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Pain Management PowerPoint Presentation

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Description : Check out this medical presentation on Orthopaedics, which is titled "Pain Management", to learn how an emergency nurse assesses, identifies and manages acute and chronic pain within the emergency setting.

Tags : Orthopaedics, Pain Management

Published on : Aug 18, 2021 | Views : 2302 | Downloads : 12

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Pain Management
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Critical outcome The emergency nurse assesses, identifies and manages acute and chronic pain within the emergency setting. 2
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Specific Outcomes Define the types of pain and complications of pain management. Delineate pain physiology and mechanisms of addressing pain with medications. Define the general assessment of the patient in pain. Delineate the nursing process and role in the management of the patient with acute and chronic pain. 3
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Specific Outcomes Apply the nursing process when analyzing a case scenario/patient simulation Predict differential diagnosis when presented with specific information regarding the history of a patient List and know the common drugs used in the emergency department to manage painful conditions and conduct procedural sedation. Consider age-specific factors. Discuss medico-legal aspects of care of patients with pain related to emergencies. 4
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Definitions Pain An unpleasant sensory and emotional experience Associated with actual or potential tissue damage or described in terms of such damage Personal and subjective experience Can ONLY be described by person experiencing pain Exists whenever the person says it does 5
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Tolerance Greatest level of discomfort a person is prepared to endure Person requires increased amount of substance to achieve desired effect 6
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Dependence Reliance on a substance Abrupt discontinuance would cause impairment of function 7
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Addiction Behavioral pattern characterized by compulsively obtaining and using a substance Results in physical, social, and psychological harm to user 8
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Allodynia Pain caused by a stimulus not normally causing pain Mechanical: Static mechanical allodynia- pain in response to a light touch/pressure Dynamic mechanical allodynia- pain in response to brushing Thermal: (Hot or Cold) allodynia- pain in response to mild skin temperatures in the affected area Can be from neuropathy, fibromyalgia, migraines or spinal cord injuries 9
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Pain Management Comprehensive approach to patient needs when experiencing problems associated with acute or chronic pain 10
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Pain Threshold Least level of stimulus intensity perceived as painful 11
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Suffering Physical or emotional reaction to pain Feeling of helplessness, hopelessness, or uncontrollability 12
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Pain Physiology Emergency nurses need an understanding of basic physiology of pain to effectively assess, intervene, and evaluate patient outcomes. 13
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Physiology Neuroanatomy Afferent pathway Nociceptors (pain receptors) in the tissues respond to pleasant and painful stimuli Stimulation of nociceptors produces impulse transmission through fibers Small C fibers: unmyelinated; transmit burning and aching sensations; relatively slow Larger A-delta fibers: myelinated; transmit sharp and well-localized sensations; relatively fast Terminate in the dorsal horn of the spinal cord Modulate pain patterns in the dorsal horn Transmit impulses to the midbrain via the neospinothalamic tract (acute pain) and to the limbic system via the paleospinothalamic tract (dull and burning pain) 14
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Central nervous system (CNS) Includes all the limbic system, reticular formation, thalamus, hypothalamus, medulla, and cortex Arousal, discrimination, and localization of pain; coping response; release of corticosteroids; cardiovascular response; modulation of spinal pain transmission 15
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Ruth Lawson, Wikimedia Commons 16
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C fiber, A delta, dorsal horn Delldot, Wikimedia Commons 17
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Efferent pathway Fibers connecting the reticular formation, midbrain, and substantia gelatinosa in the dorsal horn of the spinal cord Afferent fibers stimulate the periaqueductal gray matter in the midbrain, which then stimulates the efferent pathway Modulates or inhibits pain impulses 18
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Neuromodulation Endorphins: A group of neuropeptides that inhibit pain transmission in the brain and spinal cord Beta-Lipotropin: responsible for feeling of well-being Enkephalin: weaker than other endorphins but longer lasting and more potent than morphine Dynorphin: generally impedes pain impulse Endomorphin: very antinociceptive Opiate receptors: mu receptors on the membrane of afferent neurons, inhibit the release of excitatory neurotransmitters; beta receptors react with enkephalins to modulate pain transmission; kappa receptors produce sedation and some analgesia; sigma receptors cause pupil dilation and dysphoria 19
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Effects of medications on modulating pain Stimulation of afferent pathways results in activation of circuits in supraspinal and spinal cord levels. Each synaptic link is subject to modulation Mechanisms of drug action ASA and Acetaminophen: inhibit prostaglandin synthesis in the CNS NSAIDs: synthesized at the site of injury; inhibit prostaglandin synthesis, which reduces hyperalgesia Opiates: interact with mu and kappa receptors; powerful effect on the brainstem and the periphery Local anesthetics: block sodium channels and thus prevent transmission of nerve impulses 20
