Transcript Symptom Management - Nursing Home Net: Welcome

Pain Assessment
and Management
Lynn Cowling
Macmillan Clinical Nurse Specialist in
Palliative Care
Calderdale & Huddersfield NHS Trust
Objectives
What is pain?
 Total pain?
 Cancer pain.
 Keys to good pain management.
 Types of pain.
 Assessment.
 Management.
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What is pain?
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Pain is real regardless of its cause; pain is whatever the patient experiencing it
says it is and exists where they say it does (McCarthey 1983).
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The pain a patient describes may be seen as the tip of the iceburg, underlying
this pain is a whole range of factors, physical, emotional, social and spiritual,
each inextricably entwined (Saunders and Sykes 1983).
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Not only patients with cancer get pain. There are many different conditions,
especially in the elderly, that can cause pain and discomfort.
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These simple rules can be used to assess and manage any one suffering from
pain.
TOTAL PAIN
PHYSICAL
Caused By the illness itself
Concurrent illness
Other symptoms
Adverse effects of treatment
Pressure sores weight loss
Constipation muscle tension/spasm
PSYCHOLOGICAL
Anger at diagnosis
Anxiety, fear
Disfigurement
Fear of pain and or death
Feeling of helplessness
Depression
TOTAL
PAIN
SOCIAL
Worry about family and finances
Loss of social position
Loss of role in family
Feeling of abandonment and isolation
Concerns about dependency
Cultural
SPIRITUAL
Why has this happened to me?
Why does god allow me to suffer like this?
What is the point of all this?
Is there any meaning or purpose in life?
Am I being punished for past wrongdoings?
Cancer Pain
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80% of patients with cancer claim pain as a
major symptom.
33% have two pains.
33% have three or more pains.
50-80% of those DO NOT receive adequate pain
relief?
Cancer pain can be controlled in 80-90% of
patients and ‘acceptable relief is possible in
most of the remainder. So why does under
treatment remain a problem?
KEYS TO GOOD PAIN MANAGEMENT
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Understanding of different causes of pain.
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Assessment of pain.
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Management of pain.
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Reassessment and monitoring.
Types of Pain
There are three types of pain:
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Visceral
- tumour bulk, bowel obstruction
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Bone
- replacement of bone by
tumour, pathological fracture
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Neuropathic
- nerve injury or nerve
compression
The Pains of Malignant Disease
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Visceral
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Bone Pain
Neuropathic Pain
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Headache of
Cerebral Tumour
Deep, dull ache usually
over the tumour site
Sharp, may be spasmodic
Injury-Burning, sharp,
stinging, stabbing, numb
Compression-Ache,
throbbing, stabbing
Dull, oppressive,
vice-like
Assessment (1)
Need psychosocial and medical history but also to ask:
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Site of pain - where is the pain?
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Type of pain – what does it feel like?
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Frequency of pain – how often does it occur?
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Aggravating factors – what makes it worse?
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Relieving factors – what makes it better?
Assessment (2)
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Disability – How does the pain affect everyday activities?
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Duration of pain – how long has it been present?
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Responses to previous and current treatments?
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Meaning – what does the pain mean to the patient?
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If you have a pain assessment tool, use it!
PATIENTS THAT HAVE DIFFICULTY
COMMUNICATING
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Facial expression.
Posture.
Increased agitation or aggression.
Withdrawal.
Change in mood and behaviour.
Guarding one area of body.
Not sleeping at night.
WHO Ladder
Morphine 10mg
every 4 hours
Paracetamol 500mg
+ codeine 30mg
Paracetamol
UNCONTROLLED PAIN
+/- Paracetamol
CO –ANALGESICS
NSAIDs – bone pain, liver capsular pain
Anti-convulsants – neuropathic pain
Anti-depressants – neuropathic pain
Muscle relaxants
Anti-spasmodics
Opioids
Weak
Strong
Paracetamol
Adjuvants
Anti depressants
Anticonvulsants
Antispasmodics
Muscle relaxants
NSAID
Methods of Administration
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Oral
Rectal
Subcutaneous
Spinal
Tens
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Patch
Nerve Blocks
Surgery
Radiotherapy
Chemotherapy
NO IM OR IV DRUGS
ANALGESIA (1)
Regular doses of analgesia must be
prescribed
 Adequate doses of analgesia on an ‘as
required basis’ (PRN), in addition to the
regular medication must be made
available
 Where possible give analgesia by mouth,
by the clock and by the ladder
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ANALGESIA (2)
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Pain that does not respond to oral medication is
unlikely to respond to analgesia given by a
different route e.g. SC, IV unless there are
absorption problems
Review the effectiveness of any medication on a
regular basis
Ensure all patients on a step 2 or 3 analgesic are
on regular laxatives and that the effectiveness of
the laxative regime is being monitored
Other Pain Control Measures
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Remember the role of Explanation
 Psychological
support
 Rest
 Relaxation
 Adequate
 Heat
sleep
pads
 TENs machine and massage
 Self-help measures
Alternative Opioids
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Oxycodone
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Hydromorphone
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Fentanyl
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Methadone
THE KEYS TO GOOD PAIN ASSESSMENT
AND MANAGEMENT ARE:
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Understanding the meaning of whole pain.
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Understanding of different causes of pain.
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Assessment of pain.
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Management of pain.
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Reassessment and monitoring.
THANK YOU