2. WHAT IS PAIN ?WHAT IS PAIN ?
Pain is described as an unpleasantPain is described as an unpleasant
sensory and emotional experiencesensory and emotional experience
(IASP 1979)(IASP 1979)
Pain is what the patient saysPain is what the patient says
it is and exists when he/she says itit is and exists when he/she says it
does (McCaffrey 1989)does (McCaffrey 1989)
3. There are two types of painThere are two types of pain
AcuteAcute
ChronicChronic
4. Acute painAcute pain
Acute pain is suddenAcute pain is sudden and short lasting (lessand short lasting (less
than 3mths)than 3mths)
It is associated with actual or potential tissueIt is associated with actual or potential tissue
damage, trauma, surgery or diseasedamage, trauma, surgery or disease
It is thought that acute pain shouldIt is thought that acute pain should
subside after injury or disease has beensubside after injury or disease has been
resolvedresolved
5. Chronic painChronic pain
Chronic pain is persistent painChronic pain is persistent pain
which remains after the normalwhich remains after the normal
healing time (3mths)healing time (3mths)
It is also caused by injury,It is also caused by injury,
surgery, disease and poor painsurgery, disease and poor pain
managementmanagement
This pain can lead to alterations inThis pain can lead to alterations in
receptors and transmitters in thereceptors and transmitters in the
spinal cord and brainspinal cord and brain
Causing pain which may last forCausing pain which may last for
months or years to the sufferingmonths or years to the suffering
personperson
6. What influences pain ?What influences pain ?
Emotional stateEmotional state
PersonalityPersonality
Cultural backgroundCultural background
AgeAge
SexSex
Social factorsSocial factors
EducationEducation
Previous experiencePrevious experience
Staff attitudesStaff attitudes
Lack of informationLack of information
Type of analgesiaType of analgesia
8. The Five Families of Analgesia are:The Five Families of Analgesia are:
OpiatesOpiates
Non-opiatesNon-opiates
NSAID’SNSAID’S
AdjuvantsAdjuvants
Local anaestheticLocal anaesthetic
10. Why do we have acute painWhy do we have acute pain
services?services?
It was recommended in a governmentIt was recommended in a government
green paper that all hospitals should havegreen paper that all hospitals should have
an acute pain servicean acute pain service
The purpose for this service is to reduce theThe purpose for this service is to reduce the
severity of postoperative or post-traumaticseverity of postoperative or post-traumatic
pain (NAPP,2006)pain (NAPP,2006)
11. Acute pain can be influenced byAcute pain can be influenced by
HeadacheHeadache
MigraineMigraine
Postoperative painPostoperative pain
TraumaTrauma
DysmenorrhoeaDysmenorrhoea
labourlabour
12. Where culture and pain intersectWhere culture and pain intersect
Nurses interpret painNurses interpret pain
behaviour through theirbehaviour through their
own cultural lensown cultural lens
Often making culturallyOften making culturally
learned judgements aboutlearned judgements about
patients by the behaviourpatients by the behaviour
they displaythey display
13. Get to know your patientsGet to know your patients
Hindus believe pain must be enduredHindus believe pain must be endured
It is part of preparing for a better life in the nextIt is part of preparing for a better life in the next
cyclecycle
The devout Hindu who senses imminent deathThe devout Hindu who senses imminent death
prepares for a ‘good death’ by remaining consciousprepares for a ‘good death’ by remaining conscious
in order to experience the events to comein order to experience the events to come
Asking for pain medication, especially with
somnolent side effects, is generally avoided.”
14. Cont…Cont…
Members of the Jewish culture Voice their painMembers of the Jewish culture Voice their pain
openlyopenly
They believe pain must be shared recognised andThey believe pain must be shared recognised and
validated by othersvalidated by others
Jewish patients’ intense complainingJewish patients’ intense complaining
doesn’t necessarily mean intense pain. Rather, itdoesn’t necessarily mean intense pain. Rather, it
may relate to the need for the presence of othersmay relate to the need for the presence of others
to listen to them and affirm their experience.”to listen to them and affirm their experience.”
