Lecture 1 Flashcards
Chronic Illness, Older Persons, Pain
A government-funded, universal program.
Canadian health care is continually facing restructuring and change.
Challenges remain in the areas of client safety, service delivery, fiscal restraints, age-related demographics, and cost of new technology and drugs.
The Canadian Health Care Context
ensures coverage for medically necessary procedures.
The Canada Health Act
Costs are shared by
the federal and provincial/ territorial governments
Basing health care decisions upon evidence is essential for quality care in all domains of nursing practice.
Evidence informed practice
- Clinical state, setting, and circumstances
- Client preferences and actions
- Best research evidence
- Health care resources
Four primary elements of evidence informed practice
Another method of recording a nursing care plan
A visual diagram of client problems and interventions
Primarily in nursing education
Clinical (critical) pathways
Concept map
Health promotion
Prevention and health protection
Health maintenance, restoration, and palliation
Professional relationships
Capacity building
Access and equity
Professional responsibility and accountability
Core expectations for CHN practice
Health promotion and teaching
End of life care
Rehabilitation
Support for the caregiver
Support maintenance
Currative intervention
Home care encompasses
An array of services for people of all ages
Provided in the home and community setting
Home care
The rates of disease in a population
Morbidity
The rates of deaths in a population
Mortality
A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 2011)
Health
Multiple social and economic factors, the physical environment, and individual behaviour that interact to influence health
Determinants of health
is a condition that a practitioner views from a pathophysiological model.
Disease
is the human experience of symptoms and suffering
Illness
Refers to how the disease is perceived, lived with, and responded to by individuals and their families
Illness
________ and _______ illnesses can affect a person simultaneously.
Acute and chronic
presence of two or more chronic illness that are not directly related to each other in a person at the same time.
Comorbidity
simultaneous occurrence of several chronic medical conditions in the same person, may or may not be related to each other.
Multimorbidity
a complex interaction between health conditions, personal factors, and the environment.
Disability
- Processing emotions
- Adjusting to changes to self and life
- Integrating illness into daily life
- Determining the meaning of illness to base decisions
Four tasks of successful self-management
Young–old adult (_____ years)
65–74
Middle–old (______ years)
75–84
Old–old adult (older than _____ years)
85
Weak compromised health, higher risk/more risk factors
Frail older adult
Own home
Adult lifestyle communities or retirement communities
Assisted-living facilities (ALFs)
Independent living options
Mental capacity
Power of attorney
Advance directive
are all examples of
Legal issues
Adult day care programs
Home health care
Community-based care for those with special needs
Need to evaluate client’s ability to make decisions
Resuscitation
Treatment of infections
Issues of nutrition and hydration
Transfer to more intensive treatment units
are all areas of
Ethical concern
Comprehensive geriatric assessment
History using a functional health pattern format
Physical assessment
Cognitive assessment
Assessment of ADLs and IADLs
Social–environmental assessment
Nursing assessment: older adults
Whatever and whenever the person experiencing ____ says it is
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
Multidimensional and entirely subjective
Pain
can be experienced in the absence of identifiable tissue damage.
Pain
not synonymous with suffering.
Subjective: client’s experience and self-report is essential.
Pain
Can be problematic when dealing with clients who are nonverbal or cognitively unable to rate
Nonverbal information such as behaviours aids the assessment of ____
Pain
Transformation of stimuli into electrochemical energy
Release of pain-medicating chemicals
Nociceptors
Transduction
Large-diameter, A-delta fibres, and small diameter
C fibres
Transmission
Subjective phenomenon of pain (pain varies person to person)
“How is it felt?”
Complex behavioural, psychological, and emotional factors
Perception
Neural activity that controls pain transmission to neurons
Both peripheral and central nervous systems
Descending pain system
Enkephalins and endorphins
Modulation
The recognition of the sensation as painful
Sensory-pain elements include pattern, area, intensity, and nature (PAIN).
Sensory-Discriminative
Emotional response to pain experience:
Anger
Fear
Depression
Anxiety
Are examples of ________-Affective factors
Motivational-Affective
Observable actions used to express or control the pain
Behavioural
Beliefs, attitudes, memories, and meaning attributed to pain
The meaning of pain to the client is important in individual response to pain.
The meaning of pain and related responses are critical aspects of nursing pain assessment.
Cognitive
Includes demographics, support systems, social roles, past pain experiences, and cultural aspects
Sociocultural
Referred
Neuropathic
Phantom
Cancer
Central
Vascular
Classifications of pain
Equianalgesic dose
Scheduling analgesics
Titration
are all examples of
Drug therapy for pain
Dose of one analgesic equivalent in pain-relieving effects compared with another analgesic
Equianalgesic dose
Fast-acting drugs for breakthrough
Long-acting drugs for constant pain
Scheduling analgesics
Dose adjustment based on assessment of the analgesic effect versus adverse effects
Use the smallest dose to provide effective pain control with fewest adverse effects
Titration
“Step 1” drugs
Nonopioid analgesics (Aspirin and other salicylates, other nonsteroidal anti-inflammatory drugs [NSAIDs], and acetaminophen [Tylenol])
Mild pain
“Step 2” drugs
Mu: morphine, oxycodone, hydromorphone, methadone
Opioid agonists (morphine)
Antagonists (naloxone)
Mixed (pentazocine, butorphanol)
Mild to moderate pain
“Step 3” drugs
Most are mu-receptor agonists
Potent
No analgesic ceiling
Can be delivered via many routes
Moderate to severe pain
Synthetic drugs that bind to the opiate receptors to relieve pain
Mild agonists: codeine, hydrocodone
Strong agonists: morphine, hydromorphone hydrochloride, oxycodone, meperidine, fentanyl, methadone
Meperidine: not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures.
