Pain Flashcards
Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a change in the nervous system, as well as being reflective of the patient’s past pain experiences and the meaning of pain.
What are the dimensions of pain?
cognitive, affective, physiologic, behavioral, sociocultural
Cognitive dimension of pain
Beliefs, attitudes, memories, and meaning attributed to pain that can influence the patient’s response to pain and should be incorporated into the comprehensive treatment plan
Affective dimension of pain
Emotional response to pain experience. Responses may include anger, fear, depression or anxiety. May be relieved by pain reflief and influenced by spirituality
Physiologic dimension of pain
Transmission of nociceptive stimuli that communicates tissue damage to the CNS
Behavioral dimension of pain
Observable actions used to express or control pain include facial expressions, social withdrawal, decrease in physical activity, use of relaxation and taking medications. Responses may also include fear, depression and anxiety
Sociocultural dimension of pain
Includes demographics, support systems, social roles, and culture. Age, gender, and education may influence beliefs and coping strategies. Sociocultural dimension of pain must be assessed without stereotyping
Narcotic Tolerance
This is the need for an increased dose to maintain the same degree of pain control. It is not as common as people think. If this develops the MD may choose to rotate drug instead of increasing the dose.
Physical Dependence
This is an expected response to ongoing exposure to pharmacologic agents manifested by withdrawal symptoms when blood levels drop abruptly. The drug should be tapered to avoid this barrier.
Addiction
This is a neurobiolgic condition where there is a drive to obtain and take substances for other than prescribed therapeutic value.
Endorphins
opiate-like peptides produced naturally by the body at neural synapses in the CNS which modulate the transmission of pain perception. They raise the pain threshold, produce sedation and euphoria.
Pain Threshold
The level that must be reached for an effect to be produced
Referred Pain
Pain that is perceived in an area distant from the site of the stimuli
Intractable Pain
Pain that continues to occur even with optimal medical management
Phantom Pain
A pain syndrome that occurs following surgical or traumatic amputation of a limb. The client experiences pain in the missing body part even though there is complete mental awareness that the limb is gone.
Somatic Pain
Pain arising from nerve receptors originating in the skin or close to the surface of the body
Visceral Pain
Pain arising from body organs, dull and poorly localized due to low number of nocipceptors
Neurogenic Pain
Also referred to as neuropathic pain. Arising from nerves
Gate Control Theory
Proposed by Ronald Melzack and Patrick Wall, gate control theory suggests that the spinal cord contains a neurological “gate” that either blocks pain signals or allows them to continue on to the brain. Unlike an actual gate, which opens and closes to allow things to pass through, the “gate” in the spinal cord operates by differentiating between the types of fibers carrying pain signals. Pain signals traveling via small nerve fibers are allowed to pass through, while signals sent by large nerve fibers are blocked. According to this theory synapses in the dorsal horns act as a gate that closes to keep impulses from reaching the brain or open to permit impulses to ascend to the brain. Gate control theory is often used to explain phantom or chronic pain.
Gate Control Theory & Nursing
The Gate Control Theory is one approach that helps to explain how thoughts and emotions of an individual modify the perception of pain. Clinically, RNs can use this model to treat the underlying causes of pain with nursing interventions such as massage, heat, cold, imagery, distraction, empathy and support
Factors that can affect an individual’s perception of and reaction to pain
- Ethnic and cultural values
- Developmental stage
- Environment and support individuals
- Past pain experiences
- Anxiety and stress
- Pain barriers
Infant (1 Month to 1 Year) Pain Perception, Behavioral responses and TNIs
- Give a glucose pacifier.
- Use tactile stimulation. Play music or tapes of a heartbeat
Toddler (1 to 2 Years) Pain Perception, Behavioral responses and TNIs
- No formal concept of pain related to immature thought process and poorly developed body image
- Reacts as intensely to painless procedures as to ones that hurt, especially when restrained
- Intrusive procedures, such as temperatures are very distressing
- Reacts to pain with physical resistance, aggression, negativism, and regression
Preschool (3 to 5 Years)Pain Perception, Behavioral responses and TNIs
- Pain perceived as punishment for bad thoughts or behavior
- Difficulty understanding that painful procedures help them get well
- Cannot differentiate between “good” pain (as a result of treatment) and “bad” pain (resulting from injury or illness)
- Reacts to painful procedures with aggression and verbal reprimands, e.g., “I hate you.” “You’re mean.”
- Distract the child with toys, books, pictures.
- Involve the child in blowing bubbles as a way of “blowing away the pain.”
