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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
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