Pain Assessment & Management Flashcards
Chronic pain affects more Americans than _________________.
DM, Cancer, Heart Disease
Who is pain unaddressed and inappropriately addressed in?
Females & minorities
Multi-modal approach for pain
Ketamine therapy, holistic options (PT, acupuncture), anti-depressants, CBD, mushrooms
How can we make a difference in pre-op w/ pain management?
- Pre-op Meds
- Pain management plan
*they need to understand our goal is to make their pain manageable
What pain medication can we give patients who are physiologically unstable?
Ketamine
-give a sub-dissociative dose
-0.2-0.3mg/kg
Psychosocial contributor to pain
Financial stress, impaired sleep, anxiety
Where did opioid safety concerns arise from?
Overuse, overprescribing, driven by money
-street drugs: fentanyl & synthetics
Balance w/ Pain Management
- Balance safe opioid/analgesia prescribing
- High-risk pt. Recognition
- Be mindful of different types of pain, individual pain factors, and comorbidities
Pts responses to pain may be related to _______________.
- Genetics
- Age, gender, ethnicity
- Socioeconomic and psychiatric factors
- Catastrophizing
- Culture, religion
- Previous experiences
- Pt perceptions & expectations
Patient perceptions
- Perceived effective communication w/ physicians and nurses
- Perceived responsiveness by the treating team
- Perceived empathy by the treating team
Ultra-rapid metabolizers
- Convert codeine more rapidly to morphine
*potential for Supra-therapeutic dosing
Slow metabolizers
- Don’t metabolize codeine - never reach therapeutic levels
Concern drugs w/ genetic polymorphisms
- Muscle relaxants & analgesics
-worry about pts who metabolize muscle relaxants quickly
Genetic metabolism in African Americans & Caucasians
Equal populations of fast and slow metabolizers
Asian/Native American Genetic metabolism
- 90% fast metabolizers
Gender & Pain
- Females display more sensitivity & express their pain more frequently and effective
- Males: more exaggerative
Ethnicity & pain
- Can be r/t disease process
-sickle cell patients
Causes of whole body pain
- Fibromyalgia
- Depression
- Vascular issues
- DM
- Spinal injuries
*pain in one leg: DVT
Socioeconomic and psychiatric factors r/t pain
- Rural areas & lower socioeconomic status - report higher levels of pain
- Previous pain experiences: alters activity in certain brain regions responsible for pain processing
- Mood disorders/psych disorders: development of chronic pain
What is pain catastrophizing?
Exaggerative cognitive response to an anticipated or actual painful stimulus
-affects how individuals experience & express pain
Ex of catastrophizing: magnification
- Response that symptoms can be or are greater than expected
“I’m afraid something serious might happen” - What we can do:
-pre-op versed
-precedex
Rumination
- Individual focuses repeatedly on attributes of an event that evoke a negative emotional response
-fixated on 1 thing
Helplessness
Belief that there is nothing anyone can do to improve a bad situation
“There is nothing I can do to reduce the intensity of my pain”
Culture/religion r/t pain
- How pts cope can be influenced by their support system
-cultural/religious ties: better support
-variations in cultural norms: influence how people express pain/expect it to be managed
Nociceptive Pain Definition
Direct tissue injury from noxious stimuli
-somatic/visceral
-1st trigger
Clinical Examples of Nociceptive Pain
bone fractures, fresh surgical incision, fresh burn
Treatment options for nociceptive pain
may include both opiate & non-opiate medications depending on injury
Inflammatory Pain
Result of increased inflammatory mediators that control nociceptive input & released @ sites of tissue inflammation
Clinical Examples of inflammatory pain
late stages of burn healing, neuritis, arthritis, appendicitis, inflammatory bowel disease
Treatment options for inflammatory pain
anti-inflammatory agents
Neuropathic pain
- Result of injury to nerves leading to an alteration in sensory transmission
Clinical Examples of Neuropathic pain
Diabetic neuropathy, peripheral neuropathic pain, post-herpetic neuralgia, chemo pain
Treatment options for neuropathic pain
tricyclic, SNRIs, gabapentinoids, antidepressants
Idiopathic pain
cause unknown
Clinical Examples of idiopathic pain
chronic back pain w/o preceding trauma or obvious inciting event
Treatment options for idiopathic pain
Difficult to adequately address pain, underlying etiology unknown, especially in emergencies
Somatic Pain
A-delta fiber activity in peripheral tissues
-Injury to skin, muscle, bone, joint, connective tissue, deep tissue pain
-musculoskeletal pain
-pain well localized, sharp, worse w/ movement
Clinical Examples of Somatic pain
superficial lacerations, superficial burns, superficial abscesses, fractures, pelvic pain
Treatment options for somatic pain
topical/LA, opiates, non-opiates
Visceral Pain
C-fiber activity - Internal pain, occurs from internal organs or tissues that support them
-poorly localized, vague deep aches, colicky, cramping
Clinical Examples of visceral pain
Appendicitis, peptic ulcer disease, diverticulitis, endometriosis, ureteral stones, uterine fibroid pain, pyelonephritis, biliary colic
Treatment options for visceral pain
opiates, systemic pain control, nerve blocks, mobilizing
things we do that cause visceral pain
- Opioids
- Constipation
Acute Pain
<3mos.
