Hi everyone, this is Kari and this lecture will review caring for patients with acute and chronic pain. In front of you, you should have your acute and chronic pain PowerPoint, which we're going to use to go through the lecture. I'm also going to be talking about the WHO ladder and the sample morphine PCA order set.
All these documents are found online in the Providing Comfort lesson. Some of the concepts we'll be reviewing today go back to content from first and second semester classes. I'll go through those kind of quickly and then we'll focus more on the critical thinking that nurses use while they are caring for patients in pain. All right, we'll get started. As you know, pain is considered the fifth vital sign.
Nurses should always ask about pain severity while gathering vital signs. The patient is always the authority on their experience. We cannot judge their pain level based on what they look like, what they sound like, or how they're acting. We must believe their self-report until proven otherwise. There are occasionally patients who may be addicted to pain medication, which we need to be watching for.
But this will not be the case with the majority of patients. We should believe what patients say and act promptly to relieve their pain. Nurses also need to respect their values and their preferences. For example, some cultures don't believe in taking pain medicine. To them, it's important to go through the suffering.
and so we're not going to judge their preferences either. Do be aware that the Joint Commission has standards for pain management and these are standards that you will be held accountable for as a nurse in assessing and managing your patient's pain. There's also a link to those specific standards online if you would like to take a look at them.
Also be aware that there are populations who are especially at risk for inadequate pain management. Those are older adults, especially those in long-term care facilities. who may have dementia or difficulty communicating their pain.
For example, my colleague gives the example of a nurse caring for a patient with dementia. The nurses caring for the patient were concerned because he was constantly banging his head against the wall and they thought it was a behavior related to the dementia. Well, it turns out he was in pain.
Once someone considered that and started giving him scheduled acetaminophen, he stopped banging his head on the wall and that was the only way he could communicate his pain level. Substance abusers are at risk for inadequate pain management because they do still have pain and their pain still needs to be managed. We just need to be part of the team in deciding which pain medications are best for them that aren't going to add to their substance abuse problem.
Those patients whose primary language is not English are certainly at risk as well, and it may be difficult for them to communicate their pain level to us. So we have to be vigilant in monitoring their pain. Okay, acute versus chronic pain.
I think most of you know the difference. Acute pain has a short-term duration and usually is well-defined. An example would be post-operative pain. The pain decreases as you heal from surgery. It's reversible, and it can range from mild to severe, and it can be accompanied by anxiety and restlessness.
Anxiety and restlessness are associated with the body's implicit need to try to get away from that pain. That's why you often see the fight or flight type reactions with acute pain. Often you see increased vital signs such as increased heart rate, increased blood pressure, and increased respiratory rate. These patients may also appear diaphoretic. Chronic pain lasts longer.
It's usually longer than three months, and it's usually not related to a specific well-defined cause. It's not reversible like acute pain. It can range from mild to severe, and because it's so long-term, It's often accompanied with depression, fatigue, and it starts to affect people's ability to function. So we need to consider those additional ramifications as well.
There are different sources of pain that are described in the table here, ranging from somatic pain to visceral pain and neuropathic pain. And what I want you to think about is, why do we care as nurses? Well, we care because there are different medications that work best for different sources of pain.
For example, patients with diabetes or other types of neuropathic pain may describe the pain as burning or tingling. Vicodin and other opioids do not tend to work well on that type of pain, especially since it is usually a chronic problem. However, other medications such as gabapentin, which is actually an anticonvulsant medication, does work well on that type of pain. So this is why it's always important for us to ask the characteristics of pain, which we're going to talk here about in a little bit.
This slide shows a pretty simple diagram of the gait control theory of pain, which you should be aware of. There's actually an anatomical spot at the base of the brain that closes the gait to the pain impulses that are being sent from the peripheral areas. There are different things that can control that gait.
Endorphins, which are the feel-good hormones, close the gate. And this is why those non-pharmacological interventions tend to work really well. This includes relaxation breathing, distraction, visualization, etc.
There are also medications that can close that gate. For example, aloe vera or amitriptyline is a very old tricyclic antidepressant that you will see ordered for patients. Many times when you see that ordered, it is not for an antidepressant.
