Transcript From Pain to Comfort

From Pain to Comfort
Meg Beturne MSN,RN,CPAN,CAPA
Objectives
Define pain
 Discuss pain assessment and management
utilizing ASPAN’s Clinical Practice Guideline
 Identify pharmacological and nonpharmacological interventions
 Describe the challenge of chronic pain in
perioperative areas
 Discuss comfort management

PAIN DEFINED
Pain is usually a localized physical
suffering associated with bodily disorder
 Pain is one of the body’s most important
protective mechanisms
 Pain is a complex mechanism with
unpleasant physical, emotional and
cognitive components associated with
actual or potential tissue damage

Pain: The Sixth Vital Sign
Pain is “whatever the person experiencing
it says it is, and existing whenever the
person says it does”- Gold Standard
 The patient is the ONLY one who can
accurately describe his/her pain
 It is subjective
 All pain should be considered REAL
 Pain can negatively affect the body
McCafferty,2011

Newest Insights



Definition of Pain refined:
Person’s inability to verbally communicate
does not preclude the possibility that pain
is present
Does not negate the responsibility of
healthcare providers to treat it!
Case Scenario
Example: 30 year old female SBO first day
post-op; tells you she is in pain & is on
phone talking. Do you still believe her?
 YES! Pain is subjective and she is using
distraction successfully which is a nonpharmacological way to manage pain
 Since it is distracting her from the pain,
you can now medicate her appropriately

Pain Pathways





Nociceptors: give the body the ability to
produce pain
Nerve endings present in skin, viscera,
blood vessels, muscle, joints
Activated by noxious stimuli, leads to
inflammation & release of bradykinin &
prostaglandins
Pain impulses initiated by direct tissue
damage and by release of chemicals
Pain travels very fast!
Pain Conduction
Transduction: cutaneous nociceptors send
impulses to spinal cord
 Transmission: Impulses synapse either by
fast or slow pain fibers
 Perception: pain impulses processed by
thalmus & cerebral cortex
 Modulation: along the efferent fibers, pain
may be inhibited or modulated

Pain Threshold & Tolerance
Threshold: point at which stimulus is
perceived as painful; fairly uniform person
to person
 Tolerance: maximum intensity of duration
of pain a person is willing to endure
before needing some intervention; this
varies from person to person
 Tolerance is not to be judged as
acceptable or unacceptable by health care
providers

TYPES
Cutaneous: arises from superficial
structures ( skin and subcutaneous areas)
 Sharp, cutting, burning, throbbing,
localized
 Burn or paper cut
 Deep Somatic: originates in deep body
structures ( muscles, bones, tendons,
joints)
 Characterized as dull or diffuse
 Muscle cramps

MORE TYPES
Visceral: origin is in visceral organs
 Deep, dull, poorly localized
 Associated with nausea & vomiting,
hypotension, weakness
 Referred: perceived at a site different
from its point of origin
 Chest pain ( cardiac muscle doesn’t have
pain receptors); pain can move to left
arm, jaw
 Gallbladder pain felt in the shoulder

ACUTE PAIN






Acute: pain that extends until period of
healing (less than 6 months), “temporary”
Identifiable cause
Occurs soon after injury
Onset sudden or slow
Intensity mild to severe
Autonomic response: BP,RR,HR increased;
pupils dilated; diaphoresis, pallor, facial
grimacing, restlessness, guarding behavior
CHRONIC PAIN







Chronic: extends beyond (3-6 months)
May limit ADLs
May not have identifiable cause
Non protective ( serves no purpose)
May lead to depression, fatigue, insomnia,
anorexia, apathy & learned helplessness
Autonomic response: BP,HR, RR, Pupils,
skin are all normal
If severe & prolonged, PNS activated=
muscle tension, HR & BP low, failure of
body’s defenses
Point of Emphasis
Physiological signs ( i. e. elevated blood
pressure and elevated heart rate) are least
sensitive indicators of pain, especially in
chronic pain
 Don’t withhold pain medication because of
these changes alone

