Transcript pain - Texas Tech University Health Sciences Center

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Nursing
311112
Pain Management: Acute Pain
Brenda Threadgill, RN, BSN, MS, CHPN,
Retention Counselor, Traditional
Undergraduate Program
TTUHSC, Lubbock, TX
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Objectives
1. Recognize basic principles
and barriers.
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Objectives
2. Indicate outcomes, history,
and processes.
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Objectives
3. Identify expectations and
assessment principles.
Talking Points
• Define basic principles of pain management
• Describe barriers to good pain management
• Differentiate outcomes of good vs poor pain
management
• Discuss the history of pain and pain
treatments
Talking Points
• Discuss a brief overview of pain processes
• Identify expected findings in acute vs chronic
pain
• Describe the principles of a thorough pain
assessment
Perceptions of Pain
• John is lying in bed, watching TV
• He appears to be uncomfortable, grimacing
occasionally, changing position with difficulty,
and gritting his teeth
• Blood pressure (BP): 145/92
• Respirations: 28/minute
• Pulse: 92
Perceptions of Pain
• He had 2 acetaminophen and hydrocodone
5/500 (Lortab) 2 hours ago and his pain went
down from 7/10 to 3/10
• When you ask how his pain is doing, he tells
you his pain level is now 8/10
• What will you do?
Perceptions of Pain
• Jane is sitting up at the side of her bed,
playing cards with her sister
• They are laughing and she appears
comfortable
• BP: 115/76
• Respirations: 18/min
• Pulse: 84
Perceptions of Pain
• She had morphine 5 mg intravenous push
(IVP) 2 hours ago and her pain went from
7/10 to 3/10
• When you ask how she’s feeling, she states
that her pain is back up to an 8/10
• What are you going to do?
Perceptions of Pain
• Bill has been admitted to your floor
• He has lung cancer with metastasis to the
bone
• He came into the emergency room (ER) with
complaints of uncontrolled pain for the past 3
days
Perceptions of Pain
• His ordered pain medication is acetaminophen
and hydrocodone 5/500 (Lortab)
– 1 to 2 tabs every 6 hours
pro re nata (PRN),
of which he has been taking 2 tabs 6 times a day
Perceptions of Pain
• He rated his pain in the ER as 10/10 and was
given morphine 5 mg IVP 6 hours ago, with
minimal relief of pain
• He was then given 10 mg morphine IVP 5
hours ago, with partial relief of pain (6/10)
Perceptions of Pain
• He was given another 10 mg morphine IVP 4
hours ago, with complete relief of pain (0/10)
• He is now asleep
Perceptions of Pain
• When you go into his room to assess him, he
does not wake until you call his name and
shake him
• He talks to you appropriately and takes a drink
of water
• He states that his pain is coming back a little
and rates it as 2/10 at this time
Perceptions of Pain
•
•
•
•
BP:105/76
Respirations: 12/minute
Pulse: 74
As soon as you turn to write down his vital
signs, he has fallen asleep again
• What is your next step?
How do you feel
about these
patients?
Pain management is a
holistic combination of
science and art
Science
Research and
Technology
Person
Mind,
Body, and
Spirit
Holistic
Universal Human
Experience
Art
Unique
Experience,
Potential for
Meaning
Environment
Family,
Friends, Way
of Being
“When we honestly ask ourselves which
persons in our lives mean the most to us,
we often find that it is those who, instead
of giving advice, solutions or cures, have
chosen rather to share our pain and touch
our wounds with a warm and tender
hand.”
-Henri Nouwen
Basic Principles
1.
2.
Prevent pain whenever possible
Control pain to the level that is acceptable
to the patient
Who has pain?
• Every living creature is capable of experiencing
some degree of pain
• Every person alive has experienced pain of
some sort
• Every nurse has cared for a person
experiencing pain of some sort
Why should we care?
• Pain is a universal human phenomenon
• There are as many ways to experience pain as
there are people in the world
• Every person’s pain is unique to that person
• Nurses are the one constant in most people’s
journey to optimal pain relief
Why should we care?
