Week 5 - Pain Management Flashcards
What is Pain?
- an unpleasant, subjective sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage
- a sensory & emotional experience of discomfort
- Pain is “whatever and whenever the person says it is” (McCaffery)
Magnitude of the Pain Problem
- Unrelieved persistent pain is an epidemic (in North America)
- Pain-related disabilities account for >15% of total disabilities in Canada
- Prevalence of pain increases with age. (Up to 85% of older people in
LTC experience chronic pain)
Factors Influencing Pain Perception
1) Affective - emotions, suffering
2) Behavioural - behavioural responses
3) Cognitive - beliefs, attitudes, evaluations, goals
4) Sensory - pain perception
5) Physiological - transmission of nociceptive stimuli
Physiological Dimension of Pain
1) Transduction
1. Noxious stimuli causes cell damage with the release of sensitizing chemicals
- prostaglandins
- Bradykinin
- Serotonin
- Histamine
2. These substances activate nociceptors and lead to generation of action potential
2) Transmission: action potential continues from:
1. Site of Injury
2. Spinal cord to brainstem and thalamus
3. Thalamus to cortex for processing
3) Perception
- conscious experience of pain
4) Modulation
- neurons originating in the brainstem descend to the spinal cord and release substances (ie. endogenous opioids) that inhibit nociceptive impulses
Gate Control Theory
Large Nerve Fibers
- send brain information (ie. about being touched or feeling pressure on your skin)
- sends messages to your brain very quickly
- Stimulating large fiber activity can help “close the gates” by getting to your brain first
Small Nerve Fibers
- send your brain information about pain, temperature
- activity moves a bit more slowly
- Pain signals (carried by small fibers) are not allowed in = alters perception of pain
Acute Pain
- Suden onset
- Identifiable cause (injury, disease, surgery, psychological distress)
- Short-lived, as recovery occurs
- Usually treatable or will resolve on its own
- S & reflect sympathetic NS stimulation
- Vital signs: Increase pulse, RR, BP
- Integumentary: Diaphoresis, pallor
- Psychological: Anxiety, confusion
- Goal: pain control with eventual resolution
Persistent (Chronic Pain)
- Gradual or sudden
- Cause not always known
- Long-term (beyond expected healing time)
- Unpredictable- constant or episodic
- Predominantly behaviour S & S
- Change in affect
- Fatigue
- Withdrawal from social interaction
- Decrease physical activity
- Goal: minimize pain, enhance function & QoL
Nociceptive Pain
- Normal processing of stimuli that damages normal tissues or has
potential to do so
2 Types
1) Somatic Pain- aching or throbbing from bone, joint, muscle, skin,
connective tissue
- responds to nonopioid & opioids
2) Visceral Pain-pain arising from internal
organs
Neuropathic Pain
- Caused by damage to nerve cells or changes in CNS, abnormal processing
of stimuli - Burning, shooting, stabbing
- Often sudden, intense, lingering or short-lived
- Central or peripheral origin
- Common cause: inflammation, trauma, metabolic disease (diabetes)
- Doesn’t respond well to opioids alone, requires adjuvant analgesics
Nursing Assessment - Determine client’s perspective of pain:
- History of Pain
- Meaning of pain
- Physical Effects
- Emotional Effects
- Social Effects
- Client Expectations
Nursing Assessment - OPQRSTUV & OLD CARTSS
OPQRSTUV
- Onset
- Provoking/palliating
- Quality
- Region of body, radiation
- Severity
- Timing, treatment
- Understanding of the pain
- Value- what level of pain is acceptable
OLD CARTSS
- Onset, including past history, what was happening at time of onset
- Location, including radiation
- Duration
- Characteristics
- Aggravating factors
- Relieving factors
- Timing
- Severity
- Self-perception (understanding), acceptable level
Pain Scales
Coloured Faces
- When using the faces, children might just pick the happy face because they like it
Faces
- Works for ppl who do not speak English, have dysphagia etc
Pain Management
1) Patient &
caregiver teaching
vital, especially
self-management
2) Pharmacological +
non-pharmacological
approach required
3) Treatment is
based on patient’s
& family’s goals
4) Team approach patient family, HCT
5) Use self-reports
when possible.
