Concept Of Pain

HARRY BEL E. BAUTISTA, RN, MAN CLINICAL INSTRUCTOR

PAIN DEFINED
It is the unpleasant sensory and emotional experience resulting from actual or potential tissue damage. It is the most common reason for seeking health care and it occurs with many disorders and with some diagnostic tests and treatments. It is a subjective response to both physical and psychological stressors. Although it is typically experienced as uncomfortable and unwelcome, it also serves as a powerful protective role, warning of potentially health-threatening conditions. It is a personal, private sensation of hurt that signals current or impending tissue damage and serves to protect one from harm.

The cardinal rule in the care of patients with pain is that all pain is real even if its cause is unknown. Therefore, validation of the existence of pain is based simply on the patients report that it exists. Whatever the person experiencing it says it is, and existing whenever the person says it does the client is the only person who can accurately define and describe his or her own pain and serves as the basis for nursing assessment and care.

VALUES AND BELIEFS ABOUT PAIN

Pain can be experienced only by the person affected; that is, pain has a personal meaning.

f the client says he/she has pain, the client is in pain.

All pain is real Pain has physical, emotional, cognitive, socio-cultural, and spiritual dimensions. Pain affects the whole body, usually negatively. Pain may serve as both a response to and a warning of actual or potential trauma.

NEUROPHYSIOLOGY OF PAIN
> Pain stimulus Cutaneous nociceptors generate pain impulses Afferent/ sensory neuron A-delta fibers (fast pain); C-fibers (slow pain) Substantia gelatinosa Dorsal horn synapses relay impulses up to spinal cord Anterior spinal thalamic tract Reticular formation integrates pain response Slow pain fibers (thalamus) Fast pain fibers (cerebral cortex)

THEORIES OF PAIN

SPECIFICITY THEORY
the most widely accepted theory of pain transmission through the end of 19th century. It advances the idea that the bodys neurons and pathways for pain transmission are as specific and unique as those for other body senses, such as taste or touch. It proposes that free nerve endings in the skin act as pain receptors, accept sensory input, and transmit this input along highly specific nerve fibers. These fibers synapse in the dorsal horns of the spinal cord, and cross-over to the anterior and lateral spinothalamic tracts. The pain impulses then ascend to the thalamus and cerebral cortex, where painful sensations are perceived.

> It does not explain the differences in pain perception among individuals, nor does it satisfactorily account for the effect of physiologic variables, the effect of previous experience with pain, phantom limb pain, or peripheral neuralgias.

PATTERN THEORY
proposed in the early 1900s. It identifies two (2) major types of pain fibers, rapidly conducting and slowly conducting fibers (A-delta and C-fibers). The stimulation of these fibers forms a pattern. The theory also introduces the concept of central summation. Peripheral impulses from many fibers of both types are combined at the level of the spinal cord, and from there, a summation of these impulses ascends to the brain for interpretation.

This theory does not account for individual perceptual differences and psychologic factors.

GATE CONTROL THEORY

suggests that pain and its perception are determined by interaction of two (2) systems. The 1st of these interrelated system is the substantia gelatinosa in the dorsal horns of the spinal cord. The substantia gelatinosa regulates impulses entering or leaving the spinal cord.

The 2nd system is an inhibitory system within the brainstem.

Small diameter A-delta and C-fibers carry fast and slow pain impulses. Large diameter A-beta fibers carry impulses for tactile stimulation from the skin. In the SG, these impulses encounter a gate thought to be opened and closed by the domination of either the large diameter touch fibers or the small-diameter pain fibers. If impulses along the small diameter pain fibers outnumber impulses along the large diameter touch fibers, the gate is open, and pain impulses travel unimpeded to the brain. If the fibers predominate, they will close the gate and the pain impulses will be turned away at the gate. This explain why massaging a stabbed toe can reduce the intensity and duration of pain.

The 2nd system described, is thought to be located in the brain stem. It is believed that cells in the midbrain, activated by a variety of functions such as opiates, psychologic factors, or even simply the presence of pain itself, signal receptors in the medulla. These receptors in turn stimulate nerve fibers in the spinal cord to block the transmission of pain fibers. It is hypothesized that this brainstem regulatory system may help explain why even severe pain may not be perceived under certain circumstances, such as when an athlete fails to notice an injury until the competition is over.

