ATI SKILLS-PAIN MANAGEMENT Flashcards
Medication Tolerance
Definition
Reduced reaction to a medication when it has been taken over a period of time.
There are objective and universally applicable ways to confirm the existence of pain
True or False
False
Pain occurs on a regular schedule when analgesics are due to be administered.
TRUE OR FALSE
False
Pain
definition
an unpleasant experience associated with tissue injury and with emotional and sensory perceptual components
What blurs the lines as to the definition of pain?
Factors at play such as individual perception, communication, and endurance.
Analgesics
definition
Medications that reduce or relieve pain, including OTC and Rx Medications
What factors affect a client’s pain response and how they communicate the pain?
physical, emotional, cognitive, developmental, and cultural aspects
pain threshold
definition
the point at which a person perceives pain
pain tolerance
definition
the level of pain a person is willing to endure
What is the most reliable indicator of the presence and intensity of pain
the client’s self report
nociception
definition
incorporation of the physiologic processes associated with pain perception
What are the physiologic processes associated with pain perception
transduction
transmission
perception
modulation
transduction
definition
sensory neurons detect tissue damage through neurotransmitter sensitization of nociceptors
NSAIDs
definition
pain medications that work in the transduction process by blocking the production of substances at the site of injury, such as prostaglandin
Transmission
definition
a pain impulse is transmitted from the peripheral nerves to the spinal cord, brainstem, thalamus, and finally to the somatic sensory cortex where the impulse is perceived as pain
what medications are used to inhibit the pain transmission process
opioids
opioid
definition
naturally occurring or synthetic compounds that bind to opioids receptors of the central nervous system, usually used as analgesic agents
perception
definition
a person’s conscious awareness of the pain perception
what nonpharmacological interventions can be used to reduce the perception of pain
distraction
guided imagery
music therapy
modulation
definition
pain is modulated as descending regulatory mechanisms help prevent continuous transmission of pain signals
what medications are used to modulate pain and how do they do this
adjuvant medications such as tricyclic antidepressants by promoting reuptake of endorphins
What is the gate control theory
suggestion that pain varies with the balance between the non-nociceptive information traveling to the spinal cord through large nerve fibers and the nociceptive info traveling to the spinal cord through small nerve fibers.
in the gate control theory, what should happen if the large nerve fibers are more active than the small nerve fibers
the person should have little to no pain
how is the gate opened in the gate control theory
when there is more activity in the small nerve fibers, those nerve fibers activate projector neurons and block the inhibitory neurons
pain by duration is what
acute or chronic
acute pain
- is of a protective nature
- identifiable cause
- recent onset
- tissue injury
- short duration
- resolves as damaged tissue heals
what does acute pain trigger
a sympathetic nervous response with increases in hr, rr, and bp. also see diaphoresis, pallor, dry mouth, restlessness, nausea, anxiety, and interuption of normal physiologic processes.
chronic pain
- constant or intermittent
- 3+ months in duration
- sometimes no cause/explanation
- sometimes the cause is chronic (cancer)
- interferes with functioning
- stabilized vs during early stages
psychologic results of chronic pain
client becomes discouraged, depressed, and withdrawn. some become suicidal.
physiological responses to chronic pain
pain reducing substances like endorphins become depleted. pain signals are processed more expediently thus potentiating the painful stimulus. pain experiences stored in the cerebral cortex increasing the clients response to pain
pain by etiology
cancer pain
burn pain
cancer pain
- not all clients with cancer experience pain
- often cannot find relief
- usually due to tumor progression
burn pain
- one of the most severe acute pains
- inflammatory response makes pain intense with any manipulation of the injry
- pain management must be dynamic as the character of the pain shifts over course of recovery.
pain by pathology
nociceptive pain
neuropathic pain
nociceptive pain
pain that arises from damage to or inflammation of tissues other than that of the peripheral and central nervous system
types of nociceptive pain
somatic (musculoskeletal)
visceral (internal organ)
neuropathic pain
arises from abnormal or damaged pain nerves. often described as burning, tingling, numbness, or shooting down an arm/leg. Responds poorly to analgesics like opioids or nsaids.
