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From Pain to Comfort. Meg Beturne MSN,RN,CPAN,CAPA. Objectives. Define pain Discuss pain assessment and management utilizing ASPAN’s Clinical Practice Guideline Identify pharmacological and non-pharmacological interventions Describe the challenge of chronic pain in perioperative areas

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from pain to comfort

From Pain to Comfort


  • Define pain
  • Discuss pain assessment and management utilizing ASPAN’s Clinical Practice Guideline
  • Identify pharmacological and non-pharmacological interventions
  • Describe the challenge of chronic pain in perioperative areas
  • Discuss comfort management
pain defined
  • Pain is usually a localized physical suffering associated with bodily disorder
  • Pain is one of the body’s most important protective mechanisms
  • Pain is a complex mechanism with unpleasant physical, emotional and cognitive components associated with actual or potential tissue damage
pain the sixth vital sign
Pain: The Sixth Vital Sign
  • Pain is “whatever the person experiencing it says it is, and existing whenever the person says it does”- Gold Standard
  • The patient is the ONLY one who can accurately describe his/her pain
  • It is subjective
  • All pain should be considered REAL
  • Pain can negatively affect the body


newest insights
Newest Insights
  • Definition of Pain refined:
  • Person’s inability to verbally communicate does not preclude the possibility that pain is present
  • Does not negate the responsibility of healthcare providers to treat it!
case scenario
Case Scenario
  • Example: 30 year old female SBO first day post-op; tells you she is in pain & is on phone talking. Do you still believe her?
  • YES! Pain is subjective and she is using distraction successfully which is a non-pharmacological way to manage pain
  • Since it is distracting her from the pain, you can now medicate her appropriately
pain pathways
Pain Pathways
  • Nociceptors: give the body the ability to produce pain
  • Nerve endings present in skin, viscera, blood vessels, muscle, joints
  • Activated by noxious stimuli, leads to inflammation & release of bradykinin & prostaglandins
  • Pain impulses initiated by direct tissue damage and by release of chemicals
  • Pain travels very fast!
pain conduction
Pain Conduction
  • Transduction: cutaneous nociceptors send impulses to spinal cord
  • Transmission: Impulses synapse either by fast or slow pain fibers
  • Perception: pain impulses processed by thalmus & cerebral cortex
  • Modulation: along the efferent fibers, pain may be inhibited or modulated
pain threshold tolerance
Pain Threshold & Tolerance
  • Threshold: point at which stimulus is perceived as painful; fairly uniform person to person
  • Tolerance: maximum intensity of duration of pain a person is willing to endure before needing some intervention; this varies from person to person
  • Tolerance is not to be judged as acceptable or unacceptable by health care providers
  • Cutaneous: arises from superficial structures ( skin and subcutaneous areas)
  • Sharp, cutting, burning, throbbing, localized
  • Burn or paper cut
  • Deep Somatic: originates in deep body structures ( muscles, bones, tendons, joints)
  • Characterized as dull or diffuse
  • Muscle cramps
more types
  • Visceral: origin is in visceral organs
  • Deep, dull, poorly localized
  • Associated with nausea & vomiting, hypotension, weakness
  • Referred: perceived at a site different from its point of origin
  • Chest pain ( cardiac muscle doesn’t have pain receptors); pain can move to left arm, jaw
  • Gallbladder pain felt in the shoulder
acute pain
  • Acute: pain that extends until period of healing (less than 6 months), “temporary”
  • Identifiable cause
  • Occurs soon after injury
  • Onset sudden or slow
  • Intensity mild to severe
  • Autonomic response: BP,RR,HR increased; pupils dilated; diaphoresis, pallor, facial grimacing, restlessness, guarding behavior
chronic pain
  • Chronic: extends beyond (3-6 months)
  • May limit ADLs
  • May not have identifiable cause
  • Non protective ( serves no purpose)
  • May lead to depression, fatigue, insomnia, anorexia, apathy & learned helplessness
  • Autonomic response: BP,HR, RR, Pupils, skin are all normal
  • If severe & prolonged, PNS activated= muscle tension, HR & BP low, failure of body’s defenses
point of emphasis
Point of Emphasis
  • Physiological signs ( i. e. elevated blood pressure and elevated heart rate) are least sensitive indicators of pain, especially in chronic pain
  • Don’t withhold pain medication because of these changes alone
chronic two types
CHRONIC- Two Types
  • Chronic Non-Malignant
  • Ongoing, lasting more than 6 months
  • NOT due to life threatening causes
  • NOT responding to currently available treatments
  • May continue for remainder of life
  • Low back pain, arthritis, neuralgia, Crohn's, migraines, peripheral neuropathy
  • Chronic Malignant
  • Cancer pain
chronic pain in the sexes
Chronic Pain in the Sexes
  • Conditions associated with chronic pain in women: Fibromyalgia, IBS, Rheumatoid Arthritis, Migraines; possible hormonal links; focus on emotional aspects; more likely to seek help than males; helpful to re-label pain as being manageable
  • Conditions associated with chronic pain in men: cluster headaches, gout, heart disease; focus on sensory aspects
chronic pain surgical patient
Chronic Pain, Surgical Patient
  • Require special consideration & planning for pain management :Methadone, Suboxone
  • Request consultation with acute pain service, anesthesia consultation
  • Continually communicated individualized pain management plan
  • Add, optimize first-line meds; rotate opioids
  • Educate patient to bring in chronic pain medications ( migraine, back pain)
  • Patient role in goal setting
other pain terms
Other PAIN Terms
  • Breakthrough Pain: pain that increases above the pain addressed by the ongoing analgesics
  • Neuropathic Pain (Pathologic): arises from nervous system (peripheral or CNS)- has multiple mechanisms- shooting, sharp, electric
  • Discomfort: being uncomfortable in body or mind; mild distress
  • Suffering: feel pain/distress; sustain harm; injury, pain or death
sobering statistics
Sobering Statistics
  • 15% Americans with major trauma/surgery pain (45 million)
  • 25% Adults have chronic pain ( > 76 million) > diabetes, heart disease, cancer combined
  • 50% of inpatients/outpatients have pain
  • 30% patients give hospital low marks for pain control
  • Untreated/undertreated pain still common

