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Friday, November 26, 2010

Acute Pain

 Acute Pain

NANDA Definition
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.


Discussion of the Problem
Pain, the fifth vital sign, is a very covert condition in which a range of unpleasant sensations and a wide variety of upsetting factors may be experienced by the patient. It is the most common reason for seeking health care. Pain occurs as the result of many disorders, diagnostic tests, and treatments. Medical conditions that causes pain are as follows: hypertension, angina, myocardial infarction, thromboplebitis, DVT, pneumonia, lung cancer, ruptured intervertebral disc, upper GI bleeding, esophageal bleeding, pancreatitis, sickle cell crisis, peritonitis, renal calculi, fractures, burns, AIDS, cancer and end of life condition. Surgical interventions such as gastrectomy, cardiac surgery, thyroidectory, mastectomy and the likes also cause pain. In addition, it may also arise from emotional, psychological, cultural, or spiritual distress. Its highly subjective nature means that its assessment and management presents challenges to nurse. The description of pain is a social transaction; thus, assessment and management of it require a good rapport of the nurse and the patient.

Nursing Interventions Classification (NIC)
  • Analgesic Administration
  • Conscious Sedation
  • Pain Management
  • Patient-Controlled Analgesia Assistance

Nursing Outcomes Classification (NOC)
  • Comfort Level
  • Medication Response
  • Pain Control

Goal and Objectives
  • Patient will demonstrate relaxed body posture, facial expression, ability to rest or sleep appropriately and engage in desired activity and other methods to promote comfort
  • Patient will demonstrate use of non-pharmacological pain management
  • Patient will follow prescribed pharmacological regimen
  • Patient will verbalize methods that provide pain relief
  • Patient will verbalize sufficient relief of pain or ability to cope with incompletely relieved pain.

Subjective and Objective Data
  • Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
  • Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)
  • Changes in sleep patterns; physical/social withdrawal
·         Facial grimacing
  • Facial mask of pain; distraction
  • Guarding behavior, protecting body part
  • Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
  • Patient reports pain with varying in frequency, duration, and intensity (especially as condition worsens)
  • Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
  • Self-focused

Related Factors
·         Accumulation of fluid in abdominal/peritoneal cavity (abdominal distension)
·         Cancer invasion of pleura, chest wall
·         Cellular reactions to circulating toxins
·         Chemical contamination of peritoneal surfaces by pancreatic exudate/autodigestion of pancreas
·         Chemical irritation of the parietal peritoneum (toxins)
·         Chronic physical disability
·         Decreased myocardial blood flow
·         Diminished arterial circulation and oxygenation of tissues with production/accumulation of lactic acid in tissues
·         Extension of inflammation to the retroperitoneal nerve plexus
·         Increased cardiac workload/oxygen consumption
·         Infusion of cold or acidic dialysate, abdominal distension, rapid infusion of dialysate
·         Insertion of catheter through abdominal wall/catheter irritation, improper catheter placement
·         Intraoperative nerve trauma
·         Irritation/infection within the peritoneal cavity
·         Manipulation of injured tissues, e.g., wound debridement
·         Mediastinal incision and/or donor site (leg/arm incision)
·         Movement of bone fragments, edema, and injury to the soft tissue
·         Muscle spasms
·         Myocardial ischemia (acute MI, angina)
·         Obstruction of pancreatic, biliary ducts
·         Peripheral neuropathies, myalgias, and arthralgias
·         Persistent coughing
·         Physical agent: surgical manipulation, edema, inflammation, harvesting of bone graft
·         Presence of chest tube(s)
·         Side effects of various cancer therapy agents
·         Surgical interruption/manipulation of tissues/muscles
·         Tissue inflammation/edema formation
·         Tissue ischemia (coronary artery occlusion)
·         Traction/immobility device
  • Pain resulting from:
Ø  medical problems
Ø  diagnostic procedures or medical treatments
Ø  trauma
Ø  Physical factors: e.g., disruption of skin/tissues (incisions/drains)
Ø  emotional factors
Ø  psychological factors: e.g., fear, anxiety
Ø  spiritual, or cultural distress
Ø  biological: activity of disease process (cancer, trauma)

