This is a lecture by Sue Anne Bell from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: Pain Management
Author(s): Heather Hartney (University of Michigan), RN 2012
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3. Cri'cal
outcome
•
The
emergency
nurse
assesses,
iden'fies
and
manages
acute
and
chronic
pain
within
the
emergency
se;ng.
3

4. Specific
Outcomes
• Define
the
types
of
pain
and
complica'ons
of
pain
management.
• Delineate
pain
physiology
and
mechanisms
of
addressing
pain
with
medica'ons.
• Define
the
general
assessment
of
the
pa'ent
in
pain.
• Delineate
the
nursing
process
and
role
in
the
management
of
the
pa'ent
with
acute
and
chronic
pain.
4

5. Specific
Outcomes
• Apply
the
nursing
process
when
analyzing
a
case
scenario/pa'ent
simula'on
• Predict
differen'al
diagnosis
when
presented
with
specific
informa'on
regarding
the
history
of
a
pa'ent
• List
and
know
the
common
drugs
used
in
the
emergency
department
to
manage
painful
condi'ons
and
conduct
procedural
seda'on.
• Consider
age-­‐specific
factors.
• Discuss
medico-­‐legal
aspects
of
care
of
pa'ents
with
pain
related
to
emergencies.
5

6. Defini'ons
• Pain
– An
unpleasant
sensory
and
emo'onal
experience
– Associated
with
actual
or
poten'al
'ssue
damage
or
described
in
terms
of
such
damage
– Personal
and
subjec've
experience
• Can
ONLY
be
described
by
person
experiencing
pain
• Exists
whenever
the
person
says
it
does
6

7. Tolerance
• Greatest
level
of
discomfort
a
person
is
prepared
to
endure
• Person
requires
increased
amount
of
substance
to
achieve
desired
effect
7

8. Dependence
• Reliance
on
a
substance
• Abrupt
discon'nuance
would
cause
impairment
of
func'on
8

9. Addic'on
• Behavioral
paZern
characterized
by
compulsively
obtaining
and
using
a
substance
• Results
in
physical,
social,
and
psychological
harm
to
user
9

10. Allodynia
• Pain
caused
by
a
s'mulus
not
normally
causing
pain
• Mechanical:
– Sta'c
mechanical
allodynia-­‐
pain
in
response
to
a
light
touch/pressure
– Dynamic
mechanical
allodynia-­‐
pain
in
response
to
brushing
• Thermal:
– (Hot
or
Cold)
allodynia-­‐
pain
in
response
to
mild
skin
temperatures
in
the
affected
area
• Can
be
from
neuropathy,
fibromyalgia,
migraines
or
spinal
cord
injuries
10

11. Pain
Management
• Comprehensive
approach
to
pa'ent
needs
when
experiencing
problems
associated
with
acute
or
chronic
pain
11

12. Pain
Threshold
• Least
level
of
s'mulus
intensity
perceived
as
painful
12

13. Suffering
• Physical
or
emo'onal
reac'on
to
pain
• Feeling
of
helplessness,
hopelessness,
or
uncontrollability
13

14. Pain
Physiology
• Emergency
nurses
need
an
understanding
of
basic
physiology
of
pain
to
effec'vely
assess,
intervene,
and
evaluate
pa'ent
outcomes.
14

15. Physiology
A. Neuroanatomy
1. Afferent
pathway
a) Nociceptors
(pain
receptors)
in
the
'ssues
respond
to
pleasant
and
painful
s'muli
1)
S'mula'on
of
nociceptors
produces
impulse
transmission
through
fibers
a) Small
C
fibers:
unmyelinated;
transmit
burning
and
aching
sensa'ons;
rela'vely
slow
b) Larger
A-­‐delta
fibers:
myelinated;
transmit
sharp
and
well-­‐
localized
sensa'ons;
rela'vely
fast
2) Terminate
in
the
dorsal
horn
of
the
spinal
cord
3) Modulate
pain
paZerns
in
the
dorsal
horn
4) Transmit
impulses
to
the
midbrain
via
the
neospinothalamic
tract
(acute
pain)
and
to
the
limbic
system
via
the
paleospinothalamic
tract
(dull
and
burning
pain)
15

16. Central
nervous
system
(CNS)
• Includes
all
the
limbic
system,
re'cular
forma'on,
thalamus,
hypothalamus,
medulla,
and
cortex
• Arousal,
discrimina'on,
and
localiza'on
of
pain;
coping
response;
release
of
cor'costeroids;
cardiovascular
response;
modula'on
of
spinal
pain
transmission
16

