PAIN Flashcards
Defined as
“unpleasant sensory, emotional experience with actual or potential tissue damage”
PAIN
Pain is a __&___ experience
Personal and subjective experience
WHO is the most reliable indicator of pain and essential component of pain assessment
PATIENT.
PAIN AFFECTS EVERY ONE
…NO MATTER THE
Age
Sex
Race
Gender
Socioeconomic class
Affects every system
There are 3 types of pain.
Name them?
- Acute pain
- chronic pain
- breakthrough pain.
Which type of PAIN am I?
*Differs from chronic by duration
*Result of tissue damage; surgery; trauma
*SHORT duration and resolved with normal healing
ACUTE PAIN
WHAT type of PAIN am I?
*Can be time limited OR last a lifetime
*SUCH AS:
- Cancer
- Noncancer: peripheral neuropathy, back pain, osteoarthritis
CHRONIC PAIN
WHICH TYPE OF PAIN AM I?
chronic pain with acute exacerbations
Breakthrough pain
TWO types of CLASSIFICATION of Pain are:
- Nociceptive (physiologic) pain
- Neuropathic (pathophysiologic) pain
Example of Nociceptive (physiologic) pain
Tissue injury
Example of Neuropathic (nerve) pain
Damage to the peripheral or central nervous system
There are 4 Processes of Nociceptive (physical) Pain.
What are they?
- Transduction
- Transmission
- Perception
- Modulation
Which Nociception Process am I?
PROCESS by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors, located throughout the body in the skin, subcutaneous tissue, and visceral (organ), and somatic (musculoskeletal structures).
TRANSDUCTION
Which Nociception Process am I?
- Transduction along the A-delta fibers (rapid) and C fibers (slower impulse)
- The A-delta fibers detect thermal and mechanical injury responsible for rapid reflex withdrawal.
- C fibers respond to thermal, mechanical, and chemical stimuli.
Transmission
Which Nociception Process am I?
- A process of the neural activity associated with transmission of noxious stimuli.
*This requires higher brain structures.
Perception
Which Nociception Process am I?
- Occurs at every level from the periphery to the cortex and involves many different neurochemicals.
Modulation
DEFINE:
caused by either a lesion or a disease.
Neuropathic Pain
Neuropathic Pain:
Results from damage or dysfunction of the
peripheral OR central nervous system
Neuropathic Pain May occur in the absence of tissue ___&____.
damage and inflammation
NEUROPATHIC PAIN includes both mechanisms.
1.
2.
- Peripheral mechanisms
- Central mechanisms
Components of Pain ASSESSMENT include
- Self-report
- Location
- Intensity
- Quality
- Onset and duration
- Aggravating and relieving factors
- Effects on function and quality of life
What is the NURSES FUNCTIONAL GOAL for patient with pain?
Comfort
What is the MOST COMMON Pain scale used?
The Wong-Baker FACES Pain Scale
What scales are used to Assess the INTENSITY of pain?
5 TOTAL
- Numeric Rating Scale (NRS)
- Wong–Baker FACES Pain Rating Scale
- Faces Pain Scale—Revised (FPS-R)
- Verbal descriptor scale (VDS)
- Visual Analog Scale (VAS)
What scale is used to Assess Pain for NONVERBAL patients?
The Hierarchy of Pain Measures
What scale is used to Assess Pain for YOUNG CHILDREN?
FLACC
F- facial expression
L- Leg movmnt
A- Activity
C- Crying
C- Consolability
*Assigned scores from 0-10
What scale is used to Assess Pain for patients with ADVANCED DEMENTIA?
PAINAD
(Pain Assessment In Advanced Dementia)
What scale is used to Assess Pain for patients in CRITICAL CARE units?
CPOT
(Critical Care Pain Observation Tool)
*Indicates whether or not they may be intubated.
Gerontologic (older adults) CONSIDERATIONS while administration of Analgesic Agents
- Older Adults often live with chronic pain
- Physiologic changes and comorbidities make pain management more complicated
- Older adults are often sensitive to the effects of analgesic agents
- Analgesic agents should be initiated with LOW doses and titration should proceed slowly with assessment of patients response
How to Manage Pain?
- Effective and safe analgesia: to control pain without depressing breathing. Always count Respiratory Rate before administration of opioids. Normal Resp. rate adult: 12 to 20 b/min. Watch for Bradypnea (respiratory rate below 12) when administering opioids, DRUG OVERDOSE is the MAIN cause of Bradypnea.
- Optimal relief: so that the patient can move without extreme pain
- Comfort function goal
- Responsibility of all members of the health care team
- Pharmacologic: multimodal
- Routes and dosing: take into consideration of the type of patient and age level and rate of metabolizing drug. Every patient is different. No one size fits all.
