Transcript Pain - ONS
Pain Assessment & Management Diana Ruzicka, RN-BC, MSN Colonel (Retired), Army Nurse [email protected] Knowledge & Attitude Survey Complete the Survey while waiting for the lecture to begin • Write answers on the survey AND the answer sheet. • Pass in the answer sheet (No name please) • Answers will be distributed at the end of class. • This is a great tool to use to introduce your staff to pain management Agenda Knowledge & Attitude Survey Pain Definition Pain Assessment Pain Tx & Nursing Interventions Equianalgesic Drug Dosing Dr. Judith Paice Pain Unraveling the Mystery Definition of Pain Pain Transmission (Nociception) Concepts Tolerance Physical Dependence Psychological Dependence (Addiction) Treatments – Drug & Non-Drug Emotional Component & Suffering Why is pain poorly managed? 27 Minutes Effects of Unrelieved Pain 50 million American suffer from some form of pain Lost income, lost productivity, medical expenses DVT, pneumonia, PE, Sleep disturbances, decreases immune function, ileus, Untreated acute pain can result in chronic (persistent) pain Pain Impacts The Dimensions of Quality of Life Physical Well Being & Symptoms •Functional Ability •Strength/Fatigue •Sleep & Rest •Nausea •Appetite •Constipation Social Well Being •Caregiver burden •Roles & Relationships •Affection/Sexual Function •Appearance PAIN Psychological Well Being •Anxiety •Depression •Enjoyment/Leisure •Pain Distress •Happiness •Fear •Cognition/Attention Spiritual Well Being •Suffering •Meaning of Pain •Religiosity •Transcendence Ferrell, Wisdom, Wenzl & Schneider, 1989 (1989-1998) Classification of Pain By underlying pathology Nociceptive Somatic (Superficial or deep) Visceral Neuropathic By duration Acute Chronic (Persistent) Pain Pathway - Nociception Nociceptive Pain - Somatic Superficial Somatic (Cutaneous) Injury to skin or superficial tissue Sharp, well-defined, localized Example: Minor wounds & minor 1st degree burns Deep Somatic Injury to ligaments, tendons, bones, blood vessels, fasciae & muscles Dull, aching, poorly-localized Ex.: Sprains, broken bones, myofascial pain Nociceptive Pain - Visceral Pain originates from body organs or internal cavities Aching or cramping Often extremely difficult to localize Referred pain Visceral Pain - Radiation Liver Tumor – ® neck pain, ® chest pain (anterior & posterior) Kidney stone in ® ureter – ® inner thigh pain Neuropathic Pain Damage to peripheral nerve or CNS Burning, shooting (lancinating), stabbing, or electrical in nature Sudden, intense, short-lived, or lingering Assess, Assess & Reassess Knowledge & Attitude Survey Pain Definition Pain Assessment Pain Tx & Nursing Interventions Equianalgesic Drug Dosing Components of Pain Assessment Location* Quality* Timing Onset Duration Variation/Pattern* Rhythms Intensity Factors increasing or relieving pain* Associated symptoms or Effects of pain Effectiveness of Tx* WILDA Words Intensity Location Description Aggravating & Alleviating Factors *Maureen Carling [email protected] Pain Assessment Presence Do you have any pain? What are some reasons a patient may not tell the physician or nurse they have pain? I don’t want to bother the nurse I need the doctor to focus on my cancer, not this nagging ache in my back I am afraid the cancer may be progressing – I don’t really hurt This isn’t pain, it’s just a dull pressure Pain Assessment: Components Location - Where is it? This can assist in identifying the cause & treatment… Localized All over Referred or radiated from origin to different site Spinal Dermatomes Areas of Referred Pain Pain Assessment: Components Quality–“What does it feel like?” Description of the Pain Aches All the Time – Visceral or Soft Tissue Pain Dull steady ache, worse on movement – Bone pain Burning, Stabbing, Sometimes deep ache – Nerve Compression Comes & Goes – Colic Cramps, Spasms, Pulling, Tightening – Muscle