Pain Management: Adjuvant analgesics

Focus Topic: Pain Management

Adjuvant analgesics are drugs that have other primary indications but are used as analgesics in some circumstances. Adjuvants may be given in combination with opioids or used alone to treat chronic pain. Patients receiving adjuvant analgesics should be reevaluated periodically to monitor their pain level and check for adverse reactions.

A real potpourri

Focus Topic: Pain Management

Drugs used as adjuvant analgesics include certain anticonvulsants, local and topical anesthetics, muscle relaxants, tricyclic antidepressants, selective serotonin reuptake inhibitors, benzodiazepines, psychostimulants, and cholinergic blockers. (See Understanding adjuvant analgesics.)

Pain Management Pain Management

Pain Management: Neurosurgery

Focus Topic: Pain Management

Neurosurgery is an extreme form of pain management and is rarely needed. However, there are a number of procedures, such as rhizotomy and cordotomy, that can control pain by surgically modifying critical points in the nervous system. (See Surgical interventions for pain.)

Pain Management: TENS

Focus Topic: Pain Management

TENS relieves acute and chronic pain by using a mild electrical current that stimulates nerve fibers to block the transmission of pain impulses to the brain. The current is delivered through electrodes placed on the skin at points determined to be related to the pain. TENS is used to treat:

  • chronic pain
  • postoperative pain
  • dental pain
  • labor or pelvic pain
  • pain from peripheral neuropathy or nerve injury
  • postherpetic neuralgia
  • reflex sympathetic dystrophy
  • musculoskeletal trauma
  • phantom limb pain

Pain Management

Can’t touch this

Focus Topic: Pain Management

Although TENS therapy presents few risks, the electrodes should never be placed over the carotid sinus nerves or over laryngeal or pharyngeal muscles. Similarly, the electrodes should never be placed on the eyes or over the uterus of a pregnant patient because this treatment’s safety during pregnancy has yet to be determined.

TENS is contraindicated if the patient has a pacemaker. The current may also interfere with electrocardiography or cardiac monitoring. Furthermore, TENS shouldn’t be used when the etiology of the pain is unknown because it might mask a new pathology.

Patient preparation

Make sure that the skin beneath the electrode sites is intact. Clean it with an alcohol wipe and dry well. Clip the hair in the area if necessary. Next, if electrodes aren’t pregelled, apply a small amount of electrode gel to the bottom of each to improve conductivity. Place the electrodes on the skin. If they aren’t self-adhering, secure them with tape, leaving at least 2 (5 cm) between the electrodes.

Turn that off!

Focus Topic: Pain Management

Make sure the controls on the control box are turned to the OFF position. Attach the leadwires to the electrodes, and plug them into the control box. Set the pulse width and rate as recommended. Turn on the unit, and adjust the intensity to the prescribed setting or to the setting most comfortable for the patient. Now secure the unit to the patient. After the prescribed duration of treatment, turn the unit off and remove the electrodes. Wash and dry the patient’s skin. Then clean the unit and replace the battery pack.

Monitoring

Assess the patient for signs of excessive or inadequate stimulation. Muscle twitching may indicate overstimulation, whereas an inability to feel any tingling sensation may mean that the current is too low. If the patient complains of pain or intolerable paresthesia, check the settings, connections, and electrode placements. Adjust the settings if necessary. If you must relocate the electrodes during treatment, first turn off the TENS unit. Evaluate the patient’s response to each TENS treatment and compare the results. Also, use your baseline assessment to evaluate the effectiveness of the procedure.

Patient teaching

If the patient will use the TENS unit at home, have him demonstrate the procedure, including electrode placement, the setting of the unit’s controls, electrode removal, and proper care of the equipment. Explain that he should strictly follow the prescribed settings and electrode placements.

Warn against using high voltage, which can increase pain, or using the unit to treat pain for which he doesn’t know the cause. Also, tell the patient to notify the practitioner if pain worsens or develops at another site.

It’s electric

Focus Topic: Pain Management

If skin irritation occurs, instruct the patient to keep the area clean and apply a soothing lotion. However, if skin breakdown occurs, he should notify the practitioner. Make sure the patient understands that he should remove the unit before bathing or swimming.

