Title: Acute Pain Management
1Acute Pain Management
- Christine Gibson
- Specialist Nurse, Acute Pain Service ARI
- 2009
2Objectives
- Have an understanding of pain assessment and pain
assessment tools - Have a knowledge of analgesic drugs and side
effects of drugs - Have an understanding of routes of drug
administration - Be able to provide a definition for pain
3Role of the Acute Pain Service
- Working party report on surgical services. Royal
College of Surgeons of England and College of
Anaesthetists (1990) - 5 Nurses,3 Consultants,1 Pharmacist
- Educational,safety,supportive
4Aims
- Humanitarian
- Avoidance of pathophysiological consequences
- Avoidance of chronicity
5Patient group
- All are in patients, some telephone follow up
- All types of surgery
- Trauma
- Referrals e.g. backpain, infection, absorption
problems
6Pain ?
- The sufferers knowledge confronts the carers
belief. - There are no physiological signs that uniquely
indicate pain language. - Pain is a personal experience and is difficult to
define and measure. - It is natures way of warning and more often than
not, serves as a useful warning. - While pain can be of value it can be of no value
in excess.
7(No Transcript)
8Definition of Acute Pain
Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage. IASP (1979)
- Implies emotional component.
- Pain can exist without tissue damage.
9Definition of Pain
- Pain is whatever the experiencing person says it
is, existing whenever the experiencing person
says it does. McCaffery M. (1968)
10Acute Pain
- Nociceptive pain (the action of a peripheral
nerve which receives conveys painful stimuli to
the brain) - Derived directly from pain receptors
- Arises in damaged tissues
- Sensed in damaged area
- Has a cause which is of finite duration
- Has a purpose
11(No Transcript)
12Barriers to good pain management
- Multidisciplinary factors
- - lack of knowledge
- - failure to recognize multi - faceted nature
of pain - - poor interpretation of information
- Patient factors
- - unwillingness to report pain
- - non compliance with treatment
- - lack of knowledge / information
-
13Pain in older people
- More susceptible
- Lack of knowledge in the complexity
- Failure to assess appropriately
- An inevitable consequence of the normal ageing
process Kumar A, Allcock N, (2008)
14Why assess pain ?
- To establish degree and nature of pain
- To ensure patient comfort
- To evaluate effectiveness of analgesia
- To help alleviate anxiety
- To decide on type of analgesia
- To aid recovery and prevent complications
15(No Transcript)
16How to assess pain
- Communication with patient is essential
- Observe for changes in physiological signs
- Use a pain scoring system
- Body language?
- Consider pain as 5th vital sign
17Pain Assessment
- No one tool is suitable for all situations
- Pain is complex with many variables, apart from
the physical cause, that can influence the
patients experience and interpretation
18Pain Assessment
- One of the most important functions of the
nurse is to alleviate the suffering of people who
are experiencing pain - Schofield P(1995)
19Pain Assessment Research
- Nurses had a lack of trust in patients own
reports of pain - Some nurses had their own benchmark of what pain
level was acceptable and, possibly when and how
pain was expressed - Conclusion - nurses thought patients should did
communicate their pain. Patients thought nurses
should know. Watt-Watson J.H., Stevens B. (2001)
20Why is it difficult to treat pain?
- Prescribed opioids for a related disease e.g.
cancer - Prescribed NSAIDS for e.g. arthritis
- Chronic disease e.g. renal failure, back pain
- Take illicit drugs
- Anxious patient
- Staff/patient attitudes
21Patient Education
- Pain relief can be poor due to inadequate
education of patient expectations Khun et
al.(1990) - Patients expecting to have pain after surgery may
make fewer demands and fewer reports of pain
MacLellan,K (2004)
22Why treat pain ?
