Acute Pain Management

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Acute Pain Management

• Christine Gibson
• Specialist Nurse, Acute Pain Service ARI
• 2009

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Objectives

• Have an understanding of pain assessment and pain
  assessment tools
• Have a knowledge of analgesic drugs and side
  effects of drugs
• Have an understanding of routes of drug
  administration
• Be able to provide a definition for pain

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Role of the Acute Pain Service

• Working party report on surgical services. Royal
  College of Surgeons of England and College of
  Anaesthetists (1990)
• 5 Nurses,3 Consultants,1 Pharmacist
• Educational,safety,supportive

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Aims

• Humanitarian
• Avoidance of pathophysiological consequences
• Avoidance of chronicity

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Patient group

• All are in patients, some telephone follow up
• All types of surgery
• Trauma
• Referrals e.g. backpain, infection, absorption
  problems

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Pain ?

• The sufferers knowledge confronts the carers
  belief.
• There are no physiological signs that uniquely
  indicate pain language.
• Pain is a personal experience and is difficult to
  define and measure.
• It is natures way of warning and more often than
  not, serves as a useful warning.
• While pain can be of value it can be of no value
  in excess.

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Definition of Acute Pain
Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage. IASP (1979)

• Implies emotional component.
• Pain can exist without tissue damage.

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Definition of Pain

• Pain is whatever the experiencing person says it
  is, existing whenever the experiencing person
  says it does. McCaffery M. (1968)

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Acute Pain

• Nociceptive pain (the action of a peripheral
  nerve which receives conveys painful stimuli to
  the brain)
• Derived directly from pain receptors
• Arises in damaged tissues
• Sensed in damaged area
• Has a cause which is of finite duration
• Has a purpose

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Barriers to good pain management

• Multidisciplinary factors
• - lack of knowledge
• - failure to recognize multi - faceted nature
  of pain
• - poor interpretation of information
• Patient factors
• - unwillingness to report pain
• - non compliance with treatment
• - lack of knowledge / information

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Pain in older people

• More susceptible
• Lack of knowledge in the complexity
• Failure to assess appropriately
• An inevitable consequence of the normal ageing
  process Kumar A, Allcock N, (2008)

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Why assess pain ?

• To establish degree and nature of pain
• To ensure patient comfort
• To evaluate effectiveness of analgesia
• To help alleviate anxiety
• To decide on type of analgesia
• To aid recovery and prevent complications

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How to assess pain

• Communication with patient is essential
• Observe for changes in physiological signs
• Use a pain scoring system
• Body language?
• Consider pain as 5th vital sign

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Pain Assessment

• No one tool is suitable for all situations
• Pain is complex with many variables, apart from
  the physical cause, that can influence the
  patients experience and interpretation

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Pain Assessment

• One of the most important functions of the
  nurse is to alleviate the suffering of people who
  are experiencing pain
• Schofield P(1995)

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Pain Assessment Research

• Nurses had a lack of trust in patients own
  reports of pain
• Some nurses had their own benchmark of what pain
  level was acceptable and, possibly when and how
  pain was expressed
• Conclusion - nurses thought patients should did
  communicate their pain. Patients thought nurses
  should know. Watt-Watson J.H., Stevens B. (2001)

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Why is it difficult to treat pain?

• Prescribed opioids for a related disease e.g.
  cancer
• Prescribed NSAIDS for e.g. arthritis
• Chronic disease e.g. renal failure, back pain
• Take illicit drugs
• Anxious patient
• Staff/patient attitudes

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Patient Education

• Pain relief can be poor due to inadequate
  education of patient expectations Khun et
  al.(1990)
• Patients expecting to have pain after surgery may
  make fewer demands and fewer reports of pain
  MacLellan,K (2004)

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Why treat pain ?

• Patients deserve to be treated humanely
• Patient comfort and satisfaction should be
  considered important
• To prevent post - operative complications
• We have a professional obligation to give
  patients the best possible care
• Physiological factors
• Economic factors

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Importance of pain control

• It is now recognised that undertreatment of
  severe acute pain can have a number of harmful
  physiological and psychological effects
  (MacIntyre P, 1997)
• Effective treatment important for humanitarian
  reasons, patient comfort and satisfaction can
  significantly improve outcome
• Unrelieved acute pain complicates recovery,
  resulting in more complications, longer hospital
  stays, greater disability and potentially long
  term pain(Watt-Watson et al.1999)

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Harmful effects of undertreated acute pain

