1. Pain Management – An Introduction Thea Addison, Vicki Yates Acute Pain Nurse Specialists Derby Hospitals NHS Foundation Trust

2. Aims of the Session The Pain Team & their Role Define pain Emphasise the different pain pathways Types of pain Assessment of pain & pain tools Barriers to pain assessment Simple interventions

3. Role of the Acute Pain Team Overall responsibility for Acute Pain Management throughout the trust Expert clinical and educational pain management resource Service initially set up for post-op pain management Now - Complex diverse pain problems In-patient Pain Team - A more accurate title? Clinical / Education / Audit / Research

4. Links with Outreach Team Palliative Care Team Ward based link nurses School of Nursing Clinical facilitators + educators Other nurse specialists Regional and National Specialists in Pain

5. Definition of Pain ‘Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does’ McCaffrey(1968)

6. Definition of Pain ‘ Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is always subjective……always unpleasant and therefore also an emotional experience.’ International Association for the Study Pain (1979)

7. Why Treat Pain? Humanitarian Reasons Clinical Effects of Pain Reduces Stress Response Patient Satisfaction Promote Early Discharge

8. How Do We Feel Pain? Two Major Types of Pain Nociceptive: pain due to tissue damage Neuropathic:pain due to injury of nerve pathway - painful sensations are carried from the site of injury to the brain - treatment will depend on type of pain

9. Acute Pain Helps diagnose illness by acting as a warning mechanism - therefore is a symptom From trauma often imposes limitations, which can prevent aggravation of an injury In post-operative period serves no useful purpose and can be detrimental to the recovery of the patient Recent studies/surveys indicate that pain control still remains an inconsistent affair

10. Chronic Pain Untreated Acute Pain can become Chronic Pain

11. Chronic Pain Pain that persists beyond the expected healing time Not simply a prolonged duration of acute pain. Biological changes in central nervous system. Adaptation of autonomic nervous system. Complex Pain that is prolonged in nature, due to known reasons or absence of evident tissue damage. Complex interplay of biological & psychological factors. 7.5 million pain sufferers in UK

12. Cancer Pain Cancer is a dynamic disorder and patients may experience Acute as well as Chronic pain due to further tissue damage Pain of varied duration/commonly progressive Pain may be associated with symptoms which signal deterioration eg weight loss, anorexia, physical dependence, lack of sleep Realization of dying may result in “overwhelming pain” that is difficult to describe and to assess

13. ACUTE Transient Warning mechanism Usually decreases at around 48hrs Start at top of medication ladder CHRONIC Persistent No useful purpose Tends to increase as time goes on Starts at bottom of medication ladder

14. Pain Assessment Advantages Provides patients with an opportunity to express their pain Conveys genuine interest & concern about their pain Gives patients an active role in their pain management Can provide documented evidence of the efficacy or failure of drugs / treatments

15. Pain Assessment When Initially to understand the pain & develop a care plan Immediately following surgery / procedures Prior to & following administration of analgesia / treatments At a report in change of description, location or intensity of pain Deep breathing / coughing / moving limb etc

16. Pain Assessment – What You Need to Know Location Description Duration Pain Intensity ? Related to admission Influencing factors Deep breathing / coughing / moving limb etc Drug history

17. Pain Assessment Tools Pain Intensity Scales Visual Analogue Scales (VAS) Numeric Scales Verbal Rating Scale (VRS) Body charts

18. Pain Assessment Tools Visual Analogues Scale No The worst Pain pain imaginable Numerical Rating Scale 0 1 2 3

19. Pain Assessment Tools Verbal Rating Scales 0 = No pain 1-3 = Mild pain 4-6 = Moderate pain 7-10= Severe pain Acute Pain Chart 0 = No pain 1 = Mild pain 2 = Moderate pain 3 = Severe pain

20. Descriptive Words for Pain ThrobbingCutting BurningStinging AchingTiring BlindingIntense PenetratingNagging ShootingGnawing Searing TenderDull What makes pain better? FrightfulAnnoying Unbearable Radiating Nauseating Stabbing CrushingSmarting HurtingSplitting ViciousSpreading PiercingTorturing

21. Factors Influencing Coping Age / gender Culture / Social beliefs Emotions, eg fear, anxiety, anger, sadness & depression Fatigue, sleeplessness Past experiences Expectations Communication & information

22. PAIN IS THE 5 TH VITAL SIGN Patient assessment is the first stage in managing pain well!

23. Non-Verbal Signs Body Language- posture, lying still, rolling around, rocking, withdrawn Facial Expressions- crying, grimacing, frowning Disrupted sleep pattern Note! Patients with long standing pain may tell you they have severe pain but not display any of these signs!

24. Assessing Pain in Patients Unable to Communicate Mentally / cognitively impaired patients Sensory impaired patients Unconscious patients Neonates / children

25. Assessing Pain in Patients Unable to Communicate How Patients self-report if possible / carers report Observation of behaviour incl. posture, movement Comparing current with usual behaviour Abnormal change in behaviour eg aggression / agitation Patients interactions with others Check for full bladder / colic caused by constipation Sleep and diet

26. The Cognitively Impaired Patient Some patients who are confused in time and place will still be able to report and describe pain! Once patient becomes very vague, confused or unconscious, signs which signal pain should be looked for eg Restlessness or agitation crying out or groaning Withdrawing, localizing or guarding Rocking, immobility or rubbing the area

27. Impact of Pain Clinical:  BP,  Pulse,  Resps, sweating Functional: reduced mobility & associated problems Emotional: the meaning of pain – effects, anxiety, depression Social/occupational: role, finance, family, sexuality

28. Barriers to Pain Assessment Healthcare Professionals Attitudes Skills Knowledge / misconceptions Failure to routinely assess & document Legal aspects of drug administration Drug round times

29. Barriers to Pain Assessment Patients Want to be a ‘good patient’ Language or cultural barrier Fear of addiction/unwanted side effects /misconceptions Value of suffering - no pain / no gain Expectations and goals Reluctance to report or use word “pain” Litigation

30. Barriers to Pain Assessment Healthcare System A low priority given to pain care Restrictive regulation of controlled substances Lack of access to pain specialists Resources & workload

31. Failure to Manage Pain Well Inadequate assessment Failure to evaluate interventions Failure to reassess

32. Simple Interventions Comfort Measures Therapeutic environment Patients bodily comfort Relaxation Massage / touch Guided Imagery Diversional activities Confidence building

33. Simple Interventions Preventative Measures Positioning Carefully support painful area Attention to Dressings Provide pressure relieving mattress Hot/cold packs Ensure medications and adequate hydration is given Encourage and assist with exercise

34. Simple Intervention Recognise the power of suggestion and Patient Partnership! Listen to the patient Support the patient Reassure the patient NBBe aware of your own limitations and ask for support!

35. Benefits of Treating Pain Humanitarian - quality of life Aids recovery Reduces complications Improves patient & carers satisfaction Healthcare outcomes - can prevent readmission  hospital stay

36. Ineffective Pain Control If not achieved the “5 D’s” can occur! DISCOMFORT DISABILITY DISSATISFACTION DISEASE DEATH - COMPLAINT / LITIGATION

37. Summary Pain is an individual experience Listen to your patient Effective assessment and documentation Non-pharmacological management Evaluation/ Documentation

38. Useful websites www.painsociety.org www.ampainsociety.org www.pain-talk.co.uk www.iasp-pain.org/ www.anzca.edu.au www.medicine.ox.au.uk/bandolier www.medicines.org.uk www.painradar.co.uk

39. References McCaffery, M. (1968) Nursing Practice theories related to cognition, bodily pain, and man-environment interactions.