COMFORT EXEMPLARS Chronic Pain Osteoarthritis Rheumatoid Arthritis Degenerative Disc Disease CHRONIC PAIN • Can be intermittent, occur with flares or continuous • Can persist for months, years or lifetime • Is a major medical condition • Can affect quality of life, enjoyment, activity, employment • Linked to anxiety and depression • Primary-unrelated to other conditions • Secondary-related to underlying conditions (cancer, chronic post-op, neuropathic, musculoskeletal, visceral, etc.) CHRONIC PAIN CLASSIFICATIONS • Breakthrough pain-chronic pain with acute exacerbations • Other classifications: • Nociceptive (physiologic) • Neuropathic(pathophysiologic) • Nociplastic COMPONENTS OF PAIN ASSESSMENT • Self-report • Location • Intensity • Quality • Onset and duration • Aggravating and relieving factors • Effects on function and quality of life • Comfort–function goal https://forms.office.com/r/TBz46a6fAa ASSESSING INTENSITY: PAIN SCALES • Numeric Rating Scale (NRS) • Wong-Baker FACES Pain Rating Scale • Faces Pain Scale-Revised (FPS-R) • Verbal descriptor scale (VDS) • Visual Analog Scale (VAS) https://forms.office.com/r/TBz46a6fAa ASSESSING PAIN FOR SPECIFIC POPULATIONS The Hierarchy of Pain Measures - nonverbal patients Faces, Legs, Activity, Cry and Consolability (FLACC) scale - young children Pain in Advanced Dementia (PAINAD) scale - patients with advanced dementia Critical Care Pain Observation Tool (CPOT) - patients in critical care units CHRONIC PAIN MANAGEMENT • Effective and safe analgesia • Optimal relief • Comfort function goal • Responsibility of all members of the health care team • Pharmacologic: multimodal • Routes and dosing • Patient-controlled analgesia (PCA) CHRONIC PAIN: PHARMACOLOGIC INTERVENTIONS Steroid Injections Non-opioid medications (NSAIDS, lidocaine, etc.) • Non-neuropathic • Osteoarthritis • Low back Anticonvulsant medications (gabapentin, pregabalin, etc.) • Post herpes • Diabetic • Spinal cord injury Tricyclic antidepressants (desipramine, nortriptyline, etc.) • neuropathic Serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, etc.) • Neuropathic Dissociative anesthetic (ketamine) • Severe • Neuropathic CHRONIC PAIN: PHYSIOLOGIC BASIS FOR PHARMACOLOGIC INTERVENTIONS • Opioid analgesics act on the central nervous system to inhibit activity of ascending nociceptive pathways • NSAIDs decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin) • Local anesthetics block nerve conduction when applied to nerve fibers • Anticonvulsants work by affecting the release of neurotransmitters in the brain and nervous system, which can help reduce pain signals and stabilize nerve activity • Antidepressants modify the pain-processing pathways in the nervous system and treat any underlying mental health conditions that may be exacerbating pain • Dissociative anesthetic modulates pain pathways through N-methyl-D-aspartate (NDMA) antagonism and influence other receptors (e.g., opioid receptors) CHRONIC PAIN: ADVERSE EFFECTS OF PHARMACOLOGIC INTERVENTIONS • Respiratory depression • Sedation • Nausea/vomiting • Constipation • Pruritis • Physical dependence • Tolerance CHRONIC PAIN: ADVERSE EFFECTS OF PHARMACOLOGIC INTERVENTIONS CONTINUED • Physical dependence: • Normal response with opioid use of two weeks or more • Manifested by withdrawal symptoms • Tolerance: • Normal response with regular use of opioid • Decrease in one or more of the effects • Increased usage needed to effect pain relief CHRONIC PAIN: ADVERSE EFFECTS OF PHARMACOLOGIC INTERVENTIONS CONTINUED • Substance use disorder • Impaired use of a substance, even while experiencing major problems • Impaired control over use • Continued use despite harm • Craving for the substance • Use