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Pain Management Back to Course Index

 

 

 

PAIN MANAGMENT

 

Pain is an individualized concept that requires an equally individualized solution. It is a personal, subjective experience that can only be described by the person experiencing it. There is no physical method of measuring the quality or intensity of pain; rather, the patient who is in pain is the only person who can say how much something hurts. Margo McCaffery, a well-known expert on pain, defines pain this way: “pain is whatever the experiencing person says it is, existing whenever he or she says it does.” Professionals must rely on the patient’s description of pain, as well as the patient’s report of the success of pain relief measures.

A variety of analgesics and alternative treatments are available to assist with pain management, and medical professionals need to be familiar with these solutions for their patients’ benefit.

They must implement these measures to reduce a client’s pain to an acceptable level.

 

Physiology of Pain

There are several processes associated with nociceptors, the sensory impulses that carry pain signals. Knowledge of each of these helps us to understand what causes pain, what symptoms are common and nursing interventions for treatment.

Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors). Mechanical, thermal or chemical stimuli are detected by the nerve endings. Transduction occurs prior to the next process, transmission.

Transmission occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it. Impulses from afferent, or sensory, neurons carry impulses to the central nervous system (the brain and the spinal cord). Impulses from efferent, or motor, neurons carry impulses away from the central nervous system.

Pain threshold is the point at which a person feels pain.

Pain tolerance is the amount of pain a person is willing to bear.

Perception or awareness of pain occurs in various areas of the brain, with influences from thought and emotional processes.  There is not one specific pain center in the brain.

Modulation (the final step in the process) occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.

Neurotransmitters are released as the result of cellular damage.  Certain neurotransmitters work to incite during the transmission phase, while others work to inhibit during the modulation phase.  Some of the neurotransmitters involved in the pain process include:

  • Substance P, a neuropeptide that transmits impulses from the periphery to the brain
  • Prostaglandins increase sensitivity to pain
  • Bradykinin binds to receptors on peripheral nerves and increases pain stimuli
  • Histamine causes capillary dilation and increased capillary permeability
  • Serotonin decreases sensitivity to pain
  • Enkephalins and endorphins fight pain and are considered endogenous painkillers

 

Types of Pain

Pain differs for each person who is experiencing it. A specific type of pain may only be a small amount of discomfort for one person, while pain in the same location or from the same type of injury may be quite severe for another patient. Pain may also be divided into acute and chronic types of pain. The kind of pain the patient is experiencing affects assessment of the patient’s condition and impacts pain treatment.

Pain is categorized by duration (acute or chronic) or by origin (nociceptive or neuropathic), or by the disease or condition that causes it (e.g. cancer, diabetes, multiple sclerosis). 

Acute pain occurs for a shorter duration and is classified as occurring for six months or less. Acute pain may also only last for a few seconds or minutes before resolving. Acute pain may be severe when the pain begins but often resolves with time and treatment.4 Acute pain causes a stress response in the affected person, such as an increased heart rate and rapid breathing, but this response typically ends when the pain is resolved and the tissue has healed.5 Examples of situations where a patient may experience acute pain include surgery, burns, or cuts to the skin.

  • Acute pain is protective, temporary, usually self‑limiting, has a direct cause, and resolves with tissue healing.
  • Physiological responses (sympathetic nervous system) are fight‑or‑flight response (dilated pupils, tachycardia, hypertension, anxiety, diaphoresis, muscle tension).
  • Behavioral responses include grimacing, moaning, flinching, and guarding.
  • Interventions are aimed at treatment of the underlying problem.
  • Can lead to chronic pain if unrelieved.

Chronic pain differs from acute pain in that it can last for a much longer period of time, yet it may not be any more tolerable than acute pain sensations. Chronic pain lasts for longer than six months, and if an injury has caused the initial pain, the discomfort continues even after the initial injury or condition has been treated. Chronic pain does not elicit a stress response from the affected person because over time, the patient becomes more accustomed to the pain. A patient may be admitted for treatment that causes acute pain, yet already be suffering from chronic pain as well. A patient may develop a physiologic stress response to the acute pain from procedures or surgery, however, as the body’s response to chronic pain is continuous and he or she may have adapted to it. Over time, chronic pain can be very debilitating, resulting in other complications such as depression, irritability, and difficulties with sleeping.

Examples of conditions that may result in chronic pain include pain:

  • Arthritis
  • Cancer pain
  • Low back pain
  • Headaches (migraine, cluster, tension)
  • Fibromyalgia

 

Neuropathic pain occurs when a person experiences pain related to changes in nerve fibers, usually resulting from a type of injury or disease process. The person who experiences neuropathic pain may have no obvious injury, but still has pain because of how his nerves impact the rest of his body. Neuropathic pain causes damage to the nerve fibers, which continue to send messages to pain centers throughout the body. Neuropathic pain may also develop if the pain centers of the brain are damaged and do not receive messages correctly.

