Pain Management

Pain Management in School-Aged Children

• Growing pains are real and should not be ignored.
• Children are germ factories, increasing their risk of illness and associated pain (body aches, headaches, migraines).
• Migraines can be undiagnosed in young children.

Pain as a Symptom

• Pain is a symptom, not a disorder.
• Treating pain blindly without addressing the underlying cause is not a cure. (e.g., Morphine can mask pain but doesn't address the source).
• Children may have difficulty expressing pain, requiring careful assessment to determine the cause.

Pain and Medical Procedures

• Children with recurrent medical procedures (e.g., open-heart surgeries) experience real pain that must be recognized and anticipated.

Nurses and Pain

• Nurses often cause pain (e.g., pulling needles, setting fractures). This can have an emotional impact.

Pain: The Fifth Vital Sign

• Pain should be assessed regularly.
• Non-pharmacological pain management (e.g., distraction) can be effective, especially with pediatric patients.
• Emotional aspects of pain: Anticipation of pain can create anxiety and fear.

Sleep and Pain

• Acute pain can disrupt sleep.
• Chronic pain may become more manageable, allowing for sleep in certain positions or with medication.
• Sleep is important for healing, so pain control is necessary to promote sleep.

Family Involvement

• Parents know their children best and can provide valuable insights into their child's pain experience.
• Important to consider helicopter parents.
• Cultural considerations:
  • Matriarchal families: The matriarch's opinion on the patient's pain may heavily influence the patient's perception.
  • Arab culture: Communication and care decisions may need to involve the husband or male family members, even with female patients.
    • There can be faith restrictions where a male nurse cant touch a female patient.

Cognitive Behavioral Therapy (CBT)

• CBT is an up-and-coming approach to pain management that can reduce reliance on drugs.

Pain in the Elderly

• Elderly patients may underreport pain because they don't want to bother anyone and fear addiction to narcotics due to the opioid epidemic.
• Sensitivity to pain does not change with aging, except in uncontrolled diabetics due to nerve damage (neuropathy), often starting in the feet.

Medication Considerations in the Elderly

• Beers Criteria: Pharmacists use this to assess medications in elderly patients that could cause adverse effects.
• Drug clearance: Liver function declines with age, affecting drug metabolism and clearance, potentially leading to drug accumulation and toxicity.
• Example: Frequent administration of morphine may lead to compounding adverse effects due to decreased liver function.

Pain Examples

• Postherpetic neuralgia: Pain following a shingles outbreak (herpes virus).
• Shingles: A form of herpes virus that can be worse in adults who didn't have chickenpox as children.

Stigmas with the Elderly

• The elderly stigmas of not wanting to take pain meds even when they need them.

Interventions: Pain Assessment

• Frequency: At a minimum, every four hours, but ideally every hour as part of hourly rounding.
• Hourly rounding is important. Codes often called during shift change after long periods of no staff being present.
• Should include behavioral and non-behavioral indicators.
• Should not wake people up when they're sleeping.

Non-Pharmacologic Interventions

• Avoid being too quick to jump to drugs.
• Multimodal approach needed.
• Distraction: Playing games, watching TV (patient's choice, not the nurse's).
• PT/OT: Premedicate patients before physical therapy to help them participate comfortably.
• Guided imagery: Requires patient willingness and can be time-consuming. Can be supplemented with YouTube videos.
• Deep breathing exercises: Visualizing pain leaving the body.
• Acupuncture/acupressure, massage, hot and cold applications.

Massage

• Be mindful of inappropriate behavior and sexual harassment, document appropriately.

Multimodal Analgesia

• Combines pharmacological (NSAIDs, opioids) and non-pharmacological (relaxation, regional analgesia) approaches.
• Benefits: Lower opioid doses, reducing adverse effects.
• Goal: To transition patients off opioids before discharge, using alternative pain management methods.

Drug Therapy

• Premedicate: Administer pain medication 20 minutes before a procedure (PO).
• Drug options:
  • Non-opioids: NSAIDs, Tylenol.
  • Opioids.
  • Adjuvants: Drugs for other conditions that also help with pain (e.g., gabapentin for neuropathic pain).

