Transcript Chapter 5
Chapter 5 Pain: The Fifth Vital Sign Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Definitions of Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999). Self-report is always the most reliable indication of pain. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2 Types of Pain Types of pain: Acute pain Chronic pain: • Chronic cancer pain • Chronic non-cancer pain Sources of pain: Nociceptive pain types: • Somatic pain • Visceral pain Neuropathic pain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3 Pain Transmission Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4 Attitudes and Practices Related to Pain Attitudes of health care providers and nurses affect interaction with patients experiencing pain. Many patients are reluctant to report pain: Desire to be a “good” patient Fear of addiction Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5 Addiction, Pseudoaddiction, Tolerance, and Physical Dependence Addiction—primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations Pseudoaddiction—iatrogenic syndrome created by the undertreatment of pain Tolerance—state of adaptation in which exposure to a drug results in a decrease in one or more the drug’s effects over time Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6 Addiction, Pseudoaddiction, Tolerance, and Physical Dependence (Cont’d) Physical dependence—adaptation 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 Withdrawal or abstinence syndrome—N&V, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7 Collaborative Management History Physical assessment/clinical manifestations: Location of pain: • Localized pain • Projected pain • Radiating pain • Referred pain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8 Pain Pharmacologic Therapy— Non-Opioid Analgesics Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) are most common Most are NSAIDs, including aspirin: Can cause GI disturbances COX-2 inhibitors for long-term use Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9 Non-Opioid Analgesics (Cont’d) Acetaminophen (Tylenol): Available in liquid form; can be taken on empty stomach Preferable for patients for whom GI bleeding is likely Can cause renal or liver toxicity if used longterm Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10 Pain Pharmacologic Therapy— Opioid Analgesics Block the release of neurotransmitters in the spinal cord Drugs include codeine, oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11 Side Effects of Opioids Nausea and vomiting Constipation Sedation Respiratory depression Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12 WHO Analgesic Ladder World Health Organization’s recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain) Level 1 pain (1-3 rating)—Use non-opioids Level 2 pain (4-6 rating)—Use weak opioids alone or in combination with an adjuvant drug Level 3 pain (7-10 rating)—Use strong opioids Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13 Pain Management in End of Life Opioid regimen should stay consistent with dose in weeks before last weeks of life Generally believed that patient still feels pain when unconscious Does not hasten death unless the dose was not properly and gradually titrated Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 14 Routes of Opioid Administration Can be administered by every route used PRN range orders Patient-controlled analgesia (PCA) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15 PCA Infusion Pump Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16 Spinal Analgesia Epidural analgesia Intrathecal (subarachnoid) analgesia Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 17 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18 Implantable Devices Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19 Adjuvant Analgesics Antiepileptic drugs Tricyclic antidepressants Antianxiety agents Local anesthetics Dextromethorphan, ketamine Local anesthesia infusion pumps Topical medications Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20 Nonpharmacologic Interventions Used alone or in combination with drug therapy Physical measures Physical and occupational therapy Cognitive/behavioral measures Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21 Physical Interventions Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22 Cognitive/Behavioral Measures Strategies that can be used to relieve pain as adjuncts to drug therapy: Distraction Imagery Relaxation techniques Hypnosis Acupuncture Glucosamine Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23 Invasive Techniques for Chronic Pain Nerve blocks Spinal cord stimulation Surgical techniques: Rhizotomy Cordotomy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24 Surgical Procedures for the Alleviation of Pain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25 Community-Based Care Home care management Health teaching Health care resources Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26