Lecture 9: Pain assessment and Management Flashcards
who has the highest prevalence of persistent pain
indigenous people
consequences of untreated pain
- unnecessary suffering
- physical dysfunction and psychosocial distress
- impaired recovery from acute illness and surgery
- immunosuppression
- sleep disturbances
what is addiction
complex neurobiological condition that is a drive to obtain and take substances for other than the prescribed therapeutic value
- opioid addiction in acute care clients w no history of substance abuse is <1%
why is pain undertreated (among healthcare providers)
- if pt’s pain doesn’t seem as severe as it appears or pt is not reporting pain - can be a result of a bad assessment.
- or pt has an addiction
- bad assessment
- misconception
- not reporting
why is pain undertreated (among pt)
- fear of addiction
- beliefs and attitudes regarding pain
drug tolerance
need for an increased dose to maintain same degree of pain control
what can be confused with addiction
- drug tolerance
- physical dependence
what is physical dependence
physiological response to ongoing exposure to pharmacological agents that is manifested by a withdrawal syndrome that occurs when drug is abruptly stopped
- drug should be tapered off
what are some withdrawal sympt, how long can they last w opioids
muscle pain, sweating, diarrhea, vomiting, abdominal cramps, chills, anxiety, insomnia, tremor
can last for 3-10 days w immediate release opioids; 10-20 days with controlled-release or slow-release opioids.
what is the relationship btwn tolerance, physical dependence and addiction
tolerance and physical dependence are not indicators of addiction, but result from chronic exposure to certain drugs
what is the most serious side effect of opioids
respiratory depression is the most serious side effect of opioids
what reverses the resp effect of opioids
narcan (naloxone)
what is a common concern about providing drug to relieve pain
will participate the death of a terminally ill person
- rule of double effect
what is the rule of double effect
if an unwanted consequence occurs as a result of an action taken to achieve a moral good (i.e. pain relief), the action is justified bc the nurse’s intent is to relieve pain and not hasten death
what are the dimensions of pain
- physiological
- affective
- behaviours
- sensory
- cognitive
nociception
physiological process that communicates tissue damage to the CNS
what are the mechanisms by which pain is perceived
- transduction (stim cause cell damage with release of sensitizing chemicals, substances activate nociceptors and lead to generation of action potential)
- transmission (action potential continues site of injury to spinal cord, etc)
- perception (conscious experience of pain)
- modulation (neurons originating in the brainstem descend to the spinal cord and release substances that inhibit nociceptive impulses)
what are the sensory-pain elements
Pattern
Area
Intensity
Nature
emotional response to pain experience
anger
fear
depression
anxiety
3 dimensions of pain
- Behavioural
- Cognitive
- Sociocultural
Classification of Pain
By underlying pathology
- nociceptive pain
- neuropathic pain
By temporal nature
- acute
- persistent/chronic
what is nociceptive pain?
+ 2 types
caused by damage to tissue
- somatic pain: from bone, joint, muscle, skin or connective tissue. usually aching and throbbing, well localized.
- visceral pain: arises from internal organs. tumor involvement (aching and well localized). obstruction of hollow organ: intermittent cramping and poorly localized)
neuropathic pain
- damage to nerve cells or changes in spinal cord processing
- described as burning, shooting, stabbing, or electrical in nature
- can be sudden, intense, short-lived
- management: opioids, anticonvulsants and antidepressants
acute pain
- sudden onset
- mild to severe
- within normal time for healing
- manifestations reflect SNS activation
- treatment goal: pain control w eventual elimination
persistant/chronic pain
- gradual or sudden onset
- mild to severe
- can start as an acute injury
1st principal of pain assessment
screen for pain
“5th vital sign”
sensory pain assessment components
Pattern: onset, duration
Area: location, radiation
Intensity: severity
Nature: quality or characteristics
what is breakthrough pain
moderate to severe pain that occurs despite treatment
allodynia
pain due to a stim that does not normally provoke pain
hyperalgesia
increased pain from a stim that normally provokes pain
what is the treatment of pain for older persons
- “start low and go slow” is applied to analgesic therapy
- use of NSAIDS in elderly associated w high frequency of GI bleeding
- dangerous drug interactions on multiple drugs
- alterations in cardiac output and renal and hepatic clearance may change drug plasma concentration and duration of action
- cognitive impairment and ataxia may be exacerbated
what’s the best approach to addressing all dimensions of pain
multidisciplinary approach
med therapy: what is the nurse’s role
- selecting from the prescribed analgesic drugs
- monitoring and managing medication side effects
- calculating equianalgesic dose
- scheduling analgesic doses
- titrating opioids
analgesis ladder
- systematic plan for using analgesic drugs
- one system widely used
- made by World Health Organization
3 step approach:
1. nonopioid
2. opioid for mild to moderate pain
3. opioid for moderate to severe pain
step 1 drugs
- mild pain
- 1-3 on a scale of 0-10
- non-opioid analgesics (tylenol, aspirin, NSAIDs)
step 2 drugs
- mild to moderate pain
(4 to 6 on a scale of 0-10) - mild but persistent unlike non-opioid therapy
- morphine like agonists (codeine, oxycodone, tramadol)
- mixed agonist-antagonist (pentazocine (talwin), butorphanol (NOT recommended)
step 3 drugs
- moderate to severe pain
(4-10 on a scale of 0-10) - step 2 drugs do not produce effective pain relief
- morphine
- morphinelike agonists
(hydromorphone, fentanyl, meperidine) - potent, no analgesic ceiling, can be delivered via many routes
codeine considerations
- requires conversion to active metabolites to have any analgesic effect
- 3-10% of caucasian population are poor metabolizers and will have no analgesic effects, but all side effects when taking codeine for pain
demerol (meperidine) considerations
- repeated administration can lead to CNS stim
- not recommended for pt w renal failure, chronic pain, elderly
methadone
long-acting opioid agonist
- good option in neuropathic pain
- opioid of choice in preg
- used in prevention of withdrawal in opioid addiction
- variable equianalgesic dose to other opioids
- requires more careful initial titration
- many drug interactions
equianalgesia
- dose of one analgesic that is equivalent in pain-relieving effects compared w another analgesic
- important when substituting one analgesic for another in the event that a particular drug is ineffective or causes intolerable side effects
- generally, equianalgesic doses are provided for opioids
fentanyl equinalgesic dose
0.1-0.2 parenteral
adjuvant analgesic therapy
- used in conjunction w opioids and nonopioids
- enhance pain therapy: counteract side effects, enhance effects, possess analgesic properties of their own
TENS/PENS
put them on and they stimulate blood flow to area causing pain
