Download Pain-2005

Pain
(relates to Chapter 9, “Pain,” in the textbook)
Andrew
• 25 y.o. male
• One day post op abdominal surgery
• You enter his room and find him
smiling, joking, talking with visitor
• BP: 120/80; HR = 80; RR = 18
• Rates his pain at 8/10
Andrew
• Write what you believe is Andrew’s pain level
• (Scale 0 = no pain; 10 = worst pain)
•
0 1
2
3
4
5
6
7
8
9
10
• Write what you will document as Andrew’s pain level in his chart
• (Scale 0 = no pain; 10 = worst pain)
•
0 1
2
3
4
5
6
7
8
9
10
Andrew
You gave morphine 2 mg IV 2 hours ago
After injection, you assess his pain Q 30 minutes. Results: pain intensity
6-8 out of 10
No respiratory depression, no sedation, no side effects from morphine
He has identified 2 out of 10 as an acceptable level of pain relief
The order: Morphine 1 - 3 mg every hour as necessary for pain relief.
What will you do?
a) Administer no morphine at this time
b) Administer morphine 1 mg IV now
c) Administer morphine 2 mg IV now
d) Administer morphine 3 mg IV now
Robert
• 25 y.o. male
• One day post op abdominal surgery
• You enter his room. He is: lying
quietly in bed, grimaces as he turns in
bed
• BP: 120/80; HR = 80; RR = 18
• Rates his pain at 8/10
Robert
• Write what you believe is Andrew’s pain level
• (Scale 0 = no pain; 10 = worst pain)
•
0 1
2
3
4
5
6
7
8
9
10
• Write what you will document as Andrew’s pain level in his
chart
• (Scale 0 = no pain; 10 = worst pain)
•
0 1
2
3
4
5
6
7
8
9
10
Robert
You gave morphine 2 mg IV 2 hours ago
After injection, you assess his pain Q 30 minutes. Results: pain intensity
6-8 out of 10
No respiratory depression, no sedation, no side effects from morphine
He has identified 2 out of 10 as an acceptable level of pain relief
The order: Morphine 1 - 3 mg every hour as necessary for pain relief.
What will you do?
a) Administer no morphine at this time
b) Administer morphine 1 mg IV now
c) Administer morphine 2 mg IV now
d) Administer morphine 3 mg IV now
Discussion re Case Scenarios
• Except for behaviors – both cases were identical
• Subjective nature of pain – must accept patients’ reports
• Multiple ways of coping with pain – laughter and
distraction are common (i.e. Andrew)
• Even if we may not believe a patient is not experiencing
pain, we have no right to impose our beliefs on patients
• Better to be “duped” than provide inadequate pain relief
and nursing care
• Both Andrew and Robert should receive 3 mg IV now
(clearly the previous dose was not sufficient, thus it needs
to be increased)
Discussion from McCaffery
• Clock watchers
• Other “suspect” behaviors
Pain
• Whatever the person experiencing the pain
says it is, existing wherever the person says
it does (McCaffery)
• An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage
Pain
• A major reasons for seeking health care
• Nurses have a central role in pain
assessment and management
Pain
• A subjective experience
• Patient’s experience and self-report is
essential
• Self-report can be problematic when
dealing with special populations
• Nonverbal information such as behaviors
can also aid the assessment of pain
Nursing Roles
• Assessing pain and communicating this
information to other health care providers
• Ensuring the initiation of adequate pain
relief measures
• Evaluating the effectiveness of these
interventions
Nociception
• Nociception is the activation of the
primary afferent nerves with peripheral
terminals (free nerve endings) that
respond differently to noxious (tissuedamaging) stimuli
• Nociceptors function primarily to sense
and transmit pain signals
Dimensions of Pain
Affective
(emotions,
suffering)
Physiologic
(transmission
of nociceptive
stimuli)
Behavioral
(behavioral
responses)
PAIN
Sensory
(pain
perception)
Cognitive
(beliefs,
attitudes,
evaluations,
goals)
Fig. 9-1
Mechanism by Which Pain is Perceived
Fig. 9-2
Medications Interrupt the
Pathway
• Transduction (e.g., NSAIDS, local
anesthetics)
• Transmission (e.g., opioids)
• Perception (e.g., opioids, adjuvants,
NSAIDS)
• Modulation (e.g., tricyclic antidepressants)