It is for pain control because it works to close this gate. There are still many barriers out there to pain management, starting with health care professionals. Some physicians are not well trained in the different types of pain management, or they have their own barriers against pain management. Nurses have their own experiences.
If a patient doesn't look like they're in pain, nurses tend to question their true level of pain. A nurse's culture or a patient's culture can affect how pain is interpreted. Additionally, patients have their own misconceptions. For example, a patient may refuse to take pain medication because they believe it won't actually work when they really need it.
Or they may have a fear of becoming addicted to the pain medication. We're going to talk more about the difference between addiction and tolerance. But we as nurses must be aware of these barriers to try to overcome them in order to provide good pain management for our patients.
So here are some important concepts for you to know. Let's start with tolerance. Tolerance occurs to everyone when the body starts to adapt to the effects of the drug. So over time, an increased dose of pain medication will be needed to provide the same type of relief.
Physical dependence also occurs to everyone that has been on long-term opioids and is defined by the withdrawal symptoms that the body experiences after being on medication for a long period of time. Pseudo-addiction, which some healthcare professionals inaccurately perceive as addiction, actually results from under-treatment of pain. So the patient seems like they are drug seeking when really they're just trying to cover the pain.
And once the pain is effectively treated, those behaviors of withdrawal will also dissipate. Finally, there's addiction. Addiction is different than tolerance or physical dependence. Addiction is a long-term issue.
It's not going to occur for patients receiving a short course of opioids for acute pain, such as post-op pain. It happens over a long period of time for patients that have been on opioids long-term. And this is why opioids are not the best choice for chronic pain, because addiction can happen to anyone.
What characterizes addiction are the behaviors that happen. As a person becomes addicted to the medication, and they seek out that medication, Behaviors such as lying or stealing can occur, which actually characterizes addiction. Now let's move on to assessment of pain.
In your textbooks and in class you have likely learned PQRST for pain assessment, which is a good assessment technique. Another mnemonic that may help you with pain assessment is old carts. It's something that can be used for any chief complaint, not just pain.
So if you prefer, I encourage you to use this in your practice. All right, there are different categories of pharmacological therapy, and this ties into the WHO ladder. So let's pull up that separate document.
I also have a picture of it in the PowerPoint here. At the bottom of the WHO ladder are your non-opioid analgesics. And the safest non-opioid analgesic is Tylenol or acetaminophen.
It works for pain. It works for fever. It has very few side effects. However, when used chronically, especially more than 2,400 milligrams a day, it can cause liver damage and kidney damage.
So you would want to watch for that in patients who are receiving it chronically. And as you know, if your patient develops liver damage, what's a sign you're going to monitor for? Yellowing or jaundice is what you would notice. And you will see that first in the sclera in the whites of their eyes.
The next step up the ladder is going to be NSAIDs, non-steroidal anti-inflammatory drugs. That includes ibuprofen, naproxen, and aspirin is often classified under NSAIDs because it does work on inflammation as well. All right, toroidal is often used in conjunction with PCAs and opioids, and it's used to decrease inflammation as well. COX-2 inhibitors, those are used for long-term relief.
Technically, NSAIDs work on COX-1 and COX-2 receptors, but these COX-2 inhibitors only work on the COX-2 receptors. So Celebrex is a prescription medication that you've probably heard of or seen the commercials for. It's really good for long-term use, like for arthritis, but it can have cardiovascular side effects.
The problem with NSAIDs, all of them, is that they can cause GI upset. They can affect how well the platelets stick together, which in some cases is therapeutic. But in some cases can cause bleeding, especially GI bleeding, and that's a very common side effect, severe side effect, in our elderly population. So we have to be very careful to watch their stools for any signs of bleeding.
As you know, frank red blood is a sign of acute bleeding, but if it's higher up in the GI tract near the stomach and then it's partially digested, blood actually appears dark, black, and sticky like a tarry substance. That's called melanin, and that indicates there's a GI bleeding. going on in the upper GI tract and it always needs to be reported to the healthcare provider.