• The good:
– optimal pain relief leads to better quality of life
and better patient outcomes
• The bad:
– poor pain relief leads to negative disturbances in
health
• The ugly:
– poor pain relief leads to increased financial drains
on the healthcare system
Stand and Defend
• Nurses are the front line defenders against
pain:
– suggest and carry out medication orders
– stand guard against pain increasing or returning
– suggest and carry out non-pharmacological
interventions
– perception of caring
Frontline Advocate
• Nurses are the frontline advocates for optimal
pain relief, especially if there are inadequate
orders for pain relief
• Nurses must advocate for their patients with:
– scientific, evidence-based knowledge about pain
and pharmacology
– caring determination to get the appropriate
orders to obtain optimal pain relief for our
patients
Can we do a better job?
• Multiple studies have shown that the most
important barriers to optimal pain relief are:
– beliefs and attitudes of healthcare practitioners
– lack of organizational support
• training
• prioritization of pain assessment
• support for evidence-based practices
Can we do a better job?
– general expectations that good pain relief is often
not possible or is not a priority concern of
• healthcare practitioners
• doctors
• nurses
Does it have to be this way?
• The quickest and easiest part of the system
that can be changed is you
– taking part in learning more about pain relief
– changing your own beliefs and attitudes
– having the determined will to be a strong patient
advocate for excellence in pain relief
• Numerous studies have consistently identified
nurses as the key players in making a
difference in the best practices for pain relief
History of Pain
• We assume that pain has been around for as
long as there have been people
• We know that people in pain seek relief from
pain
• Earliest records of prescriptions go back to the
Babylonians around 3000 B.C.
History of Pain
• The Chinese (2700 B.C.) had a compendium of
herbal remedies (40 volumes) called the Pen
Tsao
• The early Egyptians (1500 B.C.) had their own
documented remedies called Ebers Papyrus
Wonder Drugs
• Decoctions from the bark of the willow tree
are some of the first recorded treatments for
pain and became the basis from which we
derived aspirin
• Aspirin is the original wonder drug and
remains one of the most widely used
medications for pain in the entire world
Wonder Drugs
• Other early remedies for pain included
fermentation and distillations of various fruits
and grains, such as:
– grapes
– barley
– corn
– wheat
Morphine
• Opium has been used for centuries for
relaxation, euphoria, and relief of pain
• The first recorded isolation of morphine from
opium occurred around 1805 by the German
chemist Friedrich Serturner
– he tested his discovery on himself and three
young friends by dosing each of them with 100mg
of unrefined morphine
– they spent the next three days suffering from
acute morphine intoxication
Morphine
– despite this inauspicious beginning, morphine
proved to be the wonder drug of the century and
remains the gold standard to which all other pain
medications are compared
What is pain?
• International Association for the Study of Pain
defines pain as:
– “an unpleasant sensory and emotional experience
arising from actual or potential tissue damage”
• Margo McCaffery defines pain as:
– “whatever the experiencing person says it is, occurring
whenever he/she says it does.”
• Cox defines pain as:
– “a complex, physiological, and psychological
phenomenon that is subjective in nature.”
Pain Concepts
• The word “pain” comes from the Latin word
poena, meaning penalty or punishment
– this concept still has relevance even today
• Pain is multidimensional
– it has many aspects:
•
•
•
•
physical
mental
emotional
spiritual
– it is rarely comprised of only one aspect and often all
aspects are involved
Pain Concepts
• Most important - it is subjective in nature
– we can look for clues to support the claim of pain
• they may or may not be there
– never look for clues to discount a report of pain
Why does pain hurt?
• Easy answer: we don’t know
• Complicated answer: we don’t know
everything
– so many pathways
– so many complicating factors
– every person is unique
Kinds of Pain
• There are multiple ways of classifying pain,
including:
– underlying pathophysiology
• nociceptive vs neuropathic pain
– length of time
• acute pain vs chronic pain
– mixed pain classification systems
• chronic noncancer pain
• chronic pain syndrome
Kinds of Pain
• Does it matter how pain is categorized?
