Pain  Final With  K I W I N
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Pain Final With K I W I N

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Pain  Final With  K I W I N Pain Final With K I W I N Presentation Transcript

  • Acute and chronic pain Contemporary and alternative treatments
  • 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 5 th vital sign.
    • Research has shown pain underestimated by HC professionals, overestimated by family
  • Is there a problem?
    • As many as 67% NZ women 65 years and older experience musculoskeletal pain (Taylor, 2005)
    • In nursing homes 45-85% report pain untreated (Flaherty, 2003).
    • Nurses may contribute to this problem (Titler & Herr, 2003)
    • Unrelieved pain can have detrimental effects (Smeltzer & Bare, 2004)
  • Pain assessment:
    • Should be as automatic as taking pulse and BP.
    • Pain is the 5 th vital sign
  • 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.
  • Descriptions of pain:
    • Duration
    • Location
    • Etiology
    • Intensity
    • Quality
    • Temporal pattern
    • Associated characteristics
  • 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.
  • The categories of pain:
    • Acute
    • Chronic (non-malignant)
    • Cancer-related pain
    • Breakthrough pain
  • 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
  • Effects Chronic Pain:
    • Suppressed immune function
    • Resultant increased tumour growth
    • Depression and lack of motivation
    • Anger
    • Fatigue
  • Pathophysiology of pain
    • Nociceptors —free nerve endings in the tissue that respond to tissue-injuring stimuli (noxious stimuli).
    • Thermoreceptors —receptors that respond to noxious temperature changes.
    • Chemoreceptors —receptors that respond to noxious chemicals.
    • Mechanical receptors —transmit a pain signal if the noxious stimuli are sufficiently strong.
  • Pathophysiology of pain:
    • Nociceptors
    • Algogenic (pain-causing) substances
    • A-delta fibres: ‘initial pain transmission’
    • Type C fibres: ‘secondary transmission’
    • Endorphins and enkephalins
    • Central nervous system
  • Nociception (or pain perception) can be divided into four phases:
    • Transduction
    • Transmission
    • Perception
    • Modulation
    • Major Sensory Pathways
  • Gate-control theory
    • Spinal Nerves (Dermatomes)
  • Descending control system:
    • Fibres that originate in brain
    • Inhibits pain after nociception occurs
    • Cognitive processes may stimulate this process
    • Classic Gate-control theory (Melzack & Wall, 1965)
  • Spinal Cord Modulation: How can the gate be closed?
    • Spinal dorsal horn—where
    • complex messaging occurs, is one
    • of the most important areas for
    • pain modulation.
  • Gate-control theory: may decrease amount pain medication needed
  • What alternative therapies can close the gate?
    • Music
    • Distraction of any sort
    • Cold (not with PVD) or heat
    • Imagery
    • Deep breathing
    • Massage
    • Vibration
    • Art therapy
  • Let’s try an experiment….
    • Have students take pen and place over nail bed and push. Describe sensation to neighbour. All the same?
    • Now try counting backwards from 10 while holding pressure on nail bed. Is the pain as bad?
  • 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.
  • So how do we deal with the problem of pain?
    • Assess it regularly using a pain scale
    • One type has faces—(Whaley & Wong, 1986).
  • Other pain scales are just numeric
  • Alternative therapies which may close the gate:
    • Cutaneous stimulation and massage
    • Ice and heat therapies
    • Transcutaneous electrical nerve stimulation
    • Distraction
    • Relaxation techniques
    • Guided imagery
    • Hypnosis
  • 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
    Taken from Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  • WHO Analgesic ladder
  • 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
    Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  • 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
  • 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).
    Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  • Pain management through medication and/or neurosurgery
    • Oral analgesia
    • PCA (Patient-controlled analgesia)
    • Cordotomy
    • Rhizotomy
    Kastinias, P., S.E. Kianda, Robinson, S. (2006).
  • Manage side-effects opiates:
    • Constipation
    • Tolerance to nausea and sedation develops in 3-7 days.
    • Use adjuvant (coanalgesic) agents with opioid:
      • Tricyclic antidepressants
      • Corticosteroids
      • Anticonvulsants
      • Muscle relaxants
      • Stimulants
    Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  • Narcotic analgesics
    • Narcotic analgesics (from the poppy)
      • Morphine
      • Codeine
      • Heroin
    • Synthetic narcotic analgesics:
      • Demerol (Meperidine)
      • Methadone
  • KIWIN™ Classification PROBLEM IDENTIFICATION Domain: Physiological domain Problem: 24. Pain Priority: High Modifier: Individual Modifier: Actual Signs and Symptoms: 01. expresses discomfort/pain 04. restless behaviour 05. facial grimaces
  • KIWIN™ Classification
    • PROBLEM PLANNING
    • Pre Intervention PRSO
    • Knowledge: Minimal knowledge
    • Behaviour: Rarely appropriate behaviour
    • Status: Extreme signs/symptoms
    • Goal: The patient will state that his pain is 0- 2/10 within 3 hours.
  • KIWIN™ Classification
    • PROBLEM INTERVENTION
    • Creation Date: 28/2/2007
    • Interventions: Treatments and Procedures
    • Targets: 39. medication administration
    • 41. medication prescription
    • 54. relaxation/breathing techniques
    • Nursing Actions: 39. Administer analgesia as charted and by utilizing pain scale. Review q2h.
    • R)
    • 41. Ensure that physician charts sufficient analgesia for patient and according to the WHO pain ladder.
    • R)
    • 54. Administer back massage to patient when in pain if he/she would like. Teach patient guided imagery during painful episodes.
    • R)