Chapter 46 Pain management Flashcards
Persistent pain contributes to
insomnia, weight gain or loss, constipation, hypertension, deconditioning, chronic stress and depression.
effective pain management ia an important aspect of nursing care to prootoe what?
Healing, prvent complications, reduce suffering and prevent the development of incurable pain states.
Pain may be described in terms of
Location, Duration, Intensity and etiology
Location
- may be complicated because some pain radiate(spread or extend) to other areas
- pain may also be referred(appear to arise in different areas) to other parts of the body;ie: cardiac pain may be felt in the shoulder or arm
- visceral pain(pain arising from organs or hollow viscera) is often perceived in an area remote from the organ causing the pain.
Duration- Acute Pain
when pain lasts only through the expected recovery period; whether it has a sudden or slow onset regardless of intensity
Duration-Chronic Pain
- also known as persistent pain
- prolonged usually recurring or lasting 3 months or longer
- interferes with functioning
Acute Pain responses(physical)
- SYMPATHETIC nervous system responses : Increased pulse rate increased respiratory rate elevated blood pressure diaphoresis dilated pupils -client may be restless/anxious -client reports pain client may exhibit behavior indicated of paincrying,rubbing area,holding area
Chronic Pain responses (physical)
-PARASYMPATHETIC responses:
vital signs normal
dry warm skin
pupils normal or dilated continues beyond healing
client is usually depressed and withdrawn
client often does not mention pain unless asked
pain behavior often absent
Cancer pain
-may result from the direct effects of the disease and its treatment or it may be unrelated
-maignant pain category
such as hiv/aids/burn pain
-treated more aggresively than non cancer pain
Intensity
-standard scale 0(no pain)-10(worst possible pain)
-1-3 Mild pain
-4-6 Moderate Pain
-7-10- Severe Pain
Mild, moderate or severe
Etiology
- Nociceptive Pain
- Neuropathic Pain
Etiology-Nociceptive Pain
- is experienced when an intact, properly functioning nervous system sends signals tht tissues are damaged requiring attention and proper care
ie: pain experienced following cut or broken bone tells you to avoid further damage until properly healed. pain then goes away when healed.
Nociceptive pain- Somatic Pain
-originates in the skin, muscles, bones or connective tissue ie: paper cut, sprained ankle common examples
Nociceptive pain-Visceral pain
- results from activation of pain receptors in the organs/hollow viscera
- characterized by cramping, throbbing,pressing or aching qualities
- also associated with feeling sick ie N/V, as in examples of labor pain, IBS
Neuropathic pain
is associated with damaged or malfunctioning nerves due to illness
- typically chronic
- described as a burning “electric shock”, tingling, dull and aching
- difficult to treat
Neuropathic Pain -Peripheral Neuropathic pain
- damage to sensitization of peripheral nerves (not brain or spine nerves)
- ie. phantom limb pain, carpal tunnel syndrome
Central Neuropathic pain
-spinal cord injury pain,post sstroke pain,multiple sclerosis, results from malfunctioning nerves in the central nervous system
Sympathetically maintained pain
- occurs occasionally when abnormal connections between pain fibers and the sympathetic nervous system perpetuate problems with both the pain and sympathetically controlled functions
- ie edea,temp, and blood flow regulation
Pain threshold
- the least amount of stimuli that is needed for a person to label a sensation as pain
- typically conducted in lab with diff stimuli
- vary between person to person, related to age, gender etc
Pain tolerance
- the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief
hyperalgesia/ hyperpathia
heightened responses to painful stimuli ie. severe pain response to paper cut
allodynia
nonpainful stimuli that produces pain
ie: contact w/ linen, contact with light)
dysesthesia
an unpleasant abnormal sensation
Common Chronic Pain Syndromes
- post-herpetic neuralgia
- phantom pain(amputation )
- trigeminal neuralgia(5th cranial nerve pain)
- headache/migraine
- low back pain
- fibromyalgia-widespread muscle pain
intractable pain
a pain state for which there is no cure possible even after treatment
sensitization