17. Ruth
Lawson,
Wikimedia
Commons
17

18. C
fiber,
A
delta,
dorsal
horn
Delldot, Wikimedia Commons
18

19. Efferent
pathway
• Fibers
connec'ng
the
re'cular
forma'on,
midbrain,
and
substan'a
gela'nosa
in
the
dorsal
horn
of
the
spinal
cord
• Afferent
fibers
s'mulate
the
periaqueductal
gray
maZer
in
the
midbrain,
which
then
s'mulates
the
efferent
pathway
• Modulates
or
inhibits
pain
impulses
19

20. Neuromodula'on
A. Endorphins:
A
group
of
neuropep'des
that
inhibit
pain
transmission
in
the
brain
and
spinal
cord
1) Beta-­‐Lipotropin:
responsible
for
feeling
of
well-­‐being
2) Enkephalin:
weaker
than
other
endorphins
but
longer
las'ng
and
more
potent
than
morphine
3) Dynorphin:
generally
impedes
pain
impulse
4) Endomorphin:
very
an'nocicep've
5) Opiate
receptors:
mu
receptors
on
the
membrane
of
afferent
neurons,
inhibit
the
release
of
excitatory
neurotransmiZers;
beta
receptors
react
with
enkephalins
to
modulate
pain
transmission;
kappa
receptors
produce
seda'on
and
some
analgesia;
sigma
receptors
cause
pupil
dila'on
and
dysphoria
20

21. Effects
of
medica'ons
on
modula'ng
pain
• S'mula'on
of
afferent
pathways
results
in
ac'va'on
of
circuits
in
supraspinal
and
spinal
cord
levels.
Each
synap'c
link
is
subject
to
modula'on
• Mechanisms
of
drug
ac'on
– ASA
and
Acetaminophen:
inhibit
prostaglandin
synthesis
in
the
CNS
– NSAIDs:
synthesized
at
the
site
of
injury;
inhibit
prostaglandin
synthesis,
which
reduces
hyperalgesia
– Opiates:
interact
with
mu
and
kappa
receptors;
powerful
effect
on
the
brainstem
and
the
periphery
– Local
anesthe'cs:
block
sodium
channels
and
thus
prevent
transmission
of
nerve
impulses
21

22. Specific
theory
– A
specific
sensa'on
that
is
independent
of
other
sensa'ons.
Experiments
on
animals
provided
clinical
evidence
of
separate
spots
for
heat,
cold,
and
touch
22

23. Gate
control
theory
– Modula'ons
of
inputs
in
the
spinal
dorsal
horns
and
the
brain
act
as
a
ga'ng
mechanism
– With
a
s'mulus,
the
following
sequence
of
events
occurs:
• The
pain
impulse
is
transmiZed
via
nociceptors
fibers
in
the
periphery
to
the
substan'a
gela'nosa
through
large
A-­‐delta
and
small
C
fibers
• A
ga'ng
mechanism
regulates
transmission
from
the
spinal
cord
to
the
brain,
where
pain
is
perceived
• S'mula'on
of
large
fibers
closes
the
gate
and
thus
decreases
transmission
of
impulses
unless
persistent
• S'mula'on
of
small
fibers
opens
the
gate
and
enhances
pain
percep'on
23

24. ..more
on
the
ga'ng
mechanism
– The
spinal
ga'ng
mechanism
is
also
influenced
by
fibers
descending
from
the
brain
– The
conduc'ng
fibers
carry
precise
informa'on
about
the
nature
and
loca'on
of
the
s'mulus
– Through
efferent
pathways
the
CNS
may
close,
par'ally
close,
or
open
the
gate
– Descending
fibers
release
endogenous
opioids
that
bind
to
opioid
receptor
sites
that
thereby
prevent
the
release
of
neurotransmiZers
such
as
substance
P,
this
inhibi'ng
transmission
of
pain
impulses
and
producing
analgesia
– Cogni've
func'on
can
also
modulate
the
pain
percep'on
and
the
individual’s
pain
response
24

