Week 4: Cognition, Sleep and Pain Flashcards
what is cognition?
all processes that refer to human thought
how people are aware of their our surrounding
how information is received, processed, stored and then used
what is the definition of cognition according to Giddens textbook?
the mental action or process of acquiring knowledge and understanding through thought, experience and the senses.
what are the six domains of cognitive function?
Perceptual motor function
Language
Learning and memory
social cognition
complex attention
executive function.
how does perception connect to cognition?
mind, brain and information processing
interpretation of the environment
related to awareness, consciousness
depends on sensory input
attention is directed on a particular area
what is memory?
retention and recall of the past
what are the different types of memory?
declarative episodic memory - specific events
declarative sematic memory - knowledge, words, facts
^ these two are long term
immediate memory attention span - short term
working memory - small amt of info can be recalled
procedural memory - muscle memory
what falls under the executive function?
higher order thinking: flexibility, adaptability, goal directedness
determines contents of consciousness
supervises voluntary activity
future oriented
what are the different levels of cognition?
higher order cognitive function - learning, comprehensive, problem solving
basic order cognitive function: perception pattern recognition
cognitive impairment: mild, moderate and severe
what are some risk factors for cognitive impairment?
advanced age
brain trauma
disease or disorder
environmental exposure
substance use disorder
genetic diseases
depression
medications
fluid and electrolytes imbalance
what are some consequences of cognitive impairment?
loss of short and or long term memory, impaired language skills, delusions and hallucinations, uncontrollable or inappropriate emotions such as severe agitation and aggression, impaired reasoning and decision making ability
What are some general management related to cognition?
Primary prevention - ex. how can we avoid drugs that cause this?
Secondary prevention (screening)
Collaborative management
Pharmacologic Agents (meds)
Family and Caregiver Support
What falls under Primary Prevention?
- promote a healthy lifestyle
- Genetic counselling (how genetic conditions might affect you or your family)
- Educating healthcare providers about latest evidence (ex. catheter use, patients restraint)
What are the two screening tool that can be used? (secondary prevention)
General Survey
Glasgow Coma Scale (GCS)
Mini Mental (you will learn in Older Client)
Where in the General Survey does observation of cognition fall into?
Physical appearance - level of consciousness (LOC)
How do you assessing level of consciousness?
Found in: general survey
in the hospital - Alert and oriented - A&Ox4
person, place, time and context
easily follows commands (hand grasps quick and easy)
Explain what falls under Alert and Oriented x4?
Alert - awake and readily aroused, oreintedx4, responds appropriately
Lethargic(Somnolent-sleepy) - drifts off to sleep when not stimulated, looks drowsy, aroused when name called, thinking slow/fuzzy, looses train of thought
Obtunded: Mainly asleep, difficult to arouse - loud shout or vigorous shake, confused, speaks in monosyllables, mumbled/incoherent
Stupor (semicoma) - Spontaneously unconscious, responds only to pain or vigorous shake, withdraws from pain, groan, mumbles
Coma - Completely unconscious, no response to pain
What is the difference between A&Ox4 and A&Ox2
A&Ox4 - alert and oriented to person, place, time and situation
A&Ox2 - alert and oriented to person and place, but does not know the time and what’s happening to them
What is the Glasgow Coma Scale?
responses from: eye opening, verbal and Motor
scores - eyes: 1-4 points
verbal - 1-5 points
motor - 1-6 points
Minor brain injury- 13-15 points
Moderate brain injury - 9-12 points
Severe Brain injury - 3-8 points
8 or less = intubate, no longer can control breathing
what are some responses to painful stimuli?
Localizes
Withdraws
grimances (making a face)
Abnormal posture (decerebrate posture - results from damage to brains stem, Decorticate - results from damage to one of both corticospinal tracts)
No response, flaccid(soft and hanging loosely or limply)
What would decerebrated and decorticate posture look like?
decerebrate- arms are adducted (towards midline) and extended, wrist inward with fingers flexed, legs are stiffly extended with plantar flexion of feet
Decorticate - arms are adducted and flexed, wrists and fingers flexed on the chest, legs are stiffly extended and internally rotated and plantar flexion of feet
which type of posture is most serious and indicated a poorer prognosis?
