Pain Management

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Pain Management in the Home Health Client : 

Pain Management in the Home Health Client Program Development: Tracie Jones, RN WCC

Activity Disclosures : 

Activity Disclosures At Home Healthcare has been approved by the Texas Nurses Association to provide continuing education credits for program participants. This program has been awarded 1 contact hour that can be used toward licensure renewal. In order to successfully complete this course, the participant must view the presentation entirely and complete a course evaluation. At Home Healthcare, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. There are not any non-endorsements of products to disclose. Presentations will not include any discussion of the unlabelled use of a product or a product under investigational use.

What is Pain? : 

What is Pain? Pain is “whatever the experiencing person says it is, existing whenever and wherever the person say it does”. Margo Macaffrey RN, 1968

International Association for the Study of Pain : 

International Association for the Study of Pain IASP Defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

Prevalence of Pain : 

Prevalence of Pain Pain of any type is the most common reason for physician consultation in the United States, prompting half of all Americans to seek medical care annually. 1/3 of cancer patients have severe pain Important reason for home care admissions Pain is a reportable outcome in home health quality assurance programs.

Acute Pain : 

Acute Pain Pain that usually stops without treatment or responds to simple measures such as resting or taking an analgesic Post-operative pain that diminishes within expected time frames Can last from moments to weeks Caused by injury or trauma Abrupt, severe, short-lived

Acute Pain : 

Acute Pain Physicians are more comfortable treating acute pain, which usually is caused by soft tissue damage, infection and/or inflammation among other causes. It is usually treated simultaneously with pharmaceuticals or appropriate techniques for removing the cause and pharmaceuticals or appropriate techniques for controlling the pain sensation, commonly analgesics. Acute pain serves to alert after an injury or malfunction of the body.

Chronic Pain : 

Chronic Pain Intractable pain that responds poorly to simple measures and interferes with one’s ability to participate in physical activity Caused by disease and normal aging May be contributed to a single factor or combination of factors Defined as "the disease of pain".

Causes of Persistent Pain : 

Causes of Persistent Pain Headache Amputation Pressure Ulcer Improper Positioning PVD Osteoarthritis Lower Back Pain Rheumatoid Arthritis Arthritis Contractures Chronic Leg Cramps Post Stroke Syndrome Myofascial Pain Neuropathic Pain Degenerative Joint Disease

Consequences of Unrelieved Pain : 

Consequences of Unrelieved Pain

Types of Pain : 

Types of Pain Nociceptive Pain Somatic Visceral Neuropathic Pain Psychogenic Pain

Nociceptive Pain : 

Nociceptive Pain Nociceptive pain is due to a stimulation of a nociceptor, due to a chemical, thermal or mechanical event. It is the result of musculoskeletal or visceral injury and/or disease. Nociceptive pain presents as a aching, sharp, or throbbing sensation. It is universal after surgery and enhanced with positioning, coughing, laughing, and deep breathing. Cancer pain is a good example of nociceptive pain.

Nociceptive Pain : 

Nociceptive Pain Somatic Pain Superficial somatic pain produces sharp, well defined localized pain of short duration Caused by injury to skin Deep somatic pain originates from ligaments, tendons, bones, muscles, fascia, and blood vessels. Produces dull, aching, poorly localized pain of longer duration Visceral Pain Originates from the body’s viscera or organs Well localized pain Pain may radiate

Neuropathic Pain : 

Neuropathic Pain Damage to the nervous system itself brought on by disease or trauma. Peripheral neuropathic pain Central neuropathic pain

Neuropathic Pain : 

Neuropathic Pain Caused by lesions or physiologic changes in the nervous system Characterized by hypersensitivity either in damaged areas or in the surrounding normal tissue Qualities of burning, numbness, tingling, touch sensitivity, sharp and shooting sensations (lancinating pain) or electric shocks

Neuropathic Pain : 

Neuropathic Pain Persistent allodynia (pain resulting from a non-painful stimulus) Includes: Diabetic neuropathy HIV neuropathy Postherpatic neuralgia Postmastectomy syndrome Radiation and chemotherapy neuropathies

Psychogenic Pain : 

Psychogenic Pain Somatoform Pain Physical pain that is caused, increased or prolonged by mental, emotional or behavioral factors.

