Pain Assessment & Management Flashcards
1
Q
Chronic pain affects more Americans than _________________.
A
DM, Cancer, Heart Disease
2
Q
Who is pain unaddressed and inappropriately addressed in?
A
Females & minorities
3
Q
Multi-modal approach for pain
A
Ketamine therapy, holistic options (PT, acupuncture), anti-depressants, CBD, mushrooms
4
Q
How can we make a difference in pre-op w/ pain management?
A
- Pre-op Meds
- Pain management plan
*they need to understand our goal is to make their pain manageable
5
Q
What pain medication can we give patients who are physiologically unstable?
A
Ketamine
-give a sub-dissociative dose
-0.2-0.3mg/kg
6
Q
Psychosocial contributor to pain
A
Financial stress, impaired sleep, anxiety
7
Q
Where did opioid safety concerns arise from?
A
Overuse, overprescribing, driven by money
-street drugs: fentanyl & synthetics
8
Q
Balance w/ Pain Management
A
- Balance safe opioid/analgesia prescribing
- High-risk pt. Recognition
- Be mindful of different types of pain, individual pain factors, and comorbidities
9
Q
Pts responses to pain may be related to _______________.
A
- Genetics
- Age, gender, ethnicity
- Socioeconomic and psychiatric factors
- Catastrophizing
- Culture, religion
- Previous experiences
- Pt perceptions & expectations
10
Q
Patient perceptions
A
- Perceived effective communication w/ physicians and nurses
- Perceived responsiveness by the treating team
- Perceived empathy by the treating team
11
Q
Ultra-rapid metabolizers
A
- Convert codeine more rapidly to morphine
*potential for Supra-therapeutic dosing
12
Q
Slow metabolizers
A
- Don’t metabolize codeine - never reach therapeutic levels
13
Q
Concern drugs w/ genetic polymorphisms
A
- Muscle relaxants & analgesics
-worry about pts who metabolize muscle relaxants quickly
14
Q
Genetic metabolism in African Americans & Caucasians
A
Equal populations of fast and slow metabolizers
15
Q
Asian/Native American Genetic metabolism
A
- 90% fast metabolizers
16
Q
Gender & Pain
A
- Females display more sensitivity & express their pain more frequently and effective
- Males: more exaggerative
17
Q
Ethnicity & pain
A
- Can be r/t disease process
-sickle cell patients
18
Q
Causes of whole body pain
A
- Fibromyalgia
- Depression
- Vascular issues
- DM
- Spinal injuries
*pain in one leg: DVT
19
Q
Socioeconomic and psychiatric factors r/t pain
A
- Rural areas & lower socioeconomic status - report higher levels of pain
- Previous pain experiences: alters activity in certain brain regions responsible for pain processing
- Mood disorders/psych disorders: development of chronic pain
20
Q
What is pain catastrophizing?
A
Exaggerative cognitive response to an anticipated or actual painful stimulus
-affects how individuals experience & express pain
21
Q
Ex of catastrophizing: magnification
A
- Response that symptoms can be or are greater than expected
“I’m afraid something serious might happen” - What we can do:
-pre-op versed
-precedex
22
Q
Rumination
A
- Individual focuses repeatedly on attributes of an event that evoke a negative emotional response
-fixated on 1 thing
23
Q
Helplessness
A
Belief that there is nothing anyone can do to improve a bad situation
“There is nothing I can do to reduce the intensity of my pain”
24
Q
Culture/religion r/t pain
A
- How pts cope can be influenced by their support system
-cultural/religious ties: better support
-variations in cultural norms: influence how people express pain/expect it to be managed
25
Nociceptive Pain Definition
Direct tissue injury from noxious stimuli
-somatic/visceral
-1st trigger
26
Clinical Examples of Nociceptive Pain
bone fractures, fresh surgical incision, fresh burn
27
Treatment options for nociceptive pain
may include both opiate & non-opiate medications depending on injury
28
Inflammatory Pain
Result of increased inflammatory mediators that control nociceptive input & released @ sites of tissue inflammation
29
Clinical Examples of inflammatory pain
late stages of burn healing, neuritis, arthritis, appendicitis, inflammatory bowel disease
30
Treatment options for inflammatory pain
anti-inflammatory agents
31
Neuropathic pain
1. Result of injury to nerves leading to an alteration in sensory transmission
32
Clinical Examples of Neuropathic pain
Diabetic neuropathy, peripheral neuropathic pain, post-herpetic neuralgia, chemo pain
33
Treatment options for neuropathic pain
tricyclic, SNRIs, gabapentinoids, antidepressants
34
Idiopathic pain
cause unknown
35
Clinical Examples of idiopathic pain
chronic back pain w/o preceding trauma or obvious inciting event
36
Treatment options for idiopathic pain
Difficult to adequately address pain, underlying etiology unknown, especially in emergencies
37
Somatic Pain
A-delta fiber activity in peripheral tissues
-Injury to skin, muscle, bone, joint, connective tissue, deep tissue pain
-musculoskeletal pain
-pain well localized, sharp, worse w/ movement
38
Clinical Examples of Somatic pain
superficial lacerations, superficial burns, superficial abscesses, fractures, pelvic pain
39
Treatment options for somatic pain
topical/LA, opiates, non-opiates
40
Visceral Pain
C-fiber activity - Internal pain, occurs from internal organs or tissues that support them
-poorly localized, vague deep aches, colicky, cramping
41
Clinical Examples of visceral pain
Appendicitis, peptic ulcer disease, diverticulitis, endometriosis, ureteral stones, uterine fibroid pain, pyelonephritis, biliary colic
42
Treatment options for visceral pain
opiates, systemic pain control, nerve blocks, mobilizing
43
things we do that cause visceral pain
1. Opioids
2. Constipation
44
Acute Pain
<3mos.
