Transcript Pain Management

Pain Management
RN Certificate in Palliative Care
Multidimensional Nature of Pain
• Experienced by 70-90% of patients with advanced
disease
• 40-50% experience moderate pain
• 25-30% have severe pain
• Unrelieved pain impacts the individual, the family and
society
Definitions of Pain
“An unpleasant sensory or emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.”
(IASP, 2013)
“Pain is whatever the person says it is, experienced
whenever they say they are experiencing it.”
(Pasero & McCaffery, 2011)
Types of Pain (Duration)
Acute Pain:
May last for a few hours, days, weeks to a few
months
Chronic Pain:
Last more than 3-6 months
Types of Pain
Somatic
Nociceptive
Visceral
Neuropathic
Mixed
Nociceptive &
Neuropathic
Pain Terms
• Allodynia
• Analgesia
• Hyeralgesia
Multiple Dimensions of Pain
Physiological
Affective
Environmental
Cognitive
Social,
Cultural,
Ethical &
Political
Behavioral
Pain Assessment (Pain Scales)
• Although pain is subjective, the ability to quantify the
intensity of pain is essential to monitoring a patient’s
response to analgesia.
• Wong Baker Faces Scale
Pain History and Assessment
History
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Location
Quality
Onset
Severity
Duration
Exacerbating factors
Alleviating factors
Medications/therapies
Impact on QOL
Physical Exam
• Non-verbals
• Observation
• Palpation
• Auscultation
• Percussion
• Diagnostics
• Ongoing Assessment and
goals
Patients at Risk for Inadequate
Pain Assessment/Management
Infant/Children
Older Adults
Language/Communication
Barriers
Addictive Disease
Uninsured/Underserved
Pain Management
• Establishing Goals
• Barriers to effective pain management include:
– Patient/family
– System
– Clinician
Pain Definitions
Addiction
Tolerance
Physical
dependence
Double
effect
• Psychological dependence. A primary, chronic neurobiologic disease with genetic, psychosocial, and
environmental factors influencing its development and manifestations.
• A state of adaptation in which exposure to a drug induces changes that result in a diminution of one
or more of the drug’s effects over time.
• Adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by…
• Abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of
an antagonist.
• If the intent for using morphine is to relieve pain and not to cause death.
Pharmacologic Interventions
WHO Ladder
Non-Opioid Analgesics
• Acetaminophen (APAP)
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Opioid Analgesics
• Short and long acting
• Meperidine
• Morphine
• Mixed agonist – antagonist
(Nubain, Talwin)
• Fentanyl
• Oxycodone
• Hydrocodone
• Methadone
• Hydromorophone (Dilaudid)
• Dual action analgesics
• Propoxyphene (Darvon,
Darvocet)
Side Effects of Opioids
• Respiratory Depression
• Constipation
• Sedation
• Urinary Retention
• Nausea and Vomiting
• Itching and Uticaria
• Myoclonus
• Allergy
Adjuvants
• Anti-depressants
• Anticonvulsants
• Corticosteroids
• Local anesthetics
• Other agents
http://www.medscape.org/viewarticle/581948
Methods of Drug Delivery
Oral
Parenteral
Rectal or stomal
Transdermal
Transmucousal, sublingual, buccal
Topical
Spinal and regional blocks
Equianalgesia
• Opioid rotation should be
considered if the opioid is
ineffective after upward
• Use equianalgesic table
titration or the adverse
• See equianalgesia presentation effects are not tolerable or
in this module
manageable
• Used when changing drug or
route
• Naloxone (Narcan)
Nonpharmacologic Interventions
Therapeutic use of
self
Physical strategies
Psychological and
Behavioral
strategies
Neurostimulation
Neuroablative
strategies
Active listening
Exercise
Stress management
TENS
Neurolytic blocks
Presence
Turning/positioning
Cognitive/behavioral
therapy
Acupuncture
Neurosurgical techniques
Empathy
Massage
Patient/family
education/counseling
Heat/cold/hydrotherapy
Palliative
radiotherapy
Difficult Pain Conditions
• Pain Crisis
• Breakthrough Pain
• Palliative Sedation
Interprofessional Collaboration
• Roles
• Nursing
• Patient/family
• Settings
• Coordination of care
• Health promotion
• Follow up
• Diversion/disposal
References
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American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction
Medicine (ASAM). (2001). Definitions related to the use of opioids for the treatment of pain. Glenview, IL:
APS.
