Transcript lecture 6: chapter 9 Pain Management 2. ppt

CHAPTER
9
Lecture Note PowerPoint Presentation
Pain Management
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 1
Define pain and the consequences of pain in
the older adult.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain and Pain Transmission
• Involves peripheral receptors and sensory
pathways and synaptic contacts in the
brain stem and spinal column
• Classified as nociceptive or neuropathic
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain and Pain Transmission
• Nociceptive pain
– May be visceral or somatic
– Designed to signal tissue damage or
inflammation
• Neuropathic pain
– Results from damage to the central or
peripheral nervous system
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Results of Untreated Pain
• Hyperalgesia
– Caused by an increased sensitivity of
nociceptors to stimuli and a reduced pain
threshold
• Hypertension, tachycardia, and even
coronary ischemia
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Results of Untreated Pain
• Depression, anxiety, decreased
socialization
• Sleep disturbance
• Impaired ambulation
• Increased healthcare use and costs
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Pain
• Time limited
• Result from surgery, medical procedures,
or injury
• May be associated with exacerbations of
chronic conditions
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Pain
• Continues over a prolonged period of time
or is associated with an injury that has not
resolved in the expected amount of time
• Affects 1:5 persons
• Related to
– Musculoskeletal disorders
– Cancer
– Neuropathic disorders
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Pain
• May impact 45–80% of nursing home
residents
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Pain
Negative consequences
– Decreased socialization
– Withdrawal from daily life
– Fatigue
– Sleep disturbance
– Irritability
– Physical deconditioning
– Stress
– Depression
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 2
Identify appropriate pain assessment
techniques, including those to use with
dementia.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain Assessment
• Measured subjectively
• Utilizes the patient’s self-report of pain
• Multiple complaints of pain must be
prioritized
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain Assessment of the Patient with
Dementia
•
•
•
•
Use simple questions or screening tools
Review nonverbal behaviors
Obtain information from family or caregiver
Perform more frequently
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain Assessment of the Patient with
Dementia
• Primary types of behaviors consistent with
the presence of pain
– Facial expression
 Grimacing
 Frowning
 Frightened face
– Verbalizations/vocalizations
 Sighing
 Moaning
 Chanting (repeating)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain Assessment of the Patient with
Dementia
• Primary types of behaviors consistent with
the presence of pain
– Body movements
 Tense posture
 Guarding
 Gait changes
 Mobility changes
– Interpersonal reactions
 Aggressiveness
 Combativeness
 Withdrawal
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain Assessment of the Patient with
Dementia
• Primary types of behaviors consistent with
the presence of pain
– Changes in activity patterns or routines
 Appetite changes
 Changes in sleep periods
 Increased wandering
– Mental status changes
 Crying
 Increased confusion
 Irritability
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Baseline Pain Assessment
• Best conducted prior to known painful
event
• Purpose
– Investigate pain terminology and behaviors
– Identify sociocultural variables influencing
pain behaviors and expression
– Obtain health history identifying
accompanying chronic conditions contributing
to the anticipated pain experience
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Baseline Pain Assessment
• Purpose
– Investigate past methods of pain relief
– Identify pain medications used in the past
– Select appropriate pain scale for later use
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 3
Describe pharmacological and
nonpharmacological approaches useful in
treating pain in the older adult.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain Management Goals
• Relieve acute and chronic pain
• Employ appropriate pharmacological and
nonpharmacological techniques
• Minimize side effects
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Box 9-5
Pain Care Bill of Rights
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Older Adults and Opioid Analgesics
• More sensitive
• Require lower starting doses to avoid
toxicity
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Challenges of Pharmacological
Management in the Older Adult
• Renal impairment
• Hepatic function impairment
• Changes in body fat distribution
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nonpharmacological Pain
Management Techniques
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•
•
•
Relaxation techniques
Heating pads
Cold compresses
Biofeedback: is a process that enables an individual to learn
how to change physiological activity for the purposes of improving
health and performance
• Music therapeutic touch
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Non-opioid Analgesics
– Used for mild to moderate nociceptive pain
– Anti-inflammatory drugs (NSAIDs)
 Carry risk of gastrointestinal bleeding and impaired
renal function
• Avoid persistent use in older adult population
 Acetaminophen (Tylenol)
• Use safe with older adults having normal kidney and liver
function and no history of alcohol abuse