Neuropathic pain may be classified into different categories, depending on whether co-existing conditions are present as well as how the pain has developed. Traumatic neuropathic pain occurs when the nerves have been injured as a result of some type of traumatic event. The injured nerves continue to send incorrect pain signals to the brain, whether the injury to the body healed or not. An example of traumatic neuropathic pain is phantom limb pain, in which a person who has had an amputated limb continues to feel pain in the missing extremity.

Metabolic neuropathic pain occurs when a person experiences sensory pain as a result of complex medical disorders that affect the metabolic system, such as malnutrition or diabetes. One of the most common conditions causing metabolic neuropathic pain is diabetic neuropathy. The patient with diabetes may suffer from nerve damage as a result of uncontrolled blood glucose levels, resulting in pain, numbness, burning, or tingling in the distal extremities.

Infectious neuropathic pain develops from an infection in the body that causes nerve damage and subsequently, chronic pain that may be constant or intermittent. Examples of infections that can cause neuropathic pain include post-herpetic neuralgia, caused by varicella zoster virus that causes chickenpox and shingles; infection with Lyme disease or HIV, and Guillain-Barré syndrome, which causes pain, weakness, and paralysis when it develops after a viral infection.

Autoimmune pain develops as a result of injury to the nerves from certain autoimmune disorders that attack the body’s own cells. Chronic inflammatory demyelinating polyneuropathy occurs when the myelin sheath over the nerves becomes damaged, resulting in pain in the extremities. Compressive pain is another type of neuropathic pain that results in physical damage to the nerves as a result of stretching, pinching, or squeezing of the nerve fibers. Examples of this type of pain include carpal tunnel syndrome and compartment syndrome.

Toxic causes of neuropathic pain result in damaged nerves due to exposure of toxic substances. Chemicals such as lead, mercury, arsenic, thallium, lithium, chemotherapy drugs; antibiotics, such as isoniazid and metronidazole; and some cardiovascular medications, including captopril and amiodarone can all cause neuropathic pain with exposure.

Nociceptive pain occurs as a response to stimuli that are perceived by the body as being painful. This type of pain stimulates the nociceptors in the body, which are nerves that transmit signals in response to harmful or noxious stimuli in the environment. Nociceptive pain is categorized as being somatic pain or visceral pain.

Somatic pain develops when the nerves send pain messages to the brain because of cell injury to body areas containing connective tissue. Somatic pain is pain that occurs in areas such as the bones, joints, muscles, or the skin.

Visceral pain occurs as pain affecting internal organs and tissues, such as the heart, gastrointestinal system, or the kidneys. A person feels visceral pain when nociceptive pain receptors in the organs respond to painful stimuli.   The pain may develop through part of a disease process, which results in cramping or tissue spasms, or in ischemia development at the site. Visceral pain may also occur as a result of injury, or through some type of medical procedure, during which the organs and tissues are moved, stretched, or manipulated, resulting in pain.

 

Assessment of Pain

Assessing the patient for pain is important for not only understanding how much pain they are having and how to treat that pain, but it is also essential for understanding how to care for the whole person. A patient in pain may also have other complications and issues that need to be managed as part of his or her care, such as difficulties with eating, problems with concentration, or impaired mobility. The patient taking pain medications may develop constipation. The location and the source of the pain can significantly impact a patient’s abilities to perform tasks, such as activities of daily living. Pain assessment is one aspect of assessing the patient’s total needs, including physical, psychological, and emotional matters that may develop when receiving care.

Pain assessment should occur at regular intervals in order to ensure that adequate pain management is taking place.

How a patient perceives pain is affected by several factors that are particular for each individual. A patient’s level of pain tolerance, cultural background, expectations for pain management, and previous experiences with pain all impact the patient’s responses to a current situation. These factors should also be recognized as part of the pain assessment process because they impact pain response.

Adequate pain assessment involves determining the location, intensity, and duration of the patient’s pain, relying on the patient’s use of words or descriptions of discomfort felt. Providing adequate pain control then means acting on how the patient has expressed pain in order to provide pain relief, as well as evaluating the effectiveness of therapy to determine its success or whether further measures are necessary.

  • Location of the pain is described as where the patient is experiencing it. This may or may not be the actual site of injury or illness that is causing the pain. If the patient is experiencing pain that is radiating, he or she may feel it at the source of the pain, as well as in the surrounding tissues.
  • Duration refers to how long the patient has been experiencing the pain.
  • Intensity refers to how severe the pain is.