15. Role of the acute pain nurseRole of the acute pain nurse
Assess patientAssess patient
Check documentationCheck documentation
Plan appropriate pain reliefPlan appropriate pain relief
Implement appropriate analgesiaImplement appropriate analgesia
Evaluate drug efficiencyEvaluate drug efficiency
Reduce patient hospital stayReduce patient hospital stay
Liaise with the multidisciplinary teamLiaise with the multidisciplinary team
Educate staff/patient on analgesic reliefEducate staff/patient on analgesic relief
Facilitate patient to make informed choiceFacilitate patient to make informed choice
Encourage patient mobility and independenceEncourage patient mobility and independence
17. Acute Pain Assessment ToolAcute Pain Assessment Tool
Score 0Score 0 No pain at restNo pain at rest
No pain on movementNo pain on movement
Score 1Score 1 No pain at restNo pain at rest
Slight pain on movementSlight pain on movement
Score 2Score 2 Intermittent pain at restIntermittent pain at rest
Moderate pain on movementModerate pain on movement
Score 3Score 3 continuous pain at restcontinuous pain at rest
Severe pain on movementSevere pain on movement
Pain scoring should be done routinely along with pulse, BPPain scoring should be done routinely along with pulse, BP
and temperature (NAPP, 2006)and temperature (NAPP, 2006)
19. Methods used to treat acuteMethods used to treat acute
painpain
Oral, Rectal, Buccal, Sub-Oral, Rectal, Buccal, Sub-
lingual, Inhalationlingual, Inhalation
Sub-cut, IMSub-cut, IM
IvIv
EpiduralEpidural
IntrathecalIntrathecal
PhysiotherapyPhysiotherapy
20. Equipment used for acute painEquipment used for acute pain
Baxter PumpsBaxter Pumps
Patient Controlled AnalgesiaPatient Controlled Analgesia
(PCA)(PCA)
Patient Controlled EpiduralPatient Controlled Epidural
Analgesia (PCEA)Analgesia (PCEA)
21. Cannula AttachmentCannula Attachment
Check patencyCheck patency
Need for drugs e.g. PCANeed for drugs e.g. PCA
Do not give blood with PCADo not give blood with PCA
Must have cannula ifMust have cannula if
epidural in progressepidural in progress
Do not take blood from theDo not take blood from the
same cannulasame cannula
22. What to look out for!What to look out for!
Respiratory depression ifRespiratory depression if
this happens;this happens;
Stop analgesiaStop analgesia
Administer oxygenAdminister oxygen
NaloxoneNaloxone
VentilateVentilate
23. When treating painWhen treating pain
Oral is always the best routeOral is always the best route
Medication must be given regular toMedication must be given regular to
work effectivelywork effectively
24. UnresolvedUnresolved pain causespain causes
SicknessSickness
ConstipationConstipation
ThrombosisThrombosis
Deterioration in mental stateDeterioration in mental state
Heart problemsHeart problems
Muscle wastageMuscle wastage
ImmobilityImmobility
Pressure soresPressure sores
StressStress
25. ImpactImpact
Increase patient hospital stayIncrease patient hospital stay
Increase the ever-growing cost to theIncrease the ever-growing cost to the
NHSNHS
Increase the possibility of acute painIncrease the possibility of acute pain
becoming chronic…becoming chronic…
27. Chronic painChronic pain
More than 750,000 people suffer from chronicMore than 750,000 people suffer from chronic
pain in the UK every year (Hoffman etpain in the UK every year (Hoffman et
al,1997)al,1997)
A fifth of those patients who sufferA fifth of those patients who suffer
from chronic pain will contemplate suicidefrom chronic pain will contemplate suicide
(Simon et al,2004)(Simon et al,2004)
