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PAIN Principles and Nursing Management

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Title: PAIN Principles and Nursing Management


1
PAIN Principles and Nursing Management
2
Disclaimer
  • Views presented in this lecture are intended to
    expand your reasoning and not to offend, demean
    or insult anybody

3
Chances are that you know someone in pain!
  • 3.2 million people are living with pain and more
    women than men are affected
  • Productivity loss is 11.7 billion annually, or
    34 per cent of total pain-related costs
  • The burden of disease accounts for a further
    third at 11.5 billion
  • Health system costs account for 7 billion,
    around 20 per cent of total pain-related costs

4
The Australian Pain Society
  • Australian Pain Society Vision
  • All people should have timely access to pain
    management.
  • Australian Pain Society Mission Statement
  • The Australian Pain Society is a
    multidisciplinary body that aims to reduce pain
    and related suffering through leadership in
    clinical practice, education, research, and
    public advocacy.

5
International Association for the study of pain
  • Vision Statement  Working together for pain
    relief throughout the world
  • Mission  IASP brings together scientists,
    clinicians, health care providers, and policy
    makers to stimulate and support the study of pain
    and to translate that knowledge into improved
    pain relief worldwide.

6
Gold Rush
7
Pain as pleasure
  • Algolagnia is a sexual tendency which is defined
    by deriving sexual pleasure and stimulation from
    physical pain, particularly involving an
    erogenous zone.
  • Sadism refers to sexual or non-sexual
    gratification in the infliction of painor
    humiliation upon or by another person. Masochism
    refers to sexual or non-sexual gratification in
    the infliction of pain or humiliation upon
    oneself

8
Pain its causes
  • Unpleasant sensory emotional experience
    associated with actual or potential tissue damage
  • May be acute or chronic
  • Pain is a subjective experience there is no
    accurate assessment for the degree of pain
    experienced

9
Pain as pain
  • pain is defined by the International Association
    for the Study of Pain (IASP) as "an unpleasant
    sensory and emotional experience associated with
    actual or potential tissue damage, or described
    in terms of such damage".
  • Pain is highly subjective to the individual
    experiencing it. A definition that is widely used
    in nursing was first given as early as 1968 by
    Margo McCaffery "'Pain is whatever the
    experiencing person says it is, existing whenever
    he says it does".

10
Stress as pain
11
Questions Regarding Pain Control
  • What about the 20 who do not get relief from the
    WHO ladder or the 46 of those whose families
    stated we failed?
  • Have the opioids been titrated aggressively?
  • Is the pain neuropathic?
  • Has a true pain assessment been accomplished?
  • Have invasive techniques been employed?
  • Have you examined the patient?
  • Is the patient receiving their medication?
  • Is the medication schedule and route appropriate?

12
Physiological effects of Pain
  • Increased catabolic demands poor wound healing,
    weakness, muscle breakdown
  • Decreased limb movement increased risk of DVT/PE
  • Respiratory effects shallow breathing,
    tachypnea, cough suppression increasing risk of
    pneumonia and atelectasis
  • Increased sodium and water retention (renal)
  • Decreased gastrointestinal mobility
  • Tachycardia and elevated blood pressure

13
Psychological effects of Pain
  • Negative emotions anxiety, depression
  • Sleep deprivation
  • Existential suffering may lead to patients
    seeking active end of life.

14
Immunological effects of Pain
  • Decrease natural killer cell counts
  • Effects on other lymphocytes not yet defined.

15
Procedure Related Pain
  • Common in all patients
  • Frequent source of pain and distress

16
Therapeutic Procedures
  • Surgery
  • Only 50 of post-operative pain is adequately
    managed
  • Post-operative pain syndromes
  • Traumatic neuroma
  • Similar to other chronic pain syndromes
  • Psychological factors important
  • Treat symptoms
  • Maintain functional status

17
Principles of Assessment
  • Assess and reassess
  • Use methods appropriate to cognitive status and
    context
  • Assess intensity, relief, mood, and side effects
  • Use verbal report whenever possible
  • Document in a visible place
  • Expect accountability
  • Include the family

18
Pain Assessment
  • What methods can be used to assess pain?

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Patient Pain History
  • Site(s) of pain?
  • Severity of pain?
  • Date of onset?
  • Duration?
  • What aggravates or relieves pain?
  • Impact on sleep, mood, activity?
  • Effectiveness of previous medication?

