Nursing

1. This PowerPoint file is a supplement to the video presentation.  Some of the educational content of this program is not available solely through the PowerPoint file.  Participants should use all materials to enhance the value of this continuing education program.

3. Nursing 311112 Pain Management: Acute Pain Brenda Threadgill, RN, BSN, MS, CHPN, Retention Counselor, Traditional Undergraduate Program TTUHSC, Lubbock, TX

4. Nursing 311112 Objectives Recognize basic principles and barriers.

5. Nursing 311112 Objectives Indicate outcomes, history, and processes.

6. Nursing 311112 Objectives Identify expectations and assessment principles.

7. Talking Points • Define basic principles of pain management • Describe barriers to good pain management • Differentiate outcomes of good vs poor pain management • Discuss the history of pain and pain treatments

8. Talking Points • Discuss a brief overview of pain processes • Identify expected findings in acute vs chronic pain • Describe the principles of a thorough pain assessment

9. Perceptions of Pain • John is lying in bed, watching TV • He appears to be uncomfortable, grimacing occasionally, changing position with difficulty, and gritting his teeth • Blood pressure (BP): 145/92 • Respirations: 28/minute • Pulse: 92

10. Perceptions of Pain • He had 2 acetaminophen and hydrocodone 5/500 (Lortab) 2 hours ago and his pain went down from 7/10 to 3/10 • When you ask how his pain is doing, he tells you his pain level is now 8/10 • What will you do?

11. Perceptions of Pain • Jane is sitting up at the side of her bed, playing cards with her sister • They are laughing and she appears comfortable • BP: 115/76 • Respirations: 18/min • Pulse: 84

12. Perceptions of Pain • She had morphine 5 mg intravenous push (IVP) 2 hours ago and her pain went from 7/10 to 3/10 • When you ask how she’s feeling, she states that her pain is back up to an 8/10 • What are you going to do?

13. Perceptions of Pain • Bill has been admitted to your floor • He has lung cancer with metastasis to the bone • He came into the emergency room (ER) with complaints of uncontrolled pain for the past 3 days

14. Perceptions of Pain • His ordered pain medication is acetaminophen and hydrocodone 5/500 (Lortab) • 1 to 2 tabs every 6 hours pro re nata (PRN), of which he has been taking 2 tabs 6 times a day

15. Perceptions of Pain • He rated his pain in the ER as 10/10 and was given morphine 5 mg IVP 6 hours ago, with minimal relief of pain • He was then given 10 mg morphine IVP 5 hours ago, with partial relief of pain (6/10)

16. Perceptions of Pain • He was given another 10 mg morphine IVP 4 hours ago, with complete relief of pain (0/10) • He is now asleep

17. Perceptions of Pain • When you go into his room to assess him, he does not wake until you call his name and shake him • He talks to you appropriately and takes a drink of water • He states that his pain is coming back a little and rates it as 2/10 at this time

18. Perceptions of Pain • BP:105/76 • Respirations: 12/minute • Pulse: 74 • As soon as you turn to write down his vital signs, he has fallen asleep again • What is your next step?

19. How do you feel about these patients?

20. Pain management is a holistic combination of science and art

21. Science Research and Technology Person Mind, Body, and Spirit Environment Family, Friends, Way of Being Holistic Universal Human Experience Art Unique Experience, Potential for Meaning

22. “When we honestly ask ourselves which persons in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.” -Henri Nouwen

23. Basic Principles • Prevent pain whenever possible • Control pain to the level that is acceptable to the patient

24. Who has pain? • Every living creature is capable of experiencing some degree of pain • Every person alive has experienced pain of some sort • Every nurse has cared for a person experiencing pain of some sort

25. Why should we care? • Pain is a universal human phenomenon • There are as many ways to experience pain as there are people in the world • Every person’s pain is unique to that person • Nurses are the one constant in most people’s journey to optimal pain relief

26. Why should we care? • The good: • optimal pain relief leads to better quality of life and better patient outcomes • The bad: • poor pain relief leads to negative disturbances in health • The ugly: • poor pain relief leads to increased financial drains on the healthcare system

27. Stand and Defend • Nurses are the front line defenders against pain: • suggest and carry out medication orders • stand guard against pain increasing or returning • suggest and carry out non-pharmacological interventions • perception of caring

