Outline
1. Remembering
2. Significant.
3. Pharmacological therapy.
4. Non-pharmacological therapy.
Just.. Remembering
❑ Pain is an unpleasant sensory and emotional experience associated with tissue damage or
described in terms of such damage.
❑ Pain is whatever the patient says it is, existing whenever he/she says it does.
❑ Women, older, child and rural residents were significantly more likely to report pain.
❑ Man- and woman-kind have been trying to figure out what pain is and how to fix it since
Adam and Eve.
Significant
❑ A wide range of drugs are used to manage pain.
❑ High specificity drugs require lower doses and have fewer side effects.
❑ Most drugs act by binding to protein targets (receptor proteins) on cell membranes.
❑ Protein targets are specific to specific tissues allowing drugs to be precisely targeted at
individual organs or cells.
Pain treatment methods
depend on:
1) Comorbidities.
2) Severity of pain.
3) Patient information.
4) Patient’s preference.
5) Routes of administration.
Types of Pain treatment
A- Pharmacological therapy
▪ Commonly referred to at pharmacotherapy or pharmaceutical therapy.
▪ It refers to the treatment of disease through the application of medications (drugs).
▪ It can be used to treat or prevent development of a disease and alleviate the pain and
symptoms of the condition.
▪ The doctor will prescribe drugs based on whether the pain is mild, moderate, or
severe.
Considerations before administering
pharmacological therapy
✓ Check medications’ rights.
✓ Closely assess of drug allergies.
✓ List of the medication's history.
✓ Recognize the possible side effects of prescribed drugs.
✓ Understand how medication may respond when combined.
✓ Understand the limitations of the medication in managing chronic pain.
✓ Understand the peak action of the medication and best time to schedule non-pharm.
Assess of the pain
Careful history
- Believe the patient and family
- Assess the nature of the pain
• Acute pain
• Distinct onset, short duration, physical signs
• Chronic/Persistent pain
• Long duration, long-standing functional impairment
• Consider neuropathic pain
Cont. Assess of the pain
▪ Consider onset, what makes pain better or worse, location, description, severity, and does pain
move?
▪ Consider multiple pain types and/or sites.
▪ Assess psychosocial status
o Emotional, Social, Cultural
▪ Assess functional status.
Medications History
▪ All medications used in the past six months dose
✓ Allergies
✓ Side effects
✓ Duration of use
✓ Frequency of use
✓ Reason for use
✓ Perception of efficacy
✓ Alternative therapies
✓ Nutritional supplements
✓ Nonprescription drug use
✓ Preferable route of administration.
▪ Social drug use (Do not forget alcohol)
W.H.O. Analgesic Ladder for pain treatment
By the 3
Strong opioid
+/- adjuvant
2
Clock Weak opioid
+/- adjuvant
1
Non-opioid
+/- adjuvant
A- Pharmacological intervention
There are three classes of drug are used for pain relief:
1- Non-opioid drugs:
▪ Its inhibition of the COX enzyme system, which leads to reduced inflammatory pain.
▪ One of the main disadvantages of the NSA is the risk of gastrointestinal side effects, especially
bleeding into the digestive tract such as paracetamol, aspirin.
2- Opioid drugs:
▪ A class of drug used to reduce moderate to severe pain.
▪ It block pain signals by binding to opioid receptors on nerve cells in the brain, spinal cord,
gastrointestinal tract, and other organs in the body.
▪ It used for pain relief are usually safe when taken for a short time and as prescribed by a health
care provider.
▪ It can be highly addictive and as a result have often been misused or abused.
▪ Such as Fentanyl, Morphine, Codeine
▪ Heroin, an illegal street drug, is also an opioid
OPIOID SIDE EFFECTS
3- Adjuvant drugs:
▪ Adjuvant drugs are most often used for neuropathic and other chronic pain problems.
▪ Adjuvant drugs can be used to enhance the effects of pain medications, treat concurrent
symptoms, and provide analgesia for other types of pain
▪ It is a group includes drugs such as antidepressants, anticonvulsants, corticosteroids, neuroleptics.
Methods of administrations
2.1- oral: is the administration of medication orally.
2.1- Local: is the local infiltration of an anesthetic medication to induce loss of sensation
to a body part.
2.3- Topical: are applied over the patient's skin either in the form of topical ointments or
transdermal patches.
