Pain Management – An Introduction

Thea Addison, Vicki Yates

Acute Pain Nurse SpecialistsDerby Hospitals NHS Foundation Trust

Aims of the Session

The Pain Team & their Role Define pain Emphasise the different pain pathways Types of pain Assessment of pain & pain tools Barriers to pain assessment Simple interventions

Role of the Acute Pain Team

Overall responsibility for Acute Pain Management throughout the trust

Expert clinical and educational pain management resource

Service initially set up for post-op pain management

Now - Complex diverse pain problems

In-patient Pain Team - A more accurate title?

Clinical / Education / Audit / Research

Links with

Outreach Team Palliative Care Team Ward based link nurses School of Nursing Clinical facilitators + educators Other nurse specialists Regional and National Specialists in Pain

Definition of Pain

‘Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does’

McCaffrey(1968)

Definition of Pain

‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is always subjective……always unpleasant and therefore also an emotional experience.’ International Association for the Study Pain (1979)

Why Treat Pain?

Humanitarian ReasonsClinical Effects of PainReduces Stress ResponsePatient SatisfactionPromote Early Discharge

How Do We Feel Pain?

Two Major Types of PainNociceptive: pain due to tissue damage

Neuropathic:pain due to injury of nerve pathway - painful sensations are carried from the site of injury to the brain - treatment will depend on type of pain

Acute Pain

Helps diagnose illness by acting as a warning mechanism - therefore is a symptom

From trauma often imposes limitations, which can prevent aggravation of an injury

In post-operative period serves no useful purpose and can be detrimental to the recovery of the patient

Recent studies/surveys indicate that pain control still remains an inconsistent affair

Chronic Pain

Untreated Acute Pain can become

Chronic Pain

Chronic Pain

Pain that persists beyond the expected healing time

Not simply a prolonged duration of acute pain. Biological changes in central nervous system. Adaptation of autonomic nervous system. Complex Pain that is prolonged in nature, due to

known reasons or absence of evident tissue damage.

Complex interplay of biological & psychological factors.

7.5 million pain sufferers in UK

Cancer Pain

Cancer is a dynamic disorder and patients may experience Acute as well as Chronic pain due to further tissue damage

Pain of varied duration/commonly progressive Pain may be associated with symptoms which

signal deterioration eg weight loss, anorexia, physical dependence, lack of sleep

Realization of dying may result in “overwhelming pain” that is difficult to describe and to assess

ACUTE

Transient Warning mechanism Usually decreases

at around 48hrs Start at top of

medication ladder

CHRONIC

Persistent No useful purpose Tends to increase as

time goes on Starts at bottom of

medication ladder

Pain Assessment

Advantages Provides patients with an opportunity to

express their pain Conveys genuine interest & concern about

their pain Gives patients an active role in their pain

management Can provide documented evidence of the

efficacy or failure of drugs / treatments

Pain Assessment

When Initially to understand the pain & develop a care

plan Immediately following surgery / procedures Prior to & following administration of analgesia /

treatments At a report in change of description, location or

intensity of pain Deep breathing / coughing / moving limb etc

Pain Assessment – What You Need to Know

Location Description Duration Pain Intensity ? Related to admission Influencing factors Deep breathing / coughing / moving limb

etc Drug history

Pain Assessment Tools

Pain Intensity Scales

Visual Analogue Scales (VAS) Numeric Scales Verbal Rating Scale (VRS) Body charts

Pain Assessment Tools

Visual Analogues ScaleNo The worstPain pain

imaginable

Numerical Rating Scale

0 1 2 3

Pain Assessment Tools

Verbal Rating Scales

0 = No pain

1-3 = Mild pain

4-6 = Moderate pain

7-10= Severe pain

Acute Pain Chart

0 = No pain

1 = Mild pain

2 = Moderate pain

3 = Severe pain

Descriptive Words for Pain

Throbbing CuttingBurningStingingAching TiringBlinding IntensePenetrating NaggingShooting GnawingSearingTender DullWhat makes pain

better?

