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  1. PAIN—the "fifth vital sign" in the care of clients; a complex subjective sensation; unpleasant sensory and emotional experience associated with real or potential tissue damage. Pain is considered to be whatever the person experiencing it says it is, existing whenever he or she says it does.
    1. Classifications:
      1. Acute pain: lasts typically less than 1 month; characterized by: tachycardia, tachypnea, increased BP, diaphoresis, dilated pupils. Responsive to analgesics.
      2. Chronic pain: persists or is recurring for longer than 3 months; often characterized by: lassitude, sleep disturbance, decreased appetite, weight loss, diminished libido, constipation, depression. Rarely responsive to analgesics.
      3. Somatogenic (organic/physiological):
        1. Nociceptive: somatic or visceral pain—sensations, normal pain transmission, such as aching or pressure (e.g., cancer pain, chronic joint and bone pain).
        2. Neuropathic: aberrant processes in peripheral and/or central nervous system; part of a defined neurological problem; sensations such as sharp, burning, shooting pain (e.g., nerve compression, polyneuropathy, central pain of stroke, phantom pain after amputation).
      4. Psychogenic (without organic pathology sufficient to explain pain).
    2. Components of pain experience—pain related to:
      1. Stimuli—sources: chemical, ischemic, mechanical trauma, extremes of heat/cold.
      2. Perception—viewed with fear by children, can be altered by level of consciousness, interpreted and influenced by previous and current experience, is more severe when alone at night or immobilized.
      3. Response—variations in physiological, cultural, and learned responses; anxiety is created; pain seen as justified punishment; pain used as means for attention-getting.
    3. Assessment:
      1. Subjective data (Table 6.10. Required Pain Assessment on Admission for Clients Who are Hospitalized):
        1. Site—medial, lateral, proximal, distal.
        2. Strength:
          1. Certain tissues are more sensitive.
          2. Change in intensity.
          3. Based on expectations.
          4. Affected by distraction or concentration, state of consciousness.
          5. Described as: slight, medium, severe, excruciating.
        3. Quality—aching, burning, crushing, dull, piercing, shifting, throbbing, tingling.
        4. Antecedent factors—physical exertion, eating, extreme temperatures, physical and emotional stressors (e.g., fear).
        5. Previous experience—influences reaction to pain.
        6. Behavioral clues—demanding, worried, irritable, restless, difficult to distract, sleepless.
      2. Objective data:
        1. Verbal clues—moaning, groaning, crying.
        2. Nonverbal clues—clenching teeth, grimacing; splinting of body parts, body position, knees drawn up, involuntary reflex movements; tossing/turning, rhythmic rubbing movements; voice pitch and speed; eyes shut.
        3. Physical clues—breathing irregularities, abdominal distention; skin color changes, skin temperature changes; excessive salivation, perspiration.
        4. Time/duration—onset, duration, recurrence, interval, last occurrence.
    4. Analysis/nursing diagnosis:
      1. Pain, acute or chronic, related to specific client condition.
      2. Activity intolerance related to discomfort.
      3. Sleep pattern disturbance related to pain.
      4. Fatigue related to state of discomfort or emotional stress.
      5. Ineffective individual coping related to chronic pain.
    5. Nursing care plan/implementation:
      1. Goal: provide relief of pain.
        1. Assess level of pain; ask client to rate on scale of 0 to 10 (0 = no pain; 10 = worst pain) or smiling/sad faces. Use age-, condition-, and language-appropriate scale (Table 6.11. Format for Assessing Pain).
        2. Determine cause and try nursing comfort measures before giving drugs:
          1. Environmental factors: noise, light, odors, motion.
          2. Physiological needs: elimination, hunger, thirst, fatigue, circulatory impairment, muscle tension, ventilation, pressure on nerves.
          3. Emotional: fear of unknown, helplessness, loneliness (especially at night).
        3. Relieve: anger, anxiety, boredom, loneliness.
        4. Report sudden, severe, new pain; pain not relieved by medications or comfort measures; pain associated with casts or traction.
