chpn hpna ppt #2 pain management
DESCRIPTION
Pain management info for Palliative NursesTRANSCRIPT
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Clinical Review for the Hospice and Palliative Nurse
Pain Management
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Objectives
1. Describe the prevalence of pain in the hospice and palliative care setting
2. Recognize the impact of pain on patients, families and the healthcare system
3. Identify common barriers to effective pain management
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Objectives
4. Define the types of pain experienced by the hospice and palliative patient
5. State the principles of effective pain management
6 Identify the components of a thorough pain assessment
7. Demonstrate the ability to do equianalgesic conversions
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Undertreatment of Pain
70-90% of patients with advance disease experience pain 50% hospitalized patient’s experience pain 80% of long term care experience pain
Only 40-50% are given analgesics Pain scores (on a 0-10 scale) greater than or equal to “5”
greatly impact on quality of life
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Impact of Poorly Controlled Pain
Physical
Psychosocial
Emotional
Financial
Spiritual
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Interdisciplinary Resources
Pain affects multiple dimensions No one discipline can address all issues Strengths and talents of many disciplines Address multiple institutional barriers On going communication
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Cost of Poor Pain Management
$100 billion per year Chronic pain is most expensive heath problem 40 million physician visits per year for pain 25% of all work days lost are due to pain Improving pain management costs less than cost of
inadequate relief
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Pain Co-morbidities
Depression Anxiety disorder Diabetes Chronic fatigue syndrome
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Barriers to Effective Pain Management
Patient / family
Healthcare Provider
Institutional
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Definition of Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (APS)
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Definition of Pain
Pain is whatever the experiencing person says it is, existing whenever he/she says it does (McCaffery & Pasero, 1999)
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Types of Pain
Acute
Accompanied by physiological
Chronic
Usually persist for longer than 3 months Autonomic nervous system adapts - patient
does not exhibit objective signs of pain
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Classification of Pain Nociceptive Pain
The normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged
Usually responsive to non-opioids and/or opioids Stimuli from somatic or visceral structures
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Types of Nociceptive Pain
Somatic Pain
Bone, Joints, Muscle, Skin, Connective tissue
Throbbing, dull
Well localized
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Types of Nociceptive Pain
Visceral Pain Visceral organs Squeezing, cramping, pressure, deep Tumor involvement of organ capsule
Aching & well localized Intermittent cramping & poorly localized
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Neuropathic Pain
Abnormal processing of sensory input by central or peripheral nervous system
Mechanisms not as well understood
Burning, shooting, tingling, numbness, radiating, electrical
Responds to adjuvant analgesics
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Neuropathic Pain
Centrally generated pain Deafferentation pain Sympathetically maintained pain
Peripherally generated pain Painful polyneuropathies Painful mononeuropathies
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APS 12 Principles of Pain Management
1. Individualize dose, route and schedule
2. Around the clock dosing
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APS 12 Principles of Pain Management
3. Selection of opioids
4. Adequate dosing for infants/children
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APS 12 Principles of Pain Management
5. Follow patients closely
6. Use equianalgesic dosing
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APS 12 Principles of Pain Management
7. Recognize and treat side effects
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APS 12 Principles of Pain Management
8. Be aware of hazards of Demerol® and mixed agonist-antagonists
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APS 12 Principles of Pain Management
9. Watch for development of tolerance
10. Be aware of physical dependence
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APS 12 Principles of Pain Management
11. Do not label a patient addicted
12. Be aware of psychological state
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WHO Ladder Recommendations
Portrays progression in the doses and types of analgesic drugs for effective pain relief
Changes as patients condition and characteristics of pain change
Orally whenever possible “By the clock” dosing Based on assessment of the individual’s pain experience
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WHO LadderStep 1 (Mild pain)
Mild Pain 1-3 on a scale of 0-10
Non-opioids Adjuvants
As analgesics To reduce side effects
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WHO LadderStep 2 (Moderate pain)
Moderate Pain 4-6 on a scale of 0-10
Opioids in low doses Non-opioids and adjuvants may be continued
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WHO LadderStep 3 (Severe pain)
Severe Pain 7-10 on a scale of 0-10
Add higher doses of opioids Continue non-opioids and adjuvants
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Pain Assessment Principles
Accept patient’s complaint of pain
History of pain
Assessment for non-verbal patients
Patient centered goals
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Pain Assessment Principles
Nonverbal signs of pain
Psychological impact of pain
Diagnostic workup
Assess effectiveness and side effects of pain medication
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Initial Pain Assessment
Onset/duration When did the pain first begin? Is it associated with a particular activity Other symptoms
Site More than 75% persons with cancer have pain in 2 or
more sites Ask patient , “To point to the pain Assess each site for pain intensity, quality, duration
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Initial Pain Assessment
Severity/intensity Select pain scale appropriate to patient
Quality Ask patient to describe their pain
Exacerbating/relieving factors What makes the pain worse or what causes the pain? Assess the pain at rest, with movement, and in relation to
daily activity Ask the caregivers how patient is doing with activities
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Initial Pain Assessment
Effects of pain on quality of life What does the pain mean to the patient and family? Does the pain keep the patient from doing activities
he/she enjoys?
