Palliative Care and Pain Management

Learning Outcomes
• Assess a person’s pain management, and implement strategies to address pain and any medication-
induced constipation in consultation with registered nurse.
• Provide the person, family or carer with opportunities to discuss spiritual and cultural issues in an
open and non-judgmental manner.
• Use effective communication techniques and access relevant support services to provide a supportive
environment for the person, family or carer.
• Monitor the person s condition and provide accurate and timely information on stages of dying to the
person, family or carer, ensuring that information-provision respects their wishes.

Pain
Definition of pain
• Pain is defined as, “an unpleasant sensory and emotional experience associated with actual or
potential tissue damage or described in terms of such damage.”
• “Whatever the person experiencing the pain says it is, existing whenever the person says it does.”
• The fact that an individual doesn’t verbalise that they do have pain doesn’t mean that they don’t have
the pain and in need of pain relief.
• According to the IASP, one learns to express pain based on experiences related to injury early in life,
therefore it is subjective.

Pain and Palliative Care

Palliative care involves the assessment and management of pain which may be:
• Unrelenting.
• Have various causative factors.
• Affect function negatively and thus independence.
• Cause an impeding sense of doom as a result of suffering and fear of death.

About Pain
Pain is….
• A sensation in a part of the body, always unpleasant and therefore an emotional experience
• An unpleasant experience may also be pain not necessarily because the usual sensory qualities of pain
are involved.
• Many people report pain in the absence of tissue damage or pathophysiological cause;
usually this happens for psychological reasons.

Physiological responses to pain

Physiological symptoms of pain:
• ↑ HR
• ↑ BP
• ↑ RR
• Dilated pupils
• Guarding of region
• Pallor
• Diaphoresis (sweating)
• Bronchial dilation - leads to ↑ 02 intake→↑HR & RR
• Peripheral vasoconstriction causing shift of blood supply from periphery to muscles and brain – leads
to ↑BP
• Pallor
• Blood glucose ↑- used for energy
• Control of body temperature during pain – leads to diaphoresis or sweating
Types of pain
• Nociceptive.
• Neuropathic.
• Psychogenic.
• Phantom.
• Referred.
• Chronic.
• Acute.

Nociceptive Pain
• This occurs through nociceptors-nerves that sense and respond to the part of the organ that has been
injured.
• The pain is typically well localised, constant, and often with an aching or throbbing quality.
• Nociceptive pain is usually time specific when the tissue damage heals, the pain typically resolves.
• Examples include sprains, bone fractures, burns, bumps, inflammation (from an infection or arthritic
disorder).

Neuropathic pain-somatosensory
• Injury or dysfunction of the PNS or CNS.
• Common in diseases affecting the nervous system, such as diabetes mellitus, multiple sclerosis or
result from surgery and /or trauma to the nervous tissue.
• Presents as tingling, burning and numbness

The somatosensory system

• The somatosensory system is the part of the sensory system concerned with the conscious perception
of touch, pressure, pain, temperature, position, movement and vibration, which arise from the
muscles, joints, skin and fascia.
• Made up of a number of receptors: thermo-receptors (action triggered by hot/cold) photoreceptors
(triggered by light) mechanoreceptors (movement).

Phantom Pain
• Perceptions that an individual experiences relating to a limb or an organ that is not physically part of
the body anymore.
• Sensation related to pain where the limb was before the amputation. E.g. Pain: to knee, when there
has been an above knee amputation.

Psychogenic pain
No obvious pathophysiological sign/symptoms, pain with no obvious tissue or organ injury may be associated
with emotional trauma or mental health behaviours.

Referred pain
• Sensation or the pain felt in a part of the body other than its actual source.
• A cardiac event, pain to the shoulder is felt.

Ischaemic pain
• Pain occurring when blood supply to an organ is restricted.
• Leading to decrease oxygenation of the tissue supplied by vessels→ build-up of metabolic wastes.