25. Neuromatrix
theory
• A
widespread
network
of
neurons
consist
of
loops
between
the
thalamus
and
cortex
and
between
the
cortex
and
limbic
systems;
neural
processes
are
modulated
by
s'muli
from
the
body
but
can
also
act
in
the
absence
of
s'muli
– S'muli
trigger
neural
paZerns
but
do
not
produce
them
– Cyclic
processing
of
impulses
produces
a
characteris'c
paZern
in
the
en're
matrix
that
leaves
a
neurosignature
– Signature
paZerns
are
converted
to
awareness
of
the
experience
and
ac'va'on
of
spinal
cord
neurons
to
produce
muscle
paZerns
for
ac'on
25

26. Neuromatrix
theory
• Neural
inputs
modulate
the
con'nuous
output
of
the
neuromatrix
to
produce
a
wide
variety
of
experiences
felt
by
the
individual
– Awareness
of
the
experience
involves
mul'ple
dimensions
(e.g.,
sensory,
affec've,
and
evalua've)
simultaneously
– Pain
quali'es
are
not
learned;
rather,
they
are
innately
produced
by
the
neurosignatures
and
interpreted
by
the
brain
26

27. Types
of
pain
•
•
•
•
Acute
Chronic
Nocicep've
Neuropathic
27

28. Acute
• Elicited
by
injury
to
body
'ssues
• Typically
seen
with
trauma,
acute
illness,
surgery,
burns,
or
other
condi'ons
of
limited
dura'on;
generally
relieved
when
healing
takes
place.
28

29. Acute
pain
Wellcome Library London, Wellcome Images
29

30. Chronic
• Elicited
by
'ssue
injury
• May
be
perpetuated
by
factors
remote
from
the
original
cause
and
extend
beyond
the
expected
healing
'me;
generally
lasts
longer
than
3
months
30

31. Chronic
pain
Adrian Cousins, Wellcome Images
31

32. Nocicep've
• Elicited
by
noxious
s'muli
that
damages
'ssues
or
has
the
poten'al
to
do
so
if
the
s'muli
are
prolonged.
– Soma'c
pain:
arises
from
skin,
muscle,
joint,
connec've
'ssue,
or
bone;
generally
well
localized
and
described
as
aching
or
throbbing.
– Visceral
pain:
arises
from
internal
organs
such
as
the
bladder
or
intes'ne;
poorly
localized
and
described
as
cramping.
32

33. Soma'c
pain
Wellcome Library London, Wellcome Images
33

34. Visceral
pain
Theuplink, Wikimedia Commons
34

35. Neuropathic
• Caused
by
damage
to
peripheral
or
central
nerve
cells
– Peripheral:
• Arises
from
injury
to
either
single
or
mul'ple
peripheral
nerves
• Felt
along
nerve
distribu'ons
• Burning,
shoo'ng,
stabbing
or
like
an
electric
shock
• Diabe'c
neuropathy,
herpe'c
neuralgia,
radiculopathy,
or
trigeminal
neuralgia
– Central:
• Associated
with
autonomic
nervous
system
dysregula'on
• Phantom
limb
pain
(peripheral)
or
complex
regional
pain
syndromes
(central)
35

36. Peripheral
neuropathic
pain
Lubyanka, Wikimedia Commons
36

37. Central
neuropathic
pain
J.H. Shepherd/Mütter Museum, Wikimedia Commons
37

38. General
strategy
•
•
•
•
•
Assessment
Analysis
Planning
and
Implementa'on/Interven'on
Evalua'on
and
Ongoing
monitoring
Documenta'on
38

39. Assessment
• Primary
and
secondary
assessment
• Focused
assessment
– Subjec've
data
collec'on
– Objec've
data
collec'on
39

40. Subjec've
data
1. HPI
(history
of
present
illness/injury)
or
Chief
Complaint
• History
of
pain
(PQRST)
– Pain
– Quality
– Region/Radia'on
– Severity
– Timing
• Efforts
to
relieve
symptoms
40

41. Subjec've
data
2. Past
medical
history
a)
b)
c)
d)
e)
f)
g)
h)
i)
Current
or
preexis'ng
diseases/illness
New
or
recurring
problem
Substance
and/or
alcohol
use/abuse
LNMP
Current
medica'ons
Non-­‐pharmacologic
interven'ons
Food
or
drink
Coping
mechanisms
Allergies
41

42. Subjec've
data
3. Psychological/social/environmental
factors:
a)
b)
c)
d)
Anxiety,
Depression
Aggrava'ng
or
allevia'ng
factors
Expressions
of
pain
Pain
behavior
is
learned,
yet
adap've,
and
it
r/t
pain
threshold
and
pain
tolerance
e) Pain
expressions
can
be
verbal,
behavioral,
emo'onal,
and
physical
42

43. Objec've
data
1. General
appearance
a) Psychological
b) Observa'ons
of
behavior
and
vital
signs
should
not
be
used
solely
in
place
of
self-­‐report
c) Posi'oning
and
movement
d) Physiologic
e) Level
of
distress/discomfort
43

44. Objec've
data
2. Obtain
pain
ra'ng
a) Adults
1.
2.
3.
4.
Visual
analog
scale
Numeric
ra'ng
scale
Graphic
ra'ng
scale
Thermometer-­‐like
scale
44

45. Visual
Analog
Scale
hZp://0.tqn.com/d/ergonomics/1/0/C/-­‐/-­‐/-­‐/painscale.jpg
45

46. Numeric
Ra'ng
Scale
hZp://0.tqn.com/d/pain/1/0/S/-­‐/-­‐/-­‐/PainScale.gif
46

47. Graphic
Ra'ng
Scale
hZp://img.medscape.com/fullsize/migrated/editorial/journalcme/2007/7993/art-­‐
mannion.box1.gif
47

48. Thermometer-­‐like
Scale
hZp://img.medscape.com/fullsize/migrated/574/105/574105.fig1.gif
48

49. Objec've
data
2. Obtain
pain
ra'ng
b) Pediatric
1.
2.
3.
4.
FACES
scale
Poker
chip
Numeric
ra'ng
scale
Color
matching
49

50. FACES
/
Numeric
combined
No
pain
Clker.com, Clker Images
Minor
pain
Moderate
pain
Severe
pain
Worst
pain
of
my
life
50

51. Objec've
data
2) Obtain
a
pain
ra'ng
c) Infant
1. Neonatal
Infant
Pain
Scale
(NIPS)
2. Neonatal
Pain,
Agita'on,
and
Seda'on
Scale
(NPASS)
3. Pain
Assessment
Tool
(PAT)
51

52. NIPS
hZp://www.natalnurses.net/images/22.jpg
52

53. NPASS
53
hZp://www.anestesiarianimazione.com/Immagini/npass%208-­‐01.jpg

54. PAT
hZp://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif
54

55. Objec've
data
• Inspec'on
– Posi'on,
skin
color,
external
bleeding,
skin
integrity,
obvious
deformity,
edema
• Ausculta'on
– Breath
sounds,
bowel
sounds
• Palpa'on
– Areas
of
tenderness:
light,
deep
– Save
painful
part
un'l
last
55

56. Diagnos'c
procedures
• Laboratory
studies
• Imaging
• Electrocardiogram
• Purpose:
TO
FIND
THE
CAUSE
OF
THE
PAIN
56

57. Analysis:
Differen'al
diagnosis
• ACUTE
PAIN
• CHRONIC
PAIN
57

58. Planning
and
Implementa'on/
Interven'ons
1. Determine
priori'es
of
care
a)
b)
c)
d)
e)
f)
g)
Maintain
ABC
Provide
supplemental
oxygen
IV
access
Obtain
and
set
up
equipment
Prepare/assist
with
medical
interven'ons
Provide
measures
for
pain
relief
Administer
pharmacological
therapy
as
ordered
58

59. Administer
pharmacological
therapy
as
ordered
1. The
World
Health
Organiza'on
(WHO)
recommends
the
use
of
the
analgesic
ladder
as
a
systema'c
plan
for
the
use
of
analgesic
medica'ons.
1. Step
1:
use
non-­‐opioid
analgesics
for
mild
pain
2. Step
2:
adds
a
mild
opioid
for
moderate
pain
3. Step
3:
use
of
stronger
opioids
when
pain
is
moderate
to
severe
59

60. Pa'ent-­‐controlled
analgesia
(PCA)
• Used
for
pa'ents
with
acute
or
chronic
pain
who
are
able
to
communicate,
understand
explana'ons,
and
follow
direc'ons
• Assess
vital
signs
and
pain
level
• Explain
the
use
of
the
pump
• Collaborate
with
the
physician,
pa'ent,
and
family
about
dosage,
lockout
interval,
basal
rate,
and
amount
of
dosage
on
demand
• Assist
the
pa'ent
to
use
the
PCA
pump
60

61. Planning
and
Implementa'on/
Interven'ons
2. Relieve
anxiety
and
apprehension
3. Allow
significant
others
to
remain
with
pa'ent
if
suppor've
4. Educate
pa'ent
and
significant
others
• about
the
efficacy
and
safety
of
opioid
analgesics
61

