MODULE 3: PATIENTS WITH PAIN Flashcards
1
Q
Four basic categories of pain?
A
1) Acute
2) Procedural
3) Chronic (non-cancer)
4) Cancer-related
2
Q
Acute pain =
Indicates?
What does it “teach” a person?
When will it decrease?
A
- Can last days to 6 months (controversial timelines)…generally, if persists beyond expected healing time, is then considered chronic
- Indicates damage or injury has occurred
- Draws attention to itself to teach person to avoid similar situations
- If no lasting damage + no systemic disease, will decrease as healing occurs
3
Q
What % of adults have moderate to severe pain after surgery?
& of hospitalized children with same?
A
½ adult
1/3 of hospitalized children
4
Q
Procedural pain =
A
- Brief, intense arises from dianostic, therapeutic or preventative procedure
- Lasts seconds to hours, can continue to become acute if sig damage occurs
Common source = needle puncture
5
Q
Chronic (non-cancer) pain
1) Constant or intermittent?
2) Does it typically have defined onset?
3) Is it easy to treat? Why or why not?
Is this kind of pain “useful” in the way that acute pain is?
A
1) Can be either
2) May have poorly defined onset
3) Origin often unclear = difficult to treat
- Pain becomes own problem (unlike usefulness of acute as warning)
- -> Can become pt primary disorder
6
Q
3 TYPES OF CHRONIC PAIN based on patho?
A
1) Nociceptive
2) Neuropathic
3) Mixed-type (Neuropathic + nociceptive)
7
Q
Chronic Nociceptive Pain =
Examples?
Pain quality?
A
Constant stimulation of pain receptors, signals tissue damage in the skin, bone, joints, or viscera
eg) arthritis, fibromyalgia
Typically aching or throbbing quality
8
Q
CHronic Neuropathic pain =
1) What is it?
2) What % of the population experiences it?
3) What causes it?
4) What is the quality of pain?
A
1) Triggered by severe nerve damage or malfunction of CNS or PNS
2) 8% of pop
3) May begin with injury, or due to nerve compression by tumours, nerve inflammation by infection, or nerve impairment from systemic disease such as diabetes;
4) Burning, tingling, or piercing quality
9
Q
Allodynia =
Examples?
A
Pain arising from nonpainful stimulus (ex: breeze) = characteristic of neuropathic pain
Ex: neuralgia, diabetic neuropathy, phantom limb pain
10
Q
Examples of mixed-type chonic pain?
A
Migraines
11
Q
What is typically the most feared outcome for cancer patients?
A
Pain (because is so ubiquitous)
12
Q
Is cancer pain acute or chronic?
A
Can be either
13
Q
What is cancer pain due to?
A
Can be:
1) Directly associated with cancer
2) Result of cancer treatment
3) Not associated (ex: post-surgical pain)
***Most direct result or tumour
14
Q
- Describe the harmful effects of acute pain (beyond the discomfort of pain itself)
A
- If unrelieved, can affect pulmonary, cardiovascular, GI, endocrine + immune systems
- Widespread endocrine, immunological + inflammatory changes with stress
- Stress response = inc metabolic rate + CO, impaired insulin response, inc cartisol, inc retention of fluids → inc risk of MI, pulmonary infec, venous thromboembolism
- Primarily harmful in those whose health is already compromised by age, illness or injury (can’t handle stress on breathing, decreased mobility, etc.)
15
Q
- Negative impacts of procedural pain beyond the experience of pain itself?
What kind of cognitive response can procedural pain lead to?
A
- Can give rise to cycle of pain, anxiety, and fear that leads to avoidance of procedure → poor medical care
- More often dread anxiety assoc with procedure than actual pain
- Leads to catastrophizing: negative cognitive response marked by preoccupation with pain stimulus, inflation of potential threat + sense of helplessness
16
Q
Negative impacts of chronic pain beyond the pain itself?
A
- Can suppress IR ⇒ promotes tumour growth
- Often results in depression + disability
- Has effects on all aspects of life
17
Q
Is a gradual increase in pain meds for chronic patients safe? Is it more or less safe to inadequately treat pain?
A
Safe to gradually inc dosage of pain meds to control progressive chronic pain – unsafe to inadequately treat pain as has other negative effects
18
Q
Pain causing substances referred to as?
A
Algogenic
19
Q
Do the large internal organs contain neurons that respond specifically to painful stimuli?