So these would be the medications used for someone experiencing mild to moderate pain. The next step up the ladder are your opioids. These work centrally, whereas your non-opioids work peripherally. They're used more for moderate to severe pain. If you look at the WHO letter, you can see where codeine, like Tylenol-3, is one of the weaker opioids.
It's short-actual. The next one would be hydrocodone, which when combined with acetaminophen is Vicodin or Norco, depending on the ratio of hydrocodone versus acetaminophen. So again, you're watching for your dosage of acetaminophen. If each Norco tablet contains 325 milligrams, we need to be sure that they're not exceeding 4 grams in one day by taking their maximum dose of Norco.
The same goes for Vicodin with a 500 milligram dose of acetaminophen per tablet. Like I said, 2400 milligrams is a safer maximum, especially for elderly, but the 4000 milligram is still recognized as the maximum by the FDA. The next step up would be oxycodone.
That can be given by itself or it can be combined with acetaminophen, which would be called Percocet. They are both short-acting and long-acting versions of oxycodone. Sometimes you'll see both ordered and used in combination, but remember that the long-acting OxyContin cannot be crushed.
Morphine is at the top of the ladder. It's considered the gold standard. There is no ceiling effect to morphine. The more morphine you give, the more it's going to work.
So that is why in end-of-life care, morphine is often the best thing that can be used because there's no ceiling effect. There's many different strengths. There's many routes. It can be given sublingually where it's just absorbed, especially in end-of-life care.
It can be given orally. It can be given IM, IV. and it's often used in PCA pumps. Hydromorphone or Dilaudid is actually stronger than morphine, and it's also used in PCA pumps.
Hydromorphone does have a sealing effect. Let's go to fentanyl. This is also used especially for chronic pain. It can be used in a patch. However, we have seen problems with all of these medications being abused by healthcare professionals as well.
So there have been instances with of fentanyl patches disappearing from patients, or even the disposed fentanyl patches can be cut up, and I don't know if they boil them or what, but then they can inject it. So you will notice that health care agencies are very specific about the wasting of these medications. If you don't give a full dosage, you only give half a pill, or you have to waste some of the liquid for an IM or IV injection, it always has to be witnessed by a second nurse.
Patches generally have to be flushed the toilet Wasted opioid medications are still flushed down the sink because of this potential problem for drug diversion. Methadone is another drug you may see used for pain. It's very complex, and it's used mostly for patients who have had substance abuse problems. It is potentially unsafe, and therefore you would most likely see it ordered by a pain specialist.
Tramadol is an atypical medication. They're still not completely sure how it works, but it works very similar to opioids. and is sometimes referred to as pseudo-opioid because it is believed to work on the same receptors but has less side effects and can be very effective for managing pain. However, because it works similarly to opioids and can be abused, most agencies have the same regulations for administration and disposal or waste of tramadol.
So make sure you're familiar with the WHO ladder. It's important for nurses to understand if you have a list of PRN medications, We need to prioritize what medication should be given for the patient's pain level. Your choice should always be based on your pain assessment.
When we give opioids, we of course need to be aware of common side effects. A very common side effect for everyone is constipation, especially if they are taking opioids on a scheduled basis. So we need to constantly monitor these patients' bowel patterns.
If they haven't had a bowel movement in two to three days, a bowel regimen needs to be started. Many times they need to be on a scheduled stool softener while they're on an opioid. Of course, you'll also include other non-pharmacological things like increased fluid intake, increased fiber, and getting them up and moving.
Nausea and vomiting is also a common side effect. It tends to be worse in the first 24 to 48 hours, and then patients often develop a tolerance to it. But you may need to administer an antiemetic such as compazine, reglan, or zofran. Zofran is one of the most commonly used because it has very few contraindications. It's expensive, but very effective.
Patients may become sedated or confused on any opioids, even low-dose opioids. So when giving the first dose, you need to be very careful monitoring their sedation, confusion, and fall risk. They do tend to develop a tolerance to this in two to three days, but if your patient is difficult to awaken, you need to stop the medication.
We're going to talk more about this later with the PCA order set, but oral medication can also cause this problem. Respiratory depression is the most life-threatening side effect that can occur. It can occur as the patient experiences a deeper level of sedation, so we need to be very careful monitoring their respiratory status, including respiratory rate and O2 sets.
If it's severe, it can be reversed with Narcan. Finally, a common side effect, especially to morphine, is pruritus or itching, and so patients may need to be on Benadryl or diphenhydramine while they're on morphine. Okay, so now let's talk more about PCA pumps.
As you know, PCA pumps are programmed so that they deliver a dose with each press of the button, and there is a lockout so patients can't get more than so many doses within an hour or so many milligrams of medication within an hour. It can also be given as a continuous infusion. This would especially be used with severe post-op pain, especially if it's awaking them at night and they're in severe pain. We should always make sure our patients understand the use of the PCA, how it works, and how it protects them.
No one should press the button except the patient. It is specifically designed that the patient has to be aware and alert enough to press the button to protect them from respiratory depression and sedation. We also need to teach them about those side effects of opioids that we just discussed, and we're going to be watching. Be watching the respiratory rate, O2 sats, and sedation level very closely. Okay, so let's take a look at the PCA order set that's online.
This is a sample from Mayo Clinic, but will look similar at any facility. You can see this one is for morphine, and like I said, you may see other medications like fentanyl or hydromorphone used in PCAs. First, I want to point out what it says at the top, and you can see that these order sets are pre-printed to make it easier for providers to place orders and are based on patients with normal kidney and liver functions.
So in the first section, you'll notice there are specific monitoring guidelines. All patients on PCA should have continuous pulse oximetry monitoring, and vital signs need to be obtained more frequently because of the risk involved with respiratory depression and sedation. The last order under monitoring notes notes that if their respiratory rate is less than 10 or they are not easily aroused to stop the PCA and start O2 and consult a respiratory therapist.
You will also notice that there is an order to notify the provider for a respiratory rate less than 8 and if naloxone Narcan is administered. Next, you will see the order for patient and family education, including teaching the patient and family. that no one is allowed to use the button except the patient. Then you will see the area where the provider can choose the level of morphine, one or two, low or high. Some facilities or medications may have three levels.
You will notice that with each level, the provider can choose to add a loading dose in the beginning and also a basal or continuous rate. Both of these have a lockout of 10 minutes Which is typical, it means the patient can't receive another dose sooner than 10 minutes, even if they push the button sooner than that. There's also a maximum dose that they can receive within a four-hour period to avoid overdosing. You also see above there that naloxone is automatically ordered to be given stat if a patient has a respiratory rate less than 8 or not easily aroused, meaning they don't respond to a loud voice or physical stimulation like a sternal rub. You can dilute 0.4 milligrams in 10 milliliters of normal saline and give it as an IV push.
and can repeat that again after two minutes if they are not awake. Do be aware though if you give Narcan it's an immediate reversal so they go from being unarousable to being in severe pain but it is needed to help prevent respiratory arrest. While you're doing that somebody should notify the physician stat the patient should be receiving oxygen someone should be calling respiratory therapy for a consult and you will be closely monitoring their vital signs. The pri- provider will then need to adjust the dosing.
This protocol does not have additional PRN medications ordered, but oftentimes there are medications automatically ordered for nausea and vomiting, pruritus, and constipation. Whenever you have a patient on a PCA, you want to make sure that you are aware of these PRN medications that are ordered so you know what is available if needed. While we're talking about this, let's also look at the PAS Sedation Scale.
This can also be found in your textbook. The Sedation Scale may be used to monitor sedation with opioid administration. This puts patients on a scale ranging from being sleepy and easy to arouse to a 4 where they're not responding.
I've also included the Richmond Agitation Sedation Scale. I have that pulled up here for you, and that's what I have seen. use the most frequently in practice to monitor for sedation during opioid administration.
You can see this one is rated a bit differently with a zero being alert and calm and then the positive numbers assessing for agitation and the negative numbers assessing for sedation. Okay, we just talked a lot about the use of PCA medications. Another route would be epidural anesthesia.
You probably saw some of this during your OB clinical where epidurals are used. They can also be used for surgery. Intrathecal anesthesia is also used for long-term pain.
