Pain Flashcards
Guide patient safety & welfare
Explain the procedure & what to expect
Monitor vitals
Minimize negative psychological responses to treatment with analgesia and maximize amnesia
Minimize fear having to do with the procedure.
And discuss medication they’ll be receiving
Minimize physical discomfort…
Before and after the procedure
Control behavior
Make sure procedure goes smoothly essenitally
Criteria for discharge
Swallow eval to see if they can drink water
AO
Stable vitals
Able to pass gas & urinate (listen to bowel sounds and check voiding)
Five things we use to choose the Level of Sedation for patients?
Airway control
- the type of surgery may need more airway control by intubation
Respiratory responsiveness
Gross motor skill
Level of awareness
Responsiveness to stimuli
Minimal light sedation
Responsiveness
Airway
Spontaneous vent
Cardiovascular
Normal response
Unaffected airway
Unaffected spontaneous vent
Unaffected cardiovascular
Moderate sedation
Responsiveness
Airway
Spontaneous vent
Cardiovascular
Purposeful response to verbal or tactile stimuli
No intervention need for airway
Adequate spontaneous vent
Usually maintained cardiovascular
Deep Sedation
Responsiveness
Airway
Spontaneous vent
Cardiovascular
Purpose response to repeated or painful stimuli
Intervention needed for airway
Compromised Spontaneous vent
Usually maintained cardiovascular
General Anesthesia
Responsiveness
Airway
Spontaneous vent
Cardiovascular
Unarousable response
Intervention needed for airway
Compromised spontaneous vent often
Impaired cardiovascular
What size of IV do you need to start for patient beforehand to prepare
Large iv that is patent
What equipment can you get ready before the proceudre
Gloves
Art line
Bronch
What dietary status do you need to make sure to keep patient on to prepare for procedure
NPO unless the physicians says otherwise. Document the last intake.
And document any meds you take & document the meds you didn’t give.
- we do this bc it can cause aspiration
What nature of an assessment are we supposed to do before a procedure?
Baseline assessments so we have a comparison
What types of consent do we need before the procedure?
And what do you need to consider
Informed consent in chart
Condier if the patient can sign? or is DPOA needed?
Emergency basis signing is allowed.
What types of instructions need to be given? And when?
Verbal & written instructions given post sedation
- for side effects and expectations
How far back do you need to document for food intake?
Just do the last known intake
What do you need to document?
Informed consent Instructions done Food intake Vital signs Review of systems
What is review of systems?
Age & weight
Allergies
Meds & if they took them. Any NPO exceptions?
Holding any meds? So they know what to give after.
Disease & expected outcomes
Previous hospitalizations
Hx of sedation or anesthesia issues
On site equipment
Standard sizes for general stuff Positive pressure Suctions Ambu NIBP 5-15 min O2 sat Capnography for co2 of 35-45 Emergency kit
Are you ready pneumonic
D-drugs E - emergency M - monitoring O - oxygen S - suction
Drugs you want in the room
Versed
Fent
Flumazemil
Narcan
Discharge criteria
Cardiovascular & airway function has to be good enough
- what are their o2 levels
- can they sustain respirations?
Are they AO?
Can they talk and verbalize?
Can they sit un-aided like they were before sedation? - can they hold their head up
Are they hydrated enough to where the meds are flushed out of their system.
What is Midazolam other name and the drug class?
Versed
Which is a benzodiazepine drug.
What does Midazolam provide
Immobility
Sedation
Amnesia
Antianxiety
Is Midazolam primary or secondary agent
Secondary - used with Fentanyl
procedures that use Midazolam
Bedside procedure
TEE
Colonoscopy
Type of monitoring for Midazolam
Cardiac monitoring
Side effect of midazolom intranasal route
Burns for 10-15 min
If you give a patient Midazolam, what is a pre-requirement?
Ability to support their airway
Midazlom antidote
And its contraindication?
Flumazenil
- contraindicated in those with epilepsy/seizures
Patient is desatting while on Midazolam. You give Flumazenil.
Why or why not would this be beneficial?
Flumazenil is the antidote for benzos like Midazolam but it won’t stop hypoventilation or breathing problems.
- it just reverses the sedation. need to give them extra respiratory support
Onset & duration of Flumaezenil?
