Pain Flashcards
What are the consequences of untreated pain
Patient Suffering
Sympathetic Stimulation
Immune suppression (increase risk of infection)
Delayed wound healing
CNS Hypersensitivity (Wind up)
Increased morbidity and mortality
Complications with Pain Assessment
Pain response is variable even among individuals, species, breed, age
Must be differentiated from stress, fear, aggression, anxiety, emergence delirium, dysphoria
Two main aspects of pain response: physiologic and behavioral
Physiologic Pain Response is and as a result causes
Releases catecholamines:
-Tachycardia, arrhythmias
-Hypertension, vasoconstriction
-Tachypnea, open-mouth breathing, or guarded, shallow breathing
-Mydriasis (dilated pupils)
Other causes of sympathetic stimulation:
- Hypoxemia
-Hypercapnia
- Stress
- Excitement
Behavioral Pain Response
Facial expression (grimace scale)
Postural changes and activity level
Changes in temperament
Vocalization (Growl, howl, purring)
Anorexia
Far more reliable indicators of pain
What are the facial expressions in cats associated with pain
Flattened ears
Flat, tense muzzle
Tucked whiskers
Fixed or staring gaze
Squinting
Avoiding eye contact
Head down
What are postural changes in cats associated with pain
Hunched, or guarding abdomen
Restless shifting position
Abnormal/awkward body position
Tense, rigid body position
Lying flat out, but not sedated
What are postural changes in dogs associated with pain
Changes in gait such as lameness or stiffness
Reluctance to move or walk
Restless and unable to find a comfortable position
Praying stance
Tense or guarded/hunched posture
What are behavioural changes in cats associated with pain
Decreased grooming
Attitude changes
Friendly cat becomes aggressive after surgery
Vocal, chatty cat becomes quiet and withdrawn
Hiding at the back of cage, avoiding human contact
Excessive grooming of surgery site
Guarding or protecting injury
Aggression
Anorexia?
What are behavioural changes in dogs associated with pain
Comfort seeking
Compare normal behavior with post-operative changes
Increased aggression or submissiveness
Withdrawn from human contact
Anorexia
Inappropriate urination or defecation
What are vocalization in cats and dogs associated with pain
Growling, whining, whimpering, barking, crying
Quiet can also be a sign of pain
Purring cats can be happy or self-soothing
Other reasons for vocalization:
Dysphoria
anxiety, stress
needing to go outside to urinate or defecate
This may be unreliable indicator of pain
How do critically ill patients show pain
Too sick to exhibit pain signs, flat out pain or in shock but may also be painful
May be more sensitive to the side effects of analgesics
Give analgesics but titrate slowly
How do you approach a pain assessment
Distance Exam
Interaction with Patient
Palpation of painful or potentially injured area
Overall appearance of Patient
How do we quantify pain?
Why use pain scales
Quantifying the degree of pain of a patient is challenging, highly subjective and varies greatly depending on each staff member assessing pain
Pain Scales help to standardized this assessment
Reminds staff to take the time to regularly assess the patient’s quality of analgesia
What is the galscow composite pain scale
Used for Canine patients
If patient receives a score of 6/24 or 5/20 this indicates need for analgesia
This is the scale used to assess pain at the VMC, you will see this on your rotations
Feline Glasgow Pain Scale(CMPS–F)
Validated (2017)
A score of 5/20 or greater indicates the need for analgesia
UNESP-Botucatu Multidimensional Composite Pain Scale is
Validated pain scale
Used for feline pain assessment
Takes into account behavioral and physiologic responses to pain
Blood pressure, anorexia, posture, activity level, etc.
Thorough description of sub classification, makes it easier to decide the level of pain
What is the feline grimace scale
FGS training manual supplementary material (springer.com)
5 parameters assessed:
Ear position, orbital tightening, muzzle tension, whisker position, head position
≥4/10 consider treating pain
How to distinguish pain from:
Emergence delirium: disorientation and excitement associated with a patient recovering from inhalant anesthetic
Short duration (usually first 10–15 minutes of recovery)
Geriatrics, blind and deaf are prone to excitable recoveries
Dysphoria:disorientation and excitement associated with some anesthetic drugs
Most commonly opioids but also ketamine and benzodiazepines
Severe Symptoms of excitation can be treated with sedatives in a quiet area to smooth out anesthetic recoveries
What are the pain scores for a patient in a kennel
LOOK AT THE CAT IN THE CAGE:
Question 1
Silent/Purring/Meowing 0
Crying/Growling/Groaning 1
LOOK AT THE CAT IN ITS CAGE:
Question 2:
Relaxed 0
Licking Lips 1
Restless/cowering at back of cage 2
Tense/crouched 3
Rigid/hunched 4
LOOK AT THE CAT IN ITS CAGE:
Question 3
Ignoring any wound or painful area 0
Attention to wound 1
What are the pain scores once a patient has been touched
APPROACH THE CAGE, CALL THE CAT BY NAME AND STROKE ALONG ITS BACK FROM HEAD TO TAIL
Question 5
Respond to stroking 0
Unresponsive 1
Aggressive 2
Palpation of Painful Site
Question 6: Response to Palpation
Do Nothing 0
Swish Tail/Flatten Ears 1
Cry/Hiss 2
Growl 3
Bite/Lash out 4
Overall Impression
Question 7
Happy and content 0
Disinterested/quiet 1
Anxious/fearful 2
Dull 3
Depressed/grumpy 4
FAS behavior and Pain assessment
FAS (fear, anxiety and stress) and pain can show similar behaviors in hospital
Facial expressions of fearful patients are different than painful
Ears and eyes are alert but may be hiding in the corner of the kennel and avoiding eye contact
Position of the back is a low profile not hunched
Pre-operatively obtain a thorough history and use this knowledge to assess if aggression is pain based
Very few cats are truly aggressive without pain or being cornered, most are fearful
Look at changes in behavior from when pre to post operation
What if the patient is painful prior to coming to the hospital?
Ex. Urethral blockage, HBC
What if the patient is normally fearful, aggressive or feral in a hospital?
Make sure patient receives adequate analgesia before waking up, as administration for analgesics post-op may be challenging
Pain assessment may be difficult post-op and there is doubt, treat pain and see if behavioral improvement occurs
Pre-emptive Analgesia is done hwo and why
Pre-emptive analgesia: administering analgesia prior to anticipated painful procedure
ex. OHE
Pre-emptive analgesia will decrease the amount and duration of pain medication required instead of treating pain as it arises
Helps to prevent wind-up pain
What is the difference b/w acute and chronic pain
Acute Pain: an immediate response that is beneficial to the patient, it is protective reflex to avoid further injury (Ex. Burn your hand on stove, you will withdrawal that hand)
Chronic Pain: is not beneficial to the patient and results in negative side effects (Ex. Arthritis can result in muscle atrophy due to decreased activity)
Signs of Chronic Pain at Home
Trouble jumping (cats)
Overgrown claws (cats)
avoiding/slow on stairs
Stiff or abnormal gait
Decreased activity levels
Spending more time alone, less social
Attacking other pets or attacking owners
Fearful, guarding site of injury
Poor coat quality
Anorexia
Inappropriate urination/defecation
What are the goals of treating acute pain
Patient comfort: ideally complete analgesia, but reduce pain to a tolerable level to decrease negative side effects of pain and return to normal behavior (hypoalgesia)
Prevent chronic pain
Prevent adverse effects of the drugs used in treating pain
excess sedation, agitation, ileus, c/v depression, hyperthermia or hypothermia, nausea
Balancing negative effects of drugs with negative effects of pain
