Pain Management and River Valley Health. The following educational presentation offers the healthcare provider a deeper foundation for successful pain management. There are five sections in this presentation. A quiz will follow each section and will be used as a indicator of learning. - PowerPoint PPT Presentation
Pain Management and Pain Management and River Valley Health River Valley Health The following educational presentation offers The following educational presentation offers the healthcare provider a deeper foundation the healthcare provider a deeper foundation for successful pain management. for successful pain management. There are five sections in this There are five sections in this presentation. presentation. A quiz will follow each section and will be A quiz will follow each section and will be used as a indicator of learning. used as a indicator of learning. Good Luck and Enjoy! Good Luck and Enjoy! Acute Pain Services Acute Pain Services
Transcript
Pain Management and Pain Management and River Valley HealthRiver Valley Health
The following educational presentation offers the The following educational presentation offers the healthcare provider a deeper foundation for successful healthcare provider a deeper foundation for successful
pain management. pain management.
There are five sections in this presentation. There are five sections in this presentation.
A quiz will follow each section and will be used as a A quiz will follow each section and will be used as a indicator of learning.indicator of learning.
Good Luck and Enjoy!Good Luck and Enjoy!
Acute Pain ServicesAcute Pain Services
SECTION 1SECTION 1
MISSION PHILOSOPHY GOALS
PAIN MANAGEMENT!!
…but WHY??
RVH MISSION RVH MISSION STATEMENTSTATEMENT
River Valley Health (RVH) values effective River Valley Health (RVH) values effective pain management. pain management.
Pain Management is a priority and we strive Pain Management is a priority and we strive for effective pain management through for effective pain management through
evidence-based pain assessment and pain evidence-based pain assessment and pain management strategies providing appropriate management strategies providing appropriate
education for patients, families and health education for patients, families and health care professionals.care professionals.
Patients have a right to pain Patients have a right to pain managementmanagement
Patients have a right to be assessedPatients have a right to be assessed Patients have a right to be involvedPatients have a right to be involved Patient’s self-report is most reliablePatient’s self-report is most reliable Pain management is a team approach Pain management is a team approach
and, and, is an ethical responsibility.is an ethical responsibility.
RVH Goals to Pain RVH Goals to Pain ManagementManagement
To assess on a individualized levelTo assess on a individualized level To encourage patient participationTo encourage patient participation To address barriers to effective pain To address barriers to effective pain
managementmanagement
To promote an interdisciplinary To promote an interdisciplinary approachapproach
To ensure medication safetyTo ensure medication safety
Systematic and thorough pain Systematic and thorough pain
assessments provide a assessments provide a baseline for pain baseline for pain
management.management.
Patient ParticipationPatient Participation
IS CRUCIALIS CRUCIAL
Patients need to know the Patients need to know the benefits of pain management benefits of pain management as well as the importance of as well as the importance of
self reporting.self reporting.
Barriers to Pain Barriers to Pain ManagementManagement
Barriers will be addressed through:Barriers will be addressed through: Literature reviewsLiterature reviews MentoringMentoring Family involvementFamily involvement Education of patients, family and health Education of patients, family and health
care providerscare providers Knowledge and attitude assessmentsKnowledge and attitude assessments
Interdisciplinary teams will be involved in Interdisciplinary teams will be involved in customizing and optimizing each customizing and optimizing each patient’s pain management plan.patient’s pain management plan.
Multimodal approaches will be used Multimodal approaches will be used combining pharmacology and non-combining pharmacology and non-
physical examination physical examination relevant laboratory and diagnostic testsrelevant laboratory and diagnostic tests
medication usage and adverse effectsmedication usage and adverse effectsunderstanding of current illnessunderstanding of current illness
effect of pain on function and ADL’s effect of pain on function and ADL’s coping responses to stress and paincoping responses to stress and pain
psychological – social variables (anxiety, depression)psychological – social variables (anxiety, depression)personal preferences and expectations/beliefs/myths personal preferences and expectations/beliefs/myths
about pain and its’ managementabout pain and its’ managementhistory of chronic painhistory of chronic pain
past success or failure with management, including past success or failure with management, including non-pharmacological interventionsnon-pharmacological interventions
socio-cultural variables (e.g. ethnicity, cultural beliefs) that socio-cultural variables (e.g. ethnicity, cultural beliefs) that may affect pain behavior and treatment, andmay affect pain behavior and treatment, and
caregiver or family reports of pain. caregiver or family reports of pain.
