癌痛的护理(英文版)2

Discussion:

Whatmighttheconsequencesbeifyoudonotbelieveyourpatient’slevelofpain?ConsequencesofUntreatedPain

Whathappensifpainisn’tproperlytreated?PoorappetiteandweightlossDisturbedsleepWithdrawalfromtalkingorsocialactivitiesSadness,anxiety,ordepressionPhysicalandverbalaggression,wandering,acting-outbehavior,resistscareDifficultywalkingortransferring;maybecomebedboundPainManagement

GuidelinesonPainManagement

LiXiaodanDiscussion:Howdoyourespondtoapatientwhowantsto“waituntilthepainissobadtheycan’tstandit〞becausetheyareafraidtheywillbecome“immune〞tothepainmedication?Whydosomepatientsnottellhealthprofessionalsabouttheirpain?CommonMisconceptionsaboutPain,cont.Morphineandotherstrongpainrelieversshouldbereservedforthelatestagesofdying.Morphineandotheropioidscaneasilycauselethalrespiratorydepression.Painmedicationshouldbegivenonlyaftertheresidentdevelopspain.Anxietyalwaysmakespainworse.CommonbiasesaboutPainDrugabusers&alcoholicsoverreacttopain

False—theyareactuallygivingyouamoretruthfulperceptionsinceinhibitionsarelowered.Clientswithminorillnesseshavelesspain

False—forthatpatient,theexperiencecouldbemajordependingonpreviousexperience.Givinganalgesicsregularlywillstartdrugdependency

False—studiesshowonly3%ofpatientseverdevelopatrueaddictionAmountofdamagedictatespainintensity

False—minorinjuriesmaycauseexcruciatingpainPsychogenicpainisnotreal False—inthatpatient’smind,theexperienceisrealHealthcarepersonnelknowbestthenatureofthepatient’spain

False—thepatientknowsbesthisorherpain

Thecommonpatient-relatedbarrierstopainmanagementContentsDefinitionofpainPainevaluationPainManagementPrecautionstogivingpainmedicationsSummaryWhatispain?OneofthemostcommonreasonspeopleseekhealthcareOneofthemostwidelyunder-treatedhealthproblemsWhatispain?TheInternationalAssociationfortheStudyofPain(IASP)hasproposedthefollowingworkingdefinition:painisanunpleasantsensoryandemotionalexperienceassociatedwitheitheractualorpotentialtissuedamage,ordescribedintermsofsuchdamage.疼痛是一种令人不快的感觉和情绪上的感受，伴有实质上的或潜在的组织损伤，疼痛是一种主观感觉。DescriptionsofPain

CategoriesofPainbyDurationChronicCancerPain

Painisexpectedtohaveanend,withcureorwithdeath.AggressivetreatmentAddictionnotaconcernCategoriesofPainbyDurationChronicNon-MalignantPainPainhasnopredictableendingDifficulttofindspecificcauseOftencan’tbecuredFrequentlyundertreatedCategoriesofPainbyTypeSomaticSource: Skin,muscle,andconnective tissueExamples:Sprains,headaches,arthritisDescription:Localized,sharp/dull,worsewith movementortouchPainmed: Mostpainmedswillhelp,if severe,needastrongermedicationCategoriesofPainbyTypeVisceralSource: InternalorgansExamples: Tumorgrowth,gastritis, chestpainDescription: Notlocalized,refers, constantanddull,less affectedwithmovementPainMed: StrongerpainmedicationsCategoriesofPainbyTypeBonePainSource: Sensitivenervefibersonthe outersurfaceofboneExamples: Cancerspreadtobone,fx, andsevereosteoporosisDescription: Tendstobeconstant,worse withmovementPainMed: Strongerpainmeds,opiateswith NSAIDSasadjunct(Non-SteroidAntiInflammtoryDrugs.NSAIDS

CategoriesofPainbyTypeNeuropathicSource: NervesExamples: Diabeticneuropathy, phantomlimbpain,cancer spreadtonerveplexisDescription: Burning,stabbing,pinsand needles,shock-like,shootingPainMeds: Opioates+tricyclic antidepressantsorotheradjuvant疼痛的评估——癌痛控制的根底Theevaluationofpain-----BasisofpaincontrolPainevaluationStandardofCare:

