Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "From Pain to Comfort Meg Beturne MSN,RN,CPAN,CAPA."— Presentation transcript:

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

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

3 PAIN DEFINED Pain is usually a localized physical suffering associated with bodily disorder Pain is usually a localized physical suffering associated with bodily disorder Pain is one of the body’s most important protective mechanisms 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 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 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 The patient is the ONLY one who can accurately describe his/her pain It is subjective It is subjective All pain should be considered REAL All pain should be considered REAL Pain can negatively affect the body Pain can negatively affect the body McCafferty,2011 McCafferty,2011

5 Newest Insights Definition of Pain refined: 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!

6

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? 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 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 Since it is distracting her from the pain, you can now medicate her appropriately

8

9 Pain Pathways Nociceptors: give the body the ability to produce pain 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 Transduction: cutaneous nociceptors send impulses to spinal cord Transmission: Impulses synapse either by fast or slow pain fibers Transmission: Impulses synapse either by fast or slow pain fibers Perception: pain impulses processed by thalmus & cerebral cortex Perception: pain impulses processed by thalmus & cerebral cortex Modulation: along the efferent fibers, pain may be inhibited or modulated 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 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: 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 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) 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) 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 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 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” 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) 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 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 Don’t withhold pain medication because of these changes alone

17 CHRONIC- Two Types Chronic Non-Malignant 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 Chronic Malignant  Cancer pain

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

20 Other PAIN Terms Breakthrough Pain: pain that increases above the pain addressed by the ongoing analgesics 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 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 Discomfort: being uncomfortable in body or mind; mild distress Suffering: feel pain/distress; sustain harm; injury, pain or death Suffering: feel pain/distress; sustain harm; injury, pain or death

21 Sobering Statistics 15% Americans with major trauma/surgery pain (45 million) 15% Americans with major trauma/surgery pain (45 million) 25% Adults have chronic pain ( > 76 million) > diabetes, heart disease, cancer combined 25% Adults have chronic pain ( > 76 million) > diabetes, heart disease, cancer combined 50% of inpatients/outpatients have pain 50% of inpatients/outpatients have pain 30% patients give hospital low marks for pain control 30% patients give hospital low marks for pain control Untreated/undertreated pain still common Untreated/undertreated pain still common CDC (2007) Fast Facts 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 Lack of expression does not equal lack of pain~ physiologic and behavioral adaptations to pain occur Not ALL causes of pain are identifiable Not ALL causes of pain are identifiable Respiratory tolerance is rapid Respiratory tolerance is rapid Sleep is possible with pain but not good quality Sleep is possible with pain but not good quality Elderly experience pain but do not express it as much and so do babies! Elderly experience pain but do not express it as much and so do babies! Addiction is rare % Addiction is rare %

23 Pain: A Perioperative Problem Nearly all patients have postoperative pain 45million: 80% rate it moderate to severe Nearly all patients have postoperative pain 45million: 80% rate it moderate to severe Pain is the most common reason for elective procedures Pain is the most common reason for elective procedures Fear of pain is the #1 reason for delaying elective surgery: reported by 59% pts. 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! 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: 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) “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 Pain Foundation,2001) “Relief of pain is a basic human right” (American Bar Association, 2000) “Relief of pain is a basic human right” (American Bar Association, 2000)

26 Ethical Duty of the Nurse Provide clinically competent, ethically defensible care Provide clinically competent, ethically defensible care Duty to relieve pain, provide humane 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 Protect patients/society from unauthorized opioid use When ethical dilemmas exist, communicate them! When ethical dilemmas exist, communicate them!

27

28 Pain Assessment Joint Commission Standards PC Assess, Treat, Reassess, Document Pain Joint Commission Standards PC Assess, Treat, Reassess, Document Pain Identifying & treating pain is part of care Identifying & treating pain is part of care Must be assessed during rest and activity Must be assessed during rest and activity Includes defining: 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 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 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 Fear, pessimism, catastrophizing  Pain, effects of drugs, death  Addiction to analgesics  Pain will be intolerable Anxiety: Cured? Anxiety: Cured?  What post-op sensations are normal? Unrealistic expectations Unrealistic expectations Interpretation of experience different than team: age, culture, background Interpretation of experience different than team: age, culture, background

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

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

34 Pediatrics Behavioral Tool Pediatrics Behavioral Tool  Difficult to distinguish pain from fear Rely on parent reports Rely on parent reports Observe behaviors Observe behaviors Can use FLACC: Face, Legs, Activity, Cry, Consolability; 0-2 each with 10 being maximum; Behavioral score only, not intensity rating 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 Facial expression, breathing, arms, legs, cry, state of arousal CRIES: scale for neonatal 32 weeks to term; Cry, Requires Oxygen, Increased vitals, Expression, Sleeplessness CRIES: scale for neonatal 32 weeks to term; Cry, Requires Oxygen, Increased vitals, Expression, Sleeplessness

