Nursing Process and Pain Management (7) 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
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.
B
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
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
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) 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.
describe the perception of pain(3)
1) when pain stimulus reaches the cerebral cortex, the brain interprets the quality of the pain and processes information from past experience, knowledge, and cultural associations
2) Perception is the point at which the person is aware of pain
3) physiological and behavioral responses occur after perceiving pain.
how does the brain process pain?
1) somatosensory cortex - identifies the location and intensity of pain
2) association cortex (limbic system) - determines how a person feels about it
there is no single pain center
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
what do pain processes require physiologically?
an intact nervous system and spinal cord
describe the sympathetic nervous systems involvement in pain
as pain impulses travel up the spinal cord, the stress response stimulate the ANS sympathetic nervous system; fight or flight
describe the ANS parasympathetic nervous systems involvement in pain
continuous, severe, or deep pain typically involving visceral organs activates the parasympathetic nervous system
what occurs when someone experiences severe traumatic pain?
this often causes people to go into shock
describe the adaptation of pain
most people adapt to their pain reflexively and physical signs return to normal baseline; normal baseline is NOT the same for everyone
what happens with vital signs when people experience pain?
patients in pain do not always present changes in their vitals; changes in vitals often indicate problems other than pain
describe the behavioral responses associated with acute pain(4):
1) clenching teeth
2) facial grimacing
3) holding or guarding the painful area
4) a bent posture
be aware: not all patients show these responses when in pain
describe the behavioral responses associated with chronic pain(4):
chronic pain affects patients’:
1) activities (eating, sleeping, socialization)
2) thinking (confusion, forgetfulness)
3) emotions (anger, depression, irritability)
4) quality of life and productivity
people with a low pain tolerance are often perceived as…
complainers.. pff.. wimps
why should you teach patients the importance of reporting their pain sooner rather than later?
to facilitate better control and optimal functional status
what are the types of pain(5)?
1) acute/transient
2) chronic/persistent (noncancer)
3) chronic episodic
4) idiopathic
5) cancer pain
describe acute/transient pain
(definition and 2 points)
protective, identifiable, and with a short duration; limited emotional response
- can inhibit 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?
improve functional status
describe cancer pain
(description and 1 point)
normal (nociceptive) pain, occuring due to 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
when there is no obvious source of pain (e.g. low back pain etc…) healthcare providers sometimes do what?
stereotype pain sufferers as malingerers, complainers, or difficult patients
studies of nurses attitudes regarding pain management show what?
that a nurse’s personal opinion about a patient’s report of pain affects pain assessment and titration of opioid doses
what must a nurse accept regarding a patient’s report of pain?
a nurse must accept the patient’s report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and evidence-based research findings
what are the physiological factors that influence pain(4)?
1) age
2) fatigue
3) genes
4) neurological function
what are some social factors that influence pain(4)?
1) attention
2) experiences
3) support
4) spirituality
what does fatigue do to the perception of pain?
fatigue increases the perception of pain and can cause problems with sleep and rest
describe the spirituality factor of pain influence
spirituality includes active searching for meaning in situations with questions such as “why am I suffering?”
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
what does the presence of pain in an older adult require?
aggressive assessment, diagnosis, and management
how does genetic makeup influence pain?
genes may affect a person’s pain tolerance
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 how coping style influences pain
pain is a lonely experience that often causes patients to feel a loss of control. coping style influences the ability to deal with the pain
describe the perception of pain people with internal loci of control have as opposed to those with 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
what does understanding the cultural meaning of pain help nurses to do?
helps them design culturally sensitive care for people with pain
successful critical thinking associated with pain requires aa synthesis of(5):
1) knowledge
2) experience
3) information gathered from patients
4) critical thinking attitudes
5) intellectual and professional standards
describe how knowledge factors into pain management:
knowledge of pain physiology and the many factors that influence pain will help you manage a patient’s pain
describe how critical thinking attitudes and intellectual standards relate to pain:
they ensure the aggressive assessment, creative planning, and thorough evaluation needed to obtain an acceptable level of patient pain relief, while balancing treatment benefits with treatment associated risks
how do you assess a patient dealing with acute pain?
- streamline your assessment and assess:
1) location
2) severity
3) quality - collect a more detailed acute pain assessment when the patient is more comfortable
what are the ABCs of pain management?
A - ask
B - believe
C - choose
D - deliver
E - empower
what is a more in depth description of 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
what happens if patients feel like you doubt the pain the are reporting exists?
they share less information about their pain experience or minimize their 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)
patients with critical illnesses that have a clouded sensorium or the presence of an NG tube or artificial airway require what kinds of questions during pain assessment?
questions that can be answered with a head nod or written responses
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 - where does it hurt?
3) severity - can you rate your pain?
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
what are some effects pain can have on a patients life(5)?