A pain scale measures the intensity of pain. Self-report is considered the primary factor and should be obtained if possible. Pain measurements are used to make an accurate diagnosis, determine a treatment plan, and evaluate the effectiveness of treatment.

The numerical rating scale is one of the most commonly used methods for assessing a patient’s pain.

The numerical rating scale is appropriate to use for most adult inpatients who are cognitively aware and who are awake to be able to respond. The numerical rating scale asks the patient to rate pain on a scale of 0 to 10. A score of 0 means the patient has no pain, while a score of 10 is the worst pain imaginable. The patient gives a number somewhere on the scale to describe his or her current level of pain.

 

Pain relief ladder was created by the World Health Organization (WHO) as a guideline for the use of drugs in the management of pain. Originally published in 1986 for the management of cancer pain, it is now widely used by medical professionals for the management of all types of pain.

The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from common, over-the-counter drugs at the lowest rung, to strong opioids.

 

The Wong-Baker Faces Pain Rating Scale is based on a numeric pain rating scale from 0-10, with zero being no pain and 10 being the worst pain imaginable. The scale includes numbers, faces (visual representation), and written descriptions. There are 6 faces in the Wong-Baker Pain Scale. The first face represents a pain score of 0 and indicates “no hurt.” The second face represents a pain score of 2 and indicates “hurts a little bit.” The third face represents a pain score of 4 and indicates “hurts a little more.” The fourth face represents a pain score of 6 and indicates “hurts even more.” The fifth face represents a pain score of 8 and indicates “hurts a whole lot” and the sixth face represents a pain score of 10 and indicates “hurts worst.”

This pain scale was originally developed for, however it can be used for all ages and children as young as 3 years old. It is a useful pain scale for children because many children may not understand rating their pain on a scale of 0-10, but are able to understand the cartoon faces and the emotions they represent and point to the one that best matches their level of pain. This pain scale is also appropriate for patients who do not know how to count and those who may have impaired brain function. Cultural sensitivity of the scale was also assessed to determine its applicability and acceptance across different cultures and “research supports cultural sensitivity of FACES for Caucasian, African-American, Hispanic, Thai, Chinese, and Japanese children.

 

Factors That Affect the Pain Experience

  • Age
    • Infants cannot verbalize or understand their pain.
    • Older adult clients can have multiple pathologies that cause pain and limit function.
  • Fatigue
    • Can increase sensitivity to pain.
  • Genetic sensitivity
    • Can increase or decrease pain tolerance
  • Cognitive function
    • Clients who have cognitive impairment might not be able to report pain or report it accurately.
  • Prior experiences
    • Can increase or decrease sensitivity depending on whether clients obtained adequate pain relief.
  • Anxiety and fear
    • Can increase sensitivity to pain
  • Support systems and coping styles
    • Presence of these can decrease sensitivity to pain.
  • Culture 
    • Can influence how clients express pain or the meaning they give to pain.

Pain may be difficult to assess among patients who are cognitively impaired and who have difficulty expressing their level of pain on a numerical scale. During these situations, it is important to assess for visual signs of pain in the patient and provide pain relief measures if the patient is showing nonverbal cues that indicate pain, such as fidgeting, grimacing, crying, moaning, being aggressive or disruptive, rocking, or pacing. Additionally, physiological changes may also be present, even if the patient is unable to state that he or she is in pain. Signs include an increased heart rate, increased respiratory rate, increased blood pressure, dilated pupils, or sweating.

 

Prevention Is The Best Pain Management Approach

Preventing pain is the best method.  Controlling weight for an individual for has arthritis in their family, regular doctor visits to monitor for health issues before they become a problems and regular exercise can all combat the issue of pain in many circumstances.  It is also helpful to know triggers for issues like migraines.  Simply avoiding red wine can significantly reduce the frequency of this sever pain if tannins trigger migraines for the client. 

Chiropractic, physical therapy, massage therapy, acupuncture and others all have “maintenance” aspects which can be used as prevention for many painful conditions. As mentioned, exercise and nutrition play a role as well. All combined, these preventative measures can avert severe medical conditions and pain. 

 

Pharmacological Pain Management Strategies

The concept of pain management means providing treatment for a patient’s pain in order to eliminate the pain or reduce it to a level that is tolerable. This is frequently accomplished through the use of pharmacotherapy.

Opioids are medications given to provide pain relief by binding to certain receptors in the spinal cord, which then blocks the perception of pain in the brain. Opiates may be made of natural substances or they may be synthetic. When opioids are used to control pain there is a fine balance that must be found between providing enough to manage pain while avoiding potential side effects such as sedation, respiratory depression, confusion, and addiction.

