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 of recent onset and commonly associated with a specific injury - lasting from seconds to 6 months. 2. CHRONIC PAIN constant or intermittent pain that persists beyond the expected healing time that can be seldom be attributed to specific cause or injury. - lasts for 6 months or longer 3. CANCER-RELATED PAIN - associated with the cancer, cancer treatment or not 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 their etiology.

HARMFUL EFFECTS OF PAIN 1. Effects of Acute Pain - Affect pulmonary, cardiovascular, gastrointestinal, endocrine and immune system increased metabolic rate and cardiac output impaired insulin response increased production of cortisol increased retention of fluids 2. Effects of Chronic Pain Suppression of the Immune Function may promote tumor growth - Depression, Disability, Anger, Fatigue Page 1

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 of bradykinin.

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Effects of Chemical Mediators - Vasodilation, Increased vascular permeability, redness, warmth and swelling of the injured area. FIRST ORDER NEURON travels from the periphery (skin, cornea, visceral organs) to the spinal cord via the DORSAL HORN Two Types of Fibers 1. A DELTA FIBERS smaller, myelinated fibers transmit nociception rapidly - produces the initial FAST PAIN 2. TYPE C FIBERS larger unmyelinated 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 are endogenous LAIMANE II Substancia gelatinosa DESCENDING CONTROL SYSTEM system of fibers that originate in the lower and midportion of the brain 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 CLASSIC GATE 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. LARGE DIAMETERS 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

PAST EXPERIENCE The way a person responds to pain is a result of many separate painful events during a lifetime. For some, past pain may have been constant and unrelenting, as in prolonged or chronic 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 never had severe pain may have no fear of such pain.

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ANXIETY AND DEPRESSION Although it is commonly believed 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 cancer pain. CULTURE Beliefs about pain and how to respond to it differ from one culture 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 other cultures help to avoid evaluating the patients behavior on the basis of ones own cultural expectations and values Regardless of the patients culture, nurses need to learn about that particular culture and be aware of power and communication issues that will affect care outcomes. AGE Age has long been the focus of research on pain perception and pain tolerance, and again the results have been inconsistent. Although some researchers have found that older adults require a higher intensity of noxious stimuli than do younger adults before they report pain (Washington, Gibson & Helme, 2000), others have found no differences in responses of younger and older adults (Edwards & Fillingim, 2000). GENDER Researchers have studied gender differences in pain levels and in response to pain, and the results have been still inconsistent. In a study of responses of men and women to chronic pain and anxiety, Edwards, Auguston and Fillingim (2000) noted no difference between genders regarding pain and depression. There was, however, a difference in anxiety and gender, with men being more anxious about their pain. PLACEBO EFFECT A placebo effect occurs when a person responds to the medication or other treatment because of an expectation that the treatment will work rather than because it actually does so. Page 5

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 any effect.

B. Nursing Assessment of Pain

1. Characteristics of Pain
INTENSITY from non to mild discomfort to excruciating PAIN THRESHOLD smallest stimulus for which a person reports pain PAIN TOLERANCE maximum amount of pain a person can tolerate TIMING onset, duration, relationship between time and intensity, and whether there are changes in rhythmic patterns LOCATION best determined by having the patient point to the area of the body 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 or stabbing can be offered PERSONAL MEANING Patients experience pain differently, and the pain experience can mean many different things. The meaning attached to the pain experience helps the nurse 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 same behavior.

