Pain Management - GCH

Pain Management - GCH

Management of Acute and Chronic Pain 2012 Developed By: 1 Kifaya Shami RN, BSN Management of Acute and Chronic Pain General Information Regarding the Program Successful completion: to receive 1.5 contact hours, the 2 Management of Acute and Chronic Pain, participants must attend the entire program, complete the post-test with a passing score of > 80% and complete/submit and evaluation form Conflict of Interest: The activity planners and presenters for Management of Acute and Chronic Pain reported no

relevant financial relationships with commercial interests or conflicts of interest related to their presentations. Commercial Support: Commercial support was not received for Management of Acute and Chronic Pain. Non-Endorsement of Products: the presence of commercial products does not imply endorsement by Garden City Hospital, Wisconsin Nurses Association, or the American Nurses Credentialing Centers Commission on Accreditation. Off-Label Use: All presenters have agreed to disclose to participants prior to their presentations if off-labeled (or unlabeled uses) of commercial products will be discussed during their presentation (s). Expiration: The expiration date for this educational Objectives Define Pain Describe the physiological process of pain Identify treatments of pain Differentiate between the misconceptions of pain management List the elements of a pain assessment

3 Prevalence of Pain 26% of U.S. adults > age 20 reported a 4 pain problem 76.2 million Americans experience persistent pain. A leading reason people seek medical care. Consumes $100 billion annually in direct and indirect costs Effects a multitude of social, economic, political, legal, and educational factors Defining Pain Pain means different things to different 5

people. It is a personal experience which can be influenced by gender and cultural norms. There are no neurophysiological or laboratory tests which can measure pain Pain Definitions: An unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain is always subjective It is the responsibility of the clinician to accept the patients report of pain Pain is whatever the experiencing Types of Pain Acute Pain that comes on quickly, is severe, and lasts a relatively short amount of time. Chronic Pain that occurs intermittently or persistently and lasts for at least three months

6 Classification of Pain Nociceptive Pain response to a stimulus short in duration acute pain Skin, muscle, bones Achy, stabbing, throbbing Burn, trauma, surgery Inflammatory Pain can present with redness or swelling Results in stretching, distention, infarction or inflammation rheumatoid arthritis, appendicitis

Neuropathic Pain results in damage to the 7 nerves usually have an underlying condition Burning, shooting, stabbing, shock-like Diabetic neuropathy, herpes zoster or shingles, chemotherapy, amputation, spine problems Central Pain Amplification

abnormal pain processing by the central nervous system fibromyalgia Characteristics of Pain Objective Guarding protective 8 behavior Diaphoresis Pallor Change in pulse, respiration rate, blood pressure Pupillary dilation Change in appetite Fatigue Weight gain/loss Shortened attention

span Altered ability to continue previous activities Subjective Complaints of pain Fear, anxiety, irritability, anger, helplessness Depression, hopelessness, suicidal thoughts Frustrated with pain Feelings of being a burden feelings of guilt ** The patients pain is real even when they do not exhibit these characteristics ** Patients with chronic pain, may not exhibit physiological symptoms of pain

Physiological Process of Pain Central Nervous System Brain awareness, movements, sensations, thoughts, speech, and memory Spinal cord Controls most bodily functions including Connected to a section of the brain called the brainstem and runs through the spinal canal. Cranial nerves exit the brainstem and function as peripheral nervous system mediators of many functions, including eye movements, facial strength and sensation, hearing, and taste. Nerve roots exit the spinal cord to both sides of the body. The spinal cord carries signals (messages) back and forth between the brain and the peripheral nerves. 9 Central Nervous System

10 Anatomy of the Spine The Spinal Cord The spinal cord is an extension of the brain and is surrounded by the vertebral bodies that form the spinal column. Within the spinal cord are 30 segments divided into 4 sections based on their location: Eight cervical segments: Signals transmitted to and/or from areas of the head, neck, shoulders, arms, and hands. Twelve thoracic segments: Signals transmitted to and/or from part of the arms, the anterior and posterior chest as well as the abdominal areas. Five lumbar segments: Signal transmitted to and/or from the legs and feet and some pelvic organs. Five sacral segments:

