PAIN MANAGEMENT. Louise Smith Clinical Nurse Specialist
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1 PAIN MANAGEMENT Louise Smith Clinical Nurse Specialist
2 Objectives To understand:- The concept of Total Pain The types of Physical Pain Holistic assessment Pain management; pharmaceutical & non pharmaceutical WHO Analgesic ladders
3 Pain is what the patient says it is An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
4 Social Physical Total Pain Psychological Spiritual
5
6 Physical pain Acute/chronic Nociceptive Neuropathic
7 Psychological pain Anxiety Depression vs. short-term low mood Coping ability Anger Emotional exhaustion Unresolved issues Not ready for death
8 Psychological Pain Each individual pain experience is influenced by a person s unique personal history, by the meaning they attach to pain and by state of mind. People will behave differently because of variations in background or personality (Sofaer 1998) It is important to realise the crucial part that psychology plays in behaviour during times of illness and indeed pain. Copyright Hospice in the Weald
9 Psychological Pain An anxious state is understandable when faced with a painful illness. Those who tend to worry more generally in life may become overwhelmed. At this point they may enter a vicious cycle : anxiety the physical experience of pain increased anxiety Copyright Hospice in the Weald
10 Social pain Isolation Loss of role Financial Letting the family down Sexual relationships
11 Social Pain The existence of social pain has long been recognised in palliative care, but according to Field (2000) it is probably the least understood. Anticipated or Actual Losses experienced are often concerned with a person s engagement with the world outside of their home and with roles and relationships within the family. Copyright Hospice in the Weald
12 Spiritual pain Loss of faith/questioning Not fair Anger/Why me
13 Spiritual pain What is spirituality? Spirituality Religion Copyright Hospice in the Weald
14 Spiritual Pain An inward journey, questioning the meaning of life, death and human existence. (Elsdon 1995) Long held belief systems will be put to the test i.e. faith in God/religious beliefs. A person in spiritual pain may display a wide variety of emotions: Past painful memories, regret, failure, guilt Present isolation, unfairness, anger Future a representation of fear and hopelessness Copyright Hospice in the Weald
15 Spiritual Pain Coping mechanisms Elusive and enigmatic. Spiritual pain may only surface when suffering can no longer be contained within the physical, social or psychological realms. Copyright Hospice in the Weald
16 Assessment Observation History taking Physical Examination at competence level Holistic
17 CARERS OBSERVATION Differences in skin integrity Differences in mobility Differences in fatigue Verbal and Non verbal signs Listening to patient and family Picking up signals Finding out what makes pain worse/better
18 Carer Management Positioning, patient, food/drinks?mechanical aids Warmth Ice packs Barrier creams/dn involvement Reporting consistent pain/hospice involvement Requesting reviews by HCP Bowel charts
19 Carer Evaluation Was positioning beneficial Was warmth/ice pack beneficial Is the barrier cream working Are the bowels open Have the DNs/Hospice/GP reviewed On going and thorough
20 MEDICATION Dossett Box As required Prompting
21 Non pharmaceutical measures Heat/Ice TENS Acupuncture Complimentary therapies Restricting movement/positioning/carers Counselling/Chaplain
22
23 The Ladder
24 Neuropathic Pain Neuropathic Pain ladder 3.GABAPENTIN 4. ADMIT FOR TRIAL OF KETAMINE DEXAMETHASONE AT ANY STAGE FOR NERVE COMPRESSION 2. AMITRIPTYLINE 1. WHO LADDER ANAESTHETIC ANALGESIC APPROACHES AT ANY STAGE 1. WHO ladder; consider tramadol at step 2; morphine is the 1st line strong opioid of choice 2. Imipramine, desipramine, nortriptyline are alternatives. Start Amitrityline 25mg unless concern re tolerance. If tricylic antidepressants are contraindicated move onto step 3. If it is appropriate to try an antidepressant at a later stage mirtazepine is an option. 3. If gabapentin is contraindicated, an alternative mechanism of action may be added to gabapentin, e.g. carbamazepine. Pregabalin acts on the same receptor as gabapentin and may be used as an alternative to gabapentin (only if gabapentin is not tolerated). Clonazepam may be used if other benzodiazepine effects are desirable: sedation, anxiolysis, muscle relaxation.
25 Side Effects of Opioids Nausea and Vomiting (20-30%) Constipation (90%) Drowsiness (temporary) Cognitive Impairment (minimal) Dry mouth Urinary retention Pruritis
26
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