Pain Managementdharl

7/28/08dharl de la peña

PAIN MANAGEMENT

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PAIN• A high unpleasant and very personal

sensation that cannot be shared with others• More than a symptom of a problem• Presents both a physiologic and psychologic

dangers to health and recovery• Viewed as an emergency situation deserving

attention and prompt treatment

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PAIN

P“ain is an unpleasant sensory and emotional experience in association

with actual or potential tissue damage, or described in terms of

such damage.”The International Association for the Study of Pain

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Types of Pain

DURATION

LOCATION -

ETIOLOGY -

ACUTE PAIN

CHRONIC ( NON-MALIGNANT PAIN )

CANCER-RELATED PAIN

Example: CHEST PAIN HEADACHE PELVIC PAIN

Example: BURN PAINPOST-HERPETIC PAIN

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Types of PainAccording to DURATION

• Acute– Lasts only through the expected recovery

period– Sudden or slow onset

• Chronic– Prolonged, recurring or persisting over 6

months or longer– Chronic malignant pain– Chronic nonmalignant pain

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Mild to severeSympathetic NS response Related to tissue injuryRestless and anxious

Reports painBehavior indicative of pain

Mild to severeParasympathetic NS response

Continues beyond healingDepressed and withdrawn

Does not mention pain unless asked

Pain behavior often absent

Acute Pain vs. Chronic Pain

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Types of PainAccording to ETIOLOGY

• Neuropathic pain– Current or past damage to the

peripheral or central nervous system and may not have a stimulus

• Intractable pain– Highly resistant to relief

• Phantom pain– Sensation perceived in a body part

that is missing

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Concepts associated with Pain

• Pain threshold

• Pain reaction

• Pain tolerance

– Maximum amount and duration of pain that an individual willing to endure

– Amount of pain stimulation a person requires in order to feel pain

– ANS and behavioral responses to pain

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Physiology of Pain

• Nociception–Transduction

–Transmission

–Perception

–Modulation

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Physiology of PainTransduction

• CHEMICAL MEDIATORS–chemicals that enhance pain perception

• Prostaglandin • Substance P• Bradykinin• Histamine

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Physiology of PainTransduction

• ENDORPHINS–“endogenous morphines”–naturally occurring analgesic in

the body– is said to be released during

exercise

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NOXIOUS STIMULI

1

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IMPULSE TRANSMISSION

2

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AFFERENT SENSORY FIBERS

3

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SPINAL CORD JUNCTIONS

4

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DORSAL HORN

5

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SYNAPSE

6

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CALCIUM AND GLUTAMATE

7

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SYNAPTIC CLEFT

8

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POST-SYNAPTIC TERMINAL

9

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NOCICEPTIVE NEURON

10

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PAIN PERCEPTION

11

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Gate Control Theory• peripheral nerve fibers carrying

pain to the spinal cord can have their input at the spinal cord level before transmission to the brain

Physiology of PainModulation

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Responses to Pain• Sympathetic NS and the Parasympathetic NS = Fight-or-flight response

• Proprioceptive reflex

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Factors Affecting the Pain Experience

• Ethnic and Cultural Values• Developmental Stage• Environment and Support People• Past Pain Experiences• Meaning of Pain• Anxiety and Stress

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Age Variations in the Pain experience

• Infant– Perceives pain; increased sensitivity

• Toddler and Preschooler– Develops ability to describe pain and its

intensity and location; crying and anger; a punishment

• School-age child– Tries to be brave; attempts to explain the

pain; may regress to an earlier stage

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• Adolescent– Slow to acknowledge pain; may be

considered weakness; appear brave in front of peers

• Adult– Gender-based behaviors; may ignore pain

• Elderly– Perceives pain as part of the aging

process; decreased sensations and perceptions of the pain

Age Variations in the Pain experience

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Nursing Assessment

• Pain History–Previous pain treatment and

effectiveness

–When and what analgesics were last taken

–Other medications being taken

–Allergies to medications

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Mnemonics for Pain Assessment

PQRST

– P

– Q

– R

– S

– T

OLD CART

OLDCART

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Why clients May be reluctant to Report Pain

• Unwillingness to trouble staff• Fear of the injectable route• Belief that pain is to be expected• Normal part of aging• Expressions of pain reveal weakness• Difficulty expressing personal discomfort• Concern about use of drugs and addiction• Will lead to further tests and expenses• Concern about unwanted side effects

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Pain Intensity or Rating Scales

• VISUAL ANALOG SCALE–the person is asked to place a

mark indicating where the current pain lies on the line

–to score the results, a ruler is placed along the line and is measured and reported in mm or cm

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Pain Intensity or Rating Scales VISUAL ANALOG SCALE

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Pain Intensity or Rating Scales

• FACES PAIN SCALE –the instrument has six faces

depicting expressions that range from contented to obvious distress.

–the patient is asked to point to the face that most closely resembles the pain intensity felt

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Pain Intensity or Rating Scales

FACES PAIN SCALE

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Pain QualityCommonly Used Pain Descriptors

• Sensory– Searing– Scalding– Sharp– Piercing– Drilling– Wrenching– Shooting– Burning– Crushing – Penetrating

• Affective– Unbearable– Killing– Intense– Torturing– Agonizing– Terrifying– Exhausting– Suffocating– Frightful– Punishing– Miserable– Heavy

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PrecipitatingPrecipitating FactorsFactors

• activities that precede pain

Alleviating FactorsAlleviating Factors anything that they have done to

alleviate pain

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• Associated Symptoms• Effects on Activities of Daily

Living• Coping Resources• Affective Responses• Observation of Behavioral

and Physiologic Responses• Daily Pain Diary

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PLACEBOPLACEBO• from the Latin for “I shall please”• is an inactive substance (pill,

liquid, etc.), which is administered as if it were a therapy, but which has no therapeutic value other than the placebo effect.

