Pain Management (Fundamentals Ch 41)

Question 1

Nonpharmacological pain management

Answer 1

• cutaneous (skin) stimulation–transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, massage
• distraction
• relaxation
• imagery
• acupuncture
• reduction of painful stimuli in environment
• elevation of edematous extremities to promote venous return and decrease swelling

Question 2

Substances that increase pain transmission and cause an inflammatory response

Answer 2

• Substance P
• Prostaglandins
• Bradykinin
• Histamine

Question 3

Substances that decrease pain transmission and produce analgesia

Answer 3

• Serotonin

- Endorphins

Question 4

Pain Categories

Answer 4

• Acute pain
• Chronic pain
• Nociceptive pain
• Neuropathic pain

Question 5

Acute pain

Answer 5

• protective, temporary, usually self-limiting, and resolves with tissue healing
• physiological responses (SNS) fight-or-flight responses: tachycardia, hypertension, anxiety, diaphoresis, muscle tension
• behavioral response: grimacing, moaning, flinching, guarding
• interventions: treatment of underlying cause

Question 6

Chronic pain

Answer 6

• not protective; ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing.
• physiological responses to not usually alter vital signs; clients may have depression, fatigue, decreased level of functioning.
• psychosocial implications may lead to disability
• may not have known cause, may not be responsive to interventions
• management aims at symptomatic relief (control of symptoms, rather than cure)
• can be malignant (also known as cancer pain; caused by a tumor or may be the result of cancer treatment) or nonmalignant (may result from injury or disease)

Question 7

Nociceptive pain

Answer 7

• arises from damage to or inflammation of tissue other than that of peripheral and central nervous systems
• usually throbbing, aching, and localized
• typically responds to opioids and nonopioid meds
• Types: a) somatic–in bones, joints, muscles, skin, or connective tissue; b) visceral–in internal organs, can cause referred pain in other body locations separate from stimulus; c) cutaneous–in skin or subcutaneous tissue

Question 8

Neuropathic pain

Answer 8

• arise from abnormal or damaged pain nerves
• phantom limb pain, pain below level of spinal cord injury, diabetic neuropathy
• usually intense, shooting, burning, or described as “pins and needles”
• pain typically responds to adjuvant meds (antidepressants, antispasmodic agents, skeletal muscle relaxants)

Question 9

Pharmacological Interventions

Answer 9

• Analgesics: a) nonopioid analgesics; b) opioid analgesics; and c) adjuvant analgesics
• Patient-controlled analgesia (PCA)

Question 10

Nonopioid analgesics

Answer 10

• acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS)–including salicylates
• treat mild to moderate pain
• be aware of hepatotoxic effects of acetaminophen. Clients with healthy liver should take no more than 4g/day.
• monitor for salicylism (tinnitus, vertigo, decreased hearing acuity)
• monitor bleeding with long-term NSAID use

Question 11

Opioid analgesics

Answer 11

• morphine sulfate, fentanyl (Sublimaze), and codeine

- treat moderate to severe pain (postop pain, myocardial infarction pain, cancer pain)

Question 12

Adverse effects of opioid analgesics to monitor

Answer 12

1. constipation: use preventative approach (monitor bm, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas)
2. orthostatic hypotension: advise clients to sit or lie down if symptoms of light-headedness or dizziness occur; avoid sudden changes in position; provide assistance with ambulation
3. urinary retention: monitor I&O, assess for distention, administer bethanechol (Urecholine), and catheterize
4. nausea/vomiting: administer antiemetics, advise clients to lay still and move slowly, eliminate odors
5. sedation: monitor loc and take safety precautions (usually precedes respiratory depression)
6. respiratory depression: monitor rate prior to and following administration. Initial treatment is generally reduction of opioids.
   * If necessary slowly administer diluted naloxone (Narcan) to reverse opioid effects

Question 13

Adjuvant analgesics

Answer 13

• enhance effects of nonopioids
• help alleviate other symptoms of pain (depression, seizures, inflammation)
• useful for treating neuropathic pain

Question 14

Adjuvant analgesics

Examples

Answer 14

• anticonvulsants: carbamasepine (Tegretol)
• antianxiety agents: diazepam (Valium)
• tricyclic antidepressants: amitriptyline (Elavil)
• antihistamine: hydroxyzine (Vistaril)
• glucocorticoids: dexamethasone (Decadron)
• antiemetics: ondansetron (Zofran)

Question 15

Patient-controlled analgesia (PCA)

Answer 15

• medication delivery system allows clients to self-administer safe doses of opioids
• morphine and hydromorphone (Dilaudid) typically used
• client is the only person who should push PCA button to prevent inadvertent overdosing