Pain Management and River Valley Health The following educational presentation offers the healthcare provider a deeper foundation for successful pain management. There are five sections in this presentation. A quiz will follow each section and will be used as a indicator of learning. Good Luck and Enjoy! Acute Pain Services
SECTION 1 MISSION PHILOSOPHY GOALS
PAIN MANAGEMENT!! …but WHY??
RVH MISSION STATEMENT River Valley Health (RVH) values effective pain management. Pain Management is a priority and we strive for effective pain management through evidence-based pain assessment and pain management strategies providing appropriate education for patients, families and health care professionals.
Pain Management Philosophy • Patients have a right to pain management • Patients have a right to be assessed • Patients have a right to be involved • Patient’s self-report is most reliable • Pain management is a team approach and, • is an ethical responsibility.
RVH Goals to Pain Management • To assess on a individualized level • To encourage patient participation • To address barriers to effective pain management • To promote an interdisciplinary approach • To ensure medication safety
Individualized Pain Assessments Systematic and thorough pain assessments provide a baseline for pain management.
Patient Participation IS CRUCIAL Patients need to know the benefits of pain management as well as the importance of self reporting.
Barriers to Pain Management Barriers will be addressed through: • Literature reviews • Mentoring • Family involvement • Education of patients, family and health care providers • Knowledge and attitude assessments
Interdisciplinary Approach Interdisciplinary teams will be involved in customizing and optimizing each patient’s pain management plan. Multimodal approaches will be used combining pharmacology and non-pharmacology interventions.
Patient Safety Medication and other treatment modalities will consider all aspects of patient uniqueness such as age and health status.
SECTION II Pain Assessment
INITIAL COMPREHENSIVE ASSESSMENTS DOES THE PATIENT REPORT PAIN? DEVELOP A BASELINE FOR PAIN MANAGEMENT ADDRESS CRUCIAL COMPONENTS “P” “Q” “R” “S” “T” & “M”
“P” - Provoking or precipitating factors“Q” - Quality (aching, throbbing etc.)“R” - Region and/or radiation“S” - Severity and symptoms“T” - Timing (occasional, intermittent, constant)“M” - Medication (use and adverse effects) CRUCIAL COMPONENTS!
Observe the patient for non-verbal indicators of pain, eg. frowning, grimacing, or reluctance to move/cough. Consider using words such as soreness, discomfort, aching when assessing for the presence of pain. Use behavioral indicators to identify the presence of pain in nonverbal patients.
Comprehensive Pain Assessments include: physical examination relevant laboratory and diagnostic tests medication usage and adverse effects understanding of current illness effect of pain on function and ADL’s coping responses to stress and pain psychological – social variables (anxiety, depression) personal preferences and expectations/beliefs/myths about pain and its’ management history of chronic pain past success or failure with management, including non-pharmacological interventions socio-cultural variables (e.g. ethnicity, cultural beliefs) that may affect pain behavior and treatment, and caregiver or family reports of pain.
Self-Reports Self-report is the primary source of assessment for verbal, cognitively intact persons. Family and care provider reports of pain are included for children and adults unable to give self report.
Frequency of Reassessment Pain will be reassessed on a regular basis according to the type and intensity of pain and the treatment plan. At least once per shiftfor inpatients. Before and after any known pain producing procedure. With each new report of pain When intensity increases When pain is not relieved by previously effective strategies. Note: Pain is reassessed after the intervention has reached peak effect
Pharmacological Interventions,Medication Routes and Reassessment Times Pharmacological Intervention/Medication route Optimal Reassessment Time (Peak effect) IV therapy15-30 minutes SC or IM therapy 15-40 minutes Immediate release oral therapy1 hour Sustained release oral therapy OR transdermal patch therapy 4 hours Epidural or patient controlled analgesia (PCA) **At least every two hours for the first 24 hours; then every 4 hours while on the Acute Pain Service. Note: Level of sedation will be assessed with opioid therapy.
Assessment Tools The RVH standard assessment tool is the 0-10 pain intensity scale.
Appropriate Tools Assessment tools should consider: • age (developmental appropriateness) • cognitive function (impairment) • language impairment, and/or language barriers. NOTE: If an alternate tool is used, the tool selected will be reliable, valid geared toward the individual. The health record will clearly state which pain assessment tool was used.
Assessment of Unexpected Pain Unexpected pain will be immediately evaluated in the context of the patient’s current health status, and will include a thorough assessment of the patient presenting problem, and recent intervention's).
Assessment in the PaediatricPopulation • Children may need encouragement to report pain. Fear of the consequences of reporting pain, such as receiving an injection is common. • Self-report tools are useful and reliable in the paediatric population. Children as young as 3 years of age can reliably rate pain intensity. • For pediatricpatients,theWong-Baker 0-10 FACESscale is used. • For children, consider the following: Ask the parent/guardian's) the words a child might use to describe pain, and observe the child for signs/behaviors indicative of pain.
