Pain Management Edt
Transcript of 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