pain part 2
- 1. Pain Management Part II
- 2. Pain Intensity or Rating Scales • Numbers • Visual analogue • Words • Colors • Faces • Behavior / physiologic signs
- 3. Pain Intensity or Rating Scales • Patient’s report of pain – Single most important indicator of intensity of pain – Provider’s overrate or underrate pain – Inaccuracy greater when patient’s pain is severe
- 4. Pain Intensity or Rating Scales • Pain intensity scales • Easy and reliable • Provide consistency in communication of pain • 0 – 10 range • Word modifiers may help some apply
- 5. Pain Intensity or Rating Scales • Effective Use – Understand use of scale – Educated about how information will be used • Determine changes in condition • Effectiveness of pain management interventions – Ensures adequate pain management achieved
- 6. Numeric Scale 0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain
- 7. No Mild Moderate Severe Very Worst Pain Severe
- 8. Visual-Analogue Scale* No Pain Worst Pain Usually 0-10 cm long line. Placed either vertical or horizontal.
- 9. VAS: Coloured Analogue Scale (Ref: McGrath, PA, et al: Pain, 1996.)
- 10. Wong-Baker FACES Pain Rating Scale 0 2 4 6 8 10
- 11. Sample of Child’s FACES Pain Rating Scale
- 12. Photographic/ Numeric Pain Scale • Oucher scale (Beyer) • White child, 3 year-old male
- 13. Photographic/ Numeric Pain Scale, cont. • Oucher scale (Beyer) • Black child, school age, male
- 14. Photographic/ Numeric Pain Scale, cont. • Oucher scale (Beyer) • Hispanic child, school age, male
- 15. Cultural Preference for Scales 100 African-American children with SCD rated preference of 3 scales: • FACES -- 56% • Black Oucher -- 26% • VAS -- 18% • Validity was strongest for FACES, then Oucher and VAS Ref: Luffy R: Pediatric Nursing, Jan 2003.
- 16. Pain Intensity or Rating Scales • Wong-Baker FACES Pain Rating Scale – Children – Elderly with impairments • Cognition • Communication – People who do not speak English • Includes number scale in relation to each expression
- 17. Pain Intensity or Rating Scales • When a scale can’t be used – Rely on observation of behavior – Rely on physiologic signs – Use input of significant others • Parents/caregivers • Help interpret observations
- 18. Nonverbal responses to pain • Facial expression • Vocalizations like moaning and groaning or crying and screaming • Immobilization of the body or body part • Purposeless body movements • Behavioral changes such as confusion and restlessness • Rhythmic body movements or rubbing
- 20. QUESTT • Question the patient • Use pain rating scale • Evaluate behavior and physiologic signs • Secure family’s involvement • Take cause of pain into account • Take action and assess effectiveness
- 21. Comprehensive Pain History • COLDERR – Character – Onset – Location – Duration – Exacerbation – Relief – Radiation
- 22. Characteristics of Pain • Quality – What does it feel like – Record patient’s words that he describes – Provides information useful in diagnosing cause of pain • Intensity – Important to obtain estimate of intensity – Evaluate effectiveness of treatment
- 23. Characteristics of Pain • Aggravating and Alleviating Factors – Include behaviors or activities that influence pain – Helps in care planning • Associated Manifestations – Impact on ADLs • Sleep, work, activities • Appetite, mood, sexual function, recreational activities – Pain is fatiguing • Longer experience pain the greater the fatigue • Stress response of pain continues in sleep – Physiological consequences • Pain more severe in morning
- 24. Characteristics of Pain • Meaning of Pain – Soldier vs civilian • Objective Data – Physiologic • Activates sympathetic nervous system – ↑ HR, RR, BP, – Diaphoresis, pallor, muscle tension, dilated pupils • Chronic pain shows adaptation
- 25. Characteristics of Pain • Behavioral – Crying, moaning – Rubbing site, restlessness – Distorted posture, clenched fists, guarding – Frowning, grimacing • Speaks of discomfort • Restless • Afraid to move
- 26. Characteristics of Pain • Location – Point to place in body – Ask if more than one site – Radiates, deep, superficial • Onset, Duration – How long existed – Triggers – Patterns – worse am, pm, getting up, etc.
