Lecture 5.pdf

The Hashemite University Faculty of Nursing Pain Assessment and Management 150702425 Chapter 8 Lecture 5: cute Pain  Learning Objectives: The learning objectives of this chapter are to:  Understand that biopsychosocial pain assessment is vital in the c...

The Hashemite University Faculty of Nursing Pain Assessment and Management 150702425 Chapter 8 Lecture 5: cute Pain  Learning Objectives: The learning objectives of this chapter are to:  Understand that biopsychosocial pain assessment is vital in the context of acute pain  Appreciate the severity of post-operative tonsillectomy pain and the need for pre-operative parent and child education  Understand the different components of shock-associated acute pain  Recognize the need for early examination and pain relief for patients with acute pain  Acute Pain in Neonates, Infants and Children  Acute pain in infants and neonates requires careful consideration because of: The immature body systems; The potential for drug-induced toxicity is increased because rates of hepatic metabolism and renal excretion are reduced. Example Considerations Aspirin Contraindicated in children under 16 years of age Non-opioid medication Dangerous if an overdose is taken (acetaminophen, NSAIDs) (may lead to liver failure) The first-line choice for infants and children for mild to moderate pain  Procedural Pain - Infants  For Infants who undergo frequent skin-piercing procedures (e.g., pre-term) the studies strongly support the use of topical analgesics (mixture of local anaesthetics (EMLA) Cream, and lidocaine )2.5% for painful skin- penetrating procedures, except for infants and children allergic to amide local anesthetics.  It recommended as has a melting point lower than either of the anesthetics alone, so that the drug can easily penetrate the skin, giving non-toxic serum blood levels.  Possible side effects: Blistering, skin blanching, and eruptions.  Cautions: o If EMLA conjunction with other preparations may drug interaction occur o removed as soon as possible after the procedure o Sufficient time needs to be given prior to the painful procedure to be effective o recommended dose should not exceed mixed doses  Procedural Pain - Children  Often react to routine immunization with fever and irritability and minor adverse reactions.  Antipyretics are frequently recommended.  Recommended to use of acetaminophen syrup (10–15 mg/kg single dose) ‘as needed’ ((not immediate)to reduce fever, pain and/or irritability in children following immunization.  Post-Operative Tonsillectomy Pain in Children  Often accompanied by the possibility of high levels of nausea and vomiting and potentially life-threatening bleeding from the tonsil bed post- tonsillectomy. While NSAIDs are widely prescribed for children following tonsillectomy, some institutions do not prescribe NSAIDs because of the potential risk for bleeding from the tonsil bed.  Post-tonsillectomy pain can be very severe, so adequate and appropriate post- operative pain relief is therefore essential to prevent sensitization, reduce patient distress and aid recovery  Infiltrated tramadol has been shown to give effective analgesia in the immediate post-tonsillectomy period  Appropriate doses of NSAIDs(PRN), to reduce local inflammation, depending on age and weight, should be given with caution orally or rectally (suppositories).  Use of opioid medications such as codeine post-tonsillectomy (and/or adenoidectomy) at home should be on an ‘as needed’ (PRN) basis only and very carefully as prescribed regarding age and specific dosing regimens  Key Issues in the Care of the Child Undergoing Tonsillectomy  Parental education regarding Pharmacological and nonpharmacological pain management techniques very important, including: o Pain management advice about the child's need for post-operative analgesia and appropriate prescribing of acetaminophen and an opioid suspension, the latter on an ‘as needed’ (PRN) basis, together with stimulant laxatives, should be included in the educational meeting with the child and the parent before surgery and reinforced immediately following surgery. o Providing Information leaflets, child-friendly educational material, books and videos can help with the preparation for surgery, reduce anxiety and pain post-tonsillectomy o Promoting the child's optimal sleep hygiene, rest and relaxation, distraction and comfort. o Drinking plenty of cold fluids to reduce inflammation, pain and the risk of infection. o Instruct child and the parent on how to use pain and side