This definition, which has endured for more than 40 years, has allowed healthcare providers to intervene and treat patients on the basis of the self-report of the pain experiencePain is always subjective
B).Results from damage of afferent nerve fibers, characterized by burning, stabbing, electrical numbing, radiating shooting pain. Either to CNS, or to periphral which further devides into polyneuropathy, or mononeuropathy (e.g. diabetic neurophathyA).is due to the activation of nociceptors at the site of tissue damage. This type of pain can Results by mechanical, chemical, or thermal stimulus, such as surgery, traumatic injury, and inflammatory processes. Its devided into either somatic: localized pain in skin, bones or muscles,joint. or visceral: poorly localized (may be referred to other areas)located in organs, characterized by having deep pressure like squeezingC). Results of non-specific origin, due to stress, anxiety, depression, or cold pressure e.g head, shoulders, abdomen, and pelvic areas
Acute pain results from activation of the pain receptors (nociceptors) at the site of tissue damage due to stimulus chemical, thermal, or mechanical stimulusThis type of pain results from surgery, traumatic injury, or a disease. self-limited and resolves over days to weeks, but it can persist for 3 months can activate the sympathetic branch of autonomic nervous system and produce such responses as tachycardia, diaphoresis, shallow respiration, restlessness, facial grimacing, pallor, and pupil dilation
The major goals in management of acute pain is to minimize the dose of medications
NSAID: Used in the inflammation, analgesics for pain of mild to moderate severity, or spasm, some agents have a role in prolonging bleeding timeShould not be combined in therapy due to increase of GI side effects.
Morphine:Morphine is considered the gold standard of opioid analgesics, morphine is not the most potent of these drugs- Bolus can be titrated upward in 1-2 mg every 1-3 hoursCI: may be of use in opioid tolerant patients such as pt on chronic opiate therapyMeperidine have fallen out of favor in recent years. This medication has a metabolite that is neurotoxic and can cause serious detrimental effects including seizures.Fentanyl: is very rapid fast acting because its lipid-soluble and penetrate bbb SC is possible but not recommended as repeated administration causes local tissue irritation, pain.
The most common adverse effects of opioids are nausea, vomiting, pruritus, constipation, and sedationopioid adverse effects are dose-related. Therefore, The lowest effective dose should always be administerede.g.1 constipation caused by direct effect of opioid on smooth muscle of GIT, therefore stimulant+ softener laxative given.e.g.2. pruritis caused by histamine release in skin, oral antihistamine given.most dangerous adverse effects of opioid analgesics is respiratory depression, respiratory assessment includes counting respiratory rate and evaluating the regularity of rhythm, depth, and sound of respirations
Skeletal muscle relaxants benzodiazepines, antihistamines, and sedatives
Determined by pain assessment + type of pain (mild, moderate, sever)The selection of route depends on clinical type of pain: acute > inj, Chronic > oral , and the required frequencies.Age, site of pain, duration of complaint, characteristic of pain, treatment history, familyand social historyThese are the factors that should be considered when choosing analgesic, e.g. bioavailability, half life, clearanceElderly patients, CNS disease, tolerance to certain drugs, compatibility between drugs
Constant pain is best treated with an "around the clock" (ATC) regimen. by giving the patient medications regularly(ATC), an adequate blood level of analgesic can be maintained RATHER THAN PRN. It is best to prevent incidental pain (pain that occurs suddenly) whenever possible by giving an analgesic before pain develops.
Acute pain can activate the sympathetic branch of the autonomic nervous system and produce such responses as hypertension, tachycardia, diaphoresis, shallow respiration, restlessness, facial grimacing, pallor, and pupil dilation
Pain management for nurses
The Need to Understand Pain and its ManagementPrepared and presented by:Soha AdloniMSc Clinical Pharmacy
Objectives: 1. Pain definitions & overview 2. Pain pathway & classification 3. Pharmacological Treatment of Acute Pain 4. Choice of Drugs in Treatment of Acute / Chronic Pain 5. Conclusion
1. Pain Definitions "Pain" is defined by IASP*: "an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage“ Pain: the least stimulus intensity at which a subject perceives pain. Margo McCaffery (1968)first defined pain: "whatever the person experiencing says it is, existing whenever he says it does.” Favorite definitions: - whatever the patient thinks it is at the present time.
