Ppt. pain

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Ppt. pain

  1. 1. PAIN
  2. 2.  “The fifth vital sign” – American Pain Society 2003 Identifying pain as the fifth vital sign suggests that the assessment of pain should be as automatic as taking a client’s BP and pulse
  3. 3.  “whatever the person says it is, existing whenever the experiencing person says it does” – McCaffery & Pasero, 1999 Emphasizes the highly subjective nature of pain
  4. 4.  Pain is the most COMMON reason clients seek medical advice Pain is a protective mechanism or a warning to prevent further injury
  5. 5. THE PATHOPHYSIOLOGY OF PAIN
  6. 6. Pain Transmission Nociceptors also called as pain receptors are free nerve endings in the skin that respond only to intense, potentially damaging stimuli (mechanical, thermal, or chemical) The joints, skeletal muscle, fascia, tendons and cornea also have nociceptors
  7. 7.  Large internal organs do not contain nerve endings Polymodal nociceptors respond to all three types of stimulus Histamine, bradykinin, acetylcholine, seroto nin, and substance P are chemicals that increase transmission of pain
  8. 8.  Prostaglandins are chemical substances that are believed to increase the sensitivity of pain receptors by enhancing the pain provoking effect of bradykinin There are 2 main types of fibers involved in the transmission of nociception: Myelinated, A delta fibers – “fast pain” Type C fibers – “second pain”
  9. 9.  Chemicals that reduce or inhibit the transmission or perception of pain include endorphins and enkephalins
  10. 10. The Gate Control Theory Proposed by Melzack and Wall in 1965 Stimulation of the skin evokes nervous impulses Stimulation of the large diameter fibers inhibits the transmission of pain, thus closing the gate
  11. 11. Types of Pain Acute Pain – usually of recent onset and commonly associated with specific injury; lasting from seconds to 6 months Chronic Pain – constant or intermittent pain that persists beyond the expected healing time and seldom attributed to a specific cause or injury; lasts for 6 months or longer
  12. 12.  Cancer – Related Pain – may be acute or chronic; can be directly associated with the cancer, a result of cancer treatment, or not associated with the cancer Pain classified by location - aids in communication about and treatment of the pain Pain classified by etiology – to predict course of pain and plan effective treatment using this categorization
  13. 13. FACTORS INFLUENCING PAIN RESPONSE
  14. 14.  Past experience Anxiety and Depression Culture Gender Genetics Placebo effect
  15. 15. PAIN ASSESSMENT
  16. 16.  Obtain a Pain History Allow the client to describe the pain to establish a trust relationship between you and the client Discover the effects of pain on the clients quality of life Assess for emotional and spiritual distress and coping abilities
  17. 17.  Ask about previous pain experience and what measures have been effective as well as those who have not Use WHAT’S UP format or PQRST or OLDCART in assessing pain
  18. 18.  W – where is the pain? Be specific. Use drawing of body if necessary H – how does the pain feel? Is it shooting, burning, dull, sharp? A – aggravating and alleviating factors. What makes the pain better? Worse? T – timing. When did the pain start? Is it intermittent? Continuous?
  19. 19.  S – severity. How bad is the pain on a 0 to 10 (0 to 5; faces) scale U – useful other data. Are you experiencing any other symptoms associated with the pain or pain treatment? Itching, nausea, sedation, constipation? P – perception. What is the client’s perception of what caused the pain?
  20. 20.  P – provoked Q- quality R – region/radiation S – severity T - timing
  21. 21.  O – onset L – location D – duration C – characteristic A – aggravating factors R – radiation T – treatment
  22. 22. Sample (PQRST) With continuous, drilling, bilateral knee pain that occurs upon ambulation; rated as 8/10 in the numeric pain rating scale, with 0 as no pain and 10 as excruciating pain.
  23. 23. Sample (OLDCART) With continuous, penetrating, right flank pain that occurred 1 hour prior to admission while client was consuming fried dried fish; rated as 9/10 in the numeric pain rating scale with 0 as no pain and 10 as excruciating pain in the pain rating scale; radiating on the left shoulder; aggravated with ambulation and consumption of salty foods such as dried fish and corned beef and alleviated with rest, deep breathing exercises, and guided imagery.