how to treat neuropathic pain
anticonvulsants
antidepressants
local anesthetics
idiopathic pain
chronic pain that persists in the absence of a detectable cause
ex. phantom pain
referred pain
originates in one place but is felt in another location far from the pain’s origin
ex. gall bladder pain being felt under the right shoulder pain
radiating pain
perceived at the source and in tissues that are adjacent to the source
intractable pain
defies relief like with advanced malignancies
ethnic background and cultural effects on pain
- pain can be viewed as a negative experience (keep to themselves)
- expressing pain can bring dishonor to the individual/family
- can be part of ritualistic practices- may be taught that being stoic is a sign of strength
guiding principles in pain management in relation to culture
- use assessment tools appropriate to clients primary language
- be sensitive to the meaning of pain in their culture
- avoid stereotyping
- encourage client to tell their stories about pain
- don’t allow your beliefs to influence
- explore fold remedies
pain in infants
- cannot verbalize the specifics
- respond by crying or withdrawing
- behavioral observation is recommended way to assess
toddler and pain
- most can describe location and intensity
- often express by crying or anger
- view pain as threat to their securities
- may associate pain with punishment
pain in school aged children and adolescents
- may view expression as a weakness or lack of bravery
- tendency not to acknowledge right away
- might try to rationalize pain
- if in persisten pain, often tend to regress to an earlier stage of development
pain in adults
- influenced by how they learned to express pain as a child
- often reluctant to express pain because it symbolizes weakness
- may not express because there is a fear of something wrong with their body, afraid of treatment, afraid of required lifestyle changes
pain in the elderly
- may not express if afraid of losing their independence
- some believe pain is a part of the aging process
- impaired perception of pain
gender expectations regarding pain
- males are told to be brave and tough and tolerate pain making them afraid to express
- females taught that showing pain or crying when hurt is acceptable
why is pain control important
improved pain control allows the client to get up sooner, breathe deeper which prevent a variety of complications like pneumonia or thromboembolism
how do you effectively manage pain
assess, understand, and treat the pain and then reassess on an ongoing basis. every client has a right to pain assessment and treatment
when do iv medications peak
within 30 minutes
when do oral medications peak
within 1 hour
if the client has pain, what do we need to find out
intensity, quality, location, timing, onset, duration, frequency, symptoms, treatment, effects on ADLs
PQRST
- provoked- cause/better/worse
- quality- what does it feel like
- region/radiation- where/local/spreading
- severity- pain scale
- timing- start/frequency/ intermittent/continuous
numeric rating scale (NRS)
0-10
0-no pain
1-3 mild
4-6 moderate
7-10 severe
Visual Analog Scale
VAS
no numbers, but client rates from none to worst possible. suitable with older children and adults. point to a number line with no numbers
image or pictorial scale
presents a series of faces
great for young children, those with cognitive difficulties, or those that do not speak the same language
FACES pain rating scale
AKA Wong Baker scale
6 cartoon like drawings
pictorial scale type
oucher pain scale
another pictorial scale
facial expressions from neutral to extremely distressed
available in several ethnic variations
assessment of pain when a client cannot communicate
- see if diagnosis usually causes pain (objective data)
- assess for possible causes
- look for behavior that indicates pain (objective data)
- other behaviors that indicate pain like combativeness or refusing care (objective data)
- ask opinions of family members (subjective, second party data)
- check for physiologic responses like elevated hr or rr (objective data) just remember pain can continue in the absence of vs changes
considerations for pain asessment in infants and children
- must assess frequently
- parents expect pain will be prevented and treated quickly.
