1. Meg Beturne MSN,RN,CPAN,CAPA
From Pain to Comfort
Meg Beturne MSN,RN,CPAN,CAPA

2. Objectives Define pain
Discuss pain assessment and management utilizing ASPAN’s Clinical Practice Guideline
Identify pharmacological and non-pharmacological interventions
Describe the challenge of chronic pain in perioperative areas
Discuss comfort management

3. PAIN DEFINED
Pain is usually a localized physical suffering associated with bodily disorder
Pain is one of the body’s most important protective mechanisms
Pain is a complex mechanism with unpleasant physical, emotional and cognitive components associated with actual or potential tissue damage

4. Pain: The Sixth Vital Sign
Pain is “whatever the person experiencing it says it is, and existing whenever the person says it does”- Gold Standard
The patient is the ONLY one who can accurately describe his/her pain
It is subjective
All pain should be considered REAL
Pain can negatively affect the body
McCafferty,2011

5. Newest Insights Definition of Pain refined:
Person’s inability to verbally communicate does not preclude the possibility that pain is present
Does not negate the responsibility of healthcare providers to treat it!

7. Case Scenario
Example: 30 year old female SBO first day post-op; tells you she is in pain & is on phone talking. Do you still believe her?
YES! Pain is subjective and she is using distraction successfully which is a non-pharmacological way to manage pain
Since it is distracting her from the pain, you can now medicate her appropriately

9. Pain Pathways Nociceptors: give the body the ability to produce pain
Nerve endings present in skin, viscera, blood vessels, muscle, joints
Activated by noxious stimuli, leads to inflammation & release of bradykinin & prostaglandins
Pain impulses initiated by direct tissue damage and by release of chemicals
Pain travels very fast!

10. Pain Conduction
Transduction: cutaneous nociceptors send impulses to spinal cord
Transmission: Impulses synapse either by fast or slow pain fibers
Perception: pain impulses processed by thalmus & cerebral cortex
Modulation: along the efferent fibers, pain may be inhibited or modulated

11. Pain Threshold & Tolerance
Threshold: point at which stimulus is perceived as painful; fairly uniform person to person
Tolerance: maximum intensity of duration of pain a person is willing to endure before needing some intervention; this varies from person to person
Tolerance is not to be judged as acceptable or unacceptable by health care providers

12. TYPES
Cutaneous: arises from superficial structures ( skin and subcutaneous areas)
Sharp, cutting, burning, throbbing, localized
Burn or paper cut
Deep Somatic: originates in deep body structures ( muscles, bones, tendons, joints)
Characterized as dull or diffuse
Muscle cramps

13. MORE TYPES Visceral: origin is in visceral organs
Deep, dull, poorly localized
Associated with nausea & vomiting, hypotension, weakness
Referred: perceived at a site different from its point of origin
Chest pain ( cardiac muscle doesn’t have pain receptors); pain can move to left arm, jaw
Gallbladder pain felt in the shoulder

14. ACUTE PAIN
Acute: pain that extends until period of healing (less than 6 months), “temporary”
Identifiable cause
Occurs soon after injury
Onset sudden or slow
Intensity mild to severe
Autonomic response: BP,RR,HR increased; pupils dilated; diaphoresis, pallor, facial grimacing, restlessness, guarding behavior

15. CHRONIC PAIN Chronic: extends beyond (3-6 months) May limit ADLs
May not have identifiable cause
Non protective ( serves no purpose)
May lead to depression, fatigue, insomnia, anorexia, apathy & learned helplessness
Autonomic response: BP,HR, RR, Pupils, skin are all normal
If severe & prolonged, PNS activated= muscle tension, HR & BP low, failure of body’s defenses

16. Point of Emphasis
Physiological signs ( i. e. elevated blood pressure and elevated heart rate) are least sensitive indicators of pain, especially in chronic pain
Don’t withhold pain medication because of these changes alone