of opioid for nontherapeutic reasons; independent of pain relief • Influenced by genetic, psychosocial, and environmental factors CHRONIC PAIN: NONPHARMACOLOGIC TREATMENT Dependent on cause: • Physical therapy • Cognitive behavioral therapy • Radiofrequency • Cervical, lumbar, sacroiliac joint, knee osteoarthritic pain, etc. • Pelvic floor exercises • Relaxation • Complimentary and alternative medicine • Herbs, chiropractic, massage, yoga, tai chi, acupuncture, etc. CHRONIC PAIN: NURSING MANAGEMENT • Identify goals for pain management • Establish nurse–patient relationship • Education • Provide physical care • Manage anxiety related to pain • Evaluate pain management strategies • Requires a collaborative approach • Must be evidence-based and comprehensive CHRONIC PAIN: ACROSS THE LIFESPAN • Sensitive to agents that produce sedation and CNS effects • Initiate with low dose and titrate slowly • Increased risk for NSAID-induced GI toxicity • Acetaminophen preferred for mild pain • Opioid dose should be reduced 25% to 50% BEWARE OF BIAS • Race • Gender • Developmental Disability • Age https://forms.office.com/r/TBz46a6fAa OSTEOARTHRITIS OSTEOARTHRITIS • Overuse of Joint→ formation of osteophytes→ degenerative changes in joints • Bone on bone • Loss of synovium • Joint space narrowing OSTEOARTHRITIS • Formation of osteophytes (bone spurs) • Proximal interphalangeal (PIP) joints: Bouchard's Nodes • Distal interphalangeal (DIP) joints: Heberden’s Nodes OSTEOARTHRITIS: RISK FACTORS • Aging: age > 60 • Obesity • Genetics • Repetitive injury to joint OSTEOARTHRITIS: SIGNS AND SYMPTOMS • Joint pain and stiffness • Crepitus • Enlargement of joint/hypertrophy • Pain with joint palpation • Loss of function • Limp with ambulation • Heberden’s nodes: enlargement of DIP joints • Bouchard’s nodes: enlargement of PIP joints • Inflammation OSTEOARTHRITIS: LABS AND DIAGNOSTICS • Labs: essentially normal in OA • X-ray: rule out fracture, spinal degeneration • Magnetic resonance imagine (MRI): show soft tissue of back, inter-vertebral disks, spinal cord and spinal nerves • Compute tomography (CT) scan: shows injury/pathology to bone • Electromyography (EMG): measures electrical impulses produced by nerves and muscles • Arthrogram: injection of contrast dye to enhance visualization of joint, bone chips, torn ligaments, or loose bodies OSTEOARTHRITIS: MEDICAL MANAGEMENT Medication Management • Acetaminophen: analgesic/ pain relief • Maximum dose: 3000mg/24 hours when used for long-term chronic management/ risk for liver toxicity • Be aware of acetaminophen in on combination with opiates • NSAID’s: Non-steroidal anti-inflammatory drugs (celecoxib, ibuprofen, naproxen, etc.) • Baseline liver/renal function and CBC required/monitored routinely • Side effects: gastrointestinal bleeding, elevated liver enzymes, renal toxicity • May be used in combination with acetaminophen • Topical NSAID’s (diclofenac patch) may relieve local pain to area, non-systemic OSTEOARTHRITIS: MEDICAL MANAGEMENT CONTINUED • Opioids • Treatment of moderate to severe pain/short term use • Monitor for adverse effects, especially elderly • Capsaicin Ointment: • Derived from hot peppers/avoid contact with eyes • Wear gloves when applying → remove gloves and wash hands • Initial burning when applied will subside • Application of heat over capsaicin could cause skin burn OSTEOARTHRITIS: MEDICAL MANAGEMENT CONTINUED • Lidoderm patch • Topical application • Apply to clean/dry skin • Remove after 12 hours • Intra-articular Injections • Glucocorticoids may be used to treat localized inflammation • Physical and occupational therapy • Exercise for muscle strengthening • Transcutaneous electrical nerve stimulation (TENS) OSTEOARTHRITIS: NURSING MANAGEMENT Assessment: • Pain • Musculo -Skeletal System • Neurologic System • Psycho-social Impact OSTEOARTHRITIS: NURSING MANAGEMENT CONTINUED • Patient Education: • Positioning • Medication management • Activity/Rest • Heat/Ice application • Alternative therapies • Promote independence • Diet: Ideal body weight • Assistive Devices RHEUMATOID ARTHRITIS RHEUMATOID ARTHRITIS • Chronic, inflammatory, and progressive disease • Autoimmune disease: WBC’s attacking the synovial tissue → inflammation extends to cartilage, tends and ligaments around joints → joint deformity and erosion → decreased range of motion and function of the affected joint • Bilateral/symmetrical: affecting multiple joints at once, usually upper joints first • Most commonly manifest the clinical features of arthritis (inflammation of a joint and pain) • Marked by periods of remission and exacerbation RHEUMATOID ARTHRITIS: STAGES • Synovitis – inflammation of synovium • Development of pannus – fibrous connective tissue and the joint space starts to disappear • Ankylosis – bone fusion, severely limited mobility RHEUMATOID ARTHRITIS: RISK FACTORS • Age 20-50 • Female gender • Genetic predisposition • Aging: early signs of RA include fatigue, joint discomfort (often attributed to other disorders) RHEUMATIC ARTHRITIS: SIGNS AND SYMPTOMS • Pain at rest • Morning Stiffness • Fatigue • Joint swelling/pain • Joint immobility /limited movement • Muscle weakness/atrophy • Joint deformity: ulnar deviation, swan neck hands RHEUMATOID ARTHRITIS: LABS & DIAGNOSTICS • Rheumatoid Factor • ESR • CRP • CBC (WBC) • Anti-CCP • X-rays ** Difficult to diagnose RHEUMATOID ARTHRITIS: MEDICAL MANAGMENT • NSAIDs • Usually start with NSAIDs • Provide analgesia and anti-inflammatory effects • Can cause GI distress and bleeding • Steroids • Strong anti-inflammatory effects used in exacerbations • Not meant for long-term treatment • Monitor blood sugar, weight, and blood pressure RHEUMATOID ARTHRITIS: MEDICAL MANAGEMENT • Disease modifying anti-rheumatic drugs (DMARDs) • Slow the progression of RA • Suppresses the immune system’s reaction to RA → decrease pain and decrease inflammation • May take weeks to recognize the effect • Plaquenil/hydroxychloroquine • Methotrexate • Sulfasalazine RHEUMATOID V. OSTEOARTHRITIS SIMILARITIES • Pain • Stiffness • Weakness • Depression DIFFERENCES • RA is warm, OA is cool • Timing: RA worse in am, OA worse with use and as the day progresses • Location: DIP is spared in RA • RA is systemic; OA is localized RHEUMATOID V. OSTEOARTHRITIS RHEUMATIC ARTHRITIS: NURSING MANAGEMENT • Assessment: • Health History • Includes onset and evolution of symptoms • Family history • Past health history • Physical exam and functional assessment • Combination of history and observation • Gait, posture, general musculoskeletal size and structure • Gross deformities and abnormalities in movement RHEUMATOID ARTHRITIS: NURSING MANAGEMENT • Potential diagnoses: • Acute on chronic pain • Fatigue • Impaired physical mobility • Self-care deficits • Disturbed body image • Ineffective coping • Complications secondary to effects of medications RHEUMATOID ARTHRITIS: NURSING MANAGEMENT • Major goals may include: • Relief of pain and discomfort • Relief of fatigue • Increased mobility • Maintenance of self-care • Improved body image • Effective coping • Absence of complications related to disease process or medications RHEUMATOID ARTHRITIS: NURSING MANAGEMENT Pain Fatigue Impaired physical mobility • Provide comfort measures • Administer anti-inflammatory analgesics • Explain energy conserving techniques • Facilitate development of activity/rest schedule • Assess need for PT/OT • Encourage independence