Nursing Diagnosis: Acute pain related to tissue damage secondary to DM Type 2 as manifested by grimacing and guarding over the

affected digit. Assessment S> Masakit paa ko. Rated pain as 7/10, radiating to the legs, characterized as sharp pain, precipitated by movement and relieved by immobility. O> grimacing when legs are touched. Guarding affected foot. With limitation in movements. Withdraws foot when touched. Explanation of the Problem Unrelieved acute pain leads to debilitation, diminished quality of life, and depression. Unrelieved acute postoperative pain leads to development of chronic pain syndromes and increased complications. In fact, unrelieved pain can kill. Source: Medical Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 440 First, tissue damage releases chemical mediators, such as prostaglandins, bradykinin, serotonin, substance P, and histamine. These substances then activate nociceptors, resulting in transduction, or the generation of an action potential (an electrical Goal and Objectives GOAL: The patient will be able to experience gradual reduction/relief of pain. OBJECTIVES: LTO: After 3 days of nursing interventions, the patient will be able to: 1. Move his left lower extremity without grimacing or difficulty. 2. Rate pain as 14/10 STO: Within the stay in the emergency room, the patient will be able to: Have no grimace when his left lower extremity if touched. Rate pain as 56/10 Interventions Assessment: Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if client denies pain. Rationale Pain is a subjective experience and must be described by the client in order to plan effective treatment. Changes in these vital signs often indicate acute pain and discomfort. Note: Some clients may have a slightly lowered BP, which returns to normal range after pain relief is achieved. Personal factors can influence pain and pain tolerance. Evaluation LTO: Fully met if: the client is able to move his left lower extremity without grimacing or difficulty Rated pain as 1-4/10 Partially met if: The client is able to move his left lower extremity with minimal grimacing and difficulty. Rated pain as 5-6/10 Not met if: No change or worsening of status. STO: Fully met if: Have no grimace when

Intervention: Reduce or eliminate factors that precipitate or increase pain experience (e.g., fear,

impulse). In the second process -- transmission -the action potential moves from the site of injury along afferent nerve fibers to nociceptors at the spinal cord. Release of substance P and other neurotransmitters carry the action potential across the cleft to the dorsal horn of the spinal cord, from where it ascends the spinothalamic tract to the thalamus and the midbrain. Finally, from the thalamus, fibers send the nociceptive message to the somatosensory cortex, parietal lobe, frontal lobe, and the limbic system, where the third nociceptive process -- perception -- occurs. Source: Wuhrman, E. and Cooney, F., (2011). Acute Pain: Assessment and Treatment. . (), pp.

Do nonpharmacologic management of pain independently.

fatigue, monotony, and lack of knowledge).

Elicit behaviours that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, music therapy, or peaceful imaging.

Factors that may left lower be precipitating extremity is or augmenting touched pain should be Rated pain as reduced or 5-6/10 eliminated to Do nonenhance the pharmacologic overall pain management of management pain program. independently. Partially met if: Relaxation Minimal techniques help grimacing reduce skeletal when touched muscle tension, Rated pain as which will 7/10 reduce the Do nonintensity of the pain. Music pharmacologic therapy functions management of as a distracter pain with from hospital minimal noise, thereby assistance. reducing emotional anxiety and pain Not met if: There is an (Gardner e t al., increase in pain 2009). T o severity, promote grimacing, and relaxation, music if patient is should: (a) be unable to do non-lyrical, (b) nonhave pharmacologic predominantly

 Create a quiet, no disruptive environment with dim lights and comfortable temperature when possible.

low tones, (c) have minimal brass and percussion, and (d) have a maximum decibel volume o f 6 0 db (Nilsson, 2008). Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction. Environmental noise is a significant barrier to sleep for hospitalized patients; research supports sleep as therapeutic to overall health, wound healing, and recovery (Gardner, Collins, Osborne, Henderson, &

pain management.

 Individualize the content of the relaxation intervention (e.g., by asking for suggestions about what the patient enjoys or finds relaxing).

Administer Pregabalin (Lyrica) as ordered.

Eastwood, 2009). Each person may find different images or approaches to relaxation more helpful than others. The nurse should have a variety of relaxation scripts or audiovisual aids to help clients find the best one for them. Pregabalin is approved in US and Europe for adjunctive therapy of partial seizures in adults, and also has been approved for the treatment of pain from diabetic neuropathy or post-herpetic neuralgia in adults. It binds with high affinity to the alpha2-

delta site (an auxiliary subunit of voltage-gated calcium channels) in central nervous system tissues which in turns leads to reduced release of neurotransmitters , eg, glutamate, substance P, and calcitonin generelated peptide (Fehrenbacher et al 2003; Sills 2006; Li et al 2006; Dooley et al 2007; Taylor et al 2007). Such decrease in neurotransmitter release from synapses in several neuronal tissues in the spinal cord and brain is likely to attenuate neuronal hyperexcitability and abnormal

synchronization and may thus explain its anticonvulsant, analgesic, and anxiolytic activity (Taylor et al 2007). Educative: Instruct client to report any improvement/exacerba tion of pain. Unrelieved pain can create other problems such as anger, anxiety, immobility, respiratory problems and delay in healing. Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. The human body is believed to have energy fields that express aberrant patterns when body systems are

Encourage verbalization about feelings of pain.

Encourage relatives to perform touch therapy.

 Encourage and assist client to do deep breathing exercises.

Encourage mobilization of extremities. Teach the use of non pharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures.

insulted. Therapeutic touch is thought to realign aberrant fields. Deep breathing for relaxation is easy to learn and contributes to pain relief and/or reduction by reducing muscle tension and anxiety. To promote circulation to prevent excessive tissue pressure. The use of non invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications. Music therapy functions as a distracter from

hospital noise, thereby reducing emotional anxiety and pain (Gardner e t al., 2009). T o promote relaxation, music should: (a) be non-lyrical, (b) have predominantly low tones, (c) have minimal brass and percussion, and (d) have a maximum decibel volume o f 6 0 db (Nilsson, 2008).

References: Comeauz, T.and Moses, S., (2013). The Effect of Complementary Music Therapy on the Patient's Postoperative State Anxiety, Pain control, and Environmental Noise Satisfaction. . 22 (), pp.314 Comeauz, T.and Moses, S., (2013). The Effect of Complementary Music Therapy on the Patient's Postoperative State Anxiety, Pain control, and Environmental Noise Satisfaction. . 22 (), pp.315 Wuhrman, E. and Cooney, F., (2011). Acute Pain: Assessment and Treatment. . (), pp. Medical Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 440 Finnerup, N. and Jensen, T. (2007). Clinical use of pregabalin in the management of central neuropathic pain. [ONLINE] Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656330/. [Last Accessed 28 November 2013]. (). Lyrica (Pregabalin). [ONLINE] Available at: http://www.medilexicon.com/drugs/lyrica_1207.php. [Last Accessed 28 November 2013]. Taylor CP, Angelotti T, Fauman E. (2006). Pharmacology and mechanism of action of pregabalin: the calcium channel alpha2-delta (alpha2-delta) subunit as a target for antiepileptic drug discovery.. [ONLINE] Available at: http://www.ncbi.nlm.nih.gov/pubmed/17126531. [Last Accessed 28 November 2013].