• Pain is a physical and emotional experience, not all in the body or all in the mind
• It is a response to actual or potential tissue damage
• Severe or persistant pain affects all body systems, causing potentially seious health problems while increasing the risk of coplications, delays in healing, and an accelerated progression of fatal illnesses
• Severe pain is viewed as anemergency situation deserving attention and prompt professional treatment

• Persisteant pain contributes to insomnia, weight gain, constipation, hypertension, deconditioning, hronic tress, depression, and immobility
• These effects interfere with work, rcreation, domestic activities, and personal care activities to the point that leads many sufferers to question if life is worth living
• Even if the original cause of the pain heals, the changes in ther nervous sytem resulting from suboptimal pain management can result in the development of incurable chronic pain

• The physiologic process by which information aout tissue damage is communicated to the Central Nervous System
• Involves four processes:
  -Transduction
  -Transmission
  -Perception
  -Modulation

• Nociceptors are receptors throughout the body that become activated by noxious stimuli (mechanical, chemical [external or internal], or thermal)
• Tissue injury triggers the release of biochemical mediators such as Bradykinin, Histamine, and Postaglandin...
• ...causing and inflammatory response
• Anti-inflammatories and Local Anesthetics inhibit transduction (Lidocaine, Ibuprofen, Cold)

• From site of transduction to the spinal cord and on to the brain
• A-delta fibers - fast and large (sharp localized pain/pleasurable skin receptors)
• C fibers - smaller, slow (dull, diffuse, achy)

• The pain is recognized, defined, and responded to by the individual experiencing the pain
• Pain Threshold - the number and intensity of stimuli necessary to produce pain (repeated experiences to pain can lower threshold)
• Pain Tolerance - duration or intensity of pain that a person is willing to tolerate (situational)

• Modulation changes the perception of pain by either facilitating or inhibiting the pain signal
• Endogenous (endorphins)/Exogenous (medications) Opioids block the transmission or reception of pain signals
• Gate Control Theory - stimulate A-delta fibers to block C fibers (TENS)
• Selective Seratonin Reuptate Inhibitors (SSRIs)
• Analgesia (lack of pain) vs. Anesthesia (lack of feeling)

• Cutaneous or Superficial Pain
• Visceral Pain (organs)
• Deep Somatic Pain (ligaments, tendons, bones)
• Radiating Pain (starts at one site and spreads out)
• Referred Pain (tissue damage is at one spot but pain is felt in a different spot)
• Phantom Pain (pain perceived in an area surgically removed)
• Psychogenic Pain (believed to arise from the mind)

• Nociceptive - arises from damage to the tissues
• Neuropathic - abnormal or damaged nerves

Acute: short in duration, rapid in onset, will get better as tissues heal, more easily treated

Chronic: lasts 6 months or more, may be related to progressive disorder, periods of remission and exacerbation, may be difficult to relieve

Intractable: chronic and highly resistant to relief

How patients describe pain:

• sharp or dull, aching, throbbing, stabbing, burning, ripping, searing, or tingling.
• Periodicity (how often): episodic, intermittent, or constant.
• Intensity: mild, distracting, moderate, severe, or intolerable.

• Surgery, Trauma, Childbirth, Infection, Angina (chest pain)
• Functions as signal, warning the person of potential or actual tissue damage
• Diminishes over time as healing occurs
• Treatment includes analgesia for symptom control and treatment of the underlying cause

• Does not appear to have an adaptive role
• Progressive disease or neuropathic pain
• Viewed as meaningless and may lead to depression, anger, anxiety, frustration, and dependance
• Definitions vary as to duration

• Emotions (fear, anxiety, anger, depression)
• Social Support
• Environment
• Past Pain Experience
• Meaning of Pain
• Mental Status

• Prevalence of chronic pain in elderly ranges from 45% to 80%
• May falsely believe that pain and suffering come with age
• May have multiple conditions presenting with vague symptoms
• May withhold complaints because of fear of the treatment, of a lifestyle change, or of becoming dependent

• Fear of being a burden or "bad patient" if they express pain or that nothing can be done about the pain
• High prevalence of cognitive, sensory-perceptual, and motor problems that interfere with a person's ability to process info and communicate
• More likely to use words "aching," "soreness," or "discomfort"
• Treatment complicated by increased sensitivity and polypharmacy

• Asian and Pacific Islander patients are often reluctant to express their pain because they believe that the pain is God's will or punishment for past sins
• Native Americans use massage, heat/cols and herbal remedies for pain relief
• In Arab cultures, patients are expected to openly express their pain and anticipate immediate relief, preferably through injections or IV
• Non-Hispanic white adults reported pain more often than adults of other races

• Pain is more than a symptom of a problem, it is a high-priority problem in itself
• Effective pain management is an important aspect of nursing care to promote healing, prevent complications, reduce suffering and prevent the development of incurable pain states
• Non-verbal patients can have pain that demands a nursing assessment

• Acute pain leads to sympathetic response (General Adaptation Syndrome) ^HR, ^BP, ^RR, peripheral constriction
• Deep or Prolonged Pain: parasympathetic response - decreased BP, HR, withdrawal, constricted pupils, slow and monotonous speech, shallow breathing

• Facial expressions: often the first indication of pain; clenched teeth, tightly shut eyes, open somber eyes, biting of lower lip
• Vocalizations: moaning, groaning, crying, screaming
• Body Positions: immobilization of body part, assuming the fetal position, restlessness, guarding, splinting or rubbing area
• Behavioral: confusion, hostility, aggression, fear, decreased attention span
• Chronic Pain usually manifests as depression, withdrawal, exhaustion, hopelessness

