Ch. 6 Flashcards
definition of pain
- unpleasant sensory and emotional experience associated with actual or potential tissue damage
*Pain is whatever the experiencing person says it is and exists whenever he or she says it does
attitudes and practices related to pain
- attitudes of health care providers and nurses affect interaction with patients experiencing pain
- many patients are reluctant to report pain: desire to be a “good” patient, fear of addiction
- opioid crisis has affected attitudes and practices in pain management
acute pain
- short-lived
- activation of sympathetic nervous system (fight or flight response)
- temporary with sudden onset, and easily localized
chronic (persistent) pain
- can last a person’s lifetime
- lasts or recurs for indefinite period (more than 3 months)
- gradual onset
- serves no biological purpose
- chronic cancer pain
- chronic non-cancer pain
major distinction between chronic and acute pain is __
the effect on biologic responses
acts as a warning sign
acute pain
acute pain results from
sudden, accidental trauma;
- surgery;
- ischemia;
- acute inflammation
absence of physiologic and behavioral responses does or does not mean absence of pain?
does not mean absence of pain
acute pain: sensory perception of pain changes as
injured area heals
acute pain responses
- increased HR, BP, RR
- dilated pupils
- sweating
chronic pain: character and quality
- often change over time
chronic pain can result in
- emotional, financial, and relationship burdens
- depression, hopelessness
chronic non-cancer pain
- global health issue for people > 65
- formerly called chronic nonmalignant pain
- neck, shoulder, low back
- misc. chronic disorders: endometriosis, diabetic neuropathy, migraines, fibromyalgia
- over half of veterans of recent wars have this condition: can cause depression, decreased sense of well-being
procedural pain
- associated with medical procedures or surgical interventions
- usually acute
categories of pain
- localized
- projected
- radiating
- referred
sources of pain
- nociceptive pain: somatic or visceral
- neuropathic pain
somatic pain
superficial pain
- in the skin
visceral pain
deeper internal pain
- abdominal organs (ie appendix)
painful stimuli often originate in
extremities
if pain is not transmitted to the brain
the person does not feel pain
which two fibers transmit periphery pain
- A delta fibers
- C fibers
older adults are at a greater risk for
under treated pain
- under treatment of cancer pain due to inappropriate beliefs about pain sensitivity, tolerance, and ability to take opioids
assessment of pain
- patients self-report is “gold standard” for assessment
nurse’s role in pain assessment
- serve as advocate
- act promptly to relieve pain
- respect patient values and preferences
- minimize/remove personal bias
PQRST of pain
P: Precipitating (makes it worse) or palliative (makes it better)
Q: Quality (stabbing, sharp, dull) or quantity (how bad)
R: Region (where is it) or radiation (traveling)
S: Severity scale (0-10)
T: Timing (when did it start/constant or intermittent)
Patients who cannot self-report pain are at higher risk for
under treated pain
- Hierarchy of Pain Measures
- Checklist of Nonverbal Pain Indicators (CNPI)
- Pain Assessment in Advanced Dementia Scale (PAINAD)
drug therapy
- Multimodal analgesia
- Multiple routes of administration (oral, IV, IM, SQ, patches)
- Around-the-clock dosing (keeps steady level of medication on board, ie order is q6h)
- Patient-controlled analgesia (PCA)
non-opioid analgesics
- Acetylsalicylic acid and acetaminophen are most common
- Most are NSAIDs, including aspirin
side effects of non-opioid analgesics: NSAIDs and Aspirin
- Can cause GI disturbances
- COX-2 inhibitors for long-term use
- Carry risk for cardiovascular and renal adverse effects
non-opioid analgesics: acetaminophen
- Available in liquid form; can be taken on empty stomach
- Preferable for patients for whom GI bleeding is likely
- Can cause liver toxicity
- Monitor for hepatotoxicity
- Concomitant Alcohol use higher risk
opioid analgesics
- Block the release of neurotransmitters in the spinal cord
- Drugs include: oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, oxymorphone
Key Principles of
Opioid Administration
- Appropriate opioid analgesic
- Titration
- Dose range
- Carefully assess older adults to avoid untreating pain
the opioid epidemic
- CAUSE: In 1995, American Pain Society declared pain as the 5th vital sign
- PROBLEM: opioid scripts quadrupled from 2000-2010
- opioid abuse declared a national public health emergency as of 2017 and remains so
- Includes misuse of prescription opioids, and illicit drugs (illegal opioid, heroin, fentanyl)
- Prevent secondary exposure
- about 50 people die every day from opioid overdose
Physical Dependence,
Tolerance, and Addiction
- Physical dependence: Normal response
- Tolerance: Normal response
- Opioid addiction: Chronic neurologic and biologic disease
- Pseudoaddiction: Mistaken diagnosis of addictive disease
dependence
Physical dependence is predictable, easily managed with medication, and is ultimately resolved with a slow taper off of the opioid.
physical dependence can be caused by
Many substances - such as caffeine, nicotine, sugar, anti-depressants, to name a few - can cause physical dependence, it is not a property unique to opioids. Physical dependence to opioids is normal and expected and a distraction from the real problem, addiction.
addiction
abnormal and classified as a disease.