TYPES OF PAIN

ACUTE PAIN
is usually temporary, has a sudden onset and is localized. It is the pain that lasts for less than 6 months and has an identified cause. It most often results from tissue injury, from trauma.

It serves as a warning of actual or potential injury to tissues.

It initiates the fight or flight autonomic stress response.

Characteristic physical responses occur including tachycardia, rapid and shallow respirations, increased BP, dilated pupils, sweating and pallor.
a. Somatic pain arises from nerve receptors originating in the skin or close to the surface of the body. It may be either sharp and well localized, or dull and diffuse. Visceral Pain arises from body organs. It is dull and poorly localized because of the low number of nociceptors. The viscera are sensitive to stretching, inflammation and ischemia but relatively insensitive to cutting and temperature extremes. It is associated with nausea and vomiting, hypotension, and restlessness. It often radiates or is referred.

a.

c.

Referred Pain is pain that is perceived in an area distant from the site of the stimuli. It commonly occurs with visceral pain as visceral fibers synapse at the level of the spinal cord, close to fibers innervating other subcutaneous tissue organs of the body. Pain in the spinal nerve may be left cutaneously in any body area innervated by sensory neurons that share the same nerve route. Body areas defined by spinal nerve route are called dermatomes.

CHRONIC PAIN
is prolonged pain, usually lasting longer than 6 months. It is not often associated with an identifiable cause at is often unresponsive to conventional medical treatment. Unlike acute pain, chronic pain has a much more complex and poorly understood purpose.

a.

Recurrent Acute Pain characterized by relatively well-defined episodes of pain interspersed with pain-free episodes. Ex. Migraine headache.
Ongoing Time-Limited Pain is identified by a defined time period. Ex. CA pain which ends with control of the disease or death. Burn pain, which ends with rehabilitation or death. Chronic Nonmalignant Pain also known as chronic benign pain, is non-life threatening pain that nevertheless persists beyond the expected time for healing. Ex. Chronic lower back pain. Chronic Intractable Nonmalignant Pain Syndrome is similar to simple chronic nonmalignant pain but is characterized by the persons ability to cope well with pain and sometimes by physical, social, and/or psychological disability resulting from the pain.

b.

c.

d.

The client with chronic pain is often depressed, withdrawn, immobile, irritable and/or controlling. The most common chronic pain condition is lower back pain. Others include: a. Neuralgias are painful conditions that result from damage to a peripheral nerve caused by infection or disease.

b. Reflex Sympathetic Dystrophies characterized by continuous severe burning pain. These conditions follow peripheral nerve damage and present the symptom of pain, vasospasm, muscle wasting and vasomotor changes.

c.

Hyperesthesias are conditions of oversensitivity to tactile and painful stimuli. Hyperesthesias result in diffuse pain that is usually increased by fatigue and emotional lability.

d. Myofascial Pain Syndrome a common condition marked by injury to or disease of muscle and fascial tissue. Pain results from muscle spasm, stiffness and collection of lactic acid in the muscle. Ex. Fibromyalgia. e. CA often produces chronic pain usually due to factors associated with the advancing disease. These factors include a growing tumor pressing on nerves or other structures, stretching of viscera, obstruction of ducts or metastases to bones. May also be associated with chemotherapy and radiation therapy.

f.

Chronic Postoperative Pain rare but may occur following incision in the chest wall, radical mastectomy, radical neck dissection and surgical amputation

CENTRAL PAIN
is related to a lesion in the brain that may spontaneously produce high frequency bursts of impulses that are perceived as pain. Thalamic pain is the most common type. It is severe, spontaneous and often continuous. It may be caused by a vascular lesion, tumor, trauma or inflammation.

PHANTOM PAIN
is a confusing pain syndrome that occurs following surgical or traumatic amputation of limb.
The client experiences pain in the missing body part even though there is complete mental awareness that the limb is gone. This may include itching, tingling or pressure sensations.

PSYCHOGENIC PAIN
experienced in the absence of any diagnosed physiologic event or cause.

FACTORS AFFECTING CLIENTS RESPONSE TO PAIN

Everyone has the same pain threshold everyone perceives pain stimuli at the same stimulus intensity. What varies then in the clients perception of and reaction to pain.

Pain Tolerance
the amount of pain a person can endure before outwardly responding to it.
The ability to tolerate pain may be decreased by repeated episodes of pain, fatigue, anger, anxiety and sleep deprivation. It may be increased by medications, alcohol, hypnosis, warmth, distraction and spiritual practices.

