PENGELOLAAN NYERI.pptx

7/26/2019 PENGELOLAAN NYERI.pptx

1/55

PENGELOLAAN NYERI

JOKO MURDIYANTO


2/55

NYERI PERSALINANDIPANDANG DARISUDUT ANESTESI

JOKO MURDIYANTO


3/55

DEFINISIPain is Unpleasant sensory

and emotional experienceassociated with actual or

potential tissue damage, ordescribe in terms of suchdamage (IASP


4/55

Pain Experience

Pain is a personal, su!ec"i#e experience "$a" co%prises &Sensor'()iscri%ina"i#e, *o"i#a"ional(a+ec"i#ean) o-ni"i#e(

e#alua"i#e)i%ensionsRonald Melzack, Textbook of Pain 4thedition

S

omatization

?????

Depression

Expec

tation&

Desir

e

Anxie

ty

Catastrophization

Mental

Phy

sical

Spiritual


5/55

.$a" is Pain/ An unpleasant sensory & emotional experience associated it!

actual or potential tissue dama"e# or descri$ed in terms o% suc!dama"e '

T!e International Association %or t!e (tudy o% )ain

(u$*ecti+e sensation )ain )erceptions ' $ased on expectations# past experience# anxiety#

su""estions A,ecti+e ' one-s emotional %actors t!at can a,ect pain experience 0e!a+ioral ' !o one expresses or controls pain o"niti+e ' one-s $elie%s .attitudes/ a$out pain

)!ysiolo"ical response produced $y acti+ation o% speci0c types o%ner+e 0$ers

1xperienced $ecause o% nociceptors $ein" sensiti+e to extrememec!anical# t!ermal# & c!emical ener"y2

3omposed o% a +ariety o% discom%orts One o% t!e $ody-s de%ense mec!anism .arns t!e $rain t!at tissues

may $e in *eopardy/ Acute +s2 3!ronic '

T!e total person must $e considered2 It may $e orse at ni"!t!en t!e person is alone2 T!ey are more aare o% t!e pain

$ecause o% no external di+ersions2


6/55

Pain Acute +s2 3!ronic

Acute pain is usually related to aneasily identi0ed e+ent or condition2

3!ronic pain may or may not $erelated to an easily identi0edpat!op!ysiolo"ic p!enomenon#

may $e multi%actorial# and may $epresent %or an indeterminateperiod o% time2


7/55


8/55

.$ere Does Pain o%e Fro%/

u"aneous Pain ' s!arp# $ri"!t#$urnin"4 can !a+e a %ast or slo onset

Deep So%a"ic Pain ' stems %romtendons# muscles# *oints# periosteum#& $2 +essels

1isceral Pain ' ori"inates %rom

internal or"ans4 di,used 5 6st& latermay $e locali7ed .i2e2 appendicitis/

Ps'c$o-enic Pain ' indi+idual %eelspain $ut cause is emotional rat!er t!anp!ysical


9/55

Pain Sources 8ast +s2 (lo )ain '

8ast ' locali7ed4 carried t!rou"! A9delta axons in s:in

(lo ' ac!in"# t!ro$$in"# $urnin"4 carried $y 3 0$ers

Nocicepti+e neuron transmits pain in%o to spinal cord

+ia unmyelinated 3 0$ers & myelinated A9delta 0$ers2 T!e smaller 3 0$ers carry impulses 5 rate o% ;2< to

=2; m>sec2

T!e lar"er A9delta 0$ers carry impulses 5 rate o% sec2

Acute +s2 3!ronic


10/55

.$a" is Re2erre) Pain/

Occurs aay %rom pain site

1xamples@ Mcurney-s point# Kerr-s si"n

Types o% re%erred pain@ Myo%ascial )ain ' tri""er points# small !yperirrita$leareas it!in a m2 in !ic! n2 impulses $om$ard 3N( &are expressed at re%erred pain Acti+e ' !yperirrita$le4 causes o$+ious complaint Batent ' dormant4 produces no pain except loss o% ROM

