Pain Management Chapter 9 PDF

Pain Management Chapter 9 1  Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the fundamental concepts of pain including the types of pain, the four processes of nociception, and neuropathic...

Pain Management Chapter 9 1  Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the fundamental concepts of pain including the types of pain, the four processes of nociception, and neuropathic pain. 2. Explain and demonstrate methods to perform a pain assessment. 3. List the first-line agents from the three groups of analgesic agents. 4. Identify the unique effects of select analgesic agents on older adults. 5. Describe practical nonpharmacologic methods that can be used in the clinical setting in patients with pain. 6. Use the nursing process as a framework for care of the patient with pain 2 Definition of Pain “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” The clinical definition of pain reinforces that pain is a highly personal and subjective experience: “Pain is whatever the experiencing person says it is, existing whenever he says it does” 3 Effects of Pain It is the primary reason people seek health care and one of the most common conditions that nurses treat. Unrelieved pain has the potential to affect every system in the body and cause numerous harmful effects, some of which may last a person’s lifetime 4 5 Types and Categories of Pain Pain often is described from the perspective of duration, as being acute or chronic (persistent Pain is also classified by its inferred pathology as being either nociceptive pain or neuropathic pain: Nociceptive (physiologic) pain and Neuropathic (pathophysiologic) -Nociceptive (physiologic) pain refers to the normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful -Neuropathic (pathophysiologic) pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the peripheral or central nervous system (CNS) or both 6 Classification of pain Acute pain Chronic pain 1 month to life long Pain, bruising, swelling Pain caused by cancer or non- Temporary loss of function cancer origin May require schedule therapy then Acute exacerbations of pain PRN therapy for short time (breakthrough) Functional impairment Neuropathic pain Progression of S&S Requires scheduled and PRN therapy 7  Nociceptive pain Physiological process: Normal processing of stimuli that damages tissues Categories and Examples: 1. Somatic Pain: Arises from bone joint, muscle, skin, or connective tissue. It is usually described as aching or throbbing in quality and is well localized 2. Visceral Pain: Arises from visceral organs, such as the GI tract and pancreas. Pharmacologic Treatment: Most responsive to nonopioids, opioids, and local anesthetics 8  Neuropathic pain Physiologic Processes: Abnormal processing of sensory input by the peripheral or central nervous system or both Categories: 1. Centrally Generated Pain. 2. Peripherally Generated Pain. Neuropathic pain is sustained by mechanisms that are driven by damage to, or dysfunction of, the peripheral or central nervous system and is the result of abnormal processing of stimuli. 9  Pain process/ Nociceptive 1. Transduction: refers to the processes by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors, which are located throughout the body in the skin, subcutaneous tissue, and visceral (organ) and somatic (musculoskeletal) structures. Noxious stimuli cause the release of a number of excitatory compounds (e.g., serotonin, bradykinin, histamine, substance P, and prostaglandins) 10  Pain process 1. Transmission: Transmission is the second process involved in nociception. Effective transduction generates an action potential that is transmitted along the A-delta (δ) and C-fibers. Noxious information passes through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord. An action potential is generated, and the impulse ascends up to the spinal cord and transmits the information to the brain, where pain is perceived. 11 Pain process 3. Perception: The third process involved in nociception is perception. Perception is the result of the neural activity associated with transmission of noxious stimuli. It requires activation of higher brain structures for the occurrence of awareness, emotions, and drives associated with pain. 12 Pain process 4. Modulation: Modulation of the information generated in response to noxious stimuli occurs at every level from the periphery to the cortex and involves many different neurochemicals. 13  Pain Assessment Pain is subjective in nature Many challenges in pain assessment Patient self-report 14  Pain assessment Comprehensive pain assessment: 1. Location of pain 2. Intensity 3. Quality 4. Onset and duration 5. Aggravating and relieving factors 6. Effect of pain on function and quality of life 15 Pain assessment tools Numeric Rating Scale (NRS): a horizontal 0- to 10- point scale Wong–Baker FACES Pain Rating Scale: The FACES scale consists of six cartoon faces (0,2,4,6,8,10) Verbal descriptor scale (VDS): A VDS uses different words or phrases to describe the intensity of pain, such as “no pain, mild pain, moderate pain, severe pain, very severe pain, and worst possible pain.” Visual Analogue Scale (VAS): a 10-cm line, as “no pain” to “pain as bad”. 16 17 18 19 Pain assessment When apply pain assessment: -During the admission assessment -Initial interview with the patient -With each new report of pain -Whenever indicated by changes in the patient’s condition -When change in treatment plan 20 Reassessment pain Following initiation of the pain management plan, pain is reassessed and documented on a regular basis to evaluate the effectiveness of treatment. At a minimum, pain should be reassessed with each new report of pain and before and after the administration of analgesic agents. The frequency of reassessment depends on the stability of the patient’s pain and is guided by institutional policy. Between 15 and 30 minutes following parenteral administration and between 1 and 2 hours following oral administration 21  Pharmacological Management of pain The recommended approach for the treatment of all types of pain in all age groups is called multimodal analgesia. A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. 22  Routes of administration The oral route is the preferred In the immediate postoperative period, the intravenous (IV) route is the first-line route of administration for analgesic. The rectal route of analgesic administration is an alternative route when oral or IV analgesic agents are not an option. The topical route of administration is used for both acute and chronic pain (the nonopoid diclofene), Local anesthetic creams (lidocaine patch 5%) Epidural analgesia is administered by clinician- administered bolus, continuous infusion (basal rate), and patient controlled epidural analgesia (PCEA). 