Pain Management

What is pain?

One of the most common reasons people seek healthcare

One of the most widely under-treated health problems

Pathophysiology A sensation caused by some type of

noxious stimulation A pattern of responses that function to

protect the individual from harm Whatever the experiencing person says

it is whenever he says it does

Components of PainPhysical

Caused by some kind of noxious stimulant

EmotionalResults of combination of thoughts, feelings, and beliefs

BehavioralPattern of responses that function to protect the individual from further harm

Causes of PainCutaneous

Direct stimulation to skin (cut)

Somatic

From musculo-skeletal system (sprained muscle)

Visceral

Arising from hollow organs (appendicitis)

Neuropathic

Damage to nervous system

Referred

Pain arising from someplace else in body

Descriptions of pain

• Chronic: occurring over a long period of time

• Acute: sudden, brief onset

Visual Analog ScaleThis is a line 10 cm. long (about 4 inches) that

is divided into ten divisions. Patients are asked to show the amount of pain on a 1-10 scale.

Researchers say that patients cannot function with a scale with more than ten points.

PQRSTThis mnemonic is devised to show the

steps in pain assessment: Provoking factors Quality Region/Radiation Severity/Symptoms Timing

• Provoking factors include what caused the pain and what might be making it worse

• Quality questions refer to how the pain feels…let the patient tell but offer suggestions if necessary, like sharp, dull, throbbing, burning, etc.

• Region….have patient point to area that hurts

• Severity can be measured with the pain rating scales

• Symptoms may accompany the pain….nausea, vomiting, etc

• Timing refers to when the pain started, how long it lasts

Be aware

• Just because a patient cannot respond to pain doesn’t mean there is no pain

• Activities of daily living (ADLs) may be effected

• Neurological status will alter the response to pain

Pain Management

Management must be timely, individualized,and bring the pain to an acceptable level of tolerance

Pharmacologic interventions

Must be individualized

• Three main categories:– Non-opioids– Opioids– Adjuvants

Non-opioids: Acetominophen (Tylenol) Aspirin NSAIDs (Advil)

Opioids Weak Strong

Codeine Hydromorhone Oxycodone Morphine Vicodin Merperidine

Adjuvants Primary function is not pain relief but provide relief

May modify mood so patient feels better

Precautions to giving pain medications

• Medication choice may depend on practitioner’s preference, however:– Should not give two analgesics

from same class at same time– Must be aware of effects of

medications– Must watch for allergic reactions

Routes of medication administration

• Oral• Injection• Intravenous (includes PCA)• Epidural• Rectal• Topical

SEVERE PAIN: Keep giving mild pain medication and add a strong opioid such as morphine or Fentanyl

MODERATE PAIN:Keep giving mild pain medication and add a mild Opioid such as codeine

MILD PAIN:Aspirin, ibuprophenAcetominophen, naprosyn

WHO Pain Ladder

Concepts of WHO Pain Ladder

• By the mouth

• By the clock

• By the ladder

• For the individual

• With attention to detail

Placebos

Controversial use of an inactive substance to satisfy the demand for medication

Non-pharmacologic interventionsPain control without using medications• Alter the environment• Relaxation and guided imagery

– Meditation• Cutaneous stimulation

– Massage, acupressure, acupuncture, TENS

• Biofeedback• Therapeutic touch• Education

JCAHO Standards for Pain Management

• Address care at the end of life

• Assess and manage pain appropriately

• Assess pain in all patients

• Support safe medication ordering and administration

• Monitor patient during post-procedure period

• Rehabilitate for optimal level of function

• Educate about pain an managing pain• Plan for discharge continued care if

needed• Collect data to monitor performance

Nurses spend more time with patients than any other provider. They must stay informed in order to give the best care to their patients.

• References:– Falk. Kim Marie. Pain Management. National

Center of Continuing Education. Catalog 98 TX.

– http://www.fxbcenter.org/caring/painladder.html

– http://www.harcourthealth.com/Mosby/Wong/fyi_03.html