Fund 50 Pain Flashcards
“Whatever the person experiencing
the pain says it is, existing whenever
the person says it does.” (McCaffery,
1968).
Influenced by many factors
1st phase
transduction - noxious stimuli.
even if a coma patient can’t express pain,
doesn’t mean they cant feel it.
Physiologic Reactions to Pain - Sympathetic stimulation: (fight the pain)
reactions that you would see from acute pain - fight or flight. ex. heart rate up, respiratory up, diaphorisis. DONT rely on vital signs for pain - they aren’t reliable.
● Pain threshold
amount of pain stimulation necessary before one
feels pain.
gate control theory
small fibers can be overridden in small fibers. use massage to override the pain.
Acute pain
3 months, beyond is chronic.
Nursing Process Assessment (don’t forget what you always forget)
always consider assessment first - pain is a vital sign.
5th VS, must be assessed at minimum with Vital Signs
Patient History
Allergies
Physical Assessment
don’t use complaint, use
reports pain
assessment (and she added a few - R & A - A migraine)
Subjective assessment remember pain is
whatever and whenever patient says it is.
Location
Intensity; use pain rating scale
Quality
Time and duration
Precipitating and aggravating factors
Relieving factors
Associated symptoms - migraine - are naseau and vomiting present.
(father reported toe pain, and no one looked. you must remove ted hose and inspect every shift)
nursing diagnosis
Pain
Pain, Chronic
Pain, Acute
Mobility, Impaired physical
planning (plan for realistic and measurable)
Set realistic and measurable goals in order to achieve maximal level of functioning. How can patient achieve it? ex - a patient who has intractable pain, pain scale of 1 or 2, unrealistic. a
What is acceptable pain level for patient?
interventions - Noninvasive***
not to be used as a substitute for pharmacologic measures for mod to severe pain.
Removal of painful stimuli
Relaxation- deep breathing
Massage
Guided imagery
Distraction
Noninvasive Interventions***
Cutaneous Stimulation - massage
Cold or heat packs - good research on cold. getting more research on heat, but inflammatory not good in the first 24 hours due to inflammation. alternate hot and cold is good.
Menthol ointments’
Contralateral Stimulation - knee surgery, they have pain on affected knee. you can massage opposite knee to help with taht
TENS***
Noninvasive
Interventions
use buzzing bee above head in pediatrics before treatment
Hypnosis
Biofeedback
TENS
Pharmacological Interventions - dependent or independent?
THIS IS a Dependent function and requires a MD order. (Dependent requires MD order, independent does not)
WHO analgesic ladder (developed to treat cancer pain, also used for chronic pain)
CDC Recommendations
Pharmacologic Interventions
Nonopioid Agents
NSAIDS (careful of kidney effect, also GI symptoms, and cardiac effects for older adults - not recommended)
Tylenol poor anti-inflammatory actions (good choice because it has least side effects - only issue is liver issues. make sure safe if someone drinks alcohol)
COX-2 Inhibitors - only one left on market is celebrex. works well for arthritis, but risk for older adults of heart attack and stroke.
These all have a ceiling effect. They won’t work if you take more. Give more bc it’s anti-inflammatory. Tylenol is 1000 mg.
Opioids work on what system of the body?
work at level of CNS
• Morphine (gold standard - measure everything against this)
• Hydromorphone
• Fentanyl
• Oxycodone
• Demerol (it’s mostly been taken out of hospitals a long time ago. there is a risk of seizure. its a good treatment for riggers - severe shivering) : Only for short-term use
Assessment - Sedation Scale: #1
1 – awake & alert
side effects
Respirations (need to monitor for this) always report respiratory w/ ppl on opiates, even if it’s normal.
Pruritis (itching)
Constipation (treatment?)
N & V (naseau and vomiting)
You will build a tolerance for all of these EXCEPT constipation
Adjunctive Medications
Enhance pain control or relieve symptoms associated with pain
Examples:
anticonvulsants i.e. Neurontin
Tricyclic antidepressants i.e. Elavil
Corticosteriods i.e. decadron (inflammation of brain, decadron will help)
Benzodiazepenes i.e. valium
narcan
be careful, don’t adminster entire 4 mg bc they will go into withdrawals and high BP. they will wake up mad. need to monitor them.
equianalgesics (equan is equal)
used to compare doses from one med to another. ie - morphine to dilaudid.
placebo
35 year old male admitted for back pain
Reports pain scale 8/10
Comfort Goal 3/10
Order: Saline 1mL intramuscular injection every
3 hours as needed for moderate to severe pain
What action would you take? clarify the order, but it won’t work. this is unethical. You will lose your license.
