癌痛的護理(英文版)2

1、Discussion:What might the consequences be if you do not believe your patients level of pain?Consequences of Untreated PainWhat happens if pain isnt properly treated?nPoor appetite and weight lossnDisturbed sleepnWithdrawal from talking or social activitiesnSadness, anxiety, or depressionnPhysical an

2、d verbal aggression, wandering, acting-out behavior, resists carenDifficulty walking or transferring; may become bed boundPain ManagementGuidelines on Pain Management Li Xiaodan Discussion:nHow do you respond to a patient who wants to “wait until the pain is so bad they cant stand it” because they a

3、re afraid they will become “immune” to the pain medication?Why do some patients not tell health professionals about their pain?The common patient-related barriers to pain managementnDrugs .nare addictingnshould be saved for when it is really needednhave unpleasant or dangerous side effects npills ar

4、e not as effective as a shotnnarcotics are only for dying peopleCommon Misconceptions about PainnThe caregiver is the best judge of pain.nA person with pain will always have obvious signs such as moaning, abnormal vital signs, or not eating.nPain is a normal part of aging.nAddiction is common when o

5、pioid medications are prescribed.Common Misconceptions about Pain, cont.nMorphine and other strong pain relievers should be reserved for the late stages of dying.nMorphine and other opioids can easily cause lethal respiratory depression.nPain medication should be given only after the resident develo

6、ps pain.nAnxiety always makes pain worse.Common biases about PainnDrug abusers & alcoholics overreact to painFalsethey are actually giving you a more truthful perception since inhibitions are lowered.nClients with minor illnesses have less painFalsefor that patient, the experience could be major dep

7、ending on previous experience.nGiving analgesics regularly will start drug dependencyFalsestudies show only 3% of patients ever develop a true addictionnAmount of damage dictates pain intensityFalseminor injuries may cause excruciating painnPsychogenic pain is not realFalsein that patients mind, the

8、 experience is realnHealth care personnel know best the nature of the patients pain Falsethe patient knows best his or her painnDefinition of painnPain evaluationnPain ManagementnPrecautions to giving pain medicationsnSummaryWhat is pain?One of the most common reasons people seek healthcareOne of th

9、e most widely under-treated health problemsWhat is pain?The International Association for the Study of Pain (IASP) has proposed the following working definition: pain is an unpleasant sensory and emotional experience associated with either actual or potential tissue damage, or described in terms of

10、such damage. 疼痛是一種令人不快的感覺和情緒上的感受，伴疼痛是一種令人不快的感覺和情緒上的感受，伴有實質(zhì)上的或潛在的組織損傷，疼痛是一種主觀有實質(zhì)上的或潛在的組織損傷，疼痛是一種主觀感覺。感覺。Descriptions of PainCategories of Pain by DurationChronic Cancer PainPain is expected to have an end, with cure or with death.nAggressive treatmentnAddiction not a concernCategories of Pain by Dura

11、tionChronic Non-Malignant PainPain has no predictable endingnDifficult to find specific causenOften cant be curednFrequently undertreatedCategories of Pain by TypeSomaticSource: Skin, muscle, and connective tissueExamples: Sprains, headaches, arthritisDescription: Localized, sharp/dull, worse with m

12、ovement or touchPain med: Most pain meds will help, if severe, need a stronger medicationCategories of Pain by TypeVisceralSource:Internal organsExamples:Tumor growth, gastritis, chest painDescription:Not localized, refers, constant and dull, less affected with movementPain Med:Stronger pain medicat

13、ionsCategories of Pain by TypeBone PainSource:Sensitive nerve fibers on the outer surface of boneExamples:Cancer spread to bone, fx, and severe osteoporosisDescription:Tends to be constant, worse with movementPain Med:Stronger pain meds, opiates with NSAIDS as adjunct (Non-SteroidAntiInflammtoryDrug

