pain part 2

Pain ManagementPain Management

Part II

Pain Intensity or Rating ScalesPain Intensity or Rating Scales

• Numbers

• Visual analogue

• Words

• Colors

• Faces

• Behavior / physiologic signs

Pain Intensity or Rating ScalesPain Intensity or Rating Scales

• Patient’s report of pain– Single most important indicator of intensity

of pain– Provider’s overrate or underrate pain– Inaccuracy greater when patient’s pain is

severe

Pain Intensity or Rating ScalesPain Intensity or Rating Scales

• Pain intensity scales

• Easy and reliable

• Provide consistency in communication of pain

• 0 – 10 range

• Word modifiers may help some apply

Pain Intensity or Rating ScalesPain Intensity or Rating Scales

• Effective Use– Understand use of scale– Educated about how information will be used

• Determine changes in condition• Effectiveness of pain management interventions

– Ensures adequate pain management achieved

No Pain Worst Pain

0 1 2 3 4 5 6 7 8 9 10

Numeric Scale

No Pain

Mild Moderate Severe Very Severe

Worst

No Pain Worst Pain

Visual-Analogue Scale*

Usually 0-10 cm long line.Placed either vertical or horizontal.

VAS: Coloured Analogue Scale(Ref: McGrath, PA, et al: Pain, 1996.)

Wong-Baker FACES Pain Rating Scale

0 2 4 6 8 10

Sample of Child’s FACES Pain Rating Scale

• Oucher scale (Beyer)

• White child, 3 year-old male

Photographic/Numeric Pain Scale

• Oucher scale (Beyer)

• Black child, school age, male

Photographic/Numeric Pain

Scale, cont.

• Oucher scale (Beyer)

• Hispanic child, school age, male

Photographic/Numeric Pain

Scale, cont.

Cultural Preference for Scales

100 African-American children with SCD rated preference of 3 scales:

• FACES -- 56%• Black Oucher -- 26%• VAS -- 18%• Validity was strongest for FACES, then

Oucher and VAS

Ref: Luffy R: Pediatric Nursing, Jan 2003.

Pain Intensity or Rating ScalesPain Intensity or Rating Scales

• Wong-Baker FACES Pain Rating Scale– Children– Elderly with impairments

• Cognition • Communication

– People who do not speak English

• Includes number scale in relation to each expression

Pain Intensity or Rating ScalesPain Intensity or Rating Scales

• When a scale can’t be used– Rely on observation of behavior– Rely on physiologic signs– Use input of significant others

• Parents/caregivers• Help interpret observations

Nonverbal responses to painNonverbal responses to pain

• Facial expression

• Vocalizations like moaning and groaning or crying and screaming

• Immobilization of the body or body part

• Purposeless body movements

• Behavioral changes such as confusion and restlessness

• Rhythmic body movements or rubbing

QUESTTQUESTT

• Question the patient

• Use pain rating scale

• Evaluate behavior and physiologic signs

• Secure family’s involvement

• Take cause of pain into account

• Take action and assess effectiveness

Comprehensive Pain History Comprehensive Pain History • COLDERR

– Character– Onset– Location– Duration– Exacerbation– Relief– Radiation

– O– L– D– D– E– R

Characteristics of PainCharacteristics of Pain

• Quality– What does it feel like– Record patient’s words that he describes– Provides information useful in diagnosing

cause of pain

• Intensity– Important to obtain estimate of intensity– Evaluate effectiveness of treatment

Characteristics of PainCharacteristics of Pain

• Aggravating and Alleviating Factors– Include behaviors or activities that influence pain– Helps in care planning

• Associated Manifestations– Impact on ADLs

• Sleep, work, activities• Appetite, mood, sexual function, recreational activities

– Pain is fatiguing• Longer experience pain the greater the fatigue• Stress response of pain continues in sleep

– Physiological consequences• Pain more severe in morning

Characteristics of PainCharacteristics of Pain

• Meaning of Pain– Soldier vs civilian

• Objective Data– Physiologic

• Activates sympathetic nervous system– ↑ HR, RR, BP, – Diaphoresis, pallor, muscle tension, dilated

pupils

• Chronic pain shows adaptation

Characteristics of PainCharacteristics of Pain

• Behavioral– Crying, moaning– Rubbing site, restlessness– Distorted posture, clenched fists, guarding– Frowning, grimacing

• Speaks of discomfort

• Restless

• Afraid to move

Characteristics of PainCharacteristics of Pain

• Location– Point to place in body– Ask if more than one site– Radiates, deep, superficial

• Onset, Duration– How long existed– Triggers– Patterns – worse am, pm, getting up, etc.