17. CHRONIC- Two Types Chronic Non-Malignant
Ongoing, lasting more than 6 months
NOT due to life threatening causes
NOT responding to currently available treatments
May continue for remainder of life
Low back pain, arthritis, neuralgia, Crohn's, migraines, peripheral neuropathy
Chronic Malignant
Cancer pain

18. Chronic Pain in the Sexes
Conditions associated with chronic pain in women: Fibromyalgia, IBS, Rheumatoid Arthritis, Migraines; possible hormonal links; focus on emotional aspects; more likely to seek help than males; helpful to re-label pain as being manageable
Conditions associated with chronic pain in men: cluster headaches, gout, heart disease; focus on sensory aspects

19. Chronic Pain, Surgical Patient
Require special consideration & planning for pain management :Methadone, Suboxone
Request consultation with acute pain service, anesthesia consultation
Continually communicated individualized pain management plan
Add, optimize first-line meds; rotate opioids
Educate patient to bring in chronic pain medications ( migraine, back pain)
Patient role in goal setting

20. Other PAIN Terms
Breakthrough Pain: pain that increases above the pain addressed by the ongoing analgesics
Neuropathic Pain (Pathologic): arises from nervous system (peripheral or CNS)- has multiple mechanisms- shooting, sharp, electric
Discomfort: being uncomfortable in body or mind; mild distress
Suffering: feel pain/distress; sustain harm; injury, pain or death

21. Sobering Statistics
15% Americans with major trauma/surgery pain (45 million)
25% Adults have chronic pain ( > 76 million) > diabetes, heart disease, cancer combined
50% of inpatients/outpatients have pain
30% patients give hospital low marks for pain control
Untreated/undertreated pain still common
CDC (2007) Fast Facts

22. The Truth About PAIN
Lack of expression does not equal lack of pain~ physiologic and behavioral adaptations to pain occur
Not ALL causes of pain are identifiable
Respiratory tolerance is rapid
Sleep is possible with pain but not good quality
Elderly experience pain but do not express it as much and so do babies!
Addiction is rare %

23. Pain: A Perioperative Problem
Nearly all patients have postoperative pain 45million: 80% rate it moderate to severe
Pain is the most common reason for elective procedures
Fear of pain is the #1 reason for delaying elective surgery: reported by 59% pts.
50% patients still have pain 1 year after surgery; 30% still have pain 10 years later!
National Center Health Statistics,2006

24. Patient Expectations If pain is present:
A professional, comprehensive assessment
Individualized evaluation methods, consistent with age, condition and ability to understand
Treatment when present, or refer for treatment
Evaluation of effects of treatments

25. Relief of Pain
“It is not the responsibility of patients to prove they are in pain; it is the nurse’s responsibility to accept the patient’s report of pain” ( American Pain Society, 2005)
“Relief of pain is a basic human right” (American Pain Foundation,2001)
“Relief of pain is a basic human right” (American Bar Association, 2000)

26. Ethical Duty of the Nurse
Provide clinically competent, ethically defensible care
Duty to relieve pain, provide humane care
Suspected or known addiction disorder
Give opioids when clinically indicated & ordered
Protect patients/society from unauthorized opioid use
When ethical dilemmas exist, communicate them!

28. Pain Assessment
Joint Commission Standards PC Assess, Treat, Reassess, Document Pain
Identifying & treating pain is part of care
Must be assessed during rest and activity
Includes defining:
How patient gets screened
Who assesses pain & when it is reassessed
How pain data is collected & recorded
When in-depth evaluation is needed

29. Joint Commission Pain Management Standard
Patients and their families must be educated about pain management plan
Patients need to report pain
Patients need to cooperate with the prescribed treatment
Scope of standard: behavioral health, critical access, home care, hospitals, long-term care and ambulatory care

30. BARRIERS to PAIN Assessment

31. Patient Barriers Fear, pessimism, catastrophizing
Pain, effects of drugs, death
Addiction to analgesics
Pain will be intolerable
Anxiety: Cured?
What post-op sensations are normal?
Unrealistic expectations
Interpretation of experience different than team: age, culture, background

