Presentation pain management

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  • skin, surfaces of the joints, periosteum , walls of the arteries, and certain structures in the skull. Other organs, such as the gut and muscles, have fewer pain receptors. It is interesting to note that the brain itself does not have any pain receptors and is therefore insensitive to pain! but also by certain products present in the body and released as a result of trauma, inflammation or other painful stimuli. Examples of these substances are bradykinins, serotonin, potassium ions and acids (such as lactic acid, which causes muscle pain after heavy exercise
  • Huge difference in copingAny threat to health or new illness acts as new problem, patient has to solve problemThe way people go about it is to problem solve... Forming an internal representation which determines what you do (how you think affects how you feel and react)IdentityCauseTimelineConsequencesCure / Control
  • Presentation pain management

    1. 1. Definition “Pain is whatever the experiencing person says it is, existing where he/she says it does” McCaffery (1980)
    2. 2. Physiology of pain In its simplest form, the pain circuit in the body can be described as follows • pain stimulates pain receptors, and this stimulus is transferred via specialised nerves to the spinal cord and from there to the brain. • The pain stimulus is processed in the brain, which then sends an impulse down the spinal cord and via appropriate nerves which command the body to react, for instance by withdrawing the hand from a very hot object.
    3. 3. Pain Receptors • Pain receptors are present everywhere in the • • • • body; Pain receptors are free nerve endings. There are three types of pain receptor stimuli: mechanical, thermal and chemical. A mechanical stimulus e.g. high pressure or stretching; thermal pain stimulus would be extreme heat or cold. Chemical pain receptors can be stimulated by chemicals from within and outside the body.
    4. 4. Pain nerve fibres • Pain stimulus is transmitted from the receptors • • through peripheral nerves to the spinal cord and from there to the brain. This happens via two different types of nerve fibre: “fast pain” and “slow pain” fibres Fast pain is well localised, sharp and “cutting” and do not radiate.
    5. 5. Fast Pain Nerve Fibres • They are thick nerve fibres called A-delta fibres. • • Because of their relative thickness. Pain stimulus are transferred very fast at a speed of 2-5s/m This allows the body to withdraw immediately from the painful and harmful stimulus in order to avoid further damage
    6. 6. Slow Pain Nerve Fibre • They are thin nerve fibres called c nerve fibres. • Pain impulse are transmitted slowly to the brain, at a speed of less than 2 m/s. • The body responds by holding the affected part immobile (guarding, spasm or rigidity), so that healing can take place.
    7. 7. Pain transmission in the spinal cord and the brain • The peripheral nerves carry the pain impulse to • • • the spinal cord. In the spinal cord, fast pain and slow pain are carried up to the brain via different pathways The impulse of the fast pain goes to the cortex, allowing for the relatively precise localisation of the pain stimulus. The impulse from slow pain is distributed diffusely in the brain, with each area eliciting a different response
    8. 8. Characteristics of fast pain and slow pain Slow Pain • Transmitted by very thin nerve fibres • Poorly localised • All internal organs (except the brain) • Body wants to be immobile to allow healing (guarding, spasm, rigidity) • Pain often radiates, or is referred 07/11/2013 Fast Pain • Transmitted by relatively thicker (and therefore faster conducting) nerve fibres • Well localised • Mainly skin, mouth, anus • Immediate withdrawal of stimulation to avoid further damage • Pain does not radiate • Little relief from opioids Reviewed by Prof CL Odendal, senior specialist at the department of anaesthesiology at the University of the Free State, April 2010.
    9. 9. Pain in the Elderly • Effects of aging on pain sensation, perception, and • behaviour are not well established Compared with younger adults, elderly persons rely more on slow/second pain (C fibre) than on fast/ first pain (A fibre). • Another well-documented finding in the elderly is a slower response time to pain • No evidence exists that pain intensity lessens with age
    10. 10. • Altered reactions to painful events may be due to loss of communications skills, cognitive abilities, or the failure of basic reflexes due to aging • Additionally, pain in the elderly may be manifested as something other than pain, such as delirium
    11. 11. Pain in Children • Children and young people have a right to appropriate • • • prevention, assessment and control of their pain Historically, pain has been underestimated and under treated in children and particularly babies. Evidence shows that pain is inadequately dealt with for children, requiring better prevention, assessment and treatment. In order to treat children's pain effectively, a thorough pain assessment is necessary; a number of guides are available to do this
