Pain Management Flashcards
1
Q
Visceral pain: associated with
A
internal organs
2
Q
Visceral pain: sensitivity
A
can be different depending on organ
3
Q
Visceral pain: internal organs: not sensitive to pain
A
lack nociceptors may withstand great deal of damage without causing pain spleen kidney pancreas
4
Q
Visceral pain: internal organs: sensitive to pain
A
significant pain from even slightest damage stomach bladder ureters
5
Q
Visceral pain: area
A
poorly defined area
6
Q
Visceral pain: capable of
A
referring pain to other remote locations away from area of injury
7
Q
Visceral pain: description
A
squeezing cramping deep ache within the internal organs
8
Q
Visceral pain: pt c/o
A
generalized “sick” feeling nausea and vomiting
9
Q
Visceral pain: treatment
A
opioids
10
Q
Neuropathic pain: results from
A
injury to nervous system
11
Q
Neuropathic pain:injury to nervous system from
A
cancer cells compressing nerves or spinal cord actual cancerous invasion into the nerves or spinal cord chemical damage to nerves caused by chemo and radiation diabetes alcohol trauma nerualgias illness affecting neural path: centrally or peripherally
12
Q
Neuropathic pain: damaged nerves
A
unable to carry information
13
Q
Neuropathic pain: damaged nerves: pain
A
severe distinct pain messages
14
Q
Neuropathic pain: damaged nerves: relay pain
A
long after the original cause of the pain is resolved
15
Q
Neuropathic pain: description
A
sharp shooting burning shocking tingling electrical in nature
16
Q
Neuropathic pain: travel
A
length of nerve path from spine to distal body part such as hand, or down buttocks to foot
17
Q
Neuropathic pain: ineffective treatement
A
NSAIDs opioids
18
Q
Neuropathic pain: opioids: adjuvants
A
adjutants may enhance the therapeutic effect of opioids
19
Q
Neuropathic pain: treatment
A
nerve blocks
20
Q
Pain assessment: sources
A
gathered from a variety observations interviews with patient and family medical records
21
Q
Pain: remember
A
subjective and personal
22
Q
Pain level: definition
A
whatever the patient says it is
23
Q
Pain assessment
A
location duration or length onset or when it begins intensity per pain scales
24
Q
Pain: influeneces
A
psychological social spiritual
25
Pain: helpful in defining pain
behavioral assessments psychological assessments subjective assessments physical demeanor vital signs
26
Pain: best assesment
patient's own report all other information is assessed as supporting this report
27
Pain: physical s/s: vital signs
systolic blood pressure heart rate respiration
28
Pain: physical s/s
vital signs muscle groups posturing verbalization facial expressions
29
Pain: physical s/s: muscle groups
tightness or tension may be felt in major muscle groups Posturing can also occur: guard areas of body, curl around themselves in a "fetal" position, hold only certain body portions rigid
30
Pain: physical s/s: verbalization
calling out increased volume in speech moaning
31
Pain: physical s/s: facial expression
flat affect grimacing distraction from surroundings
32
Somatic pain: definition
refers to messages from pain receptors located in the cutaneous of musculoskeletal tissues
33
Deep somatic pain
occurs withing the musculoskeletal tissue
34
Deep somatic pain: origin
metastasizing cancers
35
Surface somatic pain
concentrated in dermis and cutaneous layers
36
Surface somatic pain: origin
surgical incision
37
Deep somatic pain: description
dull throbbing ache well focused on area of trauma
38
Deep somatic pain: treatment
responds well to opioids
39
Surface somatic pain:description
sharper than deep somatic pain burning or pricking sensation directly focused on injury
40
Classification of pain
nociceptive pain neuropathic pain
41
Nociceptive pain: two types
visceral somatic
42
Nociceptive pain: definition
umbrella term for pain caused by stimulation of neuroreceptor
43
Nociceptive pain: stmiulation
direct result of tissue injury
44
Nociceptive pain: 4 stages
transduction transmission modulation perception
45
Nociceptive pain: 4 stages: transduction
a change occurs
46
Nociceptive pain: 4 stages: transmission
impulse transferred along the neural path
47
Nociceptive pain: 4 stages: modulation/translation
of the signal
48
Nociceptive pain: 4 stages: perception
by patient
49
Nociceptive pain: severity of pain
is proportionate to extent of injury
50
Nociceptive pain: somatic: location
cutaneous tissues bone joints muscle tissue
51
Nociceptive pain: visceral: location
internal organs protected by a layer of viscera respiratory gastrointestinal genitourinary
52
Nociceptive pain: visceral, somatic: treatment
both types are treatable with opioids
