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A presentation about pain in general for newly registered nurses.
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Basic Pain ManagementBasic Pain Management
AimTo increase awareness
of pain and pain management strategies
Objectives
Will discuss drugs used & side effects
To list some pain relief measures used in the hospital environment
Understand & discuss role in promoting
comfort
Appreciate the adverse effects of untreated pain
To discuss how pain is experienced
Introduction into Patient Controlled Analgesia and Epidural Infusions
Categories of Pain• Acute Pain is described as :Has a predictable end, lasts less than 3 months
• Chronic Pain is described as :Prolonged, lasts longer than 3 months.(McCaffery & Beebe 1994)
• Cancer Pain
What is Pain?
PAIN IS…PAIN IS…
What is Pain?
• Pain is felt by all humans beings on occasions
• It is a defence mechanism and has a useful function
• Unrelieved pain once this initial warning is received is not useful
Physical Aspects of untreated pain
–Cardiovascular –Respiratory–Mobility–Gastrointestinal
Psychological Aspects of pain–Anxiety–Lack of sleep–Withdrawal–Anger–Depression–Non compliance
The Experience of Pain• Pain perception• Sensory nerves• Transmission -slow & fast
fibres– A fibres - Early sharp pain – C fibres - Later dull pain– Processing of information
• Reflexes• Autonomic responses
– Central Control• Ascending & descending
controls
Skin Sensory Receptors
Efferent neuron
Sensation & Response
Nurses role in pain management
Identification
Evaluation
Intervention
Assessment
The Importance of Pain Assessment• Pain assessment forms the basis for effective pain
management.
• It determines the appropriate method of pain relief necessary for each individual patient.
• It allows for ongoing assessment and early detection of complications.
• Re-assessment is an effective tool for nursing interventions.
• Assessment of pain prior to clinical interventions,e.g physio, and consequent administration of analgesia, will promote maximum effectiveness of interventions.
ABC’s of pain assessment• A• Ask about pain regularly Assess pain systematically• B• Believe the patient & family in their reports of pain and what relieves
it• C• Choose pain control options appropriate for the patient• D• Deliver interventions in a timely, logical, coordinated fashion• E• Empower patients to be involved in planning their pain relief
CLINICAL FEATURES OF PAIN• ONSET
GRADUAL, SUDDEN• MAIN SITE
WOUND PAIN, CHEST, LEGS• RADIATION
PAIN MAY RADIATE TO AREAS DISTANT TO THE ORIGINAL PAIN.• CHARACTER
COLICKY, KNIFE-LIKE, BURNING, CONSTANT.• SEVERITY
NO PAIN, MILD, MODERATE, SEVERE , WORST IMAGINABLE.• DURATION
MINUTES, HOURS, DAYS, WEEKS.• AGGRAVATING FACTORS
PLUERETIC CHEST PAIN WORSE ON COUGHING DEEP BREATHING• ANGINA ASSOCIATED WITH EXERCISE• RELIEVING FACTORS
POSTURE, REST , HEAT, COLD• PREVIOUS HISTORY
OF THIS OR SIMILAR PAIN
ASSESSMENT
• PAIN ASSESSMENT SHOULD ALWAYS BE CARRIED OUT ON MOVEMENT NOT AT REST
• ASK THE PATIENT TO TAKE A DEEP BREATH / MOVE LIMB THEN ASSESS THE PAIN
• REASSESS A REASONABLE LENGTH OF TIME FOLLOWING ADMINISTRATION OF ANALGESIA– NO IMPROVEMENT, SLIGHT IMPROVEMENT, GREAT
IMPROVEMENT, NO PAIN.
• IF PAIN PERSISTS REPEAT ANALGESIA AND/OR SEEK ADVICE.
PATIENT’S PERCEPTION• THE NURSE SHOULD NOT ATTEMPT TO MAKE
ASSUMPTIONS ON THE PATIENTS BEHALF
• SEVERITY OF PAIN CAN ONLY BE REPORTED BY THE PATIENT
• IT IS INDIVIDUAL TO THE PATIENT & IS THEIR PERCEPTION OF THE PAIN
• IT IS IMPORTANT TO REPORT THE LOCATION, INTENSITY, TYPE OF PAIN IN THE NURSING DOCUMENTATION
• SIMPLY TO RECORD PATIENT RESPONSE TO THE QUESTION “HOW IS YOUR PAIN?” INVITES MISUNDERSTANDING OR DENIAL AND HINDERS QUANTIFICATION
PAIN ASSESSMENT TOOLS• Enables effective communication and assessment
by reducing the chance of error. (Overcoming bias / individual perceptions).