• Dosages not to exceed 4,000 mg/day
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Non-opioid Analgesics
– Anti-inflammatory drugs (NSAIDs)
 Cyclooxygenase-2 (COX-2)
• Tramadol
– Used for moderate pain
– May cause dizziness, nausea, and headache
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Opioid analgesics
– Used for moderate to severe pain
management
– May be used for long periods of time without
risk of organ damage
– Available in a variety of routes
– Titrate slowly
– Mild sedation and cognitive impairment are
anticipated in initial therapy
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Opioid analgesics
– Potential medications
 Morphine
 Meperidine
 Methadone
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Opioid analgesics
– Potential adverse effects
 Constipation
 Sedation
 Respiratory depression
 Nausea and vomiting
 Myoclonus
 Pruritis
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Adjuvant drugs for older patients with pain
– Not typically pain medications
– May relieve discomfort
– Potentiate the effect of pain medications
– Reduce the side effect burden
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Management
• Adjuvant drugs for older patients with pain
– Examples
 Antidepressants and anticonvulsants
 Topical analgesics
 Muscle relaxants
 Antianxiety medications
 Medications to dry secretions
 Antipruritics
 Diuretics
 Magic mouthwash
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Special Pharmacological Issues Regarding
Pain Management in the Older Person
• True drug addiction to opioid analgesics is
rare
• Physical dependency is an inevitable
consequence over time when managing
chronic pain
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Special Pharmacological Issues Regarding
Pain Management in the Older Person
• Opioids and acetaminophen or aspirin
may be mixed together to control pain
– Doses may be limited due to the toxic effects
of high salicylate or acetaminophen levels
– Acetaminophen is hepatotoxic above 4 g/day
– Aspirin may cause gastric bleeding and
abnormal function at doses above 4 g/day
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Special Pharmacological Issues Regarding
Pain Management in the Older Person
• Polypharmacy
– Refers to the excessive or unnecessary use
of medications
– Adjuvant therapy may facilitate the reduction
of medication doses to manage pain
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Principles for
Successful Pain Management
• Oral administration of pain medications is
the preferred route for the older adult
– Safest
– Least expensive
• Around-the-clock scheduling
– Most effective
– Avoids the need for the patient to ask and
wait for prn dosages
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Principles for
Successful Pain Management
• Consistent experiences of breakthrough
pain indicates the need to revise the
dosing regimen
• Crushing or chewing sustained-release
preparations destroys the controlledrelease properties
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Complementary and Alternative
Therapies
• Used as stand-alone treatments and
adjuncts to traditional pharmacological
interventions
• Assess preferences and attitudes toward
nontraditional methods
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Complementary and Alternative
Therapies
• Examples
– Chiropractic series
– Herbal remedies
– Relaxation techniques
– High-dose megavitamins
– Religious or spiritual healing
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nonpharmacological Methods to
Manage Pain in the Older Adult
• Education programs
• Spiritual intervention
• Socialization or recreational programs
– Movies
– Therapeutic use of art and music
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nonpharmacological Methods to
Manage Pain in the Older Adult
• Psychological approaches
– Counseling
– Biofeedback
– Imagery
– Hypnosis
– Relaxation
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nonpharmacological Methods to
Manage Pain in the Older Adult
• Physical therapy
– Ultrasound
– Exercise
– Hot and cold packs
• Neurostimulation
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 4
Identify the nurse’s role in treating pain in
the older adult.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assess the Patient’s Beliefs and
Willingness to Use
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•
•
•
•
•
Relaxation techniques
Heating pads or cold compresses
Biofeedback
Music
Therapeutic touch
Other methods to enhance or replace
analgesics drugs
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medication Assessment of Older
Adults with Pain
• Use of over-the-counter drugs or
supplements
• Use of herbal remedies
• Prescription medications
• Identifying medications that may
– Be ineffective
– Interact with other drugs or supplements
– Cause troubling side effects
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Urge Patients
• To seek evaluation when pain becomes
uncontrolled
• To be honest about possible needs for
increased medication dosages
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Analgesic Medication
Administration Interventions
• Monitor for adverse effects
• Provide education regarding the pain
management plan
• Implement nonpharmacological methods
as appropriate
• Maintain open lines of communication
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 5
Describe patient-family teaching guidelines
for pain management.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Family Members Should
• Recognize signs of pain
• Keep a diary of pain
• Keep a diary of responses to interventions
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.