Assessment (Dx)
  • Assess pain characteristics:
    1. Quality: is it sharp, burning, or shooting
    2. Severity: scale of 1 to 10, with 1 being least severe and 10 being the most severe. Other methods were provided below.
    3. Location: ask the patient to point is with his/her index finger
    4. Onset: is it sudden or gradual
    5. Duration: is it intermittent or continuous
    6. Precipitating factors: e.g. moving in bed
    7. Relieving factors: e.g. lying in bed








Pain Assessment Tools Neonatal/Infant Pain Scale (NIPS)
(Recommended for children less than 1 year old) - A score greater than 3 indicates pain
Pain Assessment
Score
Facial Expression


0 – Relaxed muscles
Restful face, neutral expression

1 – Grimace
Tight facial muscles; furrowed brow, chin, jaw, (negative facial expression – nose, mouth and brow)

Cry


0 – No Cry
Quiet, not crying

1 – Whimper
Mild moaning, intermittent

2 – Vigorous Cry
Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidenced by obvious mouth and facial movement.

Breathing Patterns


0 – Relaxed
Usual pattern for this infant

1 – Change in Breathing
Indrawing, irregular, faster than usual; gagging; breath holding

Arms


0 – Relaxed/Restrained
No muscular rigidity; occasional random movements of arms

1 – Flexed/Extended
Tense, straight legs; rigid and/or rapid extension, flexion

Legs


0 – Relaxed/Restrained
No muscular rigidity; occasional random leg movement

1 – Flexed/Extended
Tense, straight legs; rigid and/or rapid extension, flexion

State of Arousal


0 – Sleeping/Awake
Quiet, peaceful sleeping or alert random leg movement

1 – Fussy
Alert, restless, and thrashing

 
Children's Hospital Eastern Ontario Pain Scale (CHEOPS)
(Recommended for children 1-7 years old) - A score greater than 4 indicates pain 
Item
Behavioral
 
Definition
Score

Cry

No cry
1
Child is not crying.
 
 
Moaning
2
Child is moaning or quietly vocalizing silent cry.
 
 
Crying
2
Child is crying, but the cry is gentle or whimpering.
 
 
Scream
3
Child is in a full-lunged cry; sobbing; may be scored with complaint or without complaint.
 
Facial
Composed
1
Neutral facial expression.
 
 
Grimace
2
Score only if definite negative facial expression.
 
 
Smiling
0
Score only if definite positive facial expression.
 
Child Verbal
None
1
Child not talking.
 
 
Other complaints
1
Child complains, but not about pain, e.g., “I want to see mommy” of “I am thirsty”.
 
 
Pain complaints
2
Child complains about pain.
 
 
Both complaints
2
Child complains about pain and about other things, e.g., “It hurts; I want my mommy”.
 
 
Positive
0
Child makes any positive statement or talks about others things without complaint.
 
Torso
Neutral
1
Body (not limbs) is at rest; torso is inactive.
 
 
Shifting
2
Body is in motion in a shifting or serpentine fashion.
 
 
Tense
2
Body is arched or rigid.
 
 
Shivering
2
Body is shuddering or shaking involuntarily.
 
 
Upright
2
Child is in a vertical or upright position.
 
 
Restrained
2
Body is restrained.
 
Touch
Not touching
1
Child is not touching or grabbing at wound.
 
 
Reach
2
Child is reaching for but not touching wound.
 
 
Touch
2
Child is gently touching wound or wound area.
 
 
Grab
2
Child is grabbing vigorously at wound.
 
 
Restrained
2
Child's arms are restrained.
 
Legs
Neutral
1
Legs may be in any position but are relaxed; includes gentle swimming or separate-like movements.
 
 
Squirm/kicking
2
Definitive uneasy or restless movements in the legs and/or striking out with foot or feet.
 
