Pain Management Nursing Concepts PDF

PAIN MANAGEMENT NURSING Jason D. Cristobal, MAN, RN JASON D. CRISTOBAL RN,MAN 1 JASON D. CRISTOBAL RN,MAN 2  DEFINITION OF PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage. JASON D. CRISTOBAL RN,MAN 3   Sub...

PAIN MANAGEMENT NURSING Jason D. Cristobal, MAN, RN JASON D. CRISTOBAL RN,MAN 1 JASON D. CRISTOBAL RN,MAN 2  DEFINITION OF PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage. JASON D. CRISTOBAL RN,MAN 3   Subjective  5th vital sign  It exists whenever the patient say it does. “ All pain is real ” regardless of its cause even when the cause remains unknown ( Cardinal Rule ) JASON D. CRISTOBAL RN,MAN 4  CENTRAL NERVOUS SYSTEM (Brain and spinal cord) PERIPHERAL NERVOUS SYSTEM (Cranial and spinal nerves) SENSORY MOTOR (AFFERENT) (EFFERENT) SOMATIC AUTONOMIC SENSE (Involuntary) (Voluntary) ORGANS Cardiac & smooth Skeletal muscles muscle PARASYMPATHETIC SYMPATHETIC 5  TYPES OF PAIN Acute Pain Chronic Pain Cancer - Related Pain JASON D. CRISTOBAL RN,MAN 6  Acute pain Injury – pain(split second to 6 mos.) ,subsides as healing occurs JASON D. CRISTOBAL RN,MAN 7  Acute pain REPORTED TREATMENT NEEDED - crying - rubbing area - holding area - focusing on the pain - guarding the painful part HR, RR, BP Diaphoresis Dilated pupils JASON D. CRISTOBAL RN,MAN 8  Chronic pain Persists long after injury has healed.  lasts 6 months or longer  pain often absent and is reported unless asked JASON D. CRISTOBAL RN,MAN 9  COMPARISON ACUTE PAIN CHRONIC PAIN Client’s appearance: Client’s appearance: Anxious ----------------- → Depressed Appears restless -------- → Fatigue Appetite is decreased -- → Irritable his weight changes Mobility is decreased -- → Social withdrawn JASON D. CRISTOBAL RN,MAN 10 Quality of Life Activities Affected by Chronic pain Concentrating Having sex Exercising Sleeping Socializing JASON D. CRISTOBAL RN,MAN 11 Quality of Life Activities Affected by Chronic pain Walking Working around the house Working a full day at employment Enjoying hobbies and leisure time Caring for children Maintaining relationships with family and friends JASON D. CRISTOBAL RN,MAN 12  TYPES OF PAIN Cancer Pain – pain associated with cancer and its treatment which may be acute or chronic. Breast cancer can cause changes in skin cells that lead to feelings of pain, tenderness, and discomfort in the breast. JASON D. CRISTOBAL RN,MAN 13 JASON D. CRISTOBAL RN,MAN 14  CATEGORIES OF PAIN IN TERMS OF LOCATION: VISCERAL PAIN REFERRED PAIN JASON D. CRISTOBAL RN,MAN 15  IN TERMS OF LOCATION: 1.Visceral Pain - arises from internal organs that are diseased or injured. ISCHEMIA JASON D. CRISTOBAL RN,MAN 16 Visceral Pain  Compression of an organ (tumor) JASON D. CRISTOBAL RN,MAN 17 Intestinal distension with gas (obstructed bowel) JASON D. CRISTOBAL RN,MAN 18 Visceral Pain  Contraction (spasm) like in gallbladder or kidney stones, or muscle spasms. SPASM JASON D. CRISTOBAL RN,MAN 19  IN TERMS OF LOCATION: 2.Referred Pain (pain radiates) JASON D. CRISTOBAL RN,MAN 20  CATEGORIES OF PAIN IN TERMS OF ETIOLOGY PHYSIOLOGICAL PAIN 1.Somatic pain- skin, muscles, bones a. Superficial (Cutaneous) pain b. Deeper somatic pain 2. Visceral pain NEUROPATHIC PAIN 1.Peripheral Neuropathic pain 2. Central Neuropathic pain 3. Sympathetically maintained pain JASON D. CRISTOBAL RN,MAN 21  SOMATIC PAIN a. Superficial somatic pain (cutaneous pain) is perceived as sharp or burning pain Example: insect bite a paper cut in the finger JASON D. CRISTOBAL RN,MAN 22  SOMATIC PAIN b. Deeper somatic pain – sharp, throbbing and intense Example: an ankle sprain a fracture arthritis JASON D. CRISTOBAL RN,MAN 23  PHYSIOLOGICAL PAIN b. Visceral Pain - results from activation of pain receptors in the organs and/or hollow viscera. JASON D. CRISTOBAL RN,MAN 24 Neuropathic Pain- damage or malfunctioning nerves. Peripheral Neuropathic pain JASON D. CRISTOBAL RN,MAN 25 b. Phantom pain - Phantom Limb Pain (PLP) - 60 to 80% individuals experienced PLP - breast amputation - extraction of a tooth (phantom tooth pain) - eye removal (phantom eye syndrome) JASON D. CRISTOBAL RN,MAN 26 Neuropathic Pain- INFLATED Medical transcriptionist is an inflammatory disorder (repetitive stress, physical injury) Pianist JASON D. CRISTOBAL RN,MAN 27 CARPAL TUNNEL SYNDROME Secretary Computer programmer JASON D. CRISTOBAL RN,MAN 28  CARPAL TUNNEL SYNDROME S/S- pain,numbness, paresthesia and weakness of the median nerve. Assessment: Phalen’s Test- hold the wrist in acute flexion for 60 seconds - Numbness and burning in the fingers(+) JASON D. CRISTOBAL RN,MAN 29  CARPAL TUNNEL SYNDROME TINEL’S TEST Pain, numbness and tingling when percussing lightly over the median nerve is positive for CTS JASON D. CRISTOBAL RN,MAN 30 SURGERY JASON D. CRISTOBAL RN,MAN 31  NEUROPATHIC PAIN 2. Central Neurophatic Pain- results from malfunctioning nerves in the CNS. Examples: a. Spinal cord injury pain b. Post stroke pain c. Multiple sclerosis pain 32 SPINAL CORD INJURY PAIN JASON D. CRISTOBAL RN,MAN 33  POST STROKE PAIN Local Pain Local (mechanical)pain is usually felt in the joints. ex,. Shoulder pain Central Pain Central post-stroke pain (CPSP) is described as constant, moderate, or severe pain caused by damage to the brain. JASON D. CRISTOBAL RN,MAN 34 Nerve pain (neuropathic pain) which is caused by damage to the nerves in the brain and spinal cord. This includes altered sensations such as pins and needles, numbness, crawling or burning feelings. Musculoskeletal (nociceptive) pain which is caused by damage to muscles, tendons, ligaments and soft tissue JASON D. CRISTOBAL RN,MAN 35 3. Sympathetically maintained pain- inflammatory reaction (neurotransmitters)  sensitization of other pain fibers  vasodilation and edema JASON D. CRISTOBAL RN,MAN 36 JASON D. CRISTOBAL RN,MAN 37 GATE CONTROL THEORY JASON D. CRISTOBAL RN,MAN 38  CONDITIONS THAT OPEN OR CLOSE THE GATE CONDITIONS THAT OPEN CONDITIONS THAT CLOSE THE GATE THE GATE PHYSICAL EXTENT OF THE INJURY MEDICATION CONDITIONS INAPPROPRIATE ACTIVITY COUNTER STIMULATION, E.G. LEVEL MASSAGE EMOTIONAL ANXIETY OR WORRY POSITIVE EMOTIONS CONDITIONS TENSION RELAXATION DEPRESSION REST MENTAL INTENSE CONCENTRATION FOCUSING ON THE PAIN CONDITIONS OR DISTRACTION INVOLVEMENT AND BOREDOM INTEREST IN LIFE ACTIVITIES JASON D. CRISTOBAL RN,MAN 39 PHASES OF PAIN TRANSMISSION A fibers – small myelinated A delta fibers – fast pain (0.1 sec.) sharp,pricking,electrical pain C fibers – large unmyelinated second pain – slowly, burning, aching, throbbing pain JASON D. CRISTOBAL RN,MAN 40  Injury - Mechanical,Thermal,Chemical Local anesthesia JASON D. CRISTOBAL RN,MAN 41 PHASES OF PAIN TRANSMISSION Activates the pain JASON D. CRISTOBAL RN,MAN 42 Pain control can be made: Example- opioids (narcotic analgesics)- block the release of neurotransmitters, particularly Substance P, which stops the pain at the spinal level. JASON D. CRISTOBAL RN,MAN 43 PHASES OF PAIN TRANSMISSION JASON D. CRISTOBAL RN,MAN 44  PHYSIOLOGY OF PAIN Nerve fibers Stimuli A-delta & C-fibers (nociceptors) Cerebral cortex Thalamus Spinal cord (center for (center for (substantia interpretation of awareness of pain) Gelatinosa) pain) Pain threshold Response Pain tolerance JASON D. CRISTOBAL RN,MAN 45 PHASES OF PAIN TRANSMISSION JASON D. CRISTOBAL RN,MAN 46 HUMOR-↑endogenous opiods (ENDORPHINS) 47 JASON D. CRISTOBAL RN,MAN 48  ENDOGENOUS OPIODS B. Other endogenous opiods: - serotonin ("mood neurotransmitter) - maintains the "happy feeling".It calms anxiety, relieves feelings of depression and helps us to have a good night's sleep - epinephrine - it rapidly prepares the body for action in emergency situations JASON D. CRISTOBAL RN,MAN 49  COGNITIVE PROCESSES- may stimulate endorphin production in the descending control system. Massage, Distraction (TV & visitors) and placebo- increases the activity in the descending system. JASON D. CRISTOBAL RN,MAN 50 GATE CONTROL THEORY JASON D. CRISTOBAL RN,MAN 51  CONCEPTS ASSOCIATED WITH PAIN Hyperalgesia - excessive sensitivity to pain Intractable Pain – is pain that is highly resistant to relief or cure. JASON D. CRISTOBAL RN,MAN 52  INTRACTABLE PAIN Examples: pain from trigeminal neuralgia, cervical cancer JASON D. CRISTOBAL RN,MAN 53  CONCEPTS ASSOCIATED WITH PAIN Psychogenic Pain – is primarily due to emotional factors, with no physiologic basis. Neuropathic pain -pain that is related to damage or malfunctioning nervous tissue in the peripheral and/or CNS JASON D. CRISTOBAL RN,MAN 54  HERNIATED INTERVERTEBRAL DISK A.k.a.- slipped or ruptured disc condition in which the central part of the intervertebral disc protrudes into the spinal canal Compression of spinal nerve roots JASON D. CRISTOBAL,RN,MAN JASON D. CRISTOBAL RN,MAN 56 JASON D. CRISTOBAL RN,MAN 57  HERNIATED INTERVERTEBRAL DISK Causes: Lifting from a bent over position JASON D. CRISTOBAL,RN,MAN Causes: Degeneration and dehydration of cartilage with degenerative joint disease Cumulative effects of years of wear and tear JASON D. CRISTOBAL,RN,MAN Causes: Falls and motor vehicle accidents are less common causes JASON D. CRISTOBAL,RN,MAN  FACTORS INFLUENCING PAIN 1. Past pain experience – previous pain experience alter a client’s sensitivity to pain. JASON D. CRISTOBAL RN,MAN 61  FACTORS INFLUENCING PAIN 2. Anxiety and Depression Anxiety - concerns and fears about the underlying disease Depression - chronic pain and unrelieved cancer pain. JASON D. CRISTOBAL RN,MAN 62  FACTORS INFLUENCING PAIN 2. Anxiety and Depression JASON D. CRISTOBAL RN,MAN 63 JASON D. CRISTOBAL RN,MAN 64 FACTORS INFLUENCING PAIN 3. Meaning of Pain- accept pain (circumstances and interpretation of its significance) Positive outcome - may withstand the pain amazingly well. Example: Giving birth to a child Athlete undergoing knee surgery to prolong his career. JASON D. CRISTOBAL RN,MAN 65  FACTORS INFLUENCING PAIN 4.Ethnic and Cultural Values – beliefs about pain and how to respond to it differ from one culture to the next. Socially acceptable or unacceptable. Avoid stereotyping ,provide individualized care. JASON D. CRISTOBAL RN,MAN 66  Transcultural