53
Addiction: definition
primary and constant, neuro-biologic disease with genetic, psycho-social and environment factors that create an obsessive and irrational need or preoccupation with a substance
54
Addiction: behaviors
unrestricted, continued cravings compulsive and persistent use of a drug despite harmful experiences and S/E
55
Pseudo-addiction: definition
assumption patient is addicted to a substance when in actuality patient is not experiencing relief from medication
56
Pseudo-addiction: pain
prolonged, unrelieved pain maybe result of under-treatment
57
Pseudo-addiction: under-treatment
lead patient to become more aggressive in seeking medicated relief resulting in "drug seeker" label
58
Pain: experience
90% or all advanced disease patient will experience some level of pain
59
Pain: hospice philiosophy
relief of pain provision for comfort measures for all patients who desire to improve quality of life
60
Pain: patient's right
to accept or refuse treatment for pain
61
Pain: communication
assume patient was experiencing pain, will continue to even in an unconscious state
62
Pain: non-verbal patient: assessment data
changes in assessment data provide supporting information for continued pain assessments in non-verbal patients
63
Pain: unidimensional tools for pain assessment
Numeric rating scale (NRS) Visual analog scale (VAS) Categorical scales
64
Pain: numeric scale
most widely known rate pain 0-10; 0-5 0= no pain; highest number = worst
65
Pain: visual analog scale
line marked on one end for no pain, other end for most severe patient indicates where he feels pain is line then measured to indicated point and scored
66
Pain: categorical scales
verbal response visual response
67
Pain: categorical scales: verbal
mild discomforting distressing horrible excruciating
68
Pain: categorical scales: visual
Faces Pain Scale, Wong-Baker Faces various facial expressions to choose from
69
Pain: contolling pain with meds
does not shorten or extend life span
70
Pain: most common med for severe pain
opioids
71
Pain: common opioid choice
methadone safe inexpensive
72
Pain: meds: concerns of family
addiction S/E tolerance to pain-reducing effects
73
Pain: opioids: concern
addiction is rare respiratory depression concern when patient first introduced
74
Pain: opioids: respiratory depression
problem when first introduced overcome as body becomes use to opioid
75
Pain: opioids: tolerance
can occur
76
Pain: opioids: assessments
made to avoid under-dosing, which can cause pain to become out of control and unmanageable
77
oxycodone
synthetic formulation long-acting opioid moderate to severe pain
78
oxycodone: S/E
lightheadedness dizziness sedation nausea constipation pruritus
79
oxycodone: pain relief ratio
similar to morphine possibility of less nausea
80
oxycodone: extended-release
cannot be cut or crushed for administration
81
oxycodone: use cautiously
hypothyroidism Addison disease urethral stricture prostatic hypertrophy lung or liver disease
82
hydromorphone: route
tablets liquid suppository parenteral formulations
83
hydromorphone: advantage
synthetic used for patients with morphine allergy
84
hydromorphone: helpful
when significant S/E have occured in past or pain has been inadquately controlled with other medications
85
hydromorphone: useful for controling
cough
86
hydromorphone: serious S/E
neurotoxicity may occur myoclonus: brief, involuntary twitching of a muscle hyperalgesia: increased sensitivity to pain seizures
87
hydromorphone: use cautiously
kidney disease prostatic hypertrophy urinary problems
88
hydromorphone: common side effects
dizziness lightheadedness drowsiness upset stomach if taken without food vomiting
89
Breakthrough pain: 3 types
Incident Pain Spontaneous Pain End-of-Dose Failure
90
Breakthrough pain: incident pain
tied to a specific event, such as dressing change or physical therapy
91
Breakthrough pain: incident pain: treatment
rapid-onset, short-acting analgesic just prior to painful event
92
Breakthrough pain: spontaneous pain
unpredictable and can't be pinpointed to a relationship with any certain time or event no way to anticipate spontaneous pain
93
Breakthrough pain: spontaneous pain: neuropathic pain
adjuvant therapy may be useful
94
Breakthrough pain: spontaneous pain: treatment
rapid-onset, short acting analgesic is used
95
Breakthrough pain: end-of-dose failure
pain that specifically occurs at the end of a routine analgesic dosing cycle when medication blood levels begin to taper off
96
Breakthrough pain: end-of-dose failure: treatment
may indicate an increased dose tolerance and need for medication dose alterations