- Hold the Child to provide comfort
School-Age Children (6 to 10 Years) Pain Perception, Behavioral responses and TNIs
- Reaction to pain affected by past experiences, parental response, and the meaning attached to it.
- Better able to localize and describe pain accurately
- Pain can be exaggerated because of heightened fears of bodily injury, pain, and death
- Provide a behavioral rehearsal of what to expect and how it will look and feel.
Adolescent (11 to 18 Years) Pain Perception, Behavioral responses and TNIs
- Can locate and quantify pain accurately and thoroughly
- In general, highly controlled to responding to pain and painful procedures; brave in front of peers and not report pain
- Provide opportunities to discuss pain.
- Provide privacy.
- Present choices for dealing with pain. Encourage music or TV for distraction.
Adult Pain Perception, Behavioral responses and TNIs
- Behaviors exhibited when experiencing pain may be gender-based behaviors learned as a child.
- May ignore pain because to admit it is perceived as a sign of weakness of failure.
- May use pain for secondary gain, for example, to get attention.
- Deal with any misconceptions about pain.
- Focus on the patient’s control in dealing with the pain.
- Allay fears and anxiety when possible.
Elder Pain Perception, Behavioral responses and TNIs
- May perceive pain as part of the aging process.
- May have decreased sensations or perceptions of the pain.
- Lethargy, anorexia, and fatigue may be indicators of pain.
- May withhold complaints of pain because of fear of the treatment, of any lifestyle changes that may be involved, or of becoming dependent.
- May describe pain differently, that is, as “ache,” “hurt,” or “discomfort.”
- May have chronic pain which often results in depression, sleep disturbance, decreased motility, and social isolation
Pain Assessment
pattern, area, intensity, nature
Pain Pattern
How pain changes with time, its onset, and duration
Pain Area
Place on the body where pain is felt. helps provider to identify cause and treatment of pain. same as location of pain.
Pain Intensity
Amount of pain felt, rated using pain scales
Pain Nature
How the pain feels to the patient. The quality of pain, sharp, aching, burning, experiences such as anxiety, depression and fatigues can worsen nature of pain
Define Pain Pattern
Describes how the pain changes with time, activity or other factors. Refers to factors that increase or relieve pain
Examples of pain pattern desciptors
- Continuous, steady, constant
- Rhythmic, periodic, intermittent
- Brief, momentary, transient
Visual Analog Scale
Ask patient to place a mark on a line that best describes amount of pain. With a centimeter ruler, measure from “no pain” end of the scale to the patient’s mark and record centimeter number of the measurement of pain intensity. Example: “Patient has a 2.5 cm measurement of pain at 8 am.” At 10 am patient had a measurement of 3 cm pain. The pain would be worse at 10 am. Use with all patients age 5 or older.
Numeric Rating Scale
Explain to patient that at one end of the line is zero which means no pain. At the other end is ten which means worst possible pain. Ask patient to choose a number that best describes own pain. Use with all patients age 4 1/2 and older.
Wong FACES Pain Rating Scale
Can be used with children starting at age 3. Point to a face that best describes patient pain.
FLACC Scale
This scale is used to assess pain levels in cognitively impaired patients including patients recovering from anesthesia and children ages 2 months – 7years.
FLACC Score 0
No particular expression or smile, normal position or relaxed, lying quietly, normal position, moves easily, no cry awake or asleep, content, relaxed
FLACC Score 1
occasional grimace or frown, withdrawn, disinterested, uneasy, restless, tense, squirming, shifting back and forth, tense, moans or whimpers, occasional complaint, reassured by occasional touching, hugging or being talked to, distractible
FLACC Score 2
frequent to constant quivering chin, clenched jaw, kicking or legs drawn up, arched, rigid or jerking, crying steadily, screams or sobs frequently, frequent complaints, difficult to console or comfort
To use FLACC Scale
Assess each of the categories in the far left column to obtain a score of 0-2 then
Add the scores for all five categories to obtain a score of 0-10.
Behavioral Assessment
Behavioral assessments are important. Many individuals who are experiencing pain show it either by verbal complaints or nonverbal behaviors.
Nonverbal Facial Expressions Indicating Pain
Clenched teeth Wrinkles forehead Biting lips Scowling Closing eyes tightly Widely opened eyes or mouth
Nonverbal Vocalizations Indicating Pain
Crying Moaning Gasping Groaning Grunting
Nonverbal Body Movement Indicating Pain
Restlessness Protective body movement Muscle tension Immobility Pacing Rhythmic movement
Nonverbal Social Interaction Indicating Pain
Silence
Withdrawal
Reduced attention span
Focus on pain relief measures
Define Acute Pain
An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and DURATION OF LESS THAN 3 MONTHS OR TIME FOR NORMAL HEALING TO OCCUR.