1.

Age the older adult with normal age-related changes in neurophysiology may have decreased perception of sensory stimuli and a higher pain threshold. Sociocultural Influences persons response to pain is strongly influenced by the family, community and culture. Sociocultural influences affect the way in which a client tolerates pain, interprets the meaning of pain and reacts verbally and nonverbally. Ex. If the family of origin believes that males should not cry and must tolerate pain stoically, the male client often will appear withdrawn and will refuse pain medications.

2.

Cultural standards also teach an individual how much pain to tolerate, what types of pain to report and to whom to report the pain and what kind of treatment to seek.

3.

Emotional status the sensation of pain may be blocked by intense concentration (during sports act) or may be increased by anxiety or fear. Pain often is increased when it occurs in conjunction with other illness or physiological discomforts such as nausea and vomiting.
> Depression is clearly linked to pain: serotonin, a neurotransmitter involved in the modulation of pain in the CNS. In clinically depressed clients, serotonin is decreased leading to an increase pain sensation. > A client who perceives advantages from the sick role may be motivated to maintain pain. These advantages called secondary gain may include support from others or avoidance of disagreeable work.

4.

Past experiences with pain if the persons childhood experiences with pain were responded to appropriate by supportive adults, the adult usually will have a healthy attitude. Source and Meaning if the client perceives the pain as deserved (ex. Just punishments for sins), the client may actually feel relief that the punishment has commenced. Knowledge Deficit if the client has a clear and accurate perception of pain, it is far easier for professionals to increase the clients knowledge of both the significance of the pain and the strategies the client can use to diminish discomfort in a timely way.

5.

6.

ASSESSMENT OF PAIN

FOUR (4) ASSESSMENT AREAS

1. Client Perceptions it is the most reliable indicator of pain because it is based on the clients own statement. > Ask the client to locate the pain, to describe the quality of the pain, to indicate how the pain changes with time, and to rate the intensity of the pain.

The clients perception of pain can also be assessed by using the PQRST technique: P precipitated (triggered, stimulated), palliated (relieved), pattern Q quality and quantity. Is it sharp, stabbing, aching, burning, stinging, deep, crushing, viselike, gnawing R region (location), radiating S severity T timing

The most common method to assess the severity of pain is pain rating scale. COLDERRA C - Characteristics Dull, achy sharp, stabbing, pressure? O Onset When did it start? L Location Where does it hurts? D Duration How long does it lasts? Frequency? E Exacerbation What makes it worse? R Radiation Does it travel to another part of the body? R Relief What provides relief? A Associated s/s Nausea, anxiety, autonomic response?

Nursing Interventions for Pain Rating Scale

1. Explain the primary purpose of a pain rating scale, which is to provide consistent, prompt communication between the client and the care provider. Encourage the client to make a factual report of pain so as to avoid stoicism and exaggeration. To ensure consistent communication, explain the specific pain rating scale being used. Be sure the client can count to 10. Discuss the definition of the word pain to ensure that the client and the HCP are communicating on the same level. It is often helpful to use the clients own words when describing the pain.

2.

3.

4.

Explain to the client that the report of pain is important for promoting recovery, not just for achieving temporary comfort.

Commonly Used Pain Rating Scale

1.

Visual Analogue Scales are useful in assessing the intensity of pain. This scale includes a horizontal 10 cm line, with ends indicating the extremes of pain. The person is asked to place a mark indicating where the current pain lies on the line. To score the results, a ruler is placed along the line and the distance the person marked the line from the bottom extreme is measured and reported in cms.

2.

0 -10 Numeric Pain Intensity Scale is used for children, elderly and visually or cognitively impaired patient. The person will be asked to rate the pain from 0-10 with 0 signifying no pain and 10 signifying the worst pain.

3.

Simple Descriptive Pain Intensity Scale the patient may be asked to rate the pain on a verbal scale (e.g., none, slight, moderate, severe, or very severe). FACES Pain Rating Scale is a useful alternative particularly for children and for patients with language problems or low literacy. This tool presents a series of cartoon-like faces ranging from a happy to a crying face. The person experiencing pain is asked to point to the face that best represents how he/she feels.

4.

2.

Physiologic Responses predictable physiologic changes do occur in the presence of acute pain. These may include muscle tension, tachycardia, rapid shallow respirations, increased BP, dilated pupils, sweating, and pallor. Overtime however, the body will adapt to the pain stimulus. Thus, these physiologic changes may be extinguished in clients with chronic pain.

