MS1 Pain Management PDF

PAIN MANAGEMENT RHODA GRACE ESTIOCO-RUELOS, MAN, RN MS1 LECTURER College of Nursing-NCM 112 RHODA GRACE ESTIOCO-RUELOS, MAN, RN RHODA GRACE ESTIOCO-RUELOS, MAN, RN  OBJECTIVES At the end of the session, students should be a...

PAIN MANAGEMENT RHODA GRACE ESTIOCO-RUELOS, MAN, RN MS1 LECTURER College of Nursing-NCM 112 RHODA GRACE ESTIOCO-RUELOS, MAN, RN RHODA GRACE ESTIOCO-RUELOS, MAN, RN  OBJECTIVES At the end of the session, students should be able to; Compare characteristics of acute pain, chronic pain, and cancer pain. Describe the negative consequences of pain. Describe the physiology of pain. Describe factors that can alter the perception of pain. Demonstrate appropriate use of pain measurement instruments. Explain the physiologic basis of pain relief interventions 3 RHODA GRACE ESTIOCO-RUELOS, MAN, RN  WHAT IS PAIN? “Pain is whatever the person experiencing it says it is, and exists whenever the person says it does” McCaffery, 1979 ❑ An unpleasant sensory and emotional experience with actual or potential tissue damage. ❑ The most common reason for seeking health care. ❑ Response to and warning of actual or potential trauma RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN Protective role: warning of potential threat to health (sometimes a life-threatening condition); prompt for person to seek medical attention Stimulus for pain can be physical or mental in nature (damaged tissue or person’s dampened ego). RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN ❑ Subjective response: only felt by the person and highly individualized. Self-report is always the most reliable indication of pain. ❑ Interferes with personal relationships and influences the meaning of life. ❑ Fifth Vital sign RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Factors Affecting Response to Pain ❑ A. Pain threshold: Point at which a stimulus is experienced as pain; Higher pain thresholds reflect same for all persons, but individuals lower pain sensitivity. Lower pain have different perceptions and thresholds, reflect higher pain reactions to pain sensitivity. ❑ B. Pain tolerance: amount of pain a person can endure before outwardly responding to it ❖ 1. Decreased by repeated pain episodes, fatigue, anger, anxiety, sleep deprivation ❖ 2. Increased by alcohol, hypnosis, warmth, distraction, spiritual practices RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Factors Affecting Response to Pain ❖ C. Age-Aging decreases sensitivity for pain of low intensity. ❖ D. Sociocultural influences 1. Family beliefs, e.g., males don’t cry 2. Cultural: some persons of ethnic groups handle pain in similar manner ❖ E. Emotional status, e.g., anxiety 1. Fatigue and/or lack of sleep 2. Depression: decreased amount Depression and anxiety of serotonin, a neurotransmitter, thus can make a person increased amount of pain sensation more sensitive to pain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Factors Affecting Response to Pain ❖ F. Past experiences with pain- Past experiences and trauma can influence a person's sensitivity to pain. ❖ G. Source and meaning ❖ H. Knowledge about pain RHODA GRACE ESTIOCO-RUELOS, MAN, RN  CLASSIFICATION OF PAIN ❑Acute Pain-results from sudden accidental trauma or surgery ❖Usually sharp and localized ❖Has sudden onset, ❖lasts less than 6 months. ❖temporary, RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN ❑ Chronic Pain- Experienced in different intensities and may last for more than 6 months ❖ often dull, aching, diffuse; ❖ not always associated with specific cause, ❖ often unresponsive to conventional treatment; ❖ most common is lower back pain RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN ❑ Two subtypes of Chronic pain 1. Chronic cancer pain- associate with cancer itself, nerve compression, invasion of tissue, bone metastasis and cancer treatments. 