Classification of Pain
• Acute
• Chronic
Acute Pain
• Sudden onset
• < 3 months or as long as it takes for
normal healing to occur
• Mild-to-severe pain
• Generally can identify a precipitating
event or illness (e.g., surgery)
Acute Pain
• Course of pain ↓ over time and goes away
as recovery occurs
• Includes postoperative pain, labor pain,
pain from trauma
• Treatment includes analgesics for
symptom control and treatment of the
underlying cause
Acute Pain
• Manifestations reflect sympathetic nervous
system activation
• ↑ heart rate
• ↑ respiratory rate
• ↑ blood pressure
• Pain control with eventual elimination is
treatment goal
Chronic Pain
• Gradual or sudden onset
• > 3 month duration; may start as acute
injury or event but continues past the
normal recovery time
• May not know cause of pain
Chronic Pain
• Typically pain does not go away;
characterized by periods of waxing and
waning
• Mostly behavioral manifestations
• ↓ physical movement/activity
• Fatigue
• Withdrawal from others and social
interaction
Chronic Pain
• Can be disabling and is often accompanied
by anxiety and depression
• Treatment goals
• Pain control to the extent possible
• Focus on enhancing function and quality
of life
Assessment of Pain: PQRST
P = Provoking/Palliating factors
• What precipitates/provokes the pain? What
makes it worse?
• What makes it better (palliates)?
Q = Quality
• What does it feel like? Ask open-end questions.
R = Region/radiation
• Where is the pain? Does it travel or radiate?
Assessment of Pain: PQRST
S = Severity
• VAS (Visual analogue scale)
• Numerical scale (0 - 5; 0 - 10)
• Descriptive scale (no pain, mild, moderate, severe,
very severe, worst possible)
• FACES pain rating scale - for children, non-verbal,
language barriers
T = Time/temporal factors
• When did it begin? How long does it last? When does
it occur? Does it come and go? Is it constant?
Assessing Pain in Cognitively
Impaired/Non-verbal Adults
• Self-report whenever possible:
Often can use numerical scales if taught
0 - 5 scale may be easier
Faces scale - 6 different facial images
Assessing Pain in Cognitively
Impaired/Non-verbal Adults
• Alternatives to self-report (from most to least useful)
• Pathologic conditions or procedures known to cause
discomfort
• Behaviors
• Facial expressions (frown, grimace, contract muscles around
mouth/eyes)
• physical movements (restless, fidget, resists movement,
guarding, combativeness, hostile behavior)
• Vocalizations (moan, groan, crying)
• Proxy pain rating (family, friends, clinician) - only a
guess
• Physiological Measures (e.g., HR, RR, BP- elevated) least helpful
Points to Remember: Special
Considerations
• Prevalence of pain increases with age
• Pain is most under-treated among elderly
• No reason to believe that age or cognitive
impairment dulls sensitivity to pain
• Make sure patient can see/use assessment tool
(glasses, hearing aid, teach)
Factors affecting expression of
pain
•
Age
• pain wrongly accepted as part of aging
• sign of weakness
• don’t want to bother nurse
•
Gender
• pain experience/perception may be different between genders
• belief that men should be more stoic
•
Cultural Influences
• Cause of pain (fate, lifestyle, punishment, witchcraft)
• Emotional response and expression
• Meaning of pain
• Reports of intensity
• How it should be treated/who treats it
Why People Deny Pain
• Fear of Addiction
• Discuss this common fear
• Emphasize rarity of addiction when
opioids used for pain (< 1%)
• Fear of Developing Tolerance
• Fear analgesic might not work when
really needed
• Emphasize can increase dose
Why People Deny Pain
• Fear of Side Effects
• Teach can treat and/or prevent these
• Desire to be good patient/non-complainer
• Explain importance of pain relief in
preventing complications
• Fear of Showing Weakness
• Explain importance of pain relief for quality
of life, maintaining control of life
Indicators of Denial of Pain
• Known painful condition/procedure
• Pain behaviors (grimacing, guarding, etc.)