 
Drawn up/tensed
2
Legs tensed and/or pulled up tightly to body and kept there.
 
 
Standing
2
Standing, crouching or kneeling.
 
 
Restrained
2
Child's legs are being held down.
 
 
FLACC SCALE 

CATEGORIES

SCORING
 
0
1
2
FACE
No particular expression or smile
Occasional grimace or frown, withdrawn, disinterested.
Frequent to constant quivering chin, clenched jaw.
LEGS
Normal position or relaxed.
Uneasy, restless, tense.
Kicking, or legs drawn up.
ACTIVITY
Lying quietly, normal position moves easily.
Squirming, shifting back and forth, tense.
Arched, rigid or jerking.
CRY
No cry, (awake or asleep)
Moans or whimpers;
occasional complaint
Crying steadily, screams or sobs, frequent complaints.
CONSOLABILITY
Content, relaxed.
Reassured by occasional touching hugging or being talked to, distractable.
Difficulty to console or comfort









  • Assess degree of personal adaptation to diagnosis, such as the following: anger, irritability, withdrawal, and acceptance. The motioned factors are variable and usually affect the perception of pain or capability to cope and need for pain management.

  • Assess patient’s eagerness or capability to explore a variety of techniques intended at controlling pain. Some patients will sense uncomfortable exploring other methods of pain relief. Nevertheless, patients need to be educated that there are numerous ways to manage pain.

  • Assess patient’s outlook for pain relief. Some patients may be satisfied to have pain diminished, while others will anticipate total elimination of pain. Their expectation affects their perceptions of the effectiveness of the management modality and their willingness to partake in additional managements.

  • Determine patient’s reaction to pain and medications meant to abolish or relieve pain. It is important to help patients convey as accurately as possible the effect of pain relief procedures. Discrepancies between behavior or appearance and what patient coveys about pain relief may be more a manifestation of other methods patient is utilizing to cope with than pain relief itself.

  • Determine patient’s understanding of or preference for the array of pain-relief management available. Some patients may be uninformed of the usefulness of nonpharmacological methods and may be willing to try them alone or in combination with traditional analgesic medications.

  • Determine to what extent cultural, environmental, intrapersonal, and intrapsychic factors may add to pain or pain relief. The mentioned variables may alter the patient’s expression of his or her experience. It is important that nurses should not stereotype any patient reaction but rather appraise the unique response of each patient.

  • Monitor signs and symptoms related with pain, such as the following: ability to focus BP, color and moisture of skin, heart rate, temperature, and restlessness. Some patients deny the presence of pain. Notification of associated signs may help the nurse to evaluate pain.

  • Note for possible cause of pain. Depending on etiological factors pain responds better to different managements.

  • Note: If patient is getting epidural analgesia, evaluate the following:
1)     Numbness, tingling sensation in extremities, a metallic taste in the mouth. These symptoms may indicate an allergic response to the anesthesia agent, or an improper catheter placement.
2)     Pain relief. Intermittent epidurals need to be released at intervals.
3)     Potential epidural analgesia complications such as the following: excessive sedation, respiratory distress, urinary retention, or catheter migration. Intravascular infusion of anesthesia and respiratory depression can be potentially life-threatening.

Therapeutic Interventions (Tx)
  • Anticipate necessitate for pain relief. By preventing pain, one can most effectively deal with it. Early intervention may reduce the total quantity of analgesic required.

  • Eradicate sources of discomfort or additional stressors whenever possible. Patients may experience an increased intensity of pain or a reduced ability to tolerate painful stimuli if the milieu or intrapersonal are further stressing them.

  • Give details about the procedures before initiating them. Permits patient to set up mentally for activity and to partake in controlling level of discomfort.

  • Give rest periods to make comfort, relaxation, and sleep possible. The patient’s perception of pain may become more intense as the result of fatigue. Pain may result in fatigue in a cyclic fashion, which may result in increased pain intensity and tiredness. A quiet atmosphere, a darkened room, and a disconnected phone are all methods aimed toward promoting rest.

