Anti-inflammatory and Pain Management

Agents

1
• Inflammation is a response to tissue injury and
infection. When the inflammatory process
occurs, a vascular reaction takes place in
which fluid, elements of blood, leukocytes
(WBC) and chemical mediators accumulate at
the injured tissue or infection site.

2
• The process of inflammation is a protective
mechanism in which the body attempts to
neutralize and destroy harmful agents at the
site of injury and to established conditions for
tissue repair.

3
• Although there is a relationship between
inflammation and infection, these terms
should not be used interchangeably.

• Infection is caused by microorganisms and

results in inflammation, but not all
inflammations are caused by infections.

4
 The five characteristics of inflammation are called the
cardinal signs of inflammation.

1.Redness
2.Swelling (edema)
3.Heat
4.Pain
5.Loss of function

5
 The 2 phases of inflammation are the:
 vascular phase- which occurs 10 to 15 minutes
after an injury.
• -is associated with vasodilation
and increase capillary permeability, during
which blood substances and fluid leave the
plasma and go to the injured site
• delayed phase – occurs when leukocytes
infiltrate the inflamed tissue.

6
• Various chemical mediators are released during
the inflammation process.
• Prostaglandins that have been isolated from the
exudate at inflammatory sites are among them.
• Prostaglandins (chemical mediators) have many
effects: vasodilation, relaxation of smooth muscle,
increased capillary permeability and sensitization
of nerve cells to pain.

7
• Various chemical mediators are released during
the inflammation process.
• Prostaglandins that have been isolated from
the exudate at inflammatory sites are among
them.
• Prostaglandins (chemical mediators) have
many effects: vasodilation, relaxation of
smooth muscle, increased capillary
permeability and sensitization of nerve cells to
pain.
8
 Critical outcome
• The emergency nurse assesses, identifies and
manages acute and chronic pain within the
emergency setting.

9
 Specific Outcomes
• Define the types of pain and complications of
pain management.
• Delineate pain physiology and mechanisms of
addressing pain with medications.
• Define the general assessment of the patient
in pain.
• Delineate the nursing process and role in the
management of the patient with acute and
chronic pain.
10
 Specific Outcomes
• Apply the nursing process when analyzing a case
scenario/patient simulation
• Predict differential diagnosis when presented
with specific information regarding the history of
a patient
• List and know the common drugs used in the
emergency department to manage painful
conditions and conduct procedural sedation.
• Consider age-specific factors.
• Discuss medico-legal aspects of care of patients
with pain related to emergencies.
11
 Definitions
• Pain
– An unpleasant sensory and emotional experience
– Associated with actual or potential tissue damage
or described in terms of such damage
– Personal and subjective experience
• Can ONLY be described by person experiencing pain
• Exists whenever the person says it does

12
 Tolerance
• Greatest level of discomfort a person is
prepared to endure
• Person requires increased amount of
substance to achieve desired effect

13
 Dependence
• Reliance on a substance
• Abrupt discontinuance would cause
impairment of function

14
 Addiction
• Behavioral pattern characterized by
compulsively obtaining and using a substance
• Results in physical, social, and psychological
harm to user

15
 Allodynia
• Pain caused by a stimulus not normally causing pain
• Mechanical:
– Static mechanical allodynia- pain in response to a light
touch/pressure
– Dynamic mechanical allodynia- pain in response to
brushing
• Thermal:
– (Hot or Cold) allodynia- pain in response to mild skin
temperatures in the affected area
• Can be from neuropathy, fibromyalgia, migraines or
spinal cord injuries

16
 Pain Management
• Comprehensive approach to patient needs
when experiencing problems associated with
acute or chronic pain

17
 Pain Threshold
• Least level of stimulus intensity perceived as
painful

18
 Suffering
• Physical or emotional reaction to pain
• Feeling of helplessness, hopelessness, or
uncontrollability

19
 Pain Physiology
• Emergency nurses need an understanding of
basic physiology of pain to effectively assess,
intervene, and evaluate patient outcomes.

20
 Types of pain
• Acute
• Chronic
• Nociceptive
• Neuropathic

21
 Acute
• Elicited by injury to body tissues
• Typically seen with trauma, acute illness,
surgery, burns, or other conditions of limited
duration; generally relieved when healing
takes place.

