1. KATE BLACK KATE BRAZZALE LISA MOLONY PAIN

2. Aetiology Disorder/Disease Clinical Manifestations Pathophysiology Diagnosis Pharmacological Management Non-Pharmacological Management Complications Implications for Nursing Practice

3. WHAT IS PAIN? According to the International Association for the Society of Pain, Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. http:/www.iasppain.orgContentNavigationMenuGeneralResourceLi nks/PainDefinitions/default.htm

4. AETIOLOGY: WHAT CAUSES PAIN? “Pain can be due to a wide variety of diseases, disorders and conditions that range from a mild injury to a debilitating disease”. http://www.localhealth.com/article/pain

5. AETIOLOGY: WHAT CAUSES PAIN? Kate, if you want this picure it’s not problem, just delete this slide,

6. ACUTE PAIN “The terms acute and chronic refer exclusively to the time course of the pain, irrespective of aetiology” (Craft, Gordon, and Tiziani, 2011, p.144). Acute Pain: Usually lasts less than 3 months Sudden onset Usually well defined Predicable ending (healing) Can lead to chronic pain if left untreated Examples: cut to the finger, broken bone

7. CHRONIC PAIN Chronic Pain: Persistent or recurring pain Continues for more than 3 months May last for months or even years Can be difficult to diagnose and treat Primary goal is not total pain relief but reducing pain relief Examples include: arthritis and back pain

8. CATEGORIES OF PAIN Another way to categorise pain is on the basis of origin: Nociceptive Neuropathic Psychogenic

9. NOCICEPTIVE PAIN Nociceptive pain is directly related to tissue damage and can be either external (somatic) or internal (visceral) External / Somatic Most common type of pain Can be superficial -in the skin but may extend to the underlying tissues. Usually described as: sharp, shooting, throbbing, burning, stinging well defined area Usually lasts from a few seconds to a few days Examples include: paper cut, sprained ankle

10. NOCICEPTIVE PAIN Internal / Visceral (Deep) Less common and usually more severe Originates in the walls of visceral organs Poorly defined area Described as: deep, aching, pressing or aching Usually lasts a few days to weeks Virtually a symptom of all diseases at some point during disease progression. Often associated with feeling sick Examples include: Major surgery, labour pain, irritable bowel.

11. NEUROPATHIC PAIN Injury or disease of the central nervous system rather than the peripheral tissue. May be due to nerve compression, inflammation or trauma Usually lasts between a few months to many years. Difficult to treat due to the lack of knowledge of the underlying cause. Often associated with paraesthesia, hyperalgesia and allodynia Burning, shooting or pins and needles (not sharp like nociceptive).

12. PSYCHOGENIC PAIN Psychological, psychiatric or psychosocial at the primary causes Severe and persistent pain Appears to have no underlying pathology. Less common now due to medical technology Pain experienced (Headaches, abdominal pain, back pain) is indistinguishable from that experienced by people with identifiable injuries or diseases. This kind of pain can be very frustrating to sufferers and can interfere with their ability to function normally.

13. CLINICAL MANIFESTATIONS Pain Tolerance: The maximum level of pain that a person is able to tolerate without seeking avoidance of the pain or relief What affects Pain Tolerance? Fatigue, anger, boredom, apprehension, sleep deprivation. Alcohol consumption, medication, hypnosis, warmth, distracting activities and strong beliefs or faiths. “No two people are likely to experience the same level of pain for a given painful stimulus” (Craft et al., 2011, p.150).

14. CLINICAL MANIFESTATIONS Pain tolerance is influenced by a number of factors including; Age Cultural perceptions Expectations Gender Physical and mental health

15. CLINICAL MANIFESTATIONS Age: Different reaction to pain Understanding of pain Gender: “Females display greater sensitivity to pain than males do. There are differences in the way women cope with pain, report pain and respond to pain” (Crisp & Taylor, 2009, p.1096). Physical & Mental Health Physical mobility Depression, difficulty coping, fatigue.

16. CULTURAL VARIATIONS Cultures vary in the meaning of pain, how if it expressed and how it is treated: Meaning Expression Treatment

17. PAIN THRESHOLD Pain Threshold is the lowest point at which pain can be felt Entirely subjective May vary from person to person but changes little in the same individual over time.

18. LOCATION It is important record a patients pain location to be able to monitor any changes. Pain can feel like it is coming from one part of the body but in fact it is another, this type of pain is called referred pain.

