Pain Flashcards
1
Q
Types of Comfort
A
- Physical: bodily sensations and homeostatic mechanisms
- Psychospiritual: individual awareness of oneself and one’s relationship to a higher being
- Sociocultural: family and societal relationships
- Environmental comfort: external surroundings
2
Q
Comfort
A
- Increases patient satisfaction with shorter hospital days (pain relief, reduced stress, and healing environment)
- Maintains normal vital signs
- Provides for adequate sleep and nutrition
- Provides a sense of control
3
Q
The Sensory Experience
A
Requires:
- An experience that is received through the sense organs
- An intact CNS
- Stimuli that reaches appropriate brain center for perception of the stimuli to take place
4
Q
The Stimuli
A
- External: visual, auditory, olfactory, tactile, gustatory
- Internal: gustatory, visceral, kinesthetic
5
Q
Components of Stimuli Transmission/Sensory Experience
A
- Reception: receiving of stimuli or data
- Perception: the conscious organization and translation of the stimuli/data into meaningful information
- Reaction: response to the stimuli/data
6
Q
Sensory Alterations
A
Sensory deprivation:
- A decrease or lack of meaningful stimuli
- Pts become more aware of remaining stimuli
- Alters perception, cognition, and emotion
7
Q
S&S Sensory Deprivation
A
- Yawning
- Drowsy, sleepy
- Decreased attention span
- Disorientation
- Nocturnal confusion (sun-downing)
- Apathy
- Hallucinations, Delusions
8
Q
Sensory Overload
A
inability to process or manage the amount/intensity of sensory stimuli
3 factors:
-internal stimuli
- external stimuli
- inability to disregard stimuli selectively
9
Q
S&S Sensory Overload
A
-irritability
-disorientation
(periodic/general)
- fatigue, sleeplessness
- reduced problem-solving ability
- scattered attention
- increased muscle tension
10
Q
Those at risk for Sensory Deprivation
A
- confinement in a non-stimulating environment in a home or facility
- impaired vision/hearing
- mobility restrictions (para or quadriplegic)
- communicable diseases (AIDS)
11
Q
Those are risk for Sensory Overload
A
- pain/discomfort
- ICU’s with IVs, tubes, machines, overhead pages, disruptions
12
Q
Factors influencing sensory function
A
- Developmental
- Medications
- Cultural
- Stress
- Pre-existing illnesses
- Lifestyle & Personality
- Smoking
13
Q
What is Pain
A
- whatever the patient experiencing the pain says it is, whenever the patient says it is, and for as long as the patient says it exists
- subjective, unpleasant sensation caused by noxious stimulation of sensory nerve endings
- A sensation in which a person experiences discomfort due to irritation of sensory nerves
14
Q
Pain Characteristics
A
- very complex and individualized
- ranges from minor to severely debilitating
- impact one’s quality of life
- major reason people seek healthcare
15
Q
Function of Pain
A
- Warning system
- Aids in locating and diagnosing a problem
- Serves as a measure of effectiveness of treatments
- initiates the fight/flight mechanism
16
Q
Nurse’s Role in The Pain Process
A
- Assessing: pain scale, site, intensity
- Communicating: findings to others (MD, NP, PA)
- Assuring: adequate relief
- Evaluating: effectiveness of interventions
17
Q
Consequences of Untreated Pain
A
- unnecessary suffering
- physical and psychosocial dysfunction
- increased respiratory and cardiac workload
- impaired recovery
- immunosuppression
- sleep disturbances
- decreased GI motility
- Increased catabolism
- increased morbidity
18
Q
Physiology of Pain Perception
A
Nociceptors:
-primary sensory neurons
-detect tissue
injury/damage
-evoke the sensations of: touch, heat, cold, pain, pressure