• The trust wide tool for pain assessment is scoring on a scale of 0 – 10.
• 0 = no pain, 1– 3 = mild pain, 4 – 6 = moderate pain, 7-8 = severe pain, 9-10 = worst pain possible.
• Patients who frequently score > 6 are receiving inadequate analgesia.
PAIN ASSESSMENT TOOLS
Verbal Descriptor Scale– A list of descriptive words describing different levels
of pain intensity– E.G.: No Pain Mild Moderate Severe Worst
Numerical Rating Score– A rating score using either a verbal scoring or marking
a line marked from 0-10 or no pain to worst pain with an attached scale
0 = NO PAIN, 10= WORST IMAGINABLE PAIN.
Pain Assessment Tools
• FACES RATING SCALE– SEVERAL FACES RATING SCALES EXIST AND WERE DEVELOPED
PRIMARILY FOR USE WITH YOUNG CHILDREN. HOWEVER , FACES PAIN RATING SCALES ARE ALSO USED WITH ADULTS WHO HAVE DIFFICULTY USING THE NUMBERS ON A VISUAL/VERBAL ANALOGUE SCALE.
Behavioural Pain ScaleAdapted from FLACC scale (Merkel et al 1997)The Behavioural Pain Rating Scale (Kaplow 2000)Score 0 1 2
Frowning /Grimacing
No particular expressionOr smile
Occasional grimace or frown, withdrawn,disinterested
Frequent to constant frown, clenched jaw, quivering chin
Restlessness Quiet Slight to moderate restlessness
Very restless
Tenseness Relaxed Slight to moderate tenseness
Extreme tenseness
Patient sounds Talking in normal tone or no sound
Sighs, groans softly, occasionally complains
Moans loudly, crying, frequently complains
Consolability Content , relaxed Reassured by touching, talking
Difficult to console or comfort
Patient scores in each category, maximum score of 10 may be achieved. A pain score of 4 or more requires intervention.
Barriers to pain assessment• Communication
– Hearing– Memory
• Can they compare today’s pain with yesterday , when they can’t recall what they did 1 hour ago
• Cognitive ability• Secondary Gain
– Financial– Social– Family
How do people in pain behave?
• GRIMMACE• CRY• SHOUT• GET ANGRY• WITHDRAW• BECOME NON
COMPLIANT• LAUGH
(HYSTERICAL)
• HOLD SITE• RUB AREA• APPLY HEAT• APPLY COLD• TAKE TABLETS• CURL UP• DISTRACTION
Barriers to pain assessment
• Patients perception of pain
• Caregivers attitude to providing effective treatment
• Do nurses assume the role of proxy?– Be careful– Our understanding and recognition of pain may be
skewed or false in the cognitively impaired patient
Pain Perception
What can influence?• Gender• Age• Culture• Anxiety • Previous experience of pain
Conclusion• BELIEVE THE PATIENT
• ASSESS THE CHARACTORISTS OF A PATIENTS PAIN
• USE A SIMPLE RELIABLE CONSISTENT TOOL TO QUANTIFY PAIN LEVEL
• ASSESS PAIN REGULARLY ( 5TH VITAL SIGN)
Approaches to Pain Management
• Choice of route for administration• Treat the patient, not the problem• Allow for individual variability• Awareness of pharmacology of drugs• Useful drug combinations• Administer analgesia regularly• Use of local analgesia techniques• Non pharmacological techniques
PAIN MANAGEMENT TECHNIQUES
• STEPLADDER APPROACH
• SIMPLE ANALGESIA / STRONG ANALGESIA
• PCA (PATIENT CONTROLLED ANALGESIA)
• EPIDURAL / SPINAL ANALGESIA
• WOUND INFUSIONS
• NERVE BLOCKS
• INHALATION ANALGESIA
Causes of poor pain management • Patients vary in response to pain• Poor pain assessment• Inappropriate choice of analgesia• Incorrect dose• Wrong frequency• Wrong route or mode of delivery
Non pharmacological Interventions
»Allay anxiety
Non pharmacological Interventions
• Communication• Reassurance• Information giving• Relaxation techniques• Breathing exercises• Position• Mobilisation
• Distraction• Visualisation• TENS• Acupuncture• Massage• Aromatherapy
Analgesia for acute painSimple analgesicsAspirinParacetamol Nefopam
Combination analgesicsCo-codamolCo-drydamol
Opioid AnalgesicsCodeineDihydrocodeineTramadolMorphineoxycontin
NSAIDsIbuprofenDiclofenacNaproxen
AdjuvantsTricyclic antidepressantsAnti convulsants
Specialist DrugsKetamineCanabinnoids
Score 7-10Consider IV boluses of opiate (This can be treated gradually until the Pt is Comfortable).Give NSAIDs if not contraindicated and/or Paracetamol (These can be given rectally or intravenously)
Score 4-6Offer analgesia that is suitable in potency for severity and nature of pain. Make sure suitable analgesia isprescribed regularly. Consider non-pharmacologicalinterventions. Contact pain service if necessary.