That would be through a pain specialist. Do be aware if your patient has received epidural anesthesia. In addition to the monitoring for respiratory depression and sedation that we've talked about, there is a lower extremity weakness that can occur.
So when they first get out of bed, you need to be in the room. This cannot be delegated to the CNA because of the high risk for falling. You would certainly be monitoring their CNS sensation in those lower extremities before getting them out of bed anyways.
Another class of medication that I just want to hit on are these adjuvant analgesics. Elavil, like we discussed, is used to close the gate for chronic neuropathic pain, I've also seen it used for migraines. Anti-convulsants like gabapentin or pregabalin are also used for neuropathic pain. Sometimes patients are prescribed anti-anxiety agents like Xanax to help them relax, because as you know, the more anxious a patient is, the worse their pain will be.
We know that medical marijuana has been approved in some states, including Minnesota. It has not yet been approved for use in Wisconsin. Medical marijuana has been used for centuries to control pain, so we're going to continue to hear more about research being done on that.
Steroids may be used for bone pain or cancer pain to control inflammation. There are topical analgesics, which we'll see a lot of now, such as lidoderm patches, where these patches are applied directly over the painful area, such as knees, the back, or around surgical incisions. There's also Emla cream that can be used prior to inserting an IV to numb that area, most commonly seen with our pediatric population.
Now, don't forget about your non-pharmacological therapies. It's easy to quickly go for a pill, but don't forget about the other things that might help, including heat, ice, massage, or even electrical stimulation through a TENS unit. just your basic Cognitive behavioral therapy can be used.
Relaxation techniques are very helpful. Distraction. Turn on the TV, reading a magazine, talking with them, taking them to a different area in the hospital or to a common area or lounge where they can have conversation with others. Imagery.
Those are all common therapies that nurses can use. I do want to talk about simple relaxation techniques for a minute. We're going to talk about it more in our stress unit, but it's such an easy thing to do, especially if your patient's feeling anxious. Sometimes as simple as deep breathing can have a large effect. Have a patient put their hands on their abdomen, take a deep breath in through their nose, blow it out through their mouth.
Try to take two to three breaths like that, and it can be really helpful. Other invasive techniques that are used for chronic pain. More with pain specialists would be nerve blocks or spinal cord stimulation.
I also want to talk about pain when caring for pediatric patients. Children experience pain too, but they can have a difficult time verbalizing what it feels like or where it is. So we need to be watching them.
A lot of it is your observation. What are the nonverbals that you're seeing? What kinds of behaviors are you seeing?
Are they suddenly restless and whiny, not wanting to play like they normally would? This is where the faces scale can come in in hand. It has the smiley faces that you can show the child, and they can point to which one describes their pain level. Your non-pharmacological techniques, a lot of times sitting down and just drawing with them or playing with their toys, any type of distraction works well. And then all those types of pharmacological therapies we talked about are also used for children.
but obviously in decreased doses according to their weight. Next, we're going to talk a bit about complementary and alternative therapies for pain. You'll notice that our society is becoming more and more focused on holistic care. Many patients are already using therapies like this and don't always tell their providers because there is still a bias out there with medical professionals that these different types of therapies haven't been validated through research as well as the pharmacological therapies. The National Center for Complementary and Alternative Medicine has developed different categories for these therapies including alternative medicines such as supplements, mind-body interventions such as relaxation techniques, manipulation methods such as chiropractic or acupuncture therapy, and energy therapies including healing touch or Reiki.
Our main role as nurses is to always ask about patients use of these methods, what they are doing, and how effective is it. So instead of asking do you use any complementary or alternative medicine, you may ask a patient things like what kinds of herbal supplements do you take? They can say I don't take any or I don't take any vitamins or they might say I take vitamin b12, I take d3, I take black coal ash. You can also ask them, are you using any other approaches to your wellness or to decrease your pain besides seeing your physician? They might say, yeah, I see my chiropractor once a month and I get a massage once a month, or it really helps me to meditate every night.
As the nurse and patient advocate, it's our job to assess the patient's use of these methods and to inform the provider. So that concludes the acute and chronic pain lecture. You will be practicing applying these concepts with your assignments and in class.