Medication history Current Past Side effects
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Initial Pain Assessment
Physical Examine site(s) of pain, including referral sitesConsider disease process, extent of progression
Cultural considerations Cultural generalities and determine individual differences
Other factors Age Gender Environmental
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Communication
Physician/Nurse critical in providing excellent patient care BASICS
Background, Assessment, Symptoms/Situation, Interpretation, Communication, Successful outcome
SBAR
Situation, Background, Assessment, Recommendation
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Communication
Interdisciplinary Team Establish common goals Use common language Common knowledge base Regular communication
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Non-opioids
Used in acute and chronic pain Relief for mild/moderate pain
Most effective with nociceptive pain (muscle and joint pain)
Combined with opioid analgesics for both additive analgesic effects or opioid dose sparing effects
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Non-opioids
Acetaminophen Mechanism
not well understood
Dosing decrease for patients with hepatic impairment
Routes
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Non-opioids
Acetaminophen Side effects
Considerations Be aware of hidden doses, i.e., APAP in combination
products
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Non-opioids
NSAIDs Characteristics
analgesic effects through the inhibition of prostaglandin production
multipurpose analgesia Drug choices
If no response after 3 days of adjustment, consider switching to different NSAID
Contraindicated If patient is hypersensitive or allergic to ASA or other NSAID’s
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Non-opioids
NSAIDs Dosing
PRN basis for occasional pain Around-the-clock (ATC) for ongoing pain
Routes of Administration
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Non-opioids
NSAIDs Sides Effects
Hematologic GI Renal Cognitive Impairment Cardiovascular
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Teaching Points for Non-opioids
Risk for GI bleeding with NSAIDs
Why medication ordered
Stopping medications
Reporting side effects
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Opioids
CNS action - bind to opioid receptor site in brain and spinal cord
mu, kappa, and delta receptor sites Pain relief occurs when opioids bind to 1 or
more receptors as an agonist Agonists and agonist - antagonists
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Pure Agonist Opioids
Expect physical dependence Withdrawal will occur when abruptly stopped or naloxone
(Narcan®) is given Prevent withdrawal by reducing by 25% Tolerance to side effects other than constipation Tolerance to analgesia is rare
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Choice of Opioid Drug
One pure agonist with one route
If one not relieving pain with titration, may need to switch medication
All pure agonist have same side effects Side effects may be reported as allergies
Rapid onset formulation for breakthrough
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Opioids
Morphine Considered ‘gold standard’ for opioid analgesic Standard for comparison in opioid use Some patients cannot tolerate because of the side effects
Tolerance to side effects in a few days No tolerance to constipation
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Opioids
Codeine Appropriate for mild pain Metabolized by liver
Fentanyl Routes include IV, epidural, Topical patch
Hydrocodone Found in combination therapy with acetaminophen
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Opioids
Hydromorphone Short half life and lack of metabolite problems make it
preferable to morphine in patients with renal insufficiency, particularly the elderly
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Opioids
Meperidine Contraindicated – normeperidine (active
metabolite) acts as a CNS stimulant
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Opioids
Methadone Long half life Inexpensive Monitor closely for arrhythmias
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Opioids
Oxycodone Used in acute, cancer, chronic nonmalignant pain Mild to severe intensity
Propoxyphene Considered a weak analgesic Prescribed for mild to moderate pain Not recommended for chronic pain, cancer pain, end-of-
life care
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Mixed Agonist-antagonists
Indications Not recommended for chronic pain Ceiling doses Psychotomimetic effects
Disorientation/hallucinations
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Mixed Agonist-antagonists
Buprenorphine (Buprenex®)
Butorphanol (Stadol®)
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Mixed Agonist-antagonists
Nalbuphine (Nubain®)
Pentazocine (Talwin®)
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Opioid Dosing
Multiple routes available for pure agonists If current dose safe but ineffective, increase by 25% to
50% until pain relief occurs or unmanageable side effects present
No ceiling effect for pure agonists All opioids have side effects that eventually limit dose
escalation
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Opioid Routes
Oral/Sublingual
Usually preferred route Consider liquid if difficulty swallowing
Intramuscular
Not recommended - painfulSubcutaneous
Not used in acute pain situations Limited volume of infusion
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Opioid Routes
Intravenous Bolus provides most rapid onset of effect Peak times vary among opioids Starting doses may be one-half the oral route
Transdermal