23  Dosing regimen The basic principles of effective pain management are: (1) preventing pain (2) maintaining a pain intensity that allows the patient to accomplish functional or quality-of- life goals with relative ease. To accomplish these goals, analgesics to be administered on a scheduled around-the-clock (ATC) Patients with persistent pain in the hospital setting should be awakened to take their pain medication. ATC dosing regimens are designed to control pain for patients who report pain being present 12 hours or more during a 24-hour period PRN dosing of analgesic agents is appropriate for intermittent pain 24  Patient- Controlled Analgesia Patient-controlled analgesia (PCA) is an interactive method of pain management that allows patients to treat their pain by self-administering doses of analgesic agents. Multiple routes of administration, including oral, iv, subcutaneous, epidural, and perineural A PCA infusion device is programmed so that the patient can press a button (pendant) to self-administer a dose of an analgesic agent (PCA dose) at a set time interval (demand or lockout) as needed. The primary benefit of PCA is that it recognizes that only the patient can feel the pain and only the patient knows how much analgesic will relieve it. Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected 25  Analgesic Agents 1. Nonopoid analgesic agents : acetaminophen & NSAIDs 2. Opoid analgesic agent: Morphine, Hydromorphen, Phentanyly, & Oxydodone 3. Adjuvant analgesic agent: sometimes referred to as co-analgesic agents: Antidepressants, anticonvulsants, corticosteroids 26 Nonopoid analgesic agents Indications & administration: -Used for a wide variety of painful condition. -For mild to some moderate nociceptive pain. -Acetaminophen and an NSAID may be given concomitantly, and there is no need for staggered doses. -Acetaminophen available in many routes. IV acetaminophen is approved for treatment of pain and fever and is given by a 15-minute infusion in single or repeated doses. A benefit of the NSAID group is the availability. 27  Opioid Analgesic Agents Opioid analgesic agents exert their effects by interacting with opioid receptor sites located throughout the body, including in the peripheral tissues, GI system, and CNS; they are abundant in the dorsal horn of the spinal cord. 28 Opioid Analgesic Agents Antagonists (e.g., naloxone, naltrexone, naloxegol) are medications that also bind to opioid receptors but produce no analgesia. Antagonists are used most often to reverse adverse effects, such as respiratory depression 29  Opioid Analgesic Agents- Administration Titration: -Usually required at the start and throughout the course of treatment when opioids are given -Patients with cancer pain most often are titrated upward over time for progressive pain -Patients with acute pain, particularly postoperative pain, are eventually titrated downward and discontinued as pain resolves -The dose and analgesic effect of mu agonist opioids have no ceiling effect, although the dose may be limited by adverse effects. 30  Opioid Analgesic Agents Physical dependence: is a normal response that occurs with repeated administration of the opioid, with intensity and duration dependent upon the half-life of the medication and how long it has been used. It is manifested by the occurrence of withdrawal symptoms when the opioid is suddenly stopped or rapidly reduced, or an antagonist such as naloxone is given. Tolerance: is also a normal physiologic response that can occur with regular administration of an opioid and consists of a decrease in one or more effects of the opioid 31  Substance Use Disorder (SUD): characterized by impaired control over use, compulsive use, continued use despite harm, and desire to the substance. Withdrawal: occurs when a medication or substance to which the body has become dependent is abruptly reduced or discontinued. Is exhibited by a cascade of unpleasant symptoms including anxiety, nausea, vomiting, rhinitis, sneezing, chills, hot flashes, abdominal cramping, tremors, diaphoresis, hyperreflexia, diarrhea, piloerection, and/or insomnia 32  Opioid Analgesic Agents Selected Opioid Analgesic Agents. 1. Morphine: is the standard against which all other opioid drugs are compared. -It is the most widely used opioid worldwide, particularly for cancer pain. -It is available in a wide variety of short-acting and modified-release oral formulations and is given by multiple routes of administration. -It was the first drug to be administered intraspinally. 33  Opioid Analgesic Agents 1. Fentanyle: the most commonly used IV opioid when rapid analgesia is desired, such as for the treatment of severe, escalating acute pain, and for procedural pain when a short duration of action is desirable. - It also produces minimal hemodynamic adverse effects; preferred in patients who are hemodynamically unstable, such as the critically ill - Ideal for drug delivery by transdermal patch. 34 Opioid Analgesic Agents 3. Hydromorphone: -Is often used as an alternative to morphine, especially for acute pain. 35 Opioid Analgesic Agents Adverse effects: - The most common adverse effects of opioid analgesic agents are constipation, nausea, vomiting, pruritus, and sedation. - Respiratory depression is less common but the most feared of the opioid adverse effects. - Morphine lowers blood pressure by dilating peripheral arterioles and veins - Opioids can result in delayed gastric emptying, slowed bowel motility, and decreased peristalsis, all of which result in slow-moving, hard stool that is difficult to pass. 36 Co-Analgesic Medications The co-analgesic agents comprise the largest group of analgesic agents, which is diverse and offers many options. There is considerable variability among individuals in their response to co-analgesic agents, including to agents within the same class; often a “trial and error” strategy is used in the outpatient setting. Treatment in the outpatient setting is primarily for neuropathic pain and involves the use of low initial doses and gradual dose escalation to allow tolerance to the adverse effects. 37 38  Nursing Implications of Pain Management 1. Perform & document a comprehensive pain assessment. 2. Administer analgesic agents as prescribed. 3. Offer & educate patient how to use appropriate non- pharmacologic interventions. 4. Reassesses for degree of pain relief & presence of adverse effects at peak effect time of intervention. 5. Obtain additional prescriptions as needed. 6. Prevent & treat adverse effects. 7. Educate patient & family about the effects of analgesic agents & the goals of care; explain how adverse effects will be prevented & treated. 39 THANK YOU 40