effect dairy. o Using of flavored ice lollies may reduce the pain score of children in the immediate post-operative period, as it may inhibit nociception, reduce muscle spasms and pain- related metabolic enzyme activity. o Music, imagery, video games and other distraction cognitive behavioural activities may all help to maintain the child's equilibrium, reduce distress, raise the pain threshold and facilitate recovery  Post-operative Patient-controlled Analgesia (PCA) for Children  All opioid medication is potentially constipating, even if taken for a few doses, so a proactive approach should always be taken, with laxatives as part of the preventative regimen  Below Table shows the typical starting doses for PCA (first-line opioid analgesia) for children.  The nurse need to observes, measures, documents and monitors the patient's VS , I &O, pain medication and monitoring effectiveness, adverse opioid side-effects, especially respiratory depression, sedation, nausea and vomiting, and pruritus (itch), and advocating for medication adjustment and communicating as required with the acute care team and with the infant's or child's parents.  Acute Abdominal Pain in Adolescents and Adults  Causes of acute abdominal pain are associated with mostly: o Tissue damage for injury to abdominal organs. o inflammation of organs (e.g. acute appendicitis, acute diverticulitis or perforated viscus) o Vascular causes (e.g. cute ischemic colitis) o Visceral obstruction: (e.g. cancer invading the intestine or kidney stones which have travelled to the ureter) o Acute pain of somatic origin, arising from bone, joint, muscle, skin or connective tissues o Other  Acute Pain and Shock  All acute pain is potentially associated with shock  Shock is a clinical syndrome affecting all body systems in which cells lack an adequate blood supply, depriving them of oxygen and nutrients.  Causes of pain during shock 1. activation of the inflammatory response is common to all types of shock as a consequence of the body's response in activating the autonomic sympathetic nervous system 2. Psychological conditions such as stress, and anxiety can all contribute to pain  Nursing responsibilities: measurement, observation, documentation, and ongoing monitoring of the VS and pain  Also, recognize the harmful effects of unrelieved pain from a biopsychosocial perspective.  Harmful Effects of Unrelieved Pain Domains affected Specific responses to pain ↑ Adrenocorticotrophic hormone (ACTH), ↑ cortisal, ↑ antidiuretic hormone (ADH), ↑ Endocrine epinephrine, norepinephrine,↑ growth hormone (GH),↑ catecholamines, ↑ renin, ↑ angiotensin 11,↑ aldosterone,↑ glucagon,↑ interleukin-1; ↓ insulin, ↓ testosterone Gluconeogenesis, hepatic glycogenolysis, hyperglycemia, glucose intolerance, insulin Metabolic resistance, muscle protein catabolism, ↑ lipolysis ↑ Heart rate, ↑ cardiac output, ↑ peripheral vascular resistance, ↑ systemic vascular Cardiovascular resistance, hypertension, ↑ coronary vascular resistance, ↑ myocardial oxygen consumption, hypercoagulation, deep vein thrombosis ↓ Flows and volumes, atelectasis, shunting, hypoxemia, ↓ cough, sputum retention, Respiratory infection Genitourinary ↓ Urinary output, urinary retention, fluid overload, hypokalaemia Gastrointestinal ↓ Gastric and bowel motility Musculoskeletal Muscle spasm, impaired muscle function, fatigue, immobility Cognitive Reduction in cognitive function, mental confusion Immune Depression of immune response ↑ Behavioural and physiologic responses to pain, altered temperaments, higher Developmental somatization, infant distress behaviour; possible altered development of the pain system, ↑ vulnerability to stress disorders, addictive behaviour, and anxiety states Debilitating chronic pain syndromes: post-mastectomy pain, post-thoracotomy pain, Future pain phantom pain, postherpetic neuralgia Quality of life Sleeplessness, anxiety, fear, hopelessness, ↑ thoughts of sucide  Essential Nursing Practice in Acute Pain and Shock  Pain should be measured as the fifth vital sign, documented, addressed, and treated at the earliest opportunity to reduce shock and prevent sensitization.  Determine the client’s perception of pain: provide an opportunity for the client to express in their own words how they view the pain and the situation to gain an understanding of what the pain means to the client  Pain should be screened every time vital signs are evaluated.  Evaluate the patient’s response to pain and management strategies.  Provide measures to relieve pain before it becomes severe.  