CHRONIC- Two Types
Chronic Non-Malignant
 Ongoing, lasting more than 6 months
 NOT due to life threatening causes
 NOT responding to currently available
treatments
 May continue for remainder of life
 Low back pain, arthritis, neuralgia,
Crohn's, migraines, peripheral neuropathy
 Chronic Malignant
 Cancer pain

Chronic Pain in the Sexes
Conditions associated with chronic pain in
women: Fibromyalgia, IBS, Rheumatoid
Arthritis, Migraines; possible hormonal
links; focus on emotional aspects; more
likely to seek help than males; helpful to
re-label pain as being manageable
 Conditions associated with chronic pain in
men: cluster headaches, gout, heart
disease; focus on sensory aspects

Chronic Pain, Surgical Patient
Require special consideration & planning for
pain management :Methadone, Suboxone
 Request consultation with acute pain
service, anesthesia consultation
 Continually communicated individualized
pain management plan
 Add, optimize first-line meds; rotate opioids
 Educate patient to bring in chronic pain
medications ( migraine, back pain)
 Patient role in goal setting

Other PAIN Terms
Breakthrough Pain: pain that increases above
the pain addressed by the ongoing analgesics
 Neuropathic Pain (Pathologic): arises from
nervous system (peripheral or CNS)- has
multiple mechanisms- shooting, sharp, electric
 Discomfort: being uncomfortable in body or
mind; mild distress
 Suffering: feel pain/distress; sustain harm;
injury, pain or death

Sobering Statistics
15% Americans with major trauma/surgery
pain (45 million)
 25% Adults have chronic pain ( > 76 million)
> diabetes, heart disease, cancer combined
 50% of inpatients/outpatients have pain
 30% patients give hospital low marks for
pain control
 Untreated/undertreated pain still common
CDC (2007) Fast Facts

The Truth About PAIN
Lack of expression does not equal lack of
pain~ physiologic and behavioral
adaptations to pain occur
 Not ALL causes of pain are identifiable
 Respiratory tolerance is rapid
 Sleep is possible with pain but not good
quality
 Elderly experience pain but do not express
it as much and so do babies!
 Addiction is rare 0.1-0.3%

Pain: A Perioperative Problem
Nearly all patients have postoperative pain
45million: 80% rate it moderate to severe
 Pain is the most common reason for
elective procedures
 Fear of pain is the #1 reason for delaying
elective surgery: reported by 59% pts.
 50% patients still have pain 1 year after
surgery; 30% still have pain 10 years
later!
National Center Health Statistics,2006

Patient Expectations





If pain is present:
A professional, comprehensive assessment
Individualized evaluation methods,
consistent with age, condition and ability
to understand
Treatment when present, or refer for
treatment
Evaluation of effects of treatments
Relief of Pain
“It is not the responsibility of patients to
prove they are in pain; it is the nurse’s
responsibility to accept the patient’s report
of pain” ( American Pain Society, 2005)
 “Relief of pain is a basic human right”
(American Pain Foundation,2001)
 “Relief of pain is a basic human right”
(American Bar Association, 2000)

Ethical Duty of the Nurse
Provide clinically competent, ethically
defensible care
 Duty to relieve pain, provide humane care
 Suspected or known addiction disorder
 Give opioids when clinically indicated &
ordered
 Protect patients/society from unauthorized
opioid use
 When ethical dilemmas exist,
communicate them!

Pain Assessment
Joint Commission Standards PC 01.02.07
Assess, Treat, Reassess, Document Pain
 Identifying & treating pain is part of care
 Must be assessed during rest and activity
 Includes defining:
 How patient gets screened
 Who assesses pain & when it is
reassessed
 How pain data is collected & recorded
 When in-depth evaluation is needed

Joint Commission
Pain Management Standard
 Patients and their families must be
educated about pain management plan
 Patients need to report pain
 Patients need to cooperate with the
prescribed treatment
 Scope of standard: behavioral health,
critical access, home care, hospitals, longterm care and ambulatory care

BARRIERS to PAIN Assessment
Patient Barriers
Fear, pessimism, catastrophizing
 Pain, effects of drugs, death
 Addiction to analgesics
 Pain will be intolerable
 Anxiety: Cured?
 What post-op sensations are normal?
 Unrealistic expectations
 Interpretation of experience different than
team: age, culture, background

