pain management edt

8/6/2019 Pain Management Edt

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Responses to pain

Acute pain:

Increased Pulse rate Raised BP/ fall in BP & shock Increased respiration Dilated pupils Diaphoresis Muscle tension May rub, cry / hold area Reports pain ReducedGImotility

Chronic pain:

Vital signs usually normal

Pupils normal or dilated Dry or warm skin Depression, irritability Withdrawal from interests & relationships Disturbed sleep Reduced libido Reduced appetite

The Patient with PAIN>Assessment of PAIN PQRST

P - Position/Location; Provocation

Q - Quality

R - Radiation/Relief

S - Severity/Symptoms

T - Timing

Factors Affecting Response to Pain

A Pain threshold: Point at which a stimulus is experienced as pain; same for all persons,

but individuals have different perceptions and reactions to pain

B. Pain tolerance: amount of pain a person can endure before outwardly

responding to it

B.1. Decreased by repeated pain episodes, fatigue, anger, anxiety, sleep

deprivation

B.2.

Increased by alcohol, hypnosis, warmth, distraction, spiritual practices

C. Age

D. Socio-cultural influences

D.1. Family beliefs, e.g. males dont cry

D.2. Cultural: some persons of ethnic groups handle pain in similar manner

E. Emotional status, e.g. anxiety

E.1. Fatigue and/or lack of sleep

E.2. Depression: decreased amount of serotonin, a neurotransmitter, thus increased

amount of pain sensation

F. Past experiences with pain

G. Source and meaning

H. Knowledge about pain

Physiology of pain

Pain perception & degree of perception depends on the interaction between

1. Bodys analgesia system2. The nervous systems transmission & interpretation of stimuli.

Interaction of the following are important

Peripheral pain sensors (nociceptors) Pain producing substances (algogenic) Sensitization of nerve endings Sensory pathway Neurotransmitters


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Peripheral pain sensors:

PNS consists of primary sensory neurons (touch, heat, cold, pain & pressure) Nociceptors receptors transmitting pain sensation

Nociceptors (Primary afferent ) sensory

Mechano receptors (A Delta) Polymodal (C fibres)

Activated by threshold hormones Activated by high intensity, physical

stimuli

Mainly present in the skin Widely distributed

Myelinated Unmyelinated

Usually small Large

Respond to strong pressure and stimuli Responds to tissue damage (mechanical,

thermal, chemical)

Impulses are rapid Impulses are slow, prolonged

Pain usually sharp, localized, pricking Dull, aching, poorly localized

ENDORPHINS

Pain producing substances (algogenic/algesic):

Excitatory neurotransmitters ( other name) Released by damaged tissues Thus directly or indirectly evoke pain Eg: bradykinin, acetylcholine, potassium ions, prostaglandins & Substance P Substance P increases permeability of local blood vessels & produce local

extravasations

Gate Control Theory

Melzack and Watt Concepts : modulation of inputs in the spinal dorsal horn by the substantia

gelatinosa cells

Brain is the active system that filters, selects and modulates inputs Dorsal horns are the sites at which dynamic activities like inhibition, excitation

and modulation occurred

Peripheral nerve fibers carrying pain to the spinal cord can have their inputmodified at spinal cord level before transmission to brain

Synapses in the dorsal horn acts as gates that close or open for the painimpulses


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Pain can be reduced at 4 points- peripheral site of pain - spinal cord

- brain stem - cerebral cortex

Pharmacologic pain relief interventions

Analgesics :

- Non opioids/ non- narcotic analgesics

- NSAIDs

- Narcotic analgesics / opioids

- Adjuvants / co- analgesics

Local anesthesia Patient controlled analgesia Epidural analgesia

1 . Non narcotic analgesics

Eg. Acetaminophen , acetyl salicylic acid M

ild pain Mechanism of action:

- inhibiting synthesis of prostaglandins

- inhibiting cellular responses during inflammation

- act on peripheral nerve receptors to reduce transmission &reception of pain stimuli

2. NSAIDs

Eg : Ibuprofen,Naproxen, Indomethacin, Piroxicam,Ketoralac

Used for pain such as dysmenorrhea, headaches, rheumatoid arthritis, gout,soft tissue athletic injury