- Use non-verbal
assessments PRN
6) Routine Assessment - physical & psychosocial
Pharmacological Management
- Equianalgesic dose = dose of one analgesic that produces pain-relieving
effects equivalent to those of another analgesic - Important when substituting one analgesic for another due to ineffectiveness, intolerable side effects or route of opioid administration is changed
- Fast-acting medications should be used for breakthrough pain, long acting analgesics are more effective for constant pain (ie. cancer, chronic)
- Schedule to prevent or control pain rather than waiting until pain is
moderate to severe - Administer medication before procedures or activities that are
expected to produce pain - Patient with constant pain should receive analgesics around the clock
- Rationale: control pain before it starts, usually result in lower analgesic
requirements - Titration- adjusting dose up or down
Routes of Analgesic Administration
Variety of routes allowing for:
- Targeting of a particular anatomical source of pain
- Achievement of therapeutic blood levels rapidly
- Avoidance of some adverse effects through localized administration
- Provide analgesia if unable to swallow
- Oral
- Sublingual and buccal
- Intranasal
- Rectal
- Transdermal
- Parenteral
- Intraspinal
- PCA
The Analgesic Ladder
Mild Pain (1-3/10)
- Nonopioid analgesics (ASA, NSAIDs, Acetaminophen)
- Ceiling effect- increasing dose beyond upper limit does not decrease
pain - No tolerance or physical dependence
- Side effects: GI upset, bleeding (ASA, NSAIDs), nephrotoxicity (NSAIDs
chronic use), liver toxicity (Acetaminophen- >4000 mg/day or if liver disease present)
Mild to Moderate pain (4-6/10)
- Opioid + NSAIDs + adjuvant
- Codeine, Tramadol- may have Acetaminophen added (Tylenol #3,
Tramacet) - Opioids depress CNS
- Side effects: nausea, constipation, dizziness, sedation
- Pay attention to dose of Acetaminophen if using opioid with Acetaminophen in it.
(Max dose Acetaminophen = 4000 mg/24 hours)
Moderate to Severe Pain (4-10/10)
- Moderate to severe pain or when step 2 meds ineffective
- Morphine commonly used, fentanyl, hydrophone (Dilaudid), methadone,
oxycodone - Long-acting Morphine (MS Contin) for continuous, round-the-clock therapy
for extended period - Side effects: CNS depressant- nausea, vomiting, constipation, respiratory depression, sedation, itching, confusion, hallucinations, urinary retention
less common - Most s.e. decrease with continued use (except constipation)
- NO Meperidine (Demerol)- not responsive to Naloxone, high incidence of neurotoxicity (seizures)
What other meds should be ordered for patient receiving opioids?
- Anti-emetic
- Stool softener/laxative
Adjuvants (Coanalgesics)
- Enhance effects of opioids & nonopioids
- Possess analgesic properties
- Counteract adverse effects of other analgesics
Includes
- Corticosteroids (anti-inflammatory; to reduce pain)
- Antidepressants
- Antiseizure
- Muscle relaxant
- Anaesthetics
- Psychostimulants
- Cannabinoids
Age-Related Considerations
Older adults
- Metabolize meds more slowly, at greater risk for higher blood levels &
adverse effects - NSAIDs associated with higher risk of GI bleeds
- Polypharmacy: greater risk for drug interactions
- Cognitive impairment, ataxia increase when opioids, antidepressants,
anticonvulsants used
Children
- can not metabolize drugs as well
If you give a patient with cognitive impairment (dementia) an opiod, what are the risks?
- opioids make people confused - difficult to know if the confusion is their dementia or a side effect of the drug
- opioids can increase the fall risk of dementia patients who already have high risk of falls
Tolerance
Tolerance: need for an increased dose of opiod to maintain the same degree of analgesia
Tolerance Management
- increased dose
- change to another drug in same class
- add medication from a different class to augment pain relief
Tolerance VS. Addiction
- Physical dependence= an expected physiological response to ongoing exposure
to pharmacological agents - Manifested by a withdrawal syndrome when the drug is abruptly decreased
- Slowly wean (decrease dose) to avoid withdrawal symptoms
- Addiction (Substance misuse or substance use disorders)- neurobiological
conditions due to use of a substance in high doses or inappropriate situations
that can impact one’s health or create social problems
Non-pharmacological Methods of Pain Management: Physical Interventions
- Massage- works on principle that large fibers are stimulated, closing pain gate
- Heat & cold application
- Acupuncture
- Tens
- Exercise
Non-pharmacological Methods of Pain Management: Behavioral/Cognitive Interventions
- Provide sense of control, coping skills
- Relaxation and imagery
- Hypnosis - causes relaxation
- Distraction, reframing
- Patient education
- Psychotherapy
- Support Groups
Opioid Crisis and Role of Nurse
- use non-pharmacological interventions
- think about care biases
- provide health teaching (so clients are aware of risks)