22
 Acute pain

Wellcome Library London, Wellcome Images 23

 Chronic
• Elicited by tissue injury
• May be perpetuated by factors remote from
the original cause and extend beyond the
expected healing time; generally lasts longer
than 3 months

24
 Chronic pain

Adrian Cousins, Wellcome Images 25

 Nociceptive
• Elicited by noxious stimuli that damages
tissues or has the potential to do so if the
stimuli are prolonged.
– Somatic pain: arises from skin, muscle, joint,
connective tissue, or bone; generally well localized
and described as aching or throbbing.
– Visceral pain: arises from internal organs such as
the bladder or intestine; poorly localized and
described as cramping.

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 Somatic pain

Wellcome Library London, Wellcome Images 27

 Visceral pain

Theuplink, Wikimedia Commons 28

 Neuropathic
• Caused by damage to peripheral or central
nerve cells
– Peripheral:
• Arises from injury to either single or multiple peripheral
nerves
• Felt along nerve distributions
• Burning, shooting, stabbing or like an electric shock
• Diabetic neuropathy, herpetic neuralgia, radiculopathy,
or trigeminal neuralgia

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– Central:
• Associated with autonomic nervous system
dysregulation
• Phantom limb pain (peripheral) or complex regional
pain syndromes (central)

30
 Peripheral neuropathic pain

Lubyanka, Wikimedia Commons 31

 Central neuropathic pain

J.H. Shepherd/Mütter Museum, Wikimedia Commons 32

 General strategy
• Assessment
• Analysis
• Planning and Implementation/Intervention
• Evaluation and Ongoing monitoring
• Documentation

33
 Assessment
• Primary and secondary assessment
• Focused assessment
– Subjective data collection
– Objective data collection

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 Subjective data
1. HPI (history of present illness/injury) or Chief
Complaint
• History of pain (PQRST)
– Pain
– Quality
– Region/Radiation
– Severity
– Timing
• Efforts to relieve symptoms

35
 Subjective data
2. Past medical history
a) Current or preexisting diseases/illness
b) New or recurring problem
c) Substance and/or alcohol use/abuse
d) LNMP
e) Current medications
f) Non-pharmacologic interventions
g) Food or drink
h) Coping mechanisms
i) Allergies

36
 Subjective data
3. Psychological/social/environmental factors:
a) Anxiety, Depression
b) Aggravating or alleviating factors
c) Expressions of pain
d) Pain behavior is learned, yet adaptive, and it r/t
pain threshold and pain tolerance
e) Pain expressions can be verbal, behavioral,
emotional, and physical

37
 Objective data
1. General appearance
a) Psychological
b) Observations of behavior and vital signs should
not be used solely in place of self-report
c) Positioning and movement
d) Physiologic
e) Level of distress/discomfort

38
 Objective data
2. Obtain pain rating
a) Adults
1. Visual analog scale
2. Numeric rating scale
3. Graphic rating scale
4. Thermometer-like scale

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 Visual Analog Scale

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http://0.tqn.com/d/ergonomics/1/0/C/-/-/-/painscale.jpg
 Numeric Rating Scale

http://0.tqn.com/d/pain/1/0/S/-/-/-/PainScale.gif

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 Graphic Rating Scale

http://img.medscape.com/fullsize/migrated/editorial/journalcme/2007/7993/art-
42
mannion.box1.gif
 Thermometer-like Scale

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http://img.medscape.com/fullsize/migrated/574/105/574105.fig1.gif
 Objective data
2. Obtain pain rating
b) Pediatric
1. FACES scale
2. Poker chip
3. Numeric rating scale
4. Color matching

44
 FACES / Numeric combined

No pain Minor Moderate pain Severe pain Worst pain of my life

pain

Clker.com, Clker Images 45

 Objective data
2) Obtain a pain rating
c) Infant
1. Neonatal Infant Pain Scale (NIPS)
2. Neonatal Pain, Agitation, and Sedation Scale (NPASS)
3. Pain Assessment Tool (PAT)

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 NIPS

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http://www.natalnurses.net/images/22.jpg
 NPASS

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http://www.anestesiarianimazione.com/Immagini/npass%208-01.jpg
 PAT

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http://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif
 Objective data
• Inspection
– Position, skin color, external bleeding, skin
integrity, obvious deformity, edema
• Auscultation
– Breath sounds, bowel sounds
• Palpation
– Areas of tenderness: light, deep
– Save painful part until last

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 Diagnostic procedures
• Laboratory studies
• Imaging
• Electrocardiogram

• Purpose: TO FIND THE CAUSE OF THE PAIN

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 Analysis: Differential diagnosis
• ACUTE PAIN
• CHRONIC PAIN