2. Chronic non-cancer pain- the more common type and is associated with tissue injury that has healed or a chronic non-cancer diagnosis such as arthritis or back pain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN ❑ Primary tumors in the following locations are associated with a relatively high prevalence of pain: Head and neck (67 to 91 percent) Prostate (56 to 94 percent) Uterus (30 to 90 percent) The genitourinary system (58 to 90 percent) Breast (40 to 89 percent) Pancreas (72 to 85 percent) Esophagus (56 to 94 percent) RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Effects of Pain 1. Sleep deprivation 2. Acute pain ❖ Can affect respiratory, cardiovascular, endocrine, and immune systems. ❖ Stress response increases metabolic rate and cardiac output and increases risk for physiologic disorders. 3. Chronic pain ❖ Depression ❖ Increased disability ❖ Suppression of immune function RHODA GRACE ESTIOCO-RUELOS, MAN, RN  NEURALGIA ❑nerve pain: an intermittent and often severe pain in a part of the body along the path of a nerve, especially when there is no physical change in the nerve itself RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Common chronic pain conditions: 1. Neuralgias: pain from peripheral nerve damage sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve. Common Neuralgias ❖ Postherpetic neuralgia (pain that continues after a bout of shingles) ❖ Trigeminal neuralgia (stabbing or electric-shock-like pain in parts of the face) RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Common chronic pain conditions: 2. Dystrophies: pain from peripheral nerve damage characterized by continuous burning pain. 3. Hyperesthesia: state of over sensitivity to touch and painful stimuli. It often happens along with neuropathic pain (pain related to nerve dysfunction/damage). RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Common chronic pain conditions: 4. Phantom Pain: post amputation, the person experiences sensations and pain in the missing body part. Phantom limb pain affects 50-80% of all amputees. 5. Psychogenic pain: pain without a physiologic cause or event. A person with psychogenic pain disorder will complain of pain that does not match their symptoms. Psychogenic usually implies that psychological factors played a key causal role in the development of the illness. Example: HYPOCHONDRIA- obsession with the idea of having a serious disease but undiagnosed medical condition. Symptoms include fear of disease, anxiety and psychogenic pain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN MECHANISM ❑ 1. Nociceptive or visceral-somatic- normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged. (physiologic pain) can be acute or chronic Somatic: arises from skin, close to surface of body; sharp or dull; often with nausea and vomiting. Visceral: arises from body organs; dull and poorly localized; with nausea and vomiting; may radiate or is referred (pain perceived in area distant from stimuli) Usually responsive to opioids or non-opioids. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN ❑ Neuropathic- originally the result of nerve injury, abnormal processing of pain signals generated in either the PNS or CNS. ❑ Pathological pain ❑ Usually, chronic ❑ Can be centrally generated pain and peripherally generated pain ❑ Treatment usually includes adjuvant analgesics. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN SYNDROMES ❑ Complex regional pain syndrome- a form of chronic pain that usually affects an arm or a leg after an injury, surgery, stroke or heart attack. ❑ Postmastectomy pain syndrome- type of chronic neuropathic pain disorder that can occur following breast cancer procedures ❑ Fibromyalgia-widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN SYNDROMES ❑ Hemiplegia- symptom that involves one-sided paralysis, pain is a common clinical consequence of stroke. ❑ Pain associated with sickle cell disease- “pain crises”, or periodic episodes of extreme pain(stabbing, sharp) are a major symptom of sickle cell anemia. ❑ AIDS-related pain- influenced by HIV- induced peripheral neuropathy, drug- induced peripheral neuropathy, and chronic inflammation. (can cause joint pain) RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN SYNDROMES ❑ Burn pain- can be related to nerve problems or injury. ❑ Guillain-Barré syndrome and pain- immune system attacks the body's nerves. Tingling sensation usually worst in the feet and hands and pain intensity is moderate to severe. ❑ Opioid tolerance- characterized by a reduced responsiveness to an opioid agonist such as morphine and is usually manifest by the need to use increasing doses to achieve the desired effect. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  FACTORS THAT AFFECT PAIN RESPONSE ❑ Past experience- as well as trauma can influence a person’s sensitivity and perception of pain ❑ Anxiety and depression- can cause a person to have a lower pain threshold ❑ Culture- culture can influence many pain-related factors such as how an individual communicates pain, an individual's emotional responses to someone else's pain (empathy), pain intensity and tolerance, beliefs about and coping with pain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  FACTORS THAT AFFECT PAIN RESPONSE ❑ Gender- men and women differ in their responses to pain: they are more variable in women than men, with increased pain sensitivity and many more painful diseases commonly reported among women. ❑ Genetics- genetics have revealed that subtle changes in DNA could partly explain the variation in individual differences in pain. Various genes encoding for receptors are now known to play a major role in the sensitivity, perception and expression of pain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  FACTORS THAT AFFECT PAIN RESPONSE ❑ Gerontologic considerations- older adults are more sensitive to experimental pain than young adults, whereas others suggest a decrease in sensitivity with age. Pain is commonly not recognized and not treated in older adults compared to younger adults. ❑ Expectations- an individual's expectation can significantly alter both the perceived pain intensity and brain activation patterns during painful stimuli. For example, in placebo analgesia, expecting low pain decreases pain perception. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PATHOPHYSIOLOGY OF PAIN https://www.youtube.com/watch?v =I7wfDenj6CQ RHODA GRACE ESTIOCO-RUELOS, MAN, RN  NEUROPHYSIOLOGY OF PAIN A. Gate control theory: a mechanism in the spinal cord, in which pain signals can be sent up to the brain to be processed to accentuate the possible perceived pain, or attenuate it at the spinal cord ❑ “Gate” is the mechanism where pain signals can be let through or restricted. ❖ If the gate is open- pain signals can pass through and will be sent to the brain to perceive the pain. ❖ If the gate is closed- pain signals will be restricted from travelling up to the brain, and pain sensation won’t be perceived. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN A schematic illustration of the gate control theory When you bang your shin on a chair or table, for example, you might rub the injured spot. The increase in normal touch sensory information helps inhibit pain fiber activity, therefore reducing pain perception RHODA GRACE ESTIOCO-RUELOS, MAN, RN  NEUROPHYSIOLOGY OF PAIN B. Stimuli: nociceptors: nerve receptors for pain ends; located in numerous skin and muscles; stimulated by direct cellular damage or local release of biochemicals from cellular damage such as bradykinin C. Pain pathway https://www.youtube.com/watch?v=uOai aYDoUnA D. Endorphins (endogenous morphine) bind with opiate receptors on neuron to inhibit pain impulse transmission RHODA GRACE ESTIOCO-RUELOS, MAN, RN  The “Placebo Effect” ❑A physiologic response that results from an expectation that a treatment will work. ❑American Society of Pain Management Nurses (2005) contends that placebos should not be used to assess or manage pain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  ASSESSMENT OF PAIN Assessment: the patient’s pain goal or expectations of comfort and pain relief Meaning of pain for the patient Behaviors associated with the pain Physiologic responses to the pain Characteristics: Intensity, Timing, Location, Quality Aggravating or alleviating factors RHODA GRACE ESTIOCO-RUELOS, MAN, RN Common sites of referred pain from various body organ RHODA GRACE ESTIOCO-RUELOS, MAN, RN Pain Assessment