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0:00
Hello and welcome to the unit 10 lecture on pain management for nursing fundamentals! These are your learning objectives on the next two slides. Please review them in preparation for class and for the exam.
0:14
So let's begin with a brief review of the pain process from anatomy and physiology. So pain is transduced, or felt by nociceptors which convert the stimuli into a pain impulse. It's then transmitted from the periphery to the brain by nerve fibers to the dorsal horn of the spinal cord. And it goes up the spinal cord to the brain. So our perception of the pain stimulus is influenced by past experiences. So either we've
0:38
had a lot of pain and didn't deal well with it or we've had a little pain and we don't know how to deal with it- all of those experiences of our past kind of add together and then
0:50
influence how we feel pain today.
0:53
Modulation is the process of how pain is interpreted and perceived in the brain. So pain can be modulated by two primary types of drugs that work on the brain. These are analgesics like Tylenol and then anesthetics.
1:07
Acute pain typically happens after some sort of trauma, surgery or disease process. It decreases with time when the underlying problem gets fixed. So for example think about a time you got a paper cut- it probably hurt pretty bad, especially if you got salt from your skin into the paper cut. But once the cut healed over the pain was gone, fixed, end of story! We usually see physical or physiological signs of pain like grimacing, increased heart rate, and diaphoresis with acute pain,
1:35
but keep in mind that the absence of physical signs of pain does not mean an absence of pain. Some people just hide it better than others. Chronic pain is an abnormal pain signaling process that is not time limited and it might not have a known cause. It's usually cyclical and irreversible. The usual physiologic signs of acute pain are not seen with chronic pain though. Sometimes they can be, but generally not.
2:03
Untreated or under treated chronic pain can lead to chronic pain syndrome.
2:08
Central sensitization is a persistent pain
2:11
amplification that happens even with mild stimuli. Then hyperalgesia is an exaggerated response to normal painful stimuli. It results in a lower pain tolerance, spontaneous pain and increased sensitivity to pain.
2:26
Allodynia is an abnormal pain response signaling-
2:31
It results in perceived pain with mild or non painful stimuli. So for example, with allodynia
2:38
Diabetic neuropathy might cause an intense pain sensation if the blankets are simply touching the patient's feet, so nothing, we would normally think of as causing pain causes some significant pain for these types of patients.
2:54
With cancer, pain is often the first symptom causing patients to seek treatment and then patients might be reluctant to report increasing pain because the patients fear that an increased pain means a worsening of their disease. Patients require dedicated attention to pain management when they have cancer. And this is because cancer pain is difficult to manage because of the malignancies in their location and the rapid growth of them.
3:20
Somatic pain is a localized pain. So for example you bump your shin and have a localized pain in your shin You know it's there You know why it's going on. Then visceral pain is a deeper and more diffuse pain as seen with like a heart attack, appendicitis, or urine retention.
3:37
Neuropathic pain is related to nerve damage. Patients often report pain feeling like burning, tingling, itching, cold, shock-like, or a pinched nerve type sensation even with a very light touch. Examples include diabetic neuropathy and phantom limb pain.
3:54
So let's talk about some cultural and other considerations. So lack of English language is a definite barrier to communication about pain management. We might need to use other methods to assess pain like nonverbal indicators or pictures, which we'll talk about in a bit. Certain cultures might regard pain as punishment for wrongdoings. So they might not accept pain medications and they might not even be willing to admit that they have pain.
4:21
They might focus on natural pain management or divine healing powers for pain can rather than pain medications. Be careful not to stereotype! So for example, sometimes men are thought to be more stoic with pain in women more expressive of pain. This isn't necessarily the case, though. Sometimes the elderly will be less expressive of pain and this could be because of cognitive decline and inability to express pain.
4:48
And it might result- what you might see is an increased combativeness or agitation rather than your typical pain symptoms, so we need to be aware that not everything is cut and dry with pain and just need to make sure we do a full and detailed assessment. Several factors affect the pain response. So the affective domain relates to overall mood. Depression can make pain significantly worse while happiness can make pain significantly less noticeable.
5:17
The behavioral domain is how people react to pain. Distraction is a very effective pain management strategy, so watching TV or talking with friends or great distraction techniques that can help control pain. Confused patients or those with dementia might show agitation and aggression under with under or untreated pain. So I saw this as when I was a nursing student working in a nursing home.
