NUSC 1F18 Pain Lecture PDF

PAIN ASSESSMENT AND MANAGEMENT NUSC 1F18 - Nursing Theory: Experiencing Illness & Hospitalization IASP Definition “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” International Association for the Study of Pain, 2...

PAIN ASSESSMENT AND MANAGEMENT NUSC 1F18 - Nursing Theory: Experiencing Illness & Hospitalization IASP Definition “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” International Association for the Study of Pain, 2020. URL: https://www.iasp-pain.org/resources/terminology/#pain “My pain has had a significant impact on my life. It impacts my ability to get out of bed, get ready, go to school, go to work, exercise, and spend time with my friends and loved ones. Pain causes me to compromise on every aspect of my life.” Person living with pain https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2021.html#_Toc67582180 Implications of Pain in the Society Nearly 8 million people in Canada live with chronic pain In 2019, total cost of chronic - $38.2 - $40.3 billion Direct cost only - $15-17.2 billion Pain is the most common cause of disability in working-age adults Only 30% of ordered medication is given, 50% of patients are left in moderate to severe pain after surgery Canada. Canadian Pain Task force Report: March 2021. URL: https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisorybodies/canadian-pain-task-force/report-2021.html#_Toc67582180 Choinière, M., Dion, D., Peng, P. et al. The Canadian STOP-PAIN project – Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities?. Can J Anesth/J Can Anesth 57, 539–548 (2010). https://doi.org/10.1007/s12630-010-9305-5 Impact of untreated pain 50% of people - moderate to severe levels of depression 34.6% report thinking about suicide 72.9% report the pain interferes with their normal work 78% of visits to the emergency department Consequences of uncontrolled pain: Compromises immune function Promotes tumor growth Compromises healing Increased morbidity and mortality following surgery Choinière M, Dion D, Peng P, Banner R, Barton PM, Boulanger A, Clark AJ, Gordon AS, Guerriere DN, Guertin MC, Intrater HM, Lefort SM, Lynch ME, Moulin DE, Ong-Lam M, Racine M, Rashiq S, Shir Y, Taenzer P, Ware M. The Canadian STOP-PAIN project - Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities? Can J Anaesth. 2010 Jun;57(6):539-48. doi: 10.1007/s12630-010-9305-5. PMID: 20393821. King NB, Fraser V. Untreated pain, narcotics regulation, and global health ideologies. PLoS Med. 2013;10(4):e1001411. doi: 10.1371/journal.pmed.1001411. Epub 2013 Apr 2. PMID: 23565063; PMCID: PMC3614505. Myths and misconceptions 1. Nurses usually provide adequate medication for pain control 2. Opioid use typically leads to addiction 3. Opioids always cause heavy sedation 4. Some kinds of pain can’t be relieved 5. chronic pain can be managed well by giving opioids as a needed basis 6. older adults shouldn’t use opioids Patterson, C. (2008). Six myths about opioid use. Nursing, 38 (11), 60-61. doi: 10.1097/01.NURSE.0000341088.36942.0e. Types of Pain Acute pain Intractable pain Cancer pain Neuropathic pain Nociceptive pain Other important concepts: Pain Treshold Pain tolerance Chronic pain phantom pain Pain Mechanisms in Nociception ØTransduction ØTransmission Central Mechanisms ØModulation ØPerception Nervous System Plasticity Continuous unrelieved pain >Sensitization Peripheral sensitization > central sensitization Nature of Pain Poorly understood Subjective experience Involves physical, emotional, and cognitive components Physical and/or mental stimulus Is exhausting, demands energy, interferes with relationships Known as the 5th vital sign Nurses Role in Pain Management assessing, documenting and communicating effective pain relief measures evaluate interventions monitoring pain management strategies. 3 Top Tips for Pain Assessment: Ø Pain Score Resting and moving Ø Pain Description Ø Patient’s Pain Goal Pain Treatment – Human Right Canadian Pain Society Position Statement on Pain Treatment as a Human Right, 2010 Almost all acute and cancer pain can be relieved, and most patients with chronic noncancer pain can be helped. People have a right to access the best care possible for pain whether this be acute pain, pain caused by cancer, or chronic non-cancer pain. Evidence supports that chronic pain is not just a symptom of underlying illness or injury, but it is a disease in its own right, with significant changes in complex biological, and psychosocial functions. Routine assessment is essential for effective management. Unrelieved acute pain complicates recovery. Patients’ self-report of pain should be used whenever possible. Health professionals have a responsibility to assess pain routinely, to accept patients’ pain reports, to document them, and to intervene in order to manage pain. The best approach to pain management involves patients, families, and health professionals. Assessment of Pain Ø History, Physical Examination of systems, ØPain Description: O Onset- when