Promoting Comfort/Pain Management Study Guide
 Comfort
 The provision of comfort is a concept central to the art of nursing.
 Pain management is more than administering analgesics.
 First: understand how pain affects a patient’s ability to function
 Then: Use therapies that meet the unique needs of the patient.
 Pain and Misconceptions
 “Pain is whatever the experiencing person says it is, existing whenever he says it does.”
 Health care providers often have prejudices about patients in pain
 Nurses are often afraid of contributing to addiction and do not accept the patient’s report of pain
 JCAHO Pain Management Standards
 JCAHO requires that health care workers assess all patients for pain on a regular basis: the “fifth vital
sign.”
 Remember to document that you assessed for pain. If you provide an intervention, be sure to document
a follow-up assessment in about ___________.
 Physiology of Pain
 See video on website
 “Gate Control Theory” of Pain
 Pain impulses can be regulated or blocked by gating mechanisms along the CNS
 The brain determines if the gate will be “open” or “closed”
 Pain intensity can be controlled by psychological, physiological and pharmacological interventions to
“close the gate.”
 Ex: heat, cold, massage, TENS release endorphins which close the gate
 Physiological Reactions to Pain
 Acute pain stimulates CNS resulting in responses
 Patients with chronic pain do not have same reactions
 Unrelieved pain can _________________________ resulting in enhanced intensity, duration and
distribution of pain which contributes to chronic pain syndromes
 Behavioral responses
 Acute pain: clenching the teeth, grimacing, holding or guarding the painful part, bent posture
 Chronic pain affects the patient’s activity, thinking and emotions
 Lack of pain ___________________ does not mean the patient is not having pain; you need to help the
patient communicate the pain response effectively
 Acute vs. Chronic Pain
 Acute pain has identifiable cause; begins rapidly, varies in intensity and lasts briefly. It warns people of
injury or disease.
 Seriously threatens a patient’s recovery by hampering ability to be active and participate in self-care
 Chronic pain is prolonged
 Chronic non-cancer pain such as low back pain frequently has no cause and does not respond to
treatment. Health care workers are usually less willing to treat aggressively
 Often have periods of remissions and exacerbations
 Major cause of physical and psychological disability
 Remember to support primary family caregiver
 Factors Influencing Pain
 Age
 Observe for behavioral changes in children that indicate pain
 Pain is NOT a normal part of _____________
 Gender?
 Culture
 Affects how people perceive the cause of pain and how they react to and express pain (stoic vs.
emotive)
 Recognize how your own culture influences your attitude about pain and be sensitive to others
 Meaning of Pain Experience
 Attention/Distraction
 Anxiety
 High anxiety increase pain perception
 _________________ causes anxiety
 Depression
 High rates of depression with chronic pain; routinely assess for suicidal tendencies
 Fatigue
 Intensifies pain and decreases coping abilities
 Previous experience
 Successfully vs. unsuccessfully resolved affects pain relief
 Coping Style
 Internal loci of control vs. External loci
 Family and Social Support
 Educate the caregivers as well
 Assessing Pain
 For Acute Pain
 P: precipitating or aggravating factors
 Q: Quality of pain: “Tell me what your pain feels like.”
 somatic, visceral, neuropathic
 R: Relief measures and Region
 S: Severity: 0-10 or FACES
 T: Timing (onset, duration, pattern)
 U: Effect of pain on patient
 For chronic pain focus on emotional impact and level of function
 Be aware of patients who cannot communicate pain effectively:
 Children or developmentally delayed
 Aphasic patients
 Psychotic patients
 Patients with dementia
 Non-English speaking patients
 Assessing Pain: Objective
 Acute pain:
 VS: increased HR, RR, BP
 Pallor, Diaphoretic, dilated pupils, grimacing, restless/anxious, holding of painful part
 Chronic pain: VS normal but often emotionally depressed or withdrawn
 Assess Patient Expectations
 Always ask patients what they expect regarding their comfort needs
 What interventions they prefer
 How they expect you to administer them
 Full pain relief or reduced discomfort
 Planning
 Develop individualized plan of care
 Set Priorities
 Collaboration
 Family
 Therapists/Specialists
 Clergy
 Implementation
 Your ability to show caring (compassion) will maximize pain control.
 Task-oriented and affective touching will benefit patients
 Health Promotion
 Maintain wellness: warm baths, personal hygiene measures, schedule of adequate rest
 If limited mobility r/t pain: help them retain function. Refer to Occupational therapist (with order) as
needed
 Non-pharmacological Pain Relief Measures
 Prevent painful stimuli (positioning, smoothing wrinkled linen, change wet linen, monitor for bladder
distension; protect skin from irritants)
 Anticipatory guidance: Give detailed descriptions of procedures before to decrease anxiety
 Distraction: singing, praying, listening to music, describing photos, telling jokes and playing games
 Cutaneous stimulation
 Massage, Cold/Heat, TENS (requires order)
 Relaxation techniques
 Simple relaxation, guided imagery
 Pharmacological Therapy
 Analgesics
 _____________________________
 Acetaminophen, Tramadol (Ultram), and NSAIDs are effective for mild to moderate pain
 Ketorolac (Toradol) is injectable NSAID used for severe pain
 NSAIDS inhibit prostaglandins and inflammation
 Pharmacological Therapy
 ___________________________ are for severe pain
 Include codeine, morphine, hydromorphone (Dilaudid), Fentanyl, oxycodone, propoxyphene.
Demerol is no longer a drug of choice because of potential for seizures
 Work on CNS and can depress respirations (so assess respirations before administering)
 Other common side effects: nausea, vomiting, constipation and altered mental processes
 If used around the clock (ATC) for a week or more, expect physical dependence (withdrawal
symptoms occur if abruptly stopped). This is not the same as addiction which is psychological
dependence.
 Patient controlled analgesia (PCA)
 Safe, effective drug delivery system via an IV line that allows patients to administer pain
medications when they need them based on parameters set by the health care provider (for example,
1 mg of Morphine available every 6 minutes with a hourly limit of 10 mg)
 Can also be given at a low dose basal rate
 Patient education is CRITICAL for effective use
 Patients with Cancer Pain: can be debilitating and difficult to treat
 See WHO ladder: begin with NSAIDS the progress to opioids and adjuvants if persists
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Goal: anticipate and prevent/minimize pain
ATC or transdermal may be useful but also treat for constipation
 Hospice
 Helps terminally ill patients live at home with the help of a health care team
 Pain control is a priority
 Teach and reassure about end-of-life maximum pain relief by titrating (increasing) dosages to meet
needs and alleviate suffering
 Promoting Comfort: GI symptoms
 Promoting Comfort in the Terminally Ill Patient
 Interventions for nausea and constipation also apply to non-terminally ill patients receiving opioids
for pain relief
 Also see textbook for interventions to promote GI function and promote comfort in post-operative client
 Common antiemetic meds: Compazine, Reglan, Zofran
 Promoting Comfort: pruritis
 Pruritis (_______________) is a common side effect of Morphine.
 May require patient to be switched to alternative opioid or may be resolved with medication such as
Benadryl.
 Evaluation of Pain Management
 Compare baseline pain assessments with ongoing assessments
 Also evaluate if response to pain has changed – is patient able to perform activities that pain prevented?
 Consider abuse/misuse for long-term use– it is rare, but if suspected, refer to a pain specialist
 Ask patient if we have met their expectations