  • Place important items within easy reach. This prevents the risk or straining to reach.

  • Take action promptly to complaint of pain. Amidst painful experiences a patient’s awareness of time may become vague. Immediate responses to complaints may result in reduced anxiety in the patient. In addition, a trusting relationship is developed, when the nurse demonstrates concern for patient’s welfare and comfort.

  • Pharmacological methods:
I. Nonsteroidal anti-inflammatory drugs (NSAIDs) that may be given orally or parenterally
II. Utilization of opiates (orally, intramuscularly, subcutaneously, intravenously, patient-controlled analgesia (PCA) systems, or epidurally) Narcotics are given for severe pain, especially in the hospice or home setting.
III. Local anesthetic agents.

  • Nonpharmacological methods:
IV. Cognitive-behavioral strategies:
1.     Biofeedback, breathing exercises, music therapy
2.     Distraction techniques. Focuses the patient’s concentration upon non-painful stimuli to diminish one’s perception and experience of pain.
3.     Imagery. This uses mental picture or imagination of an event. It involves the use of the five senses to divert oneself from painful stimuli.
4.     Offer quiet, dimly lit room
5.     Relaxation exercises. These are techniques used to bring about a condition of physical and mental consciousness and calmness. The objective of these techniques is to decrease tension, then reducing pain.
V. Cutaneous stimulation:
1.     Hot or cold compress. Hot, humid compresses have a penetrating effect. The heat rushes blood to the affected region to promote healing. Cold compresses may lessen total edema and promote some numbing, thus promoting comfort.
2.     Massage and back rubs of affected area if possible. Massage and back rubs reduce muscle tension and can promote comfort.
3.     Transcutaneous electrical nerve stimulation (TENS) units

  • Administer analgesics as ordered, assessing effectiveness and noting for any signs and symptoms of undesired effects. Pain medications are absorbed and metabolized differently in every patient, so their efficacy must be assessed on a patient to patient basis. Analgesics may root untoward effects that range from mild to life-threatening.

  • Engage patient in determining his/her schedule for activities, treatments, drug administration. This strengthens the patient’s coping mechanisms and enhances his/her sense of control.

  • Notify physician if management are ineffective or if present complaint a significant change from patient’s previous experience of pain. Patients who ask for pain medications at often intervals than prescribed may actually need higher doses or more potent analgesics.

  • Propose to the patient to assume position of comfort while lying in bed or sitting in chair. May alleviate pain and improve circulation, in addition, positioning relieves muscle tension.

  • Reassure patient whenever possible, that pain is time-limited and that there are multiple approaches to reduce pain. When pain is supposed as never-ending and unresolvable, patient may give up and experience a sense of despair and loss of control.

Educative (Edx)
  • Educate patient efficient timing of medication dose in relation to probable uncomfortable activities and avoidance of peak pain periods.

  • Encourage patient to express concerns. Active-Listen these concerns and offer support by acceptance, staying with patient and providing appropriate information. Lowering anxiety level can uphold relaxation or comfort. This also permits outlet of emotions and may augment coping mechanisms.

  • Explicate origin of pain or discomfort, if known. This helps in enhancing patient’s coping ability and may lessen anxiety.

  • Instruct in/encourage proper body mechanics or body posture. Prevents stress on muscles and avoids further worsening of injury.

  • Instruct patient to assess and report efficacy of measures used. Persuade enough medication to control pain; change medication or time span as appropriate. Pain perception and pain relief are covert; therefore management of pain is best left to patient’s judgment. However, if patient is not capable to provide input, the nurse should monitor physiological and nonverbal cues of pain and administer medications on a standard basis.

  • Instruct patient to report pain promptly. This is so that relief procedures may be instituted immediately. Postponement in reporting pain hinders pain relief or may necessitate augmented dosage of medication to attain relief. Further, severe pain may induce shock by provoking sympathetic nervous system, thus creating more damage and interfering with diagnostics and relief of pain.

  • Offer anticipatory instruction on pain causes, appropriate prevention, and relief procedures.

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