Effects of Unrelieved Pain : 

Effects of Unrelieved Pain Increased physiologic stress Diminished immunocompetence Reduced mobility Increased risk of pneumonia and thromboembolism Increased work of breathing Increased myocardial oxygen demands Spiritual despair Depression Anxiety

Pain Assessment : 

Pain Assessment Important Components Regular pain assessments including patients self report of pain Standardized pain scales Consistent documentation

Numeric Rating Scales : 

Numeric Rating Scales Numeric rating scale of 0 (representing no pain) to 10 (representing the most imaginable pain possible) Most common rating scale Not effective in children

Wong Baker FACES Chart : 

Wong Baker FACES Chart Visual Chart Useful with children and people with language barriers From Hockenberry MJ, Wilson D: Wong’s essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.

Pain Threshold & Pain Tolerance : 

Pain Threshold & Pain Tolerance Pain Threshold -the minimal amount of stimulus needed to elicit a response Pain Tolerance- indicates the degree of pain which the patient can tolerate before experiencing physical or emotional impairment

OPQRST Pain Assessment Method : 

OPQRST Pain Assessment Method O (Onset) When does the pain start? Does it come and go? P (Provacation/Pallitation) What were you doing when the pain started? What caused it? What makes it better? worse? Q (Quality/Quantity) What does it feel like? Is it sharp? dull? stabbing? burning? crushing? throbbing? nauseating? shooting? twisting? stretching? R (Region / Radiation) Where is the pain located? Does the pain radiate (i.e. spread to another location, e.g., pain source is from thumb but pain spreads to elbow)? Where does it radiate? Is it all in one place? Does it go anywhere else?

OPQRST Pain Assessment Method : 

OPQRST Pain Assessment Method S (Severity/Scale) How severe is the pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever? Does it interfere with activities? How bad is it when it's at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? T (Timing) When did the pain start, at what time? How long did it last? How often does it occur? Is it sudden or gradual? What were you doing when you first experienced or noticed it? How often do you experience it: hourly? daily? weekly? monthly? When do you usually experience it: daytime? night? in the early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

Pain Management Interventions : 

Pain Management Interventions Pharmacologic Rehabilitative Behavioral

Pharmacologic Interventions : 

Pharmacologic Interventions Treat both acute and chronic pain The most common drug categories for pain management include: Nonopiods Opiods Adjuvant analgesics

WHO 3 Step Analgesic Ladder : 

WHO 3 Step Analgesic Ladder

Acetaminophen : 

Acetaminophen One of safest analgesics Treats mild pain and supplements pain management in more intense pain syndromes Useful in the management of nonspecific musculoskeletal pain, osteoarthritis Quite effective as a “co-analgesic” Reduce or avoid in patients with renal insufficiency or liver failure.

NSAIDS : 

NSAIDS Reduce the biosynthesis of prostaglandins by inhibiting COX and the cascade of inflammatory events that cause, amplify, or maintain nociception Directly affect the PNS and CNS ASA and Ibuprofen are nonselective and can cause GI ulceration, renal dysfunction, and impaired platelet aggregation

NSAIDS : 

NSAIDS Useful in treating inflammation Can cause nausea, constipation and sedation in elderly Useful in moderate to severe pain control either alone or a adjunct Decreased renal, liver failure, and platelet dysfunction are contraindications Useful in treating inflammation Can cause nausea, constipation, and sedation in elderly Useful in moderate to severe pain control either alone or a adjunct Contraindicated in patients with decreased renal function, liver failure, and platelet dysfunction

Step 2: Opiods : 

Step 2: Opiods Used to treat moderate pain Given around the clock as needed for pain Opiods include: Codeine Hydrocodone Oxycodone Darvocet TramadolMorphine Hydromorphone Oral transmucosal fentanyl citrate

Opiod Analgesics : 

Opiod Analgesics Most useful agent for the treatment of pain associated with advanced disease Reduce pain-producing signal and perception throughout the CNS regardless of the etiology of the pain

Step 3: Refractory Pain : 

Step 3: Refractory Pain Long-acting opiods for moderate to severe pain Consider using a non-opiod in conjunction with opiod and adjuvant medication as necessary Given around the clock for chronic pain

Adjuvant Analgesics : 

Adjuvant Analgesics Adjuvant analgesics are drugs whose initial use was not for pain, but rather for other conditions. Includes: Antidepressants (TCA’s: Elavil) useful in the treatment of migraine headache, tension-type headache, post-herpetic neuralgia, painful diabetic neuropathy, arthritis, low back pain, and other painful conditions. These drugs have been shown to relieve pain independent of their effects on depression; that is, patients who are not depressed may experience pain relief

Adjuvant Analgesics : 

