Chronic Pain - Home | FIG Education 6 Workbook.pdf · Chronic Pain WORKBOOK Nurse Life Care...

©2011, Shelene Giles. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Section 6

Chronic Pain

WORKBOOK

Nurse Life Care Planning - Through the Ages

©2011, Shelene Giles. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Nurse Life Care Planning - Through the Ages Section 6 - Chronic Pain

OBJECTIVE 1: Explain the classifications of chronic pain. Identify levels of impairment based on severity of chronic

pain.

OBJECTIVE 2: Describe complications related to chronic pain. Identify long term treatment and outcomes of chronic

pain.

OBJECTIVE 3: Apply and demonstrate the nursing process as a life care planning foundation for a chronic pain client.

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Agenda

Overview

Nurse Life Care Planning

Case Study

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Overview

Incidence

3rd

largest health problem in US

80% of patients seek medical care due to pain

Pain is #1 reason for unscheduled hospital admissions

40 million visits per year to physicians for “new” pain

86 million Americans affected by chronic pain to some degree

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65 million Americans suffer from painful disabilities each year

40% of acute care patients reported poor pain control

50% of dying patients reported moderate to severe pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in

terms of such damage - as defined by International Association for the Study of Pain

Pain is difficult to study because of its subjectivity with variability among individuals – even within individuals across

time and situations

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©2011, Shelene Giles · [email protected] · (828) 698-9486

Gender

Pain affects men and women differently

Estrogen and testosterone play a role in how men and women receive pain signals

Women recover more quickly, seek help more quickly, and are less likely to allow pain to control their lives

Women more likely use a variety of resource coping skills, support, and distraction when dealing with pain

Pain medications react differently in men and women

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Age

41% of adults with back pain are between 18 - 44 years old

Pain is number one complaint of older Americans

American Geriatrics Society issued guidelines for pain management in older people - Journal of American Geriatrics

Society (Vol. 46, 1998, pg 635-651)

Children unable to describe degree of pain

Special tools for measuring pain in children

Non-steroidal agents most often prescribed for pain management in younger children

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Etiology (HANDOUT - Ethics, Law, and Pain Management as a Patient Right)

Unclear etiology for chronic pain

During injury/illness, certain nerves send pain signals to brain

Pain signals continue for weeks/months/years after recovery of injury/illness

Dysfunction of certain brain chemicals that usually suppress pain

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Pathophysiology

Origin of stimulus

Nociceptors – naked nerve endings found at ends of small unmyelinated and light myelinated afferent neurons

Unimodal nociceptors are mechanosensitive only – found in skin/mucous membranes/some wall linings of body

cavities

Polymodal nociceptors are mechanosensitive, thermosensitive, and chemosensitive – more common in skin and

deep tissue

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Stimulus transmission

Stimulation of nociceptors produces impulses transmitted through Ad-fibers and C-fibers to spinal cord where

they form synapses with neurons

Myelinated Ad-fibers transmit rapidly and are responsible for initial pain response

Unmyelinated C-fibers produce slower response and felt several seconds after injury

Acute pain noted in neospinothalamic tract

Dull/burning pain noted in paleospinothalamic tract

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Termination of stimulus

Neospinothalamic tract transmits info to midbrain/postcentral gyrus/cortex

Paleospinothalamic tract transmits info to reticular formation/pons/limbic system/midbrain

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Classification

Neurogenic/neuropathic pain - peripheral nerves or central nervous system damaged - nerves themselves cause pain

and does not respond well to treatment, numbness/tingling/electrical shock

Nociceptive pain – caused by activation of nociceptors, specific to body part and function

Somatic pain - well localized, sharp/aching/throbbing, occurs in muscle/bone/deep tissue

Visceral pain - poorly localized, cramping/pressure, occurs in internal organs, deferred pain

Psychogenic pain - caused by emotional or mental health issue, not caused by disease/injury/damage to nervous

system, psychogenic pain not common - but stress/depression/mental health factors worsen pain

Unidentifiable pain - cause of pain unknown, diagnostic studies do not reveal injury/illness/damage

Central pain - pain associated with disease of central nervous system (brain and spinal cord)

