pain management ii
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Pain Management
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What is pain?
One of the most common reasons people seek healthcare
One of the most widely under-treated health problems
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Pathophysiology A sensation caused by some type of
noxious stimulation A pattern of responses that function to
protect the individual from harm Whatever the experiencing person says
it is whenever he says it does
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Components of PainPhysical
Caused by some kind of noxious stimulant
EmotionalResults of combination of thoughts, feelings, and beliefs
BehavioralPattern of responses that function to protect the individual from further harm
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Causes of PainCutaneous
Direct stimulation to skin (cut)
Somatic
From musculo-skeletal system (sprained muscle)
Visceral
Arising from hollow organs (appendicitis)
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Neuropathic
Damage to nervous system
Referred
Pain arising from someplace else in body
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Descriptions of pain
• Chronic: occurring over a long period of time
• Acute: sudden, brief onset
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Visual Analog ScaleThis is a line 10 cm. long (about 4 inches) that
is divided into ten divisions. Patients are asked to show the amount of pain on a 1-10 scale.
Researchers say that patients cannot function with a scale with more than ten points.
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PQRSTThis mnemonic is devised to show the
steps in pain assessment: Provoking factors Quality Region/Radiation Severity/Symptoms Timing
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• Provoking factors include what caused the pain and what might be making it worse
• Quality questions refer to how the pain feels…let the patient tell but offer suggestions if necessary, like sharp, dull, throbbing, burning, etc.
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• Region….have patient point to area that hurts
• Severity can be measured with the pain rating scales
• Symptoms may accompany the pain….nausea, vomiting, etc
• Timing refers to when the pain started, how long it lasts
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Be aware
• Just because a patient cannot respond to pain doesn’t mean there is no pain
• Activities of daily living (ADLs) may be effected
• Neurological status will alter the response to pain
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Pain Management
Management must be timely, individualized,and bring the pain to an acceptable level of tolerance
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Pharmacologic interventions
Must be individualized
• Three main categories:– Non-opioids– Opioids– Adjuvants
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Non-opioids: Acetominophen (Tylenol) Aspirin NSAIDs (Advil)
Opioids Weak Strong
Codeine Hydromorhone Oxycodone Morphine Vicodin Merperidine
Adjuvants Primary function is not pain relief but provide relief
May modify mood so patient feels better
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Precautions to giving pain medications
• Medication choice may depend on practitioner’s preference, however:– Should not give two analgesics
from same class at same time– Must be aware of effects of
medications– Must watch for allergic reactions
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Routes of medication administration
• Oral• Injection• Intravenous (includes PCA)• Epidural• Rectal• Topical
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SEVERE PAIN: Keep giving mild pain medication and add a strong opioid such as morphine or Fentanyl
MODERATE PAIN:Keep giving mild pain medication and add a mild Opioid such as codeine
MILD PAIN:Aspirin, ibuprophenAcetominophen, naprosyn
WHO Pain Ladder
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Concepts of WHO Pain Ladder
• By the mouth
• By the clock
• By the ladder
• For the individual
• With attention to detail
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Placebos
Controversial use of an inactive substance to satisfy the demand for medication
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Non-pharmacologic interventionsPain control without using medications• Alter the environment• Relaxation and guided imagery
– Meditation• Cutaneous stimulation
– Massage, acupressure, acupuncture, TENS
• Biofeedback• Therapeutic touch• Education
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JCAHO Standards for Pain Management
• Address care at the end of life
• Assess and manage pain appropriately
• Assess pain in all patients
• Support safe medication ordering and administration
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• Monitor patient during post-procedure period
• Rehabilitate for optimal level of function
• Educate about pain an managing pain• Plan for discharge continued care if
needed• Collect data to monitor performance
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Nurses spend more time with patients than any other provider. They must stay informed in order to give the best care to their patients.
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• References:– Falk. Kim Marie. Pain Management. National
Center of Continuing Education. Catalog 98 TX.
– http://www.fxbcenter.org/caring/painladder.html
– http://www.harcourthealth.com/Mosby/Wong/fyi_03.html