• Family/friends suspect pain
• If denial suspected
• Identify concerns and discuss
• Ultimately, must accept patient’s self-report
• Despite the prevalence of pain, many
studies document inadequate pain
management across care settings and
patient populations
Consequences of Untreated Pain
• Unnecessary suffering
• Physical and psychosocial dysfunction
• Impaired recovery from acute illness
and surgery
• Immuno-suppression
• Sleep disturbances
Reasons for Under-Treatment of
Pain
• Inadequate professional knowledge
• MDs under-prescribe; nurses under-administer
• Fear of addiction by patients and
practitioners
• Lack of knowledge re difference between
physical dependence, tolerance, addiction
Reasons for Under-Treatment of
Pain
• Inadequate assessment techniques
• Inadequate use of assessment tools
• Inadequate evaluation of effects of analgesia
• Hesitance to believe self-reports
• Lack of knowledge re cultural differences in
pain expression
• Pain management not a priority
Reasons for Under-Treatment of
Pain
• Inadequate Consumer knowledge
• That most pain can be relieved
• Fear of addiction/tolerance
Reasons for Under-Treatment of
Pain
• Communication Problems
• Professionals
• Not a priority
• May not impress upon patients importance of
achieving adequate pain control (reduces post-op
complications, reduces hospital LOS, etc)
• Consumers
• Desire to be “good” patient; don’t want to
“bother” nurse
• Cultural variations in expression
Physical Dependence
• May develop after using opioids for 1-4
weeks or longer
• If opioid stopped or antagonist is
taken/given, withdrawal symptoms
(mild-severe) occur
• Yawning, chills, GI upset, tearing of eyes
• May progress to muscle spasms,
vomiting, diarrhea
Tolerance
• May develop after using opioids for 1-4
weeks or longer
• Characterized by reduced effect of the
opioid:
• Reduced pain relief
• Decrease in side effects, such as nausea,
sedation, itching, or respiratory depression
• Treat by increasing dose
Addiction
•
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•
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Psychological dependence
Compulsive drug use
Continued craving
Opioids needed for other than pain relief
An acquired disease of brain
Rarely occurs when opioids used for pain relief
• Of 24,000 patients whose pain was treated with opioids,
< 1% became addicted (7 of 24,000 patients)
• Fear of addiction is never a reason to withhold opioids
from patients in pain
Pain Management and Substance
Abusers
• Discuss McCaffery
Pain Treatment
•
All pain treatment is guided by the same
underlying principles
1. The patient must always be believed
2. Every patient deserves adequate pain
management
3. Set goals for comfort and function
- e.g., what pain rating would allow patient to do
post-op recovery activities?
- generally ratings > 3-4 interferes with function
Pain Treatment
4. Prevent occurrence and recurrence
- Predictable pain - give analgesic before
- Pain around the clock (ATC) – analgesics
ATC (wake patient for analgesic before the
pain wakes patient)
4. All therapies must be evaluated to ensure
they are meeting patient’s goals
Drug Therapy
• Non-opioids
• Opioids
• Adjuvents
Each works on pain in different ways
(interrupt pathways in different
points/ways), so can combine different
types for maximal pain relief
Drug Therapy
• See WHO Analgesic Ladder for
management of pain (p. 142)
• See Equi-analgesic chart (McCaffery)
Non - Opioids
Acetaminophen and NSAIDS
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•
•
•
General purpose analgesics
Acute and chronic pain
Especially for mild MS pain
Also used in combination with adjuvants
and opioids for moderate - severe pain
• Have a ceiling effect - no more pain
relief will be obtained beyond a certain
dose
Non-Opioids
• Acetaminophen (i.e., Tylenol)
• Analgesic action appears to be in CNS
• Safest non-opioid for most patients, especially
elderly
• Does not increase bleeding time or cause ulcers
• May cause hepatotoxicity (do not use in chronic
liver disease or alcoholism)
• Maximum daily dose: 4000 mg
• Also an anti-pyretic (for fever)
• Not an anti-inflammatory; not anti-platelet
Non-Opioids
• NSAIDS
• ASA/Aspirin, Ibuprofin/Motrin/Advil, Celebrex,
Vioxx
• Relieve pain at site of injury and act on CNS
• Block prostaglandin production at site of injury
• When NSAID doesn’t work: increase dose or try
another type
