Mount Auburn Hospital
“The Nurses Role in
Improving Pain Management”
Julie O’Donnell, RN, BSN, BC
Objective: Distinguish the difference
between nociceptive pain and
neuropathic pain
A.) Acute VS Chronic pain
B.) Characteristics of nociceptive pain
C.) Characteristics of neuropathic pain
D.) Assessment findings
E.) Pharmacologic interventions and non-pharmacologic
interventions
Nurses know that…
"Pain is what the
person says it is
and exists
whenever he or
she says it does."
(McCaffery, 1968)
The definition of pain:
Pain is "an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, as
described in terms of such damage". (The
International Association for the Study of
Pain)
Pain Experiences are…
-unique to each
patient
-complex in nature
-influenced by
physical factors
-influenced by
psychological
factors
Pain is the #1 reason patient’s visit
their doctor…
Pain is a public health problem that
costs all of us.
Pain Transmission: Nociception
The correct sequence of events in
order…
TRANSMISSION
TRANSDUCTION
PERCEPTION
MODULATION
Pain: A Multimodal Issue
Physiological/Psychological Stressors Manifested
in the Presence of Pain
Cardiovascular
Escalated blood pressure,
rapid heart rate, increased
cardiac output, peripheral,
systemic, and coronary
vascular resistance,
myocardial oxygen
expenditure, coagulation,
deep vein thrombosis
Cognitive
Diminished cognitive
performance, confusion,
distorted disposition, high
somatization, and anxiety
Endocrine
Increased antidiuretic
hormone, epinephrine,
norepinephrine,
aldosterone, glucagons,
with decreased insulin and
testosterone
Physiological/Psychological Stressors Manifested
in the Presence of Pain
Gastrointestinal
Genitourinary
Quality of Life
Metabolic
Pulmonary
Reduced gastric and
intestinal motility
Urinary retention, fluid
burden, depression of
immune responses
Anxiety, depression
Hyperglycemia, glucose
intolerance, insulin
resistance, protein
catabolism
Suppressed volume and
flow, along sputum
retention resulting in
infection and atelectasis
Multidimensional Model of Pain
Pain
Behavior
Suffering
Nociception
Pain is
multidimensional
and complex. This
is why single
treatments are
rarely effective.
Acute vs Chronic Pain
Acute:
-usually thought to
resolve within a month
(short duration)
-pain that comes on
quickly, can be severe
but lasts a short time.
-the cause is known
-treatment typically
with analgesics
Chronic:
-usually thought to last
longer than six months
(long duration)
-“Pain that extends
beyond the expected
period of healing”
-the cause may be
known or idiopathic
-treatment needs to be
multidisciplinary
Characteristics of Nociceptive
pain
Nociceptive pain is causes by
stimulation of the peripheral
nerve fibers.
Nociceptive Pain:
Somatic and Visceral
-Somatic pain results
from irritation or
damage to the
musculoskeletal
system
-Somatic pain may
feel like a throbbing
pain
Examples: a cut to the
finger, a stretching of
a muscle
Visceral pain results
from the internal
organs
-Visceral pain is
diffuse, poorly
localized, and often
referred. It is often
described as
generalized aching or
squeezing.
Examples: organ pain
Characteristics of neuropathic pain
Neuropathic pain is a complex,
chronic pain state that usually is
accompanied by tissue injury.
With neuropathic pain, the nerve
fibers themselves may be damaged,
dysfunctional or injured.
What symptoms would my patient
show if they were having
neuropathic pain?
Symptoms may include:
Shooting and burning pain
Tingling and numbness
What causes neuropathic pain?
***Often time the cause is unknown
Facial nerve problems
HIV/AIDS
MS
Shingles
Lower back pain
Arthritis pain
Fibromyalgia
Migraine
Sickle cell disease
Malignant pain
Neuropathic pain (trigeminal neuralgia, diabetic neuropathy,
phantom limb pain, post herpetic neuralgia)
Referred pain:
Pain that
presents in an
area other than
its point of origin
Consequences of untreated pain:
-impaired sleep
-depression
-anxiety
-in older adults delirium and confusion
-decreased socialization/loss of
relationships
-nutritional deficits
-decline in ADL’s
DECREASED QUALITY OF LIFE
Principles of Assessment
Accept self report
Use the same pain scale over time
Assess when pain is both reported or
suspected
Re-assess routinely
Consider the individual, the patient’s
culture, values and beliefs
In summary…
Nociceptive pain is
greatly relieved
when healing is
complete, while
neuropathic pain
persists after
healing is
complete.
What happens if the pain is not
relieved?
Consequence of
unrelieved pain is
future pain.
Failure to
unrelieved pain
may lead to future
chronic pain
syndromes
Treatments for Chronic Pain:
Effective treatments for
neuropathic/chronic pain:
Currently there is no proven
treatment to prevent or cure
neuropathic pain (neuropathy or
never pain).
The primary goals of treatment are
to reduce the pain as much as
possible, balance the negative
side effects of the treatment, and
help patients manage any
unresolved pain.
