Chapter 43 Pain Management Flashcards
Pain Experience
Involves physical, emotional, and cognitive components
Nociceptor
Sensory peripheral pain nerve fiber
Substance P
- Causes vasodilation and edema
- Found in the pain neurons of the dorsal horn (excitatory peptide)
- Needed to transmit pain impulses from the periphery to higher brain centers
Serotonin
Inhibits pain transmission
Prostoglandins
- Increase sensitivity to pain
- Generated from the breakdown of phospholipids in cell membranes
Bradykinin
- Binds to receptors on peripheral nerves, increasing pain stimuli
- Released from plasma that leaks from surrounding blood vessels at the site of tissue injury
- Binds to cells that cause the chain reaction producing prostoglandins
Neuromodulators
Body’s natural supply of morphinelike substances
Perception
The point at which a person is aware of pain
Modulation
Inhibition of the pain impulse of the nociceptive process
Pain Threshold
The point at which a person feels pain
Pain Tolerance
Level of pain a person is willing to put up with
Acute pain
Protective; has an identifiable cause, is of short duration, and has limited tissue damage and emotional response. Eventually resolves with or without treatment, after an injured area heals.
Chronic Pain
Lasts longer than anticipated, does not always have a cause, and leads to great personal suffering. Pain that last longer than 6 monthsp
Chronic Episodic Pain
Pain that occurs sporadically over an extended duration of time.
Idiopathic Pain
Chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
Nociceptive pain
Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopiods or opiods
Somatic pain
Comes from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well-localized.
Visceral pain
Arises from visceral organs, such as the gastrointestinal tract and pancreas.
Neuropathic Pain
Abnormal processing of sensory input by the peripheral or CNS; treatment usually includes adjuvant analgesics.
Deafferentation Pain
Injury to either the peripheral or CNS. Example: Phantom pain reflects injury to the peripheral nervous system; burning pain below the level of the spinal cord lesion reflects injury to the CNS.
Sympathetically maintained pain
Associated with dysregulation of the autonomic nervous system. Examples: pain associated with reflex sympathetic dystrophy or causalgia (complex regional pain syndrome, types I and II)
Polyneuropathies
Patient feels pain along the distribution of many peripheral nerves. Ex: Diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barre syndrome
Mononeuropathies
Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: Nerve root compression, nerve entrapment, trigeminal neuralgia.
Physiological factors that influence pain
Age, fatigue, genes, neurologic function
Social factors that influence pain
Attention, previous experience, family and social support, spiritual factors
Psychological factors that can influence pain
Anxiety and coping styles
Cultural factors that can influence pain
Meaning of the pain and ethnicity
Identify the ABCDE clinical approach to pain assessment and management
- Ask about pain regularly. Assess pain systematically.
- Believe the patient and family in their report of pain and what relieves it.
- Choose pain control options appropriate for the patient, family, and setting.
- Deliver interventions in a timely, logical, and coordinated fashion.
- Empower patients and their families. Enable them to control their course to the greatest extent possible.
Identify the common characteristics of pain that the nurse would assess.
- Onset and duration
- Location
- Intensity
- Quality
- Pain pattern
- Relief measures
- Contributing symptoms
- Effects of pain in the patient
- Behavioral effects
- Influence on activities of daily living
List potential or actual nursing diagnoses related to patient in pain
- Anxiety
- Fatigue
- Hopelessness
- Impaired physical mobility, Imbalanced nutrition: Less than body requirements
- Powerlessness
- Chronic Low Self-esteem
- Insomnia
- Impaired social interaction
- Spiritual distress
- Activity intolerance
- Ineffective coping
- Fear
List the patient outcomes appropriate for the patient experiencing pain
a. Patient reports that pain is a 3 or less on a scale of 0-10, does not interfere with ADL’s, or personal pain intensity goal attained.
b. Patient identifies factors that intensify pain and modifies behavior accordingly
c. Patient uses pain-relief measures safely
The Agency for Healthcare Research and Quality (AHRQ) guidelines for acute pain management cite nonpharmacologic interventions appropriate for patients who meet certain criteria. List those criteria.
a. Find such interventions appealing
b. express anxiety or fear
c. Will possibly benefit from avoiding or reducing drug therapy
d. Are likely to experience and need to cope with a prolonged interval of postoperative pain
e. Have incomplete pain relief after use of pharmocologic interventions.
Relaxation as a nonpharmocologic intervention
Mental and physical freedom from tension or stress that provides individuals with a sense of self-control
Distraction as a nonpharmocologic intervention
Directs a patient’s attention to something other than pain and thus reduces the awareness of pain
Music as a nonpharmocologic intervention
Diverts the person’s attention away from the pain and creates a relaxation response.