21
Assessing pain in patients with dementia
  • Behavioral chances
  • Mood changes
  • Facial expression
  • Body language
  • Speech
  • Signs of physical examination

22
What Does Pain Mean to Patients?
  • Poor prognosis or impending death
  • Particularly when pain worsens
  • Decreased autonomy
  • Impaired physical and social function
  • Decreased enjoyment and quality of life
  • Challenges to dignity
  • Threat of increased physical suffering

23
Neuropathic Pain
24
Damned if do and damned if you dont
  • Over prescribing pain pain killers
  • reckless malpractice
  • charged with drug trafficking
  • manslaughter or murder
  • Under treating pain
  • sued for abuse

25
How do we get addicted
26
How do families influence addiction
27
Do families share the tablets ?
28
Some medication have socially unacceptable side
effects
29
Useful but socially unacceptable side effects
30
There is no such thing as an old junkie
31
They said go to rehab and I SAID NO NO
32
Thinking out side the circle
  • A young woman went to her doctor complaining of
    pain. "Where are you hurting?" asked the
    doctor. "You have to help me, I hurt all over",
    said the woman. "What do you mean, all over?"
    asked the doctor, "be a little more
    specific." The woman touched her right knee with
    her index finger and yelled, "Ow, that hurts."
    Then she touched her left cheek and again yelled,
    "Ouch! That hurts, too." Then she touched her
    right earlobe, "Ow, even THAT hurts", she
    cried. The doctor checked her thoughtfully for a
    moment and told her his diagnosis, "You have a
    broken finger."

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Physiology of Pain
  • Physical sensation of pain
  • Nerve endings are stimulated causing an impulse
    along the nerve pathway to the brain pain
    response
  • Psychological component
  • Emotional response based on pain threshold (level
    of nerve ending stimulus)

51
The perception of pain
  • Involves
  • Painful stimulus
  • (chemical, mechanical, thermal )
  • Tissue damage
  • Release of chemicals from damaged tissues
  • Enhanced by the release of prostaglandins
  • Stimulation of pain receptive fibres
  • (nocioreceptive)
  • Transmission of pain signals to the brain
  • recognition of pain by the brain

52
Classification of Pain
  • Acute
  • Chronic
  • 6 months or longer
  • Visceral
  • Dull aching due to stimulations of smooth muscle
    nerve endings
  • Somatic
  • Pain of skeletal muscles
  • Neuropathic
  • Burning, shooting, tingling caused by
    peripheral nerve injury
  • Psychogenic

53
Pain suppression can involve
  • Inhibition of prostaglandin production
  • Blocking transmission of pain messages
  • Blocking perception of pain at brain level
  • Non-narcotic analgesics have a direct effect on
    pain producing lesions, stopping pain at the
    source
  • Musculo-skeletal pain responds well to
    non-narcotic analgesics
  • Narcotic analgesics have an action only on the
    central nervous system
  • Non-narcotic analgesics are ineffective for
    visceral pain

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55
Non Pharmaceutical pain relief methods
56
WHO guidelines on analgesic use
  • By the ladder
  • By the clock
  • By the mouth
  • For the individual
  • With attention to detail

57
Analgesic Ladder
58
Analgesics
  • Paracetamol
  • NSAIDS
  • Narcotics/Opioids
  • Others?

59
Paracetamol
  • Action
  • Analgesic, anti-pyretic
  • Dose 0.5 1 gm, 4 hourly up to 4 gm daily.
  • Adverse Effects
  • nausea dyspepsia
  • allergic reaction
  • haematological reactions
  • hepatic necrosis
  • Nursing Points
  • Use with caution in hepatic or renal dysfunction

60
Paracetamol
  • Tylenol, Herron
  • Paralgin, Parahexal
  • Setamol, Panadol
  • Plus Codeine
  • Panadeine
  • Panadeine forte
  • Paracetamol overdose
  • Acetylcysteine (Parvolex)
  • Used for O/D 10 g or more (adult)

61
NSAIDs e.g. Diclofenac
  • Diclohexal, Fenac, Voltaren
  • inhibits biosynthesis of prostaglandins
  • anti-pyretic, anti-inflammatory, analgesic,
    anti-rheumatic
  • Uses
  • rheumatic arthritis oesteoarthritis
  • primary dysmenorrhea
  • post-operative inflammation
  • acute or chronic pain states due to inflammation
  • Dose 75 150 mg bd or tds

62
Diclofenac
  • Adverse Effects
  • gastrointestinal disturbances
  • Headache, dizziness, vertigo
  • Rash, puriris, urticaria
  • peripheral oedema
  • Nursing Points
  • should be swallowed whole with fluid and taken
    with food.
  • should not be used during pregnancy.