Adjuvant Analgesics Anticonvulsants- Gabapentin Alpha 2 Antagonists such as Zanaflex Local Anesthetics Steroids Muscle Relaxers such as Baclofen (also treats nerve pain) Topical- Lidoderm for the treatment of post herpetic neuralgia. Capsaicin (nerve pain and arthritis pain) Biophosphonates inhibit osteoclast- mediated bone reabsorption and alleviate pain related to metastic bone disease Calcitonin-useful for bone and neuropathic pain Chemotherapy and Radiation Therapy- relieves symptoms of cancer

Drug Treatment for Neuropathic Pain : 

Drug Treatment for Neuropathic Pain Corticosteroids Useful for neuropathic, visceral, and bone pain syndromes Anticonvulsants Relieve pain by blocking sodium channels Neurontin Tricyclic antidepressants Inhibits norepinephrine and serotonin reuptake Local anesthetics Antiepileptic drugs Lyrica Relieves neuropathic pain

Alternative Treatment Options : 

Alternative Treatment Options Rehabilitation Therapeutic Massage Electrical Stimulation Acupuncture Cognitive Interventions Music Therapy Rehabilitation

Rehabilitation : 

Rehabilitation Therapy is beneficial in pain management. Mobility may be improved by strengthening, stretching, and the use of assistive devices. Home settings vary in their utility for a debilitated person as does the degree of assistance that can be provided by caregivers. Therapy can improve both range of motion and passive range of motion and positioning and in doing so, alleviate pain.

Heat/Ice Treatments : 

Heat/Ice Treatments Rotate the application of heat and ice Each application should last about 20 minutes Benefits: Increase circulation Decrease swelling Reduce/ alleviate pain

Electrical Stimulation : 

Electrical Stimulation Provides short-term pain relief by delivering a low-voltage electrical current through the skin via electrodes placed near the injured tissue The electricity from the electrodes stimulates the nerves and interferes with the brains normal pain perception TENS Unit

Ultrasound : 

Ultrasound Deep heating treatment modality that is effective in heating deep joint tissues Contraindicated in acute inflammatory conditions where it may precipitate the inflammatory process

Therapeutic Massage Therapy : 

Therapeutic Massage Therapy Focus is on the whole body in relation to the soft tissues, so many experience decreased pain and anxiety Conditions: Diabetes Chronic Pain Syndromes Depression Fibromyalgia

Chiropractic & Acupuncture Treatments : 

Chiropractic & Acupuncture Treatments Chiropractic Treatments Beneficial for bone mediated pain; treatments usually involve adjusting the joints and bones in the spine using twisting, pulling, and pushing movements Acupuncture Treatments Useful for malignant pain May be an effective antidepressant Research has shown a positive effect on COPD, asthma, and cancer

Immobilization : 

Immobilization Limits mobility and relieves pain Examples: Braces Splints Support belts

Cognitive-Behavioral Therapy (CBT) : 

Cognitive-Behavioral Therapy (CBT) Based on the idea that thought and behavior patterns enhance the physical symptoms Focuses on relaxation techniques and stress management Examples: Meditation Therapeutic activities such as enjoying art, music, literature, and play

Physician Notification : 

Physician Notification Notify physician of unrelieved pain > 5 on 1-10 scale. Pain is a symptom of the disease and could signal a worsening disease processes.

Nursing Specific Interventions : 

Nursing Specific Interventions If your patient has pain during your visit, ADDRESS IT!! Don’t just tell the patient what to do. Help the patient do it. Apply a heating pad or ice pack to the site or administer pain medications. TEACH the patient alternative techniques and demonstrate how to use them. Evaluate the effectiveness of your pain interventions.

FOLLOW- UP : 

FOLLOW- UP Adequate follow-up must take place. If the patient responds to the pain medications and/or alternate treatments, call them the next day and assess if the patient’s pain remained under control. Assess for complications and side effects of the medications. Follow-up with MD regularly. Remember, you are your patient’s advocate!!

Words of Wisdom! : 

Words of Wisdom! Unrelieved pain will retard the client’s progress and can lead to further physical, functional, and emotional decline. Do your part as a clinician to keep the patient’s pain under control.

References : 

References Hockenberry MJ, Wilson D: Wong’s Essentials of Pediatric Nursing. ed. 8, St. Louis, 2009, Mosby. Philip, Ian. “Assessment in Pain of Older Adults.” Royal College of Physicians. October 2007. October 2008. http://www.rcplondon.ax.uk/pubs. Turk, Denis. Psychological Approach to Pain Management: A Practitioner's Handbook. Guilford Press. 2002.

Conclusion : 

Conclusion Please fill out and submit a course evaluation upon completion. Your certificate of completion will be emailed to you if you have provided an email address or mailed to your home. Thank you!