pain management hc

8/4/2019 Pain Management HC

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A. Concepts

Definitions of Pain

1. Pain is an unpleasant sensory and emotional experience with actual or potential

tissue damage. (Merskey and Bogduk, 1994)

2. Pain is whatever the person says it is, existing whenever the experiencing person

says it does. (McCaffery and Beebe, 1989)

Types of Pain

1. ACUTE PAIN - usually ofrecent onset and commonly associated with a specific injury

- lasting from seconds to 6 months.

2. CHRONIC PAIN constant or intermittent pain that persists beyond theexpected

healing time that can be seldom be attributed to specificcause or

injury.

- lasts for6 months or longer

3. CANCER-RELATED PAIN - associated with thecancer, cancertreatment ornot

associated with cancer.

4. PAIN CLASSIFIED BY LOCATION pelvic pain, head pain, chest pain

5. PAIN CLASSIFIED BY ETIOLOGY burn pain and postherpetic neuralgia are

examples of pain described by theiretiology.

HARMFUL EFFECTS OF PAIN

1. Effects of Acute Pain - Affect pulmonary, cardiovascular, gastrointestinal, endocrine and

immune system

increased metabolicrate and cardiac output

impaired insulin response

increased production ofcortisol

increased retention of fluids

2. Effects ofChronic Pain Suppression of the Immune Function may promote tumor

growth

- Depression, Disability, Anger, Fatigue


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Mechanism of Pain

Diagram 1.1

PATHOPHYSIOLOGY OF PAIN

PAIN TRANSMISSION

NOCICEPTORS free nerve endings in the skin that respond only to intense, potentially

damaging stimuli.

Mechanic

Thermal

Chemical

ALGOGENIC SUBSTANCES - (Pain Causing) substances that affect the sensitivity of

nociceptors

Ex. Histamine, Bradykinin, Acetylcholine, Serotonin and Substance P

NOCICEPTION pain transmission

PROSTAGLANDINS - chemical substances thought to increase sensitivity of pain receptors by

enhancing the pain provoking effect ofbradykinin.


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Effects of Chemical Mediators

- Vasodilation, Increased vascularpermeability, redness, warmth and swelling of the

injured area.

FIRSTORDER NEURON travels from the periphery (skin, cornea, visceral organs) to the

spinal cord via theDORSALHORN

Two Types of Fibers

1. A DELTA FIBERS smaller, myelinated fibers transmit nociception rapidly

- produces the initial FAST PAIN

2. TYPEC FIBERS largerunmyelinated fibers that transmit what is called second pain

- dull, aching, burning qualities that last longer than initial fast pain

ENDORPHINS & ENKEPHALINS chemicals that reduce or inhibit the transmission of pain

- morphine like neurotransmitters areendogenous

LAIMANE II Substancia gelatinosa

DESCENDINGCONTROL SYSTEM system of fibers that originate in the lower and mid-

portion of thebrain and terminate on the inhibitory interneuronal fibers in the dorsal horn of the

spinal cord

INHIBITORY INTERNEURAL FIBERS the interconnections between the descending neuronal

system and the ascending sensory tract

CLASSICGATE CONTROL THEORY OF PAIN (Melzack and Wall, 1965) proposes that

stimulation of the skin evokes nervous impulses that are transmitted by three systems located in

the spinal cord.

- substancia gelatinosa in the dorsal horn, the dorsal column fibers and central

transmission cells act to influence nociceptive impulses.

LARGEDIAMETERS FIBERS inhibits the transmission of pain, thus closing the gate.

SMALLER FIBERS gate is opened


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Illustration 1.1

FACTORS INFLUENCING THE PAIN RESPONSE

PASTEXPERIENCE

The way a person responds to pain is a result of many separate painful events during a lifetime.For some, past pain may havebeen constant and unrelenting, as in prolonged orchronic and

persistent pain. The individual who has pain for months or years may become irritable,

withdrawn, and depressed.

Once a person experiences severe pain, that person knows just how severe it can be.

Conversely, someone who has neverhad severe pain may have no fearof such pain.