14、s. NSAIDS Categories of Pain by TypeNeuropathicSource:NervesExamples:Diabetic neuropathy, phantom limb pain, cancer spread to nerve plexisDescription:Burning, stabbing, pins and needles, shock-like, shootingPain Meds:Opioates+tricyclic antidepressants or other adjuvantStandard of Care: Assessment &

15、Intervention for PainPurpose: To evaluate and manage our patients pain, through prompt attention, to achieve an outcome of pain intensity ratings on a scale of 1-10. All patients can expect to:nHave their pain assessed on admission and reassessed at regular intervals to ensure that patients pain is

16、being managed and controlled.nThe frequency of pain reassessments should be increased during the first post-operative day, or if the pain is poorly controlled, or the intervention has changed.nA pain assessment is required before and after each dose of PRN pain medication.Standard of Care: Assessmen

17、t & Intervention for PainPurpose: To evaluate and manage our patients pain, through prompt attention, to achieve an outcome of pain intensity ratings on a scale of 1-10. All patients can expect to:nReassessment of pain status should occur with each physical assessment by the registered nurse and wit

18、hin “one hour” of pain management intervention.nThe appropriate pain assessment tool will be used with the patient, dependent upon their developmental ability. “WNL” or “within normal limits” is an unacceptable phrase to assess pain.remember “0” represents no pain.Systematic evaluation of pain invol

19、ves the following steps. Evaluate its severity. Take a detailed history of the pain, including an assessment of its intensity and character. Evaluate the psychological state of the patient, including an assessment of mood and coping responses. Perform a physical examination, emphasising the neurolog

20、ical examination. Perform an appropriate diagnostic work-up to determine the cause of the pain, which may includetumour markers. Perform radiological studies, scans, etc. Re-evaluate therapy.nP recipitating/Alleviating Factors:nWhat causes the pain? What aggravates it? Has medication or treatment wo

21、rked in the past?nQ uality of Pain:nAsk the patient to describe the pain using words like “sharp”, dull, stabbing, burning”nR adiationnDoes pain exist in one location or radiate to other areas?nS everitynHave patient use a descriptive, numeric or visual scale to rate the severity of pain.nT imingnIs

22、 the pain constant or intermittent, when did it begin, and does it pulsate or have a rhythmRatings Scales to Assess Pain Rating ScalenVisual Analogue ScaleEffect sleepUnable to sleepWorst painMildModerateWorst 0 1 2 3 4 5 6 7 8 9 10NRSNo pain 0 2 4 6 8 10 Wong-Baker 面部表情量表癌癥疼痛的評估及護理對策，中華護理雜志2000無痛 有

23、點痛 輕微疼痛 疼痛明顯 疼痛嚴重 劇烈痛Ratings Scales to Assess Pain uMild pain: people can endure the pain, sleep is not affecteduModerate: obviously pain, people require to take analgesicsuSevere or Worst:Severe pain, sleep disturbed, accompanied by plant nerve disorderNonverbal Indications of Pain:nWatch for chang

24、e in behaviornCrying, moaning, calling outnAgitated or aggressive behaviornIncreased frustration or irritabilitynChanges in sleep or eating habitsnWithdrawal from friends, family, or favorite activitiesPain Management interventionsPain Managementn Pharmacologicn Rehabilitativen BehavioralPain Manage

25、ment:nEncourage analgesics to be regularly schedulednSchedule pain medication at bedtime to promote good quality of sleepnTreatment is more effective if analgesics are taken before pain is at its worstnEncourage analgesic prior to treatments or activities that aggravate their painPharmacological Int

26、erventionsnOpioids:nfor moderate or severe painnAgonistsnAgonists-antagonistsnNonopioids:nUsed alone or in conjunction with opioids for mild to moderate painnAcetaminophennNSAIDS(Non-Steroid Anti-Inflammtory Drugs. NSAIDS )nAdjuvants:nUsed for analgesic reasons and for sedation and reducing anxiety.