97
QUESTT pediatric pain assessment tool
Q = question U = use assessment tools E = evaluate S = secure T = take cause of pain into consideration T = take action to treat pain
98
QUESTT pediatric pain assessment tool: Q
question both the child an parent about the pain experience
99
QUESTT pediatric pain assessment tool: U
use assessment tools and rating scales that are appropriate to the developmental stage and situation and understanding of the child
100
QUESTT pediatric pain assessment tool: E
evaluate the patient for both behavioral and physiological changes
101
QUESTT pediatric pain assessment tool: S
secrue the parent's participatoin in all stages of the pain evaluation and treatment process
102
QUESTT pediatric pain assessment tool: T
take the cause of the pain into consideration during the evaluation and choice of treatment methods
103
QUESTT pediatric pain assessment tool: T
take action to treat the pain appropriately, and then evaluate the results on a regular basis
104
ABCDE pain assessment
A = ask regularly B = believe patient C = choose appropriate pain control D = deliver pain relief E = empower patient
105
ABCDE pain assessment: A
ask regularly and consistently use same systematic approach every time pain is assessed
106
ABCDE pain assessment: B
believe patient's report of pain and how it is best relieved
107
ABCDE pain assessment: C
Choose appropriate pain control options according to the needs of the patient, family and setting
108
ABCDE pain assessment: D
deliver pain relief in a timely, consistent and coordinated manner
109
ABCDE pain assessment: E
empower patient and family with information and an active voice in their care Care and pain relief should always be patient driven
110
Myoclonus: definition
presents as sudden, uncontrollable, nonrhythmic jerking of the extremities
111
Mycolonus: jerking
can be induced by tapping on the affected muscle group
112
Myoclonus: critical
early identification and rapid treatment
113
Myoclonus: for patient
can be exhausting
114
Myoclonus: can progress towards
severe neurological dysfunction seizures
115
Myoclonus: main cause
result of opioids given in high doses, particularly in patients with renal failure
116
Myoclonus: other causes
brain surgery intrathecal catheter placement AIDS dementia hypoxia
117
Nocturnal myoclonus: definition
nonrhythmic jerking of the extremities just prior to sleep
118
Nocturnal myoclonus: preceds
common preceds opioid-induced myoclonus
119
Myoclonus: treatment
opioid rotation use of adjuvants to reduce amount of opioid needed
120
Physical dependence: defiinition
condition of bodily adaptation to the presence of a specific drug or chemical
121
Physical dependence: removal of drug
or rapid reduction in dosage will result in withdrawal symptoms
122
Physical dependence: s/s
does not present with psychological and environmental dependence
123
Addiction: s/s
psychological and environmental dependence obsessive and irrational need or preoccupation with a substance unrestricted continued cravings compulsive and persistent use of a drug despite harmful experiences and S/E
124
Tolerance: defintion
adaptation of the body to continued exposure to a drug or chemical
125
Tolerance: effects of drug
at the same level of exposure are minimized over time
126
Tolerance: dosing
additional dosing is required to maintain the same outcomes
127
Pseudo-tolerance
misguided perception of health care provider that a patient's need for increasing doses of a drug is due to the development of tolerance when in reality disease progression or other factors are responsible
128
Multidimensional tools for pain
Initial Pain Assessment Tool Brief Pain Inventory McGill Pain Questionnaire
129
Initial Pain Assessment Tool
specific to initial patient evaluation assesses characteristic of pain, patient's manner of expressing pain, and effects of pain on quality of life
130
Initial Pain Assessment Tool: diagram
used to indicate pain locations and a scale rates pain intensity
131
Brief Pain Inventory
meant to quickly identify pain intensity and related restrictions series of questions about pain over 24 hours location, intensity, quality of life, type and patient's response to treatments
132
McGill Pain Questionnaire
assesses pain on three levels identifying words selected by patient to describe their pain can be used with other tools both long and shotr forms
133
McGill Pain Questionnaire: three levels of assessment
sensory affective evaluative
134
nociceptors: definition
primary neurons, or sensory receptors,responding to stimulus in skin, muscle and joints, as well as stomach bladder and uterus.
