Mount Auburn Hospital “The Nurses Role in Improving Pain Management”

1. Mount Auburn Hospital“The Nurses Role in Improving Pain Management” Julie O’Donnell, RN, BSN, BC

2. Objective: Distinguish the difference between nociceptive pain and neuropathic pain • A.) Acute VS Chronic pain • B.) Characteristics of nociceptive pain • C.) Characteristics of neuropathic pain • D.) Assessment findings • E.) Pharmacologic interventions and non-pharmacologic interventions

3. Nurses know that… • "Pain is what the person says it is and exists whenever he or she says it does." (McCaffery, 1968)

4. The definition of pain: • Pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, as described in terms of such damage". (The International Association for the Study of Pain)

5. Pain Experiences are… -unique to each patient -complex in nature -influenced by physical factors -influenced by psychological factors

6. Pain is the #1 reason patient’s visit their doctor… • Pain is a public health problem that costs all of us.

7. Pain Transmission: NociceptionThe correct sequence of events in order… • TRANSMISSION • TRANSDUCTION • PERCEPTION • MODULATION

8. Pain: A Multimodal Issue

9. Cardiovascular Cognitive Endocrine Escalated blood pressure, rapid heart rate, increased cardiac output, peripheral, systemic, and coronary vascular resistance, myocardial oxygen expenditure, coagulation, deep vein thrombosis Diminished cognitive performance, confusion, distorted disposition, high somatization, and anxiety Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons, with decreased insulin and testosterone Physiological/Psychological Stressors Manifested in the Presence of Pain

10. Gastrointestinal Genitourinary Quality of Life Metabolic Pulmonary Reduced gastric and intestinal motility Urinary retention, fluid burden, depression of immune responses Anxiety, depression Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism Suppressed volume and flow, along sputum retention resulting in infection and atelectasis Physiological/Psychological Stressors Manifested in the Presence of Pain

11. Multidimensional Model of Pain • Pain is multidimensional and complex. This is why single treatments are rarely effective.

12. Acute: -usually thought to resolve within a month (short duration) -pain that comes on quickly, can be severe but lasts a short time. -the cause is known -treatment typically with analgesics Chronic: -usually thought to last longer than six months (long duration) -“Pain that extends beyond the expected period of healing” -the cause may be known or idiopathic -treatment needs to be multidisciplinary Acute vs Chronic Pain

13. Characteristics of Nociceptive pain Nociceptive pain is causes by stimulation of the peripheral nerve fibers.

14. -Somatic pain results from irritation or damage to the musculoskeletal system -Somatic pain may feel like a throbbing pain Examples: a cut to the finger, a stretching of a muscle Visceral pain results from the internal organs -Visceral pain is diffuse, poorly localized, and often referred. It is often described as generalized aching or squeezing. Examples: organ pain Nociceptive Pain: Somatic and Visceral

15. Characteristics of neuropathic pain • Neuropathic pain is a complex, chronic pain state that usually is accompanied by tissue injury. • With neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional or injured.

16. What symptoms would my patient show if they were having neuropathic pain? • Symptoms may include: • Shooting and burning pain • Tingling and numbness

17. What causes neuropathic pain? • ***Often time the cause is unknown • Facial nerve problems • HIV/AIDS • MS • Shingles • Lower back pain • Arthritis pain • Fibromyalgia • Migraine • Sickle cell disease • Malignant pain • Neuropathic pain (trigeminal neuralgia, diabetic neuropathy, phantom limb pain, post herpetic neuralgia)

18. Referred pain: Pain that presents in an area other than its point of origin

19. Consequences of untreated pain: • -impaired sleep • -depression • -anxiety • -in older adults delirium and confusion • -decreased socialization/loss of relationships • -nutritional deficits • -decline in ADL’s • DECREASED QUALITY OF LIFE

20. Principles of Assessment • Accept self report • Use the same pain scale over time • Assess when pain is both reported or suspected • Re-assess routinely • Consider the individual, the patient’s culture, values and beliefs

21. In summary… • Nociceptive pain is greatly relieved when healing is complete, while neuropathic pain persists after healing is complete.

22. What happens if the pain is not relieved? • Consequence of unrelieved pain is future pain. Failure to unrelieved pain may lead to future chronic pain syndromes

23. Effective treatments for neuropathic/chronic pain: Currently there is no proven treatment to prevent or cure neuropathic pain (neuropathy or never pain). The primary goals of treatment are to reduce the pain as much as possible, balance the negative side effects of the treatment, and help patients manage any unresolved pain. Interdisciplinary approach Pain clinics Treatments for Chronic Pain:

24. Pop Quiz • Q: The least reliable tool for assessing pain in a cognitively intact adult is: • a.) Changes in Vital signs • b.) Observations of patients behavior • c.) Assuming pain present with painful procedures • d.) Patient’s self report

25. Non-pharmacologic interventions: • -accupuncture • -biofeedback • -distraction • -deep breathing • -massage • -guided imagery • -hot and cold • -laughter • -music

26. Objective: Discuss the myths and misconceptions about pain • A.) providers misconceptions about pain • B.) patients misconceptions about pain • C.) pseudoaddiction vs addiction • D.) tolerance vs physical dependence • E.) patient advocacy