Signals transmitted to and/or from the lower back and 11 buttocks, pelvic organs and genital areas, and some locations in the legs and feet. Peripheral Nervous System Nerve fibers that exit the brainstem and spinal cord become part of the peripheral nervous system. Nerve roots leave the spinal cord to the exit point between two vertebrae and are named according to the spinal cord segment from which they arise. Mixed motor and sensory peripheral nerves are formed by fibers that carry motor input to limbs and fibers that provide sensory output to the spinal cord 12 Dermatomes Nerves located in the spinal cord supply a unique

sensation such as pain, touch, or temperature directly from the nerve root to the brain. Each nerve supplies a sensation to a specific area. 13 Normal Pain Processing Pain Pathways Pain perception begins with the activation of the peripheral nerve receptors. The stimulus is generated at the end of the peripheral nerve which then causes a pain signal to travel to the dorsal horn of the spinal cord. When the impulse reaches the brain, pain is then perceived and modulated down the descending tract.

14 Importance of Treating Pain Pain is a real problem and most often under-treated. Leads to failure to achieve adequate results 15 for at least 40% of patients experiencing pain despite effective treatment modalities Results in unnecessary patient suffering Reduced functioning Exhaustion Depression Loss of hope Diminished quality of life Exacerbates cognitive impairment and malnutrition Impact of Pain on the

Dimensions of Quality of Life Physical Psychological Functional Ability Strength / Fatigue Anxiety Sleep & Rest Nausea Enjoyment/Leisure Depression Appetite Pain distress Happiness Constipation

Fear Cognition / Attention 16 Impact of Pain on the Dimensions of Quality of Life Social Spiritual Caregiver burden Roles and Suffering relationships Affection/Sexual function Appearance

17 Meaning of pain Religiosity Health Facilities Accreditation Program Standards of Care Patient rights regarding effective pain management Effective treatment of pain based on evidence based practice Medication, procedures, alternate therapies Written plan of care including the 18 assessment of pain, the use of quantifiable tools (eg: various pain scales), continued monitoring of treatments, reassessment of the effectiveness of treatments (desirable/undesirable)

Education related to treatment therapies Healthcare providers Pain Care Bill of Rights Patients who report pain should have their 19 pain report taken seriously, they should be treated with dignity and respect by doctors, nurses, pharmacists, and other healthcare providers Pain should be thoroughly assessed and promptly treated Patients should participate actively in decisions about how to manage their pain Pain should be reassessed regularly and treatment adjusted if pain has not been eased Patients should be referred to pain Barriers to Pain Management Patient Barriers:

Reluctance to report pain Reluctance to take pain medications as 20 prescribed Concerns about addiction Belief that pain is inevitable and not treatable Lack of access to pain management professionals Fear of masking new symptoms Cost of pain medications and/or other treatment modalities Lack of comprehensive insurance coverage Barriers to Pain Management Professional Barriers: Some health care professionals have little or no training in pain management Inadequate knowledge of pain mechanisms Inadequate knowledge of pain assessment

Inadequate knowledge of the appropriate use of pain medications Concerned about medication side effects Fear of regulatory scrutiny 21 Overcoming Barriers Use evidence to ensure standardized, appropriate treatment: Address clinical problems based on scientific evidence Recognize unique situations, flexible process Some things to consider individual experience with pain treatment preferences organization resources and capacity Educate health care providers Educate patient and family

Studies show a improvement of pain when 22 misconceptions are cleared due to patients become more receptive to and responsive to physicians and treatments Overcoming Barriers Make pain management a organization- wide priority Interdisciplinary approach Develop a Pain Management Program Conduct a comprehensive pain assessment & reassessment Provide the foundation for pain management and control Pain assessment mnemonics

S.O.C.R.A.T.E.S Pain L.O.A.D & T.R.A.C O.L.D.C.A.R.T 23 Conduct regular screenings of Pain Cultural Considerations Health care providers should become familiar with the different cultures of their patient population Recognize and respect the cultural impact on 24 the expression of pain Different ethnic groups express pain and suffering differently Culture affects behavioral responses to pain and treatment preferences May be assessed using universal pain scale