2. Instruments for Assessing 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 Page 6

 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 or frown, withdrawn, disinterested

Frequent to constant quivering of chin, clenched jaw

Leg

Normal relaxed

position,

Uneasy, restless, tense

Kicking, or drawn up

legs

Activity

Lying quietly, normal position, moves easily

Squirming, and forth

shifting

back

Arched, rigid, or jerking

Cry

No cry

Moans or whimpers, complains occasionally

Cries steadily, screams or sobs, complains frequently Difficult to console or comfort

Consolability

Content, relaxed

Reassured by constant hugging, or being talked to, can be distracted

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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 - similar to the Wong-Baker Pain Rating Scale but 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 age children 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 Assessment Scales

1. Use appropriate pain assessment tool. 2. Use pain assessment tools consistently. 3. When a person with pain is cared for at home by family caregivers, teach the patient and the family caregivers 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 the child. U Use pain rating scales. E Evaluate behavior and physiological changes. S Secure parents involvement. T Take cause of pain into account. Take action and evaluate results Page 9

Adult Pain Assessment

Mnemonics for Adult Pain Assessment OLDCART O Onset L Location D Duration C Characteristics A Aggravating Factors R Relieving Factors T Treatment PQRST P Provoked Q Quality R Region or radiation S Severity T Timing

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 body requirements 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) Page 10

2. Assessing the Effectiveness of these interventions 3. Monitoring for Adverse Effects 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 may be accomplished by pharmacologic or nonpharmacologic means, but most success will be achieved with a combination of both. 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 are essential to success, and it is essentially characterized by trust. By conveying to the patient the belief that he or she has pain, the nurse often helps reduce the patients anxiety. Teaching patients about pain and strategies to relieve it may reduce pain in the absence of other pain relief measures and may enhance the effectiveness of the pain relief measures 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 the efforts 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 may become increasingly anxious. Teaching the patient about the nature of the impending painful experience and the ways to reduce pain often decreases anxiety. Anxiety resulting from anticipation of pain or the pain experience itself may often be managed effectively by establishing a relationship with the patient and by patient teaching. A patient who is anxious about pain may be 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 the only one. Nonpharmacological nursing activities can assist in relieving pain with usually low risk to the patient. Although such measures are not a substitute for medication, they may be all that is necessary or appropriate to relieve episodes of pain lasting only seconds or minutes. 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 may be effective pain relief strategies in some circumstances; however, their effectiveness and mechanism of action need further study. Proponents believe that ice and heat stimulate the non-pain receptors in the same receptor field 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 gate control theory of pain and explains the effectiveness of cutaneous stimulation when applied in the same area as an injury. 3. Psychoeducational Approaches Cognitive Behavioral Techniques - are used to reduce the bodys unproductive responses to stress, helping to relieve pain or improve the ability to tolerate it. DEEP BREATHING AND PROGRESSIVE MUSCLE RELAXATION Skeletal muscle relaxation is believed to reduce pain by relaxing 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 by counting 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, rhythmic breathing may also be used as a distraction technique. GUIDED IMAGERY Guided imagery is using ones imagination in a special way to achieve a specific positive effect. If guided imagery is to be effective, it requires a considerable amount of time to explain the technique and time for the patient to practice.  NURSING CONSIDERATION The nurse instructs the patient to close the eyes 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 comfortable body. 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 yug meaning to bind or to yoke, is the uniting of all the powers of the body, mind, and spirit. Yoga is an approach to living a balanced life based on ancient teaching found in Hindu spiritual treatises (the Upanishads) 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 relieve both acute and chronic pain (Johnson & Petrie, 1997). Distraction is thought to reduce the perception of pain by stimulating the descending control system, resulting in fewer pain stimuli being transmitted to the brain. The effectiveness 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 particularly difficult 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 include but 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 the exception of macrobiotic dieting) are probably not harmful. However, they have yet to be proven effective by the standards used to evaluate the effectiveness of medical and nursing interventions.

