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Project: Ghana Emergency Medicine Collaborative Document Title: Pain Management Author(s): Heather Hartney (University of Michigan), RN 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

GEMC - Pain Management - for Nurses

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This is a lecture by Sue Anne Bell from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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Page 1: GEMC - Pain Management - for Nurses

Project: Ghana Emergency Medicine Collaborative Document Title: Pain Management Author(s): Heather Hartney (University of Michigan), RN 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.

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Cri'cal  outcome  

•   The  emergency  nurse  assesses,  iden'fies  and  manages  acute  and  chronic  pain  within  the  emergency  se;ng.  

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Specific  Outcomes  

•  Define  the  types  of  pain  and  complica'ons  of  pain  management.  

•  Delineate  pain  physiology  and  mechanisms  of  addressing  pain  with  medica'ons.  

•  Define  the  general  assessment  of  the  pa'ent  in  pain.  

•  Delineate  the  nursing  process  and  role  in  the  management  of  the  pa'ent  with  acute  and  chronic  pain.  

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Specific  Outcomes  •  Apply  the  nursing  process  when  analyzing  a  case  scenario/pa'ent  simula'on  

•  Predict  differen'al  diagnosis  when  presented  with  specific  informa'on  regarding  the  history  of  a  pa'ent  

•  List  and  know  the  common  drugs  used  in  the  emergency  department  to  manage  painful  condi'ons  and  conduct  procedural  seda'on.  

•  Consider  age-­‐specific  factors.  •  Discuss  medico-­‐legal  aspects  of  care  of  pa'ents  with  pain  related  to  emergencies.  

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Defini'ons  

•  Pain  – An  unpleasant  sensory  and  emo'onal  experience  – Associated  with  actual  or  poten'al  'ssue  damage  or  described  in  terms  of  such  damage  

– Personal  and  subjec've  experience  •  Can  ONLY  be  described  by  person  experiencing  pain  •  Exists  whenever  the  person  says  it  does  

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Tolerance  

•  Greatest  level  of  discomfort  a  person  is  prepared  to  endure  

•  Person  requires  increased  amount  of  substance  to  achieve  desired  effect  

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Dependence  

•  Reliance  on  a  substance  •  Abrupt  discon'nuance  would  cause  impairment  of  func'on  

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Addic'on  

•  Behavioral  paZern  characterized  by  compulsively  obtaining  and  using  a  substance  

•  Results  in  physical,  social,  and  psychological  harm  to  user  

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Allodynia  •  Pain  caused  by  a  s'mulus  not  normally  causing  pain  •  Mechanical:  

–  Sta'c  mechanical  allodynia-­‐  pain  in  response  to  a  light  touch/pressure  

–  Dynamic  mechanical  allodynia-­‐  pain  in  response  to  brushing  

•  Thermal:  –  (Hot  or  Cold)  allodynia-­‐  pain  in  response  to  mild  skin  temperatures  in  the  affected  area  

•  Can  be  from  neuropathy,  fibromyalgia,  migraines  or  spinal  cord  injuries  

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Pain  Management  

•  Comprehensive  approach  to  pa'ent  needs  when    experiencing  problems  associated  with  acute  or  chronic  pain  

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Pain  Threshold  

•  Least  level  of  s'mulus  intensity  perceived  as  painful  

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Suffering  

•  Physical  or  emo'onal  reac'on  to  pain  •  Feeling  of  helplessness,  hopelessness,  or  uncontrollability  

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Pain  Physiology  

•  Emergency  nurses  need  an  understanding  of  basic  physiology  of  pain  to  effec'vely  assess,  intervene,  and  evaluate  pa'ent  outcomes.  

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Physiology  A.  Neuroanatomy  

1.  Afferent  pathway  a)  Nociceptors  (pain  receptors)  in  the  'ssues  respond  to  

pleasant  and  painful  s'muli  1)  S'mula'on  of  nociceptors  produces  impulse  transmission  

through  fibers  a)  Small  C  fibers:  unmyelinated;  transmit  burning  and  aching  

sensa'ons;  rela'vely  slow  b)  Larger  A-­‐delta  fibers:  myelinated;  transmit  sharp  and  well-­‐

localized  sensa'ons;  rela'vely  fast  2)  Terminate  in  the  dorsal  horn  of  the  spinal  cord  3)  Modulate  pain  paZerns  in  the  dorsal  horn  4)  Transmit  impulses  to  the  midbrain  via  the  neospinothalamic  

tract  (acute  pain)  and  to  the  limbic  system  via  the  paleospinothalamic  tract  (dull  and  burning  pain)  