Benefits:- No sedation

- No interference with bowel or bladder function

Nursing alert : Do not use in older clientsChronic use is not advised

3. Narcotic analgesics

Eg: meperidine, methylmorphine, morphine sulphate, fentanyl,hydromorphone

Used in moderate pain Acts on CNS & cause depressing and stimulating effects. Also acts in centers of

brain & spinal cord to modify perception of & reaction to pain

Nausea, vomiting, constipation ,altered mental processes are common sideeffects

Opiates can cause respiratory depression4. Adjuvants

Sedatives, anti-anxiety agents, muscle relaxants Eg: amitriptyline, hydroxyzine, & diazepam Enhance pain control / relieve depression & nausea Can be given alone or with analgesics Indicated for chronic pain, pain associated with anxiety, depression, nausea &

vomiting

Drowsiness, impaired coordination, judgement & mental alertness Misuse is a serious health problem

5. Local anesthesia

Temporary loss of sedation by inhibition of nerve conduction Topical application on skin &mucous

membrane / injected to anesthetize a body part

Side effects- itching / burning of skin

- localized rash

- change in heart rate- increased risk of systemic side effects


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Systolic BP falls < 90mm/Hg:

Stop the infusion Reassure the patient Assess the clinical condition & call anesthetist Follow instructions immediately Obstetric clients left lateral position Other clients legs to be elevated. Do not lower head Administer O2 - 4 li/min to treat hypoxia

Lowered respiration:

Stop the infusion O2 at 4 L / min Continuous monitoring & recording Inform anesthetist

PrepareN

ARC

AN

0.4 mg Assess O2 saturation Assist in intubation & mechanical intubation

High block:

Observe for numbness of chest & arms, for dyspnea & dysphagia Stop the infusion Inform anesthetist immediately Provide management as prescribed & record

Post epidural management: Monitor vital signs IV infusion Assess sensory & motor function Observe patient for voiding / urinary catheter Remove epidural catheter by sterile technique, & must be checked by 2 nurses

to ensure tip of catheter is complete and record

Observe for any complications and refer if neededSpinal anesthesia

A fine needle is inserted from the skin through the dura and arachnoid materinto the subarachnoid space

Enables the injection of analgesic agents directly into the cerebrospinal fluidWORLD HEALTHORGANIZATIONNARCOTICLADDER

Algorithm for pain management WHO committee on cancer painmanagement

Tailoring the pharmacologic therapy to the level of pain experienced by the

patient

Three step ladder approach

If guidelines fail to provide pain relief, alternative techniques should beimplemented

Eg: transdermal fentanyl patches, epidural opioid infusion, sympathetic nerve blocks

WHO - NARCOTICLADDER

Step 3 - Strong opioids +/- non opioids

eg : morphine + NSAIDS for strong pain

Step 2 -Moderate opioids +/- non opioidseg : codeine +NSAIDs for moderate to severe pain

Step 1 - Non opioids +/- adjuvant medications

eg : NSAIDs , diazepam for mild to moderate pain

Surgical interventions for pain relief

1. Dorsal rhizotomy2. Chordotomy


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Dorsal Rhizotomy

Dorsal nerve roots ( posterior) are resected as they enter spinal cord Effective for local pain relief Loss of pain sensation but has full motor function

***TRIGEMINALNEURALGIA (CNV)

Cordotomy

Extensive & involves resection of the spinothalamic tract ( unrelieved pain) Risk of permanent paralysis is more due to edema / accidental resection of

motor nerves

Permanent loss of pain & temporary sensation in the affected areasSurgical interventions for pain relief

Nursing alerts:

Assess for parasthesia Change in temperature sensation Loss of motor function

Non pharmacologic interventions

Cognitive behavioral approaches:

1. Distraction

Diverting attention Reducing awareness of pain Increase pain tolerance

eg : music, TV, radio, playing game, reading, conversing, using computer etc

2. Reducing pain perception

Removing / preventing painful stimuli especially for clients who areimmobilized

Consider aspects that can cause discomfort & pain and avoid them Control painful stimuli in your clients environment,

eg: change wet dressings, positioning the client, preventing urinary retention, avoid

exposing skin to irritants

3. Bio-feed back

Using a machine that measures the degree of muscular tension with skinelectrodes in microvolts

