3/10/2015. SPEAKER NAME AND CREDENTIALS: Roberta Goff, MSN Ed, RN-BC, ACNS-BC, ONC

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1 GOAL OF PROGRAM: To gain understanding about caring for different pain populations and keeping them safe. SUCCESSFUL COMPLETION: To receive contact hours, participants must attend the entire program. Please return your completed evaluation form to the conference registration desk at the end of the conference 1 PLANNING COMMITTEE NAMES AND CREDENTIALS: Nancy Irish, MSN, RN-BC Roberta Goff, MSN ED, RN-BC, ACNS-BC, ONC Vickie Harrington-Thompson BS, RN, CMSRN SPEAKER NAME AND CREDENTIALS: Roberta Goff, MSN Ed, RN-BC, ACNS-BC, ONC 2 The activity planners and the speaker for Excellence in Nursing have reported no conflicts of interest related to the presentation. 3 1

2 No Commercial support or sponsorship was received for the Excellence in Nursing presentation. NON-ENDORSEMENT OF PRODUCTS: The discussion of commercial products during the conference does not imply endorsement by Munson Medical Center, Wisconsin Nurses Association, or the American Nurses Credentialing Center s Commission on Accreditation. 4 The learner will be able to differentiate the difference between chronic pain pathways and acute pain pathways The learner will be able to describe risks for and assessment of sedation The learner will be able to state 3 medications that could be used for a patient who is opioid-naïve The learner will be able to express alternative treatments for those with pain 6 2

3 7 Chronic pain has become a label that is fraught with negativity and stereotypes Persistent pain fosters more of a positive undertone and hope 8 Unpleasant sensory and emotional experience arising from actual or potential tissue damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than 6 months persisting a month longer than the usual course of an acute disease 9 3

4 Neuropathic Central neuropathic Poststroke syndrome Spinal cord injury Complex regional pain syndrome (types I and II) Peripheral neurogenic Peripheral neuropathy Radiculalgia Radiculopathy Radiculitis Phantom limb pain Residual limb pain Fibromyalgia Myofascial pain 10 Physical dependence Tolerance Addiction Chronic Pain Syndrome Drug-Seeking Factitious Disorder Malingering Pseudoaddiction Psychogenic Pain Disorder Somatoform Disorder Substance Abuse 11 Fear of addiction Building tolerance Limitations of activities such as driving Harm to the immune system Opioid-induces hyperalgesia Opioid-induced hypogonadism Can t I just have cancer please? 12 4

5 Patients receiving long-term opioid therapy may need up to a fourfold higher opioid dose than someone who is opioid-naïve. Make sure that the patient gets normal doses of home pain medications before surgery Have the down and dirty talk about exactly how much pain medication they were taking at home Ask how they cope with pain at home Add a non-opioid to the pain regimen early on 13 Frequent Flyer, Drug Seeker, Chronic Painer Evidence suggests that pain in people with addictive disease are undertreated Giving medications will not worsen the disease and not giving them will not help with recovery Withholding opioids could put them into serious withdrawal 14 Pain Management in Patients with Addictive Disease patients with addictive disease and pain have the right to be treated with dignity, respect, and the same quality of pain assessment and management as all other patients. 15 5

6 Whatever the experiencing person says it is, existing whenever the experiencing person says it does. (Margo Mcaffery) Pain perception is an inherent quality of life that appears early in ontogeny to serve as a signaling system for tissue damage. (Anand & Craig) Acute pain is a warning signal to the body that something is wrong or needs attention (Bonica) 16 Recent onset Peripheral nociceptors are involved in the transmission of sensation Usually associated with the sympathetic portion of the autonomic nervous system responses Treatment is focused on the cause 17 Opioids, Alpha 2 Agonist, Anticonvulsants, TCA TCA, SNRI Local anesthesia, Alpha 2 Agonists, NSAIDs Local, NSAIDs, Cox 2 inhibitor, Acetaminophen, capsaicin 18 6

7 All opioid naïve patients Opioid tolerant patients receiving more opioid than they are tolerant to Coexisting conditions such as chronic pulmonary disease, major organ failure, obesity, and those with sleep apnea Age greater than 65, especially with comorbidities Those whose pain was uncontrolled, but is now controlled 19 Opioid Naïve: No daily use of opioids within the past 7 days. Opioids are sedating sedation causes CO 2 retention followed by respiratory depression leading to respiratory arrest Start low-go slow! 20 Rate (less than 6 needs action) Needs to be counted for at least 1 full minute Quality (compare to baseline) Depth Effort Noise (snoring) Regularity 21 7

8 Highly reliable measure of the quality of ventilation Early indicator of impending respiratory depression Uses a nasal cannula to detect expired CO 2 Programmed to alarm and when the device detects a reading outside of the preset parameters If the monitoring module is attached to a PCA or PCEA, the opioids will actually stop infusing if respiratory depression is realized 22 Safe pain management Reduce Naloxone usage 23 ASSESSMENT: What is the nature and characteristics of the pain? What works at home? Are there medications you are not willing to try? 24 8

9 Especially in the elderly, many times plain acetaminophen is enough. If the patient does not have any contraindications, there are a variety of NSAIDS that could be offered. A drug like Tramadol is often a great starting point for more severe pain For severe pain, start with the lowest dose of opioid. 25 Adjuvant medications Ice Heat Repositioning Distraction Home coping measures

10 Dykstra, K. (2012). Perioperative pain management in the opioidtolerant patient with chronic pain: An evidence-based practice project. Journal of Perianesthesia Nursing, 27(6), pp McCaffery, M. & Pasero, C. (1999). Pain: Clinical manual (2 nd ed.). St. Louis, MO: Mosby Pasero, C. & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis, MO: Mosby Elsevier St. Marie, B. (2010). Core curriculum for pain management nursing (2 nd ed.). Kendall Hunt Publishing 28 REMEC SITES: Please make sure to fill out your evaluations and sign-in sheets. They need to be mailed to Nancy Irish in Staff Development in order to receive your CEUs