PAIN MANAGEMENT IN BEDSIDE NURSING.pptx

Pain management in bedside nursing

1. PAIN MANAGEMENT IN BEDSIDE NURSING

2. The role of bedside nursing is becoming increasingly important as healthcare systems become more complex and patients require more specialized care. The importance of bedside nursing cannot be overstated. Bedside nurses directly contribute to better patient outcomes, improved patient satisfaction and increased healthcare efficiency. INTRODUCTION

3. INTRODUCTION CONTD. What is bedside nursing? This can be described as direct patient care as face-to-face contact between nurses and their patients for the purposes of assessing, diagnosing, or treating illnesses or injuries. Bedside nursing and patient pain management When it comes to pain management, bedside nurses are the first responders to patient needs. They assess pain levels, implement appropriate pain management strategies and advocate on behalf of their patients’ needs.

4. WHAT IS PAIN? The International Association for the Study of Pain (IASP, 2023) defines pain as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’. Pain is subjective and difficult to quantify, because it has both an affective and a sensory component. Although the neuroanatomic basis of pain reception develops before birth, individual pain responses are learned in early childhood and are affected by social, cultural, psychological, cognitive, and genetic factors, among others. Those factors account for differences in pain tolerance among humans. An important function of pain is to alert the body to potential damage

5. TYPES OF PAIN There are five common types of pain, but some pain can fit into more than one category, which is where the complication comes in. Acute pain Acute pain means the pain is short in duration (relatively speaking), lasting from minutes to about three months (sometimes up to six months). Acute pain also tends to be related to a soft-tissue injury or a temporary illness, so it typically subsides after the injury heals or the illness subsides. Chronic pain Chronic pain is longer in duration. It can be constant or intermittent. For example, headaches can be considered chronic pain when they continue over many months or years – even if the pain isn’t always present. Chronic pain is often due to a health condition, like arthritis, fibromyalgia, or a spine condition.

6. Neuropathic pain This pain is due to damage to the nerves or other parts of the nervous system. It is often described as shooting, stabbing, or burning pain. It can also affect sensitivity to touch and can make someone have difficulty feeling hot or cold sensations. It is a common type of chronic pain. It may be intermittent, and can be so severe that it makes performing everyday tasks difficult. Because the pain can interfere with normal movement, it can also lead to mobility issues. Nociceptive pain This pain is a type of pain caused by damage to body tissue. People often describe it as being a sharp, achy, or throbbing pain. It’s often caused by an external injury. This type of pain is often experienced in the joints, muscles, skin, tendons, and bones. It can be both acute and chronic.  

7. Radicular pain Radicular pain is a very specific type of pain can occur when the spinal nerve gets compressed or inflamed. It radiates from the back and hip into the leg(s) by way of the spine and spinal nerve root. People who have radicular pain may experience tingling, numbness, and muscle weakness. Pain that radiates from the back and into the leg is called radiculopathy. It’s commonly known as sciatica because the pain is due to the sciatic nerve being affected. This type of pain is often steady, and people can feel it deep in the leg. Nociplastic pain Nociplastic pain arises as result of changes in nociception without any demonstrable pathology.

8. CAUSES OF PAIN Some causes of normal pain A minor burn A pulled or strained muscle A tension headache Post-surgical pain at the incision site A broken bone A minor ankle sprains Labor and delivery Some causes of pain that may require medical attention  Arthritis A herniated disc in the neck or back Cancer Chronic migraine headaches A compressed or pinched nerve Heart attack Stroke

9. PHYSIOLOGY OF PAIN Pain receptors, located in the skin and other tissues, are nerve fibres with endings that can be excited by three types of stimuli—mechanical, thermal, and chemical. Chemical substances produced by the body that excite pain receptors include bradykinin, serotonin, and histamine. Prostaglandins are fatty acids that are released when inflammation occurs and can heighten the pain sensation by sensitizing the nerve endings; that increase in sensitivity is called hyperalgesia. The dual-phase experience of acute pain is mediated by two types of primary afferent nerve fibres that transmit electrical impulses from the tissues to the spinal cord via the ascending nerve tracts.

10. PHYSIOLOGY CONTD. The A delta fibres are the larger and the most rapidly conducting, because of their thin myelin covering, and, therefore, they are associated with the sharp, well-localized pain that first occurs. They are activated by mechanical and thermal stimuli. Smaller, unmyelinated C fibres respond to chemical, mechanical, and thermal stimuli and are associated with the lingering, poorly localized sensation that follows the first quick sensation of pain. Pain impulses enter the spinal cord, where they synapse primarily on the dorsal horn neurons in the marginal zone and substantia gelatinosa of the gray matter of the spinal cord. That area is responsible for regulating and modulating the incoming impulses.