A
No, pain originating in these areas d/t intense stimulation of receptors that have other purposes – pain here from stretch, inflammation, ischemia, dilation, etc.
20
Q
2 examples of morphine-like endogenous neurotransmitters?
A
1) Endorphins
2) Enkephalins
21
Q
Involvement of what parts of the neuro system are responsible for the individual variations in the perception of noxious stimuli? (by way of being involved in the conscious perception of pain)
A
The reticular formation, limbic, and reticular activating systems
22
Q
How does distraction inhibit pain?
A
Cognitive processes may stimulate endorphin production in the descending control system –> this system is suppresses the ascending transmission of painful stimuli –> if activated, less noxious stimuli transmitted to consciousness
23
Q
Gate control theory was first theory to propose…
A
That psychological factors play a role in the perception of pain
- brought about use of cognitive behavioral pain management techniques
- explains use of distraction or music therapy to relieve pain
24
Q
Outline the Gate Control Theory.
A
- Proposed that stimulating of the skin evokes nervous impulses that are then tramistted by three systems located in spinal cord: substantia gelatinosa in dorsal horn, dorsal column fibres, and central transmission cells → act to influence nocicceptive impulses
- Stimulation of large-diameter fibres inhibits transmission of pain = “closing” the gate
- Stimlation of small fibres = “opening” of gate
- Influenced by nerve impulses that descend from the brain
25
List 7 factors influencing the pain response
1) Past experiences with pain
2) Anxiety
3) Culture
4) Age
5) Gender
6) Genetics
7) Expectations about pain relief
* *Can all decrease or increase pain
26
How does past experience with pain influence pain perception?
- if more experience, likely to have more anxiety about subsequent events
- may have less tolerance (want to relieve sooner for fear it will become more intense)
- likely worse is poorly managed in past
27
How does anxiety affect pain perception?
- not all anxiety makes pain worse, but if r/t to pain may inc perception
- if anxiety unrelated pain, may serve as distraction from pain
28
Is it more effective to direct pain treatment at the pain itself or the anxiety?
Most effective to treat pain – giving antianxiety (as tends to happen) may cause sedation and inhibit ability to report pain, take deep breaths, get out of bed, cooperate with treatment plan
29
Are psychological, sociocultural, or biological mechanisms responsible for cultural differences in pain?
All of them!
30
Factors that help explain differences in pain experience/response in cultures?
- Age
- Gender
- Education Level
- Income
- Degree to which a person identifies with cultural influences and adopts new health behaviors or relies on traditional health beliefs and practices
- Nature of past interactions with healthcare (may have frustration with hc if pain was not adequately acknowledged before - could be due to issues of racism, etc.)
31
Should a nures react to a person’s perception of pain, or their behavior?
Perception - cannot reply on behavior as is customary to avoid outward expression of pain in some cultures
32
What should be communicated to patients for nurse to better be able to evaluate pain when cultural differences exist?
Pt needs to be instructed on how + what to communicate about pain
33
Describe the mechanism by which aging causing dec/inc perception in pain:
Loss of myelinated and unmyelinated fibres with age → dec in myelinated partily responsible for dec in expression of myelin proteins, causing gradual reduction in blood flow → reduced peripheral nerve fx + perception of pain
--> Some claim age related loss likely due to disease process, not just “aging” (lack of strong evidence in this regard…)
34
Why is pain more difficult to assess in elderly?
Elderly more reluctant to report pain b/c see as part of aging process; less able to describe due to cognitive changes
35
Why will smaller doses of pain meds possibly be more effective + last longer in older adults than young?
b/c greater fat to muscle ratio + slower metabolism
36
Reasons that elderly don't seek pain relief?
- May see as normal process of aging
- May fear addiction
- May fear that pain indicates serious illness, or pain meds = loss of independence
37
Should a nurse judge adequacy of pain treatment based on age?
No, should be based on pt report of pain + pain relief!
38
Risk factors for chronic pain in Canadian women?
1) Age
2) Education
3) Marital status
39
T/F: The prevalence of of many conditions associated with pain (ex: migraine, IBS, osteoarthritis, fibromyalgia) are more prevalent in men than women.
F
40
T/F women more likely to report pain, frustration + fear.
T in some studies.
41
Common misconceptions about pain/barriers to pain management?
