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PAIN MANAGEMENT
Geriatric Nursing
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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
Jefferson C. Ramos, RMT, RN
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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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PHARMACOLOGIC CONSIDERATIONS
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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PHARMACOLOGIC CONSIDERATIONS
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
Jefferson C. Ramos, RMT, RN