Pain - Skills

8/22/2019 Pain - Skills

http://slidepdf.com/reader/full/pain-skills 1/67

DR. REX KARL S. TEOXON

PAINBy:

REX KARL S. TEOXON, RN, MD




Definition of PAIN

It is an unpleasant sensory and emotional

experience associated with actual or

potential tissue damage.

Pain is highly subjective and individual and it

is the body’s defense mechanism indicating

that there is a problem.




Types of Pain

Pain is described in terms of

Location Duration

Origin

Cause / physiologic basis




Types of Pain contd….

1. Location in the body :

Radiating pain: it is perceived from the source of

the pain and extends to near by tissues. Egcardiac pain

Referred pain: pain from one part of theabdominal viscera may be perceived in an area of

the skin remote from the organ causing pain





Intractable pain: which is highly resistant to relief

eg: Pain in advanced malignancy

Neuropathic pain: due to result of disturbance of theperipheral CNS, which is often severe

(shooting or stabbing pain)

Phantom pain: painful sensation perceived in a part

of the body that is missing





2. Acco rding to Orig in:

Cutaneous pain: sharp pain arising from skin andsubcutaneous tissue

Deep somatic pain: diffuse pain arising fromligaments,tendons,bones,blood vessels and nerveseg: sprain

Visceral pain: due to stimulation of pain receptors inthe abdominal cavity, cranium and thorax

eg: burning aching feeling of pressure caused by

muscle spasm in obstructed bowel





3. Acco rd ing to Du rat ion :

Acute pain - lasts upto 6 months

- sudden & slow onset- mild to severe pain

Chronic pain - lasts more than 6 months

- difficult to relieve

- eg. Chronic malignant pain




Comparison of acute & chronic pain

Acute pain

Warns of injury

Recent onset

Mild –severe

Lasts few seconds to 6

months

Anxiety follows

eg. Surgical interventions,

trauma

Chron ic pain

No purpose

Continuous/ intermittent

Mild – severe

Lasts long 6 months and

more

Depression follows

eg. cancer, arthritis,

trigeminal neuralgia




Responses to pain

Acu te pain:

Increased Pulse rate

Raised BP/ fall in BP & shock

Increased respiration

Dilated pupils

Diaphoresis

Muscle tension

May rub, cry / hold area

Reports pain

Reduced GI motility

Chronic pain:

Vital signs –usually normal

Pupils normal or dilated

Dry or warm skin Depression, irritability

Withdrawal from interests &

relationships

Disturbed sleep

Reduced libido

Reduced appetite





4. Acco rding to the physio logic basis o f pain

Mechanical - trauma

- blockage of body duct

- tumor

- muscle spasm

Thermal - extreme heat or cold





Chemical - Tissue ischemia Blocked

artery

stimulation of pain receptors

accumulation of

lactic acid




Concepts associated with pain

Pain sensation / threshold

Pain reaction

Pain tolerance




Physiology of pain

Pain perception & degree of perception

depends on the interaction between

1. Body’s analgesia system

2. The nervous system’s transmission &

interpretation of stimuli.




Physiology of pain contd…

Interaction of the following are important

Peripheral pain sensors (nociceptors) Pain producing substances (algesic)

Sensitization of nerve endings

Sensory pathway Neurotransmitters





Peripheral pain sensors:

PNS consists of primary sensory neurons(touch, heat, cold, pain & pressure)

Nociceptors – receptors transmitting pain

sensation





Nociceptors (Primary afferent ) sensory

Polymodal (C fibres)Mechano receptors (A Delta)

Activated by high intensity, physical

stimuli

Activated by threshold hormones

Widely distributedMainly present in the skin

UnmyelinatedMyelinated

LargeUsually small

Responds to tissue damage

(mechanical, thermal, chemical)

Respond to strong pressure and

stimuli

Impulses are slow, prolongedImpulses are rapid

Dull, aching, poorly localizedPain usually sharp, localized,

pricking





Pain p roduc ing subs tances (algesic):

Excitatory neurotransmitters ( other name)

Released by damaged tissues

Thus directly or indirectly evoke pain

Eg: bradykinin, acetylcholine, potassium ions,

prostaglandins & Substance P Substance P increases permeability of local

blood vessels & produce local extravasations




Cell damage (mechanical, thermal, chemical)

