L7: Pain Management Flashcards
what is McCaffrey’s classic definition of pain?
pain is whatever the experiencing person says it is, existing whenever he says it does
what does effective pain management do(5)?
1) improves quality of life
2) reduces physical discomfort
3) promotes earlier mobilization and return to baseline functional ability
4) results in fewer hospital and clinic visits
5) decreases hospital lengths of stay
These reduce healthcare costs
caring for patients in pain requires recognition that…
pain can and should be relieved
The Institute of Medicine (IOM) in conducting an extensive examination of pain as a public health problem. The results of the IOM study were released in the 2011 report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” This report…
acknowledges the tragic epidemic of pain in the United States and calls for major coordinated efforts to develop safe effective preventive and management strategies.
what does The Joint Commission pain standard require?
requires healthcare providers to assess all patients for pain on a regular basis
The nature of Pain(5):
* what components are involved?
* how is it perceived by people?
* what does pain reduce?
* how do you measure it?
* what can it lead to?
1) pain involves physical, emotional, and cognitive components
2) pain is subjective and individualized
3) pain reduces quality of life
4) subjectively, pain is not measurable objectively
5) pain may lead to serious physical, psychological, social, and financial consequences
what are the four physiological processes of normal pain?
1) transduction
2) transmission
3) perception
4) modulation
describe the transduction of pain:
a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential.
describe the transmission of pain:
excitatory neurotransmitters transmit the pain signal across synaptic clefts, spreading the “pain message” and causing an inflammatory response. This pain message is transmitted to the cerebral cortex for analysis.
What are the two roles of neurotransmitters during nerve transmission?
They either excite during transmission or inhibit during modulation.
What do excitatory neurotransmitters do?
They send electrical impulses across the synaptic cleft between two nerve fibers, enhancing transmission of the pain impulse.
What happens when a pain stimulus reaches the cerebral cortex?
The brain interprets the quality of the pain and processes information from past experience, knowledge, and cultural associations.
What cortex identifies the location and intensity of pain?
somatosensory cortex
What cortex determines how a person feels about the pain?
association cortex, primarily the limbic system.
Is there a single pain center in the brain?
No, there is no single pain center.
How do nerve impulses from painful stimuli travel?
They travel along afferent (sensory) peripheral nerve fibers.
What are the (2) types of peripheral nerve fibers that conduct painful stimuli?
Fast, myelinated A-delta fibers and very small, slow, unmyelinated C fibers.
What sensations do A-delta fibers send?
Sharp, localized, and distinct sensations that specify the source of the pain and detect its intensity.
What type of impulses do C fibers relay?
Poorly localized, visceral, and persistent impulses.
describe the perception of pain
Perception is the point at which the person is aware of pain
includes physiological and behavioral responses
describe the modulation of pain:
once the pain perceives pain, there is a release of inhibitory neurotransmitters such as: endorphins (endogenous opioids), serotonin, norepinephrine, and gamma-aminobutyric acid (GABA), that hinder the transmission of pain and help produce an analgesic effect
- inhibits pain impulse and serves as a protective reflex
describe the ANS parasympathetic nervous systems involvement in pain
continuous, severe, or deep pain typically involving visceral organs activates the parasympathetic nervous system
describe the sympathetic nervous systems involvement in pain
the stress response stimulate the ANS sympathetic nervous system; fight or flight
what are the types of pain(5)?
1) acute/transient
2) chronic/persistent (noncancer)
3) chronic episodic
4) idiopathic
5) cancer
describe acute/transient pain
(definition and 2 points)
protective, identifiable, and with a short duration; limited emotional response
- threatens patients’ recovery by inhibiting ability to become active and involved in self-care
- all focus is on pain relief which delays physical and psychological progress while pain persists
describe chronic/persistent pain (noncancer)
(definition and 2 points)
is not protective, has no purpose, and may or may not have an identifiable cause
- may be viewed as a disease since it has a distinct pathology that causes changes which may worsen over time.
- unknown cause of chronic pain frequently leads to psychological depression, and even suicide.
what is the goal of healthcare workers treating chronic pain?
The goal of chronic noncancer pain is to improve functional status with a multimodality plan
describe cancer pain
(description and 1 point)
normal (nociceptive), resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damaged pain nerves.
