Pain Management Flashcards
How is pain classified?
Duration: - acute - chronic - acute on chronic Cause: - cancer - non-cancer Mechanism: - nociceptive - neuropathic
How is chronic pain defined?
Pain lasting > 3 months
Pain lasting after normal healing
What is nociceptive pain and how does it feel to the patient?
Obvious tissue injury or illness
–> sharp +/- dull, well localised
What is neuropathic pain and how does it feel to the patient?
Nervous system damage or abnormality
–> burning, shooting, numbness, pins + needles, poorly localised
Which non-drug treatments are available for pain management?
Physical:
- rest, ice, compression, elevation
- surgery
- acupuncture, massage., physiotherapy
Psychological:
- explanation, reassurance, counselling
Which drugs are classed as simple analgesics?
Paracetamol (acetaminophen)
NSAIDs - diclofenac, ibuprofen etc
Which opioid is considered ‘mild’?
Codeine
Tramadol
Give some examples of strong opioids
Morphine Diamorphine Oxycodone Methadone Fentanyl Pethidine
Apart from simple analgesia and opioids, give some examples of other drugs used to manage pain:
Tricyclic antidepressants --> e.g. amitriptyline Anticonvulsants --> e.g. gabapentin Ketamine Local anaesthetics Clonidine
How is pain assessed during routine nursing observations?
Pain score:
0 = no pain at rest or on movement
1 = no pain at rest, slight pain on movement
2 = intermittent pain at rest, moderate pain on movement
3 = continuous pain at rest, severe pain on movement
What is the treatment for mild pain (score 0-1)?
Paracetamol 1g 6 hourly
When should the standard dose of paracetamol be reduced?
If < 50kg
What is the treatment for moderate pain (score 1-2)?
Paracetamol (as before)
+ Codeine or Tramadol
+/- NSAIDs
What is the standard dose for codeine?
30-60mg 4 hourly
max 240mg/24hr
What is the standard dose for tramadol?
50-100mg 4 hourly
Which NSAIDs are good for post-op pain?
Diclofenac PO/PR
Ketorolac IV
What is the treatment for severe pain (score 3 or predicted severe)?
Continue paracetamol + NSAIDs (if tolerated) Replace codeine/tramadol with either: - oromorph - PCA morphine - short duration morphine - regional technique e.g. epidural
When should NSAIDs be used with caution?
Elderly
Dehydration
Asthma
When are NSAIDs contraindicated?
Renal dysfunction
Coagulopathy
Peptic ulcer disease
What is the process for giving oromorph to improve severe pain?
Give 10mg/5ml and wait one hour
Assess + document: pain, sedation, nausea + RR
If no improvement, repeat up to 2x unless sedation or RR < 10
What is the criteria for administration of IV morphine?
Adults only Pain score 2 or 3 Systolic BP > 100 HR 60-100 RR > 8 Sedation score 0-1 Oxygen sats > 95% Oxygen therapy started before drug given Facilities to monitor patient 20 mins after dose
When is IV morphine indicated?
Good for treating any severe pain –> titrated to effect
What needs to be assess prior to initiating opiate titration?
Pain
Sedation
Nausea
Respiratory rate
What should be done if a patient taking opiates is unresponsive/sedation score = 3?
Give oxygen 6 l/min
Discontinue opiates
Give naloxone
Contact pain team for advice on alternative analgesia
What is the dose of naloxone used for opiate toxicity?
40mg increments titrated to effect + reassess patient
if you give a large bolus –> reverse all analgesia causing a lot of pain for patient
What does PCA stand for?
Patient controlled analgesia
What is the standard prescription for a PCA?
1mg of morphine, 5 minute lock out
Who prescribes/organises PCA?
Acute pain team
When should a PCA be stopped?
When the patient is able to tolerate oral analgesia
How do epidurals work for pos-op pain management?
Sited by anaesthetist in theatre and left in for a few days
- infusion of local anaesthetic + opioid e.g. fentanyl
Which blood test must be checked before insertion of an epidural and why?
Coagulation –> must be normal before insertion and removal to prevent epidural haematoma
(do not given LMWH within 12 hours)
