This document discusses pain assessment in inpatient settings, with a focus on aging and palliative populations. It emphasizes the importance of thorough pain assessment using tools like the numeric pain scale or behavioral assessment tools. It also stresses the need to assess for sedation when treating pain and reassessing patients on a schedule based on medication peaks. The document provides guidance on pain assessment and management for aging patients and those who are dying, noting the need to avoid assumptions and still properly assess and treat pain. It promotes the idea of bolusing pain medication before increasing continuous infusions.
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Pain is a common yet complex biopsychosocial phenomenon that affects every aspect of a patient’s life
Optimal management often requires good assessment, formulation of the problem in the patient, and combining pharmacological and non-pharmacological (psychological and social) interventions
Ideal pain clinic
Promoting multidisciplinary team approach
Coordinating all specialist effort
Measuring the outcome of treatment offered
Promoting palliative model rather than curative models of pain treatments
Identifying complications of IPM and promoting safe and base-evidence intervention
Nursing Assessment Of The New Chronic Pain Patient Sr Christine Wakefieldepicyclops
Lecture given to the North British Pain Association on 16th May 2008 by Sr Christine Wakefield. In this talk, Sr Wakefield discusses the role of the nurse specialist in the assessment of the newly-referred patient with chronic pain. www.nbpa.org.uk
Pain is a common yet complex biopsychosocial phenomenon that affects every aspect of a patient’s life
Optimal management often requires good assessment, formulation of the problem in the patient, and combining pharmacological and non-pharmacological (psychological and social) interventions
Ideal pain clinic
Promoting multidisciplinary team approach
Coordinating all specialist effort
Measuring the outcome of treatment offered
Promoting palliative model rather than curative models of pain treatments
Identifying complications of IPM and promoting safe and base-evidence intervention
Nursing Assessment Of The New Chronic Pain Patient Sr Christine Wakefieldepicyclops
Lecture given to the North British Pain Association on 16th May 2008 by Sr Christine Wakefield. In this talk, Sr Wakefield discusses the role of the nurse specialist in the assessment of the newly-referred patient with chronic pain. www.nbpa.org.uk
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Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
a. Understand the prevalence and nature of pain concerns in returning combat veterans.
b. Understand that pain issues are part of a complex group of co-occurring and inter-related issues.
c. Describe a collaborative, bio-psycho-social approach to address pain issues.
d. Understand the stepped-care, collaborative approach in VA.
e. Understand how to implement collaborative pain care on PACT teams - a nuts and bolts approach
This two-part class will begin by highlighting collaborative pain care in Primary Care using real-life scenarios that address the complex issues and needs of returning Veterans and then move on to address how to apply a nuts-and-bolts approach within a Patient Aligned Care Team in the VA.
HISTORY OF 3-STEP LADDER WHO
1980 – WHO establishes Cancer Control Programme
Cancer prevention
Early diagnosis with curative treatment
Pain relief and palliative care
1986 – ” Cancer Pain Relief “ published by WHO
Step Ladder WHO
Updated on 1996
Worldwide acceptance protocol
Today, worldwide consensus favouring its used for management of all pain associated with serious illness
We live in an era of medication, but what else can we do to improve mental health? Are we excessively prescribing, can we approach medicine in a more holistic way?
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ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
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How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
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CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
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The Promise: CRISPR offers exciting possibilities:
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Research: Studying gene function to unlock new knowledge.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
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The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
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2015: Pain Assessment, the Key to Treating Pain in the Inpatient Setting-Yi
1. C A S S I A Y I , A P R N , M S N , C N S , C C R N
Pain Assessment, the Key to
Treating Pain in the Inpatient
Setting
Considerations in The Aging And Palliative Populations
2. Objectives
Apply the Pain Assessment Hierarchy to pain
assessment and reassessment in all patient
populations
Review importance of sedation assessment
Make the connection between good assessment and
good management
3. Hierarchy Of Pain Assessment
Self
Report
Behavioral
assessment
Assume or Anticipate
pain (APP)
4. The Numeric Pain Scale
Ask your patient to rate his or her pain on a scale of
0-10, 0 being no pain, and 10 being the worst pain
8. Behavioral Score Does Not Equal Intensity!!!!
Example= Two people may have the same cut on
their finger…
Person #1 may be crying,
squeezing his finger, and grimacing.
Person #2 may be just grimacing
This does not mean that Person #1 is experiencing more
pain….he just displaying behaviors of pain differently.
9. Pain and the Dying patient
Pain is not automatic!
Pain must be assessed, just like with any other
patient population!
• Don’t misinterpret other signs/symptoms of dying
with pain!
• Restlessness, agitation, moaning, and groaning may
accompany terminal delirium
• If the diagnosis is unclear, a trial of opioid may be
necessary to judge whether pain is driving the
observed behaviors
10. Respiratory Variations in the Dying patient- NOT
indicator of pain
Patterns:
Tachypnea, Apnea
Chin-lift, jaw-jerk*
Diminishing tidal volume
Oropharyngeal secretions*
Symptoms: generally
comfortable
Distressing to family, not to
patient
Management
Family support
Oxygen variably effective
Opioids (rarely)
11. Palliative Patients are at Increased Risk of Pain
Disease Process
Immobility (who’s driving this??)
Skin break down
Dyspnea
12. Pain Reassessment
Reassessment times should coincide with peak
medication effectiveness, when the patient will
feel the greatest effects of analgesia and will also
experience the peak of side effects.