- Complaining about pain will distract my doctor from his responsibility: curing my illness
- Pain is a natural part of aging
- I don't want to both the nurse
- Pain medicine can't really control pain
- People get addicted to pain medication easily
- It is easier to put up with pain than with the side effects of pain meds
- Good patients avoid talking about their pain
- Pain medicine should be saved for when the pain gets worse
- Pain builds character - it's good for you
- Patients should expect to have pain, it's a part of almost every hospitalization
42
Is there a correlation between pain intensity and the stimulus that produced it?
No! Is individual.
43
Should you offer someone cues when asking about quality of pain?
Not unless pt cannot describe
| - important to write down all words used by the pt
44
Important to ask about pain affect on:
- ADL's
- Quality of sleep
- Level of anxiety
45
Are nonverbal + behavioral cues of pain reliable for determining intensity or presence of pain
No - not reliable or consistent
46
How is pain in unconscious people treated?
Is always assumed + treated
47
Is the use of physiological indicators (diaphoresis, tachycardia, etc.) reliable for pain assessment?
No, unrelieable - responses to initial stress, could also be due to hypovolemic shock
--> important to consider but a lack of pain indicators does not necessarily indicate a lack of pain!
48
Characteristics of an effective pain scale?
- must require little effort for pt
- be easy to understand + use
- be easily scored
- be sensitive to small changes in characteristic being measured
49
Are family members appropriate interpreters?
No
50
If a person is seriously ill, in severe pain, or has just returned from surgery, what is likely the most appropriate pain scale?
0-10 (or 0-5 if needed)
* A written scale may not be possible in these circumstances
51
What kind of pain scales are effective for those with chronic or terminally ill?
Those that include location and pattern of pain - can help to track profession of pain + effectiveness of treatment
52
Special consideration for pain assessment in home care pts?
- Pain scale can assess effectiveness of interventions if used before + after interventions are implemented
- Patient and family members can be taught to use the scale to assess + manage pain at home
53
Role of nurse in pain management?
- Perform assessment
- Identify goals
- Perform teaching (explain sensitization)
- Perform physical care
- Help relief pain with pharmacologic and nonpharmacologic measures
- Assess effectiveness of interventions
- Monitor for adverse effects
- Serve as advocate
54
What is the process of "sensitization" and why is it important to inform clients of this phenomenon?
= pain will become more intense with subsequent activation of noxious stimuli
-Many will wait until pain becomes unbearable before requesting meds…should be taught will be more effective if intervene before this point (before sensitization occurs)
(if procedural pain is avoided, sensitization doesn’t occur)
55
Importance of personal care in pain management?
Providing clean gown and measures to feel refreshed inc level of comfort + effectiveness of pain relieving measures
56
What to teach to address the relationship between pain and anxiety?
- Teaching about what to expect + pain management strategies can reduce anxiety; lessen threat of pain + inc sense of control
- Ex) if taught pain will not disappear, is less likely to become anxious when pain persists
57
Are medications the last resort of pain management?
No, should not be thought of in this way.
58
3 general categories of analgesic agents?
1) OPIOIDS
2) NSAIDS
3) LOCAL ANESTHETICS, with possible adjuvant agents such as anti-depressant and anticonvulsant meds
59
Special considerations for pain at end of life? Possible barriers?
- Pain is one of most feared symptoms at end of life
- Barriers include lack of education (of the nurse regarding pain management info) + fear of addiction (on both part of nurse and patient, family)
- Family may have fears around social stigma of addiction
- Need thorough assessment but this may be hampered by confusion, delirium, unconsciousness
- -> caregivers taught to observe for signs of restlessness or facial expressions
- Bowel care important
- Resp rate 6 or greater considered adequate - need to assess regularly to adjust opioids if necessary (at very end of life balance between suppressing effects + pain management becomes decision)
60
When a patient says they have experienced allergies to pain killers in the past, why is it important to investigate further?
Often misunderstand "adverse effects" to be allergies --> common reports of nausea, vomiting, pruritis are NOT ALLERGIES.
61
Name 4 Adverse Effects of opioids
1) Resp depression + sedation
2) Nausea + vomitting
3) Constipation
4) Pruritis
62
When is sedation d/t opioids likely to occur? Does tolerance develop quickly?
- Likely with inc in dose
| - Tolerance develops quickly, so sedation likely to not occur with subsequent similar doses
63
How to reduce nausea + vomiting in pts receiving opioids?
- Slow position changes (often trigger)
- Hydration
- Antiemetic agents
* Opioid induced nausea + vomiting usually subside within few days
64
Which populations are likely to have severe constipation from opioid use?
Post-operative and cancer treatment
65
Who is at greater risk of adverse effects from opioids?
