Pain Management 2024/2025 PDF

Pain Pain Management Prepared by: Dr/ Rasha Mohamed Elauoty Lecturer in Adult Health Nursing Department Faculty of Nursing - Helwan University Faculty of Nursing Helwan University 2024/2025  Pain...

Pain Pain Management Prepared by: Dr/ Rasha Mohamed Elauoty Lecturer in Adult Health Nursing Department Faculty of Nursing - Helwan University Faculty of Nursing Helwan University 2024/2025  Pain Outlines  Introduction  Definition of pain  Effect of pain  Pain pathophysiology  Factors influencing pain  Types of pain  Assessment of pain  Pain management: * Pharmacological management * Non pharmacological management * Nursing management  Nursing process  Assessment  Nursing Diagnosis  Planning  Implementation  Evaluation  References  Pain Objectives: By the end of this lecture each participant Will be able to:  Define the of pain related concepts  Identify physiology of pain  Enumerate physical responses to pain  Discuss the factors influencing pain  Differentiate between types of pain  Identify important consideration for assessing pain.  Describe the quality of major pain.  Discuss pain managements.  Pain Pain Introduction Pain management is considered such an important part of care that the American Pain Society coined the phrase “Pain: The 5th vital sign to emphasize its significance and to increase the awareness among health care professionals of the importance of effective pain management. Documentation of pain assessment is now as prominent as the documentation of the “traditional” vital sign. Definition of pain The International Association for the Study of Pain (IASP) states that pain is “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain Threshold:  Is the minimum intensity at which a person begins to perceive, or sense, a stimulus as being painful  The point at which a stimulus, usually one associated with pressure or temperature, activates pain receptors and produces a sensation of pain. Individuals with low pain thresholds experience pain much sooner and faster than those with higher thresholds; individuals' reactions to stimulation of pain receptors vary.  The point at which a stimulus causes pain. It varies widely among individual.  For example, when listening to a sound, the level of loudness, or pressure, at which the sound becomes painful is described as the pain threshold for that person at that time. Pain tolerance  Is the maximum amount, or level, of pain a person can tolerate or bear.  The level of stimulation at which pain becomes intolerable.  Pain  Having a high pain tolerance is not necessarily a good thing, because it can result in patients not feeling, or ignoring, their body’s warning signals that something is wrong.  For example, people who are less sensitive to pain may be at increased risk of having a “silent” heart attack, because they do not notice the classic symptoms of a heart attack. Effects of pain  Pain interferes with sleeping quality and quantity  Increase metabolism and myocardial oxygen demand" consumption”  Suppression of immune system with increased the risk for infection.  There is a link between chronic pain and depression, anxiety.  Reduction in cognitive function. Classification of pain: 1- Acute pain usually of recent onset and commonly associated with a specific injury and described as lasting from seconds to 6 months such as surgery, broken bones and cuts. Acute pain can be treated with opioids and nonpharmacological treatments such as ice packs , heat packs, or physical therapy. 2- Chronic pain is classified as being of cancer or non-cancer Origin defined as a pain that lasts for 6 months or longer is often difficult to treat because the cause or origin may be unclear and ranges from mild to severe on a daily basis such as diabetis, headach and back pain. Without proper medication, chronic pain can negatively affect one’s quality of life. This could lead to depression or anxiety. 3- Nociceptive pain is a result of tissue damage. It can be described as a throbbing, sharp, or achy pain. This pain is caused by external injuries such as falling, bumping into things, or being hit.  Pain - Nociceptive pain can be felt in the skin, tendons, muscles, joints, and bones. It can be treated with antidepressants, opioids or physical therapy. 4- Neuropathic pain is due to nerve damage. It may feel like a stabbing sensation, burning, shooting pain, or sharp pain. It can cause difficult feeling sensations such as hot, cold, and touch. - Neuropathic pain can be a result of cancer, alcoholism, stroke, limb amputation, chemotherapy, radiation, or diabetes. Although radicular pain is occasionally listed as a major type of pain, it is a type of neuropathic pain. 5- Cutaneous pain is caused by stimulation of the cutaneous nerve endings in the skin and results in a well-localized “burning” or “prickling” sensation. 6- Somatic pain is non-localized and originates in support structures such as tendons, ligaments, and nerves; jamming a knee or finger will result in somatic pain. 7- Visceral pain is discomfort in the internal organs and is less localized and more slowly transmitted than cutaneous pain. 8- Referred pain the sensation of pain is not felt in the organ itself but instead is perceived at the spot where the organs were located during fetal development Pathophysiology of Pain: Classic descriptions of pain typically include four processes (Transduction, Transmission, Perception and Modulation) 1- Transduction: the conversion of the energy from a noxious thermal, mechanical, or chemical stimulus into electrical energy (nerve impulses) by sensory receptors called nociceptors.  