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PAIN MANAGEMENT Terminology Addiction - a behavioral pattern of substance use characterized by compulsion to take the drugs primarily to experience

its psychic effects Dependence - occurs when the patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued Pain tolerance- the maximum intensity or duration of pain that a person is willing to endure Placebo effects - analgesia that results from the expectation that a substance will work Definition of Pain - It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. - Pain is highly subjective and individual and it is the body s defense mechanism indicating that there is a problem. - Unpleasant sensory and emotional experience associated with actual or potential tissue damage - Also called as fifth vital sign whatever the person says it is, existing whenever the experiencing persons says it does means the patient is the best authority on the existence of pain. Types of Pain Pain is described in terms of - Location - Origin - Duration - Cause / physiologic basis SIGNIFICANCE - SUBJECTIVE Response - PROTECTIVE WARNING of potential threat to health - FIFTH VITAL SIGN 1.Location in the body :  Radiating pain: it is perceived from the source of the pain and extends to near by tissues. Eg cardiac pain  Referred pain: pain from one part of the abdominal viscera may be perceived in an area of the skin remote from the organ causing pain

Intractable pain: which is highly resistant to relief eg: Pain in advanced malignancy  Neuropathic pain: due to result of disturbance of the peripheral CNS, which is often severe (shooting or stabbing pain)  Phantom pain: painful sensation perceived in a part of the body that is missing 2. According to Origin:  Cutaneous pain: sharp pain arising from skin and subcutaneous tissue  Deep somatic pain: diffuse pain arising from ligaments,tendons,bones,blood vessels and nerves eg: sprain  Visceral pain: due to stimulation of pain receptors in the abdominal cavity, cranium and thorax eg: burning aching feeling of pressure caused by muscle spasm in obstructed bowel 3. According to Duration:  Acute pain - lasts upto 6 months - sudden & slow onset - mild to severe pain  Chronic pain - lasts more than 6 months - difficult to relieve - eg. Chronic malignant pain Comparison of acute & chronic pain Acute pain  Warns of injury  Recent onset  Mild severe  Lasts few seconds to 6 months  Anxiety follows eg. Surgical interventions, trauma Chronic pain  No purpose  Continuous/ intermittent  Mild severe  Lasts long 6 months and more  Depression follows eg. cancer, arthritis, trigeminal neuralgia 

Responses to pain Acute pain:  Increased Pulse rate  Raised BP/ fall in BP & shock  Increased respiration  Dilated pupils  Diaphoresis  Muscle tension  May rub, cry / hold area  Reports pain  Reduced GI motility Chronic pain:  Vital signs usually normal  Pupils normal or dilated  Dry or warm skin  Depression, irritability  Withdrawal from interests & relationships  Disturbed sleep  Reduced libido  Reduced appetite The Patient with PAIN >Assessment of PAIN PQRST P - Position/Location; Provocation Q - Quality R - Radiation/Relief S - Severity/Symptoms T - Timing Factors Affecting Response to Pain A Pain threshold: Point at which a stimulus is experienced as pain; same for all persons, but individuals have different perceptions and reactions to pain B. Pain tolerance: amount of pain a person can endure before outwardly responding to it B.1. Decreased by repeated pain episodes, fatigue, anger, anxiety, sleep deprivation B.2. Increased by alcohol, hypnosis, warmth, distraction, spiritual practices C. Age

D. Socio-cultural influences D.1. Family beliefs, e.g. males don t cry D.2. Cultural: some persons of ethnic groups handle pain in similar manner E. Emotional status, e.g. anxiety E.1. Fatigue and/or lack of sleep E.2. Depression: decreased amount of serotonin, a neurotransmitter, thus increased amount of pain sensation F. Past experiences with pain G. Source and meaning H. Knowledge about pain

Physiology of pain Pain perception & degree of perception depends on the interaction between 1. Body s analgesia system 2. The nervous system s transmission & interpretation of stimuli. Interaction of the following are important  Peripheral pain sensors (nociceptors)  Pain producing substances (algogenic)  Sensitization of nerve endings  Sensory pathway  Neurotransmitters