  24. 24. Daily Pain Diary For clients who experience chronic pain May help the client and nurse identify pain patterns and factors that exacerbate or mediate pain The record can include: time or onset of pain, activity before pain, pain-related positions or behaviors, pain intensity level, use of analgesics or other relief measures, duration of pain, time spent in relief activities.
  25. 25. Visual Analogue Scales Useful in assessing the intensity of pain Includes a horizontal 10cm line, with anchors indicating the extremes of pain The client is asked to place a mark indicating where the current pain lies on the line Left: none or no pain Right: severe or worst possible pain
  26. 26. Faces Pain Scale This instrument has six faces depicting expressions that range from contented to obvious distress The client is asked to point to the face that most closely resembles the intensity of his or her pain
  27. 27. Guidelines for Using Pain Assessment Scale Written pain scale may not be possible if a person is seriously ill, is in severe pain, or has just returned from surgery The scale should be used consistently The nurse teaches the client how to use the pain scale before the pain occurs
  28. 28.  Numerical rating should be documented and used to assess the effectiveness of pain relief interventions Pain scale may help assess the effectiveness of the interventions if the scale is used before and after the interventions are implemented
  29. 29. NON PHARMACOLOGIC INTERVENTIONS
  30. 30.  Non-pharmacologic nursing activities can assist in pain relief Not a substitute for medication Combining nonpharmacologic interventions with medications may be the most effective way to relieve pain
  31. 31. Cutaneous stimulation and massage The gate control theory of pain proposes that stimulation of fibers that transmit nonpainful sensations can block or decrease the transmission of pain impulses Rubbing the skin and using heat & cold are based on this theory
  32. 32.  Massage is a generalized cutaneous stimulation of the body that often concentrates on the back and shoulders Massage have an impact in the descending control system and does not merely stimulate nonpain receptors Promotes comfort through muscle relaxation
  33. 33. Thermal therapies Proponents believe that ice and heat stimulate the nonpain receptors in the same receptor field as the injury Ice should be placed on the injury site immediately after injury or surgery Ice therapy after joint surgery can significantly reduce the amount of analgesic medication required
  34. 34.  Assess skin first before applying ice Ice should be applied on an area for no longer than 15 to 20 minutes at a time and should be avoided in clients with compromised circulation Application of heat increases circulation to an area and contributes to pain reduction by speeding healing
  35. 35.  Both ice and heat therapy must be applied carefully and monitored closely to avoid injuring the skin Neither therapy should be applied to areas with impaired circulation or used in clients with impaired sensation
  36. 36. Transcutaneous electrical nerve stimulation (TENS) Uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain Decreases pain by stimulating the nonpain receptors in the same area as the fibers that transmit pain
  37. 37. Distraction Involves focusing the client’s attention on something other than the pain Thought to reduce the perception of pain by stimulating the descending control system Effectiveness depends on the client’s ability to receive and create sensory input other than pain
  38. 38.  Examples are watching TV, listening to music, complex physical and mental exercises Stimulation of sight, sound, and touch is likely to be more effective than the stimulation of a single sense
  39. 39. Relaxation techniques Believed to reduce pain by relaxing tense muscles that contribute to the pain Consists of abdominal breathing at a slow, rhythmic rate The client may close both eyes and breathe slowly and comfortably
  40. 40. Guided imagery Using one’s imagination in a special way to achieve a specific positive effect May consist of combining slow, rhythmic breathing with a mental image of relaxation and comfort The client is asked to practice guided imagery for about 5 minutes, three times a day
  41. 41. Hypnosis Has been effective in relieving or decreasing the amount of analgesic agents required in clients with acute and chronic pain Mechanism is unclear Induced by specially skilled people
  42. 42. Music therapy An inexpensive and effective therapy for the reduction of pain and anxiety
  43. 43. PHARMACOLOGIC INTERVENTIONS
