Chronic Pain Nursing Process

Question 1

Assessment

Answer 1

PQRST

• *P** ain is real (believe the patient)
• *A** sk about the pain
• *I** solation (psych. & social problems)
• *N** otice pain characteristics
• *E** valuate pain characteristics
• *D** oes pain impair function?

** O** nset ** C** haracteristics

L ocation ** A** ggravating factors

** D** uration ** R** elieving factors

                                     **T**reatment previously tried

OBSERVE: grimacing, crying, slow movements, unwillingness to move, increased wandering, restlessness, agitation, altered sleep, decreased appetite, guarding

Question 2

Common Diagnosis 1

Answer 2

Elimination

• Alteration in bowel elimination (BM frequency) related to gastric and bowel motility with opioid
• Altered pattern of urinary elimination ( urinary output) related to unrelieved pain

Fluid and electrolytes

• Fluid retention related to urinary output
• Hyperkalemia related to fluid retention
• Common diagnoses:cont’d

_Activity and Rest************_

• Restricted mobility or immobility r/to chronic pain
• Potential for muscle contracture related immobility
• Potential for sleep pattern disturbances r/t :
• Chronic pain
• Anxiety

Question 3

Common Diagnosis 2

Answer 3

Self-care deficit related to:

• Chronic pain
• Fatigue

Common diagnoses: Oxygenation

• Potential for ventilatory impairment related to:
• cough reflex
• Sputum production and retention
• Atelectasis
• When does this happen? 24 hours may think its infection but it comes later

Protection

• Potential for impaired skin integrity r/t immobility
• Potential for infection r/t :
• Ventilatory impairment
• Depressed immune system

Self concept

• Anxiety, fear, powerlessness, hopelessness, thoughts of suicide, self-esteem r/t unrelieved pain

Interdependence

• Altered family processes…
• Loneliness r/t social isolation
• Inadequate resources r/t lack of knowledge…

Question 4

Treatment Goals

Answer 4

• Reduce the pain experience whenever possible
• Develop a plan using variety of pain control methods: analgesics and non pharm. Techniques
• Use ice packs, warm compress before meditation and all the weird stuff
• Restore/improve functioning, activity
• Develop self/help and maintenance skills: improve depression and anxiety
• Improve relationships with family, friends, health-care providers

Chronic pain, goals

Directly addressing chronic pain:

• Reducing pain whenever possible (many ways)
• Improving or restoring function
• Developing coping skills
• Decreasing depression, anxiety, fear
• Improving relationship with family members and caregivers

Question 5

Interventions

Answer 5

*******Manipulate relevant stimuli:

• Patient education
• Pharmacological management (opioid and non opioid)
• Adjuvant pain control medications
• Non pharmacological measures (201 lecture notes) know what fits with what

Multidisciplinary approach:

Pain specialist, Physiotherapy, Occupation therapy, Social worker, Psychologist, Chaplain, support groups.

Chronic pain: interventions long term

• Pain management specialists and programs
• Make clinic appointments promptly, waiting exacerbates
• Seek second opinion
• Home care
• Palliative care facility

Question 6

Pharm Interventions

Answer 6

• change in behaviour, consider pain first
• Use combination drug and non drug measures
• Adequate amount and dose correctly (opioids start with lower dose)
• Choose least side effects, as simple as possible – choosing the drug with the least side effects
• Non-invasive first, around the clock – PO first then injection then work your way up
• Monitor and anticipate side effects

Question 7

Types of Analgesics

Answer 7

Mild to moderate: nonopioids:

• Acetominophen / NSAIDS, Naproxen, Celebrex^

_Moderate to Severe: *Opioids (long acting, quick acting):_

• fentanyl, oxycodone, Hydromorphone, codeine, can use in combination with nonopioid
• know!!!!!!
• how much to give when the order is two tablets? Use 1 first if not relieved then give the second one. May give the second pill in the 4 hours

For breakthrough: rapid-onset opioids: relieves pain quickly, used with long acting opioid

• (fentanyl patch Q3 days), hydromorphone Q2H PRN for breakthrough
• If pt received Tylenol should you give breakthrough? OR what to give next to Tylenol???
• When to give breakthrough? Will be given if patient is still not relieved READ YOUR DAMN TEXT!!!!
• Half life is different for every patient
• Visit patient q30mins
• If all medication is not working talk to MD
• Breakthrough dose is always half of opioid, should never be more than opioid

Very very important!!!!!!
Need to know when the medication will peak and how long it lasts. Text has excellent references.

Question 8

Opioid Special Considerations

Answer 8

• With opioid always need simultaneous order for laxatives!!!!!!!!!!!!!!!
• Lactulose is amazing and Colace is garbage we need explosions!!!!!!
• Can have temporary side effects –nausea / vomiting, not always reason to stop as system will get used to effects.
• Anti emetics can also have constipating side effects
• Anti emetics may make the pt drowsy or light headed

May need to increase opioid dose slightly r/t tolerance NOT ADDICTIONS!!!!!!

• Tolerance manifests over 2-3 weeks so will need more analgesia for effectiveness. See this in cancer patients.
• ** Addiction:** use of opiates for reasons other than physical pain. People in physical pain on long term analgesia are not addicts !

Question 9

OOIQ Sedation Scale

Answer 9

Sleep, easily arousable by gentle tap on shoulder

1. Pt is awake and alert . Capable of performing ADL`s
2. Occasionally drowsy, easy to arouse, still able to perform ADL`s
3. Frequently drowsy, arousable, drifts off to sleep during conversation, decreased respiration rate, decreased depth of respirations, pupils constricted to less than 3 mm

• Opioid dose may be too high, spaced too closely together or liver not metabolizing it properly ex. Codeine
• Do v.s , call MD. Monitor pt

4. Somnolent, minimal or no response to stimuli. Pt is significantly sedated and requires stat intervention. Resp depression less than 8/min with apneic periods pinpoint pupils.D_o VS, call MD, prepare Narcan. Document interventions and patient response. !!!!!!!!_

Question 10

Treating Breakthrough Pain

Answer 10

• Occurs while pt is on analgesia already
• Assess usual baseline pain
• Where? When? Intensity? Pattern?
• What usually helps?
• Any non pharmacological options? Positioning?
• How effective is breakthrough/prn analgesia?
• Does regular dose need to be changed ?

Question 11

Complementary Medications

Answer 11

• Antidepressants: treat tingling, burning nerve pain
• (TCA’s-Elavil, Sinequan) (SNRI’s –Effexor)
• Anti-anxiety: muscle spasms (severe pain)
• Diazepam, lorazepam
• Antihistamines: control N&V, help sleep, control itching
• Diphenhydramine
• Steroids: bone pain (spinal cord, brain tumors), inflammation, increase appetite Prednisone, dexamethasone
• Neuropathy analgesics: Neurotin, gabapentin, anticonvulsants (dilantin) !!!!!!!!

Question 12

Non Pharm

Answer 12

• *Relaxation**: breathing, soothing music
• *Biofeedback:** learn to control HR, BP, muscle tension
• *Imagery:** deliberate daydream, remove oneself in thought to another place, time
• *Distraction:** activity to occupy attention
• *Hypnosis**: open to suggestion, relax

Question 13

Who would you involve

Answer 13

Multidisciplinary Team ****GOING TO ASK WHO WOULD U INVOLVE?!?!!?

• Patient
• Family
• Nurse /pain nurse specialist
• MD
• Pharmacist
• Occupational Therapist
• Art – Music Therapists
• Psychologist
• Social worker