Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 15 Pain Management
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hydromorphone
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levorphanol
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meperidine
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methadone
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morphine
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oxycodone
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Antispasmotics.
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Muscle relaxers.
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Neuropathic pain relievers:
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tricyclic antidepressants:
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amitriptyline
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desipramine
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nontricyclic antidepressants:
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bupropion
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anticonvulsants:
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carbamazapine
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clonazepam
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gabapentin
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pregabalin
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Anxiolytics.
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Steroids.
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Heat/cold.
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Transcutaneous electrical nerve stimulator (TENS) unit.
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Epidural injection.
NURSING DIAGNOSES
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Acute pain
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Powerlessness
NURSING INTERVENTIONS
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Cold or hot packs.
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Massage.
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Physical therapy.
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Acupuncture.
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Biofeedback.
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Chiropractic.
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Meditation.
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Support groups.
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Prayer.
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Explain to the patient:
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Diagnoses.
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Tests and treatments.
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Use of pain medication, timing, and side effects.
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Use of alternative therapies.
Chronic Pain
Chronic pain is lingering pain after identification of etiology of the initial onset. It
may be less intense after 4 to 6 months, or may be the same degree of pain.
WHAT WENT WRONG?
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Arthritis
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Backaches
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Cancer
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Headaches
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Neurogenic pain
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Psychogenic pain
PROGNOSIS
Prognosis for chronic pain is poor. Adjuvant modalities may help ease the long-
term effects of chronic pain.
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CHAPTER 15 Pain Management
HALLMARK SIGNS AND SYMPTOMS
In addition to the above, other manifestations may include:
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Anger
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Decreased mobility
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Decreased energy
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Depression
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Restlessness or anxiety
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Tense muscles
INTERPRETING TEST RESULTS
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Heart rate, blood pressure, and respiratory rate may be elevated.
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Pain scales.
TREATMENTS
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Anxiolytics.
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Antidepressants.
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Neuroleptics.
NURSING DIAGNOSES
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Chronic pain
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Hopelessness
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Self-esteem, situational low
NURSING INTERVENTIONS
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Recommend counseling or joining a support group.
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Daily exercise.
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Physical therapy.
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Massage.
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Deep breathing and meditation.
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Biofeedback.
Peripheral Neuropathy
This is the degeneration or disease of the peripheral nerves that affect motor
and/or sensory nerves. The peripheral nerves include all but the brain and spinal
cord.
WHAT WENT WRONG?
The neuropathies are poorly understood. When peripheral nerves are damaged,
the brain becomes confused when processing communication from the damaged
nerves. Pain or numbness may be out of proportion to the damage or may be pres-
ent where skin and tissue are intact. Peripheral neuropathy may affect motor nerves,
sensory nerves, or both. It is often a sequelae (secondary result) of poorly con-
trolled diabetes, autoimmune diseases, hypothyroidism, toxic substances, HIV/AIDS,
vitamin deficiencies, alcohol abuse, or some infections.
PROGNOSIS
Treating the underlying disease state may help to relieve the pain. Often, treating
the pain is the best option.
HALLMARK SIGNS AND SYMPTOMS
Symptoms result from pressure on the nerve or damage to the nerve, either sen-
sory or motor.
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Pain.
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Numbness.
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Tingling.
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Muscle weakness.
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CHAPTER 15 Pain Management
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Loss of sensation.
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Burning.
INTERPRETING TEST RESULTS
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History and physical.
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Reflexes.
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Sensation.
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Muscle strength.
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EMG—electomyography.
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Nerve conduction studies.
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Low serum level of vitamin B
12
, which may be the cause of nerve disturbances.
TREATMENT
Treatment options include management of the underlying disease to ameliorate the
neuropathy and treatment of the pain or symptoms caused by the neuropathy.
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Pain relief—see this chapter.
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Antiseizure medication:
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gabapentin
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pregabalin
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carbamazepine—helps neuropathic pain for unknown reasons
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Tricyclic antidepressants:
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amitriptyline
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desipramine
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imipramine—works by blocking the signals sent to the brain
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Lidocaine patch—a topical anesthetic applied directly to the site.
NURSING DIAGNOSES
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Risk for peripheral neurosensory dysfunction
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Alterations of tactile sensory perception
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NURSING INTERVENTIONS
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Relaxation.
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Biofeedback.
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Acupuncture.
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Protect feet—loss of sensations will make injuries undetectable.