Provide pharmacologic pain management as ordered.  Perform nursing care during the peak effect of analgesics.  Evaluate the effectiveness of analgesics as ordered and observe for any signs and symptoms of side effects.  Cont…Essential Nursing Practice in Acute Pain and Shock  Temperature: a raised temperature contributes to the body's stress response and efforts to regain homeostasis by the autonomic nervous system.  The nurse has close contact with the patient and his or her family, all of whom may be anxious and require empathic, supportive communication and explanations of procedures, what to expect, and changes in the patient's health status. The patient may be confused or agitated.  Acute appendicitis -pain  Appendicitis is regularly misdiagnosed and is a major cause of litigation.  The initial distension of the appendix  causes a periumbilical visceral pain that is poorly localized and generated by spinal afferents innervating visceral organs.  When the inflammation is limited to the appendix, the visceral pain is felt as gnawing and aching.  When the inflammation increases the pain becomes somatic and sharp in quality, and more localized  Acute appendicitis –pain management  At one time, healthcare professionals believed that pain medications made diagnosing appendicitis difficult, delaying a definitive diagnosis when every hour matters. However, we now know that pain relievers do not influence diagnosis, so there’s no reason to suffer while waiting for the doctor or surgery.  It is now standard practice to immediately administer pain medications such as opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetaminophen upon admission to an emergency room.  Diagnosis, Treatment and Nursing Care of the Patient with Myocardial Infarction  Pathophysiology  The term acute coronary syndrome (ACS) was derived from the similarity of the symptoms of unstable angina pectoris with myocardial infarction, so that the two conditions are indistinguishable by symptoms.  The common mechanism for acute coronary syndrome is the rupture or erosion of a coronary artery fibrous plaque, which leads to platelet aggregation and adhesion, localized thrombosis, distal thrombus embolization and vasoconstriction, resulting in myocardial ischaemia due to the reduction of coronary blood flow.  Diagnosis of Myocardial Infarction  Patients may present with severe chest pain (typically refers to the left arm, neck and jaw), along with a difficulty with breathing (dyspnoea), anxiety, nausea and vomiting, and gastric indigestion.  Their vital signs may show autonomic, sympathetic nervous system arousal associated with early shock, with rapid pulse and respiration, lowered or raised blood pressure and cool, clammy, pale skin.  Pain cannot be used as an indicator to distinguish between myocardial ischemia and myocardial infarction. Sometimes myocardial ischemia does not present with pain and is ‘silent’.   Immediate Care for Pts with ACS  Administration of oxygen (2–4 L/min if the patient is hypoxic)  the pain of myocardial infarction is usually severe and requires potent opiate analgesia. Intravenous morphine (repeated as necessary) is the drug of choice and is not only a powerful analgesic but also has a useful anxiolytic effect.  glyceryl trinitrate for pain relief  Aspirin (162–325 mg) as an anti-platelet to prevent further clotting. Other anticoagulation medication can be given.  An intravenous antiemetic should be given.  2ND Clinical Example- A Case of Acute Coronary Syndrome Mrs D, a 70-year-old European lady with a history of depression and obesity and a long-term heavy smoker, has not complied with taking her antidepressant medication and has not slept well for the past month. Her family noted that Mrs D has recently put on additional weight, is spending much time ruminating, watching television and eating convenience snacks. Her daughter was about to suggest that Mrs D should visit her GP to have a check up when Mrs D sustained very severe chest pain. She vomited once, late one evening. Mrs D managed to call her daughter, just saying ‘HELP … my chest…’ before she collapsed. Her daughter contacted the emergency services who responded promptly and a neighbour gave the ambulance paramedics access to Mrs D's house. The paramedics found Mrs D in a shocked state, barely conscious, with rapid, shallow breathing, a thready pulse with tachycardia and very low blood pressure. Mrs D was given oxygen and intravenous fluids and transferred to the city hospital emergency department. On