(clerotomic & Dermatomic )ain ' deep pain4 mayori"inate %rom sclerotomic# myotomic# or dermatomicn2 irritation>in*ury (clerotome@ area o% $one>%ascia t!at is supplied $y a sin"le

n2 root

Myotome@ m2 supplied $y a sin"le n2 root

Dermatome@ area o% s:in supplied $y a sin"le n2 root


11/55

Ter%inolo-' !oxious' !arm%ul# in*urious

Noxious stimuli ' stimulit!at acti+ate nociceptors.pressure# cold>!eatextremes# c!emicals/

!ociceptor " ner+e receptors

t!at transmits pain impulses Pain #hreshold' le+el o%

noxious stimulus reCuired toalert an indi+idual o% apotential t!reat to tissue

Pain #olerance' amount o%pain a person is illin" or

a$le to tolerate Accommodationphenomenon' adaptation $yt!e sensory receptors to+arious stimuli o+er anextended period o% time .e2"2super0cial !ot & cold a"ents/2$ess sensiti%e to stimuli&

'yperesthesia " a$normalacuteness o% sensiti+ity totouc!# pain# or ot!ersensory stimuli

Paresthesia " a$normal

sensation# suc! as$urnin"# pric:in"# tin"lin"

Inhibition " depression orarrest o% a %unction Inhibitor' an a"ent

t!at restrains>retardsp!ysiolo"ic# c!emical#or en7ymatic action

Analgesic " a neurolo"ic orp!armacolo"ic state in!ic! pain%ul stimuli areno lon"er pain%ul


12/55

3ues"ions "o As4 aou" Pain

)attern@ onset & duration Area@ location Intensity@ le+el

Nature@ description


13/55

uestions to As: a$out

)ainP Q R S T (ECG format)

)ro+ocation ' Eo t!e in*ury occurred & !atacti+ities t!e painuality 9 c!aracteristics o% pain ' Ac!in"

.impin"ement/# urnin" .n2 irritation/# (!arp

.acute in*ury/# Radiatin" it!in dermatome

.pressure on n2/F

Re%erral>Radiation 'Re%erred ' site distant to dama"ed tissue t!at

does not %ollo t!e course o% a perip!eral n2Radiatin" ' %ollos perip!eral n24 di,use(e+erity ' Eo $ad is itF )ain scale

Timin" ' G!en does it occurF p2m2# a2m2# $e%ore#durin"# a%ter acti+ity# all t!e time


14/55

uestions to As: a$out

)ainL O A T E SL5 Loca"ion6

O 5 O"$er S'%p"o%s6 5 $arac"er& )eep, urnin-, "$roin-7

A 5 A--ra#a"in- an) Alle#ia"in- 2ac"ors6

T 5 Ti%in-6E 5 E+ec"& 'our )ail' rou"ine/

S 5 Se#eri"'6


15/55

T'pes o2 Ner#es A,erent .Ascendin"/ ' transmit

impulses %rom t!e perip!ery to t!e$rain

8irst Order neuron

(econd Order neuron

T!ird Order neuron 1,erent .Descendin"/ ' transmit

impulses %rom t!e $rain to t!eperip!ery


16/55

Firs" Or)er Neurons

(timulated $y sensory receptors 1nd in t!e dorsal !orn o% t!e spinal cord Types

A9alp!a ' non9pain impulses

A9$eta ' non9pain impulses Bar"e# myelinated Bo t!res!old mec!anoreceptor4 respond to li"!t touc!

& lo9intensity mec!anical in%o A9delta ' pain impulses due to mec!anical pressure

Bar"e diameter# t!inly myelinated

(!ort duration# s!arp# %ast# $ri"!t# locali7ed sensation.pric:lin"# stin"in"# $urnin"/ 3 ' pain impulses due to c!emicals or mec!anical

(mall diameter# unmyelinated Delayed onset# di,use na""in" sensation .ac!in"#

t!ro$$in"/


17/55

Secon) Or)er Neurons

Recei+e impulses %rom t!e 8ON in t!e dorsal!orn Bamina II# (u$stantia Helatinosa .(H/ 9 determines

t!e input sent to T cells %rom perip!eral ner+e

# ells (transmission cells)transmission cell t!atconnects sensory n2 to 3N(4 neurons t!at or"ani7estimulus input & transmit stimulus to t!e $rain