in mobility RHEUMATOID ARTHRITIS: NURSING MANAGEMENT Complications secondary to medications • Perform periodic clinical assessment and laboratory evaluation • Provide education about correct self-administration, potential side effects, and importance of monitoring • Counsel regarding methods to reduce side effects and manage symptoms • Administer medications in modified doses as prescribed if complications occur DEGENERATIVE DISC DISEASE DEGENERATIVE DISC DISEASE: PATHOPHYSIOLOGY • DDD is a condition where intervertebral discs lose hydration, elasticity, and structural integrity, leading to pain and mobility issues • Disc dehydration and loss of proteoglycans leading to decreased disc height and elasticity • The nucleus pulposus changes losing hydration and reducing its shock-absorbing capacity • Microtears or annulus fibrosus degeneration may occur causing inflammation and pain • As the disc degenerates, vertebral bone spurs (ostephytes) may form, causing nerve compression DEGENERATIVE DISC DISEASE: ETIOLOGY Aging Genetic predisposition Trauma/injury Lifestyle factors • Natural wear and tear on spinal discs due to aging processes • Genetic factors may influence disc structure and degeneration rate • Previous spinal injuries can accelerate disc degeneration • Smoking, obesity, and sedentary lifestyle can worsen disc health DEGENERATIVE DISC DISEASE: RISK FACTORS • Age • Most common in individuals over age 40 • Gender • Slightly more common in men, but affects both genders • Occupational factors • Jobs involving heavy lifting, bending, or prolonged sitting • Obesity • Increased weight adds stress to intervertebral discs • Genetics • Family history can predispose individuals to early degeneration DEGENERATIVE DISC DISEASE: SIGNS AND SYMPTOMS • Pain • Low back pain or neck pain often radiating to the extremities • Numbness and tingling • From nerve compression • Muscle weakness • Due to nerve involvement • Reduced mobility • Stiffness, difficulty bending, twisting, or sitting for prolonged periods • Pain aggravated by movement • Pain often worsens with activity or prolonged sitting DEGENERATIVE DISC DISEASE: LABS AND DIAGNOSTICS • Physical examination • Assessing range of motion, neurological symptoms, and pain response • Imaging studies • X-ray to identify disc space narrowing and osteophytes • Magnetic resonance imaging (MRI) for detailed visualization of disc structure, nerve compression, and soft tissues • Computed tomography (CT) scan provides additional details on bone structures and can help detect herniated discs • Electrodiagnostic studies • Nerve conduction studies or electromyography to assess nerve involvement DEGENERATIVE DISC DISEASE: MEDICAL MANAGEMENT Medications NSAIDS for pain and inflammation Muscle relaxants to reduce muscle spasms Corticosteroid injections to reduce inflammation around nerve roots Analgesics for severe pain Physical therapy exercises to strengthen muscles and improve flexibility Surgical interventions if conservative treatment fails Discectomy, spinal fusion, or artificial disc replacement DEGENERATIVE DISC DISEASE: NURSING MANAGEMENT • Assessment • • • • • Pain level Mobility Neurological function Response to treatment Pain management • Administer prescribed medications • Use non-pharmacological methods like heat/ice • Educate about posture and body mechanics • Patient education • • • Importance of weight management, exercise, and smoking cessation Instruction on safe lifting techniques and ergonomic modifications Rehabilitation Support • Assist with physical therapy routines and mobility aids as needed KNOWLEDGE CHECK https://forms.office.com/r/95SXWee3xw APPLICATION ACTIVITY HTTPS://FORMS.OFFICE.COM/R/PEGR8KE6A4