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Types of pain

Acute pain

Results from disease, inflammation, or injury to tissues

Sudden onset

Accompanied by anxiety or emotional distress

Usually diagnosed and treated - short term

Pain is self limiting - confined to given period of time and severity

Often associated with autonomic symptoms – tachycardia, sweating, hypertension, vasoconstriction

Can become chronic pain

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Chronic pain

Widely believed to represent disease itself

Worsened by environmental and psychological factors

Persists over longer period of time

Resistant to most medical treatment

Usually not associated with autonomic symptoms

Can cause severe problems

Pain management is integral part of treating chronic pain

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Chronic Pain Syndrome

Likelihood of developing Chronic Pain Syndrome (CPS) is unrelated to pain intensity

Psychological variables (depression & somatic focus) and self-perceived disability consistently found to be most

accurate predictors of subsequent pain syndrome development

Defined by psychosocial dysfunction

Symptoms usually develop slowly over course of months/years

More symptoms present - more severe CPS

(HANDOUT - Kinesiophobia Among Patients with Musculoskeletal Pain in Primary Healthcare)

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Pain Cycle

Pain

Disability

Distress

Experience of pain includes emotional reaction and is influenced by many factors - prior experiences with pain, meaning

given to pain, emotional stresses, and family/cultural influences

Pain is subjective phenomenon and clinicians cannot reliably detect its existence or quantify its severity without asking

patient directly

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Symptoms

Pain that does not go away as expected

Described as shooting, burning, aching, pounding, or electrical

Associated discomfort, soreness, tightness, stiffness, or weakness

Fatigue, impatience, loss of motivation, sleeplessness

Weakened immune system - leading to frequent infection/illness

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Mood changes - hopelessness, fear, irritability, anxiety, stress

Depression - worsens pain, vicious cycle

Disability from school, work, or activities of daily living

Pain behaviors vary from individual to individual

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10 indicators of pain – developed by University of Alabama (UAB) to assist healthcare professionals when observing

pain

1. Verbal vocal complaints

2. Nonverbal vocal complaints

3. Down time – time spent lying down each day between 8am and 8pm because of pain

4. Facial grimaces

5. Standing posture – stooped, favoring one side of body

6. Mobility – limping, slow pace

7. Body language – clutching or rubbing site of pain

8. Use of visible supportive equipment – braces, crutches, cane

9. Stationary movement – squirming, restlessness

10. Use of medication

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Care

Assessment (HANDOUT - Chronic Pain Assessment and Validation) (HANDOUT – Assessment Tools)

Detailed medical history

Comprehensive assessment - medical, psychological, psychosocial

Pain diary

Physical exam - musculoskeletal system, nervous system, cognitive

Mental health assessment - rule out psychological diagnosis which can contribute to chronic pain

Diagnostic studies - x-rays, MRI, CT scan, ultrasound, myelogram, discogram, EMG/NCV studies, angiogram,

vascular studies, bone scan

Lab work

Diagnostic procedures - nerve blocks/injection, identify nerve causing pain

Referral to specialist (pain management, physiatrist, neurologist, anesthesiologist)

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Co-morbidities

Pre-existing health problems

Overall general health condition

Lifestyle choices

Smoking

Addictions

Psychiatric illness/psychological diagnosis

Psychological stress

Aging

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Diagnoses

Arachnoiditis

1 of 3 membranes covering brain/spinal cord (arachnoid membrane) becomes inflamed

Produce disabling, chronic, progressive pain

Arthritis

Osteoarthritis

Rheumatoid arthritis

Ankylosing spondylitis

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Sciatica

Pressure on sciatic nerve

Pain in buttocks

Common cause is herniated disc

Spondylolisthesis

Vertebra extends over another vertebra

Causes pressure on nerves

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Spinal stenosis

Narrowing of canal surrounding spinal cord

Occurs naturally with aging

Causes weakness and pain in legs

Relieved by sitting down

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Radiculopathy (HANDOUT - Evaluation and Management of Low Back Pain)

