Pain Management

Mrs. Samia Almusalhi

Pain management strategies

• The goal is to relieve the pain to tolerable level

Pharmacologic interventions

1. Pre-medication assessment:• Ask about allergy to medication, OTC (over the

counter), assess pain intensity after previous dose of medication

2. Medication used to treat pain are:• Opioids analgesic agents:• NSAID:• Local anesthetic agent:• Tricyclic anti-depresent agents and anti-seizure

medication:

Agents used to treat pain:

• Opioids analgesic agent:• It is given by IV, SC, oral, Intra-spinal, rectal,

and trans-dermal.• Although oral is peripheral it is must be given

frequently in large amount. • Adverse effect: respiratory depression (asses

it), tolerance, and sedation (pressure ulcer) nausea and vomiting (prevented by anti-emetic and hydration), constipation (laxatives and more fluids or supp) or pruritus (antihistamine).

• Epidural opioids might cause urine retention (catheter till patient is improved).

NSAID

• It thought to decrease enzyme involved in the production of prostaglandin from inflamed tissue it cause pain, fever and inflammation

• Ibubrufen is effective for mild to moderate pain• It is releives post operative pain if it is give in

intra-operative stage.• precaution with kidney dysfunction, dehydrated

and elderly patients.• NSAIDS might increase the effect of warfarin

Local anesthetic agents

• It acts by blocking nerve ending when applied directly to nerve fibers.

• They can be applied injury site or to thoracic or abdominal surgery when injected intercostly.

• Vasoconstrive agent is to be available in case of toxicity.

Topical application

a. EMLA cream for pain of invasive procedure as LP and IV lines.

b. Lidocaine 5% patch is another example.

c. Intra-spinal administration: it is through epidural catheter to the nerve root.

Tricyclic antidepressant agents and anti-seizure medication

• If pain is neurologic in origin is difficult to treat so if it is associated with burning pain the above named drugs might beresponsive.

• Its effects starts after 3 weeks

Patient controlled analgesia

• P 248 and 249

Routes of administration

• Parentral routes: (IV IM SC) are more rapid but short duration. IV occurs within minutes. Continues infusion provides continues effect. SC given for severe pain and for who does not get IV access.

• Oral route: used if patient tolerate oral

medication, if doses gradually increased chance of respiratory depression is controlled, if Parenteral route to oral to changes dose should be carefully adjusted to prevent withdrawal reaction.

• Rectal route: for patient who can not get medication by other route, or with bleeding disorder.

• Transdermal route: used to absorb medication by skin to get consistent opioids serum level. It is slowly and systematically absorbed.

Intraspinal and epidural routes • Infusion of medication to epidural space is

used to relieve pain in post operative patient.

• Pain relieved from intra-spinal administration of opioids is based on the existence of opioids receptors in the spinal cord.

• Headache, respiratory depression might be caused by this route.

Site of intraspinal and epidural routes

Teaching patient self care

• Explain the purpose of each medication, time, side effects,

• Reassure pain can managed at home

• Instruct about assessment of pain, administer medicaiton to releive pain,

• Allow self administration of medicaiton

• Instruct aobut respiratory depression with opioids.

• Prevent or treat constipation

• Keep medication a way from children

• Continuity of care: home visiting in necessary to ensure continuity of pain management, ensure proper supply of analgesics, assess items used (pump), assess need to change medication dose,,,,,,,,,,,,,,,,,,

Non pharmacological

• Massage: rubbing the skin and use of heat and cold simulate the fiber that transmit non-painful sensation.

• Thermal therapies: same, ice should be placed at injury site immediately for 15-20min after skin assessment and not in patient with impaired circulation. Heat therapy increase blood supply lead to rapid healing.

• Transcutaneous electrical nerve stimulation: TENS, pattery operated unit with electrodes applied to skin to produce vibration sensation in area, for acute and chronic pain. It stimulate non pain receptors.

Distraction:

• Distraction: focusing patient attention on other than the pain. It stimulate the descending control system. E.g: TV, music, physical and mental exercise.

• Relaxation technique: relaxing the tense muscle, as abdominal breathing in slow and rhythmic rate, it helps in releiving fatigue.

• Guided imagery:

• Hypnosis: by specialized person as psychologist or with specialized nurse. Patient might learn to do it themselves.

• Music therapy: for pain

and anxiety reduction.

• Alternative therapies: herbal therapy, reflexology, acupressure, therapeutic touch, macrobiotic dieting.

Evaluating pain management strategies:

• Page 259

•Thank you