Professional Barriers
Mistaken beliefs about pain & treatment
 Inconsistent assessment & reassessment
 Systems barriers ( computers, access to
resources)
 Inadequate “handoff” communication
 Biases, attitudes

Other Barriers
Self-reports in pre-op are limited
 Misunderstandings of pain scales
 Over-reporting/underreporting of pain
 When to assume pain is present/relieved?
 Patients unable to report pain using usual
self-report tools ( infants, unconscious,
cognitively impaired, ventilated,
impending death

Pediatrics Behavioral Tool
Difficult to distinguish pain from fear
 Rely on parent reports
 Observe behaviors
 Can use FLACC: Face, Legs, Activity, Cry,
Consolability; 0-2 each with 10 being
maximum; Behavioral score only, not
intensity rating

NIPS-Neonatal Infant Pain Scale
Facial expression, breathing, arms, legs, cry,
state of arousal
 CRIES: scale for neonatal 32 weeks to term;
Cry, Requires Oxygen, Increased vitals,
Expression, Sleeplessness

CPOT
Critical Care Pain Observation Tool
 0-8 behavioral scale
 2 points for each category:
 facial expression
 body movements
 muscle tension
 ventilator tension or verbalization

Cognitive Impaired
Assess at rest and activity
 Insure functioning hearing aid
 Have eyeglasses handy
 Repeat questions and allow time for
responses
 Enlarged font helps
 Self-report with descriptors, not numbers!
 Consider behaviors: eating, sleeping,
mood, body movement

Special Considerations









Elderly: pain prevalence 2-fold higher >60
Report of pain altered
Have acute & chronic painful diseases
Take many medications
Have multiple diseases
^ sensitivity: therapeutic, toxic drug effects
Prone to constipation (opioids)
NSAIDs;> risk GI, renal, platelet problems
> Sensitivity to analgesic effects: higher
peek effect, longer duration, dose titration
Special Considerations






Known/suspected chemical dependency:
Experience variety of health problems
Possible withdrawal from opioid absence,
causing > HR, restlessness, sleeplessness
Focus on managing PAIN , not
detoxification!
Don’t forget non-drug interventions
Higher loading & maintenance doses of
opioids may be required to reduce pain
intensity
ASPMN Position Statement






Pain Assessment in non verbal patients
When possible, obtain self-report
Look for possible pathologies, procedures or
other causes of pain
Observe for behaviors that may indicate
presence of pain
Obtain input from caretakers who know
patient & usual behaviors & responses to pain
Use an analgesic trial & observe for changes
in behavior
ASPAN Clinical Guideline
Introduced in JOPAN in 2003, available now
on ASPAN web site
 Speaks to Assessment, Interventions and
Expected Outcomes
 Includes all phases of practice including:
Preoperative Phase, Post Anesthesia Phase I,
and Post Anesthesia Phase II or Extended
Observation

Assessment Begins With…











Pre-op Data:
Vital signs & comfort goals
Medical history
Pain history
Pain behaviors
Analgesic history
Patient’s preferences
Pain/comfort acceptable levels
Comfort history
Cultural, religious factors
Educational needs
Interventions Begin in…








Pre-op:
Discuss pain & comfort assessment
Discuss with patient/family about
reporting pain & available pain relief
Dispel misconceptions about pain & pain
management
Encourage preventive approach
Educate purpose of meds & nonpharmacological measures
Discuss outcomes based on goals
Arrange for interpreter, signer as needed
Outcomes to Strive For!






Pre-op
Patient states understanding of care plan
Patient states understanding of pain
intensity scale, pain relief/comfort goals
Patient establishes realistic & achievable
pain relief/comfort goals
Patient understands PCA equipment
Patient understands benefit of non-drug
interventions
Post anesthesia Phase I







Assessment:
Type of surgery, anesthesia technique, etc
Analgesics, etc given inter-op
Pain & comfort levels
Status/ vital signs: ABCD
Age, cognitive ability & cognitive learning
method
ASSESSMENT DATA!
Assessment Data
Subjective data: who, what, where, why &
when are first clues of pain assessment
 Objective data: observation of facial
grimace, teeth clenching, frowning,
moaning, crying
 Physiological changes: increase BP, rise in
HR, increase in RR are signs that support
the patient’s subjective pain response

