31 Pain, comfort, and sleep

Question 1

Gate control theory

Answer 1

Pain transmission is viewed as being controlled by a gate mechanism in the CNS. Opening the gate allows the transmission of pain sensation, and closing the gate blocks the transmission

Question 2

Endorphins

Answer 2

endogenous, naturally occurring, opiate-like peptides that reduce or block the perception of pain; comes from the words morphine and endogenous

Question 3

Nociceptive pain; found where; examples

Answer 3

involves injury to the tissue where nociceptors are located; found in skin, joints, or organ viscera; trauma, burns, surgery

Question 4

Nociceptive pain involves four phases

Answer 4

transduction, transmission, perception, modulation

Question 5

Transduction phase

Answer 5

begins when tissue damage causes the release of substances that stimulate the nociceptors and start the sensation of pain

Question 6

Transmission phase

Answer 6

involves movement of the pain sensation to the spinal cord

Question 7

Perception phase

Answer 7

occurs when pain impulses reach the brain and the pain is recognized

Question 8

Modulation phase

Answer 8

occurs when the neurons in the brain send signals back down the spinal cord by release of neurotransmitters

Question 9

Neuropathic pain

Answer 9

usually associated with a dysfunction of the nervous system- specifically, an abnormality in processing sensations

Question 10

Examples of neuropathic pain

Answer 10

pain receptors in the body become sensitive to stimuli and send pain signals more easily. Nerve endings grow additional branches that send stronger pain signals to the brain. As branches grow they influence touch and warmth receptors, these receptors began to send pain signals. In some cases (DM, Guillanin- Barre syndrome, MS, cancer, HIV, and nutritional deficiencies) the pain signal that normally moves from the periphery toward the brain reverses and is sent in the opposite direction

Question 11

Type of pain pt is experiencing will help determine what

Answer 11

best method to relieve pain

Question 12

Standards relative to direct pt care state:

Answer 12

-pt has right to appropriate assessment and management of pain
-pain is assessed in all pt’s
-pt’s are educated about pain and managing pain as part of treatment, as appropriate
-discharge process provides for containing pain care based on the pt’s assessed needs at the time of discharge

Question 13

How treatment differs per type of pain (acute and chronic)

Answer 13

-acute pain is usually well controlled with analgesics or surgery
-chronic pain is usually treated with pharmacologic and nonpharmacologic treatments

Question 14

cause of acute pain is often easily _____

Answer 14

determined

Question 15

acute pain may be accompanied by an increase in what

Answer 15

increased: heart rate, bp, rr

Question 16

acute pain relieved by

Answer 16

rest of affected part, medications for infections and inflammations

Question 17

What’s the issue with taking pain medications before seeing the dr

Answer 17

can mask symptoms that the dr needs to observe to establish a diagnosis

Question 18

Acute pain is often a warning of this; what does it allow

Answer 18

potential or true tissue damage; allows pt to withdraw from the source or to seek help in relieving symptoms

Question 19

How is pain transmitted

Answer 19

to the brain through the nervous system- afferent (sensory) neurons leading to the spinal nerves and then to the brain

Question 20

Gate theory: how do the small and large diameter nerve fibers differ

Answer 20

-gate may be opened by activity in the small-diameter from things like tissue damage.
-large-diameter nerve fibers such as massage or vibration seem to close the gate

Question 21

What’s a possible reason people who are bored and lonely seem to have more intense pain than when they are occupied or distracted by visitors or an interesting program or activity

Answer 21

brainstem impulses caused by a high sensory input seem to close the gate, where a lack of this input allows the gate to open

Question 22

Chronic pain maybe expresses as this type of pain ___; and be treated with _____ and _____ interventions

Answer 22

-dull, constant, shooting, tingling, or burning
-both pharmacologic and nonpharmacologic interventions

Question 23

5 types of pain

Answer 23

acute
nociceptive
chronic
phantom
neuropathic

Question 24

Treatment of nociceptive pain may be directed towards-

Answer 24

one or all four phases

Question 25

NSAIDs work by

Answer 25

blocking the production of the substances that trigger the nociceptors in the transduction phase

Question 26

Drugs that interfere with the transmission phase

Answer 26

opioids

Question 27

Phase where nonpharmacologic treatments may be effective- such as guided imagery

Answer 27

perception phase

Question 28

Drugs that block the neurotransmitter uptake work in this stage

Answer 28

modulation

Question 29

Phantom pain may be controlled by (when conventional methods do not work)

Answer 29

continuous electrical stimulation from electrodes surgically implanted in the thalamus

Question 30

Why an older person might not express pain; what they may say instead

Answer 30

-they may believe it’s a logical consequence of aging
-they do not want to be a bother
-because they have been culturally trained not to complain
–aching, soreness, discomfort, stiffness rather than pain

Question 31

Neuropathic pain treated with (4)

Answer 31

NSAIDs, tricyclic antidepressants, anticonvulsants, or corticosteroids

Question 32

An illness that usually occurs after a mild viral infection such as a sore throat, or flu, or after vaccination or surgical procedure

Answer 32

Guillain-Barre syndrome

Question 33

How can fear and apprehension affect pain; what nonpharmacological treatment might relieve pain

Answer 33

may accelerate pain; relaxation

Question 34

Focused assessment: What to ask; Hx of pain

Answer 34

-events of factors that precipitate the pain
-location
-radiation
-intensity
-quality (what the pain feels like)
-aggravating factors
-relieving measures
-past: episodes, successful treatments, surgeries

Question 35

Focused assessment: What to ask; Medications

Answer 35

past and present treatment - Rx’s, otc’s, herbal, alcohol or drug use

Question 36

Focused assessment: verbal indicators

Answer 36

the severity of pain (pain scale), words used to describe pain, moaning, crying, as well as timing of when the pain began and whether it has changed