- Untreated hypothyroidism (more susceptible to analgesic effects + side effects)
- Dec resp reserve d/t disease or agent more at risk of depressant effects (watch for resp depression)
- Dehydrated = greater risk of nausea + vom
- Those on other meds (can cause exaggerated response)
66
When first administering opioid, nurse should note?
After what point is more med indicated if not seeing adequate pain response?
BP, pulse, HR + pain scale
If after 30 mins (or sooner if IV) pt is reasonable alert + has satisfactory resp rate, BP and pulse, then further action is necessary.
67
Is there a determined max safe dose or easily identifiable safe serum level of opioids?
No - is individual
68
Tolerance =
Need for increasing doses to achieve same effect
69
Does physical dependence on an opioid indicate addiction?
No
| - Is common with opioid tolerance and does not indicate addiction
70
What is addiction?
A behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects.
71
Should addiction be considered when caring for patients in pain?
No - risk is no negligible that should not be taken into consideration
--> even with those with hx of addiction, should remain aware of right for everyone to have pain management
72
How do local anesthetics work?
Block nerve conduction when applied directly to nerve fibres
| - Will enter bloodstream rapidly, so typically administered with vasoconstrictor to minimize systemic absorption
73
Which conditions are NSAIDS typically quite effective with?
When should a smaller dose be used?
Should look for what possible side effect as nurse?
Very helpful with arthritic diseases + cancer-related bone pain;
- use smaller dose for kidney dysfunction, elderly + dehydrated
- bruise easily (anti-coagulant), look for GI pain + bleeding
74
What kind of drugs are used to treat neurologic pain?
Tricyclic antidepressants
Antiseizure agents
* Pain of neuroloc origin difficult to treat and generally not very responsive to opioid therapy
75
What is multimodal or balanced analgesia?
Refers to use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects and less risk of toxicity for any one drug
- Each drug works through different mechanism
76
Is a PRN "Pro Re Nata" method of pain management effective?
No - end up having to give intermittent high doses, which often pose greater risk of sedation
- allows serum levels to fall below effective range, rather than continued supply that will ensure consistent management
77
Why is the "preventative approach" to pain relief best? (giving consistent doses, not waiting until pain is reported)
Reduces peaks + troughs in serum level and provides more pain relief with fever adverse effects
- Smaller doses needed so less likely to develop tolerance
78
What is PCA?
Patient Controlled Analgesia
- Pt controls own opioid admin by pushing button
- Best if given larger bolus dose before PCA begins to have pain effectively managed
- Pt instructed not to wait until pain returns to push button - give on schedule with additional doses if necessary
- Be aware distractions - need to ensure still getting doses if visiting, etc.
79
Drug considerations in elderly?
- Most sensitive, inc risk of toxicity
- Likely more drug interactions
- GI, renal, and liver fx decreased (changes absorption + metabolism)
- Distribution of meds affected by changes in weight, protein stores, and fluid distribution
- Meds slower to metabolize, remain in higher [ ] in blood for longer
- Inc susceptibility to depression of nervous & resp systems
-
80
Massage as pain control method
- Promotes relaxation of muscles
| - Acts through mechanism like gate control theory: has impact through descending control systme
81
Thermal therapies (hot & cold) in pain management
- Needs further investigation
- Simulates nonpain receptors in same field as injury (gate control)
- Ice reduces amount of other analgesia needed - best if put on injury immediately after it occurs; keep for max of 15-20 mins
- Heat can reduce pain by speeding healing
82
TENS =
Transcutaneous Electrical Nerve Stimulation
| - Simulates nonpain receptors in same field as injury (gate control)
83
What kinds of distraction make it more effective for pain management?
- More sensory modalities
- That which requires active participation of pt
- Interest in stimuli
84
Nonpharmacologic pain interventions?
- Massage
- Thermal therapies
- Transcutaneous Electrical Nerve Stimulation
- Distraction
- Relaxation techniques
- Guided imagery
- Hypnosis
- Music therapy
- Alternative therapies
- Neurologic + neurosurgical techniques: stimulation,
85
How to approach alternative therapies in care:
- Do not discount possible placebo effect (or other effect) of the therapies
- best if used in conjunction with traditional therapies
- Balance not discouraging hope for positive effect with responsibility to protect pt from potential harmful + very expensive therapies
86
Intractable pain =
Pain that cannot be treated through usual techniques - may require neurologic and neurosurgical interventions
87
At what age can a child point to pain?