11. PHYSIOLOGY CONTD . Two different pathways, the spinothalamic and spinoreticular tracts, transmit impulses to the brainstem and thalamus. Spinothalamic input is thought to effect the conscious sensation of pain, and the spinoreticular tract is thought to effect the arousal and emotional aspects of pain. Pain signals can be selectively inhibited in the spinal cord through a descending pathway, which originates in the midbrain and ends in the dorsal horn. That analgesic response is controlled by neurochemicals called endorphins, which are opioid peptides such as enkephalins that are produced by the body. Those substances block the reception of pain stimuli by binding to neural receptors that activate the pain-inhibiting neural pathway. That system can be activated by stress or shock and is probably responsible for the absence of pain associated with a severe injury.

12. PATHOPHYSIOLOGY OF PAIN Nociceptive pain arises as a consequence of the inflammatory process in non-neurological tissue and involves the process of nociception. Nociception is the process starting with a noxious stimulus and ending with the perception of pain, which may then be further modulated. Identifying four stages: transduction, transmission, perception and modulation. Transduction is the conversion of one type of energy into another. All the stimuli need to be converted into the electrical energy of the neuronal action potential. Transmission follows the three - neurone sensory pathway. The peripheral neurone runs from the receptor through the dorsal root ganglion into the spinal cord where it synapses with the spinal neurone in the substantia gelatinosa of the dorsal horn. The spinal neurone then crosses over and ascends via the spinothalamic tract to the thalamus, where it synapses with the third neurone that travels on to the somatosensory cortex Perception is characterized by conscious awareness of pain once it has reached the somatosensory cortex Modulation is the ability to influence and change the pain signals.

13. PATHOPHYSIOLOGY CONTD . Nociceptive or inflammatory pain is induced by a range of chemicals that are formed or released following non-neural tissue injury. Damage to cell walls leads to the formation of arachidonic acid under the influence of the enzyme phospholipase A2. Arachidonic acid is then converted into two groups of chemicals that can stimulate or influence the pain receptors. One group of chemicals, the prostaglandins, are produced under the influence of cyclooxygenase. These have a hyperalgesic and vasodilatory effect. The production of prostaglandins is influenced by the presence of bradykinin, which is produced when cells are damaged. Once produced the prostaglandins lower the nociceptor threshold thereby enhancing the action of both bradykinin and 5-hydroxytriptamine (serotonin) on the nociceptors and increasing pain perception, causing primary hyperalgesia. The second group of chemicals produced under the influence of5-lipoxygenase are the leukotrienes. Only one of these is inflammatory and of relevance to the induction of pain.

14. MANAGEMENT OF PAIN Pain management involves pharmacological and non-pharmacological treatment approaches. Pharmacological management: There are many different types of pain medications (called analgesics) that can be administered by various routes. Analgesics are classified as nonopioids, opioids, or adjuvants An adjuvant is a medication that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when administered with opioids. Examples of adjuvant medications include antidepressants (e.g., amitriptyline) and anti-seizure medications (e.g., gabapentin). A general rule of thumb when administering analgesics is to use the lowest dose of medication, with fewest potential side effects and the least invasive route of administration, to effectively treat the level of pain as reported by the patient.

15. The WHO ladder was originally developed by the World Health Organization for selecting analgesics for patients with cancer pain, but it can be broadened to illustrate this rule of thumb for managing pain appropriately for all patients. For example, if a patient reports a pain level of “2,” then a nurse typically starts at the lowest rung of the WHO ladder and administers a prescribed nonopioid via the oral route. If the nonopioid is not effective, then a prescribed adjuvant medication may be administered, or the nurse may decide to step up a rung on the ladder and administer a prescribed oral opioid for mild to moderate pain. On the other hand, if a patient reports severe pain, the nurse may start at the top rung of the ladder and administer a prescribed opioid for moderate to severe pain via the intravenous route for rapid relief.

16. Pharmacological management Nonopioid Analgesics: Nonopioid analgesics include acetaminophen and NSAIDs. Acetaminophen (Tylenol) is used to treat mild pain and fever but does not have anti-inflammatory properties. Acetaminophen is safe for all ages and can be administered using various routes, such as orally, rectally, and intravenously. A potential severe side effect of acetaminophen is hepatotoxicity (severe liver damage). Severe liver damage may occur if an adult patient takes more than 4,000 mg of acetaminophen in 24 hours (or 3,200 mg for older adults or 2,000 mg for chronic alcoholics) or consumes three or more alcoholic drinks every day while using acetaminophen. Nursing role: Because some medications are combined with acetaminophen or are prescribed “as needed,” the nurse must calculate the cumulative dose of acetaminophen over the previous 24-hour period before administering an additional dose.

17. Pharmacological contd. Nonsteroidal anti-inflammatories (NSAIDs): provide mild to moderate pain relief and also reduce fever and inflammation by inhibiting the production of prostaglandins. Examples of NSAIDs include ibuprofen, naproxen, and ketorolac. All NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke, with the risk being higher if the patient takes more than is directed or takes it for longer than directed. Nursing role: The nurse ensures to administer such medications after food or with food. Common side effects include dyspepsia, nausea, and vomiting, so it is helpful to administer this medication with food.