CDC (2007) Fast Facts

the truth about pain
The Truth About PAIN
  • Lack of expression does not equal lack of pain~ physiologic and behavioral adaptations to pain occur
  • Not ALL causes of pain are identifiable
  • Respiratory tolerance is rapid
  • Sleep is possible with pain but not good quality
  • Elderly experience pain but do not express it as much and so do babies!
  • Addiction is rare 0.1-0.3%
pain a perioperative problem
Pain: A Perioperative Problem
  • Nearly all patients have postoperative pain 45million: 80% rate it moderate to severe
  • Pain is the most common reason for elective procedures
  • Fear of pain is the #1 reason for delaying elective surgery: reported by 59% pts.
  • 50% patients still have pain 1 year after surgery; 30% still have pain 10 years later!

National Center Health Statistics,2006

patient expectations
Patient Expectations
  • If pain is present:
  • A professional, comprehensive assessment
  • Individualized evaluation methods, consistent with age, condition and ability to understand
  • Treatment when present, or refer for treatment
  • Evaluation of effects of treatments
relief of pain
Relief of Pain
  • “It is not the responsibility of patients to prove they are in pain; it is the nurse’s responsibility to accept the patient’s report of pain” ( American Pain Society, 2005)
  • “Relief of pain is a basic human right” (American Pain Foundation,2001)
  • “Relief of pain is a basic human right” (American Bar Association, 2000)
ethical duty of the nurse
Ethical Duty of the Nurse
  • Provide clinically competent, ethically defensible care
  • Duty to relieve pain, provide humane care
  • Suspected or known addiction disorder
  • Give opioids when clinically indicated & ordered
  • Protect patients/society from unauthorized opioid use
  • When ethical dilemmas exist, communicate them!
pain assessment
Pain Assessment
  • Joint Commission Standards PC 01.02.07 Assess, Treat, Reassess, Document Pain
  • Identifying & treating pain is part of care
  • Must be assessed during rest and activity
  • Includes defining:
  • How patient gets screened
  • Who assesses pain & when it is reassessed
  • How pain data is collected & recorded
  • When in-depth evaluation is needed
joint commission
Joint Commission
  • Pain Management Standard
  • Patients and their families must be educated about pain management plan
  • Patients need to report pain
  • Patients need to cooperate with the prescribed treatment
  • Scope of standard: behavioral health, critical access, home care, hospitals, long-term care and ambulatory care
patient barriers
Patient Barriers
  • Fear, pessimism, catastrophizing
  • Pain, effects of drugs, death
  • Addiction to analgesics
  • Pain will be intolerable
  • Anxiety: Cured?
  • What post-op sensations are normal?
  • Unrealistic expectations
  • Interpretation of experience different than team: age, culture, background
professional barriers
Professional Barriers
  • Mistaken beliefs about pain & treatment
  • Inconsistent assessment & reassessment
  • Systems barriers ( computers, access to resources)
  • Inadequate “handoff” communication
  • Biases, attitudes
other barriers
Other Barriers
  • Self-reports in pre-op are limited
  • Misunderstandings of pain scales
  • Over-reporting/underreporting of pain
  • When to assume pain is present/relieved?
  • Patients unable to report pain using usual self-report tools ( infants, unconscious, cognitively impaired, ventilated, impending death
pediatrics behavioral tool
Pediatrics Behavioral Tool
  • Difficult to distinguish pain from fear
  • Rely on parent reports
  • Observe behaviors
  • Can use FLACC: Face, Legs, Activity, Cry, Consolability; 0-2 each with 10 being maximum; Behavioral score only, not intensity rating
nips neonatal infant pain scale
NIPS-Neonatal Infant Pain Scale
  • Facial expression, breathing, arms, legs, cry, state of arousal
  • CRIES: scale for neonatal 32 weeks to term; Cry, Requires Oxygen, Increased vitals, Expression, Sleeplessness
  • Critical Care Pain Observation Tool
  • 0-8 behavioral scale
  • 2 points for each category:
  • facial expression
  • body movements
  • muscle tension
  • ventilator tension or verbalization
cognitive impaired
Cognitive Impaired
  • Assess at rest and activity
  • Insure functioning hearing aid