Define Chronic Pain
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a DURATION OF GREATER THAN 3 MONTHS. (PER MCC GUIDELINES)
State in which the individual experiences pain that persists for a period of time beyond the usual course of acute illness or a reasonable duration for the injury to heal, is associated with a chronic pathological process or recurs at intervals for months or years
Defining Characteristics Acute Pain
Expressions of pain are extremely variable and cannot be used in lieu of self report
- Loss of appetite
- Inability to deep breathe, ambulate, work, sleep, perform ADLs
- Guarding
- Self-protective behavior
- Self focus
- Narrowed focus
- Distraction behavior ranging from crying to laughing
- Muscle tension or rigidity
Onset Acute Pain
Sudden
Severity Acute Pain
Mild to severe
Onset Chronic Pain
Gradual or Sudden
Severity Chronic Pain
Mild to severe
Defining Characteristics Chronic Pain
Expressions of pain are extremely variable and cannot be used in lieu of self report
- Loss of appetite
- Inability to deep breathe, ambulate, work, sleep, perform ADLs
- Guarding
- Fatigue
- Withdrawal from others and social isolation
- Self-protective behavior
- Self focus
- Narrowed focus
- Distraction behavior ranging from crying to laughing
- Muscle tension or rigidity
Course of pain Acute Pain
Over time and goes away as recovery occurs related to tissue injury; resolves with healing
Course of Pain Chronic Pain
typically pain does not go away, periods of waxing and waning, continues after healing and withdrawn
Physical and Behavioral Manifestations Acute Pain
SYMPATHETIC PHYSIOLOGIC RESPONSE “Flight or fight” response increase blood pressure increase heart rate increase respiratory rate Diaphoresis Dilated pupils
BEHAVIORAL RESPONSE
- i ncrease anxiety and restlessness
- Crying, rubbing area, holding area
- Patient reports pain
Physical and Behavioral Manifestations Chronic Pain
PARASYMPTHETIC PHYSIOLOGIC RESPONSE normal vital signs
Dry, warm skin
Normal or dilated pupils
BEHAVIORAL RESPONSE
- Depression and withdrawn
- Pain behavior often absent
- Patient often does not report pain unless asked
TNI Acute Pain
- Uses pain rating scale to identify current level of pain and determine a comfort/function level
- Reports that the pain management regimen relieves pain to a (specify level) with acceptable or manageable side effects.
- States an ability to obtain sufficient amounts of rest and sleep.
TNI Chronic Pain
- Uses pain rating scale to identify current level of pain and determine a comfort/function level
- States a specific plan for pharmacological and non-pharmacological pain relief
- Demonstrates ability to pace self, taking rest breaks before they are needed.
- Performs ADLs with minimal interference from pain and medication side effects.
Examples of Acute Pain
- Somatic
- Visceral
- Referred pain
Examples of Chronic Pain
- Phantom
- Psychogenic
- Intractable
Treatment goals Acute Pain
pain control with eventual elimination
Treatment goals Chronic Pain
Enhance function and quality of life
World Health Organization Three Step Analgesic Ladder
The World Health Organization Three Step Analgesic Ladder is a guide to selecting the initial analgesic level and dosing. The ladder presents a treatment model for pain where treatment gets more aggressive the further up the ladder you go. Continued reassessment is needed to modify the treatment plan based on the patient’s response.
World Health Organization Mild Pain
1-3 on scale. Nonopiod medication with an adjuvant medication if the patient has neuropathic pain
World Health Organization Moderate Pain
4-6 on scale. Opioid medication in low dose is added with the nonopioid and adjuvant medication continued
World Health Organization Severe Pain
7-10 on the scale. Higher doses of the opioid, nonopiod and adjuvant medications are continued. When a patient presents with severe pain ordered medications are prescribed at the appropriate level for that patient’s pain
What is the limitation of the World Health Organization’s three step analgesic ladder?
