MedicalSurgical Nursing Concepts amp Practice 3 rd edition Copyright 2017 Elsevier Inc All rights reserved Review the gate control theory of pain and its relationship to nursing care ID: 738007
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Chapter 7Care of Patients with Pain
Medical-Surgical Nursing: Concepts & Practice3rd edition
Copyright © 2017, Elsevier Inc. All rights reserved.Slide2
Review the gate control theory of pain and its relationship to nursing care.Demonstrate an understanding of the current view of pain as a specific entity requiring appropriate intervention.Compare nociceptive pain and neuropathic pain and nursing care for each.
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Theory ObjectivesSlide3
Explain how pain perception is affected by personal situations and cultural backgrounds.Analyze the major differences between acute and chronic pain and their management.Demonstrate the use of the nursing process when caring for patients experiencing pain.Give examples of the different pharmacologic approaches to pain that include the use of adjunctive measures.
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Theory
Objectives (Cont.)Slide4
Demonstrate use of appropriate pain evaluation tools for a variety of patients.Recognize common side effects of analgesics and describe techniques for addressing them.Employ nonpharmacologic approaches to pain management with a variety of patients.
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Clinical Practice ObjectivesSlide5
Definition of painGate control theory (GCT)Nursing applications of GCTPieces of painEndorphins
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Theories of PainSlide6
A neurologic response to unpleasant stimuli 6
PainSlide7
When the gate is open, the pain sensation is allowed through.When the gate is closed, the pain sensation is blocked.Stimuli other than pain pass through the same gate.
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Gate Control TheorySlide8
When a large volume of nonpainful stimuli is competing for the gate, pain impulses may be blocked.A high volume of pain, however, may override other stimuli and pass through the gate, causing the individual to perceive the pain.
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Gate Control Theory
(Cont.)Slide9
Two types of nerve fibers—small-diameter and large-diameter—carry pain stimuli.Activity in the small-diameter nerve fibers seems to open the gate, and activity in the large-diameter nerve fibers seems to close it.Massage and vibration produce activity in the large-diameter nerve fibers.
9
Nursing Application of the
Gate
Control TheorySlide10
High levels of sensory input create brainstem impulses that seem to close the gate.Distraction in the form of activity or social interaction produces these brainstem impulses.An increase in anxiety seems to open the gate, and a decrease in anxiety seems to close it.The fear that pain will not be controlled may actually increase pain intensity, and knowing that pain can be or is being controlled may reduce pain.
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Nursing Application of the
Gate
Control
Theory (Cont.)Slide11
The more intense the pain, the greater the number of pieces.Therefore, a greater number of pieces of analgesia will be required to control pain.
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Pieces of PainSlide12
Endorphins (endogenous morphine) can attach to pain receptors and block pain sensation.They appear to modify and inhibit unpleasant stimuli, reduce anxiety, and relieve pain.Endorphins also may produce feelings of euphoria and well-being.For example, the “runner’s high” is believed to occur because endorphins are released after physical exercise.
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EndorphinsSlide13
Associated with pain stimuli from either somatic (body tissue) or visceral (organs) structures
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Nociceptive PainSlide14
Somatic nociceptive pain arises from injury to tissue where pain receptors called nociceptors are located.These nociceptors may be found in the skin, connective tissue, bones, joints, or muscles.Trauma, burns, or surgery may cause injuries triggering somatic nociceptive pain.
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Somatic Nociceptive PainSlide15
Visceral nociceptive pain arises from pathophysiology in visceral organs such as the organs of the gastrointestinal tract.Pathologic conditions triggering visceral nociceptive pain include tumors and obstructions of the organs.
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Visceral Nociceptive PainSlide16
Transduction begins when tissue damage causes the release of substances that stimulate the nociceptors and initiates the sensation of pain.Transmission involves movement of the pain sensation to the spinal cord.Perception occurs when impulses reach the brain and the pain is recognized.Modulation occurs when neurons in the brain send signals back down the spinal cord by release of neurotransmitters.
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Four Phases of Nociceptive PainSlide17
17Slide18
Treatment of nociceptive pain may be directed toward one or all of the four phases.Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking the production of the substances that trigger the nociceptors in the transduction phase.Opioids interfere with the transmission phase.Drugs that block neurotransmitter uptake work in the modulation stage.