Peripheral pain sensors:  PNS consists of primary sensory neurons (touch, heat, cold, pain & pressure)  Nociceptors receptors transmitting pain sensation ENDORPHINS Nociceptors (Primary afferent ) sensory Mechano receptors (A Delta) Activated by threshold hormones Mainly present in the skin Myelinated Usually small Respond to strong pressure and stimuli Impulses are rapid Pain usually sharp, localized, pricking Polymodal (C fibres) Activated by high intensity, physical stimuli Widely distributed Unmyelinated Large Responds to tissue damage (mechanical, thermal, chemical) Impulses are slow, prolonged Dull, aching, poorly localized

Pain producing substances (algogenic/algesic):  Excitatory neurotransmitters ( other name)  Released by damaged tissues  Thus directly or indirectly evoke pain  Eg: bradykinin, acetylcholine, potassium ions, prostaglandins & Substance P  Substance P increases permeability of local blood vessels & produce local extravasations Gate Control Theory  Melzack and Watt  Concepts : modulation of inputs in the spinal dorsal horn by the substantia gelatinosa cells  Brain is the active system that filters, selects and modulates inputs  Dorsal horns are the sites at which dynamic activities like inhibition, excitation and modulation occurred  Peripheral nerve fibers carrying pain to the spinal cord can have their input modified at spinal cord level before transmission to brain  Synapses in the dorsal horn acts as gates that close or open for the pain impulses

 Pain can be reduced at 4 points - peripheral site of pain - spinal cord - brain stem - cerebral cortex

Pharmacologic pain relief interventions Analgesics : - Non opioids/ non- narcotic analgesics - NSAIDs - Narcotic analgesics / opioids - Adjuvants / co- analgesics  Local anesthesia  Patient controlled analgesia  Epidural analgesia 1 . Non narcotic analgesics  Eg. Acetaminophen , acetyl salicylic acid  Mild pain  Mechanism of action: - inhibiting synthesis of prostaglandins - inhibiting cellular responses during inflammation

- act on peripheral nerve receptors to reduce transmission &reception of pain stimuli 2. NSAIDs  Eg : Ibuprofen, Naproxen, Indomethacin, Piroxicam, Ketoralac  Used for pain such as dysmenorrhea, headaches, rheumatoid arthritis, gout, soft tissue athletic injury  Benefits: - No sedation - No interference with bowel or bladder function  Nursing alert : Do not use in older clients Chronic use is not advised 3. Narcotic analgesics  Eg: meperidine, methylmorphine, morphine sulphate, fentanyl, hydromorphone  Used in moderate pain  Acts on CNS & cause depressing and stimulating effects. Also acts in centers of brain & spinal cord to modify perception of & reaction to pain  Nausea, vomiting, constipation ,altered mental processes are common side effects  Opiates can cause respiratory depression 4. Adjuvants  Sedatives, anti-anxiety agents, muscle relaxants  Eg: amitriptyline, hydroxyzine, & diazepam  Enhance pain control / relieve depression & nausea  Can be given alone or with analgesics  Indicated for chronic pain, pain associated with anxiety, depression, nausea & vomiting  Drowsiness, impaired coordination, judgement & mental alertness  Misuse is a serious health problem 5. Local anesthesia  Temporary loss of sedation by inhibition of nerve conduction  Topical application on skin &mucous membrane / injected to anesthetize a body part  Side effects - itching / burning of skin - localized rash - change in heart rate - increased risk of systemic side effects

6. Patient Controlled Analgesia (PCA)  A drug delivery system which is a safe method for post operative, traumatic & obstetrics, burns, terminal care pediatrics and cancer pain management  Involves IV drug administration  Goal : to maintain a constant plasma level of analgesic so that the problems of as needed dosing (PRN) are avoided  Client preparation & teaching is important  Check IV line & PCA device regularly Advantages of PCA  Easy access for clients for medication  Allows self administration with no risks  Pain relief without depending on nurses  Small doses of medications at short intervals for sustained pain relief  Stabilized serum drug levels  Decreased anxiety  Increased mobility for clients  Decreased risk of DVT  Patient has more control on pain management  Enhances patient participation in treatment  Less sedatory effects &nausea experienced due to small doses received  Shorter hospital stay Disadvantages of PCA  Patient becomes dependant on PCA  If mobility is contraindicated, client may move due to decreased or no pain by PCA  Respiratory depression  Side effect may be constipation  Mechanical failure of pump  Relatives may press button for client  Wrong programming parameters  Incorrect placing of syringe can cause infusion of excessive drug doses  Costly & if client cannot understand the system 7. Epidural analgesia  Permits control / reduction of severe pain without more serious sedative effects by blocking pain transmission at nerve root / spinal cord level  Can be short / long term depending on the clients condition  It involves placement of a catheter through a needle in the epidural space just outside the dura mater so continuous infusions of analgesic agents can be given

