Pain Assessment and Management

Lynn CowlingMacmillan Clinical Nurse Specialist in Palliative Care Calderdale & Huddersfield NHS Trust

Objectives

What is pain? Total pain? Cancer pain. Keys to good pain management. Types of pain. Assessment. Management.

What is pain?

Pain is real regardless of its cause; pain is whatever the patient experiencing it says it is and exists where they say it does (McCarthey 1983).

The pain a patient describes may be seen as the tip of the iceburg, underlying this pain is a whole range of factors, physical, emotional, social and spiritual, each inextricably entwined (Saunders and Sykes 1983).

Not only patients with cancer get pain. There are many different conditions, especially in the elderly, that can cause pain and discomfort.

These simple rules can be used to assess and manage any one suffering from pain.

TOTAL PAINPHYSICAL

Caused By the illness itselfConcurrent illnessOther symptoms

Adverse effects of treatmentPressure sores weight loss

Constipation muscle tension/spasmPSYCHOLOGICAL SOCIAL Anger at diagnosis Worry about family and finances Anxiety, fear Loss of social position Disfigurement Loss of role in familyFear of pain and or death TOTAL Feeling of abandonment and isolation

Feeling of helplessness PAIN Concerns about dependency Depression Cultural

SPIRITUALWhy has this happened to me?

Why does god allow me to suffer like this?What is the point of all this?

Is there any meaning or purpose in life?Am I being punished for past wrongdoings?

Cancer Pain 80% of patients with cancer claim pain as a

major symptom. 33% have two pains. 33% have three or more pains. 50-80% of those DO NOT receive adequate pain

relief? Cancer pain can be controlled in 80-90% of

patients and ‘acceptable relief is possible in most of the remainder. So why does under treatment remain a problem?

KEYS TO GOOD PAIN MANAGEMENT

Understanding of different causes of pain.

Assessment of pain.

Management of pain.

Reassessment and monitoring.

Types of Pain

There are three types of pain:

Visceral - tumour bulk, bowel obstruction

Bone - replacement of bone by tumour, pathological fracture

Neuropathic - nerve injury or nerve compression

The Pains of Malignant Disease

Visceral Deep, dull ache usually over the tumour site

Bone Pain Sharp, may be spasmodic Neuropathic PainInjury-Burning, sharp,

stinging, stabbing, numbCompression-Ache,

throbbing, stabbing Headache of Dull, oppressive, Cerebral Tumour vice-like

Assessment (1)Need psychosocial and medical history but also to ask:

Site of pain - where is the pain?

Type of pain – what does it feel like?

Frequency of pain – how often does it occur?

Aggravating factors – what makes it worse?

Relieving factors – what makes it better?

Assessment (2)

Disability – How does the pain affect everyday activities?

Duration of pain – how long has it been present?

Responses to previous and current treatments?

Meaning – what does the pain mean to the patient?

If you have a pain assessment tool, use it!

PATIENTS THAT HAVE DIFFICULTY COMMUNICATING

Facial expression. Posture. Increased agitation or aggression. Withdrawal. Change in mood and behaviour. Guarding one area of body. Not sleeping at night.

WHO Ladder

Paracetamol

Paracetamol 500mg+ codeine 30mg

Morphine 10mg every 4 hours

+/- Paracetamol

UNCONTROLLED PAIN

CO –ANALGESICS

NSAIDs – bone pain, liver capsular pain

Anti-convulsants – neuropathic pain

Anti-depressants – neuropathic pain

Muscle relaxants

Anti-spasmodics

Paracetamol OpioidsWeakStrong

AdjuvantsAnti depressantsAnticonvulsantsAntispasmodicsMuscle relaxantsNSAID

Methods of Administration

Oral Rectal Subcutaneous Spinal Tens

Patch Nerve Blocks Surgery Radiotherapy Chemotherapy

NO IM OR IV DRUGS

ANALGESIA (1)

Regular doses of analgesia must be prescribed

Adequate doses of analgesia on an ‘as required basis’ (PRN), in addition to the regular medication must be made available

Where possible give analgesia by mouth, by the clock and by the ladder

Pain that does not respond to oral medication is unlikely to respond to analgesia given by a different route e.g. SC, IV unless there are absorption problems

Review the effectiveness of any medication on a regular basis

Ensure all patients on a step 2 or 3 analgesic are on regular laxatives and that the effectiveness of the laxative regime is being monitored

ANALGESIA (2)

Other Pain Control Measures

Remember the role of-ExplanationPsychological supportRestRelaxationAdequate sleepHeat padsTENs machine and massageSelf-help measures

Alternative Opioids

Oxycodone

Hydromorphone

Fentanyl

Methadone

THE KEYS TO GOOD PAIN ASSESSMENT AND MANAGEMENT ARE:

Understanding the meaning of whole pain.

Understanding of different causes of pain.

Assessment of pain.

Management of pain.

Reassessment and monitoring.

THANK YOU