5:42
And what happened was one nurse was diverting or stealing fentanyl patches from Alzheimer's unit residents. So the residents were getting more agitated and combative, but they couldn't tell us their pain and they couldn't tell us what was going on. So on top of that they were withdrawing from physical dependence on narcotics. So no wonder they were having behavioral issues! They were miserable and they couldn't let anybody know about it! The cognitive domain is what we think about pain.
6:09
People have different meanings that they associate with pain which can make the pain response worse. So for example, if they think that their pain- they know their pain is related to Cancer and they know they're gonna die, and this is the thought process going on in their head, that's going to intensify that feeling of pain because then they have the stress of what's going on with them on top of that pain response making it worse.
6:35
So that Joint Commission requires that healthcare workers assess all patients for pain on a regular basis. Remember to document that you assessed for pain or there's no way to show that it was done. And that
6:47
documentation includes a full pain assessment, which we'll get to in a couple slides here. If you provide an intervention be sure to document to follow up assessment within an hour and maybe even sooner if it's an IV pain medication.
7:03
So we've already established that a thorough pain assessment is a must! We want to watch for physiological symptoms, especially if the patient appears to be under reporting pain, but remember not everyone in pain is showing physiological symptoms. We want to take a look at the Associated symptoms also. Why might a patient be nauseated from pain? If we think critically about this, we would ask questions like is the pain in the abdomen or back? Is it related to GI problems or kidney stones?
7:33
Why do heart attack patients get nauseous? Well, the answer is that the emotional stress or visceral pain in general plays a part in the nausea. It can also cause itching. Opioid medications can easily cause nausea, vomiting, itching, and constipation. Always assess the history to determine the cause. So what can we do for these associated symptoms? Well, minimize the stress response, use relaxation, deep breathing exercises, position of comfort, maybe lotion or antihistamines for itching,
8:04
increase fluids for nausea and constipation, and then we also want to increase movement and fiber for constipation.
8:13
Assessing across the lifespan can have its unique challenges. Not everyone can use a 0 to 10 pain scale. Children can use a faces scale or the oucher scale. There's a series of faces that go from smiling to crying and then they point out the one that best matches how they're feeling. Now something to keep in mind, is it sometimes adults have difficulty with the 0 to 10 number scale also so we can use the face of scale for them to if we need to.
8:38
This also works with non-english speaking patients because generally, the faces are
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globally accepted representations of being happy or being uncomfortable.
8:53
For infants and any patient who can't self-report pain, such as intubated patients we want to use a non verbal pain scale such as the flacc scale.
9:03
Now this slide describes the old carte method of pain assessment. It's important to address all of these items to be Joint Commission compliant, but more importantly, a thorough assessment of your patient's pain allows you to better form a plan of care to treat their pain. And then we want to chart all these things also.
9:20
Pqrst is another way of obtaining detailed pain assessment. You'll be practicing either this method or the old carte method in skills class and generally speaking either one can be used depending on your personal preference.
9:35
So patients have many barriers to getting pain relief. Some may not have ability to pay for doctor visits or prescriptions. Some are scared that they're going to become addicted so they go without pain management. Patients need to be reassured that narcotic pain treatment for acute, short-term pain has a less than 1% chance of addiction. Sometimes we as health care providers think the patient's "faking it" just to get pain meds because they don't "look" like they hurt,
10:01
so we're reluctant to give them pain medicines. Maybe the patient's reporting severe pain but is interacting with visitors and watching TV. We need to take their reports of pain seriously, even if they aren't acting the part, because the patient is the authority of their own pain level and no one else can tell that. Also, what we have to remember is that sometimes people become addicted to pain medicine as a result of chronic pain.
10:27
They might have impaired control over their problem now, but very well may still have pain that needs managed. They are entitled to adequate pain relief and might require higher doses than what a normal patient population would. So think about this scenario for a minute to build on your critical thinking: So a chronic pain patient is admitted and their usual dose of narcotic is methadone
10:50
180 milligrams daily, treated at the local methadone clinic. The patient reports as pain is adequately controlled at home. However, the care provider that meeting him feels that this dose is way too much and they say that the methadone clinic always over prescribes and so they're just going to order methadone 20 milligrams a day instead of the home dose. Think about what are the ramifications of this order?