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

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

38 Special Considerations Elderly: pain prevalence 2-fold higher >60 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: 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 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 Introduced in JOPAN in 2003, available now on ASPAN web site Speaks to Assessment, Interventions and Expected Outcomes 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 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: 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: 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 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: 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 Subjective data: who, what, where, why & when are first clues of pain assessment Objective data: observation of facial grimace, teeth clenching, frowning, moaning, crying 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 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 Dilatation of pupils and/or wide opening of eyelids Shivering Shivering Change in skin and body temperature Change in skin and body temperature Increased muscle tone Increased muscle tone Sweating Sweating

48 ASSESSMENT Location: examine site Location: examine site Intensity- use easy, fast, multicultural, multilingual pain scale: 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 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 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) 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 Important to have scales translated into languages of populations served

50

51 ASSESSMENT (cont) Obtain description of quality of pain 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 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 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) 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 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! Don’t dismiss the patient’s self-report of pain they are experiencing!

54 ASSESSMENT (cont) Assess other causes of pain 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) 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! Communicate & document all data!

55 Case Scenario Patient had anterior/posterior lumbar fusion done for an acute incident 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 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 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 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 Value stoicism and problem-focused coping Expecting a certain degree of pain Expecting a certain degree of pain Is drug seeking, solely on the basis of: 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 Nurse is better judge of pain than patient Pain is punishment for sins/wrong-doing Pain is punishment for sins/wrong-doing

58 Case Scenario Mrs. Smith is an elderly, Hispanic patient who is status post hip replacement 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? 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? 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? Are personal, cultural, spiritual or ethnic beliefs in play? Do not assume anything! Do not assume anything!

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

60 Non-Drug Interventions (cont) Complementary: 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 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 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 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 1. Oral Analgesia 2. IV Analgesia 2. IV Analgesia 3. PCA Analgesia 3. PCA Analgesia 4. Epidural Analgesia 4. Epidural Analgesia

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

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

66 Other Routes Transdermal: Fentanyl (Duragesic patch) Transdermal: Fentanyl (Duragesic patch)  persistent, chronic pain; can’t take oral meds  non-adherent patients; recovering addicts  opioid tolerant kids > 2yrs with cancer pain  hr application period  patient preference, no stigma, bypasses GI Oral transmucosal (sublingual, buccal): Actiq 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 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 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 Rectal: almost all oral meds can be given this way Intramuscular: unreliable, painful, not recommended unless there is no IV Intramuscular: unreliable, painful, not recommended unless there is no IV Subcutaneous: same as IM Subcutaneous: same as IM

68 Oral Agents Non-narcotics: 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 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 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 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 Bextra and Vioxx: withdrawn- increased cardiovascular risk, increased M.I. and stroke post CABG

71 Adverse Effects May alter hemostatic balance May alter hemostatic balance Avoid in high risk CV patients Avoid in high risk CV patients GI toxicity, increases greatly if 2 NSAIDs are given; consider Nexium or Prilosec in high risk 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 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 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 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> 50 kg. give 1000mg q 6 hr or 650mg q 4 hr to max of 4, 000mg per day Adults/teens 2-10 years: 15mg/kg q 6hr or 12.5mg/kg q 4 hr to max of 75mg/kg/day= 3,750mg/day Adults/teens 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 Within 15 min. increased level in plasma Cost= $11/dose Cost= $11/dose

73 IV Ketorolac: short term pain management- 5 days IV Ketorolac: short term pain management- 5 days Dose: < 65: 30mg q6h(120mg/day=max) Dose: < 65: 30mg q6h(120mg/day=max) Pedi dose: 0.5mg/kg q6h Pedi dose: 0.5mg/kg q6h Correct hypovolemia before administration 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 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 Fentanyl: 25-50mcg IVP q5 min prn Morphine Sulfate: 2mg IVP q5min prn Morphine Sulfate: 2mg IVP q5min prn Oxycodone (Percocet): 1-2 tabs q 4-6 hrs prn Oxycodone (Percocet): 1-2 tabs q 4-6 hrs prn Hydromorphone (Dilaudid) 1-2mg IV, 2-4mg po Hydromorphone (Dilaudid) 1-2mg IV, 2-4mg po Hydrocodone ( Vicodin):5/500mg-1tab q4hrs- not to exceed 8tabs in 24hrs. Hydrocodone ( Vicodin):5/500mg-1tab q4hrs- not to exceed 8tabs in 24hrs. Oxycontin ( MS ER): 30mg- 1tab q12 hrs Oxycontin ( MS ER): 30mg- 1tab q12 hrs Tylox 5/500mg: 1tab q6hrs prn Tylox 5/500mg: 1tab q6hrs prn Tylenol #3: 300/30mg 1tab q4hrs prn Tylenol #3: 300/30mg 1tab q4hrs prn