Release of neurotransmitters ( algesics)

Activation of C & A delta fibers

Transmission of pain impulses

1. Along nociceptor fibers to spinal cord wheresynapsis takes place in the dorsal horn

2. From the spinal cord to the brain stem

3. Through connections between thalamus & cortex(spino thalamic tract)




Pain Perception & Modulation

Nociception: continues through reticular formation,

thalamus, limbic system and cortex

Conscious pain perception – occurs at brain stem &

thalamic level

Interpretation, localization & monitoring – cortex

Midbrain gets stimulated & descending nerve fibers

conduct impulses from brain to spinal cord

Endorphins are released which decreases/block pain




Gate Control Theory

Concepts : modulation of inputs in the spinal

dorsal horn by the substantia gelatinosa cells

Brain is the active system that filters, selects andmodulates inputs

Dorsal horns are the sites at which dynamicactivities like inhibition, excitation and modulation

occurred




Gate control theory contd…

Peripheral nerve fibers carrying pain to the spinal cord

can have their input modified at spinal cord level

before transmission to brain

Synapses in the dorsal horn acts as gates that closeor open for the pain impulses

Pain can be reduced at 4 points

- peripheral site of pain - spinal cord

- brain stem - cerebral cortex




Pharmacologic pain relief interventions

Analgesics :

- Non opioids/ non- narcotic analgesics

- NSAIDs

- Narcotic analgesics / opioids

- Adjuvants / co- analgesics

Local anesthesia Patient controlled analgesia

Epidural analgesia

P ti t C t ll d A l i




Patient Controlled Analgesia

(PCA)

A drug delivery system which is a safe method for postoperative, traumatic & obstetrics, burns, terminal care

pediatrics and cancer pain management

Involves IV drug administration

Goal : to maintain a constant plasma level of

analgesic so that the problems of as needed dosing

(PRN) are avoided

Client preparation & teaching is important

Check IV line & PCA device regularly




Advantages of PCA

Easy access for clients for medication Allows self administration with no risks

Pain relief without depending on nurses Small doses of medications at short intervals

for sustained pain relief

Stabilized serum drug levels

Decreased anxiety




Advantages of PCA

Increased mobility for clients Decreased risk of DVT

Patient has more control on pain management Enhances patient participation in treatment

Less sedatory effects &nausea experienceddue to small doses received

Shorter hospital stay




Disadvantages of PCA Patient becomes dependant on PCA

If mobility is contra indicated, client may move due todecreased or no pain by PCA

Respiratory depression

Side effect may be constipation

Mechanical failure of pump

Relatives may press button for client

Wrong programming parameters

Incorrect placing of syringe can cause infusion of excessive drug doses

Costly & if client can’t understand the system




Non pharmacologic interventions

Cognit ive behavioral app roaches:

1. Distraction

Diverting attention Reducing awareness of pain

Increase pain tolerance

eg : music, TV, radio, playing game, reading,

conversing, using computer etc…

Cognitive behavioral approaches





contd…

2. Reducing pain perception

Removing / preventing painful stimuli especially for

clients who are immobilized

Consider aspects that can cause discomfort & pain

and avoid them

Control painful stimuli in your clients environment,

eg: change wet dressings, positioning the client,preventing urinary retention, avoid exposing skin to

irritants






contd…

3. Bio-feed back

Using a machine that measures the degree of

muscular tension with skin electrodes in microvolts

A poly graph machine records the tensional level for

the client to see

Client learns to use relaxation technique / imagery to

reduce tension

Produce deep relaxation

Effective for muscle tension & migraine headaches






contd… 4. Hypnosis

Called as therapeutic suggestion

Induces trance like state using focusing & relaxation

techniques, giving the patient suggestions that may behelpful after the return of an alert state of consciousness

Intense concentration reduces apprehension or stress

Should be done by trained person

Only effective when the individual cooperates

5 Physical approaches to pain




5. Physical approaches to painmanagement

Goals:

to provide comfort

to correct physical dysfunctions

to alter physiological responses

to reduce fears associated with pain related immobilit

Examples:

1. Acupressure / acupuncture

2. Cutaneous stimulation (massage, heat application, TENS,)

3. Binders, Chiropractice




6. Acupressure / Acupuncture

Chinese technique Various points in the body stimulate the flow of Qi

(chee) or natural meridians ( lines/passage ways) of energy that pass through the body

Used for backache, migraines

Post operative pain

Acupressure - application of pressure to various

points of body Acupuncture – insertion of extremely fine needles

into various points of the body. The needles unblockthe meridians allowing free flow of energy and relief

of symptoms




Acupuncture

Acupuncture is a traditional Chinese

medicine that stimulates specific points in

the body in order to restore a proper

balance of various chemicals. This

practice is used to treat a range of

conditions, including chronic pain, drugaddiction, arthritis, and mental illness.




7. Cutaneous stimulation

Massage – stimulates circulation, relaxesmuscles, increases patients sense of well being

Application of heat – used to soothe / relievepain from muscular strain / overwork

eg: for healing tissues

Application of cold – reduces swelling, calmingmuscle spasms, reducing pain in joints &muscles




Cutaneous stimulation contd…

TENS (Transcutaneous Electric Nerve Stimulation

Placing electrodes on the painful area of patient’

skin

Low current running through the electrodes acts

to block the pain sensation.

Must have a doctor’s order

Should be done by a trained person

Used for post operative pain and post traumatic

patients




Cutaneous stimulation contd…

Percutaneous Electrical Stimulation (PENS)

For relief of back pain, headaches

Electric current sent through thin needle probes

positioned in soft tissues & muscles of the back




8. Binders

Clothes wrapped around a limb / body part

Used for strains, sprains & surgical incisions

Supports the surface & internal tissues during

movement, coughing and other activities




9. Chiro-practice

Involves manipulation or adjustment of the

joints and adjacent tissues of the body,

particularly spinal column

Non-invasive

Drug free treatment

Should be done a doctor chiro-practitioner.




10. Rest and sleep

May be interrupted due to pain, fear or side

effects of medication

Assist patient in obtaining enough sleep and

rest so as to promote healing & maintain health




11. Use of Placebos

Any medication / procedure that produces an

effect resulting from its implicit / explicit intent

from its specific physical / chemical properties

eg : normal saline, empty capsules,or same

procedure like electrodes with notherapeutic value




Biofeedback in Progress

A patient at a biofeedback clinicsits connected to electrodeson his head and finger.Biofeedback is a technique inwhich patients attempt to

become aware of and thenalter bodily functions such asmuscle tension and bloodpressure. It is used in treatingpain and stress-relatedconditions, and may helpsome paralyzed patientsregain the use of their limbs.




Barriers to pain management

Patient factors :

Fear of discussing pain

Fear of being labelled a complainer

Fear that treatment will be discontinued

Fear that pain discussion will divert the

physician’s attention from the underlying

disease

Fear of taking pain medications ( opioids)




Barriers to pain management (cont)

Profess ional facto rs:

Poor pain assessment skills

Concern about drug side effects

Exaggerated fear of addiction

Lack of knowledge and skills in pain

management





Health system facto rs:

Unavailability of some drugs

Cost of care

Unavailability of doctors, nurses, and other

healthcare professionals

Inadequate physician reimbursement for painmanagement and palliative care





Other facto rs:

Ethnic and cultural values

Individual management strategies

Environmental support

Support of other people

Previous experience

The meaning of current pain

Anxiety and stress levels

Overcoming barriers to pain




Overcoming barriers to painmanagement

Principles:

Respect patient’s autonomy

- treat patients as individuals

- no two patient experience same pain

The willingness to do good for patients

Commitment to avoid harm to patients

- untreated patients suffer physically,psychologically and emotionally

Justice – equal treatment for all patients






management contd..