• On admission
• At rest and during activity
• When patient complains of pain
• Before implementing pain management and 30 to 45 minutes later
• Before and after each potentially painful treament or procedure
• As 5th Vital Sign

• Location
• Quality
• Intensity, Strength, and Severity
• Timing: Onset, Duration, Frequency
• Aggravating/Relieving Factors

• Associated symptoms such as anxiety, fatigue and depression
• Effect on ADLs
• Meaning of Pain
• Past pain experiences
• Treatments that have been effective
• Pain relief goals
• Coping resources
• Assess for knowledge deficits, fear of addiction

• Ineffective Breathing Pattern
• Hopelessness
• Anxiety
• Ineffective Coping
• Impaired Physical Mobility
• Self-Care Deficit
• Distrubed Sleep Pattern

• Risk for Injury r/t ecreased sensorium or level of consciousness (LOC), over dosage, side effects secondary to opioid use
• Impaired gas exchange r/t respiratory depression secondary to increasing doses of IV Dilaudid
• Constipation r/t use of post-operative pain medication (Percoset)

• Follow the principles of pain assessment
• Base the treatment plan on the patient's goals
• Use both drug and non-drug therapies
• Address pain using a multi-disciplinary approach
• Prevent and/or manage side effects
• Offer pain therapies before procedures and/or ambulation
• Incorporate patient and family teaching throughout assessment and treatment

• Non-pharmacological Methods
• Anesthetics/Analgesics
• Nonopioid analgesics
  -Mild to Moderate Nociceptive Pain
• Opioid Analgesics
  -Moderate to Severe Pain
• Adjuvant Analgesics
  -Enhance the effects of opiates and alleviate symptoms that aggravate pain; also alleviates neuropathic pain

• Cutaneous Stimulation
• Massage, Back Rub
• Empathy
• Therapeutic Touch
• Alternative Disciplines
• Immobilization & Splinting
• Distratction, Progressive Relaxation, Imagery, Deep Breathing
• Heat/Cold
• R.I.C.E. (rest, ice, compression, elevation)
• Herbs
• Aromatherapy
• Surgery, TENS

• Tylenol (aetaminophen): analgesia and antipyretic effects, toxic to liver in large doses
• NSAIDs (Non-Steroidal Anti-Inflammatories): broad class of drugs with varying efficacy
  -Interfere with production of prostaglandin (works on transduction phase of pain)

• aspirin (acetylsalicylic acid or ASA): effective for mild pain, but limited use due to side effects, including gastric upset, platelet dysfunction, bleeding, tinnitis, decreased hearing acuity
• ibuprofen (Motrin, Advil): side effects can be serious and include renal failure, cardiovascular thrombotic events, and GI bleed (take w/food)
• Cox II inhibitors (Celebrex)
• naproxen (Aleve)
• ketorolac (Toradol)

• Bind with opiates receptor sites in CNS to block the pain response (modulate pain perception)
• Mu, Kappa, Delta, Sigma
• Most opioids are Mu Agonists: morphine, oxycodone, oxycontin, hydrocodone, codeine, methadone, hydromorphone (Dilaudid), fentanyl, Demerol (meperidine)
• Opioids are commonly prescribed with a non-opioid analgesic: Tylenol #3 (codeine/acetaminophen), Vicodin (hydrocodone/acetaminophen), Percoset (oxycodone/acetaminophen), Percodan (oxycodone/aspirin)

• Oral (tab, liquid, lollipop)
• Nasal
• Transdermal
• Rectal
• Subcutaneous
• Intramuscular
• Intravenous
• Intravenous - Patient Controlled Analgesia (PCA)
• Intra-articular
• Intraspinal and Epidural

• Most common include: constipation, pruritis (itching), orthostatic hypotension, urinary retention, nausea/vomiting, seation, and respiratory depression
• Diminishes with continued use except constipation
  -fluids, dietary roughage and exercise may not be sufficient. Bowel regimen and laxatives or stool softeners are probably necessary
• Many side effects are treated with other medications

• Excessive sedation will precede respiratory depression
• Patients at risk for respiratory depression include those who are opioid naive, elderly, have underlying lung disease, or are receiving other CNS depressants
• Always assess the patient for level of alertness and respiratory status before and after administering opioid
• Reduce dose or administer and opioid antagonist such as Naloxone (Narcan)

• Stimulate soe opioid receptors and block others
• Mixed agonist/antagonists bind as as agonists on the kappa receptor and as weak antagonists on the mu receptor to produce less respiratory depression than drugs that act at only mu receptors
• Examples: Stadol, Nubain
• Causes more dysphoria and agitation
• Can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs

• Developed originally for other purposes and found later to be effective for pain. Used in conjunction with other pain therapies
• Antidepressants (Celexa)
• Antianxieties (Xanax)
• Antiseizures (Lyrica)
• Corticosteroids (prednisone)

• Most people don't have pain from that particular illness
• There is no obvious physical cause for the pain
• There are no physical or behavioral signs of pain
• The patient is drug seeking
• Too much of an opiate will cause respiratory depression
• Pain is a normal component of aging

• Fear of addiction
• Fear of tolerance
• Concern about side effects
• Fear of injections
• Desire to be a "good patient"
• Forgetting to take the analgesic
• Fear of distracting caregiver from treating disease
• Concern the pain signifies disease progression
• Sense of fatalism
• Ineffective medication

• Cause of pain, if known
• Duration/healing process
• Use of pain scale
• Dosing, interval, route of pain options (ATC [around the clock] or PRN)
• Side effects
• Balance of pain relief and mobility
• Take before pain is severe (take when pain is about a 4)

• Assessment of pain including subjective and objective findings
• Intervention (MAR and non pharmacologic)
• Evaluation of all treatment modalities (including effectiveness, side effects, and intervention if not effective)