- unrelenting crying can be associated with abuse
- assessment can be challenging
- parents know their child best
- providing care can cause them pain like vaccines and taking blood samples
what are the long term consequences of pain in infancy
neurological development, pain sensitivity, emotional and behavioral development and learning
CRIES pain scale
uses score of 0-2 in five categories for infants
* crying
* increase in oxygen requirement from baseline
* increase in vital signs from baseline
* expression on face
* sleeping
FLACC pain scale
- ages 2 months to 7 years
- used when child cannot express pain verbally
- 0-2 in each category
- parents can use
- facial expression
- leg movement
- activity
- crying
- consolability
what is the most important info when assessing a child for pain
what the child tells you if they can communicate verbally. if not, use a behavioral or other tool appropriate to development and communication abilities
at what age can a child generally rate their pain
3 years and older
what are behavioral changes that indicate a child is in pain
- activity level, appearance, behavior, and vs
- remember language, ethnic background and culture can affect how the child expresses pain
bias in assessment of pain
- must be free of biac, preconceived notions, and misconceptions about pain and pain relief
myths about clients who have a history of substance use disorder
things that are NOT true
- are already self medicated
- do not require analgesia
- tend to overreact/exaggerate
- are drug seekers
- are not truthful about perception of pain
other myths regarding pain
- administering analgesics/opioids will lead to addiction
- clients with minor issues have less pain than those who have major alterations
- hospitalized clients should expect to have pain
- chronic pain is psychological
- if they don’t complain, they don’t have pain
- if unconscious/asleep, they do not have pain
myths about pain
(continued)
- infants/newborns do not feel pain
- those with dementia cannot feel pain
- Tx is not necessary if they have cognitive impairment
- irreversible/uncontrolled pain is a part of aging
- exaggerated reports of pain are common among those over 65
- strong analgesics should not be used for older adults
what kind of relationship should we develop with clients and why
as applicable to pain
a therapeutic relationship that incorporates teaching and encouraging them to report pain early. you want them to tell you before the pain goes beyond the mild stages so you can offer interventions and avoid progression
clients have the right to expect their health care team will
- be committed to preventing/managing their pain
- share info with them about pain and pain relief
- respect their reports of pain and respond appropriately
- consult with pain management experts
client responsibilities regarding pain management
- ask for pain relief sooner rather than later
- work with hc team to develop pain management plan
- help the hc team evaluate pain and effectiveness of interventions
- share info/concerns they have about pain meds
basic essential for guiding pain management
- always believe the client
- the client is entitled to adequate pain relief (basic hum and legal right)
- pain is an urgent situation
- base interventions on the clients pain relief goals
- use analgesics as prescribed
- incorporate alternative therapies when possible
- work with other hc team members
- evaluate effectiveness
- prevent/minimize side/adverse effects of analgesia
- educcate client and family about pain and pain management
titration
definition
increasing/decreasing amounts of pharmaceutical agents to determine a therapeutic level or effect
what does the joint commission require documentation of in regards to pain
regular pain assessment
all pain management interventions
reassessment of the response to interventions
how should nonpharmacological interventions be viewed in pain mangement
as approches to pain relief that increase the effectiveness of analgesic meds. they should work together
examples of nonpharmacological interventions
relaxation
distraction
cutaneous stimulation like thermal therapies, massage, accupressure, transcutaneous electrical nerve stimulation (tens)
guided imagery
hypnosis
biofeedback
music therapy
exercise
control the environment
progressive muscle relaxation
systematic approach to release tension in major muscle groups.
technique to relieve tension by contracting and relaxing particular muscles
cutaneous stimulation
techniques that refocus clients attention on tactile stimuli rather than painful sensations. skin triggers release of endorphins.
equipment for providing a massage
lotion/lubricant
towel
ppe
sequence for providing a massage
- check emr for contraindications
- provide analgesia if needed
- hand hygiene, id client, explain procedure
- lotion/lubricant in warm water or warm it in hands
- apply ppe
- observe for reddened skin or lesions
- use smooth strokes and various strokes based on client preference
- dry the skin
- remove ppe, hand hygiene
- reposition client
- document
transcutaneous electrical nerve stimulation (TENS)
delivers mild electric current over painful region via electrodes applied to the skin to reduce pain perception
biofeedback
involves collecting data about physiologica responses of the autonomic nervous system to varaious thoughts, feelings and stimuli like temp, muscle tension, and brain waves. helps learn how to adjust and control body responses.