Tra+el alon" t!e spinot!almic tract )ass t!rou"! Reticular 8ormation

Types Gide ran"e speci0c

Recei+e impulses %rom A9$eta# A9delta# & 3

Nocicepti+e speci0c Recei+e impulses %rom A9delta & 3

1nds in t!alamus


18/55

T$ir) Or)er Neurons

e"ins in t!alamus 1nds in speci0c $rain centers

.cere$ral cortex/

)ercei+e location# Cuality# intensity

Allos to %eel pain# inte"rate pastexperiences & emotions anddetermine reaction to stimulus


19/55

Descen)in- Neurons

Descendin" )ain Modulation .Descendin")ain 3ontrol Mec!anism/

Transmit impulses %rom t!e $rain.corticospinal tract in t!e cortex/ to t!e spinalcord .lamina/ )eriaCuaductal Hray Area .)HA/ ' release

en:ep!alins Nucleus Rap!e Ma"nus .NRM/ ' release serotonin

T!e release o% t!ese neurotransmitters in!i$itascendin" neurons

(timulation o% t!e )HA in t!e mid$rain & NRMin t!e pons & medulla causes anal"esia2

*ndogenous opioid peptides9 endorp!ins &


20/55

Neuro"rans%i""ers 3!emical su$stances t!at allo ner+e impulses to mo+e

%rom one neuron to anot!er 8ound in synapses

(u$stance ) 9 t!ou"!t to $e responsi$le %or t!etransmission o% pain9producin" impulses

Acetylc!oline ' responsi$le %or transmittin" motor ner+eimpulses

1n:ep!alins ' reduces pain perception $y $ondin" to painreceptor sites

Norepinep!rine ' causes +asoconstriction = types o% c!emical neurotransmitters t!at mediate pain

1ndorp!ins 9 morp!ine9li:e neuro!ormone4 t!ou"!t to pain t!res!old $y $indin" to receptor sites (erotonin 9 su$stance t!at causes local +asodilation &

permea$ility o% capillaries ot! are "enerated $y noxious stimuli# !ic! acti+ate

t!e in!i$ition o% pain transmission 3an $e eit!er excitatory or in!i$itory


21/55

Sensor' Recep"ors

*ec$anorecep"ors' touc!# li"!t or deeppressure Meissner-s corpuscles .li"!t touc!/# )acinian

corpuscles .deep pressure/# Mer:el-s corpuscles

.deep pressure/ T$er%orecep"ors 9 !eat# cold Krause-s end $ul$s .temp & touc!/# Runi

corpuscles .in t!e s:in/ ' touc!# tension# !eat4 .in*oint capsules & li"aments ' c!an"e o% position/

Propriocep"ors ' c!an"e in len"t! ortension Muscle (pindles# Hol"i Tendon Or"ans

Nocicep"ors' pain%ul stimuli mec!anosensiti+e c!emosensiti+e


22/55

Ner#e En)in-s A ner+e endin" is t!e termination o% a ner+e 0$er

in a perip!eral structure2 .)rentice# p2 ?/ Ner+e endin"s may $e sensory .receptor/ or motor

.e,ector/2

Ner+e endin"s may $e@Respond to p!asic acti+ity 9 produce an impulse

!en t!e stimulus is or # $ut not durin"sustained stimulus4 adapt to a constant stimulus.Meissner-s corpuscles & )acinian corpuscles/

Respond to tonic receptors produce impulses aslon" as t!e stimulus is present2 .muscle spindles#%ree n2 endin"s# Krause-s end $ul$s/

(uper0cial ' Mer:el-s corpuscles>dis:s# Meissner-scorpuscles

Deep ' )acinian corpuscles#


23/55

Ner#e En)in-s

Mer:el-s corpuscles>dis:s 9

(ensiti+e to touc! &+i$ration

(lo adaptin"

(uper0cial location

Most sensiti+e Meissner-s corpuscles '

(ensiti+e to li"!t touc!& +i$rations

Rapid adaptin"