WHO Analgesic Ladder

• Guideline for treating pain, not a strict law.
• Start low (non-opioids) and progressively advance until pain is controlled, then go backwards.
• Trial and error approach.
• Avoid opioids in patients with altered mental status due to potential CNS depression and interference with neurological assessments.

Non-Opioid Analgesics

• Acetaminophen (Tylenol): Monitor liver function. Daily Limits:
  • Healthy individual: $4000$ mg.
  • Elderly: $3000$ mg.
  • Alcoholics and Non-Alcoholics: $2000$ mg.
• NSAIDs: Non-selective, block COX-1 and COX-2: Patient specific for drug prescriptions.

COX-1 and COX-2

• COX-1: Mucosal lining in stomach, antiplatelet effects. Blocking can cause ulcers and bleeding.
• COX-2: Pain, fever. Selectively blocking only Cox two we are not inhibiting platelet aggregation on COX-one. Risk for MI or history of MI, this is absolutely country in the game.
• Aspirin: Has irreversible and antiplatelet effects and NSAIDs reversible.

NSAIDs Considerations

• Platelet Inhibition: Stop taking aspirin one week before elective surgery because platelets live about a week.
• Risk of ulcers and hypertension.

Renal-Induced Hypertension

• Prostaglandins: NSAIDs block these, which are needed for mucosal lining in your stomach and to open afferent arteriole for the kidney.
• Renal Induced Hypertension: Prostaglandins are needed to open your afferent arteriole of the kidney. If constricted the afferent arteriole to the kidney, we have reduced blood flow to the kidney, and the efferent aren't erial says release the renin.
• Constricting the afferent arteriole leads to reduced blood flow. The efferent arteriole then releases renin, activating the RAS cascade and causing hypertension.
• Celebrex: Is the only selective COX-2 inhibitor on the market. Contraindicated in patients with risk of MI or history of MI.
• Toradol: Prescription-grade NSAID with a 5-day limit. Has a five day limit because because it's nephrotoxic.

Opioids

• Bind to mu receptors.
• No ceiling dose; the maximum dose is limited by adverse effects (respiratory depression).
• Start low and go slow, especially with the elderly.

Opioid Naive vs. Opioid Tolerant

• Opioid naive: Someone who does not take opioids regularly, requiring lower doses.
• Opioid tolerant: Someone who uses drugs recreationally or for chronic pain management, requiring higher doses.
• Important to get a good patient history.

Opioid Conversions

• Math is involved with math.
• Ten milligram IV MORPHINE = 30 milligrams P O.
• Make sure when ordering meds and switching between them they are correct
• Conversion chart is used to convert between IV and PO doses; it hangs in every med room.

Methadone

• It is used to come some people off of drugs. Great. Specifically heroin. Yes. This is the drug. Methadone is used for getting people off heroin, and it's just as addictive as heroin

Patient-Controlled Analgesia (PCA)

• The patient must be cognitively intact.
• Patient controlled: the patient must push the button themselves.
• Two-nurse sign-off is required to set up.
• Basal rate: Continuous infusion (e.g., morphine PCA basal rate $0.2$ mg/hour).
• Demand rate: Bolus dose when the patient pushes the button (e.g., demand rate push button, $0.2$ mg with 20-minute lockout).
  Can be administered at a nasal route.
• Chart demands and amount administered to know if medication is working.

Interspinal Analgesia

• Epidurals: Most common in labor and delivery.
• Placement by anesthesiologist, management by anesthesiologist.
• Intermittent or continuous boluses.

Adverse effects

• Narcan: Blocks opioids.
• Opioids: Have a longer half life than narcan, give another dose or a consistent drip.
• Lots of other adjuvants used for pain.
• Cannabis: Not given on the hospital.
• Ketamine: a hallucigetic that actually does not relieve any pain but just acts as a hallucinogen.

Education is Important

• Explain why drugs are being given and how to report changes.
• Train people to be able to use these scales.
• Teach people they're not gonna become addicts.
• Make sure to take pain meds: " You're not impressing me, sir Graham."
• Identify acceptable functional level of pain.
• We want to identify how they want to measure levels of pain.