3.

Behavioral Responses there is a group of behaviors so typical of persons in pain that the behavior are referred to as pain behaviors. They include bracing or guarding the painful part, taking medication, crying, moaning, grimacing, withdrawing from activity and socialization, becoming immobile, talking about pain, holding the painful area, breathing with increased effort, exhibiting a sad facial expression and being restless. Behavioral responses to pain may or may not coincide with the clients report of pain and are not very reliable cues to the pain experience

4.

Clients Attempt at Pain Management this information is individualized and client specific including many factors such as culture, age, and client knowledge.
The nurse should obtain detailed descriptions of actions the client or SO took, when and how these measures were applied, and how well they worked.

POTENTIAL NURSING DIAGNOSES RELATIVE TO PAIN

1. Pain R/T inflammation and swelling of abdominal incision. 2. Pain R/T muscle spasms following fracture of the femur. 3. Chronic Pain R/T recurring migraine headache . 4. Anxiety R/T lack of knowledge about pain management in the postoperative period.

5. Powerlessness R/T inability to control chronic pain

6. Fatigue R/T inability to rest or have uninterrupted sleep secondary to severe pain.

7. Ineffective Individual Coping R/T failure of medications to control chronic pain.

8. Constipation R/T side effects of narcotic analgesics

9. Self-Care Deficit: Bathing/hygiene R/T inability to use upper extremities secondary to the pain from RA. 10. Hopelessness R/T lack of relief of CA pain. 11. Impaired Physical Mobility R/T pain from CA metastases to the spine. 12. Risk for Self-Directed Violence R/T long-term chronic pain

NURSES ROLES IN PAIN MANAGEMENT

The nurse helps relieve pain by administering pain-relieving interventions including both pharmacologic and nonpharmacologic approaches. 1. Identifying Goals for Pain Management - the information obtained from the assessment is used to identify goals for managing pain.

Factors to be considered to determine the goal:

a. Severity of the pain, as judged by the patient.

b. Anticipated harmful effects of pain. A high risk patient is at much greater risk for the harmful effects of pain than a young healthy individual. c. Anticipated duration of pain. > In patients with pain from a disease such as CA, the pain may be prolonged, possibly for the remainder of the patients life. >The goals for the patient may be accomplished by pharmacologic or nonpharmacologic means, but most success will be achieved with a combination of both.

2.

Establishing Nurse-Patient Relationship a positive N-P relationship and teaching are keys to managing analgesia in the patient with pain, because open communication and patient cooperation are essential to success.

3.

Client and Family Teaching providing information about impending pain and pain management to the client and family to lessen anxiety about the unknown and to provide the client with a means of controlling the pain. > Explain what will happen, when it will happen, what it feels like, and what to do to help oneself during the event. > Studies have demonstrated that providing this information has increased pain tolerance and reduced amount of medications needed.

What to Teach to the Client and Family?

a. specific drugs to be taken, including the frequency, potential S/E, possible drug interactions, and any special precautions to be taken (such as taking food or avoiding alcohol). how to administer the drugs (if they are administered by any route other than by mouth. The importance of taking pain medication before pain becomes severe.

b.

c.

d. An explanation that the risk of addiction to medication is very small when they are used for pain relief and management. e. f. The importance of scheduling periods of rest and sleep. The name of a person to contact if pain is not controlled.

4.

Providing Physical Care the patient in pain may be unable to participate in the usual ADLs or to perform usual self-care and may need assistance to carry out these activities. > The patient is usually more comfortable when physical and selfcare needs have been met.

5.

Managing Anxiety Related to Pain

PAIN MANAGEMENT
A. NON-PHARMACOLOGIC INTERVENTIONS

Can assist in relieving pain with usually low risk to the patient. In instances of severe pain that lasts for hours or days, combining nonpharmacologic interventions with medications may be the most effective way to relieve pain.

1.

Guided Imagery is using ones imagination in a special way to achieve a specific positive effect. It is also called creative visualization, and is uses imaginative power of the mind to create a scene or sensory experience that relaxes the muscles and moves the attention of the mind away from the pain experience.

Procedure:
> The nurse instructs the patient to close the eyes and breathe slowly in and slowly out.
> With each slowly exhaled breath, the patient imagines muscle tension and discomfort being breathed out, carrying away pain and tension and leaving behind a relaxed and comfortable body.