Differences in Responses to pain: a. Puerto Ricans - loud and spoken in their expression of pain JASON D. CRISTOBAL RN,MAN 67  Transcultural Differences in Responses to pain: b. African Americans - pain & suffering is a part of life and is to be endured. - deny or avoid dealing with pain till it becomes unbearable JASON D. CRISTOBAL RN,MAN 68  Transcultural Differences in Responses to pain: c. Mexican Americans - pain is a part of life - pain indicates seriousness of an illness. - enduring pain is a sign of strength. JASON D. CRISTOBAL RN,MAN 69. d. Asian Americans Chinese culture values silence. - Quiet when in pain → do not want to cause dishonour to themselves and their family. Japanese - stoic (minimal and nonverbal expressions) response to pain. May even refuse pain medication. Filipino - believe that pain is “ God’s will". Some elderly client may refuse pain medication. JASON D. CRISTOBAL RN,MAN 70 e. Native Americans - Quiet, less expressive, may tolerate high level of pain. - may not request pain medication - may tolerate pain until they are physically disabled. JASON D. CRISTOBAL RN,MAN 71 f.Arab Americans Pain responses:  considered private  reserve for immediate family, not with health professionals. - JASON D. CRISTOBAL RN,MAN 72 g. Italians - voicing pain is considered acceptable. JASON D. CRISTOBAL RN,MAN 73 Culturally competent :Nurses-  knowledgeable - responses to pain.  sympathetic - concerns  skills to address pain in a cultural sensitive way. JASON D. CRISTOBAL RN,MAN 74  FACTORS INFLUENCING PAIN 5. Gender – women have higher pain intensity and fear compared to men. JASON D. CRISTOBAL RN,MAN 75  FACTORS INFLUENCING PAIN 6. Placebo Effect – response to the medication /treatment because of an expectation that the treatment will work. A placebo - saline solution or a starch tablet - produces an effect similar to a prescribed drug. JASON D. CRISTOBAL RN,MAN 76  FACTORS INFLUENCING PAIN 7. Environment and Support people – - hospital, with its noises, lights and activity, can compound pain. - Lonely persons (without a support network) may perceive pain as severe JASON D. CRISTOBAL RN,MAN 77  FACTORS INFLUENCING PAIN 8.Age – older people differ from the way younger people respond.  small doses of analgesic agents may be sufficient to relieve pain  slower metabolism  a greater ratio of body fat to muscle mass JASON D. CRISTOBAL RN,MAN 78  PAIN ASSESSMENT Two Major components of pain assessment 1. Pain History 2. Direct observation of behaviours, physical signs of tissue damage and secondary physiologic responses of the client. GOAL: TO GAIN AN OBJECTIVE UNDERSTANDING OF THE SUBJECTIVE EXPERIENCE JASON D. CRISTOBAL RN,MAN 79  WHY MEASURE PAIN? For documentation Produces a baseline to assess therapeutic interventions. Facilitates communication between staff looking at the patient JASON D. CRISTOBAL RN,MAN 80 Pain Intensity Scales JASON D. CRISTOBAL RN,MAN 81 JASON D. CRISTOBAL RN,MAN 82 Faces pain scale JASON D. CRISTOBAL RN,MAN 83 JASON D. CRISTOBAL RN,MAN 84  PAIN ASSESSMENT PAIN RATING SCALE: FLACC Scale- 5 categories F – face, L –legs, A- Activity, C- cry,C-consolability - for preverbal or non verbal children from infancy to 7 years - For cognitively impaired person (ICU) JASON D. CRISTOBAL RN,MAN 85 BEHAVIORAL PAIN SCALE - FLACC Face Leg Activity Cry Consolability pain scale JASON D. CRISTOBAL RN,MAN 86  SENSORY IMPAIRED BRAILLE ALPHABET JASON D. CRISTOBAL RN,MAN 87 JASON D. CRISTOBAL RN,MAN 88 BRAILLE MOBILE PHONE JASON D. CRISTOBAL RN,MAN 89  SENSORY IMPAIRED Braille touch screen phone JASON D. CRISTOBAL RN,MAN 90 JASON D. CRISTOBAL RN,MAN 91  SENSORY IMPAIRED TRANSLATOR JASON D. CRISTOBAL RN,MAN 92 JASON D. CRISTOBAL RN,MAN 93  TIMING LOCATION PERSONAL MEANING AGGRAVATING FACTORS ALLEVIATING FACTORS JASON D. CRISTOBAL RN,MAN 94 PAIN BEHAVIORS JASON D. CRISTOBAL RN,MAN 95 PAIN MANAGEMENT JASON D. CRISTOBAL RN,MAN 96 NON-PHARMACOLOGIC INTERVENTIONS JASON D. CRISTOBAL RN,MAN 97  SLEEP Rest increases pain tolerance and improves response to analgesia Keep sleep interruptions to a minimum JASON D. CRISTOBAL RN,MAN 98 CUTANEOUS STIMULATION AND MASSAGE JASON D. CRISTOBAL RN,MAN 99  THERMAL THERAPY Stimulate the non-pain receptors in the same receptor field as the injury. 1. Ice therapy 2. Heat therapy As a general rule, apply ice - new injuries heat - older, long-standing problems JASON D. CRISTOBAL RN,MAN 100  Ice therapy placed in the injury site immediately after injury or surgery. reduces localized swelling through vasoconstriction JASON D. CRISTOBAL RN,MAN 101  Ice Therapy Assess the skin before ice application. Avoid - compromised circulation. Apply - no longer than 15 to 20 min at a time - no more frequent than once an hour. Nerve injury and frost bite may result when used longer. JASON D. CRISTOBAL RN,MAN 102 FROSTBITE Prolonged exposure to cold. Damage to the blood vessels May necessitate amputation of the affected area. 103  Heat therapy Soothing and promotes vasodilation of the area Increases the blood flow to an area and helps reduce pain by speeding