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Central  nervous  system  (CNS)  

•  Includes  all  the  limbic  system,  re'cular  forma'on,  thalamus,  hypothalamus,  medulla,  and  cortex    

•  Arousal,  discrimina'on,  and  localiza'on  of  pain;  coping  response;  release  of  cor'costeroids;  cardiovascular  response;  modula'on  of  spinal  pain  transmission  

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Ruth  Lawson,  Wikimedia  Commons     17  

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C  fiber,  A  delta,  dorsal  horn  

Delldot, Wikimedia Commons 18  

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Efferent  pathway  

•  Fibers  connec'ng  the  re'cular  forma'on,  midbrain,  and  substan'a  gela'nosa  in  the  dorsal  horn  of  the  spinal  cord  

•  Afferent  fibers  s'mulate  the  periaqueductal  gray  maZer  in  the  midbrain,  which  then  s'mulates  the  efferent  pathway  

•  Modulates  or  inhibits  pain  impulses  

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Neuromodula'on  A.  Endorphins:  A  group  of  neuropep'des  that  inhibit  

pain  transmission  in  the  brain  and  spinal  cord  1)  Beta-­‐Lipotropin:  responsible  for  feeling  of  well-­‐being  2)  Enkephalin:  weaker  than  other  endorphins  but  longer  

las'ng  and  more  potent  than  morphine  3)  Dynorphin:  generally  impedes  pain  impulse  4)  Endomorphin:  very  an'nocicep've  5)  Opiate  receptors:  mu  receptors  on  the  membrane  of  

afferent  neurons,  inhibit  the  release  of  excitatory  neurotransmiZers;  beta  receptors  react  with  enkephalins  to  modulate  pain  transmission;  kappa  receptors  produce  seda'on  and  some  analgesia;  sigma  receptors  cause  pupil  dila'on  and  dysphoria  

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Effects  of  medica'ons  on  modula'ng  pain  

•  S'mula'on  of  afferent  pathways  results  in  ac'va'on  of  circuits  in  supraspinal  and  spinal  cord  levels.  Each  synap'c  link  is  subject  to  modula'on  

•  Mechanisms  of  drug  ac'on  –  ASA  and  Acetaminophen:  inhibit  prostaglandin  synthesis  in  the  CNS  

–  NSAIDs:  synthesized  at  the  site  of  injury;  inhibit  prostaglandin  synthesis,  which  reduces  hyperalgesia  

–  Opiates:  interact  with  mu  and  kappa  receptors;  powerful  effect  on  the  brainstem  and  the  periphery  

–  Local  anesthe'cs:  block  sodium  channels  and  thus  prevent  transmission  of  nerve  impulses  

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Specific  theory  

– A  specific  sensa'on  that  is  independent  of  other  sensa'ons.  Experiments  on  animals  provided  clinical  evidence  of  separate  spots  for  heat,  cold,  and  touch  

 

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Gate  control  theory  – Modula'ons  of  inputs  in  the  spinal  dorsal  horns  and  the  brain  act  as  a  ga'ng  mechanism  

– With  a  s'mulus,  the  following  sequence  of  events  occurs:  

•  The  pain  impulse  is  transmiZed  via  nociceptors  fibers  in  the  periphery  to  the  substan'a  gela'nosa  through  large  A-­‐delta  and  small  C  fibers  

•  A  ga'ng  mechanism  regulates  transmission  from  the  spinal  cord  to  the  brain,  where  pain  is  perceived  

•  S'mula'on  of  large  fibers  closes  the  gate  and  thus  decreases  transmission  of  impulses  unless  persistent  

•  S'mula'on  of  small  fibers  opens  the  gate  and  enhances  pain  percep'on  

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..more  on  the  ga'ng  mechanism  

– The  spinal  ga'ng  mechanism  is  also  influenced  by  fibers  descending  from  the  brain  

–  The  conduc'ng  fibers  carry  precise  informa'on  about  the  nature  and  loca'on  of  the  s'mulus  

–  Through  efferent  pathways  the  CNS  may  close,  par'ally  close,  or  open  the  gate  

–  Descending  fibers  release  endogenous  opioids  that  bind  to  opioid  receptor  sites  that  thereby  prevent  the  release  of  neurotransmiZers  such  as  substance  P,  this  inhibi'ng  transmission  of  pain  impulses  and  producing  analgesia  

–  Cogni've  func'on  can  also  modulate  the  pain  percep'on  and  the  individual’s  pain  response  