- Patients deserve to be treated humanely
- Patient comfort and satisfaction should be
considered important - To prevent post - operative complications
- We have a professional obligation to give
patients the best possible care - Physiological factors
- Economic factors
23Importance of pain control
- It is now recognised that undertreatment of
severe acute pain can have a number of harmful
physiological and psychological effects
(MacIntyre P, 1997) - Effective treatment important for humanitarian
reasons, patient comfort and satisfaction can
significantly improve outcome - Unrelieved acute pain complicates recovery,
resulting in more complications, longer hospital
stays, greater disability and potentially long
term pain(Watt-Watson et al.1999)
24Harmful effects of undertreated acute pain
- Respiratory- decreased cough and lung volume,
atelectasis, sputum retention,infection,
hypoxaemia - Cardiovascular - tachycardia, hypertension,
increased myocardial oxygen consumption,
myocardial ischaemia, deep vein thrombosis - Gastrointestinal - decreased gastric and bowel
motility - Genitourinary - urinary retention
25- Neuroendocrine - increase in levels of
catecholamines, cortisol, glucagon, growth
hormone, vasopressin, aldosterone and insulin - Psychological - anxiety, fear, lack of sleep
- Musculoskeletal - muscle spasm,
immobility(increasing risk of deep venous
thrombosis)
26Postoperative pain management major challenge
- Understanding of acute pain physiology has
advanced and new methods of pain management have
emerged - Studies show postoperative pain continues to be
inadequately treated and patients still suffer
moderate to severe pain after surgery
Wilder-Smith Schuler1992,Watt-Watson et
al.(2001)
27Good pain management
- Communication
- Tailored to individual
- Holistic
- Multidisciplinary Documentation
- Continuity
- Education of staff, patients,
- relatives and visitors
28(No Transcript)
29Management of acute pain
- Analgesic drugs are used to treat acute pain, the
choice of drug dependent on the intensity of pain
being experienced.
30Multimodal analgesia
- Paracetamol (acetaminophen)
- Non Steroidal Anti Inflammatory Drugs
- (NSAIDS) e.g. ibuprofen, diclofenac, ketorolac
- Opioids e.g. morphine, oxycodone, fentanyl,
pethidine
31Analgesic Ladder
32Golden Rules
- By the clock
- By the ladder
- By the mouth
33Methods of administration
- Epidural Analgesia
- Patient Controlled Analgesia intra - venous
- Intra Muscular Injection
- Sub Cutaneous
- Oral
- Rectal suppositories
- Transdermal
- Inhalation gas
- Regional Nerve Blocks e.g. Paravertebral Brachial
Plexus - Wound Infiltration
- Reflexology
- Reassurance
34Opioid
- Opioid is a blanket term used for any drug
which binds to the opioid receptors in the CNS.
35Opioids for acute pain (ARI)
- Morphine
- Diamorphine
- Fentanyl
- Oxycodone
- Tramadol
- MST continus
- Hydormorphone
- Codeine
- Dihydrocodeine
36Adverse effects of opioids
- Respiratory Depression
- Sedation
- Nausea and Vomiting
- Pruritus
- Urinary retention
- Hallucinations
37Norman, age 28, 2nd post op day following
abdominal surgery
- Laughing, smiling
- BP120/80, P 80, R 18
- Painscore of 8 when asked
- What do you think his painscore is?
38James, age 25, 2nd postop day following abdominal
surgery
- Quiet , expressionless, talking little
- BP 120/80, P80, R18
- Painscore 1 when asked
- What do you think his painscore is
39References
- Kumar A., Allcock N. Pain in older people. Pain
News Autumn 2008 p19-20 - McCaffery M.(1968) Nursing Practice theories
related to cognition bodily pain and man
environment interactions.University of California
at Los Angeles Students Store.p95 - Macrae W.A.Chronic pain after surgery.British
Journal of Anaesthesia 87(1)88-98 (2001) - Macintyre P.E. , Ready L.B.Acute Pain Management.
A Practical Guide.W.B Saunders Company 1997 - MacLellan K.Postoperative painstrategy for
improving patient experiences.Journal of Advanced
Nursing.Vol46(2)April 2004 p179-185 - Royal College of Surgeons of England and College
of Anaesthetists (1990)Report of a working Party
of the Commission on the Provision of Surgical
Services
40- Schofield P.Using assessment tools to help
patients in pain.Professional Nurse Vol 10, 11
703-706 - Subcommittee on Taxonomy for the International
Association for the Study of Pain (1979) - Watt-Watson J.H., Stevens B. (2001) Managing pain
after coronary bypass graft Journal of
Cardiovascular Nursing 12 p.39-51 - Watt-Watson J.H., Stevens B., Garfinkel P.,
Streiner D. Gallop R. (2001) Relationships
between nurses pain knowledge and pain
management outcomes for their postoperative
cardiac patients.Journal of Advanced Nursing ,36
535-545 - Wilder-Smith C.H. Schuler.L.(1992)Postoperative
analgesiapain by choice?The influence of patient
attitudes and patient education.Pain 50,527-262