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Specific theory A specific sensation that is independent of other sensations. Experiments on animals provided clinical evidence of separate spots for heat, cold, and touch 21
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Gate control theory Modulations of inputs in the spinal dorsal horns and the brain act as a gating mechanism With a stimulus, the following sequence of events occurs: The pain impulse is transmitted via nociceptors fibers in the periphery to the substantia gelatinosa through large A-delta and small C fibers A gating mechanism regulates transmission from the spinal cord to the brain, where pain is perceived Stimulation of large fibers closes the gate and thus decreases transmission of impulses unless persistent Stimulation of small fibers opens the gate and enhances pain perception 22
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..more on the gating mechanism The spinal gating mechanism is also influenced by fibers descending from the brain The conducting fibers carry precise information about the nature and location of the stimulus Through efferent pathways the CNS may close, partially close, or open the gate Descending fibers release endogenous opioids that bind to opioid receptor sites that thereby prevent the release of neurotransmitters such as substance P, this inhibiting transmission of pain impulses and producing analgesia Cognitive function can also modulate the pain perception and the individual’s pain response 23
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Neuromatrix theory A widespread network of neurons consist of loops between the thalamus and cortex and between the cortex and limbic systems; neural processes are modulated by stimuli from the body but can also act in the absence of stimuli Stimuli trigger neural patterns but do not produce them Cyclic processing of impulses produces a characteristic pattern in the entire matrix that leaves a neurosignature Signature patterns are converted to awareness of the experience and activation of spinal cord neurons to produce muscle patterns for action 24
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Neuromatrix theory Neural inputs modulate the continuous output of the neuromatrix to produce a wide variety of experiences felt by the individual Awareness of the experience involves multiple dimensions (e.g., sensory, affective, and evaluative) simultaneously Pain qualities are not learned; rather, they are innately produced by the neurosignatures and interpreted by the brain 25
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Types of pain Acute Chronic Nociceptive Neuropathic 26
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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. 27
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Acute pain Wellcome Library London, Wellcome Images 28
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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 29
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Chronic pain Adrian Cousins, Wellcome Images 30
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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. 31
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Somatic pain Wellcome Library London, Wellcome Images 32
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Visceral pain Theuplink, Wikimedia Commons 33
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Neuropathic Caused by damage to peripheral or central nerve cells Peripheral: Arises from injury to either single or multiple peripheral nerves Felt along nerve distributions Burning, shooting, stabbing or like an electric shock Diabetic neuropathy, herpetic neuralgia, radiculopathy, or trigeminal neuralgia Central: Associated with autonomic nervous system dysregulation Phantom limb pain (peripheral) or complex regional pain syndromes (central) 34
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Peripheral neuropathic pain Lubyanka, Wikimedia Commons 35
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Central neuropathic pain J.H. Shepherd/Mütter Museum, Wikimedia Commons 36
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General strategy Assessment Analysis Planning and Implementation/Intervention Evaluation and Ongoing monitoring Documentation 37
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Assessment Primary and secondary assessment Focused assessment Subjective data collection Objective data collection 38
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Subjective data HPI (history of present illness/injury) or Chief Complaint History of pain (PQRST) Pain Quality Region/Radiation Severity Timing Efforts to relieve symptoms 39
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Subjective data Past medical history Current or preexisting diseases/illness New or recurring problem Substance and/or alcohol use/abuse LNMP Current medications Non-pharmacologic interventions Food or drink Coping mechanisms Allergies 40
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Subjective data Psychological/social/environmental factors: Anxiety, Depression Aggravating or alleviating factors Expressions of pain Pain behavior is learned, yet adaptive, and it r/t pain threshold and pain tolerance Pain expressions can be verbal, behavioral, emotional, and physical 41
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Objective data General appearance Psychological Observations of behavior and vital signs should not be used solely in place of self-report Positioning and movement Physiologic Level of distress/discomfort 42
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Objective data Obtain pain rating Adults Visual analog scale Numeric rating scale Graphic rating scale Thermometer-like scale 43
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Visual Analog Scale http://0.tqn.com/d/ergonomics/1/0/C/-/-/-/painscale.jpg 44
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Numeric Rating Scale http://0.tqn.com/d/pain/1/0/S/-/-/-/PainScale.gif 45
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Graphic Rating Scale http://img.medscape.com/fullsize/migrated/editorial/journalcme/2007/7993/art-mannion.box1.gif 46
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Thermometer-like Scale http://img.medscape.com/fullsize/migrated/574/105/574105.fig1.gif 47
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Objective data Obtain pain rating Pediatric FACES scale Poker chip Numeric rating scale Color matching 48
