Chronic Pain Management Janet Messamore, APRN, CDE

PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

Prior Learning Objectives: Apply the basic principles of pain management: Person with pain is the authority on the pain Pain experience is complex and includes sensory and emotional components There are differences in acute, chronic non-cancer pain and cancer-related pain The major types of pain are nociceptive and neuropathic and have differences in quality and presentation. There are patient and family related barriers to adequate pain management.

Nociceptive Pain – Somatic Pain Aching, often constant May be dull or sharp Often worse with movement Well localized Eg/ – Bone & soft tissueBone – chest wall

Nociceptive Pain – Visceral Pain Constant or crampy Aching Poorly localized Referred Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction

COMPONENTDESCRIPTORSEXAMPLES Steady, Dysesthetic Burning, Tingling Constant, Aching Squeezing, Itching Diabetic neuropathy Post-herpetic neuropathy Paroxysmal, Neuralgic Stabbing Shock-like, electric Shooting Lancinating trigeminal neuralgia may be a component of any neuropathic pain FEATURES OF NEUROPATHIC PAIN

Name patient and/or family barriers?

Prior Learning Objectives: Use a standard pain assessment tool to assess: – Location, intensity, quality, pattern, alleviating and aggravating factors, medication history, responses to pas treatments and other relevant factors such as the patients’ lifestyle, impact of the pain on the patients life. – Provide accurate, objective and timely documentation of the pain assessment – Perform regular, ongoing reassessment of pain

Example Of A Numbered Scale

Chronic Pain Assessment Parameters ** General H/P is critical L = Location of pain M = Manner of expressing pain Medications N = Number of pain O = Origin of pain Own attitude toward pain and treatment P = Precipitating factors Psycho-social assessment Q = Quality R = Radiation S = Severity/Suffering T = Timing

Prior Learning Objectives: Review non-pharmacological interventions -Cognitive-Behavioral such as distraction, guided imagery, biofeedback, music, humor, cognitive reframing, relaxation and meditation -Physical such as massage, positioning, heat and cold and yoga. Review pharmacological interventions using these three major classes of analgesic drugs: non-opiods, opiods, and adjuvants

Chronic Pain Medications Refer to M-25 to M-29

+/- adjuvant Non-opioid Weak opioid Strong opioid Pain persists or increases By the Clock W.H.O. ANALGESIC LADDER +/- adjuvant 1 2 3

Learning Objectives for Today Upon completion of talk today, the learner will be able to utilize the nursing process for a chronic pain patient.  Assessment collect comprehensive data pertinent to the pain problem  Diagnosis analyze assessment data to develop nursing diagnoses and plan interventions, teaching plans, and desired outcomes.  Outcomes Identification identify expected outcomes for an individualized plan for the patient with chronic pain

Learning Objectives (continued)  Planning develop a pain management plan that prescribes strategies and alternatives to attain expected outcomes  Interventions including coordination of care and health teaching and health promotion  Evaluation evaluate progress towards attainment of chronic pain management outcomes

Assessment Pain pattern: onset, duration, Location: may be able to specify, may not, radiation to another spot? Intensity: may use pain scales adjusted to age and cognitive development Quality: nature or characteristics of pain Associated symptoms: ?anxiety, fatigue, depression Management strategies: what have they used in past or currently? Impact of pain: quality of life, sleep, work ADLs

Nursing Diagnosis Impaired Comfort r/t altered health status Disturbed Energy r/t unbalanced energy field Chronic Sorrow r/t chronic illness Actual or potential tissue damage r/t surgery Activity intolerance r/t pain Others: constipation, fatigue, fear, hopelessness, ineffective coping, insomnia, interrupted family processes, social isolation

Outcomes Identification Patient will verbalize and demonstrate (nonverbal cues) relief or control of pain or discomfort. (impaired comfort) Verbalize recognition of interpersonal and family dynamics and reactions that affect the pain problem.(interrupted family processes) Demonstrate or initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions. (disturbed energy)

Planning Set goals for pain relief Assess for etiology and precipitating factors. Develop individualized treatment plan and determine patient response to chronic pain situations in the past if relevant. Review client expectations Anticipate teaching needs

Interventions  Anticipate need for pain relief  Respond immediately to complaint of pain  Eliminate additional stressors or sources of discomfort whenever possible  Provide rest periods to facilitate comfort, sleep, and relaxation  Utilize nonpharmacological methods as possible  Evaluate effectiveness and observe for side effects  Notify physician if interventions are unsuccessful

Reassessment/Evaluation Individual response to interventions Perception of pain, effects on lifestyle and expectations of therapeutic regimen Pain relief or decrease in pain Goal attainment Modifications to plan of care Referrals made if identified Discharge teaching

Questions?