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 Planning and
Implementation/Interventions
1. Determine priorities of care
a) Maintain ABC
b) Provide supplemental oxygen
c) IV access
d) Obtain and set up equipment
e) Prepare/assist with medical interventions
f) Provide measures for pain relief
g) Administer pharmacological therapy as ordered

53
 Administer pharmacological therapy
as ordered
1. The World Health Organization (WHO)
recommends the use of the analgesic ladder
as a systematic plan for the use of analgesic
medications.
1. Step 1: use non-opioid analgesics for mild pain
2. Step 2: adds a mild opioid for moderate pain
3. Step 3: use of stronger opioids when pain is
moderate to severe

54
Patient-controlled analgesia (PCA)
• Used for patients with acute or chronic pain
who are able to communicate, understand
explanations, and follow directions
• Assess vital signs and pain level
• Explain the use of the pump
• Collaborate with the physician, patient, and
family about dosage, lockout interval, basal
rate, and amount of dosage on demand
• Assist the patient to use the PCA pump
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 Planning and
Implementation/Interventions
2. Relieve anxiety and apprehension
3. Allow significant others to remain with
patient if supportive
4. Educate patient and significant others
• about the efficacy and safety of opioid analgesics

56
 Evaluation and Ongoing Monitoring
1. Continuously monitor and treat as indicated
2. Monitor patient response/outcomes, and
modify nursing care plan as appropriate
3. If positive patient outcomes are not
demonstrated, reevaluate assessment
and/or plan of care

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 Documentation
• Document vitals and pain score before and
after intervention along with patient response

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 Age-related concerns
1. Pediatrics: Growth or development related
• Children’s pain tolerance increases with age
• Children’s developmental level influences pain
behavior
• Localization of pain begins during infancy
• Preschoolers can anticipate pain
• School age children can verbalize pain and
describe location and intensity

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 Pediatrics “Pearls”
• Children may not admit to pain to avoid
injection
• Distraction techniques can aid in keeping the
child’s mind occupied and away from pain
• Opioids are no more dangerous for children
than for adults

60
 Age Related concerns
2. Geriatrics: Age related
• Pain is not a normal aging consequence
• Chronic pain alters the person’s quality of life
• Chronic pain may be caused by a myriad of
conditions

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 Geriatric “Pearls”
• Adequate treatment may require deviation
from clinical pathways
• Administer pain relieving medications at lower
dose and increase slowly

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Barriers to effective pain management
1. Attitudes of emergency health care providers
2. Hidden biases and misconceptions about
pain
3. Inadequate pain assessment
4. Failure to accept patients’ reports of pain
5. Withholding pain-relieving medication
6. Exaggerated fears of addiction
7. Poor communication

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 Improving pain management
• Changing attitudes
• Continuing education related to the realities
and myths of pain management
• Evidence-based practice
• Cultural sensitivity

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 Procedural sedation
• The Joint Commission (TJC) has standard
definitions for four levels of sedation and
anesthesia:
1. minimal sedation
2. moderate sedation/analgesia
3. deep sedation/analgesia (pt not easily aroused)
4. anesthesia (requires assisted ventilation)

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 Procedural sedation
• Indications: suturing, fracture reduction,
abscess incision and drainage, joint relocation
• Assessment: Allergies, Last oral intake

66
 Procedural Sedation
• Procedure:
– Baseline VS and LOC
– Explain procedure to patient and family
– Obtain venous access
– Equipment: cardiac monitor, blood pressure monitor, pulse
oximeter, suction, oxygen equipment, endotracheal
intubation equipment and capnography device, IV supplies,
reversal agents.
– Assist with medications
– Maintain continuous monitoring during procedure
– Document vital signs, LOC, and cardiopulmonary status
every 15 min.
– Post procedure discharge criteria

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 Medication review
• Non-narcotic
• Narcotics
• Sedatives / anesthetics
• Local anesthetics

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 ANTI-INFLAMMATORY AGENTS
Drugs such as aspirin inhibit the biosynthesis of
prostaglandin and are therefore called
prostaglandin inhibitors.
• It affects the inflammatory process; they are
more commonly called anti-inflammatory
agents.

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 Anti-inflammatory agents also:

• Relieve pain
• Reduced elevated body temperature
• Inhibit platelet aggregation
• Aspirin is the oldest anti-inflammatory drug,
but it was first used for its analgesic and
antipyretic properties.