Other Physiological Signs
Dilatation of pupils and/or wide opening of
eyelids
 Shivering
 Change in skin and body temperature
 Increased muscle tone
 Sweating

ASSESSMENT
Location: examine site
 Intensity- use easy, fast, multicultural,
multilingual pain scale:
 Poker chip, Oucher scale
 Visual Analog Scale: pt. places mark on line
 Numeric Rating Scale: 0 to 10
 Wong Baker Faces Pain Scale: 3+ to adult
 Behavioral Rating Scale
 Body Diagram, Daily Diary
 Verbal Descriptor Scale: no pain to worse pain

Pain Rating Scales
Purpose: communication tool- here is
where you are now and here is where we
want you to be
 Documenting ratings helps evaluate trends
and treatment effectiveness
 Know which scale is most appropriate to
use ( i.e Wong-Baker preferred by African
American children)
 Important to have scales translated into
languages of populations served

ASSESSMENT (cont)
Obtain description of quality of pain
 Character, frequency, duration
 Achy, pulling, throbbing, burning, sharp,
dull, cramping, prickling, hurting
 Remember data obtained pre-op regarding
onset & duration; may apply post-op
 What time of day is pain worse?
 What gets pain started?
 Does the pain stay or come and go?
 How much pain in an average day?

ASSESSMENT (cont)
Remember data on pain aggravating &
alleviating factors obtained pre-op; may
apply post-op
 What makes pain worse or better?
 What other things have you tried to make
pain better that worked or didn’t work
 Seek information on impact of pain on
activities of daily living (ADL)
 Does pain cause problems with ADL?
 How upsetting is the pain?

ASSESSMENT (cont)
Describe pain behavior indicators
 Reluctance to move
 Quiet & withdrawn
 Facial expressions (grimace)
 Anxious, restless
 Crying, moaning, whimpering
 Desperate, using PCA frequently
 Don’t dismiss the patient’s self-report of
pain they are experiencing!

ASSESSMENT (cont)
Assess other causes of pain
 Chronic back/neck pain
 Bladder distention
 Hemorrhage, ischemia, rupture of viscus
 Nausea and vomiting
 Perform re-assessment for response to
medications for pain ( Joint Commission)
 How effective? LOC? Vital Signs? Extra
meds needed for breakthrough pain?
 Communicate & document all data!

Case Scenario
Patient had anterior/posterior lumbar
fusion done for an acute incident
 This patient also had chronic low back
pain that was 9/10 on a daily basis even
while taking narcotics
 Goal in PACU was to return patient to his
baseline level of pain
 It required Morphine 30mg & Dilaudid
10mg to return him to normal level of pain
which was 9/10

BARRIERS to PAIN Management
Biases as Barriers
Value stoicism and problem-focused
coping
 Expecting a certain degree of pain
 Is drug seeking, solely on the basis of:
 Report of pain greater than expected
 Pain medication requirements higher than
usual
 Lifestyle, diagnosis or demographic factors
 Nurse is better judge of pain than patient
 Pain is punishment for sins/wrong-doing

Case Scenario
Mrs. Smith is an elderly, Hispanic patient
who is status post hip replacement
 PCT informs you that Mrs. Smith needs
pain medicine. Should you just give it?
 NO, you assess her; determine type of
pain present; is that pain indicating a
problem? Could it be arthritis acting up?
 Are personal, cultural, spiritual or ethnic
beliefs in play?
 Do not assume anything!

Non-Drug Interventions
Positioning/repositioning/ambulation assist
 Elevation affected limbs
 Applying ice or heat therapy
 Covering incision with pillow (coughing)
 Rhythmic deep breathing, counting slowly
 Warm blankets, warming machines
 Non-stimulating environment (noise, light)
 Family, friends visiting ( or NOT)
 Attention from staff (schmooze factor)

Non-Drug Interventions (cont)










