Pain Evaluation and Treatment Plan - Essay Example

Pain evaluation and treatment plan Pain evaluation and treatment plan Pain evaluation and treatment plan Different types of post-operative pain inamputation Pain management following amputation varies from person to person depending on each incident which led to the amputation. Here the focus is on a patient with diabetic neuropathy who had below-the-knee amputation. Every patient with amputation has had pain of some sort positively in the post-operative period which is usually neuropathic pain (Nelson-Hogan, 2007). The immediate post-operative pain is similar in all surgeries where muscles, bones, nerves and skin are incised. The pain subsides following drug therapy. This pharmaceutical treatment controls the pain which subsides speedily along with the inflammatory swellings, healing of tissues and stabilization (Jeffries, 1998). Research has indicated that early intervention helps to reduce the risk of chronic pain of amputation. Surgeons now have the tendency to use pain medication during the immediate post-operative period. Continuous post-operative epidural analgesia, an anesthesiological intervention, is another effective treatment. Narcotics and non-narcotic analgesics may be used in reducing dosages till the pain subsides. Patients with phantom limb pain when diagnosed must be referred to a center with comprehensive pain management (Jeffries, 1998). Tingling, warmth, cold, cramps, constriction or other sensations could trouble the patient from the area which had the limb (Jeffries, 1998). This is the phantom limb sensation which is mainly a cortical phenomenon (Nelson-Hogan, 2007). Children who never had a limb also report similar stories. It is important to differentiate pain in a phantom limb from a stump or residual limb pain. The number of amputees who have experienced phantom pain is 60-70% of them. After a year, 40 % is still distressed by pain. The pain reduces in frequency with the passage of time. Usually this pain is resistant to treatment and equally frustrating to the patient and medical fraternity (Jeffries, 1998). Management for phantom limb pain could include cognitive behavior treatment or more precisely, thermal biofeedback, to convince the patient that such a pain could not occur as there were no limb in that position. The brain which recognizes this absent limb would soon lose the feeling. The residual limb pain is due to the enormous disruption of tissue in surgery (Jeffries, 1998). Pain in the residual limb could also be due to mechanical factors like a new prosthesis or a poorly fitting one, injury to the limb, a neuroma in an area not protected, mechanical rubbing of the skin and other mechanical causes. Myofascial Pain Syndrome of the shoulder is one cause of pain especially when a heavy prosthesis is being used in the lower extremity (Nelson-Hogan, 2007). Orthotic experts could help in the relief of this syndrome. In diabetics, the pain could be answered by the poor circulation or neuropathy. Both cause the limb to heal badly and slowly. The neuropathy further causes a reduction in sensation which allows the residual limb to be mechanically injured frequently with delayed healing (Jeffries, 1998). The possibility of gangrene continuing its fatal process may also be thought about in post-operative pain in diabetic neuropathy, especially if the initial indication for amputation had been gangrene. If this were the reason for the pain, more surgery may be indicated for amputation at a higher level. Acute pain from an abdominal hysterectomy Pain after abdominal hysterectomy can be due to many reasons: incision pain, pain from deeper visceral structures and dynamic pain during straining, coughing or movement, which can be severe (Gupta et al, 2004). Visceral pain would be severe for 48 hours. This pain must be assessed by the Visual Analogue Scale if necessary and then pain relief may be checked later with the same scale. Moderate to severe pain is related to abdominal hysterectomy whether salpingo-oophorectomy has been done or not (Ng et al, 2002 cited in Gupta et al, 2004). Pharmaceutical treatment is the first line of management. Narcotics or opioids like morphine could be given as a patient-controlled analgesia (PCA). The pain is usually relieved by this. Large quantities could produce symptoms like nausea, vomiting and fatigue (Gupta et al, 2004). Drowsiness could occur and inhibit mobility. Wound hyperalgesia occurs due to both spinal and central excitation. Spinal excitation for pain occurs when excitatory amino acid transmitters activate the dorsal horn NMDA receptors (N methy D aspartate). The opioids act by depressing the spinal excitation by inhibition of the initial wide dynamic range response of the dorsal horn neuron to “incoming nociceptive C-fiber volleys” (Wilder-Smith et al, 1998). Fentanyl and Magnesium and ketamine when used with general anesthesia all suppressed spinal excitation and reduced the use of opioid drugs to treat postoperative pain (Wilder-Smith et al, 1998). Etoricoxib, an oral non-steroidal anti-inflammatory drug and a selective COX-2 inhibitor, is another drug which can be given in a single dose (120mg or 180 mg) before