135
nociceptors: neurons
specialized responses for: mechanical stimuli thermal stimuli chemical stimuli
136
nociceptors: neuron stimulation
result of direct tissue injury
137
nociceptors: 4 stages
transduction transmission modulation perceptoin
138
nociceptors: 4 stages: transduction
where a change occurs
139
nociceptors: 4 stages: transmission
where impulse is transferred along the neural path
140
nociceptors: 4 stages: modulation
or translation of signal
141
nociceptors: 4 stages:perception
perception of pain by patient
142
nociceptors: injury
nociceptors initiate process that begins depolarization of peripheral nerve
143
nociceptors: axons
A or C A carry pain messages faster thatn C mesage fast
144
nociceptors: message
passes along the neural pathway and creates a perception of pain
145
Schedule II drugs: disposal law
should be discarded by nurse or medical professional who is responsible for medication management at the time of death of a patient i
146
Schedule II drugs: time of medication waste
needs to occur as soon after the death as reasonable and needs to be witnessed and verified by a second qualified individual
147
Schedule II drugs: disposal: belong to
drugs have been paid for as part of patient's care, so they do not belong to hospice of palliative care program
148
Schedule II drugs: disposal: pharmacy stock
can't be returned to pharmacy stock because there is no guarantee medications have not been altered
149
: benefits
anti-inflammatory analgesic antipyretic
150
NSAIDS use: first line defense against
pain caused by inflammatory conditions
151
NSAIDS use: opioids adjuvuncts
used in conjunction with opioid therapy to reduce amount of opioid needed
152
NSAIDS use: disadvantage
GI bleeding or ulceration decreased renal function impaired platelet aggregation
153
NSAIDS use: therapeutic effects
may not extend beyond 6-12 months of use
154
NSAIDS use: increased risk
short-term memory loss may occur in older patients increased cardiovascular risk with prolonged use
155
NSAIDS use: allergy
patients allergic to sulfa drugs can also experience a cross-sensitivity to some types of NSAIDS
156
Pain assessment: JACHO: core principle
All patients have right to appropriate assessment and management of pain
157
Pain assessment: JACHO: caregivers
should encourage all patients to report pain and follow through with pain-relieving treatments
158
Pain assessment: JACHO: assessment
must be appropriate for patient and address all aspects of pain
159
Pain assessment: JACHO: family
should be included in assessment process
160
Pain assessment: JACHO: most accurate indicator
patient's own description always subjective clinician should accept and respect patient's report
161
Pain assessment: JACHO: individual pain
unique dependent on many contributing factors: heredity energy level coping skills prior experiences
162
Pain assessment: JACHO: physiological and behavioral observatins
should not replace information obtained directly from patient when it can be communicated Pain can be present w/o physiological evidence or cause
163
Pain assessment: JACHO: chronic pain
can create an overall lower threshold of tolerance for pain and other stimuli
164
Pain assessment: JACHO: unrelieved pain
has adverse effects on all aspects of patient's life
165
Perception: importance
to assess and treat all aspects of patient's pain
166
Unrelieved pain
has adverse effects on all aspects of patient's life
167
Pain does not occur in
isolation
168
Pain intensity
individual perception based on physical, psychological, social and spiritual factofs
169
Pain can be present
without a known or visible cause
170
Patient's total pain: contributing factors
heredity energy level coping skills support systems prior experiences tissue damage other physical influences
171
Pain: other symptoms and concerns
experience by patient compounds the suffering associated with pain
172
Pain: chronic
can create an overall lower threshold of tolerance for pain and other stimnuli
173
Non drug therapies
cognitive-behavioral techniques physical measures
174
Cognitive-behavioral therapies: used to
improve coping and relaxation techniques
175
Cognitive-behavioral therapies: examples
guided imagery hypnosis biofeedback distraction with music or humor prayer or other spiritual routines simple exercises rest breathing exercises meditation patient education about nature and causes
176
Patient education about nature and causes of pain
can help patients feel more in control and less anxious in dealing with pain
177
Physical measures of pain relief: examples
heat and cold massage reflexology acupuncture chiropractic transcutaneous electrical nerve stimulation (TENS)
178
Physical measures of pain relief: refractory pain
nerve blocks cordotomy (surgical option)
179
Substandard pain assessment: causes
nurses fail to recognize importance of full pain assessment interpersonal factors failure in healthcare system
180
Substandard pain assessment: failure to recognize importance
result of inadequate knowledge perceived lack of time necessary therefore given low prioirty
181
Substandard pain assessment: interpersonal factors
inability to establish rapport or empathize with patient personal prejudice and bias
182
Substandard pain assessment: failure in healthcare system
lack of provider accountability policies criteria availability of pain assessment tools
183
Last hours of life
assessment of pain continues in last hours of life medication adjusted accordingly
184
Last hours of life: pain level
pain does not necessarily increase as death approaches
185
Last hours of life: unconscious state
it can be assumed if pain was present prior to loss of consciousness it will continue in patient's unconscious state should be assessed and treated
186
Last hours of life: research
