5 pain management

8/3/2019 5 Pain Management

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PAIN MANAGEMENT

Geriatric Nursing

Jefferson C. Ramos, RMT, RN


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NOCICEPTION

the neural processes of encoding and

processing noxious stimuli

Noxious stimuli an actually or potentiallytissue damaging event



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PAIN

An unpleasant sensory and emotional

experience which we primarily associate with

tissue damage or describe in terms of such

damage, or both

Always subjective



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PATHOPHYSIOLOGY OF PAIN



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Pain

Activation of the

Central Nervous

System

at the Spinal CordLevel

Tissue DamageActivation of the

Peripheral Nervous

System

Transmission of the

Pain Signal to the

Brain

THE PAIN RESPONSE

Samad TA et al. Nature. 2001;410:471-5.



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THE PAIN PATHWAY

Pain PerceptionBrain

Dorsal Root

Ganglion

Dorsal Horn

Nociceptor

Spinal Cord

Gottschalk A et al.Am Fam Physician. 2001;63:1979-84.

Fields HL et al. Harrisons Principles of Internal Medicine. 1998:53-8.



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Nociceptive PainNeuropathic Pain

Mixed Pain

Idiopathic Pain

Phantom Limb Pain

CLASSIFICATION OF PAIN



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NOCICEPTIVE PAIN

pain that is proportionate to the degree of

actual tissue damage

Serves a protective function

2 types

Somatic

Visceral



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NEUROPATHIC PAIN

Also known as Neurogenic Pain

Disproportionate to the degree of tissue

damage



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MIXED PAIN

Neuropathic pain

Nociceptive pain

Nociceptive pain may coexist with acomponent of neuropathic pain



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IDIOPATHIC PAIN

No underlying lesion found yet, despite

investigation

Pain disproportionate to the degree of clinicallydiscernible tissue injury



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Examples

Peripheral

Post-herpetic neuralgia

Trigeminal neuralgia Diabetic peripheral neuropathy

Post-surgical neuropathy

Post-traumatic neuropathy

Central

Post-stroke pain

Commondescriptors2

Burning

Tingling Hypersensitivity to touch or cold

Examples

Pain due to inflammation

Limb pain after a fracture

Joint pain in osteoarthritis

Post-operative visceral pain

Commondescriptors2

Aching

Sharp

Throbbing

Examples

Low back pain withradiculopathy

Cervical

radiculopathy

Cancer pain

Carpal tunnel

syndrome

Mixed PainPain with

neuropathic and

nociceptive

components

Neuropathic PainPain initiated or caused by a

primary lesion or dysfunction

in the nervous system

(either peripheral orcentral nervous system)1

Nociceptive PainPain caused by injury to

body tissues

(musculoskeletal,

cutaneous or visceral)2

PRESENTATION ACROSS PAIN

STATES VARIES


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Pharmacologic

Non-pharmacologic

PAIN RELIEF



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PHARMACOLOGIC

INTERVENTIONSStep Approach (0 10 scale)

Step 1: Mild Pain (0 3)

Acetaminophen (< 4,000 mg/day) & NSAIDs

Step 2: Moderate Pain (4 6)

Low-dose, short-acting Opioids withAcetaminiphen & NSAIDs

Step 3: Severe Pain (7 10)Opioids not used in combination with Tylenol or

NSAIDs



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PHARMACOLOGIC

INTERVENTIONS Route of Choice: ORAL

If patient cannot swallow:

SL,S

ubQ, IV, Rectal, Topical Prescribe half a dose given to younger clients:

to prevent adverse reactions

start low & go slow



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PHARMACOLOGIC CONSIDERATIONS

Acetaminophen

Levels should not exceed 4,000/day

Well tolerated for long-term useFor musculoskeletal pain

NSAIDs

Use with caution in clients with ulcer

diseases, and CHF



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Opioids

Moderate to severe pain

Start with short half-life (morphine, hydromorphone,

oxycodone) then longer half-life (fentanyl patch,

methodone)

Constipating concurrent bowel program is

essentialStimulant and stool softener at start of therapy



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Morphine

gold standard

Most commonly used opioid

If sedation or confusion develops after a few days

of use, switch to another another opioid

Long-acting can only be used after a few days of

trial with short-acting morphine



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NON-PHARMACOLOGIC

INTERVENTIONS

Acupuncture

Tai Chi/Yoga

Guided imagery Biofeedback

Music therapy



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WONG-BAKER FACES PAIN RATING

SCALE



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Palliative Care

Hospice Care

CARE OF THE DYING



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PALLIATIVE CARE

Philosophy care for those persons with life-limiting illnesses who are not yet eligible forhospice care

Comprehensive management of the physical,psychological, social, spiritual and existential

needs of patients

Goal achieve the best possible quality of life for

patients and their families

Control of pain, psychological, social, and spiritual

problems



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HOSPICE CARE

Created in order to provide comfort and dignity

at end of life

Eligibility is based on a life expectancy of 6months or less if an illness runs its normal

course


5 pain management

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