Pain management is a core component of nursing care. Uncontrolled pain can have many negative effects on the individual and therefore as nurses this must be one of our priorities in provision of care.
To effectively manage pain, we must first understand the pathophysiology of pain, how to complete effective pain assessments and implement strategies to decrease the experience of pain for the individual.
Patient Controlled Analgesia (PCA) is effective for pain management and can be used in many settings so it is essential for nurses who are caring for patients using PCA to be educated on its use and potential complications.
Pain is a highly subjective experience. It can be impacted by biological, psychological and social experiences and therefore is extremely personalised to the individual. Pain is a common occurrence and can be quite debilitating for the person experiencing it.
The International Association for the Study of Pain describes pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. (1)
Pain experiences can be categorised as acute, chronic or cancer-related depending on its duration. (1)
Pain can also be described based according to its etiology.
Nociceptive pain can be caused by ischaemia, trauma, chemical irritants and extremes of temperature and is due to stimulation of the nociceptors (peripheral nerve fibres).
Neuropathic pain results from damage or malfunction of nerve fibres in the peripheral or central nervous systems and is often described as a burning sensation or pins and needles.
Psychogenic can be complex pain that is not fully acknowledged or understood and exists in the absence of known pathophysiology and is associated with mental and emotional behaviours. It includes ‘Phantom’ pain and referred pain. (2)
Unrelieved pain can have many negative impacts on the individual. It can affect the pulmonary, cardiovascular, gastro-intestinal, endocrine and immune systems. Patients with unrelieved chronic pain often experience an increase in disability along with increased levels of depression, fatigue and anger.
The body’s response to stress causes an increased metabolic rate, increased cardiac output, impaired insulin response, increased production of cortisol and increased retention of fluids. Chronic pain, as a stressor, also causes this response in a person. (1)
The pain pathway
There are four steps which occur along the pain pathway:
- Transduction: The process by which the afferent nerve endings participate in translating noxious stimuli (eg. Pinprick) into nociceptive impulses.
- Transmission: The process by which impulses are sent to the dorsal horn of the spinal cord and then along the sensory tracts to the brain.
- Modulation: The process of softening or amplifying pain related neural signals, primarily in the dorsal horn of the spinal cord, but also elsewhere, with input from the ascending and descending pathways.
- Perception: The subjective experience of feeling pain that results from the interaction of transduction, transmission, modulation and psychological aspects of the individual.
Nociceptors are peripheral receptors that respond to tissue-damaging or potentially tissue damaging stimuli. These are located throughout our body and are essential components in the pain pathway. The mechanisms regarding the physiology and psychology of pain are not fully understood however there are several theories regarding pain including: Biomedical model, Gate control theory and Biopsychosocial models (discussed in detail within the online tutorial). (3)
An accurate pain assessment is needed in order to provide effective pain management.
Because pain is a very subjective experience, the best measure of pain is a valid self-report of the pain. Patients can indicate pain in a number of ways including verbal reports on pain and non-verbal cues including grimacing.
Therefore, an effective pain assessment relies on communication between the nurse and the patient.
When assessing an individual’s pain, the following guideline may be used:
- A history of the present pain
- Onset and duration
- Quality and characteristics
- Aggravating or relieving factors
- Use of pain assessment tools
- Associated physical effects
- Patient factors such as knowledge, expectations and preferences for pain management.
Pain should be assessed on movement as well as at rest and always remember to evaluate any pain management strategies used. (4)
Management of pain
The World Health Organization (WHO) developed a guide to pharmacological management of pain which consists of a 3-step ladder.
- Non-opioid analgesics and/or adjuncant therapy
- Weak opioids and/or non-opioid analgesics and/or adjunct therapy
- Strong opioids and/or non-opioid analgesics and/or adjuvant therapy
- Transcutaneous electrical nerve stimulation (TENS)
- Manual therapy/physiotherapy
- Complementary therapies
- Invasive procedures for pain management (5)
What is Patient-Controlled Analgesia (PCA)?
PCA allows the patients to control the administration of their own medication within the safety parameters set by the doctor or nurse practitioner. This can be done by intravenous, subcutaneous, epidural or oral routes and can be used in either a hospital or home setting.
Generally when we think of the term PCA, we envision PCA infusions post operatively. However this term is used for the general process in which the individual determines when and how much analgesia they receive, regardless of the drug or route used.
A PCA pump can allow a continuous infusion of medication, also known as the basal rate, to infuse into the patient. Then in addition to this, a patient can have extra medication or bolus doses when they are experiencing increased pain by pressing a button linked to the PCA pump.
Safety measures for this type of analgesia include the use of a lock-out function. This stops the patient from having unsafe levels of the medication by programming a timer on the PCA pump to stop the individual from having additional doses of the medication until a specified time period has elapsed.
So no matter how many times they press the button in that time period, no additional medication will be administered. Patients who use a PCA often achieve better pain relief and have greater patient satisfaction than those having conventional opioid analgesia.
The goal is to achieve a therapeutic level of analgesia and to allow the patient to maintain that level by using the PCA pump. (6)
In this tutorial, we discuss the use of a PCA as a PCA pump being used via an intravenous route.
Reading the complete tutorial will give you two hours of Continuing Professional Development (CPD) hours. It covers pain, pain assessments and management, PCA and medication, prescribing requirements, safe use, patient education, complications, ceasing the PCA and medications errors.
To access the course go to the ANMF’s Continuing Professional Education (CPE) website or follow this link http://anmf.cliniciansmatrix.com
- Farrell, M & Dempsey J (eds) 2013, Smeltzer & Bare’s Textbook of Medical-Surgical Nursing, 3rd edn, Lippincott, Williams & Wilkins, Broadway, 2013, pp.221
- Koutoukidis, G, Stainton, K & Hughson, J (eds) 2013, Tabbner’s Nursing Care Theory and Practice, 6th edn, Elsevier, Chatswood
- Koutoukidis, Stainton and Hughson 2013; Van Griensven et al. 2014; Zacharoff et al. 2010, A Textbook for Health Professionals, 2nd edn, Elsevier, Sydney
- Macintyper & Schug 2007; Acute Pain Management: A Practical Guide, 3rd edn, Elsevier, Sydney; Tollefson, J, Bishop, T, Jelly, E, Watson, G & Tambree, K 2012, Essential Clinical Skills, 2nd edn, Cengage Learning, South Melbourne
- Van Griensven, H, Strong, J & Unruh, AM (eds) 2014, Pain: A Textbook for Health Professionals, 2nd edn, Elsevier, Sydney
- Farrell, M & Dempsey J (eds) 2013, Smeltzer & Bare’s Textbook of Medical-Surgical Nursing, 3rd edn, Lippincott, Williams & Wilkins, Broadway; Macintyre & Schug 2007, Acute Pain Management: A Practical Guide, 3rd edn, Elsevier, Sydney; Van Griensven, H, Strong, J & Unruh, AM (eds) 2014, Pain: A Textbook for Health Professionals, 2nd edn, Elsevier, Sydney