has confirmed administering opioids at end of life does not hasten nor prolong dying process patient's prior medication regimen should be continued
187
Last hours of life: medication regimen: adjustments
made in consideration of reduced renal or hepatic clearance
188
Last hours of life: route
needs to be assessed for appropriateness and adjusted as needed loss of consciousness inability to swallow
189
Ketamine: pain crisis: treatment
initial bolus: 0.1 mg/kg IV if no improvement 5 minutes later, second bolus: double dosage may be repeated as needed
190
Ketamine: pain crisis: boluses
should be followed by decrease in patient's current opioid use by 50% and infusion of ketamine
191
Ketamine: pain crisis: infusion dose
0.015 mg/kg/min or 1 mg/min for a 70 kg person
192
Ketamine: pain crisis: no IV access
subcutaneous 0.3 - 0.5 mg/kg
193
Ketamine: pain crisis: concurrent treatment
benzodiazepines: prevent hallucinations or frightful dreams
194
Ketamine: pain crisis: observe for
increased secretions
195
Ketamine: pain crisis: secretions treatment
glycopyrrolate scopolamine atropine
196
Subjective nature of pain
patient my inadvertently sabotage attempts at a full pain assessment and subsequent treatment
197
Lack or rapport with nurse might create
patient unwilling to communicate extent of pain fear he will be seen as a "bother" or drug seeker
198
If patient's attitude is fatalistic
might feel pain is inevitable and must be tolerated may feel treatments will be ineffective may lack understanding about effective treatment methods
199
Barriers for effective pain assessment
cultural religious age-related effective communication skills unfounded beliefs about pain and treatment
200
Opioid analgesic therapy
widely used method of chronic pain control
201
Opioid analgesic therapy: IM
last resort except in presence of a "pain emergency" rare since it can be given SubQ
202
Opioid analgesic therapy: trans-dermal and transmucosal
by pass eternal route optimal for continuous pain control effective for eliminating breakthrough pain
203
Opioid analgesic therapy: changing from one opioid to another, or alternating delivery method
may be necessary because of incomplete cross-tolerance among opioids occurs
204
Opioid analgesic therapy: changing analgesics or method of delivery
may result in a decreased ddrug requirement
205
Opioid analgesic therapy: morphine equivalents
use morphine equivalents as common factor for all dose conversionsn
206
Opioid analgesic therapy: morphine equivalents
reduce medication errors
207
Opioid analgesic therapy: S/E
sedation constipation nausea myoclonus
208
Effective pain control begins with
initial evaluation
209
Goal of palliative care
bring pain that is not well controlled withing patient's own comfort level within the first 48 hours
210
Pain after 48 hours of initial assessment
should be maintained within patient's own comfort level with provisions for breakthrough pain episodes and changes in overall pain llevels
211
Pain out of control
should be managed by active intervention within a predetermined time limit
212
Mission of palliative care
to improve overall quality of patient's life
213
No patient should
face death or die in presence of uncontrolled pain
214
Adverse effects
should be treated in timely manner
215
Should be taken into account with every prescription
individual patient's needs costs practicality convenience
216
Guideline to improve quality pain managemnt
prescription monitor patient status frequently and adjust analgesics around-the-clock- pain relief immediate-release options avoid mixing agonist-antagonist opioids monitor for drug-drug and drug disease interactions manage S/E be familiar with pain experts in care community
217
Adjust analgesics based on
patient's goals results of full pain assessments including needs for supplemental analgesics, sleep, emotions and quality-of-life factors
218
Around the clock pain relief
provided in form of sustained-release options consistent dosing schedules
219
Immediate release options
provided for breakthrough pain
220
Avoid mixing
agonist-antagonist opiioids
221
Monitor and manage
drug-drug interactions drug-disease interactions manage known S/E
222
Be familiar with
additional resources of pain management experts in care community make referrals as needed when pain cannot be adequately controlled
223
Pain documentation
initial assessment patient's goals and expectations current analgesic routine bodily functions interdisciplinary progress notes pain treatments related pain factors patient teaching interventions adverse effects
224
Pain documentation: initial comprehensive pain assessment
current pain management regimen patient's past experience with pain and its control
225
Pain documentation: patient goals and expectations
should be addressed
226
Pain documentation: current analgesic routine
should be addressed with any concerns regarding drugs in use
227
Pain documentation: bodily fucntions
affected by medications are to be reviewed, including bowels, balance and other quality of life issues
228
Pain documentation: interdisciplinary progress notes
recurrent pain assessments with baseline pain scores breakthrough pain episodes timing severity related causes treatments
229
Pain documentation: pain treatments
non-pharmacological timing results
230
Pain documentation: related pain factors
sleep activity levels social interaction mood
231
Pain documentation: patient teaching interventions
described and evaluated for effectiveness
232
Pain documentation: adverse effects
changes in bowel functions sedation nausea vomiting
233
Pain crisis: assess for
change in mechanism or location of pain
234
Pain crisis: differentiate between
terminal anxiety or agitation and physical causes of pain
235
Pain crisis: begin with
a rapid increase in opioid treatment
236
Pain crisis: unresponsive to opioid titration
