Med-Surg COncept of PAin


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Med-Surg COncept of PAin

  1. 1. CHAPTER 20 Clients with Pain Nhelia B. Perez RN, MSN Northeastern College – Nursing Department Santiago City, Philippines
  2. 2. THE PHYSIOLOGY OF PAIN <ul><li>Nociceptor Activation </li></ul><ul><li>* Bradykinin </li></ul><ul><li>* prostaglandin </li></ul><ul><li>* substance P </li></ul><ul><li>* Histamine </li></ul><ul><li>* Serotonin </li></ul><ul><li>* leukotrienes </li></ul><ul><li>* nerve growth factor </li></ul>
  3. 3. <ul><li>Fast Pain </li></ul><ul><li>Slow pain </li></ul>
  4. 4. Spinal Cord <ul><li>Dorsal horn </li></ul><ul><li>Spinal cord </li></ul><ul><li>Spinothalamic tract </li></ul><ul><li>Thalamus </li></ul><ul><li>C fiber – substantia gelatinosa </li></ul><ul><li>Synapse on interneurons </li></ul><ul><li>Thru neurotransmitters </li></ul>
  5. 5. <ul><li>Sensory cortex </li></ul><ul><li>Brain – limbic system </li></ul><ul><li>Brain stem </li></ul>
  6. 6. Brain <ul><li>Nociceptive Sensory info </li></ul><ul><li>Multiple ascending pathways </li></ul><ul><li>Spinothalamic tracts </li></ul><ul><li>Spinoreticular tract </li></ul><ul><li>Thalamus </li></ul><ul><li>Cerebral cortex and limbic system </li></ul><ul><li>Amygdala via the spinomesencephalic tract </li></ul><ul><li>Pain elicits an autonomic response directly via the spinohypothalamic tract. </li></ul>
  7. 7. Conscious Perception of Pain Hyperalgesia
  8. 8. PAIN SUPPRESSION APPROACHES <ul><li>Nociceptor </li></ul><ul><li>Synaptic Interruption </li></ul><ul><li>Gate Theory </li></ul><ul><li>Brain Chemicals and Analgesics </li></ul>
  9. 9. The Fifth Vital Sign <ul><li>Acute pain </li></ul><ul><li>Chronic (malignant)pain </li></ul><ul><li>Cancer-related pain </li></ul><ul><li>Pain classified by location </li></ul><ul><li>Pain classified by etiology </li></ul>
  10. 10. Chronic Pain <ul><li>Chronic Persisten Pain </li></ul><ul><li>Chronic Intermittent Pain </li></ul><ul><li>Chronic Malignant Pain </li></ul>
  11. 11. SOURCES OF PAIN <ul><li>Cutaneous Pain </li></ul><ul><li>Somatic Pain </li></ul><ul><li>Visceral Pain </li></ul><ul><li>Referred Pain </li></ul><ul><li>Neuropathic Pain </li></ul><ul><li>Breaktrhough pain </li></ul><ul><li>Phantom limb sensation </li></ul><ul><li>Psychogenic Pain </li></ul>
  12. 12. FACTORS AFFECTING PAIN <ul><li>Perception of Pain </li></ul><ul><li>Socio Cultural Factors </li></ul><ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Meaning of Pain </li></ul><ul><li>Anxiety </li></ul><ul><li>Past experience with Pain </li></ul>
  13. 13. Medications to Control Pain <ul><li>Local Anesthetic Agent </li></ul><ul><li>Nerve blocks </li></ul><ul><li>Topical Local Anesthesia </li></ul><ul><li>Analgesics </li></ul><ul><li>* Non-opioid Analgesics </li></ul><ul><li>e.g. aspirin </li></ul><ul><li>Salycylate Salts </li></ul><ul><li>Acetaminophen </li></ul><ul><li>NSAID’s </li></ul>
  14. 14. <ul><li>Opioid Analgesics </li></ul><ul><li>e.g. Opioid agonist </li></ul><ul><li>Opioid antagonist </li></ul><ul><li>Opioid Agonist – Antagonist </li></ul><ul><li>Methadone </li></ul>
  15. 15. <ul><li>Adjuvant Medications </li></ul><ul><li>* Antidepressants </li></ul><ul><li>* Anti-Anxiety Agents </li></ul><ul><li>* Anticonvulsants </li></ul><ul><li>* Corticosteroids </li></ul><ul><li>* Miscellaneous Agents </li></ul>
  16. 16. ORAL POTENCY <ul><li>Ceiling Effect </li></ul><ul><li>Tolerance </li></ul><ul><li>Dependence </li></ul><ul><li>Production of Metabolites </li></ul>
  17. 17. NURSING MGT <ul><li>Misconception and Myths </li></ul><ul><li>Assessment </li></ul><ul><li>Diagnosis, Outcomes and Interventions </li></ul>
  18. 18. Numeric Rating Scale Ask the patient to rate their pain intensity on a scale of 0 (no pain) to 10 (the worst pain imaginable). Some patients are unable to do this with only verbal instructions, but may be able to look at a number scale and point to the number that describes the intensity of their pain.