Complementary:
Relaxation, Massage therapy, backrub
Reflexology, Acupuncture
Humor
Reiki treatment, Therapeutic Touch
Distraction, Biofeedback
Guided imagery: pleasant sounds, smells
Hypnotism
Music Therapy, tapes of calming sounds
Prayer, visit from chaplain/cleric, religious
objects/symbols
Problems with Herbs
St. John’s Wart: use- depression /anxiety
 May cause increased effects of opioids
 May cause decreased effect of Elavil or
Digoxin
 Will cause increase in effect of
antidepressants
 Ginko Biloba
 May interfere with anticonvulsants
 When taken with NSAIDs, will cause
significant bleeding problems

Surgical/Acute Pain







Prevention is best approach: means
around the clock pain management
Allows patient to know their pain needs
will be met
Helps reduce anxiety about return of pain
May result in decreased doses, fewer side
effects, less time in pain
Physical activity may increase ~problems
caused by immobility can be avoided
Avoid actions that > pain
Patient to request med before pain severe
Methods of Pain
Management
1. Oral Analgesia
2. IV Analgesia
3. PCA Analgesia
4. Epidural Analgesia
Important Patient Data
Let’s review one more time!
 Any known allergies
 Patient baseline renal, bowel, bladder and
liver function
 Previous opioid use
 Health habits including drug/alcohol usage
 Baseline mental status
 Any other medications used
 Age, cultural, religious factors

Multimodal Approach
Appropriate combinations attack more
than one mechanism
 The synergistic action results in lowered
doses and a decrease in adverse effects
 Intensity/type of pain determine the route
 Oral: less invasive, preferred route for
chronic, persistent pain; great choice for
mild to moderate pain
 IV: severe, escalating pain
 Epidural: effective- delayed onset

Other Routes
Transdermal: Fentanyl (Duragesic patch)
 persistent, chronic pain; can’t take oral meds
 non-adherent patients; recovering addicts
 opioid tolerant kids > 2yrs with cancer pain
 48-72 hr application period
 patient preference, no stigma, bypasses GI
 Oral transmucosal (sublingual, buccal): Actiq
 rapid onset Fentanyl for breakthrough pain in
opioid tolerant patient; ideal for sudden onset
 sugar matrix on a stick ( 2.5-5 hrs)

Intranasal: Ketorolac (Sprix Nasal Spray)
for acute pain in ambulatory care
 Topical: EMLA (5% lido-prilocaine cream)
takes 60 min; Synera (mix of lido &
tetracaine) apply 20 min for analgesia
 Rectal: almost all oral meds can be given
this way
 Intramuscular: unreliable, painful, not
recommended unless there is no IV
 Subcutaneous: same as IM

Oral Agents




Non-narcotics:
Acetaminophen: reduces pain & fever; No
anti-inflammatory affect; No adverse
effects on kidney, gastric lining, platelets;
exceeding maximum dose: hepatotoxic
Usual dose: 650-1000mg p.o. Q4H,
maximum dose: 4GM/24hours, > 5GM=
toxicity!
Beware of other medications that contain
Acetaminophen! ( Vicodan, Percocet)
Oral Agents




Non-narcotics: mild to moderate pain
NSAIDs (anti-inflammatory/ antipyretic):
act on peripheral nerve system; ASA,
Motrin, Celebrex, Ketorolac (Toradol),
Naprosyn, ibuprofen; Do not give ASA with
NSAIDs; monitor for signs of GI bleeding
Maximum dose ibuprofen: 3200mg in
24hours
Motrin dosing: 600-800mg every 6h
NSAIDs
Effective for mild to moderate pain
 With opiods, these agents can have an
opiod sparing effect: lowers opiod
requirement and reduces potential for
opiod- related side effects
 Bextra and Vioxx: withdrawn- increased
cardiovascular risk, increased M.I. and
stroke post CABG

Adverse Effects
May alter hemostatic balance
 Avoid in high risk CV patients
 GI toxicity, increases greatly if 2 NSAIDs
are given; consider Nexium or Prilosec in
high risk patients
 Renal effects: can be avoided if patient
well hydrated
 Bone healing: stopping drug restores
normal healing after 14-21 days; avoid in
smokers or metabolic bone disease