healing. JASON D. CRISTOBAL RN,MAN 104  Heat therapy  compress and packs - used in 15 to 20 min.  always check temp before application Not used in areas:  with impaired circulation  with impaired sensation  painful area that is the site of acute untreated infection JASON D. CRISTOBAL RN,MAN 105  Transcutaneous Electrical Nerve Stimulation (TENS) Acute pain (e.g. post-op pain) Chronic pain (e.g. chronic low back pain) Battery operated Electrodes applied to the skin Client can adjust both voltage and pulsation JASON D. CRISTOBAL RN,MAN 106  TENS Mechanism based on GATE CONTROL THEORY: Electric signals: - block pain signals before they reach the brain. JASON D. CRISTOBAL RN,MAN 107  TENS Nursing Responsibilities: Do not place electrodes over  Broken skin - hemorrhage  Incision site - hemorrhage  Carotid sinus – cardiac problems  Eyes – increase intraocular pressure  Pharyngeal or laryngeal muscles – laryngeal spasm  Uterus of pregnant women – uterine contraction  Skin with diminished sensation – skin irritation Do not use in client with cardiac pacemaker. JASON D. CRISTOBAL RN,MAN 108  TENS Check for redness (more than 30 minutes) - reposition JASON D. CRISTOBAL RN,MAN 109  DISTRACTION Any activity that takes a person attention away from the pain JASON D. CRISTOBAL RN,MAN 110  TYPES OF DISTRACTION VISUAL- Watching a basketball game or a boxing match JASON D. CRISTOBAL RN,MAN 111 TYPES OF DISTRACTION Visual JASON D. CRISTOBAL RN,MAN 112  TYPES OF DISTRACTION Visual Reading Watching TV/playing their favorite DVD JASON D. CRISTOBAL RN,MAN 113 Auditory - Listening to music JASON D. CRISTOBAL RN,MAN 114  HUMOR JASON D. CRISTOBAL RN,MAN 115  TYPES OF DISTRACTION TACTILE Massage Holding or stroking a pet or toy JASON D. CRISTOBAL RN,MAN 116  TYPES OF DISTRACTION Intellectual  Hobbies -story writing  Hobbies (writing a story) Card games  Crossword puzzles LLECTUAL Sudoku  Scrabble Crossword puzzles  Word factory Card games  Chess Hobbies (writing a JASON D. CRISTOBAL RN,MAN 117  TYPES OF DISTRACTION Other examples: Visits from family and friends Involve the toddler /preschooler in blowing bubbles as a way of “blowing away the pain”. JASON D. CRISTOBAL RN,MAN 118  Relaxation Techniques a.k.a “tension release” Conscious relaxation of muscle groups. Abdominal breathing at a slow, rhythmic rate. JASON D. CRISTOBAL RN,MAN 119  Guided imagery  It is a combination of slow, rhythmic breathing with a mental image of relaxation and comfort. FAVORITE VACATION SETTING JASON D. CRISTOBAL RN,MAN 120  HYPNOSIS During hypnosis, your body relaxes and your thoughts become more focused. It lowers blood pressure and heart rate, and changes certain types of brain wave activity. JASON D. CRISTOBAL RN,MAN 121  Music therapy Music Therapy – reduces pain and anxiety JASON D. CRISTOBAL RN,MAN 122  AROMATHERAPY means "treatment using scents". Essential oils - added to the bath or massaged into the skin, inhaled directly or diffused to scent an entire room.  alleviate tension and fatigue  invigorate the entire body JASON D. CRISTOBAL RN,MAN 123  Reflexology/massage Thai Massage (lazy man's yoga) - incorporates stretching and smooth flowing massage strokes to stimulate circulation and flexibility JASON D. CRISTOBAL RN,MAN 124  ACUPRESSURE Finger pressure is applied on different 'pressure points' on the body, stimulating the corresponding glands of the body. JASON D. CRISTOBAL RN,MAN 125 Seated Acupressure Massage is based on a traditional form of Japanese massage call "ANMA", which means press and rub. It works on the muscular, circulation and nervous systems, stimulating over 60 specific pressure points on the head, neck, shoulders, back and arms JASON D. CRISTOBAL RN,MAN 126  ACUPRESSURE JASON D. CRISTOBAL RN,MAN 127  ACUPRESSURE JASON D. CRISTOBAL RN,MAN 128  Acupuncture A Chinese technique of pain control by insertion of fine needles at specific points on the body. Needle insertion activates production of endorphins. JASON D. CRISTOBAL RN,MAN 129  Biofeedback Uses a machine that uses electrodes attached to the skin to measure the degree of muscular tension JASON D. CRISTOBAL RN,MAN 130 JASON D. CRISTOBAL RN,MAN 131  Biofeedback The machine has color lights that change (red to yellow to green) – VISUAL DISPLAY Audible tone that change from high pitch to lower as the patient relaxes – AUDITORY DISPLAY JASON D. CRISTOBAL RN,MAN 132 Magnetic therapy Magnetic device when placed on or near the body to relieve pain and facilitate healing. JASON D. CRISTOBAL RN,MAN 133 PHARMACOLOGIC INTERVENTIONS JASON D. CRISTOBAL RN,MAN 134 ANESTHETIC AGENTS JASON D. CRISTOBAL RN,MAN 135  Regional anesthesia Depresses superficial nerves and interfere with the conduction of pain impulses from certain area or region. The patient remains conscious. JASON D. CRISTOBAL RN,MAN 136  Topical application Direct application  mucosal membrane  serous surface  open wound. It blocks the peripheral nerves JASON D. CRISTOBAL RN,MAN 137  Topical anesthesia Uses: Respiratory passages - eliminates laryngeal reflexes and cough. Technique : spray, instillation- cream, jelly, eye drop Examples : Xylocaine, Pontocaine, EMLA- emulsion of local anesthetics- lumbar puncture/ IV insertion, preprocedure (applied 60-90 min ) 138 Simple local infiltration – the agent is injected into the tissue Around the incisional area. Example: Xylocaine 1-2% JASON D. CRISTOBAL RN,MAN 139 Intraspinal Narcotic Infusion:  Uses narcotics or local anesthetic agents for relief of acute or chronic pain.  