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PLACEBO EFFECTPLACEBO EFFECT• occurs when a person responds to

the medication or other treatment because of the expectation that the treatment will work

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ETHICAL ADMINISTRATION OF PLACEBOS

• A placebo effect is not an indication that the person does not have pain; rather, it is a true physiologic response

• Placebos should never be used to test the person’s truthfulness about pain or as the first-line of treatment

• A positive response to a placebo (ex. A reduction in pain) should never be interpreted as an indication that the person’s pain is not real

• A patient should never be given a placebo as a substitute for pain medication

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NURSE’S ROLE IN PAIN NURSE’S ROLE IN PAIN MANAGEMENTMANAGEMENT

• Administers pain-relieving medication

• Assesses the effectiveness of the medications

• Serves as an advocate for the patient when the prescribed medication is ineffective

• Educator to the patient and family on how to manage pain effectively.

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PAIN MANAGEMENT PAIN MANAGEMENT STRATEGIESSTRATEGIES

• PHARMACOLOGIC– Makes use of pain

medications as ordered by the physician

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• NON-PHARMACOLOGIC– Other measures to

relieve pain other than administering pain medications

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PHARMACOLOGIC INTERVENTIONS

• Before administering pain medications, the nurse should:1.) Ask for previous history of drug allergy

2.) Ask patient’s current medications

3.) Ask the patient’s current pain status

4.) Check vital signs

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APPROACHES FOR USING

ANALGESIC AGENTS• Balanced Anesthesia Approach

• PRN Approach

• Preventive Analgesia or Pre-Emptive Analgesia

• Patient-Controlled Analgesia

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APPROACHES FOR USING APPROACHES FOR USING ANALGESIC AGENTSANALGESIC AGENTS Balanced Analgesia Approach

– Refers to use of MORE THAN ONE form of analgesia concurrently to obtain more relief with fewer side effects

– Example:• Morphine 30mg• 8 mg morphine + 30 mg ketorolac

** Both approaches offers the same pain relief but the second

approach has lesser side effects

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APPROACHES FOR USING APPROACHES FOR USING ANALGESIC AGENTSANALGESIC AGENTS

PRN Approach• “PRO RE NATA” – “as needed approach”• The medication is administered when the

patient complains of pain• Some patients remained in pain because

they are not aware that they have to ask for pain medications

• This is the standard method used in the past.

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APPROACHES FOR USING APPROACHES FOR USING ANALGESIC AGENTSANALGESIC AGENTS

Preventive Analgesia or Pre-Emptive Analgesia

• “An ounce of preventions is better than a pound of cure”

• Administration of pain medications 1-2 hours before the scheduled procedure

• It is also the administration of pain medications ROUND THE CLOCK (RTC)

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APPROACHES FOR USING APPROACHES FOR USING ANALGESIC AGENTSANALGESIC AGENTS Patient-Controlled Analgesia

• Used to manage post-operative pain or chronic pain

• Allows the patient to personally control the administration of pain medication

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• PCA PUMP• permits the patient to self-administer extra

medication with increasing pain• is electronically controlled by a timing device• patients can administer small amounts of

medication at a time• the timer can be programmed so even if the

patient pushes the button a couple of times, no additional doses are released

APPROACHES FOR USING APPROACHES FOR USING ANALGESIC AGENTSANALGESIC AGENTS Patient-Controlled Analgesia

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NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS

CUTANEOUS STIMULATION• MASSAGE– generalized

cutaneous stimulation of the body

– causes the release of endorphins, decreasing pain.

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NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS

ICE AND HEAT THERAPY• May be effective pain-relief strategies but

their mechanisms of action are not well understood.

• ICE THERAPY

– should be placed on the injury site immediately after injury

– application should not be longer than 30mins (long applications may cause frostbite or nerve injury)

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• Application of heat increases blood flow to an area.

NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS

HEAT THERAPY

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• ICE AND HEAT THERAPIES

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NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS

TRANSCUTANEOUS ELECTRICALNERVE STIMULATION (TENS)

• Makes use of a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating or buzzing sensation in the area of pain

• Stimulates non-pain receptors, thus blocking pain sensation

• Another possible explanation is the placebo effect

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NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS

DISTRACTION• Involves focusing the patient’s attention on something rather than the pain

• Doesn’t relieve severe pain

• DISTRACTION TECHNIQUES

- Watching TV- Listening to music

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NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS

RELAXATION TECHNIQUES• Effective in controlling

low back pain• Skeletal muscle

relaxation is believed to reduce pain by relaxing muscles that contribute to pain.

• Example:– Benson’s Relaxation

Technique

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NON-PHARMACOLOGIC NON-PHARMACOLOGIC INTERVENTIONSINTERVENTIONS GUIDED IMAGERY

• Using one’s imagination in a special way to distract one’s self from an uncomfortable sensation

• Advice Guided Imagery for 5 minutes 3x a day

• ** This may not work in severe pain

Sacrifices are sometimes useless especially if that someone doesn’t know how to appreciate…

They’ll come to realize important things when it’s already late…

TOO LATE!!!