Pain Management

1
Pain Management An Introduction

• Thea Addison, Vicki Yates
• Acute Pain Nurse Specialists
• Derby Hospitals NHS Foundation Trust

2
Aims of the Session

• The Pain Team their Role
• Define pain
• Emphasise the different pain pathways
• Types of pain
• Assessment of pain pain tools
• Barriers to pain assessment
• Simple interventions

3
Role of the Acute Pain Team

• Overall responsibility for Acute Pain Management
  throughout the trust
• Expert clinical and educational pain management
  resource
• Service initially set up for post-op pain
  management
• Now - Complex diverse pain problems
• In-patient Pain Team - A more accurate title?
• Clinical / Education / Audit / Research

4
Links with

• Outreach Team
• Palliative Care Team
• Ward based link nurses
• School of Nursing
• Clinical facilitators educators
• Other nurse specialists
• Regional and National Specialists in Pain

5
Definition of Pain

• Pain is whatever the experiencing person says it
  is, existing whenever the experiencing person
  says it does
  McC
  affrey(1968)

6
Definition of Pain

• Pain is an unpleasant sensory and emotional
  experience associated with actual or potential
  tissue damage. Pain is always subjectivealways
  unpleasant and therefore also an emotional
  experience.
  
  
  
  
  International Association for
  the Study Pain (1979)

7
Why Treat Pain?

• Humanitarian Reasons
• Clinical Effects of Pain
• Reduces Stress Response
• Patient Satisfaction
• Promote Early Discharge

8
How Do We Feel Pain?

• Two Major Types of Pain
• Nociceptive pain due to tissue damage
• Neuropathicpain due to injury of nerve pathway -
  painful sensations are carried from the site of
  injury to the brain -
  treatment will depend on type of pain

9
Acute Pain

• Helps diagnose illness by acting as a warning
  mechanism - therefore is a symptom
• From trauma often imposes limitations, which can
  prevent aggravation of an injury
• In post-operative period serves no useful
  purpose and can be detrimental to the recovery of
  the patient
• Recent studies/surveys indicate that pain control
  still remains an inconsistent affair

10
Chronic Pain

• Untreated Acute Pain can become Chronic Pain

11
Chronic Pain

• Pain that persists beyond the expected healing
  time
• Not simply a prolonged duration of acute pain.
• Biological changes in central nervous system.
• Adaptation of autonomic nervous system.
• Complex Pain that is prolonged in nature, due to
  known reasons or absence of evident tissue
  damage.
• Complex interplay of biological psychological
  factors.
• 7.5 million pain sufferers in UK

12
Cancer Pain

• Cancer is a dynamic disorder and patients may
  experience Acute as well as Chronic pain due to
  further tissue damage
• Pain of varied duration/commonly progressive
• Pain may be associated with symptoms which signal
  deterioration eg weight loss, anorexia, physical
  dependence, lack of sleep
• Realization of dying may result in overwhelming
  pain that is difficult to describe and to assess

13

• CHRONIC
• Persistent
• No useful purpose
• Tends to increase as time goes on
• Starts at bottom of medication ladder

• ACUTE
• Transient
• Warning mechanism
• Usually decreases at around 48hrs
• Start at top of medication ladder

14
Pain Assessment

• Advantages
• Provides patients with an opportunity to express
  their pain
• Conveys genuine interest concern about their
  pain
• Gives patients an active role in their pain
  management
• Can provide documented evidence of the efficacy
  or failure of drugs / treatments

15
Pain Assessment

• When
• Initially to understand the pain develop a care
  plan
• Immediately following surgery / procedures
• Prior to following administration of analgesia
  / treatments
• At a report in change of description, location or
  intensity of pain
• Deep breathing / coughing / moving limb etc

16
Pain Assessment What You Need to Know

• Location
• Description
• Duration
• Pain Intensity
• ? Related to admission
• Influencing factors
• Deep breathing / coughing / moving limb etc
• Drug history

17
Pain Assessment Tools

• Pain Intensity Scales
• Visual Analogue Scales (VAS)
• Numeric Scales
• Verbal Rating Scale (VRS)
• Body charts

18
Pain Assessment Tools

• Visual Analogues Scale
• No The worst
• Pain pain
  imaginable
• Numerical Rating Scale
• 0 1 2 3
  

19
Pain Assessment Tools

• Verbal Rating Scales
• 0 No pain
• 1-3 Mild pain
• 4-6 Moderate pain
• 7-10 Severe pain

• Acute Pain Chart
• 0 No pain
• 1 Mild pain
• 2 Moderate pain
• 3 Severe pain

20
Descriptive Words for Pain

• Throbbing Cutting
• Burning Stinging
• Aching Tiring
• Blinding Intense
• Penetrating Nagging
• Shooting Gnawing
• Searing
• Tender Dull
• What makes pain better?

