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Pain Management

Pain Management. Safety, Security and Comfort Needs of the Acutely Ill Client:. PAIN The 5th Vital Sign. Definitions of Pain. “Pain is whatever the experiencing person says it is, existing whenever he/she says it does.” -Mc Caffery 1968

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Pain Management

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  1. Pain Management

  2. Safety, Security and Comfort Needs of the Acutely Ill Client: PAIN The 5th Vital Sign

  3. Definitions of Pain • “Pain is whatever the experiencing person says it is, existing whenever he/she says it does.” -Mc Caffery 1968 • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” - Intl. Assoc. for the study of pain

  4. Food for Thought • Costs $100 Billion each year • Longer hospitalization • Rehospitalizations • ER visits • Sick days • Permanent Disability • Only 30% of cancer patients get adequate pain relief • 15-20% of Americans have acute pain • 25-30% of Americans have chronic pain • Leading cause disability for those < 45 y/o

  5. The Mechanisms of Pain • Transduction- • Transmission- movement of pain impulses • Perception- recognition of pain • Modulation- activation

  6. The Mechanisms of Pain • Transduction- • Conversion of mechanical, thermal or chemical stimulus into a neuronal action. • Peripheral nerve sites- peripheral afferent nociceptor (PAN) • Action Potential causes movement of pain stimulus What causes it? • Nociceptive- Release of Chemicals • Neuropathic- Abnormal processing of stimuli by the nervous system

  7. The Mechanisms of Pain • Transmission- movement of pain impulses from the site of transduction to the brain. • Transmission along the nociceptor fibers to the level of the spinal cord. • Dorsal horn processing. (Dermatomes) • Transmission to the thalamus and the cortex.

  8. The Mechanisms of Pain • Perception- recognition of pain • However, there is no precise location where pain perception occurs. • Individualized • Imagery is a good pain-reduction therapy. • Subjective • Sensory: Recognition that you have pain. • Affective: Emotional responses to pain. • Behavioral: How someone expresses or controls pain. • Cognitive: Person’s beliefs & attitudes about pain. • Sociocultural: Age, Gender, education level, culture and support systems.

  9. The Mechanisms of Pain • Modulation- activation of descending pathways that either inhibit or facilitate effects on pain transmission.

  10. Types of Pain Nociceptive Pain • Normal processing of stimuli that damages or has the potential to damage, normal tissues if prolonged. • Different types of origins: • Somatic Pain: Arises from bone, joint, muscle, skin or connective tissue. • Visceral Pain: Arises from visceral organs, such as pancreas or stomach.

  11. Somatic Pain • Described as “achy”, stabbing, sharp • Examples: • Bone pain, fractures • Muscle tears, sprains • Joint pain • Soft tissue injury

  12. Visceral Pain • Diffuse and difficult to localize if d/t obstruction of hollow viscus • Sharp, aching when due to injury to other visceral structures such as; • Pancreatitis • Kidney Stones • Menstrual Cramps • Bowel Obstruction

  13. Neuropathic Pain • Multiple Pain Syndromes • Often difficult to treat. • Believed to be the abnormal firing of the peripheral or central nervous system. • Often described as burning, stinging, shooting, traveling, or electric-like. • Caused by phantom limb pain, complex regional limb pain complex regional pain syndromes, diabetic neuropathy, post-herpetic neuralgia, or trigeminal neuralgia

  14. Normal processing of stimuli that damages normal tissue. Responds to opioids or nonopiods. Somatic pain- arises from bone, joint, muscle, skin or connective tissue Visceral pain Tumor involvement that causes aching and is fairly well-localized Obstruction causes intermittent cramping and poor localized pain. Abnormal processing by peripheral or central nervous system. Responds to adjuvant analgesics. Centrally Generated Pain Peripherally Generated Pain- Pain felt along entire nerve pathways. Peripheral nerve injury- pain felt partially along the damaged nerve Comparing Nociceptive & Neuropathic Pain

  15. ACUTE Sudden Short Duration < 3 months Mild--> Severe Can identify specific cause. Predictable prognosis Can be single event or recurrent.  as healing progresses. CHRONIC Continues for more than one month after healing or an acute lesion, or Recurs over a chronic period of time. Pathophysiology may be unclear. Unpredictable prognosis Is associated with a lesion that is not expected to heal. Chronic cancer pain or chronic non-malignant pain. Acute VS. Chronic Pain

  16. Sources of Pain

  17. May be associated with sympathetic hyperactivity and anxiety. Usually resolves Treated with short-acting drugs. May be associated with depressed mood, sleep disturbance and disability. Treated with long-acting drugs and adjuvant therapy. Acute VS. Chronic Pain Cont’

  18. Pharmacology of Pain Management • Individualized- Based on the patient’s medical and pain histories. • Multi-modal- Targets multiple sites of action. • Optimize effects • Minimize adverse effects

  19. Pharmacology of Pain Management Cont’ • Routes of Administration • Oral • Sublingual • Transmucosal (Actiq) • Transdermal (Fentanyl duragesic patch) • Parenteral: IV, IM, SQ • Nebulized • Rectal • Epidural/Intrathecal (Morphine, Fentanyl)

  20. Pharmacology of Pain Management Cont’ • How do Opioids work? • Opioids act on the opioid receptor sites and activate endogenous pain suppression systems in the CNS (Mu receptor sites). • Receptor sites are found in: • Dorsal horn of the spinal cord • Pituitary gland • GI tract • Endogenous & exogenous opioids control pain by locking onto opioid receptor sites and blocking the release of neurotransmitters.