The misconception that mild to moderate pain opioids, such as codeine, must be used in step three. It is recommended that smaller doeses of strong opioids, such as morphine, are just as effective and preclude having to switch medications at a later time
TNIs for Acute and Chronic Pain
- Assess whether patient is experiencing pain at the time of the interview. If so, provide appropriate interventions to provide pain reflief. Assess patient’s pas experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects, typical coping responses, and how they express pain on initial interview
- Teach patient to report pain location, intensity, using a pain rating scale and quality when experiencing pain. Find out about patient’s pain reaction, pain threshold, and pain tolerance
- Determine patient’s current medication use
- Administer ordered pain medications. It is important to use the least invasive route of administration capable of providing adequate pain control. Oral is the route of choice with a functioning GI tract
Pain Reaction
the autonomic nerous system and behavioral responses to pain
Pain Threshold
Intensity of the noxious stimuli necessary for the individual to perceive pain
Pain Tolerance
Duration of time of the intensity of which an individual accepts a stimulus above the pain theshold becaore making a verbal or overt pain response
When is around the clock pain medication especially helpful?
24-48 hours after surgery
What would you administer for acute pain?
opioids po or iv
What would you administer for chronic pain?
opioids po
What types of medications are considered for chronic pain?
adjuvant medications that are analgesic may be considered in combination to allow for lower dosages of individual medications
What route is avoided for pain management?
IM route because of unreliable absorption, pain, and inconvenience
What route is preferred for rapid control of severe pain?
IV
For ongoing, chronic pain, what would you give?
analgesic around the clock
What would you give for intermittent pain?
prn dosing
What would you assess with opioids?
pain intensity, sedation, RR & status, constipation, N/V, urinary retention.
Opiods may cause what?
resp. depression because they reduce the responsiveness of carbon dioxide chemoreceptors located in the resp. centers of the brain
What should you discuss with a patient on pain medications and experiencing pain?
fears of undertreated pain, addiction, and overdose. Opioid tolerance and physical dependence are expected with long term use of opioids from chronic pain and should not be confused with addiction which is extremely rare for patients using opioids for pain relief
When should you reassess effectiveness of IV analgesics?
30 minutes after IV administration
When should you reassess effectiveness of po analgesics?
1 hour
Key Components of Documentation for pain
- description of pain - use patient’s own words
- location
- intensity
- quality
- radiation
- time of onset
- factors that aggravate pain
- factors that relieve pain
- methods used to promote comfort
- patient’s response
Patient/Family Teaching Pain
Provide written materials on pain control
Explain pain assessment process and purpose of the pain rating scale.
Teach patient to use the pain rating scale to rate intensity of past or current pain
Demonstrate medication administration and use of supplies and equipment. If PCA is ordered, determine patient’s ability to press appropriate button. Remind patients and staff that the PCA button is for patient-only use.
Reinforce importance of taking pain medications to keep pain under control.
Demonstrate use of appropriate nonpharmacological approaches for controlling pain such as heat, cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music, and television.
Guidelines for Assessment and Treatment of Acute and Chronic Pain After Surgery
- Focus on prevention or control.
- Accept patient’s report of pain level and act on it accordingly.
- Differentiate the types of pain. Assess and document acute pain and chronic pain separately so you can see which aspect of the pain experience is more problematic.
- Research shows that around-the-clock administration of pain medication is more effective than PRN.
- Do not make the mistake of using behavioral or vital signs to judge the patient’s pain. A patient with chronic pain may not look or act in pain and probably will not have elevations in blood pressure or pulse rate that you assess with someone with acute pain.
- Select the smallest dose to provide effective pain control with fewest side effects.
What are the negatives of pain?
effects quality of life; it interferes with ADL’s, prevents relaxation and sleep; increases anxiety, depression, stress and fatigue
Cancer Acute Pain
severe and lasts a short time….surgical incision
Cancer Chronic Pain
pain that lasts for a long time. those with chronic cancer pain may also experience breakthough pain, a transient increase in pain that exceeds the level managed by pain medication used on a continuous basis.
Somatic Cancer Pain
commonly arises from metastases from the bone and pain r/t surgery. It is localized and described as stabbing, throbbing, dull, or aching
Visceral Cancer Pain
common in pancreatic cancer as well as patient with metastasis to the abdomen. Described as pressure like cramping, gnawing, or squeezing. Some patients may experience referred pain as a result of visceral pain
Neuropathic Cancer Pain
may result from a tumor compressing or infiltrating the nerves or spinal cord. It can also result from chemical damage to the nervous system by cancer treatment. It is typically described as sharp, burning, or shooting and is often accompanied by numbness and tingling. Patient may also report allodynia (pain provoked by normal non-painful stimulus such as light touch).
