Lecture Notes - Patient Care Concepts Applied to Nursing

Prepared by: Karlene Wan (Miss) - December 2016

Pain

Objective (1) State the Definition of Pain

Pain is “an unpleasant sensory or emotional experience associated with
actual or potential tissue damage, or described in terms of such damage”,
American Pain Society as cited in Berman & Snyder (2012).

Objective (2) Differentiate between chronic and acute Pain

Acute Pain Chronic Pain

1. Pain behaviour - exhibited(eg.crying) not exhibited

2. Nervous Stimulation - sympathetic system parasympathetic system

3. Relation to - pain resolves with continues beyond the

tissue injury tissue healing healing period
4. Reporting pain - usually reported often not reported

5. Emotional response - may be restless likely to be withdrawn

and anxious and depressed

Objective (3) Outline various misconceptions about pain

 Misconception - young children/ infants lack the nervous system development to

sense pain
Fact - young children can and do sense pain. The challenge for nurses/
doctors is that they are unable to verbalize their feelings

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  Misconception –the nurse or doctor are the best persons to determine the presence and
severity of pain
Fact - the patient is the best person to determine the presence and
severity of pain
 Misconception - patients with a low pain tolerance should make more effort to cope
with pain and should not receive as much pain medication as they
desire.
 Fact - It has been shown by research that doctors do not like patients
who are unable to bear pain. However doctors / nurses should not
impose their own values on the patients.
 Misconception - visible signs of pain (eg.crying, holding the area, grimacing) can be
used to confirm the presence and severity of pain.
 Fact - lack of visible expression of pain, does not mean absence of pain.
The response to pain is influenced by different factors.

Objective (4) Describe factors affecting pain perception

 Culture - influences a person’s behaviour, values and attitudes, including pain.

Some cultures consider it appropriate to readily express pain, whereas

other groups expect a stoic response, which is to bear the pain without

complaining.

 Ethnic Influences - each ethnic group perceives pain differently. For example, in

some cultures, pain is viewed as an imbalance between

Yin and Yang (Chinese), whereas Mexicans consider it a

necessary part of life.

 Age - children pain express differently than adults –some may become irritable ,

and restless, while others may kick and scream.

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  Gender – boys are not encouraged to cry if in pain, rather they are expected to be

strong and brave. Girls on the other hand, are expected to cry and indeed

they are consoled and cuddled.

 Religious Beliefs – some person’s religious conviction is that pain is punishment

from God, whereas others have their faith shaken to think that a loving

God would allow them to experience pain. Either way, it will determine

how they will respond.

 Past Pain Experience –if persons had positive responses when they experienced pain

in the past, then they are likely to expect the same response when pain is

experienced again. The converse is also true, that persons who have had

negative /unpleasant experiences with pain, will anticipate pain more,

become distressed at the possibility of experiencing more pain and be less

able to cope with it.

 Anxiety and Other Stressors – when patients are anxious , pain is perceived as more

intense. For example, persons who are taught pre-operatively what to expect

In the post-operative period, experienced less need for analgesics. Also

When there is fatigue and muscular tension, pain perception may be

Increased.

 Environmental and Support Persons - the presence of loved ones tend to make the pain

more bearable for some, others don’t want their loved ones to see them in

pain . Also the unfamiliar and depersonalized environment of health care

facilities, may increase the pain perception.

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 Objective (5) Discuss various responses to pain

Responses to pain has three (3) components

- physiological

- behavioural

- affective

Physiological responses

The symptoms represent the activation of the flight or fight

response - sympathetic nervous system (SNS)

 Changes occur in the vital signs (over a short period –hours)

Increased pulse and B/P

Respiration - short and shallow breathing

 Pupillary dilation

 Muscle tension and rigidity

 Increased adrenalin

 Increased blood glucose

Behavioural (voluntary ) response

 Withdrawal from the pain stimulus

 Restlessness

 Protecting the area

 A reluctance to move

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Affective (psychological) response

 Crying

 Withdrawal

 Anxiety depression

 Fear

 Anger

 Powerlessness

 Hopelessness

Objective 6: List the consequences of unrelieved pain

 CNS - increased sensitivity to pain

- the development of chronic pain syndrome

- sleep disturbances

 Respiratory – the short shallow breathing leads atelectasis (collapse of the lung). This

in turn reduces the oxygen levels, resulting in increased myocardial

workload.

 GI - loss of appetite

 Immune - healing of ulcers slowed

- increased susceptibility to infections

 Musculo-Skeletal – reduced mobility leading to muscle atrophy and painful spasms

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Objective 7: Identify pain scales utilized for various age groups

 Pain scales are used to assess the intensity of pain. Commonly used ones are outlined.

For children 2 months to seven (7) years, a behavioural scale is used –FLACC

F - facial expression

L - leg movement

A – activity

C – crying

C – consolability

 For children who are not yet able to speak, older adults, persons who are cognitively

impaired, or don’t speak, the Wong-Baker scale is used. It shows a series of faces in

various stages of distress. The person in pain can then point to the one that best

reflects how they are feeling.

 For children seven (7) years to adults, a numeric scale is used. It is numbered from 0

to 10 with zero being the lowest and ten being the highest. The person in pain can

then indicate which number best reflects how they are feeling.

 Pain levels – 1-2 mild

3-4 moderate

4-6 moderate to severe

6-7 severe

8-10 very severe

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Objective 8: Apply nursing and non-pharmacological management of the patient with

Pain

 Distraction - removes the focus from the pain , thereby reducing the perception

of pain

- Listening to music -can be soothing , relaxing , distracting from the pain

perception

- Imagery - can decrease the pain sensation by focussing on something. Example,

imagining the quiet flow of a river, or recalling a happy time.

 Relaxation techniques - stress causes an increase in pain. Relaxation techniques help

reduce pain by reducing the muscle tension -example

deep breathing exercises.

 Massage - increases superficial circulation, thereby decreasing

muscle tension, which in turn reduces pain intensity. It

also has the effect of decreasing anxiety.

 Immobilization - of the body part, example a fracture. Pain is reduced when

normal body alignment is maintained.

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Objective 9: Discuss medical and pharmacological management of the patient with

Pain

Pain relieving drugs (analgesics) are the mainstay of the pharmacological management of the

patient with pain. Three (3) classes of analgesics are used.

 Non-opioids - used for mild to moderate pain, example

– Acetaminophen (Panadol)

- non-steroidal analgesics (NSAIDS ) eg. aspirin and voltaren

- common side effects –GI disturbances (indigestion and bleeding)

and masking the signs of infection .

 Opioids - used for moderate to severe pain, example

(Narcotics) - Pethidine

- Morphine

- Common side effects – respiratory depression, sedation (often

a desirable side effect), nausea and constipation

 Adjuvant drugs - are drugs used for other purposes, but which can enhance the

effect of opioids, thereby increasing the pain relieving effect.

They are best used for treatment of neuropathic pain. These drugs

may also lessen the side effects of the opioids, as well as reduce

anxiety about the pain.

Examples – anti-convulsants, and antidepressants

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 References

Berman, A. & Snyder, S.(2012). Kozier and Erb’s Fundamentals of nursing : Concepts,

process and practice (9th ed. ) .Upper Saddle River , NJ :Pearson

Taylor, C.R., Lillis, C., Lemone, P., &Lynn,P. (2011). Fundamentals of nursing : The art and

science of nursing care (7thed.) . Philadelphia, PA :Wolters Kluwer Health /

Lippincott,Williams and Wilkins

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