19
Q
Processes of Nociception
A
- Transduction: conversion of a stimulus into a neural action potential (mechanical, thermal, chemical)
- Transmission: movement of the painful impulse to the brain
Substance P is the believed neurotransmitter to be responsible for pain transmission up the cord - Perception: pain is recognized, defined, and responded to. Dependent upon the pain and its site
- Modulation: The “descending” system. Neurons send signals down the spinal column to release various substances. Inhibition of the nociceptive ascending impusles
20
Q
Types of Nerve Fibers
A
- “A” Fibers: Myelinated, fatty covering, sharp, pricking, localized pain
- “C” Fibers: Unmyelinated, no fatty sheath, dull, burning, diffuse pain, aching
21
Q
Interactional Responses to Pain
A
- Physiologic: stimulus transmission
- Sensory: recognition, pattern, area, intensity, nature
- Affective: motivational, fear, anger, depression, anxiety
- Behavioral: observable actions, facial expressions, guarding, crying
- Cognitive: beliefs, attitudes, memories, and meaning attributed to pain
22
Q
Sources of Pain
A
- Physiological
- Psychological
- Environmental
23
Q
Physiological Pain Types
A
Types:
-Mechanical: Tearing (kidney stone), Pressure (edema), Infection, muscle spasm
- Thermal: Electrical currents, sunburn, lightning
- Chemical: histamines, enzymes, prostaglandins, Caustic Agents (lye)
24
Q
Physiological Effects of Pain
A
- Dilation of bronchi
- Increase RR and HR
- Peripheral vasoconstriction (pallor, elevated BP)
- Elevated Glucose
- Diaphoresis (sweating)
- increased muscle tension
- decreased GI motility
25
Decompensated Physiological Effects of Pain
- Rapid, irregular breathing
- N/V
- Weakness
- Exhaustion
26
Physiological Variables
- body image
- personality
- previous experiences
- pain trajectory
- Anticipatory pain
- pain control
- anxiety
27
Increased Tolerance: Physiological effects of pain
- happy, contented, actively involved
| - experiences little discomfort from moderate pain
28
Increased Perception: Physiological effects of pain
- depressed, loneliness, anger, bored
| - concentrates on pain more
29
Psychological Sources of Pain
-Intrapersonal: stress, coping, cultural, ethnic
30
Environmental Sources of Pain
-Extrapersonal: occupational noises
31
Environmental Variables
Night: Increases pain perception
Day: Decreases pain perception
32
Sociocultural Variables
- Demos
- Support Systems
- Social Roles
- Culture: pain expression, drug use, pain-related beliefs, coping
- Cognitive style: high achievers, high intelligence
- Cultural: affects ones attitudes and beliefs
- Attitudes & Values: Gives meaning to pain
- Sex: Females are more expressive
- Birth Order: First born usually less tolerant to pain
33
Sociocultural Effects of Pain
- Depends on past experiences: inability to cope if none
- Depends on ones value system: personal weakness, deserved punishment
- Cultural Variables
34
Developmental Variable
Age:
- Younger: Fearful, Unfamiliar experience
- Older: Experienced (know what to expect)
35
Spiritual Variable
- Persons with deep religious faith have higher pain tolerance
- Affects attitudes and beliefs
36
Endorphins
- Natural supply of opium-like substances
- Endogenous Morphine
- "morphine within"
- Produces analgesia, inhibits pain perception
- Activated by stress and pain
- Located in the brain, spinal cord, and GI tract
37
Pain Transmission Theory
Gate Control Theory:
- Peripheral nerve fibers can be altered at the spinal cord level
- Synapses in the dorsal horn act as gates
- Backrubs (touch), warm compresses (temp), TENS, & distraction CLOSE the gates
38
Which statement is true?