Discussion
Divide into groups and discuss the factors influencing pain.
Psychosocial factors influencing pain
Age
• The age and development of a client is an important variable that influences the experience of pain.
• Young children have difficulty understanding pain and the procedures nurses administer that may
cause pain.
• Older adults may be at greater risk of having painful conditions, pain is not an inevitable part of
ageing.
• Once an older client suffers pain, there can be serious impairment of functional status.
• Mobility, ADL’s, social activities outside the home and activity tolerance can all be reduced.
Gender
• Evidence suggests that women and men differ in their experience of pain, as well as in their response
to pain treatment.
• Women are at greater risk of a variety of chronic pain conditions such as headache, abdominal pain
and musculoskeletal pain.
• Experimental evidence also suggests that women may be more sensitive to pain, less tolerant of pain
and more able to discriminate among different levels of pain than men.

Perception of pain
Family and social support
• People in pain often depend on family members or close friends for support, assistance or protection.
• Although pain still exists, the presence of a loved one can minimise loneliness and fear.
• An absence of family or friends can often make the pain experience more stressful.
• The presence of parents is especially important for children experiencing pain.
Culture
• The multicultural nature of the Australasian population means that nurses will encounter a variety of
responses to pain in their work environment.
• Aboriginal and Torres Strait Islander people tend to be very orientated towards their families and are
frequently not willing to share personal information with strangers.
• For this reason, these people may appear withdrawn and non-communicative until a level of trust and
confidence has been established with hospital staff.
• While it is important that nurses are knowledgeable about cultural differences in response to pain, we
need to be careful not to stereotype clients based on their cultural background.
• There is also diversity within each culture.
• Indo-Chinese clients may often be quite stoic, not requesting pain relief themselves.
• They may instead delegate a member of their family to approach the nurse for assistance.
• People of Middle eastern origin may express pain through facial expression, body posture and
moaning or soft cries.
• Some may believe, that pain is something to be endured to facilitate cleansing of the soul and for this
reason may not seek analgesia.
Fatigue
• Fatigue heightens the perception of pain. The sense of exhaustion intensifies pain and decreases
coping abilities.
• Pain beliefs
• As active processors of information, people with pain problems develop underlying beliefs, attitudes
and assumptions in an attempt to make sense of their pain condition.
Coping strategies
• Faced with chronic pain, individuals also learn and utilise a variety of strategies to help them cope or
deal with their pain.

Discussion
Factors that alleviates pain
• Relaxation
• Diversional therapy (concentrating on something other than the pain can distract patient from their
pain).
• Activity - the right amount of exercise and detract from the pain
• Other variables: heat, acupuncture.
Pain Management
Routes of medication
• Oral
• Subcutaneous route
• Intramuscular
• Syringe driver

Oral
• Oral medication is absorbed in the gastrointestinal tract.
• Slower onset- prolonged effect.
• Convenient, cheap, no need for sterilization, variety of dose forms.
• This can take time and can also reduce the effectiveness of the medication.
• The dosage of some medication can be significant requiring a large number of tablets difficult to take

Presentations
Tablet: powdered dosage form, compressed into hard disks or cylinders.
Capsule: solid dosage form encased in a gelatin shell.
Enteric coated/pills: tablet that does not dissolve in the stomach, the coatings dissolve in the intestines where
it is absorbed.

Administration
Swallowing: as a patient’s condition deteriorates the ability to swallow will be affected, swallowing medication
will be difficult and challenging in this case mode of administration will change to either subcutaneous (S/C) or
Intramuscular (IM).

Subcutaneous (S/C)
Definition: injection into the hypodermis layer (subcutaneous layer).
Advantages
• Rapid absorption is faster onset than oral.
• S/C injections only allow for small dosage at a time.
• Clients may have a butterfly needle inserted under the skin and held in place by a transparent
dressing.
• Medication is administered when necessary.
• When client has nausea and vomiting post therapy and requires pain relief.
In situ for 3 days.

