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    1. Pain Lecture in Basic Nursing Thursday November 1. 2007 Margrethe Truelsen

    2. Pain Content of Lecture Definition of pain Physiology Pain assesment Barriers for pain-relief and pain-perception Pain Treatment - pharmacological - others Specific pain - cancer patients - dying patients - operation Cases and questions

    3. Pain WHO's definition of pain: an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Under normal circumstances, one tries to avoid pain. If you experience pain you want to do something about it, like taking pain killers, seeking medical help, or avoiding movements or positions that make the pain worse.

    4. Pain When the body has been damaged, like a cut or a fracture, pain is experienced. Also, pain is a warning signal and lets the body know that if nothing is done, the body is at risk for damage, for example when touching a very hot object. Pain activates the sympathetic nervous- system, resulting in increased heartrate and blood-pressure as well as reduced blood- circulation in the skin (capillaries). If sudden pain occurs, the body is withdrawn quickly and automaticly from the cause of the pain.

    5. Physiology Pain is noticed through painfibres, which is special sensoric neurons with several painreceptors. The painreceptors are also called nociceptors and are affected by both temperature, chemical and mechanical stimuli in the tissue. In the dorsal horn of the spinal cord the painfibres transmit the painsignal to neurons, which then carries it to the brain. Transmitting of the signal is controlled by gating. Small cells releasing trans- mitter substances that allows the signal to move on. These substances are also known as endorphins (opioids).

    6. Physiology

    7. Nociceptive pain Somatic - originates from bones, ligaments, skin, muscle etc. - high density of nociceptors. - pain is easy to localise. - the feeling of the pain is sharp. Visceral - originates from internal organs or hollow structures. - low density of nociceptors. - pain is hard to localise. - the feeling of the pain is aching, gnawing. Sometimes nausea.

    8. Pain Sensitisation: When the pain-pathway becomes oversensitive it is called sensitisation. If the nociceptors continues to register signals, they will become very sensitive and begin to react to even weak stimuli. This can lead to chronic pain. Referred pain: Painfibres from the skin and from the internal organs can meet the same neuron in the spinal cord. When the signal is transmitted, the brain can think that the pain comes from a different place than where it originates. This is called referred pain. An example is a heart attack, where the patient feel the pain in the left shoulder and left arm.

    9. Pain assesment As a nurse it is very important to collect data about the patients pain. But pain is a very complicated thing to measure, because it is a subjective feeling and often difficult to describe. Pain is not only a physical sensation, but also an emotional experience and the nurse must listen carefully to the patient in order to understand and asses the quality of the pain. Several tools have been developed to try and standardise the measurement of pain. I will present some of them on the next slide.

    10. Pain assesment VAS Visual Analogue Scale Is shaped like a 10 cm ruler. One end is no pain and the other end is worst imaginable pain. Between these two points is a marker that the patient can move and place where he finds suitable. Sometimes it can also have pictures of facial expressions. NRS Numerical Rating Scale Very similar to VAS, but instead of words and pictures there is a numerical scale from 1 to 10 and the patient rate his pain according to this. VDS Verbal Descriptor Scale This scale consists of 3-5 words describing pain and the patient can choose which term describes his pain best. This scale is not very sensitive and maybe more difficult for the patient.

    11. Pain assesment These tools require the cooperation of the patient and the result can only be compared to other measurements from the same patient. It is not possible to compare results from different patients. Sometimes the patient is not capable of describing his pain (for example confused patients, children etc.) Then the nurse must observe other signs of pain like high pulse and blood pressure, cold but sweating. If the patient is restless, irritable and fidgety it can also be a sign of pain.

    12. Barriers for pain-relief and pain-perception Barriers in the patient: Many circumstances influence the way the pain is experienced by the patient. - Knowledge and information about the cause of the pain. - Expectations about the pain and pain-relief. Patient can feel bad about asking for pain-medication for different reasons; do not want to trouble the nurse, do not like eating pills or get injections, afraid to be addicted to the medicin. Barriers in the nurse: If the prescription from the doctor is p.n. (pro necessitate) then it is the nurse' responsibility to make sure that the patient has no pain. Some nurses are afraid that opoids will cause addiction and therefore tend to give the patient less than needed. Some nurses think that the pain medication will hide other symptoms. Finally many wards lack guidelines for use of pain-medication.

    13. Pain Treatment - pharmacological Paracetamol: This drug is a weak analgetic and is used for mild to moderate pain. It has a systemic effect on the CNS (Central Nerve System). Since the drug rarely has side effects it is commonly used. Overdose can affect the liver though, and it is important to administer antidote immidiately to avoid liver failure. NSAID: Non-stereoid anti-inflammatory drugs covers a range of different substances (salicylic acid, ibuprofen etc). They prevent activation of the nociceptors and are also used for mild to moderate pain. The side effect is a risk of stomach and intestinal bleeding or ulceration, since the drug inhibits blood-coagulation.