Self-ReportsSelf-Reports
Self-report is the Self-report is the primary sourceprimary source of assessment of assessment for verbal, cognitively intact persons. for verbal, cognitively intact persons.
Family and care provider reports of pain Family and care provider reports of pain are are includedincluded for children and adults unable to give for children and adults unable to give
self report. self report.
Frequency of Frequency of ReassessmentReassessment
Pain will be reassessed on a regular basis according to Pain will be reassessed on a regular basis according to the type and intensity of pain and the treatment plan.the type and intensity of pain and the treatment plan.
At least once per shiftAt least once per shift for inpatients.for inpatients.Before and afterBefore and after any known pain producing any known pain producing procedure.procedure.With each newWith each new report of pain report of painWhen intensityWhen intensity increases increasesWhen pain is notWhen pain is not relieved by previously effective relieved by previously effective strategies. strategies.
Note:Note: Pain is reassessed after the intervention has Pain is reassessed after the intervention has reached peak effectreached peak effect
Pharmacological Interventions,Pharmacological Interventions,Medication Routes and Reassessment Medication Routes and Reassessment
TimesTimes Pharmacological Intervention/Medication routePharmacological Intervention/Medication route Optimal Reassessment Time (Peak effect)Optimal Reassessment Time (Peak effect)
IV therapyIV therapy 15-30 minutes15-30 minutesSC or IM therapy 15-40 minutesSC or IM therapy 15-40 minutes
Epidural or patient controlled analgesia (PCA)Epidural or patient controlled analgesia (PCA) ****At least every two hours for the first 24 hours; then every 4At least every two hours for the first 24 hours; then every 4 hours while on the Acute Pain Service.hours while on the Acute Pain Service.
Note: Note: Level of sedation Level of sedation will be assessed with opioid therapy.will be assessed with opioid therapy.
Assessment ToolsAssessment Tools
The RVH standard assessment tool is the 0-10 The RVH standard assessment tool is the 0-10 pain intensity scale. pain intensity scale.
Appropriate ToolsAppropriate Tools
Assessment tools should consider:Assessment tools should consider:
• age (developmental appropriateness)age (developmental appropriateness)• cognitive function (impairment)cognitive function (impairment)• language impairment, and/or language language impairment, and/or language
barriers.barriers.
NOTE: If an alternate tool is used, the tool selected will be reliable, valid geared NOTE: If an alternate tool is used, the tool selected will be reliable, valid geared
toward the individual. The health record will clearly state which pain toward the individual. The health record will clearly state which pain assessment tool was used.assessment tool was used.
Assessment of Unexpected Assessment of Unexpected PainPain
Unexpected pain will be immediately Unexpected pain will be immediately evaluated in the context of the patient’s evaluated in the context of the patient’s current health status, and will include a current health status, and will include a
thorough assessment of the patient thorough assessment of the patient presenting problem, and recent presenting problem, and recent
intervention's).intervention's).
Assessment in the Assessment in the PaediatricPaediatricPopulationPopulation
Children may need encouragement to report pain. Fear of the Children may need encouragement to report pain. Fear of the consequences of reporting pain, such as receiving an injection is consequences of reporting pain, such as receiving an injection is common.common.
Self-report tools are useful and reliable in the paediatric population. Self-report tools are useful and reliable in the paediatric population. Children as young as 3 years of age can reliably rate pain intensity.Children as young as 3 years of age can reliably rate pain intensity.
For pediatricFor pediatric patients,patients, thethe Wong-Baker 0-10 FACESWong-Baker 0-10 FACES scale is usedscale is used..
For children, consider the following:For children, consider the following:
Ask the parent/guardian's) the words a child might use to describe Ask the parent/guardian's) the words a child might use to describe pain, and observe the child for signs/behaviors indicative of pain. pain, and observe the child for signs/behaviors indicative of pain.
