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Evaluate patient’s response to pain and It is important to help patients express as factually
medications or therapeutics aimed at abolishing as possible (i.e., without the effect of mood,
or relieving pain. emotion, or anxiety) the effect of pain relief
measures. Discrepancies between behavior or
appearance and what patient says about pain
relief (or lack of it) may be more a reflection of
other methods patient is using to cope with than
pain relief itself.
Assess to what degree cultural, environmental, These variables may modify the patient’s
intrapersonal, and intrapsychic factors may expression of his or her experience. For example,
contribute to pain or pain relief. some cultures openly express feelings, while
others restrain such expression. However, health
care providers should not stereotype any patient
response but rather evaluate the unique response
of each patient.
Evaluate what the pain means to the individual. The meaning of the pain will directly influence the
patient’s response. Some patients, especially the
dying, may feel that the "act of suffering" meets a
spiritual need.
Assess patient’s expectations for pain relief. Some patients may be content to have pain
decreased; others will expect complete elimination
of pain. This affects their perceptions of the
effectiveness of the treatment modality and their
willingness to participate in additional treatments.
Assess patient’s willingness or ability to explore Some patients will feel uncomfortable exploring
a range of techniques aimed at controlling pain. alternative methods of pain relief. However,
patients need to be informed that there are
multiple ways to manage pain.
Assess appropriateness of patient as a patient- PCA is the intravenous (IV) infusion of a narcotic
controlled analgesia (PCA) candidate: no (usually morphine or Demerol) through an infusion
history of substance abuse; no allergy to pump that is controlled by the patient. This allows
narcotic analgesics; clear sensorium; the patient to manage pain relief within prescribed
cooperative and motivated about use; no history limits. In the hospice or home setting, a nurse or
of renal, hepatic, or respiratory disease; manual caregiver may be needed to assist the patient in
dexterity; and no history of major psychiatric managing the infusion.
disorder.
Monitor for changes in general condition that For example, a PCA patient becomes confused
may herald need for change in pain relief and cannot manage PCA, or a successful
method. modality ceases to provide adequate pain relief,
as in relaxation breathing.
If patient is on PCA, assess the following:
• Pain relief The basal or lock-out dose may need to be
increased to cover the patient’s pain.
• Intactness of IV line If the IV is not patent, patient will not receive pain
medication.
• Amount of pain medication patient is If demands for medication are quite frequent,
requesting patient’s dosage may need to be increased. If
demands are very low, patient may require further
instruction to properly use PCA.
• Possible PCA complications such as Patients may also experience mild allergic
excessive sedation, respiratory distress, response to the analgesic agent, marked by
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• Possible PCA complications such as Patients may also experience mild allergic
excessive sedation, respiratory distress, response to the analgesic agent, marked by
urinary retention, nausea/vomiting, generalized itching or nausea and vomiting.
constipation, and IV site pain, redness, or
swelling
If patient is receiving epidural analgesia, assess
the following:
• Pain relief Intermittent epidurals require redosing at intervals.
Variations in anatomy may result in a "patch
effect."
• Numbness, tingling in extremities, a These symptoms may be indicators of an allergic
metallic taste in the mouth response to the anesthesia agent, or of improper
catheter placement.
• Possible epidural analgesia Respiratory depression and intravascular infusion
complications such as excessive sedation, of anesthesia (resulting from catheter migration)
respiratory distress, urinary retention, or can be potentially life-threatening.
catheter migration
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Nonpharmacological methods include the following:
I. Cognitive-behavioral strategies as follows:
i. Imagery The use of a mental picture or an imagined event
involves use of the five senses to distract oneself
from painful stimuli.
ii. Distraction techniques Heighten one’s concentration upon nonpainful
stimuli to decrease one’s awareness and
experience of pain. Some methods are breathing
modifications and nerve stimulation.
iii. Relaxation exercises Techniques are used to bring about a state of
physical and mental awareness and tranquility.
The goal of these techniques is to reduce
tension, subsequently reducing pain.
iv. Biofeedback, breathing exercises,
music therapy
II. Cutaneous stimulation as follows:
i. Massage of affected area when Massage decreases muscle tension and can
appropriate promote comfort.
ii. Transcutaneous electrical nerve
stimulation (TENS) units
iii. Hot or cold compress Hot, moist compresses have a penetrating effect.
The warmth rushes blood to the affected area to
promote healing. Cold compresses may reduce
total edema and promote some numbing,
thereby promoting comfort.
Give analgesics as ordered, evaluating Pain medications are absorbed and metabolized
effectiveness and observing for any signs and differently by patients, so their effectiveness
symptoms of untoward effects. must be evaluated from patient to patient.
Analgesics may cause side effects that range
from mild to life-threatening.
Notify physician if interventions are unsuccessful Patients who request pain medications at more
or if current complaint is a significant change frequent intervals than prescribed may actually
from patient’s past experience of pain. require higher doses or more potent analgesics.
Whenever possible, reassure patient that pain is When pain is perceived as everlasting and
time-limited and that there is more than one unresolvable, patient may give up trying to cope
approach to easing pain. with or experience a sense of hopelessness and
loss of control.
If patient is on PCA:
Dedicate use of IV line for PCA only; consult IV incompatibilities are possible.
pharmacist before mixing drug with narcotic
being infused.
If patient is receiving epidural analgesia:
Label all tubing (e.g., epidural catheter, IV tubing
to epidural catheter) clearly to prevent
inadvertent administration of inappropriate fluids
or drugs into epidural space.
For patients with PCA or epidural analgesia:
Keep Narcan or other narcotic-reversing agent In the event of respiratory depression, these
readily available. drugs reverse the narcotic effect.
Post "No additional analgesia" sign over bed. This prevents inadvertent analgesic overdosing.
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PATIENT TEACHING RATIONALE
Provide anticipatory instruction on pain causes,
appropriate prevention, and relief measures.
Explain cause of pain or discomfort, if known.
Instruct patient to report pain. Relief measures may be instituted.
Instruct patient to evaluate and report
effectiveness of measures used.
Teach patient effective timing of medication
dose in relation to potentially uncomfortable
activities and prevention of peak pain periods.
For patients on PCA or those receiving epidural analgesia:
Teach patient preoperatively. Anesthesia effects should not obscure teaching.
Teach patient the purpose, benefits, techniques
of use/action, need for IV line (PCA only), other
alternatives for pain control, and of the need to
notify nurse of machine alarm and occurrence
of untoward effects.
Reference: Nursing Care Plans – Gulanick, Myers, Klopp, Galanes, Gradishar, Puzas
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