Damage to spinal nerve roots

Causes pressure on nerves

Headaches

Migraines

Cluster headaches

Tension headaches

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Head and facial pain

Temporomandibular joint syndrome - TMJ

Cranial neuralgia

Trigeminal neuralgia

Myofascial pain syndrome - injury/trauma or overuse of muscles

Trigger points

Fibromyalgia

Polymyositis/dermatomyositis

Spasticity

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Neuropathic pain

Injury to nerves - peripheral or central nervous system

Can occur in any part of body

Described as hot, burning, pins/needles, numbness, electricity

Common diagnoses

Diabetic neuropathy

Phantom limb pain

Post-herpetic neuralgia

Complex regional pain syndrome (CRPS) - injury or noxious stimuli to nerve fibers in extremity - mainly

median/sciatic/ tibial/ulnar, develops after injury/surgery (onset immediately or delayed for months), symptoms -

burning pain, allodynia (pain due to stimulus that does not normally provoke pain), edema, changes in blood

flow/skin temperature - colder/color - shiny, hair loss, muscle atrophy, excessive perspiration, hyperalgesia

(increased response to pain), hypersensitive to temperature/touch; guarding, pain not proportional to injury/surgery;

symptoms can travel to other extremities

CRPS I - formerly reflex sympathetic dystrophy, not limited to single peripheral nerve, nerve study would rule

out CRPS I

CRPS II - formerly causalgia, damaged peripheral nerve, nerve study would confirm CRPS II

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(HANDOUT - Evidence Based Guidelines for Complex Regional Pain Syndrome Type I)

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Other

Vascular - inflammation of blood vessels, interruption between blood vessels and nerves

Ischemia - lack of blood supply to organs/tissues/limbs

Circulatory problems

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CPS Cycle

more PAIN

INACTIVITY

WEAKNESS

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Treatment (HANDOUT - Assessment and Management of Chronic Pain) (HANDOUT - MAMC Chronic Pain

Outpatient Management Guideline)

Studies show the presence of CPS strongly suggests that medical interventions (including surgery) will not be effective -

accurately distinguishing between chronic pain and CPS is critical for effective treatment

Pain management is complex biological, psychological, social, spiritual, and cultural process

Most successful treatment plans incorporate psychological, physical, and pharmacological (non-invasive and invasive)

components provided by interdisciplinary team

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Combination therapy is more effective than single therapy for long term pain management

Early treatment of pain syndromes improve outcomes

Primary goals are to reduce/remove pain to greatest extent possible

Improve functioning to greatest extent possible

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(HANDOUT – Diagnosis and Treatment of Depressive Illness in Chronic Pain Patients: Effects on Functional

Restoration)

Psychological Examples of traditional psychological approaches

Education

Psychotherapy - cognitive behavioral therapy

Relaxation training

Biofeedback

Support group

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Physical

Examples of traditional physical approaches

Facility

Physical therapy

Occupational therapy - ultrasound, iontophoresis, conditioning, strengthening, flexibility, mobility

Home modalities

Transcutaneous electrical nerve stimulation (TENS) unit - lead attached to skin patch, brief pulses of electricity to nerve

endings in skin to relieve pain, alters pain signals that travel to brain

Ultrasound

Heat/cold

Home exercise program

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Alternative - compliments traditional treatment for psychological and physical approaches

Biofeedback - method of consciously controlling a body function that is normally regulated automatically by body

(example - skin temperature)

Relaxation therapy/guided imagery - series of thoughts/suggestions that directs person's imagination toward

relaxed/focused state

Exercise - walking, yoga

Chiropractic therapy

Acupuncture

Acupressure/reflexology

Healing touch - influences person's physical or emotional health without physically touching person

Meditation/distraction

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Homeopathic medicine - belief that body has ability to heal itself

Aromatherapy - essential oils

Hydrotherapy/aquatic therapy

Hypnosis

Humor therapy

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Music therapy

Magnet field therapy

Massage therapy

Naturopathy - organize foods, exercise, healthy/balanced lifestyle to prevent disease and treat illness

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Pharmacological/Non-invasive (HANDOUT – Pharmacological and Nonpharmacological Pain Management)

(HANDOUT - Palliative Care & Pain Management, Table 5-3 & Table 5-4)

Over-the-counter medication

Analgesic - Acetaminophen

Non steroidal anti-inflammatory (NSAID) - Aspirin, Ibuprofen, Naproxen, , used for cold/sinus/allergies

Topical and transdermal - Capsaicin, Biofreeze, creams/gels

Prescription medications (HANDOUT – Chronic Pain Medications: Current Trends for Life Care Planners)

