Nursing Care Plan For Pain

Nursing Care Plan For Pain

 

Pain or fear of pain

  • serves as a common link among people who require health care.
  • every person has at one time or the other experienced pain.
  • no equipment can accurately measure pain.

Traditionally

pain was viewed as:

  • something harmful and has nothing good.
  • a symptom that prompts individuals to seek health care

Currently

we view pain not just as a symptom but as a specific problem that requires to be treated. And that the patient must be part of the management team.

• Only the client knows where pain is and how intense it is. is important to NOT underestimate patient’s verbalization of pain, because pain is whatever the patient says it is and it occurs whenever the patient says it does.

• Therefore one of the most important function of the professional nurse is an accurate pain assessment

–  guide the physician in taking decision about the management of the client.

 

Definitions of PAIN

• Pain is a neurological response to an unpleasant sensory stimuli & emotional experience associated with actual or potential tissue damage

Others describe pain as:

• Associated with a DISEASE or an INJURY

• FEELING of DISTRESS, SUFFERING, AGONY CAUSED BY STIMULATION of NERVE ENDINGS SCATTERED THROUGHOUT the BODY

• UNIVERSAL experience

WARNING SIGNAL

 

THEORIES of PAIN

1. Specific Theory

body’s neurons and pathways for pain transmission are specific and unique as those for other body senses

– taste or touch

 

2. Pattern Theory

Two types of pain fibers:

Rapidly conducting fibers

Slowly conducting fibers

Peripheral impulses from many fibers of both types are combined at the level of the spinal cord,  the summation of these impulses, ascends to the brain for interpretation

 

3. Gate-Control Theory

Pain and its perception are determined by the interaction of two systems:

The substantia gelatinosa in the dorsal horns of the spinal cord that regulates impulses entering or leaving the spinal cord

The second is an inhibitory system within the brain stem (medulla)

• PAIN may be thought of as being CONTROLLED by a “GATE” in the CENTRAL NERVOUS SYSTEM

• WHEN GATE is OPEN , PAIN SENSATION is ALLOWED THROUGH

Gate-Control Theory

Gate-Control Theory

 

• Activity in the pain fibres – opens the gate

• Activity in other sensory nerves – closes the gate

• Messages from the brain – concentrating on the pain or trying not to think about it

 

IMPLICATIONS of GATE CONTROL THEORY to NURSING PRACTICE:

Two TYPES of NERVE FIBERS carry PAIN STIMULI:

• SMALL DIAMETER NERVE FIBERS seems to OPEN the GATE

• LARGE DIAMETER: seems to CLOSE the GATE

• WHEN there is large VOLUME of NONPAINFUL STIMULI PAIN may be blocked

• HIGH VOLUME of PAINFUL STIMULI May override other STIMULI & PASS through GATE

 

MASSAGE & VIBRATION

• produce activity in large diameter nerve fibers

• high levels of sensory input create brain stem impulses that seem to close the gate

DISTRACTION

• in the form of activity or social interaction produce activity in large nerve fibers

INCREASE in ANXIETY —- OPEN GATE

DECREASE in ANXIETY —-CLOSE GATE

“PIECES OF PAIN”

The MORE INTENSE the PAIN:

The GREATER NUMBER of PIECES, and therefore GREATER “PIECES” of ANALGESIA will be REQUIRED

 

ENDORPHINS

(ENDOGENOUS MORPHINES)
– naturally present in neurons in brain, spinal cord, & gastrointestinal tract
– CAN ATTACH to PAIN RECEPTORS & BLOCK PAIN SENSATIONS

PATHOPHYSIOLOGY OF PAIN

Pain results from release of various chemicals from damaged cells

According to pathology, pain categorized as:

  • nociceptive
  • neuropathic
  • According to onset, intensity, duration,
  • pain can be experienced as:
    • acute
    • chronic

    Nociceptive pain

    NOXIOUS STIMULI TRANSMITTED from POINT of CELLULAR INJURY over PERIPHERAL SENSORY NERVES to PATHWAYS between SPINAL CORD & THALAMUS & from THALAMUS to CEREBRAL CORTEX