Interdisciplinary approach
Pain clinics
Pop Quiz
Q: The least reliable tool for
assessing pain in a cognitively intact
adult is:
a.) Changes in Vital signs
b.) Observations of patients behavior
c.) Assuming pain present with painful
procedures
d.) Patient’s self report
Non-pharmacologic interventions:
-accupuncture
-biofeedback
-distraction
-deep breathing
-massage
-guided imagery
-hot and cold
-laughter
-music
Objective: Discuss the myths and
misconceptions about pain
A.) providers
misconceptions
about pain
B.) patients
misconceptions
about pain
C.) pseudoaddiction
vs addiction
D.) tolerance vs
physical
dependence
E.) patient advocacy
Pain Questionnaire Handout
True or False?
Answers:
1.) F: Pain can increase myocardial
demands
2.) F: It’s the patient
3.) F: Must manage tolerance
4.) True
5.) F: Indicates poor pain control
6.) F: Dose is not holding them for time
frame ordered
Pain Questionnaire Handout
True or False?
7.) F: Balanced analgesia
8.) F: Antacids blocks NSAID
absorption
9.) F: no high when pain
10.) F: the antidepressants are used
to treat certain types of pain and
relieving depression is not the intent
directly
Providers: Myths and
Misconceptions about pain
-Pain perception decreases with age
-If the vital signs are good the patient
isn’t in pain
-If the patient is asleep they are free
of pain
Patients: Myths and Misconceptions
about pain
-”Good” patients don’t report pain
- Pain is punishment
-Addiction is common
-Strong pain medicine should be saved for
later
-The health care provider will know if I am
in pain
-No pain, no gain
-Pain is normal part of aging
Myths about pain:
Doctors and nurses are the experts about pain.
THE REALITY: The older adult is the expert. Pain
is a complex, subjective experience that is best
described by the person who feels it. When the
older adult cannot report pain because of cognitive
impairment or stroke, the people who know the
individual best should be consulted. These people
usually include family members and nursing
assistants.
Myths about pain:
It’s important to be stoic about pain.
THE REALITY: Stoicism can prevent health care
providers from identifying and treating pain.
Reference:
http://www.geriatricpain.org/Content/Management/
Pages/default.aspx
Pseudoaddiction vs Addiction
According to the U.S.
National Institute of Health,
National Cancer Institute
(2004), “The term
pseudoaddiction was
coined to depict the
distress and drug-seeking
that can occur in the
context of unrelieved pain.
Pseudoaddiction vs Addiction
The American Society
for Addiction Medicine
defines addiction as
physical and/or
psychological
dependence on
substances. Addiction
is defined as the
continued use of a
addictive substance or
behaviors despite
adverse
consequences.
Pseudoaddiction vs Addiction
A person who is addicted to drugs
also develops psychological
dependence on the drug not just a
physical dependence.
Pseudoaddiction vs Addiction
Addiction can also be viewed as a
continued involvement with a
substance or activity despite the
negative consequences associated
with it.
Tolerance vs Physical dependence
Physical
dependence occurs
when a person's body
becomes accustomed
to and dependent on
the presence of a
particular drug. When
the dose is lowered or
the drug is stopped,
the person will begin
to notice withdrawal
symptoms.
Tolerance
Normal biologic
adaptation
May develop at
different rates
Exposure to drug
the effect of the
drug over time
NOT ADDICTION
What will my patient exhibit if they
are showing signs of withdrawing?
Some withdrawal
symptoms feel like a
flu bug.
Physical dependence
A person can be physically dependent
on a drug but not addicted to it.
When a medication is stopped it is
expected that our patients can show
signs of withdrawal.
At Risk: People with addiction
disorders
Requests for pain meds are often
perceived as addiction
We cannot withhold meds due to past
addictive disorders
Relapse may be a consequence of
undermedicating true pain
Person may “self medicate” their pain
Guidelines for treating patients
with addiction disorder:
Define and treat
pain syndrome
Identify history of
substance abuse
Establish
parameters/make
contracts
Discuss
consequences of
noncompliance
Use adjuvant
medications
Use non-opiod
treatments
Use controlled
release opiod
agonists
Close watch on
behaviors and
compliance with
plan
Patient Advocacy
When drug users become tolerant to
a drug's effects, they must increase
the dose to feel the same effects of
the original dose.
This is why it is important to teach our
patients about slowly cutting down
their pain medications when
appropriate.
Objective: Identify the cultural
barriers to providing acceptable
pain management to patients.
A.) Patient populations at risk for
undertreatment of pain
B.) How to perform a cultural pain
assessment?
C.) Knowledge of Self/Identify our
own biases about pain
D.) Evidence Based Practice
Which patient populations are at
risk for undertreatment of pain?
Minorities are three
times as likely to be
under treated.
Patients receiving a
poor pain assessment
from an inexperienced
health care provider.
People with noncancer pain.
Which patient populations are at
risk for undertreatment of pain?
People with "Good" performance
status, such as someone who
appears to be coping well and
performing activities adequately.
People over the age of 70.
HOW CULTURE AFFECTS THE
PAIN EXPERIENCE
People from cultures that value
stoicism tend to avoid vocalizing with
moans or screams when they are in
pain.
