Chapter 10 Flashcards
Acute pain
pain that is sudden in onset, usually subsides when treated, and typically occurs over less than a 6-week period
- sudden onset
- breaking a bone
- post operative pain
- kidney stone
- traumatic injury
Addiction
A chronic, neurobiological disease whose development is influenced by genetic, psychosocial, and environmental factors
-same as psychologic dependence)
Adjuvant analgesic drugs and examples
Drugs that are added for combined therapy with a primary drug and may have additive or independent analgesic properties
“in addition to analgesic” drugs
-assist primary drugs in relieving pain
-might be able to give less dosage of an opiod and sub with these
-not always labeled as painkillers
-ex: NSAIDs, antidepressants, anticonvulsants, corticosteroids
ex: adjuvant drugs for neuropathic pain: amitriptyline (antidepressant) and gabapentin or pregabalin (anticonvulsants)
Agonist
a substance that binds to a receptor and causes a response
agonists-antagonists
substances that bind to a receptor and cause a partial response that is not as that caused by an agonist
-aka partial agonists
anelgesics
medications that relieve pain without causing loss of consciousness
-“pain killers”
antagonist
a drug that binds to a receptor and prevents (blocks) a response
breakthrough pain
pain that occurs between doses of pain medication
cancer pain
pain resulting from any of a variety of causes related to cancer and/or the metastasis of cancer
central pain
pain resulting from any disorder that causes central nervous system damage
chronic pain
persistent or recurring pain that is often difficult to treat. It includes any pain lasting longer than 3 to 6 months, pain lasting longer than 1 month after healing of an acute injury, or pain that accompanies a nonhealing tissue injury
- often difficult to treat
- tolerance to medicine
- can develop physical dependence
deep pain
pain that occurs in tissues below skin level; opposite of superficial pain
gate theory
the most well described theory of pain transmission and pain relief; uses a gate model to explain how impluses from damaged tissues are sensed in the brain
narcotics
a legal term that originally applied to drugs that produce insensibility or stupor, especially opiods; currently used to refer to any medically used controlled substance and to refer to any illicit or “street” drug
-however this term is falling out of use in favor of opoid
neuropathic pain
pain that results from a disturbance of function in a nerve
nociception
processing of pain signals in the brain that gives rise to the feeling of pain
nociceptors
a subclass of sensory nerves (A and C fibers)
nonopiod anelgesics
anelgesics that are not classified as opiods
nonsteroidal antiinflammatory drugs (NSAIDs)
a large, chemically diverse group of drugs that are anelgesics and also possess antiinflammatory and antipyretic activity
opiod anelgesics
synthetic drugs that bind to opiate receptors and relieve pain
-there’s currently an opiod problem
opiod naive
describes patients who are receiving opiod anelgesics for the first time and therefore are not accustomed to their effects
- Never taken it/have had minimal exposure to opiods
- should not load them up on opiods if they have never been exposed
opiod tolerance
a normal physiologic condition that results from long-term opiod use, in which larger doses of opiods are required to maintain the same level analgesia and in which abrupt discontinuation of the drug results in withdrawal symptoms
-may need different type of opiod or amount
opiod tolerant
the opposite of someone who is opiod naive; describes patients who have been receiving opiod anelgesics (legally or otherwise) for a period of time (1 week or longer)
opiod withdrawal
the signs and symptoms associated with abstinence from or withdrawal of an opiod analgesic when the body has become physically dependent on the substance
opiods
a class of drugs used to treat pain; this term is often used interchangeably with the term narcotic
pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
- “pain is what the patient says it is”
- cultures and health beliefs influence how pain is expressed
pain threshold
the level of stimulus that results in the sensation of pain
pain tolerance
the amount of pain a patient can endure without its interfering with normal function
- varies from person to person
- subjective response to pain, not a physiologic function
- varies by attitude/environment/culture
partial agonist
a drug that binds to a receptor and causes a response that is less than that cause by a full agonist (same as agonist-antiagonist)
phantom pain
pain experienced in the area of a body part that has been surgically or traumatically remove
physical dependence
a condition in which a patient takes a drug over a period of time and unpleasant physical symptoms (withdrawal symptoms) occur if the drug is stopped abruptly or smaller doses are given
-if patient does not get drug = miserable
psychological dependence
a pattern of compulsive use of opiods or any other addictive substance characterized by a continuous craving for the substance and the need to use it for effects other than pain relief (also called addiction)
referred pain
pain occuring in an area away from the organ of origin
somatic pain
pain that originates from skeletal muscles, ligaments, or joints
special pain situations
the general term for pain control situations that are complex and whose treatment typically involves multiple medications, and nonpharmacologic therapeutic modalities
Superficial pain
pain that originates from the skin or mucous membranes; opposite of deep pain
synergistic effects
drug interactions in which the effect of a combination of two or more drugs with similar actions is greater than the sum of the individual effects of the same drugs given alone
tolerance
the general term for a state in which repetitive exposure to a given drug, over time, induces changes in drug receptors that reduce the drug’s effects
-have to take more and more of the drug to get the same effect
vascular pain
pain that results from pathology of vascular or perivascular pain
visceral pain
pain that originates from organs or smooth muscles
world health organization (WHO)
An international body of health care professionals that studies and responds to health needs and trends worldwide
Never tell a patient…
You will not experience any pain
chronic nonmalignant pain
- arthritis
- fibromyalgia
PCA
patient controlled analgesia
- “dope on a rope”
- nurse interprets order
- program the pump
- big syringes
- there are settings so patient cannot OD
- relatively safe
- if patient is hitting the button a lot, the prescription might need to change
PCA by proxy
someone else does it for you
Patients are scared of
being addicted to pain medicine
If someone has a history of analgesic addiction, and they have been clean
potential for addiction is real
breakthrough pain
before the next dose is due, patient is in agony
Do we use placebos to manage pain?
