6comfort-and-pain-management.ppt

COMFORT AND PAIN MANAGEMENT

RIZALDY N. ACIERTO, RN

PAIN  Unpleasant, subjective sensory and emotional experience associated with an actual or potential tissue damage • A sensation of physical or mental hurt or suffering that causes distress or agony to the one experiencing it • Subjective experience

NATURE OF PAIN • Subjective, highly individualized • Stimulus can be physical and/or mental in nature • Pain is tiring, places demands on person’s energy • Can interfere with relationships and influence the meaning of life

COMFORT •Concept central to the art of nursing •Through comfort measures nurses provide strength, hope, solace, support, encouragement, and assistance

•As subjective as pain

1. PATTERN THEORY  Pain is perceived whenever the stimulus is intense enough 2. SPECIFICITY THEORY  There are specific nerve receptors for a particular stimuli 3. GATE CONTOL THEORY  Conceptualizes that there is a gate in the spinal cord

4. AFFECT THEORY -Pain is emotional The intensity of pain perceived depends on the value of the organ affected to the individual

5. PARALLEL PROCESSING MODEL Physiologic or neurologic deciphering of the pain sensation and the cognitive emotional properties occur along different nerve fibers

PHYSIOLOGY OF PAIN STIMULI NERVE FIBERS A-DELTA FIBERS (large, myelinated)

C- FIBERS (small, unmyelinated)

SPINAL CORD THALAMUS CEREBRAL CORTEX RESPONSE

COMFORT/PAIN

• True or False? • The nurse is the best judge of a patient’s pain

ANSWER: FALSE

• Pain is SUBJECTIVE – only the client can judge the level and severity of pain

FACTORS THAT MAY AFFECT OF 1.PERCEPTION AGE *Child – may not recognize sensation of pain or PAIN

may have paradoxical reactionAdolescent – may be expressed as “attitude,” anger, aggressionOlder adult – may have trouble verbalizing because of perception that pain is “normal” part of aging

FACTORS THAT MAY AFFECT PAIN

2. SEX -men has higher tolerance of pain than women 3. Culture

• May impact level of pain one is willing to endure • Need to use assessment tools that are culturally sensitive

FACTORS THAT MAY AFFECT PAIN 5. PSYCHOLOGICAL FACTORS 6. PREVIOUS EXPEREINCE 7. RELIGIOUS BELIEFS 8. EXPECTED RESPONSE 9. SETTING 10. DIAGNOSIS 11. KNOWLEDGE

TERMS RELATED TO PAINAmount of pain 1. PAIN THRESHOLD stimulation a person requires before feeling pain 2. PAIN TOLERANCE The maximum amount and duration of pain that an individual is willing to endure 3. PAIN PERCEPTION The actual feeling of pain

4. BRADYKININ5. HYPERALGESIA

TYPES OF RESPONSES TO PAIN 1.INVOLUNTARY RESPONSES -physiologic responses are mediated by the autonomic nervous system 2. VOLUNTARY RESPONSES a.Behavioral responses b.Emotional responses

STAGES OF PAIN RESPONSE 1.ACTIVATION

2.REBOUND

3.ADAPTATION

TYPES AND ORIGINS OF PAIN 1. CUTANEOUS / SUPERFICIAL PAIN It occurs over the body surface or skin segment 2. SOMATIC PAIN Arises from bone, joint, muscle, skin or connective tissue. Usually aching, throbbing, well-localized pain.Responds to traditional analgesia 3. VISCERAL PAIN Arises from visceral organs such as the GI tract, heart, and pancreas. Can be subdivided further: 1. Tumor involvement of organ 2. Obstruction of hollow viscus

4. NEUROPATHIC/PYSCHOGENIC PAIN Abnormal processing of

sensory input by the peripheral or CNS.Treatment usually with tricyclic antidepressants, SSRI’s, anticonvulsants.Centrally generated pain.Peripherally generated pain 5. REFERRED PAINPain perceived at an area other than the site of injury 6. INTRACTABLE PAIN Pain that is resistant to cure or relief

7. PHANTOM PAIN Actual pain felt in a body part that is no longer present

8. RADIATING PAIN Felt at the source and extends to surrounding tissues 9. INTERMITTENT PAIN Pain that stops and starts again 10. ISCHEMIC PAIN Pain as a result of the metabolic need for oxygen.Warning sign of tissue damage.Cardiac pain (angina, MI).Vascular pain- Peripheral vascular disease, intermittent claudication

10. IDIOPATHIC PAIN

•Chronic pain in the absence of an identifiable cause •Complex Regional Pain Syndrome

11. CANCER PAIN •Pain that is due to tumor progression •Related to pathology, invasive procedures, infection, toxicities of Rx •Can be acute or chronic, nociceptive or neuropathic •At the actual site or distant to the site (Referred pain)

PAIN MODULATION *endogenous opioids- chemical regulators that may modify pain 1.Enkephalins Inhibits the release of substance P 2. Endorphins More potent than enkephalins 3. Dynorphins 50 times more potent than endorphins

PAIN ASESSMENT

P Aggravating Factors, Relief

Q • Character • What does it feel like? • Sharp? • Dull? • Aching? • Stabbing? • Burning? • Crushing?Tingling?

