1. Pain Mary Corcoran RN,BSN, MICN

2. Pain In ER Most frequent Complaint Traditionally inadequately treated for many patients ED Nurses are the patients primary advocate for control of pain

3. Types of pain Acute Sudden onset Chronic Prolonged- Months to years Cancer May increase with treatment, or changes in the disease process Neuropathic Burning, numbness sensation- usually peripheral Visceral Cramping, bloating, stretching sensation- usually abdominal Somatic Aching, or throbbing- joint type pain

4. Definitions of Pain Terminology Allodynia- Pain due to stimulus that does not normally provoke pain Analgesia- Absence of pain in response to a stimulus that should be painful Hyperalgesia- An increased response to a stimulus that is normally painful Hypersthesia- Increased sensitivity to stimulation, excluding special senses Neuralgia- Pain in the distribution of a nerve or verves

5. Definitions cont Neuritis- Inflammation of a nerve or nerves Neuropathy- A disturbance of function or pathologic change in a nerve Noxious Stimulus- a stimulus damaging to normal tissue Pain Threshold- The least experience of pain that a patient can recognize Pain Tolerance Level- The greatest level of pain that a patient can tolerate Parasthesia- An abnormal sensation whether spontaneous or evoked

6. Definitions of Addiction Tolerance- A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drugs effects over time Physical Dependence- A state of adaptation that includes tolerance and a withdrawal syndrome with dosage decrease or agonist administration Addiction- is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestation Pseudoaddiction- patients exhibit behaviors of addiction, which resolve when the pain is treated

7. Pathophysiology Nociceptors Pain receptors located in the skin, muscle, joints, arteries and viscera Stimulated by chemical, thermal or mechanical stimuli Examples of stimuli Laceration, Burns, or strain to a muscle (inflammation)

9. Pathophysiology The Brain The third order neurons, located in the Thalamus, Brain stem, and midbrain, communicate with the CNS, and triggers communication between all areas of the brain The limbic and reticular tracts respond to pain signals- resulting in the person arousing to danger, release of stress hormones, and emotional response to pain

10. Pathophsiology Pain Modulation and Endogenous Opioids These work together to decrease the sensation of pain, allowing the body to suffer debilitating pain, and still survive (ie endorphins)

11. Barriers to pain management The perception of “Drug Seeking” Disparities in treatment of minorities and women Fear of negative physiologic effects of opioid administration Physician and RN lack of education regarding pain management Inadequate treatment of high-risk patients Older adults, Developmentally delayed, non-English, and children The belief that physiologic signs are more reliable than patient self report

12. How do we assess pain? Most adults will be able to use a simple 0-10 scale to describe the severity of their pain

13. What about kids? Most school age children (5+) will be able to use the Wong- Baker FACES Scale

14. What about babies? Children age 3mo-7yrs can be scored using the FLACC scale

17. How do we Treat Pain? Pharmacologic Non-Pharmacologic Opioids Morphine, Dilaudid, Fentanyl NSAIDS Motrin, Toadol PCA Opioids administered by patient Topical Lidocaine LET/TAC solution, EMLA cream Positioning/Elevation Heat/Cold therapy Heat for chronic Cold for acute Distraction technique Reading, movies, talk etc Works well for children

18. Procedural Sedation MINIMAL- pt responds normally MODERATE (“Conscious”)- airway and CV function maintained DEEP- pt not easily aroused ANESTHESIA- required assisted ventilation Sedation- minimizes movement, pain, and anxiety during procedure