Non-opioid analgesics are drugs that are typically used for mild to moderate pain relief. These medications can be bought over the counter. There is a ceiling as to how much analgesia these medications can provide, so giving more or repeating doses in an effort to increase comfort may not be effective or safe.

Adjuvant medications, also called co-analgesics, are those that are not designed for analgesia. They have other puposes when used alone, however, when combined with opioid or non-opioid analgesics there can be a greater effect on pain relief.   An example of this would be an antidepressant used in combination with an analgesics for better pain control.

Epidural analgesia involves administering medications for pain control into a catheter that has been placed in the epidural space in the spinal column. The epidural space lies between the meninges covering the spinal cord and the walls of the vertebral canal. The space contains spinal nerves, as well as blood vessels and adipose tissue. When it is cannulated and medication is administered, pain control can be achieved because the medication can quickly impact pain receptors in the nerves of the spinal cord, blocking pain messages to the brain.

A nerve block is a pain control measure that involves injecting medication into a specific nerve in order to numb a certain part of the body. The nerve block is performed prior to a procedure or treatment to cause the area to become numb enough that the patient does not feel pain associated with treatment or for a period of time afterward. 

 

Nonpharmacological Pain Management Strategies

Nonpharmacologic therapies for pain control can help to relieve pain by making the patient more comfortable and changing the way the body perceives pain. Some types of nonpharmacologic measures that may be used for pain control include massage, heat or cold therapy, transcutaneous electrical nerve stimulation, acupuncture and acupressure and cognitive-behavioral therapy. These physical modalities increase circulation and reduce the level of pain or change the thought process for focusing on pain.

Transcutaneous electrical nerve stimulation is the use of a small electric stimulator that is attached to the skin in painful areas. An electrical current blocks the sensation of pain.

Heat therapy causes vasodilation and promotes blood flow to the area. Generally, the treatment is discontinued after 15 to 30 minutes, because if it is applied for more than 1 hour, the body responds by reducing blood flow to the skin by a reflex vasoconstrictive response. Aquathermia pads and heat pads are examples of dry heat. Warm moist heat is applied using a warm moist compress, or soaking a body part by using a sitz bath.

Cold therapy reduce swelling and pain.  Generally, the treatment is discontinued after 5 minutes or when the area begins to feel numb.   Prolonged exposure to cold, as with heat, results in reflex vasodilation. Ice bags, ice collars, and ice gloves are used as therapy to a localized area.

Massage stimulates circulation, relaxes the client’s muscles and can reduce anxiety. It decreases pain by increasing circulation to the area. The massaging of areas where skin integrity is impaired or there is a change in the appearance of the skin should be avoided, a blood clot is possible, or an infection is present. 

Acupuncture and acupressure involve stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure).

Cognitive‑behavioral measures are aimed at changing the way a client perceives pain, and physical approaches to improve comfort. Distraction, relaxation, guided imagery, biofeedback and Reiki are examples of cognitive-behavioral strategies to reduce pain. 

 

Other Strategies for Effective Pain Management

  • Take a proactive approach by giving analgesics before pain becomes too severe. It takes less medication to prevent pain than to treat pain.
  • Instruct clients to report developing or recurrent pain and not wait until pain is severe (for PRN pain medication).
  • Explain misconceptions about pain (medication dependence, pain measurement and perception).
  • Help clients reduce fear and anxiety.
  • Create a treatment plan that includes both nonpharmacological and pharmacological pain‑relief measures.

 

Concerns about Addiction

One in three Americans currently experience ongoing pain.  Providing adequate pain management without promoting opioid use disorder is a challenge for health care providers. Concerns about opioid use disorder should not be minimized.

Patients who are prescribed opioids for an extended period (months, years) may develop a physical dependence on them as repeated exposure can cause the body to physically adapt to their presence. Also, continued use may result in the body building a tolerance (that is, more of the drug is needed to achieve the desired effect compared with when it was first prescribed). A patient may also experience withdrawal symptoms upon abrupt cessation of drug use. Thus, individuals taking prescribed opioid medications should not only be given these medications under appropriate medical supervision, but they should also be medically supervised when stopping use in order to reduce or avoid severe withdrawal symptoms. Symptoms of withdrawal can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (cold turkey), and involuntary leg movements.

 

 

Summary

Pain continues to be a mechanism that drives people to seek treatment, undergo procedures, or learn techniques to find ways to manage it. Understanding ways of managing it and recognizing signs of its escalation should be a core component of nursing care.

 

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