- A patient senses pain at the actual site of the tumor or distant to the site, called referred pain.
what is referred pain?
pain felt in an area distant to the site of tissue damage
describe chronic episodic pain
pain that occurs sporadically over an extended duration
describe idiopathic pain
chronic pain without an identifiable physical or psychological cause
What are the (5) Factors Influencing Pain?
Physiological
Social
Psychological
Pain tolerance
Cultural
what are the physiological factors that influence pain(4)?
1) age
2) fatigue
3) genes
4) neurological function
what does fatigue do to the perception of pain?
fatigue increases the perception of pain and can cause problems with sleep and rest
how does age influence pain and pain management?
are-related changes and increased frailty can lead to:
1) a less predictable response to analgesic medications
2) increased sensitivity to medications
3) potential harmful drug effects
how does genetic makeup influence pain?
genes may affect a person’s pain tolerance
what are some social factors that influence pain(4)?
1) attention
2) previous experiences
3) family and social support
4) spirituality
describe the effect attention has on the perception of pain
Increased attention - associated with increased perception of pain
Decreased attention - associated with diminished pain response
what are the psychological factors that influence pain(2)?
1) anxiety
2) coping style
what are the cultural factors that influence pain(2)?
1) individual’s meaning of pain
2) ethnicity
describe how anxiety influences the perception of pain
anxiety often increases the perception of pain and the perception of pain causes anxiety
describe the perception of pain: internal loci of control VS external loci of control
internal loci of control - perceive themselves as having control over events in their life and the outcomes such as pain
external loci of control - perceive that other factors in their life, such as nurses, are responsible for the outcome of events
how do you assess a patient dealing with acute pain?
- streamline your assessment and assess:
1) location
2) severity
3) quality
Ask questions to determine the onset, duration, and time sequence of pain.
- collect a more detailed acute pain assessment when the patient is more comfortable
what are the ABCs of pain management?
Ask - ask about pain regularly and assess pain systematically
Believe - believe the patient and family in their report of pain and what relieves it
Choose - choose pain control options appropriate for the patient, family, and setting
Deliver - deliver interventions in a timely, logical, and coordinated fashion
Empower - enable them to control their course to the greatest extent possible.
why is pain assessment not simply a number?
relying solely on a number fails to capture the multidimensionality of pain and may be unsafe
Use other signs when you suspect a patient may be under reporting pain, but do not use them as a standard for titration
what is the most reliable indicator of pain’s existence and intensity?
a patient’s self-report
pain assessments of people with cognitive impairments often require assessment approaches that involve:
1) close observation of vocal response
2) facial movements (grimacing, clenched teeth)
3) body movements (restlessness, pacing)
4) Social Interactions
What are the characteristics of pain that need to be identified during a pain assessment?
1) timing - when did it start? how long does it last?
2) location
3) severity
4) quality - can you describe the pain? (learn words pt uses to describe the pain and use them when assessing)
5) precipitating factors - does anything cause or make the pain worse?
6) relief measures - is there anything that helps with the pain?
7) effects of pain on the patient - does the pain affect your behavior or ADLs?
what is the purpose of the pain scale?
to identify pain intensity over time
what are some common precipitating factors(7)?
1) physical movement
2) positions
3) drinking coffee or alcohol
4) urination
5) swallowing
6) eating food
7) psychological stress
what are some symptoms that can either cause worsening pain or be caused by pain(8)?
1) depression
2) anxiety
3) fatigue
4) sedation
5) anorexia
6) sleep disruption
7) spiritual distress
8) guilt
what are some common methods patients report relieves some of the pain they’re feeling(5)?
1) using ritualistic behavior (pacing, rocking, rubbing)
2) eating
3) meditation
4) praying
5) applying heat or cold to painful site
When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient’s pain. Which of the following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judges of their pain.
C. Regular use of narcotic analgesics leads to drug addiction.
D. Amount of pain is reflective of actual tissue damage. Be
B
what are Concomitant symptoms?
symptoms that exist at the same time that usually increases pain severity
what are some common Concomitant symptoms that are often related to pain(7)?
1) nausea
2) headache
3) dizziness
4) urge to urinate
5) constipation
6) depression
7) restlessness
the symptoms depend on the cause and location of the pain
Certain types of pain have
predictable concomitant symptoms.
what are some nonpharmacological pain-relief interventions(9)?