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ANXIETY ANDDEPRESSION

Although it is commonlybelieved that anxiety will increase pain, this is not necessarily true.

Research has demonstrated no consistent relationship between anxiety and pain, nor has

research shown that preoperative stress reduction training reduces postoperative pain (Keogh,

Ellery, Hunt et al., 2001; Rhudy & Meagher, 2000).

Just as anxiety is associated with pain because of concerns and fears about the underlying

disease, depression is associated with chronic pain and unrelieved cancerpain.

CULTURE

Beliefs about pain and how to respond to it differ from oneculture to the next. Cultural factors

must be taken into account to effectively manage pain. Inconsistent results, methodologic

weakness or flaws (Lasch, 2000), and failure of many researchers to carefully distinguish

ethnicity, culture and race make it difficult to interpret the findings of many of these studies.

Factors that help to explain differences in a cultural group include age, gender, education level,

and income.

Recognizing the values of ones own culture and learning how these values differ from those of

othercultures help to avoid evaluating the patients behavioron thebasis of ones own cultural

expectations and values

Regardless of the patients culture, nurses need to learn about that particularculture and be

aware of powerand communication issues that will affect care outcomes.

AGE

Age has long been the focus ofresearch on pain perception and pain tolerance, and again the

results havebeen inconsistent. Although someresearchers have found that olderadults require

a higher intensity of noxious stimuli than do youngeradults before theyreport pain (Washington,

Gibson & Helme, 2000), others have found no differences in responses ofyounger and older

adults (Edwards & Fillingim, 2000).

GENDER

Researchers have studied gender differences in pain levels and in response to pain, and the

results havebeen still inconsistent.

In a study ofresponses of men and women to chronic pain and anxiety, Edwards, Auguston and

Fillingim (2000) noted no differencebetween genders regarding pain and depression. Therewas, however, a difference in anxiety and gender, with men being more anxious about their

pain.

PLACEBOEFFECT

A placebo effect occurs when a person responds to the medication orother treatment because

of an expectation that the treatment will work ratherthan because it actually does so.


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A patients positive expectations about treatment may increase the effectiveness of a

medication or other intervention. Often the more cues the patient receives about the

interventions effectiveness, the more effective it will be. A person who is informed that a

medication is expected to relieve pain is more likely to experience pain relief than one who is

told that a medication is unlikely to have anyeffect.

B. Nursing Assessment of Pain

1. Characteristics of Pain

INTENSITY from non to mild discomfort to excruciating

PAIN THRESHOLD smallest stimulus forwhich a person reports pain

PAIN TOLERANCE maximum amount of pain a person can tolerate

TIMING onset, duration, relationship between time and intensity, and whetherthere

arechanges in rhythmic patterns

LOCATION best determined by having the patient point to the area of thebody

involved. This is especially helpful if the pain radiates (referred pain)

QUALITY if quality of pain cannot be described, words such as burning, aching,

throbbing orstabbing can be offered

PERSONALMEANING Patients experience pain differently, and the pain experience

can mean many different things. The meaning attached to the pain experience helps thenurse understand how the patient is affected and assists in planning treatment.

AGGRAVATING AND ALLEVIATING FACTORS - what makes pain worse and what

makes it better, and asks specifically about the relationship between activity and pain.

Knowledge of alleviating factors assists the nurse in developing a treatment plan.

PAIN BEHAVIORS not all patients exhibit the same behaviors, and there may be

different meanings associated with the samebehavior.

2. Instruments forAssessing Perception of Pain

Purposes:

a. to document the need for intervention

b. to evaluate the effectiveness of the intervention

c. to identify the need for alternative or additional interventions if the initial

intervention is ineffective in relieving the pain


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C.R.I.E.S Neonatal Post-operative Pain Measurement Scale

