Basic Pain ManagementBasic Pain Management

AimTo increase awareness

of pain and pain management strategies

Objectives

Will discuss drugs used & side effects

To list some pain relief measures used in the hospital environment

Understand & discuss role in promoting

comfort

Appreciate the adverse effects of untreated pain

To discuss how pain is experienced

Introduction into Patient Controlled Analgesia and Epidural Infusions

Categories of Pain• Acute Pain is described as :Has a predictable end, lasts less than 3 months

• Chronic Pain is described as :Prolonged, lasts longer than 3 months.(McCaffery & Beebe 1994)

• Cancer Pain

What is Pain?

PAIN IS…PAIN IS…

What is Pain?

• Pain is felt by all humans beings on occasions

• It is a defence mechanism and has a useful function

• Unrelieved pain once this initial warning is received is not useful

Physical Aspects of untreated pain

–Cardiovascular –Respiratory–Mobility–Gastrointestinal

Psychological Aspects of pain–Anxiety–Lack of sleep–Withdrawal–Anger–Depression–Non compliance

The Experience of Pain• Pain perception• Sensory nerves• Transmission -slow & fast

fibres– A fibres - Early sharp pain – C fibres - Later dull pain– Processing of information

• Reflexes• Autonomic responses

– Central Control• Ascending & descending

controls

Skin Sensory Receptors

Efferent neuron

Sensation & Response

Nurses role in pain management

Identification

Evaluation

Intervention

Assessment

The Importance of Pain Assessment• Pain assessment forms the basis for effective pain

management.

• It determines the appropriate method of pain relief necessary for each individual patient.

• It allows for ongoing assessment and early detection of complications.

• Re-assessment is an effective tool for nursing interventions.

• Assessment of pain prior to clinical interventions,e.g physio, and consequent administration of analgesia, will promote maximum effectiveness of interventions.

ABC’s of pain assessment• A• Ask about pain regularly Assess pain systematically• B• Believe the patient & family in their reports of pain and what relieves

it• C• Choose pain control options appropriate for the patient• D• Deliver interventions in a timely, logical, coordinated fashion• E• Empower patients to be involved in planning their pain relief

CLINICAL FEATURES OF PAIN• ONSET

GRADUAL, SUDDEN• MAIN SITE

WOUND PAIN, CHEST, LEGS• RADIATION

PAIN MAY RADIATE TO AREAS DISTANT TO THE ORIGINAL PAIN.• CHARACTER

COLICKY, KNIFE-LIKE, BURNING, CONSTANT.• SEVERITY

NO PAIN, MILD, MODERATE, SEVERE , WORST IMAGINABLE.• DURATION

MINUTES, HOURS, DAYS, WEEKS.• AGGRAVATING FACTORS

PLUERETIC CHEST PAIN WORSE ON COUGHING DEEP BREATHING• ANGINA ASSOCIATED WITH EXERCISE• RELIEVING FACTORS

POSTURE, REST , HEAT, COLD• PREVIOUS HISTORY

OF THIS OR SIMILAR PAIN

ASSESSMENT

• PAIN ASSESSMENT SHOULD ALWAYS BE CARRIED OUT ON MOVEMENT NOT AT REST

• ASK THE PATIENT TO TAKE A DEEP BREATH / MOVE LIMB THEN ASSESS THE PAIN

• REASSESS A REASONABLE LENGTH OF TIME FOLLOWING ADMINISTRATION OF ANALGESIA– NO IMPROVEMENT, SLIGHT IMPROVEMENT, GREAT

IMPROVEMENT, NO PAIN.

• IF PAIN PERSISTS REPEAT ANALGESIA AND/OR SEEK ADVICE.

PATIENT’S PERCEPTION• THE NURSE SHOULD NOT ATTEMPT TO MAKE

ASSUMPTIONS ON THE PATIENTS BEHALF

• SEVERITY OF PAIN CAN ONLY BE REPORTED BY THE PATIENT

• IT IS INDIVIDUAL TO THE PATIENT & IS THEIR PERCEPTION OF THE PAIN

• IT IS IMPORTANT TO REPORT THE LOCATION, INTENSITY, TYPE OF PAIN IN THE NURSING DOCUMENTATION

• SIMPLY TO RECORD PATIENT RESPONSE TO THE QUESTION “HOW IS YOUR PAIN?” INVITES MISUNDERSTANDING OR DENIAL AND HINDERS QUANTIFICATION

PAIN ASSESSMENT TOOLS• Enables effective communication and assessment

by reducing the chance of error. (Overcoming bias / individual perceptions).

