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Pain Management In Nursing4 With K I W I N


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Pain Management

Pain Management In Nursing4 With K I W I N

  1. 1. Acute and chronic pain Contemporary and alternative treatments
  2. 2. Pain—the definition…. <ul><li>An unpleasant sensory and emotional experience associated with actual or potential tissue damage. </li></ul><ul><li>Most common reason for seeking health care. </li></ul><ul><li>Pain is considered the 5 th vital sign. </li></ul><ul><li>Research has shown pain underestimated by HC professionals, overestimated by family </li></ul>
  3. 3. Is there a problem? <ul><li>As many as 67% NZ women 65 years and older experience musculoskeletal pain (Taylor, 2005) </li></ul><ul><li>In nursing homes 45-85% report pain untreated (Flaherty, 2003). </li></ul><ul><li>Nurses may contribute to this problem (Titler & Herr, 2003) </li></ul><ul><li>Unrelieved pain can have detrimental effects (Smeltzer & Bare, 2004) </li></ul>
  4. 4. Pain assessment: <ul><li>Should be as automatic as taking pulse and BP. </li></ul><ul><li>Pain is the 5 th vital sign </li></ul>
  5. 5. Common Misconceptions among Elderly and Nurses <ul><li>Pain is unavoidable. </li></ul><ul><li>Pain is a punishment. </li></ul><ul><li>Asking for pain medication is too demanding and means I’m not a good patient. </li></ul><ul><li>Pain medication are addictive. </li></ul><ul><li>Taking pain medications means I’ll lose my independence and mental clarity. </li></ul><ul><li>Pain is not harmful. </li></ul><ul><li>Nurses don’t have the time to give extra medication. </li></ul><ul><li>Elderly patients have decreased sensations of pain. </li></ul><ul><li>Elderly patients who are cognitively impaired don’t feel pain. </li></ul><ul><li>A sleeping patient is not in pain. </li></ul><ul><li>Elderly patients complain more about pain as they age. </li></ul><ul><li>Narcotics will hasten death. </li></ul><ul><li>Potent analgesics are addictive. </li></ul><ul><li>Potent pain meds will cause respiratory depression. </li></ul>
  6. 6. Descriptions of pain: <ul><li>Duration </li></ul><ul><li>Location </li></ul><ul><li>Etiology </li></ul><ul><li>Intensity </li></ul><ul><li>Quality </li></ul><ul><li>Temporal pattern </li></ul><ul><li>Associated characteristics </li></ul>
  7. 7. Pain threshold : amount of pain stimulation a person requires before feeling pain. Pain tolerance : the highest intensity of pain that the person is willing to tolerate.
  8. 8. The categories of pain: <ul><li>Acute </li></ul><ul><li>Chronic (non-malignant) </li></ul><ul><li>Cancer-related pain </li></ul><ul><li>Breakthrough pain </li></ul>
  9. 9. Effects of acute pain: <ul><li>Neuroendocrine response to stress </li></ul><ul><ul><li>Increased metabolic rate </li></ul></ul><ul><ul><li>Increased cardiac output </li></ul></ul><ul><ul><li>Impaired insulin response </li></ul></ul><ul><ul><li>Increased retention of fluids </li></ul></ul><ul><ul><li>Increased risk for physiologic disorders </li></ul></ul><ul><ul><li>Decreased deep breathing and mobility </li></ul></ul>
  10. 10. Effects Chronic Pain: <ul><li>Suppressed immune function </li></ul><ul><li>Resultant increased tumour growth </li></ul><ul><li>Depression and lack of motivation </li></ul><ul><li>Anger </li></ul><ul><li>Fatigue </li></ul>