1. Psychogenic pain is not real.
2. Regular administration of analgesics will not cause dependency.
3. Tolerance to analgesics means a person has become addicted.
4. The amount of tissue damage will describe the amount of pain associated with it.
2. Regular administration of analgesics will not cause dependency.
39
Common Biases & Misconceptions
- Pts with minor illnesses have less pain than those with severe illnesses
- Administering analgesics regularly will lead to drug addiction
- The amount of tissue damage in an injury accurately indicates the amount of pain
- Psychogenic pain in not real
- Drug abusers and alcoholics over-react to pain
- Health care personnel are the best authorities on the nature of the client's pain
40
Tolerance
A "neuroadaptive" mechanism characterized by decreasing effects of a drug at a constant dose or the need for higher doses to maintain an effect
41
Pain Threshold
The point at which a person first perceives the pain
42
At Risk Population for Pain
- Pre-op patients
- Patients preparing for childbirth
- Patients with altered internal or external integrity
- Clients with localized area of inflammation
43
Nursing History
- Client Interview: Most important
- full description of characteristics of pain
- pain trajectory
- client's response
- variable affecting the pain
- assessment of previous records regarding pain
44
Nursing Assessment
- Location
- Type
- Intensity
- Quality
- Duration
- Control
- Nonverbal & physiological expressions
- Verbalization of fears and expectations
45
Pain Intensity
Verbal scales: 0-10 & Wong-Baker FACES
ANVPS: Adult non-verbal pain scale
DVPRS: Defense and Veterans Pain Rating Scale (0-10 and faces)
RASS: Richmond Agitation-Sedation Scale
46
Behavioral Cues during Physical Assessment
- Nonverbal: facial grimacing, guarding position, clinched teeth/fist, crying, moaning
- Physiological: Increased HR, RR, BP, Diaphoresis, Increased muscle tension
47
Acute vs. Chronic
- Rapid vs Sudden
- External agent or disease process vs unknown or ineffective treatment
- Mild to severe vs Difficult to evaluate
- Up to 6 months and diminishes with time vs prolonged
- Can ID the pain areas vs difficult to distinguish pain from non-pain
- self-limited or readily corrected vs continuous or intermittent
- suffering decreases over time vs suffering usually increases over time
- Action is to relieve the pain vs modify the pain experience
- Prognosis eventually complete relief vs complete relief not usually possible
- Tx: Analgesics vs Opioids
48
Chronic Pain
considered a specific disease
- treated at pain clinics or as in-patients
- types: intractable, benign, or persistent
49
Intractable pain
having no relief
50
Benign pain
no known disease or injury
51
Persistent
does not subside after injury heals
52
Chronic Pain Management
- Lasts more than 6 months
- Nerve blocks, epidurals
- Acupuncture
- Biofeedback: alteration of body function through mental concentration
- TENS
- Hypnosis
- Neurosurgery
- Operant conditioning
53
Neurosurgery
- neurectomy
- rhizotomy
- chordomtomy
54
TENS
Transcutaneous Electric Nerve Stimulation (TENS)
- Stimulates Endorphin Production
- Battery transmitter, wires and electrodes attached to the skin at pain point
- Turned on when pain felt
- Produces buzzing/tingling sensation
- Nerve function not damaged
- Study: Greater pain relief than narcotics
55
Operant Conditioning
Reward and Praise for "pain work"
56
Hypnosis
- alters the perception of pain
- works through positive suggestions made to the subconscious
- used when pain is aggravated by stress and tension
57
Nursing Diagnoses for pain
- Altered Comfort
- Knowledge Deficit
- Ineffective Coping
58
Altered Comfort Nursing Diagnoses
- interventions that explore methods to alleviate pain for the client
- Criteria for evaluation:
- pain is minimized, controlled or relieved
- Ability to resume ADL's
- Uninterrupted sleep
- Patient report
59
Knowledge Deficit
- assess what is known
- explain cause of pain
- include family members
Criteria for Evaluation:
-client is aware of precipitating factors
-can verbalize methods for relief
60
Ineffective Coping
- determine how client dealt with pain in the past
- Meet psychological needs
- Be non-judgmental and accepting
Criteria for Evaluation:
- client identifies coping patterns
- verbalizes fears associated with pain
61
The best indicator for evaluation of a client’s pain is:
1) The amount of pain medication asked for and taken.
