资料文稿说明案例pain management far

PainManagementPain…Whatistherealdefinitionofpain?Andwhatispainmanagement??Howcanthisinformationhelpme???Definition

Anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamageordescribedintermsofsuchdamage.Painiswhatevertheexperiencingpersonsaysitis.Maynotbedirectlyproportionaltoamountoftissueinjury.Highlysubjective,leadingtoundertreatment.TypesofPain1. Acute2. Cancer3. Chronicnon-malignantAcutePainAcutepainpresentsmostoftenwithaclearcause,relativelybriefindurationandsubsidesashealingtakesplace.

AcutepainisoftenaccompaniedbyobservableobjectivesignsofpainincreasedpulserateincreasedbloodpressureNon-verbalsignsandsymptomssuchasfacialexpressionsandtensemuscles.

ChronicPainPainthatispersistentandrecurrent.

Whenpainpersists,itservesnousefulpurposeandmaydramaticallydecreasethequalityoflifeandfunction.Chronicpainrarelyhasanyobservableorbehavioralsignsalthoughpersonsmayappearanxiousordepressed.CancerPainPainthatisassociatedwithcancerorcancertreatment.MaybeattributedtoTumorlocationChemotherapyRadiationtherapySurgicaltreatmentSeveralPainTheoriesTheory#1

Cousins’TheoryofPathophysiologyofAcutePainSevere,unrelievedacutepainresultsinabnormallyenhancedphysiologicalresponsesthatleadtopronouncedandprogressivelyincreasingpathophysiologyPathophysiologysignificantorgandysfunctionmorbidityandmortalityHarmfulEffectsCardiovascularandrespiratorysystemsaresignificantlyaffectedbythepathophysiologyofpainadrenergicstimulationhypercoagulation,leadingtoDICheartratecardiacoutputmyocardialoxygenconsumptionTheoriesofPain#2

Selye’sTheoryofStressandGeneralAdaptationSyndromeDuringtheinitialassault(traumaticinjuryandaccompanyingpain),aconcentrationofeffortatsiteofdemandoccurs.AdaptiveresponsesattempttoachievehomeostasisepinephrineandcatecholaminesreleasedTheStageofResistance

(everythingisbeingusedup)EnergyNutrientsOxygenTheStageofExhaustion

(homeostasisvs.death)ThebodycannolongersustainitsadaptiveresponsesDevastatingsequelaeIrreversibleorgandamageanddeathofthepatient

Theory#3

NeumanSystemsModelIndividualspossessauniquecentralcoreofsurvivalfactorsIndividualspossesslinesofdefenseswhichattempttokeeptheindividualinasteadystateWhatinfluenceslinesofresistance?PastandpresentconditionsoftheindividualAvailableenergyresources(painconsumesenergy)Amountofenergyrequiredforadaptation(rememberSelye’stheoryofadaptation)Patient’sperceptionofthestressorProvidingtimelyandeffectivepainmanagementtotheinjuredpatientcanhelpstrengthenthepatient’slinesofresistance17PathophysiologyPaininvolvesthereleaseofpotentmediatorsofinflammationandismodulatedbyneurocognitivefactorsresultinginanunpleasantsensoryandemotionalexperience.Theperipheralnervoussystemgeneratesthesensationofsomaticpainbyregisteringtheoriginalnoxiousstimulusandconductsittothecentralnervoussystem.Process#1TransductionThesubstancesreleasedfromthetraumatizedtissueare: prostaglandins bradykinin serotonin substanceP histamineSo,forinstanceNon-steroidalanti-inflammatories,suchasibuprofen,areeffectiveinminimizingpainbecausetheyminimizetheeffectsofthesesubstancesreleased,especiallyprostaglandins.Corticosteroids,suchasdexamethasoneusedforcancerpain,alsointerfereswiththeproductionofprostaglandins.Process#2—Transmission