• The trust wide tool for pain assessment is scoring on a scale of 0 – 10.

• 0 = no pain, 1– 3 = mild pain, 4 – 6 = moderate pain, 7-8 = severe pain, 9-10 = worst pain possible.

• Patients who frequently score > 6 are receiving inadequate analgesia.

PAIN ASSESSMENT TOOLS

Verbal Descriptor Scale– A list of descriptive words describing different levels

of pain intensity– E.G.: No Pain Mild Moderate Severe Worst

Numerical Rating Score– A rating score using either a verbal scoring or marking

a line marked from 0-10 or no pain to worst pain with an attached scale

0 = NO PAIN, 10= WORST IMAGINABLE PAIN.

Pain Assessment Tools

• FACES RATING SCALE– SEVERAL FACES RATING SCALES EXIST AND WERE DEVELOPED

PRIMARILY FOR USE WITH YOUNG CHILDREN. HOWEVER , FACES PAIN RATING SCALES ARE ALSO USED WITH ADULTS WHO HAVE DIFFICULTY USING THE NUMBERS ON A VISUAL/VERBAL ANALOGUE SCALE.

Behavioural Pain ScaleAdapted from FLACC scale (Merkel et al 1997)The Behavioural Pain Rating Scale (Kaplow 2000)Score 0 1 2

Frowning /Grimacing

No particular expressionOr smile

Occasional grimace or frown, withdrawn,disinterested

Frequent to constant frown, clenched jaw, quivering chin

Restlessness Quiet Slight to moderate restlessness

Very restless

Tenseness Relaxed Slight to moderate tenseness

Extreme tenseness

Patient sounds Talking in normal tone or no sound

Sighs, groans softly, occasionally complains

Moans loudly, crying, frequently complains

Consolability Content , relaxed Reassured by touching, talking

Difficult to console or comfort

Patient scores in each category, maximum score of 10 may be achieved. A pain score of 4 or more requires intervention.

Barriers to pain assessment• Communication

– Hearing– Memory

• Can they compare today’s pain with yesterday , when they can’t recall what they did 1 hour ago

• Cognitive ability• Secondary Gain

– Financial– Social– Family

How do people in pain behave?

• GRIMMACE• CRY• SHOUT• GET ANGRY• WITHDRAW• BECOME NON

COMPLIANT• LAUGH

(HYSTERICAL)

• HOLD SITE• RUB AREA• APPLY HEAT• APPLY COLD• TAKE TABLETS• CURL UP• DISTRACTION

Barriers to pain assessment

• Patients perception of pain

• Caregivers attitude to providing effective treatment

• Do nurses assume the role of proxy?– Be careful– Our understanding and recognition of pain may be

skewed or false in the cognitively impaired patient

Pain Perception

What can influence?• Gender• Age• Culture• Anxiety • Previous experience of pain

Conclusion• BELIEVE THE PATIENT

• ASSESS THE CHARACTORISTS OF A PATIENTS PAIN

• USE A SIMPLE RELIABLE CONSISTENT TOOL TO QUANTIFY PAIN LEVEL

• ASSESS PAIN REGULARLY ( 5TH VITAL SIGN)

Approaches to Pain Management

• Choice of route for administration• Treat the patient, not the problem• Allow for individual variability• Awareness of pharmacology of drugs• Useful drug combinations• Administer analgesia regularly• Use of local analgesia techniques• Non pharmacological techniques

PAIN MANAGEMENT TECHNIQUES

• STEPLADDER APPROACH

• SIMPLE ANALGESIA / STRONG ANALGESIA

• PCA (PATIENT CONTROLLED ANALGESIA)

• EPIDURAL / SPINAL ANALGESIA

• WOUND INFUSIONS

• NERVE BLOCKS

• INHALATION ANALGESIA

Causes of poor pain management • Patients vary in response to pain• Poor pain assessment• Inappropriate choice of analgesia• Incorrect dose• Wrong frequency• Wrong route or mode of delivery