  • Have eyeglasses handy
  • Repeat questions and allow time for responses
  • Enlarged font helps
  • Self-report with descriptors, not numbers!
  • Consider behaviors: eating, sleeping, mood, body movement
special considerations
Special Considerations
  • Elderly: pain prevalence 2-fold higher >60
  • Report of pain altered
  • Have acute & chronic painful diseases
  • Take many medications
  • Have multiple diseases
  • ^ sensitivity: therapeutic, toxic drug effects
  • Prone to constipation (opioids)
  • NSAIDs;> risk GI, renal, platelet problems
  • > Sensitivity to analgesic effects: higher peek effect, longer duration, dose titration
special considerations1
Special Considerations
  • Known/suspected chemical dependency:
  • Experience variety of health problems
  • Possible withdrawal from opioid absence, causing > HR, restlessness, sleeplessness
  • Focus on managing PAIN , not detoxification!
  • Don’t forget non-drug interventions
  • Higher loading & maintenance doses of opioids may be required to reduce pain intensity
aspmn position statement
ASPMN Position Statement
  • Pain Assessment in non verbal patients
  • When possible, obtain self-report
  • Look for possible pathologies, procedures or other causes of pain
  • Observe for behaviors that may indicate presence of pain
  • Obtain input from caretakers who know patient & usual behaviors & responses to pain
  • Use an analgesic trial & observe for changes in behavior
aspan clinical guideline
ASPAN Clinical Guideline
  • Introduced in JOPAN in 2003, available now on ASPAN web site
  • Speaks to Assessment, Interventions and Expected Outcomes
  • Includes all phases of practice including: Preoperative Phase, Post Anesthesia Phase I, and Post Anesthesia Phase II or Extended Observation
assessment begins with
Assessment Begins With…
  • Pre-op Data:
  • Vital signs & comfort goals
  • Medical history
  • Pain history
  • Pain behaviors
  • Analgesic history
  • Patient’s preferences
  • Pain/comfort acceptable levels
  • Comfort history
  • Cultural, religious factors
  • Educational needs
interventions begin in
Interventions Begin in…
  • Pre-op:
  • Discuss pain & comfort assessment
  • Discuss with patient/family about reporting pain & available pain relief
  • Dispel misconceptions about pain & pain management
  • Encourage preventive approach
  • Educate purpose of meds & non-pharmacological measures
  • Discuss outcomes based on goals
  • Arrange for interpreter, signer as needed
outcomes to strive for
Outcomes to Strive For!
  • Pre-op
  • Patient states understanding of care plan
  • Patient states understanding of pain intensity scale, pain relief/comfort goals
  • Patient establishes realistic & achievable pain relief/comfort goals
  • Patient understands PCA equipment
  • Patient understands benefit of non-drug interventions
post anesthesia phase i
Post anesthesia Phase I
  • Assessment:
  • Type of surgery, anesthesia technique, etc
  • Analgesics, etc given inter-op
  • Pain & comfort levels
  • Status/ vital signs: ABCD
  • Age, cognitive ability & cognitive learning method
assessment data
Assessment Data
  • Subjective data: who, what, where, why & when are first clues of pain assessment
  • Objective data: observation of facial grimace, teeth clenching, frowning, moaning, crying
  • Physiological changes: increase BP, rise in HR, increase in RR are signs that support the patient’s subjective pain response
other physiological signs
Other Physiological Signs
  • Dilatation of pupils and/or wide opening of eyelids
  • Shivering
  • Change in skin and body temperature
  • Increased muscle tone
  • Sweating
  • Location: examine site
  • Intensity- use easy, fast, multicultural, multilingual pain scale:
  • Poker chip, Oucher scale
  • Visual Analog Scale: pt. places mark on line
  • Numeric Rating Scale: 0 to 10
  • Wong Baker Faces Pain Scale: 3+ to adult
  • Behavioral Rating Scale
  • Body Diagram, Daily Diary
  • Verbal Descriptor Scale: no pain to worse pain
pain rating scales
Pain Rating Scales
  • Purpose: communication tool- here is where you are now and here is where we want you to be
  • Documenting ratings helps evaluate trends and treatment effectiveness
  • Know which scale is most appropriate to use ( i.e Wong-Baker preferred by African American children)
