Transcript PAIN LECTURE - Stacy House

Coping with Pain
Mary Roche, RN, MSN, CS
Community College of Rhode Island
July 21, 2015
November 18, 2002
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Multidimensional Experience
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Physical
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Medical-Surgical conditions
(special standards for acute post-operative pain)
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Social
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Psychological
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Support system & societal response
Coping abilities, internal locus of control vs. external
locus of control
Cultural
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Emotionally expressive, introverted, stoic
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Stereotypes, Attitudes
and Misconceptions
• Weakness or wimp
• Part of old age
• If medication ordered, will get it without
asking
• Fear of addiction
• Infants, children, elderly have decreased
sensation
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Gerontological Considerations
• Reduced sensory perception and increased
pain threshold
• Frail elderly or those with altered mental
status under treated
• Other diseases complicate the assessment
of pain
• May not want ‘to bother anyone’
• Fear that pain indicates their demise or
serious illness
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What is Pain?
‘Pain is whatever the experiencing person says
it is, existing whenever he [she] says it does.’
- McCaffery (1979)
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Concepts Associated with Pain
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Tolerance
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Threshold
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Decreased pain relief despite increase in
dosage
Amount of pain stimulation a person requires
to feel pain
Physical Dependence
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Body has become accustomed to the drug &
withdrawal symptoms would occur if abruptly
stopped
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Concepts Associated with Pain
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Addiction
Drugs are regularly taken indiscriminately in
excessive quantities to the extent that the
person’s physiological, psychological or social
functioning is impaired.
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Pseudoaddiction
Drug seeking behavior addiction, but due to
unrelieved pain.
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Physiological Components
of Pain
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Transduction
Noxious substance changes to an electrical
stimulus by activating nociceptors
(afferent nerve fibers that initiate the pain
experience).
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Neurotransmitters
Thermal
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heat & cold
Mechanical
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pressure, friction edema
Chemical
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gastric enzymes, histamines, caustic
substances
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Transmission
Passage of electrical impulse from the site of
injury through the dorsal horn of spinal nerves &
up the spinalthalmic tract to the brain.
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Gate Control Theory
Facilitation or inhibition of the
transmission of pain
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Type A – larger fibers/acute pain
Type C – smaller fibers/chronic pain
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Reaction to Pain
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Behavioral
Physiological/Sympathetic
Physiological/Parasympathetic
Affective
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Types of Pain
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Types of Pain
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Somatic
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Smooth muscle walls,
receptors in abdominal
cavity, cranium, & thorax
Visceral
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Phantom
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Neuropathic
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Arises from ligaments,
tendons, bones
Sensations of burning,
tingling felt in absent limb
Pain signal from injury to
higher centers of brain
Referred
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Pain experienced from a
site distant from injury
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Acute Pain
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Usually sudden, selflimiting < 6 months
Precipitating event
Resolves with treatment
Restless, anxious,
crying
vs.
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Chronic Pain
May be sudden or
gradual with periods of
remission &
exacerbation > 6 mo.
May not be associated
with injury
Difficult to treatment
Depressed, withdrawn
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Pain History/Subjective
P-
Factors that provoke or palliate, previous therapy
Q - Quality of pain – ‘What does pain feel like’
R - Region of body, location
S - Severity, intensity, pain scales
T - Timing, duration
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Objective Assessment of Pain
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Vital Signs
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Behavior
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avoid painful area until other areas assessed
Effects on ADL’s
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sweating, grimacing, splinting
Palpation
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increase pulse, BP, respiration
appearance, may limit self-care
Concomitant symptoms
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nausea, headache, dizziness, restlessness, depression
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Nursing Diagnoses
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Statement: Acute or Chronic
Related Factors/Etiology:
 Biopathophysiological (mechanical) tissue
trauma – musculoskeletal disorders, uterine
contractions, visceral disorders
 Treatment Related – Surgery, diagnostic
tests, chemotherapy, radiation therapy
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Planning Interventions
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Team Effort
Involvement of Patient & Family
Multiple Approaches
Level of Acceptable Side Effects
Acute Versus Chronic Pain
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Expected Outcomes
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Describes how unrelieved pain will be
managed
Performs activities with an acceptable level
of pain
States an ability to obtain sufficient amount
of sleep
Reports pain before it becomes severe
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Interventions for Pain Control
General Principles
1.
Individualize
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2.
3.
4.
5.