18. Pharmacological contd. Opioid Analgesics: Opioids are used to treat moderate to severe pain and work by blocking the release of neurotransmitters involved in the processing of pain. Different opioids have different amounts of analgesia, ranging from codeine used to treat mild to moderate pain, up to morphine, used to treat severe pain and considered to be at the top of the WHO ladder. Morphine is also commonly used to treat cancer pain and end-of-life pain because there is no “ceiling effect,” meaning the higher the dose, the higher the level of analgesia. Morphine is administered via various routes of administration, including orally, rectally, subcutaneously, intramuscularly, and intravenously. Nursing role: As always, check for current dosage ranges before administering medications. Monitor patient during administration for any sign of reaction.

19. Non-pharmacological Non-pharmacological pain management (NPPM) is an intervention without the use of medications. Non-pharmacological methods do not replace pharmacological treatments but are complementary to medication treatments. There are various NPPM practices that nurses can apply in nursing care. Physical methods such as massage, movement restriction/rest, repositioning, and cold and hot application have important pain-relieving effects. Cognitive behavioral and psychological therapies which include relaxations, patient education, breathing techniques, and attention distraction are important NPPM practices. Other NPPM practices include emotional support/reassurance, touching, and creating a comfortable environment.

20. NURSING ROLE Intervention Examples Distraction Describing photos, telling jokes, and playing games Relaxation Rhythmic breathing, meditation, prayer, imagery, and music therapy Basic comfort measures Proper positioning and therapeutic environment Avoiding sudden movement Reducing pain stimuli within the environment Cutaneous stimulation Acupuncture and acupressure Massage: 3-5 minutes offers benefits Transcutaneous Electrical Nerve Stimulation (TENS) unit: a specialized stimulator placed over the area of pain Application of heat or cold Heat: vasodilation increases blood flow; duration should be 5-20 minutes based on patient tolerance Cold: vasoconstriction reduces blood flow; cold numbs nerve sensations; duration should be no longer than 20 minutes Cool baths and moist, cool compresses Mind-body therapies Meditation and mindfulness Aromatherapy Lotions and moisturizing cream Avoiding strong smells Exercise Physical activity, Aerobics, Yoga Therapy Physical therapy, Occupational therapy

21. PAIN SCALE ASSESSMENT CRIES Pain Scale The CRIES Pain Scale assesses: Crying Oxygenation Vital signs Facial expression Sleeplessness It's often used for babies 6 months and younger. It's widely used in neonatal intensive care units (NICU). FLACC Pain Scale . The FLACC Pain Scale is based on observations made by a healthcare provider. Originally created to evaluate young children, it can be used for anyone who cannot communicate. FLACC stands for: Facial expression Leg tension or relaxation Activity (still or squirming with pain) Crying Consolability (whether you can be comforted) Zero to two points are assigned for each of the five categories. Then the overall score is tallied. Scores are interpreted as follows: : Relaxed and comfortable 1 to 3 : Mild discomfort 4 to 6 : Moderate pain 7 to 10 : Severe discomfort/pain By recording the FLACC score on a regular basis, healthcare providers can gain some sense of whether someone's pain is increasing, decreasing, or staying the same. 

22. Assessment contd. The Color Analog Scale (CAS) uses colors to represent different levels of pain on a pain scale: Red :   Severe pain Yellow :   Moderate pain Green : Comfortable The colors are usually positioned in a line with corresponding numbers or words that describe your pain. The Color Analog Scale is often used for children and is considered reliable.

23. Assessment contd. Faces : Expressions range from smiling to highly distressed Colors : Green for no pain, then moving through the spectrum to red for the worst possible pain Numbers : 0 for no pain, 10 for the worst possible pain Descriptors : These include "hardly notice pain," "hard to ignore, avoid usual activities," and "can't bear the pain, unable to do anything"

24. CASE STUDY Miss A.S was brought into the GOPD in obvious distress, she was seen by the doctor on duty after which a medical diagnosis of Peptic Ulcer Disease was made. Nursing care pan on the nursing diagnosis: Acute pain related to inflammatory process evidenced by verbalization of a pain score at 6/10

25. NURSING CARE PLAN S/N Date and Time Nursing Diagnosis Objective Nursing Intervention Scientific Rationale Evaluation 1. 3/02/2024 3:00pm Acute pain related to effect of gastric acid secretion on the damaged lining evidenced by verbalization of a pain score at 6/10 Patient will report satisfactory pain control between 2-4 on the pain scale within 20-40 minutes of Nursing Intervention Assess patient’s level of pain using numerical pain scale Assessment of pain using a numerical scale serves as baseline data for proper management Patient verbalized that pain reduced by 3 on the pain scale after 20 minutes of Nursing Intervention (3/10). Place patient in a comfortable position Placing patient in comfortable position relieved pressure and associated discomfort Provide diversional therapy e.g music therapy distraction helps decrease the production of gastric acid thereby reducing pain Administer prescribed drug therapy e.g antacids, analgesic Antacids buffer gastric acid and prevent the formation of pepsin. This mechanism of action promotes healing of ulcer. Analgesics help block the pain receptors, thereby providing relief from pain Encourage patient to have meals at regular intervals in a relaxed setting An irregular schedule of meals may interfere with regular administration of medications  

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