essential pain management cc by-nc-sa: this work is licensed under a creative commons...
TRANSCRIPT
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ESSENTIAL PAIN MANAGEMENT
CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
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EPM Aims
1.To improve understanding of pain2.To teach a simple framework for managing
pain3.To reduce pain management barriers
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Workshop Plan 1
• Pain basics– What is pain?– Why should we treat pain?– Classification of pain– Physiology and pathology– Pain treatment– Barriers to treatment
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Workshop Plan 2
• Practical pain management– Case discussions– Overcoming barriers
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Untreated Pain
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Untreated Pain
• Often hidden (not recognized)• Causes a lot of suffering• But … can often be treated simply and cheaply
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Approach to Pain
• Recognize• Assess• Treat
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Approach to PainR
• Recognize– Does the patient have pain?– Do other people know the patient has pain?
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Approach to PainA
• Assess– How severe is the pain?– What type of pain is it?– Are there other factors?
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Approach to PainT
• Treat– What non-drug treatments can I use?– What drug treatments can I use?
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?
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IntroductionSummary
• At the end of this course, you will be able to:
1. Understand the importance of treating pain2. Recognize, assess and treat different types of
pain3. Identify and address barriers where you work
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What is Pain?
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What is Pain?Aims
• To define pain• To give examples of pain
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What is Pain?
• Group discussion
– Think of a patient / friend / relative who had pain.– How did the person describe the pain?– How was it treated?
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What is Pain?
• International Association for the Study of Pain– Pain is "an unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or described in terms of such damage”.
• What does this mean?• Are there any other definitions?
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What is Pain?
• Unpleasant• Emotions are important• The cause is not always visible
• “Pain is what the patient says hurts.”
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Is this man feeling pain?
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?
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What is Pain?Summary
• Pain is an unpleasant sensory and emotional experience
• Pain is what the patient says hurts!
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Why Should We Treat Pain?
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Why Should We Treat Pain?Aims
• To understand the reasons for treating pain• To understand the benefits for the patient,
family and society
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Case 1
• Mr T is a 29-year-old man with a fast growing mouth cancer that has spread to his bones. He has severe face pain. He is expected to die within 6 months and the surgeons do not want to operate. He is married with two children, aged 11 and 8
• Why should we treat his pain?
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Case 2
• Mrs G is a 54-year-old woman who has just had a laparotomy for bowel obstruction. You see her on the surgical ward soon after the operation. She appears to be in pain.
• Why should we treat her pain?
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Why Pain Matters
• For the patient– Physical • Suffering, poor sleep, decreased appetite• Medical complications
(e.g. heart attack, pneumonia)– Psychological• Depression, anxiety
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Why Pain Matters
• For the family– Unable to function as part of the family
(e.g. as a father / mother)– Lost income
• For society– Greater health costs
(e.g. delayed hospital discharge)– Unable to contribute to the community
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Painful SCC (xeroderma pigmentosum)
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Advantages of Treating Pain
• For the patient– Fewer physical and psychological problems– Greater dignity (esp. cancer pain)
• For the family– Able to function as part of the family– Able to provide for family
• For society– Lower health costs
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?
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Why Should We Treat Pain?Summary
• Treating pain is the “humane” thing to do!• Treating pain has many benefits– For the patient– For the family– For society
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Classification of Pain
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Classification of PainAims
• To classify types of pain• To understand that treatment depends on the
pain type
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Classification of Pain
• Not all pain is the same!• Three main questions:
1. How long has the patient had pain?2. What is the cause?3. What is the pain mechanism?
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Classification of Pain
Duration AcuteChronicAcute on chronic
Cause CancerNon-cancer
Mechanism Nociceptive (physiological)Neuropathic (pathological)
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Acute versus Chronic
• Acute– Pain of recent onset and probable limited duration
• Chronic– Pain persisting beyond healing of injury– Often no identifiable cause– (Pain lasting for more than 3 months)
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Cancer versus Non-Cancer
• Cancer pain– Progressive– May be mixture of acute and chronic
• Non-cancer pain– Many different causes– Acute or chronic
Can you give examples?
