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Chapter 5   pain - the fifth vital sign
 

Chapter 5 pain - the fifth vital sign

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  • Discuss three reasons why pain is undertreated, especially in the United States.
  • Differentiate between the two major sources of pain—nociceptive and neuropathic—including the types of each.Describe how you plan to advocate for patients who are experiencing pain.  Think of a situation when it was difficult to believe a particular patient’s report of pain.  How did you react?  How should you react? 
  • Identify the three groups of medications that are used to manage pain.  Give examples of each, including advantages and disadvantages.  What are the nursing considerations for older adults when administering each of the three categories?
  • Write a description of a patient in pain who is exhibiting some of the characteristic nonverbal behaviors.
  • Discuss the types of pain that are effectively treated with these types of analgesia.  Have students plan nursing care that uses all of the steps of the nursing process.
  • Make a list of non-pharmacologic interventions for pain, including physical measures, physical therapy, cognitive/behavioral measures, relaxation techniques, hypnosis, and acupuncture.  Include a brief description of each and some types of pain that are effectively relieved with each.

Chapter 5   pain - the fifth vital sign Chapter 5 pain - the fifth vital sign Presentation Transcript

  • Chapter 5Pain: The Fifth Vital SignElsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
  • Definitions of Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999). Self-report is always the most reliable indication of pain. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2
  • Types of Pain Types of pain:  Acute pain – usually from injury, disease, or surgery  Chronic pain: • Chronic cancer pain - cancer, HIV • Chronic non-cancer pain– usually associated with tissue injury that has healed, chronic back pain, arthritis Sources of pain:  Nociceptive • Somatic pain – cutaneous, superficial, sharp, burning (acute- incisional, chronic-bone mets) • Visceral pain – organs and linings of cavities, dull, aching, cramping (acute-chest tubes, chronic-pancreatitis) • Neuropathic pain – nerve fibers, spinal cord, shooting, burning, fiery, painful numbness (acute-phantom limb pain, chronic- diabetic neuropathy) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3
  • Characteristics of Acute/Chronic Acute Chronic Short duration  Lasts longer than 3 months Well-defined cause  May not have defined cause Decreases with healing  Begins gradually and Is reversible persists Ranges from mild to severe  Exhausting and useless May be accompanied by  Ranges from mild to severe restlessness and anxiety  May be accompanied by depression, fatigue, decreased functionality Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4
  • Attitudes and Practices Related to Pain Attitudes of health care providers and nurses affect interaction with patients experiencing pain Many patients are reluctant to report pain:  Desire to be a ―good‖ patient  Fear of addiction  Fear of falling Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5
  • Addiction, Pseudoaddiction, Tolerance, and Physical Dependence Addiction—primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations Pseudoaddiction—iatrogenic syndrome created by the undertreatment of pain Tolerance—state of adaptation in which exposure to a drug results in a decrease in one or more the drug’s effects over time Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6
  • Addiction, Pseudoaddiction, Tolerance, and Physical Dependence (Cont’d) Physical dependence—adaptation manifested by a drug-class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist Withdrawal or abstinence syndrome—N&V, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7
  • Collaborative Management History  Any precipitating factors, aggravating factors, character and quality of pain, location, duration Physical assessment/clinical manifestations:  Location of pain: • Localized pain – confined to the site of origin • Projected pain – along a specific nerve root • Radiating pain – diffuse pain around site of origin not well localized • Referred pain – perceived in an area distant from the site of painful stimuli Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8
  • Assessing Nonverbal Patients Six common indicators  Facial expressions – grimacing, crying  Vocalizations – moaning, screaming  Body movements – restlessness  Changes in interpersonal interactions  Changes in activity patterns or routines  Mental status changes – confusion, increased confusion Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9
  • Pain Pharmacologic Therapy— Non-Opioid Analgesics Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) are most common Most are NSAIDs, including aspirin:  Can cause GI disturbances  COX-2 inhibitors for long-term use Acetaminophen (Tylenol):  Available in liquid form; can be taken on empty stomach  Preferable for patients for whom GI bleeding is likely  Can cause renal or liver toxicity if used long-term Ketorolac – toradol  Popular NSAID for short term use Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10
  • Pain Pharmacologic Therapy— Opioid Analgesics Block the release of neurotransmitters in the spinal cord Drugs include codeine, oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone – morphine is the gold standard There is no ceiling in the dose of a pure opioid agonist Can be administered via all available routes Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11
  • Side Effects of Opioids Nausea and vomiting – early side effects, often antiemetic give concurrently Constipation – inhibits peristalsis, initiate measures such as stool softeners and laxatives Sedation – depress CNS, monitor sedation levels Respiratory depression – more apt to occur in an opioid naïve patient, reversal agent (Narcan) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12
  • WHO Analgesic Ladder World Health Organization’s recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain) Level 1 pain (1-3 rating)—Use non-opioids Level 2 pain (4-6 rating)—Use weak opioids alone or in combination with an adjuvant drug Level 3 pain (7-10 rating)—Use strong opioids Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13