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Despite the lack of scientific evidence that these therapies are effective, a patient may find any one of them helpful via the placebo response.  NURSING CONSIDERATION 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 may receive, the nurse encourages the patient to assess the effectiveness of the therapy continually 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  NURSING CONSIDERATION 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 y y y y y Amethyst aquamarine, turquoise rose quartz amber, topaz moonstone jasper, garnet, and ruby headaches, hangover neck and throat pain for heartaches, chest pains epigastric pain dysmenorrhea pain of the genitals

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Herbal Medicine
y y y y ginger eucalyptus fresh papaya juice aloe vera - insect bites, joint pain - muscle and joint pain - heartburn, ulcers, back pain - burns, cut

PHARMACOLOGIC INTERVENTIONS
Managing a patients pain pharmacologically is accomplished in collaboration with the physician or other primary care 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 for allergies to medications and nature of previous allergies.

b. Obtain medication history. (current, usual, or recent use of prescription or OTC drugs or herbal 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 administer analgesic medications is by asking the patient to rate the pain and by observing the response to medications. 1. Balanced Anesthesia refers to use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects. 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 for the patient to complain of pain then administer analgesia

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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 be based on the patients requirements rather than on an inflexible standard of routine. 5. Patient-Controlled Analgesia (PCA) used to manage postoperative pain as well as chronic pain. It allows patients to control the administration of their own medication within predetermined safety limits. 3 GENERAL CATEGORIES OF ANALGESICS LOCAL ANESTHETICS Work by blocking nerve conduction when applied directly to the nerve fibers. They can 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 be administered through an epidural catheter. Topical Application ex. Emulsion of Local Anesthetics (EMLA cream); to be effective, 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, or on demand as the patient requires it, and is often combined with the epidural 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, the route 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 of COX 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 more rapidly than oral administration, but these effects are of shorter duration. (Indicated in patients who are not permitted oral intake or is vomiting) a. Intramuscular b. Intravenous c. Subcutaneous 2. ORAL ROUTE preferred over parenteral administration because it is easy, noninvasive, and not painful 3. RECTAL ROUTE 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. TRANSDERMAL ROUTE 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 cancer patients who are at home or in hospice care and who have been receiving oral sustained-release morphine. 5. TRANSMUCOSAL ROUTE 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 other methods. 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 satisfactorily by the usual approaches, including medications. Such pain usually is the result of malignancy (especially of the cervix, bladder, prostate, and lower bowel), but it may occur in other conditions, such as postherpetic neuralgia, trigeminal neuralgia, spinal cord arachnoiditis, and uncontrollable ischemia and other forms of tissue destruction.

3 Neurologic and Neurosurgical Methods for Pain Relief

STIMULATION PROCEDURES - Electrical stimulation, or neuromodulation, 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 INTRASPINAL OPIOIDS (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 they enter 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, the complications 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 of extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumbar level, usually between 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 the changes in neurologic function that accompany the procedure. After the procedure, the patients pain level and neurologic function are assessed. Other nursing interventions that may be 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 be reported. TEACHING PATIENTS SELF-CARE y The patient and family need to understand the purposes of each medication, the appropriate time to use it, the associated side effects, and strategies that can be used to prevent these problems. The patient and family often need reassurance that pain can be successfully managed at home. y Inadequate control of pain at home is a common reason people seek health care or are readmitted to the hospital. y Opportunities are provided for the patient and family members to practice administering the medication until they are comfortable 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 for candy. Page 19

CONTINUING CARE A referral to a home care nurse is indicated to patients who are receiving parenteral or intraspinal analgesia at home. The home care 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 or family administers prescribed analgesic medications correctly 3. Uses nonpharmacologic pain strategies as recommended 4. Reports minimal effects of pain and minimal side effects of interventions

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REFERENCES:
Brunner & Suddarths (MEDICAL-SURGICAL NURSING) Vol. 1; 10th Edition pages 216-245 By: Suzanne C. Smeltzer and Brenda G. Bare Adele Pillitteri Maternal & Child Health Nursing (Care of the Childbearing &Childrearing Family) Vol. 2; 3rd Edition FUNDAMENTALS OF NURSING (Concepts, Process, and Practice) 7th Edition By: Barbara Kozier, Glenora Erb, Audrey Berman & Shirlee Snyder

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