2.4- Regional: is the injection of a local anesthetic to block a group of sensory nerve
fibers as spinal anesthesia.
2.5 Patient-Controlled Analgesia
(PCA)
❑ A drug delivery system is a safe method for pain management that many patients prefer
to self-administer opioids (morphine and fentanyl) with minimal risk of overdose.
❑ PCA infusion pumps are portable, computerized and contain a chamber for a syringe that
delivers a preset dose of opioid .
❑ The patient pushes a button attached to the PCA device to receive a preset dose.
A- Nerve Blocks
• For acute and postoperative pain and some chronic pain problems, temporary nerve
blocks (neural blockades) can provide short-term relief.
• In this procedure, a doctor injects a local anesthetic into or around nerves or below
the skin in the area where there is pain.
• The anesthetic interrupts the transmission of pain signals to the brain. In a procedure
called a neurolytic block (neurolysis).
B- Epidural and Intrathecal Pumps
• The pain that is more widespread, it interrupts using epidural or intrathecal pumps that
act directly on nervous system changes how neurons act (neuromodulation)
o Epidural: refers to the space just outside the spinal cord’s outer membrane.
o Intrathecal” refers to the space between the sheaths covering the spinal cord.)
• These pumps are either carried in a pouch or placed under the skin to deliver
medication continuously to broad areas.
C- Palliative Surgery or Radiation Therapy
• Surgery is a procedure to remove a tumor and sometimes, some surrounding healthy
tissue.
• This goal of the surgery is to reduce pain and other symptoms so people with cancer
can tolerate their quality of life.
• It may be used to prevent or control pain-causing cancer complications.
• Palliative surgery and radiation are focused on comfort. It used primarily for people
with advanced cancer.
Risky group for Over-sedation
▪ Smoker ▪ Use of other sedating drugs
▪ Snoring ▪ Sleep apnea or sleep disorder diagnosis
▪ Older age ▪ Longer length of time receiving general anesthesia
▪ Morbid obesity ▪ Thoracic or other surgical incisions that may impair breathing
▪ Opioid habituation ▪ Pre-existing pulmonary or cardiac disease, dysfunction, or major
▪ Post-surgery status organ failure
▪ Now, recent opioid use
Opioid Risk tool (Lynn. 2005)
▪ This tool should be administered to patients upon an initial visit prior to beginning
opioid therapy for pain management.
o A score of 3 or lower indicates low risk for future opioid abuse.
o A score of 4 to 7 indicates moderate risk for opioid abuse.
o A score of 8 or higher indicates a high risk for opioid abuse.
2- Non-Pharmacological intervention
There are many non pharmacologic interventions to give pain relief, especially when
used in conjunction with pharmacologic measures.
Described as physical and cognitive-behavioral interventions, many of these
approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the scope of
nursing practice
Important of non-Pharmacological
intervention
▪ Manage pain.
▪ Reduce stress
▪ Reduce in depression
▪ Encourage positive changes in mood
▪ Increase awareness of self and environment
Who use regularly non-pharmacological
intervention
▪ Former smokers.
▪ More women than men.
▪ People with higher education levels.
▪ Chronic Ill Health (Cancer, AIDS, Long term conditions)
▪ Those with gastrointestinal disorders or sleeping Problem
▪ People with back, neck, head, joint aches or other painful conditions.
Nursing care principles before starting
nonpharmacological therapy
❑ Maintain patient trust.
❑ Act in patients’ best interests.
❑ The registered nurse must document the care.
❑ The proposed therapy must not be prohibited by law
❑ Respect patient autonomy with respect to health care goals.
❑ The client must have given informed consent to the proposed therapy.
❑ Communicate effectively, openly with patients and health care members.
Cont. Nursing care principles before starting
nonpharmacological therapy
Prior starting nonpharmacological therapy, it is expected that the nurse would consider each of the following principles:
❑ Be able to manage any expected or unexpected outcomes of the therapy.
❑ Nurses must be aware of values, goals, and beliefs of personal culture.
❑ The nurses must understand the purpose of the therapy (including indications and contraindications,
risks and expected outcomes - to assess whether, it may be appropriate for that client.
❑ All adverse reactions must be reported to the physician and the pharmacist immediately.