  19. 19. <ul><li>Color Scale </li></ul><ul><li>This scale is a colored stripe in which color gradually changes from white (no pain) through shades of pink to dark red (worst possible pain). Ask the patient to point to the area on the scale that shows their level of pain. To obtain a number for documentation use the scale parallel to the color stripe to find the number corresponding to the area where the patient points. </li></ul>
  20. 21. <ul><li>Word Graphic Scale </li></ul><ul><li>This scale can be used with patient as young as 6 years of age. It uses a line with words to describe pain intensity from &quot;no pain&quot; to &quot;worst possible pain&quot;. Show and explain the scale to the patient and then ask him or her to point (or mark) anywhere along the line that shows how much pain they have. To find a number for documentation count the black dots, starting with zero at the far left, to the area where the patient points, up to ten at the far right. </li></ul>
  21. 23. Wong-Baker FACES Pain Rating Scale <ul><li>This scale can be used with young children (sometimes as young as 3 years of age). It also works well for many older children and adults as well as for those who speak a different language. Explain that each face represents a person who may have no pain, some pain, or as much pain as imaginable. Point to the appropriate face and say: </li></ul><ul><li>(0) &quot;This face is happy and does not hurt at all.&quot; (2) &quot;This face hurts just a little bit.&quot; (4) &quot;This face hurts a little more.&quot; (6) &quot;This face hurts even more.&quot; (8) &quot;This face hurts a whole lot.&quot; (10) &quot;This face hurts as much as you can imagine, but you don't have to be crying to feel this bad.&quot; </li></ul>
  22. 25. <ul><li>FLACC Scale This is a behavior scale that has been tested with children age 3 months to 7 years. Each of the five categories (Faces, Legs, Activity, Cry, Consolability) is scored from 0-2 and the scores are added to get a total from 0-10. Behavioral pain scores need to be considered within the context of the child's psychological status, anxiety and other environment factors. </li></ul>
  23. 26. 2 Difficult to console or comfort 1 Reassured by occasional touching, hugging or &quot;talking to, distractible 0 Content, relaxed Consolability 2 Crying steadily, screams or sobs, frequent complaints 1 Moans or whimpers, occasional complaint 0 No cry (awake or asleep) Cry 2 Arched, rigid, or jerking 1 Squirming, shifting back and forth, tense 0 Lying quietly, normal position, moves easily Activity 2 Kicking, or legs drawn up 1 Uneasy, restless, tense 0 Normal position or relaxed Legs 2 Frequent to constant frown, clenched jaw, quivering chin 1 Occasional grimace or frown, withdrawn disinterested 0 No particular expression or smile Face
  24. 27. INTERVENTIONS <ul><li>Licensed Nurse Role: Knowledge Based Practice </li></ul><ul><li>Knowledge of Self </li></ul><ul><li>Knowledge of Pain </li></ul><ul><li>Knowledge of the Standard of Care </li></ul><ul><li>The standard of care is effective ongoing pain assessment and pain management. This includes but is not limited to: </li></ul><ul><li>1. Acknowledging and accepting the patient’s pain </li></ul>
  25. 28. <ul><li>2. Identifying the most likely source of the </li></ul><ul><li>patient’s pain; </li></ul><ul><li>3. Assessing pain at regular intervals, with </li></ul><ul><li>each new report of pain or when pain is </li></ul><ul><li>expected to occur or reoccur. </li></ul><ul><li>Assessment includes but is not limited </li></ul><ul><li>to: </li></ul><ul><li>a) The patient’s level of pain utilizing a </li></ul><ul><li>pain assessment tool; </li></ul>
  26. 29. <ul><li>b) Barriers to effective pain management, </li></ul><ul><li>which may include personal, cultural and </li></ul><ul><li>Institutional barriers. Sources of these </li></ul><ul><li>barriers may include but are not limited to </li></ul><ul><li>patient, family, significant other, physician, </li></ul><ul><li>nurse and institutional constraints; </li></ul>
  27. 30. <ul><li>4. Reporting the patient’s level of pain; </li></ul><ul><li>5. Developing the patient’s plan of care that includes an interdisciplinary plan for effective pain management involving the patient, family and significant other; </li></ul>
  28. 31. <ul><li>6. Implementing pain management strategies and indicated nursing interventions including: a) Aggressive treatment of side effects (i.e. nausea, vomiting, constipation, pruritus etc), b. Educating the patient, family and significant other(s) regarding, </li></ul><ul><li>(i) Their role in pain management, </li></ul><ul><li>(ii) The detrimental effects of unrelieved pain, </li></ul><ul><li>(iii) Overcoming barriers to effective pain </li></ul><ul><li>management, (iv) The pain management plan and expected outcome of the plan;. </li></ul>
  29. 32. <ul><li>7. Evaluating the effectiveness of the </li></ul><ul><li>strategies and the nursing interventions; </li></ul><ul><li>8. Documenting and reporting the interventions, patient’s response, outcomes; and </li></ul><ul><li>9. Advocating for the patient and family for effective pain management. </li></ul>
  30. 33. Non-Pharmacologic ApproachesTo Pain A. Non-pharmacologic interventions should routinely be used. Although these strategies alone are frequently insufficient for moderate to severe pain, they are usually helpful in conjunction with pharmacological therapy. Such strategies may include: B. Cognitive-behavioral Education Relaxation, imagery Psychotherapy, counseling Hypnosis Biofeedback Music, literature, art, play Prayer, meditation
  31. 34. <ul><li>C. Physical Massage Acupuncture, acupressure Application of heat or cold TENS Immobilization, graded mobilization Therapeutic exercise D. Nonpharmacologic interventions may be provided, based on training, by: Physicians Nurses Physical, occupational, recreation, art, music, child-life or other therapists Social workers Religious or spiritual leaders Clinical psychologists Others </li></ul>