NO
The nurse is giving the patient gapapentin, even though he does not have seizures. Why is he getting this medicine
He has neuropathic pain
mild agonists
codeine, hydrocodone
strong agonists
morphine, hydromorphone, oxycodone, oxymorphone, meperidine, fentanyl, and methadone
Meperidine
not recommended for long-term use because of the the accumulation of a neurotoxic metabolite, normerperidine, which can cause seizures and sedation
Which routes can we use
IV oush IM SubQ tablets elixers instant relief (IR) slow release (SR)
Why do we use analgesics?
moderate to severe pain
- post op
- cancer treatment
- chronic noncancer pain
- obstetric analgesia
Opiods are also used for
- cough center suppression
- treatment of diarrhea
- balanced anathesia
Lomotil
-have opium in it
ampule
have to break the top
patches
go on skin, change every 3 days
- where gloves when you put them on
- special way to dispose of them, addicts will go through trash and try to find them
Equinalgesia
ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia
hydromorophone (dilaudid)
seven times more potent than morphine
opiod analgesics contraindications
- known drug allergy
- severe asthma
- respiratory insufficiency
- elevated intracranial pressure
- morbid obesity or sleep apnea
- paralytic ileus
- pregnancy
paralytic ileus
- when your SI is paralyzed
- if you have this, at risk for drug toxicity
adverse effects
CNS depression
- nausea and vomiting
- urinary retention
- diaphoresis and flushing
- pupil constriction (miosis)
- constipation
- itching
naloxone
narcan (reverse the effects of opiods)
-used when patient is having severe respiratory depression
naltrexone
ReVia
toxicity and management of overdose
-regardless of withdrawal symptoms, when a patient experiences severe respiratory depression, an opiod antagonist should be given
opiod withdrawal/opiod abstinince syndrome manifested
within minutes, they are screaming/thrashing/sweating/ in pain but at least they’re breathing
opiod analgesics interactions
AABBM
- alchol
- antihistamines
- barbituates
- benzodiazepines
- monoamine oxidase inhibitors
Fentanyl
- synthetic opiod (Schedule II) used to treat moderate to severe pain
- parenteral injections, transdermal pathces, buccal lozenges (fentora), and buccal lozenges on a stick (Actiq)
Morphine
- naturally occuring alkaloid derived from the opium poppy
- drug prototype for all opiod drugs; schedule II controlled substance
- indication: severe pain
- high abuse potential
- oral, injectable, and rectal dosage froms; also extended-release forms
- also helps with anxiety
Morphine
- naturally occuring alkaloid derived from the opium poppy
- drug prototype for all opiod drugs; schedule II controlled substance
- indication: severe pain
- high abuse potential
- oral, injectable, and rectal dosage froms; also extended-release forms
- also helps with anxiety
naloxone hydrochloride (NArcan)
- pure opiod antagonist
- indicated in cases of suspected acute opiod overdose
- if you suspect it, it never hurts to give it
nonopiod analgesics acetaminophen (tylenol)
- analgesic and antipyretic effects
- little to no inflammatory effects
- brings down fever
- available over the counter (OTC) and in combination products with opiods
Acetaminpehn: indications
- mild to moderate pain
- fever
- alternative for those who cannot take aspirin products
acetaminphen: dosage
- 3000 mg/day (most an adult should take)
- sometimes the dosages may be exceeded because not realizing it’s also in their cold medicine
Acetaminophen: toxicity and managing overdose
- even though availible OTC, lethal when overdosed
- overdose, whether intentional or resulting from chronic unintentional misuse, causes hepatic necrosis: hepatotoxocity
- long-term ingestion of large doses also cause nephronopathy
- recommended antidote: acetylcysteine regimen (smells like rotten eggs) MUCOMYST
Analgesics: Nursing implications
- before beginning therapy, perform a thorough
- see powerpoint
What 3 receptors are thought to be involved in pain?
- Mu receptors in dorsal horn of spinal cord
- kappa receptors
- delta receptors
What is pain peception closely linked to?
the number of mu receptors
- when the number of receptors is high, pain sensitivity is diminished
- when the number of receptors is low, relatively minor noxious stimuli may be perceived as painful
What causes a lowered pain threshold?