Pain 2- Transmission: Effective transduction generates an action potential that is transmitted along the A-delta fibers that carry impulses rapidly result in sharp, acute pain and C fibers that carry impulses at slower rate result in aching, burning sensation that following immediate discomfort, Pain impulses move to sequentially higher levels in the brain as RAS, thalamus, cerebral cortex. 3- Perception: when the impulse has been transmitted to the cortex and is interpreted by the brain, the information is available on a conscious level. It is then that the person becomes aware of the intensity, location, and quality of pain. 4- Modulation refers to the activation of descending neural pathways that inhibit transmission of pain. “The pathways are described as descending because they involve neurons originating in the brain stem that descend to the dorsal horn of the spinal cord. The descending fibers release substances that produce analgesia by blocking the transmission of noxious stimuli. Pain modulation is a result of the effects of endogenous opioids, also called encephalons and endorphins. Characteristics of pain  Severity of pain ranges from none to mild discomfort to excruciating.. ( mild, moderate, sever)  Pain  Timing when the pain started and whether it is constant or intermittent  Location of pain is best determined by having the patient point to the area of the body involved.  Quality of pain described as sharp, shooting, burning.  Alleviating factors: ask the patient what makes the pain better  Aggravating factors: ask the patient what makes the pain worse  History: Ex. Past pain experience  Pain Behaviors These nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence of or the degree of pain experienced. Physiological responses to pain:  Cardiovascular system Increase heart rate, cardiac output, hypertension, myocardial oxygen consumption.  Respiratory system Increase respiratory rate , shallow respiration, decrease tidal volume and hypoxemia  Central nervous system Mental confusion, loss of consciousness and also increases pupil size.  Gastrointestinal system Decrease gastric and bowel motility& also there are (GIT) disturbances  Genitourinary system Increase urinary output  Musculoskeletal system General weakness, muscle spasm  Endocrine  Pain Pain triggers a response in the amygdala, which drives the hypothalamus to produce corticotrophin-releasing hormone (CRH); this is transmitted to the anterior pituitary gland, where it activates the SNS and stimulates the production of adrenocorticotrophin (ACTH). The SNS also stimulates the adrenal medulla to release adrenaline and noradrenaline, Factors influencing pain: Pain is influenced by many factors, including physiological, psychological, social and spiritual factors Physiological factors:-  Pain a- Age: is an important variable that influences pain, particularly in infants and older adults. - The ability of older clients to interpret pain can be complicated by the presence of multiple diseases with vague symptoms that may affect similar parts of the body. B- Fatigue: fatigue heightens the perception of pain. Pain is often experienced less after a restful sleep than at the end of a long day. C- Genes: Recently, research on animal models suggests that genetic information passed on by parents might increase or decrease the person's sensitivity to pain. D- Neurological function: Any factor that interrupts or influences the normal pain reception or perception affects the client's awareness and response to pain. Ex. A client who has a spinal cord injury or peripheral neuropathy as in diabetes mellitus experiences altered pain sensation. Certain pharmacological agents influence pain perception and response as analgesics, sedatives and anesthetics depress functions of the central nervous system (CNS). 2- Social factors: a- Attention: the degree to which a client focuses attention on pain can influence pain perception. Increased attention has been associated with increased pain. So distraction has been associated with a diminished pain response by focusing a client's attention and concentration on other stimuli. Ex. Relaxation, guided imagery and massage. B- Previous experience: If a person has had repeated experiences with the same type of pain, but the pain has been successfully relieved it becomes easier to interpret the pain sensation.  Pain C- family& social support: people in pain often depend on family members or close friends for support, assistance or protection. The presence of loved one can minimize loneliness and fear. 3- Spiritual factors: Spirituality is a concept that stretches beyond religion. Spiritual questions may include: why has this happened to me? Why me?, Why now? Requesting a clergy consult for a client with chronic pain is recommended. 