an increased sensitivity of a receptor after repeated activation by noxious stimuli
windup
progressive increase in excitability and sensitivity of spinal cord neurons, leading to persistent, increased pain
nociception
the physiological process related to pain perception
4 processes involved in nociception
- transduction
- transmission
- perception
- modulation
Types of Painful Stimuli-Transduction
MECHANICAL
* trauma to body tissues - tissue damage, direct irritation of pain receptors, inflammation
* alterations in body tissues - pressure on pain receptors
* blockage of a body duct - distention of the lumen of the duct
* tumor - pressure on pain receptors, irritation of nerve endings
* muscle spasm - stimulation of pain receptors
THERMAL
* extreme heat or cold - tissue destruction; stimulation of thermosensitive pain receptors
CHEMICAL
* tissue ischemia - stimulation of pain receptors because of accumulated lactic acid and other chemicals and enzymes in tissues
* muscle spasm - tissue ischemia secondary to mechanical stimulation
nociceptors
specialized pain receptors
transduction
nociceptors are excited by stimuli
transmission
- pain impulses travel from the peripheral nerve fibers to the spinal cord
- spinal cord ascending via spinothalamic tracts
- transmission of signals between the thalamus to the somatic sensory cortex where pain perception occurs
perception
when the client becomes conscious of the pain
modulation
descending system, when neurons in the thalamus and brainstem send signals back down to the dorsal horn of the spinal cord, endogenous opioids, serotonin, and norepinephrine are released
Factors affecting pain experience
- ethnic and cultural values pg 1211 table
- developmental stage pg 1212 look at older adults
- environment and support people
- previous pain experiences
- meaning of pain
Ineffective pain control in older adults
Affects:
- activity tolerance
- mobility
- ability to socialize
- sleep disturbance
- ability to perform ADLs
- ability to remain as independent as possible
why clients may be reluctant to report pain
BOX 46-2 PAGE 1214
- unwillingness to trouble staff who are perceived as busy
- don’t want to be labeled as a complainer or bad
- fear of the injectable route of analgesic administration (especially children)
- belief that unrelieved pain is expected, normal part of recovery or aging
- belief that others will think they are weak if they express pain
- difficulty or inability to communicate their discomfort
- concern about risks associated with opioid drugs (addiction)
- concern about unwanted side effects, especially opioids
- concern that use of drugs now will render the drug inefficient later in life
- fear that reporting pain will lead to further tests or expenses
- belief that nothing can be done to control pain
- belief that enduring pain and suffering may lead to spiritual enlightenment
Pain History
- previous pain treatment and effectiveness
- when and what analgesics were last taken
- other medications being taken
- allergies to medications
Assessing Pain
Page 1215 chart
- location
- pain intensity (rating scales)
- pain quality (description)
- pattern (onset, duration, recurrence)
- precipitating factors (precede pain)
- alleviating factors (remedies)
- associated symptoms
- effect on ADLs
- coping resources
- affective responses
pain management
the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client
Types of pain scales used
- -Wong Baker FACES(older adults, communication barriers ie language,preverbal children
- Brief Pain inventory(BPI) Short film mcgill Pain questionaire(SF-MPQ)
- FLACC scale: children 2 mos-7 yrs old
Pattern of Pain
-pattern of pain includes time of onset,duration,recurrence, intervals w/o pain
precipitating factors
- certain activities sometimes precede pain
ie: physical exertion may preced chest pain, therefore may avoid
Alleviating factors
-nurses ask patients what has been done to allieviate pain ie. home remedies, meds, rest
effect of pain in adl’s
knowing how adl’s are affected by pain helps the nurse understand the clients perspective on the pain’s severity.
ie: sleep, appetite, concentration, work/school
Daily Pain Dairy
- Used for chronic pain
- help identify pain patterns
- time of onset, activity,physical pain character/intensity level,emotions, and use mf meds?