32. Professional Barriers
Mistaken beliefs about pain & treatment
Inconsistent assessment & reassessment
Systems barriers ( computers, access to resources)
Inadequate “handoff” communication
Biases, attitudes

33. Other Barriers Self-reports in pre-op are limited
Misunderstandings of pain scales
Over-reporting/underreporting of pain
When to assume pain is present/relieved?
Patients unable to report pain using usual self-report tools ( infants, unconscious, cognitively impaired, ventilated, impending death

34. Pediatrics Behavioral Tool
Difficult to distinguish pain from fear
Rely on parent reports
Observe behaviors
Can use FLACC: Face, Legs, Activity, Cry, Consolability; 0-2 each with 10 being maximum; Behavioral score only, not intensity rating

35. NIPS-Neonatal Infant Pain Scale
Facial expression, breathing, arms, legs, cry, state of arousal
CRIES: scale for neonatal 32 weeks to term; Cry, Requires Oxygen, Increased vitals, Expression, Sleeplessness

36. CPOT Critical Care Pain Observation Tool 0-8 behavioral scale
2 points for each category:
facial expression
body movements
muscle tension
ventilator tension or verbalization

37. Cognitive Impaired Assess at rest and activity
Insure functioning hearing aid
Have eyeglasses handy
Repeat questions and allow time for responses
Enlarged font helps
Self-report with descriptors, not numbers!
Consider behaviors: eating, sleeping, mood, body movement

38. Special Considerations
Elderly: pain prevalence 2-fold higher >60
Report of pain altered
Have acute & chronic painful diseases
Take many medications
Have multiple diseases
^ sensitivity: therapeutic, toxic drug effects
Prone to constipation (opioids)
NSAIDs;> risk GI, renal, platelet problems
> Sensitivity to analgesic effects: higher peek effect, longer duration, dose titration

39. Special Considerations
Known/suspected chemical dependency:
Experience variety of health problems
Possible withdrawal from opioid absence, causing > HR, restlessness, sleeplessness
Focus on managing PAIN , not detoxification!
Don’t forget non-drug interventions
Higher loading & maintenance doses of opioids may be required to reduce pain intensity

40. ASPMN Position Statement
Pain Assessment in non verbal patients
When possible, obtain self-report
Look for possible pathologies, procedures or other causes of pain
Observe for behaviors that may indicate presence of pain
Obtain input from caretakers who know patient & usual behaviors & responses to pain
Use an analgesic trial & observe for changes in behavior

41. ASPAN Clinical Guideline
Introduced in JOPAN in 2003, available now on ASPAN web site
Speaks to Assessment, Interventions and Expected Outcomes
Includes all phases of practice including: Preoperative Phase, Post Anesthesia Phase I, and Post Anesthesia Phase II or Extended Observation

42. Assessment Begins With…
Pre-op Data:
Vital signs & comfort goals
Medical history
Pain history
Pain behaviors
Analgesic history
Patient’s preferences
Pain/comfort acceptable levels
Comfort history
Cultural, religious factors
Educational needs

43. Interventions Begin in…
Pre-op:
Discuss pain & comfort assessment
Discuss with patient/family about reporting pain & available pain relief
Dispel misconceptions about pain & pain management
Encourage preventive approach
Educate purpose of meds & non-pharmacological measures
Discuss outcomes based on goals
Arrange for interpreter, signer as needed

44. Outcomes to Strive For! Pre-op
Patient states understanding of care plan
Patient states understanding of pain intensity scale, pain relief/comfort goals
Patient establishes realistic & achievable pain relief/comfort goals
Patient understands PCA equipment
Patient understands benefit of non-drug interventions

45. Post anesthesia Phase I
Assessment:
Type of surgery, anesthesia technique, etc
Analgesics, etc given inter-op
Pain & comfort levels
Status/ vital signs: ABCD
Age, cognitive ability & cognitive learning method
ASSESSMENT DATA!