Four major classes of prescription medications to treat chronic pain - 1) non-opioid, 2) opioid, 3) adjuvant analgesics -

medications originally used to treat other conditions and have cross-over relief from chronic pain (example - anti-

depressant, anti-convulsants), and 4) other - medications with no direct pain-relieving properties, but prescribed in pain

management regimen (example - insomnia, anxiety, depression, and muscle spasms)

Non-opioids

Analgesic - Acetaminophen, Aspirin

Non steroidal anti-inflammatory (NSAID)/COX-2 inhibitor - Relafen, Toradol, Voltaren, Indocin, Feldene,

Daypro

(HANDOUT – The Marginalization of Chronic Pain Patients on Chronic Opioid Therapy) (HANDOUT - Use of

Chronic Opioid Therapy in Chronic Noncancer Pain)

Opioids

Long-acting/sustained or extended release – Morphine, Oxycodone, Fentanyl

Sedative/tranquilizer - Ambien, Lunesta, Rozerem

Topical and transdermal - EMLA cream, Lidocaine patch, Duragesic patch, creams/gels with compound

medications

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Adjuvants/Other - does not directly provide analgesia, used more extensively in chronic pain than acute pain

Anti-depressants

Tricyclic anti-depressants – Elavil, Sinequan, Remeron, Pamelor

Selective Serotonin Re-uptake Inhibitors - Prozac, Zoloft, Paxil, Celexa, Lexapro

Selective Serotonin and Norepinephrine Re-uptake Inhibitors - Cymbalta, Effexor, Wellbutrin

Corticosteroids - Prednisone

Anti-convulsants/anti-eleptics - Neurontin, Lyrica, Dilantin, Keppra, Topamax, Tegretol, Klonopin

Muscle relaxants - Soma, Flexeril, Robaxin, Skelaxin, Valium, Parafon Forte

Benzodiazepines

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Pharmacological/Invasive (HANDOUT - Botulinum Toxins for Analgesia) (Consensus Guidelines for the Selection

and Implantation of Patients with Noncancer Pain for Intrathecal Drug Delivery)

Intramuscular medications

Trigger point injections

Botox injections

Intravenous medications

Epidural steroid injections - cervical, thoracic, lumbar, caudal

Nerve block therapy

Spinal joint blocks - facet neurotomy, facet injections

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Radiofrequency ablation/lesioning

Intra-disk Electrothermal Therapy (IDET)

Vertebroplasty/kyphoplasty

Dorsal column stimulation/neurostimulation therapy - treats chronic intractable pain (neuropathic)

Intrathecal drug infusion system - treats pain or spasticity

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Health Care Expenses

Billions of $$ spent each year for unrelieved pain

Direct costs for care related to migraine headaches exceeded $2.4 billion/year in U.S.

Average cost for 1st year of pain management related to failed back surgery was $34,716 in U.S.

Annual total of direct and indirect costs for chronic pain estimated $295 billion/year

Annual total of direct and indirect costs for chronic back pain estimated $100 billion/year

Pain medication - 2nd most frequently prescribed drug during MD and ER visits

Surgery - 2nd most common treatment for chronic pain

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Implantable devices - initial costs for screening/hospital/professional charges range $27,577 - $55,135

Multidisciplinary pain rehabilitation centers - only 6% of patients treated by pain specialists participate, average cost is

$15,339

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Nurse Life Care Planning Process

Assessment

Location/onset/duration/intensity

Character

Associated symptoms

Aggravating and alleviating factors

Previous treatment outcomes

Psychological intervention

Family history of chronic pain, substance abuse, physical/sexual abuse

Assess for secondary gain

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Assess for impact of pain on social, physical, occupational, and sexual function and overall quality of life

Observe all cues

Neurologic

Musculoskeletal

Psychosocial

FIM-FAM

Bathing/showering/hygiene

Grooming

Dressing

Feeding

Mobility

Transportation

Living arrangements

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Nursing Diagnosis

Chronic pain

Risk for injury

Social isolation

Spiritual distress

Ineffective individual coping

Activity intolerance

Anxiety and fear

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Outcomes

Collaboration

Pain management

Physiatrist

Physicians

Therapists (OT, PT, psych)

Home health providers

Equipment vendors

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Medical Research (HANDOUT - Practice Guidelines for Chronic Pain Management)