Spasm Stinging Discomfort, Superficial Burning, Stabbing, Sometimes Deep Ache, Lancinating, Numbness – Nerve Destruction Pain, Deafferentation, Neuropathic Pain The Carling Story Pain Assessment: Components Timing Onset Duration “When did it start?” “How long does it last?” Variation/Pattern/Rhythms “Is it constant or does it come and go?” Pain Assessment: Components Intensity Determine effectiveness of treatment Is NOT a “pain assessment” Pain Intensity Scales Simple Descriptive Pain Intensity Scale 0–10 Numeric Pain Intensity Scale (p14) Visual Analog Scale Wong Baker Faces Pain Rating Scale (p14) Pain Assessment: Intensity Pain Assessment: Components Behavioral Pain Assessment Scale Some patients cannot report pain Neonatal Pain Assessment Scale PainAD Scale (p15) Modified Behavioral Scale (p15) FLACC Scale (p16) (p14) PatientParent Behavior VS Pain Assessment: Components Alleviating Factors “What makes it better?” Aggravating Factors “What make it worse?” Pain of spinal stenosis worse with walking Pleuritic pain worse with breathing Cardiac chest pain NOT better or worse with breathing Pain Assessment: Components Effectiveness of Treatment Inquire about strategies used Effective and ineffective Drug & Non-Drug Reassessment How did “X” affect your pain 1) 2) 3) 4) Does it completely relieve your pain? Does it just ease it a little? Does it not touch the pain at all? or 0-10 Numeric pain intensity scale Reassess each pain Pain Assessment: Components Associated symptoms Can worsen pain Anxiety Fatigue Depression Nausea, Diaphoresis, Radiate to jaw Pain Assessment: Components Effects of Pain Sleep Appetite Physical Activity Relationship with others (e.g. irritability) Emotions (e.g. anger, suicidal, crying) Concentration Other Pain Assessment: Components Patient’s Goal for Pain Relief Function Able to breast feed infant Able to ambulate Able to enjoy grandchildren Intensity “0 out of 10” “3 out of 10” Components of Pain Assessment Location* Quality* Timing Onset Duration Variation/Pattern* Rhythms Intensity Factors increasing or relieving pain* Associated symptoms or Effects of pain Effectiveness of Tx* WILDA Words Intensity Location Description Aggravating & Alleviating Factors *Maureen Carling [email protected] Pain Assessment Exercise Exercise: Pairs – One Nurse, one patient Patient – Do not share scenario with your nurse. Answer questions when asked. Nurse – complete a pain assessment using “Assessment of Pain” tool by Maureen Carling Final – When completed, compare assessment with scenario. Five minutes Assessment of Pain A. Do you have any pain? Yes/No __Yes_____ B. Location of pain(s) – Use body chart to map and number each site of pain C. Quality of each pain and state if continuous or intermittent. (Quote patient’s own words) 1. Burning (5/10) - C 2. Burning (5/10) - C 3. Dull achy pressure (3/10->8/10) – I->C 3 Difficult to move arm; almost unbearable Throbs all the time 4. __________________________ 5. ___________________________ 6. ___________________________ 1 7. ___________________________ 8. ___________________________ 2 D. Present Pain Medication 1. None______________________ 2. None______________________ 3. Motrin 3/108/10 4. __________________________ 5. ___________________________ 6. ___________________________ E. Assess the effectiveness of each medication against each pain e.g. “When you take your _______tablet, does it completely relieve your pain, just ease it a little, or does it not touch the pain at all?” F. What makes the pain better? Motrin used to help arm pain but no longer does; Must keep arm still to control pain. G. What makes the pain worse? Pain is continuous. ?Taxol -- burning pain Date: 12 May 2009 Signature of Assessor: Edwina Smith, RN Tool by Maureen Carling, RN [email protected] © 1994, all rights reserved Pain Treatment – Drug Therapy Non-Opioids Analgesics Opioids Analgesics