Pain Management

Med-Surg

Interesting Facts on Pain

• Unrelieved pain can decrease the quality of life more than any other single health-
  related problem.

• Pain is the leading cause of disability.
  — Chronic non-cancer pain is the most common cause of long-term disability.

• Pain is the most common reason people seek medical care.

• It is the #1 reason people take medication.

• Pain is inadequately treated in all health care settings

How does pain affect us

• Physically

• Mentally

• Economically

• Socially

• Spiritually

• Increased length ofhospital stays, ADLs, sleeplessness, hopelessness, O2 demand, productivity

Pain

• is an unpleasant sensory and emotional experience associated with actual or
  potential tissue damage.

• The most reliable indicator of pain is the patient’s self-report.

• Categories of Pain Include:
  — Nociceptive pain.
  — Neuropathic pain.
  — Acute pain.
  ▪ Procedural pain.
  — Chronic pain.
  ▪ Cancer pain

Nociceptive Pain

• Is the result of actual or potential tissue damage or inflammation.
  ▪ Somatic pain: surface level pain
  ▪ Visceral pain: pain to organs (inside)

• Nociceptive pain transmission is identified by four processes:
  ▪ Transduction
  ▪ Transmission
  ▪ Perception
  ▪ Modulatio

Transduction Nocicieptive Pain

• When injury occurs, neurons are activated

• the biological process where specialized nerve endings turn physical harm into an electrical signal

Transmission Nocicieptive Pain

• A-delta fibers are faster, milenated, intermetate pain

• C fibers are slower, unmilenated, continous throbbing pain

— travels up the spinal cord to the brain

• specialized nerve endings detect, convert, and transmit noxious (harmful) stimuli to the brain

Perception Nocicieptive Pain

• The conscious awareness of pain.

• the final stage in the nervous system where sensory signals reach the brain, turning into a conscious, subjective experience of hurt

Modulation Nocicieptive Pain

• Descending signals can block or partially block the transmission of pain.

• the nervous system's process of turning pain signals up or down at the spinal cord and brain before you fully feel them

Gate Control Theory

• According to this theory a gating mechanism exists in the spinal cord.

• when gate is closed, pain cannot travel to brain and back down to tell you are in pain

Neuropathic Pain

• Pain that occurs from damage or dysfunction of the Peripheral Nervous System
  (PNS) and/or the Central Nervous system (CNS).

• Neuropathic pain may occur without Tissue Damage or Inflammation

• How do we assess Neuropathic Pain?

- LANSS pain scale: Leeds Assessment of Neutopathic Signs & Symptoms

Acute pain

• Almost everyone experiences acute pain at some point.

• Typically localized to an affected area.

• Has a sudden onset but is temporary or short lived.

• Can develop into chronic pain.

Chronic Pain

• Pain that lasts or recurs for anindefinite period, usually more than 3 months.

• The onset is gradual

Nursing Responsibilities for pain

• Pain is NOT just a number.

• Comprehensive Pain Assessment.

• Noticing and recognizing cues.

• Subjective and objective assessment findings.

• Educate the patient and family.

• Provide Interventions
  — Pharmacologic
  — Non-Pharmacologic

“SOCRATES” Comprehensive Pain Assessment

• Site: where is the pain?

• Onset: what were they doing when the pain started?

• Character” what does the pain feel like?

• Radiates: does the pain go anywhere else?

• Associated symptims: nausea vomiting, etc

• Time/duration: how long have they had the pain?

• Exacerbating/relieving factors: does anything make the pain better or worse

• Severity: obtain the initial pain score

Pain Scales

• Numeric Rating Scale (NRS) - from 0-10 with “0” being no pain and “10” being the worst pain

• Verbal Descriptor Scale (VDS) - Uses different words or phrases
  to describe pain “Mild, Moderate, Severe, Worst Pain

• Wong-Baker FACES Pain Rating Scale: used for ages 3 years and up, you have the patient point to the face on the scale to assist in rating their pain

Pain Subjective Assessment Data

• Location

• Intensity

• Quality

• Onset & Duration

• Relieving & aggravating factors

• Effect of pain on function & quality of life

• Comfort-function outcomes

Pain Objective Assessment Data

• Consider patient’s condition or exposure to procedure.

• Observe behavioral signs

• Evaluate physiologic indicators

• Conduct analgesic trial

Interventions: Multimodal Analgesia

• Using two or more classes of analgesics or interventions to target different pain
  mechanisms in PNS/CNS
  — Non-opioid analgesics
  — Opioid analgesics
  — Adjuvant analgesics

• Consider the routes of administration.