nontradition pain therapies
herbal remedies, therapeutic touch, chelation, reflexology, magnetic therapy, and homeopathy
complementary therapies
treatment approaches used to complement conventional medical Tx
three categories of meds to manage pain
nonopioids
opioids
adjuvents
nonopioids
do not contain narcotics
physical dependence
adaptive state characterized by a medication class specific withdrawal syndrome induced with abrupt cessation, rapid dose reduction, or administration of an antagonist
WHO’s analgesic ladder for treatment of pain
- step 1: non opioid- +/- adjuvant
- step 2: opioid for moderate pain +/- non opioid +/- adjuvant
- step 3: opioid for moderate to severe pain +/- non opioid +/- adjuvant
acetaminophen indications
minor aches and pains
fever
acetaminophen adverse reactions
rare
liver injury from overdose
ibuprofen indications
mild to moderate pain
arthritis
menstrual pain
fever
ibuprofen adverse effects
gastrointestinal upset
bleeding
aspirin indications
headache
mild pain
inflammation
fever
in low doses –> supresses platelet aggregation
aspirin adverse effects
gastrointestinal upset
bleeding
renal impairment with excessive use
ketorolac indications
moderate to severe pain
short term use only
ketorolac adverse effects
gi upset
bleeding
renal impairment
celecoxib indications
arthritis
acute pain
menstrual pain
celecoxib adverse effects
gi upset
abdominal pain
possible cardiovascular effects
nonopioid medications examples
acetaminophen
ibuprofen
aspirin
ketorolac
celecoxib
adjuvant medication examples
anticonvulsants
antidepressants
corticosteroids
anticonvulsant examples
carbamazepine
clonazepam
gabapentin
anticonvulsants considerations
used for chronic neuropathic pain. requires monitoring of blood levels and titration. may require trials to determine the best choice with the fewest adverse effects
antidepressants examples
duloxetine
amitriptyline
antidepressants considerations
used for chronic neuropathic pain
may require trials to determine best choice with fewest adverse effects
corticosteroids examples
dexamethasone
prednisone
corticosteroids considerations
used for anti inflammatory effect. cannot be given simultaneously with NSAIDs
opioids for moderate to severe pain
morphine
butorphanol
oxycodone
opioids for cough and mild to moderate pain
codeine
opioids for moderate pain
hyydrocodone
opioids for severe pain
hydromorphone
fentanyl
mild pain
- 0-3 rating
- treated with nonopioid meds
- have analgesic ceiling
analgesic ceiling
the point at which the medication has reached its peak effect and additional amounts of the same medication will have no additional effect
mild to moderate pain
- 4-6 rating
- combo of nonopioid and opioid meds with adjuvant prn like acetaminophen and hydrocodone
difference in nonopioids and opioids on Tx of pain
nonopioids act locally to reduce pain and inflammation while opioids act on higher centers of the brain and spinal cord to modify perceptions of pain
severe pain
- 7-10 rating
- treated with opioids plus adjuvants prn
opioid monitoring
- given in scheduled doses
- can cause serious adverse effects like respiratory depression
- diligent monitoring is crucial
route of analgesic administration
- oral is preferred
- if need for immediate relief or for the dose to be titrated, may be prescribed intravenous
- intramuscular
patient controlled analgesia (pca)
medication delivery system that uses a computerized pump with a button that the client can press to deliver a dose through the iv catheter
intramuscular route of analgesic administration
- least preferable
- erratic absorption
- risk of tissue damage
- espcially avoided in children
- for clients who cannot swallow but do not need iv dosing
scheduling of analgesic administration
- prn is acceptable for intermittent pain
- continuous or chonic pain indicates around the clock dosing
- bolus dosing is preferable to clients who have breakthrough pain
breakthrough pain
pain that occurs when pain has previously been reduced to a tolerable level. often occurs when previous dose is wearing off
adverse effects of analgesics
- better to prevent or treat adverse effects if the client is receiving adequate pain relief
- constipation- stool softeners
- nausea- antiemetics
opioid induced respiratory depression
- follow facility protocols
- improve oxygenation
- stimulate respiration
- initiate opioid reversal
- summon the rapid response team for aggressive intervention
opioid reversal
unless severe, want to administer naloxone in low doses as prescribed to improve respiration without negating the analgesic effect
clients who are tolerant or dependent on opioid meds or alcohol might need what
higher than usual doses of some meds
tolerance
develops as physiological response to the med decreases after repeated admin. happens if taking the same med or related substance consistently over a period of time. ex: opioids and barbiturates
dependence
developing when a client needs a substance to function. different from tolerance. stopping substance abruptly causes withdrawal symptoms like irritability, n&v, abdominal cramping, delirium, muscle twitching, sweating and convulsions. take a long time to develop
addiction
compulsive, inappropriate use of a substance. tolerance and dependence are physical responses to prolonged med use. chemical changes in brain result in strong cravings compelling the purseon to use despite knowing the negative consequences
fear of addiction
clients experiencing acute pain are afraid of opioids because they don’t want to become addicted but addiction is unlikely when pain meds are used appropriately
effects of unrelieved pain
- stresses many body systems
- endocrine and cv systems increase activity
- metabolism speed up
- respiratory, gi, and gu systems decrease
- musculoskeletal system becomes erratic
- mobility and immune system become depressed
unrelieved acute pain can lead to what
chronic pain. both reduce quality of life. those who cannot sleep, eat, or experience life without pain may experience worsening hopelessness
special strategies for pain management in pediatrics
- breastfeeding or admin of sucrose/glucose after injections
- comfort hold
- distraction/deep breathing
should i be concerned about admin analgesics to clients with Hx of substance use disorder
no. it is a common fear and barrier to pain management. Tx as perscribed. assessment should be complete and documented. it is not your responsibility to prevent people seeking health care to obtain meds
what if i do not believe a client is hurting
you can’t feel what they feel or hold them to your beliefs. everyone expresses pain differently.