  11. 11. Pathophysiology of pain <ul><li>Nociceptors —free nerve endings in the tissue that respond to tissue-injuring stimuli (noxious stimuli). </li></ul><ul><li>Thermoreceptors —receptors that respond to noxious temperature changes. </li></ul><ul><li>Chemoreceptors —receptors that respond to noxious chemicals. </li></ul><ul><li>Mechanical receptors —transmit a pain signal if the noxious stimuli are sufficiently strong. </li></ul>
  12. 12. Pathophysiology of pain: <ul><li>Nociceptors </li></ul><ul><li>Algogenic (pain-causing) substances </li></ul><ul><li>A-delta fibres: ‘initial pain transmission’ </li></ul><ul><li>Type C fibres: ‘secondary transmission’ </li></ul><ul><li>Endorphins and enkephalins </li></ul><ul><li>Central nervous system </li></ul>
  13. 13. Nociception (or pain perception) can be divided into four phases: <ul><li>Transduction </li></ul><ul><li>Transmission </li></ul><ul><li>Perception </li></ul><ul><li>Modulation </li></ul>
  14. 14. <ul><li>Major Sensory Pathways </li></ul>
  15. 15. Gate-control theory
  16. 16. <ul><li>Spinal Nerves (Dermatomes) </li></ul>
  17. 17. Descending control system: <ul><li>Fibres that originate in brain </li></ul><ul><li>Inhibits pain after nociception occurs </li></ul><ul><li>Cognitive processes may stimulate this process </li></ul><ul><li>Classic Gate-control theory (Melzack & Wall, 1965) </li></ul>
  18. 18. Spinal Cord Modulation: How can the gate be closed? <ul><li>Spinal dorsal horn—where </li></ul><ul><li>complex messaging occurs, is one </li></ul><ul><li>of the most important areas for </li></ul><ul><li>pain modulation. </li></ul>
  19. 19. Gate-control theory: may decrease amount pain medication needed
  20. 20. What alternative therapies can close the gate? <ul><li>Music </li></ul><ul><li>Distraction of any sort </li></ul><ul><li>Cold (not with PVD) or heat </li></ul><ul><li>Imagery </li></ul><ul><li>Deep breathing </li></ul><ul><li>Massage </li></ul><ul><li>Vibration </li></ul><ul><li>Art therapy </li></ul>
  21. 21. Let’s try an experiment…. <ul><li>Have students take pen and place over nail bed and push. Describe sensation to neighbour. All the same? </li></ul><ul><li>Now try counting backwards from 10 while holding pressure on nail bed. Is the pain as bad? </li></ul>
  22. 22. Why have a pain scale? <ul><li>Sometimes hard to put words to pain </li></ul><ul><li>Pain is multi-faceted (How long? Where? How intense? What kind feeling? </li></ul><ul><li>Visual scales help us understand where pain located. </li></ul><ul><li>Faces help us understand how pain makes patient feel. </li></ul><ul><li>Numeric scales help quantify pain using numbers. </li></ul>
  23. 23. So how do we deal with the problem of pain? <ul><li>Assess it regularly using a pain scale </li></ul><ul><li>One type has faces—(Whaley & Wong, 1986). </li></ul>
  24. 24. Other pain scales are just numeric
  25. 25. Alternative therapies which may close the gate: <ul><li>Cutaneous stimulation and massage </li></ul><ul><li>Ice and heat therapies </li></ul><ul><li>Transcutaneous electrical nerve stimulation </li></ul><ul><li>Distraction </li></ul><ul><li>Relaxation techniques </li></ul><ul><li>Guided imagery </li></ul><ul><li>Hypnosis </li></ul>
  26. 26. Pharmacological management: <ul><li>Selection of appropriate drug, dose, route and interval </li></ul><ul><li>Aggressive titration of drug dose </li></ul><ul><li>Prevention of pain and relief of breakthrough pain </li></ul><ul><li>Use of coanalgesic medications </li></ul><ul><li>Prevention and management of side effects </li></ul>Taken from Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  27. 27. WHO Analgesic ladder