• NSAIDS are also
• anti-inflammatory
• anti-pyretics (for fever)
• anti-platelet (prevent clotting)
Non- Opioids
• NSAIDS
• Common side effects
• heartburn, GI ulceration, GI bleeding
• risk of ulcers increases with increased dose
• Increased bleeding time
• Use cautiously in elderly - prone to GI
problems, platelet dysfunction, renal
problems
Opioids
Two Categories
• Morphine like (mu agonists) - largest
group**
• Agonist-antagonists
Opioids: Mu agonists
• Examples: morphine, demerol, darvon
• Bind to/activates mu opiod receptor sites in spinal cord,
preventing transmission of pain impulses
• Mainstay of acute and cancer pain treatment
• No ceiling on dose (increasing does increases effect; no
maximum dose); can increase dose until desired effect
obtained or side effects are unacceptable/unmanageable
• Relieves all types of pain
• Routes: oral, IM (not recommended b/c unreliable
absorption and painful), IV, rectal, topical
Opioids: Mu agonists
• Side effects:
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N&V
Constipation (most common - prevent with laxatives)
Itching
Drowsiness
Respiratory depression (generally not a problem if
dosing is correct)
• Monitor respiratory status
• Most at risk are opioid naive
• Naloxone (narcan) to revers effects of narcotics
• Sedation/drowsiness (safety precautions very impt)
• precedes resp depression, so can serve as a warning
• See McCaffery, Pg 18
Sedation Scale
•
•
•
•
S = sleeping, easy to arouse – okay
1 = awake and alert – okay
2 = slightly drowsy, easy to arouse – okay
3 = frequently drowsy, drifts off to sleep during
conversation; should decrease dose by 25-50%
• 4 = somnolent, minimal to no response to
physical stimulation - stop opioid, consider
antagonist (naloxone)
Note: Opiods have greater effect and last longer in the
elderly; use caution - start with lower dose; increase dose
more slowly. Avoid demeral.
Adjuvant Analgesic Therapy
• Primary use is other than pain relief (e.g.,
anticonvulsants, antidepressants)
• Useful for some painful conditions
• Mostly used for neuropathic pain
• Mechanisms of action and side effects vary
across different medications
Combining Analgesics
• Combining analgesics from > 1 group sometimes
improves pain relief
• To attack more than one pain mechanism
• Reduce side effects by using lower doses of each
analgesic
• Can combine acetaminophen with NSAIDS
• Do not combine NSAIDS with each other
(increases risk of side effects)
Combining Analgesics
• Combine opioids with non-opioids (e.g.
tylenol with codeine)
• All mu agonists work in same way,
therefore do not combine; simply increase
dose
• Combine adjuvant(s) with opioid and nonopioids (especially for neuropathic pain)
Pharmacologic and Nonpharmacologic
Therapies for Pain
Fig. 9-11
Surgical Therapies
• Performed for severe pain that is unresponsive to
all other therapies
• Nerve blocks
• Used to reduce pain by interrupting
transmission of nociceptive input
• Neural blockade with local anesthetics is
sometimes used for peri-operative pain
• For intractable chronic pain when
conservative therapies fail
Nonpharmacologic Therapy
• Can reduce the dose of an analgesic
required to control pain and thereby
minimize side effects of drug therapy
• Some strategies are believed to alter
ascending nociceptive input or stimulate
descending pain modulation mechanisms
Nonpharmacologic Therapy
• Physical pain relief strategies
• Acupuncture
• Application of heat and cold
• Exercise
• Massage
• Percutaneous electrical nerve
stimulation (PENS)
Nonpharmacologic Therapy
• Physical pain relief strategies (cont.)
• Transcutaneous electrical nerve
stimulation (TENS)
• Vibration
Nonpharmacologic Therapy
• Cognitive therapies
• Distraction
• Hypnosis
• Imagery
• Relaxation
Placebos
• Any medication that produces an effect b/c
of its implicit/explicit intent and not b/c of
its physical or chemical properties (e.g.,
sugar pills, saline injections)
• What does it mean when relief is obtained
from placebos?
• Are placebos ethical? (College of Nurses)
Nursing Diagnoses – Pain
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Activity intolerance
Acute pain
Anxiety
Chronic pain
Constipation
Disturbed sleep pattern
Disturbed thought process
Nursing Diagnoses – Pain
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Fatigue
Fear
Hopelessness
Ineffective coping
Ineffective role performance
Powerlessness
Social isolation