Tylenol Aspirin NSAIDs Opioid Agonists** Weak mu agonists Partial Agonists Mixed agonist-antagonists Adjuncts Drugs Anticonvulsants Antidepressants Pain Treatment – Basic Principle Administer analgesics on a regular schedule if pain is present most of the day. Equianalgesic Drug Dosing Equianalgesic doses are approximate Titrate to individual response Rescue dose for breakthrough pain PO 10-15% of the 24hr dose prn q1-2hr IV 25-50% of the hourly opioid infusion q 15-30 min. Top of Equianalgesic Chart p20 Equianalgesic Drug Dosing For mild pain use non-opioids or 25% For hourly IV infusion rate divide by 4 For patients over 70yrs, consider starting lower & increasing slower starting parenteral dose by 25-50% Oral doses are NOT starting doses NR=Not recommended Top of Equianalgesic Chart p20 PROBLEM #1 Patient is taking 6mg oral hydromorphone (Dilaudid) every three hours. Convert this to continuous-release or sustained release morphine. Drug Conversion using Ratios Problem #1: Patient is taking 6mg oral hydromorphone (Dilaudid) every three hours. Convert this to continuous-release or sustained release morphine. Calculate the 24-hr dose of medication pt currently taking 6mg x 8 (every 3 hours) = 48mg hydromorphone/24 hrs Review the equianalgesic chart for equivalence guidelines 7.5mg oral hydromorphone = 30mg oral morphine Drug Conversion using Ratios Problem #1: Patient is taking 6mg oral hydromorphone (Dilaudid) every three hours. Convert this to continuous-release or sustained release morphine. Equation 30mg oral morphine 7.5mg oral Dilaudid = X mg Morphine 48mg oral Dilaudid Cross multiply to solve for “x” 30 x 48 = 7.5 x 1440 = 7.5x 1440/7.5 = x 192 = x Drug Conversion using Ratios Problem #1: Patient is taking 6mg oral hydromorphone (Dilaudid) every three hours. Convert this to continuous-release or sustained release morphine. Divide the dose by the number of administration times per day to obtain the interval dose Continuous release morphine is dosed every 12 hrs 192mg / 2 (bid) = 96mg orally twice daily 100mg tablet or 90 mg [three 30mg tablets] Breakthrough dose 10-15% of the 24 hour dose 180mg/24hrs (90mg bid) 10%=18mg; 15%=27mg 15-30mg MSIR every 2hrs as needed for breakthrough pain Drug Conversion using Ratios PROBLEM #2 What dose of oxycodone is equivalent to 50mg oral Demerol? Tylox 2 tabs every 4 hours is not controlling your patient’s pain. Would it be more effective to place her on Demerol (meperidine) 50mg every 4 hours? PROBLEM #2 What dose of oxycodone is equivalent to 50mg oral Demerol? Review the equianalgesic chart for equivalence guidelines 20mg oral oxycodone = 300mg oral meperidine (Demerol) Equation 20mg oral oxycodone 300mg oral Demerol = X mg oral oxycodone 50mg oral Demerol Cross multiply to solve for “x” 20mg x 50mg = 300mg x 1000mg = 300x 1000/300 = x 3.33 = x PROBLEM #2b: Tylox 2 tabs every 4 hours is not controlling your patient’s pain. Would it be more effective to place her on Demerol 50mg every 4 hours? What dose Tylox contain? If two(2) Tylox are taken each dose, what dose of oxycodone & Tylenol is consumed? 5mg oxycodone & 500mg Tylenol 10 mg oxycodone & 1000mg Tylenol Should you switch to Demerol 50mg? No – You will be decreasing the analgesia from the 10mg to 3.33mg PROBLEM #2b: Is it appropriate to order/administer Tylox 2 every 4 hours? Why or why not? 500mg Tylenol x 2 tablets x 6 doses/24 hrs = 6000mg Tylenol What is the maximum dose of Tylenol for 24 hours? 