  21. Pharmacology of Pain Management Cont’ • How NSAID’s and Acetaminophen work? • Non-opioids include NSAID’s, Tylenol and Aspirin. • They act on the peripheral nerve endings at the site of injury altering the prostaglandin system. • NSAID’s have an anti-inflammatory effect. • Acetaminophen does NOT have an anti-inflammatory effect. Like ASA, it has analgesic and antipyretic effects. • Side effects: • NSAID’s: GI irritation, possible nephrotoxicity. • Acetaminophen can cause hepatoxicity. • Limit 4 grams/24hr

  22. Pharmacology of Pain Management Cont’ • Short Acting Pain Medications • Provide analgesia within 30 min. • Diluadid, Morphine • Actiq-fastest acting oral medication- onset within 5 min. (transmucosal) • MSIR oral solution/Roxanol-elixir form of morphine. • Helpful for pts. with difficulty swallowing. • Titratable. • Oxycodone/MSIR tablets- used for short-term therapy or supplemental dosing (breakthrough pain). • Compounds: Tylenol #3, Hydrocodone- Lortab/Vicodin, Oxycodone- Percocet. • Propoxyphene- Darvon/Darvocet

  23. Pharmacology of Pain Management Cont’ • Long Acting Opioids • Usually used for long-term pain. • For patients requiring frequent breakthrough dosed of opioids. • More predictable serum levels • Easier to use; lower dosing intervals, improved compliance

  24. MSContin/Oxycontin 8-12 hour duration DO NOT CRUSH TABLETS!!! Reassess and titrate as needed. 12-24 titration Fentanyl/duragesic Transdermal 72 H duration Convenient Reassess and titrate as needed. Effective for patients with chronic pain and intolerance to orals. Do not cut patch. Place above waist and not on bone. 24-48 titration Comparing Long Acting Opioids

  25. Pharmacology of Pain Management Cont’ • Meperidine • Has a metabolite that is 2x as potent as a convulsant and 1/2 as potent as an analgesic. • Breaks down to nomeperidine which has an active metabolite that accumulates w/multiple dosing. • Hepatic or renal failure and increases toxicity. • Accumulation of active metabolites can produce irritability, tremors, muscle twitching, jerking, agitation or seizures.

  26. Common Nonopiod Analgesics

  27. Adjuvant Analgesics • Nontraditional analgesics, most approved for other indications. • Multipurpose drugs • For muscloskeletal pain • Muscle relaxants (Baclofen, Zanaflex) • For neuropathic pain • Antidepressants- SSRI’s, TCA’s, SSRI's (Pamelor, Cymbalta) • Anticonvulsants- Topamax, Gabapentin, Lyrica • Approved for post-herpatic neuralgia, diabetic neuropathy.

  28. Non-pharmacological Treatments • Rehabilitative: such at PT/OT • Psychological • Interventional • Nerve blocks • Trigger point injections • Complementary therapies • Acupuncture • Breathing (Lamaze) • Relaxation /Yoga • Meditation • Hypnosis • Massage • Transcutaneous Electrical Nerve Stimulation (TENS)

  29. Nursing Pain Assessment • Subjective Assessment • “I have pain….”; Pt. complains of pain. • It is what the client says it is. • Location- Where? • Description- How does it feel? • Objective Assessment • Intensity- Rating scale: • 0 =  pain • 10 = worst possible pain • Duration- When did it start, How long does it last, Is it continuous or intermittent?

  30. Nursing Pain Assessment • Objective Assessment cont.’ • Alleviating & contributing factors • What makes the pain better or worse? • Associative factors • Nausea • Vomiting • Altered LOC • Impact of pain • How does it affect their lives? • Past/Pertinent medical hx • Past pain experiences • Recent surgery, chemical use or abuse

  31. Nursing Pain Assessment • Objective Assessment cont.’ • Vital Signs • Face • Facial grimace • Clenched jaw • Muscle tone • Relaxed • Rigid • Vocalization • Moaning, crying, grunting, whimpering

  32. Nursing Diagnosis • Alteration in Comfort • Impaired Gas Exchange • Alteration in Cardiac Output • Potential for Ineffective Airway Clearance • Anxiety • Impaired Physical Mobility • Ineffective Coping • Potential for Infection • Altered Bowel Elimination

  33. Planning, Goal Setting & Interventions • Alleviate Pain!!!!!!!! Improve Comfort. • By when? • From what to what? 0-10 • Interventions • Pain Medication!! • Adjuvants • Positioning • Responsibility • Involve Family • Humor • Preventing Complications!!!!!!

