Pain and Pain Management HLT54121 PDF

HLTENN040 • Administer and monitor medicines and Intravenous Therapy • HLT54121 Christine Prendergast HLT54121 DIPLOMA OF NURSING HLT54121 DIPLOMA OF NURSING Acknowledgement of Country We respectfully acknowledge the Wurundjeri People of the Kulin Nation, who are the Traditional Owners of the l...

HLTENN040 • Administer and monitor medicines and Intravenous Therapy • HLT54121 Christine Prendergast HLT54121 DIPLOMA OF NURSING HLT54121 DIPLOMA OF NURSING Acknowledgement of Country We respectfully acknowledge the Wurundjeri People of the Kulin Nation, who are the Traditional Owners of the land on which Swinburne’s Australian campuses are located in Melbourne’s east and outer-east, and pay our respect to their Elders past, present and emerging. We are honoured to recognise our connection to Wurundjeri Country, history, culture, and spirituality through these locations, and strive to ensure that we operate in a manner that respects and honours the Elders and Ancestors of these lands. We also respectfully acknowledge Swinburne’s Aboriginal and Torres Strait Islander staff, students, alumni, partners and visitors. We also acknowledge and respect the Traditional Owners of lands across Australia, their Elders, Ancestors, cultures, and heritage, and recognise the continuing sovereignties of all Aboriginal and Torres Strait Islander Nations. HLT54121 DIPLOMA OF NURSING What is Pain? • Pain is a Symptom • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage • Pain is something we experience • Pain has an intensity and a character HLT54121 DIPLOMA OF NURSING Classification of pain Somatic pain Referred to as musculo-skeletal pain and comes from: skin, musclejoints, bones and ligaments Is usually sharp and well localised Can be reproduced by touching or moving the area involved HLT54121 DIPLOMA OF NURSING Classification of pain Non centralised pain Neuropathic may be due to nerve degeneration, nerve pressure, nerve inflammation, nerve infection Sympathetic - occurs more commonly after fractures and soft tissue injuries of the arms and legs Due to an over activity of SNS, CNS, PNS mechanisms HLT54121 DIPLOMA OF NURSING Descriptions of pain HLT54121 DIPLOMA OF NURSING Mechanism of pain 1. Stimulation of pain receptors • Injury causes the release of various chemicals by the damaged cells • Chemicals released include histamine, serotonin (5HT), bradykinin and prostaglandins. • These chemicals are part of the inflammatory process • Pain receptors are stimulated by these chemicals released during the injury HLT54121 DIPLOMA OF NURSING Mechanism of pain 2. Generation of pain signals • Pain signals are generated by the pain receptors • The signals are transmitted via the sensory nerves to the spinal cord (dorsal root ganglion). HLT54121 DIPLOMA OF NURSING Mechanism of pain 3. Processing of pain signal The pain impulses are processed A physical response is made (withdrawing your hand from a flame) This is an automatic reflex that does not involve the brain or conscious thought. HLT54121 DIPLOMA OF NURSING Mechanism of pain 4. Physiologic response to pain Further processing occurs in the thalamus (brain) with signals being sent to areas controlling blood pressure, heart rate, breathing, and emotions. An acute pain event often causes a rise in HR, BP, and RR, as well as a change in emotions and behaviour e.g. shouting "ouch", contorted facial expressions, etc https://www.youtube.com/watch?v=uOaiaYDoUnA&t=73s HLT54121 DIPLOMA OF NURSING Nursing Role in Pain management •Assessment of the pain •Relief by pharmacological and/or non pharmacological means •Support •Education In assessing your patient’s pain: What signs would be observable? What questions would be relevant? HLT54121 DIPLOMA OF NURSING Factors affecting perception of pain • • Age (ability to express yourself) Gender (stereotypes) • • Culture Emotional state (exhaustion decreases tolerance) • • Environment Self image (self perception – by others) • • Time of day (night increases pain) Previous experience HLT54121 DIPLOMA OF NURSING Clinical signs of pain Symptoms of pain may include: •Guarding •Narrowed focus, altered time perception, withdrawal from social contact •Vocalization such as moaning, crying •Restlessness, pacing, limping •Facial mask of pain, grimacing etc. •Increase in HR, BP Clinical signs may be absent in a patient suffering chronic pain ! HLT54121 DIPLOMA OF NURSING Pain Assessment •Location •Intensity •Verbal description of symptoms •Physical signs •Acute, chronic causes •Psychological – anxiety etc •Pain relief measures used •Impact on pt, family, social and work •Impact on quality of life HLT54121 DIPLOMA OF NURSING Pain Intervention Pharmacological: •Opioid/Opiates •Non opioid •Patient Controlled Analgesia •Epidurals •Nerve blocks HLT54121 DIPLOMA OF NURSING Pain Intervention Non pharmacological •Tens machines •Acupuncture •Heat/cold packs •Massage •Exercise •Rest, elevation HLT54121 DIPLOMA OF NURSING Complementary Therapies Passive Modalities Acupuncture Acupressure Hypnosis Massage PT/OT Heat/Cold TENS Active Modalities • Relaxation techniques • Biofeedback • Deep Breathing • Guided imagery • Distraction • Visualization HLT54121 DIPLOMA OF NURSING Pain Scoring Tools Pain measurement tools are specific to the individual and should not be used to compare patients •Verbal numerical scale (number 0-10) •PQRST (provocative, quantity, region, severity, timing) •Visual analogue scale (0-10) •Pain indicator & Assessment Chart (PINDA) •Wong- Baker pain scale •The Abbey Pain Scale (dementia pts) HLT54121 DIPLOMA OF NURSING Pain Scoring Tools Explain to the person that each face represents a person who has no pain (hurt), or some, or a lot of pain. Face 0 doesn’t hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little bit more. Face 6 hurts even more. Face 8 hurt a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain. Ask the person to choose the face that best depicts the pain they are experiencing. HLT54121 DIPLOMA OF NURSING Pain Scoring Tools PQRST P = Palliating or Provoking factors Q = Quality = Is the pain dull, sharp, or throbbing R = Radiate = Does the pain radiate to anywhere S = Strength/Score = Score pain between 0 and 10. T = Time = How long have you had the pain HLT54121 DIPLOMA OF NURSING Pain Management Pain can be poorly managed because: •Nurses or patients may expect a reasonable amount of pain should be tolerable. •Health beliefs, attitudes, knowledge and/or skill are different from one nurse to another •There are discrepancies between patient self scoring versus their body language •No allowances for cultural/gender/ethnicity HLT54121 DIPLOMA OF NURSING Pain Management Pain can be poorly managed because: •Poor nursing prioritization i.e. dressings, obs, ADL’s •Patients do not like to pester “over-worked” nurses •Poor prescribing by medical staff •Inadequate communication between nursing staff and or nursing staff and patients / nursing staff and doctors •Regular administration times are not adhered to leading to a chronic pain cycle •A nurse/doctor does not believe what the patient says – (avoid value judgments) •REMEMBER- PAIN IS SUBJECTIVE HLT54121 DIPLOMA OF NURSING NSAID- Non Steroidal Antiinflammatory Drugs Widely used as analgesia in osteoarthritis, joint, ligament & muscle disease & trauma • Cox 1 and 2 inhibitors • Salicylates Mechanism of action: • Suppress formation of prostaglandins (prostaglandins cause pain, inflammation and swelling) HLT54121 DIPLOMA OF NURSING NSAID- Non Steroidal Anti-inflammatory Drugs (Cox Inhibitor medication) COX enzymes cause pain and inflammation in response to prostaglandin release • • • Prostaglandin release results in inflammation Prostaglandins enhance the action of histamine Prostaglandins enhance the transmission of pain COX inhibitor medications block the action of this enzyme to prevent pain, swelling, inflammation HLT54121 DIPLOMA OF NURSING Adverse effects • GIT irritation – nausea, dyspepsia, GI ulceration or bleeding • Salt and fluid retention • Raised liver enzymes • Hypertension • Topical – skin irritation erythema, itching, rash Toxicity is related to dose & duration of treatment NSAIDs- GI considerations http://www.youtube.com/watch?v=KWEYCJIyUEI NSAIDs and renal function http://www.youtube.com/watch?v=6rKLesy4 AYA HLT54121 DIPLOMA OF NURSING Non-selective --> most adverse effects COX 1 inhibitors – Ibuprofen (Nurofen) Naproxen (Naprosyn) Diclofenac (Voltaren) Indomethacin (Indocid) Selective --> less adverse effects COX 2 inhibitors– Celecoxib, Meloxicam Parecozib HLT54121 DIPLOMA OF NURSING Nursing considerations • • • • • About 60% patients will respond to NSAID- good for somatic pain NSAID’s may be used with paracetamol or an opioid Low dose aspirin use can be continued Observe and report any swollen ankles, difficulty in breathing, black stools or dark coffee colored vomit Measure FBE, renal and liver function prior to treatment starting due to liver metabolism and renal excretion • Many should be administered with food to prevent gastric irritation HLT54121 DIPLOMA OF NURSING Acetylsalicylic Acid (Aspirin preparations) Oral, rapidly absorbed Actions: •Antipyretic •Analgesic •Anti-inflammatory •Anti-platelet effects- stops platelets sticking together HLT54121 DIPLOMA OF NURSING Gastric irritation & ulceration Anaemia (with long term use) Drug interactions- do not give to patients on warfarin Contraindicated in younger teenagers and children due to incidence of Reye’s syndrome where aspirin causes a rise in body temperature instead of decrease • Avoid use in gout due to ↑ excretion of uric acid • Renal damage with long term use • Can cause tinnitus/ringing in ears/deafness with long term use • • • • HLT54121 DIPLOMA OF NURSING Action •Analgesic, •Anti-pyretic, •Minimal anti-inflammatory effect •Very common over the counter medication for treatment of headache, somatic pain, fever Adverse effects • Low therapeutic index – risk of over dosage. Maximum of 4g per day in adults • Liver failure if overdose occurs HLT54121 DIPLOMA OF NURSING Preferred pain relief in children as does not cause Reye’s Syndrome Can give concurrently with an NSAID e.g Ibuprofen and Paracetamol as different mechanism of action Mechanism of action of paracetamol not clearly understood Beware: other analgesia may contain paracetamol so ensure you don’t ‘double up’ e.g Digesic, Capadex, Mersyndol, etc. HLT54121 DIPLOMA OF NURSING References Bullock, S. & Manias, E. (2011). Fundamentals of Pharmacology (6th ed). Frenchs Forest, Australia: Pearson Education Australia. Bryant, B. & Knights, K. (2011). Pharmacology for Health Professionals (3rd ed). Chatswood, Australia: Elsevier. Koutoukidis, G., Stainton, K & Hughson, J. (2013) Tabbner’s Nursing Care Theory and Practice (6th ed). Sydney, Australia: Elsevier. McKenna, L. (2013). Pharmacology. Sydney: Lippncott Williams & Wilkins. Tiziani, A. (2010) Havards Nursing Guide to Drugs 8th Ed. Elsevier, Marrickville