Deb Gordon RN, DNP, FAAN Nursing Orientation

Transcription

1 Deb Gordon RN, DNP, FAAN Nursing Orientation 1

2 Introduce & Discuss: HMC policy overview Pain screening, assessment, reassessment IV PCA, Epidural, PNC analgesia Pain Relief Service Joint Commission pain standards Improving patient satisfaction 2

3 Reasons for pain control Humane and ethical Negative physiological and psychological consequences neuroendocrine immune response function & quality of life issues untreated pain can sensitize the nervous system It s required by regulatory agencies

4 Patients have the right to appropriate assessment and management of pain Patients self-report is the gold standard Age and condition appropriate assessment tools One identified, minimum assessment = location, severity, character, goal for pain relief Patient and family education and involvement is essential 4

5 Numerical Rating Scale (for adults and children >10 years of age) 0-10 where zero is no pain and 10 is the worst pain imaginable Descriptive Scale (for adults and children >10 years of age) None, mild, moderate, severe, very severe, unbearable Oucher Score (for children 4-10 years of age) 0-10 using pictures or numbers where 0 is no hurt and 10 is the biggest hurt you could ever have FLACC behavioral observational Score (for children <4 years of age) 0 10 where each parameter, face, legs, activity, crying, consolability is given a 0 2 and added together for the total score 5

6 FLACC PAIN SCALE Categories Scoring Face No particular expression or smile, eye contact and interest in surroundings Occasional grimace or frown, withdrawn, disinterested, worried look to face, eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed Frequent to constant frown, clenched jaw, quivering chin, deep furrows on forehead, eyes closed, mouth opened, deep lines around nose/lips Legs Normal position or relaxed Uneasy, restless, tense, increased tone, rigidity, intermittent flexion/extension of limbs Kicking or legs drawn up, hypertonicity, exaggerated flexion/extension of limbs, tremors Activity Lying quietly, normal position, moves easily and freely Squirming, shifting back and forth, tense, hesitant to move, guarding, pressure on body part Arched, rigid, or jerking, fixed position, rocking, side to side head movement, rubbing of body part Cry No cry/moan (awake or asleep) Moans or whimpers, occasional cries, sighs, occasional complaint Crying steadily, screams, sobs, moans, grunts, frequent complaints Consolability Calm, content, relaxed, does not require consoling Reassured by occasional touching, hugging, or talking to. Distractible Difficult to console or comfort Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2 which results in a total score between zero and ten. Used for children < 4 years of age. 6

7 Behavioral indicators: Facial indicators (grimacing/frowning/wincing, drawn around mouth and eyes, teary/crying, wrinkled forehead Movements (no movement, slow/decreased/ hesitant/cautious, restlessness, seeking attention through movements) Vocalizations ( ouch, that hurts, cursing during movement, or exclamations of protest: stop, that s enough ) Posturing/Guarding (rigid, splinting, tense/stiff) Physiological indicators (not always reliable): heart rate blood pressure respiratory rate Perspiration Pallor 7

8 Assessment is ongoing The frequency of assessment different for each patient! Screen for regularly for pain Frequent at initiation and at change of treatment plan With new reports of new or worse pain- i.e. post-op At Appropriate interval following intervention Task reminder min after IV, min after PO Per specific pain management protocols (e.g. epidurals, IV PCA, ketamine) 8

9 My Pain is 20/10!!!!! Tight rope of over-sedation and pain, avoiding respiratory depression Tolerance to opioids does not always make it safe Behavior patterns sometimes challenging Pay attention to your own beliefs and judgments Communicate respect and empathy Develop trust and rapport 9

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14 Acute Care Sedation Assessment Score ICU Richmond Agitation/Sedation Score (RASS) 14

15 ACUTE PAIN Facilitate recovery from the underlying injury, surgery, or disease Reduce neuroendocrine stress Minimize impact of pain on recovery activities Control and reduction of pain to acceptable level Minimize pharmacologic side effects Prevent chronic pain CHRONIC PAIN Restore function Physical, emotional, social Decrease pain Treat underlying cause where possible Minimize medication use Correct secondary consequences of pain Postural deficits, weakness, overuse Maladaptive behavior, poor coping It is generally not possible or safe to eliminate all pain, but our goal is to reduce your pain to a reasonable level as well as manage any unpleasant side effects of pain medicines and help you recover. 15

16 Although analgesics are the mainstay, cognitive and physical strategies are essential Cognitive Education/instruction Distraction Relaxation Music Physical Cold Heat Massage Pain Trauma Opioids α 2 -Agonists Centrally acting analgesics Anti-inflammatory agents Local anesthetics Opioids α 2 -Agonists Anti-inflammatory agents Local anesthetics Local anesthetics Anti-inflammatory agents Opioids Adapted from Gottschalk A, et al.. Am Fam Physician. 2001;63:

17 Patients often feel judged Understand tolerance may be present Clear communications between staff and patient and family Avoid parenteral opioids if possible Avoid short-acting PRN formulations When possible, use schedule and long-acting opioids Combine opioids with nonopioids and other multimodal strategies Consider resources: PRS, Rehab Psych 17

18 Wrong dose and improper monitoring are most common issues Risk factors for respiratory depression obesity, very young or old age, very ill, concurrent CNS depressants Do not rely on pulse oximetry alone to detect respiratory depression can suggest adequate oxygenation in active respiratory depression, especially when supplemental oxygen is used When used oximetry should be continuous rather than intermittently 18