Other cultural groups tend to be more
expressive about pain. They learned
from childhood that when one is in
pain, the appropriate response is to
moan or cry.
Cultural Assessment Pop Quiz
During your initial assessment of Mr. T’s
pain he tells you that he is in terrible pain
but just wants to endure it. The best
response to this statement would be:
A.) Tell him not to endure the pain
B.) Further explore what he means by his
statement
C.) Provide information about the harmful
effects of unrelieved pain.
D.) Offer him analgesic medication
CULTURAL PROBLEMS
COMPLICATING PAIN
MANAGEMENT
Language and interpretation problems
Nonverbal communication problems
Culturally or linguistically inappropriate
pain assessment tools
Underreporting
Reluctance to use pain medications
Providers' fears of drug abuse.
CULTURAL PROBLEMS
COMPLICATING PAIN
MANAGEMENT
Prejudice and discrimination.
HOW CULTURE AFFECTS THE
PAIN EXPERIENCE
“People from different cultures
conceptualize and describe pain
using different cognitive frameworks.
Being asked to characterize pain
using an unfamiliar descriptive
context may result in inadequate pain
control.”
Reference: (Green CR, et al,2003)
HOW CULTURE AFFECTS THE
PAIN EXPERIENCE
Culture also influences beliefs about
what pain treatments are appropriate.
In the Western biomedical culture,
medications are the first line of
defense, whereas Eastern cultures
tend to prefer medicinal herbs, touch,
and energy therapies such as
acupuncture and yoga.
Examining our own biases…
The tendency to feel that one's own
cultural norms are correct and to
evaluate others' beliefs in light of
them is known as ethnocentrism.
Most of us tend to believe that
attitudes and behaviors that match
our own are correct and those that
don't are abnormal, wrong, or inferior.
HOW CULTURE AFFECTS PAIN
ASSESSMENT AND
MANAGEMENT
As Nurses we need to first examine
our own cultural beliefs about pain.
As Nurses we need to remember that
patients' diverse cultural patterns
usually aren't right or wrong or normal
or abnormal, just different that ours.
Activities that enhance pain
management
Show respect for other cultures
Promote a feeling of acceptance
Avoid stereotyping
Understand individuals goals and
expectations
Use appropriate assessment tools
Call an interpreter if we need to or
use the interpreter phone
Evidence Based Practice
The information obtained from a
culturally sensitive assessment will
allow nurses to develop a pain
management plan that meets the
professional standard of care and is
culturally acceptable to the patient. To
do this, nurses can group what
they've discovered about how the
patient's culture influences her or his
pain and improve pain management.
In Summary:
All patients have a right to effective
pain management.
Understanding the influences culture
has on patients' pain experiences and
attitudes regarding treatments will
permit nurses to achieve better pain
outcomes for all of them.
In Summary:
Use the nursing process
Gather pertinent objective and
subjective data
Accept self report
Develop individual plans of care
Reassessment is key in order to
evaluate and revise the plan
THANK YOU SO MUCH FOR
COMING TODAY!
Please enjoy some candy!
References:
1.) McCaffery, M. (1968) Nursing Practice Theories Related to Cognition, Bodily
Pain, and Environment.
2.) Institute of Medicine Report from the Committee on Advancing Pain Research,
Care, and Education: Relieving Pain in America, A Blueprint for Transforming
Prevention, Care, Education and Research. The National Academies Press, 2011.
3.) National Centers for Health Statistics, Chartbook on Trends in the Health of
Americans 2006, Special Feature: Pain.
4.) Results from the 2009 National Survey on Drug Use and Health (NSDUH):
National Findings, SAMHSA (2010).
5.) Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on
Drug-Related Emergency Department Visits, SAMHSA (December 2010).
6.) Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States,
1999--2008, Centers for Disease Control and Prevention Analysis: Morbidity and
Mortality Weekly Report (MMWR), November 4, 2011 / 60(43);1487-1492.
7.) Jacques, A. (1992) Do you believe I am in pain? Professional Nurse; 7: 4, 249251.
8.) Frantsve, L.M., Kerns, R. (2007) Patient-provider interactions in the
management of chronic pain: current findings within the context of shared
medical decision-making. Pain Medicine; 8: 1, 25-35.
9.) Clarke, K., Iphofen, R. (2005) Believing the patient with chronic pain: a review
of the literature. British Journal of Nursing; 14: 9, 490-493.
10.) Green CR, et al. The unequal burden of pain: confronting racial and ethnic disparities
References:
10.) Green CR, et al. The unequal burden of pain: confronting racial and ethnic disparities
pain. Pain Med 2003
11.) American Nurses Association. Position statement on discrimination and racism in health
care. 1991
12.) International Study of Pain: An unpleasant experience that we primarily associate with
tissue damage or describe in terms of tissue damage or both." Merskey, H. (1964), An
Investigation of Pain
13.) Spanwick CC (editors) (2000). Pain management: an
interdisciplinary approach. Churchill Livingstone, Edinburgh. Bulletin of the
IACFS/ME