1- Health education
• Most important of increasing a patient’s understanding of their condition and treatment.
• Self-management of rely heavily on provision of information and communication practice.
• Primary focus for long term conditions commonly involves promotion of informed lifestyle
choices, risk-factor modification, and active patient self-management.
2) Comfort measures:
• Such as clean, smooth sheets, soft, supportive pillows, warm blankets, and a soothing
environment have been used by nurses throughout history to relieve pain and suffering.
3) Position change and movement:
• We are well-known pain-relieving interventions. Moving the body, even a small amount,
relieves muscle spasm and provides a degree of pain relief. So important is movement of the
body to health.
4) Massage:
• Relieves muscle spasm, improves circulation, and provides cutaneous stimulation.
• While there are many different massage techniques, they all involve rubbing the skin in
various patterns and degrees of pressure.
5) Energy therapy (Energy Healing):
• A form of complementary and alternative medicine based on the belief that a vital energy flows through
the human body.
• The goal of energy therapy is to balance the energy flow in the patient. It is used to reduce stress and
anxiety and promote well-being.
6) Massage:
• Relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While
there are many different massage techniques, they all involve rubbing the skin in various
patterns and degrees of pressure.
7) Applications of hot and cold:
• Are effective pain-relieving measures when used appropriately, hot decreases muscle
spasm and increases blood flow to an area. Cold decrease blood flow, oedema, and
inflammation and may decrease muscle spasm and pain.
8) Transcutaneous electrical nerve stimulation (TENS):
• Provides a continuous, mild electric current via 2 to 4 electrodes placed on the skin near
a painful site.
9) Distraction:
• Older patients find watching TV or listening to music helpful.
• Distraction should not be a substitute for explaining what to expect.
10) Touch:
• Nurses, when using touch, are usually trying to convey understanding, support, warmth,
concern, and closeness to the patient.
• Touching not only contributes to the patient’s sense of well-being, but also promotes
physical recovery from disease.
11) Imagination:
• Guiding a patient through an imaginary mental image of sights, sounds, tastes,
smells, and feelings can often help shift attention away from the pain
12)Relaxation:
• Patient can be guided through relaxation exercises such as deep breathing and Stretching to reduce
discomfort.
• It is useful ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate.
• They induce a state of altered consciousness and give patient a sense of control and peace of mind.
• Such as Meditation, Zen, yoga, and other such interventions may effectively relieve pain. One such
exercise involves controlled breathing.
13) Acupuncture: :
It is an invasive procedure that involves insertion of needles at various points
in the body to relieve pain.
14) Reflexology:
Reflexology is a holistic healing technique involving various physiological methods and
approaches of ancient arts.
It based on stimulation points on the soles of the feet and almost the same as massage
because it touches soft tissues for healing purposes.
13) Acupuncture:
▪ It involves stimulating sensory nerves under the skin and in the muscles.
▪ It is an invasive procedure that involves insertion of fine needles at various points in the body.
▪ It is a treatment derived from ancient Chinese medicine.
14) Acupressure:
▪ It is a type of massage therapy in which manual pressure is applied to specific points on the body.
▪ It is a practice of traditional Chinese medicine (TCM) practice that is similar to acupuncture, except that it
uses fingertip pressure instead of needles.
15- Virtual Reality
• Making it easier for patients with pain to do their exercises.
• VR changes the focus from pain to an absorbing alternative reality that entrances,
motivates and encourages them to complete perform the task.
• Helping patients to be able to practice specific movements without the risk of
further injuring.
16- Aromatherapy
• It is an alternative medicine therapy that can be beneficial in the inpatient or
outpatient setting for symptom management for pain
• Breathing in the aroma, along with the active ingredients, from essential oils or
applying them in a lotion
17- Herbal medicine
• Provides alternatives to drugs for pain management.
• Ingredients made from plant parts, such as leaves, roots or flowers.
• Herbal remedies are being found to lower pain levels and decrease inflammation.
18- Self-hypnosis
• It is a way to direct your attention to something other than your pain.
• For example, repeat a positive statement about ignoring the pain or seeing the pain
in a positive way.
3-SURGICAL THERAPY
Nerve block:
• Nerve block to reduce the pain when more are used conservative
therapies failure
Palliative Surgical and/ or radiation Intervention.
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Any Questions