Cutaneous Stimulation as a nonpharmocologic intervention
Includes massage, warm bath, ice bag, and TENS. Reduces pain perception by releasing endorphins, which block the transmission of painful stimuli.
Herbals as a nonpharmocologic intervention
Not sufficiently studied, however many use herbals such as ecchinacea, ginseng, gingko, biloba, and garlic supplements.
Reducing pain perception as a nonpharmocologic intervention
One simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback.
Identify three types of analgesics used for pain relief
a. Nonopioids
b. Opioids
c. Adjuvants or coanalgesics.
Defines Adjuvants or Coanalgesics
A variety of medications that enhance analgesics or have analgesic properties that were originally unknown
What is a patient-controlled analgesia?
Allows patients to self administer opioids with minimal risk of overdose.
What is the goal of patient-controlled analgesia?
Maintain a constant plasma level of analgesic to avoid the problems of prn dosing.
Explain the purpose of perineural local anesthetic infusion.
To manage pain from a variety of surgical procedures with a pumps that is set as a demand or continuous mode and left in place for 48 hours
Local anesthesia
Intended for local infiltration of an anesthetic medication to induce loss of sensation to a body part.
Regional anesthesia
Is the injection of a local anesthetic to block a group of sensory nerve fibers.
Epidural anesthesia
Permits control or reduction of severe pain and reduces the patient’s overall opioid requirement; can be short term or long term.
Complications of opioid epidural analgesia are:
Nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritis
List the goals for the care of a patient with epidural infusions. Describe one action for each goal.
a. Prevent catheter displacement: Secure the catheter (if not connected to an implanted reservoir) carefully to outside skin.
b. Maintain catheter function: Check the external dressing around the catheter site for dampness or discharge. (Leak of cerebrospinal fluid may develop
c. Prevent infections: Use strict aseptic technique when caring for catheter
d. Monitor for respiratory depression: Monitor vital signs, especially respirations, per policy.
e. Prevent undesirable complications: Assess for itching (pruritus) and nausea and vomiting.
f. Maintain urinary and bowel function: Monitor intake and output.
Transdermal fentanyl
100 times more potent than morphine in predetermined doses that provide analgesic for 48-72 hours; useful when unable to take oral meds.
Transmucosal fentanyl
Used to treat breakthrough pain in opioid tolerant patients, the unit is placed in the mouth and dissolved, not chewed.
Incident pain
Type of breakthrough pain. Pain that is predictable and elicited by specific behaviors such as physical therapy or wound dressing changes.
End of dose pain
Type of breakthrough pain. Pain that occurs toward the end of the usual dosing interval of regularly scheduled analgesic.
Spontaneous pain
Type of breakthrough pain. Pain that is unpredictable and not associated with any activity or event.
Patient barriers to effective pain management
Fear of addiction, worry about side effects, fear of tolerance (“wont be there when I need it”), take too many pills already, fear of injections, concern about not being a “good” patient, dont want to worry family and friends, may need more tests, need to suffer to be cured, pain is for past indescretions, inadequate education, reluctance to discuss pain, pain is inevitable, pain is part of aging, fear of disease progression, primary care providers and nurses are doing all they can, forget to take analgesics, fear of distracting primary health care providers from treating illness, primary health care providers have more important or ill patients to see, suffering in silence is noble and expected.
Health Care provider barriers to effective pain management
Inadequate pain assessment, concern with addiction, opiophobia (fear of opioids), fear of legal repercussions, no visible cause of pain, patients must learn to live with pain, reluctance to deal with side effects of analgesics, fear of giving a dose that will kill the patient, not believing the patients report of pain, primary health care provider time constraints, inadequate reimbursement, belief that opioids mask symptoms, belief that pain is part of aging, overestimation of rates of respiratory depression.
Health Care system barriers to effective pain management
Concern with creating addicts, ability to fill prescriptions, absolute dollar restriction on amount reimbursed for prescriptions, mail order pharmacy restrictions, nurse practitioners and physician assistants not used efficiently, extensive documentation requirements, poor pain policies and procedures regarding pain management, lack of money, inadequate access to pain clinics, poor understanding of economic impact of unrelieved pain.
Physical dependence
A state of adaptation that is manifested by a drug class-specific withdrawal syndrom produced by abrupt cessasion, rapid dose reduction, decreasing blood level of the drug, or administration of an antagonist
Drug tolerance
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effects over time.
Addiction
A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Placebo
A medication or procedure that produces positive or negative effects in patients that are no related to the placebo’s specific physical or chemical properties.