Scheduling
Utilize a preventative approach when scheduling.
Before a painful event
ATC if pain is present most of the day
ATC vs PRN Around the clock is most effective and
most appropriate choice for pain management. May
use prn for breakthrough pain
Patient Controlled Analgesia (PCA) - patient controls dosing. there is a lock out. No one should press it but the patient, even the nurse. if they are overly sedated, they can’t press the button
usually no more than 5 day prescription. usually try to get patient off before they leave hospital.
administration routes
Oral - rectal - intramuscular
- subcutaneous - Intravenous
- PCA (patient-controlled
analgesia) - Transdermal
Epidural & intrathecal
administration
most dangerous route is IM - because the absorption is not steady. can result in aspiration, abcesses.
safest route is oral.
evaluation
Must document, evaluation, and perform assessment every time. Imperative to assess effectiveness of
interventions and document. Also important to
evaluate for potential side effects in relation to
interventions and document.
geriatric considerations - start with what?
start w/ acetominophen, then opioids (low dose), NSAID/cox 2. if patient has other signs of pain, pacing, etc. assume pain is present and medicate.
Sensory Deprivation (think of the senses)
hearing, vision, not having glasses. confusion w/ older adults. interventions - try to orient them. turn on TV or music. engage in conversation. have family members come by. move closer to nurse’s station, shared room. activities outside of room.
pathology of pain - Nociceptive Pain: (muscles and organs are nociceptive to pain)***
caused by damage to somatic or
visceral tissue (can sharp or stabbing)
pathology of pain - Neuropathic pain***
pain sustained by abnormal processing of sensory input by peripheral or CNS (use gaba)
physiological response to pain - Parasympathetic - think of your stomach when you get a migraine
bp decreases, nausea, vomiting, - can be severe or viseral pain (migraine) heart attack.
physiological response to pain - psychological factors
chronic pain - suicide.
● Pain tolerance
amount of pain one is willing to endure. need to take pain before it gets really bad - harder to get down when it’s so high.
● Drug dependence
physical (ex steroid - cannot abpurtly stop) also opioids.
psychological - craving for a drug to relieve pain. it is a brain disorder. requires multidisciplinary approach.
psuedoaddiction
someone who has addictive personality traits (dr. shopper, at ED a lot) they need to exaggerate their results because they are undermedicated.
Chronic pain
no treatment.
Cancer Pain
many reasons, tumors, bone pain, surgery, chemo, neuropathy
Intractable Pain
no way out pain, usually hospitalized with this.
Phantom Pain
menthal ointments, mirrors.
Radiating - and ex.
goes from one area to another, heart attack
Pain Visceral - and is it common or not?
in visceral organs, not many nociceptors, so it’s not common. it’s usually referred pain.
hypercapnia
Excess of dissolved carbon dioxide (C02) in the blood
Etiology:
Hypoventilation**caused by too many sedatives - ativan, valium
Sedatives
Lung disorders (chronic COPD)
Hypercapnia can be acute or chronic
In chronic conditions, kidneys can compensate for high
blood pH (kidney produces bicarbonate)
**** Respiratory drive changes to low O2 vs high CO2 as in
COPD - don’t over oxygenatic or correct CO2 levels in these patients
Severe hypercapnia causes CNS depression that may
lead to somnolence and progress to coma and death
**COPD patients retain CO2
high CO2 can cause cardiac arrest
**Atelectasis (on exam)
collapse of lung d/t deflated or fluid filled alveoli and chronic hypoventilation
Most common respiratory complication post-op
to ****prevent collapse use spirometer, ambulate, sit patient up, pain medication
Loss of lung volume due to inadequate lung expansion (collapse) of the alveoli that prevents normal ventilation
-One of the most common respiratory complications after surgery.
