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Pain Management RN Certificate in Palliative Care Multidimensional Nature of Pain • Experienced by 70-90% of patients with advanced disease • 40-50% experience moderate pain • 25-30% have severe pain • Unrelieved pain impacts the individual, the family and society Definitions of Pain “An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (IASP, 2013) “Pain is whatever the person says it is, experienced whenever they say they are experiencing it.” (Pasero & McCaffery, 2011) Types of Pain (Duration) Acute Pain: May last for a few hours, days, weeks to a few months Chronic Pain: Last more than 3-6 months Types of Pain Somatic Nociceptive Visceral Neuropathic Mixed Nociceptive & Neuropathic Pain Terms • Allodynia • Analgesia • Hyeralgesia Multiple Dimensions of Pain Physiological Affective Environmental Cognitive Social, Cultural, Ethical & Political Behavioral Pain Assessment (Pain Scales) • Although pain is subjective, the ability to quantify the intensity of pain is essential to monitoring a patient’s response to analgesia. • Wong Baker Faces Scale Pain History and Assessment History • • • • • • • • • Location Quality Onset Severity Duration Exacerbating factors Alleviating factors Medications/therapies Impact on QOL Physical Exam • Non-verbals • Observation • Palpation • Auscultation • Percussion • Diagnostics • Ongoing Assessment and goals Patients at Risk for Inadequate Pain Assessment/Management Infant/Children Older Adults Language/Communication Barriers Addictive Disease Uninsured/Underserved Pain Management • Establishing Goals • Barriers to effective pain management include: – Patient/family – System – Clinician Pain Definitions Addiction Tolerance Physical dependence Double effect • Psychological dependence. A primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. • A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. • Adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by… • Abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. • If the intent for using morphine is to relieve pain and not to cause death. Pharmacologic Interventions WHO Ladder Non-Opioid Analgesics • Acetaminophen (APAP) • Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Opioid Analgesics • Short and long acting • Meperidine • Morphine • Mixed agonist – antagonist (Nubain, Talwin) • Fentanyl • Oxycodone • Hydrocodone • Methadone • Hydromorophone (Dilaudid) • Dual action analgesics • Propoxyphene (Darvon, Darvocet) Side Effects of Opioids • Respiratory Depression • Constipation • Sedation • Urinary Retention • Nausea and Vomiting • Itching and Uticaria • Myoclonus • Allergy Adjuvants • Anti-depressants • Anticonvulsants • Corticosteroids • Local anesthetics • Other agents http://www.medscape.org/viewarticle/581948 Methods of Drug Delivery Oral Parenteral Rectal or stomal Transdermal Transmucousal, sublingual, buccal Topical Spinal and regional blocks Equianalgesia • Opioid rotation should be considered if the opioid is ineffective after upward • Use equianalgesic table titration or the adverse • See equianalgesia presentation effects are not tolerable or in this module manageable • Used when changing drug or route • Naloxone (Narcan) Nonpharmacologic Interventions Therapeutic use of self Physical strategies Psychological and Behavioral strategies Neurostimulation Neuroablative strategies Active listening Exercise Stress management TENS Neurolytic blocks Presence Turning/positioning Cognitive/behavioral therapy Acupuncture Neurosurgical techniques Empathy Massage Patient/family education/counseling Heat/cold/hydrotherapy Palliative radiotherapy Difficult Pain Conditions • Pain Crisis • Breakthrough Pain • Palliative Sedation Interprofessional Collaboration • Roles • Nursing • Patient/family • Settings • Coordination of care • Health promotion • Follow up • Diversion/disposal References • American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction Medicine (ASAM). (2001). Definitions related to the use of opioids for the treatment of pain. Glenview, IL: APS. • Berry, P. H. & Paice, J. A. (2010) Pain Management. In Hospice and Palliative Nurses Association (HPNA) Core curriculum for the generalist hospice and palliative nurse, 3 rd edition (Chapter IV, pp. 47-68). Dubuque, IA: Kendall Hunt. • Dalton, J. A. & McNaull, F. (1998) A Call for standardizing the clinical rating of pain intensity using a 0-10 rating scale. Cancer Nurse, 21, p 46-49 • Doufas, A. (2003). Dexmedetomidine and Meperidine Additively Reduce the Shivering Threshold in Humans Stroke, 34 (5), 1218-1223 • Fink, R. M. & Gates, R. A. (2010). Pain Assessment. In B. R. Ferrell, & N. Coyle (Eds.), Oxford textbook of palliative nursing, 3rd edition (Chapter 6, pp.137-160). New York, NY: Oxford University Press. • Hawley P. (2009) Non-Tricyclic Antidepressants for Neuropathic Pain. Fast Facts and Concepts. Retrieved on April 11, 2013 from: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_187.htm • International Association for the Study of Pain (IASP), (2013). IASP taxonomy. Retrieved April 11, 2013 from: http://www.iasppain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm • Lopez, G., & Reddy, S.K. (2011). Pain assessment and management. In S. Yennurajalingam & E. Bruera (Eds.), Oxford American handbook of hospice and palliative medicine (Chapter 4, pp.31-72). New York, NY: Oxford University Press References • National Comprehensive Cancer Network (NCCN) Practice Guidelines. (2012).Oncology – Adult Cancer pain: Version 2. 2012. Retrieved April 11, 2013 from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp • National Consensus Project (NCP) for Quality Palliative Care (2013). Clinical practice guidelines for quality palliative care, 3rd edition. Pittsburg, PA: National Consensus Project for Quality Palliative Care • Old, J. L. & Swagerty, D. L. (2007) A Practical Guide to Palliative Care, Philadelphia, PA: Lippincott Williams & Wilkins. • Paice, J.A. (2010). Pain at the end of life. In B. R. Ferrell, & N. Coyle (Eds.), Oxford textbook of palliative nursing, 3rd edition (Chapter 7, pp. 161-185). New York, NY: Oxford University Press. • Pasero, C., & McCaffery, M. (2005). No self-report means no pain-intensity rating: Assessing pain in patients who cannot provide a report. American Journal of Nursing, 105(10), 50-53. • Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacological manangement. New York, NY: Mosby Elsevier. • Rosielle D. (2009) The Lidocaine Patch. Fast Facts and Concepts.Retreived April 11, 2013 from: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_148.htm • Reisfield, G. M. & Wilson, G. R. (2009) Blocks of the Sympathetic Axis for Visceral Pain. 2nd Edition. Fast Facts and Concepts. Retrieved on April 11, 2013 from: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_097.htm • Von Gunten, C. F. (2009) Morphine and Hastened Death, 2nd Edition. Fast Facts and Concepts. Retrieved April 11, 2013 from : http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_008.htm • Woodalll H. E., Chiu, A. & Weissman, D. E. (2013) Opioid Allergic Reactions. Fast Facts and Concepts. Retrieved April 11, 2013 from: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_175.htm • World Health Organization (WHO), (2013). WHO’s pain ladder. Retrieved April 11, 2013 from: http://www.who.int/cancer/palliative/painladder/en/ WWW.CSUPALLIATIVECARE.ORG