Pain Management

Question 1

Type of Pain Based Off Duration: Acute

Answer 1

• Duration: <3 mo
• Signs:
  
  • ↑ HR
  • ↑ BP
  • ↑ RR
  • Guarding
  • Facial grimacing
  • Nausea
• Examples: diverticulitis, burn wounds, etc.

Question 2

Type of Pain Based Off Duration: Chronic

Answer 2

• Duration: > 3 mo
• Signs:
  
  • Fatigue
  • Insomnia
  • Anorexia
  • Weight loss
  • Apathy
  • Hopelessness
  • Depression
  • Anger
• Examples: arthritis, neuropathy, etc.

Question 3

Type of Pain Based Off Duration: Breakthrough

Answer 3

• Sudden spike in acute pain when pain had been under control and at comfortable lvl
• Controlled pain w/ transient increase in pain

Question 4

Mechanisms of Pain: Nociceptive

Answer 4

• Nociceptive: type of nerve that report to brain there’s any pain going on
• Somatic: sharp, throbbing, well-localized
  
  • Comes from bones, joints, muscle, skin, connective tissue
  • Ie. fractures
• Visceral: achy, localized/diffused, intermittent
  
  • Comes from visceral organs like GI tract
  • Ie. diverticulities

Question 5

Mechanisms of Pain: Neuropathic

Answer 5

• Neuropathic: injury to nerves themselves
• Peripheral: prickling, pins/needles, burning, numbness/tingling
  
  • Ie. diabetic peripheral neuropathy

Question 6

If someone is clearly in severe pain, limit OLDCART to just →

Answer 6

• Severity
• Location
• Characteristics

Question 7

For Pts Unable to Report Pain, Use What?

Answer 7

• Use objective assessment → assess risk factors + do thorough head-to-toe assessment
• Look for any areas that may be causing pain

Question 8

Multimodal approach

Answer 8

• using 2 or more meds w/ different actions to control pain rather than 1 large dose of one med to lessen side-effects of any one med

Question 9

What do we need to remember about med administration and time?

Answer 9

• We’re trying to prevent spikes and pain so ⇒ give meds around the clock (ATC) instead of PRN basis as much as possible
• Scheduled 0900 and 2100

Question 10

Non-Opioids for Mild-Moderate (4-7/10) Nociceptive Pain

Answer 10

• Acetaminophen
• NSAIDs Ibuprofen & Aspirin

Question 11

Acetaminophen (tablet/IV)

Answer 11

• Max dose: 4 g/24 hrs
  
  • If pt has liver disease → 2 g/24 hrs
• Adverse effects: hepatotoxicity
• Early signs:
  
  • NV
  • Diaphoresis
  • RUQ Pain
  • ↑ AST/ALT
• Late signs
  
  • ↑↑ RUQ Pain
  • ↑↑ AST/ALT
  • Jaundice
  • Dark-colored urine

Question 12

NSAID: Ibuprofen

Answer 12

• Max Rx Strength Dose: 3200 mg/24 hrs
• Adverse effects:
  
  • GI irritation
  • Nausea
  • Abd pain
  • Bleeding risk
  • Gastric ulcers/Upper GI bleeding
  • Hematemesis
  • Black, tarry stools
• Monitor labs:
  
  • Platelets: If ↓ ⇒ hold med
  • Bleeding times (PT/INR, PTT): If PT, INR, PTT ↑ ⇒ hold med
  • H & H

Question 13

NSAID: Aspirin

Answer 13

• Max Dose: 4 g/ 24 hrs
• Rarely given in acute care as PRN
• Not typically given on a PRN basis bc of its antiplatelet aggregation properties
• Adverse effects:
  
  • GI irritation
  • Gastric ulcers/Upper GI bleeding
  • Inhibits platelet aggregation (clot formation) → ↑ risk of bleeding
• Monitor labs:
  
  • Platelets
  • Bleeding times (PT, INR, PTT)
  • H & H

Question 14

Opioids for Moderate-Severe Pain (7/8-10)

Answer 14

• Common opioids: Hydrocodone, Morphine, Fentanyl, Oxycodone
• Dosing: use lowest effective dose
• Opioid-naive & older adults → “start low & go slow”
• Adverse effects:
  
  • Sedation (DLOC, lethargic, etc.) → respiratory depression (↓ RR & depth)
    
    • Remember: sedation usually comes BEFORE respiratory depression !!!
  • Constipation → always consider bowel regimen
• Antidote: Naloxone (Narcan)
• Available as nasal spray, subcut/IM/IV

Question 15

Adjuvants for Neuropathic/ Chronic Pain

Answer 15

• Anticonvulsant: Gabapentin
  
  • Adverse effects:
    
    • Drowsiness
    • Dizziness
    • ↓ LOC
• Corticosteroid: Prednisone:
  
  • Adverse effects:
    
    • ↑ blood glucose
    • Delayed healing
    • Cutaneous atrophy (thinning of skin)
  • Don’t stop abruptly bc steroids work as negative feedback so if you stop then your body goes into adrenal insufficiency