(different languages available) Enhance cultural sensitivity by working closely with the patients and their family to develop mutual goals Whenever possible, implement healthcare practices specific to the patients cultural group Use teaching material in the patients primary language and/or utilize resources such as Nursing Responsibilities Primary role in effective pain management It is a moral obligation or duty to assess pain and 25 offer adequate pain management as needed Believe the patients report of pain Do not get into a power struggle with the patient Studies show high satisfaction scores even if the pain level is high when patients are comfortable with their healthcare provider and feel that providers are doing everything they

can to help control their pain Able to assess for pain, communicate findings to physician, and manage effective interventions HFAP includes effective pain management as part of their standards of care Under treated pain is a violation of patients right Elements of a Pain Assessment Frequency of pain 26 assessment is linked to the adequacy of pain management How often should pain be assessed? On admission to hospital After any procedure, surgery or change in

condition With new complaints of pain Before and after activity At change of shift or change of caregivers Upon receiving patients from Monitor and Reassess: Patients condition, cause of pain, pain intensity At appropriate intervals following pain interventions Monitor the 4 As: Analgesia response

to pain interventions Activities of Daily Living- functional status Adverse Side Effects: Sedation Side effects of treatment Aberrant drug taking behaviors if Pain Assessment Mnemonics Pain L.O.A.D Location-Ask the patient: Where is your pain? Onset- When did your pain start?, How often does it occur? Does it change? Rest and activity pattern of pain? (constant, intermittent) Acuity-Rate your pain using validating

scales Description- Patients own words, 27 Describe your pain/what does it feel like (achy, stabbing, burning, pressure, Other assessments to track.. Pain T.R.A.C Treatment Current or previous treatment to relieve your pain Routine How has the pain affected your routine/ADLs? Aggravating factors What makes it worse/or better? Compliance History of compliance to pain medication or other treatment Pain Goal Try to maintain at an acuity rating of 3 or less. For chronic

28 pain patients, ask them their goal. Ensure goals are realistic Consider the patients individual goal and expectations from a functional perspective walk without pain, sleep longer, participate with S.O.C.R.A.T.E.S Site: Where is pain located? Onset: When did the pain start, was it 29 sudden or gradual? Character: What is the pain like? Ache, sharp, shooting? Radiation: Does the pain travel anywhere? Associations: Are there any signs/symptoms associated with this pain? Time course: Does the pain follow a pattern?

Exacerbating/Relieving factors: Does anything change the pain? O.L.D.C.A.R.T O: Onset of Pain L: Location(s) of pain D: Duration- How long has it been present? C: Characteristics severity , quality A: Aggravating Factors- what makes it worse? R: Relieving Factors- What makes it batter T: Treatment- Interventions current and past 30 Assessing Individuals with Addictions Use a nonjudgmental approach Use a multimode approach to controlling pain Opioid and nonopioid medication, regional

anesthesia techniques (injections) May require more medicine than the typical patient Prevent withdrawal symptoms Treat coexisting psychological disorders Anxiety, depression, personality disorders Treat an identified addiction as a primary illness Sleep disturbance, functional disabilities, 31 substance abuse Ongoing Reassessment Pain level Every 2-4 hours Patients response to treatment

One hour post intervention Changes in pain 32 management program Effect of the patients pain on a daily living Risks associated with pain, such as Tools to Assess Pain Utilize the same scale throughout assessments to maintain a consistent measure of pain intensity Pain Scales: Numeric Pain Intensity Scale

Numeric scale ranging from 0 through 10 0 represents no pain and 10 is worst pain possible 33 Wong-Baker FACES Pain Rating Scale Five faces ranging from smiling to tearful and the patient chooses the face that closely represents their pain level, best used in children Pain Scales Verbal descriptor scale Choose the best phrase to describe pain: no pain, mild pain, moderate pain, severe pain Checklist of Nonverbal Pain Indicators 6 behaviors assessed: vocalization, facial grimacing, bracing, rubbing, restlessness, vocal complaints Best used for nonverbal, cognitively impaired, or critically ill patients 34

1. Score each column separately 2. Score 0 if the behavior was not observed 3. Score 1 if the behavior was observed, even briefly 4. Total each column separately The resulting two pain score between 0 and 5 reflect pain observed with movement and at rest. 35 Treatment Options Interdisciplinary Management of Symptoms Modifying the sources of pain Alter the perception of pain Blocking its transmission to the nervous system Pharmacological

Anticipate, recognize and treat adverse effects Non-pharmacological or Complimentary 36 Therapies Interventional Medicine (minimally invasive procedures) 37 Pharmacological Approach Many forms of pain medicine available Oral medication Nasal sprays Ointments Liquid Transdermal patches Patient controlled pain pumps (PCA)

