Basic Human Needs

Comfort and Pain

Management

Donna M Penn RN MSN CNE

 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
 Comfort

• Concept central to the art of nursing

• Through comfort measures nurses
provide strength, hope, solace, support,
encouragement, and assistance
• As subjective as pain
 Pain
• McCaffery on Pain-Pain is whatever the
experiencing person says it is, existing
whenever the person says it does.

• Pain relief is a basic legal right (American Bar

Association, 2000)

• Nurses are ethically and legally

responsible for managing pain and
relieving suffering.
 Pain Management
• Effective pain management reduces
physical discomfort
• Promotes earlier mobilization and return
to work
• Shortens hospital stay and reduces
health care costs
Pain Management
 Nature of Pain
• Subjective, highly individualized
• Stimulus can be physical and/or mental
in nature
• Pain is tiring, places demands on
person’s energy
• Can interfere with relationships and
influence the meaning of life
 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
 Physiology of Pain
Categories
• Acute
• Chronic
• Idiopathic Pain
• Cancer pain
• Pain by Inferred Pathology/Nociceptive &
Neuropathic
• Pain as a result of a Metabolic
Need/Ischemic Pain
 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
 Somatic Pain
• Arises from bone, joint, muscle, skin or
connective tissue
• Usually aching, throbbing, well-localized
pain
• Responds to traditional analgesia
 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
 Neuropathic Pain
• Abnormal processing of sensory input
by the peripheral or CNS
• Treatment usually with tricyclic
antidepressants, SSRI’s,
anticonvulsants
• Centrally generated pain
• Peripherally generated pain
 Idiopathic Pain

• Chronic pain in the absence of an

identifiable cause
• Complex Regional Pain Syndrome
 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
 Nociceptive Pain
• Transduction

• Transmission

• Perception

• Modulation
 Transduction
• Begins in periphery
• Pain producing stimuli sends impulse to
nerve fiber
• Pain fiber enter spinal tract
• Pain message is prevented from reaching
brain or enters cerebral cortex
• Once in cerebral cortex pain perception
interpreted causing a response
 Transduction
• All cellular damage caused by thermal,
mechanical, or chemical stimuli result in the
release of pain producing substances
• Bradykinin, Histamine, Substance P
• These pain producing substances surround
the pain fibers in the extracellular fluid,
spreading the pain message and causing the
inflammatory response
 Transduction
• Nerve impulses resulting from the
painful stimulus travel along peripheral
nerve fibers
• Two types of peripheral nerve fibers
conduct pain
1. Fast, myelinated A-delta
2. Slow, unmyelinated C
 Transmission
• Neuroregulators affect the transmission
of nerve stimuli
• Substances are found at the site of a
nociceptor at nerve terminals within the
dorsal horn of the spinal tract and at
receptor sites within the spinothalmic
tract
 Transmission
• Neurotransmitters
1. Substance P
2. Serotonin
3. Prostaglandins
• Neuromodulators
1. Endorphins
2. Bradykinin
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
 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
 Perception
• Point at which person is aware of pain
• Pain stimuli are transmitted up spinal cord to
thalamus and midbrain
• From thalamus, fibers transmit pain message
to cortex, frontal lobe, & limbic system
• Somatosensory cortex-identifies location &
intensity of pain
• Association cortex- how we feel pain
 Perception
• Limbic system-controls emotion,
anxiety, & emotional reaction to pain
• Responses to pain can be physiological
and behavioral
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)
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
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
 Modulation
• Process of inhibiting or changing pain
impulse
• Final process in nociception
• Involves release of serotonin and endorphins
• Work to inhibit pain or provide an analgesic
effect
• Release of endorphins can raise an
individuals pain threshold
 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)
 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
 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)
Factors Influencing Pain
• Age
• Gender
• Culture
• Meaning of pain
• Attention
• Anxiety
• Fatigue
• Previous Experience
• Coping Style
• Family & Social Support
 Nursing Process
Assessment
• AHCPR guidelines for assessing pain
• Clients expression of pain
• Characteristics of pain
• Onset & duration
• Location
• Intensity (Pain scales-numerical,
FACES)
 Assessment
• Quality
• Pain pattern
• Concomitant Symptoms
• Effect of pain on client (physical,
behavioral, effect on ADL)
 Nursing Process
Nursing Diagnosis
• Anxiety
• Alteration in Comfort
• Self-care Deficit
• Sleep Pattern Dysfunction
• Sexual Dysfunction
 Nursing Process
Implementation
• 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
 Non-pharmacological
Methods
Acupuncture
• Relaxation
• Guided Imagery
• Distraction
• Music
• Biofeedback
• Self-Hypnosis
• Reducing Pain Perception
• Cutaneous Stimulation (Heat or Cold
application, massage, TENS unit)
Pharmacologic Methods
• Require a physicians order
• Guidelines set by regulatory agencies
• Analgesics most common method
• Tendency to under treat with pain meds
 Analgesics
• Non-opioid or non-narcotic agents &
non-steroidal anti-inflammatory agents
(NSAIDS)
• Narcotics, Opioids
• Adjuvants, Co-analgesics
 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
 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
 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
 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
 Adjuvant Therapy
• Sedatives, anti-anxiety, & muscle
relaxants
• Enhance pain control or relieve
symptoms associated with pain
• Vistaril, Elavil, Thorazine, Valium,
Ativan, Xanax
 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
 PCA Prescription
• Loading Dose
• Basal (Continuous rate)
• On demand dose
• Hourly maximum amounts can be
prescribed
 Local & Regional
Anesthetics
• Wound suturing
• Delivery of baby
• Performing simple surgery
• Epidural Analgesia for post-op pain
management, L&D pain, chronic cancer
pain
 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
 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
 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
 Clicker Question

• 1. When a smiling and cooperative client complains of

discomfort, nurses caring for this client often harbor
misconceptions about the client’s 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 client’s pain. The most appropriate
action for the nurse to take when assessing the client’s 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 client’s
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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