  44. 44. Premedication assessment The nurse should ask the client about allergies to medications and the nature of any previous allergic responses The nurse obtains the client’s medication history, along with a history of health disorders
  45. 45. APPROACHES FOR USING ANALGESIC AGENTS
  46. 46. Balanced analgesia Refers to the use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects Using two or three types of agents simultaneously can maximize pain relief while minimizing the potentially toxic effects of any one agent
  47. 47. Pro re nata The nurse waits for the client to complain of pain and then administer analgesia
  48. 48. Preventive approach Currently considered as the most effective strategy because a therapeutic serum level of medication is maintained Smaller doses of medication are needed Better pain control can be achieved
  49. 49.  In using this approach, the nurse should assess the client for sedation before administering the next dose The goal is to administer analgesia before the pain becomes severe
  50. 50. Patient controlled analgesia Used to manage postoperative pain as well as persistent pain Allows clients to control the administration of their own medication within predetermined safety limits Is electronically controlled by a timing device
  51. 51.  The timer can be programmed to prevent additional doses from being administered until a specified time period has elapsed (lock- out time) and until the first dose has had time to exert its maximal effect Continue monitor respiratory status Instruct client not to wait until the pain gets severe before pushing the button
  52. 52.  Remind client not to be so distracted with a visitor or activity so that he/she will not forget to administer the drug If PCA is to be used in the client’s home, he/she and family are taught about the operation of the pump as well as the side effects of the medication and strategies to manage them
  53. 53. Nonopioids Generally the first class of drugs used for treatment of pain Useful for acute and chronic pain from a variety of causes such as: surgery, trauma, arthritis, and cancer Have a ceiling effect to analgesia
  54. 54.  A ceiling effect indicates that there is a dose beyond which there is no improvement in the analgesic effect and there may be an increase in side effects Does not produce tolerance or physical dependence Most nonopioids have antipyretic effects Works primarily at the site of injury, or peripherally
  55. 55.  NSAIDs block synthesis of prostaglandin Examples are salicylates (aspirin); NSAIDS (ibuprofen, ketorolac, naproxen); COX-2 inhibitors (celecoxib); acetaminophen
  56. 56. Celecoxib (Celebrex) Inhibition of prostaglandin synthesis, primarily through inhibition of cyclooxygenase-2 (COX2). This results in anti- inflammatory, analgesic, and antipyretic activities For osteoarthritis, rheumatoid arthritis, and acute pain in adults
  57. 57.  Monitor CBC, liver/renal function tests, and for signs and symptoms of GI bleeding Remember: NSAIDS!!!
  58. 58. Opioids The goal of administering this medication is to relieve pain and improve quality of life Opioids are classified as full agonists, partial agonists, or mixed agonists and antagonists Full agonists have complete response at the opioid receptor site
  59. 59.  Partial agonists has lesser response The mixed agonists and antagonists activates one type of opioid receptor while blocking another Opioids alone have no ceiling effect to analgesia Controlled-release opioids such as oxycodone (Oxycontin) and morphine (MS Contin) are effective for prolonged, continuous pain
  60. 60.  Controlled or time-release medication should never be crushed, but always taken whole Common adverse effects of opioids are: CRINCS!C- constipationR- respiratory depressionI- itchingN- nausea, vomitingC- constricted pupilsS- sedation
  61. 61. Morphine Is the drug of choice for the treatment of moderate to severe pain Used as a standard against which all other analgesics are compared Long acting (4-5 hours)
  62. 62. Hydromorphone (Dilaudid) Commonly used for moderate to severe pain Shorter acting than morphine but has a faster onset Good option for pain management in most clients
  63. 63. Meperidine (Demerol) Should be reserved for healthy clients requiring opioids for a short period or for those who have unusual raections or allergic responses to other opioids Produces a toxic metabolite called normeperidine
  64. 64.  Normeperidine is a cerebral irritant that can cause adverse effects ranging from dysphoria and irritable mood to seizures Should be avoided in clients over the age of 65, in those with impaired renal function, and in those receiving MAOI antidepressants
  65. 65. Fentanyl (Sublimaze,Duragesic) Can be administered parenterally, intraspinally, or by transdermal patch