75 Misc. Meperedine (Demerol) mg Meperedine (Demerol) mg  Not appropriate for first-line opioids  Used for shivering  Neurotoxic- causes seizures Stadol, Nubain: agonist-antagonist Stadol, Nubain: agonist-antagonist  Ceiling on dose: ^ don’t increase relief Suboxone: combo of buprenorphine & naloxone; sublingual tablet or film 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 Used to manage moderate to severe pain Bind to opiate receptors in the brain to alter perception of pain Bind to opiate receptors in the brain to alter perception of pain Addictive, cause psych & physical dependence Addictive, cause psych & physical dependence Side effects: sedation, dizziness, respiratory depression, impaired thinking, urinary retention, constipation, pruritis, dry mouth, nausea/ vomiting, sleep disturbances 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 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 Morphine1030 Fentanyl0.1NA Dilaudid Demerol Methadone2010 OxycodoneNA30 MS Contin NA60

78 Patient Controlled Analgesia Rationale for PCA: 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 Adequate pain control in a safe manner Keeps serum level within therapeutic range Keeps serum level within therapeutic range Patient can breathe deeply and ambulate early, reducing post-op complications Patient can breathe deeply and ambulate early, reducing post-op complications Patient more comfortable and less anxious, enhancing patient satisfaction Patient more comfortable and less anxious, enhancing patient satisfaction

80 PCA Patient selection: 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 Medications: Morphine, Hydromorphone, Fentanyl

81 PCA (cont) Tell patient & family rationale for PCA Tell patient & family rationale for PCA Identify any side effects (opioids) 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 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 Family may be instructed to participate Joint Commission has Sentinel Alert on PCA by Proxy Joint Commission has Sentinel Alert on PCA by Proxy

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

83 Regional Anesthetics Topical: Topical: Lidocaine patch 5% (Lidoderm) 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 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 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) Transcutaneous electrical nerve stimulator: (TENS)

85 Epidural Analgesia Rationale: 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 Opiods have synergistic effect with local anesthetics-doses of both can be lowered

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

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

88 Epidural Medications Fentanyl Fentanyl Sufentil Sufentil Morphine Morphine Hydromorphone Hydromorphone Ropivacaine Ropivacaine Bupivicaine Bupivicaine

89 Complications & Adverse Effects Complications: Complications:  Total or high spinal block  IV injection  Dural puncture resulting in a headache  Bleeding resulting in hematoma  Catheter problems (migration, breakage) Adverse Effects 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 S= Sleep, easy to arouse, respiratory depth & regularity compares to baseline; no action 1= Awake and alert, no action needed; may increase opioid dose 1= Awake and alert, no action needed; may increase opioid dose 2= occasionally drowsy, easy to arouse, 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 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 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 Assess and monitor patient’s level of sedation and respiratory status frequently for first 8-12 hours Encourage deep breathing Encourage deep breathing Encourage use of incentive spirometer 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 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 Analgesic in some painful conditions, but primary indication is other than analgesia Include: 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 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) Steroids: Decadron, Prednisone, Solumedrol (metastatic bone cancer pain)

94 Misc. Medications Tramadol (Ultram):analgesic that augments pain signal transmission inhibition; 50mg tab Tramadol (Ultram):analgesic that augments pain signal transmission inhibition; 50mg tab Tapentadol ( Nucynta): acute, chronic, neuropathic pain; costly; fewer GI side effects 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 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) Ketamine: used for patients requiring very high doses of opiods (chronic pain, history heroin addiction, neuropathic pain, OIH)

95 Documentation Pain Management 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 Balanced Analgesia  Use continuous, multimodal approach  Considered ideal by experts  Use combined analgesic regimen Preemptive Analgesia Preemptive Analgesia  Intervention implemented before noxious stimuli experienced  Reduces CNS impact Provision for added analgesics for breakthrough or ongoing extreme pain Provision for added analgesics for breakthrough or ongoing extreme pain

97 Expected Outcomes Patient maintains hemodynamic stability, including respiratory/cardiac status & LOC Patient maintains hemodynamic stability, including respiratory/cardiac status & LOC Patient states achievement of pain relief/comfort treatment goals Patient states achievement of pain relief/comfort treatment goals Patient states he/she feels safe & secure with instructions 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 at least 1 non-pharmacological method Patient shows effective use of PCA Patient shows effective use of PCA Patient states evidence of receding pain & increased comfort 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 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 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 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 ! 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 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 Find the right balance for each individual patient: quality of life, pain relief and adverse effects

100 Stopping Pharmacological Measures When pain is relieved When pain is relieved Adverse effects have occurred: 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 Pain control= greater comfort during recovery to get well faster Less pain= ability to ambulate early, do breathing exercises and get strength back quicker 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 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 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. 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 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 Nurses’ have control over caring & comfort

103 Comfort Management Nurses assess patients’ holistic comfort needs on an individual basis Nurses assess patients’ holistic comfort needs on an individual basis 3 types of comfort needs 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 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 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: 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: 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: 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: 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= Pain Control and Comfort Interventions=HAPPINESS!


Download ppt "From Pain to Comfort Meg Beturne MSN,RN,CPAN,CAPA."

Similar presentations


Ads by Google