46. Assessment Data
Subjective data: who, what, where, why & when are first clues of pain assessment
Objective data: observation of facial grimace, teeth clenching, frowning, moaning, crying
Physiological changes: increase BP, rise in HR, increase in RR are signs that support the patient’s subjective pain response

47. Other Physiological Signs
Dilatation of pupils and/or wide opening of eyelids
Shivering
Change in skin and body temperature
Increased muscle tone
Sweating

48. ASSESSMENT Location: examine site
Intensity- use easy, fast, multicultural, multilingual pain scale:
Poker chip, Oucher scale
Visual Analog Scale: pt. places mark on line
Numeric Rating Scale: 0 to 10
Wong Baker Faces Pain Scale: 3+ to adult
Behavioral Rating Scale
Body Diagram, Daily Diary
Verbal Descriptor Scale: no pain to worse pain

49. Pain Rating Scales
Purpose: communication tool- here is where you are now and here is where we want you to be
Documenting ratings helps evaluate trends and treatment effectiveness
Know which scale is most appropriate to use ( i.e Wong-Baker preferred by African American children)
Important to have scales translated into languages of populations served

51. ASSESSMENT (cont) Obtain description of quality of pain
Character, frequency, duration
Achy, pulling, throbbing, burning, sharp, dull, cramping, prickling, hurting
Remember data obtained pre-op regarding onset & duration; may apply post-op
What time of day is pain worse?
What gets pain started?
Does the pain stay or come and go?
How much pain in an average day?

52. ASSESSMENT (cont)
Remember data on pain aggravating & alleviating factors obtained pre-op; may apply post-op
What makes pain worse or better?
What other things have you tried to make pain better that worked or didn’t work
Seek information on impact of pain on activities of daily living (ADL)
Does pain cause problems with ADL?
How upsetting is the pain?

53. ASSESSMENT (cont) Describe pain behavior indicators Reluctance to move
Quiet & withdrawn
Facial expressions (grimace)
Anxious, restless
Crying, moaning, whimpering
Desperate, using PCA frequently
Don’t dismiss the patient’s self-report of pain they are experiencing!

54. ASSESSMENT (cont) Assess other causes of pain Chronic back/neck pain
Bladder distention
Hemorrhage, ischemia, rupture of viscus
Nausea and vomiting
Perform re-assessment for response to medications for pain ( Joint Commission)
How effective? LOC? Vital Signs? Extra meds needed for breakthrough pain?
Communicate & document all data!

55. Case Scenario
Patient had anterior/posterior lumbar fusion done for an acute incident
This patient also had chronic low back pain that was 9/10 on a daily basis even while taking narcotics
Goal in PACU was to return patient to his baseline level of pain
It required Morphine 30mg & Dilaudid 10mg to return him to normal level of pain which was 9/10

56. BARRIERS to PAIN Management

57. Biases as Barriers Value stoicism and problem-focused coping
Expecting a certain degree of pain
Is drug seeking, solely on the basis of:
Report of pain greater than expected
Pain medication requirements higher than usual
Lifestyle, diagnosis or demographic factors
Nurse is better judge of pain than patient
Pain is punishment for sins/wrong-doing

58. Case Scenario
Mrs. Smith is an elderly, Hispanic patient who is status post hip replacement
PCT informs you that Mrs. Smith needs pain medicine. Should you just give it?
NO, you assess her; determine type of pain present; is that pain indicating a problem? Could it be arthritis acting up?
Are personal, cultural, spiritual or ethnic beliefs in play?
Do not assume anything!

