Pain Management C. Calzolari 2014

What is Pain? Pain is subjective. Pain is a multidimensional experience Pain is whatever the patient says it is. Nurses most forego their own values and experience of pain and focus on the patient’s experience of pain

Why Do We Experience Pain? It is protective. How? It is a signal. What?

Cause of Pain Nociceptive pain(pain receptors) – most common. Respond to stimulation. Visceral – organs , linings of cavities Somatic – Skin, muscles, bones, connective tissue Neuropathic pain – complex and often chronic. Nociceptive pain may occur due to trauma, surgery or inflammation. Neuropathic pain – nerve injury from DM, CVA, tumor, viral infection, meds such as chemotherapy. http://youtu.be/n2Jzt3zd8vQ skip

Classification of Pain Acute Can Identify Cause Temporary Activates SNS - BP, HR, RR, more blood to brain, dilates pupils Acute pain – short duration, rapid onset. May last up to 6 mos. Mostly associated with injury or surgery. IT IS PROTECTIVE in nature

Classification of Pain Chronic Longer Duration – lasts beyond healing phase Interferes with ADLs Remissions & exacerbations Stimulates PNS - or normal Vital Signs Affective Responses Lasts 6 mos or longer Can be related to progressive or chronic disorders. Neuropathic pain is an example. Affective Responses – anxiety, depression, anger, fear, exhaustion, hopelessness, irritability Why? Lack of purpose of pain and uncertainty of duration

Classification of Pain Intractable Chronic Resistant to pain relief Multi-Disciplinary Approach

Descriptions of Pain Based on site, cause, duration and quality.

Site of Pain Cutaneous or superficial pain Visceral pain Deep somatic pain Radiating pain Referred pain Phantom pain Psychogenic pain Cutaneous or superficial pain- arises in the skin or subq tissue example touch something hot and feel pain. Visceral pain – stimulation of deep internal pain receptors – abdominal cavity, cranium, thorax. Example – menstrual cramps, labor pain, gi disorders. Deep somatic pain- originates in the ligaments, tendons, nerves, blood vessels, bones. . Examples: fractures, arthritis. More diffuse lasts longer. Radiating pain – extends to other areas – sore throat pain may expand to hands and ears. Referred pain – occurs in area distant from original site.. Chest pain may be felt in right or left hand, or jaw. Phantom pain – pain from site that was surgically removed. Person may perceive burning, itching, deep pain in that area. Psychogenic pain – arises from mind – no physical cause can be identified.

Duration of Pain Acute Chronic Intractable Acute pain – short duration, rapid onset. May last up to 6 mos. Most ly associated with injury or surgery. IT IS PROTECTIVE in nature. Chronic pain – lasts 6 mos or longer. Interferes with daily activities. Can be related to progressive disorder, or

Take the Vocabulary Quiz

Application How would you classify the pain that the following patients are experiencing? ● A patient with metastatic cancer Answer: Chronic pain

A patient with back pain that was the result of an automobile injury a year ago Answer: Chronic pain, potentially neuropathic pain

A patient with a broken leg Answer: Acute deep somatic pain

Quality of Pain Only the patient can describe the quality of their pain. They may use words such as: Sharp Dull Throbbing Stabbing Burning Ripping Tingling Intermittent Constant Mild Intense Severe Sharp- Dull- mild, difficult to describe Throbbing- Stabbing- Burning- Ripping- Tingling-

Factors Which Influence Pain Emotions Developmental Stage Communication Impairments Pain Threshold Culture

Factors Which Influence Pain Emotions: Anxiety Fear Guilt Anger Helplessness Exhaustion Irritability Depression A person’s emotional response to pain is affected by previous pain experiences. Think of a child who received a shot at a MD’s office.

Factors Which Influence Pain Developmental Stage: Infants and children Adults Older Adults

Factors Which Influence Pain Communication Impairment: Those who have had a CVA, speak another language or are cognitively impaired. You will need to observe nonverbal cues for pain. Facial expressions Vocalizations Changes in physical activity Change in vital signs Change in routines Mental status changes

Factors Which Influence Pain Culture: Involves the patient’s expression of pain, the family’s response to the situation and the nurse’s attitude. William & Hopper: Box 10.2 – page 143-144

Factors Which Influence Pain Pain Threshold: The point at which the receptors in the frontal cortex recognizes and defines a stimulus as pain. Varies from person to person. Pain Tolerance: The duration or intensity of pain that a person is willing to endure.

Pharmacological Pain Relief Measures Analgesics Nonopioids – acetaminophen, salicylates, NSAIDS and COX -2 inhibitors Opioids - morphine, codeine, hydromorphone, methadone, meperdine, oxycodone, sublimaze patch

Analgesics At the site of an injury, the body produces prostaglandins, which increase pain sensitivity. Aspirin prevents the production of prostaglandins. Acetaminophen is believed to block pain impulses in the brain itself. Local anesthetics intercept pain signals traveling up the nerve. Opiate drugs, which act primarily in the central nervous system, block the transfer of pain signals from the spinal cord to the brain. Illustration by Lydia V. Kibiuk, Baltimore, MD

Routes of Administration Oral – preferred route Nasal Transdermal Rectal Subcutaneous Intramuscular – least preferred Intravenous PCA – patient controlled analgesia Intraspinal analgesics

Adverse Affects of Pain Medications Nonopioids – GIB, inhibition of platelet aggregation, renal insufficiency, hypersensitive reactions in persons with asthma, liver necrosis with OD of Tylenol. Opioids – respiratory depression, hypotension, drowsiness, constipation, nausea, vomiting, constricted pupils.