Parental Non-opioids
IV acetaminophen (Ofirmev): single or
repeat dosing- 15 min. infusion
 Adults/teens> 50 kg. give 1000mg q 6 hr or
650mg q 4 hr to max of 4, 000mg per day
 Adults/teens < 50kg. and kids > 2-10 years:
15mg/kg q 6hr or 12.5mg/kg q 4 hr to max
of 75mg/kg/day= 3,750mg/day
 Within 15 min. increased level in plasma
 Cost= $11/dose

IV Ketorolac: short term pain
management- 5 days
 Dose: < 65: 30mg q6h(120mg/day=max)
 Pedi dose: 0.5mg/kg q6h
 Correct hypovolemia before administration
 IV Ibuprofen: approved for fever & acute
pain in adults; 400-800mg over 30min q
6h; maybe preferable to Ketorolac- less
inhibition of action

OPIOIDS
Fentanyl: 25-50mcg IVP q5 min prn
 Morphine Sulfate: 2mg IVP q5min prn
 Oxycodone (Percocet): 1-2 tabs q 4-6 hrs prn
 Hydromorphone (Dilaudid) 1-2mg IV, 2-4mg
po
 Hydrocodone ( Vicodin):5/500mg-1tab q4hrsnot to exceed 8tabs in 24hrs.
 Oxycontin ( MS ER): 30mg- 1tab q12 hrs
 Tylox 5/500mg: 1tab q6hrs prn
 Tylenol #3: 300/30mg 1tab q4hrs prn

Misc.
Meperedine (Demerol) 12.5-50 mg
 Not appropriate for first-line opioids
 Used for shivering
 Neurotoxic- causes seizures
 Stadol, Nubain: agonist-antagonist
 Ceiling on dose: ^ don’t increase relief
 Suboxone: combo of buprenorphine &
naloxone; sublingual tablet or film
 For treatment of addiction
 May be habit forming, many side effects

OPIOIDS
Used to manage moderate to severe pain
 Bind to opiate receptors in the brain to alter
perception of pain
 Addictive, cause psych & physical dependence
 Side effects: sedation, dizziness, respiratory
depression, impaired thinking, urinary
retention, constipation, pruritis, dry mouth,
nausea/ vomiting, sleep disturbances
 Goal: find balance between pain relief & side
effects; ask patient if he/she wants more

Equivalency Dosing of Opioids
DRUG
Morphine
Parental Dose
Equivalent to
10mg IV MS
10
Oral Dose
equivalent to
30mg Oral MS
30
Fentanyl
0.1
NA
Dilaudid
1.5
7.5
Demerol
75-100
300
Methadone
20
10
Oxycodone
NA
30
MS Contin
NA
60
Patient Controlled Analgesia





Rationale for PCA:
Patient titrates analgesics to needs,
bypassing unavoidable delays when
analgesics are provided on request
Intermittent & steady-state analgesia that
is patient-activated~ avoid peaks & valleys
Blood level of meds can be maintained
within an effective range
Patient takes active role in care
Desired Outcomes
Adequate pain control in a safe manner
 Keeps serum level within therapeutic
range
 Patient can breathe deeply and ambulate
early, reducing post-op complications
 Patient more comfortable and less
anxious, enhancing patient satisfaction

PCA
Patient selection:
 Alert with clear sensorium ( except
palliative care)
 Intellectually, emotionally & physically
capable of understanding & operating PCA
 Developmentally capable of understanding
& operating PCA
 Medications: Morphine, Hydromorphone,
Fentanyl

PCA (cont)
Tell patient & family rationale for PCA
 Identify any side effects (opioids)
 2 RNs double check dosage orders upon
initiation of infusion, when accepting
patients from another unit and when
parameters change
 Family may be instructed to participate
 Joint Commission has Sentinel Alert on
PCA by Proxy

Disadvantages
Disadvantages
 Potential for overdose
 Limited nursing contact
 Requires IV access
 Potential for programming errors
 Non-candidates
 Major psych disorder
 Hemodynamically unstable
 Inadequate controlled seizure disorder
 Medical condition= restricted use of
opiates

Regional Anesthetics
Topical:
 Lidocaine patch 5% (Lidoderm)
 Shingles, Crohn's disease, low back and
neck pain, migraine
 Analgesic, not anesthetic
 Minimal adverse events
 Pliable adhesive- apply directly to painful,
intact site; change q 24; may wear 4 safely


