PAIN MANAGEMENT Louise Smith Clinical Nurse Specialist
Objectives To understand:- The concept of Total Pain The types of Physical Pain Holistic assessment Pain management; pharmaceutical & non pharmaceutical WHO Analgesic ladders
Pain is what the patient says it is An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Social Physical Total Pain Psychological Spiritual
Physical pain Acute/chronic Nociceptive Neuropathic
Psychological pain Anxiety Depression vs. short-term low mood Coping ability Anger Emotional exhaustion Unresolved issues Not ready for death
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 2012 8
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 2012 9
Social pain Isolation Loss of role Financial Letting the family down Sexual relationships
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 2012 11
Spiritual pain Loss of faith/questioning Not fair Anger/Why me
Spiritual pain What is spirituality? Spirituality Religion Copyright Hospice in the Weald 2012 13
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 2012 14
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 2012 15
Assessment Observation History taking Physical Examination at competence level Holistic
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
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
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
MEDICATION Dossett Box As required Prompting
Non pharmaceutical measures Heat/Ice TENS Acupuncture Complimentary therapies Restricting movement/positioning/carers Counselling/Chaplain
The Ladder
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.
Side Effects of Opioids Nausea and Vomiting (20-30%) Constipation (90%) Drowsiness (temporary) Cognitive Impairment (minimal) Dry mouth Urinary retention Pruritis