Intramuscular (IM)
• Medication is administered into the muscle tissue.
• Rapid onset and absorption.
• Larger quantities can be administered than S/C.

Syringe driver
Small pump that delivers medication into the subcutaneous tissue,
by slowly infusing the medication over time. Client does not need to
be repeatedly injected. Clients can be cared for in the home,
making management of symptoms easing the burden on family
members and later in the dying phases.

Nursing interventions
Observations: For adverse symptoms rate is configured per doctor’s orders. Signs of swelling and redness at
site. The infusion is progressing without interruption. Infusion is progressing by the gradual decrease of the
medication left in the syringe.
Not water proof, need to be protected when in washing and giving drinks.
Analgesics
• The correct dose of analgesia for a client is the dose at which that patient reports pain relief.
• Treatment must be carefully monitored for relief and avoiding side effects.
• Most patients will have nausea and may need antiemetic's with the analgesia.

Types of Analgesia
• Non opioids- simple analgesics
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Opioids

Non-opioids analgesia and NSAIDs

• Do not contain narcotic properties.
• Simple analgesia treating mild-moderate pain and pyrexia.
• Works on the Peripheral Nervous System.
• Action is thought to inhibit prostaglandin formation→ the sensory neurons less likely to receive the
pain signal.
• Once an injury has occurred prostaglandins can limit the healing process, cause increased
inflammation and pain.
• Prostaglandins increase the sensitivity of nerve endings to pain.
• Simple analgesics and NSAIDs block the synthesis of prostaglandins.
• Alleviate pain and inflammation.

Nursing interventions
• Limits for paracetamol are monitored, over medicating can lead to liver toxicity
caution used when treating patients with liver disease.
• NSAIDs must be given with food as they may cause bleeding in the gastrointestinal tract
• Caution with asthmatics, NSAIDs may cause bronchospasm.
• Salicylates have anticoagulating properties and may cause bleeding.
• Can be used in conjunction with opioids.
• Paracetamol can be taken with NSAIDs, especially if patient has a sensitivity to aspirin.
Examples:
Simple analgesia: Paracetamol - Panadol
NSAIDS: Ibuprofen
Salicylates: Aspirin

Opioids
• Managing moderate to severe pain.
• Opioids can act on several sites in the Central Nervous system rather than the P.N.S.
• Alter the release of neurotransmitters:
Bind to the opioid receptors distributed in the brain.
Pain transmission is disrupted at several sites along the CNS→ altered perception and response to
pain.

Nursing interventions
• Monitoring of respiratory rate and conscious levels is a priority for all nurses.
• Orthostatic hypotension is another adverse reaction.
• Nausea +/- vomiting.
• Pruritus: sensitivity, not necessarily allergic reaction.
• Assistance required if patient needs to be mobilized or out of bed.
• Patient to be monitored post administration.
Sedation Score
Frequent observation chart
Sedation Score Scale:
0=awake and alert
1S=asleep easy to rouse
1=mild sedation easy to rouse
2=moderate sedation easy to rouse
3=difficult to rouse

Opioids
Examples:
• Morphine
• Fentanyl
• Methadone
• Oxycodone

Morphine
Classification: Opioid analgesic
Class: Narcotic S8 schedule
Administered O, Rectal, S/C, IM and IV
Continuous infusion – 0.8–10 mg/hr;
Bolus of 15 mg.
Mechanism of Action: Morphine binds to opiate receptors in CNS-perception and response to painful stimuli is
altered and a generalised CNS depression is produced.

Actions of Opioids
• Opioids act by attaching to specific proteins base opioid receptors, located in the brain and spinal
cord. When morphine attaches to the receptors, they reduce the perception of pain.
• Endogenous peptides, (endorphins) are produced naturally in the body, these endogenous receptors
decrease with pain, morphine attaches to opioid receptors and morphine may mimics these and
cause sedation.

