癌痛的护理英文PPT课件

1、Discussion: What might the consequences be if you do not believe your patients level of pain?第1页/共59页Consequences of Untreated PainWhat happens if pain isnt properly treated? Poor appetite and weight loss Disturbed sleep Withdrawal from talking or social activities Sadness, anxiety, or depression Ph

2、ysical and verbal aggression, wandering, acting-out behavior, resists care Difficulty walking or transferring; may become bed bound第2页/共59页Pain ManagementGuidelines on Pain Management Li Xiaodan 第3页/共59页Discussion: How do you respond to a patient who wants to “wait until the pain is so bad they cant

3、 stand it” because they are afraid they will become “immune” to the pain medication?Why do some patients not tell health professionals about their pain?第4页/共59页The common patient-related barriers to pain management Drugs . are addicting should be saved for when it is really needed have unpleasant or

4、 dangerous side effects pills are not as effective as a shot narcotics are only for dying peopleCommon biases about Pain第5页/共59页Common Misconceptions about Pain The caregiver is the best judge of pain. A person with pain will always have obvious signs such as moaning, abnormal vital signs, or not ea

5、ting. Pain is a normal part of aging. Addiction is common when opioid medications are prescribed.第6页/共59页Common Misconceptions about Pain, cont. Morphine and other strong pain relievers should be reserved for the late stages of dying. Morphine and other opioids can easily cause lethal respiratory de

6、pression. Pain medication should be given only after the resident develops pain. Anxiety always makes pain worse.第7页/共59页Common biases about Pain Drug abusers & alcoholics overreact to painFalsethey are actually giving you a more truthful perception since inhibitions are lowered. Clients with mi

7、nor illnesses have less painFalsefor that patient, the experience could be major depending on previous experience. Giving analgesics regularly will start drug dependencyFalsestudies show only 3% of patients ever develop a true addiction Amount of damage dictates pain intensityFalseminor injuries may

8、 cause excruciating pain Psychogenic pain is not realFalsein that patients mind, the experience is real Health care personnel know best the nature of the patients pain Falsethe patient knows best his or her painThe common patient-related barriers to pain management第8页/共59页Contents Definition of pain

9、 Pain evaluation Pain Management Precautions to giving pain medications Summary第9页/共59页What is pain? One of the most common reasons people seek healthcare One of the most widely under-treated health problems第10页/共59页What is pain?The International Association for the Study of Pain (IASP) has proposed

10、 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 such damage. 疼痛是一种令人不快的感觉和情绪上的感受，伴有实质上的或潜在的组织损伤，疼痛是一种主观感觉。第11页/共59页Descriptions of PainCategories of Pain by DurationChronic Ca

11、ncer PainPain is expected to have an end, with cure or with death. Aggressive treatment Addiction not a concern第12页/共59页Categories of Pain by DurationChronic Non-Malignant PainPain has no predictable ending Difficult to find specific cause Often cant be cured Frequently undertreated第13页/共59页Categori

12、es of Pain by TypeSomaticSource: Skin, muscle, and connective tissueExamples: Sprains, headaches, arthritisDescription: Localized, sharp/dull, worse with movement or touchPain med: Most pain meds will help, if severe, need a stronger medication第14页/共59页Categories of Pain by TypeVisceralSource:Intern

13、al organsExamples:Tumor growth, gastritis, chest painDescription:Not localized, refers, constant and dull, less affected with movementPain Med:Stronger pain medications第15页/共59页Categories of Pain by TypeBone PainSource:Sensitive nerve fibers on the outer surface of boneExamples:Cancer spread to bone

14、, fx, and severe osteoporosisDescription:Tends to be constant, worse with movementPain Med:Stronger pain meds, opiates with NSAIDS as adjunct (Non-SteroidAntiInflammtoryDrugs. NSAIDS 第16页/共59页Categories of Pain by TypeNeuropathicSource:NervesExamples:Diabetic neuropathy, phantom limb pain, cancer sp

15、read to nerve plexisDescription:Burning, stabbing, pins and needles, shock-like, shootingPain Meds:Opioates+tricyclic antidepressants or other adjuvant第17页/共59页疼痛的评估癌痛控制的基础The evaluation of pain- Basis of pain control第18页/共59页Standard of Care: Assessment & Intervention for PainPurpose: To evalua

16、te 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: Have their pain assessed on admission and reassessed at regular intervals to ensure that patients pain is being managed and controlled. The frequ

17、ency of pain reassessments should be increased during the first post-operative day, or if the pain is poorly controlled, or the intervention has changed. A pain assessment is required before and after each dose of PRN pain medication.第19页/共59页Standard of Care: Assessment & Intervention for PainP

18、urpose: 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: Reassessment of pain status should occur with each physical assessment by the registered nurse and within “one hour” of pain man

19、agement intervention. The 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.第20页/共59页Systematic evaluation of pain involves the following

20、 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 neurological examination.