• Preemptive analgesia.

• Around the Clock (ATC) Dosing

• Patient Controlled Analgesia (PCA)

Non-Opioid Analgesics

Acetaminophen

• Works on the CNS

• Analgesic & Antipyretic

• HEPATOTOXIC (liver)

• Max dose of 4000 mg/day

• Max dose for older adults is 3000 mg/day

IV Acetaminophen

• Typically 15 minute infusion, comes in glass bottle- “vented” tubing
  required

Nonsteroidal Anti-inflammatory Drugs (NSAIDS)

• Works in the PNS

• Analgesic, antipyretic, & anti-inflammatory

• NEPHROTOXIC (kidneys)

• Inhibits platelet aggregation

• Most common side effect: gastric irritation & ulcers.

Common NSAIDS

• Ibuprofen, Naproxen, celecoxib.

• IV: Toradol (Ketorolac)

• Topical: Voltaren (diclofenac) gel

Opioid Naive

• Have not recently taken opioids on a regular basis to become tolerant to
  the effects of the opioid.

Opioid Tolerant

• Taken enough opioids for a long enough period of time to develop tolerance to
  the effects

Older Adults & Opioids

Patients older than 65:

• Slower Metabolism

• Slower Absorption

• Distribution Changes

Pure Opioid Agonists

• The first line choice for moderate to severe pain

• Has no ceiling.(no max dose)

• Morphine- the gold standard

• Dilaudid (Hydromorphone)- Immediate Release/ Extended Release

• ALERT: approximately 5x STRONGER than Morphine

• Fentanyl (shorter duration)-Used more with end-organ failure

• Fentanyl Transdermal Patches- absorption can be affected by heat

— Dispose of properly

— Can take 12-24 hours to start being effective

Agonist-Antagonist (Miixed) Opioids

• Agonist- produces analgesia

• Antagonist- lowers the risk of severe side effects
  — Nubain (Nalbuphine hydrochloride)
  — Stadol (Butorphanol)

Opioid Administration

Routes of administration:

• PO, IM, IV, SL, Transdermal

• Titrations

Dose range orders

• Hospitals MUST have policies with these orders

Opioid Side Effects

• Opioid Induced Constipation (OIC)

• Nausea/Vomiting

• Pruritus (itching)

• Sedation

• Respiratory Depression

Adjuvants in Pain Management

• Adjuvants have a primary indication/use other than for pain.
  — Used in conjunction with opioids.

• Anticonvulsants- Gabapentin & Pregabalin

• Antidepressants- Tricyclic antidepressants; Serotonin and norepinephrine reuptake
  inhibitors (SNRIs).

• Muscle Relaxants- Methocarbamol, Cyclobenzaprine, Baclofen, Tizanidine.

Other Pharamcologic Treatments for Pain

• Spinal Analgesia:
  ▪ Epidural
  ▪ Morphine, Dilaudid, Fentanyl

• Peripheral Nerve Blocks:
  ▪ Anesthetic to target specific nerve

• Local Anesthetic:
  ▪ Injectable or topical

• Sustained Release Anesthetics

Pasero Opioid-Induced Sedation Scale (Poss) with Interventions

• S=sleep, easy to around; acceptable, no action necessary, may increase opiod dose if needed

• 1 = awake alert

- Acceptable; no action necessary, may increase opiod dose if needed

• 2 = slightly drowsy; easily aroused

- Acceptable; no action necessary, may increase opiod dose if needed

• 3 = frequently drowsy, arousable, drifts off to sleep during conversation

- Unacceptable; monitor resp. status & sedation level closely until sedation level is stable at less than 3 & resp.status is satisfactory, notify provider consider reducing dose & adding non-opioid; ask pt to take deep breaths every 15-30 mins

• 4 = somnolent, minimal or no response to physical or verbal stimuli

- Unacceptable, stop opioid (consider naloxone), call rapid response team, stay with pt, stimulate & support respirations

Tools for monitorig patient on opioids

• Capnography: Measures exhaled Carbon Dioxide (EtCO2).

• Pulse Oximetry: Measures Oxygen Saturation (O2 SAT).

Narcan (Naloxone)

• is a Reversal agents for Opioids

• Can be given IV, IM, or Intranasal.

• Typical dose is 0.4-0.8 mg

• IV dose may be 0.4-2 mg every 2-3 minutes up to a max dose of 10 mg

• Slowly TITRATE until effective

Phyiscal Dependence, Tolerance, & Addiction

• Physical dependence: response occurs with repeat administration of opioid for
  several days.