Frightful AnnoyingUnbearable RadiatingNauseating StabbingCrushing SmartingHurting SplittingVicious SpreadingPiercing Torturing

Factors Influencing Coping

Age / gender Culture / Social beliefs Emotions, eg fear, anxiety, anger, sadness &

depression Fatigue, sleeplessness Past experiences Expectations Communication & information

PAIN IS THE 5TH VITAL SIGN

Patient assessment is the first stage in managing pain well!

Non-Verbal Signs

Body Language- posture, lying still, rolling around, rocking, withdrawn

Facial Expressions-crying, grimacing,frowning

Disrupted sleep pattern

Note! Patients with long

standing pain may tell you they have severe pain but not display any of these signs!

Assessing Pain in Patients Unable to Communicate

Mentally / cognitively impaired patients Sensory impaired patients Unconscious patients Neonates / children

Assessing Pain in Patients Unable to Communicate

How Patients self-report if possible / carers report Observation of behaviour incl. posture, movement Comparing current with usual behaviour Abnormal change in behaviour eg aggression /

agitation Patients interactions with others Check for full bladder / colic caused by

constipation Sleep and diet

The Cognitively Impaired Patient

Some patients who are confused in time and place will still be able to report and describe pain!

Once patient becomes very vague, confused or unconscious, signs which signal pain should be looked for eg Restlessness or agitation crying out or groaning Withdrawing, localizing or guarding Rocking, immobility or rubbing the area

Impact of Pain

Clinical: BP, Pulse, Resps, sweating Functional: reduced mobility & associated

problems Emotional: the meaning of pain – effects,

anxiety, depression Social/occupational: role, finance, family,

sexuality

Barriers to Pain Assessment

Healthcare Professionals Attitudes Skills Knowledge / misconceptions Failure to routinely assess & document Legal aspects of drug administration Drug round times

Barriers to Pain Assessment

Patients Want to be a ‘good patient’ Language or cultural barrier Fear of addiction/unwanted side effects

/misconceptions Value of suffering - no pain / no gain Expectations and goals Reluctance to report or use word “pain” Litigation

Barriers to Pain Assessment

Healthcare System

A low priority given to pain care Restrictive regulation of controlled substances Lack of access to pain specialists Resources & workload

Failure to Manage Pain Well

Inadequate assessment

Failure to evaluate interventions

Failure to reassess

Simple Interventions

Comfort Measures

Therapeutic environment Patients bodily comfort Relaxation Massage / touch Guided Imagery Diversional activities Confidence building

Simple Interventions

Preventative Measures Positioning Carefully support painful area Attention to Dressings Provide pressure relieving mattress Hot/cold packs Ensure medications and adequate hydration

is given Encourage and assist with exercise

Simple Intervention

Recognise the power of suggestion and Patient Partnership!

Listen to the patient Support the patient Reassure the patient

NB Be aware of your own limitations and ask for support!

Benefits of Treating Pain

Humanitarian - quality of life Aids recovery Reduces complications Improves patient & carers satisfaction Healthcare outcomes -

can prevent readmission hospital stay

Ineffective Pain Control

If not achieved the “5 D’s” can occur!

DISCOMFORTDISABILITYDISSATISFACTIONDISEASEDEATH

- COMPLAINT / LITIGATION

Summary

Pain is an individual experience Listen to your patient Effective assessment and documentation Non-pharmacological management Evaluation/ Documentation

Useful websites

www.painsociety.org www.ampainsociety.org www.pain-talk.co.uk www.iasp-pain.org/ www.anzca.edu.au www.medicine.ox.au.uk/bandolier www.medicines.org.uk www.painradar.co.uk

References

McCaffery, M. (1968) Nursing Practice theories related to cognition, bodily pain, and man-environment interactions.