Infiltration: 0.5% to 2%Lido (with/out Epi)
Peripheral Nerve Block: specific site to block
conduction; pre and post surgery
 Interscalene, axillary, intercostal, sciatic
 Complications: nerve damage, failed block,
hematoma, reaction to local
 Epidural: solution into epidural space-single
injection, repetitive bolus injections ( by
catheter), continuous infusion ( by catheter)for labor analgesia, chronic pain
 Transcutaneous electrical nerve stimulator:
(TENS)

Epidural Analgesia
Rationale:
 Allows for high concentration of drug at
desired spinal cord receptors
 Minimal amount of opiod enters systemic
circulation, where opiod can cause
undesired side effects
 Allows for selective analgesia depending
on location of catheter
 Opiods have synergistic effect with local
anesthetics-doses of both can be lowered

Desired Outcomes
Intense, prolonged analgesia
 Limiting total amount of systemic opiods
 Decrease potential for opiod related side
effects
 Less sedation
 Earlier mobilization: < incidence of DVTs
 Ability to cough, deep breathe, clear
secretions
 Decrease cardiac workload & oxygen use
 Decrease costs due to shorter LOS

Contraindications
Patient refusal
 Shock
 Hypovolemia
 Coagulopathies
 Skin lesions at site of injection
 History of adverse reactions to opiods
 Sleep apnea
 Lack of familiarity of technique

Epidural Medications
Fentanyl
 Sufentil
 Morphine
 Hydromorphone
 Ropivacaine
 Bupivicaine

Complications & Adverse Effects
Complications:
 Total or high spinal block
 IV injection
 Dural puncture resulting in a headache
 Bleeding resulting in hematoma
 Catheter problems (migration, breakage)
 Adverse Effects
 Pruritis, nausea, urinary retention
 Mild to moderate sedation, hypotension

Sedation Assessment
S= Sleep, easy to arouse, respiratory depth &
regularity compares to baseline; no action
 1= Awake and alert, no action needed; may
increase opioid dose
 2= occasionally drowsy, easy to arouse, no
action needed; may increase opioid dose
 3=frequently drowsy, arousable, falls asleep
mid-sentence; add non-opioid & decrease
opioid 25-50%; increase monitoring to level 3
 4= somnolent, minimal/no response; stop
opioid ,stimulate, consider Naloxone

Treating Respiratory Depression
Assess and monitor patient’s level of
sedation and respiratory status frequently for
first 8-12 hours
 Encourage deep breathing
 Encourage use of incentive spirometer
 If unresponsive to physical stimulation with
shallow respirations & RR < 8/min, pinpoint
pupils: Give Naloxone (Narcan)- ( reversal
agent) 0.1-0.4mgm IV titrated slowly over 23 min

Adjuvants
Analgesic in some painful conditions, but
primary indication is other than analgesia
 Include:
 Anticonvulsants: Tegretol, Klonopin,
Dilantin, Neurontin (gabapentin), Lyrica
(pregabalin)
 First line for neuropathic pain, acute pain
management ( persistent post surgical and
burns); Opioid-sparing
 Adverse effects: sedation, unsteadiness,
nausea, dizziness

Adjuvants
Antidepressants: Nortriptyline (Pamelor),
Cymbalta, Effexor
 First line for neuropathic pain
 Adverse effects: dizziness, orthostatic
hypotension, sedation, dry mouth
 Steroids: Decadron, Prednisone,
Solumedrol (metastatic bone cancer pain)

Misc. Medications
Tramadol (Ultram):analgesic that augments
pain signal transmission inhibition; 50mg tab
 Tapentadol ( Nucynta): acute, chronic,
neuropathic pain; costly; fewer GI side effects
 Methadone: effective analgesic for patients
with difficult to control pain; has long half
life- make dose adjustments slowly
 Ketamine: used for patients requiring very
high doses of opiods (chronic pain, history
heroin addiction, neuropathic pain, OIH)