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Invasive oral cancer
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Nociceptive Pain
• Obvious tissue injury or illness• “Physiological pain”• Description– Sharp ± dull– Well localised
Can you give examples?
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Neuropathic Pain
• Nervous system damage or abnormality• “Pathological pain”• Tissue injury may not be obvious• Description– Burning, shooting ± numbness, pins and needles– Not well localised
Can you give examples?
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Examples of Pain Types
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Acute Non-Cancer Pain
• Examples– Fracture, appendicitis
• Symptom of tissue injury or illness• Useful• Usually nociceptive• Occasionally neuropathic (e.g. sciatica)
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Chronic Non-Cancer Pain
• Examples– Headache, back pain
• Usually no obvious injury• Not useful• Complex, may be mixed nociceptive and
neuropathic• Does not respond to usual drug treatment
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Cancer Pain
• Examples– Oral cancer, uterine cervical cancer
• Features of acute and chronic pain– May be acute on chronic
• Often mixed nociceptive and neuropathic pain• Usually gets worse over time if untreated
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?
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Classification of PainSummary
• Deciding on the type of pain is important– Acute / chronic– Cancer / non-cancer– Nociceptive / neuropathic
• Treatment depends on the pain type
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Pain Physiology and Pathology
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Pain Physiology and PathologyAims
• To understand normal pain physiology– Pain pathway – Factors affecting the pain signal
• To understand the basis of neuropathic pain(pathology)
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Nociception and Pain
• Nociception– How pain signals get from the site of injury to the
brain• Pain perception– How we “feel” pain
• Nociception is not the same as pain!
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Is this man feeling pain?
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PainWhat the patient says hurts.
What must be treated.
Injury
Beliefs/concerns about pain
Psychol. factorsanxiety/anger/depression
Cultural issuesLanguage, expectations
Other illnesses
Coping strategies
Social factorse.g. family, work
Nociception is not the same as pain!
Modified from Analgesic Expert Group. Therapeutic Guidelines 2007
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Physiology
• 4 steps:– Periphery– Spinal cord– Brain– Modulation
• We will look at each step
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Periphery
• Tissue injury• Release of chemicals• Stimulation of pain
receptors (nociceptors)
• Signal travels in Aδ or C nerve to spinal cord
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Spinal Cord
• Dorsal horn is the “first relay station”
• Aδ or C nerve synapses (connects) with second nerve
• Second nerve travels up opposite side of spinal cord
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Brain• Thalamus is the
“second relay station”• Connections to many
parts of the brain– Cortex– Limbic system– Brainstem
• Pain perception occurs in the cortex
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Modulation
• Descending pathway from brain to dorsal horn
• Usually decreases pain signal
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Why is pain physiology important?
• Many factors affect how we “feel” pain.– Psychological factors are very important.
• Different treatments work on different parts of the pathway.– More than one treatment may be needed.
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Neuropathic Pain
• “Pathological” pain• Abnormality of:– Peripheral nerves– Spinal cord or brain
• Needs to be treated differently
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Neuropathic Pain
• Peripheral– Damaged nerves (e.g. trauma, diabetes)– Abnormal firing of nerves
• Central– Changes in “wiring”– Abnormal firing– Loss of modulation
How do patients describe their pain?
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?
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Pain Physiology and PathologySummary
• Many factors affect how we “feel” pain.• Different treatments work on different parts of
the pain pathway.• Neuropathic pain is “pathological” pain and
needs to be treated differently.
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Pain Treatment Overview
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Pain Treatment OverviewAims
• To discuss non-drug and drug treatments where you work
• To classify pain treatments
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Pain Treatment
• Group discussion
– What non-drug treatments are available where you work?
– What drug treatments are available where you work?