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Neuromatrix  theory  •  A  widespread  network  of  neurons  consist  of  loops  between  the  thalamus  and  cortex  and  between  the  cortex  and  limbic  systems;  neural  processes  are  modulated  by  s'muli  from  the  body  but  can  also  act  in  the  absence  of  s'muli  –  S'muli  trigger  neural  paZerns  but  do  not  produce  them  –  Cyclic  processing  of  impulses  produces  a  characteris'c  paZern  in  the  en're  matrix  that  leaves  a  neurosignature  

–  Signature  paZerns  are  converted  to  awareness  of  the  experience  and  ac'va'on  of  spinal  cord  neurons  to  produce  muscle  paZerns  for  ac'on  

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Neuromatrix  theory  

•  Neural  inputs  modulate  the  con'nuous  output  of  the  neuromatrix  to  produce  a  wide  variety  of  experiences  felt  by  the  individual  – Awareness  of  the  experience  involves  mul'ple  dimensions  (e.g.,  sensory,  affec've,  and  evalua've)  simultaneously  

– Pain  quali'es  are  not  learned;  rather,  they  are  innately  produced  by  the  neurosignatures    and  interpreted  by  the  brain  

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Types  of  pain  

•  Acute  •  Chronic  •  Nocicep've  •  Neuropathic  

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Acute  

•  Elicited  by  injury  to  body  'ssues  •  Typically  seen  with  trauma,  acute  illness,  surgery,  burns,  or  other  condi'ons  of  limited  dura'on;  generally  relieved  when  healing  takes  place.  

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Acute  pain  

Wellcome Library London, Wellcome Images 29  

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Chronic  

•  Elicited  by  'ssue  injury  •  May  be  perpetuated  by  factors  remote  from  the  original  cause  and  extend  beyond  the  expected  healing  'me;  generally  lasts  longer  than  3  months  

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Chronic  pain  

Adrian Cousins, Wellcome Images 31  

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Nocicep've  

•  Elicited  by  noxious  s'muli  that  damages  'ssues  or  has  the  poten'al  to  do  so  if  the  s'muli  are  prolonged.  – Soma'c  pain:  arises  from  skin,  muscle,  joint,  connec've  'ssue,  or  bone;  generally  well  localized  and  described  as  aching  or  throbbing.  

– Visceral  pain:  arises  from  internal  organs  such  as  the  bladder  or  intes'ne;  poorly  localized  and  described  as  cramping.  

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Soma'c  pain  

Wellcome Library London, Wellcome Images 33  

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Visceral  pain  

Theuplink, Wikimedia Commons 34  

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Neuropathic  •  Caused  by  damage  to  peripheral  or  central  nerve  cells  –  Peripheral:  

•  Arises  from  injury  to  either  single  or  mul'ple  peripheral  nerves  

•  Felt  along  nerve  distribu'ons  •  Burning,  shoo'ng,  stabbing  or  like  an  electric  shock  •  Diabe'c  neuropathy,  herpe'c  neuralgia,  radiculopathy,  or  trigeminal  neuralgia  

–  Central:  •  Associated  with  autonomic  nervous  system  dysregula'on  •  Phantom  limb  pain  (peripheral)  or  complex  regional  pain  syndromes  (central)  

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Peripheral  neuropathic  pain  

Lubyanka, Wikimedia Commons 36  

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Central  neuropathic  pain  

J.H. Shepherd/Mütter Museum, Wikimedia Commons 37  

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General  strategy  

•  Assessment  •  Analysis  •  Planning  and  Implementa'on/Interven'on  •  Evalua'on  and  Ongoing  monitoring  •  Documenta'on  

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Assessment  

•  Primary  and  secondary  assessment  •  Focused  assessment    

– Subjec've  data  collec'on  – Objec've  data  collec'on  

 

 

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Subjec've  data  

1.  HPI  (history  of  present  illness/injury)  or  Chief  Complaint  •  History  of  pain  (PQRST)    

–  Pain  –  Quality  –  Region/Radia'on  –  Severity  –  Timing  

•  Efforts  to  relieve  symptoms  

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Subjec've  data  

2.  Past  medical  history  a)  Current  or  preexis'ng  diseases/illness  b)  New  or  recurring  problem  c)  Substance  and/or  alcohol  use/abuse  d)  LNMP  e)  Current  medica'ons  f)  Non-­‐pharmacologic  interven'ons  g)  Food  or  drink  h)  Coping  mechanisms  i)  Allergies  

