Care Conference Pain Management

PAIN MANAGEME

NT

TYPES OF PAIN• Acute• Chronic• Nociceptive• Neuropathic

7

ACUTE• Elicited by injury to body tissues• Typically seen with trauma, acute

illness, surgery, burns, or other conditions of limited duration; generally relieved when healing takes place.

CHRONIC• Elicited by tissue injury• May be perpetuated by factors remote from

the original cause and extend beyond the expected healing time; generally lasts longer than 3 months

P a i n c l a s s i fi c a ti o nC l i n i c a l t y p e s

Acute pain Chronic pain Results from noxious stimuli

that activates nociceptors neuron

It accompanies surgery, traumatic injury, tissue damage, and inflammatory processes.

Self-limited, resolves over days to weeks, but can persist for 3 months

Treatment is short term and curative

Results from: nociceptors, visceral, or somatic

It accompanies chronic disease, untreated condition.

Unresolved as long as underlying cause is present.

Treatment goal oriented, multidisciplinary approaches.

NOCICEPTIVE• Elicited by noxious stimuli that damages

tissues or has the potential to do so if the stimuli are prolonged.– Somatic pain: arises from skin, muscle, joint,

connective tissue, or bone; generally well localized and described as aching or throbbing.

– Visceral pain: arises from internal organs such as the bladder or intestine; poorly localized and described as cramping.

NEUROPATHIC

CARECONFERENCE

PATIENT BIODATA• Mrs T• F/54• Med History – Hypertension (2010)• Surg History – Nil• Family History – Nil• Allergic – Nil• Admission – 27/5/16 @ 2130HRS

ON ADMISSION• Wheel chair.

• C/O skidded and fall at home with injury to left elbow.

• ▲Displaced # right lateral humerus

• Conscious, anxious.

ASSESSMENT

• VITAL SIGN : Temperature – 37.4˚C Heart Rate – 98 bpm Respiration – 22 bpm Pain Score - 5/10 Weight – 67 kg

ACTIVITIES DAILY LIVING

• Ambulate

• Side rail

• All normal

PHYSICAL EXAMINATION

• Bandage and arm sling at right hand• IV branula 23G at left hand

Seen by MO :- IM Pethidine 50mg STAT (given at 1930 hrs)- X-ray right hand

Tab PCM 1gm TDS IM Pethidine 50mg 8 hourly / PRN For ORIF & K-wiring right humerus and

cast / backslab CM ↓GA Call case at 11am on 28/5/16

S/B Dr J at casualty at 2015Hrs :

ANATOMY&

PHYSIOLOGY

Peripheral Excitatory Mediators(Pain)

Substance

Receptor Mechanism

Substance P(SP)

NK1 neuronal excitability, edema

Prostaglandin(PG)

PG Sensitize nociceptors, inflammation, edema

Bradykinin B2 (normal)B1 (inflammation)

Sensitize nociceptors PG production

Histamine H1 C-fiber activation, edema,vasodilatation

Serotonin 5-HT3 C-fiber activation, release SPNorepinephrine

(NE)

1 Sensitize nociceptorsActivate nociceptors

TREATMENT

OPERATION• Open reduction

internal fixation & K-wiring left humerus ↓ GA on 28th May 2016

POST OPERATIVE ORDER

• Allow orally• Discharge CM• Tab Arcoxia 120mg OD• IV Unasyn 1.5gm TDS

MEDICATION

Combination AnalgesicsRationale

Multimodal analgesiaMultiple sites of action target multiple pain

pathwaysComplementary pharmacokinetic activityPotentially synergistic analgesic effect Reduced adverse event profile with comparable

efficacy

DRUGS DATE ORDERED

DATE OFF

IM Pethidine 50mg STAT 27/5/16 27/5/16

Tab PCM 1gm TDS 27/5/16 29/5/16

Tab Arcoxia 120mg OD 28/5/16 29/5/16

IM Pethidine 50mg 8hrly /PRN

27/5/16 29/5/16

IV Unasyn 1.5gm TDS 28/5/116 29/5/16

COMPLICATION

PAINASSESSMENT

NURSING CARE PLAN

&

GENERAL STRATEGY• Assessment• Analysis• Planning and

Implementation/Intervention• Evaluation and Ongoing monitoring• Documentation

ASSESSMENT• Primary and secondary

assessment• Focused assessment –Subjective data collection–Objective data collection

27/5/16 @ 2130HRS

• VITAL SIGN : Temperature – 37.4˚C Heart Rate – 98 bpm Respiration – 22 breath/min Pain Score - 5/10 Weight – 67 kg Tab PCM 1gm given Informed to NBM 12MN

27/5

2130hr

IA

MRS T

XXXXX

F / 54

DR J

5

A

Righthand

Movehand

Rest

5

1234

27/5/162130hr

IA5√

T. PCM1gm

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27/5/16 @ 2230HRS

• VITAL SIGN : Pain Score - 2/10 No medication given

27/5/162130hr

IA5√

T. PCM1gm

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F / 54

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27/5

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27/5/162130hr

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27/5/16 @ 2330HRS

• PATIENT WAS SLEEPING Snoring

27/5/162130hr

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2230hr

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27/5/162130hr

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28/5/16 @ 0200HRS

• PATIENT WAS SLEEPING Snoring

27/5

2130hr

RA

MRS T

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F / 54

DR J

27/5

2230hr

IA

27/5

2330hr

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27/5/162130hr

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28/5/16 @ 0600HRS

• VITAL SIGN : Temperature – 36.5˚C Heart Rate – 91 bpm Respiration – 19 bpm Pain Score - 2/10 No medication given. Pre med at

0800hrs.

27/5

2130hr

RA

MRS T

XXXXX

F / 54

DR J

27/5

2230hr

IA

27/5

2330hr

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27/5/162130hr

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28/5/16 @ 0700HRS

• VITAL SIGN : Pain Score - 3/10 Patient just took bath No medication given

27/5/162130hr

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T. PCM1gm

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27/5

2130hr

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F / 54

DR J

27/5

2230hr

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27/5/162130hr

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