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Non-Drug Treatments
• Physical– Rest, ice, compression, elevation– Surgery– Acupuncture, massage, physiotherapy
• Psychological– Explanation– Reassurance– Counseling
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Placebo Treatment
• Group discussion
– What is placebo?– Is it helpful or unhelpful?
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Placebo Treatment
• Psychological factors are important.• If a placebo treatment works, this does not
mean the patient did not have pain or was telling lies!
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Drug Classification
• Simple analgesics– Paracetamol (acetaminophen)– Anti-inflammatory medicines– Aspirin, ibuprofen
• Opioids– Mild– Codeine
– Strong–Morphine, pethidine
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Drug Classification
• Other analgesics– Amitriptyline– Carbamazepine– Local anaesthetics– Ketamine– Tramadol– Clonidine– Entonox (N2O/O2)
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Treatments - Periphery
• Non-drug treatments– Rest, ice,
compression, elevation
• Anti-inflammatory medicines
• Local anaesthetics
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Treatments - Spinal Cord
• Non-drug treatments– Acupuncture,
massage
• Local anaesthetics• Opioids• Ketamine
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Treatments - Brain
• Non-drug treatments– Psychological
• Drug treatments– Paracetamol– Opioids– Amitriptyline– Clonidine
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?
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Pain Treatment OverviewSummary
• Both non-drug and drug treatments are important.
• Different treatments work on different parts of the pain pathway.
• Analgesics can be classified into simple analgesics, opioids and other drugs.
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Pain Drugs
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Pain DrugsAims
• To summarise the major advantages and disadvantages of important drugs
• To discuss drug addiction
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Paracetamol (Acetaminophen)
• Advantages– Cheap, safe– Can be given orally or rectally– Good for:• Mild pain (by itself)• Mod-severe pain (with other drugs)
• Disadvantages– Liver damage in overdose
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Anti-Inflammatory Medicines
• Aspirin, ibuprofen• Advantages– Cheap, generally safe– Good for nociceptive pain• Best given regularly with paracetamol
• Disadvantages– Gastrointestinal and renal side effects
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Codeine
• Advantages– Cheap, safe– Good for mild-moderate acute nociceptive pain• Best given regularly with paracetamol
• Disadvantages– Constipation– Not good for chronic pain– Myths about addiction
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Opioids and Addiction
• Group discussion
– Do opioids cause addiction?– Would this stop you giving opioids to a patient
who has pain?
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Opioids and Addiction
• Pain is sometimes poorly treated because of concerns about addiction.
• Addiction is very rare in:– Acute pain– Cancer pain
• Addiction is more likely in chronic non-cancer pain.
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Morphine 1
• Advantages– Cheap, generally safe– Can be given orally, IV, IM, SC– Effective if given regularly– Good for:• Mod-severe acute nociceptive pain (e.g. post-op pain)• Chronic cancer pain
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Morphine 2
• Disadvantages– Constipation– Respiratory depression in high dose– Myths about addiction– Regulations about use
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Pethidine
• Advantages– Cheap– Can be given orally, IV, IM– Can be good for severe acute nociceptive pain
• Disadvantages– Must be given more often than morphine– Breakdown product (norpethidine) can cause
convulsions– Not good for chronic pain
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Amitriptyline• Increases descending inhibitory signals• Advantages– Cheap, safe in low dose– Good for neuropathic pain– Also treats depression, poor sleep
• Disadvantages– Anti-cholinergic side effects (glaucoma, urinary
retention)
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Anti-Epileptic Drugs
• Carbamazepine (Tegretol)• Sodium valproate (Epilim)• “Membrane stabilisers”– Reduce abnormal firing of nerves
• Good for neuropathic pain
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Entonox (N2O/O2)
• Advantages– Fast onset / fast offset– Good for:• Labour pains• Short painful procedures (e.g. dressing changes)
• Disadvantages– Need cylinder and mask
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Drug TreatmentsAcute noci mild
Acute nocisevere
Acute neuro
Chronic non-cancer
Chronic cancer
Paracetamol +++ ++ + + +NSAIMs ++ ++ + ± ±Codeine ++ + ±Morphine +++ ++ - +++Amitriptyline - - ++ ++ ++Carbamazepine - - ++ + +
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?
