Download Pain lecture 2013

ACUTE AND CHRONIC PAIN
PAIN — THE DEFINITION….
“An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage.”
(IASP,1994)
The 5th Vital sign
THE CONCEPT OF PAIN
McCaffery (1983)
“All Pain is real regardless of its cause.
Pain is whatever the person
experiencing it says it is and exits where
he says it does.”
“it is not the responsibility of patients to prove that they are in
pain, it is the nurses responsibility to believe them”
COMPLEXITIES OF PAIN
A subjective phenomena
 Unpleasant and distressful
 Can be disabling
 Not simply a sensation
 Perceived in terms of tissue damage even
if there is no apparent damage
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PATHOPHYSIOLOGY OF PAIN
Nociceptors—free nerve endings in the tissue
that respond to tissue-injuring stimuli (noxious
stimuli).
 Thermoreceptors—receptors that respond to
noxious temperature changes.
 Chemoreceptors—receptors that respond to
noxious chemicals.
 Mechanical receptors—transmit a pain signal if
the noxious stimuli are sufficiently strong.
PATHOPHYSIOLOGY OF PAIN:
Nociceptors (latin = hurt)
 Algogenic (pain-causing) substances
 A-delta fibres: ‘initial pain transmission’
 Type C fibres: ‘secondary transmission’
 Endorphins and encephalins
 Central nervous system
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NOCICEPTION (OR PAIN PERCEPTION) CAN BE
DIVIDED INTO FOUR PHASES:
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Transduction
Transmission
Perception
Modulation
PAIN
THE GATE CONTROL
THEORY
SIGNIFICANCE OF GATE CONTROL THEORY
Psychological factors play a roll in perception of
pain
 Guided research towards cognitive- behavioural
aproaches to pain management
 Helps to explain how interventions such as
distraction and music therapy provide pain
relief.
 Phantom pain debate
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WHAT ALTERNATIVE THERAPIES CAN
CLOSE THE GATE?
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Music
Distraction of any sort
Cold (not with PVD) or heat
Imagery
Deep breathing
Massage
Vibration
Art therapy
hypnosis
LET’S TRY AN EXPERIMENT….
take pen and place over nail bed and
push. Describe sensation to
neighbour. All the same?
Now try counting backwards from 10
while holding pressure on nail bed. Is
the pain as bad?
PAIN…….
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is the most common reason
for seeking health care
is considered the 5th vital
sign
is underestimated by health
care professionals
and overestimated by family
Is a FOUR letter word
Please assist immediately
----- now !!!!!!
PAIN IS ………….
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Catergorised according
to duration, location and
aetiology
Pain experience is
unique to the individual
Influenced by – culture,
beliefs, ability to cope
and previous experience
FACTORS INFLUENCING RESPONSE TO PAIN
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Culture and differences
Anxiety and depression
Gender
Ageing
Past experiences
IS THERE A PROBLEM?
As many as 67% NZ women 65 years and
older experience musculoskeletal pain
(Taylor, 2005)
 In nursing homes 45-85% report pain
untreated (Flaherty, 2003).
 Nurses may contribute to this problem (Titler
& Herr, 2003)
 Unrelieved pain can have detrimental effects
(Smeltzer & Bare, 2004)
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COMMON MISCONCEPTIONS
AMONG ELDERLY AND NURSES
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Pain is unavoidable.
Pain is a punishment.
Asking for pain medication is too
demanding and means I’m not a
good patient.
Pain medication are addictive.
Taking pain medications means I’ll
lose my independence and mental
clarity.
Pain is not harmful.
Nurses don’t have the time to give
extra medication
Pain means illness is getting
worse
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Elderly patients have decreased
sensations of pain.
Elderly patients who are
cognitively impaired don’t feel
pain.
A sleeping patient is not in pain.
Elderly patients complain more
about pain as they age.
Narcotics will hasten death.
Potent analgesics are addictive.
Potent pain meds will cause
respiratory depression.
Side effects are worse than pain
itself
MISCONCEPTIONS ABOUT PAIN AND
ANAL GESIA
Good patients avoid talking about pain
 Pain medicine should be saved in case pain
gets worse
 Pain is good – builds character
 NO PAIN NO GAIN
 Addiction happens easily
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PAIN THRESHOLD: AMOUNT OF PAIN
STIMULATION A PERSON REQUIRES
BEFORE FEELING PAIN.
Pain tolerance: the highest
intensity of pain that the person is
willing to tolerate.