  • Important to have scales translated into languages of populations served
assessment cont
  • Obtain description of quality of pain
  • Character, frequency, duration
  • Achy, pulling, throbbing, burning, sharp, dull, cramping, prickling, hurting
  • Rememberdata obtained pre-op regarding onset & duration; may apply post-op
  • What time of day is pain worse?
  • What gets pain started?
  • Does the pain stay or come and go?
  • How much pain in an average day?
assessment cont1
  • Rememberdata on pain aggravating & alleviating factors obtained pre-op; may apply post-op
  • What makes pain worse or better?
  • What other things have you tried to make pain better that worked or didn’t work
  • Seek information on impact of pain on activities of daily living (ADL)
  • Does pain cause problems with ADL?
  • How upsetting is the pain?
assessment cont2
  • Describe pain behavior indicators
  • Reluctance to move
  • Quiet & withdrawn
  • Facial expressions (grimace)
  • Anxious, restless
  • Crying, moaning, whimpering
  • Desperate, using PCA frequently
  • Don’t dismiss the patient’s self-report of pain they are experiencing!
assessment cont3
  • Assess other causes of pain
  • Chronic back/neck pain
  • Bladder distention
  • Hemorrhage, ischemia, rupture of viscus
  • Nausea and vomiting
  • Perform re-assessment for response to medications for pain ( Joint Commission)
  • How effective? LOC? Vital Signs? Extra meds needed for breakthrough pain?
  • Communicate & document all data!
case scenario1
Case Scenario
  • Patient had anterior/posterior lumbar fusion done for an acute incident
  • This patient also had chronic low back pain that was 9/10 on a daily basis even while taking narcotics
  • Goal in PACU was to return patient to his baseline level of pain
  • It required Morphine 30mg & Dilaudid 10mg to return him to normal level of pain which was 9/10
biases as barriers
Biases as Barriers
  • Value stoicism and problem-focused coping
  • Expecting a certain degree of pain
  • Is drug seeking, solely on the basis of:
  • Report of pain greater than expected
  • Pain medication requirements higher than usual
  • Lifestyle, diagnosis or demographic factors
  • Nurse is better judge of pain than patient
  • Pain is punishment for sins/wrong-doing
case scenario2
Case Scenario
  • Mrs. Smith is an elderly, Hispanic patient who is status post hip replacement
  • PCT informs you that Mrs. Smith needs pain medicine. Should you just give it?
  • NO, you assess her; determine type of pain present; is that pain indicating a problem? Could it be arthritis acting up?
  • Are personal, cultural, spiritual or ethnic beliefs in play?
  • Do not assume anything!
non drug interventions
Non-Drug Interventions
  • Positioning/repositioning/ambulation assist
  • Elevation affected limbs
  • Applying ice or heat therapy
  • Covering incision with pillow (coughing)
  • Rhythmic deep breathing, counting slowly
  • Warm blankets, warming machines
  • Non-stimulating environment (noise, light)
  • Family, friends visiting ( or NOT)
  • Attention from staff (schmooze factor)
non drug interventions cont
Non-Drug Interventions (cont)
  • Complementary:
  • Relaxation, Massage therapy, backrub
  • Reflexology, Acupuncture
  • Humor
  • Reiki treatment, Therapeutic Touch
  • Distraction, Biofeedback
  • Guided imagery: pleasant sounds, smells
  • Hypnotism
  • Music Therapy, tapes of calming sounds
  • Prayer, visit from chaplain/cleric, religious objects/symbols
problems with herbs
Problems with Herbs
  • St. John’s Wart: use- depression /anxiety
  • May cause increased effects of opioids
  • May cause decreased effect of Elavil or Digoxin
  • Will cause increase in effect of antidepressants
  • Ginko Biloba
  • May interfere with anticonvulsants
  • When taken with NSAIDs, will cause significant bleeding problems
surgical acute pain
Surgical/Acute Pain
  • Prevention is best approach: means around the clock pain management
  • Allows patient to know their pain needs will be met
  • Helps reduce anxiety about return of pain
  • May result in decreased doses, fewer side effects, less time in pain
  • Physical activity may increase ~problems caused by immobility can be avoided
  • Avoid actions that > pain
  • Patient to request med before pain severe
methods of pain management