Crying, Requires O2 saturation >95%, Increased vital signs, Expressions, and

Sleepiness

FLACC Pain Assessment Tool

- suitable for children less than 3 years of age or unable to communicate

FLACC Pain Assessment Tool Table 1.1

0 1 2

Face No particular

expression

Occasional grimace orfrown, withdrawn,

disinterested

Frequent toconstant quivering

of chin, clenched

jaw

Leg Normal position,

relaxed

Uneasy, restless, tense Kicking, or legs

drawn up

Activity Lying quietly,normal position,

moves easily

Squirming, shifting backand forth

Arched, rigid, orjerking

Cry No cry Moans or whimpers,

complains occasionally

Cries steadily,

screams or sobs,

complains

frequently

Consolability Content, relaxed Reassured by constanthugging, orbeing talked to,

can be distracted

Difficult to consoleorcomfort


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Poker Chip Tool

- suitable for children over 3 years of age

- uses 4 poker chips in determining level of pain

Wong-Baker FACES Pain Rating Scale

- can be used with young children as young as 3 7 years old

- faces are pattern from Smiley

Oucher Pain Scale- similarto the Wong-BakerPain Rating Scalebut uses real-life pictures

Word Graphic Scale

- can be used with patient as young as 6 years old

- Uses a line with words to describe pain intensity from no pain to worst pain.

Word Graphic Pain Rating Scale Illustration 1.2

Numerical or Visual Analog Scale

- can be used by school agechildren who understand proportionality of numbers

- uses a line to describe pain intensity from no pain to worst possible pain

Pain Logs and Diaries

- Keeping of pain record


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Pain Logs and Diaries Table 1.2

Date Describe

Pain

Describe

Situation or

Activity

Physical

Pain

Sensation

(1 10)

Describe

Sensation

Emotional

Distress

(1-9)

Describe

Distress

Actions

taken

Guidelines for Using Pain AssessmentScales

1. Use appropriate pain assessment tool.

2. Use pain assessment tools consistently.

3. When a person with pain is cared forat homeby familycaregivers, teach the patient and the

familycaregivers to use a pain assessment scale to assess and manage pain.

4. Terms and language use must be understandable to patients.

Pediatric Pain Assessment

The QUEST Principles of Pediatric Pain Assessment

Q Question thechild.

U Use pain rating scales.

E Evaluatebehaviorand physiological changes.

S Secure parents involvement.

T Takecause of pain into account.

Take action and evaluateresults


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Adult Pain Assessment

Mnemonics forAdult Pain Assessment

OLDCART PQRST

O Onset P Provoked

L Location Q Quality

D Duration R Region orradiation

C Characteristics S Severity

A Aggravating Factors T Timing

R Relieving Factors

T Treatment

C. Nursing Care of a Client Experiencing Pain

Analysis

Potential Nursing Diagnoses

1. Acute pain

2. Chronic pain

3. Impaired physical mobility

4. Activity intolerance

5. Altered nutrition: less than bodyrequirements

6. Impaired social interaction

Planning/Implementation

Nurses Role in Pain Management

IDENTIFYING GOALS FOR PAIN MANAGEMENT

The nurse helps relieve pain by

1. Administering pain relieving interventions (pharmacologic and nonpharmacologic)


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2. Assessing theEffectiveness of these interventions

3. Monitoring forAdverseEffects

4. Serving as Advocate for the Patient when the prescribed intervention is ineffective in

relieving pain

5. Serves as an Educator to the patient and family

Factors to be considered

1. Severity of Pain as judged by patient

2. Anticipated Harmful Effects of Pain

3. Anticipated Duration of Pain

The goals for the patient maybe accomplished by pharmacologic ornonpharmacologic means,

but most success will be achieved with a combination ofboth.

ESTABLISHING THE NURSE-PATIENT RELATIONSHIP AND TEACHING

A positive nurse-patient relationship and teaching are keys to managing analgesia in the patient

with pain because open communication and patient cooperation areessential to success, and it

is essentiallycharacterized by trust.

- Byconveying to the patient thebelief that he or she has pain, the nurse often helps

reduce the patients anxiety.

- Teaching patients about pain and strategies to relieve it mayreduce pain in the absence

of other pain relief measures and may enhance the effectiveness of the pain reliefmeasures used.

PROVIDING PHYSICAL CARE

The patient in pain may be unable to participate in the usual activities of daily living or to

perform usual self-care and may need assistance to carry out these activities.

