Pain Management In Nursing4 With K I W I N

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).

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

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)

Pain Management In Nursing4 With K I W I N

by gerlam on Jan 23, 2008

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