switching to benzodiazepines may produce response
237
Pain crisis: benzodiazepines
diazepam lorazepam
238
Pain crisis: unresponsive to benzodiazepines
assess for drug absorption
239
Pain crisis: invasive routes
generally avoided unless necessary only guaranteed route of drug delivery is IV
240
Pain crisis: any question about absorption
appropriate to establish parenteral access
241
Pain crisis: IM
last resort
242
Pain crisis: resources exhausted
seek pain management consultation as quickly as possible
243
Pain crisis: alternative methods of terminal pain control
radiotherapy anesthetic or neuroabliatve procedures
244
Addiction challenges: important
to choose a long-acting opioid that can facilitate around the clock dosing and minimize need for short-term medications used for "breakthrough" doses
245
Addiction challenges: short-term medication
should be very limited or eliminated entirely i possible
246
Addiction challenges: non-drug adjuvants
use whenever possible: relaxation techniques distraction biofeedback TNS therapeutic communication
247
Addiction challenges: short term medication
non-opioid is best
248
Addiction challenges: limit
amount of medication available to patient at any given time
249
Addiction challenges: monitor
for compliance with pill counts urine toxicology screens referral to addictions specialist
250
Neuropathic Pain Scale
way to assess and provide information about specific types and degrees of sensations experience by patients living with neuropathic pain
251
Neuropathic Pain Scale: 8 common qualities of neuropathic pain
sharp dull hot cold sensitive itchy deep surface
252
Neuropathic Pain Scale: rate each sensation
on a number scale from 0 to 10 10 is worst imaginable sensation
253
Adjuvant: definition
complimentary treatment used in an effort to reduce and supplement current pharmacological responses
254
Adjuvant: pain control use
reduce amount of medication enhance overall analgesic effects
255
Adjuvant: pharmacological choices
antidepressants anticonvulsants corticosteroids
256
Adjuvant: nonpharmacologic
meditation hot or cold application acupuncture
257
meperidine
opioid analgesic
258
meperidine: use
American Pain Society strongly discourage use of, especially in long-term palliative care setting
259
meperidine: analgesic effect
does not have a long-lasting analgesic effect only last 2-3 hours
260
meperidine: repeated doses
may lead to CNS toxicity result of ineffective metabolite clearance
261
meperidine: renal insufficiency
patients with are unable to excrete byproduct of meperidine from system
262
meperidine: accumulation of by product
called normeperidine results in chronic muscle twitching or new-onset seizures
263
meperidine: metabolities
linked to increase in pain perception and intensity
264
Normeperidine: toxicity
not easily reversed does not respond to naloxone
265
Morphine: advantage
no ceiling dose different forms of administration used as equivalency standard for other opioids
266
Morphine: no ceiling dose
as tolerance incrases or disease progresses dose can be graually incrased to an infintie level
267
Morphine: different forms of administration
IV, IM, immediate release, sustained release, long-acting, liquid oral preparations, and suppositories
268
Morphine: S/E
sedation respiratory depression itching nausea chronic spasms or twitching of muscle groups constipation
269
Morphine: constipation
experienced by all patients receiving opioids should be planned for and treated aggressively
270
Morphine: hallucinations
common when morphine is initiated
271
Morphine: after first few days
most patients will overcome respiratory depression, nausea, itching and extreme sedation
272
Conscious sedation: definition
a minimally depressed state of awareness in which patient maintains ability to respond appropriately to verbal and physical stimulus and commands
273
Conscious sedation: patients capable of
maintaining their own airways, as well as continuing to protect themselves with reflexive responses
274
Conscious sedation: maintained with
analgesics and sedatives in order to perform various medical and surgical procedures
275
Conscious sedation: procedure
must be used with precaution in order to prevent loss of consciousness
276
Conscious sedation:equipment for emergency
airway management resuscitation medications for sedation reversal
277
Conscious sedation: medications for sedation reversal
naloxone benzodiazepines
278
ketorolac: classification
NSAID
279
ketorolac: use
analgesic antipyretic anti-inflammatory
280
ketorolac: action
inhibits synthesis of prostaglandins within body
281
ketorolac: therapeutic use time frame
short-term therapy of 5 days of less
282
ketorolac: route
oral IM ophthalmic solutions
283
ketorolac: ophthalmic solution
effective in treating: general eye pain irritation r/t seasonal allergies
284
ketorolac: contraindictated
renal disease
285
ketorolac: S/E
edema hypertension rash nausea constipation diarrhea vomiting drowsiness dizziness headache
286
ketorolac: serious risk factors
stomach ulceration bleeding perforation renal damage hemorhage
287
Pediatric patient: pain assessment:
consider chronological and developmental age of child parameters identify underlying cause of pain any non-pharmacological measures methods for pharmacological interventions is child able to speak
288
Pediatric patient: chronological and developmental age of child
help determine which measure the child might use to express pain, as well as treatments
289
Pediatric pain: parameters
presence of and parameters surrounding chronic illness, as well as neurologicla impariment
290
Pediatric pain: pharmacological interventions
weight of child in kilograms determines appropriate dosages of medications
291
Pediatric pain: is child able to speak?
speak same language ? any barriers to communication or pain relief measures?
