1. Pain Management Objectives: to describe basic pain management techniques related to types of pain, how to recognize pain, and how to use pharmacological and non- pharmacological pain treatments.

2. Objectives cont. Understand how the management of pain affects the quality of life. Understand how the management of pain affects the quality of life. Develop an awareness of misconceptions and consequences of untreated pain. Develop an awareness of misconceptions and consequences of untreated pain. Recognize different types of pain and identify appropriate traditional and non- traditional treatments Recognize different types of pain and identify appropriate traditional and non- traditional treatments Utilize pain assessment tools as needed for patients. Utilize pain assessment tools as needed for patients. Understand that all caregivers have a role in assessment and treatment of pain. Understand that all caregivers have a role in assessment and treatment of pain.

3. Introduction Pain is the conscious experience of discomfort. Pain is the conscious experience of discomfort. Nociceptors transmit pain action potentials to the brain Nociceptors transmit pain action potentials to the brain One person’s report of severe pain may seem like almost nothing compared to another. One person’s report of severe pain may seem like almost nothing compared to another. Caregiver’s challenge is to assess all relevant factors without imposing personal biases. Caregiver’s challenge is to assess all relevant factors without imposing personal biases. Patients' self-report of pain is the single most reliable indicator of pain. Patients' self-report of pain is the single most reliable indicator of pain.

4. Common Misconceptions about Pain The caregiver is the best judge of pain. The caregiver is the best judge of pain. A person with pain will always have obvious signs such as moaning, abnormal vital signs, or not eating. A person with pain will always have obvious signs such as moaning, abnormal vital signs, or not eating. Pain is a normal part of aging. Pain is a normal part of aging. Morphine and other strong pain relievers should be reserved for the late stages of dying. Morphine and other strong pain relievers should be reserved for the late stages of dying. Anxiety always makes pain worse. Anxiety always makes pain worse.

5. Consequences of Untreated Pain/Mistreated Pain Poor appetite and weight loss Poor appetite and weight loss Disturbed sleep Disturbed sleep Withdrawal from talking or social activities Withdrawal from talking or social activities Sadness, anxiety, or depression Sadness, anxiety, or depression Physical and verbal aggression, wandering, acting-out behavior, resists care Physical and verbal aggression, wandering, acting-out behavior, resists care Difficulty walking or transferring; may become bed bound Difficulty walking or transferring; may become bed bound Incontinence, skin ulcers, impaired immune function Incontinence, skin ulcers, impaired immune function

6. Descriptions of Pain ( Duration) Acute Pain Brief duration, goes away with healing, usually 6 months or less. Not necessarily more severe than chronic Not necessarily more severe than chronic May be sudden onset or slow in onset May be sudden onset or slow in onset Examples are broken bones, strep throat, and pain after surgery or injury Examples are broken bones, strep throat, and pain after surgery or injury

7. Descriptions of Pain (Duration) Chronic (cancer) Pain Pain is expected to have an end, with cure or with death. Aggressive treatment Aggressive treatment Addiction not a concern Addiction not a concern

8. Categories of Pain by Duration Chronic Non-Malignant Pain Pain has no predictable ending Difficult to find specific cause Difficult to find specific cause Often can’t be cured Often can’t be cured Frequently undertreated Frequently undertreated Depression common Depression common

9. Categories of Pain by Type Somatic Source: Skin, muscle, and connective tissue Examples: Sprains, headaches, arthritis Description: Localized, sharp/dull, worse with movement or touch with movement or touch Pain med: Most pain meds will help, if severe, need a stronger medication medication

10. Categories of Pain by Type Visceral Source:Internal organs Examples:Tumor growth, gastritis, chest pain Description:Not localized, refers, constant and dull, less affected with movement Pain Med:Stronger pain medications

11. Categories of Pain by Type Neuropathic Source:Nerves Examples:Diabetic neuropathy, phantom limb pain, cancer spread to nerve plexis Description:Burning, stabbing, pins and needles, shock-like, shooting Pain Meds:Opioates+tricyclic antidepressants

12. Other Types of Pain Referred Pain- pain felt in part of the body, other than the source Referred Pain- pain felt in part of the body, other than the source

13. Other Types of Pain Phantom Pain- Although the limb is no longer there, the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. Sometimes, the brain memory of pain is retained and is interpreted as pain, regardless of signals from injured nerves. Phantom Pain- Although the limb is no longer there, the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. Sometimes, the brain memory of pain is retained and is interpreted as pain, regardless of signals from injured nerves.

14. Pain Assessment Asking about pain is an important part of ALL assessments!! Should be done: periodically, after a treatment, when a change in physical or mental status is noted Should be done: periodically, after a treatment, when a change in physical or mental status is noted Assessments to identify and treat pain must be ongoing. Assessments to identify and treat pain must be ongoing. Elderly residents require frequent monitoring for pain. Elderly residents require frequent monitoring for pain.

15. Non-Traditional Treatments for Pain Hypnosis- behavioral suggestion therapy, lower state of consciousness Hypnosis- behavioral suggestion therapy, lower state of consciousness Meditation-peaceful state of consciousness Meditation-peaceful state of consciousness Thermal Therapy- adding moist or dry heat Thermal Therapy- adding moist or dry heat Acupuncture-systematic pricking the skin with needles Acupuncture-systematic pricking the skin with needles Acupressure-pressure points Acupressure-pressure points

16. Non-Traditional Treatments for Pain Imagery- imaging a peaceful situation Imagery- imaging a peaceful situation Distraction-providing another event or idea to distract the brain from the pain source Distraction-providing another event or idea to distract the brain from the pain source Biofeedback- Electrical stimulation Biofeedback- Electrical stimulation TENS- low voltage electrical currents TENS- low voltage electrical currents

17. Traditional Treatments for Pain Rules of thumb, common sense rules: Use the lowest effective dose by the simplest route. Use the lowest effective dose by the simplest route. Assess side effects and Treat or prevent side effects, such as constipation and nausea. Change medication as necessary. Assess side effects and Treat or prevent side effects, such as constipation and nausea. Change medication as necessary. Reevaluate and adjust medications at regular intervals and as necessary. Reevaluate and adjust medications at regular intervals and as necessary. Do not stop pain medication in terminal patients. Change the route if needed. Do not stop pain medication in terminal patients. Change the route if needed.

18. Managing Pain Always report pain. Pain IS NOT a normal part of aging. Always report pain. Pain IS NOT a normal part of aging. Use relaxation methods to decrease anxiety and muscle tension. Use relaxation methods to decrease anxiety and muscle tension. Incorporate Non-traditional treatments when possible Incorporate Non-traditional treatments when possible Music, art, and meditation can be very helpful. Music, art, and meditation can be very helpful.

19. Pain Management Risks NSAIDS risk gastric, liver, and renal toxicity NSAIDS risk gastric, liver, and renal toxicity Drug interactions common Drug interactions common Side effects Side effects Elderly at risk for both under and over treatment of pain. Elderly at risk for both under and over treatment of pain.