Opioid drugs
Drug reaches a maximum analgesic effect.
Analgesia does not improve, even with higher doses.
Codeine phosphate
Pentazocine
Nalbuphine
Opioid ceiling effect
Three classifications based on their actions:
Agonists
Agonists–antagonists
Antagonists (nonanalgesic)
Opioid analgesics: mechanism of action
Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia
Examples: morphine, hydromorphone, oxycodone, hydrocodone bitartrate, fentanyl
Continuous release vs. immediate release formulations
Equianalgesia
Mainly used to alleviate moderate to severe pain
Often first line agents analgesic in immediate post operative setting
Often given with adjuvant analgesic drugs to assist primary drugs with pain relief
Balanced anaesthesia
Opioids are also used for:
Cough centre suppression
Treatment of diarrhea
Opioid analgesic: Indications
Known drug allergy
Severe asthma
Use with extreme caution in patients with the following:
Respiratory insufficiency
Elevated intracranial pressure
Morbid obesity or sleep apnea
Paralytic ileus
Pregnancy
Opioid analgesic: contraindications
Central nervous system (CNS) depression
Leads to respiratory depression
Most serious adverse effect
Nausea, vomiting, constipation, biliary tract spasm
Urinary retention
Hypotension, palpitations, flushing
Itching, rash, wheal formation
Pinpoint pupils indicating a possible overdose
Opioid analgesics: adverse effects
A common physiological result of chronic opioid treatment
State of adaptation
Result: larger dose is required to maintain the same level of analgesia
Tolerance
Physiological adaptation of the body to the presence of an opioid
Opioid tolerance and _________ are expected with long-term opioid treatment and should not be confused with psychological dependence (addiction).
Physical dependence
a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief
Addiction
______ interactions:
Alcohol
Antihistamines
Barbiturates
Benzodiazepines
Promethazine
Monoamine oxidase inhibitors
Others
Opioid interactions
Natural opiate alkaloid (Schedule I) obtained from opium
Less effective
Ceiling effect
More commonly used as an antitussive drug
Gastrointestinal (GI) disturbance
Codeine sulphate
Synthetic opioid (Schedule I) used to treat moderate to severe pain
Parenteral injections, transdermal patches (Duragesic Mat®), sublingual effervescent tablet (Fentora®)
Fentanyl
Hydromorphone (________®): very potent opioid analgesic; Schedule I drug
1 mg of intravenous (IV) or intramuscular (IM) hydromorphone is equivalent to 7 mg of morphine.
Dilaudid
Synthetic opioid analgesic (Schedule I)
Opioid of choice for detoxification treatment of opioid addicts in maintenance programs
Renewed interest in the use of methadone for chronic (e.g., neuropathic) and cancer-related pain
Prolonged half-life of the drug: cause of unintentional overdoses and deaths
Cardiac dysrhythmias
Methadone Hydrochloride
Naturally occurring alkaloid derived from the opium poppy
Drug prototype for all opioid drugs; Schedule I controlled substance
Indication: severe pain
Oral, injectable, and rectal dosage forms; also extended-release forms
Morphine sulphate
Pure opioid antagonist
Drug of choice for the complete or partial reversal of opioid-induced respiratory depression
Indicated in cases of suspected acute opioid overdose
Failure of the drug to significantly reverse the effects of the presumed opioid overdose indicates that the condition may not be related to opioid overdose.
Naloxone Hydrochloride
Used in conjunction with opioids and nonopioids
Sometimes called coanalgesics
Enhance pain therapy through one of three mechanisms:
Enhancing the effects of opioids and nonopioids
Possessing analgesic properties of their own
Counteracting adverse effects of other analgesics
Adjuvant Analgesic Therapy
Analgesic and antipyretic effects
Little to no anti-inflammatory effects
Available over the counter (OTC) and in combination products with opioids
Acetaminophen
______: mechanisms of action
Similar to that of salicylates
Blocks pain impulses peripherally by inhibiting prostaglandin synthesis
Acetaminophen
Maximum daily dose for healthy adults is 4 g/day, but Health Canada is considering lowering*
2 000 mg for older adults and those with liver disease
Inadvertent excessive doses may occur when different combination drug products are taken together.
Be aware of the ________ content of all medications taken by the patient (OTC and prescription).
*Note: As of the date of writing of this text, Health Canada had not yet made this decision.
Acetaminophen: Dosage
Should not be taken in the presence of following:
Drug allergy
Liver dysfunction
Possible liver failure
G6PD deficiency
Dangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic.
Acetaminophen: Contraindications & Interactions
Related to the marigold family
Anti-inflammatory properties
Used to treat migraine headaches, menstrual cramps, inflammation, and fever
May cause GI distress, altered taste, muscle stiffness, joint pain
May interact with aspirin and other NSAIDs, as well as anticoagulants
Feverfew
Tolerance
Dependence
Addiction
Barriers to effective pain management
Fear of hastening death by administering analgesics
Use of placebos in pain assessment and treatment
Ethical issues in pain management