- A fresh gown and change and bed linens, along with theefforts to make the patient feel

refreshed (e.g. brushing of teeth, combing of hair)

- Gives the opportunity to perform a complete assessment and identify problems that may

contribute to the patients discomfort and pain.

- Appropriate gentle and physical touch


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MANAGING ANXIETY RELATED TO PAIN

The patient who anticipates pain maybecome increasingly anxious. Teaching the patient about

the nature of the impending painful experience and the ways to reduce pain often decreases

anxiety.

Anxietyresulting from anticipation of pain or the pain experience itself may often be managed

effectivelybyestablishing a relationship with the patient and by patient teaching.

A patient who is anxious about pain maybe less tolerant of the pain, which in turn may increase

the anxiety level. To prevent the pain and anxiety from escalating, the anxiety-producing cycle

must be interrupted.

NONPHARMACOLOGIC INTERVENTIONS

Although pain medication is the most powerful pain relief tool available to nurses, it is not theonly one. Nonpharmacological nursing activities can assist in relieving pain with usually low risk

to the patient. Although such measures are not a substitute formedication, they maybe all that

is necessary orappropriate to relieveepisodes of pain lasting only seconds orminutes.

1. Physiatric Approaches

a. Therapeutic Exercise

a.1 Strengthens weak muscles

a.2 Mobilizes stiff joints

a.3 Decrease anxiety and stress

b. Heat Therapy

b.1 Increase blood flow to the skin

b.2 Dilate blood vessels, increasing oxygen and nutrients to local tissues

b.3 Decrease joint stiffness by increasing muscle elasticity

c. Cold Therapy

c.1. Reduces pain and tension of muscles through constriction of blood vessel

c.2. Reduces swelling if applied soon after injury

- Ice and heat therapies maybeeffective pain relief strategies in somecircumstances; however,

theireffectiveness and mechanism of action need furtherstudy. Proponents believe that ice and

heat stimulate the non-pain receptors in the samereceptorfield as the injury.


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2. Non-Invasive Stimulatory Approaches

a. Transcutaneous Electrical Nerve Stimulation (TENS)

- a method of applying a gentle electric current to the skin to relieve pain.

- It has been used in both acute and chronic pain relief and is thought to decrease pain by

stimulating the non-pain receptors in the same area as the fibers that transmit the pain. This

mechanism is consistent with the gatecontrol theory of pain and explains theeffectiveness of

cutaneous stimulation when applied in the same area as an injury.

3. Psychoeducational Approaches

Cognitive Behavioral Techniques

- are used to reduce thebodys unproductiveresponses to stress, helping to relieve pain

or improve the ability to tolerate it.

DEEP BREATHING AND PROGRESSIVE MUSCLE RELAXATION

Skeletal musclerelaxation is believed to reduce pain byrelaxing tense muscles that contribute

to pain.

A simple relaxation technique consists of abdominal breathing at a slow, rhythmic rate. A

constant rhythm can be maintained bycounting silently and slowly with each inhalation (in, two,

three) and exhalation (out, two, three).

NURSING CONSIDERATION

When teaching this technique, the nurse may count out loud with the patient at first.

Slow, rhythmicbreathing may also be used as a distraction technique.

GUIDED IMAGERY

Guided imagery is using ones imagination in a special way to achieve a specific positiveeffect.

If guided imagery is to beeffective, it requires a considerable amount of time to explain the

technique and time forthe patient to practice.


The nurse instructs the patient to close theeyes and breathe slowly in and out.

With each slowly exhaled breath, the patient imagines muscle tension and discomfort being

breathed out, carrying away pain and tension and leaving behind a relaxed comfortablebody.

With each inhaled breath, the patient imagines healing energy flowing to the are of discomfort.


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YOGA AND MEDITATION

The word yoga, derived from the Sanskrit root yugmeaning to bind or to yoke, is the uniting

of all the powers of thebody, mind, and spirit. Yoga is an approach to living a balanced life

based on ancient teaching found in Hindu spiritual treatises (theUpanishads) written in 800-400

BC. On the other hand, meditation is a technique used to quiet the mind and focus it in the

present and to release fears, worries, anxieties, and doubts concerning the past and the future.