Psychological - Physical - Pharmacological approach yields best outcome for pain management

Agency for Healthcare Research and Quality (ahrq.gov) - National Guideline Clearinghouse

Journal of American Society of Interventional Pain Physicians (painphysicianjournal.com)

Department of Veterans Affairs (healthquality.va.gov/) (HANDOUT - VA CGP Management of Opioid Therapy for

Chronic Pain)

American Pain Society - Clinical Practice Guidelines (HANDOUT - Clinical Guidelines for the Use of Chronic Opioid

Therapy in Chronic Noncancer Pain)

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Chronic Complications

Opioid side effects

Central nervous system - sense of emotional well being/euphoria, drowsiness/sedation, sleep disturbance,

hallucinations, potential for diminished psychomotor performance, dysphoria, agitation, dizziness, seizure, hyperalgesia

Respiratory - respiratory depression due to toxicity or medication combining

Ocular - constriction of pupil

Gastrointestinal - constipation, nausea, vomiting, delayed gastric emptying

Genitourinary - urinary retention

Endocrine - hormonal and sexual dysfunction

Cardiovascular - decreased blood pressure, slowed heart rate, peripheral edema

Musculoskeletal - muscle rigidity/contractions, osteoporosis

Integumentary - itching (not allergic reaction)

Immune - suppression, at risk for infection/illness

Pregnancy and breast feeding - all opioids cross placenta, neonatal depression if opioids used during labor, use with

caution during breast feeding

Analgesic tolerance - decreased duration of analgesia, then decreased effectiveness

Withdrawal syndrome - may occur with abrupt opioid cessation

(HANDOUT - SCI Related Pain: Diagnosis, Treatment and Life Care Considerations) (HANDOUT - LCP for

Pediatric Chronic Pain Patients) (HANDOUT - LCP for the Amputee with Chronic Pain)

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Planning

Treatment Recommendations in Nurse Life Care Plan

Medical

Physician appointments/evaluations

Pain management

Neurological

Musculoskeletal

Genitourinary

Gastrointestinal

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Surgeries/Procedures (invasive vs. non-invasive)

Injections

Blocks

Spinal cord stimulator (HANDOUT - Neurostimulation Therapy - Commonly Billed Codes) (HANDOUT -

Neuromodulation Products) screening - psychological evaluation

trial

implantation

reprogramming

revision

Intrathecal infusion pump (HANDOUT - Intrathecal Drug Delivery - Commonly Billed Codes) (HANDOUT - External

Pump Trailing System) screening - psychological evaluation

trial

implantation

refill

revision

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Hospitalizations

Inpatient pain program

Exacerbations

Detoxification program

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Therapeutic Evaluations

OT

PT

Psychological

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Therapeutic Modalities

OT

PT

Psychological (individual & family)

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Diagnostic Studies

Neuropsychological

Musculoskeletal - x-rays, MRI, CT scan, bone scan

Neurological - EMG/NCV studies

Lab Work

Comprehensive metabolic panel - includes BUN & creatinine (liver & kidney function - should establish baseline &

then periodic follow-up

Therapeutic drug assay

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Medications

Non-opioid

Opioid

Adjuvant

Other

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Medical Supplies

TENS unit - leads/electrodes, wired, pads, unit, battery

Muscle stimulator - leads/electrodes, wired, pads, unit, battery

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Durable Medical Equipment/Aids for Independent Function

Hospital bed vs. electric bed & mattress/overlay

Transfer bench

Shower chair

Elevated toilet seat with rails

Recliner chair

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Mobility

Cane

Walker

Manual wheelchair

Power wheelchair

Motorized scooter

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Non-medical

Home care/living arrangements

Home

Home health care vs. respite care

Unskilled

Skilled

Assisted living

Skilled nursing facility

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Architectural renovations

Barrier free

Wheelchair accessible design

Assistive technology

OT home evaluation

Contractor home evaluation

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Transportation

Wheelchair accessible transportation

Personal vehicle

Handicap driver evaluation

Handicap driver training

Handicap parking permit

Vehicle modifications

Public transportation

Private transportation

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Educational/Vocational

Vocational evaluation

Vocational case management

Vocational retraining

Vocational modifications

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Other

Case management

Support group - pain associations/conferences

Fitness - gym vs. home

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