> With each inhaled breath, the patient imagines healing energy flowing to the area of discomfort. OR > The nurse can facilitate this technique by asking the client for some descriptions of what the client finds most relaxing. > The nurse then speaks to the client in a calm, soothing voice about those places or situations.

2.

Relaxation Techniques involve the learning of activities that deeply relax the body and mind.
> Relaxation distracts the client, lessens the effects of stress from pain, increases pain tolerance, increases the effectiveness of other pain relief measures and increases perception of pain control. a. Diaphragmatic breathing can relax muscles, improve O2 levels, and provide a feeling of release from tension. The use of diaphragmatic breathing is more effective when the client either lies down or sits comfortably, remains in a quiet environment, and keeps the eyelid closed. Inhaling and exhaling slowly and regularly is also helpful.

Procedure:
a.1. explain the procedure to the client. a.2. position the client in a high or semi-fowlers position a.3. ask the client to place the hands lightly on the abdomen a.4. instruct the client to breathe in deeply through the nose, allowing the chest and abdomen to expand. a.5. have the client hold his breath for a count of 5. a.6. tell the client to exhale completely through pursed lips, allowing the chest and abdomen to deflate. a.7. have the client repeat the exercise 5 times consecutively.

b. Progressive Muscle Relaxation (PMR) may be used alone or in conjunction with deep breathing to help manage the pain. > The client must be taught to tighten one group of muscle (such as those of the face), hold the tension for a few seconds, then relax the muscle group completely. > The client should repeat these actions for all parts of the body. > This method is also effective when the client lies or sits comfortably, is in quiet environment, and keeps the eyelids closed.

c.

Meditation is a process whereby the client empties the mind of all sensory data, and typically, concentrates on a single object, word or idea.

> This activity produces a deeply relaxed state in which O2 consumption decreases, muscles relax, and endorphins are produced.
> At its deepest level, meditation may resemble a trance.

3.

Hypnosis is a trance state in which the mind becomes extremely suggestible. > To achieve hypnosis, the client sits or lies down in a dimly lighted, quiet room. > The therapist suggests that the client relax and fix attention on an object.

> The therapist then repeats in a calm, soothing voice simple phrases, such as instructions to relax and listen to the therapists voice.

> The client gradually becomes more and more relaxed and falls into a trance in which the client is no longer aware of the physical environment and hears only the therapists voice. > During this state, the therapist may make suggestions to encourage pain relief.

4.

Transcutaneous Electrical Nerve Stimulation (TENS) a TENS unit is consists of low-voltage transmitter connected by wires to electrodes that are placed directly on the client over painful area.

> The client experiences a gentle tapping or vibrating sensation over the electrodes.
> The client can adjust the voltage to achieve maximum pain relief.

> It is believe that TENS electrodes stimulate the large diameter Abeta touch fibers to close the gate in the substantia gelatinosa.
> It is also theorized that TENS stimulates endorphin release by inhibitory neurons.

5.

Ice and Heat Therapies- it is believe that ice and heat stimulate the nonpain receptors in the same receptor field as the injury. > Neither therapy should be applied to areas with impaired circulation.

6.

Distraction involves the redirection of the clients attention away from the pain and onto something that the client finds more pleasant.
> It is thought to reduce the perception of pain by stimulating the descending control system, resulting in fewer painful stimuli being transmitted to the brain. > Distraction activities may range from simple activities such as watching TV or listening to music, to highly complex physical and mental exercises.

> Participating in an activity that promotes laughter, such as reading a joke book or viewing a comedy has been found to be highly effective in pain relief. > Laughing for 20 minutes or more is known to produce an increase in endorphins that may continue pain relief even after the client stops laughing.

7 . Cutaneous Stimulation it is believed that stimulation of the skin is effective in relieving pain because it prompts closure of the gate in the substabtia gelatinosa. a. Touch the nurse places hands on the clients body or less than 1 inch above clients body to realign energy. It may initiate gate closure. It also relays or communicates caring.

b. Pressure the nurse places head firmly on or around the area where the client feels the pain. It may relieve pain, decrease bleeding, and prevent swelling, but benefits are temporary; when pressure is lifted, pain returns.

c. Massage the nurse gently or briskly stimulates clients subcutaneous tissues by kneading, pulling, or pressing with fingers, palms or knuckles.