  66. 66. Methadone (Dolophine) Is a potent analgesic that has a longer duration of action than morphine Has a very long half life and accumulates in the body with continued dosing Well absorbed from the GI tract and is very effective when given orally also used in drug treatment programs during detoxification from heroin and other opioids
  67. 67. Opioid Antagonists Naloxone (Narcan) is a pure opioid antagonist that counteractsthe effects of opioids Often used in the emergency department setting for treatment of opioid overdose Some analgesics are classified as combined agonist and antagonist. These drugs bind with some opioid receptors and block others
  68. 68.  The most commonly used agonist-antagonist drugs are butorphanol (Stadol) and nalbuphine (Nubain) Nalbuphine can be used to treat itching and nausea that may accompany the administration of opioids
  69. 69. Analgesic Adjuvants Are classes of medications that may potentiate the effects of opioids or nonopioids Are especially important when treating pain that does not respond well to traditional analgesics alone
  70. 70. Steroids May reduce pain by decreasing inflammation and the resultant compression of healthy tissues
  71. 71. Benzodiazipines Midazolam (Versed) or diazepam (Valium) are effective for the treatment of anxiety or muscle spasms associated with pain These drugs do not provide pain relief except in the treatment of muscle spasms May cause sedation
  72. 72. Tricyclic antidepressants Amitriptyline, imipramine, desipramine, and doxepin have been shown to relieve pain related to neuropathy and other painful nerve related conditions Must be taken for days to weeks before they are fully effective
  73. 73.  Instruct clients to continue taking the medications even if they seem ineffective at first Additional benefits of this class of medications may include mood elevation and improved ability to sleep
  74. 74. Anticonvulsants Carbamazepine (Tegretol) and gabapentin (Neurontin) are often used to relieve the sharp or cutting pain caused by peripheral nerve syndromes These medications must be taken regularly before full benefit is realized
  75. 75. ROUTES FOR ANALGESIC ADMINISTRATION
  76. 76. Oral Preferred route in most cases Convenient, inexpensive Slower onset than IV Can provide consistent blood levels
  77. 77. Rectal May be used to provide local or systemic pain relief Can be used when client is unable to take oral medication May be difficult to administer
  78. 78. Transdermal patch For chronic pain Easy to apply; delivers pain relief for 3 days without patch change 12-hour delay before effective drug level reached, and delay in excreting once removed
  79. 79.  May be less effective in smokers owing to circulatory alterations Absorption may be increased with fever Use caution not to touch medication when applying
  80. 80. Intravenous Preferred route for post operative and chronic cancer pain for clients who cannot tolerate oral route Provides rapid relief; continuous infusion provides steady drug level Difficult to use in home care setting Follow instructions for administration
  81. 81. Intramuscular For acute pain Rapid pain relief Painful Use only if other routes cannot be used
  82. 82. Subcutaneous May be used if IV route is problematic Can deliver effective pain relief Injection may be painful May be effective for treatment of chronic cancer pain
  83. 83. Intraspinal (epidural orsubarachnoid) May be used for traumatic injuries or chronic pain unrelieved by other methods May be able to control pain with lower doses of opioid because relief is delivered closer to site of pain; fewer systemic side effects Requires single or continuous injection in back; may be associated with intense itching
  84. 84. SURGICAL INTERVENTIONS
  85. 85. Cordotomy Is the division of certain tracts of the spinal cord May be performed percutaneously, by the open method after laminectomy, or by other techniques Is performed to interrupt pain transmission
  86. 86.  Care must be taken to destroy only the sensation of pain, leaving motor functions intact
  87. 87. Rhizotomy Sensory nerve roots are destroyed where they enter the spinal cord A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input Is usually performed to relieve severe chest pain
  88. 88.  The spinal roots are divided and banded with a clip to form a lesion and produce subsequent loss of sensation
  89. 89. assignment Write at least 3 nursing interventions for each of the following side effects of opioid analgesic agents:1. Respiratory depression2. Nausea and vomiting3. Constipation4. Itching

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