Should resolve w/ normal healing
-EX: post-op pain, fracture bones, appendicitis, crush injuries, L&D pain
Treatment options for acute pain
opiates, non-opiates
Chronic pain
> 3 months
-extends beyond time of normal wound healing
-development of neurophysiological changes int he CNS
-EX: low back pain, neck pain, chronic pancreatitis, fibromyalgia
Treatment options for chronic pain
depends on the nature of the pain
Acute on chronic:
Time of acute exacerbations of a chronic painful syndrome or new acute pain in a person suffering from a chronic conditions
-EX: sickle cell exacerbation, cancer, RA, abscess in sickle cell pt.
Causes of flare-ups w/ sickle cell:
Dehydration, increased metabolic demands (exercise), stress
Pain Intensity
Subjective data, based on pain score and history/physical
Essential elements to pain assessment
- detailed history of current pain
- previous pain history
Basics of Pain Assessment
- Onset: sudden/gradual
- aggravating & alleviating factors: what makes it better/worse?
- Quality: ask if the pt. can describe it
- location: does it radiate?
- Severity: pain scale
- Circumstances: when did the pain start?
Assessing functionality & Pain
can they work? are they on light duty?
Are they coping w/ the pain?
Why are tumors problematic for pain?
- cause neuropathic pain
- cause inflammatory pain
- involve bone, vessels, nerves, and organs
- cause HA, seizures, constipation, abdominal pain 4. cause
Procedures r/t cancer that are painful
- biopsies (skin, bone marrow) - somatic/visceral
- radiation, surgery, chemo
What shows up on a UDS?
- cocaine
- opioids/BZDs
- amphetamines
- marijuana
- codeine
*fent patches do not (synthetic), street fentanyl does not
Pain control for port access
LA, EMLA cream, lidocaine cream
Pain assessment in intubated ICU patients
- assess v/s - HTN, tachycardia
- visual distress
- consider nerve blocks
Pain management for Herpes Zoster (shingles)
- lidocaine patches
- gabapentin
- tx underlying condition - antiviral
Migraine pain management
- R/O stroke, bleed, and red-flag signs
- tx migraine
OPQRST
O: onset - what were they doing? sudden/gradual
P: provocation & palliation - better or worse w/ activity/positioning/adjuvant (what meds? heat? ice?)
Q: Quality - ask pt. to describe it
R: region/radiation - referred/localized
S: severity - pain scale
T: timing - when did it start? how long has it been going on? has it happened before?
SOCRATES
Site
Onset
Character
Radiation
Associations
Time course
Exacerbating/relieving factors
Severity
What populations is assessing pain challenging in?
- age
- level of development
- communication skills/language
- cognitive skills
- prior pain experience 6. associated beliefs
physical exam: appearance
- obese/emaciated
- histrionic: exaggerated, dramatic
- flat affect
physical exam: posture
- splinting
- scoliosis/kyphosis
Pain physical exam: gait
- antalgic: limp
- hemiparetic
- assistive devices
Pain physical exam: facial expression
- grimacing
- tense
- diaphoretic
- anxious
pain physical exam: v/s
- SNS overactivity
- temp asymmetry
Pain: inspection
- skin: color changes, hair loss, flushing, goose bumps, sweating
- muscle: atrophy/spasm
- edema
Pain: palpation
- demarcation of painful area
- detection of changes in pain intensity in the area
- trigger points
- changes in sensory/pain processing
Pain: MS systems
- flaccidity: paralysis
- abnormal movements: neuro damage, impaired proprioception
- limited ROM: disc disease, arthritis, pain
Pain: neuro exam
- cranial nerve exam
- motor strength
- spinal nerve function: DTRs, pinprick, proprioception
- Coordination: Romberg’s test, toe-heel, finger to nose
Pt. cues: position of comfort
- give meds before you move them
- ketamine - pain relief & cooperative
- induce on the stretcher/bed
Pt. cues: psychological
- skin flushing, diaphoresis
- vocalizations
- facial expressions
- body posture/movement
- motor response
*baseline mental status: can they communicate w/ you?