1) cognitive and behavioral approach
2) relaxation and guided imagery
3) distraction
4) music
5) cutaneous stimulation massage
6) cold and heat application
7) transcutaneous electrical nerve stimulator (TENS)
8) herbals
9) reducing pain perception and reception
What are (4) guidelines for individualizing pain therapy?
- Use different types of pain-relief measures.
- Use measures that patient believes are effective.
- Keep an open mind about ways to relieve pain.
- Keep trying. When efforts at pain relief fail, do not abandon the patient but reassess the situation.
What are some common holistic health approaches?
- wellness education (Health literacy significantly affects a patient’s pain experience and understanding of pain management strategies.)
- regular exercise
- rest
- attention to good hygiene practices and nutrition
- management of interpersonal relationships.
what is the most common and effective method of pain relief?
analgesics
what are the three types of analgesics?
1) nonopioids (acetaminophen, NSAIDs)
2) opioids
3) co-analgesics/adjuvants
describe acetaminophen
1) nonopioid analgesic
2) has no anti-inflammatory or antiplatelet effects
describe NSAIDs (4)
(nonsteroidal antiinflammatory drugs)
1) nonopioid analgesics (aspirin and ibprofen)
2) provide mild/moderate pain relief
3) most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli
4) long-term use associated with GI bleeding and renal insufficiency
what are some adverse effects of opioid analgesics?
1) nausea
2) vomiting
3) constipation
4) itching
5) urinary retention
6) altered mental process
7) sedation
can cause respiratory depression
when a patient is converted from IV opioid analgesics to PO, why do the dosages become much higher?
because of the first-pass effect of medication metabolized in the liver
Describe co-analgesics/adjuvants drugs
co-analgesics and adjuvants drugs are used to treat other conditions, but they also have analgesic qualities (tricyclic antidepressants and
anticonvulsants).
Follow these guidelines from the American Society for Pain Management Nurses:
1) Avoid administration of partial doses at more frequent intervals so as to not under dose a patient with small, frequent, ineffective doses from within a range.
2) Avoid making a patient wait a full time interval after giving a partial dose within the allowed range.
3) Wait until peak effect of the first dose has been reached before giving a subsequent dose.
what is PCA?
Patient controlled analgesia. Allows patients to control when they take their PRN medications including: analgesics, antiemetics, and anxiolytics
what form of administration is patient controlled analgesia?
1) IV
2) SUBQ
3) oral (rare)
what are the benefits of PCAs?
1) patient gains control over pain
2) pain relief does not depend upon nurse availability
3) decreases anxiety
4) decreased medication use
5) stabilizes serum drug concentrations for sustained relief
what are commonly used topical analgesics(2)?
1) NSAID products (ketoprofen patch)
2) capsaicin
Eutectic Mixture of Local Anesthetics (EMLA) should not be placed…
1) around the eyes
2) tympanic membrane
3) over large skin surfaces
Describe a Lidoderm patch
a topical analgesic that is effective for cutaneous neuropathic pain (e.g. postherpetic neuralgia) in adults
How do you use a Lidoderm patch?
Adults: place three patches, cut to size, on and around the pain site.
Use a 12h on 12h off schedule
what is local anesthesia used for?
How are they administered?
1) topically on the skin or mucous membranes
2) injecting them subcutaneously or intradermally
how are local anesthetics administered(2)?
1) topically on the skin or mucous membranes
2) injecting them subcutaneously or intradermally
3) perineural local anesthetic infusion
what is regional anesthesia?
injection or infusion of local anesthetics to block a group of sensory nerve fibers
what is perineural local anesthetic infusion?
peri-neural: Next to nerve
a surgeon places the tip of an un-sutured catheter near a nerve or group of nerve fibers and the catheter exits from the surgical wound (common after surgery)
what are common side effects for topical anesthetic?
