care conference pain management
TRANSCRIPT
PAIN MANAGEME
NT
TYPES OF PAIN• Acute• Chronic• Nociceptive• Neuropathic
7
ACUTE• Elicited by injury to body tissues• Typically seen with trauma, acute
illness, surgery, burns, or other conditions of limited duration; generally relieved when healing takes place.
CHRONIC• Elicited by tissue injury• May be perpetuated by factors remote from
the original cause and extend beyond the expected healing time; generally lasts longer than 3 months
P a i n c l a s s i fi c a ti o nC l i n i c a l t y p e s
Acute pain Chronic pain Results from noxious stimuli
that activates nociceptors neuron
It accompanies surgery, traumatic injury, tissue damage, and inflammatory processes.
Self-limited, resolves over days to weeks, but can persist for 3 months
Treatment is short term and curative
Results from: nociceptors, visceral, or somatic
It accompanies chronic disease, untreated condition.
Unresolved as long as underlying cause is present.
Treatment goal oriented, multidisciplinary approaches.
NOCICEPTIVE• Elicited by noxious stimuli that damages
tissues or has the potential to do so if the stimuli are prolonged.– Somatic pain: arises from skin, muscle, joint,
connective tissue, or bone; generally well localized and described as aching or throbbing.
– Visceral pain: arises from internal organs such as the bladder or intestine; poorly localized and described as cramping.
NEUROPATHIC
CARECONFERENCE
PATIENT BIODATA• Mrs T• F/54• Med History – Hypertension (2010)• Surg History – Nil• Family History – Nil• Allergic – Nil• Admission – 27/5/16 @ 2130HRS
ON ADMISSION• Wheel chair.
• C/O skidded and fall at home with injury to left elbow.
• ▲Displaced # right lateral humerus
• Conscious, anxious.
ASSESSMENT
• VITAL SIGN : Temperature – 37.4˚C Heart Rate – 98 bpm Respiration – 22 bpm Pain Score - 5/10 Weight – 67 kg
ACTIVITIES DAILY LIVING
• Ambulate
• Side rail
• All normal
PHYSICAL EXAMINATION
• Bandage and arm sling at right hand• IV branula 23G at left hand
Seen by MO :- IM Pethidine 50mg STAT (given at 1930 hrs)- X-ray right hand
Tab PCM 1gm TDS IM Pethidine 50mg 8 hourly / PRN For ORIF & K-wiring right humerus and
cast / backslab CM ↓GA Call case at 11am on 28/5/16
S/B Dr J at casualty at 2015Hrs :
ANATOMY&
PHYSIOLOGY
Peripheral Excitatory Mediators(Pain)
Substance
Receptor Mechanism
Substance P(SP)
NK1 neuronal excitability, edema
Prostaglandin(PG)
PG Sensitize nociceptors, inflammation, edema
Bradykinin B2 (normal)B1 (inflammation)
Sensitize nociceptors PG production
Histamine H1 C-fiber activation, edema,vasodilatation
Serotonin 5-HT3 C-fiber activation, release SPNorepinephrine
(NE)
1 Sensitize nociceptorsActivate nociceptors
TREATMENT
OPERATION• Open reduction
internal fixation & K-wiring left humerus ↓ GA on 28th May 2016
POST OPERATIVE ORDER
• Allow orally• Discharge CM• Tab Arcoxia 120mg OD• IV Unasyn 1.5gm TDS
MEDICATION
Combination AnalgesicsRationale
Multimodal analgesiaMultiple sites of action target multiple pain
pathwaysComplementary pharmacokinetic activityPotentially synergistic analgesic effect Reduced adverse event profile with comparable
efficacy