1) less able to participate in routine activities, leading to physical deconditioning
2) impaired sleeping
3) impaired sexual relations
4) threaten ability to work
5) can impair social life
what are some 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
what are Concomitant symptoms?
symptoms that exist at the same time
what do Concomitant symptoms do to pain severity?
usually increases pain severity
professional standards of care regarding pain management are available where(2)?
1) agency policies
2) through professional organizations such as the American Society for Pain Management Nursing (ASPMN)
a comprehensive pain management plan includes a variety of resources from the healthcare team such as(8):
1) APRNs
2) Doctors of pharmacology
3) PTs
4) OTs
5) physicians
6) social workers
7) psychologists
8) clergy
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
describe relaxation and guided imagery interventions for pain
allows patients to alter affective-motivational and cognitive pain perception
describe relaxation interventions for pain
serves as a mental and physical freedom from tension or stress that provides individuals a sense of self-control
describe distraction interventions for pain
directs a patients attention to something other than pain and thus reduces awareness of it
describe music therapy interventions for pain
may be useful in treating acute or chronic pain, stress, anxiety, and depression
describe cold and heat application, massage, and TENS interventions for pain
stimulation of the skin may be helpful in reducing pain perception
describe cold and heat interventions for pain
relieve pain and promote healing
describe transcutaneous electrical nerve stimulation interventions for pain
stimulation of the skin with a mild electrical current which is passed through external electrodes
describe herbal and dietary supplements such as echinacea, ginseng, ginkgo biloba, and garlic for pain
conflicting research evidence; many still use them to treat pain
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)
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 level of pain are opioids prescribed for?
prescribed for moderate/severe pain
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
what type of analgesic is usually necessary for patients with acute pain or cancer pain of moderate to severe intensity?
opioid analgesics
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
what form of administration is patient controlled analgesia?
1) IV
2) SUBQ
3) oral (rare)
what does PCAs allow?
allows patients to control when they take their PRN medications including analgesics, antiemetics, and anxiolytics
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 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 or adjuvants and progressing toward opioids
- the bidirectional approach would include a step down approach for patients with intense acute pain, uncontrolled cancer pain, and breakthrough pain
what do all patients on chronic opioid therapy require?
monitoring and follow up
how many 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 method is preferred over PO?
rectal
what is step one of the analgesic ladder?
what are commonly used topical analgesics(2)?
1) NSAID products (ketoprofen patch)
2) capsaicin
where do you not place eutectic mixture of local anesthetics (EMLA)(3)?
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)
how do you use a Lidoderm patch?
Adults: place three patches, cut to size, on and around the pain site using 12h on 12h off schedule
what is local anesthesia used for?
used during brief surgical procedures (e.g. removal of skin lesion or suturing a wound)
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 perineural local anesthetic infusion?
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
what is regional anesthesia?
injection or infusion of local anesthetics to block a group of sensory nerve fibers
what are common side effects for a skin applied topical anesthetic(2)?
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 in peripheral nerves and epidural infusions may do what?
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
what does epidural analgesia accomplish?
controls or reduces pain and reduces 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
because the epidural space is a highly vascular area, patients with epidural catheters are at risk for what?
the development of epidural hematomas which can lead to ischemia of the spinal cord. if unaddressed, serious neurological complications can occur
you maintain the (BLANK) to patients receiving local or regional anesthesia
responsibility for providing emotional support
why do you not administer supplemental doses of opioids or sedative/hypnotics to someone receiving epidural analgesia??
because of possible additive central nervous system adverse effects
anticoagulant and antiplatelet medications should not be administered to a patient receiving epidural analgesia until safe use can be verified with a pain specialist. why?
because of increased risk of bleeding and hematoma formation
patients need to receive thorough education about epidural analgesia including…
action of thee medication and the advantages and disadvantages related to the therapy
how do you provide emotional support to a patient receiving local or regional anesthesia?
explain the insertion technique and warn them that they will temporarily lose sensory function within minutes of injection
when patients receive epidural analgesia, how often do you monitor them?
initially check vitals, respiratory status, and skin color about 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
what is breakthrough cancer pain?
BTCP - a transient worsening of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger
The American Pain Society reports that the primary goal in treating chronic noncancer pain with opioids is to…
increase patients’ level of function rather than just to provide pain relief
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?
1) patient barriers
2) healthcare provider barriers
3) healthcare system barriers
what are examples of patient barriers to effective pain management(3)?
1) fear of addiction
2) fear of side effects
3) fear of tolerance
what are examples of healthcare provider barriers to effective pain management(3)?
1) inadequate pain assessment skills
2) no pain management protocols available
3) concern with addiction or accidental overdose
what are examples of healthcare system barriers to effective pain management(3)?
1) concern with creating addicts
2) difficulty filling prescriptions
3) limitation on reimbursement for prescriptions