what if a client stops breathing because i administered pain meds
sedation occurs before respiratory depression so respiratory compromise is preventable. monitor carefully. start low and go slow.
naloxone
antidote or opioid antagonist that can quickly reverse the effects of opioids
can massage help clients pain
yes. it relaxes and trigger release of endorphins.
is a pain goal of 5 acceptable
no. pain ratings greater than 3 indicate moderate to sever pain. pain increases stress and reduces immune system function
if a client needs more opioids to manage pain, should i be concerned about addiction
no. tolerance to opioids develops over time. the client might need higher doses. tolerance is not addiction
if a clients pain does not seem to be relieved with various interventions, would it be okay to ask for a placebo
no. experts discourage this. it is deceptive and unethical
placebo
substances or treatments that produce an effect in some people that is unrelated to the Tx specific properties
how can i provide pain relief when im already to busy
helping manage pain will help you manage client care more effectively reducing nursing care needs
if the client is breathing 10x/min, should i stop pain meds and give naloxone
wake the client
count rr again
if they arouse easily and talks clearly, continue monitoring
if difficult to stimulate give naloxone as prescribed with caution
what is the initial recommended dose of naloxone
0.4 iv push undiluted over 2 minutes. repeat 2-3 minutes prn. naloxone may be given iv infusion. it wears off more quickly than opioid so must continue to monitor
a nurse is caring for 2 clients who are 2 hr postoperative following the same procedure. which factor should the nurse expect to be similar for both clients
a. perception of intensity of pain
b. prescriptions containing guidelines for pain med admin
c. goal of pain management for each client
d. level of pain indicated by each client on a numeric pain scale
b
a nurse is preparing to asses the pain level of a 4 yr old child. which of the following pain assessment tools should the nurse use
a. cries instrument
b. comfort behavior scale
c. faces
d. painad scale
c
a nurse is speaking with a client who reports experiencing frequent, severe migraines and asks if you can tell them about biofeedback. which is the correct response?
a. it measures skin tension and uses learned techniques to relieve pain
b. provides soothing visual images id by the client to promote relaxation
c. it includes listening to an increasing volume of music until the pain subsides
d. stimulates the skin with a mild electric current when pain occurs
a
a nurse is planning to admin a dose of morphine sulfate iv for a client who is postoperative. which protocol should the nurse use?
a. withold the med for a rr of 14/min
b. perform iv injection over 1 minute
c. avoid admin of opioid agonists on a fixed schedule
d. have opioid antagonist available during admin
d
a nurse is caring for a client prescribe iv morphine via pca with a demand of 1 mg/15 min and a 4 mg/hr lockout. client reports unbearable pain after attempting 6 demand doses within 1 hr. after assessing pain, which action should the nurse take
a. check iv site and pca pump for proper functioning
b. teach the client proper use of pca system
c. ask provider to increase the morphine dose and shorten the interval between doses
d. encourage family to admin a dose of morphine via pca when the client is in too much pain to do it themselves
a
during a pain assessment, a nurse asks questions about the quality of an adult clients pain. which statement by the client refers to pain quality
a. the pain began last night and has gotten worse
b. pain is at a 9 on a 0-10 scale
c. pain feels like being stabbed by a knife
d. pain is worse when bending over at waist
c
a nurse is caring for a client admitted to the ed for severe pain following fall from a ladder. client reports taking opioid Rx for chronic pain. Which of the provider Rx for inital pain relief should the nurse question
a. morphine sulfate
b. naloxone
c. fentanyl
d. hydromorphone
b
it is not appropriate because it can cause severe opioid withdrawal in a client who is physically dependent on opioids