Pain clinics
Treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain relief measures.
Palliative care
Care provided with the goal to live life fully with an incurable condition
Hospice Care
Provided at the end of life; it emphasizes quality of life over quantity.
Identify some principles to evaluate related to pain management
Evaluate the patient for the effectiveness of the pain management after an appropriate period of time; entertain new approaches if no relief; evaluate the patient’s perception of pain
Pain is a protective mechanism warning of tissue injury and is largely a(n):
Subjective experience. Only the person knows if the pain is present and what the experience is like
A substance that can cause analgesia when it attaches to opiate receptors in the brain is:
Endorphin. When the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids (endorphins) that hinder the transmission of pain and help produce an analgesic effect
To adequately assess the quality of a patient’s pain, which question would be appropriate?
“Tell me what your pain feels like.” A patient’s self report of pain is the single most reliable indicator of the existence and intensity of pain.
The use of patient distraction in pain control is based on the principle that:
The reticular formation can send inhibitory signals to gating mechanisms. The reticular activating system inhibits painful stimuli is a person receives sufficient or excessive sensory input; with sufficient sensory stimulation, a person is able to ignore or become unaware of pain.
Teaching a child about painful procedures is best achieved by:
Relevant play directed toward procedure activities. Developmental differences are found among age groups; therefore, the nurse needs to adapt approaches for assessing a child’s pain and how to prepare a child for a painful procedure.
Four physiological processes of nociceptive pain:
Transduction, Transmission, perception, modulation
Transduction
Thermal, chemical or mechanical stimuli usually cause pain. Transduction converts energy produced by these stimuli into electrical energy.
Histamine
Produced by mast cells causing capillary dilation and increases capillary permeability.
Factors influencing pain for older adults.
Muscle mass decreases, body fat increases, and percentage of body water decreases.
Older adults frequently eat poorly, resulting in low serum albumin levels. Many drugs are highly protein bound.
A decline of renal and liver function. Results in reduced metabolism and excretion of drugs. May experience a greater peak effect and longer duration of analgesics.
Age related changes to skin such as thinning or loss of elasticity affect absorption rate of analgesics.
True or False:
Infants cannot feel pain
False: Infants have the anatomical and functional requirements for pain processing by mid to late gestation
True or False:
Infants are just as sensitive to pain as older children and adults.
True
True or False:
Infants cannot express pain
False: Although infants cannot verbalize pain, they respond with behavioral cues and physiological indicators that are observable.
True or False:
Infants must learn about pain from previous painful experiences
False: Pain requires no prior experience.
True or False:
Use behavioral cues (facial expressions, cry, body movements) and physiological indicators of pain (changes in vitals) to reliably assess pain in infants
True
Superficial or cutaneous pain
Pain resulting from stimulation of skin. Pain is of short duration and localized. It usually is a sharp sensation. Examples: Needlestick, small cut or laceration.
Deep or Visceral Pain
Pain resulting from stimulation of internal organs. Pain is diffuse and radiates in several directions. Duration varies, but it usually lasts longer than superficial pain. Pain is sharp, dull, or unique to organ involved. Examples: Crushing sensation (angina pectoris), burning sensation (gastric ulcer)
Referred pain
Common phenomenon in visceral pain because many organs themselves have no pain receptors. Entrance of sensory neurons from affected organ in same spinal cord segment as neurons from areas where individual feels pain; perception of pain in unaffected areas. Example: Myocardial infarction, which causes referred pain to the jaw, left arm, and left shoulder.
Radiating Pain
Sensation of pain extending from initial site of injury to another body part. Feels as though it travels down or along body part. It is intermittent or constant. Example: Low back pain from ruptured intravertebral disk accompanied by pain radiating down leg from sciatic nerve irritation.
Two types of sensory nerve fibers
- Fast myelinated A-delta fibers: send sharp, localized, distinct sensations
- Slow, small, unmyelinated C fibers: send poorly localized, burning, persistent pain
Transmission
Sending of impulse across a sensory pain nerve fiber (nociceptor)
Perception
The patient’s experience of pain
Modulation
Inhibition of pain/ release of inhibitory neurotransmitters
Gating Mechanism
- in the central nervous system (CNS) regulate or block pain impulses.
- Pain impulses pass through when a gate is open & are blocked when a gate is closed.
- Closing the gate is the basis for non-pharmacological pain relief interventions.
Safety guidelines for when a PCA pump is used.
- The patient is the only person who should press the button to administer the pain medication when PCA is used.
- Monitor the patient for signs & symptoms of oversedation and respiratory depression
