pain part 2


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  • Step 1 For clients with mild pain (1-3 on a 0-10 scale) Use of nonopioid analgesics (with or without a coanalgesic) Step 2 Client has mild pain that persists or increases Pain is moderate (4-6 on a 0-10 scale) Use of a weak opioid (e.g. Codeine, tramadol, pentazocine) or a combination of opioid and nonopioid medicine (oxycodone with acetaminophen, hydrocodone with ibuprofen) Step 3 Client has moderate pain that persists or increases Pain is severe (7-10 on a 0-10 scale) Strong opioids (e.g. Morphine, hydromorphone, fentanyl)
  • pain part 2

    1. 1. Pain Management Part II
    2. 2. Pain Intensity or Rating Scales• Numbers• Visual analogue• Words• Colors• Faces• Behavior / physiologic signs
    3. 3. Pain Intensity or Rating Scales• Patient’s report of pain – Single most important indicator of intensity of pain – Provider’s overrate or underrate pain – Inaccuracy greater when patient’s pain is severe
    4. 4. Pain Intensity or Rating Scales• Pain intensity scales• Easy and reliable• Provide consistency in communication of pain• 0 – 10 range• Word modifiers may help some apply
    5. 5. Pain Intensity or Rating Scales• Effective Use – Understand use of scale – Educated about how information will be used • Determine changes in condition • Effectiveness of pain management interventions – Ensures adequate pain management achieved
    6. 6. Numeric Scale 0 1 2 3 4 5 6 7 8 9 10No Pain Worst Pain
    7. 7. No Mild Moderate Severe Very WorstPain Severe
    8. 8. Visual-Analogue Scale*No Pain Worst Pain Usually 0-10 cm long line. Placed either vertical or horizontal.
    9. 9. VAS: Coloured Analogue Scale (Ref: McGrath, PA, et al: Pain, 1996.)
    10. 10. Wong-Baker FACES Pain Rating Scale0 2 4 6 8 10
    11. 11. Sample of Child’s FACES Pain Rating Scale
    12. 12. Photographic/Numeric Pain Scale• Oucher scale (Beyer)• White child, 3 year-old male
    13. 13. Photographic/ Numeric Pain Scale, cont.• Oucher scale (Beyer)• Black child, school age, male
    14. 14. Photographic/ Numeric Pain Scale, cont.• Oucher scale (Beyer)• Hispanic child, school age, male
    15. 15. Cultural Preference for Scales100 African-American children with SCD rated preference of 3 scales:• FACES -- 56%• Black Oucher -- 26%• VAS -- 18%• Validity was strongest for FACES, then Oucher and VASRef: Luffy R: Pediatric Nursing, Jan 2003.
    16. 16. Pain Intensity or Rating Scales• Wong-Baker FACES Pain Rating Scale – Children – Elderly with impairments • Cognition • Communication – People who do not speak English• Includes number scale in relation to each expression
    17. 17. Pain Intensity or Rating Scales• When a scale can’t be used – Rely on observation of behavior – Rely on physiologic signs – Use input of significant others • Parents/caregivers • Help interpret observations
    18. 18. Nonverbal responses to pain• Facial expression• Vocalizations like moaning and groaning or crying and screaming• Immobilization of the body or body part• Purposeless body movements• Behavioral changes such as confusion and restlessness• Rhythmic body movements or rubbing
    19. 19. QUESTT• Question the patient• Use pain rating scale• Evaluate behavior and physiologic signs• Secure family’s involvement• Take cause of pain into account• Take action and assess effectiveness
    20. 20. Comprehensive Pain History• COLDERR – Character – Onset – Location – Duration – Exacerbation – Relief – Radiation
    21. 21. Characteristics of Pain• Quality – What does it feel like – Record patient’s words that he describes – Provides information useful in diagnosing cause of pain• Intensity – Important to obtain estimate of intensity – Evaluate effectiveness of treatment
    22. 22. Characteristics of Pain• Aggravating and Alleviating Factors – Include behaviors or activities that influence pain – Helps in care planning• Associated Manifestations – Impact on ADLs • Sleep, work, activities • Appetite, mood, sexual function, recreational activities – Pain is fatiguing • Longer experience pain the greater the fatigue • Stress response of pain continues in sleep – Physiological consequences • Pain more severe in morning
    23. 23. Characteristics of Pain• Meaning of Pain – Soldier vs civilian• Objective Data – Physiologic • Activates sympathetic nervous system – ↑ HR, RR, BP, – Diaphoresis, pallor, muscle tension, dilated pupils • Chronic pain shows adaptation
    24. 24. Characteristics of Pain• Behavioral – Crying, moaning – Rubbing site, restlessness – Distorted posture, clenched fists, guarding – Frowning, grimacing• Speaks of discomfort• Restless• Afraid to move
    25. 25. Characteristics of Pain• Location – Point to place in body – Ask if more than one site – Radiates, deep, superficial• Onset, Duration – How long existed – Triggers – Patterns – worse am, pm, getting up, etc.