19. SIGNS AND SYMPTOMS: Signs: Change in temperature Blood pressure Respiratory rate Heart rate Short of breath Sweating Pallor Dilated pupils Swelling Symptoms: Fatigue Feeling sick Weakness Numbness Tenderness Change in behaviour Unable to sleep

20. PATHOPHYSIOLOGY

22. DIAGNOSIS Diagnosis of Pain is complicated. To diagnose pain, Nurses rely on Objective Data. Visual signs. Subjective Data. Patients descriptions. Characteristics of Pain.

23. DIAGNOSIS Characteristics of Pain OPQRST Mnemonic Onset Provocation Quality Region/Radiation Severity Time

24. DIAGNOSIS 1.Onset What was the patient doing at the time? What precipitated the pain? 2.Provocation Aggravating Factors: What causes the Pain to increase? Alleviating Factors: What makes it better or worse?

25. DIAGNOSIS 3. Quality Get the patient to describe their pain to you in specific terms. What does it feel like? 4. Region/Radiation Where is the pain? Where does the pain radiate? Is it in one place? Does it go anywhere else? Did it start elsewhere and now localised to a different spot?

26. DIAGNOSIS 5. Severity Pain Rating On a scale of 1 to 10, 10 being the worst pain you have experienced, what number would you assign to your discomfort? Does their pain change with medication? Wong-Baker Faces Pain Rating Scale. Used for Children People whose first language is not English.

27. DIAGNOSIS

28. 6. Time When did the pain start? How long has the patient has this pain? Are there any Associated Phenomena? Factors consistent with pain e.g. Anxiety Physiological responses Sympathetic stimulation Parasympathetic stimulation Vital signs, skin colour, perspiration, pupil size, nausea, muscle tension, anxiety Behavioural Responses Posture, gross motor activities

29. DIAGNOSTIC TESTS Tests to verify pain. CT/CAT scan Computed Tomography or Computed Axial Tomography X-rays to produce an image of a cross-section of the body. MRI Scan Large magnet, radio waves and a computer produces detailed images of the body. Discography/Myelograms A contrast dye is injected into the spinal disk to enhance the X-Ray.

30. DIAGNOSTIC - TESTS EMG (Electromyography) Evaluate the activity of the muscles. Bone Scans Diagnose and monitor infection and fracture of the bone Ultrasound Imaging High frequency sound waves to develop an image of the affected area.

31. DIAGNOSTIC TESTS Psychological Assessment Psychosocial involvement. Questionnaires.

32. GENERAL PRINCIPLES OF PAIN MANAGEMENT Treat the cause of pain where possible, not just the symptom Make accurate diagnosis and assessment of pain extent and type to ensure appropriate analgesic prescription Keep the patient pain free Dose at regular specified intervals, particularly for chronic pain (rather than PRN) Avoid the chronic pain stress cycle and 'sick role‘ Follow the WHO analgesia ladder Prevent adverse effects of opioids Develop a patient management plan

33. PHARMACOLOGICAL MANAGEMENT WHO has developed a three-step ladder for pain relief If pain occurs, the use of oral of drugs should be administered in the following order: 1.non-opioids 2.mild opioids 3.strong opioids Image: World Health Organization http://www.who.int/cancer/palliative/painladder/en/

34. PHARMACOLOGICAL MANAGEMENT Involves the management of pain through analgesics Analgesic: a compound that relieves pain by altering perception of nociceptive stimuli without producing anaesthesia or loss of consciousness Three types of analgesics: 1.Opioids (narcotic) analgesics 2.Non-opioid analgesics (NSAIDs) 3.Adjuvants (DISCUSS HERE WHAT ADJUVANTS ARE OR ADD IN A SLIDE LATER)

35. PHARMACOLOGICAL MANAGEMENT Routes of administration: Oral Intravenously Continuous infusion (via SC or IV routes) Rectally Transdermal administration Inhalation

36. OPIOIDS Generally prescribed for moderate – severe pain Act on CNS by binding with opiate receptors to modify perception and reaction to pain The most commonly used opioid is morphine

37. OPIOIDS Add table of commonly used opioids, advantages/disadvantages

38. OPIOIDS Adverse drug reactions may include: respiratory depression excessive sedation constipation nausea vomiting tolerance dependence dysphoria (a mood of general dissatisfaction, restlessness, anxiety)

39. NSAID S Non-steroidal anti-inflammatory drugs Used to treat mild – moderate pain Work by acting on peripheral nerve receptors to reduce transmission and reception of pain stimuli Common NSAIDs include: Paracetamol Aspirin Ibuprofen Naxopren (arthritis)

40. NSAID S Adverse reactions may include: gastrointestinal tract disorders (dyspepsia, nausea and vomiting, diarrhoea/constipation) renal damage asthma attacks skin reactions sodium retention and consequent heart failure and hypertension Large overdoses of paracetamol can cause fatal acute liver damage if not promptly treated.