Non pharmacological Interventions

»Allay anxiety

Non pharmacological Interventions

• Communication• Reassurance• Information giving• Relaxation techniques• Breathing exercises• Position• Mobilisation

• Distraction• Visualisation• TENS• Acupuncture• Massage• Aromatherapy

Analgesia for acute painSimple analgesicsAspirinParacetamol Nefopam

Combination analgesicsCo-codamolCo-drydamol

Opioid AnalgesicsCodeineDihydrocodeineTramadolMorphineoxycontin

NSAIDsIbuprofenDiclofenacNaproxen

AdjuvantsTricyclic antidepressantsAnti convulsants

Specialist DrugsKetamineCanabinnoids

Score 7-10Consider IV boluses of opiate (This can be treated gradually until the Pt is Comfortable).Give NSAIDs if not contraindicated and/or Paracetamol (These can be given rectally or intravenously)

Score 4-6Offer analgesia that is suitable in potency for severity and nature of pain. Make sure suitable analgesia isprescribed regularly. Consider non-pharmacologicalinterventions. Contact pain service if necessary.

Score 1-3If patient is happy with pain relief and coping with Expected immobility then continue as before.Re-assess at least twice daily.

10

9

8

7

6

5

4

3

2

1

0

As much painAs I canPossibly bear

Severe Pain

Moderate Pain

Little Pain

Discomfort

No Pain at all

PAIN SCORE = 8 - 10

PAIN SCORE = 5 - 7

PAIN SCORE = 2 - 4

PAIN SCORE =0 - 1

SIMPLE ANALGESIC

PRN Paracetamol

1gram 4 times a day

(oral, intravenous or retal)

Or

Regular Paracetamol

1 gram 4 times a day

(oral or rectal)

Ensure no other prescription contains Paracetamol

SIMPLE ANALGESIC + NSAID

Regular Paracetamol

1 gram 4 times a day

(oral, intravenous or ,rectal)

And

PR/PO Diclofenac 50mgs

3 times a day

(75 mg BD if Dyloject used)

150 mg in 24 hours (oral, intravenous or rectal)

or

Ibuprofen 200mg QDS, increase to 400mgs TDS if required (oral) –up to 1200 mg

See contra -indications to NSAIDs on other side of chart

SIMPLE ANALGRESIC + NSAID

+MILD OPIATE

Regular Paracetamol 1 gram 4 times a day (oral, intravenous or rectal)

And

Regular NSAIDS - Diclofenac

or

Ibuprofen

And

PRN Dihydrocodeine/codeine

30mg 3 hourly (oral) max 240 mg

or

PRN Oral morphine solution

10 – 20mg 2 - 4 hourly

Is a laxative required?

See Constipation Guidelines

Is nausea a problem - see

Post-operative Nausea &Vomiting Guidelines

SIMPLE ANALGESIC + NSAID + STRONG OPIATE

Regular Paracetamol 1 gram 4 times a day (oral, intravenous or rectal)

And

Regular NSAIDs –Diclofenac

or

Ibuprofen

And

Stop mild opiate

to

STRONG OPIATE

PRN Oral morphine solution 10-20 mg

2 hourly (oral)

If pain persists consider IV/IM opiate 10 mg 2-4 hourly

or morphine PCA (according to existing guidelines)

Is there another cause for patients increase in pain?

Is a laxative required?

See constipation guide

Is nausea a problem - see Post-operative Nausea & Vomiting Guidelines

ADULT ANALGESIA STEP LADDER

Opioid AnalgesicsSide Effects• Respiratory depression • Nausea• Sedation• Confusion• Pruritis• Constipation

NSAID’SNSAID’S• Should be prescribed regularly to maximise benefit

– Not PRN – Reduces opioid requirements (25%)

• Side Effects– Gastro Intestinal– Renal Impairment– Cardiovascular– Hypersensitivity– Fluid Retention

NSAID’S CAUTIONS

Recognise ” at risk” patients

• Age• Previous peptic ulcer disease• Anti coagulants• Steroids• Dehydrated• Diuretics• ACE inhibitors