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Pain DrugsSummary
• Pain can be treated with relatively cheap and safe drugs.
• Opioid addiction is rare in acute or cancer pain.
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Barriers to Pain Treatment
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Barriers to Pain TreatmentAims
• To understand some of the reasons why pain may not be treated adequately
• To think about some solutions
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Barriers to Pain Treatment
• Group Discussion– Pain is often not treated as well as it could be.
What are some of the reasons for this?• Patients• Drugs• Health workers• System issues
– What are the main barriers where you work?– What can be done about these barriers?
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?
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Barriers to Pain TreatmentSummary
• There are many reasons why pain is not treated as well as it could be.
• Important barriers are attitudes, lack of staff and lack of drugs.
• How can YOU overcome these barriers where you work?
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Basic Approach to Pain Management
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Basic ApproachAims
• To give a simple framework for managing patients with pain
• To illustrate the use of this framework for different types of pain
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Approach to Pain
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Approach to Pain
• Recognize• Assess• Treat
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Approach to PainRecognize
• Does the patient have pain?– Ask– Look (frowning, moving easily, sweating?)
• Do other people know the patient has pain?– Other health workers– Patient’s family
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Approach to PainAssess
• Measure the severity– What is the pain score?• At rest• With movement
– How is the pain affecting the patient?• Can the patient move, cough?• Can the patient work?
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Measuring Pain
• Helps guide treatment• Methods– Verbal (e.g. mild, moderate, severe)– Numerical• 0 (no pain) to 10 (worst pain imaginable)
– Visual• Visual Analogue Scale (VAS)• “Faces” pain scale
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Visual Analogue Scale
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Faces Pain Scale
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Approach to PainAssess
• Make a pain diagnosis!– Acute or chronic?– Cancer or non-cancer?– Nociceptive or neuropathic?• Look for neuropathic features:
– Burning or shooting pain– Phantom limb pain– Other features (pins and needles, numbness)
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Approach to PainAssess
• Are there other factors?– Physical factors (other illnesses)– Psychological and social factors• Anger, anxiety, depression• Lack of social supports
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Approach to PainTreat
• Non-Drug Treatments– RICE• Rest, ice, compression, elevation of injuries
– Nursing care– Surgery, acupuncture, massage etc– Psychological• Explanation and reassurance• Input from social worker / pastor
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Approach to PainTreat
• Drug Treatments – Nociceptive Pain– Mild• Paracetamol (± NSAIM)
– Moderate• Paracetamol (± NSAIM) + codeine
– Severe• Paracetamol (± NSAIM) + morphine
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Approach to PainTreat
• Drug Treatments – Neuropathic Pain– Traditional drugs may not be as useful– Use other drugs early• Amitriptyline• Carbamazepine
• Don’t forget non-drug treatments
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Approach to PainExample 1
• Mr D is a 32-year-old man who caught his right hand in a piece of machinery at work and now has a large open wound with several broken bones.
• How would you manage his pain?
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Approach to PainExample 2
• Jon is an 8-year-old boy with probable appendicitis. He is in the Emergency Department and will have to wait several hours for an operation.
• How would you manage his pain?
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Approach to PainExample 3
• Miss B is a 24-year-old woman who has a two year history of severe headache. She was seen at the regional hospital 6 months ago and was told that there was “nothing wrong inside her head” and she was going to have to live with the pain.
• How would you manage her pain?
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Approach to PainExample 4
• Maria is a 12-year-old girl with burns to her chest and abdomen. She needs dressing changes every 2-3 days.
• How would you manage her pain?
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?
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Approach to PainSummary
• Recognize• Assess– Measure severity– Make a pain diagnosis– Consider other factors
• Treat– Non-drug treatments– Drug treatments