• Tolerance: response that occurs with regular administration of opioids & consists of
  a decrease in one or more effects of opioids.

• Addiction/Opioid Use Disorder: Chronic neurologic and biologic disease

The Opioid Epidemic: The evolving role of nursing

• Opioid dependence and associated drug-related overdoses and deaths
  are serious public health problems in the United States.

• Registered nurses are on the front lines of addressing the epidemic by educating patients to understand the risks and benefits of pain treatment options, to include
  opioids, and by recognizing those at risk for substance use disorder.” (ANA, 2018)

The Ethical Responsibility to Manage Pain and the Suffering It Causes

Statement of ANA Position
American Nurses Association (ANA) believes:

• Nurses have an ethical responsibility to relieve pain and the suffering it causes

• Nurses should provide individualized nursing interventions

• The nursing process should guide the nurse’s actions to improve pain management

• Multimodal and interprofessional approaches are necessary to achieve pain relief

• Pain management modalities should be informed by evidence

• Nurses must advocate for policies to assure access to all effective modalities

• Nurse leadership is necessary for society to appropriately address the opioid epidemic

Complementary Alternative Medicine Intergrative Modalities

• Non-pharmacologic interventions to manage pain and enhance
  comfort

4 Categories:

• Body-based (physical) modalities
  - Acupuncture, massage, chiropractic, physical therapy

• Mind-Body Therapies (cognitive-behavioral)
  - Humor, Imagery, Distraction, Meditation, Prayer, Yoga

• Biologically Based Therapies
  - Herbs, Vitamins

• Energy Therapies
  - Reiki, Healing Touch, Therapeutic, Magnets

Body-based (physical) modalities Alternative Medicine for pain

• Physical/occupational therapy

• Aquatherapy

• Acupuncture

• Low impact exercise

• Yoga

• Heat or cold therapy

• Massage

• Transcutaneous electric nerve stimulation (TENS)

Acupuncture

• Placement of Small Needles at Specific Points on the Body

• Restores & Balances Energy Pathway

Massage Therapy

• Application of Soft Tissue Manipulation Techniques

• Increases Circulation

Reiki

• Healing Technique Based on the Principle that the Therapist can Channel Energy into the
  Patient by Means of Touch

• “Laying of Hands”

• “Energy Healing”

• Assess for Safety, Potential Interactions, Adverse Reactions

• Educate on the Importance of Utilizing Qualified Practitioners

Medical Marijuana

• Over 31 US jurisdictions (including the District of Columbia), Guam, and Puerto Rico passed legislation legalizing cannabis for medical use. Research using cannabis is also prohibited.

• In the U.S., cannabis is a Schedule I Controlled Substance. Therefore, medical providers cannot prescribe cannabis & pharmacies cannot dispense cannabis.

• However, jurisdiction statutes and rules provide for the manufacture, distribution, and use of cannabis for medical purposes

Medical Marijuana Programs (MMP)

• Defined & described within the statute of the specific jurisdiction. Rules may be located through the jurisdiction’s Dept of Health.

• A health care provider does not prescribe cannabis.

• The MMP will specify qualifying conditions & certifying process
  • If qualifying condition is certified by states MMP, patient registers and can obtain
  cannabis from a jurisdiction authorized cannabis dispensary.

• Must be aware of medical marijuana administration concerns – nurse may not
  administer unless specifically authorized by jurisdiction law.

• Approach patient without judgment regarding the patient’s choice of treatment

NCSBN Medical Marijuana education for Nursing students

• Have an understanding of cannabis pharmacology & research associated with it.
  Current evidence exists for cannabis use (in Texas) for:
  — epilepsy
  — seizure disorder
  — multiple sclerosis
  — spasticity
  — amyotrophic lateral sclerosis
  — autism
  — cancer
  — post-traumatic stress disorder
  — an incurable neurodegenerative disease

• Adverse effects of cannabis influenced by patient’s condition & current medications

• Variable effects of cannabis dependent on type of product & route of administration

• Risks to adolescents, fertility, neonates

• Safety considerations: administration only by certified patient or designated caregiver; storage considerations; disposal

Home Care Management Patient & Family Education

• Education:
  — Medications:
  — What medication?
  — When can it be administered?
  — ATC dosing or do they have to ask for the medicine?
  — Side Effects

• How to Prevent Constipation

• Safety

• Correct dosing and intervals