62. Evalua'on
and
Ongoing
Monitoring
1. Con'nuously
monitor
and
treat
as
indicated
2. Monitor
pa'ent
response/outcomes,
and
modify
nursing
care
plan
as
appropriate
3. If
posi've
pa'ent
outcomes
are
not
demonstrated,
reevaluate
assessment
and/or
plan
of
care
62

63. Documenta'on
• Document
vitals
and
pain
score
before
and
amer
interven'on
along
with
pa'ent
response
63

64. Age-­‐related
concerns
1. Pediatrics:
Growth
or
development
related
• Children’s
pain
tolerance
increases
with
age
• Children’s
developmental
level
influences
pain
behavior
• Localiza'on
of
pain
begins
during
infancy
• Preschoolers
can
an'cipate
pain
• School
age
children
can
verbalize
pain
and
describe
loca'on
and
intensity
64

65. Pediatrics
“Pearls”
• Children
may
not
admit
to
pain
to
avoid
injec'on
• Distrac'on
techniques
can
aid
in
keeping
the
child’s
mind
occupied
and
away
from
pain
• Opioids
are
no
more
dangerous
for
children
than
for
adults
65

66. Age
Related
concerns
2. Geriatrics:
Age
related
• Pain
is
not
a
normal
aging
consequence
• Chronic
pain
alters
the
person’s
quality
of
life
• Chronic
pain
may
be
caused
by
a
myriad
of
condi'ons
66

67. Geriatric
“Pearls”
• Adequate
treatment
may
require
devia'on
from
clinical
pathways
• Administer
pain
relieving
medica'ons
at
lower
dose
and
increase
slowly
67

68. Barriers
to
effec've
pain
management
1. A;tudes
of
emergency
health
care
providers
2. Hidden
biases
and
misconcep'ons
about
pain
3. Inadequate
pain
assessment
4. Failure
to
accept
pa'ents’
reports
of
pain
5. Withholding
pain-­‐relieving
medica'on
6. Exaggerated
fears
of
addic'on
7. Poor
communica'on
68

69. Improving
pain
management
• Changing
a;tudes
• Con'nuing
educa'on
related
to
the
reali'es
and
myths
of
pain
management
• Evidence-­‐based
prac'ce
• Cultural
sensi'vity
69

70. Procedural
seda'on
• The
Joint
Commission
(TJC)
has
standard
defini'ons
for
four
levels
of
seda'on
and
anesthesia:
1.
2.
3.
4.
minimal
seda'on
moderate
seda'on/analgesia
deep
seda'on/analgesia
(pt
not
easily
aroused)
anesthesia
(requires
assisted
ven'la'on)
70

71. Procedural
seda'on
• Indica'ons:
suturing,
fracture
reduc'on,
abscess
incision
and
drainage,
joint
reloca'on
• Assessment:
Allergies,
Last
oral
intake
71

72. Procedural
Seda'on
• Procedure:
– Baseline
VS
and
LOC
– Explain
procedure
to
pa'ent
and
family
– Obtain
venous
access
– Equipment:
cardiac
monitor,
blood
pressure
monitor,
pulse
oximeter,
suc'on,
oxygen
equipment,
endotracheal
intuba'on
equipment
and
capnography
device,
IV
supplies,
reversal
agents.
– Assist
with
medica'ons
– Maintain
con'nuous
monitoring
during
procedure
– Document
vital
signs,
LOC,
and
cardiopulmonary
status
every
15
min.
– Post
procedure
discharge
criteria
72

73. Medica'on
review
•
•
•
•
Non-­‐narco'c
Narco'cs
Seda'ves
/
anesthe'cs
Local
anesthe'cs
73

74. Non-­‐narco'c
• Acetaminophen
• Salicylates
• NSAIDs
74

75. Narco'c
•
•
•
•
•
Codeine
Fentanyl
Hydromorphone
Morphine
sulfate
Oxycodone
75

76. Seda'ves
/
Anesthe'cs
•
•
•
•
•
•
Diazepam
Ketamine
Lorazepam
Midazolam
Propofol
Etomidate
76

77. Local
anesthe'cs
•
•
•
•
•
•
Lidocaine
Mepivacaine
Procaine
Tetracaine
LET
(lidocaine,
epinephrine,
tetracaine)
EMLA
cream
77

78. 78