Assessment of pain in the cognitively impaired Patients with cognitive impairment CAN provide an accurate report of pain/ discomfort. For the frail elderly, non-verbal or non-cognizant persons, screen the patient to assess if the following markers are present: • Patient states he/she has pain. • Change in the patient’s condition. • Patient is diagnosed with a chronic painful disease. • History of chronic unexpressed pain. • Patient has received pain medication for >72 hours. • Distress related behavior or facial grimacing is present. • Family/ caregivers indicate that pain is present.
SECTION III Intervention for Pain Management
The RVH Pain Care Committee has reviewed the current literature for effective pain management and provides the following guidelines for clinicians
ADVOCATE…TAILOR…CONSIDER Advocate for the use of the most effective analgesic dosage and least invasive pain management modalities. Tailorthe route to the individual and care setting. Consider the options. Note: The oral route is the preferred route for persistent pain and for acute pain as healing occurs. IV administration is the parenteral route of choice after major surgery, usually via bolus and continuous infusion. A butterfly injection system is often used to administer intermittent subcutaneous analgesics.
REFERRALS Refer persons with persistent pain whose pain is not relieved after following standard principles of pain management. Refer to a multidisciplinary team member with the expertise in the area of concern, the complex emotional, psycho/social, spiritual and concomitant medical factors involved.
DRUGS The three major classes of drugs that are used alone or, more commonly, in combination to manage pain are: non-opioid analgesics opioid analgesics, and adjuvant medications.
Step-wise Approach Select the analgesics which are appropriate to match the intensity of pain (unless contraindicated due to age, renal impairment or other issues related to the drug). Mild to moderate pain - acetaminophen or NSAIDS (unless the person has a history of ulcers or a bleeding disorder. Moderate to severe pain - initially use an opioid analgesic, taking into consideration previous opioid use and adverse effects. Note: The use of the WHO Analgesic ladder is recommended for the treatment of chronic cancer pain.
TIMING is everything! Recognize that opioids should be administered on a regular time schedule according to the duration of action and depending on the expectation regarding the duration of severe pain. • If severe pain is expected for 48 hours post-operatively, routine administration may be needed for that period of time. • Late in the post-operative course, analgesics may be effective given on an as needed basis. • In persistent cancer pain, opioids are administered on an around the clock basis, according to their duration of action. Long acting opioids are more appropriate when dose requirements are stable.
Intramuscular route… is not recommended because it is painful and absorption is not reliable. So….avoid this route when possible. Note: Meperidine is not recommended for the treatment of pain, it is contraindicated in persistent pain due to the buildup of the toxic metabolite normeperedine, which can cause seizures and dysphoria. Meperidine toxicity is not reversible by naloxone.
Equianalgesic Table Use a table to ensure equivalency when switching analgesics.
Monitor ...patients taking opioids for potential toxicity. Watch for unacceptable adverse effects: myoclonus confusion delirium refractory to prophylactic treatment. Note: In the presence of inadequate pain relief advocate for a change in treatment plan as required.
Anticipate …that individuals taking opioids may have common adverse effects such as nausea and vomiting, constipation and drowsiness. Institute prophylactic treatment as appropriate.
Recognize …that anti-emetics have different mechanisms of action and selection of the right anti-emetic is based on this understanding and etiology of the symptom.
Constipation Use prophylactic measures for the treatment of constipation unless contraindicated. Laxatives should be prescribed and increased as needed to achieve the desired effect as a preventative measure routine administration of opioids.
Addiction? Tolerance? Dependence? Clarify the difference between addiction, tolerance and physical dependence to alleviate misbeliefs that can prevent optimal use of pharmacological methods for pain management.
Addiction Addiction is a psychological dependence and is rare with persons taking opioids for persistent pain.
Tolerance Persons using opioids on a long term basis for pain control may be on the same dose for years, but may require upward adjustments of dosage with signs of tolerance. Tolerance is usually not a problem and people can be on the same dose for years.
Dependence Persons who no longer need an opioid after long term use need to reduce their dose slowly over several weeks to prevent withdrawal symptoms because of physical dependence.
Safe Medication Prescription and Ordering The implications of medication treatments on specific patient populations will be taken into consideration, including, but not limited to: • the elderly • paediatric populations • patients with polypharmacy • patients with addiction issues • patients who are cognitively impaired, and • patients with a history of sleep apnea
Interdisciplinary Approach The care of persons experiencing pain may be carried out by an interdisciplinary team member: physicians nurses pharmacists psychologists social workers, and other therapeutic services. Provider’s roles and responsibilities are determined by the organization’s policies, the providers scope of practice / standards of practice professional skills, competence, and credentials, and the care or rehabilitation required.
Non-Pharmacological Interventions Non-pharmacologic interventions are divided into three categories: physical interventions cognitive behavioral techniques family interventions.
Physical Interventions …including: • cutaneous stimulation, such as the application of heat or cold • transcutaneous electrical nerve stimulation (TENS) • exercise • physical or occupational therapy • massage, and acupuncture.
Cognitive Behavioral Strategies Intended to alter belief structures such as attitudes, pain and suffering. Strategies include… • psycho education (info. regarding normal and abnormal emotional reactions to pain) • distraction • relaxation • guided imagery • biofeedback • hypnosis.
Family Interventions Patient and family education and counseling.