1. Pain Definitions Analgesia: Absence of pain in response to stimulation which would normally be painful (e.g. using drugs) Nociceptor: A sensory receptor of the peripheral (somatosensory nervous system) that transmits noxious stimuli to CNS. Noxious stimulus: A stimulus that is damaging or threatens damage to normal tissues (chemical, mechanical, thermal) Pain threshold: The minimum intensity of a stimulus that is
1. Pain Overview Factors affecting pain perception AGE MEANING CULTURE OF PAIN PAINPain Control EXPERIENCE ATTENTION Sex Anxiety
2. Pain classification Diagnostic classificationA. Nociceptive pain I. Somatic: well localized; e.g. skin, bones II. Visceral: poorly localized; e.g. organsB. Neuropathic pain I. Central: Localized and diffused; burning, stabbing pain e.g. CNS II. Peripheral: localized neuropathiesC. Idiopathic pain usually in head, shoulders, or pelvic areas
2. Pain classification Clinical types Acute pain Chronic pain Results from noxious Results from: stimuli that activates nociceptors, visceral, or nociceptors neuron somatic It accompanies surgery, traumatic injury, tissue It accompanies chronic damage, and inflammatory disease, untreated processes. condition. Self-limited, resolves over days to weeks, but Unresolved as long as can persist for 3 months underlying cause is Treatment is short term present. and curative
Acute Pain Goals:1. provide analgesia2. lessen side effects of analgesics3. Minimize the dose of medication Effective Pain control1. Early mobilization2. Shorter hospitalization3. Reduce costs4. Increase patient satisfaction Analgesics:1. Multimodal analgesics, preemptive analgesia2. Parenteral, PCA, Epidural3. ATC first 24 hrs post surgery, then prn
Anxiety Increasehospitalization Family and costs worries If pain is inadequately controlled, what are the consequences? Medication Depression worries Impaired Sleep ambulatio disturbances n
What is the pain score for this player? Pain is whatever the patient thinks it is at thepresent time. Pain is always subjective to the patient’s report
3. Pharmacological Treatment of Pain A B C Non- Opioids AdjuvantsOpioids
3. Pharmacological Treatment of Pain A- NSAIDs mechanism of action
3. Pharmacological Treatment of Pain A- NSAIDsKetorolac (Toradol): Postoperatively for max 5 days Reduce amount of opioid requirement, reduce S.E’s Dose= 15 – 30 mg IV / IM Q6hrsCox-2 inhibitors: Effective anti-inflammatory in arthritis Carry cardiovascular risk warning Less GI S.E’s
3. Pharmacological Treatment of Pain B- Opioids Oral, Rectal, IV, IM, SC, EquianalgesicMorphine pca, Epi, potency 10 mg IMMeperidine IV, IM, pca, Epi 75 mg(Pethidine) IV, Epi, pca, Transdermal 100 mcgFentanyl patches, sublingual lollipopsCodeine Oral, Rectal, IV, IM. 130 mg(Solpadeine: codeine8mg/Aceta./caffeine) Oral, IV, SC, IM, Rectal, 1.5 mgHydromorphone pcaTramadol Oral, IV, IM, SC 100 mg(Tramal)
B- Opioids / Narcotic analgesics Morphine: Gold standard opiate Bolus: 2-5 mg slowly over 5min (Q 1-3 hrs). CI: 1mg/hr titrated to the desired analgesic effect. IM; 5-10 mg (Q3-4 hrs). SC: not recommended in repeated dose. Meperidine: used in acute pain only, alternative for morphine intolerance. limited use due to toxic metabolite, sedative, and emetic effect. Fentanyl: 100 times more potent, rapid onset of action given bolus, CI, oral, patches. Tramadol: Acts on opioid & non-opioid receptors (moderate pain)
B- Opioids Side Effects Nausea and vomiting Constipation Pruritis Irritable movement Psychomimetic effects Sedation Broncho-constriction Respiratory DepressionN.B: If respiratory depression/sedation develops, the nurse must be familiar with administration of Naloxone, which will reverse the effect . Naloxone is diluted (0.4 mg in 10 mL NS) every 1-2 min until the patients respiratory status improves and the patient starts to arouse.
3. Pharmacological Treatment of Pain C- AdjuvantsAgents used to induce analgesic effect indirectly Local anesthetics Antidepressants Anticonvulsants Corticosteroids Muscle relaxants Anti histamines
4. Choice of Drugs in Treatment of Acute / Chronic Pain
4. Choice of Drugs in Treatment of Acute / Chronic Pain
4. Choice of Drugs in Treatment of Acute / Chronic Pain1) Severity of pain2) Routes of administration3) Patient information4) Pharmacokinetic of drug5) Patient’s preference
5. Conclusion If pain is not controlled effectively, it can result in negative physiologic and psychological consequences. Nurses must learn how to properly assess pain and how to optimize safe pain management for all patients in their care. Frequency/ routes of administering analgesics are highly significant in treatment: - Opioid ATC vs. prn in the first 24 hrs post surgery - Analgesics could be given in incidental pain - IV vs. SC vs. IM Opioids can be titrated upward for maximum efficacy, but are limited by their side effects.
5. Conclusion The administration of Opioid + non-opioid promote co-analgesic effect (reduced doses, lessen S.E’s). Acute pain can activate the sympathetic branch producing : hypertension, tachycardia, diaphoresis, shallow respiration, restlessness, facial grimacing, pallor, and pupil dilation Addiction is so rare when Opioids are taken for medical reasons.
Case1: Post operative (sleeve) patient , ordered for morphine 3mg Q4 hrs, perfalgan 1g Q6hrs. Patient received 2 doses of morphine, and 4 doses of perfalgan during the first 24 hrs; but still in pain, what is the cause of his pain?a. Patient is complainer & will be fine in few hoursb. Need different analgesic than morphinec. Morphine was given prn not ATCd. Patient is sedated and can not be assessed probablyPain assessment for effective pain control:a. Pain score 4 – 7b. Multimodal analgesic (opioid + non-opioid)c. Morphine should be given ATCd. Pain assessment should be done appropriately
Case 2: LSCS patient is receiving Epidural in the first 24hrs. Pain is increasing with time, but nurse keeps comforting patient that “it will go away”. The correct nurse’s response should be:a. Check the epidural catheter siteb. Check the epidural pumpc. Call the anesthesiologist for pain assessmentd. Assess the patient for pain score over timePain assessment for effective pain control:a. Pain catheter could be dislocatedb. Epidural pump may not be delivering medicationc. Anesthesiologist is called if neededd. Pain is “whatever the patient thinks it is at the present time”
Case 3: Patient with moderate - sever pain was ordered for morphine 5mg Q4hrs, perfalgan 1 g Q6hrs. Patient was requesting pain killers due to constant pain around the clock, but nurse administer morphine 1mg Q4hrs instead because of fear of addiction. What are the consequences of this action on patient’s pain control?a. Reducing the dose will reduce addiction possibilities of morphineb. Pain will increase with timec. Patient’s pain is tolerable and will decrease as soon as he mobilized. Physician will be glad that the nurse has taken this action Pain assessment for effective pain control:a. Addiction is so rare when Opioids are taken for medical reasons.