Methods of PainManagement

1. Oral Analgesia

2. IV Analgesia

3. PCA Analgesia

4. Epidural Analgesia

important patient data
Important Patient Data
  • Let’s review one more time!
  • Any known allergies
  • Patient baseline renal, bowel, bladder and liver function
  • Previous opioid use
  • Health habits including drug/alcohol usage
  • Baseline mental status
  • Any other medications used
  • Age, cultural, religious factors
multimodal approach
Multimodal Approach
  • Appropriate combinations attack more than one mechanism
  • The synergistic action results in lowered doses and a decrease in adverse effects
  • Intensity/type of pain determine the route
  • Oral: less invasive, preferred route for chronic, persistent pain; great choice for mild to moderate pain
  • IV: severe, escalating pain
  • Epidural: effective- delayed onset
other routes
Other Routes
  • Transdermal: Fentanyl (Duragesic patch)
  • persistent, chronic pain; can’t take oral meds
  • non-adherent patients; recovering addicts
  • opioid tolerant kids > 2yrs with cancer pain
  • 48-72 hr application period
  • patient preference, no stigma, bypasses GI
  • Oral transmucosal (sublingual, buccal): Actiq
  • rapid onset Fentanyl for breakthrough pain in opioid tolerant patient; ideal for sudden onset
  • sugar matrix on a stick ( 2.5-5 hrs)

Intranasal: Ketorolac (Sprix Nasal Spray) for acute pain in ambulatory care

  • Topical: EMLA (5% lido-prilocaine cream) takes 60 min; Synera (mix of lido & tetracaine) apply 20 min for analgesia
  • Rectal: almost all oral meds can be given this way
  • Intramuscular: unreliable, painful, not recommended unless there is no IV
  • Subcutaneous: same as IM
oral agents
Oral Agents
  • Non-narcotics:
  • Acetaminophen: reduces pain & fever; No anti-inflammatory affect; No adverse effects on kidney, gastric lining, platelets; exceeding maximum dose: hepatotoxic
  • Usual dose: 650-1000mg p.o. Q4H, maximum dose: 4GM/24hours, > 5GM= toxicity!
  • Beware of other medications that contain Acetaminophen! ( Vicodan, Percocet)
oral agents1
Oral Agents
  • Non-narcotics: mild to moderate pain
  • NSAIDs (anti-inflammatory/ antipyretic): act on peripheral nerve system; ASA, Motrin, Celebrex, Ketorolac (Toradol), Naprosyn, ibuprofen; Do not give ASA with NSAIDs; monitor for signs of GI bleeding
  • Maximum dose ibuprofen: 3200mg in 24hours
  • Motrin dosing: 600-800mg every 6h
  • Effective for mild to moderate pain
  • With opiods, these agents can have an opiod sparing effect: lowers opiod requirement and reduces potential for opiod- related side effects
  • Bextra and Vioxx: withdrawn- increased cardiovascular risk, increased M.I. and stroke post CABG
adverse effects
Adverse Effects
  • May alter hemostatic balance
  • Avoid in high risk CV patients
  • GI toxicity, increases greatly if 2 NSAIDs are given; consider Nexium or Prilosec in high risk patients
  • Renal effects: can be avoided if patient well hydrated
  • Bone healing: stopping drug restores normal healing after 14-21 days; avoid in smokers or metabolic bone disease
parental non opioids
Parental Non-opioids
  • IV acetaminophen (Ofirmev): single or repeat dosing- 15 min. infusion
  • Adults/teens> 50 kg. give 1000mg q 6 hr or 650mg q 4 hr to max of 4, 000mg per day
  • Adults/teens < 50kg. and kids > 2-10years: 15mg/kg q 6hr or 12.5mg/kg q 4 hr to max of 75mg/kg/day= 3,750mg/day
  • Within 15 min. increased level in plasma
  • Cost= $11/dose