  • Nursing Interventions to Prevent SE of Opioids Constipation  Assess bowel habits, push fluids, encourage activity, bulk, roughage, track BMs, administer stool softeners, laxatives, suppositories Nausea and Vomiting  Assess actual cause, temporary SE, antiemetic prophylactically, oral compazine, reglan before meals and at bedtime Sedation and Confusion  Assess actual cause, may occur after 2-3 days, caffeine may counteract effect, consider opioid rotation Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 14
  • Nursing Interventions to Prevent SE of Opioids Respiratory Depression  Rarely seen in patients with severe pain caused by cancer  Recognize pain and stress counteract respiratory depression  Respiratory depression usually preceded by sedation  Monitor sedation level and respiratory status frequently for the first 24-48 hours  Respiratory rate alone is NOT indicative of respiratory status  In an unresponsive patient administer Narcan and observe the patient Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15
  • Pain Management in End of Life Opioid regimen should stay consistent with dose in weeks before last weeks of life Generally believed that patient still feels pain when unconscious Does not hasten death unless the dose was not properly and gradually titrated Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16
  • Routes of Opioid Administration Can be administered by every route used  Oral  Rectal  Intramuscular  Transdermal  Topical  Sublingual  Subcutaneous  Intravenous  PCA  Spinal (Epidural and Intrathecal) PRN range orders  Prescribing guidelines  Monitoring guidelines Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 17
  • Spinal Analgesia Epidural Analgesia Intrathecal Analgesia  Intrathecal catheter and infusion pump placement is surgery to insert a catheter into the spinal fluid of the lumbar region and connect it to a pump underneath the abdominal skin that delivers medicine to the catheter. This procedure is used to control pain or other conditions that cannot be adequately treated by oral medication or treatments. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18
  • Disks, Spurs, Stenosis: Slippage, and Osteoporosis Chapter 6 Oxford Aaron Filler, Dermatome Map of the Body University MD, PhD Press On- FRCS (SN) Line About the Illustrations Table of Gloss Index Book Contents ary S e ar c h th is si te Sponsored Links Spine Links Search: Buy from Find a Each of the spinal nervesAmazon.c Doctor to National provides sensation at a predictable areaof skin. Pain radiating down Library of om SpineUni Center for Advanced Spinal the leg to the small toe in the general pattern of Medicine verse.co Neurosurgery - visit the S1 dermatome suggests that a herniated disk may be pinching the S1 nerve root in m the Neurography Institute - spine. Reproduced from Atlas of Human visit Anatomy by Frank Netter, MD, with permission of Icon Learning Systems/Elsevier.Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19
  • Ramsey Sedation ScaleScore Response1 Anxious or Restless or Both2 Cooperative, Oriented, and Tranquil3 Responding to Commands4 Brisk Response to Stimulus5 Sluggish Response to Stimulus6 No Response to Stimulus Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20
  • Implantable DevicesElsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21
  • Adjuvant Analgesics Antiepileptic drugs Tricyclic antidepressants Antianxiety agents Local anesthetics Dextromethorphan, ketamine Local anesthesia infusion pumps Topical medications Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22
  • Nonpharmacologic Interventions Used alone or in combination with drug therapy Physical measures Physical and occupational therapy Cognitive/behavioral measures Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23
  • Physical InterventionsElsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24
  • Cognitive/Behavioral Measures Strategies that can be used to relieve pain as adjuncts to drug therapy:  Distraction  Imagery  Relaxation techniques  Hypnosis  Acupuncture  Glucosamine Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25
  • Invasive Techniques for Chronic Pain Nerve blocks Spinal cord stimulation Surgical techniques:  Rhizotomy  Cordotomy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26
  • Community-Based Care Home care management Health teaching Health care resources Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 27
  • Pediatric Analog Sedation Score. Elsharkawi N G Anesth Analg 1999;88:227-227 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 28©1999 by Lippincott Williams & Wilkins
  • Question The nurse assesses the sedation level of a patient receiving epidural morphine analgesia after a knee replacement. When assessing the patient for side effects of the drug, the nurse notes that the patient is slightly drowsy but can be easily aroused. What is the nurses best action at this time? A. Stop the morphine infusion immediately. B. Document the assessment on the sedation scale. C. Notify the charge nurse on the unit. D. Ask another nurse to assess the patient. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 29
  • LEARNING OUTCOMES Safe and Effective Care Environment Act as an advocate for patients in acute and chronic pain. Develop a teaching/learning plan for managing pain as part of community-based care. Health Promotion and Maintenance Teach patients in pain about complementary and alternative therapies as additions to their established plan of care. Perform a complete pain assessment, and document per agency policy. Psychosocial Integrity Discuss the attitudes and knowledge of nurses, physicians, and patients regarding pain assessment and management. Physiological Integrity Differentiate between addiction, pseudoaddiction, tolerance, and physical dependence. Compare and contrast the characteristics of the major types of pain and examples of each. Explain the role of non-opioid analgesics in pain management. Compare common opioid analgesics, using an equianalgesic chart. Develop a plan of care to prevent common side effects of opioid analgesics. Compare the advantages and disadvantages of drug administration routes. Determine the patient’s need for pain medication, including PRN and adjuvant therapy. Prioritize care for the patient receiving patient-controlled analgesia. Provide care for a patient receiving epidural analgesia. Identify special considerations for older adults related to pain assessment and management. Incorporate complementary and alternative therapies into the patient’s plan of care as needed to control pain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 30