NSAID’s INTERACTIONS• Anti coagulants• ACE inhibitors• Anti hypertensives• Diuretics• Lithium

Paracetamol• Is suitable 1st line analgesia for most patients if given

regularly• Effective• Well tolerated• Inexpensive• Underestimated analgesia• Well absorbed 30 - 60 minutes onset of action• Available as :

– soluble tablets, liquids, suppositories, Intravenous injection

Methods

Patient Controlled Analgesia(PCA)

• Method introduced in the early 90’s– Principle around before that

• Cardiff palliator– Overall concept

• Patient is the best judge of their pain

‘Pain is what the patient says it is

and exists when they say it does’

Why patient controlled analgesia?

• The Cycle of Pain Relief

Benefits of PCA

• Reduces delay• Reduces puncture site injury• May reduce postoperative morbidity• May reduce hospital stay• Patient in control

Patient Controlled Analgesia

PCA

IM

0 1 2 3 4 5

Epidural AnalgesiaEpidural Analgesia

Epidural Infusion AnalgesiaEpidural Infusion Analgesia

• Why epidural analgesia?– major surgery (esp. high abdominal/thoracic)– obese– respiratory disease– trauma - fractured ribs

Benefits of Epidural Analgesia• Improved pulmonary function• Less risk of arterial & venous thrombosis • Decrease in cardiovascular complications• Reduce risk of sluggish bowel movement • Early mobilisation• Shorter hospital stay

Why not an Epidural?• Absolute

– Patient refusal– Abnormal clotting– Infection (local septicaemia)

• Relative– Raised intracranial pressure– Spinal deformities– CNS disorders– Severe obesity– Drugs-Aspirin, NSAID’s Heparin Warfarin

Epidural SpaceThe epidural space (epi = outside)• lies between the dura mater and the vertebrae

and ligaments of the spinal canal

• The epidural space allows drugs to be injected near to the spinal cord and the nerves surrounding it. Narcotics given epidurally diffuse slowly into the subarachnoid space and then pass to the opioid receptors in the dorsal horn of the spinal cord

Epidural Space

Pharmacology• Opioids and Local Anaesthetics are the two classes of

drugs commonly used for epidural analgesia

• They can be given as repeated boluses or continuous infusion

• They can be given alone or as a combination ,these drugs are mixed with 0.9% normal saline

• Epidural drugs should be preservative free

Local Anaesthetic• These diffuse rapidly from the epidural space into the CSF.

Local anaesthetic drugs introduced into the epidural space block nerves in the following order

– Sympathetic nerves

– Sensory nerves in order of increasing diameter• (temperature, pain, touch, pressure)

– Motor fibres

Spread of L.A. in epidural space• Site of injection - Lumbar is the easiest • Volume of solution – larger volume greater

area blocked• Position of patient• Speed of injection -rapid injection spreads

solution upwards & downwards• Concentration of solution

Acute Complications Systemic Toxic Reaction

Caused by high levels of LA in the cardiovascular system Because of:

• Unrecognized IV injection of LA• Excessive volume of local anaesthetic• Both of the above• LA administered too quickly (particularly

top-ups)• LA administered too frequently

Systemic Reaction to LA Mild

Circum-oral tinglingTinnitus Metallic taste Nausea DrowsinessBlurred vision

ModerateConfusionSlurred speechMuscle twitching

SevereAboveComaCardiopulmonary arrest

Complications of epidural infusion• Headache• Severe hypotension• Leg weakness• Meningitis• Temporary nerve damage• Epidural haematoma• Epidural abscess • Paralysis

Spinal (Intrathecal) Analgesia

Main differencesEpidural / Spinal

Epidural• Location

– Outside dura• Onset

– Slow(30mins)• Duration

– Short (2 - 4 hrs)• Maintenance

– Continuous/ top –up• Mobility

– Mobile• Risks

– Dural tap

Spinal

– Subarachnoid /CSF

– Quick (5 mins)

– Long ( 6 – 8hrs )

– Mainly single shot

– Not mobile

– Post spinal Headache

To conclude

• Use analgesics in a logical stepwise manner– Choice of analgesia is determined by

• Type & Severity of pain• Individual patient factors

• Treat acute pain promptly• Review analgesia regularly