A poly graph machine records the tensional level for the client to see Client learns to use relaxation technique / imagery to reduce tension


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Produce deep relaxation Effective for muscle tension & migraine headaches

Biofeedback in Progress

A patient at a biofeedback clinic and sits connected to electrodes on his head and

finger. Biofeedback is a technique in which patients attempt to become aware of and

then alter bodily functions such as muscle tension and blood pressure. It is used in

treating pain and stress-related conditions and may help some paralyzed patients

regain the use of their limbs.

4. Hypnosis

Called as therapeutic suggestion Induces trance like state using focusing & relaxation techniques, giving the

patient suggestions that may be helpful after the return of an alert state of

consciousness

Intense concentration reduces apprehension or stress Should be done by trained person Only effective when the individual cooperates

5. Physical approaches to pain management

Goals:

to provide comfort to correct physical dysfunctions to alter physiological responses to reduce fears associated with pain related immobility

Examples:

1. Acupressure / acupuncture2. Cutaneous stimulation (massage, heat application, TENS,)3. Binders, Chiropractice

a. Acupressure / Acupuncture

Chinese technique Various points in the body stimulate the flow of Qi

(chee) or natural meridians ( lines/passage ways) of energy that pass through

the body

Used for backache, migraines Post operative pain Acupressure - application of pressure to various points of body Acupuncture insertion of extremely fine needles into various points of the

body. The needles unblock the meridians allowing free flow of energy and

relief of symptoms

Acupuncture

Acupuncture is a traditional Chinese medicine that stimulates specific points in the

body in order to restore a proper balance of various chemicals. This practice is used to

treat a range of conditions, including chronic pain, drug addiction, arthritis, and mental

illness.

b. Cutaneous stimulation

Massage stimulates circulation, relaxes muscles, increases patients sense ofwell being

Application of heat used to soothe / relieve pain from muscular strain /overwork

eg: for healing tissues

Application of cold reduces swelling, calming muscle spasms, reducing painin joints & muscles

TENS (Transcutaneous Electric Nerve Stimulation)

Placing electrodes on the painful area of patients skin Low current running through the electrodes acts to block the pain sensation. Must have a doctors order


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Management of side effects

Constipation Nausea Sedation, drowsiness, clouded thinking Slowed breathing

Cancer pain management after hospital stay

Long term pain management is essential Pain relieving medicines Supportive care Psychological support Complementary therapy

- yoga, meditation

- imagery

- spiritual healing

- music

- nutritional counseling

Nursing process approach to pain management

Assessment:

Goal is to gain an objective understanding of a subjective experience Accurate pain assessment Physiologic, psychologic, behavioral, emotional, & socio cultural Listen to your patient Establish trust

Assessment

Subjective assessment:

location of pain Intensity of pain - visual analogue scale

- numeric pain intensity scales

- simple descriptive scale

Quality hammer like , piercing like a knife, Pattern onset, duration, recurrence or intervals without pain Precipitating factors: physical exertion, emotional stressors Alleviating factors: home remedies, rest

Verbal Score Observer scoring

0 = No pain Appears pain free

1-3 = Hurts little Comfortable except on movement

4-6 = Hurts a lot Uncomfortable

7-8 = Really hurts a lot Distressed can be comforted

9-10 = Extremely hurts Distressed

Assessment (cont)

Associated symptoms : nausea, vomiting Effect on ADL Coping responses : prayer, distraction Daily pain diary

Objective assessment

Behavioral responses Physiological responses


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Nursing Diagnosis:

- Acute pain, chronic pain, alteration in comfort

- specify the location of pain

- etiologic / precipitating factors

- other diagnoses related to pain

eg: sleep pattern disturbance

alteration in nutrition

ineffective individual coping

self care deficit

Planning expected outcomes

* Choose the pain relief measures appropriate for the client based on assessment

data

-Implementation

-Evaluation of the plan

-Documentation

pain management edt

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