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 Non-narcotic
• Acetaminophen
• Salicylates
• NSAIDs

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 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
(NSAIDS)

NSAIDS are aspirin and aspirin like drugs.

• Their roles are analgesics and anticoagulants.
• These drugs may be called prostaglandin
inhibitors with varying degrees of analgesic
and antipyretic effects,
• but they are used primarily as anti-
inflammatory to relieve inflammation AND
PAIN.

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Their antipyretic effect is less than their anti-inflammatory
effect.
• NSAIDS preparations are not suggested for use in
alleviating mild headaches and mildly elevated
temperature.
• Preferred drugs for headaches and fever are:
• Aspirin
• Acetaminophen
• Ibuprofen (given to children and adults with high fever)
• NSAIDS are more appropriate for reducing swelling, pain
and stiffness in joints.

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 Narcotic
• Codeine
• Fentanyl
• Hydromorphone
• Morphine sulfate
• Oxycodone

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 Sedatives / Anesthetics
• Diazepam
• Ketamine
• Lorazepam
• Midazolam
• Propofol
• Etomidate

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 Local anesthetics
• Lidocaine
• Mepivacaine
• Procaine
• Tetracaine
• LET (lidocaine, epinephrine, tetracaine)
• EMLA cream

76
 There are seven (7) groups of
NSAIDS:
1. Salicylates
• Aspirin comes from the family of salicylates
derived from salicylic acid.
• Aspirin is also called acetylsalicylic acid (ASA)
after the acetyl group used in the composition
of aspirin. The abbreviation frequently used
for aspirin is ASA.

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 There are seven (7) groups of
NSAIDS:
2. Para-Chlorobenzoic Acid
• One of the first NSAIDS introduced was
Indomethacin (Indocin), a para- chlorobenzoic
acid.

• It is used for rheumatoid arthritis, gouty

arthritis and osteoarthritis and is a potent
prostaglandin inhibitor.

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 There are seven (7) groups of NSAIDS:
3. Phenylacetic Acid Derivative
• Diclofenac sodium (Voltaren), a phenylacetic
acid derivative hasaplasma half-life of 8 to 12
hours.
• Its analgesic and anti-inflammatory effects are
similar to those of aspirin, but it has minimal
to no antipyretic effects.
• It is indicated for rheumatoid arthritis,
osteoarthritis and ankylosing spondylitis.
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 There are seven (7) groups of NSAIDS:

4. Propionic Acid Derivatives

•  Propionic acid group is relatively new group
of NSAIDs.
• These drugs are aspirin like but have stronger
effects and create less GI irritation.
• Drugs in this group are highly protein-bound,
drug interactions might occur especially when
given with another highly protein-bound drug.

80
 There are seven (7) groups of NSAIDS:

5. Fenamates
• The fenamate group includes potent NSAIDs used for
acute and chronic arthritic conditions.
• Side effects:
• Gastric irritation, patient with history of peptic ulcer
should avoid
• Edema, dizziness, tinnitus and pruritus.
• Two fenamates are: meclofenamate sodium
monohydrate and Mefenamic Acid
•  
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 There are seven (7) groups of
NSAIDS:
• Oxicams   an oxicam is indicated for long-term
arthritic conditions such as rheumatoid
arthritis and osteoarthritis.
• It too can cause gastric problems like:
ulceration and epigastric distress.
• It is well tolerated and it has a long life, which
allows it to be taken only once a day.

82
 There are seven (7) groups of NSAIDS:
• 7. Selective COX-2 Inhibitors (Second
Generation NSAIDs)
• COX-2 Inhibitors became available in the last
several years to decrease inflammation and
pain.

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• Most NSAIDs are nonselective inhibitors that
inhibit COX-1 and COX-2, by inhibiting COX-1,
protection of the stomach lining is decreased
and the clotting time is also decrease, which
may benefit the client with cardiovascular or
coronary artery disease. (CAD)

84
• Older adults frequently use NSAIDs to treat
pain associated with inflammation caused by:
• Osteoarthritis
• Rheumatoid arthritis
• Neuromuscular- skeletal disorders.

85
As older adults age, the number of drugs taken daily
increase, drug interactions are more common
especially when numerous drugs are taken with
NSAIDs.
• With the use of NSAIDs, GI distress is four times
more common in older adults.