1) pruritus (burning of the skin)
2) localized rash
application of a topical anesthetic to a vascular mucous membrane increases the chance of what?
increases the chance of systemic effects like a change in HR
The use of local anesthetics on peripheral nerves and epidural infusions may have what effect?
block motor nerves in addition to sensory nerves leading to temporary paralysis of affected body part
what does epidural analgesia treat(4)?
effectively treats:
1) acute postoperative pain
2) rib fracture pain
3) labor and delivery pain
4) chronic cancer pain
reducing a patient’s overall opioid requirement which minimizes adverse effects
is epidural analgesia a long-term or a short-term therapy?
can be either or depending on a patient’s condition and life expectancy
One of the concerns related to the use of peripheral and epidural anesthetic techniques?
because the epidural space is a highly vascular area, patients with epidural catheters are at risk for developing epidural hematomas which can lead to ischemia of the spinal cord. If unaddressed, serious neurological complications can occur.
why do you NOT administer supplemental doses of opioids or sedative/hypnotics to someone receiving epidural analgesia?
risk of possible additive central nervous system adverse effects
With a patient receiving epidural analgesia, anticoagulants and antiplatelets…
should not be administered to a until safe use can be verified with a pain specialist because of increased risk of bleeding and hematoma formation
What interventions are available when severe pain persists despite medical treatment?
Invasive interventions:
available invasive interventions include: intrathecal implantable pumps or injections, spinal cord and
deep brain stimulation, neuroablative procedures (cordotomy, rhizotomy), trigger point injections, cryoablation, and intraspinal medications.
when patients receive epidural analgesia, how often do you monitor them?
initially assessments every 15 minutes. Once stabilized, monitoring occurs about every hour for 12-24 hours.
when severe pain persists despite medical treatment, what are some more invasive treatments available(6)?
1) intrathecal implantable pumps or injections
2) spinal cord and deep brain stimulation
3) neuroblative procedures
4) trigger point injections
5) cryoablation
6) intraspinal meds
Describe the prevalence of chronic or acute cancer pain.
chronic or acute cancer pain ranges from 64% in patients with metastatic, advanced or terminal phases of the disease, 59% in patients on anticancer treatment, and 33%
in patients after curative treatment.
what is breakthrough cancer pain (BTCP)?
BTCP - a transient worsening of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger,despite relatively stable and adequately controlled background pain.
According to the American Pain Society, what is the primary goal in treating chronic noncancer pain with opioids?
he primary goal is to increase patients’ level of function rather than just to provide pain relief
A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be:
A. adjunctive therapy.
B. nonopioids.
C. NSAIDs.
D. PCA pain management.
D
what is the analgesic ladder?
a three step approach to manage cancer pain that begins with NSAIDs and/or adjuvants and progresses to opioids
what is the bidirectional approach to the analgesic ladder?
- the original analgesic ladder progresses up the steps starting from NSAIDs
- the bidirectional approach would include a step down approach for patients with intense acute pain, uncontrolled cancer pain, and breakthrough pain
what can be considered the 4th step of the 3-step analgesic ladder?
The fourth step recommends neurosurgical and other invasive procedures and also includes
management of pediatric pain and acute pain in emergency departments and in postoperative situations.
What portion of people with chronic persistent pain become addicted to opioids?
6-10%
when patients are unable to swallow, have nausea or vomiting, or are near death, what administration method is preferred?
rectal
define physical dependence on a drug
a state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by an abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
define addiction
a primary, chronic, neurobiological disease with genetic, psychological, and environmental factors influencing its development and manifestations
define drug tolerance
a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more effects of the drug over time
what are barriers to effective pain management?
List some examples.
1) patient barriers
ie fear of addiction, worry about side effects, Fear of tolerance (will not be there when I need it)
2) healthcare provider barriers. ie Inadequate pain-assessment skills, No pain-management protocols available, Concern with addiction or accidental overdose
3) healthcare system barriers.
ie Concern with creating “addicts”, Difficulty in filling prescriptions, Limitation on reimbursement for prescriptions
Define “pain contracts”
Many patients on long-term opioid medications enter into “pain contracts” that state the expected responsibilities of both the patient and healthcare provider. If the patient violates the agreement or if assessment data indicate potential violation of the contract, help to identify additional resources to
aid the patient in addressing the addictive illness.
What are some examples of Restorative and Continuing Care?
Pain clinics, palliative care, and hospices
1. Pain centers treat patients on an inpatient or outpatient basis.
2. The goal of palliative care is to learn how to live life fully with an incurable condition.
3. Hospices are programs for end-of-life care.
A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when:
A. you compare assessed pain w/baseline pain.
B. body language is incongruent with reports of pain relief.
C. family members report that pain has subsided.
D. vital signs have returned to baseline.
A
Who is allowed to press the button to administer the pain medication when PCA is used?
Only the patient