TNIs for Cancer-Related Pain
Confirm that sufficient ATC and PRN analgesics are ordered and available.
Make certain that the clients can obtain prescribed analgesics at their usual pharmacy or that an alternate source is found.
Instruct clients receiving chronic opioid therapy to carry written documentation of their current analgesic regimen (drug, dose, frequency, and route) and treating physician (with phone number) when leaving their home. This information can be essential should an emergency arise.
Be aware of the analgesic effect of corticosteroids. If they are tapered, it may necessitate increasing opioids to provide the same analgesia. Also, the reverse may be true; if steroids are added, it may be necessary to decrease the opioids administered to prevent side effects.
Increasing pain or decreasing analgesic effectiveness, without change in analgesic regimen, frequently means advancing diseases, not tolerance. Additional assessment of the cause of pain is necessary. This may result in diagnosis of treatable conditions.
As cancer progresses, continually assess whether pain is being controlled and the patient is satisfied with the method of control.
Avoid the IM route. Consider the use of an indwelling subcutaneous needle should repeated injections become necessary.
Educate the client and caregiver to identify situations that require professional intervention (e.g., unrelieved pain, acute changes in severity, location, or duration of pain, or unrelieved complications of the pain management regimen).
Understand that the use of morphine, methadone, or the IV route may have special meaning to a client or family. For example, use of morphine or the IV route may be interpreted that the client is close to death when in fact the client may not be, or the use of methadone may be interpreted that the client is a drug addict when in fact methadone may be an effective analgesic for that particular client.
Individuals with chronic cancer-related pain who experience acute pain episodes (such as surgery) will need continued treatment of their chronic cancer-related pain in addition to treatment of the acute pain.
Be aware of a client’s goals of care. Goals of care an include any one or combination of the following: maximizing survival, maximizing function, and maximizing comfort. Knowledge of goals of care is necessary when evaluating the risk/benefit ratio of pain treatments. For example, in an opioid-naive, fragile client whose only goals is to maximize survival, it may be necessary to limit the use of opioids. In the dying client, it may not be possible to maximize function and comfort. A decision will need to be made as to what the primary goal is to ensure appropriate treatment.
Some health care professionals mistakenly believe that if a cancer client is dying, the opioid used for pain relief should be changed to morphine. This is not necessary as long as the prescribed analgesic controls the pain without dose-limiting side effects.
Be very cautious about the use of naloxone (Narcan) in opioid-tolerant clients. Be aware of the goals of care. Rule out progression of disease and other medications as the cause of deteriorating respiratory status. If administration of naloxone is appropriate, administer slowly, titrating to effect to avoid precipitating withdrawal and severe pain.
Inpatient Cancer Pain Teaching
- Instruct clients on admission to send home any analgesics they may have brought with them.
- Early on if a possibility exists that the client will be discharged or transferred with a PCA pump, epidural catheter, or other high-tech analgesic intervention, evaluate client’s home situation and insurance coverage to determine whether this will be a safe and insurance-covered situation.
Home Care Cancer Pain Teaching
- Encourage client and/or caregiver to use a pain control record to keep track of medication use, especially use of PRN doses and pain ratings after pain relief measures.
- Encourage client and/or caregiver to notify primary physician that medication supply is getting low in enough time to have prescriptions renewed without an interruption in analgesic regimen. It is often a good idea to have a separate 3-day to 4-day supply kept for use in emergencies.
- Consider the need for parenteral medications in the home, and identify and educate the caregiver who could administer this medication should the need arise. Make sure that the client and caregiver know who is to be contacted should a situation arise that requires professional intervention. This should cover situations arising 24 hours a day, 7 days a week.
Emergency Department Cancer Pain Teaching
- Quickly identify the extent of disease, goals of care, DNR status, and present analgesic regimen (especially specific analgesic use and effectiveness in the last 48 hours). Is this client opioid naive or tolerant? Has this client been able to take analgesics by the route prescribed?
- Be very cautious about the use of naloxone (Narcan).