Indications:  Analgesia during labor  Surgery  Supplement to GA  For post operative pain control  Fractured ribs to enable adequate respiratory function  Access for drug administration to relieve intractable pain Advantages :  Excellent anesthesia  Minimal sedation  Long duration of action  Early ambulation  No repeated injections  No significant effect on sensation  Little effect on blood pressure / heart rate Nursing alert:  Prevent catheter displacement  Maintain catheter function  Monitor for respiratory depression  Prevent undesirable complications  Maintain urinary & bowel functions Contraindications for use:  If patient does not consent to the procedure  Hemorrhagic disorders ( hematoma)  Local sepsis ( meningitis / epidural abscess)  Allergy to LA agents / opiates  Abnormalities of spine  Pre-existing hypotension  Patients with neurological problems  Inadequate / unavailable facilities to safely monitor and care for clients Complications of epidural analgesia:  Hypotension due to peripheral vasodilatation and lack of intravascular volume  Loss of sensation which can lead to bladder distension  Loss of motor function, headaches, infection, nausea, vomiting & pruritis  Respiratory depression

Systolic BP falls < 90mm/Hg:  Stop the infusion  Reassure the patient  Assess the clinical condition & call anesthetist  Follow instructions immediately  Obstetric clients left lateral position  Other clients legs to be elevated. Do not lower head  Administer O2 - 4 li/min to treat hypoxia Lowered respiration:  Stop the infusion  O2 at 4 L / min  Continuous monitoring & recording  Inform anesthetist  Prepare NARCAN 0.4 mg  Assess O2 saturation  Assist in intubation & mechanical intubation High block:  Observe for numbness of chest & arms, for dyspnea & dysphagia  Stop the infusion  Inform anesthetist immediately  Provide management as prescribed & record Post epidural management:  Monitor vital signs  IV infusion  Assess sensory & motor function  Observe patient for voiding / urinary catheter  Remove epidural catheter by sterile technique, & must be checked by 2 nurses to ensure tip of catheter is complete and record  Observe for any complications and refer if needed Spinal anesthesia  A fine needle is inserted from the skin through the dura and arachnoid mater into the subarachnoid space  Enables the injection of analgesic agents directly into the cerebrospinal fluid WORLD HEALTH ORGANIZATION NARCOTIC LADDER  Algorithm for pain management WHO committee on cancer pain management  Tailoring the pharmacologic therapy to the level of pain experienced by the patient  Three step ladder approach

If guidelines fail to provide pain relief, alternative techniques should be implemented Eg: transdermal fentanyl patches, epidural opioid infusion, sympathetic nerve blocks  WHO - NARCOTIC LADDER

Step 3 - Strong opioids +/- non opioids eg : morphine + NSAIDS for strong pain Step 2 - Moderate opioids +/- non opioids eg : codeine + NSAIDs for moderate to severe pain Step 1 - Non opioids +/- adjuvant medications eg : NSAIDs , diazepam for mild to moderate pain Surgical interventions for pain relief 1. Dorsal rhizotomy 2. Chordotomy

Dorsal Rhizotomy  Dorsal nerve roots ( posterior) are resected as they enter spinal cord  Effective for local pain relief  Loss of pain sensation but has full motor function ***TRIGEMINAL NEURALGIA (CN V) Cordotomy  Extensive & involves resection of the spinothalamic tract ( unrelieved pain)  Risk of permanent paralysis is more due to edema / accidental resection of motor nerves  Permanent loss of pain & temporary sensation in the affected areas Surgical interventions for pain relief Nursing alerts:  Assess for parasthesia  Change in temperature sensation  Loss of motor function

Non pharmacologic interventions Cognitive behavioral approaches: 1. Distraction  Diverting attention  Reducing awareness of pain  Increase pain tolerance eg : music, TV, radio, playing game, reading, conversing, using computer etc 2. Reducing pain perception  Removing / preventing painful stimuli especially for clients who are immobilized  Consider aspects that can cause discomfort & pain and avoid them  Control painful stimuli in your clients environment, eg: change wet dressings, positioning the client, preventing urinary retention, avoid exposing skin to irritants 3. Bio-feed back  Using a machine that measures the degree of muscular tension with skin electrodes in microvolts  A poly graph machine records the tensional level for the client to see  Client learns to use relaxation technique / imagery to reduce tension