2) The use of a pain scale.
3) The client’s verbal report of pain.
4) An increasing amount of medication required to relieve pain.
3) The client’s verbal report of pain.
62
Nonpharm Techniques for Pain Control
- Distraction
- Progressive relaxation techniques
- Promote rest
- Cutaneous stimulation
- Guided imagery
- Therapeutic touch
63
Distraction
painful stimuli is inhibited through excessive meaningful sensory input
attention is directed away from the pain to other stimuli in the environment
64
Progressive relaxation techniques
contraction and relaxation of muscle groups in a systematic way
begins with face and ends at the feet
65
Promote Rest
- client becomes fatgued and exhausted
- usual rest and sleep pattern
- decrease the number of interruptions
- admin mild sedation
- maintain a quiet environment
- offer warm, non-caffeinated drink before sleep
- provide rest periods during the day
66
Cutaneous Stimulation
-interferes with pain perception by lightly rubbing the affected area
- backrubs
- massage
- apply heat or cold packs
67
Guided Imagery
purposeful use of one's imagination in a specific way to achieve relaxation and control
68
Therapeutic Touch
- mechanism not understood
| - works for some, but not all
69
Basic Principles of Pain Management
- patient must be believed
- patient deserves adequate pain management
- treatment must be based on the patient's goals
- treatment plan should include combinations of drug and nondrug therapies
- multidisciplinary approach should be used
- ongoing evaluation to ensure patient goals are being met
- prevention of drug side effects are managed
- patient/family teaching is the cornerstone of the treatment plan
70
WHO
World Health Organization
The analgesic ladder
71
The Analgesic Ladder
Step 1: ASA, Acetaminophen, NSAID's
Step 2: Codeine, Oxycodone
Step 3: Morphine, Hydromorphone, Methadone
72
Step 1
ASA, Acetaminophen, NSAID's
- Mild pain (1-3 pain score)
- nonopioid analgesics & Adjuvant drugs
ACTION: "Ceiling effect", do not produce tolerance/dependence, available without a prescription
73
Step 2
Codeine, Oxycodone
- Mild to moderate pain (4-6 pain score)
- persistent pain despite Nonopioid therapy
- use of opioids with adjuvant drugs
74
Common opioids (Combined with nonopioid)
Codeine --> Tylenol #3
Hydrocodone --> Vicodin
Oxycodone --> Darvon
75
Step 3
Morphine, Hydrocodone, Methadone
- Moderate to severe pain (7-10 pain score)
- Opioids with Step 1 & Adjuvant Drugs (Morphine, Fetanyl, Hydromorphone, Methadone, Oxycodone)
- More potent, No "ceiling effect", dose limiting side effects
76
Adjuvant Therapy
- enhance pain therapy by 3 mechanisms
| - used at all steps of the analgesia ladder
77
3 Mechanisms of Adjuvant Therapy
1. enhance the effects of opioid & non-opioids
2. possess analgesic properties
3. counteracts the side effects of analgesics
78
Antidepressant Adjuvant Therapy
- prevent cellular reuptake of seratonin & norepinephrine
- inhibit the transmission of nociceptive signals
- Elavil, Sinequan, Tofranil PM, Paxil, Zoloft, Prozac
79
Antiseizure Agents Adjuvant Therapy
- stablize neuron membrane & prevent transmission
| - Neurontin, Tegretol, Klonopin
80
a2 Adrenergic Agonists Adjuvant Therapy
- possibly effect modulation and transmission
| - Catapres (Clonidine)
81
Corticosteroids Adjuvant Therapy
- ability to decrease edema & inflammation
| - Decadron & Medrol
82
Local Anethetics Adjuvant Therapy
- interrupt transmission of pain signals
| - Given oral, parenteral, & topical
83
Placebos
any medication or treatment that produces an effect because of its intent and not its physical properties
- requires a physician's order
- most frequent types are 9% NS and sugar pills
- increases endorphin levels