    12. 12. • British association for Emergency Medicine Clinical Effectiveness committee: Guideline for the management of pain in children
    13. 13. How do we assess pain? • Self report • Use pain rating tools • Non-verbal signs • Assess on movement • Document
    14. 14. Pain Assessment Severe Pain (3) “Pain is whatever the patient says it is” „Hurts as much as I can imagine Moderate Pain (2) „Hurts more‟ Mild Pain (1) „Hurts just a little bit‟ No Pain (0) „Happy because I don‟t hurt at all‟ Always assess on movement
    15. 15. Other Pain tools • • • • • • Intensity scores - VAS, Categorical Pain relief scales Cognitively impaired Paediatric Critical care Chronic Pain – – – – McGill Questionnaire Quality of Life Questionnaire Brief Pain Inventory Pain Self Efficacy Questionnaire
    16. 16. What do we assess? • Location • Duration • Type • Intensity
    17. 17. What needs to be considered when assessing pain? • • • • • • • Subjective Age Communication Psychiatric factors Cognitively impaired Culture Knowledge of pain treatments • Expectations of pain • treatments Language barriers
    18. 18. Barriers to pain assessment in the older person • Failure to recognise • Failure to assess • Assume stoicism • Patients & carers expectations of pain in ageing • May use different words e.g. discomfort, ache, soreness • Time consuming
    19. 19. Inadequate pain management can cause: • physiological effects (increased HR, BP, delayed • • • • • • • gastric emptying, increased adrenaline production) post-operative complications (respiratory infection, VTE, PE) delayed discharge mobilisation difficulties restlessness, irritability, aggression raised levels of anxiety sleep disturbances distress and suffering (Sjostrom et al 2000, Macintyre & Ready 2002, Carr et al 2005)
    20. 20. Pain Management and the role of Psychology
    21. 21. Acute Vs Chronic Pain  Acute Pain – Short Term – Less than 3 months – Natural Healing Occurs  Chronic Pain – – – – – Long Lasting Longer than 3 months Natural Healing occurs but huge IMPACT Pain as a result of Central NS changeslocal, spinal cord, brain
    22. 22. Why do people react so differently to Pain? Pain Beliefs About Pain Leventhal‟s Common Sense Model Action Taken / Coping
    23. 23. Chronic Pain and Psychological Distress How does psychological distress affect pain experience and management? Chronic Pain ? Anxiety & Depression
    24. 24. The BioPsychoSocial Model
    25. 25. Psychological Interventions  Cognitive Behavioural Therapy shown to be effective – Has impact on biopsychosocial variables  However, psychological interventions for chronic pain most effective when incorporate other treatment components – e.g. physiotherapy, education – Pain Management Programmes
    26. 26. Impact of Chronic Pain Reduction in activity Failed Treatments eg physio, med Pain Loss of Job, Financial Stress Being Blamed/ Faking it Relationships Physical Deconditioning Depression Hopelessness, Helplessness Anxiety Fear re Future Excess Suffering Frustration Anger Loss of Independence Boom and Bust
    27. 27. Pain Management Aims  NOT cure or pain reduction  Change the person‟s relationship with pain – Reduce disability and distress – Manage increases in pain (flare-ups) – Develop confidence in ability to carry out activities despite pain – Reduce unhelpful encounters with public and private health systems – Self-Management
    28. 28. Aims of Pain Management Improve Fitness •Education re Pain Model •Exercising •Flare-up Planning Pain •Goal Setting &Practice •Pacing •Identifying unhelpful thoughts •Relaxation •Communication Improve daily functioning Reduce anxiety/ depression Reduce Increase confidence Distress Reduce dependence Reduce incidence of Flare-Ups
    29. 29. MDT Consultants, physios, psychologists, nurses  Pain Management Programmes  – Good evidence base, improve functioning  NICE guidance 88, May 2009 – Outpatient Programmes  PMP @ Whittington, COPE @ UCH – Inpatient Programmes  INPUT Pain Management Unit @ St Thomas‟  Bath Pain Management Unit
    30. 30. References  Sharp & Keefe (2006). Psychiatry in Chronic Pain: A review and Update. Focus, American Psychiatric Association.  Turk & Okifuji (2002). Psychological factors in chronic pain: Evolution and revolution. Journal of Consulting and Clinical Psychology.  Vlaeyen & Linton, (2006). Are we „fear avoidant‟. Pain.  Vlaeyen & Morley (2005). Cognitive-Behavioural Treatments for Chronic Pain: What works for whom? Clinical Journal of Pain.  Morley, Eccleston & Williams (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain.  Nicholas M, Molloy A, Tonkin I and Beeston L (2000) Manage your Pain ABC Books, Sydney  Nice, Nice Guideline 88 (2009) – Early management of persistent nonspecific low back pain, http://www.nice.org.uk/CG88

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