 Produce deep relaxation  Effective for muscle tension & migraine headaches Biofeedback in Progress A patient at a biofeedback clinic and sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions and may help some paralyzed patients regain the use of their limbs. 4. Hypnosis  Called as therapeutic suggestion  Induces trance like state using focusing & relaxation techniques, giving the patient suggestions that may be helpful after the return of an alert state of consciousness  Intense concentration reduces apprehension or stress  Should be done by trained person  Only effective when the individual cooperates 5. Physical approaches to pain management Goals:  to provide comfort  to correct physical dysfunctions  to alter physiological responses  to reduce fears associated with pain related immobility Examples: 1. Acupressure / acupuncture 2. Cutaneous stimulation (massage, heat application, TENS,) 3. Binders, Chiropractice a. Acupressure / Acupuncture  Chinese technique  Various points in the body stimulate the flow of Qi (chee) or natural meridians ( lines/passage ways) of energy that pass through the body  Used for backache, migraines  Post operative pain  Acupressure - application of pressure to various points of body  Acupuncture insertion of extremely fine needles into various points of the body. The needles unblock the meridians allowing free flow of energy and relief of symptoms

Acupuncture Acupuncture is a traditional Chinese medicine that stimulates specific points in the body in order to restore a proper balance of various chemicals. This practice is used to treat a range of conditions, including chronic pain, drug addiction, arthritis, and mental illness.

b. Cutaneous stimulation  Massage stimulates circulation, relaxes muscles, increases patients sense of well being  Application of heat used to soothe / relieve pain from muscular strain / overwork eg: for healing tissues  Application of cold reduces swelling, calming muscle spasms, reducing pain in joints & muscles TENS (Transcutaneous Electric Nerve Stimulation)  Placing electrodes on the painful area of patient s skin  Low current running through the electrodes acts to block the pain sensation.  Must have a doctor s order


Should be done by a trained person Used for post operative pain and post traumatic patients

Percutaneous Electrical Stimulation (PENS)  For relief of back pain, headaches  Electric current sent through thin needle probes positioned in soft tissues & muscles of the back c. Binders Clothes wrapped around a limb / body part  Used for strains, sprains & surgical incisions  Supports the surface & internal tissues during movement, coughing and other activities d. Chiro-practice  Involves manipulation or adjustment of the joints and adjacent tissues of the body, particularly spinal column  Non-invasive  Drug free treatment  Should be done a doctor chiro-practitioner. 7. Rest and sleep  May be interrupted due to pain, fear or side effects of medication  Assist patient in obtaining enough sleep and rest so as to promote healing & maintain health 8. Use of Placebos  Any medication / procedure that produces an effect resulting from its implicit / explicit intent from its specific physical / chemical properties eg : normal saline, empty capsules,or same procedure like electrodes with no therapeutic value Barriers to pain management Patient factors:  Fear of discussing pain  Fear of being labelled a complainer  Fear that treatment will be discontinued  Fear that pain discussion will divert the physician s attention from the underlying disease  Fear of taking pain medications (opioids)

Professional factors:  Poor pain assessment skills  Concern about drug side effects  Exaggerated fear of addiction  Lack of knowledge and skills in pain management Health system factors:  Unavailability of some drugs  Cost of care  Unavailability of doctors, nurses, and other healthcare professionals  Inadequate physician reimbursement for pain management and palliative care Other factors:  Ethnic and cultural values  Individual management strategies  Environmental support  Support of other people  Previous experience  The meaning of current pain  Anxiety and stress levels Overcoming barriers to pain management Principles:  Respect patient s autonomy - treat patients as individuals - no two patient experience same pain  The willingness to do good for patients  Commitment to avoid harm to patients - untreated patients suffer physically, psychologically and emotionally  Justice equal treatment for all patients  Respect other culture  Educate the patient with pain management options  Create conducive environment  Utilize all available resources  Involve family members or care givers  Assess all factors affecting pain experience and deal with them appropriately  Obtain knowledge &skill in pain management  Improve communication between staff &patients  Trust and believe patients, families and caregivers on the information provided on pain experience