59. Non-Drug Interventions
Positioning/repositioning/ambulation assist
Elevation affected limbs
Applying ice or heat therapy
Covering incision with pillow (coughing)
Rhythmic deep breathing, counting slowly
Warm blankets, warming machines
Non-stimulating environment (noise, light)
Family, friends visiting ( or NOT)
Attention from staff (schmooze factor)

60. Non-Drug Interventions (cont)
Complementary:
Relaxation, Massage therapy, backrub
Reflexology, Acupuncture
Humor
Reiki treatment, Therapeutic Touch
Distraction, Biofeedback
Guided imagery: pleasant sounds, smells
Hypnotism
Music Therapy, tapes of calming sounds
Prayer, visit from chaplain/cleric, religious objects/symbols

61. Problems with Herbs St. John’s Wart: use- depression /anxiety
May cause increased effects of opioids
May cause decreased effect of Elavil or Digoxin
Will cause increase in effect of antidepressants
Ginko Biloba
May interfere with anticonvulsants
When taken with NSAIDs, will cause significant bleeding problems

62. Surgical/Acute Pain
Prevention is best approach: means around the clock pain management
Allows patient to know their pain needs will be met
Helps reduce anxiety about return of pain
May result in decreased doses, fewer side effects, less time in pain
Physical activity may increase ~problems caused by immobility can be avoided
Avoid actions that > pain
Patient to request med before pain severe

63. Methods of Pain Management
1. Oral Analgesia
2. IV Analgesia
3. PCA Analgesia
4. Epidural Analgesia

64. Important Patient Data
Let’s review one more time!
Any known allergies
Patient baseline renal, bowel, bladder and liver function
Previous opioid use
Health habits including drug/alcohol usage
Baseline mental status
Any other medications used
Age, cultural, religious factors

65. Multimodal Approach
Appropriate combinations attack more than one mechanism
The synergistic action results in lowered doses and a decrease in adverse effects
Intensity/type of pain determine the route
Oral: less invasive, preferred route for chronic, persistent pain; great choice for mild to moderate pain
IV: severe, escalating pain
Epidural: effective- delayed onset

66. Other Routes Transdermal: Fentanyl (Duragesic patch)
persistent, chronic pain; can’t take oral meds
non-adherent patients; recovering addicts
opioid tolerant kids > 2yrs with cancer pain
48-72 hr application period
patient preference, no stigma, bypasses GI
Oral transmucosal (sublingual, buccal): Actiq
rapid onset Fentanyl for breakthrough pain in opioid tolerant patient; ideal for sudden onset
sugar matrix on a stick ( hrs)

67. Intranasal: Ketorolac (Sprix Nasal Spray) for acute pain in ambulatory care
Topical: EMLA (5% lido-prilocaine cream) takes 60 min; Synera (mix of lido & tetracaine) apply 20 min for analgesia
Rectal: almost all oral meds can be given this way
Intramuscular: unreliable, painful, not recommended unless there is no IV
Subcutaneous: same as IM

68. Oral Agents Non-narcotics:
Acetaminophen: reduces pain & fever; No anti-inflammatory affect; No adverse effects on kidney, gastric lining, platelets; exceeding maximum dose: hepatotoxic
Usual dose: mg p.o. Q4H, maximum dose: 4GM/24hours, > 5GM= toxicity!
Beware of other medications that contain Acetaminophen! ( Vicodan, Percocet)

69. Oral Agents Non-narcotics: mild to moderate pain
NSAIDs (anti-inflammatory/ antipyretic): act on peripheral nerve system; ASA, Motrin, Celebrex, Ketorolac (Toradol), Naprosyn, ibuprofen; Do not give ASA with NSAIDs; monitor for signs of GI bleeding
Maximum dose ibuprofen: 3200mg in 24hours
Motrin dosing: mg every 6h

70. NSAIDs Effective for mild to moderate pain
With opiods, these agents can have an opiod sparing effect: lowers opiod requirement and reduces potential for opiod- related side effects
Bextra and Vioxx: withdrawn- increased cardiovascular risk, increased M.I. and stroke post CABG

71. Adverse Effects May alter hemostatic balance
Avoid in high risk CV patients
GI toxicity, increases greatly if 2 NSAIDs are given; consider Nexium or Prilosec in high risk patients
Renal effects: can be avoided if patient well hydrated
Bone healing: stopping drug restores normal healing after days; avoid in smokers or metabolic bone disease

