Nursing care of patients in pain.
Hey, and welcome to nursing with Dr. Hobbick. Today we're testing out some new technology. So hopefully the podcast will sound better from here on out. I've gotten some really good tips from listeners. So here we go. Today we're going to talk about chronic pain. So assessment and care of patients who have pain. So the most common reason that people seek care and take medication is because of pain. So this is something that everybody experiences with some very, very, very, very minute exceptions. And failure to manage pain is a problem worldwide. And this is something that I do see in nursing I have I don't know how to describe it. It's almost like sometimes nurses don't want to give pain medication. But here's the thing, y'all, it's not our job to decide whether or not the patient is in pain, that is a totally subjective experience, there's no way for us to measure it and thinking that we can measure the patient's pain based upon their facial expressions or, or what have you is not really, it's not accurate. So the definition of pain, of course, is it's an unpleasant sensory and emotional experience. And there may actually be tissue damage or not. So we are legally and ethically responsible for managing our patients pain and suffering. Let me say that, again, we are legally and ethically responsible for managing your patients pain and suffering. So we always want to make sure that we listen to the patient's self report of pain, that actually is the most reliable indicator of pain out there. So there's a couple of different kinds of pain that we need to know about. There's acute pain, this is a transient pain, this pain comes and goes, it's not there forever. So it's identifiable, limited emotional response happens to that. We have chronic persistent non cancer pain, that is not serving a function. Acute Pain is protective, non cancer, persistent chronic pain is not protective. It's something that has no purpose, no identifiable cause, even chronic episodic. So this would be someone who has migraines that they have pain that is chronic, but it occurs sporadically over an extended duration. cancer pain can actually be caused by nociceptive, actual tissue damage, or neuropathic, which is functioning of the nerves is is damaged or not, they're not functioning well. So cancer pain can be both acute and chronic nociceptive and or neuropathic. And then we have idiopathic pain, which is chronic pain, that we're not good at identifying the cause. So you need to know the physiology of pain. So we have I'm not going to go into anatomy physiology, I'll can review that. But transduction, transmission, perception and modulation. And when we think about this, we're thinking about how we can help the patient's pain. So knowing that we have the A delta fibers which transmit a fast local sharp pain, and then the C fibers which are slow in general. So the a Delta fibers are if you step on a nail, hopefully you don't, but if you did, you know right away immediately, Oh, that hurts right there where the nail is, it's sharp. But later on, you'll notice your whole foot is aching, that's those C fibers, the A delta or the the fast beginning ones, and they're localized C fibers are slow in general. So we do it physiological responses to pain, low to moderate pain usually is kind of superficial, we get that sympathetic stimulation. So we have an increase in heart rate, we have an increase in blood pressure. Those are things that we'll see with with low to moderate intensity pain. Unfortunately, a lot of nurses think that this applies to all pain, but it does not severe pain or deep pain can actually cause para parasympathetic stimulation, meaning that that pain can lower blood pressure, lower heart rate. So you can't look at a patient and say, well, your vital signs are fine. So you must not be in pain. I have seen that happen, y'all that is not something that is accurate. So untreated pain can actually progress to chronic pain. And we actually will see neuroplastic changes from chronic pain if it's not relieved. So you also need to think about our behavioral responses. Obviously, somebody who's in acute pain, they're going to, you know, maybe guarding so they're trying to keep somebody from touching that spot. You think about someone with abdominal pain, or they're, you know, trying to avoid using it, they might be grimacing, those kinds of things. Now, our role, excuse me is to recognize the cues that the patient's giving off now you've probably heard P Q R S T U So P palliative. When did the pain start? What kinds of things are helping the pain? What kinds of things are hurting it more? What does it feel like? That's our cue for quality? Is it sharp, burning, stabbing, Rs for radiation? Does the pain radiate anywhere? As is for the strength of the pain? This is where we're going to have them rated using the zero to 10 scale, or maybe we're using the faces. T is for timing. So does it come and go? Is it constant? And then you is an important piece you is how it affects you how it affects the patient. So we want to know is this keeping you from doing your normal activities? Is this something that is really interfering with your life? So we want to know, if the patient is expressing pain, some patients don't express it, they don't. You know, they have like a stoic countenance. So these folks, they're not going to necessarily tell you. So you always have to ask, if they're having pain, always ask your patients and be able to recognize nonverbal expressions, this becomes more important in people who are unable to self report pain. So like infants or children, people who are chronically ill, or unconscious, if they're, they have an intellectual disability or at the end of life, they may not be able to self report in that case, while we can't determine the strength of the pain, we can determine if the patient is having pain. So we want to make sure that we're using some tool to allow us to identify that pain. Now we have a couple of things that we want to do, there's not a lot, there are a lot of non pharmacological interventions we could put in place. So we can do meditation, distraction, progressive relaxation. You know, I like to read novels, so I would want to have a novel available or maybe we could Netflix write something to take your mind off of it. Because remember, one of those steps in the process of pain, physiologically is perception. So if we can take the perception away from it, it will help. There's also of course medications. More and more recently, we're getting multimodal analgesia, so I still work the floor and I see surgical patients who come back and they're now getting around the clock, acetaminophen, ibuprofen and Gabapentin and these medications are used together around the clock to help the patient's pain, especially post surgical. We use so we also use sometimes this thing called a patient controlled analgesia pump. This is a PCA and this is a device that will deliver a baseline rate of pain medication, usually an opioid, usually morphine. And the patient can also get a bolus dose by clicking a button. But there is two lockouts. The button only works every so often they can push it as many times as they want and will only work on this interval that is ordered. And then there's a maximum dose per hour that the patient could get. And this helps us to prevent any kind of overdose. We also want to make sure that we're monitoring these patients for respiratory sedation if they're taking an opioid. So non opioid analgesia Of course, we have NSAIDs non steroidal anti inflammatory drugs, we have acetaminophen, those are very reliable and very useful. Your job is to nurses to recognize when it's inappropriate to administer one of those. So if the patient is having liver problems, you don't want to give them acetaminophen if they have ulcers you want to question in order for an NSAID. Of course, we have our opioids, opioids, we've got our pure opioid agonist like morphine, fentanyl, oxycodone, oxymorphone, hydrocodone, those are all full opioid agonist we have agonist antagonist opioids like butorphanol nalbuphine. We also have our opioid antagonists. And you'll know that says Naloxone, these are medications that we typically give as an antidote. So if the patient has taken too much opioid or if we suspect that the patient is experiencing toxic effects, in other words, respiratory depression. There's also an interest spinal analgesia that you might see used I think most of the public knows of this is an epidural that women get when they're sometimes giving birth. That's a needle that goes into either the epidural or the intrathecal space, and then the medication is administered. So as the nurse we're not going to administer that unless you're a certified registered nurse anesthetist. So we need to know what the medication is so we can monitor for effectiveness and for side effects. Now, complications are pretty rare to that sort of thing, but we do need to keep an eye out for those. adjuvant adult analgesics are sometimes called co analgesics and these are medications that are used together. So that multimodal pain therapy that we talked about earlier. That's what this is so anticonvulsants the most common one we see as Gabapentin is used as a co analgesic, or as an adjuvant, antidepressant, sometimes or local anesthetics, we may give the patient a lidocaine patch that will help out. Now, we are seeing more and more medical marijuana. This is still a schedule one controlled substance as of the recording of this, and some states have legalized it, but it's still federally illegal. So the most important thing for you to know about that is nurses cannot administer medical marijuana unless they're specifically authorized by jurisdiction law. So if you don't know what your jurisdiction law is, you're not going to administer it because you can get in big trouble. So you want to make sure that if the patient has it in whatever setting you're in, they're administering it to themselves, but also make sure that the healthcare provider knows what is going on. As far as non pharmacological management, we can always involve our our fellows in physical or occupational therapy. Sometimes, walking or yoga, or even exercises done in the water swimming are good for management of pain. Sometimes we use cryo therapy or cutaneous stimulation, relaxation, breathing, artwork, mindfulness guided imagery. These are all things that can be done that don't involve medication. So I hope you enjoyed this discussion about pain management, and I'll see you next time on nursing with Dr. Hobbick.