Nurse’s RolePatient Advocate

Nurse’s RolePatient Advocate

• Primary Concern-Comfort

Practice GuidelinesPractice Guidelines

• Establish a trusting relationship

• Consider client’s ability and willingness to participate

• Use a variety of pain relief measures

• Provide pain relief before pain is severe

• Use pain relief measures the client believe are effective

• Align pain relief measures with report of pain severity

Practice GuidelinesPractice Guidelines

• Encourage client to try ineffective measures again before abandoning

• Maintain unbiased attitude about what may relieve pain

• Keep trying

• Prevent harm

• Educate client and caregiver about pain

Barriers to Effective TreatmentBarriers to Effective Treatment

• Lack of knowledge of the adverse effects of pain

• Misinformation regarding the use of analgesics

• Misconceptions about pain

• May not report pain

• Fear of becoming addicted

Pharmacologic InterventionsPharmacologic Interventions

• Opioids (narcotics)

• Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS)

• Co-analgesic drugs

Opioids (Narcotics)Opioids (Narcotics)

• Full agonists– No ceiling on analgesia– Dosage can be steadily increased to relieve

pain– morphine, oxycodone, hydromorphone

NSAIDSNSAIDS

• Vary little in analgesic potency – vary in anti-inflammatory effects, metabolism,

excretions, and side effects

• Have a ceiling effect

• Narrow therapeutic index

• acetaminophen, ibuprofen, aspirin

Coanalgesic DrugsCoanalgesic Drugs

• Antidepressants

• Anticonvulsants

• Local anesthetics

• Others

WHO Ladder Step Approach for Cancer Pain Control

WHO Ladder Step Approach for Cancer Pain Control

Rational PolypharmacyRational Polypharmacy

• Evolved from WHO three step approach• Demands health professionals be aware of all

ingredients of medications that alleviate pain • Use combinations to reduce the need for high

doses of any one medication• Maximize pain control with a minimum of side

effects or toxicity• Combined with multimodal therapy (e.g.

nondrug approaches)

Oral AdministrationOral Administration• Preferred because of ease of

administration

• Duration of action is often only 4 to 8 hours

• Must awaken during night for medication

• Long-acting preparations developed

• May need rescue dose of immediate-release medication

Transdermal AdministrationTransdermal Administration

• Transmucosa and Transnasal– Enters blood immediately– Onset of action is rapid

• Transdermal – Delivers relatively stable plasma drug level– Noninvasive

RectalRectal

• Useful for clients with dysphagia or nausea/vomiting

Medication AdministrationMedication Administration

• Intramuscular– Should be avoided– Variable absorption– Unpredictable onset of action and peak effect– Tissue damage

• Intravenous– Provides rapid and effective relief with few

side effects

IntraspinalIntraspinal• Provides superior analgesia with less medication used

PCAPCA

• Patient-controlled analgesia– Minimizes peaks of

sedation and valleys of pain that occur with prn dosing

– Electronic infusion pump

– Safety mechanisms

Cognitive-Behavioral(Mind-Body)

Cognitive-Behavioral(Mind-Body)

• Providing comfort• Eliciting relaxation

response• Repatterning thinking• Facilitating coping

with emotions

Body InterventionsBody Interventions• Reducing pain triggers• Massage• Applying heat or ice• Electric stimulation (TENS)• Positioning and bracing (selective immobilization)• Acupressure• Diet and nutritional supplements• Exercise and pacing activities• Invasive interventions (e.g. blocks)• Sleep hygiene

Mind InterventionsMind Interventions

• Relaxation and imagery

• Self-hypnosis

• Pain diary and journal writing

• Distracting attention

• Re-pattern thinking

• Attitude adjustment

• Reducing fear, anxiety, stress, sadness, and helplessness

• Providing information about pain

Spirit InterventionsSpirit Interventions

• Prayer

• Meditation

• Self-reflection

• Meaningful rituals

• Energy work (therapeutic touch, Reiki)

• Spiritual healing

Social InteractionSocial Interaction

• Functional restoration• Improved communication• Family therapy• Problem-solving• Vocational training• Volunteering• Support groups