Analgesic Adjuvants These medications may potentiate the effects of opioids or nonopioids. Examples: steroids, benzodiazepines, tricyclic antidepressants, and anticonvulsants. Able to use less opioid doses when used with these adjuvants.

Antidote Narcan (naloxone)- counteracts the effect of opioids.

Interpreting MD Orders Morphine Sulfate 2 mg. IM q 4 hours prn for surgical pain. Percocet one tab po q 6 hours prn for foot pain Duragesic patch 25mcg/hr transdermal q 72 hours at 0800. Oxycontin 20 mg. po BID OxyIR 5 mg. po q 6 hours prn for breakthrough pain

Evaluation Always re-assess your patient after administering pain medications. At what time interval?

Special Considerations The Elderly The Person with Substance Abuse or Addiction Unrelieved Pain

Nonpharmacological Pain Relief Measures Cutaneous Stimulation TENS – Trancutaneous Electrical Nerve Stimulator Acupuncture Acupressure Massage Hot and Cold TX

Transelectrical Nerve Stimulation

TENS

Acupuncture

Acupressure Based on the same principles as acupuncture, (but using pressure instead of needles), acupressure works by stimulating specific reflex points located along the lines of energy which run through the body, called meridians.

Massage

Hot & Cold Therapies

Nonpharmacological Pain Relief Measures Surgery Immobilization Splints, slings, braces Cognitive-Behavioral Interventions Distraction Relaxation Techniques Guided Imagery Hypnosis Therapeutic Touch Humor

Guided Imagery start the day meditation - guided imagery – YouTube Guided Imagery - Bubble Release - YouTube

REIKI

Biofeedback Biofeedback Session Demo – YouTube http://www.youtube.com/watch?v=a53LA7aL2Og

The Nursing Process Lets Start With You, as a student nurse and health care providers.

The HCW’s Perception of Pain What are some myths associated with pain management that you have witnessed in the healthcare setting? W&H p 145

Nursing Process: Collect Data The fifth vital sign. Accept the patient’s report of pain. Obtain a pain history. Perform a physical assessment. Observe for nonverbal indicators of pain. Use WHAT”S UP format and pain scales.

WHAT”S UP? W here is the pain? H ow does the pain feel? A ggravating & alleviating factors. T iming. S everity. U seful other data. P erception.

Pain Scales Visual Analog Scale Numerical Rating Scale The Wong-Baker FACES pain Rating Scale

Analgesic Administration Use resources to check on purposes and actions of pharmacological agents Reconcile & maintain MAR +/or Patient’s list of medications. Identify patient’s allergies and intervene as appropriate.

Identify a contraindication to administration of a prescribed medication. Acetaminophen Caution and Guidance

Case Study: Mr. Lewis Answer ONLY these questions for Now: 1. 2. 4.

Planning Use data collected to plan action with patient’s input. Teach patient to use pain scales. Set goals for acceptable pain levels. Example: you will ask your patient who is in pain, “What is an acceptable level of pain for you after we have helped you relieve your pain?” “What has helped in the past to relieve your pain?”

Drug Calculations

Nursing Diagnoses Nursing Diagnosis: Impaired Comfort Pain, acute or chronic, Impaired Comfort Others: Self-Care Deficit, Impaired Mobility, Sleep Deprivation, Ineffective Airway Clearance, Ineffective Coping.

Interventions Apply therapies for comfort. Use alternative/complementary therapies for pain management. Administer pain medication as prescribed. Identify patient expected response to pain medication. Reinforce client teaching on possible effects of medication.

Follow rights of medication administration. Maintain medication safety practice. Follow protocol for handling controlled substances. Monitor patient use of medication over time. Maintain pain control devices.

Evaluation Monitor and document patient’s response to pharmacological and non – pharmacological interventions. Notify primary healthcare provider of actual/potential adverse effects of pain medications.

Explain the protocol for withholding pain medication if patient experiences an adverse reaction. Discuss actions used in the event of adverse reactions with the use of opioids.

What Happens When Someone Has Pain? Transduction - Stimuli: mechanical, thermal, chemical Transmission- A-Delta Fibers & C Fibers Pain Perception- Cerebral Cortex & Limbic System Pain Modulation- Endogenous opioids, neurotransmitters http://youtu.be/n2Jzt3zd8vQ

Case study: Mr. Lewis Finish the case study with your partner(s)

Role Playing & Case Scenarios Utilize your Medication Research cards and The Joint Commission Handout, “SpeakUP” to perform these excercises.