PAIN Principles and Nursing Management

1. PAINPrinciples and Nursing Management

2. Disclaimer Views presented in this lecture are intended to expand your reasoning and not to offend, demean or insult anybody

3. Chances are that you know someone in pain! • 3.2 million people are living with pain and more women than men are affected • Productivity loss is $11.7 billion annually, or 34 per cent of total pain-related costs • The burden of disease accounts for a further third at $11.5 billion • Health system costs account for $7 billion, around 20 per cent of total pain-related costs

4. The Australian Pain Society • Australian Pain Society Vision • All people should have timely access to pain management. • Australian Pain Society Mission Statement • The Australian Pain Society is a multidisciplinary body that aims to reduce pain and related suffering through leadership in clinical practice, education, research, and public advocacy.

5. International Association for the study of pain • Vision Statement:  Working together for pain relief throughout the world • Mission:  IASP brings together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.

6. Gold Rush

7. Pain as pleasure • Algolagnia is a sexual tendency which is defined by deriving sexual pleasure and stimulation from physical pain, particularly involving an erogenous zone. • Sadism refers to sexual or non-sexual gratification in the infliction of painor humiliation upon or by another person. Masochism refers to sexual or non-sexual gratification in the infliction of pain or humiliation upon oneself

8. Unpleasant sensory & emotional experience associated with actual or potential tissue damage May be acute or chronic Pain is a subjective experience & there is no accurate assessment for the degree of pain experienced Pain & its causes

9. Pain as pain • pain is defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage". • Pain is highly subjective to the individual experiencing it. A definition that is widely used in nursing was first given as early as 1968 by Margo McCaffery: "'Pain is whatever the experiencing person says it is, existing whenever he says it does".

10. Stress as pain

11. Questions Regarding Pain Control • What about the 20% who do not get relief from the WHO ladder or the 46% of those whose families stated we failed?* • Have the opioids been titrated aggressively? • Is the pain neuropathic? • Has a true pain assessment been accomplished? • Have invasive techniques been employed? • Have you examined the patient? • Is the patient receiving their medication? • Is the medication schedule and route appropriate?

12. Physiological effects of Pain • Increased catabolic demands: poor wound healing, weakness, muscle breakdown • Decreased limb movement: increased risk of DVT/PE • Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis • Increased sodium and water retention (renal) • Decreased gastrointestinal mobility • Tachycardia and elevated blood pressure

13. Psychological effects of Pain • Negative emotions: anxiety, depression • Sleep deprivation • Existential suffering: may lead to patients seeking active end of life.

14. Immunological effects of Pain • Decrease natural killer cell counts • Effects on other lymphocytes not yet defined.

15. Procedure Related Pain • Common in all patients • Frequent source of pain and distress

16. Therapeutic Procedures • Surgery • Only 50% of post-operative pain is adequately managed • Post-operative pain syndromes • Traumatic neuroma • Similar to other chronic pain syndromes • Psychological factors important • Treat symptoms • Maintain functional status

17. Principles of Assessment • Assess and reassess • Use methods appropriate to cognitive status and context • Assess intensity, relief, mood, and side effects • Use verbal report whenever possible • Document in a visible place • Expect accountability • Include the family

18. Pain Assessment • What methods can be used to assess pain?

20. Patient Pain History • Site(s) of pain? • Severity of pain? • Date of onset? • Duration? • What aggravates or relieves pain? • Impact on sleep, mood, activity? • Effectiveness of previous medication?

21. Assessing pain in patients with dementia • Behavioral chances • Mood changes • Facial expression • Body language • Speech • Signs of physical examination

22. What Does Pain Mean to Patients? • Poor prognosis or impending death • Particularly when pain worsens • Decreased autonomy • Impaired physical and social function • Decreased enjoyment and quality of life • Challenges to dignity • Threat of increased physical suffering

23. Neuropathic pain is pain transmitted over damaged nerves. • Patient Description of Neuropathic Pain: • Burning, electric, searing, tingling, and migrating or traveling. • Causes of Neuropathic Pain: • Amputation, shingles (herpes zoster), AIDS (peripheral neuropathy), diabetic neuropathy, fibromyalgia, and cancers that affect the spinal cord, among others. Neuropathic Pain

24. Damned if do and damned if you don’t • Over prescribing pain pain killers reckless malpractice charged with drug trafficking manslaughter or murder • Under treating pain sued for abuse

25. How do we get addicted

26. How do families influence addiction

27. Do families share the tablets ?

28. Some medication have socially unacceptable side effects

29. Useful but socially unacceptable side effects

30. There is no such thing as an old junkie

31. They said go to rehab and I SAID NO NO

32. Thinking out side the circle • A young woman went to her doctor complaining of pain."Where are you hurting?" asked the doctor."You have to help me, I hurt all over", said the woman."What do you mean, all over?" asked the doctor, "be a little more specific."The woman touched her right knee with her index finger and yelled, "Ow, that hurts." Then she touched her left cheek and again yelled, "Ouch! That hurts, too." Then she touched her right earlobe, "Ow, even THAT hurts", she cried.The doctor checked her thoughtfully for a moment and told her his diagnosis, "You have a broken finger."

50. Physiology of Pain • Physical sensation of pain • Nerve endings are stimulated causing an impulse along the nerve pathway to the brain – pain response • Psychological component • Emotional response based on pain threshold (level of nerve ending stimulus)