19 Assess/document every 2 hrs for 8 hrs, then Q 4 hrs Resp rate and depth (full minute before stimulation) Serial sedation levels Pain intensity Side effects Total PCA dose is documented every 8 hrs, pump cleared PCA-by-proxy - instruct family/friends NOT to assist the patient with IV PCA A 2-person (RN) independent double check of PCA settings/medication is required at initiation of PCA therapy and following any changes (and at start of each shift for peds) 19

20 Use of basal infusion Use of concurrent CNS depressant Increased age Obesity Upper abdominal or thoracic surgery Sleep apnea Impaired hepatic, renal, cardiac or pulmonary function Frequent RN IV boluses PCA by proxy 20

21 Stimulate the patient!! Call 222 provide O 2, may need mechanical assist with ventilation (bag-valve mask) Administer Naloxone (Narcan) IV (with order) Draw up 1 ampule (0.4mg or 400mcg) in 10mL syringe and add NS up to 10 ml mark- give 2-3mL increments every 3-5 minutes 21

22 Assess/document every 2 hrs for 24 hrs, then Q 4 hrs Resp rate and depth (full minute before stimulation) Sedation level Pain intensity Side effects If Local Anesthetic: Assess/document BP, HR, sensory level and motor strength every 30 minutes for 2 hrs, hourly for 4 hrs, then every 4 hrs Vasodilation common results in orthostatic BP Assess the site/position of the catheter every shift May reinforce the dressing around tegaderm; do NOT replace to avoid dislodgement of catheter Bolus doses via pump only: except (fentanyl) see policy 22

23 Avoid disconnections Use separate Alaris (brain) for PNC/epidural infusions Use PNC/Epidural drug library (listed on second page); drugs are listed under Guardrails Fluids Fluids library caution with bolus dosing Epidural filter/yellow striped portless tubing Must have patent IV for 24 hrs after epidural removed 23

24 Know how to check length There are centimeter markings on epidural catheter Single marks = 1 cm When grouped together each mark = 5 For example three clustered marks = 15

25 Assess/document every 1 hrs for 4 hrs, then Q 4 hrs (and after an increase in rate or concentration) BP, HR Pain intensity Neuro-vascular check of affected extremity: color, temp, sensation, motion Observe/report signs of systemic local anesthetic toxicity Very rare ringing in ears, periorbital paresthesia, nausea May reinforce the dressing around tegaderm; do NOT replace to avoid dislodgement of catheter Managed by PRS including catheter removal 25

26 Search Ambit on intranet for video and quick reference card on Clin Ed website No need to lock Programs in mls Designed for takehome use Reprocess bottom only (not cassette and tubing) 26

27 Drugs Brand Names Duration of Analgesia Lidocaine Xylocaine 3-5 hours, variable Mepivacaine Wound infiltration Carbocaine minutes Polocaine Nerve block 4-6 hours Bupivacaine Ropivacaine Marcaine Sensorcaine Naropin Wound infiltration 2-4 hours Nerve block 8-18 hours Wound infiltration 2-6 hours Nerve block 8-15 hours Questions to Consider What kind of nerve block does the patient have? What is the extent of the motor and sensory block? Will this block affect blood pressure, heart rate, bowel function, ability to ambulate? How long will this block last? Is it likely that other nerves were blocked too, for example, those to the face, vocal cords, diaphragm, bladder? Do I need to restrict use of systemic opioids, anticoagulants, non-steroidal anti-inflammatory analgesics (NSAIDs)? Who do I call for more information or help? 27

28 Consult service that TAKES OVER Require a provider-to-provider consult Automatic consult epidurals, peripheral nerve catheters, ketamine In-depth pain history/assessment Write orders for analgesia and side effects All PRE-EXISTING analgesia and sedation orders discontinued by PRS 28

29 NMDA antagonist At low doses analgesic At high dose general anesthetic Max on med-surg floor 12mg/hr Only the Pain Relief Service may order BP, HR, RR, pain, sedation every 30 min X 1 hr, then every 2 hrs X 8 hours, then every 4 hrs Not compatible with IV Lactated ringers or potassium 29

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31 Policy Statement: Deep sedation requires a licensed anesthesia provider Minimal/Moderate sedation requires a Specialty trained RN HMC RN procedural sedation/airway training Sedation Core = 8 hours Sedation Update = 2 hour annually Classes offered in April & October Taught by Chief CRNA 31

32 Critical Care Radiology Echocardiology Lab Emergency Department (ED) Post Anesthesia Care Unit Ambulatory Procedure Area (APA) Multi Interventional Procedure Suite (MIPS) Gamma Knife Unit Endoscopy Dental/Oral Surgery Clinic Infusion Lab/Oncology Spine Clinic All other areas need to arrange for a STAT or PACU nurse to administer sedation 32

33 Be prepared to answer: When and how do you assess for pain? How do you reassess and document after a pain management intervention? How do you determine which dose to give from a range order? What are the risk factors for respiratory depression? How do you monitor for respiratory depression? What do you do when pain is uncontrolled? 33

34 How well was your pain controlled? How often did the staff do everything they could to help you with your pain? How often was your pain well-controlled? HMC scores range below local, regional, national 34

35 Individualize patient care to partner with patients Use key words I want to do everything I can to make you as comfortable as possible. I care about your pain control. Alleviate anxiety (explain rounding) Tell the patient when next dose of pain medicine is coming Use the whiteboard and encourage communication Address pain at handovers Provide complete explanation for new/modified interventions Seek alternatives to pain medicine Reposition the patient (basic comfort measures) 35

36 Thanks for your attention and welcome!