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Subjec've  data  

3.  Psychological/social/environmental  factors:  a)  Anxiety,  Depression  b)  Aggrava'ng  or  allevia'ng  factors  c)  Expressions  of  pain  d)  Pain  behavior  is  learned,  yet  adap've,  and  it  r/t  

pain  threshold  and  pain  tolerance  e)  Pain  expressions  can  be  verbal,  behavioral,  

emo'onal,  and  physical  

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Objec've  data  

1.  General  appearance  a)  Psychological  b)  Observa'ons  of  behavior  and  vital  signs  should  

not  be  used  solely  in  place  of  self-­‐report  c)  Posi'oning  and  movement  d)  Physiologic  e)  Level  of  distress/discomfort  

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Objec've  data  

2.  Obtain  pain  ra'ng  a)  Adults  

1.  Visual  analog  scale  2.  Numeric  ra'ng  scale  3.  Graphic  ra'ng  scale  4.  Thermometer-­‐like  scale    

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Visual  Analog  Scale  

hZp://0.tqn.com/d/ergonomics/1/0/C/-­‐/-­‐/-­‐/painscale.jpg  45  

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Numeric  Ra'ng  Scale  

hZp://0.tqn.com/d/pain/1/0/S/-­‐/-­‐/-­‐/PainScale.gif  

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Graphic  Ra'ng  Scale  

hZp://img.medscape.com/fullsize/migrated/editorial/journalcme/2007/7993/art-­‐mannion.box1.gif   47  

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Thermometer-­‐like  Scale  

hZp://img.medscape.com/fullsize/migrated/574/105/574105.fig1.gif  48  

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Objec've  data  

2.  Obtain  pain  ra'ng  b)  Pediatric    

1.  FACES  scale  2.  Poker  chip  3.  Numeric  ra'ng  scale  4.  Color  matching  

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FACES  /  Numeric  combined  

No  pain   Worst  pain  of  my  life  Minor  pain  

Moderate  pain   Severe  pain  

Clker.com, Clker Images 50  

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Objec've  data  

2)  Obtain  a  pain  ra'ng  c)  Infant  

1.  Neonatal  Infant  Pain  Scale  (NIPS)  2.  Neonatal  Pain,  Agita'on,  and  Seda'on  Scale  (NPASS)  3.  Pain  Assessment  Tool  (PAT)  

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NIPS  

hZp://www.natalnurses.net/images/22.jpg  52  

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NPASS  

hZp://www.anestesiarianimazione.com/Immagini/npass%208-­‐01.jpg  53  

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PAT  

hZp://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif  54  

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Objec've  data  

•  Inspec'on  –  Posi'on,  skin  color,  external  bleeding,  skin  

integrity,  obvious  deformity,  edema  

•  Ausculta'on  –  Breath  sounds,  bowel  sounds  

•  Palpa'on  –  Areas  of  tenderness:  light,  deep      –  Save  painful  part  un'l  last  

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Diagnos'c  procedures  

•  Laboratory  studies  •  Imaging  •  Electrocardiogram  

•  Purpose:    TO  FIND  THE  CAUSE  OF  THE  PAIN  

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Analysis:  Differen'al  diagnosis  

•  ACUTE  PAIN  •  CHRONIC  PAIN  

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Planning  and  Implementa'on/Interven'ons  

1.  Determine  priori'es  of  care  a)  Maintain  ABC  b)  Provide  supplemental  oxygen  c)  IV  access  d)  Obtain  and  set  up  equipment  e)  Prepare/assist  with  medical  interven'ons  f)  Provide  measures  for  pain  relief  g)  Administer  pharmacological  therapy  as  ordered  

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Administer  pharmacological  therapy  as  ordered  

1.  The  World  Health  Organiza'on  (WHO)  recommends  the  use  of  the  analgesic  ladder  as  a  systema'c  plan  for  the  use  of  analgesic  medica'ons.  1.  Step  1:  use  non-­‐opioid  analgesics  for  mild  pain  2.  Step  2:  adds  a  mild  opioid  for  moderate  pain  3.  Step  3:  use  of  stronger  opioids  when  pain  is  

moderate  to  severe  

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Pa'ent-­‐controlled  analgesia  (PCA)  

•  Used  for  pa'ents  with  acute  or  chronic  pain  who  are  able  to  communicate,  understand  explana'ons,  and  follow  direc'ons  

•  Assess  vital  signs  and  pain  level  •  Explain  the  use  of  the  pump  •  Collaborate  with  the  physician,  pa'ent,  and  family  about  dosage,  lockout  interval,  basal  rate,  and  amount  of  dosage  on  demand  

•  Assist  the  pa'ent  to  use  the  PCA  pump  

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Planning  and  Implementa'on/Interven'ons  