Rapid onset
Lasts 1 hour duration
How fast should you push Flumazenil?
Push slow bc it burns. 30 sec to 1 min
Morphine pros
Analgesic
Sedation
Some immobility
How fast should you give morphine IV?
How should you titrate?
Push it slow so the patient doesn’t end up slumped over
Titrate to effect at the lowest rate.
You give a patient morphine. How long does it take for them to expereince repsiratory depression?
Peak is at 20 minutes - so monitor them closely.
Rxn to morphine?
Histamine release but its not an allergy.
- itching, flushing, rash, hives.
Bad side effects of morphine
Respiratory depression & hypotension
Morphine antidote
Nalaxone or Narcan
Which is more potent : morphine or fent?
Fent by 100x
Routes available for Fentanyl?
Oral
IM
IV
How do we titrate Fentanyl?
Titrate to effect
Start at 1-2 mcg to begin with. Lowest dose.
Fentanyl onset & duration
Onset it rapid 1-5 minutes
Duration of 30 min to 1 hour
Fentanyl antidote
Naloxone or narcan
What speed do we push Fentanyl and why?
Give slow - can cause chest or skeletal muscle rigidity and affect breathing.
How does Narcan work? And how does that implicate the patient & us?
Displaces opioids at the receptor site - which means they will feel the pain that the opiate was covering up.
- protect yourself
How fast do we give Narcan
slowly
Narcan onset and duration
Onset is 2 min.
Duration is 15-60 minutes
How often can you repeat narcan
Repeat every 2-3 minutes
What is Ketamine (Ketolar)
Dissociative Anesthetic general anesthetic that doesn’t make someone unconscious but has catalepsy, catatonia, and amnesia. They will look awake but they really aren’t. Educate family
catalepsy = fixed posture
Can you use Ketamine for pain?
Probably not. it has those properties but don’t rely on it for analegesia
Vital signs for Ketamine
Increase HR, BP, CO, & ICP
- monitor these
What medication will we use in combination with Ketamine & why?
Use glycopyrrolate (robinul) or atropine Due to increase of secretions from ketamine & to avoid aspiration
Precedex or Dexmedetomindine
Light sedation anxiolytic and can be aroused from it.
How long should a a Precedex drip go for
24 hours
- but not a significant issue if its longer
Precedex onset for PO & IV
Half life
Duration
PO 30 minutes
IV 10 minutes
Half life 6 minutes
Duration 4 hours
Side effects of precedex
n/v
hypotension
bradycardia
Precedex side effects treatment if we decide to continue tx
(hypotension & brady)
fluids, pressors, atropine
What is Propfol
Hypnotic agent w little analgesic
Can be helpful in decreasing oxygen consumption
Propofol route
What other med do we give if we push?
IV only which can be painful if pushed
- use lidocaine
Propofol onset
Onset if 30-60 seconds
- which is helpful for when patients start bucking the vent bc we can titrate it quickly
IV needed for Propofol
Large, secure IV
You see your bottle of propofol is almost empty. What do you need to do
Go pull it. Do not wait for it to empty because it doesn’t take very long for the patient to stop feeling the effects and bucking the vent
Propofol is a lipid emulsion. Why is this important for you to consider?
You will have to change tubing every 12 hours.
Monitor triglycerides since it is lipid based & if they are too high, we have to get a new med.
What age group is Propofol not approved for
Not approved for those under 12.
- up to doctor discretion
Propofol side effect
Hypotension so be diligient about checking q15 vitals
- and if it drops, you will have to titrate it
What does the Nurse practice act say about pushing propofol
We have to take a sedation class before pushing it. If we don't, we cannot push propofol. Doctor has to be there in the room & has to be certified too.
What is PRIS or propofol related infusion syndrome?
What labs?
Propofol impairs ability to use fatty acids and so it leads to catabolism and muscle necrosis which
elevated creatinine kinase and myoglobin
What happens if PRIS occurs in critical conditions
Cardiac failure
Rhabdomyolosis
Metabolic acidosis
Renal failure
What to watch for for PRIS clues?
Elevated CK
Lactic acidosis
Hypotension
ST segment elevation
early intervention is very important.
Etomidate is used for __
RSI and allows for quick intubation
Etomidate effects on the cardiorespiratory and hemodynamics of a patient include?