IV Ketorolac: short term pain management- 5 days

  • Dose: < 65: 30mg q6h(120mg/day=max)
  • Pedi dose: 0.5mg/kg q6h
  • Correct hypovolemia before administration
  • IV Ibuprofen: approved for fever & acute pain in adults; 400-800mg over 30min q 6h; maybe preferable to Ketorolac- less inhibition of action
  • Fentanyl: 25-50mcg IVP q5 min prn
  • Morphine Sulfate: 2mg IVP q5min prn
  • Oxycodone (Percocet): 1-2 tabs q 4-6 hrs prn
  • Hydromorphone (Dilaudid) 1-2mg IV, 2-4mg po
  • Hydrocodone ( Vicodin):5/500mg-1tab q4hrs- not to exceed 8tabs in 24hrs.
  • Oxycontin ( MS ER): 30mg- 1tab q12 hrs
  • Tylox 5/500mg: 1tab q6hrs prn
  • Tylenol #3: 300/30mg 1tab q4hrs prn
  • Meperedine (Demerol) 12.5-50 mg
  • Not appropriate for first-line opioids
  • Used for shivering
  • Neurotoxic- causes seizures
  • Stadol, Nubain: agonist-antagonist
  • Ceiling on dose: ^ don’t increase relief
  • Suboxone: combo of buprenorphine & naloxone; sublingual tablet or film
  • For treatment of addiction
  • May be habit forming, many side effects
  • Used to manage moderate to severe pain
  • Bind to opiate receptors in the brain to alter perception of pain
  • Addictive, cause psych & physical dependence
  • Side effects: sedation, dizziness, respiratory depression, impaired thinking, urinary retention, constipation, pruritis, dry mouth, nausea/ vomiting, sleep disturbances
  • Goal: find balance between pain relief & side effects; ask patient if he/she wants more
patient controlled analgesia
Patient Controlled Analgesia
  • Rationale for PCA:
  • Patient titrates analgesics to needs, bypassing unavoidable delays when analgesics are provided on request
  • Intermittent & steady-state analgesia that is patient-activated~ avoid peaks & valleys
  • Blood level of meds can be maintained within an effective range
  • Patient takes active role in care
desired outcomes
Desired Outcomes
  • Adequate pain control in a safe manner
  • Keeps serum level within therapeutic range
  • Patient can breathe deeply and ambulate early, reducing post-op complications
  • Patient more comfortable and less anxious, enhancing patient satisfaction
  • Patient selection:
  • Alert with clear sensorium ( except palliative care)
  • Intellectually, emotionally & physically capable of understanding & operating PCA
  • Developmentally capable of understanding & operating PCA
  • Medications: Morphine, Hydromorphone, Fentanyl
pca cont
PCA (cont)
  • Tell patient & family rationale for PCA
  • Identify any side effects (opioids)
  • 2 RNs double check dosage orders upon initiation of infusion, when accepting patients from another unit and when parameters change
  • Family may be instructed to participate
  • Joint Commission has Sentinel Alert on PCA by Proxy
  • Disadvantages
  • Potential for overdose
  • Limited nursing contact
  • Requires IV access
  • Potential for programming errors
  • Non-candidates
  • Major psych disorder
  • Hemodynamically unstable
  • Inadequate controlled seizure disorder
  • Medical condition= restricted use of opiates
regional anesthetics
Regional Anesthetics
  • Topical:
  • Lidocaine patch 5% (Lidoderm)
  • Shingles, Crohn's disease, low back and neck pain, migraine
  • Analgesic, not anesthetic
  • Minimal adverse events
  • Pliable adhesive- apply directly to painful, intact site; change q 24; may wear 4 safely
  • Infiltration: 0.5% to 2%Lido (with/out Epi)