72. Parental Non-opioids
IV acetaminophen (Ofirmev): single or repeat dosing- 15 min. infusion
Adults/teens> 50 kg. give 1000mg q 6 hr or 650mg q 4 hr to max of 4, 000mg per day
Adults/teens < 50kg. and kids > 2-10 years: 15mg/kg q 6hr or 12.5mg/kg q 4 hr to max of 75mg/kg/day= 3,750mg/day
Within 15 min. increased level in plasma
Cost= $11/dose

73. IV Ketorolac: short term pain management- 5 days
Dose: < 65: 30mg q6h(120mg/day=max)
Pedi dose: 0.5mg/kg q6h
Correct hypovolemia before administration
IV Ibuprofen: approved for fever & acute pain in adults; mg over 30min q 6h; maybe preferable to Ketorolac- less inhibition of action

74. OPIOIDS Fentanyl: 25-50mcg IVP q5 min prn
Morphine Sulfate: 2mg IVP q5min prn
Oxycodone (Percocet): 1-2 tabs q 4-6 hrs prn
Hydromorphone (Dilaudid) 1-2mg IV, 2-4mg po
Hydrocodone ( Vicodin):5/500mg-1tab q4hrs- not to exceed 8tabs in 24hrs.
Oxycontin ( MS ER): 30mg- 1tab q12 hrs
Tylox 5/500mg: 1tab q6hrs prn
Tylenol #3: 300/30mg 1tab q4hrs prn

75. Misc. Meperedine (Demerol) 12.5-50 mg
Not appropriate for first-line opioids
Used for shivering
Neurotoxic- causes seizures
Stadol, Nubain: agonist-antagonist
Ceiling on dose: ^ don’t increase relief
Suboxone: combo of buprenorphine & naloxone; sublingual tablet or film
For treatment of addiction
May be habit forming, many side effects

76. OPIOIDS Used to manage moderate to severe pain
Bind to opiate receptors in the brain to alter perception of pain
Addictive, cause psych & physical dependence
Side effects: sedation, dizziness, respiratory depression, impaired thinking, urinary retention, constipation, pruritis, dry mouth, nausea/ vomiting, sleep disturbances
Goal: find balance between pain relief & side effects; ask patient if he/she wants more

77. Equivalency Dosing of Opioids
DRUG
Parental Dose
Equivalent to 10mg IV MS
Oral Dose equivalent to 30mg Oral MS
Morphine 10 30
Fentanyl
0.1 NA
Dilaudid
1.5
7.5
Demerol
75-100
300
Methadone 20
Oxycodone
MS Contin 60

78. Patient Controlled Analgesia
Rationale for PCA:
Patient titrates analgesics to needs, bypassing unavoidable delays when analgesics are provided on request
Intermittent & steady-state analgesia that is patient-activated~ avoid peaks & valleys
Blood level of meds can be maintained within an effective range
Patient takes active role in care

79. Desired Outcomes Adequate pain control in a safe manner
Keeps serum level within therapeutic range
Patient can breathe deeply and ambulate early, reducing post-op complications
Patient more comfortable and less anxious, enhancing patient satisfaction

80. PCA Patient selection:
Alert with clear sensorium ( except palliative care)
Intellectually, emotionally & physically capable of understanding & operating PCA
Developmentally capable of understanding & operating PCA
Medications: Morphine, Hydromorphone, Fentanyl

81. PCA (cont) Tell patient & family rationale for PCA
Identify any side effects (opioids)
2 RNs double check dosage orders upon initiation of infusion, when accepting patients from another unit and when parameters change
Family may be instructed to participate
Joint Commission has Sentinel Alert on PCA by Proxy

82. Disadvantages Disadvantages Potential for overdose
Limited nursing contact
Requires IV access
Potential for programming errors
Non-candidates
Major psych disorder
Hemodynamically unstable
Inadequate controlled seizure disorder
Medical condition= restricted use of opiates