27. Pain Questionnaire HandoutTrue or False? Answers: 1.) F: Pain can increase myocardial demands 2.) F: It’s the patient 3.) F: Must manage tolerance 4.) True 5.) F: Indicates poor pain control 6.) F: Dose is not holding them for time frame ordered

28. Pain Questionnaire HandoutTrue or False? • 7.) F: Balanced analgesia • 8.) F: Antacids blocks NSAID absorption • 9.) F: no high when pain • 10.) F: the antidepressants are used to treat certain types of pain and relieving depression is not the intent directly

29. Providers: Myths and Misconceptions about pain • -Pain perception decreases with age • -If the vital signs are good the patient isn’t in pain • -If the patient is asleep they are free of pain

30. Patients: Myths and Misconceptions about pain • -”Good” patients don’t report pain • - Pain is punishment • -Addiction is common • -Strong pain medicine should be saved for later • -The health care provider will know if I am in pain • -No pain, no gain • -Pain is normal part of aging

31. Myths about pain: • Doctors and nurses are the experts about pain. • THE REALITY: The older adult is the expert. Pain is a complex, subjective experience that is best described by the person who feels it. When the older adult cannot report pain because of cognitive impairment or stroke, the people who know the individual best should be consulted. These people usually include family members and nursing assistants.

32. Myths about pain: • It’s important to be stoic about pain. • THE REALITY: Stoicism can prevent health care providers from identifying and treating pain. Reference: • http://www.geriatricpain.org/Content/Management/Pages/default.aspx

33. Pseudoaddiction vs Addiction • According to the U.S. National Institute of Health, National Cancer Institute (2004), “The term pseudoaddiction was coined to depict the distress and drug-seeking that can occur in the context of unrelieved pain.

34. Pseudoaddiction vs Addiction • The American Society for Addiction Medicine defines addiction as physical and/or psychological dependence on substances. Addiction is defined as the continued use of a addictive substance or behaviors despite adverse consequences.

35. Pseudoaddiction vs Addiction • A person who is addicted to drugs also develops psychological dependence on the drug not just a physical dependence.

36. Pseudoaddiction vs Addiction • Addiction can also be viewed as a continued involvement with a substance or activity despite the negative consequences associated with it.

37. Tolerance vs Physical dependence • Physical dependence occurs when a person's body becomes accustomed to and dependent on the presence of a particular drug. When the dose is lowered or the drug is stopped, the person will begin to notice withdrawal symptoms.

38. Tolerance • Normal biologic adaptation • May develop at different rates • Exposure to drug the effect of the drug over time • NOT ADDICTION

39. What will my patient exhibit if they are showing signs of withdrawing? • Some withdrawal symptoms feel like a flu bug.

40. Physical dependence • A person can be physically dependent on a drug but not addicted to it. When a medication is stopped it is expected that our patients can show signs of withdrawal.

41. At Risk: People with addiction disorders • Requests for pain meds are often perceived as addiction • We cannot withhold meds due to past addictive disorders • Relapse may be a consequence of undermedicating true pain • Person may “self medicate” their pain

42. Define and treat pain syndrome Identify history of substance abuse Establish parameters/make contracts Discuss consequences of noncompliance Use adjuvant medications Use non-opiod treatments Use controlled release opiod agonists Close watch on behaviors and compliance with plan Guidelines for treating patients with addiction disorder:

43. Patient Advocacy • When drug users become tolerant to a drug's effects, they must increase the dose to feel the same effects of the original dose. • This is why it is important to teach our patients about slowly cutting down their pain medications when appropriate.

44. Objective: Identify the cultural barriers to providing acceptable pain management to patients. • A.) Patient populations at risk for undertreatment of pain • B.) How to perform a cultural pain assessment? • C.) Knowledge of Self/Identify our own biases about pain • D.) Evidence Based Practice

45. Which patient populations are at risk for undertreatment of pain? • Minorities are three times as likely to be under treated. • Patients receiving a poor pain assessment from an inexperienced health care provider. • People with non-cancer pain.

46. Which patient populations are at risk for undertreatment of pain? • People with "Good" performance status, such as someone who appears to be coping well and performing activities adequately. • People over the age of 70.

47. HOW CULTURE AFFECTS THE PAIN EXPERIENCE • People from cultures that value stoicism tend to avoid vocalizing with moans or screams when they are in pain. • Other cultural groups tend to be more expressive about pain. They learned from childhood that when one is in pain, the appropriate response is to moan or cry.

48. Cultural Assessment Pop Quiz • During your initial assessment of Mr. T’s pain he tells you that he is in terrible pain but just wants to endure it. The best response to this statement would be: • A.) Tell him not to endure the pain • B.) Further explore what he means by his statement • C.) Provide information about the harmful effects of unrelieved pain. • D.) Offer him analgesic medication

49. CULTURAL PROBLEMS COMPLICATING PAIN MANAGEMENT • Language and interpretation problems • Nonverbal communication problems • Culturally or linguistically inappropriate pain assessment tools • Underreporting • Reluctance to use pain medications • Providers' fears of drug abuse.

50. CULTURAL PROBLEMS COMPLICATING PAIN MANAGEMENT • Prejudice and discrimination.