21、 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.Standard of Care: Assessment & Intervention for Pain第21页/共59页 P recipitating/Alleviating Factors: What causes the pain? Wh

22、at aggravates it? Has medication or treatment worked in the past? Q uality of Pain: Ask the patient to describe the pain using words like “sharp”, dull, stabbing, burning” R adiation Does pain exist in one location or radiate to other areas? S everity Have patient use a descriptive, numeric or visua

23、l scale to rate the severity of pain. T iming Is the pain constant or intermittent, when did it begin, and does it pulsate or have a rhythm第22页/共59页Ratings Scales to Assess Pain Numberical Rating Scale（NRS） Visual Analogue Scale（VAS） Verbal Rating Scale（VRS）第23页/共59页Effect sleepUnable to sleepWorst

24、painMildModerateWorst 0 1 2 3 4 5 6 7 8 9 10NRSNo pain第24页/共59页 0 2 4 6 8 10 Wong-Baker 面部表情量表癌症疼痛的评估及护理对策，中华护理杂志2000无痛 有点痛 轻微疼痛 疼痛明显 疼痛严重 剧烈痛第25页/共59页Ratings Scales to Assess Pain uMild pain: people can endure the pain, sleep is not affecteduModerate: obviously pain, people require to take analgesi

25、csuSevere or Worst:Severe pain, sleep disturbed, accompanied by plant nerve disorder第26页/共59页Nonverbal Indications of Pain: Watch for change in behavior Crying, moaning, calling out Agitated or aggressive behavior Increased frustration or irritability Changes in sleep or eating habits Withdrawal fro

26、m friends, family, or favorite activities第27页/共59页Pain Management interventionsPain Managementn Pharmacologicn Rehabilitativen Behavioral第28页/共59页Pain Management: Encourage analgesics to be regularly scheduled Schedule pain medication at bedtime to promote good quality of sleep Treatment is more eff

27、ective if analgesics are taken before pain is at its worst Encourage analgesic prior to treatments or activities that aggravate their pain第29页/共59页Pharmacological Interventions Opioids: for moderate or severe pain Agonists Agonists-antagonists Nonopioids: Used alone or in conjunction with opioids fo

28、r mild to moderate pain Acetaminophen NSAIDS(Non-Steroid Anti-Inflammtory Drugs. NSAIDS ) Adjuvants: Used for analgesic reasons and for sedation and reducing anxiety. Multipurpose Tri-cyclic antidepressants Anticonvulsants第30页/共59页Pharmacologic interventions Non-opioids:Used alone or in conjunction

29、with opioids for mild to moderate pain Acetominophen (Tylenol) Aspirin NSAIDs (Advil) Opioids :for moderate or severe pain Weak Strong Codeine Hydromorhone Oxycodone Morphine Vicodin Merperidine Adjuvants:Used for analgesic reasons and for sedation and reducing anxiety. Primary function is not pain

30、relief but provide relief May modify mood so patient feels betterPain Management第31页/共59页Routes of medication administration Oral Injection Intravenous (includes PCA) Epidural Rectal TopicalPain Management第32页/共59页Concepts of WHO Pain Ladder By the mouth By the clock By the ladder For the individual

31、 With attention to detailPain Management第33页/共59页SEVERE 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 Opioid such as codeineMILD PAIN:Aspirin, ibuprophenAcetominophen, naprosyn. ANALGESIC LADDE

32、R第34页/共59页+/- adjuvantNon-opioidWeak opioidStrong opioidPain persists or increasesBy theClock. ANALGESIC LADDER+/- adjuvant+/- adjuvant123第35页/共59页Non-opioid analgesics第36页/共59页第37页/共59页Pharmacologic interventions第38页/共59页Transdermal routes:Fentanyl Transdermal Systemthe fentanyl transdermal therape

33、utic system dosing interval is usually 72 hours第39页/共59页Pharmacologic interventionsPain ManagementOpioid analgesicsnfentanyl and buprenorphine are the opioids for transdermal administration.nThe system has been demonstrated to be effective in post-operative pain and cancer painnthe fentanyl transder

34、mal therapeutic system dosing interval is usually 72 hours.第40页/共59页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 bolus of analgesic drug on demand ac

35、cording 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.第41页/共59页第42页/共59页Discussion: What a

36、re 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?SleepinessNauseaConstipation第43页/共59页Pharmacologic interventionsPain ManagementThe main adverse effects of Opioid analgesics are:nr

37、espiratory depression, apnoeansedationnnausea, vomitingnpruritusnconstipationnhypotension.第44页/共59页Other Considerations: Management of side effects Prevent and manage constipation when opioids are prescribed (stool softener with laxative should be prescribed) Nausea and sleepiness usually resolve ab

38、out 1 week after starting opioids Anti-emetic can be prescribed for first week Acetaminophen to total 4000mg or less per 24 hours (3000mg for frail elderly) Dont use more than one combination analgesic or sustained release preparation第45页/共59页What if Pain Control is Ineffective? For mild pain (1-4 o

39、ut of 10), increase dose by 25% For moderate pain (5-6 out of 10), incease opioid dose by 50% For severe pain (7-10 out of 10), increase opioid dose by 75-100% May use equianalgesic dosing tables to calculate dosage of opioids to be given in 24 hours第46页/共59页Discussion: What is the difference betwee

40、n physical dependence, tolerance, and addiction?第47页/共59页Tolerance vs. Addiction: Tolerance No “high” (opioids are metabolized differently as they address the pain) Usually some physical tolerance and dependency to pain medications developn AddictionnPsychological “high”nIntention to harm the bodynN

41、egative personal, legal or medical consequences第48页/共59页True Addiction? Addiction: Usage is out of control Obsession with obtaining a supply Quality of life does not improven Pseudo-AddictionnFrom under-treatment of painnDrug-seeking/Crisis of mistrustnBehavior and function improve when pain is reli

42、eved第49页/共59页 Assess pain using an age appropriate tool. Consider starting an around the clock regimen. Continually assess pain and modify medication regimen appropriately.Precautions to giving pain medications第50页/共59页 When to call the attending: Patient has persistent or worsening pain despite appropriate analgesic regimen. When to transfer to a higher level of care: Patient develops respiratory depress