Issues w/ pain scales
- they are subjective
- don’t take into account:
-genetics, past experiences, comorbidities, other influences
What can be the best pain intensity indicator besides a pain scale?
Patient functionality
Diff. options for pain scales
- numeric rating scale
- FACES
- critical care observation tool
- neonatal infant pain scale
- FLACC
What pain meds may work better in non-opioid naive patients?
PO XR opioids instead of IV
-they get to steady state
Pediatric Tylenol dose
15mg/kg
-PO q4-6h
-max: 90mg/kg/d
Pharmacologic Order of meds for non-opioid naive patients
- Tylenol
- celebrex
- gabapentin
- opioid
What concerns do we have w/ Toradol?
Bleeding from altering platelet function
-less of a risk now b/c we use lower doses (15-30mg)
Who are nebulized medications benefical in?
- asthmatic kids
- if they don’t have an IV
*can also give intranasal
Nebulized Ketamine Benefits - adult
- bronchodilator
- works topically: sore throat, awake intubation
Lidocaine Nebulized
Used for awake fiberoptic/glidoscope
Ketamine effects:
- pt. dissociates
- analgesia
- bronchodilator
- drooling - give a drying agent (bendaryl, glycopyrrolate)
What med do we not want to give w/ Ketamine?
Atropine - they both cause tachycardiaD
Dose differences w/ Ketamine
- low dose: sub-dissociative
- high dose: calming people, emergence delirium
Ketamine Pharmacology
- blockade NMDA, peripheral Na+ channels, and Mu opioid receptors
- provides sedation, amnesia, analgesia
- retrograde amnesia
- highly lipid soluble - crosses BBB fast - peak 1min.
Intranasal medications
Ketamine, Fent, versed, lidocaine, precedex
Intranasal administration
- use concentrated solution
-Ketamine: 50mg/mL
-fent: 50mcg/mL
-Versed: 5mg/mL
-Precedex: 200mcg/2mL - use an atomizer
-if >1mL divide b/w nares
-spray toward turbinates/pinna
Benefits of non-pharmacological pain interventions:
- improve assessment
- decrease/avoid opioids & anxiolytics
- decrease time/recovery for procedures
- decrease adverse events
Painting analogy
- non-pharmacologic interventions as the primer/base coat
- analgesic tx as the paint
Examples of non-pharmacological pain interventions
- preparation, education
- distraction: music/TV, toys
- Relaxation: breathing, meditation
- Training/Coaching
- positioning
- pressure/massage
- heat/ice/splinting
What is one of the most common mistakes in pain management?
failure to reassess in timely manner
-30min after IV
-60min after PO
*also monitor for resp. depression
consequences of unrelieved acute pain
- psychological
-PTSD
-anxiety
-catastrophizing
-depression - chronic pain syndromes
- increased M&M
-increased O2 demand
-increased metabolic rate
-CV/pulmonary complications
-impaired immune function
Chronic pain syndrome
- viscous cycle
- affects sleep, mood, activity, energy level
- physiological & psychological effects
Why do we avoid opioids on pts?
- n/v, constipation, resp. depression
- make sure the receiving team knows why
- communicate w/ hospitalist & surgeon for d/c planning
Things to consider when d/c patients w/ pain
- safety: can they get home? are they ambulatory? lethargy?
- will the pt be able to obtain their meds?
-cost, supply - clear & easy to understand instructions
Why is pain management during transition important ?
- reduces return visits
- reduces progression to chronic pain
How long does it take for acute pain to be reduced?
4-6wks
*most painful time for pt - 1st 12-48hrs
Car w/ 4 flat tires analogy
- medications only pump 1 tire
- other options:
-biofeedback
-PT
-counseling
-pacing
-nutritional guidance
-support group
*patient actively participates in
PDMP
prescription drug monitoring program
-drug monitoring log
-integrated system: pharmacies, providers