63
Other Anti-Inflammatories
  • Commonly used anti-inflammatories.
  • Diflunisal
  • Ketoprofen
  • Ibuprofen
  • Methyl Salicylate
  • Indomethacin
  • Aproxen

64
Narcotic (Opioid) Analgesics
  • Drugs that mimic endogenous opioid peptides
  • Cause prolonged activation of opioid receptors
    producing analgesia, euphoria and sedation
  • Routes may include oral, S/C, IM, IV, epidural,
    rectal, dermal patches
  • Oral absorption is irregular, up to 70 may be
    removed by 1st pass metabolism
  • Natural Opioids
  • The body has naturally occurring opioid receptors
    and produces its own opioid like compounds
  • Endorphins, dynorphins, enkephalins

65
Opioid Analgesics
  • Moderate pain
  • Codeine Phosphate
  • Dextromovamide (Palfium)
  • Detropropoxyphene (Dolobid)
  • Pentazorine (Fortral)
  • Pethidine
  • Tramadol (Tramal)
  • Moderate to Severe pain
  • Fentanyl
  • Methadone
  • Morphine
  • M.S Contin
  • Oxycodone (Endone, Proladone)

66
Opioids
  • Used for moderate to severe pain
  • Used as part of anaesthesia
  • Produses euphoria person is aware of pain, but
    is not bothered by it
  • CNS effects enhanced by alcohol. Sedatives,
    tranquillisers
  • More effective if given before onset of intense
    pain

67
Adverse effects
  • Nausea Vomiting
  • Anorexia
  • Constipation-decreased peristalsis due to opioid
    receptors in GIT
  • Difficulty voiding
  • Anti-diuretic
  • Decreased sexual function
  • Decreased cough

68
Adverse effects
  • Respiratory depression
  • Drowsiness, confusion
  • Bradycardia, postural hypotension
  • Miosis pupliary constriction
  • Euphoria or dysphoria
  • Sweating
  • Allergic reactions
  • Dependence
  • Tolerance

69
Opioid overdose Naloxone
  • Specific opioid antagonist
  • Reverses respiratory depression
  • Will precipitate a withdrawal syndrome when
    dependence has occurred
  • Overcaution in the use of opioid analgesics can
    result in unnecessarily poor pain control in
    patients

70
Morphine
  • Analgesia post operative pain, cancer
  • Relief of anxiety dyspnoea (APO)
  • Oral, S/C, IMI, IV, slow release, mixtures
  • Half life approximately 4 hours
  • High doses may be necessary in terminal cancer
  • Oxycodone Endone, Prolodone
  • Less marked side effects
  • Longer duration (8-10 hours

71
Pethidine
  • Analgesia
  • Obstetrics does not affect uterine contractions
  • Less biliary spasm than morphine
  • Less urinary retention constipation
  • No effect on cough
  • Half life approximately 3 hours
  • Less duration than morphine
  • Metabilites may accumulate causing seizures

72
Fentanyl
  • Avaliable for IV, epidural use
  • Transdermal for chronic stabilised pain
  • Patches last approx 3 days
  • Less risk of constipation

73
Tramadol
  • An atypical opioid which is a centrally acting
    analgesic, used for treating moderate to severe
    pain.
  • S4 Available oral, SR tablet (100,200,300).
  • IM. IV preparations
  • Usually does not produce respiratory depression,
    euphoria, tolerance or addiction

74
Codeine
  • If more than 8 mg prescription required
  • May be habit forming
  • Mild to moderate pain
  • Useful for cough suppression, diarrhoea

75
Equianalgesic table
Drug Dose 10mg morphine Duration (hrs) pharmakokinetics
hydromorphine IM/IV 1.5-2mg oral 6-7.5mg 2-4 2-4
Fentanyl 150-200 mcg SC/IV/transdermal 0.5-2 Useful in renal failure
Morphine IM/IV 10mg oral 30mg 2-4 2-3 (CR 12-24)
Methadone IM/O 10mg 24 Accumulates in body
Oxycodone oral 20-30mg 3-4 12-24 CR Alternative to morphine
Tramadol IM 40-50 mg oral 100mg 3-6 3-6 Low abuse potential
Pethidine IM 75-100 mg 2-3 C/I in renal failure
Codeine IM 130 mg Oral 200mg 3-4 3-4
76
Anaesthetics
  • General anaesthesia
  • Premedication
  • Induction of anaesthesia
  • Maintenace of anaesthesis
  • Reversal of anesthesia
  • Local anaesthetics
  • Local infiltration
  • Nerve blocks
  • Epidurals

77
General anaesthesia
  • Premedication (less common now)
  • Relieve anxiety (Anxiolytic)
  • Reduce saliva anticholinergic (atropine)
  • Increase stomach pH (ranididine)
  • Induction of anaesthesia
  • Thiopentone
  • Rapid acting but metabolised slowly may
    accumulate in the tissues. Used to induce
    anaesthesia
  • Propofol
  • Ketamine
  • Also has analgesic properties

78
General anaesthesia
  • Maintenance of anaesthesia
  • Inhalational anaesthetics
  • Nitrous oxide
  • Halophane etc
  • Muscle relaxants /-
  • Curare
  • Suxamethonium
  • Pancuronium etc
  • Reversal of anaesthesia
  • Anticholinesterase anticholinergic (?S/E)
  • Neostigmine atropine

79
Local Anaesthetics
80
GA for procedures in children
81
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