• Frightful Annoying
• Unbearable Radiating
• Nauseating Stabbing
• Crushing Smarting
• Hurting Splitting
• Vicious Spreading
• Piercing Torturing

21
Factors Influencing Coping

• Age / gender
• Culture / Social beliefs
• Emotions, eg fear, anxiety, anger, sadness
  depression
• Fatigue, sleeplessness
• Past experiences
• Expectations
• Communication information

22
PAIN IS THE 5TH VITAL SIGN
Patient assessment is the first stage in
managing pain well!
23
Non-Verbal Signs

• Body Language- posture, lying still, rolling
  around, rocking, withdrawn
• Facial Expressions-crying, grimacing,
• frowning
• Disrupted sleep pattern

• Note!
• Patients with long standing pain may tell you
  they have severe pain but not display any of
  these signs!

24
Assessing Pain in Patients Unable to Communicate

• Mentally / cognitively impaired patients
• Sensory impaired patients
• Unconscious patients
• Neonates / children

25
Assessing Pain in Patients Unable to Communicate

• How
• Patients self-report if possible / carers report
• Observation of behaviour incl. posture, movement
• Comparing current with usual behaviour
• Abnormal change in behaviour eg aggression /
  agitation
• Patients interactions with others
• Check for full bladder / colic caused by
  constipation
• Sleep and diet

26
The Cognitively Impaired Patient

• Some patients who are confused in time and place
  will still be able to report and describe pain!
• Once patient becomes very vague, confused or
  unconscious, signs which signal pain should be
  looked for eg
• Restlessness or agitation
• crying out or groaning
• Withdrawing, localizing or guarding
• Rocking, immobility or rubbing the area

27
Impact of Pain

• Clinical ?BP, ?Pulse, ?Resps, sweating
• Functional reduced mobility associated
  problems
• Emotional the meaning of pain effects,
  anxiety, depression
• Social/occupational role, finance, family,
  sexuality

28
Barriers to Pain Assessment

• Healthcare Professionals
• Attitudes
• Skills
• Knowledge / misconceptions
• Failure to routinely assess document
• Legal aspects of drug administration
• Drug round times

29
Barriers to Pain Assessment

• Patients
• Want to be a good patient
• Language or cultural barrier
• Fear of addiction/unwanted side effects
  /misconceptions
• Value of suffering - no pain / no gain
• Expectations and goals
• Reluctance to report or use word pain
• Litigation

30
Barriers to Pain Assessment

• Healthcare System
• A low priority given to pain care
• Restrictive regulation of controlled substances
• Lack of access to pain specialists
• Resources workload

31
Failure to Manage Pain Well

• Inadequate assessment
• Failure to evaluate interventions
• Failure to reassess

32
Simple Interventions

• Comfort Measures
• Therapeutic environment
• Patients bodily comfort
• Relaxation
• Massage / touch
• Guided Imagery
• Diversional activities
• Confidence building

33
Simple Interventions

• Preventative Measures
• Positioning
• Carefully support painful area
• Attention to Dressings
• Provide pressure relieving mattress
• Hot/cold packs
• Ensure medications and adequate hydration is
  given
• Encourage and assist with exercise

34
Simple Intervention

• Recognise the power of suggestion and Patient
  Partnership!
• Listen to the patient
• Support the patient
• Reassure the patient
• NB Be aware of your own limitations and ask for
  support!

35
Benefits of Treating Pain

• Humanitarian - quality of life
• Aids recovery
• Reduces complications
• Improves patient carers satisfaction
• Healthcare outcomes -
• can prevent readmission
  ? hospital
  stay

36
Ineffective Pain Control

• If not achieved the 5 Ds can occur!
• DISCOMFORT
• DISABILITY
• DISSATISFACTION
• DISEASE
• DEATH
• - COMPLAINT / LITIGATION

37
Summary

• Pain is an individual experience
• Listen to your patient
• Effective assessment and documentation
• Non-pharmacological management
• Evaluation/ Documentation

38
Useful websites

• www.painsociety.org
• www.ampainsociety.org
• www.pain-talk.co.uk
• www.iasp-pain.org/
• www.anzca.edu.au
• www.medicine.ox.au.uk/bandolier
• www.medicines.org.uk
• www.painradar.co.uk

39
References

• McCaffery, M. (1968) Nursing Practice theories
  related to cognition, bodily pain, and
  man-environment interactions.