41. NSAID S Aspirin vs Paracetamol Aspirin is readily available OTC. It can be used in stroke prevention due to its anti-platelet qualities. In normal doses, paracetamol is a safer OTC analgesic than aspirin for the following reasons: adverse effects and allergic reactions are rare with therapeutic doses there is low risk of gastic upset, renal impairment or peptic ulceration compared with aspirin plasma protein binding is negligible (no risk of displacement causing drug interactions) few serious adverse drug interactions may be used by children safe to use during pregnancy and lactation

42. INCLUDE SLIDE ON ADJUVANTS?

43. PHARMACOLOGICAL MANAGEMENT Other drugs useful for analgesic effects GABA analogues Capsaicin Local anasthetics (e.g. lignocaine) General anasthetics (e.g. halothane, nitrous oxide) Ethanol or phenol Cannabinoids Specific anti-migraine drugs Herbal remedies (e.g. cloves, feverfew, kava kava, St John's wort, ginger, ginseng)

44. NON-PHARMACOLOGICAL MANAGEMENT Definition? Useful for patients who: find such interventions appealing express anxiety and/or fear may benefit from avoiding or reducing drug therapy are likely to need to cope with a prolonged interval of post- operative pain have incomplete pain relief after use of pharmacological interventions are able to use the intervention without assistance (TENS, heat packs)

45. NON-PHARMACOLOGICAL MANAGEMENT RICE (rest, ice, compression, elevation) Physiotherapy Counter-irritants TENS Acupuncture Psychotherapeutic methods Surgery Community support groups Complementary and alternative medicine - aromatherapy, herbal medicines, spinal manipulation

46. HOT AND COLD THERAPY From: Clinical Psychomotor Skills pg 153

47. PSYCHOTHERAPEUTIC Psychotherapeutic methods - hypnosis, behaviour modification, biofeedback, techniques, assertiveness training, art and music therapy, the placebo effect More info on this – find some journals Heaps of info in Crisp & Taylor

48. TENS MACHINE

50. COMPLICATIONS

52. IMPLICATIONS FOR NURSING PRACTICE DELETE THIS SLIDE LATER! Instruction/education on how to use pain score Cultural implications: Non-English speaking patients Stoicism Cultural healing methods Stereotyping gender/age How is this pain likely to impact on the patients lifestyle, other people,

53. IMPLICATIONS FOR NURSING PRACTICE Planning for nursing care (from Crisp & Taylor) Synthesise information Use critical thinking to ensure client's care plan integrates key points Establish a therapeutic relationship with the patient, and discuss realistic expectations for an individualised care plan Planned interventions must be appropriate for the nature and type of pain Goals should be specific and have measurable outcomes Set priorities for treatment

54. IMPLICATIONS FOR NURSING PRACTICE Interventions Who will be involved? Oncology nurse Physiotherapist Occupational therapists The family or caregiver People in the community: visiting nurses, pharmacists, general practitioner, palliative care nurses

55. IMPLICATIONS FOR NURSING PRACTICE Implementation The patient and the nurse must work in partnership when it comes to pain management (incl: Explanation of analgesia and use of PCA) REGULAR ASSESSMENT OF PAIN STATUS (need more info on this) It is the nurse’s role to administer and monitor interventions ordered by the doctor for pain relief, and also implement independent pain relief measures that compliment those prescribed by the doctor Patient remedies are often most successful, particularly if the patient has experienced that sort of pain Generally, the least invasive theory should be tried first

56. IMPLICATIONS FOR NURSING PRACTICE Other considerations Education - clients are better prepared to handle any situation when they understand it. Confidence and tone Relevant play for children Holistic health - ongoing state of wellness Cultural implications

57. REFERENCES