Side Effects
Dependence:
• Adaptive state that develops from repeated drug medication.
• The body has developed a physiological reliance on the drug.
• Physical dependence of opioid is an expected occurrence in patients who receive continuous use of
opioids.
• May cause withdrawal symptoms by the abrupt cessation of the opioid.
Tolerance:
• Patients diminished response and effect to a drug
• Occurs when the drug is used repeatedly, and the body adapts to the continued presence of the drug.

Nursing interventions
• As a health care worker, you will spend the most time with your patient in pain, providing strategies,
interventions and assessing the pain.
• When analgesia is prescribed you will have a choice of route and interval.
• E.g.: morphine 2.5-15mg for severe pain. Panadol 1-2 tablets moderate pain.
• When the client complains of pain which analgesia do you administer?
• Which route?
• How often?

Responsibilities
• You have an onerous responsibility and the autonomy when making these decisions.
• Your responsibility to your patient does not start and finish with the administration of pain relief.
Other Therapies
Complementary therapies:
• The right to use complementary therapies.
• Clients and family involved with palliative care will inevitably want to try other forms of pain relief.
• They have a value in assisting clients to exercise control over their situation.
• Nurses need to be aware of patients utilizing. Complementary therapies, as some treatment may
interact with the drugs the patients is currently on.

Discussion
Discuss the varies complementary therapies that may be useful in the palliative care environment.

Complementary Therapies
• Homeopathy
• Music therapy
• Message
• Relaxation
• Meditation
• Reiki
• Aromatherapy
• Acupuncture

Managing personal, emotional, cultural and spiritual needs in palliative care

In addition to physical symptoms, people who are at a palliative stage often experience emotional symptoms,
such as anxiety, loneliness, depression and anger, which are all associated with grief.
As we can’t know all cultural beliefs and practices in relation to palliative care, death and dying, we should ask
the older person and their family what is important to them.
All people should be provided with the opportunity to express and live as their chosen gender identity during
palliative care.

Cultural and Spiritual Needs

• Cultural safety is providing an environment that is respectful of an individual’s culture and beliefs.
• Spiritual care may become more important to people when they are in a palliative state, and their
spiritual needs may include finalizing things they have set out to do and ‘making peace’ with others or
they may be religious or spiritual beliefs.
• It is important to be aware of any religious or spiritual beliefs or rituals a person may have during
their palliative care and after death.

Use effective communication skills to provide emotional support

• Providing emotional support and empathy to people accessing the service, their families and carers is
a key responsibility for those working with people who are at the end of their lives or have life-limiting
illnesses.
• This means you must listen to what the person, their family members and carers say, acknowledge
the impact the illness is having on those involved and provide the appropriate support.
• Respect feelings.
• Identify needs.
• Listen to feelings.

Palliative Care and Nursing

• Working in palliative care can be very satisfying, rewarding and also stressful.
• Greif is a common experience among nurses, they are confronted with loss and death on a daily basis.
Stress and burnout are significant issues and may affect:
• Quality of care
• Client satisfaction
• Staff retention
• Absenteeism
if nurses do not manage life style balance.
Professional Tip
• Your own self-awareness is a vital step in self-care allows you to understand your own reactions to
particular situations.
• Your own skills, attitude, and approach to challenging situations will affect you.
• Develop physical and emotional self-care strategies:
• Healthy diet
• Regular exercise
• Relaxation and recreation time
• Acknowledge your grief and plan time for your own grieving.
• Communicate and express your grief with co-workers, supervisors and ask for help.
• Find support from councillors/religious person and support groups.

Pain Management Nursing

• Regardless of the setting in which they work, nurses are responsible for the assessment and
management of clients with pain.
• Pain is a key consideration in all patient care, and nurses play a critical role in pain management.
• Nurses are uniquely positioned to improve patient outcomes through effective pain assessment and
management, and yet there is ample evidence over several decades of poor pain assessment and
under-treatment of patients in pain. Despite the rapidly evolving scientific base for pain management,
the data suggests that patients in pain remain poorly managed. Why might this be so?