  34. Important Definitions • Tolerance- an adaptive process due to exposure to a drug over time. Results in a decrease response to a drug’s effect over time. • Physical Dependence- a physiologic phenomenon that should be expected in persons with persistent use of certain drugs. Patients will experience a withdrawal syndrome if a drug is abruptly stopped, there is a rapid dose reduction, or if the person is given a reversal agent. Withdrawal can be prevented by gradual taper • Reversal Agents • Narcan- Opioids • Romazacon- Benzodiazapam

  35. Important Definitions Cont.’ • Pseudoaddiction- This is not true addiction and is created by under treatment of pain. A term used to describe behaviors seen in persons who fear or who are experiencing uncontrolled pain and want to obtain medication for adequate pain relief. The “clock-watching”, requesting extra opioids, and demanding behaviors are eliminated when the pain is relieved.

  36. Important Definitions Cont.’ • Addiction- A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors. Characteristics include: • Impaired control over drug use • Compulsive use • Continued use despite harm • The need to use an opioid for effects other than for pain relief and craving.

  37. Important Definitions Cont.’ • Breakthrough Pain- • Transitory increase in pain to greater than moderate intensity which occurs on top of the baseline pain. • Distinguished from: • Continuous or uncontrolled pain • Acute episodic pain. • Portenoy RK, Hagen NA. Pain, 1990;41:273-281

  38. Breakthrough Pain • 50% of all inpatients are under treated. • Types • Incident • Idiopathic/spontaneous • End-of-dose failure • Characteristics • Moderate-to-severe intensity • Rapid onset • Often unpredictable • Short duration • 3-4 episodes per day • Associated with a more severe pain syndrome • IMPAIRMENT OF QUALITY OF LIFE!!!

  39. Pain: Gerontologic Considerations • 45-80% of older adults have chronic pain. • Inadequately assessed and treated. • Common types: osteoarthritis, low back pain and previous fracture sites. • Chronic pain can lead to : • Depression • Sleep disturbances • Decreased mobility • Increased health care utilization $$$$ • Physical & social role dysfunction

  40. Ethical Issues in Pain Management • Requests for Assisted Suicide • Only legal in Oregon. • Use of Placebos • How do you feel about them? • Check institutions policy. • Cognitively impaired individuals • Patients with substance abuse problems

  41. Pain: Gerontologic Considerations Cont.’ • Believe that pain is “normal”. • Nothing can be done. • Labeled as “burdensome” or “bad pt.” • Fear of drugs. • Pain tolerance DECREASES with age. • Cognitive, sensory-perceptual , and motor problems may impair ability to communicate or process information. • Post-stroke aphasia, paraplegia, dementia, delirium, vision, hearing impairments

  42. The Effect of Pain on the Body

  43. The Effect of Pain on the Body Cont.’

  44. Myofascial Pain Syndrome • Soft Tissue Pain (Somatic) • Specific to one regional area of the body • Pressure or strain causes the pain to travel. • Cause thought to be related to muscle trauma or chronically strained muscles. • Pain originates within the fascia of skeletal muscles. • Deep aching pain accompanied by: • “Burning, stinging, and stiffness”

  45. Fibromyalgia Syndrome • Widespread, nonarticular muscloskeletal pain and fatigue with multiple tender points. • Non-degenerative, non-progressive & non-inflammatory. • Effects over 6 million Americans • More women than men; 20-55 years old. • Possible causes; • Abnormal levels of serotonin, norepi and other neurotransmitters. • Hyperfunctioning of the hypothalamic-pituitary-adrenal axis (HPA).

  46. Fibromyalgia Syndrome Treatment • Supportive management • NSAID’s • Tricyclic Anti-depressants or SSRI’s • Well balanced diet • Behavioral Therapy • Financial concerns and support • Carefully graduated exercise program.

  47. Chronic Fatigue Syndrome • Disorder characterized by debilitating fatigue and a variety of associated complaints. • 3x more likely in women; onset 25-45 years old. • Etiology unknown • Ideas: • Viral infection usually precipitates the syndrome. • Abnormal immune function. • Alterations in the CNS. • Possible dysfunction of the HPA axis. • Depression usually occurs in patients.

  48. Nursing Care of the Client with CancerEnd-of-Life Care

  49. Nursing Care of the Client with Cancer • Cancer Background A. Definition • 1. Family of complex diseases • 2. Affect different organs and organ systems • 3. Normal cells mutate into abnormal cells that take over tissue • 4. Eventually harm and destroy host • 5. Historically, cancer is a dreaded disease B. Oncology • 1. Study of cancers • 2. Oncology nurses specialize in the care, treatment of clients with cancer

  50. Nursing Care of the Client with Cancer • Incidence and Prevalence • 1. Cancer accounts for about 25% of death on yearly basis • 2. Males: 3 most common types of cancer are prostate, lung and bronchial, colorectal • 3. Females: 3 most common types of cancer are breast, lung and bronchial, and colorectal

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