Injections Different methods for different patients based on their history Oral pain medicine: convenient, low cost, 38 rapid onset Around the clock administration versus as Types of Medicine Opioids Very effective 39 analgesics Used for moderate to severe pain Have no maximum dose or duration Assess the benefits

and potential adverse side effects Do not exhibit a ceiling effect for analgesia as doses are increased NSAIDs Nonsteroidal anti- inflammatory drugs Used for mild intensity pain Can reduce fever and inhibit inflammation Higher doses have no benefit but do increases risk of side effects dramatically Risks of use: GI bleeding, impairment of renal

Non-Opioid (Mild-Moderate pain) Aspirin Hydrocodone Acetaminophen /APAP Oxycodone /APAP Morphine Hydromorphone Oxymorphone Fentanyl Codeine Non-Steroidal (NSAIDS) (topical vs. oral) check renal function

Tramadol 40 Opioid (Moderate - Severe Pain) 41 Adjuvant Medication A pain drug used mainly for another condition but can also be prescribed for pain. It is used when the first choice of drug does not fully relieve pain. Adjuvant pain drugs are often prescribed in combination with typical pain-killing drugs such as NSAIDs or opioids. Examples: Steroids Antidepressants Anxiolytics /Benzodiazepines

Anticonvulsants Antispasmodics / Muscle Relaxants World Health Organizations Pain Relief Ladder Step 1: non-opioid with or without adjuvant Step 2: Opioid for mildmoderate pain (codeine, hydrocodone, oxycodone), with or without non-opioid and/or adjuvant Step 3: Opioid for moderate to severe pain (morphine, methadone, hydromorphone, fentanyl), with or without nonopioid and/or adjuvant 42 **When signs of toxicity or severe side effects occur, reduce dose and move down the steps

Overview on Pharmacology Use the least invasive route of administration 43 whenever possible Avoid intramuscular route administration Intravenous route can be used for patients who can not tolerate oral medicine or pain is rapidly escalating and severe Intermittent pain is managed with short acting medications Constant pain is managed with around the clock dosing or long acting medications Doses of medicine are increased with consideration of the patients report of pain, adverse effects, and goals of care Equianalgesic conversions are used when changing medications and/or routes Adjuvant medications are used for neuropathic, Opioid Equianalgesic Chart

Opioid Morphine Parenter Oral al Route Route 10 mg 30mg Starting dose for Opioid Nave Start at 15 mg PO for immediate release (IR) 7.5 mg Start at 4 mg PO IR Hydromorpho 1.5 mg ne Oxycodone n/a 20 mg Fentanyl 0.1 mg n/a (100mcg)

44 Methadone 5 mg 10 mg Oxymorphon 1 mg 10 mg Start at 5 mg PO IR Start at 12 mcg patch / (25 mcg patch = 50 mg oral Morphine) 3-5 mg PO for longterm use (can accumulate due to half life) * expert physician to prescribe

Start at 10 mg po IR , Interventional Medicine Pain Procedures Epidural Steroid Injections Facet Joint Injections Sacroiliac Joint Injections Radiofrequency Ablations Nerve blocks Implantable Pain Pumps Spinal Cord Stimulators 45 Non-Pharmacological Methods for Pain Control Heat/Cold Ultrasound/ Massage Physical Relaxation/Visualization

Therapy/Exercise TENS Unit Biofeedback Aromatherapy Psychotherapy Wearable Therapies Structured Support Music Therapy Yoga Patient & Family Often used to supplement pharmacological treatments and provide another approach to resolving Education pain Massage 46 Helps address pain and quality of life Misconceptions Resulting in Under-treatment of Pain

Respiratory Depression Assess patient history for disorders that may contribute to respiratory depression (sleep apnea, elderly) Highly unlikely when medicine is slowly titrated up Side Effects: Transient and must be treated aggressively Constipation Sedation Nausea Itching 47 Addiction Physical Dependence Pain Terminology Physical Dependence A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by

abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist Tolerance A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effect over time Addiction Primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. 48 Pseudo addiction A term used to describe patient behaviors that may occur when pain is under-treated. Patients with unrelieved pain Physical