Assessment of pain in the Assessment of pain in the cognitively impairedcognitively impaired
Patients with cognitive impairment Patients with cognitive impairment CANCAN provide an accurate report of provide an accurate report of pain/ discomfort.pain/ discomfort.
For the frail elderly, non-verbal or non-cognizant For the frail elderly, non-verbal or non-cognizant persons, screen the patient to assess if the following persons, screen the patient to assess if the following markers are present:markers are present:
• Patient states he/she has pain.Patient states he/she has pain.• ChangeChange in the patient’s condition. in the patient’s condition.• Patient is diagnosed with a chronic painful disease.Patient is diagnosed with a chronic painful disease.• History of chronic unexpressed pain.History of chronic unexpressed pain.• Patient has received pain medication for >72 hours.Patient has received pain medication for >72 hours.• Distress related behavior or facial grimacing is present.Distress related behavior or facial grimacing is present.• Family/ caregivers indicate that pain is present.Family/ caregivers indicate that pain is present.
SECTION IISECTION II
SECTION IIISECTION III
Intervention for Pain
Management
The RVH Pain Care Committee has The RVH Pain Care Committee has reviewed the current literature for reviewed the current literature for effective pain management and effective pain management and provides the following guidelines provides the following guidelines
for cliniciansfor clinicians
ADVOCATE…TAILOR…CONSIDERADVOCATE…TAILOR…CONSIDER
AdvocateAdvocate for the use of the most effective analgesic for the use of the most effective analgesic dosage and least invasive pain management dosage and least invasive pain management
modalities.modalities.
TailorTailor the route to the individual and care setting. the route to the individual and care setting.
ConsiderConsider the options. the options.
Note: The oral route is the preferred route for persistent pain and for acute pain as healing occurs.Note: The oral route is the preferred route for persistent pain and for acute pain as healing occurs. IV administration is the parenteral route of choice after major surgery, usually via bolus andIV administration is the parenteral route of choice after major surgery, usually via bolus and continuous infusion. A butterfly injection system is often used to administer intermittent continuous infusion. A butterfly injection system is often used to administer intermittent subcutaneous analgesics.subcutaneous analgesics.
REFERRALSREFERRALSRefer persons with persistent pain whose Refer persons with persistent pain whose pain is not relieved after following standardpain is not relieved after following standard
principles of pain management.principles of pain management.
Refer to a multidisciplinary team member with the Refer to a multidisciplinary team member with the expertise in the area of concern, the complex expertise in the area of concern, the complex
emotional, psycho/social, spiritual and emotional, psycho/social, spiritual and concomitant medical factors involved. concomitant medical factors involved.
DRUGSDRUGS
The three major classes of drugs that are The three major classes of drugs that are used alone or, more commonly, in used alone or, more commonly, in combination to manage pain are:combination to manage pain are:
non-opioid analgesicsnon-opioid analgesics
opioid analgesics, and opioid analgesics, and
adjuvant medications.adjuvant medications.
Step-wise ApproachStep-wise ApproachSelect the analgesics which are appropriate to match the Select the analgesics which are appropriate to match the
intensity of pain (unless contraindicated due to age, intensity of pain (unless contraindicated due to age, renal impairment or other issues related to the drug). renal impairment or other issues related to the drug).
Mild to moderate painMild to moderate pain - acetaminophen or NSAIDS (unless - acetaminophen or NSAIDS (unless the person has a history of ulcers or a bleeding disorder.the person has a history of ulcers or a bleeding disorder.
Moderate to severe pain Moderate to severe pain - initially use an opioid analgesic, - initially use an opioid analgesic, taking into consideration previous opioid use and taking into consideration previous opioid use and adverse effects.adverse effects.
Note: The use of the WHO Analgesic ladderNote: The use of the WHO Analgesic ladder is recommended for the treatment ofis recommended for the treatment of
chronic cancer painchronic cancer pain..
TIMING is everything!TIMING is everything!