> Its advantages are, it may initiate gate closure, with low risk or minimal side effects, and promotes relaxation and sedation, but it is time consuming. d. Vibration the nurse uses an electrical or battery operated vibrator to stimulate the clients subcutaneous tissues.
> It may also initiate gate closure with low risk of tissue damage and less costly than TENS.

8. Acupuncture is an ancient Chinese system involving the stimulation of certain specific points on the body to enhance the flow of vital energy (chi) along pathways called meridians. > Acupuncture points can be stimulated by the insertion and withdrawing of needles, the application of heat, massage, laser, electrical stimulation or a combination of these methods.

9. Biofeedback is an electronic method of measuring physiologic responses, such as brain waves, muscle contraction, and skin temperature, and then feeding this information back to the client.

PHARMACOLOGIC PAIN RELIEF

Managing a patients pain pharmacologically is accomplished in collaboration with the physician or other primary care provider, the patient, and often the family.

Premedication Assessment
1. Ask the patient about allergies to medications and the nature of any previous allergic responses. True allergic or anaphylactic responses to opioids are rare but are not uncommon. The nurse must obtain the patients medication history (current, usual, or recent use of prescribed or OTC medications), along with a history of health problem. Before administering analgesic agents, the nurse should assess the patients status, including the intensity of current pain, changes in pain intensity after the previous dose of medication and side effects of the medications.

2.

3.

Terms Associated With Pain Medications

1. Addiction the compulsive use of a substance despite negative consequences, such as health threats or legal problems. Drug Abuse the use of any chemical substance for other than a medical purpose. Physical Drug Dependence - a biologic need for a substance. If the substance is not supplied, physical withdrawal symptoms occur. Drug Tolerance the process by which the body requires a progressively greater amount of a drug to achieve the same results. Pseudoaddicton behavior involving drug-seeking, a result of receiving inadequate pain relief.

2.
3. 4.

5.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)

act on peripheral nerve endings and minimize pain by interfering with prostaglandin synthesis. It is the treatment of choice for mild pain and continue to be effective when combined with narcotics for moderate to severe pain. They have anti-inflammatory, analgesic, and antipyretic effects.

It is believed that they inhibit the enzyme cyclooxegenase, thereby decreasing synthesis of prostaglandins.

These drugs provide analgesic effects by reducing inflammation and by perhaps blocking the generation of noxious impulses.

Examples
a. b. c. d. e. f. g. h. i. j. aspirin (ASA) b. fenoprofen calcium (Nalfon) c. ibuprofen (Motrin) d. naproxen sodium (Anaprox) e. piroxicam (Feldene) f. ketorolac tramethamine (Toradol) g.naproxen (Naprosyn) h. indomethacin (Indocin) i. ketoprofen (Orudis) j. sulindac (Clinoril)

Nursing Responsibilities
1. Do not administer aspirin with other NSAIDs. 2. Assess and document if the client is taking a hypoglycemic agents or insulin; the NSAIDs may increase the hypoglycemic effect. 3. Administer with meals, milk or a full glass of water to decrease gastric irritation. 4. Assess clients who are taking anticoagulants for bleeding; the NSAIDs increase this risk.

Client and Family Teaching

1. Drugs may cause GI bleeding (report N/V of blood, dark stools), visual disturbances (report blurred or diminished vision), hearing problems (report weight gain or edema) 2. Take medications with meals to decrease GI irritation. 3. Avoid drinking alcohol or taking any OTC drugs unless approved by the HCP. 4. The desired effects may not appear for 3-5 days and the full effects may not appear for 2-4 weeks. 5.Maintain regular health care appointment.

NARCOTICS
are derivatives of the opium plant. These drugs are the pharmacologic treatment of choice for moderate to sever pain. These drugs produce analgesic effect by binding to opioid receptors both within and outside the CNS. These drugs decrease the awareness of the sensation of pain by binding to opiate receptors in the brain and spinal cord. It is also believed that they diminish the transmission of pain impulses by altering cell membrane permeability to sodium and by affecting the release of neurotransmitters for efferent nerves sensitive to noxious stimuli

Examples:
a. buprenorphine Hcl (Buprenex) b. codeine g. nalbuphine Hcl (Nubain) c. hydromorphone Hcl (Dilaudid) d. meperidine HCl (Demerol) e. propoxyphene HCl (Darvon) f. morphine sulfate j. prophoxyphene napsylate (Darvocet N) h.oxymorphoneHCl (Numorphan) i. pentazocine (Talwin)