Catheter placed in the subarachnoid (intrathecal) or epidural space in the thoracic or lumbar area – infuse medications JASON D. CRISTOBAL RN,MAN 140 EPIDURAL ANESTHESIA Respiratory depression generally peaks 6 -12 hours after epidural administration of opioids JASON D. CRISTOBAL RN,MAN 141  Implantable infusion device or pump Implantable drug delivery systems deliver an active drug to a target organ or body compartment for prolonged periods of time. The pump is surgically implanted underneath the skin, operates by battery, and connects to a tube or catheter that is placed in the appropriate body area. Morphine pump implantation is a surgical procedure performed to permanently implant a pump that delivers morphine to Refill every the spinal fluid to treat chronic pain. 1-2 mos JASON D. CRISTOBAL RN,MAN 142 JASON D. CRISTOBAL RN,MAN 143 Intrathecal Pump Implant (“Spinal Pain Pump”) The medication contained within the pump will last about 1 to 6 months depending upon the concentration and amount infused JASON D. CRISTOBAL RN,MAN 144  DepoDur - is a morphine sulfate It is a one-time injection (during or shortly after surgery) that maintains a therapeutically effective level of morphine in the patient's bloodstream for 48 hours. JASON D. CRISTOBAL RN,MAN 145  SPINAL ANESTHESIA injection of a local anaesthetic into the subarachnoid space, generally through a fine needle. JASON D. CRISTOBAL RN,MAN 146 JASON D. CRISTOBAL RN,MAN 147  PHARMACOLOGIC PHARMACOLOGIC INTERVENTIONS INTERVENTIONS  Anesthestetic Agents  Analgesics  Adjuvant Analgesics JASON D. CRISTOBAL RN,MAN 148 NONOPIOID ANALGESICS JASON D. CRISTOBAL RN,MAN 149  SALICYLATES ANALGESIA ANTIPYRETIC ANTI-INFLAMMATORY ANTIPLATELET – M.I. JASON D. CRISTOBAL RN,MAN 150  ACETAMINOPHEN Analgesic Antipyretic Side Effects: GI irritation, occult bleeding, tinnitus, dizziness, confusion, LIVER TOXICITY Nursing considerations:  Do not exceed the recommended dose – 4 grams daily( maximum)  Antidote- acetylcysteine ( Mucomyst)  Not used more than 5 days(child), adult(10 days)151  NSAIDs (Non-steroidal Anti- inflammatory drugs) Prevents prostaglandin synthesis. Use : Rheumatoid arthritis Osteoarthritis  Mild to moderate pain  Primary dysmenorrhoea  Fever JASON D. CRISTOBAL RN,MAN 152  NSAIDs Iburpofen,(Advil, Motrin) Naproxen(Naprosyn) Ketorolac(Toradol) COX inhibitors – OSTEOARTHRITIS Celocoxib(Celebrex) No longer available: Rofecoxib (Vioxx) Valdecoxib( Bextra) JASON D. CRISTOBAL RN,MAN 153 SIDE EFFECTS NSAIDS Allergic reaction: varies from rash to anaphylaxis. Anemia, decreased platelet aggregation, prolonged bleeding time N&V, gastritis, occult GI bleeding Renal failure with high doses Toxicity: tinnitus, visual changes, alterations in mental changes JASON D. CRISTOBAL RN,MAN 154  NSAIDs Nursing Interventions Give with food, milk, full glass of water or antacid to decrease GI irritation Check auditory and visual status periodically. Instruct client to observe for any signs of bleeding. Monitor liver and renal function test in clients JASON D. CRISTOBAL RN,MAN 155  NSAIDs Nursing interventions: Avoid use of alcohol or aspirin when taking other NSAIDs Caution client that drowsiness and dizziness may occur and may impair ability to perform mechanical tasks. JASON D. CRISTOBAL RN,MAN 156 OPIOID ANALGESICS JASON D. CRISTOBAL RN,MAN 157  Opioid analgesics  Produces analgesia by acting on the CNS receptor cell  Moderate – Severe pain, cancer pain  Can suppress respiration and coughing – acts on the respiratory and cough center in the medulla  Produces euphoria, sedation, physical dependence JASON D. CRISTOBAL RN,MAN 158  2 groups of opioids: 1. FULL AGONISTS- pure opioid drugs, that bind tightly to receptor sites producing maximum pain inhibition. USE: for mild to moderate pain, severe pain, premedication Examples: – Morphine-produce analgesia, euphoria & sedation – Codeine – analgesia, euphoria, sedation & is also an antitussive. – Meperidine(Demerol)- analgesia, euphoria, sedation.Short acting than morphine. JASON D. CRISTOBAL RN,MAN 159  Meperidine (Demerol) - preoperative and postoperative medicaton  does not decrease uterine contractions  has less depressive effect on neonatal respiration than morphine. - Duration of action: 2-3 hours JASON D. CRISTOBAL RN,MAN 160  0pioid Analgesics STARTING DOSE (milligrams) Examples Moderate Pain Severe Pain Morphine 30-60 mg(oral) 10mg (parenteral) Codeine 15-30mg(oral) 60(oral) up to 360mg/24 hrs. Demerol 50mg (oral) 300mg(oral) 75mg (parenteral) Tramadol 50 -100(oral) JASON D. CRISTOBAL RN,MAN 161 Partial agonist - have only partial efficacy