2.  Relieve  anxiety  and  apprehension  3.  Allow  significant  others  to  remain  with  

pa'ent  if  suppor've  4.  Educate  pa'ent  and  significant  others  

•  about  the  efficacy  and  safety  of  opioid  analgesics  

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Evalua'on  and  Ongoing  Monitoring  

1.  Con'nuously  monitor  and  treat  as  indicated  2.  Monitor  pa'ent  response/outcomes,  and  

modify  nursing  care  plan  as  appropriate  3.  If  posi've  pa'ent  outcomes  are  not  

demonstrated,  reevaluate  assessment  and/or  plan  of  care  

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Documenta'on  

•  Document  vitals  and  pain  score  before  and  amer  interven'on  along  with  pa'ent  response  

 

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Age-­‐related  concerns  

1.  Pediatrics:  Growth  or  development  related  •  Children’s  pain  tolerance  increases  with  age  •  Children’s  developmental  level  influences  pain  

behavior  •  Localiza'on  of  pain  begins  during  infancy  •  Preschoolers  can  an'cipate  pain  •  School  age  children  can  verbalize  pain  and  

describe  loca'on  and  intensity  

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Pediatrics  “Pearls”  

•  Children  may  not  admit  to  pain  to  avoid  injec'on  

•  Distrac'on  techniques  can  aid  in  keeping  the  child’s  mind  occupied  and  away  from  pain  

•  Opioids  are  no  more  dangerous  for  children  than  for  adults  

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Age  Related  concerns  

2.  Geriatrics:  Age  related  •  Pain  is  not  a  normal  aging  consequence  •  Chronic  pain  alters  the  person’s  quality  of  life  •  Chronic  pain  may  be  caused  by  a  myriad  of  

condi'ons    

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Geriatric  “Pearls”  

•  Adequate  treatment  may  require  devia'on  from  clinical  pathways  

•  Administer  pain  relieving  medica'ons  at  lower  dose  and  increase  slowly  

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Barriers  to  effec've  pain  management  

1.  A;tudes  of  emergency  health  care  providers  2.  Hidden  biases  and  misconcep'ons  about  

pain  3.  Inadequate  pain  assessment  4.  Failure  to  accept  pa'ents’  reports  of  pain  5.  Withholding  pain-­‐relieving  medica'on  6.  Exaggerated  fears  of  addic'on  7.  Poor  communica'on  

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Improving  pain  management  

•  Changing  a;tudes  •  Con'nuing  educa'on  related  to  the  reali'es  and  myths  of  pain  management  

•  Evidence-­‐based  prac'ce  •  Cultural  sensi'vity  

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Procedural  seda'on  

•  The  Joint  Commission  (TJC)  has  standard  defini'ons  for  four  levels  of  seda'on  and  anesthesia:  1.  minimal  seda'on  2.  moderate  seda'on/analgesia  3.  deep  seda'on/analgesia  (pt  not  easily  aroused)  4.  anesthesia  (requires  assisted  ven'la'on)  

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Procedural  seda'on  

•  Indica'ons:  suturing,  fracture  reduc'on,  abscess  incision  and  drainage,  joint  reloca'on  

•  Assessment:  Allergies,  Last  oral  intake    

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Procedural  Seda'on  •  Procedure:  

–  Baseline  VS  and  LOC  –  Explain  procedure  to  pa'ent  and  family  –  Obtain  venous  access  –  Equipment:  cardiac  monitor,  blood  pressure  monitor,  pulse  oximeter,  suc'on,  oxygen  equipment,  endotracheal  intuba'on  equipment  and  capnography  device,  IV  supplies,  reversal  agents.  

–  Assist  with  medica'ons  – Maintain  con'nuous  monitoring  during  procedure  –  Document  vital  signs,  LOC,  and  cardiopulmonary  status  every  15  min.    

–  Post  procedure  discharge  criteria  

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Medica'on  review  

•  Non-­‐narco'c  •  Narco'cs  •  Seda'ves  /  anesthe'cs  •  Local  anesthe'cs  

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Non-­‐narco'c  

•  Acetaminophen  •  Salicylates  •  NSAIDs  

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Narco'c  

•  Codeine  •  Fentanyl  •  Hydromorphone  •  Morphine  sulfate  •  Oxycodone  

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Seda'ves  /  Anesthe'cs  

•  Diazepam  •  Ketamine  •  Lorazepam  •  Midazolam  •  Propofol  •  Etomidate  

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Local  anesthe'cs  

•  Lidocaine  •  Mepivacaine  •  Procaine  •  Tetracaine  •  LET  (lidocaine,  epinephrine,  tetracaine)  •  EMLA  cream  

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