Peripheral Nerve Block: specific site to block conduction; pre and post surgery

  • Interscalene, axillary, intercostal, sciatic
  • Complications: nerve damage, failed block, hematoma, reaction to local
  • Epidural: solution into epidural space-single injection, repetitive bolus injections ( by catheter), continuous infusion ( by catheter)- for labor analgesia, chronic pain
  • Transcutaneous electrical nerve stimulator: (TENS)
epidural analgesia
Epidural Analgesia
  • Rationale:
  • Allows for high concentration of drug at desired spinal cord receptors
  • Minimal amount of opiod enters systemic circulation, where opiod can cause undesired side effects
  • Allows for selective analgesia depending on location of catheter
  • Opiods have synergistic effect with local anesthetics-doses of both can be lowered
desired outcomes1
Desired Outcomes
  • Intense, prolonged analgesia
  • Limiting total amount of systemic opiods
  • Decrease potential for opiod related side effects
  • Less sedation
  • Earlier mobilization: < incidence of DVTs
  • Ability to cough, deep breathe, clear secretions
  • Decrease cardiac workload & oxygen use
  • Decrease costs due to shorter LOS
  • Patient refusal
  • Shock
  • Hypovolemia
  • Coagulopathies
  • Skin lesions at site of injection
  • History of adverse reactions to opiods
  • Sleep apnea
  • Lack of familiarity of technique
epidural medications
Epidural Medications
  • Fentanyl
  • Sufentil
  • Morphine
  • Hydromorphone
  • Ropivacaine
  • Bupivicaine
complications adverse effects
Complications & Adverse Effects
  • Complications:
  • Total or high spinal block
  • IV injection
  • Dural puncture resulting in a headache
  • Bleeding resulting in hematoma
  • Catheter problems (migration, breakage)
  • Adverse Effects
  • Pruritis, nausea, urinary retention
  • Mild to moderate sedation, hypotension
sedation assessment
Sedation Assessment
  • S= Sleep, easy to arouse, respiratory depth & regularity compares to baseline; no action
  • 1= Awake and alert, no action needed; may increase opioid dose
  • 2= occasionally drowsy, easy to arouse, no action needed; may increase opioid dose
  • 3=frequently drowsy, arousable, falls asleep mid-sentence; add non-opioid & decrease opioid 25-50%; increase monitoring to level 3
  • 4= somnolent, minimal/no response; stop opioid ,stimulate, consider Naloxone
treating respiratory depression
Treating Respiratory Depression
  • Assess and monitor patient’s level of sedation and respiratory status frequently for first 8-12 hours
  • Encourage deep breathing
  • Encourage use of incentive spirometer
  • If unresponsive to physical stimulation with shallow respirations & RR < 8/min, pinpoint pupils: Give Naloxone (Narcan)- ( reversal agent) 0.1-0.4mgm IV titrated slowly over 2-3 min
  • Analgesic in some painful conditions, but primary indication is other than analgesia
  • Include:
  • Anticonvulsants: Tegretol, Klonopin, Dilantin, Neurontin (gabapentin), Lyrica (pregabalin)
  • First line for neuropathic pain, acute pain management ( persistent post surgical and burns); Opioid-sparing
  • Adverse effects: sedation, unsteadiness, nausea, dizziness
  • Antidepressants: Nortriptyline (Pamelor), Cymbalta, Effexor
  • First line for neuropathic pain
  • Adverse effects: dizziness, orthostatic hypotension, sedation, dry mouth
  • Steroids: Decadron, Prednisone, Solumedrol (metastatic bone cancer pain)
misc medications
Misc. Medications
  • Tramadol (Ultram):analgesic that augments pain signal transmission inhibition; 50mg tab
  • Tapentadol ( Nucynta): acute, chronic, neuropathic pain; costly; fewer GI side effects
  • Methadone: effective analgesic for patients with difficult to control pain; has long half life- make dose adjustments slowly
  • Ketamine: used for patients requiring very high doses of opiods (chronic pain, history heroin addiction, neuropathic pain, OIH)
  • Pain Management
  • Date, time
  • Current regimen ( drug dose, route)
  • Patient self-report of pain and pain relief
  • Activities patient is able to perform (cough, turn, deep breathe, ambulate)
  • Side effects and level of sedation
  • Current vital signs: BP, HR, RR, O2 Sat
  • Should be re-evaluated 30 min after intervention
key concepts anesthesia
Key Concepts: Anesthesia
  • Balanced Analgesia
  • Use continuous, multimodal approach
  • Considered ideal by experts
  • Use combined analgesic regimen
  • Preemptive Analgesia
  • Intervention implemented before noxious stimuli experienced