Score 1-3If patient is happy with pain relief and coping with Expected immobility then continue as before.Re-assess at least twice daily.
10
9
8
7
6
5
4
3
2
1
0
As much painAs I canPossibly bear
Severe Pain
Moderate Pain
Little Pain
Discomfort
No Pain at all
PAIN SCORE = 8 - 10
PAIN SCORE = 5 - 7
PAIN SCORE = 2 - 4
PAIN SCORE =0 - 1
SIMPLE ANALGESIC
PRN Paracetamol
1gram 4 times a day
(oral, intravenous or retal)
Or
Regular Paracetamol
1 gram 4 times a day
(oral or rectal)
Ensure no other prescription contains Paracetamol
SIMPLE ANALGESIC + NSAID
Regular Paracetamol
1 gram 4 times a day
(oral, intravenous or ,rectal)
And
PR/PO Diclofenac 50mgs
3 times a day
(75 mg BD if Dyloject used)
150 mg in 24 hours (oral, intravenous or rectal)
or
Ibuprofen 200mg QDS, increase to 400mgs TDS if required (oral) –up to 1200 mg
See contra -indications to NSAIDs on other side of chart
SIMPLE ANALGRESIC + NSAID
+MILD OPIATE
Regular Paracetamol 1 gram 4 times a day (oral, intravenous or rectal)
And
Regular NSAIDS - Diclofenac
or
Ibuprofen
And
PRN Dihydrocodeine/codeine
30mg 3 hourly (oral) max 240 mg
or
PRN Oral morphine solution
10 – 20mg 2 - 4 hourly
Is a laxative required?
See Constipation Guidelines
Is nausea a problem - see
Post-operative Nausea &Vomiting Guidelines
SIMPLE ANALGESIC + NSAID + STRONG OPIATE
Regular Paracetamol 1 gram 4 times a day (oral, intravenous or rectal)
And
Regular NSAIDs –Diclofenac
or
Ibuprofen
And
Stop mild opiate
to
STRONG OPIATE
PRN Oral morphine solution 10-20 mg
2 hourly (oral)
If pain persists consider IV/IM opiate 10 mg 2-4 hourly
or morphine PCA (according to existing guidelines)
Is there another cause for patients increase in pain?
Is a laxative required?
See constipation guide
Is nausea a problem - see Post-operative Nausea & Vomiting Guidelines
ADULT ANALGESIA STEP LADDER
Opioid AnalgesicsSide Effects• Respiratory depression • Nausea• Sedation• Confusion• Pruritis• Constipation
NSAID’SNSAID’S• Should be prescribed regularly to maximise benefit
– Not PRN – Reduces opioid requirements (25%)
• Side Effects– Gastro Intestinal– Renal Impairment– Cardiovascular– Hypersensitivity– Fluid Retention
NSAID’S CAUTIONS
Recognise ” at risk” patients
• Age• Previous peptic ulcer disease• Anti coagulants• Steroids• Dehydrated• Diuretics• ACE inhibitors
NSAID’s INTERACTIONS• Anti coagulants• ACE inhibitors• Anti hypertensives• Diuretics• Lithium
Paracetamol• Is suitable 1st line analgesia for most patients if given
regularly• Effective• Well tolerated• Inexpensive• Underestimated analgesia• Well absorbed 30 - 60 minutes onset of action• Available as :
– soluble tablets, liquids, suppositories, Intravenous injection
Methods
Patient Controlled Analgesia(PCA)
• Method introduced in the early 90’s– Principle around before that
• Cardiff palliator– Overall concept
• Patient is the best judge of their pain
‘Pain is what the patient says it is
and exists when they say it does’
Why patient controlled analgesia?
