Pain Management Prepared & Presented by

Ahmad Thanin

Pain—the definition….

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Most common reason for seeking health care. Pain is considered the 5th vital sign.

Pain Management – is a process of assessing, treating and re-assessing pain utilizing non-pharmacologic and pharmacological method.

Common Misconceptionsamong Elderly and Nurses Pain is unavoidable. Pain is a punishment. Asking for pain medication is too

demanding and means I’m not a good patient.

Pain medication are addictive. Taking pain medications means

I’ll lose my independence and mental clarity.

Pain is not harmful. Nurses don’t have the time to

give extra medication.

Elderly patients have decreased sensations of pain.

Elderly patients who are cognitively impaired don’t feel pain.

A sleeping patient is not in pain.

Elderly patients complain more about pain as they age.

Narcotics will hasten death. Potent analgesics are

addictive. Potent pain meds will cause

respiratory depression.

Descriptions of pain:

Duration Location Etiology Intensity Quality Temporal pattern Associated characteristics

Pain assessment:

Should be as automatic as taking pulse and BP.

Pain is the 5th vital sign

Pain threshold: amount of pain stimulation a person requires before feeling pain.

Pain tolerance: the highest intensity of pain that the person is willing to tolerate.

The categories of pain:

Acute Chronic

Cancer – Related Pain

Breakthrough Pain

Pain Categories

Effects of acute pain:

Neuroendocrine response to stress Increased metabolic rate Increased cardiac output Impaired insulin response Increased retention of fluids Increased risk for physiologic disorders Decreased deep breathing and mobility

Effects Chronic Pain:

Suppressed immune function Resultant increased tumour growth Depression and lack of motivation Anger Fatigue

What alternative therapies can close the gate?

Music Distraction of any sort Ice and heat therapies Deep breathing Massage Art therapy

Alternative therapies which may close the gate:

Cutaneous stimulation and massage Transcutaneous electrical nerve

stimulation Relaxation techniques Guided imagery Hypnosis

Let’s try an experiment….

Have each attendant take pen and place over nail bed and push. Describe sensation to neighbor. All the same?Now try counting backwards from 10 while holding pressure on nail bed. Is the pain as bad?

Pharmacological management:

Selection of appropriate drug, dose, route and interval

Aggressive titration of drug dose Prevention of pain and relief of

breakthrough pain Use of coanalgesic medications Prevention and management of side

effects

WHO Analgesic ladder

WHO 3-step Analgesic ladder

COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam, Panadeine, Nurofen. Pain rating 1-2-3

Non-opioid (mild pain) +/- adjuvant

Opioid (mild to moderate pain) +/- non-opioid adjuvant +/- adjuvantCodeine, Propoxyphene, Tramadol, Sevredol, DHC Continus,

Dihydrocodeine tartate. Pain rating: 4-5-6

Opioid (moderate to severe pain) +/-non-opioid, +/-adjuvant

Step 1

Step 2

Step 3

Oxycodone, Morphine, Fentanyl, PethidineKetamine Pain rating 7-10

Analgesic ladder in action:

Step 1: non-opioid analgesics (Paracetamol and Aspirins, NSAIDS)

Step 2: mild opioid is added (not substituted) to step 1

Step 3: Opioid for moderate to severe pain is used and titrated to effect

Breakthrough pain

Use extra (rescue) doses of opioids. Use the immediate-release form of same

opioid they are on. Rescue dose 5-15% of the 24-hour dose. If 3 or more rescue doses needed/24 hrs—

need to titrate routine drug to effect (25-100% current dose).

Pain management through medication and/or neurosurgery

Oral analgesia PCA (Patient-controlled analgesia) Cordotomy: division of certain tracts of the cord.

Rhizotomy: A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input.

Universal Side Effect

Constipation. Nausea and Vomiting. Itching. Respiratory Depression.

Examples of Narcotic Analgesics

Narcotic analgesics Morphine Pethidine

Controlled Analgesic drugs Tramal

Placebo – HMG Policy

Placebo (e.g. normal saline) should not be given to treat pain even with written medical order.

Using placebo to diagnose or treat pain is considered unethical and violating patient right to have optimal pain relief

Assessment tools used at Dr. Sulaiman Al Habib Hospital Qaseem Hospital

Numeric Pain Rating Scale. Wong-Baker Face Pain Rating Scale. FLACC Scale. NIPS Pain Scale. CRIES Pain Scale. Critical Care Pain Observation Tool or CPOT. Comfort Pain Scale

Why have a pain scale?

Sometimes hard to put words to pain Pain is multi-faceted (How long? Where?

How intense? What kind feeling? Visual scales help us understand where

pain located. Faces help us understand how pain

makes patient feel. Numeric scales help quantify pain using

numbers.

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