    • Sensory perception of damage or potential damage to tissue from trauma or disease

    • Can occur as a result of receptor stimulation

    • Can be either acute or chronic

     

    Somatic pain

    Localized and acute pain caused by

    • Mechanical

    • Chemical

    • Thermal

    • electrical

    injuries/disorders affecting bones, joints, muscles, skin, or structures composed of connective tissues

     

    Visceral pain

    • Deep, acute pain arising from an internal organs that are diseased/injured
    • Not well localized
    • May be referred to another area
    • Discomfort perceived in a general area of body, but not in exact site
    • Presents as colicky, cramping, or itching pain
    • May be caused by distention or obstruction

    NEUROPATHIC PAIN

    Acute or chronic pain results from injuries/diseases directly affect the nervous system

     

    Pain Transmission

    4 PHASES:

    • TRANSDUCTION
    • TRANSMISSION
    • PERCEPTION
    • MODULATION

     

    TRANSDUCTION

    • conversion of chemical information in cell to electrical impulses that move toward spinal cord

    • chemicals such as:

    • prostaglandins, bradykinin
    • serotinin, histamine, substance p

    stimulate specialized pain receptors in peripheral nerve endings called nociceptors

     

    TRANSMISSION

    phase during which peripheral nerve fibers form synapses with neurons in spinal cord

      ascend to:

    • reticular activating system
    • limbic system
    • thalamus
    • cerebral cortex

    PERCEPTION

    • BRAIN experiences PAIN at CONSCIOUS LEVEL, but many NEURAL ACTIVITIES occur simultaneously

    • BRAIN STRUCTURES in PAIN PATHWAY help to:

    – DISCRIMINATE PAIN LOCATION

    – DETERMINE INTENSITY

    – ATTACH MEANING

    – PROVOKE EMOTIONS

    – OCCURS when PAIN THRESHOLD is reached

    – PAIN THRESHOLD

    – POINT at which PAIN

    – TRANSMITTING NEUROCHEMICALS

    – REACH the BRAIN, causing CONSCIOUS AWARENESS.

     

    PAIN TOLERANCE

    AMOUNT of PAIN PERSON ENDURES once THRESHOLD has been reached

    INFLUENCED by LEARNED BEHAVIOURS

     

    MODULATION

    BRAIN interacts with SPINAL NERVES in downward fashion to ALTER PAIN EXPERIENCE

    • PAIN SENSATION with

    • release of PAIN INHIBITING
    • NEUROCHEMICALS such as:
    • ENDOGENOUS OPIODS

    • GAMA AMINO- BUTYRIC ACID (GABA)

    • “THE WAY IN WHICH HUMANS REACT TO PAIN CAN VARY WIDELY FROM PERSON TO PERSON AND IN THE SAME INDIVIDUAL UNDER DIFFERENT CIRCUMSTANCES.” (deWit, ’98)

    • “YOU HAVE THE RIGHT TO JUDGE ME WHEN YOU HAVE WALKED IN MY SHOES FOR ONE KILOMETRE.”

     

    STRESSORS

    • PHYSIOLOGICAL:

    • CELL DAMAGE

    • PSYCHOLOGICAL:

    • ANXIETY
    • DEPRESSION
    • PAST PAIN EXPERIENCE
    • ENVIRONMENTAL CONDITON
    • HOSPITALIZATION

    DEVELOPMENTAL:

    • AGE
    • COPING MECHANISM

    SPIRITUAL:

    • DEGREE OF FAITH

     

    PAIN ASSESSMENT

    • “PAIN IS WHATEVER THE PERSON SAYS IT IS, AND EXISTS WHENEVER THE PERSON SAYS IT DOES” (McCaffery & Beebe, 1989)

    • According to the AMERICAN PAIN SOCIETY:

    PAIN ASSESSMENT –should be the 5th VITAL SIGN

     

    COMPONENTS of COMPREHENSIVE PAIN ASSESSMENT (JCAHO:JOINT COMMISION ON ACCREDITATION OF HOSPITAL ORGANIZATION)

    • ONSET—Time pain began
    • QUALITY—Description in client’s own language
    • INTENSITY—Rating for present pain,worst pain or Least pain using consistent scale.