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Nursing Implications Related to Nociceptive PainSlide19
Nonpharmacologic treatments, such as distraction and guided imagery, may be effective during the perception phase.
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Nursing Implications Related to Nociceptive Pain
(Cont.)Slide20
Associated with a dysfunction of the nervous system that involves an abnormality in the processing of sensationsThese dysfunctions in the nervous system are often associated with medical conditions rather than tissue damage.Neuropathic pain may be the result of damage to nerve roots such as compression or entrapment.
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Neuropathic PainSlide21
The pain signal that would normally move from the periphery toward the brain reverses and the signal is sent in the opposite direction.An example is phantom pain—pain felt in a limb after amputation.
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Neuropathic Pain
(Cont.)Slide22
22Slide23
Analgesics and opioids usually do not relieve neuropathic pain.Adjuvant medications such as NSAIDs, tricyclic antidepressants, anticonvulsants, and corticosteroids relieve neuropathic pain.
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Nursing Implications Related to Neuropathic PainSlide24
Pain is a subjective experience. 24
Perception of PainSlide25
Pain threshold is the point at which pain is perceived.Relaxation and distraction strategies can alter the perception of pain.
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Pain ThresholdSlide26
Pain tolerance is the length of time or the intensity of pain a person will endure before outwardly responding to it.Tolerance varies among people and is influenced by culture, pain experience, expectations, and role behaviors.
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Pain ToleranceSlide27
Pain can cause a variety of physiologic responses, includingIncreased respiratory rate, pulse, or blood pressureMuscle tensionSweatingFlushing or pallorFrowning, grimacing, or groaning
Although the presence of any of these factors may indicate pain, their absence does not prove the absence of pain. 27
Physiologic Responses to PainSlide28
A person’s cultural background influences feelings about pain.In much of Western culture, it is considered valuable to have a high pain tolerance, particularly among men.Other cultures promote the idea that to endure pain is natural or honorable.Learning to accept without judgment the various ways of coping with and expressing pain is a very necessary process for nurses.
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Cultural ConsiderationsSlide29
The idea that pain perception diminishes with age is false.In fact, perception of pain may actually increase with age, as the individual becomes frail, has more than one chronic ailment, and has fewer resources for tolerating pain.
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Older Adult Care PointsSlide30
Acute painHours to daysChronic painMonths to years
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Acute Versus Chronic Pain: DurationSlide31
Acute painGood; may resolve spontaneously or in response to analgesic therapyChronic painPoor unless complicating factors removed; spontaneous relief unusual
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Acute Versus Chronic Pain:
Prognosis
for ReliefSlide32
Acute painRelatively easy to identifyChronic painSometimes cause is known, but diagnosis may be complex or undetermined
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Acute Versus Chronic Pain: CauseSlide33
Acute painUsually transient or none; may temporarily disrupt normal activities or routineChronic painCan affect ability to earn a living, enjoy social activities, maintain self-esteem
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Acute Versus Chronic Pain: Psychosocial EffectsSlide34
Acute painMedication usually beneficial; surgery often helpfulChronic painMedications may be helpful, but patient may become dependent.Multiple medication regimen may be used.
Surgery may help but also may worsen the problem. 34
Acute Versus Chronic Pain:
Effect
of TherapySlide35
Between 50% and 70% of the older adults in the community have chronic pain.The most common conditions causing the pain are joint problems from osteoarthritis, degenerative disc disease from osteoporosis, low back pain, and pain from previous fracture sites.If their chronic pain is adequately controlled, quality of life is improved.
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Older Adult Care PointsSlide36
AppearanceBehaviorActivity levelVerbalizationPhysiologic clues
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Assessment (Data Collection)Slide37
Older patients may not report pain for a variety of reasons, and their pain is often undertreated.They may think pain is an expected part of aging.They may deny pain because it means they are getting older.They may not report pain because they believe they cannot afford the cost of tests or treatments.
