Pain Assessment & Management For General Nursing Orientation April 2012
Overview Definition of pain Barriers to effective pain management Types of pain Objective pain assessment Approaches to management
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage (International Association for the Study of Pain, 1986) Pain is whatever the experiencing person says it is, existing whenever he says it does. (McCaffery 1968) Pain <=> discomfort
Why Manage Pain? To minimize or eliminate discomfort To facilitate the recovery process To avoid or effectively manage the side effects associated with the treatment of pain Accreditation Liability (Shapiro, 1994, Sanchez-Sweatman, 1998)
Impact of Unrelieved Pain - Physiological decreased pulmonary function strain on cardiovascular system decreased bowel function impaired immune function impaired movement altered cognitive function
Impact of Unrelieved Pain - Psychological low self esteem discouragement depression isolation suffering fear of future pain
Types of Pain Acute Persistent (Chronic) Acute on Chronic Cancer
Acute Pain Short duration (hours/days/few weeks) Pain remits with resolution of the injury or disease Associated with tissue damage or nociception Pain is generally proportional to the degree of tissue damage Serves a biological function Warning of the potential for serious injury or disease Motivation to seek medical assistance Examples: Trauma (including fractures), Surgery, Labor, Medical procedures, Acute disease states
Chronic Non-Cancer Pain / Persistent Pain Pain present for 6 months or longer Pain occurs longer than the expected time to tissue healing or present in a condition where there is ongoing nociception or neuropathic pain Compromises quality of life Pain behaviours are usually absent May be nociceptive, neuropathic or both Causes include injury, malignancy, arthritis, fibromyalgia, neuropathy, unmanaged acute pain May have no apparent cause
Cancer Pain Pain caused by: The disease itself Investigations and treatment of the cancer A result of complications/treatment sideeffects (ie: neuropathic pain following chemotherapy) An increase in intracranial pressure related to brain metastases Pathological fractures
Acute on Persistent Pain Example?
Classifications Nociceptive: Direct stimulation of afferent nerves in skin, soft tissue, viscera. Opioids usually effective. Somatic Visceral Neuropathic: Abnormal processing of sensory input due to nerve damage/changes. Opioids not as effective Central Peripheral
ASSESSMENT APP-Assume Pain Present Patients who are unable to communicate and who undergo a procedure that would be painful for others should be treated for pain presumptively. (APS, 1999, p.4)
Hierarchy of Pain Intensity Measures 1) Self report 2) Pathology 3) Behaviors 4) Reports from family/sig.others 5) Physiologic measures
Objective Pain Assessment O Onset P Provocative measures Q Quality of pain R Region or radiating pain S Severity T Timing (Endorsed by RNAO)
Rating Scales-rate intensity only! Numerical rating scales Visual Analog scale New- Faces Pain Scale Revised (FPS-R) Colour intensity Word descriptive scales At NYGH numerical 0-10 is most often used to rate intensity, only one part of total pain assessment.
Faces Pain Scale Revised (FPS-R) These faces show how much something can hurt. This face (point to left-most face) shows no pain. The faces show more and more pain (point to each from left to right) up to this one (point to right-most face) it shows very much pain. Point to the face that show how much you hurt (right now). Do not use words like happy or sad. This scale is intended to measure how children or patients feel inside.
Pain Assessment-Cognitively Impaired Elders May still use self report rating scales 0-10 verbal descriptors (none, mild moderate, severe) Faces Behavioral indicators-ask family re changes in patient s usual behaviours
Pain Behaviours: Non-Verbal Cognitively Impaired Person Absence Indicators Flat affect Decreased Interaction Decreased Intake Altered Sleep Pattern Active Indicators Rocking Negative vocalizations Frown / grimacing Noisy breathing Irritability Agitation
Ongoing Assessment Reassess after time within which medication has reached its peak effect i.e. 1 hr after PO Immediate Release (IR) 4 hrs after Slow Release (SR) analgesic 15-30 min. after IV/SC/IM 24 hours after transdermal patch e.g. Fentanyl
Pharmacological Management Non-Opioids Adjuvants Opioids
Acetaminophen Max daily dose 4 grams in 24 hrs 2.6 grams in 24hrs if frail/elderly Risk of liver damage in high doses/chronic use renal failure with chronic use
NSAID Inhibit the synthesis of prostaglandins therefore preventing their contribution to the sensitization of nociceptors (nerves that transmit pain) e.g. Indocid, Ketorolac, Ibuprofen, Naproxen, ASA, celebrex, mobicox adverse effects: GI Renal (monitor Cr) Platelets
Corticosteroids Mechanism: Likely due to reduction of tumor-related edema, antiinflammatory effects, and direct effects on nociceptive neural systems Ex. Dexamethasone, prednisone, methylprednisolone
Gabapentinoids E.g. Gabapentin (Neurontin) Pregabalin (Lyrica) Effective in neuropathic pain (i.e. diabetic peripheral neuropathy and post-herpetic neuralgia) Dizziness and sedation are common side effects
Tricyclic Anti-depressants Effective for neuropathic pain in combination with opioids to reduce opioidrelated side effects e.g. Amitriptyline (anticholinergic effects), Nortriptyline, Desipramine Usually sedating Administer at hs Start low, titrate gradually q 2-3 days
Opioids Morphine (Standard) Hydromorphone (Dilaudid) Meperidine (Demerol) Codeine Oxycodone (found in percocet/percodan) Fentanyl (the only opioid available in a patch form) Methadone
Codeine Mild to moderate pain Metabolized into active form=>morphine by the liver Up to 10% of the population are nonmetabolizers of codeine: do not have any pain relief Small percentage of population hypermetabolizers ( over-dose )
Morphine For moderate to severe pain Also effective for control of dyspnea Metabolites accumulate in renal dysfunction IR, CR/SR, rectal, parenteral, and intraspinal preparations available
Oxycodone Moderate to severe pain Effective in neuropathic pain 1.5-2 times more potent than morphine Oral only Available in IR and CR
Hydromorphone Moderate to severe pain 5-7.5 times more potent than morphine No active metabolites Oral (IR, CR), rectal, parenteral, and intraspinal preparations available
Meperidine Repeated administration can lead to CNS stimulation not for long term use Not recommended for use in patients with: renal failure chronic pain elderly
Adverse Effects of Opioid Analgesics Constipation Nausea Sedation Hallucinations Urinary retention Delirium Myoclonic jerks (toxicity) Seizures Respiratory depression
Non-Pharmacological Interventions
Non-Pharmacological Interventions Cognitive and behavioral Distraction Humor Imagery Hypnosis Therapeutic Touch Relaxation techniques Biofeedback Exercise Play therapy Psychological preparation Laughter
Non-Pharmacological Interventions (cont d) Physical TENS/acupuncture Thermal stimulation Physiotherapy Massage Warm baths Heat/Cold Re-positioning
Barriers in Pain Management Patients Fear (condition worsening, addiction) Not wanting to burden family/staff Health Care Professionals Lack of knowledge, assessment skills Concern abut side effects and addiction Health Care System/society Not a priority, issues with availability
Physical Dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical Dependence Addiction
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug s effects over time Tolerance Addiction High dose Addiction
Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. 4 C s Loss of Control Compulsive use Consequences (use despite harm) Craving
THANK YOU