• Respiratory- decreased cough and lung volume,
  atelectasis, sputum retention,infection,
  hypoxaemia
• Cardiovascular - tachycardia, hypertension,
  increased myocardial oxygen consumption,
  myocardial ischaemia, deep vein thrombosis
• Gastrointestinal - decreased gastric and bowel
  motility
• Genitourinary - urinary retention

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• Neuroendocrine - increase in levels of
  catecholamines, cortisol, glucagon, growth
  hormone, vasopressin, aldosterone and insulin
• Psychological - anxiety, fear, lack of sleep
• Musculoskeletal - muscle spasm,
  immobility(increasing risk of deep venous
  thrombosis)

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Postoperative pain management major challenge

• Understanding of acute pain physiology has
  advanced and new methods of pain management have
  emerged
• Studies show postoperative pain continues to be
  inadequately treated and patients still suffer
  moderate to severe pain after surgery
  Wilder-Smith Schuler1992,Watt-Watson et
  al.(2001)

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Good pain management

• Communication
• Tailored to individual
• Holistic
• Multidisciplinary Documentation
• Continuity
• Education of staff, patients,
• relatives and visitors

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Management of acute pain

• Analgesic drugs are used to treat acute pain, the
  choice of drug dependent on the intensity of pain
  being experienced.

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Multimodal analgesia

• Paracetamol (acetaminophen)
• Non Steroidal Anti Inflammatory Drugs
• (NSAIDS) e.g. ibuprofen, diclofenac, ketorolac
• Opioids e.g. morphine, oxycodone, fentanyl,
  pethidine

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Analgesic Ladder
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Golden Rules

• By the clock
• By the ladder
• By the mouth

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Methods of administration

• Epidural Analgesia
• Patient Controlled Analgesia intra - venous
• Intra Muscular Injection
• Sub Cutaneous
• Oral
• Rectal suppositories
• Transdermal
• Inhalation gas
• Regional Nerve Blocks e.g. Paravertebral Brachial
  Plexus
• Wound Infiltration
• Reflexology
• Reassurance

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Opioid

• Opioid is a blanket term used for any drug
  which binds to the opioid receptors in the CNS.

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Opioids for acute pain (ARI)

• Morphine
• Diamorphine
• Fentanyl
• Oxycodone
• Tramadol
• MST continus
• Hydormorphone
• Codeine
• Dihydrocodeine

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Adverse effects of opioids

• Respiratory Depression
• Sedation
• Nausea and Vomiting
• Pruritus
• Urinary retention
• Hallucinations

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Norman, age 28, 2nd post op day following
abdominal surgery

• Laughing, smiling
• BP120/80, P 80, R 18
• Painscore of 8 when asked
• What do you think his painscore is?

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James, age 25, 2nd postop day following abdominal
surgery

• Quiet , expressionless, talking little
• BP 120/80, P80, R18
• Painscore 1 when asked
• What do you think his painscore is

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References

• Kumar A., Allcock N. Pain in older people. Pain
  News Autumn 2008 p19-20
• McCaffery M.(1968) Nursing Practice theories
  related to cognition bodily pain and man
  environment interactions.University of California
  at Los Angeles Students Store.p95
• Macrae W.A.Chronic pain after surgery.British
  Journal of Anaesthesia 87(1)88-98 (2001)
• Macintyre P.E. , Ready L.B.Acute Pain Management.
  A Practical Guide.W.B Saunders Company 1997
• MacLellan K.Postoperative painstrategy for
  improving patient experiences.Journal of Advanced
  Nursing.Vol46(2)April 2004 p179-185
• Royal College of Surgeons of England and College
  of Anaesthetists (1990)Report of a working Party
  of the Commission on the Provision of Surgical
  Services

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• Schofield P.Using assessment tools to help
  patients in pain.Professional Nurse Vol 10, 11
  703-706
• Subcommittee on Taxonomy for the International
  Association for the Study of Pain (1979)
• Watt-Watson J.H., Stevens B. (2001) Managing pain
  after coronary bypass graft Journal of
  Cardiovascular Nursing 12 p.39-51
• Watt-Watson J.H., Stevens B., Garfinkel P.,
  Streiner D. Gallop R. (2001) Relationships
  between nurses pain knowledge and pain
  management outcomes for their postoperative
  cardiac patients.Journal of Advanced Nursing ,36
  535-545
• Wilder-Smith C.H. Schuler.L.(1992)Postoperative
  analgesiapain by choice?The influence of patient
  attitudes and patient education.Pain 50,527-262