- Patient-controlled analgesia (PCA): *When setting up a PCA Pump for a patient make sure that the doctors orders includes a Dose Limit *
Physiologic Basis for Pain Relief- Pharmacologic Interventions
Opioid analgesics act on the_______ to INHIBIT activity of ascending nociceptive pathways
CNS
Opioid analgesic agents exert their effects by interacting with the body’s opioid receptor sites located throughout the body, including in the peripheral tissues, GI system, and CNS
The Opioid analgesics that are designated as FIRST LINE are
1.
2.
3.
4.
- morphine
- fentanyl
- hydromorphone (Dilaudid)
- oxycodone.
Common to see morphine, fentanyl and hydromorphone.
Hydromorphone (Dilaudid) is 2 to 8 times stronger than_______, also has a rapid onset.
morphine
The antagonists for opioid overdose and reverse adverse effects is called
NALOXONE
Adult dose IV o,4-2mg, may repeat q2-3 minutes up to 10mg if necessary
Physiologic Basis for Pain Relief- Pharmacologic Interventions
______ decrease pain by inhibiting Cyclo-oxygenase
(enzyme involved in production of prostaglandin)
NSAIDs
Physiologic Basis for Pain Relief- Pharmacologic Interventions
Local anesthetics block ________ when applied to nerve fibers
nerve conduction
NAME THE TWO ANALGESIC AGENTS
- NONOPIOID
- OPIOID
EXAMPLES OF NONOPIOID ANALGESIC AGENTS
- Acetaminophen (Tylenol)
- NSAIDs: ibuprofen, naproxen, celecoxib
EXAMPLES OF OPIOIDS
- Fentanyl has fast onset and short duration
- Morphine has slower onset and longer duration
- Hydromorphone has onset and duration that is intermediate between morphine and fentanyl
- Hydrocodone P.O. given to treat mild to moderate pain
MOST WIDELY USED SEDATION SCALE is called
Pasero Opioid-Induced Sedation Scale with Interventions
Adjunctive Analgesics include:
(given in addition to the main treatment to maximize its effectiveness.)
- Local anesthetics
- Lidocaine patch 5% - Anticonvulsants
- Gabapentin, pregabalin - Antidepressants
- TCAs: desipramine, nortriptyline
- SNRIs: duloxetine, venlafaxine - Ketamine
Define:
- NORMAL RESPONSE with REPEATED USE of opioid use of 2 weeks or MORE
- Manifested by withdrawal symptoms
OPIOID PHYSICAL DEPENDENCE
DEFINE:
- NORMAL RESPONSE with REGULAR USE of opioid
- Decrease in one or more of the effects
- Increased usage needed to effect pain relief
OPIOID TOLERANCE
SUBSTANCE USE DISORDERS INCLUDE:
*Impaired use of a substance, even while experiencing major problems
- Impaired control over use
- Continued use despite harm
- Craving for the substance
- Use of opioid for nontherapeutic reasons; independent of pain relief
SUBSTANCE USE DISORDERS are Influenced by
1.
2.
3.
- genetic
- psychosocial
- environmental factors
What reverses opioid side effects?
ANTAGONISTs
Define:
are medications that bind to receptors without analgesia effect
Antagonist
Antagonist have the potential to block
analgesia
Antagonist reverse adverse effects of
respiratory depression.
Most common OPIOID antagonist used is
Naloxone
reverses opioid overdose
Gerontologic Considerations when treating PAIN
- Sensitive to agents that produce sedation and CNS effects
- Initiate with LOW dose and titrate SLOWLY
- Increased risk for NSAID-induced GI toxicity
- Acetaminophen preferred for MILD pain
- Opioid dose should be reduced 25% to 50% in adults OLDER THAN 70 YRS.
______ is considered an important factor to consider when selecting an opioid dose.
AGE
Name some Nonpharmacologic Methods
- Natural products
- Herbs, botanicals, vitamins, probiotics - Mind and body practices
- Acupuncture, chiropractic manipulation, massage therapy, yoga, tai chi - Cognitive and behavioral methods: Relaxation breathing, distraction, listening, singing, imagery, humor, meditation
What consists of the Nursing Process Framework for Pain Management
- Identify goals for pain management
- Establish nurse–patient relationship, teaching
- Provide physical care
- Manage anxiety related to pain
- Evaluate pain management strategies
What are the ADVERSE EFFECTS of Analgesic agents
- Respiratory depression- FIRST! MOST IMPORTANT*
- Sedation
- Nausea, vomiting
- Constipation: decreased peristalsis
- Pruritis (itchy skin): If present, antihistamines such as diphenhydramine can be ordered.
What should the nurse consider for patients with PAIN
- Requires a collaborative approach
- Must be evidence-based and comprehensive
Is the following statement true or false?