Dependence Dependant on medications but has not lost control of use When side effects develop, attempts to cut back on medicine Things to remember: A normal 49 physiological response that often occurs with persistent use of certain medication Other classes of medication can cause physical dependence: beta

blockers, corticosteroids, antidepressants are examples Addiction Dependant on medication and lost control of use When side effects develop, ignores or does not seek management for them and increases use of medicine Red Flags: Inconsistent information about history of substance abuse Interaction with patient is

uncomfortable Past or present detoxification program (A.A., N.A.) Compliance and Prevention of Abuse Multiple measures should be initiated to ensure patients remain compliant: Recognize behaviors consistent with addiction Assess for addiction initially and throughout treatment Develop narcotic/opioid agreements Monitor prescription activity through state programs Obtain random urine drug screens Complete pill counts Provide patient education Ongoing assessments of pain therapy

50 outcomes Ethical Implications of Care Drug Seeker Clock Watcher Lack of understanding the mechanisms of pain medicine With holding prescribed medicine Personal implications with use of opioids Recognize that adherence to the prescribed regimen is not an addiction Use of placebos 51 Nursing Code of Ethics A guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession

Provision 1: The nurse in all professional 52 relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems Provision 2: The nurses primary commitment is to the patient whether an individual, family, group or community Preventing Unethical Care Provide an equally high quality of 53 care for all patients regardless of their history Understand that ALL patients are worthy of appropriate care

Provide help NOT punishment Focus on the problem, not treatment of addiction Request consult for Addiction Medicine or Social Work to Evaluate Documentation Documentation is a form of communication and it is crucial to the continuity of care, reimbursement, legal/regulatory issues and safety Ensure documentation is clear and concise Purpose of Documentation: Makes pain visible Supports ongoing interventions Promotes safety Helps protect practice Enables quality monitoring Enhances communication 54

Things to Document Patient outcomes Pain level (rest/activity) Patients current treatment for pain Patients response to treatment One hour post interventions Changes in pain management program Effect of the patients pain on a daily living Functional assessment Mood/Behavior/Relationships Risks associated with pain, such as risk for falling Unusual reactions to drug 55 Adverse reactions versus side effects Establishing Pain Relief Goals Acute Pain Facilitate recovery from the underlying injury,

surgery, or disease Reduce stress Minimize the impact of pain on activities Control and reduce the 56 pain to an acceptable level Minimize pharmacologic side effects Prevent Chronic Pain Chronic Pain Restore Function Physical, emotional, social Decrease Pain Treat underlying cause

if possible Minimize medication use Correct secondary consequences of pain Postural deficits, weakness, overuse Maladaptive behavior, poor coping Goals and Outcomes Minimize pain by utilizing multiple therapies improved quality of life Medicine

Lifestyle changes Diet Complementary therapies Interventional procedures Maximize functionality 57 Focus on Physical Therapy Daily exercise regimen Activity

Relationships Support groups Decrease psychosocial stressors References U.S. Department of Health and Human Services, Centers 58 for Disease Control and Prevention. Health, United States, 2006: chartbook on trends in the health of Americans; 2006: 68-75. Tabers Cyclopedic Medical dictionary 19th edition McCaffrey, M; Pasero, C. (1999) Pain: Clinical Manual (2 nd Ed.) Philadelphia, Mosby American Pain Society, Principles of analgesic Use in the Treatment of Acute Pain and Cancer Pain 6th Ed, 2008 Pathophysiology RN St. Marie, B. et al. (2002). Core Curriculum for Pain Management Nursing. Philadelphia, PA: American Society

of Pain Management Nurses. Partners Against Pain. http://www.partnersagainstpain.com/understanding-pain/ patient-rights.aspx Carr. D, Paice, J. (2010) An essential guide for clinical leaders. Approaches to Pain Management (2nd Ed). AAPM, APS, ASAM. Definitions Related to the Use of 59 Opioids for the Treatment of Pain. A consensus document from the American Society of Pain Medicine, the American Pain society, and the American Academy of Addiction Medicine, 2001. Cole, EB. Prescribing opioids, relieving patient suffering and staying out personal trouble with regulators. Reprising old ideas and offering new suggestions. Pain Practitioner. 2002; 12: 5-8 Feldt, KS. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing, 1(1):13-21. http://www.nursingworld.org/MainMenuCategories/

EthicsStandards/CodeofEthicsforNurses/Code-of-Et hics.pdf www.uwhealth.org/pain http://www.masspaininitiative.org/

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