BIOFEEDBACK THERAPY

It is a technique that teaches various forms of relaxation by providing a response from

physiologic processes, and it is often described as a technique to bring bodily processes under

conscious control. Specifically, biofeedback teaches clients to achieve a generalized state of

relaxation characterized by parasympathetic dominance and to reduce the pattern of physiologic

arousal manifested in stress related disorders.

DISTRACTION

Distraction helps relieveboth acute and chronic pain (Johnson & Petrie, 1997). Distraction is

thought to reduce the perception of pain by stimulating the descending control system, resulting

in fewerpain stimuli being transmitted to thebrain. Theeffectiveness of distraction depends on

the patients ability to receive and create sensory input other than pain. It may range from

simple activities, such as watching TV or listening to music, to highly complex physical and

mental exercises.

HYPNOSIS

Hypnosis, which has been effective in relieving pain or decreasing the amount of analgesic

agents required in patients with acute and chronic pain, may promote pain relief in particularlydifficult situations (e.g. burns). The mechanism by which hypnosis acts is unclear. Its

effectiveness depends on the hypnotic susceptibility of the individual (Farthing, Venturino,

Brown et al., 1997).

THOUGHT-STOPPING and REFRAMING

ALTERNATIVE THERAPIES

People suffering chronic, debilitating pain are often desperate. Often they will try anything,

recommended by anyone, at any price. Information about an array of potential therapies can be

found on the Internet and in the self-help section of the bookstore. Therapies specifically

recommended for pain from these sources includebut are not limited to chelation, therapeutic

touch, music therapy, herbal therapy, reflexology, magnetic therapy, electrotherapy, polarity

therapy, acupressure, emu oil, pectin therapy, aromatherapy, homeopathy, and macrobiotic

dieting. Many of these therapies (with theexception of macrobiotic dieting) are probably not

harmful. However, they haveyet to be proven effectiveby the standards used to evaluate the

effectiveness of medical and nursing interventions.


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Despite the lack of scientificevidence that these therapies areeffective, a patient may find any

one of them helpful via the placebo response.


The nurses role is to help the patient and family understands scientific research and

how that differs from anecdotal evidence. Without diminishing the placebo effects the

patient mayreceive, the nurseencourages the patient to assess theeffectiveness of the

therapycontinually using standard pain assessment techniques. In addition, the nurse

encourages the patient using alternative therapies to combine them with conventional

therapies and to discuss this use with the physician.

a. Acupuncture

b. Massage

c. Crystal and Gemstones Therapy

d. Magnet Therapy

e. Essential Oils/Aromatherapy

f. Herbal Therapy


- Help the patient and family understand scientific research and how that differs from

anecdotal evidence

- Encourage the patient to assess the effectiveness of the therapy continually using

standard pain assessment techniques.

- Encourage patient using alternative therapies to combine them with conventional

therapies and to discuss this use with the physician.

Crystals and Gemstones

y Amethyst - headaches, hangover

y aquamarine, turquoise - neck and throat pain

y rose quartz - forheartaches, chest pains

y amber, topaz - epigastric painy moonstone - dysmenorrhea

y jasper, garnet, and ruby - pain of the genitals


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Herbal Medicine

y ginger - insect bites, joint pain

y eucalyptus - muscle and joint pain

y fresh papaya juice - heartburn, ulcers, back pain

y aloe vera - burns, cut

PHARMACOLOGIC INTERVENTIONS

Managing a patients pain pharmacologically is accomplished in collaboration with the physician

orotherprimarycare provider, the patient, and often the family.

The pharmacologic management of pain requires close collaboration and effective

communication among health care providers.

Premedication Assessment

a. Check forallergies to medications and nature of previous allergies.

b. Obtain medication history. (current, usual, orrecent use of prescription orOTC

drugs orherbal agents.

c. Obtain health history.

d. Assess patients pain status.

APPROACHES FOR USING ANALGESIC AGENTS

Medications are most effective when the dose and interval between doses are individualized to

meet the patients needs. The only safe and effective way to administeranalgesic medications

is by asking the patient to rate the pain and by observing theresponse to medications.

