid extremes of temperature.

Acupuncture

1. A Chinese technique of pain control by insertion of fine needles at various points on the body
2. Based on Eastern philosophy where insertion of needles is thought to block energy flow and restore the body's harmony
3. Mechanism of action: two theories
1. Trigger points: the needles stimulate hypersensitive areas in muscle that produce local and referred pain. Extinction of the trigger point alleviates the referred pain.
2. Endorphin system: needle insertion activates production of endorphins (body's natural opiates).
4. Acupressure: a less invasive variation; uses finger pressure and massage

Hypnosis

1. Has been used in dental procedures, labor and delivery, pain control in cancer.
2. Mechanism is thought to be that positive suggestions alter client's perception of pain.

Behavioral Techniques

1. Types
1. Operant conditioning: based on decreasing positive reinforcement for pain behaviors
2. Biofeedback: teaches clients to control physiologic responses to pain (e.g., muscle tension, heart rate, blood pressure) and to replace them with a state of relaxation.
2. Work best in conjunction with other types of pain management and stress reduction techniques.