THE CATEGORIES OF PAIN:
 Acute
 Chronic
(non-malignant)
 Cancer-related pain
 Breakthrough pain
EFFECTS OF ACUTE PAIN
“NEUROENDOCRINE RESPONSE TO STRESS”
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Increased metabolic rate
Increased cardiac output
Impaired insulin
response
Increased retention of
fluids
Increased risk for
physiologic disorders
Decreased deep
breathing and mobility
Increased stress
EFFECTS OF CHRONIC PAIN:
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Suppressed immune
function
Resultant increased
tumour growth
Depression and lack of
motivation
Anger
Fatigue
Resultant disability –
inability to do ADL’s etc
CONSEQUENCES OF UNRELIEVED PAIN
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Physiological Cardiac, Respiratory, Gut
Psychosocial
- depression
- anger
- fear
- behavioural problems
- effect on family
- social
CONSEQUENCES…………………
PAIN ASSESSMENT:
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Should be as automatic as taking pulse and BP.
Pain is the 5th vital sign
Pain is a subjective and unique experience which
belongs to the individual
Guides the type and amount of medication to be
administered and evaluates the effects of the
intervention
Should never be based on assumption
Pain scales
WHY HAVE A PAIN SCALE?
Sometimes hard to put words to pain
 Pain is multi-faceted (How long? Where?
How intense? What kind feeling?
 Visual scales help us understand where pain
located.
 Faces help us understand how pain makes
patient feel.
 Numeric scales help quantify pain using
numbers.
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SO HOW DO WE DEAL WITH THE PROBLEM
OF PAIN?
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Assess it regularly using a pain scale
What if pt does not speak English?
Cannot communicate verbally ?
One type has faces—(Whaley & Wong, 1986).
OTHER PAIN SCALES ARE JUST NUMERIC
PQRST ASSESSMENT
Provokes- what makes it worse or better
 Quality – type – stabbing, throbbing , burning
 Region - where is it – where does it radiate
 Severity - pain score
 Timing – when and for how long
 History of the pain
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Ask the patient!!!!
DESCRIPTIONS OF PAIN:
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Duration
Location
etiology
Intensity
Quality
Temporal pattern
Associated
characteristics
PHARMACOLOGICAL MANAGEMENT:
Selection of appropriate drug, dose, route
and interval
 Aggressive titration of drug dose
 Prevention of pain and relief of breakthrough
pain
 Use of co-analgesic medications
 Prevention and management of side effects
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Taken from Alexander, L. L. (2006). Pain management,
palliative care and treatment of the terminally ill
WHO ANALGESIC LADDER
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Step 1: non-opioid
analgesics 1-3
(Paracetamol and
Aspirins, NSAIDS)
Step 2: mild opioid is
added (not substituted)
to step 1
4-6
Step 3: Opioid for
moderate to severe
pain is used and
titrated to effect 7-10
WHO LADDER WITH N.Z. DRUGS!
Step 3
Opioid (strong one) +/-non-opioid,
+/-adjuvant
Oxycodone, Morphine, Fentanyl, Pethidine
Ketamine
Pain rating 7-10
Step 2
Opioid (weak one) +/- non-opioid adjuvant +/- adjuvant
Codeine, Propoxyphene, Tramadol, Sevredol, DHC Continus,
Dihydrocodeine tartate.
Pain rating: 4-5-6
Step 1
Non-opioid (mild pain) +/- adjuvant
COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam,
Panadeine, Nurofen. Pain rating 1-2-3
BREAKTHROUGH PAIN
Periodic pain which is normally relieved by
analgesia
 Use extra (rescue) doses of opioids.
 Use the immediate-release form of same opioid
they are on.
 Rescue dose 5-15% of the 24-hour dose.
 If 3 or more rescue doses needed/24 hrs—
need to titrate routine drug to effect (25-100%
current dose).
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Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
PAIN MANAGEMENT THROUGH
MEDICATION AND/OR NEUROSURGERY
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Oral analgesia /gas
Rectal
Transdermal route (patches)
Transmucosal (for breakthrough pain)
IM, IV, Subcut (parenteral route)
Epidural and intraspinal
PCA (Patient-controlled analgesia)
Cordotomy
Rhizotomy
Kastinias, P., S.E. Kianda, Robinson, S. (2006).
MANAGE SIDE-EFFECTS OF OPIATES:
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Constipation
Tolerance to nausea and sedation develops in 3-7
days.
Use adjuvant (coanalgesic) agents with opioid:
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Tricyclic antidepressants
Corticosteroids
Anticonvulsants
Muscle relaxants
Stimulants
Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
NARCOTIC ANALGESICS
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Narcotic analgesics
(from the poppy)
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Morphine
Codeine
Heroin
Synthetic narcotic
analgesics:
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Demerol (Meperidine)
Methadone
COMMONLY USED DEVICES
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PCA pump
Epidural
PCEA
Stryker pump
Graseby pain pump
Gas - Entonox
SUMMARY
Give regular pain relief based on your assessment
Give the medication. It does not work if it is still
in the PYXIS / Cupboard
Evaluate the result regularly
Jenny Huri 2013