Recognize that opioids Recognize that opioids should be administeredshould be administered on a regular time schedule according to the on a regular time schedule according to the
duration of action and depending on the duration of action and depending on the expectation regarding the duration of severe expectation regarding the duration of severe
pain.pain.
• If severe pain is expected for 48 hours post-operatively, routine If severe pain is expected for 48 hours post-operatively, routine administration may be needed for that period of time.administration may be needed for that period of time.
• Late in the post-operative course, analgesics may be effective given Late in the post-operative course, analgesics may be effective given on an as needed basis.on an as needed basis.
• In persistent cancer pain, opioids are administered on an around the In persistent cancer pain, opioids are administered on an around the clock basis, according to their duration of action. Long acting opioids clock basis, according to their duration of action. Long acting opioids are more appropriate when dose requirements are stable.are more appropriate when dose requirements are stable.
Intramuscular route…Intramuscular route…is not recommendedis not recommended because it is painful and because it is painful and
absorption is not reliable. So….avoid this absorption is not reliable. So….avoid this route when possible. route when possible.
Note: Meperidine is Note: Meperidine is notnot recommended for the treatment of pain, it is recommended for the treatment of pain, it is
contraindicated in persistent pain due to the buildup of the toxic contraindicated in persistent pain due to the buildup of the toxic
metabolite normeperedine, which can cause seizures and dysphoria. metabolite normeperedine, which can cause seizures and dysphoria.
Meperidine toxicity is not reversible by naloxone. Meperidine toxicity is not reversible by naloxone.
Equianalgesic TableEquianalgesic TableUse a table to ensure equivalency when Use a table to ensure equivalency when
Oxycodone * Not given parenteral 10-30mg 10-15 (po) 2-4 (po)
MonitorMonitor
...patients taking opioids for potential toxicity. ...patients taking opioids for potential toxicity.
WatchWatch for unacceptable adverse effects: for unacceptable adverse effects:
myoclonusmyoclonus
confusionconfusion
delirium refractory to prophylactic treatment. delirium refractory to prophylactic treatment.
Note: In the presence of inadequate pain relief advocate for a change inNote: In the presence of inadequate pain relief advocate for a change in
treatment plan as required.treatment plan as required.
AnticipateAnticipate
……that individuals taking opioids may have that individuals taking opioids may have common adverse effectscommon adverse effects such as nausea and such as nausea and
vomiting, constipation and drowsiness. Institute vomiting, constipation and drowsiness. Institute prophylactic treatment as appropriate. prophylactic treatment as appropriate.
RecognizeRecognize
……that anti-emetics have different that anti-emetics have different mechanisms of action and selection of the mechanisms of action and selection of the
right anti-emetic is based on this right anti-emetic is based on this understanding and etiology of the understanding and etiology of the
symptom. symptom.
ConstipationConstipationUse Use prophylactic measuresprophylactic measures for the for the treatment oftreatment of constipation unless constipation unless
contraindicated. contraindicated.
Laxatives should be prescribed and Laxatives should be prescribed and increased as needed to achieve the desired increased as needed to achieve the desired
effect as a preventative measure routine effect as a preventative measure routine administration of opioids.administration of opioids.
Clarify the differenceClarify the difference between addiction, between addiction, tolerance and physical dependence to tolerance and physical dependence to alleviate misbeliefs that can prevent alleviate misbeliefs that can prevent
optimal use of pharmacological methods optimal use of pharmacological methods for pain management. for pain management.
AddictionAddictionAddiction is a psychological dependence Addiction is a psychological dependence and is rare with persons taking opioids for and is rare with persons taking opioids for
persistent pain.persistent pain.
ToleranceTolerance
Persons using opioids on a Persons using opioids on a long term long term basisbasis for pain control may be on the same for pain control may be on the same
dose for years, but may require upward dose for years, but may require upward adjustments of dosage with signs of adjustments of dosage with signs of
tolerance. tolerance.
Tolerance is usually not a problemTolerance is usually not a problem and and people can be on the same dose for years.people can be on the same dose for years.