- 27. Nurse’s Role Patient Advocate • Primary Concern-Comfort
- 28. Practice Guidelines • Establish a trusting relationship • Consider client’s ability and willingness to participate • Use a variety of pain relief measures • Provide pain relief before pain is severe • Use pain relief measures the client believe are effective • Align pain relief measures with report of pain severity
- 29. Practice Guidelines • Encourage client to try ineffective measures again before abandoning • Maintain unbiased attitude about what may relieve pain • Keep trying • Prevent harm • Educate client and caregiver about pain
- 30. Barriers to Effective Treatment • Lack of knowledge of the adverse effects of pain • Misinformation regarding the use of analgesics • Misconceptions about pain • May not report pain • Fear of becoming addicted
- 31. Pharmacologic Interventions • Opioids (narcotics) • Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS) • Co-analgesic drugs
- 32. Opioids (Narcotics) • Full agonists – No ceiling on analgesia – Dosage can be steadily increased to relieve pain – morphine, oxycodone, hydromorphone
- 33. NSAIDS • Vary little in analgesic potency – vary in anti-inflammatory effects, metabolism, excretions, and side effects • Have a ceiling effect • Narrow therapeutic index • acetaminophen, ibuprofen, aspirin
- 34. Coanalgesic Drugs • Antidepressants • Anticonvulsants • Local anesthetics • Others
- 35. WHO Ladder Step Approach for Cancer Pain Control
- 36. Rational Polypharmacy • Evolved from WHO three step approach • Demands health professionals be aware of all ingredients of medications that alleviate pain • Use combinations to reduce the need for high doses of any one medication • Maximize pain control with a minimum of side effects or toxicity • Combined with multimodal therapy (e.g. nondrug approaches)
- 37. Oral Administration • Preferred because of ease of administration • Duration of action is often only 4 to 8 hours • Must awaken during night for medication • Long-acting preparations developed • May need rescue dose of immediate- release medication
- 38. Transdermal Administration • Transmucosa and Transnasal – Enters blood immediately – Onset of action is rapid • Transdermal – Delivers relatively stable plasma drug level – Noninvasive
- 39. Rectal • Useful for clients with dysphagia or nausea/vomiting
- 40. Medication Administration • Intramuscular – Should be avoided – Variable absorption – Unpredictable onset of action and peak effect – Tissue damage • Intravenous – Provides rapid and effective relief with few side effects
- 42. Intraspinal • Provides superior analgesia with less medication used
- 43. PCA • Patient-controlled analgesia – Minimizes peaks of sedation and valleys of pain that occur with prn dosing – Electronic infusion pump – Safety mechanisms
- 44. Cognitive-Behavioral (Mind-Body) • Providing comfort • Eliciting relaxation response • Repatterning thinking • Facilitating coping with emotions
- 45. Body Interventions • Reducing pain triggers • Massage • Applying heat or ice • Electric stimulation (TENS) • Positioning and bracing (selective immobilization) • Acupressure • Diet and nutritional supplements • Exercise and pacing activities • Invasive interventions (e.g. blocks) • Sleep hygiene
- 46. Mind Interventions • Relaxation and imagery • Self-hypnosis • Pain diary and journal writing • Distracting attention • Re-pattern thinking • Attitude adjustment • Reducing fear, anxiety, stress, sadness, and helplessness • Providing information about pain
- 47. Spirit Interventions • Prayer • Meditation • Self-reflection • Meaningful rituals • Energy work (therapeutic touch, Reiki) • Spiritual healing
- 48. Social Interaction • Functional restoration • Improved communication • Family therapy • Problem-solving • Vocational training • Volunteering • Support groups
Editor's Notes
- #36: Step 1 For clients with mild pain (1-3 on a 0-10 scale) Use of nonopioid analgesics (with or without a coanalgesic) Step 2 Client has mild pain that persists or increases Pain is moderate (4-6 on a 0-10 scale) Use of a weak opioid (e.g. Codeine, tramadol, pentazocine) or a combination of opioid and nonopioid medicine (oxycodone with acetaminophen, hydrocodone with ibuprofen) Step 3 Client has moderate pain that persists or increases Pain is severe (7-10 on a 0-10 scale) Strong opioids (e.g. Morphine, hydromorphone, fentanyl)