292
Medications: neuropathic pain
anticonvulsants anesthetics antidepressants
293
Medications: neuropathic pain: dosing
as needed, but most require consistent dosing with 24-hour symptom control
294
Medications: neuropathic pain: examples
amitriptyline nortriptyline duloxetine gabapentin topical lidocaine opioids pregabalin
295
Medications: neuropathic pain: choice
type and progression of disorder associated physical and emotional problems
296
Medications: neuropathic pain: physical and emotional problems
nerve injury muscle weakness or spasms anxiety depression sleep disturbances
297
Medications: neuropathic pain: depression
amitriptyline nortriptyline duloxetine
298
Medications: neuropathic pain: anticonvulsants
gabapentin pregabapentin
299
Morphine: enteral: dose
30 mg (available as continuous and sustained-release fomulations to last 12-24 hours
300
Morphine:parenteral dosage
10 mg
301
Codeine: enteral: dose
200 mg (not generally recommended)
302
Codeine: parenteral dose
130 mg
303
Hydromorphone: enteral: dose
7.5 mg (available as a continuous-release formula lasting 24 hours)
304
Hydromorphone: parenteral: dose
1.5 mg
305
Levorphanol: acute pain episodes: enteral dose
4 mg
306
Levorphanol: acute pain episodes: parenteral dose
2 mg
307
Levorphanol: chronic pain: enteral dose
1 mg
308
Levorphanol: chronic pain: parenteral dose
1 mg
309
Bone pain: treatment options
may depend on causative agent r/t pain: primary cancer site severely weakened bones fractures
310
Bone pain: systemic treatments choices
chemotherapy radiation hormone therapy bisphosphonates surgery opioids NSAIDS COX2 inhibitors
311
Bone pain: hormone therapy: used
in presence of estrogen and androgen receptors within cancer cells
312
Bone pain: bisphosphonates: action
strengthen bone slow damage prevent fractures reduce pain
313
Bone pain: bisphosphonates: medications
ibandronate zoledronate alendronate
314
Bone pain: bisphonsphonates: S/E
fatigue fever N/V anemia
315
Bone pain: surgery
may be considered to remove cancerous cells or reinforce weakened areas of bone
316
Bone pain: opioids, NSAIDS/COX2 inhibitors
used most often for pain relief and need to be provided on consistent basis
317
Bone pain: morphine combined with ?
ibuprofen
318
Bone pain: morphine + ibuprofen
benefit of a centrally acting opioid with a peripherally acting NSAIDS
319
Bone pain: ibuprofen
acts as an effective adjuvant analgesic agent to enhance relief provided by opioid without increasing opioid S/E
320
Addiction: definition
primary and constant, neuro biologic disease with genetic, psycho-social, and environmental factors that create an obsessive and irrational need or preoccupation with a substance
321
Addictive behaviors:
unrestricted, continued cravings and compulsive and persistent use of a drug despite harmful experiences and S/E
322
Pseudo-addiction: definition
assumption the patient is addicted to a substance when in reality the patient is not experiencing relief from the medication
323
Pseudo-addiction: pain
prolonged, unrelieved pain that may be result of under-treatment
324
Pseudo-addiction: sistuation
may lead patient to become more aggressive in seeking medicated relief, resulting in inappropriate "drug seeker" label
325
Pain management: American and Alaskan natives
unwilling to show pain or request medications pain is a difficulty that must be endured rather than treated
326
Pain management: Asian and Pacific Islanders
do not vocalize pain may have an interest in pursuing nontraditional and non-pharmacological treatments, such as acupuncture, to help relive pain
327
Pain management: Black and African American
openly express pain, but still believe it is to be endured may avoid medication because of personal fears of addiction or cultural stigmattism
328
Pain management: Hispanic cultures
value ability to endure pain and suffering as a personal quality of strength expression of pain, especially for a male, is considered a sign of weakness pain is a form of godly punishment or trial
329
Pain: gender can affect
pain sensitivity tolerance distress exaggeration of pain patient's willingness to report pain displayed nonverbal cues concerning pain experience
330
Pain: Women
lower pain thresholds and less tolerance for noxious stimuli or pain factors that hinder them from doing things they enjoy