Documentation








Pain Management
Date, time
Current regimen ( drug dose, route)
Patient self-report of pain and pain relief
Activities patient is able to perform
(cough, turn, deep breathe, ambulate)
Side effects and level of sedation
Current vital signs: BP, HR, RR, O2 Sat
Should be re-evaluated 30 min after
intervention
Key Concepts: Anesthesia
Balanced Analgesia
 Use continuous, multimodal approach
 Considered ideal by experts
 Use combined analgesic regimen
 Preemptive Analgesia
 Intervention implemented before noxious
stimuli experienced
 Reduces CNS impact
 Provision for added analgesics for
breakthrough or ongoing extreme pain

Expected Outcomes
Patient maintains hemodynamic stability,
including respiratory/cardiac status & LOC
 Patient states achievement of pain
relief/comfort treatment goals
 Patient states he/she feels safe & secure
with instructions
 Patient shows effective use of at least 1
non-pharmacological method
 Patient shows effective use of PCA
 Patient states evidence of receding pain &
increased comfort

Tailor Treatment Plan
Acute pain: short-term; need to discuss
recovery/rehab milestones and patient’s
ability to meet them
 Chronic pain: discuss what patient could
do before that the pain keeps him/her
from doing now
 End of Life: discuss if there is anything
patient wants to accomplish before death
that the pain would interfere with

Be Truthful!
Zero pain is usually not possible but let
patients know you care about their pain
and will always try to do everything
possible to control it !
 Reinforce link between pain relief and
accomplishment of pain treatment goals
 Find the right balance for each individual
patient: quality of life, pain relief and
adverse effects

Stopping
Pharmacological Measures
When pain is relieved
 Adverse effects have occurred:
 Respiratory depression
 Blood pressure change of 30% or more
from baseline
 Oxygen saturation less than 90% ( unless
that is patient’s normal)
 Too much sedation, Too great decrease
LOC
 Signs of an allergic reaction to the opioid

Benefits to Pain Management
Pain control= greater comfort during
recovery to get well faster
 Less pain= ability to ambulate early, do
breathing exercises and get strength back
quicker
 Short length of stays in the hospital is also
a strong possibility= increased patient
satisfaction

Current Knowledge
Pain alters the quality of life more than
any other health-related problem
 Pain is one of the least understood, most
often under-treated and often discounted
problems of healthcare providers & pts.
 Nurses have little control over intervening
variables: social support, prognosis,
financial well-being, education, personality
traits, addictions, physical fitness,
religiosity, belief system, values, etc
 Nurses’ have control over caring & comfort

Comfort Management
Nurses assess patients’ holistic comfort
needs on an individual basis
 3 types of comfort needs
 Relief: need to have specific discomfort
relieved
 Ease: need to remain in a state of
contentment & well-being
 Transcendence: need to be strengthened,
motivated, or invigorated

Holistic Perspective
Implies desired outcome of nursing care
from using holistic intervention
 Massage= enhanced patient comfort,
compared to baseline
 Enhanced comfort has positive relationship
with health seeking behaviors
 Internal ( healing)
 External ( improved functional status,
mobility, strength, appetite, etc)
 Peaceful death: symptoms well-managed

Relationship: Comfort & Pain
Comfort is an umbrella term:
 Effective pain management significant part
 Other discomforts needing attention are:
N&V, thirst, lyte imbalance, air hunger, etc
 When pain is relieved:
 Improvement in vital signs
 Resting state induced ( patient appears
relaxed, may have eyes closed
 Muscular relaxation: facial muscles
relaxed, body tension eased

Contexts of Comfort





Comforting occurs:
Physical: bodily sensations, immune
function, homeostatic mechanism
Social-Cultural: interpersonal , family &
societal relationships; traditions/rituals
Psycho-spiritual: internal awareness of
self, esteem, identity
Environmental: external background of
human experience~ temperature, light,
sound, odor, color, furniture
Evaluate Comfort Interventions







Ask:
What analgesia did patient receive?
What other interventions were tried?
How effective were interventions in
relieving discomforts, including anxiety?
Are drugs or other interventions affecting
the vital signs?
How much activity can patient engage in
prior to experiencing pain or discomforts?
Any change in dosing of meds? Any
breakthrough pain or discomfort?
Pain Control and Comfort Interventions=
HAPPINESS!