28. Frontline Advocate • Nurses are the frontline advocates for optimal pain relief, especially if there are inadequate orders for pain relief • Nurses must advocate for their patients with: • scientific, evidence-based knowledge about pain and pharmacology • caring determination to get the appropriate orders to obtain optimal pain relief for our patients

29. Can we do a better job? • Multiple studies have shown that the most important barriers to optimal pain relief are: • beliefs and attitudes of healthcare practitioners • lack of organizational support • training • prioritization of pain assessment • support for evidence-based practices

30. Can we do a better job? • general expectations that good pain relief is often not possible or is not a priority concern of • healthcare practitioners • doctors • nurses

31. Does it have to be this way? • The quickest and easiest part of the system that can be changed is you • taking part in learning more about pain relief • changing your own beliefs and attitudes • having the determined will to be a strong patient advocate for excellence in pain relief • Numerous studies have consistently identified nurses as the key players in making a difference in the best practices for pain relief

32. History of Pain • We assume that pain has been around for as long as there have been people • We know that people in pain seek relief from pain • Earliest records of prescriptions go back to the Babylonians around 3000 B.C.

33. History of Pain • The Chinese (2700 B.C.) had a compendium of herbal remedies (40 volumes) called the Pen Tsao • The early Egyptians (1500 B.C.) had their own documented remedies called Ebers Papyrus

34. Wonder Drugs • Decoctions from the bark of the willow tree are some of the first recorded treatments for pain and became the basis from which we derived aspirin • Aspirin is the original wonder drug and remains one of the most widely used medications for pain in the entire world

35. Wonder Drugs • Other early remedies for pain included fermentation and distillations of various fruits and grains, such as: • grapes • barley • corn • wheat

36. Morphine • Opium has been used for centuries for relaxation, euphoria, and relief of pain • The first recorded isolation of morphine from opium occurred around 1805 by the German chemist Friedrich Serturner • he tested his discovery on himself and three young friends by dosing each of them with 100mg of unrefined morphine • they spent the next three days suffering from acute morphine intoxication

37. Morphine • despite this inauspicious beginning, morphine proved to be the wonder drug of the century and remains the gold standard to which all other pain medications are compared

38. What is pain? • International Association for the Study of Pain defines pain as: • “an unpleasant sensory and emotional experience arising from actual or potential tissue damage” • Margo McCaffery defines pain as: • “whatever the experiencing person says it is, occurring whenever he/she says it does.” • Cox defines pain as: • “a complex, physiological, and psychological phenomenon that is subjective in nature.”

39. Pain Concepts • The word “pain” comes from the Latin word poena, meaning penalty or punishment • this concept still has relevance even today • Pain is multidimensional • it has many aspects: • physical • mental • emotional • spiritual • it is rarely comprised of only one aspect and often all aspects are involved

40. Pain Concepts • Most important - it is subjective in nature • we can look for clues to support the claim of pain • they may or may not be there • never look for clues to discount a report of pain

41. Why does pain hurt? • Easy answer: we don’t know • Complicated answer: we don’t know everything • so many pathways • so many complicating factors • every person is unique

42. Kinds of Pain • There are multiple ways of classifying pain, including: • underlying pathophysiology • nociceptive vs neuropathic pain • length of time • acute pain vs chronic pain • mixed pain classification systems • chronic noncancer pain • chronic pain syndrome

43. Kinds of Pain • Does it matter how pain is categorized? • only in that it helps guide treatment options • mixed pain classification systems • chronic noncancer pain • chronic pain syndrome

44. Acute Pain • Acute pain is a warning • There is a physical reason for it • It is time-limited • We expect acute pain to decrease as healing takes place and eventually go away completely

45. Injury healed Injury Healing continues High pain rating Healing taking place

46. Chronic Pain • Pain lasts longer than expected (even after the injury is healed) • Not time-limited (lasts longer than 3-6 months) • There is a large psychosocial component to most chronic pain states • Chronic pain is usually much harder to manage successfully

47. Injury Chronic: Meds may not be effective Acute: Meds effective Persistent pain after original injury has healed Chronic pain Little to no pain after injury has healed

48. How do we do it? • The nursing process gives us a map to follow to provide the best practices in excellent pain relief: • assessment • nursing diagnosis • planning • implementation • evaluation

49. Assessment • Believe the patient’s self-report of pain • Do something about it

50. Pitfalls of Assessment • Assessment is where we tend to “slip up” and trust our own judgment, instead of believing the patient’s self-report of pain