The frequency of pain reassessment depends on the stability of the patient and the timing of the peak effect of the medication administered.
True
Rationale: At a minimum, pain should be reassessed with each new report of pain, and before, and after the administration of analgesic agents. General rules include, if the medication is parenteral administration reassess between 15 and 30 minutes, if oral administration reassess between 1 and 2 hours
Is the following statement true or false?
Using a placebo to treat pain is acceptable in patients with a history of opioid use disorder.
False
Rationale: Pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that there are no individuals for whom and no condition for which placebos are the recommended treatment.
Is the following statement true or false?
Nonpharmacologic pain therapies can be a replacement for pharmacologic therapies used for severe pain.
False
Rationale: Nonpharmacologic therapies are usually effective alone for mild to some moderate-intensity pain. They should not be a replacement or alternative but a complement to pharmacologic therapies as part of a multimodal approach for more severe pain.
Name the types of ANALGESIA/ANASTHESIA used in LABOR AND birth.
6 total.
- Epidural block
- Combined spinal
- Patient-controlled epidural
- Local infiltration
- Pudendal block
- Intrathecal (spinal) analgesia
Regional Analgesia/Anesthesia During Labor and birth
- Injection of Local anesthetic ( lidocaine or bupivacaine) and opioid analgesic agent (morphine or fentanyl) into the third and fourth lumbar vertebrae with needle and catheter
- continuous infusion or intermittent injection; usually started when dilation > 5 cm
What am I called?
Epidural block
Can be used for VAGINAL and CESARIAN births.
EPIDURAL BLOCK
Regional Analgesia/Anesthesia During Labor and birth
*TYPE OF Epidural that uses only an opioid WITHOUT local anesthetic is injected.
*Allows motor function to remain active.
*Called Walking epidural.
*Patient has less urinary retention.
COMBINED SPINAL EPIDURAL
Regional Analgesia/Anesthesia During Labor and birth
involves the use of an indwelling epidural catheter with an infusion of medication and a programmed pump that allows the patient to control dosing.
Patient-controlled epidural ANALGESIA
Regional Analgesia/Anesthesia During Labor and birth
local infiltration involves the injection of a local anesthetic (lidocaine) into the superficial perineal nerves to numb the perineal area.
Local Infiltration
Regional Analgesia/Anesthesia During Labor and birth
provides long-lasting perineal analgesia.
Pudendal Nerve Block
Regional Analgesia/Anesthesia During Labor and birth
*Pain management injection of an anesthetic agent with or without opioids into the subarachnoid space to provide pain relief during Labor of Cesarean Birth.
*Used for decades.
Intrathecal (spinal) analgesia
Type of Anesthesia for Emergency cesarean birth or woman with contraindication to use of regional anesthesia
General Anesthesia
Obstetrics guidelines recommend neuraxial anesthesia for Cesarean Births for most women. Neuraxial meaning (spinal anesthesia which is a local anesthesia is placed directly in the intrathecal space)
General Anesthesia is administered by
iv injections
inhalation
or both.
General Anesthesia Common FIRST STEP is
Thiopental IV to produce unconsciousness
**Thiopental IV=barbiturate used to induce general anesthesia. **
General Anesthesia SECOND STEP is
Next, muscle relaxant
General Anesthesia THIRD STEP
INTUBATION
GENERAL ANESTHESIA Final step
followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia
Myths and Misconceptions About Children and Pain
- Newborns don’t feel pain
- Exposure to pain at an early age has little or no effect later
- Infants and small children have little memory of pain
- Intensity of the child’s reaction to pain indicates intensity of pain
- A child who is sleeping or playing is not in pain
- Children are truthful when asked if they are in pain
- Children learn to adapt to pain and painful procedures
- Children experience more adverse effects of narcotic analgesics than adults do
- Children are more prone to addiction to narcotic analgesics
Indicators of Pain in Infants include
behavioral and physiologic
Indicators of Pain in Infants:
Behavioral examples include.
- Facial expressions
- body movements
- crying
- increased irritability
- refusal to move injured body part
- interrupted sleep
Indicators of Pain in Infants:
PHYSIOLOGIC examples include.