83. Regional Anesthetics Topical: Lidocaine patch 5% (Lidoderm)
Shingles, Crohn's disease, low back and neck pain, migraine
Analgesic, not anesthetic
Minimal adverse events
Pliable adhesive- apply directly to painful, intact site; change q 24; may wear 4 safely
Infiltration: 0.5% to 2%Lido (with/out Epi)

84. Peripheral Nerve Block: specific site to block conduction; pre and post surgery
Interscalene, axillary, intercostal, sciatic
Complications: nerve damage, failed block, hematoma, reaction to local
Epidural: solution into epidural space-single injection, repetitive bolus injections ( by catheter), continuous infusion ( by catheter)- for labor analgesia, chronic pain
Transcutaneous electrical nerve stimulator: (TENS)

85. Epidural Analgesia Rationale:
Allows for high concentration of drug at desired spinal cord receptors
Minimal amount of opiod enters systemic circulation, where opiod can cause undesired side effects
Allows for selective analgesia depending on location of catheter
Opiods have synergistic effect with local anesthetics-doses of both can be lowered

86. Desired Outcomes Intense, prolonged analgesia
Limiting total amount of systemic opiods
Decrease potential for opiod related side effects
Less sedation
Earlier mobilization: < incidence of DVTs
Ability to cough, deep breathe, clear secretions
Decrease cardiac workload & oxygen use
Decrease costs due to shorter LOS

87. Contraindications Patient refusal Shock Hypovolemia Coagulopathies
Skin lesions at site of injection
History of adverse reactions to opiods
Sleep apnea
Lack of familiarity of technique

88. Epidural Medications Fentanyl Sufentil Morphine Hydromorphone
Ropivacaine
Bupivicaine

89. Complications & Adverse Effects
Total or high spinal block
IV injection
Dural puncture resulting in a headache
Bleeding resulting in hematoma
Catheter problems (migration, breakage)
Adverse Effects
Pruritis, nausea, urinary retention
Mild to moderate sedation, hypotension

90. Sedation Assessment
S= Sleep, easy to arouse, respiratory depth & regularity compares to baseline; no action
1= Awake and alert, no action needed; may increase opioid dose
2= occasionally drowsy, easy to arouse, no action needed; may increase opioid dose
3=frequently drowsy, arousable, falls asleep mid-sentence; add non-opioid & decrease opioid 25-50%; increase monitoring to level 3
4= somnolent, minimal/no response; stop opioid ,stimulate, consider Naloxone

91. Treating Respiratory Depression
Assess and monitor patient’s level of sedation and respiratory status frequently for first 8-12 hours
Encourage deep breathing
Encourage use of incentive spirometer
If unresponsive to physical stimulation with shallow respirations & RR < 8/min, pinpoint pupils: Give Naloxone (Narcan)- ( reversal agent) mgm IV titrated slowly over 2-3 min

92. Adjuvants
Analgesic in some painful conditions, but primary indication is other than analgesia
Include:
Anticonvulsants: Tegretol, Klonopin, Dilantin, Neurontin (gabapentin), Lyrica (pregabalin)
First line for neuropathic pain, acute pain management ( persistent post surgical and burns); Opioid-sparing
Adverse effects: sedation, unsteadiness, nausea, dizziness

93. Adjuvants Antidepressants: Nortriptyline (Pamelor), Cymbalta, Effexor
First line for neuropathic pain
Adverse effects: dizziness, orthostatic hypotension, sedation, dry mouth
Steroids: Decadron, Prednisone, Solumedrol (metastatic bone cancer pain)

94. Misc. Medications
Tramadol (Ultram):analgesic that augments pain signal transmission inhibition; 50mg tab
Tapentadol ( Nucynta): acute, chronic, neuropathic pain; costly; fewer GI side effects
Methadone: effective analgesic for patients with difficult to control pain; has long half life- make dose adjustments slowly
Ketamine: used for patients requiring very high doses of opiods (chronic pain, history heroin addiction, neuropathic pain, OIH)