Trick question. Etomidate doesn’t usually harm anything.
It does lower cerebral blood flow by 20-30% and reduces ICP.
- not too big of a concern tho bc it works fast
Can Etomidate help with pain?
No analgeisc properties
With any type of sedation, what titration trend do we want to follow?
Start with low dose and titrate up.
Does everyone respond the same to these medications?
No! Respect that.
Make sure you have a plan..
Know plan A, B, C.. etc.
Mark all your ..
Synringes.
And know all your drugs.
What is the purpose of using a continuous sedation regiment in adults in icu?
Help deliver oxygen to them in general through vent maybe
Decrease the amount of O2 they are using as well.
Which meds are used for continuous sedation
Barbiturates or pentobarbital Propofol Benzos - Ativan/Lorazepam onset of 15-20 minutes but can last 6-8 hrs Morphine Fentanyl
Why is level of sedation controversial
bc we want them to be sedated all the way
sedation vs analgesia
they are not the same & we shouldn’t act like they are.
Sedation holidays/vacation
For sponteanous breathing & weaning them off the sedation when taking them off vent.
- do not titrate down ; you turn it off!!!
Neuromusuclar blockades are sedation T/F
false.
What do we measure for those neuromuscular blockades
Train of four
why do we limit for neuromuscular blockades duration
muscle weakness
Nurse practice act
Physician needs to be available with sedative. meds
RN competency from sedation class
Accept assignments that you know how to take
Why do we consider the appropriate drug needed with the appropriate dose?
We have a goal of the level of sedation we want to accomplish , so we need to consider the med and dosage.
Are neuromuscular blocks analgesics?
Are they sedatives?
NOOO
Are sedatives analegisics?
NOO
What do you check when switching drugs
Equianalgesic chart
Why do we do around the clock pain management
To avoid breakthrough pain
Tolerance
A given dose of the drug that produces less analgesia or requires a larger dose for the same relief
- 10 mg of one med works , they may need more.
Ceiling effect
No matter how much med you give, the med is at a point where the effects won’t increase.
Physical dependance
altered physiological state due to opiates.
Withdrawals, tearing, rhinorrhea, yawns, insomnia, pupil dilation, N&V, diarrhea and muscle spasms
Addiction
Behavior response that has overwhelming preoccupation with securing & using a drug
Coanalgesics use?
PRNS to help out with breakthrough pain
Coanalgesic drugs
Gabapentin for neuropathic & herpetic pain
Glucocorticoids for reduction of edema in tumor and nerve tissue; good for bone metsz.
5% lidocaine patches - postherpetic neuralgia - on 12 hours, off 12 hours.
- initial & date and time
PCA pumps pros
Creates less anxiety bc patient con control it a little more and it makes relief quicker.
PCA modes
Basal
Bolus
or do both
Loading dose as well
What to document for PCA pumps?
Monitor pattern of use.
Do it at beginning of shift
and at end.
What effects basal rate for pca pumps?
What labs do we need to be monitoring?
Size & weight
- larger patient, the harder it is to control pain
- watch labs for kidney function
Controversial PCA pump issue related to age
How old is old enough for a pca pump
- not all kids are smart lmao
Gerontologic expectations of pain
They think pain is apart of getting old & that they have to deal with it. They are also scared that they’ll be addicted to opioids
They’ll use less severe words like aches or sore instead of telling you they are in actual pain.
- We need to educate them about how using it as prescribed is safe
Most common painful conditions of elderly
Osteoarthritis
Low back pain
Previous fractures
Chronic pain in geriatric populations are associated with ________ _____ & _______ ______ .
Physical disability
Psychosocial problems
What can untreated chronic pain lead to in geriatric patients?
Depression Sleep issues Decreased Mobility Decreased health care utilization Physical and social role dysfunctions
Facial expressions to look for in elderly to assess for pain
Sad/frightened facial expressions
Vocalizations to assess for pain in elderly
Vocalizations - chanting, calling out/praying, profanity
Body movements to assess for pain in eldery
Body movements - fidgeting, restless, withdrawal, and resisting care
- so educate them about their care as well
Behavioral changes or patterns to assess for pain in elderly
Change in patterns - eating, sleeping (to avoid pain), immobility
Confusion & irritability
