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Pain Assessment and Management Lynn Cowling Macmillan Clinical Nurse Specialist in Palliative Care Calderdale & Huddersfield NHS Trust Objectives What is pain? Total pain? Cancer pain. Keys to good pain management. Types of pain. Assessment. Management. What is pain? Pain is real regardless of its cause; pain is whatever the patient experiencing it says it is and exists where they say it does (McCarthey 1983). The pain a patient describes may be seen as the tip of the iceburg, underlying this pain is a whole range of factors, physical, emotional, social and spiritual, each inextricably entwined (Saunders and Sykes 1983). Not only patients with cancer get pain. There are many different conditions, especially in the elderly, that can cause pain and discomfort. These simple rules can be used to assess and manage any one suffering from pain. TOTAL PAIN PHYSICAL Caused By the illness itself Concurrent illness Other symptoms Adverse effects of treatment Pressure sores weight loss Constipation muscle tension/spasm PSYCHOLOGICAL Anger at diagnosis Anxiety, fear Disfigurement Fear of pain and or death Feeling of helplessness Depression TOTAL PAIN SOCIAL Worry about family and finances Loss of social position Loss of role in family Feeling of abandonment and isolation Concerns about dependency Cultural SPIRITUAL Why has this happened to me? Why does god allow me to suffer like this? What is the point of all this? Is there any meaning or purpose in life? Am I being punished for past wrongdoings? Cancer Pain 80% of patients with cancer claim pain as a major symptom. 33% have two pains. 33% have three or more pains. 50-80% of those DO NOT receive adequate pain relief? Cancer pain can be controlled in 80-90% of patients and ‘acceptable relief is possible in most of the remainder. So why does under treatment remain a problem? KEYS TO GOOD PAIN MANAGEMENT Understanding of different causes of pain. Assessment of pain. Management of pain. Reassessment and monitoring. Types of Pain There are three types of pain: Visceral - tumour bulk, bowel obstruction Bone - replacement of bone by tumour, pathological fracture Neuropathic - nerve injury or nerve compression The Pains of Malignant Disease Visceral Bone Pain Neuropathic Pain Headache of Cerebral Tumour Deep, dull ache usually over the tumour site Sharp, may be spasmodic Injury-Burning, sharp, stinging, stabbing, numb Compression-Ache, throbbing, stabbing Dull, oppressive, vice-like Assessment (1) Need psychosocial and medical history but also to ask: Site of pain - where is the pain? Type of pain – what does it feel like? Frequency of pain – how often does it occur? Aggravating factors – what makes it worse? Relieving factors – what makes it better? Assessment (2) Disability – How does the pain affect everyday activities? Duration of pain – how long has it been present? Responses to previous and current treatments? Meaning – what does the pain mean to the patient? If you have a pain assessment tool, use it! PATIENTS THAT HAVE DIFFICULTY COMMUNICATING Facial expression. Posture. Increased agitation or aggression. Withdrawal. Change in mood and behaviour. Guarding one area of body. Not sleeping at night. WHO Ladder Morphine 10mg every 4 hours Paracetamol 500mg + codeine 30mg Paracetamol UNCONTROLLED PAIN +/- Paracetamol CO –ANALGESICS NSAIDs – bone pain, liver capsular pain Anti-convulsants – neuropathic pain Anti-depressants – neuropathic pain Muscle relaxants Anti-spasmodics Opioids Weak Strong Paracetamol Adjuvants Anti depressants Anticonvulsants Antispasmodics Muscle relaxants NSAID Methods of Administration Oral Rectal Subcutaneous Spinal Tens Patch Nerve Blocks Surgery Radiotherapy Chemotherapy NO IM OR IV DRUGS ANALGESIA (1) Regular doses of analgesia must be prescribed Adequate doses of analgesia on an ‘as required basis’ (PRN), in addition to the regular medication must be made available Where possible give analgesia by mouth, by the clock and by the ladder ANALGESIA (2) Pain that does not respond to oral medication is unlikely to respond to analgesia given by a different route e.g. SC, IV unless there are absorption problems Review the effectiveness of any medication on a regular basis Ensure all patients on a step 2 or 3 analgesic are on regular laxatives and that the effectiveness of the laxative regime is being monitored Other Pain Control Measures Remember the role of Explanation Psychological support Rest Relaxation Adequate Heat sleep pads TENs machine and massage Self-help measures Alternative Opioids Oxycodone Hydromorphone Fentanyl Methadone THE KEYS TO GOOD PAIN ASSESSMENT AND MANAGEMENT ARE: Understanding the meaning of whole pain. Understanding of different causes of pain. Assessment of pain. Management of pain. Reassessment and monitoring. THANK YOU