Assessment&InterventionforPainPurpose:Toevaluateandmanageourpatient’spain,throughpromptattention,toachieveanoutcomeofpainintensityratingsonascaleof1-10.Allpatientscanexpectto:Havetheirpainassessedonadmissionandreassessedatregularintervalstoensurethatpatient’spainisbeingmanagedandcontrolled.Thefrequencyofpainreassessmentsshouldbeincreasedduringthefirstpost-operativeday,orifthepainispoorlycontrolled,ortheinterventionhaschanged.ApainassessmentisrequiredbeforeandaftereachdoseofPRNpainmedication.StandardofCare:

Assessment&InterventionforPainPurpose:Toevaluateandmanageourpatient’spain,throughpromptattention,toachieveanoutcomeofpainintensityratingsonascaleof1-10.Allpatientscanexpectto:Reassessmentofpainstatusshouldoccurwitheachphysicalassessmentbytheregisterednurseandwithin“onehour〞ofpainmanagementintervention.Theappropriatepainassessmenttoolwillbeusedwiththepatient,dependentupontheirdevelopmentalability.“WNL〞or“withinnormallimits〞isanunacceptablephrasetoassesspain….remember“0〞representsnopain.Systematicevaluationofpaininvolvesthefollowingsteps.•Evaluateitsseverity.•Takeadetailedhistoryofthepain,includinganassessmentofitsintensityandcharacter.•Evaluatethepsychologicalstateofthepatient,includinganassessmentofmoodandcopingresponses.•Performaphysicalexamination,emphasisingtheneurologicalexamination.•Performanappropriatediagnosticwork-uptodeterminethecauseofthepain,whichmayincludetumourmarkers.•Performradiologicalstudies,scans,etc.•Re-evaluatetherapy.StandardofCare:

Assessment&InterventionforPainPrecipitating/AlleviatingFactors:Whatcausesthepain?Whataggravatesit?Hasmedicationortreatmentworkedinthepast?QualityofPain:Askthepatienttodescribethepainusingwordslike“sharp〞,dull,stabbing,burning〞RadiationDoespainexistinonelocationorradiatetootherareas?SeverityHavepatientuseadescriptive,numericorvisualscaletoratetheseverityofpain.TimingIsthepainconstantorintermittent,whendiditbegin,anddoesitpulsateorhavearhythmPainEvaluationRatingsScalestoAssessPainNumbericalRatingScale〔NRS〕VisualAnalogueScale〔VAS〕VerbalRatingScale〔VRS〕PainevaluationEffectsleepUnabletosleepWorstpainMildModerateWorst

0

1

2

3

4

5

6

7

8

910NRSNopainPainevaluation0246810Wong-Baker面部表情量表癌症疼痛的评估及护理对策，中华护理杂志2000无痛有点痛轻微疼痛疼痛明显疼痛严重剧烈痛VASPainevaluationRatingsScalestoAssessPainVerbalRatingScale〔VRS〕Mildpain:peoplecanendurethepain,sleepisnotaffectedModerate:obviouslypain,peoplerequiretotakeanalgesicsSevereorWorst:Severepain,sleepdisturbed,accompaniedbyplantnervedisorderNonverbal

Indications

of

Pain:WatchforchangeinbehaviorCrying,moaning,callingoutAgitatedoraggressivebehaviorIncreasedfrustrationorirritabilityChangesinsleeporeatinghabitsWithdrawalfromfriends,family,orfavoriteactivitiesPainManagementinterventionsPainManagementPharmacologicRehabilitativeBehavioralPain

Management:EncourageanalgesicstoberegularlyscheduledSchedulepainmedicationatbedtimetopromotegoodqualityofsleepTreatmentismoreeffectiveifanalgesicsaretakenbeforepainisatitsworstEncourageanalgesicpriortotreatmentsoractivitiesthataggravatetheirpainPharmacologicalInterventionsOpioids:formoderateorseverepainAgonistsAgonists-antagonistsNonopioids:UsedaloneorinconjunctionwithopioidsformildtomoderatepainAcetaminophenNSAIDS(Non-SteroidAnti-InflammtoryDrugs.NSAIDS)Adjuvants:Usedforanalgesicreasonsandforsedationandreducinganxiety.MultipurposeTri-cyclicantidepressantsAnticonvulsantsPharmacologicinterventionsNon-opioids:UsedaloneorinconjunctionwithopioidsformildtomoderatepainAcetominophen(Tylenol)AspirinNSAIDs(Advil)Opioids:formoderateorseverepainWeak

