Pain management

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  • Instructions:1- The patient is asked: What number on a 0 to 10 scale, where 0 means no pain and 10 as worst pain, would you give your current pain intensity?2- When the question above is not understood by the patient, it is sometimes helpful to further explain or conceptualize the Numeric Rating Scale in the following manner:0 = No Pain1-3 = Mild Pain (nagging, annoying, interfering little with ADLs)4–6 = Moderate Pain (interferes significantly with ADLs)7-10 = Severe Pain (disabling; unable to perform ADLs)3 - The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to Numeric Pain Ratings
  • Instructions:1- Explain to the patient that each face is for a person who feels happy because he has no pain (hurt or, whatever word the patient uses) or feels sad because he has some or a lot of pain.2- Ask the patient to point to each face using the words to describe the pain intensity. Face 0 doesn’t hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine.3- The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to Faces Pain Ratings
  • Instructions:1- Each of the five (5) categories is scored from 0-2, which results in a total scorebetween 0 and 10.2- The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to FLACC Scale scores.
  • Interpretation:minimum score: 0 maximum score: 7 0 No pain1 – 2 Mild discomfort2 – 4 Mild to moderate pain 4 – 7 Moderate to severe painLimitations: A falsely low score may be seen in an infant who is too ill to respond or who is receiving a paralyzing agent.
  • Instructions:1- Each of the five (5) categories is scored from 0-2, which results in a total score between 0 and 10.2-The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to CRIES Scale scores.
  • Each of the nine (9) categories is scored from 1-5, which results in a total scorebetween 9 and 45.The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to COMFORT Scale scores.Thank you Ahmad Thanin
  • Pain management

    1. 1. Pain Management Prepared & Presented by Ahmad Thanin
    2. 2. Pain—the definition….  An unpleasant sensory and emotional experience associated with actual or potential tissue damage.  Most common reason for seeking health care.  Pain is considered the 5th vital sign.  Pain Management – is a process of assessing, treating and re-assessing pain utilizing non- pharmacologic and pharmacological method.
    3. 3. Common Misconceptions among Elderly and Nurses  Pain is unavoidable.  Pain is a punishment.  Asking for pain medication is too demanding and means I’m not a good patient.  Pain medication are addictive.  Taking pain medications means I’ll lose my independence and mental clarity.  Pain is not harmful.  Nurses don’t have the time to give extra medication.  Elderly patients have decreased sensations of pain.  Elderly patients who are cognitively impaired don’t feel pain.  A sleeping patient is not in pain.  Elderly patients complain more about pain as they age.  Narcotics will hasten death.  Potent analgesics are addictive.  Potent pain meds will cause respiratory depression.
    4. 4. Descriptions of pain:  Duration  Location  Etiology  Intensity  Quality  Temporal pattern  Associated characteristics
    5. 5. Pain assessment:  Should be as automatic as taking pulse and BP.  Pain is the 5th vital sign
    6. 6. Pain threshold: amount of pain stimulation a person requires before feeling pain. Pain tolerance: the highest intensity of pain that the person is willing to tolerate.
    7. 7. The categories of pain: Acute Chronic Cancer – Related Pain Breakthrough Pain Pain Categories
    8. 8. Effects of acute pain:  Neuroendocrine response to stress  Increased metabolic rate  Increased cardiac output  Impaired insulin response  Increased retention of fluids  Increased risk for physiologic disorders  Decreased deep breathing and mobility
    9. 9. Effects Chronic Pain:  Suppressed immune function  Resultant increased tumour growth  Depression and lack of motivation  Anger  Fatigue
    10. 10. What alternative therapies can close the gate?  Music  Distraction of any sort  Ice and heat therapies  Deep breathing  Massage  Art therapy
    11. 11. Alternative therapies which may close the gate:  Cutaneous stimulation and massage  Transcutaneous electrical nerve stimulation  Relaxation techniques  Guided imagery  Hypnosis
    12. 12. Let’s try an experiment…. Have each attendant take pen and place over nail bed and push. Describe sensation to neighbor. All the same? Now try counting backwards from 10 while holding pressure on nail bed. Is the pain as bad?
    13. 13. Pharmacological management:  Selection of appropriate drug, dose, route and interval  Aggressive titration of drug dose  Prevention of pain and relief of breakthrough pain  Use of coanalgesic medications  Prevention and management of side effects
    14. 14. WHO Analgesic ladder
    15. 15. WHO 3-step Analgesic ladder COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam, Panadeine, Nurofen. Pain rating 1-2-3 Non-opioid (mild pain) +/- adjuvant Opioid (mild to moderate pain) +/- non-opioid adjuvant +/- adjuvant Codeine, Propoxyphene, Tramadol, Sevredol, DHC Continus, Dihydrocodeine tartate. Pain rating: 4-5-6 Opioid (moderate to severe pain) +/-non-opioid, +/-adjuvant Step 1 Step 2 Step 3 Oxycodone, Morphine, Fentanyl, Pethidine Ketamine Pain rating 7-10
    16. 16. Analgesic ladder in action:  Step 1: non-opioid analgesics (Paracetamol and Aspirins, NSAIDS)  Step 2: mild opioid is added (not substituted) to step 1  Step 3: Opioid for moderate to severe pain is used and titrated to effect
    17. 17. Breakthrough pain  Use extra (rescue) doses of opioids.  Use the immediate-release form of same opioid they are on.  Rescue dose 5-15% of the 24-hour dose.  If 3 or more rescue doses needed/24 hrs— need to titrate routine drug to effect (25- 100% current dose).
    18. 18. Pain management through medication and/or neurosurgery  Oral analgesia  PCA (Patient-controlled analgesia)  Cordotomy: division of certain tracts of the cord.  Rhizotomy: A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input.
    19. 19. Universal Side Effect  Constipation.  Nausea and Vomiting.  Itching.  Respiratory Depression.
    20. 20. Examples of Narcotic Analgesics  Narcotic analgesics  Morphine  Pethidine  Controlled Analgesic drugs  Tramal
    21. 21. Placebo – HMG Policy  Placebo (e.g. normal saline) should not be given to treat pain even with written medical order.  Using placebo to diagnose or treat pain is considered unethical and violating patient right to have optimal pain relief
    22. 22. Assessment tools used at Dr. Sulaiman Al Habib Hospital Qaseem Hospital  Numeric Pain Rating Scale.  Wong-Baker Face Pain Rating Scale.  FLACC Scale.  NIPS Pain Scale.  CRIES Pain Scale.  Critical Care Pain Observation Tool or CPOT.  Comfort Pain Scale
    23. 23. Why have a pain scale?  Sometimes hard to put words to pain  Pain is multi-faceted (How long? Where? How intense? What kind feeling?  Visual scales help us understand where pain located.  Faces help us understand how pain makes patient feel.  Numeric scales help quantify pain using numbers.
    24. 24. For more information, Go to

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