Pain Management (2 Nursing CEs)

Course Objectives:

Upon completion of this course the student will be able to:

• Differentiate between acute and chronic pain
• Discuss the emotional aspects of chronic pain
• Describe the components of a complete nursing pain assessment
• Detail 2 different types of pain scale assessment tools
• List 2 Medical Management options for effective pain control
• List 2 Nursing Management options for effective pain control
• Explain when it is appropriate to use a weak vs. strong opioid
• List 3 advantages for using an opioid delivery device (PCA)
• State 3 nursing responsibilities for patient who have an Epidural Catheter

Some Painful Statistics:

• Pain is one of the most common reasons that people seek medical attention
• 9 out of 10 Americans over the age of 18 suffer from pain at least once a month
• 42% of those experience pain everyday
• Approximately 40 million Americans suffer with chronic headaches, which cost the healthcare industry 4 billion dollars a year in medication
• Approximately 5 million Americans are disabled and take pain medication daily for chronic back problems 

Though the range of analgesia varies these days from lollipops to patches and the delivery devices vary from patient controlled analgesic (PCA) to implantable devices; managing a patient with pain still seems be a complicated matter. Now more than ever, it's imperative for healthcare organizations to revisit these painful issues to ensure a safe, effective, and realistic approach for caring for the patient experiencing pain.

Acute Pain - is severe and lasts a relatively short time. It is usually a signal that body tissue is being injured and the pain generally disappears when the injury heals.

Chronic or persistent pain - may range from mild to severe, and is present to some degree for long periods of time. Some people with chronic pain that is controlled by medicine can have breakthrough pain which is moderate to severe pain that "breaks through" the regular pain medicine given for chronic pain. It is felt for a short time. Breakthrough pain may occur several times a day, even though the proper dose of pain medicine is given for the chronic or persistent pain.

Nursing Assessment:

The assessment and management of pain needs to be based on understanding the pathophysiologic, emotional and spiritual components as well as having knowledge of the disease process. Because pain is very subjective, it is crucial upon admission to understand that each patient experiences pain differently and therefore treatment plans must be individualized. It is not as simple as coming up with a simple standard or protocol that can be repeated successfully patient after patient. The following are key points that should be included in a pain assessment upon admission:

A complete history (usually subjective data) that includes “OLDCART”:

O – Onset (what causes pain)

L – Location (where)

D – Duration (how long is lasts)

C – Characteristics (dull, sharp, stabbing)

A – Aggravating Factors (what increases pain)

R – Relieving Factors (what decreases pain)

T – Treatment (meds, rest/exercise, hot/cold)

A second systematic approach to gathering pain history data includes “PQRST”:

P – Pattern (location, when, how)

Q – Quality (dull, sharp, stabbing)

R – Reaction (what increases/decreases pain)

S – Severity (ranking scale)

T – Treatment (meds, rest, heat/cold)

Pain Scales:

Pain assessment tools help patients describe their pain. The pain scale is one tool commonly used to describe the intensity of the pain or how much pain the patient is feeling. Pain scales are quantitative measuring systems and include:

The Numerical Rating Scale, the person is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable).

The Visual Analog Scale is a straight line with the left end of the line representing no pain and the right end of the line representing the worst pain. Patients are asked to mark on the line where they think their pain is.

The Categorical Pain Scale has four categories: none, mild, moderate, and severe. Patients are asked to select the category that best describes their pain.

The Pain Faces Scale uses six faces with different expressions on each face. Each face is a person who feels happy because he or she has no pain or feels sad because he or she has some or a lot of pain. The person is asked to choose the face that best describes how he or she is feeling. This rating scale can be used by people age 3 years and older.

Numerical Scale

Visual Analog Scale

Categorical Scale

Pain Faces Scale

FLACC Pain Scale

The FLACC Pain Scale can be used with infant and pediatric patients age 0-3 years, cognitively impaired patients, and those patients unable to use other scales. The words above that are bolded apply to all patients EXCEPT infant and pediatric patients.

FLACC – Assess the patient in each area – total the score – evaluate the total using the 0-10 pain scale parameters.

In addition to “physical pain” a complete pain assessment will also include the following (most often seen with chronic pain):

Emotional Pain – Hearing patients complain about being incapacitated, not spending enough time with their children/family or feeling useless are all signs of emotional pain. By not appearing to be hurried, taking time to listen or just sitting down and talking for a few minutes can have a powerful impact on emotional pain.

Spiritual Pain – Hearing patients state concerns about the “meaning of life” or show signs of the grieving process (denial, anger, bargaining, depression, acceptance) are good indicators that they are suffering on a spiritual level (spiritual pain does not have to be a religious experience). As mentioned above, not appearing to be hurried, taking time to listen or just sitting down and talking for a few minutes can have a powerful impact on spiritual pain. Offering to contact the patient’s Chaplin may also be of help.

Social Pain – Signs of distancing or withdrawing from family and friends, concern regarding role changes or signs of isolation are all strong signals that your patient is suffering social pain. The best way to counter social pain is to help family and friends understand that these feelings are not a personal attack on them, and that they can help reduce this pain by making small gestures such as being present, holding the patients hand, bringing in their favorite things (pillow, blanket, music).

Financial Pain - Financial pain may occur when patients feel that financial resources are insufficient to absorb the costs of their healthcare or to care or provide for their families. The nurse can be the most helpful in assisting to decrease financial pain by helping the patient work with social workers and case managers to understand complex insurance issues, disability benefits and community resources.

Medical Management of the patient experiencing either acute or chronic pain includes:

• Medication (NSAIDS, Opioids)
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Heat/Cold
• Exercise/Massage/Physical Therapy
• Acupuncture
• Surgery (Neurectomy, Sympathectomy)

Nursing Management of the patient experiencing either acute or chronic pain includes:

• Administer ordered medication and evaluate response
• Provide appropriate positioning for alignment and comfort
• Educate regarding diaphragmatic breathing and splinting
• Monitor/Manipulate environment
• Encourage progressive relaxation or imagery
• Keep communication simple (severe causes patients in pain may lose their sense of humor and be distracted) 

Note: A large barriers to pain control includes reluctance on the part of the patient to report pain for fear of bothering people or becoming drug addicted, clarify any misconceptions that you may suspect.

Commonly used Opioids include:

• Codeine
• Demerol
• Fentanyl
• Hydrocodone
• Hydromorphone
• Levorphanol
• Morphine Sulfate
• Methadone
• Oxymorphone
• Oxycodon 

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