Respect other culture Educate the patient with pain management options

Create conducive environment

Utilize all available resources Involve family members or care givers

Assess all factors affecting pain experience and dealwith them appropriately

Obtain knowledge &skill in pain management Improve communication between staff &patients

Trust and believe patients, families and caregivers onthe information provided on pain experience

PROFESSIONALS’




PROFESSIONALS

MISCONCEPTIONS ABOUT

PAIN IN CHILDREN

• Fallacies & facts

• Fear of Addiction

• Fear of Respiratory Depression




Pain Management in Children

Fal lacies about chi ldren & pain:

Infants do not feel pain

Children tolerate pain better than adults

Children cannot tell you where they hurt

Children always tell the truth about pain

Children become accustomed to pain or painful

procedures

Behavioral manifestations reflect pain intensity

Narcotics are more dangerous for children than they

are for adults




Why is treating pain important?

Pain can affect the child’s ability to breathe easily,perform physical, and eat normally

Pain can affect his / her activity level

Pain interferes with sleep and energy level

Pain alters moods and interferes with relationships

Pain relief prevents or relieves suffering

Pain relief may help speed up healing and allowclients to leave the hospital sooner




How is pain treated in children?

1. NIPS - (Neonatal Infant Pain Scale) – For

babies

2. CHEOPS - (Children’s Hospital of EasternOntario Pain Scale)

3. OUCHER - For older children

4. Comfort Scale - For unconscious children




How is Pain Treated in Children?

Reducing pain depends on:1.Cause of the pain

2.Situation of the child is in

3.Child’s medical and psychological condition

Important thing about pain treatment is that it is

an ongoing process and to make sure that painis being relieved as best possible, withminimum side effects




How can I help the child becomfortable?

1. Be yourself

2. Speak up for the child

Know what to expect, i.e. side effects

Preventive action- planning ahead helps

Reduce stress and help child be relaxed and

distracted

“Staying ahead” of pain

After care, (i.e.) withdraw gradually




When to call the child’s doctor

If pain is not being relieved by the treatmentsprescribed

If you think the child is having side effect fromthe treatment, i.e. vomiting, itching, or urinationproblem

If child is too sleepy

If child is not making sense when he/she talks




Types of Pain in Children

Illnesses – e.g., cancer pain, flu, ear infection

Surgical Pain – inpatient or outpatient

Tests & Investigations

Injuries/Trauma – e.g., spraining an ankle,fracture




Surgical Pain

Causes:

Incision or cut

Muscle spasms or cramps (ortho surgery)

Bladder cramps

Tubes left in place post surgery

Air or blood inside the belly or chest (referred pain)

Backaches, muscular aches or other discomforts

Gas pain




Surgical Pain (cont)

Treatment:

• 1ST-2ND DAY post op are usually the worst – Strong

pain medication (IV), then to oral when allowed PO.

eg. Morphine – which is safe for babies

• DOSING is done by weight

• “Staying Ahead” of pain, then to catch up

• + non-prescription meds & anti-inflammatory drugs




Pain control

Epidurals

Nerve Blocks

Caudal Analgesia

PCA Massages & Healing touch

PT

TENS

Biofeedback, Acupuncture

Pain Control (cont)




Pain Control (cont)

• Special Instructions – emphasize that the

child does not have to “be brave” or put up with

the pain

• After Care – don’t give more than instructed; if

pain medication is not working, call the doctor

• Activity – getting out of bed & moving around

helps the body recover post surgery, WHEN

APPROPRIATE




Sedation

Type of Sedation Chosen is Based on:

1. Child’s Age

2. Child’s Weight

3. Exam to be performed

*Can either be oral or IV




Nursing care

1. MONITORING

2. TOTAL CARE (HOLISTIC) – Airway,

Positioning, Comfort Level, I&O

3. SAFETY MEASURES – Risk of fall, injuries




Aids to the Assessment of Pain

in Children

Direct communication

Indirect – behavioral methods

Physiological status




Suggestions for Improvements

in Pediatric Pain Control

Greater use of local anesthetic techniques

Patient – controlled analgesia

Psychological techniques

Biofeedback and relaxation techniques




Visual analogue scale

Verbal Score

0 1-2-3 4-5-6 7-8 9-10

No

pain

Hurts

little

Hurts a lot Really hurts

a lot

Extremely

hurts

Visual Score

Observer

scoring Appears

pain free

Comfortable

except on

movement

Uncom-

fortable

Distressed

can be

comforted

Distressed

Pain - Skills

Documents

Transcript of Pain - Skills