- decreases pain perception
- create a psychological sense of pain relief (psychogenic effect)
84
Nursing Interventions for Placebos
- explain its intent to relieve pain when administered
- administer as if it was a medication
- do not use as a form of punishment
- not to be used to prove the client is or not in pain or addicted
85
Aspirin
Acetylsalicylic Acid (ASA)
- most frequently used OTC drug
- May cause GI bleeding, epigastric distress, tinnitus
- contains anticoagulation properties
86
Tylenol
Acetaminophen
- similar to ASA, but NO ANTICOAGULATION OR ANTI-INFLAMMATORY PROPERTIES
- no epigastric distress
87
NSAID's
Nonsteriodal Anti-inflammatory Agents
- anti-inflammatory
- antipyretic
- inhibits an enzyme key to the formation of prostaglandins
- may cause GI disturbance
- Ibuprofen (Motrin)
88
Narcotics & Opiates
- Opium Alkaloids (Morphine Sulfate & Codeine)
- Synthetic (Meperidine)
- Modify perception and reaction to pain
- Used in severe pain
- Respiratory depression, major side effect
89
Morphine Sulfate
PO, IM, SQ, IV
90
Meperidine HCL
Demerol
PO, IM, or IV
91
Codeine
PO, SL
92
Oxycodone
Percocet, Percodan, Oxycontin
PO
93
Fetanyl
Siblimaze
IM, IV, Transmucosal
94
Oral Route of Administration
- route of choice
- less expensive
- oral dose > IM due to first-pass effect
95
Sublingual & Buccal Route of Administration
- Under the tongue
- Absorbed directly into systemic circulation
- Avoids first-pass effect
96
Intranasal Route of Administration
- Enters highly vascular mucosa
- Few on the market
- For Acute HA & other intense, recurrent pain
97
Rectal Route of Administration
- Useful if unable to take PO
- Suppository form
- Very effective
98
Transdermal Route of Administration
- Absorption is slow
- Most common: Fentanyl & Lidoderm
- Creams & Lotions: Aspercreme, Myoflexcream
- Ointments, Gels, Liniments, Balms: OTC products, usually strong hot/cold sensation, skin testing advisable
99
Parenteral Route of Administration
- SQ, IM, IV
- Single, repeated, & continuous dosing
- IM NOT recommended
- SQ administration is slow
- IV best route (immediate analgesia, rapid titration, continuous infusion for steady analgesia)
100
Intraspinal Delivery Route of Administration
- Epidural & Intrathecal
- intermittent bolus or continuous infusion
- surgically implanted for long term use
- highly potent drugs due to closeness to receptors
- smaller doses required
- Morphine, Fentanyl, Hydromorphone, Clonidine
101
Intraspinal Complications
- Catheter dislodgment/migration, noted by decreased pain control
- Neurotoxicity caused by many preservatives
- Infection. Rare but serious. Acute bacterial infection (Meningitis)
102
PCA Pump
- computerized pump activated by the patient
- timer permits the patient to have a certain amount of medication per minute and hour (lockout period)
- Can run as a continuous infusion (basal rate)
103
Advantages of PCA pump
- fewer post-op complication
- less total analgesic
- great sense of control
- earlier ambulation
104
How will you see PCA pump med orders
1/6/10 or 2/1/6/12
(1mg, q 6 mins, for a total of 10mg per hour)
or
(2mg basal, 1mg, q 5 mins, for a total of 10mg per hour)
105
Continuous IV Infusion Pump
- Provides for steady level of narcotic analgesia
- Ambulatory infusion pumps
- system the size of a radio transmitter
- worn in a pouch on the belt
- Narcotics may lead to addiction when administered over long periods of time (1% of 12,000 clients in one study)
106
Documentation
- Always include patients subjective description of pain
- Pain scale
- Always include location of pain
- Type of pain
- Medication given
- Effectiveness of the pain medication
107
The most effective route of administration for pain medication is...
IV