Question 37

Focused assessment: What to observe; nonverbal indicators

Answer 37

grimacing, guarding, splinting, evident muscle tension, pacing, rocking, fetal positioning, wincing, inability to sleep, restless movements, and withdrawal from others

Question 38

Focused assessment: What to ask; social or psychological factors

Answer 38

fear or anxiety, extreme stress, worry, or depression

Question 39

Focused assessment: What to ask; treatments used

Answer 39

medications, heat/cold, massage, vibration, acupuncture, chiropractic adjustment, brace or splint

Question 40

Focused assessment: What to ask; contributing factors

Answer 40

constipation, sleep deprivation, fatigue, constant cough, rash, GI upset, or reflux

Question 41

For confused pt- watch for these nonverbal cues

Answer 41

restlessness, rocking, pacing, rigidity, guarding, wincing, crying, grimacing with movement, new inability to sleep, hypersensitivity to touch, withdrawal from usual contact with others, moaning, or grunting

Question 42

TENS; brief description

Answer 42

transcutaneous electrical nerve stimulation; small electrical stimulator attached to electrodes to block pain

Question 43

TENS is more effective in treatment of chronic or acute pain

Answer 43

chronic

Question 44

PENS; brief description

Answer 44

percutaneous electrical nerve stimulation; electric current sent through thin needle probes positioned in the soft tissues and muscles of the back, series of intermittent treatments using the electric current are given

Question 45

Biofeedback is a specialized relaxation technique using a machine that measures this

Answer 45

the degree of muscular tension with electrodes

Question 46

Medical methods of pain control (4)

Answer 46

analgesic medications, patient-controlled analgesia, epidural analgesia, implantable pumps

Question 47

analgesic medication options; routes; examples

Answer 47

-oral- mild to moderate to severe (time-released morphine)
-topical- various preparations; gel, cream, patch (Lidoderm patch for neuropathic pain, Fentanyl for severe chronic pain)
-injected; IM or Subcut, usually for severe pain (usually for a relatively short period of time), lasts several hours, painful for pt, prolonged use detrimental to the tissues
-IV- given as a bolus (concentrated dose given rapidly), a slow push (over a few min), as an intermittent infusion, or by continuous infusion

Question 48

Patient-controlled pump (PCA); what benefit does this provide to the pt

Answer 48

-the most common method used for injectable opioids in acute care
-PCA reduces pt anxiety about the pain by putting pt in control, pt’s typically use less medication

Question 49

Epidural analgesia; where inserted; benefit of this type of analgesia

Answer 49

-thin catheter in epidural space near the base of the spine connects the catheter to a small battery-operated programmable pump
-this method is effective in controlling pain while allowing pt to remain alert

Question 50

Implantable pump; what type of pain; how it is implanted and when it’s refilled

Answer 50

-pt’s with chronic severe pain
-small pump implanted and attached to an intraspinal catheter providing long-term pain relief
-pump is placed in the subcutaneous tissue of the abdomen, the attached catheter is threaded intrathecally
-pump refilled every 30-90 days (depending on flow rate/ reservoir size)

Question 51

Categories of analgesic medications (4); mode of action; examples

Answer 51

-nonopioid analgesics, including NSAIDs; Block pain at the peripheral nervous system level; otc’s like aspirin, naproxen, ibuprofen, acetaminophen & Rx ibuprofen, naproxen, indomethacin
-COX-2 inhibitors; Block the COX-2 enzyme, which plays a role in arthritis pain; anti-inflammatories- celecoxib is currently the only FDA-approved COX-2 inhibitor
-narcotics or opioids; Block pain at the CNS level; Narcotic agonists- morphine, oxycodone, hydrocodone, hydromorphone, codeine, levorphanol, oxymorphone, and meperidine (used less frequent due to side effects)
-adjuvant analgesics; various methods of action; Anticonvulsants: phenytoin, carbamazepine
Antidepressants: amitriptyline, imipramine, SSRIs
Muscle relaxants: baclofen
Stimulants: caffeine, dextroamphetamine

Question 52

NIPS; PIPP

Answer 52

Neonatal Infant Pain Scale; Premature Infant Pain Profile scale

Question 53

Benefits of adequate rest in regards to analgesia

Answer 53

Increases pain tolerance and allows improved response to analgesia

Question 54

Stage of sleep when hr, bp, respirations are similar to that when awake

Answer 54

REM

Question 55

During the night person will go through how many sleep states in 90-min cycles; repeats how often

Answer 55

two; 5-6x a night

Question 56

four stages of NREM; activity; lasts

Answer 56

-transition stage; light sleep, relaxed muscles; few min
-stage 2; deeper sleep, larger brain wave activity w/ bursts of electrical activity; 10-20 min
-stage 3; delta sleep or slow-wave sleep, rr and hr slow, body becomes immobile, dreaming; 20-40 min
-stage 4; deepest stage, difficult to arouse the sleeping person; 30 min

Question 57

Sleep needs: Newborn, age 1, preschool, school-age, adolescents, adults

Answer 57

16hrs; 12-14hrs; 11-13 hrs; 10-11 hrs; 9-10 hrs; 8 hrs

Question 58

transient insomnia

Answer 58

caused by stress, excitement, or change in sleeping arrangements

Question 59

chronic insomnia root

Answer 59

may be underlying medical, behavioral, or psychiatric problem (like depression)

Question 60

Adults with sleep apnea have an increased risk of; infants with sleep apnea have an increased risk of

Answer 60

heart attack; SIDS