        5. Remove pain stimulus:
          1. pillImageAdminister pain medication—nonopioids: NSAIDs—ketorolac (Toradol); opioids: first-line analgesics include morphine, hydromorphone, fentanyl, oxycodone, hydrocodone (see Table 8-13. Properties of Selected Analgesic Agents ); adjuvants: local anesthetics, sedatives, muscle relaxants; give at appropriate time intervals; do not withhold due to overestimated danger of addiction.
          2. Avoid cold (to reduce immediate tissue reaction to trauma).
          3. Apply heat (to relieve ischemia).
          4. Change activity (e.g., restrict activity in cardiac pain).
          5. Change, loosen dressing.
          6. Comfort (e.g., smooth wrinkled sheets, change wet dressing).
          7. Give food (e.g., for ulcer).
          8. Decrease stimulation (e.g., ↓ bright lights, noise, temperature).
        6. Reduce pain receptor reaction.
          1. pillImageOintment (use as coating).
          2. Local anesthetics.
          3. Padding (of bony prominences).
        7. Assist with medical-surgical interventions to block pain impulse transmission:
          1. Injection of local anesthetic into nerve (e.g., dental).
          2. Cordotomy—sever anterolateral spinal cord nerve tracts.
          3. Electrical stimulation—transcutaneous (skin surface), percutaneous (peripheral nerve).
          4. Peripheral nerve implant—electrode to major sensory nerve.
          5. Dorsal column stimulator—electrode to dorsal column.
        8. Minimize barriers to effective pain management:
          1. pillImageAchieve "balanced analgesia"; around-the-clock administration of NSAIDs or acetaminophen if possible, continuous infusion, patient-controlled analgesia (PCA); combination therapy (opioids, nonopioids, adjuvants).
          2. Accept client and family report of pain.
          3. Discuss fear of addiction with client family (incidence <1% when opioids taken for pain relief).
          4. Discuss fear of respiratory depression with staff; preventable; related to sedation.
        9. Document response to pain relief measures.
      2. Goal: use nonpharmacological methods to reduce pain.
        1. Distraction, such as TV (cerebral cortical activity blocks impulses from thalamus).
        2. Aromatherapy—assists in relaxation.
        3. Hypnosis—assess appropriateness for use for psychogenic pain and for anesthesia; client needs to be open to suggestion.
        4. Acupuncture—assess emotional readiness and belief in it.
      3. Goal: alter interpretation and response to pain.
        1. pillImageAdminister narcotics—result: no longer sees pain as disturbing.
        2. pillImageAdminister hypnotics—result: changes perception and decreases reaction.
        3. Help client obtain interpersonal satisfaction from ways other than attention received when in pain.
      4. pillImageGoal: promote client control of pain and analgesia: patient-controlled analgesia (PCA), an analgesia administration system designed to maintain optimal serum analgesia levels; safely delivers intermittent bolus doses of a narcotic analgesic; preset to maximum hourly dose.
        1. Advantages: decreased client anxiety; improved pulmonary function; fewer side effects.
        2. Limitations: requires an indwelling intravenous line; analgesia targets central pain, may not relieve peripheral discomfort; cost of PCA unit.
      5. Goal: health teaching.
        1. Explain causes of pain and how to describe pain.
        2. Explain that it is acceptable to admit existence of pain.
        3. Relaxation exercises.
        4. Biofeedback methods of pain perception and control.
        5. Proper medication administration (PCA, continuous around-the-clock dosing), when necessary, for self-care.
    6. Evaluation/outcome criteria:
      1. Verbalizes comfort; awareness of pain decreased.
      2. Knows source of pain; how to reduce stimulus and perception.
      3. Uses alternative measures for pain relief.
      4. Able to cope with pain (e.g., remains active, relaxed appearance; verbal and nonverbal clues of pain absent).