can happen after surgery to any patient
nursing diagnosis
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Gas Exchange
Impaired Spontaneous Ventilation (too much pain meds, stroke)
Dysfunctional Oxygenation Weaning
Risk for Aspiration
**** Risk for Atelectasis
Diagnose, treatment plan, goal (you need this for nursing care plan)
Hypoxemia V.S. Hypoxia***
Hypoxemia: low arterial blood oxygen levels (O2 level less than 80)
Hypoxia: inadequate oxygenation of the organs and tissues
-Decreased oxygen supply: acute blood loss,
-Increased oxygen demand: fever
-Ineffective external respiration: pneumonia, pulmonary edema,
-Altered internal respiration: severe sepsis**
-Shunting: septum foramen ovale (baby)
-Circulatory compromise: severe heart failure, cardiogenic shock
Respiratory Infections***
Common Respiratory Infections that Interfere with Gas Exchange
1. Upper Respiratory infections
Stuffy nose, sore throat, cough, sneezing, tearing
2. Influenza
Viral infections more severe than common cold, may
involve lower respiratory tract, cold-like symptoms,
fever, fatigue
3. Lower Respiratory Tract Infection
***Pneumonia is RESPIRATION (increases secretion in airways, affects respiration and gas exchange in alveoli), Respiratory Syncytial Virus (RSV),
tuberculosis
**elderly get more sick from respiration, Covid causes scarring of lung tissue
RESPIRATORY ASSESSMENT***
Demographics (age, residence (exposed to pollutants, occupation)
Health history (allergies (pets, pollen), medications, health problems)
Lifestyle – smoking, recreational drugs
2. Physical Assessment
*** Inspect: rates, effort, symmetric, cyanosis, nails
Palpate: tactile fremitus (vibration of lungs - check both sides at the same time), crepitus (air in subcutaneous tissue - it’s a little bump)
Percuss: consolidation (if normal, it should be hollow)
Auscultate: rhonchi, crackles, wheezing
Assessing Respiratory Effort**
- BODY POSITIONING
Tripod breathing (leaning forward) – sign of respiratory distress - CONVERSATIONAL DYSPNEA
Inability or difficulty to speak complete sentences
without stopping to breath, pausing for breath
**7. STRIDOR
High-pitched whistling sound (hear a lot in babies, if in adult, very serious. ALWAYS go to stridor patient first, everything else can wait)
Caused by partial obstruction of larynx or trachea - WHEEZE
Musical sound produced by air passing through
narrow airways
chronic COPD or heart failure, important to assess talking, if they can only speak in 2 words without breath, they are getting worse.
Nursing Intervention/Implementation**(what part of intervention for breathing)
- Med administration such as inhalers, nebulizers***(every 4 hours as needed, or for acute every 4 hours around the clock. for someone who is wheezing, but don’t give it too often bc it’s a CNS stimulant)
- Promote Optimal Respiratory Function
Deep breathing exercises, infection prevention,
immunization, smoking cessation, positioning, ICS, treat
PNA, aspiration precaution - Mobilizing secretions (loosen and mobilize)
Turn, cough and deep breathing promotes ventilation
and gas exchange
Maintain hydration to keep secretions thin and mobile
Perform Chest Physiotherapy (physically helping patient to loosen secrection in lungs) - Postural drainage, chest percussion, chest vibration
acute kidney injury***▪ Prerenal-factors (just what’s on the outside - definition only, not examples)
external to kidneys that reduce renal blood flow
diagnostic lab of renal function(comprehensive)
MOST important thing to remember is you need comprehensive tests to assess renal function
BUN Byproduct from protein catabolism.
Cleared by kidneys, Not specific to
renal function
8-25 mg/dl
Protein breakdown, dehydration,
overhydration, liver failure influence
value
specimen collection***
Specimen Collection:
• Ensure patient and all caregivers understand the importance of collecting all urine during the 24 hrs• Post sign in bathroom with start and end time and date of collection• Have patient empty bladder and discard which will be the ”start time”• Put “ALL” UOP in 24hrs in the urine container (usually on ice)• At the end of 24 hrs, have pt void again and place urine in container.
**If any urine gets discarded
CAUTI prevention***
❖Insert catheters only for appropriate indications
➢ Consider external urinary collection devices
**Remove catheter as soon as possible
**Normal and expected to feel burning sensation initially after
catheter removal
❖Ensure sterile technique throughout insertion procedure
❖Maintain a closed drainage system
❖Maintain unobstructed urine flow (keep foley bag below level of bladder)
❖Proper hand hygiene and Standard Precautions
❖Foley and perineal care every shift (follow facility policy)
preventing and treating constipation***
Dietary: High fiber with adequate fluids
➢20-35 g fiber/day
➢Fluids 1.8 to 2.5L /day
➢Avoid caffeinated drinks
❖ Do not delay urge to defecate
(Results in hard stool, decrease urge)
***Exercise
❖ Medication: stool softeners, laxatives, enemas, suppositories, PO narcan, digital dis-impaction
preventing and Treating Diarrhea***
Definition of diarrhea is ≥ 3 loose stools in a 24hr period
Etiologies:
Excessive use of laxatives
Certain antibiotics
Infectious – Clostridium Difficile ***Initiate enteric contact isolation and
send stool sample for C-diff
Complications:
Dehydration
Electrolyte abnormalities
Moisture associated skin damage (Incontinence Associated dermatitis
Ileostomy**
End of ileum (small intestine) brought through opening to abd wall to
form a stoma
acute kidney injury***▪ Intrarenal-factors
causing direct damage to kidneys/ATN (acute tubular necrosis)
acute kidney injury***Postrenal-factors (if you can’t pee, it’s obstructed. that’s it)