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FACES / Numeric combined No pain Worst pain of my life Minor pain Moderate pain Severe pain Clker.com, Clker Images 49
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Objective data Obtain a pain rating Infant Neonatal Infant Pain Scale (NIPS) Neonatal Pain, Agitation, and Sedation Scale (NPASS) Pain Assessment Tool (PAT) 50
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NIPS http://www.natalnurses.net/images/22.jpg 51
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NPASS http://www.anestesiarianimazione.com/Immagini/npass%208-01.jpg 52
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PAT http://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif 53
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Objective data Inspection Position, skin color, external bleeding, skin integrity, obvious deformity, edema Auscultation Breath sounds, bowel sounds Palpation Areas of tenderness: light, deep Save painful part until last 54
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Diagnostic procedures Laboratory studies Imaging Electrocardiogram Purpose: TO FIND THE CAUSE OF THE PAIN 55
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Analysis: Differential diagnosis ACUTE PAIN CHRONIC PAIN 56
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Planning and Implementation/Interventions Determine priorities of care Maintain ABC Provide supplemental oxygen IV access Obtain and set up equipment Prepare/assist with medical interventions Provide measures for pain relief Administer pharmacological therapy as ordered 57
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Administer pharmacological therapy as ordered The World Health Organization (WHO) recommends the use of the analgesic ladder as a systematic plan for the use of analgesic medications. Step 1: use non-opioid analgesics for mild pain Step 2: adds a mild opioid for moderate pain Step 3: use of stronger opioids when pain is moderate to severe 58
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Patient-controlled analgesia (PCA) Used for patients with acute or chronic pain who are able to communicate, understand explanations, and follow directions Assess vital signs and pain level Explain the use of the pump Collaborate with the physician, patient, and family about dosage, lockout interval, basal rate, and amount of dosage on demand Assist the patient to use the PCA pump 59
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Planning and Implementation/Interventions Relieve anxiety and apprehension Allow significant others to remain with patient if supportive Educate patient and significant others about the efficacy and safety of opioid analgesics 60
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Evaluation and Ongoing Monitoring Continuously monitor and treat as indicated Monitor patient response/outcomes, and modify nursing care plan as appropriate If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care 61
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Documentation Document vitals and pain score before and after intervention along with patient response 62
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Age-related concerns Pediatrics: Growth or development related Children’s pain tolerance increases with age Children’s developmental level influences pain behavior Localization of pain begins during infancy Preschoolers can anticipate pain School age children can verbalize pain and describe location and intensity 63
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Pediatrics “Pearls” Children may not admit to pain to avoid injection Distraction techniques can aid in keeping the child’s mind occupied and away from pain Opioids are no more dangerous for children than for adults 64
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Age Related concerns Geriatrics: Age related Pain is not a normal aging consequence Chronic pain alters the person’s quality of life Chronic pain may be caused by a myriad of conditions 65
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Geriatric “Pearls” Adequate treatment may require deviation from clinical pathways Administer pain relieving medications at lower dose and increase slowly 66
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Barriers to effective pain management Attitudes of emergency health care providers Hidden biases and misconceptions about pain Inadequate pain assessment Failure to accept patients’ reports of pain Withholding pain-relieving medication Exaggerated fears of addiction Poor communication 67
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Improving pain management Changing attitudes Continuing education related to the realities and myths of pain management Evidence-based practice Cultural sensitivity 68
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Procedural sedation The Joint Commission (TJC) has standard definitions for four levels of sedation and anesthesia: minimal sedation moderate sedation/analgesia deep sedation/analgesia (pt not easily aroused) anesthesia (requires assisted ventilation) 69
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Procedural sedation Indications: suturing, fracture reduction, abscess incision and drainage, joint relocation Assessment: Allergies, Last oral intake 70
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Procedural Sedation Procedure: Baseline VS and LOC Explain procedure to patient and family Obtain venous access Equipment: cardiac monitor, blood pressure monitor, pulse oximeter, suction, oxygen equipment, endotracheal intubation equipment and capnography device, IV supplies, reversal agents. Assist with medications Maintain continuous monitoring during procedure Document vital signs, LOC, and cardiopulmonary status every 15 min. Post procedure discharge criteria 71
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Medication review Non-narcotic Narcotics Sedatives / anesthetics Local anesthetics 72
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Non-narcotic Acetaminophen Salicylates NSAIDs 73
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Narcotic Codeine Fentanyl Hydromorphone Morphine sulfate Oxycodone 74
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Sedatives / Anesthetics Diazepam Ketamine Lorazepam Midazolam Propofol Etomidate 75
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Local anesthetics Lidocaine Mepivacaine Procaine Tetracaine LET (lidocaine, epinephrine, tetracaine) EMLA cream 76
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THE END 77