pseudoaddiction
a condition that results from the undertreatment of pain where the client may become so focused on obtaining medications for pain relief that they become angry and demanding, “clock watch”, seem “drug seeking”
Clients in Pain - culturally responsive care
- respect clients as individuals - clients hold different beliefs about pain, inquire about the patient’s beliefs and ways to cope with pain
- respect the client’s response to pain by - the patient has the right to respond to pain in the way they learned is appropriate, recognizing that expressions of pain vary widely and no expression is good or bad
- recognize the variation within a culture by avoiding stereotyping an individual
- expressions of pain vary between cultures and within cultures
addiction
a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors, characterized by behaviors that include one or more of the following
- impaired control over drug use
- compulsive use
- continued use despite harm
- craving
physical dependence
state of adaptation that is manifested by drug class specific withdrawl syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level, and/or administration of an antagonist
tolerance
a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time
Key strategies in Pain Management
- acknowledging and accepting patient’s pain
- assisting support persons
- reducing misconceptions about pain
- reducing fear and anxiety
- preventing pain
preemptive analgesia
the administration of analgesics before surgery to decrease or relieve pain after surgery
WHO 3 step analgesic ladder
- 1- nonopioid
- 2 - opioid for mild to moderate pain
- 3 - opioid for moderate to severe pain
Categories and examples of analgesics
NONOPIOID/ NSAIDS FOR MILD PAIN * acetaminophen - Tylenol * acetylsalicylic acid - aspirin * choline magnesium trisalicylate - Trilisate * ibuprofen - advil * indomethacin sodium trihydrate - Indocin * naproxen, naproxen sodium - Naprosyn, Anaprox * ketorolac - Toradol * Piroxicam - Feldene * Meloxicam - Mobic * celecoxib - Celebrex Cox II NSAID OPIOID ANALGESICS FOR MODERATE PAIN * hydrocodone - Lortab, Vicodin * codeine - Tylenol 3 * tramadol - Ultram, Ultracet * Pentazocine - Talwin OPIOID ANALGESICS FOR SEVERE PAIN * Fentanyl citrate - Sublimaze, transdermal patches * Hydromorphone hydrochloride - Dilaudid * Oxycodone - OxyContin * Morphine sulfae - morphine * oxymorphone - Opana * methadone - Dolophine COANALGESICS * tricyclic antidepressants - nortriptyline, amitriptyline * anticonvulsants - gabapentin, pregabalin * topical local anesthetic - Lidoderm
nonsteroidal anti-inflammatory drugs
NSAIDS, useful for the management of acute and chronic pain - examples; aspirin , advil, ibuprofen
opioids
- full agonists
- mixed agonists-antagonists
- partial agonists
agonist analgesic
bind tightly to mu receptor sites producing maximum pain inhibition
full agonists
- morphine
- fentanyl
- oxycodone
- hydromorphone
agonist-antagonist analgesic
can act like opioids and relieve pain when given to a client who has not taken any pure opioids
partial agonists
have a ceiling effect in contrast to a full agonist, block the mu receptor site or neutral at mu receptor but bind to kappa receptor site
opioid side effects page 1230 box 46-8
- respiratory depression
- sedation
- nausea/vomiting
- urinary retention
- blurred vision
- sexual dysfunction
- constipation
- pruritius
Sedation scale
S = sleep, easy to arouse 1 = awake and alert 2 = slightly drowsy, easily aroused 3 = frequently drowsy, arousable, drifts off to sleep during conversation 4 = somnolent, minimal or no response to physical stimulation
equianalgesia
relative potency of various opioid analgesics compared to a standard dose of parenteral morphine
coanalgesic
adjuvant, a medication that is not classified as a pain medication, may potentiate the effects of an analgesic
placebo
any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its specific physical or chemical properties
routes for opiate delivery
- oral
- transnasal
- transdermal
- transmucosal
- rectal
- topical
- subcutaneous
- intramuscular
- IV
- intraspinal
bolus
single or repeated doses
continuous infusion by pump
internal or external to provide a continuous infusion of pain relievers
continuous plus intermittent bolus
continuous infusion with rescue doses
continuous local anesthetics
continuous subcutaneous administration of long acting local anesthetics near a surgical site
patient controlled analgesia
PCA pump, patient pushes button for more pain reliever release
-Nursing inter: Children:include parents in teaching,assess childs ability to use client control button
older adults: monitor drug s. effects, use cautiously in pts pulmonary/ renal issues , asses clients cognitive/physical ability to use button
physical interventions
- massage
- application of heat or cold
- acupressure
- contralateral stimulation
Nonpharmacological Pain Management
- physical interventions
- immobilization/bracing
- transcutaneous electrical nerve stimulation (TENS)
- cognitive behavioral interventions
- selected spiritual
Cognitive Behavioral Interventions
- distraction
- eliciting the relaxation response
- repatterning unhelpful thinking
- facilitating coping
Types of Distraction
page 1230 box 46-9
VISUAL DISTRACTION * reading or watching tv * watching a baseball game * guided imagery AUDITORY DISTRACTION * humor * music TACTILE DISTRACTION * slow, rhythmic breathing * massage * holding or stroking a pet or toy INTELLECTUAL DISTRACTION * crossword puzzles * card games * hobbies
nerve block
a chemical interruption of a nerve pathway, effected by injecting a local anesthetic into the nerve
-no more than 3 injections a year
Fibromyalgia can lead to?or any pain?
Social isolation and decreased activities
Observation of pain
Nonverbal responses-
- facial impressions (grimacing)
- vocalizations-moaning/crying/screaming
Clinical alert of pain
Perception is reality! Clients self report of pain is what must be used to determine pain intensity
Physiologic responses of pain
Pallor
Diuphresis
Practice guidelines
- establish trusting relationship
- consider clients ability and willingness to participate
Barriers to effective pain management
- lack of knowledge oh adverse effects of pain
- misinformation of analgesics
- misconception about pain
- may not report pain
- fear of becoming addicted