- anger
- anxiety
- depression
- discomfort
- fear
- isolation
- chronic pain
- sleeplessness
- discomfort
What causes a raised pain threshold?
- diversion
- empathy
- rest
- sympathy
- medications (anelgesics, antianxiety drugs, antidepressants)
Acute onset and duration
onset: sudden, usually sharp and localized, physiologic response (SNS: tachycardia, sweating, pallor, increased blood pressure)
duration: limited (has an end)
Examples of acute pain
- myocardial infarction
- appendicitis
- dental procedures
- kidney stones
- surgical procedures
Chronic onset and duration
onset: slow (days to months); long duration; dull, persistent, aching
- persistant or recurring (endless)
Examples of chronic pain
- arthritis
- cancer
- lower back pain
- peripheral neuropathy
What are potential adverse effects that accompany the use of opiods?
- constipation
- nausea and vomiting
- sedation and vomiting
- sedation and mental clouding
- respiratory depression
- subacute overdose
Constipation management
- increased intake of fluids
- stool softeners
- stimulants (bisacodyl or senna)
nausea and vomiting management
antiemetics such as phenothiazines
Sedation and mental clouding management
-safety precautions implemented
respiratory depression management
for sever respiratory depression, opiod antagonists may be needed
subacute overdose management
-holding one or two doses of an opiod anelgesic is enough to judge if there is a mental and respiratory depression is associated with the opiod
Dilauudid is _____ time more potent than morphine
7
Guidelines for fentanyl transdermal patches
- only for opiod tolerant patients
- no heat on patch
- applied for 72 hours
- patient should fold in half and throw it down the toilet
What are contraindications for anelgesic use?
- known drug allergies
- sever asthma
opiod-induced cardiovascular adverse effects
- hypotension
- flushing
- bradycardia
opiod-induced central nervous adverse effects
- sedation
- disorientation
- euphoria
- lightheadedness
- dysphoria
opiod-induced gastrointestinal adverse effects
- nausea
- vomiting
- constipation
- bilary tract spasm
opiod-induced genitourinary adverse effects
-urinary retention
opiod-induced integumenraty adverse effects
- itching
- rash
- wheal formation
opiod-induced respiratory adverse effects
- respiratory depression
- possible aggravation of asthma
If patient has pain/coughing, you should administer
codeine sulfate (D)
If patient needs general anesthesia, relief of moderate to severe pain, or relief of chronic pain (including cancer pain), you should administer
fentanyl
If you need something stronger than morphine, you should administer
hydromorphine
When should you use meperidine?
Trick question! don’t because it has unpredictable effects of neurometabolites at analgesic doses and risk for seizures
If patient needs opiod analgesia, relief of chronic pain, opiod addition maintenance, and opiod detoxification you should administer
methadone
If patient needs an opiod analgesic you should use
morphine sulfate
If patient needs relief of moderate to severe pain and the medication should not be crushed, ___________ should be administered?
morphine sulfate, continuous relief
If patient needs relief of moderate to severe pain, you should administer __________
oxycodone, immediate release
If patient needs relief of moderate to severe pain and the drug cannot be crushed you should use __________
oxycodone, continuous release
If the patient needs to be treated for opioid overdose and postoperative anesthesia reversal
naloxone HCl
If the patient needs to be treated for maintenance of an opiod-free state
naltrexone HCl
If the patient needs relief of mild to moderate pain
acetominophen (Tylenol, others)
If the patient needs relief of moderate to moderately severe pain
tramadol (Ultram)
Who should aspirin not be given to? Why?
Children and adolescent patients because of the risk of Reye’s syndrome
When giving an IV, infuse over the recommended time (usually 3-5 min). Always assess respirations before, during, and after use. Give IM as ordered.
buprenorphine and butorphanol
Give PO doses with food to minimize GI tract upset; ceiling effects occur with oral codeine resulting in no increase of analgesia with increased dosage
codeine
Administer parenteral doses over 1-2 minutes as ordered and as per manufacturer guidelines in regard to mg/min to prevent CNS depression and possible cardiac or respiratory arrest. Be sure to remove resifual amounts of the old patch before application of a new patch. Dispose of patches properly to avoid inadvertant contact with children or pets.
fentanyl
May be given subcut, rectally, IV, PO, or IM
hydropmorphone
Given by a variety of routes; IV, IM, or PO; highly protein bound, so watch for interactions with toxicity. Monitor older adult patients for increased sensitivity.
merperidine
Availible in a variety of forms; subcut, IM, PO, IV, extended and immediate release; morphine sulfate for epidural infusion. Always monitor respiratory rate.
morphine
IV doses of 10 mg given undiluted over 5 min
nalbuphine
Antagonist given for opiod overdose; 0.4 mg usually given IV over 15 sec or less. Reverses analgesia as well.
naloxone
often mixed with acetaminophen or asprin; PO and suppository dosage forms. Now availible in both immediate and sustained-release tablets.
oxycodone