1. Balanced Anesthesia refers to use of more than one form of analgesia concurrently to

obtain more pain relief with fewersideeffects.

2. Pro Re Nata as needed, the past standard method used by most nurses and physicians in

administering analgesia

- the standard practice was for the nurse to wait forthe patient to complain of

pain then administeranalgesia


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3. Preventive Approach with the preventive approach, analgesic agents are administered at

set intervals so that the medication acts before the pain becomes severe and before the serum

opioid level falls to a sub-therapeutic level.

4. Individualized Dosage the dosage and the interval between doses should bebased on the

patients requirements rather than on an inflexible standard ofroutine.

5. Patient-Controlled Analgesia (PCA) used to manage postoperative pain as well as chronic

pain. It allows patients to control the administration of theirown medication within predetermined

safety limits.

3 GENERAL CATEGORIES OF ANALGESICS

LOCAL ANESTHETICS

- Work byblocking nerveconduction when applied directly to the nerve fibers. Theycan

be applied directly to the site of injury (e.g. topical anesthetic spray for sunburn) or

directly to nerve fibers by injection or at the time of surgery. They can also beadministered through an epidural catheter.

- Topical Application ex. Emulsion ofLocal Anesthetics (EMLA cream); to beeffective, it

must be applied to the site 60 to 90 minutes before the procedure

- Intraspinal Administration the anesthetic agent can be administered continuously in

low doses, intermittently on a schedule, oron demand as the patient requires it, and is

often combined with theepidural administration of opioids. Surgical patients treated with

this combination experience fewer complications after surgery, ambulate sooner, and

have shorter hospital stays than patients receiving standard therapy (Correll, Viscusi,

Grunwald et al., 2001).

OPIOIDS

The goal of administering opioids is to relieve pain and improve quality life; therefore, theroute

of administration, dose, and frequency are determined on an individual basis.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

- Are thought to decrease pain by inhibiting cyclo-oxygenase (COX), the rate-limiting

enzyme involved in the production of prostaglandin from traumatized or inflamed tissues.

Two types ofCOX

1. COX-1 : is involved with mediating prostaglandin formation involved in the maintenance of

physiologic functions.

2. COX-2 : mediates prostaglandin formation that results in symptoms of pain, inflammation,

and fever.


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ROUTES OF ADMINISTRATION

1. PARENTERAL produces effects morerapidly than oral administration, but theseeffects

are of shorter duration. (Indicated in patients who are not permitted oral intake or is

vomiting)

a. Intramuscular

b. Intravenous

c. Subcutaneous

2. ORALROUTE preferred over parenteral administration because it is easy, non-

invasive, and not painful

3. RECTALROUTE indicated in patients who cannot take medications by any other

route or with bleeding problems such as hemophilia. The onset of action of opioids

administered is unclear but is delayed compared with other routes of administration.

Similarly, the duration of action is prolonged.

4. TRANSDERMALROUTE has been used to achieve a consistent opioid serum level

through absorption of the medication via the skin. This route is most often used for

cancerpatients who are at home or in hospicecare and who havebeen receiving oralsustained-release morphine.

5. TRANSMUCOSALROUTE used in periods called breakthrough pain, an oral dose

of a short-acting transmucosal opioid that has a rapid onset of action.

6. INTRASPINAL & EPIDURAL ROUTES used for effective control of pain in

postoperative patients and those with chronic pain unrelieved by othermethods.

NEUROLOGIC AND NEUROSURGICAL APPROACHES

- In some situations, especially with long-term and severe intractable pain, usual

pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those

situations, neurologic and neurosurgical approaches to pain management may be

considered. Intractable pain refers to pain that cannot be relieved satisfactorilyby the

usual approaches, including medications. Such pain usually is theresult of malignancy

(especially of thecervix, bladder, prostate, and lowerbowel), but it may occur in other

conditions, such as postherpetic neuralgia, trigeminal neuralgia, spinal cord

arachnoiditis, and uncontrollable ischemia and otherforms of tissue destruction.