Side Effects
1. depresses respiration 2. stimulates the vomiting center 3. depresses the cough reflex 4. induces peripheral vasodilation resulting in hypotension 5. constricts the pupil 6. decreases intestinal peristalsis 7.addictive, causing psychologic and physical dependence

Nursing Responsibilities
Narcotics are regulated, the nurse must record the date, time, clients name, type and amount of the drug used, and sign the entry in a narcotic inventory sheet. If the drug must be wasted after it is signed-out, the act must be witnessed and the narcotic sheet signed by the nurse and the witness. Keep a narcotic antagonist, such as naloxone, immediately available to treat respiratory depression Assess allergies or adverse effects from narcotics previously experienced by the client.

Assess for any respiratory disease such as asthma that might increase the risk of respiratory depression. Assess the characteristics of the pain and the effectiveness of drugs have been previously used to treat the pain. Take and record baseline vital signs before administering the drug. Administer the drug following established guidelines. Monitor VS, LOC, pupillary response, nausea, bowel function, urinary function, and effectiveness of pain management. Provide for client safety.

Client and family Teaching:

The use of narcotics to treat severe pain is unlikely to cause addiction. Do not drink alcohol Do not take OTC drugs unless approved by HCP. Increase intake of fluids and fibers in diet to prevent constipation The drugs often cause dizziness, drowsiness and impaired thinking; use caution when driving or making decisions. Report decreasing effectiveness or the appearance of SE to the physician.

ANTIDEPRESSANTS
antidepressants within the tricyclic and related groups act on the production and retention of serotonin in the CNS, thus inhibiting pain sensation. They also promote normal sleeping patterns, further alleviating the suffering of the client in pain. Examples: amitriptyline (Elavil) imipramine (Tofranil)

LOCAL ANESTHETICS
block the initiation and transmission of nerve impulses in a local area, thus blocking pain as well. a. Topical Application EMLA cream (eutectic mixture or emulsion of local anesthetics) has been effective for preventing pain associated with invasive procedures such as lumbar puncture or the insertion of IV lines. To be effective, it must be applied 60-90 minutes before the procedure. a. Intraspinal Administration a local anesthetic administered through an epidural catheter is applied directly to the nerve root

SURGICAL DESTRUCTION OF PAINFUL STIMULI

1.

Cordiotomy is an incision into the anterolateral tracts of the spinal cord to interrupt the transmissionof pain.

> Because it is difficult to isolate the nerves responsible for upper body pain, this surgery is most often performed for pain in the abdominal region and legs, including severe pain from terminal CA. > A percutaneous cordiotomy produces lesions of the anterolateral surface of the spinal cord by means of a radiofrequency current.

2. Neurectomy is the removal of a nerve. It is sometimes used for pain relief. > A peripheral neurectomy is the severing of a nerve at any point distal to the spinal cord.

3. Sympathectomy involves destruction by injection or incision of the ganglia of sympathetic nerve, usually in the lumbar region or the cervicodorsal region at the base of the neck.

4.

Rhizotomy is surgical severing of the dorsal spinal roots. > It is most often performed to relieve the pain of CA of the head, neck or lungs. > A rhizotomy may be performed not only by injecting a chemical such as alcohol or phenol into the subarachnoid space or by using a radio frequency current to selectively destroy pain fibers.

EVALUATING PAIN MANAGEMENT STRATEGIES

An important aspect of caring for the patient in pain is reassessing the pain after the intervention has been implemented. If the interventions were ineffective, the nurse needs to consider other measures.

Expected Outcomes:
1. Achieves pain relief
a. rates pain at a lower intensity (on a scale of 0-10) after intervention.

b. Rates pain at a lower intensity for longer periods.

2. Patient or family administers prescribed analgesic medications correctly.

a. states correct dose of medication

b. administers correct dose using correct procedure c. identify side effects of medication d. describe actions taken to prevent or correct side effects

3. Uses pharmacologic pain strategies as recommended a. reports practice of non-pharmacologic strategies b. describes expected outcomes on non-pharmacologic strategies

4. Reports minimal effects of pain and minimal side effects of interventions a. participates in activities important to recovery (e.g., drinking fluid, coughing and ambulating)

b. participates in activities important to self and to family.

5. Reports adequate sleep and absence of fatigue and constipation.