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Opioid Routes
Transdermal Medication is delivered continuously through skin Caution patients that increased heat to patch or skin area
may increase release of medication Best results when applied to skin without hair and
adequate subcutaneous tissue
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Opioid Routes
Rectal Alternative to patients who cannot swallow Onset of action may be within 10 minutes
Stomal Not equivalent to rectal administration Starting dose should be considered same as oral or rectal
route
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Opioid Routes
Intraspinal Used for postoperative pain, cancer pain Opioid binds to receptors of spinal cord at level of
injection Dose related side effects: nausea, itching, urinary
retention
Patient Controlled Analgesia
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Opioid Routes
Patient Controlled Analgesia Predetermined dose of opioid delivered based on time
intervals Primarily used in acute pain situations Allows greater control over pain experience
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Management ofOpioid Side Effects
Constipation Most common side effect of opioids Bowel regimen
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Management ofOpioid Side Effects
Nausea and Vomiting May be due to
stimulation of chemoreceptor trigger zone in brain slowing of GI motility effects on balance and equilibrium of inner ear
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Management of Opioid Side Effects
Sedation Usually when opioids started or dose increased Tolerance will occur over period of days to weeks
Pruritus Can occur with any associated histamine release &
commonly with morphine May be generalized, usually localized to face, neck, chest Usually not accompanied by rash
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Management ofOpioid Side Effects
Mental status change Cause of increased anxiety and fear for patients, families,
caregivers Assess to ensure that opioid is cause
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Management of Opioid Side Effects
Respiratory depression Considered clinically significant when there is a decrease
in rate and depth of respirations from baseline Tolerance develops over period of days to weeks Longer patient on opioid, less likely to develop Prevention by appropriate titration, monitoring of sedation
levels Monitor sedation levels respiratory status, every 1-2 hours
for first 24 hours in opioid naïve
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Opioid Teaching Points
Discuss effects of unrelieved pain Review how to administration Side effects Fear of addiction Written information
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Equianalgesia
Doses of various opioids analgesics that provide approximately the same pain relief
Charts Consistent
Most use morphine 10 mg and every 4 hour dosing as basis
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Sample Equianalgesic Chart
Drug Dose (mg)
Parenteral
Dose (mg)
Oral
Duration (hours)
Morphine (IR) 10 30 3-4
Hydromorphone 1.5 7.5 3-4
Oxycodone (long acting)
---- 20 8-12
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Titration of opioids
Adjusting the amount of dose of an opioid
Make increases at the onset or peak effect
Provide smallest dose that provides greatest relief with fewest side effects
Titrate in increments of 25% to 100%
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Methods of Titration
Add total of scheduled doses and immediate-release over 24 hr period
Increase by 50% if initial dose not effective
Provide breakthrough dosing
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Breakthrough Dosing
Referred to as rescue dosing or supplemental dosing Occurs in 2/3 of patients receiving opioids for chronic
malignant pain Assessing for breakthrough – no tool – rely on patient’s
report of pain
Types
Incident - elicited by specific activities Spontaneous End-of-dose failure
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Rescue Dosing
1/10 to 1/6 of total daily dose Adjust when ATC dose increases Provide every 1-2 hrs May be taken with ATC dose Increase ATC dose if received more than 3 rescue doses
in a 24 period
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Calculating Rescue Dose
ATC dose in 24 hrs
Divided by 10 (1/10) or 6 (1/6)
Equals IR rescue dose to be given every 3 hrs PRN
180mg in 24 hrs
180 ÷ 10 = 18 or 180 ÷ 6 = 30
18mg to 30mg PO every 3 hr PRN
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Calculating Rescue Dose
Example
Oral Transmucosal Fentanyl Citrate Must convert opioid to morphine using equianalgesic chart or
manufacturer recommendation 200 g transdermal fentanyl = 400 mg morphine (total
fentanyl gs x 2 for morphine equivalent) 400 10 (1/10 or 10%) = 40 mg 400 6 (1/6 or 15%) = 70 mg Immediate release rescue dose = 40-70 mg PO every 1-2 hour
PRN
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Calculating Rescue Dose
Parenteral opioid infusions Recommended rescue dose for patients receiving
continuous parenteral or epidural opioid infusion is 25-50% of hourly opioid dose
Should be offered every 30 minutes if not using Patient Controlled Analgesia (PCA)
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Adjuvants
Non pain medications that have analgesic effects on certain types of pain
Chronic neuropathic pain Additional therapy to opioids Distinct primary therapy
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Adjuvants
Choice of Drug Depends on type of pain, patient age, and other medical
condition Individual response Sequential trials
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Tricyclic Antidepressants