did it start, how long does it last? P: Provocative- what triggers the pain or makes it worse? Q: Quality of the Pain- tell me what your pain feels like? R: Region/Radiation of the pain S: Severity: On a scale of 1-10 how would you rate the degree of pain? T: Timing-Time of onset; duration of the pain Do you have pain free periods? Treatments: alleviating features U: Understanding: how does this impact you? Any other symptoms? V: Values: What is your goal for this pain? How do you view pain? Other Questions to ask: ØAssociated symptoms, ØEffects on ADL ØPast Pain Experiences ØMeaning of their pain ØCoping strategies ØAffective response- are they anxious, frightened , depressed.... Evidenced-based Pain Measurement Tools Multilanguage tool How’s YOUR PAIN? CPOT- Tool for Intubated Patients Nursing Diagnosis Andrea Box, 75 year old female fell and broke her right hip while shopping. She had surgery with internal fixation with a pin and plate repair yesterday. She rates her pain as a 6/10 and goes up to a 9 when she moves. Morphine 10 mg S/C Q4 h is ordered. Andrea received analgesic 5 hours ago. She states, “I try to hold out as long as I can before asking for a pain killer.” Pain –Related Nursing Diagnoses ØIneffective airway clearance related to weak cough secondary to post operative incisional abdominal pain. ØAnxiety related to past experiences of poor control of pain and to the anticipation of pain. ØImpaired physical mobility related to arthritic pain in knee and ankle joints. ØIneffective coping related to prolonged continuous back pain, ineffective pain management and inadequate support systems. Planning ØPatient centered goal(s) (i.e. The patient will experience minimal post operative pain or discomfort.) Ø Modify or minimize pain to enable partial or complete resumption of ADL ØEnhance ability to control pain ØDemonstrate actions to control pain and associated symptoms Implementation Key Strategies in Pain Management ØVerbally acknowledge the presence of pain. ØListen to what the patient says about the pain; behavioural cues. ØConvey that you need to understand the patient’s pain experience and whether treatments are effective. ØUse psychometrically valid tools to measure pain intensity, quality and impact. ØAttend to patient’s report of pain promptly. Pharmacological Pain Management Multimodal approach – 2 or more analgesia agents that act by different mechanisms 20-60% reduction in opioid use with addition of adjuvants prevention is better than treatment – give meds regularly titrate drugs to effect avoid IM injections Who analgesic ladder Step 2 Mild-mod Step 1 Mild Non narcotics ASA Acetaminophen NSAID Non narcotic or week narcotic ASA& codeine Step 3 Mod - severe Moderate strength narcotic Codeine Morphine Oxycodone Levorphenol oxymorphone Adjuvant therapy with all steps Step 4 severe Strong narcotics Morphine hydromorphone Pharmacological Options in Pain Management Adjuvant Therapy Tricyclic antidepressants Anticonvulsants Alpha-2 Agonists Benzodiazepines Muscle Relaxants Topical Agents Nociceptive Pain Neuropathic Pain Side effects - Opioids COMMON ADVERSE EFFECTS Constipation LESS FREQUENT ADVERSE EFFECTS Urinary Retention Nausea Pruritis Sedation Severe Myoclonustwitching Confusion Dry Mouth Agitation Respiratory Depression RARE ADVERSE EFFECTS Allergy Routes of Opioid Delivery Oral Subcutaneous Intramuscular Intravenous Transnasal Transdermal Rectal Intraspinal Intraspinal- Epidurals ØAnalgesics are delivered adjacent to the opioid receptors in the dorsal horn of the spinal cord. ØTypically Morphine or Fentanyl are used with a local anesthetic (i.e. Bupivicaine). ØLess risk of infection, or spinal headache. Epidural- Three Modes of Delivery Bolus: Epidural for single dose as in spinal anesthesia- C section delivery. Continuous Infusion administered by a pump: used for acute postoperative pain or chronic pain. + Continuous plus Intermittent Bolus: continuous infusion with rescue doses for breakthrough pain. Nursing Interventions - Epidural Nursing Goal Interventions Maintain Client Safety Label tubing, infusion bag, pump as EPIDURAL(minimize confusion); signage above pt’s bed, secure sections with tape. If not continuous infusion- tape all ports so no injections are permitted, Do not use any alcohol in any care of catheter or insertion site, may be neurotoxic Maintain Catheter Integrity Secure catheter with tape; Bolus injection ensure has not migrated to subarachnoid space- withdraw less that 1 mil of fluid, Assist pt. To reposition or move out of bed, maintain sterile/occlusive dressing over insertion site. Assess insertion site post bolus for any leakage. Prevent Infection Use strict aseptic techniques, sterile occlusive dressing, inspect for signs of infection Maintain urinary and bowel function Prevent respiratory depression I/O; bowel/urinary distension; Assess sedation level and resp. status Q1h x 24 hours, then Q4h thereafter, No other opioids while epidural going, Narcan 0.4mg on hand, notify MD if RR