admission, Mrs D was extremely anxious and shocked, and had severe pain in her chest and left arm. The nurse in charge of her care introduced herself and told Mrs D she would be cared for immediately and her pain would be treated at the earliest opportunity. The nurse made Mrs D as comfortable as possible, checking her respirations and oxygen levels. The nurse fully assessed Mrs D's pain, noting location, factors which made the pain worse, pain quality (which in Mrs D's case was strong ‘pressure, squeezing’ pain), intensity, the time the pain started and pain pattern/temporality. The nurse regularly checked Mrs D's respirations, pulse, blood pressure and temperature, documenting Mrs D's vital signs, with pain as the fifth vital sign. The nurse noted Mrs D's colour as pale and skin temperature as cool. The nurse commended a fluid intake and output chart for Mrs D, documenting the intravenous fluid intake. When Mrs D's daughter arrived at the emergency department, she gave the nurse Mrs D's full medical and biosychosocial history and lifestyle, indicating, when asked, that Mrs D had never had a heart attack. The nurse worked with the emergency department physician, who prescribed oxygen and medication interventions. The nurse and physician worked with the emergency department team to care for Mrs D.  2ND Clinical Example- A Case of Acute Coronary Syndrome ….. (Assignment)  Q1. What is Mrs D's suspected diagnosis and how is Mrs D's nursing care prioritized immediately on arrival to the emergency department?  Q2. The ECG confirms an elevated ST segment on two contiguous ECG leads, which is indicative of an acute myocardial infarction associated with cardiac muscle injury. With a confirmed diagnosis of STEMI and blood specimens confirmed as positive by laboratory tests for increased cardiac troponin I, T and C, creatinekinase MB and myoglobin, how does Mrs D's initial nursing management proceed?  1ST: Clinical Example -A Case of Acute Pain A 14-year-old white adolescent male, Jack, presented at the emergency department at 7 pm on a Tuesday evening, accompanied by his father. Checking his observations, the nurse found that Jack had a fever (T 38.5C; 101.3F). When the nurse asked Jack where his pain was, Jack indicated his right lower abdomen (right lower quadrant). Jack rated his pain as 9 (on a 0–10 Number Rating Scale) and described his pain as the worst pain possible (on a Verbal Rating Scale), and as aching and gnawing and sharp in quality. Jack had rapid breathing, very rapid pulse-tachycardia and lowered blood pressure. The nurse documented the five observations, with pain as the fifth vital sign. Jack's father indicated that Jack had vomited frequently all day, had had no food and only a little water to drink, vomiting back any fluids taken. Jack lay on his left side on the hospital trolley with his hips and knees flexed to try to reduce the severe pain sensation and did not feel like talking. The nurse gently asked Jack: (a) when the pain started – Jack replied that the pain started in the middle of his tummy over the past day; (b) when Jack had last eaten – Jack replied he had eaten the previous day; and (c) when Jack had last passed urine and had a bowel movement – Jack replied that he had passed urine and had a bowel movement the previous day (Monday morning) and the nurse documented this information. The nurse also asked Jack if he had taken any recreational drugs or alcohol recently and told Jack this information was very important to prevent any side-effects from his hospital treatments. Jack replied that he had not taken recreational drugs or alcohol and the nurse documented this information.  1ST: Clinical Example -A Case of Acute Pain ….. (Assignment)  Q1. How are Jack's immediate nursing intervention requirements addressed?  Q2: How will Jack's immediate medical and nursing care interventions proceed?  Q3. Are there competing issues in this instance? If so, how does current knowledge and patient-centred interdisciplinary care address them?  Evaluation of Abdominal Pain by Physical Examination  The examination of the patient with acute abdominal pain by the nurse and the doctor is helped by using the PQRST mnemonic: P3 – positions, and interventions (if any), which make the pain better and factors which make the pain worse Q – pain quality R3 – region where the pain is felt, and if and where the pain radiates to another location S – pain severity T3 – time and mode of onset of the pain, how the pain has progressed and whether there have been previous episodes.