causing mechanical obstruction to flow of urine
▪ Potentially reversible
▪ Older adults more vulnerable
**Characteristics of stoma - pale = ? and purple = ?
➢ pink/red normal (pale-anemia, maroon/purple-ischemia)
**stoma - Characteristics of drainage/stool
depends on new or existing ostomy and location of ostomy
❖ Note amount and frequency
respiratory assessment - during the physical assessment, inspect what? (SCREN for respiratory)
*** Inspect: rates, effort, symmetric, cyanosis, nails
stoma edema (what causes it)
severe due to obstruction, allergic rxn, gastroenteritis
stoma bleeding
small amount normal due to high vascularity
how often to change ostomy bag?
❖ Change ostomy bag every 3 days or policy (more frequent if needed)
ppl with stomas often need what type of support?
❖ Physical and Psychological support
assessment - sedation scale #2
2 – occasionally drowsy, easy to
rouse
assessment - sedation scale #3 (fell asleep taking 3 times)
3 – frequently drowsy, arousable, falls
asleep during conversation
assessment - sedation scale #4
4 – somnolent, minimal or no response
to physical stimulation
sensory overload***
ppl in and out. alarms. ICU. lights left on. smells. being near nurses station. shared room. also internal stimuli - trach tube, CNS disorders. interventions - ear plugs, lights off, door closed, moving patient. uninterrupted sleep.
sensory deprivation - nursing process***
Nursing Process
Assessment
Nursing Diagnosis
Sensory/Perceptual Alteration
Social Isolation
Planning
Implementation
Evaluation
Sedation Scale:
1 – awake & alert
2 – occasionally drowsy, easy to
rouse
3 – frequently drowsy, arousable, falls
asleep during conversation
4 – somnolent, minimal or no response
to physical stimulation
most dangerous and safest routes of administration
most dangerous route is IM - because the absorption is not steady. can result in aspiration, abcesses.
safest route is oral.
what type of pain is damage to somatic or
visceral tissue (can sharp or stabbing) called?
nonciceptive pain
Use Metered Dose Inhaler (MDI) for children/ adults who
can’t keep inhaled medication in
Picker’s 8 Principles of Pt Centered Care
- Respect for pt’s preferences and expressed needs 2. Coordination and integration of care
a. Interpersonal and teamwork and collaboration is important 3. Information and Education - Physical Comfort
- Emotional Support
- Involvement of Family and Friends 7. Continuity and Transition
- Access to Care
Long term goal is how long?
Long term goal is > 7 days
inflammatory stage lasts how long? (wounds)
2-3 days
Remodeling (maturation) begins when?
Begins 3 weeks after injury
venous ucler color
Yellow slough ot ruddy skin
Desiccation skin
Desiccation: process of drying up
diabetics have what type of ulcers?
Venous insufficiency CVD
Beta-hemolytic strep presence
Beta-hemolytic strep presence in ANY NUMBER indicates an infected wound
wound healing Autolytic and enzymatic
Autolytic: use of your body’s own enzymes
Enzymatic: products that contain enzymes
how fast for wounds to heal?
Expected path for wound healing is that the wound should be 20% smaller at week 2 and 40-50% at week 4 to heal in 12 weeks
Regenerative/ Epithelial Healing
Regenerative/ Epithelial Healing
Wound only involves epidermis and dermis
New tissue can’t be distinguished from intact skin
TNM numbers
Tumor: how big tumor is 0-3 (3 largest)
Nodes: number of nodes involved 0-2 (2 all nodes involved)
Metastases: how far it traveled 0-2 (0 is not metastases)
late effects of radiation
Late Effects
May be chronic
Fibrotic changes
Increased risk for other malignancies
Hematopoietic Growth Factors
Hematopoietic Growth Factors
Colony Stimulating Factors
stimulate production, maturation, regulation and activation of cells in hematologic system (Neupogen)
Erythropoietin (ex: Epogen for chemo-related anemia)
