Pain Management PDF

Pain Adult Health Nursing NUR 351 Dr. Abdo M. Al-Husami Copyright © 2017, Elsevier Inc. All Rights Reserved.  Outlines ▪ Introduction ▪ Definition of pain ▪ Pain mechanisms ▪ Classification of pain types ▪ Nursing pr...

Pain Adult Health Nursing NUR 351 Dr. Abdo M. Al-Husami Copyright © 2017, Elsevier Inc. All Rights Reserved.  Outlines ▪ Introduction ▪ Definition of pain ▪ Pain mechanisms ▪ Classification of pain types ▪ Nursing process in the care of patient in pain ▪ Pain management strategies Introduction ▪ One major reason people seek health care ▪ 25 million people experience acute pain from injury or surgery ▪ Chronic pain affects over a million American adults ▪ 60% of cancer patients experience pain during treatment Copyright © 2017, Elsevier Inc. All Rights Reserved. Definition of Pain ▪ “Unpleasant sensory and emotional experience associated with actual or potential tissue damage.” IASP ▪ American Pain Society considered the pain is 5th vital sign. Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain Mechanisms ▪ Nociception: Physiologic process that communicates tissue damage to the CNS ▪ Involves 4 processes: ▪ Transduction ▪ Transmission ▪ Perception ▪ Modulation Copyright © 2017, Elsevier Inc. All Rights Reserved. Mechanism of Pain Perception Nociceptive pain originates when the tissue is injured. 1, Transduction occurs when there is release of chemical mediators. 2, Transmission involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3, Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back down the spinal cord to modify incoming impulses. (Developed by McCaffery M, Pasero C, Paice JA. Modified from McCaffery M, Pasero C: Pain: clinical manual, ed 2, St Louis, 1999, Mosby) Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification of Pain types ▪ By underlying pathology (The cause) ▪ Nociceptive ▪ Neuropathic ▪ By duration ▪ Acute ▪ Chronic Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification of Pain types Copyright © 2017, Elsevier Inc. All Rights Reserved. Areas of Referred Pain Fig. 9-2. Typical areas of referred pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification of Pain types Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Pain Assessment ▪ Methods of pain assessment ▪ Health history (Direct interview) ▪ Observation ▪ Physical examination ▪ Diagnostic studies Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Pain Assessment ▪ Health history (Direct interview) Gathering information directly from the patient about their pain experience.It includes a group of questions about pain characteristics using a mnemonic tools: OLDCARTS SOCRATES PQRST Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain Assessment Pain Characteristics ▪ Onset ▪ Radiation ▪ Location ▪ Timing ▪ Duration ▪ Severity ▪ Character /Quality /Intensity ▪ Associated symptoms ▪ Alleviating and aggravating factors of pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain intensity Scales : Numeric Rating Scale (NRS) A simple scale where patients rate their pain on a scale of 0 to 10. Fig. 9-3. Pain thermometer scale. The patient is asked to circle words next to the thermometeror to mark the area on the thermometer to indicate the intensity of pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain intensity Scales : Pain Thermometer Fig. 9-3. Pain thermometer scale. The patient is asked to circle words next to the thermometeror to mark the area on the thermometer to indicate the intensity of pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain intensity Scales : Visual Analog Scale (VAS) A continuous scale presented as a 10 cm line, with endpoints labeled “No pain” and “Worst pain imaginable.” Patients mark a point on the line that represents their pain. Worst pain No pain imaginable Fig. 9-3. Pain thermometer scale. The patient is asked to circle words next to the thermometeror to mark the area on the thermometer to indicate the intensity of pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain intensity Scales : Wong-Baker FACES Pain Rating Scale Ascale that uses facial expressions to represent different pain levels. Fig. 9-3. Pain thermometer scale. The patient is asked to circle words next to the thermometeror to mark the area on the thermometer to indicate the intensity of pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Pain Assessment ▪ Methods of pain assessment ▪ Observation: Assessing pain through visual and behavioral cues e.g facial expression , posture ,behavior ▪ Physical examination:Hands-on evaluation of the patient’s physical condition e.g Palpation to identify tenderness, ROM testing. Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Pain Assessment ▪ Methods of pain assessment ▪ Diagnostic studies e.g (e.g., X-rays, MRI, CT scans) or laboratory tests, may be utilized to identify or rule out underlying causes of pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Pixland/Jupiterimages/Thinkstock) ▪ B.H., a 52-year-old woman, describes her lumbar back pain as starting 2 months ago and gradually increasing in intensity. She notes that the pain radiates down her left leg and worsens with prolonged sitting. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Pixland/Jupiterimages/Thinkstock) ▪ During the examination, B.H. is observed to be sitting with a slight forward lean and frequently shifting positions to relieve discomfort, indicating the presence of pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Pixland/Jupiterimages/Thinkstock) ▪ Upon palpation, B.H. experiences tenderness over the lower lumbar spine. A straight leg raise test exacerbates her leg pain, suggesting nerve involvement. ▪ An MRI reveals degenerative disc disease between L1-L2 and L2-L3 is the cause of B.H.’s pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing process in the care of patient in pain Nursing diagnoses ▪ Acute pain related to injury agents ▪ Chronic pain related to chronic inflammatory process ▪ Ineffective breathing pattern related to abdominal ▪ Fatigue related to stress of chronic pain ▪ Impaired physical mobility related to chronic pain ▪ Risk for activity intolerance ▪ Risk for constipation related to NSAID Copyright © 2017, Elsevier Inc. All Rights Reserved. Pain Management Strategies ▪ Strategies include ▪ Drugs (Pharmacological) ▪ Nondrug therapies (Non-pharmacological) Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy ▪ 3 categories of medications ▪ Nonopioid ▪ Opioid ▪ Adjuvant Copyright © 2017, Elsevier Inc. All Rights Reserved. Nonopioids ▪ It worked mainly on the peripheral nervous system, at the site of injury, rather than in the central nervous system ▪ Examples :Acetaminophen, aspirin and other salicylates, and NSAIDs (e.g ibuprofen, naproxen, ketorolac and diclofenac K). Nursing considerations for Nonopioids ▪ Do not produce tolerance or addiction ▪ Many are OTC ▪ Used for mild pain to moderate pain. ▪ It used for acute and chronic pain such as arthritis , trauma ▪ Major side-effects “nausea, vomiting, increased bleeding tendencies” Copyright © 2017, Elsevier Inc. All Rights Reserved. Opioids ▪ Bind to receptors in the CNS ▪ Inhibition of transmission of nociceptive input ▪ Activation of descending inhibitory pathways(Modulation) ▪ Examples :Morphine, ethadone,Codeine,Tramadol Copyright © 2017, Elsevier Inc. All Rights Reserved. Opioids Nursing considerations for opioids ▪ Used for severe pain ▪ Common side effects ▪ Constipation (most common) ▪ Nausea/vomiting ▪ Sedation ▪ Respiratory depression Copyright © 2017, Elsevier Inc. All Rights Reserved. Adjuvant Analgesic Therapy ▪ Used alone or in conjunction with opioids and nonopioids ▪ Generally developed for other purposes, but also effective for pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Adjuvant Therapy ▪ Corticosteroids e.g Dexamethasone Mechanisms of action is ability of CS to decrease edema and inflammation ▪ Antidepressants e.g Amitriptyline ,Duloxetine ▪ Antiseizure drugs e.g Gabapentin ▪ GABA receptor agonists e.g Baclofen ▪ Local anesthetics e.g Lidocaine Copyright © 2017, Elsevier Inc. All Rights Reserved. Adjuvant Therapy Nursing considerations ▪ Avoid high doses for long-term use of Corticosteroids ▪ Monitor side effects ▪ Taper doses gradually for antidepressants, and Antiseizure to prevent withdrawal symptoms. ▪ Apply lidocaine patches only to intact skin, remove after 12 hours, and rotate application sites to avoid skin irritation. Copyright © 2017, Elsevier Inc. All Rights Reserved. Nondrug Therapy ▪ Reduces dose of analgesic required and minimizes side effects ▪ Possibly alters perception or stimulates descending pain modulation mechanisms Copyright © 2017, Elsevier Inc. All Rights Reserved. Nondrug Therapy Physical Pain Relief Strategies ▪ Massage:Massage relieves pain by increasing circulation, reducing muscle tension, promoting endorphin release, and enhancing relaxation and flexibility. ▪ Exercise: Exercise acts via many mechanisms to relieve pain. It enhances circulation and cardiovascular fitness, reduces edema, increases muscle strength and flexibility, and enhances physical and psychosocial functioning Copyright © 2017, Elsevier Inc. All Rights Reserved. Nondrug Therapy ▪ Transcutaneous electrical nerve stimulation (TENS) or PENS ▪ Delivery of an electrical current through electrodes on the skin. ▪ It works by stimulating sensory nerves, blocking pain signals to the brain, and promoting the release of endorphins ▪ Acupuncture ▪ Traditional Chinese medicine ▪ Heat and cold therapy Copyright © 2017, Elsevier Inc. All Rights Reserved. TENS Treatment Insert Fig. Transcutaneous electrical nerve stimulation (TENS) treatment being given for treatment of pain after shoulder surgery (©Noel Moore/Hemera/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved. Nondrug Therapy Cognitive therapies ▪ Distraction ▪ Hypnosis ▪ Relaxation Copyright © 2017, Elsevier Inc. All Rights Reserved.