Chapter Four Denim E.

Maghanoy

Symptom Management

Click to edit Master subtitle style

4/14/12

4/14/12

Click to edit Master subtitle style

PAIN

4/14/12

Definition
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP, 1994)
4/14/12

If the pain is unrelieved, the sufferer can become withdrawn, unable to focus and their whole personality can appear to be changed as their quality of life diminishes.

4/14/12

Incidence of Pain
-

Two-thirds suffer from pain One-third do not Pain becomes moderate to severe in 40-50% of patients and it varies according to primary site. This becomes very severe or excruciating in 25-30% of cases.
4/14/12

Physiology
Types of Pain:
1.

Physiologic Chronic Neuropathic Somatic Visceral

2.

3.

4.

5.

4/14/12

Physiologic Pain
-

Occurs when the nociceptive system warns of impending injury to the body, providing direct pain information to the brain.

There is a close correlation between the intensity of the stimulus and the
4/14/12

intensity of the pain

Chronic Pain
-

Nociceptors become sensitized after an injury so that they become increasingly sensitive with each application of the noxious stimuli, thus giving a greater response or hyperalgesia

4/14/12

N-methyl-D-aspartate is involved in

Acute Pain versus Chronic Pain

-

Mild to severe PNS SNS Normal to Related VS tissue injury Continues beyond healing Client appears restless and anxious Client reports pain appears depressed and withdrawn Client exhibits behaviors indicative of Client pain often does not mention pain unless asked
4/14/12

Neuropathic Pain
-

One of the most common causes of complex pain is current or past damage to nerve fibers Pain does not require presence of an identifiable noxious stimulus and is due to aberrant processing of information in the peripheral or CNS Associated with tumor compression, infiltration of peripheral nerves, 4/14/12 nerve roots, or the type of spinal

Somatic Pain
-

Pain that arises in the skin, muscle, periosteum, or fascia

Well-localized May be described as sharp, burning, constant, aching, and gnawing

4/14/12

Visceral Pain
-

Results from infiltration, compression, distension, or stretching of the thoracic, or abdominal viscera, usually as a result of primary or metastatic tumor growth

4/14/12

May be described as intense, deep,

Evaluation
-

The latest WHO definition of palliative care refers to the requirement for impeccable assessment of pain and other problems. Collaboration is important Pain is subjective and patient is the main assessor of pain, working in 4/14/12

The SIGN Guidelines

-

Site and number of pains Intensity and severity of pains Radiation of pain Timing of pain Quality of pain Aggravating and relieving factors
4/14/12

Etiology

Factors that may Affect the Experience of Pain

-

Anxiety Feeling of helplessness and loss of control Adjustment disorder Worries about family and finances Fear of treatments, physical and mental impairment, and death Thoughts
4/14/12

Management
WHO Guidelines:
1.

By Mouth By the Clock By the Ladder

2.

3.

4/14/12

WHO Three-step Ladder

Morphine, Hydromorph one, Fentanyl

Codeine, Tramadol, Pentazocine

4/14/12

Acetaminophen and NSAIDs

Monitoring Pain
It is helpful to establish:
-

The site of the particular pain Whether it is linked to movement or rest

The level of pain

4/14/12

Key Communication Issues

-

Patients may in some circumstances deny pain until it becomes intolerable, because to admit the pain would mean having to face their own impending death. A common misconception is that if a cancer patient is prescribed with morphine they are going to die soon.
4/14/12

On Morphine Issues
Among 1055 respondents,
-

72% thought that it was dangerous 40% thought that it impaired the ability to think clearly

48% thought that it was associated with unpleasant side effects

4/14/12

43% thought that it prevented normal life

In reality,
-

Addiction is very rarely a problem The correct use of morphine is likely to prolong life because pain will be relieved

4/14/12

Predictable Side Effects of Morphine

1.

Nausea and Vomiting - usually settles within 5-10 days

- can be treated with Metoclopramide and Haloperidol 2. Drowsiness 3. Constipation - prophylactic aperient with a stimulant and softening laxatives
4/14/12 4. Dry mouth, hypotension, confusion,

Complex Pain
This happens when pain does not respond to the above strategies. The nurse, being with the patient for longer than the physician has to make decisions about the administration of what is often a variety of prescribed drugs based on assessment of the patients pain and knowledge of appropriate interventions.
4/14/12

A sound knowledge of the pain

Opioid Toxicity
- Whether patient is opioid-naive
-

The degree to which the pain is responsive to opioids The titration rate Renal and hepatic function Additional medication
4/14/12

Signs of Opioid Toxicity

-

Agitation Vivid dreams and nightmares Hallucinations Confusion Myoclonic jerks

4/14/12

Nursing Responsibilities
-

Monitor for signs of toxicity If toxicity is suspected, reduce dose Ensure adequate hydration In cases of toxicity, change morphine to other analgesics
4/14/12

Neuropathic Pain
-

Adjuvant analgesics such as TCAs and Anticonvulsants Corticosteroids

4/14/12

Sensitization and WindUP

- Use of anaesthetic ketamine and subanaesthetic levels

4/14/12

Alternative Interventions
-

Radiotherapy and Chemotherapy Biphosphonates for bone pain Neurolytic and neurological procedures

4/14/12

Non-Drug Interventions
-

Aromatherapy Massage Hypnosis Relaxation therapy Spiritual care

4/14/12

Click to edit Master subtitle style

Be back in a jiffy

End

4/14/12