• The Cycle of Pain Relief
Benefits of PCA
• Reduces delay• Reduces puncture site injury• May reduce postoperative morbidity• May reduce hospital stay• Patient in control
Patient Controlled Analgesia
PCA
IM
0 1 2 3 4 5
Epidural AnalgesiaEpidural Analgesia
Epidural Infusion AnalgesiaEpidural Infusion Analgesia
• Why epidural analgesia?– major surgery (esp. high abdominal/thoracic)– obese– respiratory disease– trauma - fractured ribs
Benefits of Epidural Analgesia• Improved pulmonary function• Less risk of arterial & venous thrombosis • Decrease in cardiovascular complications• Reduce risk of sluggish bowel movement • Early mobilisation• Shorter hospital stay
Why not an Epidural?• Absolute
– Patient refusal– Abnormal clotting– Infection (local septicaemia)
• Relative– Raised intracranial pressure– Spinal deformities– CNS disorders– Severe obesity– Drugs-Aspirin, NSAID’s Heparin Warfarin
Epidural SpaceThe epidural space (epi = outside)• lies between the dura mater and the vertebrae
and ligaments of the spinal canal
• The epidural space allows drugs to be injected near to the spinal cord and the nerves surrounding it. Narcotics given epidurally diffuse slowly into the subarachnoid space and then pass to the opioid receptors in the dorsal horn of the spinal cord
Epidural Space
Pharmacology• Opioids and Local Anaesthetics are the two classes of
drugs commonly used for epidural analgesia
• They can be given as repeated boluses or continuous infusion
• They can be given alone or as a combination ,these drugs are mixed with 0.9% normal saline
• Epidural drugs should be preservative free
Local Anaesthetic• These diffuse rapidly from the epidural space into the CSF.
Local anaesthetic drugs introduced into the epidural space block nerves in the following order
– Sympathetic nerves
– Sensory nerves in order of increasing diameter• (temperature, pain, touch, pressure)
– Motor fibres
Spread of L.A. in epidural space• Site of injection - Lumbar is the easiest • Volume of solution – larger volume greater
area blocked• Position of patient• Speed of injection -rapid injection spreads
solution upwards & downwards• Concentration of solution
Acute Complications Systemic Toxic Reaction
Caused by high levels of LA in the cardiovascular system Because of:
• Unrecognized IV injection of LA• Excessive volume of local anaesthetic• Both of the above• LA administered too quickly (particularly
top-ups)• LA administered too frequently
Systemic Reaction to LA Mild
Circum-oral tinglingTinnitus Metallic taste Nausea DrowsinessBlurred vision
ModerateConfusionSlurred speechMuscle twitching
SevereAboveComaCardiopulmonary arrest
Complications of epidural infusion• Headache• Severe hypotension• Leg weakness• Meningitis• Temporary nerve damage• Epidural haematoma• Epidural abscess • Paralysis
Spinal (Intrathecal) Analgesia
Main differencesEpidural / Spinal
Epidural• Location
– Outside dura• Onset
– Slow(30mins)• Duration
– Short (2 - 4 hrs)• Maintenance
– Continuous/ top –up• Mobility
– Mobile• Risks
– Dural tap
Spinal
– Subarachnoid /CSF
– Quick (5 mins)
– Long ( 6 – 8hrs )
– Mainly single shot
– Not mobile
– Post spinal Headache
To conclude
• Use analgesics in a logical stepwise manner– Choice of analgesia is determined by
• Type & Severity of pain• Individual patient factors
• Treat acute pain promptly• Review analgesia regularly