Pain Management

What is pain? One of the most common reasons people seek healthcare One of the most widely under-treated health problems

Pathophysiology A sensation caused by some type of noxious stimulation A pattern of responses that function to protect the individual from harm Whatever the experiencing person says it is whenever he says it does

Components of Pain Physical Caused by some kind of noxious stimulant Emotional Results of combination of thoughts, feelings, and beliefs Behavioral Pattern of responses that function to protect the individual from further harm

Causes of Pain Cutaneous Direct stimulation to skin (cut) Somatic From musculo-skeletal system (sprained muscle) Visceral Arising from hollow organs (appendicitis)

Neuropathic Damage to nervous system Referred Pain arising from someplace else in body

Descriptions of pain Chronic: occurring over a long period of time Acute: sudden, brief onset

Visual Analog Scale This is a line 10 cm. long (about 4 inches) that is divided into ten divisions. Patients are asked to show the amount of pain on a 1-10 scale. Researchers say that patients cannot function with a scale with more than ten points.

PQRST This mnemonic is devised to show the steps in pain assessment: Provoking factors Quality Region/Radiation Severity/Symptoms Timing

Provoking factors include what caused the pain and what might be making it worse Quality questions refer to how the pain feels…let the patient tell but offer suggestions if necessary, like sharp, dull, throbbing, burning, etc.

Region….have patient point to area that hurts Severity can be measured with the pain rating scales Symptoms may accompany the pain….nausea, vomiting, etc Timing refers to when the pain started, how long it lasts

Be aware Just because a patient cannot respond to pain doesn’t mean there is no pain Activities of daily living (ADLs) may be effected Neurological status will alter the response to pain

Pain Management Management must be timely, individualized, and bring the pain to an acceptable level of tolerance

Pharmacologic interventions Must be individualized Three main categories: Non-opioids Opioids Adjuvants

Non-opioids: Opioids Adjuvants Acetominophen (Tylenol) Aspirin NSAIDs (Advil) Opioids Weak  Strong Codeine  Hydromorhone Oxycodone  Morphine Vicodin  Merperidine Adjuvants Primary function is not pain relief but provide relief May modify mood so patient feels better

Precautions to giving pain medications Medication choice may depend on practitioner’s preference, however: Should not give two analgesics from same class at same time Must be aware of effects of medications Must watch for allergic reactions

Routes of medication administration Oral Injection Intravenous (includes PCA) Epidural Rectal Topical

WHO Pain Ladder SEVERE PAIN: Keep giving mild pain medication and add a strong opioid such as morphine or Fentanyl MODERATE PAIN: Keep giving mild pain medication and add a mild Opioid such as codeine MILD PAIN: Aspirin, ibuprophen Acetominophen, naprosyn

Concepts of WHO Pain Ladder By the mouth By the clock By the ladder For the individual With attention to detail

Placebos Controversial use of an inactive substance to satisfy the demand for medication

Non-pharmacologic interventions Pain control without using medications Alter the environment Relaxation and guided imagery Meditation Cutaneous stimulation Massage, acupressure, acupuncture, TENS Biofeedback Therapeutic touch Education

JCAHO Standards for Pain Management Address care at the end of life Assess and manage pain appropriately Assess pain in all patients Support safe medication ordering and administration

Monitor patient during post-procedure period Rehabilitate for optimal level of function Educate about pain an managing pain Plan for discharge continued care if needed Collect data to monitor performance

Nurses spend more time with patients than any other provider Nurses spend more time with patients than any other provider. They must stay informed in order to give the best care to their patients.

References: Falk. Kim Marie. Pain Management. National Center of Continuing Education. Catalog 98 TX. http://www.fxbcenter.org/caring/painladder.html http://www.harcourthealth.com/Mosby/Wong/fyi_03.html