4 grams (4000mg) Pain Treatment – Drug Therapy Non-Opioids Analgesics Opioids Tylenol Aspirin NSAIDs Opioid Agonists Weak mu agonists Partial Agonists Mixed agonist-antagonists Adjuncts Anticonvulsants Antidepressants Pain Treatment – Drug Therapy Adjuncts Anticonvulsants - lancinating Antidepressants - burning Corticosteroids (Decadron, Prednisone, methylprednisolone) – bone metastasis Muscle Relaxants Adrenergic Agonists – neuropathic IT Anesthetics Pain Treatment – Routes Oral & Sublingual Rectal Topical & Transdermal Intranasal Parenteral Subcutaneous Intramuscular Intravenous IVPB IVP Continuous IV Infusion IV PCA* Epidural or Intrathecal* Regional – Nerve Blocks Non-Pharmacologic Therapies Physical & Cognitive Therapies Acupuncture Heat & Cold Exercise Massage PENS & TENS Pressure Vibration Activity Splint Immobilization Positioning Dim Lights Distraction Music Radio TV Reading Hypnosis Imagery Relaxation breathing Art therapy Progressive muscle relaxation Syllabus [email protected] TJC Standards r/t Pain Management Excellent tool to assess compliance Pain Knowledge & Attitude Survey – 40 item Pain Guidelines Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (5th ed) – American Pain Society American Society of Pain Management Nurses (ASPMN) Pain Clinical Manual (1999wait for new edition)-McCaffery & Pasero Pain/Palliative Care Resource Center (online)-Dr. Betty Ferrell Pain Management Workshop CD set – Maureen Carling Conclusion Knowledge & Attitude Survey Pain Definition Pain Assessment Pain Tx & Nursing Interventions Equianalgesic Drug Dosing Questions? [email protected] ADDITIONAL DATA SLIDES Pain Treatment – IV PCA (Patient Controlled Analgesia) Loading Dose / Bolus Dose PCA dose Lockout Time Interval Basal / Continuous Rate* One hour limit (or 4 hour limit) Hospital Order Standard Orders Pain Treatment – IV PCA (Patient Controlled Analgesia) Nursing Considerations Pump programming errors Over sedation – monitor sedation Appropriate Drug Appropriate concentration programmed 1mg/ml Morphine 0.2mg/ml Dilaudid 25mcg/ml Fentanyl Watch for increasing sedation; SEDATION PRECEDES RESPIRATORY DEPRESSION!! Pain Treatment – IV PCA (Patient Controlled Analgesia) Nursing Considerations Know hospital’s policy Dual check of PCA pump at set up Vital signs – Every 4 hours Sedation – every 30min x 4, then every 2hrs Document # of PCA injections and # of attempts every 4 hours on flow sheet Side effect management: Pruritis, urinary retention, nausea, vomiting, sedation, headache, respiratory depression, hypotension Sedation Sedation precedes respiratory depression 0 1 2 3 S = = = = = Alert Occ. drowsy, easy to arouse Freq. drowsy, easy to arouse Somnolent, difficult to arouse Normal sleep, easy to arouse Pain Treatment – Intraspinal Delivery Epidural – Epidural space Intrathecal – Subarachnoid space Percutaneously placed temporary catheter Surgically implanted catheter Epidural Analgesia Opioids Opioid Bolus Dose Morphine 1-10 mg Peak in blood 30-60 min Duration Infusion Rate/hr 6-24 hr 0.5-2 mg Fentanyl 50-200 mcg 10-15 min 4-5 hr 50-100 mcg Dilaudid 0.5-3.0 mg 10-20 min 6-17 hrs 0.15-0.3 mg Demerol 10-40 mg 10-20 min 4-6 hr 5-20 mg Local Anesthetic 0.625mg/ml (1/16%) 1.25mg/ml (1/8%) Side Effects of Epidural Analgesia Local Anesthetic Sensory Loss Motor weakness Postural blood pressure drops Venous pooling Urinary retention Opioids Nausea & Vomiting Pruritis (Itching) Respiratory Depression Urinary Retention Motor weakness Side Effects of Epidural Analgesia Sensation T12 - Hips T10 – Umbilicus T6 – Xiphoid T4 - Nipples Motor N = Normal D = Diminished Fentanyl – lipophilic (more soluble in lipids) acts more quickly, remains in area, bolus+infusion Morphine (Duramorph preservative free) hydrophilic, rostral spread, lasts longer, single IT Pain Treatment – Interventional Therapy Nerve Blocks – Regional anesthesia Local infiltration of anesthetics into the surgical area Injection of anesthesia into a specific nerve Occipital or pudendal block Injection – nerve plexus Brachial plexus block Celiac plexus block Pain Treatment – Interventional Therapy Neuroablative Techniques – Destroy nerve interrupting pain transmission Neurectomies, rhizotomies & sympathectomies Cordotomies Tractotomies Surgical resection – Thermocoagulation – Radiofrequency coagulation