Ex. Buspirone, Aripiprazole, Buprenorphine JASON D. CRISTOBAL RN,MAN 162  TYPES OF OPIOIDS 2. AGONIST- ANTAGONIST ANALGESIC  It can block other opioid analgesics when given to a patient who has been taking pure opioids (antagonist effect) Examples: 1. Nalbuphine (Nubain) 3. Pentazocine (Talwin) 2.Butorphanol (Stadol) 4.Buprenornorphine (Buprenex) JASON D. CRISTOBAL RN,MAN 163  COMMON OPIOID SIDE EFFECTS 1. Respiratory depression most serious S.E. Nursing Actions:  Use with caution especially in elderly, very ill patients, asthma and those with respiratory depression. JASON D. CRISTOBAL RN,MAN 164  Administer an opioid antagonist,such as NARCAN until respirations return to an acceptable rate.  slowly by IV route with 10ml of saline. Monitor the client and repeat the procedure as required.  If the client is receiving IV PCA, stop or slow the infusion. JASON D. CRISTOBAL RN,MAN 165  COMMON OPIOID SIDE EFFECTS 2. Nausea and Vomiting Nursing Actions:  Inform patient - Tolerance to this emetic effect generally develops after several days of opiate therapy.  Provide an antiemetic as required.  Changed the analgesic as indicated.  Adequately hydrate patient and change his position slowly. JASON D. CRISTOBAL RN,MAN 166  COMMON OPIOID SIDE EFFECTS 3. Constipation Nursing Actions:  Increase fluid intake (e.g.6-8 glasses daily).  Increase fiber and bulk- forming agents to the diet.(e.g. fresh fruits and vegetables)  Increase exercise regimen.  Administer stool softeners and if necessary provide a laxative. JASON D. CRISTOBAL RN,MAN 167 COMMON OPIOID SIDE EFFECTS 4. Pruritus Nursing Actions:  Apply cool packs, lotion, and diversional activity.  Administer an antihistamine( Benadryl).  Inform the client that tolerance also develops to pruritus. JASON D. CRISTOBAL RN,MAN 168  COMMON OPIOID SIDE EFFECTS 5. Urinary retention Nursing Actions:  May need to catheterize the patient.  Administer narcotic antagonist: Naloxone Hydrochloride (Narcan). JASON D. CRISTOBAL RN,MAN 169  COMMON OPIOID SIDE EFFECTS 6. Sedation Nursing Actions:  Inform client that tolerance usually develops over 3-5 days.  Administer a stimulant - Dexedrine or Ritalin each morning JASON D. CRISTOBAL RN,MAN 170 ADDICTION – compulsion to take the substance primarily to experience its psychic effects. TOLERANCE – need for increasing or more frequent/larger doses of the medication to achieve the initial effects of the drug. PHYSICAL DEPENDENCE – abrupt cessation of the opiod, or administration of an opioid antagonist, results in a WITHDRAWAL SYNDROME. JASON D. CRISTOBAL RN,MAN 171  Routes of administration 1. Parenteral (IM, IV or SC) - for NPO and vomiting patients - produces effects more rapidly than oral administration. - IV dose is smaller & prescribed at shorter intervals (peaks rapidly [usually within minutes]and metabolized quickly) - slow IV push (over a 5-10 min period) or by continuos infusion (PCA) - preferred parenteral route in most acute care situations 172  Routes of administration 2. Oral - if patient can tolerate medication by mouth - easy to administer and is less invasive - opioids relieve severe pain if the doses are high enough 173  Routes of administration 3. Rectal - for patient who cannot take medications by any other route - indicated for patients with bleeding problems (hemophilia), dying 4. Transdermal route - used to achieve consistent opioid serum level through absorption of the medication via the skin. - most often used in the home or hospice care settings for cancer patients Transdermal opiods - fentanyl (Duragesic) - buprenorphine (Buprenex) JASON D. CRISTOBAL RN,MAN 174  Routes of administration 5.Transmucosal route  Breakthrough pain – a sudden and temporary increase in pain occuring in a patient being managed with opioid analgesia. - Nasal sprays  butorphanol ( Stadol )  fentanyl (Duragesic)  Sufentanil (Sufenta)  Morphine – analgesia is achieved in 5 to minutes JASON D. CRISTOBAL RN,MAN 175 Patient-Controlled Analgesia (PCA) Type of intravenous pump that allows the client to administer narcotic analgesic (e.g., morphine) on demand within preset dose & frequency limits JASON D. CRISTOBAL RN,MAN 176 JASON D. CRISTOBAL RN,MAN 177  Patient-Controlled Analgesia (PCA) Goal is to achieve more constant level of analgesia as compared to prn IM injections Causes less sedation & lower risk of respiratory depression For postoperative pain management; also used for intractable pain in terminal illness. JASON D. CRISTOBAL RN,MAN 178  Nursing Interventions (PCA)  Instruct client in use of PCA pump Demonstrate how to push control button (10 – 15 min) Explain concept of client- controlled analgesia  Assess client’s level of consciousness, respiratory rate, & degree of pain relief frequently  Keep control button within client reach. “PCA by proxy” – trained family member, name must be noted in the medical order JASON D. CRISTOBAL RN,MAN 179  ADJUVANT MEDICATIONS Drugs - specific uses that can provide analgesia Anticonvulsants – nerve injury – trigeminal neuralgia Examples: Carbamazepine (Tegretol), Phenytoin (Dilantin) Antidepressants – promote normal sleeping patterns in clients with chronic pain Examples: Amytriptyline (Elavil), Doxepin (Sinequan) Local anesthetics – used for a nerve block or given via a spinal route Example: lidocaine, EMLA,Bupivacaine JASON D. CRISTOBAL RN,MAN 180  Corticosteroids – for metastatic bone cancer Examples: Dexamethasone (Decadron), Prednisone (Deltasone) Muscle Relaxants – for muscle spasms and anxiety Examples: Methocarbamol (Robaxin), Cyclobenzaprine (Flexeril) Benzodiazepines – for muscle spasm and anxiety Examples: Alprazolam (Xanax), Lorazepam (Ativan) JASON D. CRISTOBAL RN,MAN 181  Antihistamines – for nausea and anxiety Examples: Hydroxyzine ( Vistaril, Atarax) Psychostimulants – analgesic effect, cancer pain Examples: Dextroamphetamine,Methyphenidate (Ritalin) Clonidine- pain from spinal cord injury, phantom limb pain, peripheral nerve injury JASON D. CRISTOBAL RN,MAN 182 Approaches for using Analgesic agents Balance Analgesia Pro Re Nata Preventive Approach JASON D. CRISTOBAL RN,MAN 183  Balance analgesia Use of more than 1 form of analgesia concurrently to obtain more pain relief with fewer side effects. It minimizes the potentially toxic effects of any one agent To relieve a certain pain When used alone - morphine 15 mg When combined - morphine 8 mg and 30 mg of ketorolac (Toradol) JASON D. CRISTOBAL RN,MAN 184  Pro Re Nata Waits for the patient to complain of pain and then administer analgesia. Effect- it leaves the patient sedated or in pain Opioid analgesia – the serum level of opioids must be maintained at a minimum therapeutic level 185  Preventive approach to pain Analgesics - given at set intervals, to act before the pain becomes severe before the serum opioid level decreases to a subtherapeutic level. GOAL- to provide analgesia before the pain gets severe Smaller doses - pain does not escalate to a level of severe intensity. Less medication, tolerance prevented and side effects (sedation, constipation) of analgesic decreased JASON D. CRISTOBAL RN,MAN 186 Relationship of mode of delivery of analgesia to serum therapeutic level JASON D. CRISTOBAL RN,MAN 187 NEUROSURGICAL INTERVENTIONS JASON D. CRISTOBAL RN,MAN 188  Spinal cord stimulation A surgically implanted device allows the patient to apply pulsed electrical stimulation to the dorsal aspect of the spinal cord to block pain impulses. JASON D. CRISTOBAL RN,MAN 189 JASON D. CRISTOBAL RN,MAN 191  Deep brain stimulation a surgical treatment involving the implantation of a medical device called a brain pacemaker which sends electrical impulses to specific parts of the brain. JASON D. CRISTOBAL RN,MAN 192 Deep brain stimulation (DBS) is DBS in select brain regions has provided therapeutic benefits for otherwise treatment- resistant movement and affective disorders such as chronic pain, Parkinson's disease tremor and dystonia Deep brain stimulation Electrode – connected to a radiofrequency device or pulse generator system operated by external telemetry. For neuropathic pain – stroke, brain or spinal cord injuries, phantom limb pain JASON D. CRISTOBAL RN,MAN 194 Neurosurgical Procedures For Pain Control Performed for persistent intractable pain of high intensity Involves surgical destruction of nerve pathways to block transmission of pain JASON D. CRISTOBAL RN,MAN 195 JASON D. CRISTOBAL RN,MAN 196  Neurectomy Interruption of cranial or peripheral nerves by incision or injection to alleviate localized pain JASON D. CRISTOBAL RN,MAN 197 - EXTREME PAIN IN THE BACK OF THE THROAT, TONGUE AND EAR. ATTACKS OF INTENSE, ELECTRIC SHOCK-LIKE PAIN CAN OCCUR WITHOUT WARNING OR CAN BE TRIGGERED BY SWALLOWING JASON D. CRISTOBAL RN,MAN 198 JASON D. CRISTOBAL RN,MAN 199 JASON D. CRISTOBAL RN,MAN 200  Laparoscopic Presacral Neurectomy(LPSN) is the surgical removal of the presacral plexus – the group of nerves that conducts the pain signal from the uterus to the brain. Indicated for the treatment central dysmenorrheal (painful periods), adenomyosis, and endometriosis JASON D. CRISTOBAL RN,MAN 201  RHIZOTOMY is a surgical procedure to sever nerve roots in the spinal cord. Laminectomy is necessary Interruption of posterior nerve root close to the spinal cord Results in permanent loss of sensation Performed to alleviate pain of the head and neck from cancer or neuralgia. JASON D. CRISTOBAL RN,MAN 202 LAMINECTOMY RHIZOTOMY JASON D. CRISTOBAL RN,MAN 203 Rhizotomy  Trigeminal neuralgia is an inflammation of the trigeminal nerve, causing extreme pain and muscle spasms in the face. - electric shock-like facial pain can occur without warning or be triggered by touching specific areas of the face. JASON D. CRISTOBAL RN,MAN 205 JASON D. CRISTOBAL RN,MAN 206  The motor root, which controls the chewing muscles is preserved. The sensory root fibers, which transmit the pain signals to the brain, are severed JASON D. CRISTOBAL RN,MAN 207 CORDOTOMY Interruption of pain-conducting pathways with the spinal cord Laminectomy usually required. May be done by percutaneous needle insertion. Interrupts conduction of pain and temperature