28. What influences chronic pain?What influences chronic pain?
AgeAge
IllnessIllness
Lack of educationLack of education
Emotional stateEmotional state
Social and cultural backgroundSocial and cultural background
Lack of supportLack of support
Poor mobilityPoor mobility
Poor pain managementPoor pain management
30. Consequences of persistent painConsequences of persistent pain
DepressionDepression
Mood and behaviour changesMood and behaviour changes
Social withdrawalSocial withdrawal
Sleep disturbanceSleep disturbance
Decline in economic statusDecline in economic status
DisabilityDisability
SuicideSuicide
31. So how does chronic pain effectSo how does chronic pain effect
the working person?the working person?Take time off work
Feel the
need for care
Visit GP
Medication
Social isolationDepression
Fear job loss
Pain
32. Impact on societyImpact on society
The TUC reported that BritishThe TUC reported that British
businesses lose an estimated 4.9businesses lose an estimated 4.9
million days to employeemillion days to employee
absenteeism through work relatedabsenteeism through work related
back painback pain
The All Party Parliamentary GroupThe All Party Parliamentary Group
on Endometriosis revealed theon Endometriosis revealed the
average woman with this conditionaverage woman with this condition
loses 55 working days per yearloses 55 working days per year
The National Rheumatoid ArthritisThe National Rheumatoid Arthritis
Society estimated that 9.4 millionSociety estimated that 9.4 million
working days are lost throughworking days are lost through
Rheumatoid ArthritisRheumatoid Arthritis
33. Aim of the GovernmentAim of the Government
The public health White Paper aims toThe public health White Paper aims to
strengthen the ongoing Governmentstrengthen the ongoing Government
programmes such as “Back in Work” toprogrammes such as “Back in Work” to
tackle the problemtackle the problem
As part of the healthy workplaceAs part of the healthy workplace
initiativeinitiative
By encouraging companies to adoptBy encouraging companies to adopt
“back in work” friendly policies“back in work” friendly policies
Over 300 business organisations haveOver 300 business organisations have
already registered and have been short-already registered and have been short-
listed with a chance of receiving a grantlisted with a chance of receiving a grant
of up to £50.000of up to £50.000
Although the money is incentive forAlthough the money is incentive for
businesses, the government aims tobusinesses, the government aims to
improve health by making it everybody'simprove health by making it everybody's
business.”business.”
35. CINDERELLA SERVICE STILL?CINDERELLA SERVICE STILL?
There is still a wide variation in the availability of chronic painThere is still a wide variation in the availability of chronic pain
servicesservices
Both funding and staffing levels vary greatly between districtBoth funding and staffing levels vary greatly between district
hospitals, from hospital to hospital and from region to regionhospitals, from hospital to hospital and from region to region
within the UKwithin the UK
Many services fall short of the recommended levels of 10Many services fall short of the recommended levels of 10
consultant sessions per 10,000 peopleconsultant sessions per 10,000 people
The Clinical Standards Advisory GroupThe Clinical Standards Advisory Group
recommends consultants provide three dedicated sessions perrecommends consultants provide three dedicated sessions per
week – 10% of services failed on this standardweek – 10% of services failed on this standard
36. Cont…Cont…
GP referrals vary taking between 4-110 weeks toGP referrals vary taking between 4-110 weeks to
see a chronic pain consultantsee a chronic pain consultant
Consultant referrals take between 4-133 weeks toConsultant referrals take between 4-133 weeks to
get patients’ on pain management programmesget patients’ on pain management programmes
With only 58% of clinics offering outpatient PainWith only 58% of clinics offering outpatient Pain
Management ProgrammesManagement Programmes
Demand is so great for chronic pain services that 8Demand is so great for chronic pain services that 8
services have closed their GP referral listsservices have closed their GP referral lists
However treatment to alleviate chronicHowever treatment to alleviate chronic
pain is a human right (WHO,2000)pain is a human right (WHO,2000)
38. Biopsychosocial assessment ofBiopsychosocial assessment of
chronic painchronic pain
Effect of pain on behaviour, lifestyleEffect of pain on behaviour, lifestyle
and relationshipsand relationships
Degree of disability related to pain,Degree of disability related to pain,
e.g. depressione.g. depression
Manner of expressing painManner of expressing pain
Understanding of painUnderstanding of pain
Coping and adaptive skillsCoping and adaptive skills
Interpersonal and family supportInterpersonal and family support
systemssystems
MotivationMotivation
Sleep, appetiteSleep, appetite
Financial aspectsFinancial aspects
Other factors influencing pain e.g.Other factors influencing pain e.g.
