Pain as fifth vital sign 2.0.pptx

pain

1. Pain as fifth vital sign

2. Outline 1) Definition of pain and approach to pain 2)Pain assessment 3) Classification of pain 4) Acute pain management 5) Morphine pain protocol 6) Management of opioid side effect

3. DEFINITION OF PAIN “ An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage International association for the Study of Pain (IASP – Merskey )

4. WHAT DOES THAT MEAN? What we (health care provider) understand …. • Unpleasant • Emotions are important • The cause is not always visible For the patient….. PAIN is what the patient says…… HURTS

5. Approach to Pain Management R ecognize A ssess T reat

6. PAIN ASSESSMENT

7. WHY ASSESS / MEASURE PAIN? • Produce a baseline to assess therapeutic interventions e.g. administration of analgesic drugs • Facilitate communications between staff looking after the patient • For documentation

8. HOW TO ASSESS PAIN P : Place or site of pain “where does it hurt?” Record on a body chart A : Aggravating factors “what makes your pain worse?” I : Intensity “How bad is the pain?” N : Nature and neutralising factors “what does it feel like’ “What makes the pain better?”

9. MOH PAIN SCALE On a scale of ‘0’ to ’10’(show the pain scale). If ‘0’ = no pain, and 10 = worst pain you can imagine, what is your pain score now? Patient is asked to slide the indicator along the scale to show the severity of pain, which is recorded as a number ( 0 to 10)

10. PAIN MEASUREMENT • Scale used in children/infants and in cognitively impaired patients • Faces scale (self report scale) • FLACC scale (behavioural pain scale)

11. WONG BAKER FACES PAIN RATING SCALE Category 1 2 Face No particular expression or smile Occasional grimace, frown, disinterested, Frequent to constant Clenched jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking, legs drawn up Activity Lying quietly, moves easily Squirming, shifting back and forth, tense Arched, jerking, rigid Cry No cry (awake or sleep) Moan or whimpers Crying steadily, screaming or sobs Consolability Content, relaxed Reassured by occasional touch, hug Difficult to console

12. WHEN SHOULD PAIN BE ASSESSED 1.At regular interval • as the 5 th vital signs during routine observation of BP, HR, RR, and temperature • This can be done 4hourly, 6houry, or 8 hourly 2.On admission of patient 3.On transfer in of patient

13. 4. At other times apart from scheduled observations: • ½ to 1 hour after administration of analgesics and nursing intervention for pain relief • During and after any painful procedures in the ward e.g. wound dressing • Whenever the patient complains of pain

14. WHO SHOULD BE ASSESSED? ALL patients • Patient in labourroom • Operating theatre (recovery room) • ICU/ HDU/CCU • Ambulatory day care units • Clinics

15. SELECTION OF ASSESSMENT TOOL • Recommendations by Ministry of Health, Malaysia Age Scale Adult MOH pain scale Pediatrics 1month- 3 years FLACC scale 3 years- 7 years Wong baker scale > 7 years MOH pain scale • Sedated patients • Unconscious patient • Record ‘unable to assess/score’

16. CLASSIFICATION OF PAIN BASIS TYPE OF PAIN Duration Acute Chronic Acute on chronic Cause Cancer Non cancer Mechanism Nociceptive Neuropathic  Acute pain – pain associated with tissue injury e.g. pain after surgery, fracture, burns, inflammation, etc. o Nociceptive somatic pain is usually well localized, described as sharp, aching or throbbing, often worse on movement. o Visceral pain is usually poorly localized; described as deep, cramping, gnawing or colicky.

17. DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN Acute pain Chronic pain Onset& timing Sudden,short duration Resolves /disappears when tissue heals Insidious onset Pain persists despite tissue healing Sign Warning sign of actual or potential tissue damage Not a warning signal of damage False alarm Severity Correlates with amount of damage Severity not correlated with damage CNS involvement CNS intact-acute pain is a symptoms CNS may be dysfunctional-chronic pain is a disease Psychological effect Less, but unrelieved pain anxiety and sleeplessness (improves when pain is relieved) Often associate with depression, anger, fear, social withdrawal etc.

18. NOCICEPTIVE vs NEUROPATHIC PAIN Nociceptive pain Neuropathic pain Well localized Not well localized Sharp Worse with movement Burning Shooting Numbness Pins and needles Obvious tissue injury or illness Tissue injury may not be obvious Inflammation Nerve injury Changes in wiring Abnormal firing Loss modulation

19. ACUTE PAIN MANAGEMENT

20. TREATMENT -PERIPHERY • Non drug treatment (RICE) • Rest • Immobilisation • Cold compression • Elevation • Drug treatment: • Anti-inflammatory drugs • NSAIDS/ COX 2 inhibitors • Local anaesthetic agents

21. Treatment –spinal cord • Non drug treatment: • Acupuncture • Massage • Medications: • Local anaesthetics • Opioids • Ketamine

22. TREATMENT -BRAIN • Non drug treatment • Psychological - Explanation - Reassurance - Counselling • Drug treatment: • Paracetamol • Opioids • Amitriptyline • Clonidine

23. ANALGESIC STRATEGIES: • Inhibit • ascending pain signal • Enhance • descending inhibition

24. MORPHINE PAIN PROTOCOL • Use for rapid control of severe acute pain • Route: IV • Morphine dilution: 10 mg/10 ml (1mg/ml) • Monitoring (every 5 minutes) • Pain score • Sedation score • Respiratory rate

25. MANAGEMENT OF OPIOID SIDE EFFECTS Nausea and vomiting • A common side effect of opioids • Treat nausea and vomiting and continue giving opioids

26. RESPIRATORY DEPRESSION • Very uncommon • May occur with overdose of opioids, always associated with sedation • Risk of respiratory depression is minimal • If strong opioids are titrated to effect • Only used to relieve pain ( ie not to help patients to sleep or to calm down agitated patients) • Risk of respiratory depression also minimal in patients on chronic opioids use (e.g. patients on morphine for cancer pain)

27. • Confirm diagnosis • Respiratory rate < 8/minute & sedation score=2 (difficult to arouse) • Or Sedation score = 3 (unarousable) • Pin Point pupils • Sedation score • 0 = none (patient is alert) • 1 = mild (patient is sometimes drowsy) • 2 = moderate (patient is often drowsy but easily arousable) • 3 = unarousable • S = patient is sleeping, easily arousable

28. MANAGEMENT OF RESPIRATORY DEPRESSION 1.Stop the drug and call for help 2.Administer oxygen –face mask or nasal prongs 3.Stimulate the patient-tell him/her to breathe 4.Dilute naloxone 0.4mg/mg in 4 mls • Give 0.1 mg (1ml) every 1-2 minutes until the patient wakes up or respiratory rate >10/min 5.Monitor RR, sedation score hourly for 4 hours 6.Give another dose of naloxone if respiratory depression recurs 7.Refer to ICH/HDU for close monitoring (patient may require naloxone infusion)

29. THANK YOU