Cancer Pain: Persistent pain
continuous pain that is present for most of the day for more than three months. around the clock medication
Cancer Pain: Breakthrough Pain
sudden flare of pain that breaks through around the clock medication used to treat persistent pain. med taken as needed to quickly relieve breakthough pain
Oxycodone with acetaminophen (Percocet) Class
narcotic (opioid)
Hydromorphone (Dilaudid) Class
narcotic (opioid)
Hydrocodone/Acetominophen (Vicodin) Class
narcotic (opioid)
Codeine Class
narcotic (opioid)
Morphine sulfate Class
narcotic (opioid)
Oxycodone Class
narcotic (opioid)
Midazolam (Versed) Class
benzodiazepine
Hydroxyzine (Vistaril, Atarax) Class
antiemetic/antihistamine
Ibuprofen (Motrin) Class
NSAID
Ketorolac (Toradol) Class
NSAID
Acetylsalicylic Acid (Aspirin) Class
NSAID
Acetaminophen (Tylenol) Class
non opioid analgesic
Naloxone (Narcan) Class
narcotic antagonist
Flumazenil (Anexate) Class
benzocliazepam receptor antagonist
NSAID Use
- Mild to moderate pain
- antipyretic
- antiinflammatory
NSAID Action
Prostaglandin synthesis inhibition
Ibuprofen (Motrin) Side/Adverse Effects
GI bleeding, headache, hepatitis, N, anaphylaxis anorexia, nephrotoxicity, blood dyscrasias
Acetylsalicylic acid (aspirin) side/adverse effects
GI bleeding, nausea, vomiting, hepatitis, Reye’s Syndrome, (children), anaphylaxis, laryngeal edema, seizures, coma, hemolytic anemia, blood dyscrasias
Ketorolac (toradol) side/adverse effects
GI bleeding, drowsiness, perforation, nephrotoxicity, dysuria, hematuria, oliguria, azotremia, blood dyscrasias
Non-opioid analgesic Use
- mild to moderate pain
- antipyretic
Non-opioid analgesic Action
prostaglandin sythesis inhibition
Acetaminophen (tylenol) adverse/side effects
hepatoxicity, blood dyscrasias, hepatotoxicity, cyanosis, anemia, neutropenia, jaundice, CNS stimulation, convulsions, coma, death, renal failure
Narcotic Use
acute and chronic pain
Narcotic Action
binds to opiate receptors in the CNS
Oxycodone with Acetaminophen (Percocet) Side/Adverse Effects
confusion, sedation, dizziness, headache, euphoria, constipation, respiratory depression, nausea, vomiting, anorexia, cramps
Codeine side/adverse effects
confusion, sedation, drowsiness, seizures, circulatory collapse, nausea, vomiting, anorexia, respiratory depression, anaphylaxis
Hydrocodone/acetaminephen (vicodin) side/adverse effects
drowsiness, convulsions, circulatory depression, nausea, vomiting, anorexia, constipation, respiratory depression
Morphine Sulfate side/adverse effects
confusion, thrombocytopenia, bradycardia, shock, cardiac arrest, respiratory depression
Hydromorphone (dilaudid) side/adverse effects
drowsiness, dizziness, confusion, headache, sedation, euphoria, seizures, nausea, vomiting, anorexia, constipation, cramps, rash, respiratory depression
all narcotics result in what?
initial drowsiness
Nursing Implications for co-alagesic/adjuvants
- Coadministration with opioid analgesics may have additive analgesic effects and may permit lower opioid doses
- Combined doses of acetaminophen and salicylates should not exceed the recommended dose of either medication given alone
- May be administered with food, milk, or antacids to decrease GI irritation
Nursing Implications for OTC non opioid analgesics
- Coadministration with opioid analgesics may have additive analgesic effects and may permit lower opioid doses
- Combined doses of acetaminophen and salicylates should not exceed the recommended dose of either medication given alone
- May be administered with food, milk, or antacids to decrease GI irritation
- Do not produce tolerance or addiction
Nursing Implications for narcotic opioid analgesics
- Regularly administered doses are more effective than prn administration
- Analgesic is more effective if given before pain becomes severe
- Advise client to make position changes slowly to prevent orthostatic hypotension
- Assess bowel function regularly
- Assess for dizziness, drowsiness, euphoria regularly
- Used cautiously in clients with respiratory problems
Ibuprofen and Ketorolac can be classified as NSAIDs and what?
non-opioid analgesics
What is the max amount that Ketorolac (Tylenol) can be administered IM/IV?
5 days
Reye Syndrome
viral illness that can cause acute encephalopathy rash vomiting confusion coma and resp arrest
IS aspirin recommended for children?
no. reye syndrome
What is the max amount of acetaminophen that can be administered in a 24 hour period?