anesthesia in order to reduce the dose of morphine after surgery for pain (Chau-in et al, 2008). Meloxicam, another non-steroidal drug and a COX-2 inhibitor given as 15 mg. rectally, helped to reduce the pain after surgery but failed to reduce the usage of morphine (Thompson et al, 2000). Local anesthetic infiltration could reduce postoperative pain to a limited extent. Subcutaneous infusion or intraperitoneal injection of anesthetic could also help. These infiltrations act only for about 4 hours. The intraperitoneal injection of this anesthetic has the advantage of an opioid-sparing effect for 4-24 hours (Gupta et al, 2004). Levobupivacaine has been found to be an effective intraperitoneal anesthetic (Gupta et al, 2004). Postoperative nausea was reduced with this anesthetic but not post- operative vomiting. Advising the patient can reduce the dynamic pain that results from movement. Telling the patient to hold the abdomen while changing position in bed is one advice that could help prevent pain. Adjusting the intake of food to semi-solids or liquids could be another. Persistent pain could signify a mistake somewhere during the operation. Investigations like an X-ray or abdominal scan could reveal an instrument or swab left behind or a bleeder or some other surgical problems. Another surgery may be done if the necessity arises. Non migraine headaches These could be a primary tension headache or secondary headaches caused by tumor or stroke or fasting (Young and Silberstein, 2004). Treatment will depend on what the cause of the headache is. Tension headache caused by the stresses of life may be treated by a few of the suggestions which follow: cessation of smoking, aerobic exercise for 20 minutes for four days per week and walking if aerobic exercise is not tolerated. Exercise reduces tension and anxiety and refreshes the mind. Energy level will be improved and the ability to focus is increased. Headache sufferers benefit from exercise, good healthy practices, regular meals, proper sleep and customary practices (Young and Silberstein, 2004). Exercise and movements increase the release of endorphins by the brain. These natural hormones fight pain and the headache. Severe headaches can be a problem if arising due to a psychological reason. Where stress is the trigger, biofeedback and relaxation can help. These patients require a combination of medicines and a psychological management plan. Family involvement would play a great role if the relationship among the members is good (Young and Silberstein, 2004). Acute headaches may subside with non-steroidal anti-inflammatory drugs as pharmaceutical treatment if moderate in nature; severe headaches may require Triptan. Headaches can be prevented by 50-75mg of Amitryptiline, a tricyclic anti-depresssant. Better results are obtained when beta blockers are combined with anti-depressants (Chronic daily headaches, Mayo Clinic). Non- steroidal anti- inflammatory drugs are preferred when withdrawing from other pain relievers. Occasionally a local anesthetic injection around a nerve helps. People with frequent headaches may require a combination of the exercise, sleep, regular practices and meals along with non-steroidal drugs and psychological therapy like biofeedback. Investigations and surgery may be indicated in headaches caused by tumors or strokes (brain surgery or cardiac surgery). If fasting is the cause, breaking of the fast adequately and rehydration and feeding of the patient must be done. Considering that pain management mostly adopts a combination of treatments and the choice varies based on the cause of pain, patients with chronic pain or headache would benefit from any hospital which provides all the options for chronic pain management. References: Chau-in, W., Thienthong, S., Pulnitiporn, A, Tanatanatewin, W, Prasertcharoensuk, W. and Sriraj, W. (2008). Prevention of postoperative pain after abdominal hysterectomy by single dose Etoricoxib. Chronic daily headaches, Retrieved on 21/12/09. http://www.mayoclinic.com/health/chronic-daily-headaches/DS00646 Mayo Foundation for Medical Education and Research Gupta, A., Perniola, A., Axelsson, K., Thorn, S.E. Crafoord, K. and Rawal, N. (2004). Postoperative pain after abdominal hysterectomy: A double blind comparison between placebo and local anaesthetic infused intraperitoneally. Anesthesia Analgesia, Vol. 99, p. 1173-1179 Jeffries,G.E. (1998). Pain Management Post amputation pain, In Motion Vol. 8, Issue 2, Amputee Coalition America Nelson-Hogan, D. (2007). Diagnosis and treatment of post-amputation pain. The Pain Practitioner, Fall 2007, Vol. 17, No. 3. Thompson, J.P., Sharpe, P., Kiani, S. and Owen-Smith, O. (2000). Effect of meloxicam on postoperative pain after abdominal hysterectomy. British Journal of Anaesthesia, Vol. 84, No. 2, p. 151-154 Wilder-Smith, O.H.G., Arendt-Nielsen, L.,Gaumann, D. Tassonyi, E. and Rifat, K.R. (1998). Sensory changes and pain after abdominal hysterectomy: A comparison of anesthetic supplementation with fentanyl Versus magnesium or Ketamine. Anesthesia Analgesia, Vol. 86, p. 95-101 Young, W.B. and Silberstein, S.D. (2004). Migraine and Other Headaches. 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