DependenceDependencePersons who no longer need an opioid after Persons who no longer need an opioid after
long term use long term use need to reduceneed to reduce their dose their dose slowlyslowly over several weeks to prevent over several weeks to prevent
withdrawal symptoms because of physical withdrawal symptoms because of physical dependence.dependence.
Safe Medication Prescription Safe Medication Prescription and Orderingand Ordering
The implications of medication treatments on The implications of medication treatments on specific patient populations will be taken into specific patient populations will be taken into consideration, including, but not limited to:consideration, including, but not limited to:
• the elderly the elderly • paediatric populationspaediatric populations• patients with polypharmacypatients with polypharmacy• patients with addiction issuespatients with addiction issues• patients who are cognitively impaired, andpatients who are cognitively impaired, and• patients with a history of sleep apneapatients with a history of sleep apnea
The care of persons experiencing pain may be carried out by an The care of persons experiencing pain may be carried out by an interdisciplinary team member:interdisciplinary team member:
physiciansphysiciansnursesnursespharmacistspharmacistspsychologistspsychologistssocial workers, social workers, and other therapeutic services.and other therapeutic services.
Provider’s roles and responsibilities are determined by the organization’s Provider’s roles and responsibilities are determined by the organization’s policies, the providers scope of practice / standards of practice professionalpolicies, the providers scope of practice / standards of practice professionalskills, competence, and credentials, and the care or rehabilitation required. skills, competence, and credentials, and the care or rehabilitation required.
Intended to alter belief structures such as Intended to alter belief structures such as attitudes, pain and suffering. attitudes, pain and suffering.
Strategies include…Strategies include…• psycho education (info. regarding normal and psycho education (info. regarding normal and
abnormal emotional reactions to pain)abnormal emotional reactions to pain)• distractiondistraction• relaxationrelaxation• guided imageryguided imagery• biofeedbackbiofeedback• hypnosis.hypnosis.
Family InterventionsFamily Interventions
Patient and family Patient and family educationeducation and and counselingcounseling. .
SECTION IIISECTION III
SECTION IVSECTION IV
DocumentationDocumentation
DocumentationDocumentation
Includes…Includes…
• initial comprehensive assessmentinitial comprehensive assessment• treatments / strategies for pain managementtreatments / strategies for pain management• reassessment according to the patient’s needs, reassessment according to the patient’s needs,
established RVH pain standards, and the types of established RVH pain standards, and the types of interventions, andinterventions, and
• assessment tool used to measure the patient’s self-assessment tool used to measure the patient’s self-report of painreport of pain
• Tracking of the efficacy of the intervention(s), Tracking of the efficacy of the intervention(s), (example: 0-10 intensity scale) (example: 0-10 intensity scale)
Forms for Forms for DocumentationDocumentation
Pain assessment and management is documented Pain assessment and management is documented using:using:
• specific order sheets for PCA and neuraxial analgesiaspecific order sheets for PCA and neuraxial analgesia• admission assessment forms and/or electronic admission assessment forms and/or electronic
templatestemplates• flow sheetsflow sheets• progress notes or focus noteprogress notes or focus note• pain flow sheetspain flow sheets• care plans, and care plans, and • continuity of care forms.continuity of care forms.
Components of Components of DocumentationDocumentation
Documentation will Documentation will facilitate team communicationfacilitate team communication about pain management about pain management
and includes:and includes:
pain assessmentspain assessmentsadmission and ongoing pain interventionsadmission and ongoing pain interventions
patient’s response to interventionspatient’s response to interventionsadverse and side effectsadverse and side effects
patient’s response to treatment of those effectspatient’s response to treatment of those effectsinterdisciplinary plan of care.interdisciplinary plan of care.
SECTION IVSECTION IV
SECTION VSECTION V
EducationEducation
RVH recognizes thatRVH recognizes that
quality pain managementquality pain management
involves attention to ongoinginvolves attention to ongoing
educational efforts,educational efforts,
continuous learning, andcontinuous learning, and
sharing of information. sharing of information.
Key ComponentsKey Components
• ProvidingProviding appropriate appropriate staff educationstaff education that takes that takes into account knowledge and beliefs about pain into account knowledge and beliefs about pain management.management.