95. Documentation Pain Management Date, time
Current regimen ( drug dose, route)
Patient self-report of pain and pain relief
Activities patient is able to perform (cough, turn, deep breathe, ambulate)
Side effects and level of sedation
Current vital signs: BP, HR, RR, O2 Sat
Should be re-evaluated 30 min after intervention

96. Key Concepts: Anesthesia
Balanced Analgesia
Use continuous, multimodal approach
Considered ideal by experts
Use combined analgesic regimen
Preemptive Analgesia
Intervention implemented before noxious stimuli experienced
Reduces CNS impact
Provision for added analgesics for breakthrough or ongoing extreme pain

97. Expected Outcomes
Patient maintains hemodynamic stability, including respiratory/cardiac status & LOC
Patient states achievement of pain relief/comfort treatment goals
Patient states he/she feels safe & secure with instructions
Patient shows effective use of at least 1 non-pharmacological method
Patient shows effective use of PCA
Patient states evidence of receding pain & increased comfort

98. Tailor Treatment Plan
Acute pain: short-term; need to discuss recovery/rehab milestones and patient’s ability to meet them
Chronic pain: discuss what patient could do before that the pain keeps him/her from doing now
End of Life: discuss if there is anything patient wants to accomplish before death that the pain would interfere with

99. Be Truthful!
Zero pain is usually not possible but let patients know you care about their pain and will always try to do everything possible to control it !
Reinforce link between pain relief and accomplishment of pain treatment goals
Find the right balance for each individual patient: quality of life, pain relief and adverse effects

100. Stopping Pharmacological Measures
When pain is relieved
Adverse effects have occurred:
Respiratory depression
Blood pressure change of 30% or more from baseline
Oxygen saturation less than 90% ( unless that is patient’s normal)
Too much sedation, Too great decrease LOC
Signs of an allergic reaction to the opioid

101. Benefits to Pain Management
Pain control= greater comfort during recovery to get well faster
Less pain= ability to ambulate early, do breathing exercises and get strength back quicker
Short length of stays in the hospital is also a strong possibility= increased patient satisfaction

102. Current Knowledge
Pain alters the quality of life more than any other health-related problem
Pain is one of the least understood, most often under-treated and often discounted problems of healthcare providers & pts.
Nurses have little control over intervening variables: social support, prognosis, financial well-being, education, personality traits, addictions, physical fitness, religiosity, belief system, values, etc
Nurses’ have control over caring & comfort

103. Comfort Management
Nurses assess patients’ holistic comfort needs on an individual basis
3 types of comfort needs
Relief: need to have specific discomfort relieved
Ease: need to remain in a state of contentment & well-being
Transcendence: need to be strengthened, motivated, or invigorated

104. Holistic Perspective
Implies desired outcome of nursing care from using holistic intervention
Massage= enhanced patient comfort, compared to baseline
Enhanced comfort has positive relationship with health seeking behaviors
Internal ( healing)
External ( improved functional status, mobility, strength, appetite, etc)
Peaceful death: symptoms well-managed

105. Relationship: Comfort & Pain
Comfort is an umbrella term:
Effective pain management significant part
Other discomforts needing attention are: N&V, thirst, lyte imbalance, air hunger, etc
When pain is relieved:
Improvement in vital signs
Resting state induced ( patient appears relaxed, may have eyes closed
Muscular relaxation: facial muscles relaxed, body tension eased

106. Contexts of Comfort Comforting occurs:
Physical: bodily sensations, immune function, homeostatic mechanism
Social-Cultural: interpersonal , family & societal relationships; traditions/rituals
Psycho-spiritual: internal awareness of self, esteem, identity
Environmental: external background of human experience~ temperature, light, sound, odor, color, furniture

107. Evaluate Comfort Interventions
Ask:
What analgesia did patient receive?
What other interventions were tried?
How effective were interventions in relieving discomforts, including anxiety?
Are drugs or other interventions affecting the vital signs?
How much activity can patient engage in prior to experiencing pain or discomforts?
Any change in dosing of meds? Any breakthrough pain or discomfort?

108. Pain Control and Comfort Interventions=
HAPPINESS!