Older people often will say they have “soreness” or “discomfort” rather than pain.Assess further if such comments are made. 37
Older Adult Care PointsSlide38
Several rating scales have been developed for use in pain evaluation.When using a pain rating scale, it is important that the nursing staff use it consistently and that the patient fully understands how to use it.The type of scale being used and any pertinent information about how the patient uses the scale must be included in the patient care plan.
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Pain Rating ScalesSlide39
Pain is rated as a number from 0 to 5 or 10, with 0 indicating no pain and the highest number indicating the greatest amount of pain imaginable.Numbered scales can be used very effectively with people who have a good understanding of the numerical concept and who like a strictly logical approach.They are not appropriate for young children, anyone who has difficulty with numbers, or anyone who is confused or disoriented.
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Numbered ScaleSlide40
40Slide41
Photographs or simple drawings of faces with expressions showing a pain-free state (happy and smiling) that progress through a series of faces showing increased discomfort
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Visual ScaleSlide42
Allows the patient to select colors that represent varying degrees of painThe patient selects a color that represents no pain; a color that represents severe pain; and then one, two, or three other colors for pain levels in between.This scale is often used with children, but very young children cannot understand more than three or four possible choices.
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Color ScaleSlide43
Uses five poker chips or other identical, plain objects that represent “pieces” of painThe patient indicates the degree of pain by selecting the number of chips that equals the intensity of pain being experienced.
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Pieces of Pain ScaleSlide44
Used with patients who are cognitively impaired or cannot speak.The nurse assesses the patient’s behavior in categories such as facial expression, limb movement, and activity level.A score from 0 to 2 is obtained for each category, and the category scores are added together to arrive at a pain score total of 0 to 10.It is useful when assessing the pain of confused or nonverbal adults, infants, and young children.
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Behavioral Pain (FLACC) ScaleSlide45
A more accurate assessment of pain in older adults is obtained when several types of pain scales are used, such as a number scale, a visual scale, and a behavioral scale
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Older Adult Care PointsSlide46
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Wong-Baker FACES Pain Rating Scale
From
Hockenberry
MJ, Wilson D: Wong’s essentials of pediatric nursing, ed. 9, St. Louis, 2013, Mosby.Slide47
47
FLACC Scale for Pain Assessment for Cognitively Impaired Person
Copyright 2002, reprinted with permission from The Regents of the University of Michigan.Slide48
Language barriersCultural considerationsPain expression and meaningPreferences and actionReferred pain and heart painOutward appearance of pain
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Data Collection DifficultiesSlide49
In determining the patient’s perception of pain, which question(s) would be useful in assessing pain? (Select all that apply.)“Where are you hurting?”“What pain control measures have worked for
you in the past?”“How would you describe your pain?”“What were you doing before the onset of the pain?”“Did another person witness your pain?”
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Audience Response Question 1Slide50
Overall goal is relief of painIndicate actions that promote comfortTeam approachNonpharmacologic and pharmacologic interventionsType of medication, method of delivery, and comfort measuresPain management needs—family situation, cultural influences, financial constraints, and nature of pain (acute or chronic)
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PlanningSlide51
ReassessAppropriate interventionsAdjunctive measuresTeachingPrevent complications from medications
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ImplementationSlide52
Prominent documentation of any known drug allergiesAccurate recording of pertinent information obtained during the initial assessment phase, such as current medications, previous experience with pain, analgesics, and adjuncts to pain reliefPatient and family teaching regarding dose, frequency, and the need to consult with the physician or nurse before taking any other medications to avoid dangerous interactions
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Prevent ComplicationsSlide53
Appropriate monitoring of effects of any medications given and prompt notification of the physician if medications fail to relieve pain or should problems occurAccurate and complete documentation of any adverse reactions to treatment and communication of that information to other health care providers, to the patient, and to appropriate family members
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Prevent
Complications (Cont.)Slide54
Assess before and after interventions.Assess effectiveness of medications.Oral medications may take 60 minutes to take effect.Injections are effective in 45 to 60 minutes.IV medications are effective within 15 to 30 minutes.