3
88
What age of children can use a 0-10 pain scale?
Older school-age and adolescents
89
Why might a child not express pain/
- Want to be brave
- Doesn't understand that pain can be taken away
- Egocentric stage (preschooler) may assume adult should already know about pain
90
What should a nurse establish with parents when managing their child's pain?
Establish with parents your role and their roles in detecting child in pain and ensure they know what pain relief measures exist
91
Is it safe to assume that a child who sleeps or plays is not in pain?
No, may sleep from exhaustion of pain, may play to distract self
92
Cues for pain in infants?
tears, high-pitched harsh cry, stiff posture, alterations in facial expression, quivering chin, lack of play, fisting
– most important sign in infant is cannot be comforted completely
93
Considerations for pain in a toddler:
lack vocab to describe or experience to compare level of pain
- may use terms like “boo-boo” rather than pain
- toddler may react aggressively to pain or avoid being touched or held
-
94
Pain in the preschooler:
- often use comforting measures such as gritting teeth, pulling on ear, etc
- egocentric so may not report because assume adult already knows about the pain
- may believe it to be punishment for being bad; may withdraw
95
Pain in school-age children:
- preadolescents still difficulty describing
- may think you as authority know about pain
- may regress to baby talk or lying in fetal position
- old enough to manage momentary pain with distraction techniques
- may be in middle school before can use numerical measurement (can simply to 0-5)
96
Considerations for pain in adolescents?
May try to be stoic
| - Esp important to look for clenching + guarding
97
In nursing diagnosis of pain in children, what is the diagnosis often focussed on?
Stress, fear, or anxiety that pain produces
98
Common causes of under-treatment of pain in children (relating to nurse)?
- don’t believe children experience pain
- are afraid of addiction
- fear of resp depression
99
During the implementation phase with children with pain, what are important aspects of nursing care?
- educate parents on importance of pain relief (so don’t undermedicate at home with fear of addiction, etc.)
- provide alternatives to injection if necessary
- assist with complementary therapies
100
Somatic pain =
pain that originates from deep body structures such as muscles of bones (ex: sprained ankle)
101
Pain threshold =
What is this most influenced by?
point at which individual feels pain
| – probab most influenced by heredity
102
Pain tolerance =
What is this most influenced by?
- Point at which not willing to bear any additional pain
| – probab most affected by culture
103
How will children often try to modify pain?
Rubbing or shifting of body part
104
Example of distraction technique can use with children during injections?
Get to say "ouch" when injected
| Have prize for after
105
What is important to explain to children prior to a procedure to minimize anxiety?
What will and will not happen
106
Three way that gating mechanisms can be stimulated?
1) cutaneous stimulation (activates nearby peripheral nerve fibres)
2) distraction (cells in brainstem that register pain are busy with other stimuli)
3) anxiety reduction (pain impulses perceived more rapidly if anxious)
107
What is "Situation of meaning"
Ex?
- guided imagery technique to help child place nonpainful meaning on painful procedure
- works with both acute + chronic pain
- requires practice
- ex: picture needle as space ship; ask for details: “what colour is it?”
108
What is "thought stopping"
Child learns to stop anxious thoughts by substituting positive or relaxing thought
- requires practice
- ask child to think of set of positive thigns about approaching feared procedure (ex: dad will be with me); practice reciting list every time anxiousness returns
109
Is it good to present oral meds to children as candy?
No!
110
Should IM's be used for pain meds in children?
No, as general rule should be avoided b/c limited sites + don't like injection
111
Why should NSAIDS not be used beyond prescription in children?
Risk of GI irritation
112
Which common pain killer should children not receive & why?
ASA (aspirin) esp with flu symptoms b/c risk of Reye’s syndrome
113
When is IV admin of pain meds best for children?
- acute pain
- when requiring frequent doses but GI tract cannot be used
- in emerg
114
Is resp depression normal for children receiving accurate doses of pain meds?
No, not with accurate doses
115
How young can children be and use PCA?
5 or 6
116
What is "conscious sedation"?
- depressed consciousness brought from IV analgesia therpy
| - can still respond to instructions, all reflexes in tact; alleviates anxiety, pain + reduces memory
117
When is epidural analgesia effective for children?
Can provide analgesia to lower body for 12 to 24 hours
- very effective for post-surgery
- does not enter CSF so spinal headaches very rare
118
Resp depression less than _____/min may warrant less opioid
6
119
PQRST
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Pain
Quality
Region
Severity
Timing
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