Should resolve w/ normal healing
-EX: post-op pain, fracture bones, appendicitis, crush injuries, L&D pain
45
Treatment options for acute pain
opiates, non-opiates
46
Chronic pain
> 3 months
-extends beyond time of normal wound healing
-development of neurophysiological changes int he CNS
-EX: low back pain, neck pain, chronic pancreatitis, fibromyalgia
47
Treatment options for chronic pain
depends on the nature of the pain
48
Acute on chronic:
Time of acute exacerbations of a chronic painful syndrome or new acute pain in a person suffering from a chronic conditions
-EX: sickle cell exacerbation, cancer, RA, abscess in sickle cell pt.
49
Causes of flare-ups w/ sickle cell:
Dehydration, increased metabolic demands (exercise), stress
50
Pain Intensity
Subjective data, based on pain score and history/physical
51
Essential elements to pain assessment
1. detailed history of current pain
2. previous pain history
52
Basics of Pain Assessment
1. Onset: sudden/gradual
2. aggravating & alleviating factors: what makes it better/worse?
3. Quality: ask if the pt. can describe it
4. location: does it radiate?
5. Severity: pain scale
6. Circumstances: when did the pain start?
53
Assessing functionality & Pain
can they work? are they on light duty?
Are they coping w/ the pain?
54
Why are tumors problematic for pain?
1. cause neuropathic pain
2. cause inflammatory pain
3. involve bone, vessels, nerves, and organs
4. cause HA, seizures, constipation, abdominal pain 4. cause
55
Procedures r/t cancer that are painful
1. biopsies (skin, bone marrow) - somatic/visceral
2. radiation, surgery, chemo
56
What shows up on a UDS?
1. cocaine
2. opioids/BZDs
3. amphetamines
4. marijuana
5. codeine
*fent patches do not (synthetic), street fentanyl does not
57
Pain control for port access
LA, EMLA cream, lidocaine cream
58
Pain assessment in intubated ICU patients
1. assess v/s - HTN, tachycardia
2. visual distress
3. consider nerve blocks
59
Pain management for Herpes Zoster (shingles)
1. lidocaine patches
2. gabapentin
3. tx underlying condition - antiviral
60
Migraine pain management
1. R/O stroke, bleed, and red-flag signs
2. tx migraine
61
OPQRST
O: onset - what were they doing? sudden/gradual
P: provocation & palliation - better or worse w/ activity/positioning/adjuvant (what meds? heat? ice?)
Q: Quality - ask pt. to describe it
R: region/radiation - referred/localized
S: severity - pain scale
T: timing - when did it start? how long has it been going on? has it happened before?
62
SOCRATES
Site
Onset
Character
Radiation
Associations
Time course
Exacerbating/relieving factors
Severity
63
What populations is assessing pain challenging in?
1. age
2. level of development
3. communication skills/language
4. cognitive skills
5. prior pain experience 6. associated beliefs
64
physical exam: appearance
1. obese/emaciated
2. histrionic: exaggerated, dramatic
3. flat affect
65
physical exam: posture
1. splinting
2. scoliosis/kyphosis
66
Pain physical exam: gait
1. antalgic: limp
2. hemiparetic
3. assistive devices
67
Pain physical exam: facial expression
1. grimacing
2. tense
3. diaphoretic
4. anxious
68
pain physical exam: v/s
1. SNS overactivity
2. temp asymmetry
69
Pain: inspection
1. skin: color changes, hair loss, flushing, goose bumps, sweating
2. muscle: atrophy/spasm
3. edema
70
Pain: palpation
1. demarcation of painful area
2. detection of changes in pain intensity in the area
3. trigger points
4. changes in sensory/pain processing
71
Pain: MS systems
1. flaccidity: paralysis
2. abnormal movements: neuro damage, impaired proprioception
3. limited ROM: disc disease, arthritis, pain
72
Pain: neuro exam
1. cranial nerve exam
2. motor strength
3. spinal nerve function: DTRs, pinprick, proprioception
4. Coordination: Romberg's test, toe-heel, finger to nose
73
Pt. cues: position of comfort
1. give meds before you move them
2. ketamine - pain relief & cooperative
3. induce on the stretcher/bed
74
Pt. cues: psychological
1. skin flushing, diaphoresis
2. vocalizations
3. facial expressions
4. body posture/movement
5. motor response
*baseline mental status: can they communicate w/ you?