4 grams
What is considered the gold standard for the management of severe pain?
morphine
Drug Antagonist
antidote to drug
Midazolam (Versed) Use
-induce amnesia, reduce anxiety, induce and maintain conscious sedation
Midazolam (Versed) Action
acts at many levels of the CNS to produce generalized CNS depression
Midazolam (Versed) Side/Adverse Effects
- Laryngospasm
- Respiratory depression/apnea
- Bronchospasm
- Cardiac arrest
- Nausea and vomiting
Midazolam (Versed) Nursing Implications
- When client is premedicated with a narcotic agonist analgesic, the conscious sedation period may be marked by hypotension
- site for redness, pain, swelling
- amnesia in elderly may be ↑
Benzodiazepine Receptor Antagonist
Flumazenil (anexate, romazicon)
Use of Flumazenil (anexate, romazicon)
reversal of sedative effects of benzodiazepines
Action of Flumazenil (anexate, romazicon)
inhibits actions of benzodiazepines on CNS
Side/Adverse Effects of Flumazenil (anexate, romazicon)
-dizziness, seizure, dysrhythmias
Nursing Implications for flumazenil (anexate, romazicon)
-assess for seizures, allergic reactions, may be repeated in one minute intervals prn
Narcotic Antagonist
naloxone (narcan)
Use of naloxone (narcan)
complete or partial reversal of narcotic depression and resp. depression
Action of naloxone (narcan)
competes with opioids at opiate receptor sites
Side/Adverse Effects of naloxone (narcan)
ventricular tachycardia
Nursing Implications of naloxone (narcan)
-monitor VS closely, may be repeated every 2-3 minutes
Hydroxyzine (vistaril, atarax) Use
preoperative sedation, often combined with opioid analgesics, antimetic
Hydroxyzine (vistaril, atarax) Action
Acts as a CNS depressant at the sub cortical level of the CNS, has anticholinergic, antihistamine, and antimetic properties
Hydroxyzine (vistaril, atarax) Side/Adverse Effects
drowsiness, dry mouth, pain at IM site
Hydroxyzine (vistaril, atarax) Nursing Implications
caution patient to ask for assistance when OOB
Nursing Responsibilities Morphine Sulfate immediate release
- Pain relief in 30-60 minutes
- If you miss a dose, take the dose ASAP. If it is almost time for the next dose, skip the missed dose; do not take 2 doses at one time.
- Inform provider if you begin to take any new medicine (prescribed or OTC).
- Do not suddenly stop; morphine must be stopped gradually
Side/Adverse effects of Morphine sulfate immediate release
resp depression, constipation, N/V, drowsiness, confusion
Action of Morphine Sulfate Immediate Release
opioid narcotic depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors
Action of Sustained-Release Morphine (MS Contin)
opioid narcotic depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors
Side/Adverse Effects of Sustained-Release Morphine
resp depression, constipation, N/V, drowsiness, confusion
Nursing Responsibilities of Sustained-Release Morphine
- Pain relief in 2 hours.
- Short-acting pain medications will be ordered to use for breakthrough pain between doses.
- If you miss a dose, take the dose ASAP. If it is almost time for the next dose, skip the missed dose; do not take 2 doses at one time. If you miss a dose by 4 or more hours, take short-acting pain medication until the next dose is due.
- Inform provider if you being to take any new medicine (prescribed or OTC)
- DO NOT BREAK, CRUSH, OR CHEW TABLETS.
- Do not suddenly stop; morphine must be stopped gradually
High dose opioid therapy
5-100 mg per hour of morphine
Why is morphine the medication of choice?
administered by all route, metabolized quickly and completely, economical
Neurogenic Pain
originates in nerves themselves rather in other damaged organs that are innervated by them. may be severe, throbbing, burning, or stabbing in character, hallmark of neurogenic or neuropathic pain is its localization to specific dermatomes or nerve distributions
Gabapentin (Neurontin) Class
Anticonvulsant
Side/Adverse effects of Gabapentin (Neurotin)
dizziness, drowsines, UTI, rhinitis, leukopenia, diplopia
Nursing Implications for Gabapentin (Neurotin)
give 2 hours before of after antacids, cap may be opened and contents sprinkled in food or in juice but do not crush or chew cap, must grad increase of decrease doses to prevent adverse reactions, teach patient/family to avoid driving and other activities that require alertness due to potential dizziness or drowsiness
Oxycodone Action
Opioid (narcotic): inhibits ascending pain pathways in the CNS, increases pain threshold, alters pain perception.
Controlled-Release Oxycodone Action
Opioid (narcotic): inhibits ascending pain pathways in the CNS, increases pain threshold, alters pain perception.