11:18
Well, the patient likely will not have an adequate pain relief and they might start going through withdrawal. How can you as a nurse best advocate for your patient? Remind the provider of these ramifications- remind them that this patient has a pain control regimen at home that's working for them, they don't look sedate, they don't look out order, they need to have their pain managed!
11:41
But then think about this: what if the patient was admitted with a respiratory failure second to a decreased level of consciousness?
11:49
Well, in this case the safest thing for the patient would be to decrease the amount of narcotic given, but you want to be careful, you know because we need them to maintain their airway, so we want to give airway support. Some providers might jump to giving a narcotic reversal like narcan, but we need to be careful and keep in mind if we do this, this can cause instant withdrawal symptoms because the opioids are kicked off the receptor sites in the brain immediately and
12:17
if that patient is used to having that narcotic on board, they're instantly going to go into withdrawal from that. It's going to make for a pretty miserable patient!
12:28
Now this chart outlines some key terms associated with pain management the main difference is that physical dependence occurs normally as patients use opioids chronically. And these patients are able to maintain a normal use of their medications as prescribed. Addiction on the other hand, is characterized by impaired control or compulsive use of a medication, often for effects other than pain control like to get high or to
12:56
escape reality. Though they might very well need the pain control also, like I said before so we need to be careful in that to just pull their pain medicines away because they might really need them for a medical condition also.
13:11
You can check out this table in your book for nursing diagnosis statements related to pain. Outcomes and interventions are also given so this is a good place to start if we're going to think about writing a care plan for somebody with acute pain problems.
13:31
Next we set our goals and our outcome criteria. Remember, it's not going to be possible to achieve a zero out of ten pain score for all patients, so make sure that your pain score goal aligns with your patients personal
13:43
acceptable pain score level, and also that it's realistic with the disease process.
13:48
Sometimes we have to go with an acceptable pain level that the patient sets rather than a number that we think is appropriate. So maybe the patient is saying "my pain scores a 0/10. I'm not happy unless I'm a zero out of ten, but they just had a big bowel surgery". It's gonna be very very difficult to get them down to a zero out of ten without completely sedating them and making them
14:13
unresponsive, so we need to work with our patient and kind of explain that and maybe after you talk to your patient, they're like "well, yes, I'm really okay with like a two out of a ten or something."
14:26
So the World Health Organization or WHO
14:30
set guidelines for choosing a pain management strategy. They advocate using the less invasive, less risky pain medications first to minimize side effects and to minimize risk of addiction problems. So the first line of treatment for mild pain usually like a one to a three would be a non opioid prescription like tylenol, ibuprofen or naproxen sodium. The second line treatment for moderate pain usually like a four to six
14:58
is gonna be a weak opioid prescription like tramadol or vicodin. And then the third line of treatment for severe pain which is like a seven or ten is gonna be a strong opioid like morphine or fentanyl. Proceeding with the WHO pain ladder helps prevent potential narcotic dependence and abuse as well as serious side effects like respiratory depression and constipation. And then if you see on the little picture there, adjuvant analgesia is listed and that just means that medications that
15:28
go along with pain medicines and they might make a pain medication work better, but they're not directly a pain medicine themselves.
15:37
This slide lists of medications recommended for Tier one of the who ladder which remember is mild pain so you can read through that. And
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then if we move up the who ladder to moderate to severe pain,
15:52
Opioids are recommended. A critical point to think about is to assess respirations before administering any of these medications, because they can have a significant effect on respiratory rate. Most are going to decrease the respiratory rate, especially if the patient's given too much for what they can handle. We want to always consider a bowel management plan because opioids slow down the GI tract and can cause severe constipation. And then if these are used for more than a week we can expect
16:19
physical dependence to some degree and so we might get some withdrawal symptoms if they're abruptly stopped.
16:28
And then narcan is given to reverse opioid overdose, but like I mentioned it causes acute withdrawal symptoms if the patient's opioid dependent, so we want to be real careful giving that.