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EvaluationSlide55
Accurate documentationInitial pain assessmentLocationIntensityDuration of the painMethod used to assess
Aggravating factorsAlleviating factors 55
DocumentationSlide56
Measures taken (e.g., analgesic medication, adjunctive measures)Evaluation of effectiveness of measuresPhysician notification of problems or concerns and physician response, if applicableRelated patient or family education
56
Documentation
(Cont.)Slide57
Effective pain management is not just a matter of giving the right medicine at the right time.It is a combination of pharmacologic and nonpharmacologic approaches that together give the individual the greatest possible degree of comfort for the longest possible time.
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Managing PainSlide58
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The Analgesic LadderSlide59
Oral analgesicsIntramuscular analgesicsSubcutaneous analgesicsTopical analgesicsTransdermal patchesBuccal swabs
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Pharmacologic ApproachesSlide60
IV analgesicsPatient-controlled analgesiaEpidural analgesicPeripheral nerve catheter
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Pharmacologic Approaches
(Cont.)Slide61
AntidepressantsChemotherapeutic agents and immunosuppressantsAnticonvulsantsMuscle relaxantsMarijuana
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Nonanalgesic
Medications
Used
for Pain ControlSlide62
Aspirin and anticoagulant effectsAcetaminophen and liver toxicity
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Special Considerations in
Pain
ManagementSlide63
Reduced tolerance for medicationsDiminished muscle and fatty tissue for intramuscular injections
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Older Adult Care PointsSlide64
Rights of medication administrationSide effects and complicationsConstipation—fluid and fiberDrowsiness and euphoriaItching and hivesRespiratory depression
Addiction to narcotics 64
Nurse ResponsibilitiesSlide65
Encourage increased intake of fluids and fiber.Administer an ordered stool softener.Monitor for bloating, discomfort, and lack of daily bowel movement.
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Older Adult Care PointsSlide66
No scientific evidence has proven that opioids can hasten death when used to control pain.Health care providers have moral obligation to adequately treat pain even at the very end of life.Opioids must be administered for the purpose of relieving pain and not to purposefully hasten death.
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End-of-Life Narcotic Pain ControlSlide67
Some drugs are considered especially risky to administer to older patients.Propoxyphene (contained in Darvon and Darvocet) can be toxic.Tramadol (Ultram) and meperidine (Demerol) lower the seizure threshold and should be used cautiously.
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Older Adult Care PointsSlide68
SleepHeat and coldMentholDistractionRelaxationGuided imageryMeditationHypnosisBiofeedback
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Nonpharmacologic
Approaches
Music
Binders
Massage
Acupuncture and acupressure
Transcutaneous electrical nerve stimulation
Spinal cord stimulatorSlide69
SympathectomiesRhizotomiesCordotomies
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Invasive TreatmentsSlide70
Complementary and alternative therapies are used more for pain relief than for anything else.Therapies used include relaxation, meditation, biofeedback, yoga, hypnosis, imagery, chiropractic, acupuncture, acupressure, massage, aromatherapy, and herbal preparations and supplements.Research from the National Institutes of Health has proven that acupuncture is effective for many patients for various pain problems.
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Complementary and Alternative Therapies for Pain ReliefSlide71
Skin is thin and burns more easily.Stroke patients and those with diabetic neuropathy frequently have areas of lost or diminished sensation.Patients with senile dementia may not recognize that something is too hot.Even an alert and oriented older person frequently falls asleep and may be burned.
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Older Adult Care PointsSlide72
Monitor any heat application very carefully.Do not apply heat to any areas where nerve damage or decreased sensation has occurred.
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Older Adult Care
Points (Cont.)Slide73
Which statement(s) by a nurse promote(s) the use of massage in reducing pain? (Select all that apply.)“Family members can perform it safely and effectively.”
“It stimulates the circulation in reddened areas.”“It relaxes the muscles.”“It increases the general sense of well-being.”“It uses short, mild strokes.”
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Audience Response Question 2Slide74
Community careSocial workerTeaching on complementary and alternative resourcesExtended careAdequate pain management to promote rest and rehabilitation
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Nursing ResponsibilitiesSlide75
Home careDischarge teaching and resourcesConsider adjuncts to pain managementFamily involvementSubcutaneous PCARole of LPN/LVN
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Nursing
Responsibilities (
Cont
.)