In co-administration with opioids, interaction may result in higher opioid concentrations
Analgesia usually occurs within 1 week May be effective for both lancinating and continuous
neuropathic pain Not indicated for acute pain In palliative care, strongest indication in neuropathic pain
not responding to opioids In terminal care, benefits from non-analgesic effects
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Tricyclic Antidepressants
Choice of Drug Amitriptyline (Elavil®) Imipramine (Tofranil®) Doxepin (Sinequan®) Clomipramine (Anafranil®) Desipramine (Norpramine®) Nortriptyline (Aventyl®, Pamelor®)
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Tricyclic Antidepressants
Dosing Start low: elderly 10 mg; younger 25 mg Increase by same amount as starting dose Evaluate and increase every 3 to 5 days
Side Effects Orthostatic hypotension Sedation / mental clouding Antocholergic effects
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SSRIs
Duloxetine (Cymbalta®) Venlafaxine (Effexor®) Paraxetine (Paxil®) Fluoxetine (Prozac®)
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Anticonvulsants
First line drugs for chronic lancinating neuropathic pain Variability among drugs is great Analgesia similar mechanism that inhibit seizure activity Lessens conduction of pain signals along damaged
peripheral nerves
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Anticonvulsants
Gabapentin (Neurontin) Considered first line drug of choice for all types of
neuropathic pain due to effectiveness of analgesic action and low side effect profile
Carbamazepine (Tegretol) Effective in lancinating neuropathic pain
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Anticonvulsants
Phenytoin (Dilantin) Clonazepam (Klonopin) Valproic acid (Depakene) Baclofen (Lioresal)
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Other Adjuvants
Corticosteroids Considered multipurpose adjuvant analgesic Mechanism of action as analgesia is unknown
Drug of choice dexamethasone (Decadron) Prednisone and methylprednisolone
Adverse Effects Short Term Therapy Long Term Therapy
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Other Adjuvants
Local anesthetic agents Local action with minimal systemic side effects Limited information on long term safety and effectiveness
Medications Mexiletine (Mexitil) Tocainide (Tonocard) Lidocaine
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Other Adjuvants
Adverse Effects Central nervous system effects Caution or avoid use with patients with preexisting heart
disease such as cardiac dysrhythmias, those receiving antiarrhythmic drugs, cardiac insufficiency
If topical route used, side effects include redness, edema, and abnormal sensation at the site of application
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Other Adjuvants
Psychostimulants
Multipurpose for acute or chronic pain Useful in nociceptive or neuropathic pain
Caffeine (PO) Used in combination products for relief of headache
Dextroamphetamine: (Dexedrine) (PO) Methylphenidate: (Ritalin) (PO)
Side Effects Insomnia, anorexia, tremulousness, anxiety, agitation,
cognitive changes
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Other Adjuvants
Teaching Points May take days to weeks for pain relief Reassessment and titration may be necessary Review adverse effects Provide educational materials
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Addiction
“A pattern of compulsive drug use characterized by a continued craving for an opioid for effects other than pain relief” (APS, 1999)
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Pseudoaddiction
The patient who seeks additional medications appropriately or inappropriately secondary to significant undertreatment of the pain syndrome
Behaviors cease when pain is treated
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Tolerance
A form of neuroadaptation to the effects of chronically administered opioids which is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects
Clinicians should not fear tolerance in patients with extended life expectancy
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Physical Dependence
A physiological state in which abrupt cessation of the opioid results in withdrawal syndrome
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Physical Dependence
Pain management for Substance abuse history
Accept patient’s report of pain Clinicians most likely to under medicate
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Physical Dependence
Pain management for Active addict – general guidelines
Reassure patient of staff commitment to pain management of all patients
Inpatient Consider IV PCA: gives patient control, avoids
confrontation with staff, safely regulates dosingOutpatient less frequent dosing increases compliance to treatment plan
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Physical Dependence
Pain management for Patient recovering from addiction
Acknowledge patient’s addiction history Offer non-pharmacologic and non-opioid pain
management options Differentiate between addiction and physical
dependence If relapse occurs, intensify recovery effort - do
not terminate pain care
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Special Populations
Geriatric Dying Pediatric Cognitive Impaired Veteran
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Special PopulationsGeriatric
Age classifications
Younger old: age 65 to 75 years Older old: age 75 to 85 years Oldest old: over 85 years
Most under treated population for pain Rule of thumb: start low and go slow
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Special PopulationsGeriatric
Common types of pain Acute pain Cancer pain
Chronic nonmalignant pain