  • Reduces CNS impact
  • Provision for added analgesics for breakthrough or ongoing extreme pain
expected outcomes
Expected Outcomes
  • Patient maintains hemodynamic stability, including respiratory/cardiac status & LOC
  • Patient states achievement of pain relief/comfort treatment goals
  • Patient states he/she feels safe & secure with instructions
  • Patient shows effective use of at least 1 non-pharmacological method
  • Patient shows effective use of PCA
  • Patient states evidence of receding pain & increased comfort
tailor treatment plan
Tailor Treatment Plan
  • Acute pain: short-term; need to discuss recovery/rehab milestones and patient’s ability to meet them
  • Chronic pain: discuss what patient could do before that the pain keeps him/her from doing now
  • End of Life: discuss if there is anything patient wants to accomplish before death that the pain would interfere with
be truthful
Be Truthful!
  • Zero pain is usually not possible but let patients know you care about their pain and will always try to do everything possible to control it !
  • Reinforce link between pain relief and accomplishment of pain treatment goals
  • Find the right balance for each individual patient: quality of life, pain relief and adverse effects
stopping pharmacological measures
Stopping Pharmacological Measures
  • When pain is relieved
  • Adverse effects have occurred:
  • Respiratory depression
  • Blood pressure change of 30% or more from baseline
  • Oxygen saturation less than 90% ( unless that is patient’s normal)
  • Too much sedation, Too great decrease LOC
  • Signs of an allergic reaction to the opioid
benefits to pain management
Benefits to Pain Management
  • Pain control= greater comfort during recovery to get well faster
  • Less pain= ability to ambulate early, do breathing exercises and get strength back quicker
  • Short length of stays in the hospital is also a strong possibility= increased patient satisfaction
current knowledge
Current Knowledge
  • Pain alters the quality of life more than any other health-related problem
  • Pain is one of the least understood, most often under-treated and often discounted problems of healthcare providers & pts.
  • Nurses have little control over intervening variables: social support, prognosis, financial well-being, education, personality traits, addictions, physical fitness, religiosity, belief system, values, etc
  • Nurses’ have control over caring & comfort
comfort management
Comfort Management
  • Nurses assess patients’ holistic comfort needs on an individual basis
  • 3 types of comfort needs
  • Relief: need to have specific discomfort relieved
  • Ease: need to remain in a state of contentment & well-being
  • Transcendence: need to be strengthened, motivated, or invigorated
holistic perspective
Holistic Perspective
  • Implies desired outcome of nursing care from using holistic intervention
  • Massage= enhanced patient comfort, compared to baseline
  • Enhanced comfort has positive relationship with health seeking behaviors
  • Internal ( healing)
  • External ( improved functional status, mobility, strength, appetite, etc)
  • Peaceful death: symptoms well-managed
relationship comfort pain
Relationship: Comfort & Pain
  • Comfort is an umbrella term:
  • Effective pain management significant part
  • Other discomforts needing attention are: N&V, thirst, lyte imbalance, air hunger, etc
  • When pain is relieved:
  • Improvement in vital signs
  • Resting state induced ( patient appears relaxed, may have eyes closed
  • Muscular relaxation: facial muscles relaxed, body tension eased
contexts of comfort
Contexts of Comfort
  • Comforting occurs:
  • Physical: bodily sensations, immune function, homeostatic mechanism
  • Social-Cultural: interpersonal , family & societal relationships; traditions/rituals
  • Psycho-spiritual: internal awareness of self, esteem, identity
  • Environmental: external background of human experience~ temperature, light, sound, odor, color, furniture
evaluate comfort interventions
Evaluate Comfort Interventions
  • Ask:
  • What analgesia did patient receive?
  • What other interventions were tried?
  • How effective were interventions in relieving discomforts, including anxiety?
  • Are drugs or other interventions affecting the vital signs?
  • How much activity can patient engage in prior to experiencing pain or discomforts?
  • Any change in dosing of meds? Any breakthrough pain or discomfort?