A presentation about pain in general for newly registered nurses.

1. Neill Whyborne Nurse Specialist Acute Pain Basic Pain Management

2. Aim To increase awareness of pain and pain management strategies

5. What is Pain? PAIN IS…

10. Skin Sensory Receptors

11. Efferent neuron Sensation & Response

12. Nurses role in pain management Identification Evaluation Intervention Assessment

13. Pain Assessment

22. Behavioural Pain Scale Adapted from FLACC scale (Merkel et al 1997) The Behavioural Pain Rating Scale (Kaplow 2000) Score 0 1 2 Frowning / Grimacing No particular expression Or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin Restlessness Quiet Slight to moderate restlessness Very restless Tenseness Relaxed Slight to moderate tenseness Extreme tenseness Patient sounds Talking in normal tone or no sound Sighs, groans softly, occasionally complains Moans loudly, crying, frequently complains Consolability Content , relaxed Reassured by touching, talking Difficult to console or comfort Patient scores in each category, maximum score of 10 may be achieved. A pain score of 4 or more requires intervention.

33. Analgesia for acute pain Simple analgesics Aspirin Paracetamol Nefopam Combination analgesics Co-codamol Co-drydamol Opioid Analgesics Codeine Dihydrocodeine Tramadol Morphine oxycontin NSAIDs Ibuprofen Diclofenac Naproxen Adjuvants Tricyclic antidepressants Anti convulsants Specialist Drugs Ketamine Canabinnoids

34. Score 7-10 Consider IV boluses of opiate (This can be treated gradually until the Pt is Comfortable). Give NSAIDs if not contraindicated and/or Paracetamol (These can be given rectally or intravenously) Score 4-6 Offer analgesia that is suitable in potency for severity and nature of pain. Make sure suitable analgesia is prescribed regularly. Consider non-pharmacological interventions. Contact pain service if necessary. Score 1-3 If patient is happy with pain relief and coping with Expected immobility then continue as before. Re-assess at least twice daily. 10 9 8 7 6 5 4 3 2 1 0 As much pain As I can Possibly bear Severe Pain Moderate Pain Little Pain Discomfort No Pain at all

35. PAIN SCORE = 8 - 10 PAIN SCORE = 5 - 7 PAIN SCORE = 2 - 4 PAIN SCORE =0 - 1 SIMPLE ANALGESIC PRN Paracetamol 1gram 4 times a day (oral, intravenous or retal) Or Regular Paracetamol 1 gram 4 times a day (oral or rectal)  Ensure no other prescription contains Paracetamol SIMPLE ANALGESIC + NSAID Regular Paracetamol 1 gram 4 times a day (oral, intravenous or ,rectal) And PR/PO Diclofenac 50mgs 3 times a day (75 mg BD if Dyloject used) 150 mg in 24 hours (oral, intravenous or rectal) or Ibuprofen 200mg QDS, increase to 400mgs TDS if required (oral) –up to 1200 mg  See contra -indications to NSAIDs on other side of chart SIMPLE ANALGRESIC + NSAID +MILD OPIATE Regular Paracetamol 1 gram 4 times a day (oral, intravenous or rectal) And Regular NSAIDS - Diclofenac or Ibuprofen And PRN Dihydrocodeine/codeine 30mg 3 hourly (oral) max 240 mg or PRN Oral morphine solution 10 – 20mg 2 - 4 hourly  Is a laxative required? See Constipation Guidelines  Is nausea a problem - see Post-operative Nausea &Vomiting Guidelines SIMPLE ANALGESIC + NSAID + STRONG OPIATE Regular Paracetamol 1 gram 4 times a day (oral, intravenous or rectal) And Regular NSAIDs –Diclofenac or Ibuprofen And Stop mild opiate  to STRONG OPIATE PRN Oral morphine solution 10-20 mg 2 hourly (oral) If pain persists consider IV/IM opiate 10 mg 2-4 hourly or morphine PCA (according to existing guidelines)  Is there another cause for patients increase in pain?  Is a laxative required? See constipation guide  Is nausea a problem - see Post-operative Nausea & Vomiting Guidelines ADULT ANALGESIA STEP LADDER

41. Methods

45. Patient Controlled Analgesia Time PCA IM 0 1 2 3 4 5 Pain Relief Side- Effects

46. Epidural Analgesia

51. Epidural Space

58. Spinal (Intrathecal) Analgesia