(uper0cial location )acinian corpuscles 9

(ensiti+e to deeppressure & +i$rations

Rapid adaptin"

Deep su$cutaneoustissue location

Krause-s end $ul$s '

T!ermoreceptor Runi corpuscles>endin"s

T!ermoreceptor (ensiti+e to touc! &

tension

(lo adaptin" 8ree ner+e endin"s 9

A,erent Detects pain# touc!#

temperature#mec!anical stimuli


24/55

Nocicep"ors (ensiti+e to repeated or prolon"ed

stimulation Mec!anosensiti+e ' excited $y stress &

tissue dama"e 3!emosensiti+e ' excited $y t!e releaseo% c!emical mediatorsrady:inin# Eistamine# )rosta"landins#

Arac!adonic Acid )rimary Eyperal"esia ' due to in*ury (econdary Eyperal"esia ' due to

spreadin" o% c!emical mediators


25/55

Pain on"rol T$eories

Hate 3ontrol T!eory 3entral iasin" T!eory

1ndo"enous Opiates T!eory


26/55

Ga"e on"rol T$eor' Mel7ac: & Gall# 6L< (u$stantia Helatinosa .(H/ in dorsal !orn o%

spinal cord acts as a "ate- ' only allos onetype o% impulses to connect it! t!e (ON

Transmission 3ell .T9cell/ ' distal end o% t!e(ON

I% A9$eta neurons are stimulated ' (H isacti+ated !ic! closes t!e "ate to A9delta &3 neurons

I% A9delta & 3 neurons are stimulated ' (H is$loc:ed !ic! closes t!e "ate to A9$etaneurons


27/55

Ga"e on"rol T$eor' Hate 9 located in t!e dorsal !orn o% t!e spinal cord (maller# sloer n2 carry pain impulses Bar"er# %aster n2 0$ers carry ot!er sensations

Impulses %rom %aster 0$ers arri+in" 5 "ate 6st

in!i$itpain impulses .acupuncture>pressure# cold# !eat# c!em2 s:inirritation/2

rain

)ain

Eeat# 3old#Mec!anical

Hate .Tcells> (H/


28/55

en"ral 0iasin- T$eor'

Descendin" neurons are acti+ated$y@ stimulation o% A9delta & 3neurons# co"niti+e processes#

anxiety# depression# pre+iousexperiences# expectations

3ause release o% en:ep!alins .)AH/and serotonin .NRM/

1n:ep!alin interneuron in area o%t!e (H $loc:s A9delta & 3 neurons


29/55

En)o-enous Opia"es T$eor'

Beast understood o% all t!e t!eories

(timulation o% A9delta & 3 0$ers causes

release o% 9endorp!ins %rom t!e )AH & NRM

A3TE>9lipotropin is released %rom t!eanterior pituitary in response to pain ' $ro:endon into 9endorp!ins and corticosteroids

Mec!anism o% action ' similar to en:ep!alinsto $loc: ascendin" ner+e impulses

1xamples@ T1N( .lo %reC2 & lon" pulseduration


30/55

Goals in *ana-in- Pain

Reduce pain 3ontrol acute pain

)rotect t!e patient %rom %urt!erin*ury !ile encoura"in"pro"ressi+e exercise

O"$ "


31/55

O"$er 8a's "o

con"rol pain 1ncoura"e central $iasin" ' moti+ation#relaxation# positi+e t!in:in"

Minimi7e tissue dama"e

Maintain communication > t!e at!lete I% possi$le# allo exercise Medications


32/55

E%pa" "a$ap 9siolo-i n'eri &

Proses "rans)u4si

)roses dimana suaturan"san" nyeri .noxious stimuli/ diu$a! men*adisuatu a:ti0tas listri:# yan" a:an diterima ole!u*un"9u*un" sara%2

Proses "rans%isi

(e$a"ai peram$atan ran"san" melalui sara% sensoris menyusul prosestransdu:si2Proses %o)ulasi )roses dimana ter*adiintera:si antara sistem anal"esi: endo"enden"an asupan nyeri yan" masu: :e :ornuposterior2Persepsi Easil a:!ir dari proses yan":omple:s dan uni: yan" men"!asil:an suatu

perasaan yan" su$ye:ti%2


33/55

f i


34/55

fracture/Postoperative

Onoin or

impen!in in"ury

sprain

#nflamation $

#nfection

#nfiltrate! or compresse!