3 Neurologic and Neurosurgical Methods forPain Relief

STIMULATION PROCEDURES- Electrical stimulation, orneuromodulation, is a method of suppressing pain by applying

controlled low-voltage electrical pulses to the different parts of the nervous system.

Electrical stimulation is thought to relieve pain by blocking painful stimuli (the gate

control theory).

ADMINISTRATION OF INTRASPINALOPIOIDS (see previous discussion)


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INTERRUPTION OF PAIN PATHWAYS

- A treatment that is considered permanent other than stimulation procedures which are

reversible.

y RHIZOTOMY sensory nerve roots are destroyed where theyenter the spinal

cord. A lesion is made in the dorsal root to destroy neuronal dysfunction and

reduce nociceptive input. With the advent of microsurgical techniques, thecomplications are few, with mild sensory deficits and mild weakness.

y NERVE BLOCK

A. Epidural Anesthesia blocks sensory, motor, and autonomic

functions, but it is differentiated from spinal anesthesia by the injection

site which is the spinal canal in the space surrounding the dura mater,

and the amount of anesthetic used.

B. Spinal Anesthesia is a type ofextensiveconduction nerveblock that

is produced when a local anesthetic is introduced into the

subarachnoid space at the lumbar level, usuallybetween L4 and L5.

y NEURECTOMY

y SYMPATHECTOMY

NURSING INTERVENTIONS

The specific nursing care of patients who undergo neurologic and neurosurgical procedures for

the relief of chronic pain depends on the type of procedure performed, its effectiveness in

relieving the pain, and thechanges in neurologic function that accompany the procedure. After

the procedure, the patients pain level and neurologic function are assessed. Other nursing

interventions that maybe indicated include positioning, turning and skin care, bowel and bladder

management, and interventions to promote safety. Pain management remains an important

aspect of nursing care with each of these procedures.

PROMOTING HOME AND COMMUNITY-BASED CARE

In preparing the patient and family to manage pain at home, the patient and family need

to be taught and guided about what type of pain or discomfort to expect, how long the

pain is expected to last, and when the pain indicates a problem that should bereported.

TEACHING PATIENTSSELF-CARE

y The patient and family need to understand the purposes of each medication, the

appropriate time to use it, the associated sideeffects, and strategies that can be used to

prevent these problems. The patient and family often need reassurance that pain can besuccessfully managed at home.

y Inadequatecontrol of pain at home is a common reason people seek health care orare

readmitted to the hospital.

y Opportunities are provided for the patient and family members to practice administering

the medication until they arecomfortable and confident with the procedure.

Education for patients and families must stress the need for keeping analgesic agents

away from children, who might mistake them forcandy.


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CONTINUING CARE

A referral to a homecare nurse is indicated to patients who arereceiving parenteral or

intraspinal analgesia at home. The homecare nurse makes a home visit to asses the

patient and to determine if the pain management program is being implemented and if

the technique for injecting or infusing the analgesic agent is being carried out safely and

effectively.

REASSESSMENTS

An important aspect of caring for the patient in pain is reassessing the pain after the

intervention has been implemented. The measures effectiveness is based on the

patients assessment of pain, as reflected in pain assessment tools. If the intervention

was ineffective, the pain relief goals need to be reassessed in collaboration with the

physician. The nurse serves as a patient advocate in obtaining additional pain relief.

EVALUATION

Expected Patient Outcomes

1. Achieves pain relief

2. Patient orfamily administers prescribed analgesic medications correctly

3. Uses nonpharmacologic pain strategies as recommended

4. Reports minimal effects of pain and minimal sideeffects of interventions


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REFERENCES:

Brunner & Suddarths (MEDICAL-SURGICAL NURSING) Vol. 1; 10th Edition pages 216-245By: SuzanneC. Smeltzerand Brenda G. Bare

Adele Pillitteri Maternal & Child Health Nursing (Care of the Childbearing &ChildrearingFamily) Vol. 2; 3rd Edition

FUNDAMENTALS OF NURSING (Concepts, Process, and Practice) 7th EditionBy: Barbara Kozier, Glenora Erb, Audrey Berman & Shirlee Snyder

pain management hc

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