Pain Management In Nursing4 With K I W I N

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)