Impulsespinalcordbrainstemthalamuscentralstructuresofbrainpainisprocessed.Neurotransmittersareneededtocontinuethepainimpulsefromthespinalcordtothebrain—opioids(narcotics)areeffectiveanalgesicsbecausetheyblockthereleaseofneurotransmittersProcess#3—PerceptionofPainTheendresultoftheneuralactivityofpaintransmissionItisbelievedpainperceptionoccursinthecorticalstructures—behavioralstrategiesandtherapycanbeappliedtoreducepain.Braincanaccommodatealimitednumberofsignals—distraction,imagery,relaxationsignalsmaygetthroughthegate,leavinglimitedsignals(suchaspain)tobetransmittedtothehigherstructures.Process#4—ModulationofPainChangingorinhibitingpainimpulsesinthedescendingtract(brainspinalcord)Descendingfibersalsoreleasesubstancessuchasnorepinephrineandserotonin(referredtoasendogenousopioidsorendorphins)whichhavethecapabilityofinhibitingthetransmissionofnoxiousstimuli.Helpsexplainwidevariationsofpainamongpeople.Cancerpainrespondstoantidepressantswhichinterferewiththereuptakeofserotoninandnorepinephrinewhichincreasestheiravailabilitytoinhibitnoxiousstimuli.PainAssessmentInitialPainAssessmentshouldinclude:Location(s)IntensitySensoryqualityAlleviatingandaggravatingfactorsAnynewonsetofpainrequiresanewcomprehensivepainassessment.24Avalueassignedbyapatientisnotanabsolutevaluebutratherareferencepoint

basedonpastpersonalexperience.

Theidealpainassessmenttooliseasytoadminister,reliable,valid,andapplicabletoallpatients,irrespectiveofeducation,culture,orpsychologicalordevelopmentallevel.PainScalesCommonMisconceptionsaboutPainThecaregiveristhebestjudgeofpain.Apersonwithpainwillalwayshaveobvioussignssuchasmoaning,abnormalvitalsigns,ornoteating.Painisanormalpartofaging.Addictioniscommonwhenopioidmedicationsareprescribed.CommonMisconceptionsaboutPain,cont.Morphineandotherstrongpainrelieversshouldbereservedforthelatestagesofdying.Morphineandotheropioidscaneasilycauselethalrespiratorydepression.Painmedicationshouldbegivenonlyafterthepatientdevelopspain.Anxietyalwaysmakespainworse.28Theadministrationofpharmacologicagentsisthemainstayofacutepainmanagement.

ThekeytoeffectivepharmacologicpainmanagementintheEDisselectionofanagentappropriatefortheintensityofpain,promptonsetofanalgesicactivity,easeofadministration,safety,andefficacy.

Acutepainisusuallyaccompaniedbyanxietyandfeelingsoflossofcontrol.Ifreassurancecombinedwithananalgesicdoesnotsuffice,ananxiolyticmayberequired.PAINTREATMENTTheterm"tieredapproach"topainmanagementmeansstartingwithanagentoflowpotencyandaddingorchangingtoagentsofhigherpotencyifpainpersists.

Thetieredapproachforacutepainmanagementunnecessarilysubjectsthepatienttomoreprolongedsuffering.Itispreferabletoselectinitialanalgesicsthatareappropriatetotreattheintensity(mild,moderate,severe)ofthepatient'spain.

PAINTREATMENTAgentssuchasNSAIDsshouldbeconsideredformildtomoderatepain,andsystemicopioidsformoderatetoseverepain.InspecificinstancessuchasrenalandbiliarycolicaparenteralNSAIDmaycontrolseverepain,althoughcombinationtherapywithanopioidisusuallysuperior.