- Changes in heart rate
- respiratory rate
- oxygen saturation levels
- vagal tone
- plantar or palmar sweating
Using Age-Appropriate Language to Assess Pain in Older Children:
For Toddlers:
are likely to understand words such as “owie” or “boo-boo”
Using Age-Appropriate Language to Assess Pain in Older Children:
For Preschoolers:
may need to be coaxed to discuss their pain as they feel it is something to be expected
Using Age-Appropriate Language to Assess Pain in Older Children:
For School age children:
can usually report type, location, and severity because of their well-developed language skills
Using Age-Appropriate Language to Assess Pain in Older Children:
For Teens:
concern about body image and fear of losing control may result in denying pain or refusing medication
Name 4 Factors Affecting Children’s Responses to Pain
- Type of pain
- Extent of pain
- Age/developmental level
- Cultural/family norms surrounding expression of pain
Key Principles of Pain Assessment
Use QUESTT
- Question the child
- Use a reliable and valid pain scale
- Evaluate the child’s behavior and physiologic changes to establish a baseline and determine the effectiveness of the intervention
- Secure the parent’s involvement
- Take the cause of pain into account when intervening
- Take action
Health History Data Related to Pain Assessment
Location, quality, severity, and onset of the pain, as well as the circumstances in which the child experiences the pain.
Conditions, if any, that preceded the onset of pain and conditions that followed the onset of pain
Any measures that increase or decrease the pain
Any associated symptoms, such as weight loss, fever, vomiting, or diarrhea, that may indicate a current illness
Any recent trauma, including any interventions that were used in an attempt to relieve the pain
Name 5 Pediatric PAIN Assessment Tools
- FACES pain rating scale (ages 3+, emoticon-like faces)
- Oucher pain rating scale (ages 3+, actual photos of children, must know number values)
- Poker chip tool ( ages 3+, uses 1 to 4 poker chips to describe pain)
- Visual analog and numeric scales (ages 5+, scales of 0–10)
- Adolescent pediatric pain tool (ages 8 to 15, measures pain location, intensity, and quality)
NAME 6 Pediatric Physiologic and Behavioral Pain Assessment Tools
- Premature Infant Pain Profile
- Neonatal Infant Pain Scale
3 Riley Infant Pain Scale - Pain Observation Scale for Young Children
- CRIES Scale for Neonatal Postoperative Pain Assessment
6.FLACC Behavioral Scale for Postoperative pain in young Children
2 Techniques for Pain Management
- Nonpharmacologic
- Pharmacologic
Examples of Nonpharmacologic
Relaxation, distraction, guided imagery, massage
Examples of Pharmacologic
Analgesics, patient-controlled analgesia, local analgesia, epidural analgesia, conscious sedation
Biophysical Interventions for Pain Management
3 examples
- Nonnutritive sucking with sucrose (infants or toddlers)
- Heat and cold applications
- Massage and pressure
3 types of Medications Used for Pain Management
- Analgesics
- Nonopioid and opioids - Adjuvant (used to ENHANCE effects of pain meds)
- Benzodiazepines
- Anticonvulsants - Anesthetics
Preferred routes for medications used for PAIN.
- Oral, rectal, intravenous, topical, or local nerve block routes
- Epidural administration and moderate sedation also can be used
Nurse’s Role in Pharmacologic Pain Management
- Adhering to the rights of medication administration
- Knowledge about the drug’s pharmacokinetics and pharmacodynamics
- Assessment is crucial and ongoing
- Monitor physiologic parameters:
a. level of consciousness
b. vital signs
c. oxygen saturation levels
d. urinary output
e. monitor for signs of adverse effects (respiratory depression) - Assess the child’s and parents’ emotional status
- Teach the child and parent’s about the drug
Common Adverse Events Associated With Use of Opioid Medications
Name 3
Constipation
Pruritus
Nausea and vomiting
Required Interventions When a Child Is Receiving Moderate (Conscious) Sedation
- Moderate sedation is a medically controlled state of depressed consciousness
- Ensuring that emergency equipment is readily available
- Maintaining a patent airway
- Monitoring the child’s level of consciousness and responsiveness
- Assessing the child’s vital signs (especially pulse rate, heart rate, blood pressure, and respiratory rate)
- Monitoring oxygen saturation levels
Nurse’s Role in Managing Procedure-Related Pain
- Use topical anesthetic at site of a skin or vessel puncture
- Use nonpharmacologic strategies for pain relief - first.
- Prepare child/family ahead of time about the procedure
- Use therapeutic hugging to secure the child
- Use the SMALLEST-gauge needle possible
- Use intermittent infusion device or PICC for multiple samples
- Opt for venipuncture in newborns instead of heel sticks if large amount needed
- Use kangaroo care for newborns before and after heel stick
- Provide nonnutritive sucking before the procedure
Nurse’s Role in Managing Chronic Pain
- Similar to that for the child experiencing acute pain or procedure-related pain
- Assessment of the child’s pain is key
- Onset, duration, intensity, and location of pain
- Alleviating or exacerbating factors
- Impact on child’s daily life
- Effect on child and family’s stress level
- Methods used to alleviate pain (including home remedies or alternative therapies)
- Physical examination - Multiple nonpharmacologic and pharmacologic strategies combined to provide pain relief