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Pain Management: Cognitive-behavioral techniques

Focus Topic: Pain Management

Behavior modification and relaxation techniques can be used to help the patient reduce the suffering associated with pain. These techniques include biofeedback, distraction, guided imagery, hypnosis, and meditation. These “mind-over-pain” techniques allow the patient to exercise a degree of control over his pain. In addition, they have the added benefit of being virtually risk-free with few contraindications. Even so, if the patient has a significant psychiatric problem, a psycho therapist should teach him the relaxation techniques.

Patient preparation

Because all of these techniques require concentration, try to choose a time when the patient isn’t feeling pain or when pain is at its lowest ebb. However, if pain is persistent, begin with short, simple exercises and build on the patient’s abilities.

First, relaxxxxx…

Focus Topic: Pain Management

Choose a quiet location and dim the lights. Have the patient remove or loosen restrictive clothing. To help the patient lessen muscle tension, tell him to alternately tighten and relax a specific group of muscles — for example, muscles in his neck — while concentrating on tension and relaxation. Repeat the exercise for all muscles groups. If a particular muscle group is painful, move on to the next group.

Good feedback

Focus Topic: Pain Management

Biofeedback requires the use of a special machine that allows the patient to see how his body reacts to his efforts. When the patient is connected to the machine, he performs the relaxation technique that he finds most beneficial. The equipment provides feedback regarding his progress with tones, lights, or a digital readout. In this way, the patient can determine which techniques work best to promote relaxation and reduce pain.

Forgetting to feel the pain

Focus Topic: Pain Management

Distraction is a technique that involves focusing on music, a book or magazine, or the television or a movie instead of pain and related health issues. If the patient listens to music, suggest that he use a headset to help him focus on the music or imagery produced by the music. Keeping time to the beat or increasing the volume can help if the pain worsens. Other distraction strategies include singing, rhythmic breathing, and meditation.

I have a dream

Focus Topic: Pain Management

In guided imagery, the patient concentrates on visualizing the calm and peaceful images described by the leader, either you or a recording. Many recordings are available, so the patient should experiment to find imagery that helps him most. Quiet and peaceful nature imagery — for example, the smell of spring grass, the sound of rolling ocean surf, or the burbling of a forest brook — seems to be most effective.

Look into my eyes

Focus Topic: Pain Management

Hypnosis is performed by a qualified therapist. During the session, the therapist may use techniques such as symptom suppression, which helps block the patient’s awareness of pain, or symptom substitution, which encourages a positive interpretation of pain.

Acting differently

Focus Topic: Pain Management

In behavior modification therapy, the patient is encouraged to identify behaviors that reinforce or exacerbate pain, suffering, and disability, such as being overly dependent on others or using a cane when it isn’t medically indicated. With the therapist’s help, the patient defines specific goals, such as reducing his dependence on others, and then uses positive and negative reinforcement to shed old behaviors and promote new, beneficial patterns of behavior.

Monitoring

Remember to be consistent when working with the patient, and make sure that all staff members are aware of the patient’s choices for cognitive pain reduction. If the patient becomes frustrated with his progress with any of these techniques, calmly have him stop and try again later. End each session on a positive note by pointing out improvements; even small improvements show progress.

Patient teaching

If the patient has overwhelming psych o social problems, recommend that he seek therapy. Provide him with referrals to appropriate professionals. Any gains in pain management may be quickly lost unless he deals with these factors.

For all others, help develop a plan for using the cognitive-behavioral strategies at home. A plan will increase the likelihood that the patient will continue to benefit from these strategies after he’s home again.

Pain Management: Nursing care of the patient in pain

Focus Topic: Pain Management

These nursing interventions are appropriate for a patient in pain:

  • Assess the pain’s location and ask the patient to rate the pain using a pain scale.
  • Ask the patient to describe the pain’s quality and pattern, including any precipitating or relieving factors.

Making faces

Focus Topic: Pain Management

  • Monitor the patient’s vital signs and note subjective responses to pain, such as facial grimacing and guarding the affected part of the body.
  • Administer pain medication around-the-clock, as ordered. This schedule is preferred to as-needed dosing because it avoids major peaks and valleys of pain and relief. Teach the patient the importance of taking the prescribed analgesics before the pain becomes severe.
  • Provide comfort measures, such as back massage, positioning, linen changes, and oral or skin care.
  • Teach noninvasive techniques to control pain, such as relaxation, guided imagery, distraction, and cutaneous stimulation.
  • Explain the role of sleep and the importance of being well rested.
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