PAINTREATMENTAcutevs.ChronicPainManagementAcutePainMostoftentreatedwith:NSAIDSOpioidsLocalanestheticsSplintingPositioningchangesIceChronicPainMostoftentreatedwith:Anti-seizuremedicationsAnti-depressantmedicationsNSAIDSImplantabledevicesPsychologicaltherapyAcupunctureWhenallelsefailsandbenefitsoutweighrisksOpioidsOpioidanalgesicsarethecornerstoneofpharmacologicmanagementofmoderatetosevereacutepain.OpioiduseintheEDisoftenaffectedbyconcernfortheprecipitationofadverseevents,suchasrespiratorydepressionorhypotension,orforfacilitatingdrug-seekingbehavior.Ourgreatestconcerns,however,shouldbetheunderuseofopioidsandinadequatedosingwhenused.Properuseofopioidsrequiresconsiderationofthefollowing:1.Routeofadministrationanddesiredtimeofonsetofaction2.Initialdose3.Frequencyofadministrationtitratedagainstanalgesicresponse4.Concurrentuseofnonopioidanalgesicsandadjunctiveagents5.Incidenceandseverityofsideeffects6.WhethertheanalgesicwillbecontinuedorambulatorysettingPatientsdiffergreatlyintheirresponsetoopioidanalgesics.Variationsarerelatedtoage,bodymass,andpreviousorchronicexposuretoopioids.Relativepotencyestimatesprovidearationalbasisforselectingtheappropriatestartingdosetoinitiateanalgesictherapy,changingtherouteofadministration,orswitchingtoanotheropioid.

OpioidAnalgesicsAcetaminophen

isaneffectiveanalgesicthatisadequateformildtomoderatepain.Acetaminophendoesnotaffectplateletaggregation,anditisnotananti-inflammatory.Nochangeisrequiredforrenalormildhepaticimpairment.Therecommendedmaximumadultdailydoseforrepetitiveuseis4gramsperday.NonopioidAgents

NonopioidAgents

The

NSAIDs,

includingaspirin,naproxen,indomethacin,ibuprofen,areexcellentanalgesicsandanti-inflammatoryagents.Theydonotcausesedationorrespiratorydepressionorinterferewithbowelorbladderfunction.NSAIDshavesignificantopioiddose-sparingeffects.TherearePO,PR,IV,andtopicalpreparations.NonopioidAgents

TreatmentofPainRulesofthumb,commonsenserules:Usethelowesteffectivedosebythesimplestroute.Startwiththesimplestsingleagentandmaximizeit’spotentialbeforeaddingotherdrugs.Usescheduled,long-actingpainmedicationsforconstantorfrequentpain,withprn,short-actingmedicationavailableforbreakthrough.Treatbreakthroughpainwithone-thirdthe12hoursscheduleddose.TreatmentofPain,cont.Ifthreeormoreprndosesareusedinaday,increasethescheduleddose.Increaseby¼-½ofthepriordose.Increasetheprndosewhenyouincreasethescheduleddose.Bevigilantatassessingthesideeffectsofmedication.Treatorpreventsideeffects,suchasconstipationandnausea.Changemedicationasnecessary.Traditionally,nonpharmacologictechniquesofpainmanagementintheEDarelimitedtoapplicationofheatorcoldandimmobilizationandelevationofinjuredextremities.OthertechniquesmayprovetohavearoleintheEDandpost-EDsetting.Examplesincludecognitive-behavioraltechniques,whichareeffectiveinreducingpainandanxiety,maycontrolmildpainwhenusedalone,andenhancepatientsatisfaction.NonpharmacologicModalitiesThesetechniquesincludereassurance,explanation,relaxation,music,psychoprophylaxis,biofeedback,guidedimagery,hypnosis,anddistraction.Theyareausefuladjuncttopharmacologicmanagementofmoderatetoseverepain.Successfulapplicationofthesetherapiesrequiresacognitivelyintactpatientandskilledpersonnel,butmanyofthetechniquesrequireonlyafewminutestoteachthepatient.NonpharmacologicModalitiesPhysicalnonpharmacologicagentsarebecomingincreasinglyrelevanttoEDpainmanagement.Inadditiontothetraditionaltechniquesnotedabove,thelesscommonlyusedphysicalmodalities,suchastranscutaneouselectricalnervestimulationandacupuncture,mayhavesomepotentialroleintheEDinthefuture.Althoughspecifictechnicalskillsandequipmentarerequired,thereisnoneedforIVaccess,andthereisnosystemiceffectsuchasrespir