    LOCATION – SITE OF PAIN

    DURATION – HOW LONG PAIN HAS EXISTED

    VARIATION – PAIN CHARACTERISTICS THAT CHANGE

    PATTERNS – REPETIVENESS OR LACK OF IT

     

    ALLEVIATING FACTORS

    FACTORS OR TECHNIQUE THAT REDUCE PAIN

    AGGRAVATING FACTORS

    FACTORS OR TECHNIQUE THAT INCREASE PAIN

    PRESENT PAIN MANAGEMENT APPROACHES TO CONTROL AND THEIR EFFECTIVENESS.

    PAIN MANAGEMENT HISTORY

    PAST CONTROL MEASURES AND THEIR EFFECTIVENESS

    RESPONSE MANNER OF EXPRESSING BELIEF THAT IS RELATED TO PAIN

    EFFECTS OF PAIN

    ALTERATION IN LIFE STYLE,SELF –CARE, SLEEP,DIET ETC.

    • PERSON’S GOAL — EXPECTATIONS FOR RELIEF OF PAIN.

    • PHYSICAL ASSESSMENT — ASSESSMENT OF STRUCTURES THAT RELATE TO SITE OF PAIN.

     

    PAIN ASSESSMENT TOOLS

    NUMERIC SCALE

    Best scientific tool for measuring pain intensity: it is the patient self report

    0 ——————————————- 10

    No pain                                  Worst pain Imaginable

     

    NUMERIC SCALE

    Visual Analouge

    – Pain relief scale (no relief of pain, complete relief)

    –  Pain intensity scale (least possible pain, worst possible pain)

    Numeric rating scale

    Numeric rating scale

    WONG – BAKER FACES PAIN RATING SCALE

    The face rating scale primarily measures the severity of pain and possibly, to lesser the extent, its affective components

     

    Verbal rating Scale

    Verbal rating Scale

    patient can describe the degree of pain by choosing the vertical line that corresponds to the intensity of pain he/she is feeling

     

    SUBJECTIVE DATA

    • LOCATION of the PAIN

    • QUALITY: CRUSHING, STABBING, ACHING, TINGLING, KNIFE-LIKE

    • INTENSITY MILD, MODERATE, SEVERE

    • PAIN SCALE

     

    OBJECTIVE DATA

    PHYSIOLOGICAL

    • RAPID, SHALLOW,

    • GUARDED RESPIRATION

    •  PALLOR

    • DIAPHORESIS

    • PULSE

    • BP

    • DILATED PUPILS

    • TENSE MUSCLES

    BEHAVIORAL

    • CRYING

    • MOANING

    • TOSSING ABOUT IN BED

    • DRAWING UP KNEES

    • RUBBING the PART

    • LACK of CONCENTRATION

    • MORE IRRITABLE

    • MORE SHORT TEMPERED

    • UNCOOPERATIVE

    PAIN MANAGEMENT

    GENERAL TECHNIQUES:

    (1)     BLOCKING PERCEPTION

    INTERRUPTING PAIN TRANSMITTING CHEMICALS at SITE of INJURY

    (2)     COMBINING ANALGESICS with OTHER DRUGS

    (3)     USING GATE CLOSING MECHANISMS

    (4)     ALTERING PAIN TRANSMISSION at LEVEL of SPINAL CORD

    (5)   DRUG THERAPY/MEDICATIONS CORNERSTONE for MANAGING PAIN

     

    NON-DRUG INTERVENTIONS

    “THE BRAIN CAN ACCOMMODATE LIMITED NUMBER OF SENSORY SIGNALS.”(Mc Caffery & Pasero,’99)

     

    • DISTRACTION, RELAXATION, IMAGERY TECHNIQUES:

    DIRECT ATTENTION AWAY from PAIN SENSATION

    • STIMULATE VISUAL PORTION of BRAIN (CORTEX in right hemisphere) where abstract & creative activities take place

    • BRAIN responds by RELEASING GABA, SEROTONIN

    • HEAT and COLD = THERMAL THERAPY

    • COLD: INITIALLY

    •  LOCALIZED SWELLING

    • VASODILATION

    o TRANSCUTANEOUS ELECTRICAL STIMULATION (TENS)

    DELIVERS BURSTS of ELECTRICITY to SKIN & NERVES; SAFE

     

    • ELECTRICAL NERVE STIMULATION, ACUPUNCTURE, & ACUPRESSURE

    • STIMULATE NERVE FIBERS

    which CONDUCT TACTILE or VIBRATORY SENSATIONS over PATHWAYS SHARED for TRANSMITTING PAIN

     

    ACUPUNCTURE & ACUPRESSURE

    ACUPUNCTURE – LONG, THIN NEEDLES INSERTED into SKIN

    ACUPRESSURE – USES TISSUE COMPRESSION

    • MECHANISM:

    • CUTANEOUS STIMULI

    • CLOSE “GATE”

    • RELEASE of ENDORPHINS & ENKEPHALINS

    • PERCUTANEOUS ELECTRICAL NERVE STIMULATION

    • COMBINES ACUPUNCTURE & TENS FOR LOW BACK PAIN, BONE CANCER,

    SHINGLES, MIGRAINE

     

    OTHER NON-INVASIVE TECHNIQUES

    IMAGERY, BIOFEEDBACK, HUMOR, BREATHING EXERCISES, PROGRESSIVE RELAXATION & DISTRACTION, HYNOPSIS

     

    DRUG ADMINISTRATION

    -       ORAL

    -       RECTAL

    -       TRANSDERMAL

    -       PARENTERAL

     

    PATIENT CONTROLLED ANALGESIA (PCA)

    CLIENT ADMINISTERS OWN NARCOTICS THRU IV PUMP SYSTEM

    pca

     

    INTRASPINAL ANESTHESIA

    Into SUBARACHNOID

    (INTRATHECAL) or EPIDURAL SPACE thru catheter inserted by physician

     

    SPINAL SURGERY TECHNIQUES

    INTRACTABLE PAIN – DOES NOT RESPOND to ANLGESICS, NON-INVASIVE MEASURES

    RHIZOTOMY – INVOLVES LAMINECTOMY followed by

    • POSTERIOR NERVE ROOT before it enters the SPINAL CORD.

    • CORDOTOMY – INTERRUPTION of PAIN PATHWAYS in SPINAL CORD

     

    Nursing Care Plan

    NURSING DIAGNOSIS:

    PAIN related to cellular injury or disease as manifested by stating, “I’m in severe pain”; rating pain at 10 using a numeric scale; pointing to the lower left abdominal quadrant; describing the pain as “continuous, throbbing, and starting this morning” without any known cause

    EXPECTED OUTCOME:

    • Client will rate the pain intensity at his tolerable level of “5” within 30 minutes of implementing a pain management technique

     

    Nursing Action/Rationale

    1. ASSESS CLIENT’S PAIN EVERY 2 HOURS WHILE AWAKE & 30 MINUTES after IMPLEMENTING PAIN MANAGEMENT TECHNIQUE

    QUICK INTERVENTIONS PREVENT or MINIMIZE PAIN

    2. MAKE THERAPEUTIC USE OF SELF

    NURSE PROVIDES COMFORT, SUPPORT AND ENCOURAGEMENT. STAYS WITH CLIENT,LISTENS TO HIM AND MAKES him /her RELAX.

    3. DETERMINE CLIENT’S CHOICE FOR PAIN RELIEF TECHNIQUES

    ENCOURAGE & RESPECT CLIENT’S PARTICIPATION IN DECISION MAKING

    4) MODIFY FACTORS THAT CONTRIBUTE TO PAIN SUCH AS FULL BLADDER, UNCOMFORTABLE POSITION, NOISE,ETC.

    MULTIPLE STRESSORS DECREASE PAIN TOLERANCE REDUCE MUSCLE TENSION

    5)  EXPLAIN THE NATURE OF PAIN

    KNOWLEDGE/UNDERSTANDING

    6) a. PROVIDE DISTRACTION FROM PAIN

    BRAIN SENDS SIGNALS TO UPWARD PATH OF

    PAIN TO THALAMUS TO BLOCK THE PAIN

    b. ASSIST CLIENT to VISUALIZE a PLEASANT EXPERIENCE

    USE GUIDED IMAGERY

    IMAGING INTERRUPTS PAIN PERCEPTION CLIENT HAS CONTROL OF SELF (Distractive technique).

     

    7) PLAN for PERIODS of REST between ACTIVITY FATIGUE INTERFERES with PAIN TOLERANCE

    8) REASSURE CLIENT there are MANY WAYS to MODIFY PAIN EXPERIENCE

    SUGGESTING there are ADDITIONAL UNTRIED OPTIONS HELPS ALLEVIATE DESPAIR

    9) a. PROMOTE RELAXATION EXERCISE

    b. HELP CLIENT FOCUS on deep BREATHING, RELAXING MUSCLES, WATCHING TELEVISION, PUTTING TOGETHER a PUZZLE, or TALKING to SOMEONE on the PHONE

    DIVERTING ATTENTION to SOMETHING other than PAIN REDUCES PAIN PERCEPTION

    RELIEFS MUSCLE TENSION.

    10) APPLY WARM or COOL COMPRESS to a PAINFUL SENSORY SITE

    FLOODING the BRAIN with ALTERNATIVE STIMULI CLOSES the SPINAL GATE

    11) GENTLY MASSAGE a PAINFUL AREA or the SAME AREA on the OPPOSITE SIDE of the BODY (CONTRALATERAL MASSAGE)

    USE CUTANEOUS STIMULATION

    MASSAGE PROMOTES the release of ENDORPHINS & ENKEPHALINS

    RELIEF PRESSURE/SWELLING.

    GATE THEORY LARGE FIBRES ARE OPEN

    12) PROMOTE LAUGHTER BY SUGGESTING that CLIENT RELATEs a HUMOROUS STORY or watch a VIDEO or COMEDY of his/her CHOICE

    LAUGHTER RELEASES ENDORPHINS & ENKEPHALINS that PROMOTE FEELING of WELL-BEING

    13) ADMINISTER PRESCRIBED ANALGESICS OR ALTERNATIVE PAIN MANAGEMENT TECHNIQUES PROMPTLY

    SUFFERING CONTRIBUTES to the PAIN EXPERIENCE & CAN be REDUCED BY PROMPT NURSING RESPONSE

     

    14) ADVOCATE on CLIENT’S BEHALF FOR HIGHER DOSES of PRESCRIBED ANALGESICS or addition of ADJUVANT DRUG THERAPY if PAIN is NOT RELIEVED satisfactorily

    JCAHO STANDARDS MANDATE for NURSES & care WORKERS to FACILITATE PAIN RELIEF

    15) ADMINISTER a prescribed ANALGESIC before a PROCEDURE or ACTIVITY that is likely to result in or INTENSIFY PAIN

    PROPHYLACTIC INTERVENTIONS FACILITATE KEEPING PAIN at a MANAGEABLE LEVEL

     

     

    Nursing Evaluation

    Expected Outcomes

    • CLIENT REPORTS that PAIN is GONE or at a TOLERABLE LEVEL of “5” within 30 MINUTES.

    • CLIENT perceives the PAIN EXPERIENCE REALISTICALLY and COPES EFFECTIVELY. 

    • CLIENT PARTICIPATES in SELF-CARE ATIVITIES without UNDUE PAIN.

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