past pain experience, loss of control,past pain experience, loss of control,
difficulties with the health systemdifficulties with the health system
39. Managing chronic painManaging chronic pain
Diagnose and treat causeDiagnose and treat cause
Avoid unnecessaryAvoid unnecessary
investigationsinvestigations
Treat exacerbating co-Treat exacerbating co-
morbidities, e.g. depressionmorbidities, e.g. depression
Set realistic goalsSet realistic goals
Prevention- seating,Prevention- seating,
clothing, positioningclothing, positioning
40. Methods used in chronic painMethods used in chronic pain
AnalgesicsAnalgesics
AcupunctureAcupuncture
Tens MachineTens Machine
AromatherapyAromatherapy
PhysiotherapyPhysiotherapy
HypnotherapyHypnotherapy
Spinal blocksSpinal blocks
CounsellingCounselling
Education programmesEducation programmes
41. Barriers of effective painBarriers of effective pain
management in the communitymanagement in the community
Lack of knowledgeable carersLack of knowledgeable carers
Assessment inadequateAssessment inadequate
Poor quality of life - disability,Poor quality of life - disability,
depressiondepression
Lack of collaborationLack of collaboration
Burden on the caregiverBurden on the caregiver
Non-complianceNon-compliance
42. Over coming pain managementOver coming pain management
barriers in the communitybarriers in the community
Be aware of age-related bias inBe aware of age-related bias in
health care workershealth care workers
Use standard assessmentUse standard assessment
protocolsprotocols
Individualise plan of care -Individualise plan of care -
simplify treatments - minimisesimplify treatments - minimise
night-time monitoringnight-time monitoring
Educational support - addressEducational support - address
misbeliefs, e.g. fears ofmisbeliefs, e.g. fears of
addiction- counsel patient andaddiction- counsel patient and
caregiver about medication usecaregiver about medication use
and how to deal with sideand how to deal with side
effectseffects
43. Cont…Cont…
Use calendars and pill organisersUse calendars and pill organisers
Use home-care nursing agenciesUse home-care nursing agencies
Recommend pain logs/diariesRecommend pain logs/diaries
Consider inpatientConsider inpatient
hospitalisation/respite carehospitalisation/respite care
Listen to family caregiverListen to family caregiver
Reinforce pain managementReinforce pain management
principlesprinciples
Communicate regularly with nurseCommunicate regularly with nurse
and familyand family caregivercaregiver
The who analgesic ladder is used in practice to manage pain effectively!!
The pain team focus on following this step up and step down approach to manage patients pain!!!!
The acute pain team start at the top of the ladder and work their way down
While the chronic pain team start at the bottom of the ladder and work their way up
The Five Families of Analgesia are aimed to provide pain relief for patients ……
Opiates are… morphine,
Non- opiates are…paracetamol
NSAID’S are…Diclofenic,
Adjuvants are…Amitriptyline
Local anaesthetic are…lidnocaine
Dysmenorrhoea is painful periods
When visiting patients on the ward----this is the first thing the pain team look at……
On many occasions nurses reported their patients were in pain---but very few patient had their pain score documented…
Considering this is a legal document--it is important to document patients pain and sedation score each time you carry out observations, give medication or ask the patient about HIS/HER pain….
If this information is not documented how can you stand up in a court room and say “the patient was in pain and prove they needed pain relief”….??? “drug overdose”
One problem is…the trust has only 26 pumps And you must have training to use these pumps
why is oral the best route??? This causes less stress to patient and has no risk of infection as it is non-intrusive
This can… as above!
Illness such as - Cancer, Arthritis, Neuropathic pain, Musculoskeletal disease, Sickle Cell or Back Pain
Lack of education- to patient’s on their … medication, treatment available and condition they have
Age of patient– for example-older people tend except what the doctor says, and have difficulty telling people in authority exactly how they feel.
Social background- more affluent people are more likely to seek help, accept advice given and eat healthy food to help with their condition. while people in lower social economic backgrounds are more likely to blame their condition on others, require constant guidance, want a quick fix solutions, and take no responsibility to help themselves.
Poor pain management- Attitude of Doctor, wrong analgesic relief, psychological state of the person and time the patient has waited to see a pain doctor
Lack of support- Lack of resources, depends on the area you live, the resource available in the area, to the type of help you will receive.
Poor mobility- PT age, disease, wound brake down, fear of movement, communication breakdown between doctor/patient, lack of help, advice and support for patients with chronic pain in the community.
Because there are many bio-psycho-social factors that influence chronic pain, this can lead to many problems…
Lead to…
For instance a man with chronic back pain ,
The Trades Union Congress (TUC) is a British organisation that represents the UK's trade unions
Although these surveys show the enormous problem of chronic pain, there does not appear to be an accurate measure of the total burden to industry in relation to chronic pain.
sounds like a good idea!
However investigations such as-Blood tests- X-rays- CAT scan- MRI scans- Myelograms
Blood tests look @ red & white cells & plts( for haem probs)
biochem checks liver & kidney function & looks at factors for rheumatoid aswell as some cancers and acute inflammatory or infection.
Xrays show structures bones and joints
CAT show tissues and musclesMRI is the 1st choice for RAPID AND ACURATE DIAGNOSIS AND to MONITOR PROGRESS
Myelogram/ultrasound shows structure and can distinguish between fluid and solid objects
If acute pain is not treated effectively it will turn into chronic pain,
this will affect;
Lifestyle
Cost to the NHS