%tumors&

stranulate!

%scar tissue&

Muscle Stretch

inflame! %infection &

Type or Category of Pain

:6 Ps'c$o-enic

clear t!atno somatic disorder

is present

;6 Nocicep"i#e3aused $y acti+ity

in neural pat!aysin response to potentiallytissue9dama"in" stimuli


35/55

Hoals

62 De0ne t!e se+erityo%

pain=2 Assistin t!e selection

o% appropriateanal"esia

?2 1+aluate t!e response

to treatment)ain Assessment

*e"$o

)s

62 (el% Report

=2 Team Approac!


36/55

T!e Met!odolo"yo% )ain Assessment

The Assessment of the Patient with Pain, Steven Richeimer, M.D. Director USC Pain Management, USC Medica Center, !os Angees, CA, USA, "##$

Eistory

)ast Medical Eistory

3urrent Medications

)!ysical 1xamination

(pecial Test

)syc!olo"ical1+aluation


37/55

62 BI(T1N

=2 BO3AT1

?2 BOOK

A(I3


38/55

'ocation% Patient or nurse mar(s !ra)in

#ntensity% Patient rates the pain* Scale +se!,

-uality% +se patint.s )or!s/ e** pric(/ ache/ 0urn/ sharp/ hot etc.

Onset/ !uration/ variations/ rhythms %spontaneus or evo(e!&,

Manner of expressin pain,

1hat relieves the pain?

&Pain 'ehavio(r)


39/55

1hatcauses orincreases the pain?

Effect of pain% %2ote !ecrease! function/ !ecrease! 3uality of life&

Other comments,

Plan,

Accompanying symptoms &eg na(sea)

Seep

Appetite

Physica activity

Reation with others &eg irrita*iity)

+motion &eg anger, s(icida, crying)

Consentration

ther


40/55

)ain Assessment (cales

Uni-Dimensiona Scae M(ti-Dimensiona Scae

Onlymeas(res pain intensity Appropriate for acute pain

The most common scae (sed inoutcomeassessment &Anagesic

efficacy)

ot! in"ensi"' >se#eri"'?andunpleasan"ness >a+ec"i#e?

Appropriate %or c$ronic pain Researc$ @pa"$op$'siolo-' S$oul) e use) in clinical

ou"co%e assess%en"

4er0al 5atin Scale %45S&

2one/ mil!/ mo!erate/ severe

2umeric 5atin Scale %25S&

4isual Analo Scale %4AS&

Pictorial Scale

Mc6ill Pain -uestionnaire %MP-&

7he 8rief Pain #nventory %8P#&

7he Memorial Pain Assessment Car!


41/55

Photoraphic$2umeric Pain Scale


42/55

Photoraphic$2umeric Pain Scale

M !ifi !


43/55

Mo!ifie!

Mc6ill Pain

-uestionnaire

6#P ai:=Q#LP Bumayandan sedan"

.Meliala# 6/

6< Minutes

Sensori4A2e4"i2

E#alua"i2*aca%6=!r


53/55

Opioids Anal"esic

62Morp!ine i+ dose ;26 m">:" it!additional doses o% ;2;< m">:"2

=2Meperidine i+ dose 6 m">:" it!additional doses ;2< m">:"2

?28entanyl i+ dose = ' ? mc">:" it!additional doses titrated $y ;2< mc">:"

until desired le+el o% anal"esia is reac!ed2


54/55

Pae)ia"rics

Morp!ine .i2d2 ;2;< ';26 m">:" i+# t!entitrate# maximum 6; m">dose2

or

8entanyl .i2d 69= ">:"# t!en titrate#maximum 6;; ">dose/


55/55

TERI*A ASIBPERBATIANNYA.ASSALA*UALAIU*

Documents

PENGELOLAAN NYERI.pptx