– only in that it helps guide treatment options
– mixed pain classification systems
• chronic noncancer pain
• chronic pain syndrome
Acute Pain
•
•
•
•
Acute pain is a warning
There is a physical reason for it
It is time-limited
We expect acute pain to decrease as healing
takes place and eventually go away completely
Injury
healed
Injury
Healing
continues
High pain
rating
Healing
taking
place
Chronic Pain
• Pain lasts longer than expected (even after the
injury is healed)
• Not time-limited (lasts longer than 3-6
months)
• There is a large psychosocial component to
most chronic pain states
• Chronic pain is usually much harder to
manage successfully
Injury
Chronic:
Meds may not
be effective
Persistent pain
after original
injury has
healed
Chronic
pain
Acute:
Meds
effective
Little to no
pain after
injury has
healed
How do we do it?
• The nursing process gives us a map to follow
to provide the best practices in excellent pain
relief:
– assessment
– nursing diagnosis
– planning
– implementation
– evaluation
Assessment
1.
2.
Believe the patient’s self-report of pain
Do something about it
Pitfalls of Assessment
• Assessment is where we tend to “slip up” and
trust our own judgment, instead of believing
the patient’s self-report of pain
Tools
• Easiest to use: scales
– numeric scale
• 0 = no pain to 10 = worst pain
– verbal descriptor scale
• mild pain
• moderate pain
• severe pain
– Wong-Baker faces scale
• happy face to crying face
– colors scale
• white for no pain to red for worst pain
Filling out the Picture
• Location of the pain
• Pattern of the pain
– When does it happen?
– What causes it to start or get worse?
– What causes it to stop or get better?
– How long does it last?
– How does it affect your activities/your quality of
life?
– How have you coped with pain in the past?
Filling out the Picture
• One thing that is often overlooked is asking
the patient about his/her beliefs about pain,
as well as his/her expectations and goals for
pain relief
Helping with the Words
• Quality of the pain
– nociceptive pain descriptors
•
•
•
•
•
•
dull
sharp
aching
pressure
gnawing
cramping
Helping with the Words
– neuropathic pain descriptors
• burning
• tingling
• numbing
Helping with the Words
• Intensity of the pain:
– mild pain
•
•
•
•
annoying
nagging
uncomfortable
troublesome
– moderate pain
•
•
•
•
distressing
miserable
grueling
horrible
Helping with the Words
– severe pain
•
•
•
•
•
intense
excruciating
dreadful
unbearable
agonizing
Helping with the Words
• It is perfectly acceptable to combine a scale
and a list of descriptors and intensity words,
as long as you do not guide the patient to a
rating or words
Intangible Aspects of Pain
• Emotional and spiritual pain need additional
assessment
• Ask questions (gently, but thoroughly)
• Be present to hear the answers
• Listen to what is not said – pursue the obvious,
but listen for what is not being said
• Emotional and spiritual pain relate to the physical
• People fear pain (the great spoken dread)
– people fear abandonment even more (the great
unspoken dread)
Special Circumstances
• Psychosocial issues can confuse and
complicate pain management
– our own psychosocial issues come into play when
we work with patients
– chronic pain generally has more psychosocial
context than acute pain
– some patients may feel that they need to suffer or
be punished (for a variety of reasons)
– some caregivers may feel that the patient needs
to suffer or be punished
Suffering
• All suffering involves pain but not all pain is
suffering
• Suffering is multidimensional pain, taken to a
deeper level, usually involving more than just
physical pain
• Grief and existential despair can be catalysts
for suffering
Suffering
• May grieve the loss of:
– relationship
– health
– life
• May ask existential questions:
– Why? Why is this happening?
– Is this all there is?
– Am I alone?
– Am I being punished?
Suffering
• The best way to help those who are suffering
is to be present with them in their pain
• Help them to find meaning in their pain – ask
them to tell you about their pain and what it
means to them
• Give them the opportunity to talk
• Refer to counseling or to a spiritual
practitioner of their choice, if agrees
Medications
• Patients may have very real fears about using
medications, particularly opioids
– fear of addiction
– fear of worsening disease process
– fear that medications won’t be strong enough later on
if used now
– fear of hastening death
– fear of losing control
– fear of being sedated and abandoned
• Intractable pain is our “skeleton in the closet”,
but it is real
Nursing
311112
Pain Management:
Pain
Acute
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Release Date:
5/01/2012
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Nursing
311112
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Conflicts of Interest:
Brenda Threadgill, RN, BSN, MS, CHPN has disclosed that no financial
interests, arrangements or affiliations with organization/s that could be
perceived as a real or apparent conflict of interest in employment, leadership
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