sense in affected parts. Done for pain felt in the legs and trunk. JASON D. CRISTOBAL RN,MAN 208 Cordotomy: severing the nerve fibers Cordotomy on one or both sides of the spinal cord that travel the express routes to the brain. Cordotomy affects the sense of temperature as well as pain, since the fibers travel together in the express route. C1-C2 cordotomy JASON D. CRISTOBAL RN,MAN 209 JASON D. CRISTOBAL RN,MAN 210 NEUROSURGICAL PROCEDURE Sympathectomy Pathways of the sympathetic division of the autonomic nervous system are severed. It eliminates vasopasm, improves peripheral blood supply and is effective in the treatment of painful vascular disorders such as angina pectoris. JASON D. CRISTOBAL RN,MAN 211 Sympathectomy JASON D. CRISTOBAL RN,MAN 212 JASON D. CRISTOBAL RN,MAN 213 JASON D. CRISTOBAL RN,MAN 214 HERNIATED DISC JASON D. CRISTOBAL RN,MAN 215  Nursing responsibilities  Provide pre and post-op care for a laminectomy  Assess extremities for sensation (ex. Touch, pain, temperature,) and movement.  Monitor skin for signs of damage or pressure  Teach client ways to compensate for loss of sensation in affected parts  Visually inspect skin for signs of injury or pressure  Check temperature of bath water  Avoid use of hot water bottles, heating pads  Avoid extremes of temperature JASON D. CRISTOBAL RN,MAN 216  Surgical procedures for chronic back pain relief Kyphoplasty- is a procedure whereby a balloon is inserted through a needle to the fractured vertebra. JASON D. CRISTOBAL RN,MAN 217 JASON D. CRISTOBAL RN,MAN 218 JASON D. CRISTOBAL RN,MAN 219 Surgical procedures for chronic back pain relief Vertebroplasty- is a similar procedure; it also involves the injection of cement but without the use of balloon. More than one vertebral fracture can be treated at a time. Note:Both procedures can be done under local anesthesia and in an outpatient basis. JASON D. CRISTOBAL RN,MAN 220  Using a special x-ray machine, a bone needle is guided through the skin and into the fractured vertebra. A cement-like material called polymethylmethacrylate acrylic cement (PMMA) is injected into the vertebra. The needle is removed and the cement hardens, stabilizing the vertebra JASON D. CRISTOBAL RN,MAN 221 JASON D. CRISTOBAL RN,MAN 222 JASON D. CRISTOBAL RN,MAN 223 GENERAL NURSING INTERVENTIONS Establish nurse – client relationship. Let the client know that you believe that his pain is real. Respect the client’s attitudes and behavioural responses to pain using a standardized pain scale appropriate to age and condition. Document effectiveness of interventions in a timely manner. JASON D. CRISTOBAL RN,MAN 224 GENERAL NURSING INTERVENTIONS Assess characteristics of pain and evaluate client’s response to interventions. Promote rest and relaxation. Prevent fatigue. Teach relaxation techniques, e.g. slow, rhythmic breathing, guided imagery. JASON D. CRISTOBAL RN,MAN 225 GENERAL NURSING INTERVENTIONS Institute comfort measures. Positioning: support body parts. Decrease noxious stimuli such as noise or bright lights. Provide cutaneous stimulation: massage, pressre, baths, vibration, heat,cold packs JASON D. CRISTOBAL RN,MAN 226 GENERAL NURSING INTERVENTIONS Relieved anxiety and fears. Spend time with the client. Offer reassurance, explanations. Provide distraction and diversion, e.g. music, puzzles JASON D. CRISTOBAL RN,MAN 227 Administer pain medication as needed  Administer pain medication in early stages before the pain becomes severe.  Administer pain medication prior to procedure that produces discomfort.  If pain is present most of the day, a preventative approach may be used, e.g. an around the clock schedule may be ordered in place of a prn schedule.  Document effectiveness of intervention. JASON D. CRISTOBAL RN,MAN 228  EXPECTED PATIENT OUTCOMES FOR THE PATIENT WITH PAIN Relief of pain, evidenced when the patient  Rates pain at a lower intensity(on a scale of 0 to 10) after intervention.  Rates pain at a lower intensity for longer period Correct administration of prescribed analgesic medications, evidenced when the patient or family  States correct dose of the medication.  Administers correct dose using correct procedure.  Identifies side effects of medication  Describes actions taken to prevent or correct side effects JASON D. CRISTOBAL RN,MAN 229 EXPECTED PATIENT OUTCOMES FOR THE PATIENT WITH PAIN Use of nonpharmacologic pain strategies asrecommended, evidenced when the patient:  Reports practice of nonpharmacologic strategies.  Describes expected outcomes of nonpharmacologic strategies. JASON D. CRISTOBAL RN,MAN 230  EXPECTED PATIENT OUTCOMES FOR THE PATIENT WITH PAIN Minimal effects of pain and minimal S.E. of interventions, evidenced when the patient: 1. Participates in activities important to: - recovery - self and family activities 2. Reports adequate sleep and absence of fatigue and constipation. JASON D. CRISTOBAL RN,MAN 231 JASON D. CRISTOBAL RN,MAN 232 v JASON D. CRISTOBAL RN,MAN 233 JASON D. CRISTOBAL RN,MAN 234 JASON D. CRISTOBAL RN,MAN 235 THANK YOU JASON D. CRISTOBAL RN,MAN 236