16:46
Safe effective drug delivery system
16:49
by an IV line is the basis behind
16:54
patient controlled analgesia. So if this allows patients to administer pain medications when they need them based on parameters set by the healthcare provider. So for example, they might order that the patient can have one milligram of morphine every six minutes with an hourly limit of ten milligrams. The machine only allows the set dose to be administered, even if the patient's pushing the button more frequently. So important education to provide the patients and families
17:19
is that ONLY the patient should push the button. The risk for the family pushing the button and not the patient is that if the patient becomes too sleepy to push the button and then the family comes along and thinks "oh, the patient looks like they're hurting- we're gonna give them a dose." So then they push the button for the patient. Then the patient winds up with even more sedation medication on board because that's what the pain medicines do is they can cause some sedation, so they become
17:50
even more that way and they get too much medication for what their body can handle. So the patient was already too sedated and now they just got another medication dose from the family, so then they're really going to be at risk for side effects from this PCA. Another thing to consider is what if your patient
18:10
can have a PCA dose of 4 times in an hour, or every 15 minutes, but then you go in and you assess their PCA usage and see that they've actually hit the button ten times in the past hour!
18:24
What do you think? Is their pain managed?
18:31
Probably not, because they felt the need for pain medicine every six minutes. So over half of their PCA attempts were not given to them because it was too soon. So in this case the nurse should do a full pain reassessment to validate our assumptions if the pain is not controlled and then we're going to update the provider if this is the case as we need to just request an increase in pain medication.
18:55
Constantly monitoring respiratory status is necessary with a PCA to catch problems early. So this means respiratory rate, O2sat and CO2 levels should be considered throughout the treatment because these are going to tell us if we have a drop in our oxygen saturation or an increase in our co2, meaning that we are
19:19
hypoventilating and retaining co2.
19:23
And then for intra-spinal, you'll learn a little bit more about these and advanced skills, but just be aware that it is one of the delivery methods and this would be like an epidural that actually goes into the spine to deliver medications.
19:41
So non- pharmacologic pain relief is important for patients because not everybody needs the pain medicine. Sometimes heat or cold or massage or the TENS unit is enough to get them through what's going on So heat, remember, we get vasodilation and increased blood flow and we should keep our duration of heat five to twenty minutes based on patient tolerance. Cold we get vasoconstriction. So we don't want any more than twenty minutes because we don't want to have tissue ischemia. And then massage
20:13
can be beneficial- we're not licensed massage therapists, but sometimes a back rub goes a long way for somebody with back pain. And then TENS unit are specialized stimulators that's placed over the area of pain and what this does is provides an electrical impulse to alleviate pain perceptions.
20:33
These are some cognitive and behavioral strategies that can be used to minimize pain perception and increase ability to handle pain, so if you're not familiar with these I would look them up in your text a little bit more especially focus on things like
20:48
rhythmic breathing and meditation and visualizing and distraction are probably the more common ones that we use.
20:58
So, how do we implement these things? A couple things that can be helpful is number one patient education. We to Set pain level expectations appropriate So what's happened? sometimes in my practice is that sometimes the surgeons are going to tell the patients in their pre-op visit that they might be a little uncomfortable after surgery when the reality is that they're likely going to have a lot of pain and this sets the patient up for
21:28
disappointment when they get out of surgery and they have 10 out of 10 pain when the surgeon told them "Well, you're just gonna have a little discomfort," which maybe they interpret it as a 2 out of 10 pain. Then sometimes just telling the patients why they're having pain and what they can do about it helps. So for example, post-op open-heart surgery patients usually have a lot of drain pain from drains in their chest. We need to explain to them why they're having back pain and that
21:54
narcotics won't necessarily help it but shifting their shoulders or repositioning might move the drains off the nerves inside of their chest wall, and this is what's causing their pain. So if they can get those drains to shift a little bit then they're gonna have our relief in pain and most patients don't know that so we need to just explain different techniques besides pain medicines I can help them.
22:18
And then taking time and offering yourself and showing compassion can help your patients with their pain control also, because it shows the patient that you care and and you're trying to understand what they're going through. Then as a reminder for mild pain start with Tylenol versus starting with narcotics, but you want to check the porter's to make sure you're
22:41
there's an order for Tylenol just to validate your thinking- obviously if there's no order we can't start there.
22:50
Evaluation of pain management is also important So if we gave a tier-one pain medication, we need to make sure that it's helped the pain. If not, we need to reassess and come up with a different strategy or perhaps a different pain level goals. Maybe they need a little bit stronger pain medicine next. Generally, reassessing pain levels within an hour after giving the medication is appropriate
23:15
Oral meds may take up to an hour to start to work but IV meds generally work faster. So about 30 minutes is a good recheck timeframe for that. Thanks for listening and this concludes the presentation on pain management. Have a great day
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