Pain Flashcards
Pain
Universal, complex personal experience
Pain is inadequately treated in all health care settings
One major reason people seek health care
Nurses have a central role in assessment and management
Populations at highest risk for inadequate pain control:
Older adults
Substance abusers
Those whose primary language differs from that of the health care professional
Definitions of Pain
Unpleasant sensory/emotional experience associated with actual or potential tissue damage
Whatever person experiencing it says it is; exists whenever person says it does
Self-report always most reliable indication of pain
Types of Pain
Acute pain
Short-lived
Results from sudden, accidental trauma; surgery; ischemia; inflammation
Chronic (persistent) pain-More than 3 months
Cancer pain
Non-cancer pain
Acute Pain
Major distinction from chronic pain is the effect on biologic responses
Acts as warning sign
Activation of sympathetic nervous system
“Fight-or-flight” reactions
Acute Pain Responses
Increased heart rate
Increased blood pressure
Increased respiratory rate
Dilated pupils
Sweating
Chronic (Persistent) Pain
Persists or recurs for indefinite period (more than 3 months)
Onset is gradual
Character and quality can change over time
Can result in emotional, financial, and relationship burdens, as well as depression/hopelessness
Categorization of Pain by Underlying Mechanisms
Nociceptive pain
Somatic-
Visceral
Neuropathic pain
Nociceptive Pain
Damage to somatic or visceral tissue
Surgical incision, broken bone, or arthritis
Usually responsive to opioids and nonopioid medications
Somatic Pain
Superficial or deep
Localized
Arises from bone, joint, muscle, skin, or connective tissue
Visceral Pain
Tumor involvement or obstruction
Arises from internal organs such as the intestine and bladder
Neuropathic Pain
Damage to peripheral nerve or CNS-Neurontin
Numbing, hot-burning, shooting, stabbing, or electrical in nature
Sudden, intense, short-lived, or lingering
Pain Transmission
Painful stimuli often originate in extremities
If pain is not transmitted to the brain, person feels no pain
Two specific fibers transmit periphery pain:
A delta fibers
C fibers
Pain Assessment
Patient’s self-report is “gold standard” for pain existence and intensity assessment
Nurse’s role
Accept patient self-report
Serve as advocate
Act promptly to relieve pain
Respect values and preferences of patient
Location
Intensity
Quality
Onset and duration
Aggravating and relieving factors
Effect of pain on function and quality of life
Comfort-function outcomes
Patient’s acceptable level of pain
Areas of Referred Pain
What is breakthrough pain?
Beyond the treated pain
Transient, moderate to severe
Occurs beyond treated pain
Usually rapid onset and brief duration with variable frequency and intensity
What is End-of-dose failure
Dosage is not holding patient such as fentanyl patch good for 72 hours. Stops working after 48 hours
Associated symptoms of Pain
Can worsen pain
Anxiety
Fatigue
Depression
Psychosocial Assessment
All pain holds unique meaning for the
person experiencing it
Remain objective; advocate for proper pain control
Ask open-ended questions
Pain Reassessment
Critical to reassess at appropriate intervals, guided by
Pain severity
Physical and psychosocial condition
Type of intervention
Risks of adverse effects- IE- opioids check resp
Institutional policy
Assessment Challenges
Patients who cannot self-report pain are at highest risk for undertreated pain
Hierarchy of Pain Measures
Checklist of Nonverbal Pain Indicators (CNPI)
Pain Assessment in Advanced Dementia Scale (PAINAD)- Used a lot
CPOT-Critical care pain tool
Pharmacologic Management of Pain
Analgesic agents are first-line therapy
Individualized treatment plan based on comprehensive assessment
Clarify desired outcomes
Discuss options and preferences with patient and family
Re-evaluate as needed
Pharmacologic Management of Pain
Three categories of medications
Nonopioid- Tylenol, NSAIDS,
Opioid
Adjuvant
Nonopioids
Analgesic ceiling
Increasing dose above upper limit produces no greater analgesia.
Do not produce tolerance or addiction
Many are OTC.
Aspirin and other salicylates (Trilisate)
Acetaminophen
NSAIDs
Some NSAIDs are equal to aspirin.
Others have better efficacy
Decrease production of pain –sensitizing chemicals .
Side effects include GI problems, renal insufficiency, and hypertension.
Pharmacologic Management of Pain Epidural and PCA
Multimodal analgesia
Preemptive analgesia
Multiple routes of administration-
epidural-Respiratory depression, constipation, URINARY RETENTION
Around-the-clock dosing
Patient-controlled analgesia (PCA)-Respiratory status-double sign when handing off patient
Analgesics by Classification: Non-Opioids Health Teaching
Ask about use of non-opioids
Clarify brand names vs. over-the-counter names
Inform patients about combination products containing non-opioids
Advise not to exceed safe maximum daily dose due to adverse side effects
Full or mu agonists
Morphine, fentanyl, hydromorphone, oxycodone, hydrocodone
Mixed agonists antagonists
Butorphanol, nalbuphine
Partial agonists
Buprenorphine
Physical Dependence, Tolerance, and Addiction
Physical dependence: Normal response
Tolerance: Normal response
Opioid addiction: Chronic neurologic and biologic disease
Pseudoaddiction: Mistaken diagnosis of addictive disease
Side Effects of Opioids
Constipation
Urinary retention
Nausea
Vomiting
Pruritus
Sedation
Respiratory depression (less common, most feared)
Adjuvant Analgesics
Anticonvulsants and antidepressants
Local anesthetics
Considerations for Older Adults: Opioids
Start with low doses and titrate slowly
Systematic assessment of patient response
Teach caregivers measures to reduce falls and accidents
Home safety assessment is recommended
Nonpharmacologic Interventions
Should be used to complement, not replace, pharmacologic therapies
Physical modalities
Cognitive-behavioral strategies
Physical Interventions
Physical therapy
Occupational therapy
Aquatherapy
Functional restoration-Patients with chronic conditions and are improving in the ADL type skills
Acupuncture
Low-impact exercise such as walking or yoga
Cutaneous stimulation – for example, TENS
Cognitive/Behavioral Strategies
Prayer
Relaxation breathing
Artwork
Meditation
Hypnosis
Virtual reality
Community-Based Care
Home care management
Self-management education
Health care resources
The patient is receiving the first dose of an opioid analgesic for pain. The nurse expects the patient will also be ordered a(n):
Antacid agent
Anti-anxiety agent
Laxative or stool softener
Breakthrough pain reliever
Which patient would benefit most from the use of a patient-controlled analgesia pump?
75-year-old woman with confusion who is in the last stages of the dying process
15-year-old girl who is recovering from a head injury from an automobile accident
42-year-old man who is mentally alert and is recovering from a fractured femur
60-year-old man who is mentally alert and is experiencing left-sided weakness after a stroke