5-45 minutes for IV opioids
45-75 min for PO opioids
15. Why is the Sedation Assessment
So Important?
Remember sedation ALWAYS precedes respiratory
depression!! If we can catch the patient while they
are sedate, we should be able to prevent all opioid
related respiratory depression!
If left untreated,
can lead to
This
This
16. Sleep and Assessing Pain
If your patient is asleep when you need to
reassess for pain, this could mean 2 things:
Your patient is finally able to sleep! Assess the respiratory status
and review previous sedation assessment. If normal, do not wake
the patient up!
-OR-
The pain medication you gave made your patient sedate. If the
respiratory assessment is abnormal, wake the patient up! Further
evaluation is required.
17. What is a Good Respiratory Assessment?
Respiratory Assessment Includes:
Observe for a full minute!
Assess the rate
Assess the rhythm
Assess the depth
Assess respiratory effort. Are they snoring?
18. Do our Current Assessment Tools
work????
Self-report= gold standard
Problem with self-report using a uni-dimensional
scale
Pain is a multi-dimensional complex experience- Dynamic!
Numeric scale difficult for some to use
Requires linguistic and social skills
Patients modulate pain behaviors and self-report based on
their perception of what’s in their best interest
Providers see verbal and non-verbal signs of pain, but
can only respond to reported number
Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676
24. PlasmaConcentration
0
Time
IV Peak
20 min
PO / PR/ IM
60 minutes
60 min
SQ Peak
A little longer than IV
30 min 60 min
Morphine IV
Peak effect: 20 minutes
Half-life: 2-4 hours
Continuous morphine infusion :
Time to steady state: 10-20
hours
25. PlasmaConcentration
0
Time to Drip Steady State
164 8 12
Time ( hours )
20 24
50%
75%
87.5%
93.75%
97%
100%
Pain Control
Change GTT
Steady State
26. Pain Management with Geriatric Patients
Analgesic therapy issues
Physiologic changes
Absorption
Distribution
Metabolism
Elimination
Opioids
Recommend reducing initial opioid dosing
by 25-50% in elderly patient
27. • Retrospective study at UC San Diego
• Patients who died while receiving Continuous
Morphine Infusion (CMI) from 2012-2013
N=190
• Mean age was 66.4 years (range: 19-99 years)
• 109 males and 81 females
• At initiation of CMI, 25.8% (n=49) had an oncologic
diagnosis and 73.2% (n=139) were in the ICU.
Morphine Study at UCSDH
Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at End
of Life. Submitted to Journal of Palliative Medicine January 2015
28. • Prior to CMI initiation, 40.5% (n=77) were opioid naïve
• 85% (n=160) had documented indication for CMI (e.g.
compassionate extubation or comfort care with pain/dyspnea)
• 60% (n=120) did not receive any bolus doses prior to CMI
initiation and of these 23% were opioid naïve (n=44)
• Between start and end of CMI
+130% in rate of CMI
+442% morphine IV dose
Patients on CMI:
24.2% (n=46) had a GFR < 30 mL/min
73.1% (n=139) a GFR >30 mL/min
2% (n=5) were not recorded
A Few Key Findings from Morphine Study
Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at
End of Life. Submitted to Journal of Palliative Medicine January 2015
29. What is the Goal?
Continuous Infusion Bolus
• Achieve continuous pain/agitation
control by administering a
continuous infusion (at the lowest
possible dose to minimize
accumulation)
• Assess the effect of the continuous
drip rate when steady state is
reached
(5-72 hours with pain meds)
• Should not be used for patients
with anuria or oliguria
There are 2 goals of IV boluses for
patients who are already on a
continuous drip:
1. To treat a pain score or agitation
level that is above/beyond the
patient’s consistent level.
2. Indicates if the continuous IV
infusion needs to be increased
30. Continuous Infusions- Back to Basics! Bolus 1st!
Bolus
Re-Assess
Still have pain? Re-
Bolus!
No more pain? If
painful stimuli is
constant, titrate up!
Assess
Start Here!
31. In Conclusion….
Assess, Assess, Assess before you treat!
Assess for sedation, not just pain!
Pain and sedation assessment will help you decide
HOW to treat.
Pain assessment is still important in the palliative
population! Don’t make assumptions!
Consider lower doses in the aging population
Bolus before you titrate!
32. References
Vila Jr H, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management
before and after implementation of hospital-wide pain management standards: is patient
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Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management
Nursing guidelines on monitoring for opioid-induced sedation and respiratory
depression. Pain Management Nursing. 2011;12(3):118-145. e110.
Gupta A, Daigle S, Mojica J, Hurley RW. Patient perception of pain care in hospitals in
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Ahlers A, Gulik L, Veen A, et al. D. Comparison of different pain scoring systems in
critically ill patients in a general ICU. Critical Care. 2008; 12:R15.
Drew D, Gordan D, Renner L, et al. The use of "as needed" range orders for opioid
analgesics in the management of pain: a consensus statemetns of the american society of
pian management nurses and the american pain society. Pain Mangement Nursing.
2014; 15(2) 551-554.
The joint commission sentinel event alert. A Complementary Publication of the Joint
Commission. 2012; 49.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of
pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care
Medicine. 2013;41(1):263-306.
Schilling A, Corey R, Leonard M, et al. Acetaminophen: old drug, new
warnings.Cleavelant Clinical Journal of Medicine. 2010; 7(1) 19-27.