86
• With the use of NSAIDs, GI distress is four
times more common in older adults.
• The introduction of COX-2 inhibitors has
decreased the incidence of GI problems
associated with NSAIDs use.
• Edema is likely to occur, renal function should
be evaluated and older adults should increase
their fluid intake for adequate hydration, to
decrease possible complications, the NDAIDs
dose should be lowered.
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 DISEASE – MODIFYING ANTIRHEUMATIC DRUGS
(DMARD)

• DISEASE – MODIFYING ANTIRHEUMATIC

DRUGS
• When NSAIDs do not control immune-
mediated arthritic disease sufficiently, other
drugs, although more toxic can be prescribed
to alter the disease process.

88
 The disease – modifying ant rheumatic drugs
(DMARDs) include:

• Gold drug therapy

• Immunosuppressive agents
• Immunomodulators
• Antimalarials

89
 Gold Drug Therapy
  chrysotherapy or
Gold drug therapy, called
heavy metal therapy, is the most frequently
used DMARD.
• It is used to arrest progression of rheumatoid
arthritis and prevent deformities caused by
the disease.

90
 Gold Drug Therapy
• It depresses migration of leukocytes and
suppresses prostaglandin activity.
• It is not used in the early stages of arthritis
unless the illness is progressing rapidly and is
unresponsive to other therapy, nor is it used
in far-advanced arthritis.
• It is used for palliative, not curative, effects.
Response is alleviating symptoms is slow.

91
• With injectable gold, results may take up to 2
months; oral dosages could take 3 to 6
months for clinical response.
• The half-life of gold is 7 to 25 days and gold
drugs are highly protein-bound.
• Blood should be monitored for blood
dyscrasia before and during parenteral or oral
gold therapy.

92
• The gold salt auranofin ( Ridaural) is the only
gold preparation that can be administered
orally, maybe absorb erratically so parenteral
may be advisable.
• The parenteral gold salt is gold sodium
thiomalate (Myochrysine), switching from
parenteral to oral gold preparations maybe
necessary for long term use.

93
 Immunosuppressive Agents
Immunosuppressive are used to treat
refractory RA (arthritis that does not respond
to anti-inflammatory drugs)
• In low doses, selected immunosuppressive
agents have been effective in the treatment
of RA.
• Drugs such as:
• Azathioprine (Imuran) , Methotrexate
( Mexate) , Cyclophosphamide ( Cytoxan)

94
 Immunomodulators

Immunomodulators treat moderate to severe

RA by disrupting the inflammatory process
and delaying the disease progression.

• Anakinra (Kineret) is administered SC, the

peak is 3 to 7 hours, and the half-life is 6
hours.

95
 Antimalarials
Antimalarial drugs may be used to treat RA
when other methods of treatment fail.
• The mechanism of action of antimalarials in
suppressing RA is unclear.
• The effect may take 4 to 12 weeks to become
apparent and antimalarials are usually used in
combination with NSAIDs in clients whose
arthritis is not under control.

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• Low purine diet

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 Antigout Drugs
Gout has been called the “disease of kings”
because in the past royalty ate rich foods,
drank wine and alcohol and suffered from gout.
• Gout is an inflammatory condition that attacks
joints, tendons and other tissues.
• It may be called gouty arthritis; the most
common site of acute gouty inflammation is at
the joint of the big toe.
• Drug: Colchicine

98
 Antigout Drugs

• The first drug used to treat gout was

Colchicine, introduced 1936.
• This anti-inflammatory gout drug inhibits the
migration of leukocytes to the inflamed site.
• It is effective in alleviating acute symptoms of
gout, but it is not effective in decreasing
inflammation occurring in other inflammatory
disorders.

99
 Uric Acid Inhibitor
Allopurinol (Zyloprim), first marketed in 1963,
is not an anti-inflammatory drug, instead it
inhibits the final steps of uric acid biosynthesis
and therefore lowers serum uric acid levels,
preventing the precipitation of an attack.

• This drug is frequently used as a prophylactic

to prevent gout. It is a drug of choice for
clients with chronic tophaceous gout.

100
 Uricosurics

• Uricosurics increase the rate of uric acid

excretion by inhibiting its reabsorption. These
drugs are effective in alleviating chronic gout,
but they should not be used during acute
attacks.

101
• Probenecid (Benemid) is a uricosuric that has been
available since 1945.
• Side Effects and Adverse Reactions
• Flushed skin, sore gums, headache
• Kidney stones resulting from uric acid could be
prevented by increasing water intake and
maintaining a urine pH above 6.
• Blood dyscrasias occur lately.
• Aspirin use should be avoided, because it causes uric
acid retention.
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