Side/Adverse Effects Oxycodone
Respiratory depression Constipation N/V Drowsiness Confusion
Side/Adverse Effects Controlled-Release Oxycodone
Respiratory depression Constipation N/V Drowsiness Confusion
Route Oxycodone
PO dosing q3-4 hours taken with or without meals
Route Controlled-Release Oxycodone
PO dosing q12 hours taken with or without meals
Nursing Responsibilities for Oxycodone
Nursing Responsibilities:
- Pain relief in 30-60 minutes.
- If you miss a dose, take the dose ASAP. If it is almost time for the next dose, skip the missed dose; do not take 2 doses at one time.
- Inform provider if you begin to take any new medicine (prescribed or OTC).
- Do not suddenly stop; oxycodone must be stopped gradually.
- Do not run out of pills, get a new prescription filled a few days before pills run out
Nursing Responsibilities for Controlled-Release Oxycodone
- Pain relief in 2 hours.
- Short-acting pain meds will be ordered to use for breakthrough pain between doses.
- If you miss a dose, take the dose ASAP. If it is almost time for the next dose, skip the missed dose; do not take 2 doses at one time. If you miss a dose by 4 or more hours, take short-acting pain med until next dose is due.
- Inform provider if you begin to take any new medicine (prescribed or OTC).
- DO NOT BREAK, CRUSH, OR CHEW TABLETS.
- Do not suddenly stop; oxycodone must be stopped gradually
Is fentanyl patch a high alert med?
yes
Fetanyl patch class
duragesic
Action Fetanyl Patch
opioid analgesic, inhibits ascending pain pathways in CNS increases pain threshold, alters pain, used for management of chronic pain
Route Fetanyl Patch
transdermal. dosing in mcg/hr. change patch every 72 hours, patch releases med slowly, it can take 12-18 hours to feel relief when starting the patch or increasing the dose, short-acting pain meds will be ordered to use in between patch changes if needed to control pain
Side/Adverse effects of fetanyl patch
resp depression, constipation, n/v, drowsiness, confusion
Nursing responsibilities fetanyl patch
- Apply the patch on skin above the waist (front or back of the body can be used).
- If skin has body hair, clip hair close to skin. DO NOT SHAVE SKIN.
- Do not place on cut or irritated skin.
- Make sure skin is dry. Do not use soap, lotions, or alcohol on skin where patch will be placed.
Steps: - Take patch out of protective pouch.
- Pull protecting backing off and discard.
- Apply patch immediately to dry, non hairy area of skin.
- Press patch firmly on skin with the palm of your hand for approximately 20 seconds.
- Wash hands.
- After 72 hours, remove old patch and apply new patch in a different place.
- If patch falls off of skin, replace with new patch.
- Discard by following agency policy for disposal).
- DO NOT apply heat, such as a heating pad or prolonged hot shower, over the patch. This may increase the dose and cause side effects.
- Do not suddenly stop; opioids must be stopped gradually.
Subcutaneous Continuous Infusion
of morphine. appropriate for relieving chronic cancer pain for a client that cannot swallow or has uncontrolled n/v. also, it can be used when a venous access device has not been established. it is easy to establish and is especially useful for end-of-life care
SC Infusion
- an infusion site can usually accept 2-3 mL/hr
- use a 25-27 gauge butterfly needle, place on the upper arm, chest, abdomen or thigh
- keep site as visible as possible by covering with transparent dressings
- SC infusion pumps can deliver continuous or PCA dosing
Action of SC Infusion
opioid analgesic highly concentrated solutions of hydromophone or morphine are used for SC infusion
Side/Adverse effects SC infusion
- Local skin irritation, inflammation, leakage, site bleeding or infection can occur; these indicate the need for a needle site change.
- Be aware of side/adverse effects of the prescribed opioid being administered via the SC infusion pump.
Nursing Responsibilities for SC infusion
- Site should be checked at least twice daily (q4 hours if the infusion rate is > 1.5 ml/hr).
- Infusion site changed every 7 days or sooner if local skin reactions occur.
- As soon as possible before d/c determine whether SC infusion will be continued at home. Assess patient and family willingness to maintain pump at home. Make appropriate referrals to home care, pharmacy, etc.
- Begin instructions on SC pump care ASAP. Give patient and family time to practice working with pump and supplies before d/c.
- Before discontinuing the infusion pump, determine the need for alternative analgesia. If patient will be receiving short-acting oral opioids, give the first dose 1 hour before stopping the SC infusion. IF the patient will be receiving controlled-release opioids, give the first dose 2 hours before stopping the SC infusion.