StrongCodeine

HydromorhoneOxycodone

MorphineVicodin

MerperidineAdjuvants:Usedforanalgesicreasonsandforsedationandreducinganxiety.PrimaryfunctionisnotpainreliefbutprovidereliefMaymodifymoodsopatientfeelsbetterPainManagementRoutesofmedicationadministrationOralInjectionIntravenous(includesPCA)EpiduralRectalTopicalPainManagementConceptsofWHOPainLadderBythemouthBytheclockBytheladderFortheindividualWithattentiontodetailPainManagementSEVEREPAIN:KeepgivingmildpainmedicationandaddastrongopioidsuchasmorphineorFentanylMODERATEPAIN:KeepgivingmildpainmedicationandaddamildOpioidsuchascodeineMILDPAIN:Aspirin,ibuprophenAcetominophen,naprosyn.ANALGESICLADDER+/-adjuvantNon-opioidWeakopioidStrongopioidPainpersistsorincreasesBytheClock.ANALGESICLADDER+/-adjuvant+/-adjuvant123Non-opioidanalgesicsPharmacologicinterventionsTransdermalroutes:FentanylTransdermalSystemthefentanyltransdermaltherapeuticsystemdosingintervalisusually72hoursPharmacologicinterventionsPainManagementOpioidanalgesicsfentanylandbuprenorphinearetheopioidsfortransdermaladministration.Thesystemhasbeendemonstratedtobeeffectiveinpost-operativepainandcancerpainthefentanyltransdermaltherapeuticsystemdosingintervalisusually72hours.PharmacologicinterventionsPainManagementPatient-controlledanalgesia(PCA)Thisisatechniqueofparenteraldrugadministrationinwhichthepatientcontrolsaninfusiondevicethatdeliversabolusofanalgesicdrug‘ondemand’accordingtoparameterssetbythephysician.Long-termPCAincancerpatientsismostcommonlyaccomplishedviathesubcutaneousrouteusinganambulatoryinfusiondevice.Inmostcases,PCAisaddedtoabasalinfusionrateandactsessentiallyasarescuedose.Discussion:Whatarethecommonconcernsthatpatientsmayhaveaboutpainandopioids?Whatarecommonsideeffectswhenstartinganopioidmedication,andhowshouldthenurseintervene?SleepinessNauseaConstipationPharmacologicinterventionsPainManagementThemainadverseeffectsofOpioidanalgesicsare:respiratorydepression,apnoeasedationnausea,vomitingpruritusconstipationhypotension..Other

Considerations:ManagementofsideeffectsPreventandmanageconstipationwhenopioidsareprescribed(stoolsoftenerwithlaxativeshouldbeprescribed)Nauseaandsleepinessusuallyresolveabout1weekafterstartingopioidsAnti-emeticcanbeprescribedforfirstweekAcetaminophentototal4000mgorlessper24hours(3000mgforfrailelderly)Don’tusemorethanonecombinationanalgesicorsustainedreleasepreparationWhat

if

Pain

Control

is

Ineffective?Formildpain(1-4outof10),increasedoseby25%Formoderatepain(5-6outof10),inceaseopioiddoseby50%Forseverepain(7-10outof10),increaseopioiddoseby75-100%Mayuseequianalgesicdosingtablestocalculatedosageofopioidstobegivenin24hoursDiscussion:

Whatisthedifferencebetweenphysicaldependence,tolerance,andaddiction?Tolerance

vs.

Addiction:ToleranceNo“high〞(opioidsaremetabolizeddifferentlyastheyaddressthepain)UsuallysomephysicaltoleranceanddependencytopainmedicationsdevelopAddictionPsychological“high〞IntentiontoharmthebodyNegativepersonal,legalormedicalconsequencesTrue

Addiction?Addiction:UsageisoutofcontrolObsessionwithobtainingasupplyQualityoflifedoesnotimprove

Pseudo-AddictionFromunder-treatmentofpainDrug-seeking/CrisisofmistrustBehaviorandfunctionimprovewhenpainisrelievedAssesspainusinganageappropriatetool.Considerstartinganaroundtheclockregimen.Continuallyassesspainandmodifymedicationregimenappropriately.Precautionstogivingpainmedications Whentocalltheattending:Patienthaspersistentorworseningpaindespiteappropriateanalgesicregimen.Whentotransfertoahigherlevelofc