  28. 28. Analgesic ladder in action: <ul><li>Step 1: non-opioid analgesics (Paracetamol and Aspirins, NSAIDS) </li></ul><ul><li>Step 2: mild opioid is added (not substituted) to step 1 </li></ul><ul><li>Step 3: Opioid for moderate to severe pain is used and titrated to effect </li></ul>Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  29. 29. WHO 3-step Analgesic ladder COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam, Panadeine, Nurofen. Pain rating 1-2-3 Non-opioid (mild pain) +/- adjuvant Opioid (mild to moderate pain) +/- non-opioid adjuvant +/- adjuvant Codeine, Propoxyphene, Tramadol, Sevredol, DHC Continus, Dihydrocodeine tartate. Pain rating: 4-5-6 Opioid (moderate to severe pain) +/-non-opioid, +/-adjuvant Step 1 Step 2 Step 3 Oxycodone, Morphine, Fentanyl, Pethidine Ketamine Pain rating 7-10
  30. 30. Breakthrough pain <ul><li>Use extra (rescue) doses of opioids. </li></ul><ul><li>Use the immediate-release form of same opioid they are on. </li></ul><ul><li>Rescue dose 5-15% of the 24-hour dose. </li></ul><ul><li>If 3 or more rescue doses needed/24 hrs—need to titrate routine drug to effect (25-100% current dose). </li></ul>Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  31. 31. Pain management through medication and/or neurosurgery <ul><li>Oral analgesia </li></ul><ul><li>PCA (Patient-controlled analgesia) </li></ul><ul><li>Cordotomy </li></ul><ul><li>Rhizotomy </li></ul>Kastinias, P., S.E. Kianda, Robinson, S. (2006).
  32. 32. Manage side-effects opiates: <ul><li>Constipation </li></ul><ul><li>Tolerance to nausea and sedation develops in 3-7 days. </li></ul><ul><li>Use adjuvant (coanalgesic) agents with opioid: </li></ul><ul><ul><li>Tricyclic antidepressants </li></ul></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Muscle relaxants </li></ul></ul><ul><ul><li>Stimulants </li></ul></ul>Alexander, L. L. (2006). Pain management, palliative care and treatment of the terminally ill
  33. 33. Narcotic analgesics <ul><li>Narcotic analgesics (from the poppy) </li></ul><ul><ul><li>Morphine </li></ul></ul><ul><ul><li>Codeine </li></ul></ul><ul><ul><li>Heroin </li></ul></ul><ul><li>Synthetic narcotic analgesics: </li></ul><ul><ul><li>Demerol (Meperidine) </li></ul></ul><ul><ul><li>Methadone </li></ul></ul>
  34. 34. KIWIN™ Classification PROBLEM IDENTIFICATION Domain: Physiological domain Problem: 24. Pain Priority: High Modifier: Individual Modifier: Actual Signs and Symptoms: 01. expresses discomfort/pain 04. restless behaviour 05. facial grimaces
  35. 35. KIWIN™ Classification <ul><li>PROBLEM PLANNING </li></ul><ul><li>Pre Intervention PRSO </li></ul><ul><li>Knowledge: Minimal knowledge </li></ul><ul><li>Behaviour: Rarely appropriate behaviour </li></ul><ul><li>Status: Extreme signs/symptoms </li></ul><ul><li>Goal: The patient will state that his pain is 0- 2/10 within 3 hours. </li></ul>
  36. 36. KIWIN™ Classification <ul><li>PROBLEM INTERVENTION </li></ul><ul><li>Creation Date: 28/2/2007 </li></ul><ul><li>Interventions: Treatments and Procedures </li></ul><ul><li>Targets: 39. medication administration </li></ul><ul><li>41. medication prescription </li></ul><ul><li>54. relaxation/breathing techniques </li></ul><ul><li>Nursing Actions: 39. Administer analgesia as charted and by utilizing pain scale. Review q2h. </li></ul><ul><li>R) </li></ul><ul><li>41. Ensure that physician charts sufficient analgesia for patient and according to the WHO pain ladder. </li></ul><ul><li>R) </li></ul><ul><li>54. Administer back massage to patient when in pain if he/she would like. Teach patient guided imagery during painful episodes. </li></ul><ul><li>R) </li></ul>