R • Location of the pain

• Affectation

S • Intensity

• Use of pain scale

T • Duration

• Onset • Acute –lasts for less than 6months .Chronic –lasts for more than 6months

SURGICAL INTERVENTIONS FOR 1. NEURECTOMYIncision of the cranial or PAIN peripheral nerves 2. RHIZOTOMY Interruption of the anterior and posterior nerve root area close to the spinal cord 3. CORDOTOMY/ SPINOTHALAMIC TRACTOTOMY Surgical interruption of pain conducting pathways within the spinal cord

4. TRACTOTOMY

Surgical resection of the anterolateral pathway in the brainstem 5. GYRECTOMY

Removal of the postcentral gyrus 7. HYPOPHYSECTOMY Destroying of the pituitary gland by injection with absolute alcohol

NURSING CARE OF PATIENT WITH PAIN 1. Techniques that stimulates the skin  Therapeutic touch  Contralateral stimulation  Vibration  Heat and cold application  Counterirritants

 Acupuncture/ acupressure  TENS

2. Techniques that distract attention Staring Slow, rhythmic breathing Recite, sing Describe something in detail .Listen to music Conversation Read, play games.Offer a favorite toy

3. Techniques that promote relaxation A. Conventional method: Guided imagery Meditation,Yoga, Biofeedback .Autogenic training B. Analgesic

C. Placebo- a non organic substance that satisfies the patient’s request for analgesic

PHARMACOLOGIC METHODS

• Require a physicians order • Guidelines set by regulatory agencies • Analgesics most common method • Tendency to under treat with pain meds

ANALGESICS • Non-opioid or non-narcotic agents & non-steroidal anti-inflammatory agents (NSAIDS) • Narcotics, Opioids • Adjuvants, Co-analgesics

NSAIDS • Relief of mild to moderate pain • Believed to inhibit prostaglandins & inhibits cellular response during inflammation • Acts on peripheral nerve receptors to reduce the transmission & reception of pain • Does not cause sedation or respiratory depression or interfere with bowel/bladder function • Avoid prolonged or overuse in elderly

NSAIDS

• Used in arthritic pain, minor surgical, dental procedures, low back pain, should be initially used in mildmoderate post-op pain

• Motrin, Naprosyn, Indocin,Toradol

OPIOIDS • Moderate to severe pain.Act on CNS, act on higher brain centers & spinal cord binding with opiate receptors to modify perception of or reaction to pain.Risk for depression of vital nervous system functions

OPIOIDS • If pain is anticipated for longer than 12-24 hours, ATC timing should be used instead of PRN timing • Opioids can be used effectively with elderly, START LOW & GO SLOW • Morphine, Demerol, Codeine, Percocet, Fentanyl, Hydromorphone • Opioid antagonist- NARCAN-reverses effect

ADJUVANT THERAPY

• Sedatives, anti-anxiety, & muscle relaxants • Enhance pain control or relieve symptoms associated with pain • Vistaril, Elavil,Thorazine,Valium, Ativan, Xanax

PATIENT-CONTROLLED ANALGESIA PCA • Drug delivery system • Patients have control over pain therapy

• Safe method for post-op, traumatic, or cancer pain • Self-administration without risk of overdose • IV administration

PCA PRESCRIPTION • Loading Dose • Basal (Continuous rate)

• On demand dose • Hourly maximum amounts can be prescribed

LOCAL & REGIONAL ANESTHETICS • Wound suturing

• Delivery of baby

• Performing simple surgery

• Epidural Analgesia for post-op pain management, L&D pain, chronic cancer pain

• On-Q Pain Pump

EPIDURAL PAIN MANAGEMENT • Short or long term • Administered into spinal epidural space • Catheter is left in place, secured with tape and dressing.Can be continuous infusion or daily injection

EPIDURAL PAIN MANAGEMENT • Monitor hourly for:

1. Catheter Displacement 2. Catheter Function 3. Respiratory Depression 4. Side effects: N/V, itching, urinary retention, constipation 5. Pain effect

CANCER PAIN • MANAGEMENT Long acting preparations, sustained release • Drug dependence low in cancer related pain • Can develop tolerance, requiring higher doses • Goal is to minimize pain, rather than cure it

PROCEDURE PAIN MANAGEMENT • Turning • Tracheal Suctioning.Placement of central line, chest tubes. Dressing changes.Getting patient OOB.Prior to Physical Therapy

PAIN MANAGEMENT