- a primary condition manifesting as uncontrollable cravings, inability to control drug use, compulsive drug use, and use despite doing harm to oneself or others.
strong cravings are common to all addictions or dependences?
addictions
opioid naïve
person who has not recently taken enough opioid on a regular basis to become tolerant to the effects
opioid tolerant
person who has taken an opioid long enough at doses high enough to develop tolerance to many of the effects
US department of HHS identifies 5 priorities for safe opioid use:
- Public health surveillance
- Improving access to treatment and recovery
- Promoting use of overdose reversing meds
- Providing support for research on pain and addiction
- Advancing better practices for pain management
- Multi-modal pain management
patient education: opioid use
- Risks of opioid medications
- Expected time frame – short term if possible
- Proper storage and disposal
- Do not keep for another time
- Alternatives to opioids to reduce risk for misuse and abuse
drug formulation terminology
Short acting, fast acting, immediate release (IR), normal release
- Onset in about 30 minutes; short duration of 3 to 4 hours
Modified-release, extended release (ER), sustained release (SR), controlled release (CR)
- Release over a prolonged period
- Never crush, break, or have patients chew!
opioids to avoid
meperidine & codeine
- cause severe side effects
- other opioid choices will work better
WHO analgesic ladder
World Health Organization’s recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain)
Level 1 pain (1-3 rating)—Use non-opioids
Level 2 pain (4-6 rating)—Use weak opioids alone or in combination with an adjuvant drug
Level 3 pain (7-10 rating)—Use strong opioids
Level 1 pain
- 1-3 rating
- use non-opioids
Level 2 pain
- 4-6 rating
- use weak opioids alone or in combination with an adjuvant drug
Level 3 pain
- 7-10 rating
- use strong opioids
adverse effects of opioids
- N/V
- constipation
- sedation
- respiratory depression
- pruritus
pain management in end of life care
- Opioid regimen should stay consistent with dose in weeks before last weeks of life
- Generally believed that patient still feels pain when unconscious
- Does not hasten death unless the dose was not properly and gradually titrated
routes of opioid administration
- can be administered by every route used
- PRN range orders
- PCA
medical marijuana
- Schedule I controlled substance
- Some U.S. states have legalized medical cannabis (still federally illegal)
- Medical use is legalized in Canada
- Medical Marijuana Program (MMP)
- Health care provider does not prescribe, but assesses and determines qualifying conditions
- a lot of insurances do not cover the cost
- Endocannabinoid system: THC (psychoactive component), CBD, CBN
is medical cannabis regulated by the FDA?
no
nurse can only administer medical marijuana if
specially authorized by jurisdiction law
who can give medical marijuana if the nurse cannot?
- patient or designated caregiver
adjuvant analgesics
- Anticonvulsants (gabapentin- neuropathy pain)
- Tricyclic antidepressants
- Local anesthetics
- Local anesthesia
- infusion pumps
- Topical medications
non-pharmacologic interventions of pain
*Used alone or in combination with drug therapy
- Physical measures
- Physical and occupational therapy
- Cognitive/behavioral measures
physical measures
- application of heat, cold, or pressure
- therapeutic massage
- vibration
- transcutaneous electrical nerve stimulation (TENS unit)
cognitive/behavioral measures of pain managment
- Distraction
- Imagery
- Relaxation techniques
- Hypnosis
- Acupuncture
- Glucosamine
localized pain
localized to one area
ie right lower quadrant
projected pain
not well localized- all over a general area
ie all over abdomen
radiating pain
pain radiates through mutliple parts of body
ie sciatica
referred pain
pain is not felt where it originated from
- ie gallbladder attack, pain is felt in scapula
neuropathic pain
affects the nerve endings
- pain and burning in legs and feet (sometimes numbness)
- very common in diabetic patients
considerations for pain medication use with older adults
- start low and go slow with drug dosing
- increasing doses to achieve adequate pain relief
comprehensive pain assessment
- location: where is it?
- intensity: 0-10 scale
- onset and duration: when did it start? how long does it last?
- aggravating and relieving factors: what makes it worse/better?
- effect of pain on function and quality of life
- comfort-function (pain intensity) outcomes
- other information: cultural considerations, values, beliefs
pain assessment intensity scales
- numeric rating scale 0-10
- wong-baker faces pain rating scale, used with kids and non-verbal adults (ie. stroke patients)
adapted hierarchy of pain assessment for patients who cannot self-report pain verbally
- be aware of potential causes of pain
- attempt to obtain self-report
- observe behaviors (grimacing, crying, fetal position, guarding)
- seek proxy reporting
- conduct an analgesic trial
reversal agent for any opioid overdose
naloxone (narcan)
- nasal spray (carried by certain teachers, police officers, firemen)
- IV (hospital)
*both work very quickly: patient will wake up, breathing increases
can you crush a med that is extended release?
no
what is PCA?
patient controlled analgesia through an IV
can be basal or demand
- basal: small infused dose, dont have to push any buttons
- demand: patient pushes button and gets dose
safety mechanisms of PCA
- person needs to be A&O
- patient is only one pushing the button
- lockout dose
monitoring and assessment when patient is on PCA
monitor RR*, HR, O2
- if RR and O2 drop, can give naloxone as antidote
benefits of PCA
patient can control when they get medication
- patient cannot OD due to lockout dose
- always locked by a key- cannot change dose or medication without key
