The correct response is to assess the patient for pain score over time. Telling the patient it will go away without assessment is not appropriate care. The nurse needs to properly assess the pain and its progression to determine if additional intervention is needed
Similar to The correct response is to assess the patient for pain score over time. Telling the patient it will go away without assessment is not appropriate care. The nurse needs to properly assess the pain and its progression to determine if additional intervention is needed
Similar to The correct response is to assess the patient for pain score over time. Telling the patient it will go away without assessment is not appropriate care. The nurse needs to properly assess the pain and its progression to determine if additional intervention is needed (20)
IGNOU MSCCFT and PGDCFT Exam Question Pattern: MCFT003 Counselling and Family...
The correct response is to assess the patient for pain score over time. Telling the patient it will go away without assessment is not appropriate care. The nurse needs to properly assess the pain and its progression to determine if additional intervention is needed
1. The Need to Understand Pain
and its Management
Prepared and presented by:
Soha Adloni
MSc Clinical Pharmacy
2. 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
3. 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.
4. 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
5. 1. Pain Overview
Factors affecting pain perception
AGE MEANING
CULTURE OF PAIN
PAIN
Pain Control EXPERIENCE ATTENTION
Sex
Anxiety
8. 2. Pain classification
Diagnostic classification
A. Nociceptive pain
I. Somatic: well localized; e.g. skin, bones
II. Visceral: poorly localized; e.g. organs
B. Neuropathic pain
I. Central: Localized and diffused; burning, stabbing pain
e.g.
CNS
II. Peripheral: localized neuropathies
C. Idiopathic pain
usually in head, shoulders, or pelvic areas
9.
10. 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
11. Acute Pain
Goals:
1. provide analgesia
2. lessen side effects of analgesics
3. Minimize the dose of medication
Effective Pain control
1. Early mobilization
2. Shorter hospitalization
3. Reduce costs
4. Increase patient satisfaction
Analgesics:
1. Multimodal analgesics, preemptive analgesia
2. Parenteral, PCA, Epidural
3. ATC first 24 hrs post surgery, then prn
12. Anxiety
Increase
hospitalization Family
and costs worries
If pain is inadequately
controlled, what are the
consequences?
Medication
Depression
worries
Impaired Sleep
ambulatio disturbances
n
13. What is the pain score for this player?
Pain is whatever the patient thinks it is at the
present time.
Pain is always subjective to the patient’s report
17. 3. Pharmacological Treatment of Pain
A- NSAIDs
Ketorolac (Toradol):
Postoperatively for max 5 days
Reduce amount of opioid requirement, reduce
S.E’s
Dose= 15 – 30 mg IV / IM Q6hrs
Cox-2 inhibitors:
Effective anti-inflammatory in arthritis
Carry cardiovascular risk warning
Less GI S.E’s
18. 3. Pharmacological Treatment of Pain
A- NSAIDs
Side effects:
Prolong bleeding time
Gastric erosions/ ulceration/ perfusion
Affect kidney function:
_ Water / electrolyte balance
_ Interfere with diuretics/ antihypertensive
_ Renal injury / nephrotic syndrome
19. 3. Pharmacological Treatment of Pain
B- Opioids
Oral, Rectal, IV, IM, SC, Equianalgesic
Morphine pca, Epi, potency
10 mg IM
Meperidine IV, IM, pca, Epi 75 mg
(Pethidine)
IV, Epi, pca, Transdermal 100 mcg
Fentanyl patches, sublingual
lollipops
Codeine Oral, Rectal, IV, IM. 130 mg
(Solpadeine: codeine
8mg/Aceta./caffeine)
Oral, IV, SC, IM, Rectal, 1.5 mg
Hydromorphone pca
Tramadol Oral, IV, IM, SC 100 mg
(Tramal)
20. 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)
21.
22. B- Opioids Side Effects
Nausea and vomiting
Constipation
Pruritis
Irritable movement
Psychomimetic effects
Sedation
Broncho-constriction
Respiratory Depression
N.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
patient's respiratory status improves and the patient starts to
arouse.
23. 3. Pharmacological Treatment of Pain
C- Adjuvants
Agents used to induce analgesic effect indirectly
Local anesthetics
Antidepressants
Anticonvulsants
Corticosteroids
Muscle relaxants
Anti histamines
24. 4. Choice of Drugs in Treatment of Acute /
Chronic Pain
25. 4. Choice of Drugs in Treatment of
Acute / Chronic Pain
26. 4. Choice of Drugs in Treatment of
Acute / Chronic Pain
1) Severity of pain
2) Routes of administration
3) Patient information
4) Pharmacokinetic of drug
5) Patient’s preference
27. 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.
28. 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.
29. 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 hours
b. Need different analgesic than morphine
c. Morphine was given prn not ATC
d. Patient is sedated and can not be assessed probably
Pain assessment for effective pain control:
a. Pain score 4 – 7
b. Multimodal analgesic (opioid + non-opioid)
c. Morphine should be given ATC
d. Pain assessment should be done appropriately
30. 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 site
b. Check the epidural pump
c. Call the anesthesiologist for pain assessment
d. Assess the patient for pain score over time
Pain assessment for effective pain control:
a. Pain catheter could be dislocated
b. Epidural pump may not be delivering medication
c. Anesthesiologist is called if needed
d. Pain is “whatever the patient thinks it is at the present time”
31. 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
morphine
b. Pain will increase with time
c. Patient’s pain is tolerable and will decrease as soon as he
mobilize
d. 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.
Editor's Notes
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