331
Pain: women: seek help
for pain related problems sooner than men and respond better to herapy
332
Pain:women:visceral pain
women experience more visceral pain than men
333
Pain:men:somatic pain
more prone to experience somatic pain
334
Pain:men: emotion
more stoicism regarding pain than women
335
Pain:neuropathic: genders
experienced equally between men and women
336
Pain experiences
individual differ between sexes
337
Acetaminophen (APAP)
safest analgesics for long-term use
338
Acetaminophen (APAP): used for
mild pain adjuvant with other analgesics for more severe pain nonspecific musculoskeletal pain osteoarthritis limited anti-inflammatory nature
339
Acetaminophen (APAP): use cautiously
in persons with altered liver or kidney function history of alcohol use
340
Acetaminophen (APAP): dosed
dosed separately from any opioid analgesic, which should be given separately as well
341
Acetaminophen (APAP): separate dosing
allows for individual titration of each drug to assess individual needs and S/E separately
342
Methadone: useful for
treating severe or chronic pain helpful in presence of neuropathic pain
343
Methadone: long acting relief
long acting pain relief factor for a lower cost than many comparable medications
344
Methadone: dosing ratios
exact dosing ratios with morphine remain unclear
345
Methadone: metabolism
can be increased or decreased by many other medications
346
Methadone: opioid addiction
used to treat opioid addiction
347
Methadone: US law
prescription of methadone for addiction in detoxification or maintenance programs requires a special license and patient enrollment
348
Methadone: prescription
words "for pain" needs to be clearly stated
349
Methadone: S/E
drowsiness weakness headache N/V constipation sweating flushing sedation decreased respiration irregular herat rate
350
Oral transmucosal fentanyl citrate: consists of
fentanyl on an oral applicator
351
Oral transmucosal fentanyl citrate: dosage
starting at 200 mcg
352
Oral transmucosal fentanyl citrate: route
patient applies dosage to the buccal mucosa between the cheek and gum for rapid absorption and subsequent pain relief
353
Oral transmucosal fentanyl citrate: useful for
managing breakthrough pain
354
Oral transmucosal fentanyl citrate: pain relief
begins within 5 minutes
355
Oral transmucosal fentanyl citrate: second dose
wait 15 minutes
356
Oral transmucosal fentanyl citrate: swallowing
can affect timing of pain relief onset
357
Oral transmucosal fentanyl citrate: peak
20 - 40 minutes
358
Oral transmucosal fentanyl citrate: duration
2-3 hours
359
Oral transmucosal fentanyl citrate: S/E
somnolence nausea dizziness
360
Oral transmucosal fentanyl citrate: drinks
alter oral secretion of pH and absorption rate coffee tea juices
361
Pain: HIV/AIDS patient: sources
aphthous ulcer and oral candidiasis arthralgia hepatotoxicity herpes simplex virus 2 (HSV-2) isosporiasis myalgia neuralgia and peripheral neuropathy Stevens-Johnson syndrome (SJS) cryptococcal meningitis
362
Pain: HIV/AIDS patient: aphthous ulcer and oral candidiasis
produce painful sores within the oral cavity dysphagia may be experienced
363
Pain: HIV/AIDS patient: arthralgia
joint pain with heat, redness, tenderness, loss of motion, and swelling
364
Pain: HIV/AIDS patient: cryptococcal meningities
life-threatening fungal infection resulting in headache, dizziness and stiff neck coma and death can occur
365
Pain: HIV/AIDS patient: hepatotoxicity
liver damage resulting in N/V, abdominal pain, loss of appetite, diarrhea, fatigue and weakness, jaundice, swelling and weight gain
366
Pain: HIV/AIDS patient: herpes simplex virus 2 (HSV-2)
produces painful sores around the anus or genitals
367
Pain: HIV/AIDS patient: isosporiasis
gastrointestinal infection diarrhea, fever, headache, abdominal pain, vomiting, and weight loss
368
Pain: HIV/AIDS patient: myalgia
condition of muscle pain and tenderness, general discomfort and weakness throughout enite body
369
Pain: HIV/AIDS patient: neuralgia and peripheral neuropathy
sources of chronic nerve pain
370
Pain: HIV/AIDS patient: Stevens-Johnson syndrome (SJS)
reaction to medications and creates a severe to fatal skin rash with red, blistered and painful spots on skin, mouth, eyes, genital, and moist area of the body or internal organs