ACRONYM O = Onset P = Provocation Q = Quality R = Radiation S = Severity T = Time W = Words I = Intensity L = Location D = Duration A = Aggravate / alleviate RHODA GRACE ESTIOCO-RUELOS, MAN, RN Pain Assessment ACRONYM RHODA GRACE ESTIOCO-RUELOS, MAN, RN Pain Assessment ACRONYM RHODA GRACE ESTIOCO-RUELOS, MAN, RN Pain Assessment ACRONYM RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Nursing Process in Care of Client Experiencing Pain A. Assessment: 4 aspects 1. Client’s perception of pain Pain rating scale; location; quality; pattern; precipitating and relieving factors; impact of pain; physiologic and behavior changes 2. Physiologic response to acute pain: tachycardia, increased blood pressure, muscle tension, dilated pupils, sweating 3. Behavioral responses to acute pain: guarding, facial expressions, withdrawing 4. Client’s management of pain and effectiveness: Denial of pain: due to fear, misconceptions RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN B. Diagnosis: acute or chronic pain C. Nursing interventions: 1. Acknowledges and documents pain 2. Administers prescribed analgesics 3. Utilizes non-pharmacologic methods and comfort measures 4. Teaches clients and family about pain, medications, comfort measures 5. Suggests referrals as necessary D. Evaluation: utilizes client perception and pain rating scale to document changes in pain RHODA GRACE ESTIOCO-RUELOS, MAN, RN  The Seven Attributes of a Symptom 1 – Location: where is it? Does it radiate? 2 – Quality: what is it like? 3 – Quantity or severity: how bad is it? (pain scale) 4 – Timing: when did/ does it start? How long did/ does it last? How often did/ does it come? 5 – Setting in which it occurs: environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to1 – Location: where is it? Does it radiate? 6 – Exacerbating/ remitting factors: does anything make it better or worse? 7 – Associated manifestations: have you noticed anything else that accompanies it? RHODA GRACE ESTIOCO-RUELOS, MAN, RN PAIN INTENSITY SCALES RHODA GRACE ESTIOCO-RUELOS, MAN, RN FACES PAIN SCALE RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN RELIEF ❑ Non-pharmacological -Cognitive, behavioral and physical approaches. ❑ Pharmacological -narcotic and non-narcotic analgesics. ❑ Combination approaches ❑ Neuro-Surgical interventions RHODA GRACE ESTIOCO-RUELOS, MAN, RN  NONPHARMACOLOGIC INTERVENTIONS ❑ Cutaneous stimulation, massage, and use of hot and cold may be explained by the gateway theory. ❑ Use of heat and cold changes blood flow to the areas and promotes healing. ❑ Use of distraction, relaxation, and guided imagery may redirect attention, promote muscle relaxation, and affect perception or reception of pain stimulus in the brain. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PHARMACOLOGIC PAIN RELIEF INTERVENTIONS ❑ Give analgesics before pain begins or becomes severe ❑ Balanced anesthesia ❑ “PRN” medications (pro re nata) ❑ Routine administration: Round the Clock (RTC) or preventive approach ❑ PCA: Patient-Controlled Analgesia ❑ Local anesthetics ❑ Topicals and patches ❑ Intraspinal administration RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PHYSIOLOGIC BASIS FOR PAIN RELIEF PHARMACOLOGIC INTERVENTIONS ❑ Opioid analgesics act on the CNS to inhibit activity of ascending nociceptive pathways. ❑ NSAIDs decrease pain by inhibiting cyclo-oxygenase, which is the enzyme involved in the production of prostaglandin. ❑ Local anesthetics block nerve conduction when applied to the nerve fibers. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  COLLABORATIVE CARE OF CLIENTS IN PAIN ❑Medications: most common approach to pain management ❑Nurse needs to know for each medication: classification; physiologic action; peak effect, adverse effects, antidote, nursing implications RHODA GRACE ESTIOCO-RUELOS, MAN, RN  COLLABORATIVE CARE OF CLIENTS IN PAIN ❑ Classifications of meds: 1. Non-narcotic analgesics: (e.g. acetaminophen) mild to moderate pain 2. NSAIDs: (aspirin, ibuprofen) peripheral nerve endings; interfere with prostaglandin synthesis 3. Narcotics (e.g., morphine) or Synthetic narcotics (Oxycodone): act within and outside CNS 4. Antidepressants: (such as tricyclic antidepressants) promote serotonin and inhibit pain, promotes sleep 5. Local anesthetics RHODA GRACE ESTIOCO-RUELOS, MAN, RN  GERONTOLOGIC CONSIDERATIONS ❑ More likely to have adverse drug effects and drug interactions ❑ Increased likelihood of chronic illness ❑ May need to have more time between doses of medication due to decreased excretion and metabolism related to aging changes RHODA GRACE ESTIOCO-RUELOS, MAN, RN  OPIOID TOLERANCE AND ADDICTION ❑Maximum safe opioid dosage must be individually assessed. ❑Tolerance develops in all patients who take opioids for prolonged periods. ❑With tolerance, increased usage is needed to effect pain relief. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  OPIOID TOLERANCE AND ADDICTION ❑ Dependence occurs with tolerance and physical symptoms occur when the opioid is discontinued. ❑ Addiction is a behavioral pattern characterized by the need to take the drug for its psychic effects. ❑ Addiction from therapeutic use of opioids is negligible. RHODA GRACE ESTIOCO-RUELOS, MAN, RN PCA line introduced into the injection port of a primary line RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN ❑ Route: affects how much medication is needed to relieve pain; dosages differ with route; ❖ Most common routes Oral: simplest method Transdermal: delivers continuous level of medication Intravenous: provides most rapid onset (but short duration) unless available as PCA RHODA GRACE ESTIOCO-RUELOS, MAN, RN Administration Routes for Analgesics RHODA GRACE ESTIOCO-RUELOS, MAN, RN  CATEGORIES RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Adverse Effects of Analgesic Agents Respiratory depression Sedation Nausea and vomiting Constipation Pruritus RHODA GRACE ESTIOCO-RUELOS, MAN, RN  PAIN RHODA GRACE ESTIOCO-RUELOS, MAN, RN Neurologic and Neurosurgical Methods for Pain Control ❑ Intrathecal and epidural catheters RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Neurologic and Neurosurgical Methods for Pain Control ❑ TENS units-transcutaneous electrical nerve stimulation- is a method of pain relief involving the use of a mild electrical current ❑ Complementary therapies ❖ Acupuncture ❖ Biofeedback ❖ Hypnotism ❖ Relaxation (guided imagery, meditation) ❖ Distraction ❖ Cutaneous stimulation (massage RHODA GRACE ESTIOCO-RUELOS, MAN, RN  Neurologic and Neurosurgical Methods for Pain Control ❑ Interruption of pain pathways Cordotomy- A surgical procedure that is used to relieve pain by cutting certain nerves in the spinal cord that send pain signals Rhizotomy-a minimally invasive surgical procedure to remove sensation from a painful nerve by killing nerve fibers responsible for sending pain signals to the brain. Neurectomy-transection of a cranial or peripheral nerve(nerve resection). RHODA GRACE ESTIOCO-RUELOS, MAN, RN  CORDOTOMY ❑ A surgical procedure in which the fibers of the lateral spinothalamic tract are divided to avoid transmission of impulses related to pain and temperature. ❑ Performed to relieve intractable pain in the lower trunk and legs and usually done in patients with extensive cancer of the pelvis RHODA GRACE ESTIOCO-RUELOS, MAN, RN  RHIZOTOMY ❑ Resection of a posterior nerve root just before it enters the spinal cord. ❑ Useful in controlling severe pain in the upper trunk such as caused by cancer of the lung. RHODA GRACE ESTIOCO-RUELOS, MAN, RN  NEURECTOMY ❑ Interruption of the peripheral cranial nerve supplying the area wherein the nerve fibers to the affected area are severe damaged from the cord (cell body). Used in 5th nerve resection from trigeminal neuralgia. RHODA GRACE ESTIOCO-RUELOS, MAN, RN NEURECTOMY OF FOOT RHODA GRACE ESTIOCO-RUELOS, MAN, RN  REFERENCES MEDICAL SURGICAL NURSING By Ignatavicius 8th edition MEDICAL SURGICAL NURSING By Brunner & Suddarth’s, 15th edition https://ecampusontario.pressbooks.pub/health assessment/chapter/the-pqrstu-assessment/ https://nurseslabs.com/nursing-health- assessment-mnemonics-tips/ RHODA GRACE ESTIOCO-RUELOS, MAN, RN THANK YOU. GOD BLESS RHODA GRACE ESTIOCO-RUELOS, MAN, RN