1 / 22

PAIN MANAGEMENT

PAIN MANAGEMENT. Paula A. Caron MS, APRN, ACHPN New Hampshire Hospice and Palliative Care Organization Annual Conference November 10, 2011. Assumptions…………… . You know basic physiology about pain You know the definition of pain

lamond
Télécharger la présentation

PAIN MANAGEMENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. PAIN MANAGEMENT Paula A. Caron MS, APRN, ACHPN New Hampshire Hospice and Palliative Care Organization Annual Conference November 10, 2011

  2. Assumptions…………… • You know basic physiology about pain • You know the definition of pain • You know adjuncts to pharmacologic management of pain (massage, acupuncture, TENS, etc) • You have basic pain assessment skills

  3. Pain Satisfaction(?type of pain) • More than 75% of a sample of 316 people reported being satisfied with their pain management • Nearly half rated their pain as moderate to severe • Dawson et al (2002) Journal of Pain and Symptom Management, 23, 211-221.

  4. Pain Satisfaction • 81% of 191 patients reported satisfaction with pain management despite 76% of them describing their pain as moderate to severe • Svensson, et al (2001) European Journal of Pain, 5, 125-133

  5. “being listened to” ranked most important over pain management which was ranked second in a survey asking patients to rank nursing interventions • Webb & Hope (1995), Clinical Journal of Oncology Nursing, 4, 101-108.

  6. Research has shown that relief of pain is not as important to satisfaction as are communication, staff behavior and empathy • Hallstrom & Elander (2001), Nursing Ethics, 8, 409-418. • Corroborated by Dawson et al where the patient-provider relationship was an important predictor of patient satisfaction • Dawson et al (2002), Journal of Pain and Symptom Management, 23, 211-221.

  7. Inadequate pain assessment is probably the most common barrier to successful management • Therefore, adequate assessment is key to successful management • AND……….patient satisfaction DUH

  8. So in the process of conducting a thorough assessment, the nurse conveys a sense of caring which not only validates the pain experience but may actually be therapeutic to reduce pain levels

  9. Opioid Therapy: Guidelines • Use a long-acting drug and a breakthrough medication • Increase breakthrough dose as the baseline dose increases • Treat side effects aggressively and proactively; some will extinguish (sedation, nausea)

  10. Routes of administration • Transdermal • Fentanyl • Topical • EMLA, Lidoderm • Parenteral • IV/SQ/IM • IM worst way • Spinal • Epidural/Intrathecal • Oral • Immediate Release • Long Acting • Liquid • Mucosal • Actiq • Rectal • 90% concentration achieved

  11. Where to start…… • If patient is opioid naive, start with oxycodone or morphine • Oxycodone 5 mg Sig: 1-2 tabs every 2 hours prn pain • Morphine 15 mg Sig: ½ to 1 tab every 2 hours prn pain Ask patient to keep a log (if outpatient) of use

  12. Where to start……… • If a patient is using more than 4 doses of short acting medication a day to stay comfortable OR If pain is not well relieved Consider addition of a long acting opioid

  13. So which one? • Long acting formulations available: • Morphine • Oxycodone • Fentanyl • Methadone

  14. TOLERANCE PSYCHOLOGICAL DEPENDENCE / ADDICTION PHYSICAL DEPENDENCE

  15. Tolerance • A state of adaptation in which exposure to a drug results in a decrease in the drugs effect over time. • Physiologic Dependence • A state of physical adaptation that is manifested by a specific withdrawal syndrome that is produced by rapid cessation of the drug. • Addiction • A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors

  16. TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

  17. PHYSICAL DEPENDENCE A normal physiological phenomenon in which awithdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

  18. PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

  19. Beware of the Pseudoaddict!! Pseudoaddiction is .. • The behavioral manifestations of addiction that occur as a result of under treated pain • Moaning/crying when you enter the room • Clock watching • Frequent requests for more medication • Pain that seems “excessive” for the stimulus • Patient has no other history to suggest addiction • Behaviors cease with adequate pain treatment

  20. Pseudoaddiction Typically occurs in the hospitalized patient, in pain, who has opioids ordered: • At inadequate potency or dose • At excessive dosing intervals • And when the behavior is reinforced by MD or RN behavior that tends to limit opioid use: “you really shouldn’t be having this much pain” “you have to wait another two hours for your next dose of medication”

  21. Opioids • Adverse Effects • Allergic Reactions - extremely rare • Respiratory Depression - extremely rare • Almost always preceded by sedation • Most common in an opioid naïve patient • RR of 6-8 may be normal if oxygenation is ok • Narcan can be given - mix one ampule (0.4mg) in 10cc of saline and push 1ml at a time. Duration is 30-60minutes • Constipation - expected and doesn’t get better • “The hand that writes the opioid order without writing a bowel prep is the hand that does the disimpaction” • EG: Senokot 1-2 po bid with MOM QHS, prn

  22. Opioids • Adverse Effects • Sedation • Can occur, but tolerance usually develops • If a patient has been exhausted from pain, relieving the pain may finally allow them to rest • Urinary Retention • More common with opioid naïve patients and those receiving meds spinal route. Tolerance in a few days. • Nausea/Vomiting • Tolerance usually occurs • Pruritus • Tolerance usually occurs

More Related