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Exercise.
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Remove pressure from affected limbs.
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Heat/cold application.
Phantom Limb Pain
Pain, mild to severe, felt in the area where an extremity has been amputated, is
called phantom limb pain.
WHAT WENT WRONG?
The nerve endings at the surgical site continue to relay pain signals to the brain. The
missing limb could be the result of surgical amputation or trauma.
PROGNOSIS
Some patients experience little or no phantom pain. Other patients’ pain dimin-
ishes with time. Poor prognosis is associated with ongoing pain for 4 to 6
months.
HALLMARK SIGNS AND SYMPTOMS
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Pain distal or proximal to the amputation
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Itch
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Cramps
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Tingling
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TREATMENT
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Physical therapy.
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Analgesics.
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Pain relievers.
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Neuroleptics:
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gabapentin
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pregabalin
NURSING DIAGNOSES
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Pain, discomfort
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Powerlessness
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Grieving
NURSING INTERVENTIONS
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Heat.
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Massage.
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Explain to the patient:
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Nerve conduction.
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Medications, timing, and side effects.
Substance Use Disorders
Substance abuse is defined as an irresistable urge for drugs, alcohol, or other
substances, including physical, physiological, and psychological longings, and
a need for more and greater dosages to satisfy the cravings. Abused substances
produce euphoria and intoxication, which include changes in mental status,
decreased coordination, and slurred speech. Seizures and loss of consciousness
are late signs. Usual abused substances include alcohol, club or illegal drugs,
and cigarettes. However, food, caffeine, and sex may be included in some def-
initions.
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WHAT WENT WRONG?
Research shows a varied set of internal and external circumstances leading to drug
abuse. There seems to be a genetic factor involved, as well as environmental and
social elements. Individuals may slowly begin a habit for pleasure, depression,
hunger issues, weight reduction, societal pressures, or to escape from pressure.
Teen use often begins early.
PROGNOSIS
Prognosis depends on the drug, its potency, the duration of usage, and genetic fac-
tors of the user. Research shows that a history of prolonged abuse changes some
brain functions, leading to increased cravings. Substance use disorders may start
with one substance and may progress to others; for example, it is not uncommon
to begin with marijuana and progress to cocaine or heroin.
HALLMARK SIGNS AND SYMPTOMS
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Removing oneself from sports, work, and friends
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Decrease in grades, interest in school
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Irritability, depression
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Stealing money to support habit
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Hangovers
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Forgetfulness from effects of drug on the brain
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Fever
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Epistaxis from nasal administration, snorting
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Pain at injection sites
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Tremors
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Chest pain
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Abdominal pain
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Discolored, dark urine
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Tobacco:
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Heart disease
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Lung cancer
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Emphysema
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Peptic ulcers
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Stroke
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Alcohol:
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Depression
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Slurred speech
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Diminished coordination
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Decreased inhibitions
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Irregular heartbeat
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Anxiety
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Seizures
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Liver failure
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Cannabis (marijuana):
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Diminished memory and coordination
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Progression to harsher drugs
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Stimulants/amphetamines (cocaine, methedrine, ecstasy, methylphenidate,
phenmetrazine, methamphetamines):
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Change in pupil size
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Paranoia
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Heart damage
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Hyperactivity
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Tachycardia
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Hypertension
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Stroke
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Psychoses
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Coma
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Opioids/narcotics (heroin, opium):
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Change in pupil size
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Vomiting, diarrhea
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Confusion
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Bradypnea
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HIV/AIDs
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Designer/club drugs:
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Respiratory depression
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Euphoria
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Tremors
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Hallucinations
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Paranoia
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Tachycardia
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Benzodiazepines/barbiturates [Rohypnol, GHB (hydroxybutyrate G)]:
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Hypotension
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Sedation
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Confusion
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Cramps
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Dissociative anesthetics [PCP (phencyclidine), ketamine]:
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Impairs memory
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Aggression
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Depression
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Dyspnea
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Hallucinogenics (LSD, mescaline):
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Hallucinations
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Tachycardia
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Delusions
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Paranoia
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Inhalants (aerosols, solvents, gasoline, lighter fluid, paint thinners, cleaning
fluids):
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Euphoria
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Confusion
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Hallucinations
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Memory loss
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Vomiting
INTERPRETING TEST RESULTS
For alcoholism, several screening tests are available to assess for dependency. The
CAGE screening test is commonly used: