Approaches to pain management

There are four approaches for using analgesia, they are as follows;
– PRN
– Preventive approach
– Individualized dosage
– Patient controlled analgesia

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Analgesia as required approach:

The PRN approach to administrating analgesia, is giving the analgesia when it is needed. The patient is either sedated or in pain for long periods of time. The serum level of the opoid must be maintained for effective pain relief. When the serum level decreases, the individual will consequently experience pain. It is important that the nurse doesn??™t delay administering the analgesia when required, as the lower the serum level, the harder it is to achieve a therapeutic level with the subsequent dosage.

Preventive approach:

With the preventive approach the therapeutic serum level is maintained. The analgesia is administered at set intervals, therefore the pain medication acts before the pain becomes severe. The difference between the preventive approach and the PRN approach is that the preventive approach doesn??™t wait for the patient to complain of pain and is administered on a time basis as opposed to a pain basis. Smaller doses of analgesia are required with this approach because the pain is not allowed to escalate. It is vital that the nurse assess the patient??™s sedation level prior to each dose.

Individualized dosage

The individualized dosage is based on patient requirements rather than routine. The nurse should assess the patient and give the required dose of analgesia, based on the severity of the patient??™s pain. It is important that the nurse doesn??™t under medicate the patient due to fear of side effects and addiction etc. The nurse must monitor the patient for side effects of the analgesia. Prior to the 1st dosage it is imperative to get a baseline assessment of the patient??™s respiratory rate, blood pressure, and pain score. Once the nurse administers the analgesia, it is important that she evaluates the effectiveness of the intervention after thirty minutes. If the pain is not relieved in thirty minutes and if the patients BP, RR and alertness is stable then, changes in the analgesia needs to be considered.

Pharmacological treatments

There are three basic pharmacological agents, they are as follows;
– non opoids
– opoids ??“ weak and strong
– adjuvant drugs

The individual will always start with a non opoid medication. The two most common non opoid drugs are paracetemol and Non- Steroidal Anti ??“ Inflammatory Dugs. Non opoids are unique in that they have a ceiling effect to their analgesia efficacy. This means that once the maximum dose has been reached that further doses will not have any more analgesia effect. At this stage, if the patient pain is not well controlled the patient must be changed to another analgesic:
– non opoid and opoid
– non opoid and adjuvant
– or to consider the use of the WHO analgesia ladder

The WHO analgesia ladder is most commonly utilized for control of pain in cancer patients however; this analgesia system is widely used for controlling pain in all conditions. The patient starts with an non opoid and a adjuvant drug. If the pain persists they are giver a weak opoid and a non opoid and a adjuvant drug. If the pain still persists, the patient is given a stronger opoid for moderate to severe pain, a non opoid and a adjuvant drug if required.

Paracetemol ??“ common non opoid analgesia

Paracetemol is an analgesia with an anti pyretic effect. The analgesia doesn??™t have any anti inflammatory properties. Paracetemol is considered a ???morphine sparing agent??™ in that it is used to reduce the total required dose of the opoid. The drug has a ceiling effect in that once the patient has received the maximum dose, further doses will not have any effect on controlling the patients pain. It is also important that the nurse ensures not to exceed 4000mg/ 24hrs when given paracetemol as the antidote is poisoning.

Paracetemol does not cause gastric irritation but is toxic to the liver. For this reason, it is imperative that paracetemol is used with caution for individuals with liver disease. It should also be used with caution for individuals that drink alcohol as it can enhance their risk of hepatotoxic.

Non Steroidal Anti Inflammatory:

There are several NSAIDs available; however aspirin is most commonly utilized in the clinical setting. NSAIDs have analgesia, anti- pyretic and anti-inflammatory effects. There act upon stopping the synthesis of prosoglandin which is a mediator of pain. Cycloxygenase is a NSAID blocker that blocks the synthesis of prostaglandins. They are more effective in inflamed than non inflamed tissues. It is essential that no two combinations of NSAIDs are given at the one time.

Because prostaglandins have a function to protect gastric mucosa, as NSAIDs act by inhibit the formation of prostaglandin, there is a risk that they can lead to erosion of the stomach mucosa. It is therefore, imperative that the nurse advices the patient to take NSAIs with food. A histamine blocker may also need to be prescribed to protect the stomach.

NSAIDs are also highly nephrotoxic and therefore should be avoided in the elderly. They have a high risk of renal impairment as the preventing the production of prostaglandins cause lowering of the GFR.

There is a huge risk of bleeding with their use. Another reason, to avoid NSAIDs in the elderly is that the elderly have a five times greater risk of death form GI bleed with the use of NSAIDs.

There are NSAIDs with prostaglandin analogue available such as Diclofenac. They can also be applied topically, such as Ibugel.

Pharmacological treatments opoids

There are several weak opoids, strong opoids and agonist and antagonist drugs available in health care. The most common weak opoids are codeine and tramadol. Stronger opoids include morphine, hydromorphine, oxycodone and fentanyl.

Opoids work on the brain and spinal cord.
In the brain, the opoids act on the limbic system and eliminate the subjective feeling of pain. It results in enhancing the pain inhibiters by descending pathways.

In the spinal cord, the opoid acts on receptors of interneurons and depression of pain transmission (Lipp 1991). Opoids activate the modulating neurons in the spinal cord and inhibit the transmission of pain from the afferent nociceptors to the spinal cord.

All pain responds to opoids, however some types of pain are more responsive than others.

Adjuvant drugs potentiate the activity of another drug, and therefore assist the treatment of a condition. There use is dependent on the cause of the pain and the type of side effects. An example includes anti histamine (Pirotin).

Again it is imperative that the nurse monitors for side effects of the intervention after administering the opoid. Opoids have many side effects including:
– Naseau and vomiting
– Sedation
– Urinary retention
– Pruritus
– Sedation
– Decreased respiratory rate
– Constipation
– Cognitive changes- confusion
– Hypotension
(Ferrell 1995)

Respiratory depression

Respiratory depression is a rare side effect if the dosage is gradually increased. However, it is more likely to occur if there is a rapid escalation in the dose of the opoid for breakout or acute pain. There is also an increased risk of respiratory depression if the patient has an epidural catheter in the thoratic region. If opoids are used with other respiratory depressants, the risk of this side effect is also greater.

It is important that the nurse assesses the patients respiratory rate, prior to given the opoid to get a base line reading. The opoid must be with held if the patient RR is below 8/min or if the patient is sedated when awake. Having given the opoid, the respiratory rate must be checked regularly. The nurse must assess the patients RR more frequently ie every 15 ??“ 30 mins if they already have a co-existing respiratory or renal condition. If the patient RR deteriorates much from their baseline, the opoid must be stopped and the nurse must give an opoid antidote such as Naloxone as prescribed.

Sedation

Patients that are in pain cannot cough or breathe sufficiently, and are therefore at a greater risk of chest infection. Patients in pain, are more immobile and are therefore at a greater risk of DVTs and pulmonary embolism

Pruritus

It is vital to assess if the patient has an allergy to heat or if they have a tendency to get skin allergies. Most of the cases a an anti- histamine is administered to control the itching.

Inadequate pain relief

The patient??™s pain relief may be inadequate, insufficient or infrequent which can result in the patient experiencing unnecessary pain and suffering.

Constipation;

It is imperative that the patient is stated on a bowel monitoring protocol once they commence opoid therapy. The patient??™s bowel movements should be monitored daily. The patient should also be given regular laxatives as prescribed. It is important that the patient doesn??™t eat too much fibre as this can worsen the constipation effect for the patient on opoid therapy. The patient should be encouraged to maintain a good oral fluid intake.

Best strategies to reduce side effects

The nurse must always strive towards achieving a balance between adequate pain relief and tolerable side effects. The dose of the opoid should be gradually reduced ie by 25050% as the pain improves and becomes less severe. The WHO analgesia ladder is a good analgesia protocol to follow as the patients analgesia requirements decrease as the pain improves. The nurse must always consider a non opoid which we explained earlier as a morphine sparing agent that can be given to reduce the total dose of the opoid (Pasero 1999).
It is hard to resolve constipation quickly; however the nurse can monitor the bowel movements daily and ensure the patient is given regular laxatives

Maxolon is a commonly used drug for the side effect of Naseau and vomiting. This drug has both analgesia and anti- emetic properties, and is often given to elderly patients. (Kander & Lisander 1993). It is vital that the nurse assures oral hygiene standards are maintained.

Short term cognitive impairment is common for individuals who have just started on opoids. It is important to be aware that acute confusion may be due to electrolyte imbalance and therefore, the patient must be encouraged to increase their oral fluid intake.
However the nurse must assess other possible causes such as, hypoxia, urinary retention, constipation and infection etc.

Non pharmacological approaches

There are several non pharmacological approaches that can be taken; distraction, massage, and acupuncture are the most commonly utilized ones in the hospitals.

Opoid use in the elderly

The opoid therapy should be commenced at 25-50% lower dose that the general adult dose (AGS 1998). The dose should then be gradually increased according to the patients severity. Repeat doses may be given if the previous analgesia dose isn??™t effective and if the patient??™s side effects remain stable/ minimal.

Opoid administration in the elderly

It is important the nurse uses the least invasive site and safest route in administering analgesia ie the oral route. If the elder is unable to tolerate the oral route, the sublingual or rectal route must be considered. An IV epidural may be needed for severe pain post surgery. IM injections should be avoided in the elderly as they have less fatty and muscular tissue, so it may be very painful. There is also a risk of toxicity and altered analgesia serum levels with repeated IM injections. IM administration has slow absorption and delayed effects also.
It is important to choose the correct approach that will maintain a stable serum level of analgesia for the elderly patient (APS 1999). PCA may be suitable post surgery if the patient is not cognitively impaired. If the patient is on a PCA it is vital that the patient is aware of its use.

Treatment of pain in the elderly

Mild to moderate:

First step is WHO ladder
NSAID if patient on anticoagulants use with caution
Note confusion due to toxitity and renal accumulation
Monitor input and output chart

Moderate to severe

Initially opoid
Opoid and non opoid
Remember to check hepaticv and renal function prior to administration

Pain is whatever bodily hurt the patient reports existing, whenever the patient says it is (Smetlxer & Bare 2002)

Nurse must be aware to validate the pain and reasons why patients may be reluctant to report pain

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