Surgical Pain Causes:  Incision or cut  Muscle spasms or cramps (ortho surgery)  Bladder cramps  Tubes left in place post surgery  Air or blood inside the belly or chest (referred pain)  Backaches, muscular aches or other discomforts  Gas pain) Treatment: 1ST-2ND DAY post op are usually the worst Strong pain medication (IV), then to oral when allowed PO. eg. Morphine which is safe for babies DOSING is done by weight Staying Ahead of pain, then to catch up + non-prescription meds & anti-inflammatory drugs Pain control  Epidurals  Nerve Blocks  Caudal Analgesia  PCA  Massages & Healing touch  PT  TENS  Biofeedback, Acupuncture Special Instructions emphasize that the child does not have to be brave or put up with the pain After Care don t give more than instructed; if pain medication is not working, call the doctor Activity getting out of bed & moving around helps the body recover post surgery, WHEN APPROPRIATE Overview of Cancer Pain  All cancer patients experience pain  Pain is the commonest symptom associated with cancer  Non physical stressors can influence the pain experience Types of cancer pain  Acute tumor growth  Chronic over several weeks  Breakthrough pain special dose or treatment when pain breaks through normal pain medication

 Neuropathic pain injury /compression of nerves  Nociceptive pain inflammatory response to ongoing tissue damage  Visceral pain injury to internal organs, difficult to locate  Somatic pain involves bone, can be pinpointed Sources of cancer pain  Pain may be from the tumor or side effect of treatment  May be directly related to tissue damage from tumors  Pain may be due to the type of treatment (surgery, CT,RT, immunotherapy)  Muscle aches can develop due to inactivity  Pain can be independent of cancer / treatment (headache, backache, arthritis) Treating Cancer Pain  Cancer pain cannot be relieved completely  Therapy can lessen pain for nearly all patients  Effective pain relief improves quality of life  Research -WHO three step ladder approach Assessment of cancer pain  INDIVIDUALIZED assessment  Encourage clients to report pain  Intensity of pain assessment on a 0 -10 scale  Effort to provide adequate analgesia & ongoing assessment Management of cancer pain  Combination of therapy  Neurosurgical approaches  Psychological approaches-psychotherapy, cognitive behavioral therapy  Complementary approaches- meditation, movement therapy, massage  Removal or reduction of underlying cancer( but this may be a source of pain) Pharmacologic & anesthetic approaches:  Oral, rectal, transdermal, PCA, nerve blocks  Mild to moderate pain non opioids (Tylenol) - NSAIDs (Aspirin - combined therapy  Moderate to severe pain - opioids ( morphine, fentanyl, codeine) - combined with non- opioids & NSAIDs  Adjuvants - antidepressants, anti convulsants, steroids, local anesthetics

Management of side effects  Constipation  Nausea  Sedation, drowsiness, clouded thinking  Slowed breathing Cancer pain management after hospital stay  Long term pain management is essential  Pain relieving medicines  Supportive care  Psychological support  Complementary therapy - yoga, meditation - imagery - spiritual healing - music - nutritional counseling Nursing process approach to pain management Assessment:  Goal is to gain an objective understanding of a subjective experience  Accurate pain assessment  Physiologic, psychologic, behavioral, emotional, & socio cultural  Listen to your patient  Establish trust Assessment Subjective assessment:  location of pain  Intensity of pain - visual analogue scale - numeric pain intensity scales - simple descriptive scale  Quality hammer like , piercing like a knife ,  Pattern onset, duration, recurrence or intervals without pain  Precipitating factors: physical exertion, emotional stressors  Alleviating factors: home remedies, rest

Verbal Score 0 1-3 4-6 7-8 9-10

Observer scoring = No pain Appears pain free = Hurts little Comfortable except on movement = Hurts a lot Uncomfortable = Really hurts a lot Distressed can be comforted = Extremely hurts Distressed

Assessment (cont)  Associated symptoms : nausea, vomiting  Effect on ADL  Coping responses : prayer, distraction  Daily pain diary Objective assessment  Behavioral responses  Physiological responses

Nursing Diagnosis: - Acute pain, chronic pain, alteration in comfort - specify the location of pain - etiologic / precipitating factors - other diagnoses related to pain eg: sleep pattern disturbance alteration in nutrition ineffective individual coping self care deficit Planning expected outcomes * Choose the pain relief measures appropriate for the client based on assessment data -Implementation -Evaluation of the plan -Documentation