• ProvidingProviding and involvingand involving patients and families in patients and families in education prior to admission whenever possible.education prior to admission whenever possible.
• ProvidingProviding patients and family members with patients and family members with information and brochuresinformation and brochures..
• Identifying beliefs, values, barriers and Identifying beliefs, values, barriers and readinessreadiness for education of the patient and family. for education of the patient and family.
• Dispelling mythsDispelling myths about pain, pain treatment and about pain, pain treatment and addiction.addiction.
Staff EducationStaff EducationEducational opportunities related to pain management include:Educational opportunities related to pain management include:
• specific care area / unit orientationspecific care area / unit orientation• RVH’s Grand Rounds and Nursing Grand RoundsRVH’s Grand Rounds and Nursing Grand Rounds• ethics roundsethics rounds• RVH’s annual pain conferenceRVH’s annual pain conference• clinical education sessions, andclinical education sessions, and• self-learning modules. self-learning modules.
Additional resources and information about analgesics and Additional resources and information about analgesics and analgesic dosing is readily available through the acute pain nurse, analgesic dosing is readily available through the acute pain nurse, Pharmacy, Oncology, and Palliative Care Services. Pain resource Pharmacy, Oncology, and Palliative Care Services. Pain resource manuals are available on the individual nursing units.manuals are available on the individual nursing units.
Patient and Family Patient and Family EducationEducation
Ensure that the patient and family have a clear Ensure that the patient and family have a clear understanding of the right to appropriate pain understanding of the right to appropriate pain
management. management.
The following are key components: The following are key components: • Patients have the right to the best pain relief possible. Patients have the right to the best pain relief possible.
Reassure the patient that the health care team considers Reassure the patient that the health care team considers his/her pain management to be very important. his/her pain management to be very important.
• Provide education to the patient and his/her their family. Provide education to the patient and his/her their family. • Explain the benefits of pain management including the Explain the benefits of pain management including the
potential for a quicker recovery, shorter hospital stay, and potential for a quicker recovery, shorter hospital stay, and the potential for improved quality of life.the potential for improved quality of life.
Patient Information Patient Information and Brochuresand Brochures
Patients and/ or family members are provided with information Patients and/ or family members are provided with information about pain management.about pain management.
““Managing Your Pain”Managing Your Pain” booklet – Oncology Service booklet – Oncology Service““Welcome to PCA”Welcome to PCA” video – Surgical Program video – Surgical Program““Patient Controlled Analgesia”Patient Controlled Analgesia” pamphlet– Surgical Program“ pamphlet– Surgical Program“““Epidural Pain Management”Epidural Pain Management” pamphlet – Surgical Program pamphlet – Surgical Program““Managing Pain”Managing Pain” pamphlet – Surgical Program and pamphlet – Surgical Program and pain articlespain articles in River Valley News. in River Valley News.
Barriers to Barriers to EffectiveEffective Pain ManagementPain Management
Identification of Barriers and AttitudesIdentification of Barriers and Attitudes+ Addressing Barriers and Attitudes + Addressing Barriers and Attitudes = Quality Pain Management= Quality Pain Management
Ongoing education will address:Ongoing education will address:
• patient reluctance to report painpatient reluctance to report pain• education needs of patient/family regarding effective pain education needs of patient/family regarding effective pain
management management • the importance of an interdisciplinary approach and communication, the importance of an interdisciplinary approach and communication,
physician and nursing attitudes and beliefs that result in hesitancy to physician and nursing attitudes and beliefs that result in hesitancy to prescribe and administer adequate doses of opioids for pain. prescribe and administer adequate doses of opioids for pain.
Dispelling Dispelling Misconceptions Around Misconceptions Around
PainPainRVH will continue to explore ways to clarify for RVH will continue to explore ways to clarify for patients and clinicians the patients and clinicians the differencesdifferences between between addiction, tolerance, and physical dependence.addiction, tolerance, and physical dependence.
Fears and misconceptionsFears and misconceptions concerning opioid concerning opioid medications medications can preventcan prevent optimal use of optimal use of
pharmacological methods for pharmacological methods for painpain managementmanagement..
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