4- Psychological factors: a- Anxiety: Anxiety often increases the perception of pain and pain may also cause feelings of anxiety. Critically ill or injured clients who often perceive a lack of control over their environment and care may have high anxiety levels. B- Coping style: coping style influence the ability to deal with pain. Clients often find various ways to cope with the physical and psychological effect of pain. It is important to understand a client's coping resource during a painful experience these resources such as communicating with a supportive family, exercise or singing. 5- Cultural factors: a- Meaning of pain: The meaning that a person associates with pain affects the experience of pain and how one adapts to it. A person will perceive pain differently if it suggests a threat, loss, punishment, or challenge. Ex. A woman in labor will perceives pain differently than a woman with a history of cancer who is experiencing a new pain and fearing recurrence. B- Ethnicity: cultural beliefs and values affect how individuals deal with pain. Individuals learn what is expected and accepted by their culture, including how to react to pain. Pain scale:  Pain 1- Numeric Rating Scale (NRS): 2- Wong – Baker FACES Pain Rating Scale:. 3- Faces Pain Scale - Revised (FPS - R): 4- Verbal descriptor scale (VDS): Visual Analog Scale (VAS):  Pain Pain Managements Pharmacological Management Either alone or in combination with other therapeutic measures. - Pharmacological intervention may be: 1. Non Opioid drugs 2. Opioid drugs 3. Adjuvant drugs 1. Non Opioid drugs Non Opioid drugs are non-narcotics including: - NSAID - Acetaminophen Indications  Mild to some moderate nociceptive pain.  All surgical patients should routinely be given NSAID, Acetaminophen in scheduled doses pre-operatively and throughout the post operatively course. Adverse effects - Hepatotoxicity, as a result of overdose. - NSAID increase bleeding time. - NSAID can cause gastric toxicity, ulceration. - Rarely renal toxicity. 2. Opioid drugs - Refers to narcotic drugs Examples including :( Morphine-Codeine sulfate-Fontanel) Indications - Pain is no longer controlled with non-Opioid - Treating moderate to severe pain.  Pain Adverse effects - Nausea, constipation - Respiratory depression - Addiction (compulsive use, continued use despite harm) - Physical dependence (manifested as withdrawal symptoms when Opioid rapidly or suddenly stopped) - Tolerance (decrease in effect). Patient controlled analgesia - PCA is an intervention that allows patients to self-administer narcotic pain medication through the use of an infusion device programmed so that the patient can press a button to self-administer a dose of analgesic Advantages of PCA  Only the patient knows how much analgesic will relieve his /her pain  Pain is kept within a constant tolerable level  Less drug is actually used  Rapid pain relief Disadvantage: It is for patient use only and that unauthorized activation of the PCA button c) Adjuvant drugs Analgesic drugs are combined with the wide range of adjuvant drugs to improve Pain control.  local anesthetics Safe and effective use of all types of pain as Lidocaine patch 5%.  Anti-convulsions act by blocking potassium, calcium flux  Antidepressants as tricyclic antidepressants, selective serotonin reuptake inhibitors. Non pharmacological pain management  Pain Non pharmacological methods are usually effective alone for mild some moderate intensity pain, and should be complemented pharmacological therapies for more severe pain.  Body based modalities As: -Application of heat or cold massage -Physical therapy, aqua therapy -Acupuncture -Percutaneous Electrical Nerve stimulation  Cognitive behavioral methods -Relaxation breathing -Listening, Singing -Imagery (intentional day dreaming) -Pray -Hypnosis -Meditation  Biologically based therapies -Taking herbs, vitamins, and proteins  Energy therapy - Yoga Surgical management Intractable pain can be relieved with surgery  Rhizotomy: surgical sectioning of a nerve root close to the spinal cord to prevent sensory impulses from traveling to the brain.  Cordotomy surgical interruption of pain pathway in the spinal cord. Nursing role in pain management: 1. Pain is assessed by the nurse by collecting and analyzing subjective and objective data. Pain is a subjective experience that cannot scientifically be proven to be or not be present.  Pain 2. The client's subjective complaints of pain are far more accurate than other indicators of pain, such as the client's vital signs and behavioral changes, such as crying and guarding the area of the body affected by the pain. 3. The PQRST method is a useful way for nurses to assess pain. The PQRST method consists of: - P: Precipitation: What precipitated the pain symptoms? - Q: Quality: What is the quality of the pain? Is it dull, sharp, deep, superficial, burning, aching, or stabbing? - R: Region: Where is the pain? What region or area is painful? - S: Severity and Symptoms: What is the intensity of the pain on a scale of 1 to 10 with 1 being minimal pain and 10 as the most intense pain? - T: Triggers and Timing: What triggers and starts your pain? When did the pain begin? 4. Assess client needs for pain management. 5. Recognize differences in client perception and response to pain. 6. Apply knowledge of pathophysiology to non-pharmacological comfort/palliative care interventions. 7. Incorporate deep breathing technique into client plan of care. 8. Counsel client regarding deep breathing technique. 9. Respect client palliative care choices. 10. Plan measures to provide comfort interventions to clients with anticipated or actual impaired comfort. 