    26. 26. Nurse’s Role Patient Advocate• Primary Concern-Comfort
    27. 27. Practice Guidelines• Establish a trusting relationship• Consider client’s ability and willingness to participate• Use a variety of pain relief measures• Provide pain relief before pain is severe• Use pain relief measures the client believe are effective• Align pain relief measures with report of pain severity
    28. 28. Practice Guidelines• Encourage client to try ineffective measures again before abandoning• Maintain unbiased attitude about what may relieve pain• Keep trying• Prevent harm• Educate client and caregiver about pain
    29. 29. Barriers to Effective Treatment• Lack of knowledge of the adverse effects of pain• Misinformation regarding the use of analgesics• Misconceptions about pain• May not report pain• Fear of becoming addicted
    30. 30. Pharmacologic Interventions• Opioids (narcotics)• Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS)• Co-analgesic drugs
    31. 31. Opioids (Narcotics)• Full agonists – No ceiling on analgesia – Dosage can be steadily increased to relieve pain – morphine, oxycodone, hydromorphone
    32. 32. NSAIDS• Vary little in analgesic potency – vary in anti-inflammatory effects, metabolism, excretions, and side effects• Have a ceiling effect• Narrow therapeutic index• acetaminophen, ibuprofen, aspirin
    33. 33. Coanalgesic Drugs• Antidepressants• Anticonvulsants• Local anesthetics• Others
    34. 34. WHO Ladder StepApproach for Cancer Pain Control
    35. 35. Rational Polypharmacy• Evolved from WHO three step approach• Demands health professionals be aware of all ingredients of medications that alleviate pain• Use combinations to reduce the need for high doses of any one medication• Maximize pain control with a minimum of side effects or toxicity• Combined with multimodal therapy (e.g. nondrug approaches)
    36. 36. Oral Administration• Preferred because of ease of administration• Duration of action is often only 4 to 8 hours• Must awaken during night for medication• Long-acting preparations developed• May need rescue dose of immediate- release medication
    37. 37. Transdermal Administration• Transmucosa and Transnasal – Enters blood immediately – Onset of action is rapid• Transdermal – Delivers relatively stable plasma drug level – Noninvasive
    38. 38. Rectal• Useful for clients with dysphagia or nausea/vomiting
    39. 39. Medication Administration• Intramuscular – Should be avoided – Variable absorption – Unpredictable onset of action and peak effect – Tissue damage• Intravenous – Provides rapid and effective relief with few side effects
    40. 40. Intraspinal• Provides superior analgesia with less medication used
    41. 41. PCA• Patient-controlled analgesia – Minimizes peaks of sedation and valleys of pain that occur with prn dosing – Electronic infusion pump – Safety mechanisms
    42. 42. Cognitive-Behavioral (Mind-Body)• Providing comfort• Eliciting relaxation response• Repatterning thinking• Facilitating coping with emotions
    43. 43. Body Interventions• Reducing pain triggers• Massage• Applying heat or ice• Electric stimulation (TENS)• Positioning and bracing (selective immobilization)• Acupressure• Diet and nutritional supplements• Exercise and pacing activities• Invasive interventions (e.g. blocks)• Sleep hygiene
    44. 44. Mind Interventions• Relaxation and imagery• Self-hypnosis• Pain diary and journal writing• Distracting attention• Re-pattern thinking• Attitude adjustment• Reducing fear, anxiety, stress, sadness, and helplessness• Providing information about pain
    45. 45. Spirit Interventions• Prayer• Meditation• Self-reflection• Meaningful rituals• Energy work (therapeutic touch, Reiki)• Spiritual healing
    46. 46. Social Interaction• Functional restoration• Improved communication• Family therapy• Problem-solving• Vocational training• Volunteering• Support groups