    14. Pain Treatment - pharmacological Opioids This drug binds to the natural opioid-receptors in the neurons and thereby inhibits the pain-signal. It is a powerful analgetic and is used for strong pain. It has several side effects like nausea, constipation, sedation and in worst case it can repress respiration. The drugs can be divided into weak opiods and strong opioids and there is a risk that the strong opiods can cause addiction. This happens very rarely and only if they are used in the wrong way. Weak Opiods: Codein, Tramadol Strong Opioids: Morphine, Fentanyl, Methadone

    15. Pain Treatment - other Massage: Touching and pressing the skin can relieve pain because it stimulates the same neurons as the pain signal. In this way the two signals compete and the patient feel less pain. Heat/cold: Cold and hot compresses have the same effect as massage. They compete with the pain-signal and the patient feel relieved of the pain. Acupuncture: Is used in many situations also in western hospitals. It is said to release the natural opiods of the body.

    16. Pain Treatment - other Relaxing Techniques: Since a part of the pain experince is psycologic and emotional, it can be relieved by different methods of relaxing. Breathing exercises or music can be used to make the patient relax. Information: Many patients are in pain because they are anxious and nervous about their disease and the symptoms and because they do not know what is going to happen. So a way to relieve the pain is to listen carefully to the patients concern and to give him the information he needs to feel more calm.

    17. Pain Treatment - administration It is always the doctor that prescribes pain medication for the patients, but it is most often the nurses who administers the medicin. It is important that the nurse understands the reason for the prescribed medicin, so she is capable of answering questions from the patient and to provide the right information. Depending on the prescription it is up to the nurse, in cooperation with the patient, to asses the pain and in some cases to decide when to administer the medication.

    18. Pain Treatment - administration Regularly This method is not very demanding for the nurse, she just hands out the prescribed medicin at certain dessignated times. A bad thing about this method is that the timepoints may not be when the patient actually needs the medicin. PN (Pro necessitate when needed) When the prescription says PN, it is up to the nurse and the patient to asses the pain and to decide when to administer the medicin. It is important that the nurse has time to listen to the patient and to hand out the medicin when he needs it. PCA (Patient controlled administration) In this method the patient decides when to take the pain medication. He can have pills with him and take it when the pain occurs. For strong pain he may have an intravenous catheter and a pump, so when he presses a button a certain amount of medicin is released.

    19. Specific pain Cancer patients Cancer is a very complicated disease and pain treatment for these patients can be difficult. The pain often consists of both acute and chronic pain and has components of nociceptive and neuropathic pain. It is important to diagnose and treat the neuro- pathic pain as well as the nociceptive. Neuropathic pain does not respond to normal pain medication, but other drugs can be used like antidepressives, antiepileptic or glucocorticoids. It is important that the pain medication is distributed so the patient is relieved from pain both day and night. Regular intervals between the medicin is a good way to ensure this.

    20. Specific Pain Dying patients An important difference when you are taking care of a dying patient, is that the goal is not to cure the patient but to relieve him from pain and suffering. Many dying patients is more afraid of the pain than of death itself. Pain of dying patients also consist of many emotional aspects: Psychological pain afraid of pain/death, anxiety. Social pain worrying about relatives, afraid of dying alone without saying goodbye. Spiritual pain worrying about what comes after death, about the meaning of life. Relieve of physical pain is not enough, it is important to be with the patient and talk about all his worries.

    21. Specific Pain - Operation Pain treatment is extremely important in connection with an operation. Both before, during and after the operation the patient should be relieved of pain. Before if the patient is in pain before the operation, he should be given pain medication. This helps the patient relax and be more calm about the operation. During depending on the form of anaesthetic used, pain medication should be considered. Normally the patient is in universal anaesthetic and will not feel any pain. When local anaesthetic is used, it is important to cover all areas at risk of pain. After when the patient is waking up and in the days after operation, it is very important to keep the patient free from pain. This will help the patient to get mobilised and to have a fast recovery.

    22. Case Mr Lin is 58 years old and admitted to your ward because of lung cancer. He has been in and out of the hospital for several months and this time he is admitted because his pain is getting worse. Until now he has a patch with depot-fentanyl that he changes every day and then he has p.n. Morphine 5mg. Recently he uses a lot of p.n. medication and therefore the doctor changed the prescription so that he now gets 20mg morphine regularly x3/day. You think Mr Lin looks very tired and suffering from pain when you enter the room. You ask him to describe his pain. Mostly it hurts all over my body inside and outside, but sometimes I feel like my skin is burning, it is a strange tingling feeling. I also feel nauseous very often.

    23. Questions for case What do you think could be the cause of Mr Lin's pain ? What will you tell/suggest the doctor about Mr Lin's pain ? What will you say to Mr Lin ? Mr Lin has just had an increase in his pain medication, what should you be aware of in Mr Lin's situation ?