DRUGS DATE ORDERED
DATE OFF
IM Pethidine 50mg STAT 27/5/16 27/5/16
Tab PCM 1gm TDS 27/5/16 29/5/16
Tab Arcoxia 120mg OD 28/5/16 29/5/16
IM Pethidine 50mg 8hrly /PRN
27/5/16 29/5/16
IV Unasyn 1.5gm TDS 28/5/116 29/5/16
COMPLICATION
PAINASSESSMENT
NURSING CARE PLAN
&
GENERAL STRATEGY• Assessment• Analysis• Planning and
Implementation/Intervention• Evaluation and Ongoing monitoring• Documentation
ASSESSMENT• Primary and secondary
assessment• Focused assessment –Subjective data collection–Objective data collection
27/5/16 @ 2130HRS
• VITAL SIGN : Temperature – 37.4˚C Heart Rate – 98 bpm Respiration – 22 breath/min Pain Score - 5/10 Weight – 67 kg Tab PCM 1gm given Informed to NBM 12MN
27/5
2130hr
IA
MRS T
XXXXX
F / 54
DR J
5
A
Righthand
Movehand
Rest
5
1234
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
√
√
√
√
27/5/16 @ 2230HRS
• VITAL SIGN : Pain Score - 2/10 No medication given
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
√
√
√
√
27/5
2130hr
RA
MRS T
XXXXX
F / 54
DR J
27/5
2230hr
IA
5
A
Righthand
Movehand
Rest
5
1234
2
A
Righthand
Movehand
Rest
2
1234
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
√
√
√
√
27/5/16 @ 2330HRS
• PATIENT WAS SLEEPING Snoring
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
27/5/162330hr
√-
1234
√
√
√
√
27/5
2130hr
RA
MRS T
XXXXX
F / 54
DR J
27/5
2230hr
IA
27/5
2330hr
IA
5
A
Righthand
Movehand
Rest
5
1234
2
A
Righthand
Movehand
Rest
2
1234
0
----0
1234
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
27/5/162330hr
√-
1234
√
√
√
√
28/5/16 @ 0200HRS
• PATIENT WAS SLEEPING Snoring
27/5
2130hr
RA
MRS T
XXXXX
F / 54
DR J
27/5
2230hr
IA
27/5
2330hr
IA
5
A
Righthand
Movehand
Rest
5
1234
2
A
Righthand
Movehand
Rest
2
1234
0
----0
1234
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
27/5/162330hr
√-
1234
√
√
√
√
28/5/16 @ 0600HRS
• VITAL SIGN : Temperature – 36.5˚C Heart Rate – 91 bpm Respiration – 19 bpm Pain Score - 2/10 No medication given. Pre med at
0800hrs.
27/5
2130hr
RA
MRS T
XXXXX
F / 54
DR J
27/5
2230hr
IA
27/5
2330hr
IA
28/5
0600hr
IA
5
A
Righthand
Movehand
Rest
5
1234
2
A
Righthand
Movehand
Rest
2
1234
0
----0
1234
2
2
A
Righthand
Movehand
Sleep
1234
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
27/5/162330hr
√-
1234
√
√
√
√
28/5/160600hr
RA
√
√√√√
√
√
√√√
2
-
-
-
-
-
----
28/5/16 @ 0700HRS
• VITAL SIGN : Pain Score - 3/10 Patient just took bath No medication given
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
27/5/162330hr
√-
1234
√
√
√
√
28/5/160600hr
RA
√
√√√√
√
√
√√√
2
-
-
-
-
-
----
28/5/160700hr
√-
1234
27/5
2130hr
RA
MRS T
XXXXX
F / 54
DR J
27/5
2230hr
IA
27/5
2330hr
IA
28/5
0600hr
IA
28/5
0700hr
IA
5
A
Righthand
Movehand
Rest
5
1234
2
A
Righthand
Movehand
Rest
2
1234
0
----0
1234
2
2
A
Righthand
Movehand
Sleep
1234
3
3
1234
A
Righthand
Movehand
Rest
27/5/162130hr
IA5√
T. PCM1gm
-
√√√√
√
√
√√√
-
-
-
----
27/5/162230hr
√-
1234
27/5/162230hr
RA2√
√√√√
√
√
√√√
-
-
-
-
-
----
27/5/162330hr
√-
1234
√
√
√
√
28/5/160600hr
RA
√
√√√√
√
√
√√√
2
-
-
-
-
-
----
28/5/160700hr
√-
1234
28/5/160700hr
RA3√
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√
√
√√√√
-
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ANY