Acute and chronic pain Contemporary and alternative treatments
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Acute and chronic painContemporary and alternative treatments
Pain—the definition….
An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Most common reason for seeking health care.
Pain is considered the 5th vital sign. Research has shown pain underestimated
by HC professionals, overestimated by family
Is there a problem?
As many as 67% NZ women 65 years and older experience musculoskeletal pain (Taylor, 2005)
In nursing homes 45-85% report pain untreated (Flaherty, 2003).
Nurses may contribute to this problem (Titler & Herr, 2003)
Unrelieved pain can have detrimental effects (Smeltzer & Bare, 2004)
Pain assessment:
Should be as automatic as taking pulse and BP.
Pain is the 5th vital sign
Common Misconceptionsamong Elderly and Nurses Pain is unavoidable. Pain is a punishment. Asking for pain medication is too
demanding and means I’m not a good patient.
Pain medication are addictive. Taking pain medications means
I’ll lose my independence and mental clarity.
Pain is not harmful. Nurses don’t have the time to
give extra medication.
Elderly patients have decreased sensations of pain.
Elderly patients who are cognitively impaired don’t feel pain.
A sleeping patient is not in pain.
Elderly patients complain more about pain as they age.
Narcotics will hasten death. Potent analgesics are
addictive. Potent pain meds will cause
respiratory depression.
Descriptions of pain:
Duration Location Etiology Intensity Quality Temporal pattern Associated characteristics
Pain threshold: amount of pain stimulation a person requires before feeling pain.
Pain tolerance: the highest intensity of pain that the person is willing to tolerate.
The categories of pain:AcuteChronic (non-malignant)Cancer-related painBreakthrough pain
Effects of acute pain:
Neuroendocrine response to stress Increased metabolic rate Increased cardiac output Impaired insulin response Increased retention of fluids Increased risk for physiologic disorders Decreased deep breathing and mobility
Effects Chronic Pain:
Suppressed immune function Resultant increased tumour growth Depression and lack of motivation Anger Fatigue
Pathophysiology of pain
Nociceptors—free nerve endings in the tissue that respond to tissue-injuring stimuli (noxious stimuli).
Thermoreceptors—receptors that respond to noxious temperature changes.
Chemoreceptors—receptors that respond to noxious chemicals.
Mechanical receptors—transmit a pain signal if the noxious stimuli are sufficiently strong.
Pathophysiology of pain:
Nociceptors Algogenic (pain-causing) substances A-delta fibres: ‘initial pain transmission’ Type C fibres: ‘secondary transmission’ Endorphins and enkephalins Central nervous system
Nociception (or pain perception) can be divided into four phases:
Transduction Transmission Perception Modulation
Major Sensory Pathways
Gate-control theory
Spinal Nerves (Dermatomes)
Descending control system:
Fibres that originate in brain Inhibits pain after nociception occurs Cognitive processes may stimulate this
process Classic Gate-control theory (Melzack &
Wall, 1965)
Spinal Cord Modulation: How can the gate be closed?
Spinal dorsal horn—where
complex messaging occurs, is one
of the most important areas for
pain modulation.
Gate-control theory: may decrease amount pain medication needed
What alternative therapies can close the gate?
Music Distraction of any sort Cold (not with PVD) or heat Imagery Deep breathing Massage Vibration Art therapy
Let’s try an experiment….
Have students take pen and place over nail bed and push. Describe sensation to neighbour. All the same?Now try counting backwards from 10 while holding pressure on nail bed. Is the pain as bad?
Why have a pain scale?
Sometimes hard to put words to pain Pain is multi-faceted (How long? Where?
How intense? What kind feeling? Visual scales help us understand where
pain located. Faces help us understand how pain
makes patient feel. Numeric scales help quantify pain using
numbers.
So how do we deal with the problem of pain?
Assess it regularly using a pain scale One type has faces—(Whaley & Wong, 1986).
Other pain scales are just numeric
Alternative therapies which may close the gate:
Cutaneous stimulation and massage Ice and heat therapies Transcutaneous electrical nerve
stimulation Distraction Relaxation techniques Guided imagery Hypnosis
Pharmacological management:
Selection of appropriate drug, dose, route and interval
Aggressive titration of drug dose Prevention of pain and relief of
breakthrough pain Use of coanalgesic medications Prevention and management of side
effectsTaken from Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
WHO Analgesic ladder
Analgesic ladder in action:
Step 1: non-opioid analgesics (Paracetamol and Aspirins, NSAIDS)
Step 2: mild opioid is added (not substituted) to step 1
Step 3: Opioid for moderate to severe pain is used and titrated to effect
Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
WHO 3-step Analgesic ladder
COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam, Panadeine, Nurofen. Pain rating 1-2-3
Non-opioid (mild pain) +/- adjuvant
Opioid (mild to moderate pain) +/- non-opioid adjuvant +/- adjuvantCodeine, Propoxyphene, Tramadol, Sevredol, DHC Continus,
Dihydrocodeine tartate. Pain rating: 4-5-6
Opioid (moderate to severe pain) +/-non-opioid, +/-adjuvant
Step 1
Step 2
Step 3
Oxycodone, Morphine, Fentanyl, PethidineKetamine Pain rating 7-10
Breakthrough pain
Use extra (rescue) doses of opioids. Use the immediate-release form of same
opioid they are on. Rescue dose 5-15% of the 24-hour dose. If 3 or more rescue doses needed/24 hrs—
need to titrate routine drug to effect (25-100% current dose).
Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
Pain management through medication and/or neurosurgery
Oral analgesia PCA (Patient-controlled analgesia) Cordotomy Rhizotomy
Kastinias, P., S.E. Kianda, Robinson, S. (2006).
Manage side-effects opiates:
Constipation Tolerance to nausea and sedation develops in 3-
7 days. Use adjuvant (coanalgesic) agents with opioid:
Tricyclic antidepressants Corticosteroids Anticonvulsants Muscle relaxants Stimulants
Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
Narcotic analgesics
Narcotic analgesics (from the poppy) Morphine Codeine Heroin
Synthetic narcotic analgesics: Demerol (Meperidine) Methadone
KIWIN™ ClassificationPROBLEM IDENTIFICATION
Domain: Physiological domain
Problem: 24. Pain
Priority: High
Modifier: Individual
Modifier: Actual
Signs and Symptoms: 01. expresses discomfort/pain
04. restless behaviour
05. facial grimaces
KIWIN™ Classification
PROBLEM PLANNING
Pre Intervention PRSO
Knowledge: Minimal knowledge
Behaviour: Rarely appropriate behaviour
Status: Extreme signs/symptoms
Goal: The patient will state that his pain is 0- 2/10 within 3 hours.
KIWIN™ ClassificationPROBLEM INTERVENTIONCreation Date: 28/2/2007Interventions: Treatments and ProceduresTargets: 39. medication administration
41. medication prescription54. relaxation/breathing techniques
Nursing Actions: 39. Administer analgesia as charted and by utilizing pain scale. Review q2h.R)41. Ensure that physician charts sufficient
analgesia for patient and according to the WHO pain ladder.
R)54. Administer back massage to patient
when in pain if he/she would like. Teach patient guided imagery during painful
episodes.R)
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