75
Issues w/ pain scales
1. they are subjective
2. don't take into account:
-genetics, past experiences, comorbidities, other influences
76
What can be the best pain intensity indicator besides a pain scale?
Patient functionality
77
Diff. options for pain scales
1. numeric rating scale
2. FACES
3. critical care observation tool
4. neonatal infant pain scale
5. FLACC
78
What pain meds may work better in non-opioid naive patients?
PO XR opioids instead of IV
-they get to steady state
79
Pediatric Tylenol dose
15mg/kg
-PO q4-6h
-max: 90mg/kg/d
80
Pharmacologic Order of meds for non-opioid naive patients
1. Tylenol
2. celebrex
3. gabapentin
4. opioid
81
What concerns do we have w/ Toradol?
Bleeding from altering platelet function
-less of a risk now b/c we use lower doses (15-30mg)
82
Who are nebulized medications benefical in?
1. asthmatic kids
2. if they don't have an IV
*can also give intranasal
83
Nebulized Ketamine Benefits - adult
1. bronchodilator
2. works topically: sore throat, awake intubation
84
Lidocaine Nebulized
Used for awake fiberoptic/glidoscope
85
Ketamine effects:
1. pt. dissociates
2. analgesia
3. bronchodilator
4. drooling - give a drying agent (bendaryl, glycopyrrolate)
86
What med do we not want to give w/ Ketamine?
Atropine - they both cause tachycardiaD
87
Dose differences w/ Ketamine
1. low dose: sub-dissociative
2. high dose: calming people, emergence delirium
88
Ketamine Pharmacology
1. blockade NMDA, peripheral Na+ channels, and Mu opioid receptors
2. provides sedation, amnesia, analgesia
3. retrograde amnesia
4. highly lipid soluble - crosses BBB fast - peak 1min.
89
Intranasal medications
Ketamine, Fent, versed, lidocaine, precedex
90
Intranasal administration
1. use concentrated solution
-Ketamine: 50mg/mL
-fent: 50mcg/mL
-Versed: 5mg/mL
-Precedex: 200mcg/2mL
2. use an atomizer
-if >1mL divide b/w nares
-spray toward turbinates/pinna
91
Benefits of non-pharmacological pain interventions:
1. improve assessment
2. decrease/avoid opioids & anxiolytics
3. decrease time/recovery for procedures
4. decrease adverse events
92
Painting analogy
1. non-pharmacologic interventions as the primer/base coat
2. analgesic tx as the paint
93
Examples of non-pharmacological pain interventions
1. preparation, education
2. distraction: music/TV, toys
3. Relaxation: breathing, meditation
4. Training/Coaching
5. positioning
6. pressure/massage
7. heat/ice/splinting
94
What is one of the most common mistakes in pain management?
failure to reassess in timely manner
-30min after IV
-60min after PO
*also monitor for resp. depression
95
consequences of unrelieved acute pain
1. psychological
-PTSD
-anxiety
-catastrophizing
-depression
2. chronic pain syndromes
3. increased M&M
-increased O2 demand
-increased metabolic rate
-CV/pulmonary complications
-impaired immune function
96
Chronic pain syndrome
1. viscous cycle
2. affects sleep, mood, activity, energy level
3. physiological & psychological effects
97
Why do we avoid opioids on pts?
1. n/v, constipation, resp. depression
2. make sure the receiving team knows why
3. communicate w/ hospitalist & surgeon for d/c planning
98
Things to consider when d/c patients w/ pain
1. safety: can they get home? are they ambulatory? lethargy?
2. will the pt be able to obtain their meds?
-cost, supply
3. clear & easy to understand instructions
99
Why is pain management during transition important ?
1. reduces return visits
2. reduces progression to chronic pain
100
How long does it take for acute pain to be reduced?
4-6wks
*most painful time for pt - 1st 12-48hrs
101
Car w/ 4 flat tires analogy
1. medications only pump 1 tire
2. other options:
-biofeedback
-PT
-counseling
-pacing
-nutritional guidance
-support group
*patient actively participates in
102
PDMP
prescription drug monitoring program
-drug monitoring log
-integrated system: pharmacies, providers