27、nMultipurposenTri-cyclic antidepressantsnAnticonvulsantsPharmacologic interventionsNon-opioids:Used alone or in conjunction with opioids for mild to moderate painAcetominophen (Tylenol)AspirinNSAIDs (Advil)Opioids :for moderate or severe painWeak StrongCodeine HydromorhoneOxycodone MorphineVicodin M

28、erperidineAdjuvants:Used for analgesic reasons and for sedation and reducing anxiety.Primary function is not pain relief but provide reliefMay modify mood so patient feels betterPain ManagementRoutes of medication administrationnOralnInjectionnIntravenous (includes PCA)nEpiduralnRectalnTopicalPain M

29、anagementConcepts of WHO Pain LaddernBy the mouthnBy the clocknBy the laddernFor the individualnWith attention to detailPain ManagementSEVERE PAIN: Keep giving mild pain medication and add a strong opioid such as morphine or FentanylMODERATE PAIN:Keep giving mild pain medication and add a mild Opioi

30、d such as codeineMILD PAIN:Aspirin, ibuprophenAcetominophen, naprosynW.H.O. ANALGESIC LADDER+/- adjuvantNon-opioidWeak opioidStrong opioidPain persists or increasesBy theClockW.H.O. ANALGESIC LADDER+/- adjuvant+/- adjuvant123Non-opioid analgesicsPharmacologic interventionsTransdermal routes:Fentanyl

31、 Transdermal Systemthe fentanyl transdermal therapeutic system dosing interval is usually 72 hoursPharmacologic interventionsPain ManagementOpioid analgesicsnfentanyl and buprenorphine are the opioids for transdermal administration.nThe system has been demonstrated to be effective in post-operative

32、pain and cancer painnthe fentanyl transdermal therapeutic system dosing interval is usually 72 hours.Pharmacologic interventionsPain ManagementPatient-controlled analgesia (PCA)nThis is a technique of parenteral drug administration in which the patient controls an infusion device that delivers a bol

33、us of analgesic drug on demand according to parameters set by the physician.n Long-term PCA in cancer patients is most commonly accomplished via the subcutaneous route using an ambulatory infusion device. nIn most cases, PCA is added to a basal infusion rate and acts essentially as a rescue dose.Dis

34、cussion:nWhat are the common concerns that patients may have about pain and opioids?What are common side effects when starting an opioid medication, and how should the nurse intervene?SleepinessNauseaConstipationPharmacologic interventionsPain ManagementThe main adverse effects of Opioid analgesics

35、are:nrespiratory depression, apnoeansedationnnausea, vomitingnpruritusnconstipationnhypotension.Other Considerations:nManagement of side effectsnPrevent and manage constipation when opioids are prescribed (stool softener with laxative should be prescribed)nNausea and sleepiness usually resolve about

36、 1 week after starting opioidsnAnti-emetic can be prescribed for first week nAcetaminophen to total 4000mg or less per 24 hours (3000mg for frail elderly) nDont use more than one combination analgesic or sustained release preparationWhat if Pain Control is Ineffective?nFor mild pain (1-4 out of 10),

37、 increase dose by 25%nFor moderate pain (5-6 out of 10), incease opioid dose by 50%nFor severe pain (7-10 out of 10), increase opioid dose by 75-100%nMay use equianalgesic dosing tables to calculate dosage of opioids to be given in 24 hoursDiscussion: What is the difference between physical dependen

38、ce, tolerance, and addiction?Tolerance vs. Addiction:nTolerancenNo “high” (opioids are metabolized differently as they address the pain)nUsually some physical tolerance and dependency to pain medications developn AddictionnPsychological “high”nIntention to harm the bodynNegative personal, legal or m

39、edical consequencesTrue Addiction?nAddiction:nUsage is out of controlnObsession with obtaining a supply nQuality of life does not improven Pseudo-AddictionnFrom under-treatment of painnDrug-seeking/Crisis of mistrustnBehavior and function improve when pain is relievednAssess pain using an age appropriate tool.nConsider starting an around the clock regimen.nContinually assess pain and modify medication regimen appropriately.nWhen to call the attending:nPatient has persistent or worsening pain despite appropriate analgesic regimen.nWhen to transfer to a