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Berry, P. H. & Paice, J. A. (2010) Pain Management. In Hospice and Palliative Nurses Association (HPNA) Core
curriculum for the generalist hospice and palliative nurse, 3 rd edition (Chapter IV, pp. 47-68). Dubuque, IA:
Kendall Hunt.
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Dalton, J. A. & McNaull, F. (1998) A Call for standardizing the clinical rating of pain intensity using a 0-10
rating scale. Cancer Nurse, 21, p 46-49
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Doufas, A. (2003). Dexmedetomidine and Meperidine Additively Reduce the Shivering Threshold in
Humans Stroke, 34 (5), 1218-1223
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Fink, R. M. & Gates, R. A. (2010). Pain Assessment. In B. R. Ferrell, & N. Coyle (Eds.), Oxford textbook of
palliative nursing, 3rd edition (Chapter 6, pp.137-160). New York, NY: Oxford University Press.
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Hawley P. (2009) Non-Tricyclic Antidepressants for Neuropathic Pain. Fast Facts and Concepts. Retrieved on
April 11, 2013 from: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_187.htm
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International Association for the Study of Pain (IASP), (2013). IASP taxonomy. Retrieved April 11, 2013
from: http://www.iasppain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm
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Lopez, G., & Reddy, S.K. (2011). Pain assessment and management. In S. Yennurajalingam & E. Bruera (Eds.),
Oxford American handbook of hospice and palliative medicine (Chapter 4, pp.31-72). New York, NY: Oxford
University Press
References
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National Comprehensive Cancer Network (NCCN) Practice Guidelines. (2012).Oncology – Adult Cancer pain: Version 2. 2012. Retrieved
April 11, 2013 from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
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National Consensus Project (NCP) for Quality Palliative Care (2013). Clinical practice guidelines for quality palliative care, 3rd edition.
Pittsburg, PA: National Consensus Project for Quality Palliative Care
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Old, J. L. & Swagerty, D. L. (2007) A Practical Guide to Palliative Care, Philadelphia, PA: Lippincott Williams & Wilkins.
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Paice, J.A. (2010). Pain at the end of life. In B. R. Ferrell, & N. Coyle (Eds.), Oxford textbook of palliative nursing, 3rd edition (Chapter 7, pp.
161-185). New York, NY: Oxford University Press.
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Pasero, C., & McCaffery, M. (2005). No self-report means no pain-intensity rating: Assessing pain in patients who cannot provide a report.
American Journal of Nursing, 105(10), 50-53.
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Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacological manangement. New York, NY: Mosby Elsevier.
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Rosielle D. (2009) The Lidocaine Patch. Fast Facts and Concepts.Retreived April 11, 2013 from:
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_148.htm
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Reisfield, G. M. & Wilson, G. R. (2009) Blocks of the Sympathetic Axis for Visceral Pain. 2nd Edition. Fast Facts and Concepts. Retrieved on
April 11, 2013 from: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_097.htm
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Von Gunten, C. F. (2009) Morphine and Hastened Death, 2nd Edition. Fast Facts and Concepts. Retrieved April 11, 2013 from :
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_008.htm
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Woodalll H. E., Chiu, A. & Weissman, D. E. (2013) Opioid Allergic Reactions. Fast Facts and Concepts. Retrieved April 11, 2013 from:
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_175.htm
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World Health Organization (WHO), (2013). WHO’s pain ladder. Retrieved April 11, 2013 from:
http://www.who.int/cancer/palliative/painladder/en/
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