11.Provide non-pharmacological comfort measures. Collaborative care management Nursing management of the patient experiencing pain: 1- Assessment:  Pain  Health history: collect data by asking about the previously experienced pain. Assess subjective and objective data at least once a shift. Subjective data: Pain is a subjective experience so it is important for the nurse to obtain accurate information from the patient concerning the pain including: Characteristics and description of pain: To evaluate the characteristics of pain use the mnemonic PQRST: P: Provoking factors: what makes the pain worse or relieves it. Q: Quality: dull, sharp, crushing. R: Region or radiation: site and radiation to other areas S: severity or intensity T: Time: onset, duration, frequency and cause.–Ask the patient if medications are taken for relieving the pain and determine the name, dose, frequency, and the effect of the drug. Objective data: by observing the patient by the nurse. A—Physiologic Signs - Pulse: increased rate. - Respiration: increased depth and frequency. - Blood Pressure: increased systolic and diastolic - Diaphoresis, Pallor. - Dilated pupils. - Muscle tension. (Face, body) - Nausea and vomiting (if pain is severe. B-Behavioral Signs: - Rigid body position. - Restlessness. - Clenched teeth and fists. - Crying and Frowning  Pain Use the numeric rating scale of pain (0 to 10 scale where 0 is no pain and 10 is the worst possible pain). Guidelines for Using Pain Assessment Scales  Using a written scale to assess pain may not be possible if a person is seriously ill, is in severe pain, or has just returned from surgery. In these cases, the nurse can ask the patient, “On a scale of 0 to 10, 0 being no pain and 10 being a pain as bad as it can be, how bad is your pain now?” For patients who have difficulty with a 0 to 10 scale, a 0 to 5 scale may be tried.  Whichever scale is used, it should be used consistently. Most patients usually can respond without difficulty. Ideally, the nurse teaches the patient how to use the pain scale before the pain occurs (e.g., Before surgery). The patient's numerical rating is documented and used to assess the effectiveness of pain relief interventions.  Physical Examination: examine the patient's appearance, facial expressions, vital signs, skin moisture and color, verbal responses. 2- Nursing diagnosis: Acute pain related to muscle spasm as manifested by patient complain& facial expression. - The expected outcome for the patient is: patient will state pain intensity as mild or less. 3- Nursing planning: set priorities based on the client's level of pain and its effect on the client's condition. 4- Nursing intervention: - pain management by pharmacological and non pharmacological pain relief interventions. - Placebos: are sugar pills with no active ingredient but they can produce positive or negative responses in patients who take them. - The use of placebos to treat pain is discouraged and considered unethical and deceitful by many professional organizations.  Pain - Reassure patient that you know the pain is real and will assist him or her in dealing with it. - Use pain assessment scale to identify the intensity of pain. - Assess and record pain and its characteristics: location, quality, frequency, and duration. - Administer balanced analgesics as prescribed to promote optimal pain relief. - Re administers pain assessment scale. - Document severity of patient's pain on chart. - Obtain additional prescriptions as needed. - Identify and encourage patients to use strategies that have been successful with previous pain. - Teach patient additional strategies to relieve pain and discomfort: distraction, relaxation, cutaneous stimulation, etc. - Instruct patient and family about potential side effects of analgesics and their prevention and management 5. Evaluation: the nurse evaluates psychological as well as physiological responses to pain.  Pain Reference 1. Patterson, M., Shelda L. & Falk,K (2023). Pain: Assessment and Management 2. Deborah Dowell, MD, MPH (2021). Draft Updated CDC Guideline for Prescribing Opioids: Background, Overview, and Progress 3. The Royal College of Emergency Medicine ( 2021). Management of Pain in Adults, Best Practice Guideline 4. Ackley, B. , J. , Ladwig, G. , B. , & Makic, M. , B. , F. (2016). Nursing Diagnosis Handbook-E-Book: An Evidence-Based Guide to Planning Care, 11th edition chapter (4)640-643. 5. Brunner & Suddarth’s (2020). textbook of medical-surgical nursing. — 14th ed, Elsevier. 6. Berman, T., Snyder, S. , & Fredsen, G. (2016). Kozier&Erabs, fundamental of nursing text book, 10 Ed England, Julie Levin Alexander, p 1656. 7. Ellison, D. , L. (2017). Physiology of Pain, Critical care nursing clinics of North America, 29(4) 397-406. 8. Mary E. Lynch MD, FRCPC, Kenneth D. Craig, FCAHS, Philip W. Peng MBBS, (2022). Clinical Pain Management: A Practical Guide. Print ISBN: 9781119701156 |Online ISBN:9781119701170 |DOI:10.1002/9781119701170 Important links: https://youtu.be/8QHjx6hMcLY https://youtu.be/MH5UxisYm9I https://youtu.be/psDx1V-gllA https://youtu.be/f1-mHcC2404 https://www.webmd.com/pain-management/video/josh-sackman https://health.mil/News/Gallery/Videos/2022/10/04/Pain -Management- Options https://www.health.mil/News/Gallery/Videos/2022/09/12/Essentials - of-Quality-Pain-Care