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Special PopulationsGeriatric
Analgesic Therapy issues Physiologic changes Absorption Distribution
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Special PopulationsGeriatric
Analgesic Therapy issues Metabolism Elimination
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Special PopulationsGeriatric
Analgesic Therapy Acetaminophen
Generally well-tolerated by elderly NSAIDs
Increased risk of GI problems, renal insufficiency, platelet dysfunction
Always take NSAIDs with food and water
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Special PopulationsGeriatric
Analgesic Therapy Opioids
Recommend reducing initial opioid dosing by 25-50% in elderly patient
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Special PopulationsGeriatric
Analgesic Therapy Drug selection Adjuvants
Tricyclic Antidepressants Anticonvulsants Local Anesthetics
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Special Populations Cognitively Impaired
Cognitively Impaired High risk for under treatment Assessment ability to report pain 0-5 scale Collaborate with family or caregiver to determine
behaviors that indicate pain
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Special PopulationsDying
Dying Pain assessment continues to be a priority at end-of-life Palliative Sedation or Therapeutic Sedation
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Special PopulationsPediatrics
Pediatric Consider age, developmental level, verbal capabilities, past
experiences, cultural factors, types of pain Child self report of pain considered most reliable and valid
indicator Medication dose determined by body weight (kilogram) Learn the child's word for pain
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Special PopulationsVeterans
Pain may be seen as a weakness Military taught to ‘grin and bear it’ Many suffer in silence, do not report pain Assess for pain in consistent manner Provide interdisciplinary, multimodal approach to pain
management
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Non-pharmacological Pain Management
Use concurrently with medications Methods
Cognitive-behavioral Relaxation Guided imagery Distraction
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Non-pharmacological Pain Management
Methods Physical interventions
Hot and Cold Massage Positioning Exercise
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Non-pharmacological Pain Management
Methods Physical interventions
Positioning Exercise
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Non-pharmacological Pain Management
Complementary therapies
Therapeutic touch Music therapy Aromatherapy
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Ethical Considerations
Related to Pain Management Patient rights Relief from pain
The Joint Commission American Nurses Association
Double Effect distinguishing between harming and benefiting patient
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Ethical Considerations
Related to Pain Management Principle of Double Effect
Found in situations when distinguishing between harm and benefit
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Ethical Considerations
Related to Pain Management Advocacy Nurses have duty to relieve pain and suffering Patient and family view nurse as advocate which increases
trusting relationship
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References
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3. McMillan S. Pain and pain relief experienced by hospice patients with cancer. Cancer Nursing. 1996;19:298-307.
4. Warfield C, Kahn C. Acute pain management: programs in U.S. hospitals and experiences and attitudes among U.S. adults. Anesthesiology. 1995;83:1090-1094.
5. Ferrell BR, Dean G. The meaning of cancer pain. Seminars in Oncology Nursing. 1995:11(1):17-22.
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10. American Pain Society. Principles of analgesic use in the treatment of acute pain and cancer pain. 3rd ed. Skokie, IL: American Pain Society; 1999.
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12. (AHCPR). A.f.H.C.P.a.R. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. Rockville, MD: Public Health Service, U.S. Department of Health and Human Services; 1992.
13. Fink R, Gates R. Pain assessment. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006:97-129.
14. Foley KM. Pain assessment and cancer pain syndromes. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford University Press: 2005: 298-316.
15. (AHCPR). A.f.H.C.P.a.R. Cancer Pain Management. Clinical Practice Guideline. Rockville, MD: Public Health Service, U.S. Department of Health and Human Services; 1994.
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17. Coyle N, Layman-Goldstein M. Pain assessment and pharmacological interventions. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. 2nd New York, NY: Springer; 2006: 345-405 .
18. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
19. Mariano C. Holistic integrative therapies in palliative care. In: Matzo ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006: 51-86.
20. Stanley KJ, Zoloth-Dorman L. Ethical considerations. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 1031-1053. 21. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
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21. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
22. Mariano C. Holistic integrative therapies in palliative care. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006: 51-86.
23. Stanley KJ, Zoloth-Dorman L. Ethical considerations. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 1031-1053.
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