Choice of drug matched with patient’s response &
titrate dosage up or down
Use oral or intravenous route versus
intramuscularly
Plan care around periods of greatest comfort
Medicate ½ hour before activity or procedure
Add Prn doses of medication for breakthrough
pain
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Classification of Analgesics
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Non-opiod (non-narcotic)
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Acetaminophen
- NSAIDS:
ASA, Advil, Motrin, Naprosyn, Feldene
Toradol (Ketorolac)
Cox – 2 Inhibitors (Vioxx & Celebrex)
- Side Effects:
Gastric erosion, GI bleeding, fluid retention,
Platelet dysfunction, & renal insufficiencies
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Classification of Analgesics
Opiod Analgesics: Synthetic Narcotics
Commonly Used:
- Morphine Sulfate, Oxycontin
- Dilaudid (hydromorphone)
- Oxycodone (Percodan, Percocet, Oxycontin SR
- Demerol (Meperidine)
- Fentanyl
- Codeine Plain
- Tylenol 300 mg - # 2 (15 mg), # 3, (30 mg) # 4
(60mg)
- Vicodin (Hydrocodone 5/500, 7.5/750, 10/660
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Opiod vs. Non-Opiod
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Acts CNS level versus peripheral nerves
May result in physical dependence &
withdrawal symptoms
Tolerance may occur to analgesic effect
Respiratory Depression
No ceiling or limit for increasing doses
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Side Effects of Narcotics
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GI
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Cognitive
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sedation, confusion, depression
Respiratory Depression <11 Hold
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Nausea & vomiting, constipation
Narcan (naloxone) to reverse opiod induced
respiratory depression (caution with post-operative
pain - reverses analgesia)
Neurological:
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agitation, tremors, fear (withdrawal)
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Routes of Administration
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PO
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SC
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Inexpensive, convenient, non-invasive, Effective if
dose high enough & given around clock
Inconsistent absorption, effective when IV not
available
IM
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Unreliable absorption, poor choice with elderly or
children, can result in sterile abscess or fibrosis of
muscle
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Routes of Administration
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IV
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Intrathecal
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Intermittent of continuous via PCA
Transdermal
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Allows immediate drug diffusion in cerebral spinal fluid
Epidural
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Most efficient, allows for rapid titration, steady state with PCA
or Drip
Duragesic Patch q 72 H
Rectal Suppository
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Morphine
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Treatment of Malignant Pain
WHO Analgesic Ladder
1 Non-opiod
+/- Adjuvant
2 Opiod – Mild to Moderate Pain
+/- Non-opiod
+/- Adjuvant
3 Opiod – Moderate to Severe Pain
+/- non-opiod
+/- Adjuvant
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Adjuvants to Analgesics
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Anti-anxiety
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Antihistamine, Anitemetic
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(diminishes nausea & vomiting, sedation)
Phenergan (promethazine), Vistaril
(hydroxyzine), Reglan
Anticonvulsants
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Ativan PO or IV
Tegratol, Dilantin
Antidepressants
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Elavil
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Titrating and Schedule of doses
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Adequate loading dose followed by increment
small additional doses until relief
Maintaining consistent blood serum levels
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use of sustained release drug q 8-12 h; q 24 h; q 72 h
Rescue Dosing
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breakthrough pain
immediate release drug with short half life
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Equianalgesic Conversion
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Use – changing from po dose to
parenteral or from parenteral to po
Equagesic Charts Opiods:
Drug
Codeine
Morphine
Dilaudid
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Parenteral
103 mg
10 mg
2 mg
Oral
200 mg
30 mg
7.5 mg
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Non-pharmacological
Interventions
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Heat & cold
Progressive relaxation
Massage
Meditation, Guided Imagery
Music
Biofeedback
Transcutaneous Electric Nerve Stimulation
Therapeutic Touch
Yoga
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Nursing Responsibilities for Pain
Management
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Maintain a therapeutic relationship
Assess & document systematically
Intervene using a multidiscipline team
approach for maximum relief
Advocate for the patient
Educate patient & family
Clarify orders
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The End
Mary Roche, MSN, RN, CS
7/21/2015
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Thank You for Your Attention
Mary Roche, MSN, RN, CS
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Presentation Credits
This presentation was developed under contact with Peter Martin, dba
Stacy House Designs for Mary Roche and Joan Glasheen with
materials submitted by Joan Glasheen.
The presentation is the sole, copyrighted property of Mary Roche.
Copies of this and other presentations can be seen on the Internet at
http://www.stacyhouse.com. Please fill out the guestbook
selection when visiting that site.
Thank you.
Mary Roche & Peter Martin
November 18, 2002
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The End
Mary Roche, MSN, RN, CS
7/21/2015
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