Decerebrate posture
what is the Mini Mental State Examination?
used to assessment cognitive disfunction (learn more in older client)
true of false: cognition impacts all areas of healthcare
true
true of false: collaborative approach is a critical element for communication and determining care plans
true
true or false: collaborative approach is a mono disciplinary approach to care for those with cognitive impairment
false; multi
Is delirium an example of cognitive impairment?
yes
what is delirium?
delirium is essentially an acute confessional state - sudden decline (hours to few days). includes - memory, thinking, language, behaviour and mood/personality
true of false: nearly 30% of older medical patient experience delirium at some time during hospitalization
true!
True or false: delirium is a state of disturbed consciousness and is not a medical emergency
false; it IS a medical emergency
what are some individual experiences to delirium?
dulled awareness
reduced ability to focus, sustain and shift attention
Memory and judgment impaired
Disorientation
Change in speech
Emotional swings
Restlessness
what assessment can you use to diagnosis delirium?
Confusion Assessment Method (CAM)
what does the CAM consist of?
*If feature 1 and 2 and either 3 or 4 are present - a diagnosis of delirium is suggested
Feature 1: Acute onset and fluctuating course
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions:
* Is there evidence of an acute change in mental status from the patient’s baseline?
* Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or
increase and decrease in severity
Feature 2: Inattention
* This feature is shown by a positive response to the following question:
* Did the patient have difficulty focusing attention, for example, being easily distracted, or having difficulty keeping track of what was being said
Feature 3: Disorganized thinking
* This feature is shown by a positive response to the following question:
* Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Feature 4: Altered level of consciousness
* This feature is shown by any answer other than “alert” to the following question:
* Overall, how would you rate this patient’s level of consciousness? Alert (normal), vigilant (hyper-alert), lethargic (drowsy, easily aroused), stupor (difficult to arouse), or coma (unarousable)
what are some differences between delirium and dementia within onset?
delirium - Intermittent, abrupt onset
dementia - progressive cognitive decline
what are some differences between delirium and dementia within the description?
delirium - Acute change in cognitive functioning - short term
dementia - Chronic confusion - long term
what are some differences between delirium and dementia within the etiology?
delirium - Underlying imbalance; Physiological condition
dementia - Alzheimer’s disease; vascular dementia
what are some differences between delirium and dementia within the common clinical manifestations?
delirium - Difficult concentrating, restlessness, irritability, disturbed sleep, tremulousness, poor appetite, hallucinations, mood swings, violent, decreased LOC
dementia - Memory loss, impaired learning, depression, anxiety, muscle rigidity, mood changes, apathy, agitation, wondering
what are some ways to manage delirium?
prevention of delirium: avoid factors known to aggravate delirium
-polypharmacy, dehydration, immobilization, sensory impairment, disruption of sleep-wake cycle
promote - sleep, fluid intake, nutrition, comfort
Recognize the condition AND uncover and treat the underlying condition
what are some causes of delirium?
Infection - antibiotics
Pain-analgesia
Sleep related sedatives
dehydrate-nutrition-fluid/electrolytes
decreased O2 - may need IV O2
what are some common supplement for delirium?
sedatives hypnotics
what are some reasons why pharmacological treatment would be necessary?
to control behavioural alterations
sleeplessness
anxiety
agitation
depression
true or false: are sedative hypnotics relate to dose dependent effect
YES
at low doses what can sedative hypnotics do?
calm the CNS WITHOUT inducing sleep
at high doses what can sedative hypnotics do?
Calm the CNS TO the point of causing sleep
what are two meds we will be studying that fall under Sedative Hypnotics?
Benzodiazepines and Barbiturates
what drug don’t we critically study anymore? why?
Barbiturates - because its dangerous and is no longer/rarely used
please explain in depth how benzodiazepine works?
within the GABA receptor lies binding sites, when Benz binds it acttaches and ENHANCES what the natural GABA does - opens the door and chloride flows in, neutron stops firing - CNS is calmed down
how does barbiturate work? (not studied anymore)
the GABA receptor contains barb binding sites, and when it binds it essentially keep them open for prolonged period of time - thats why it can be dangerous (therapeutic index is more narrow)
what are some GOOD benzodiazepines (anxiolytics - anti anxiety) remember it increases power
hint: think of the suffix
Diazepam(Valium)
Iorazepam(Ativan)
Midazolam(Versed)
other benzo like effects-
zoplicone (Immovane)
what are some BAD barbiturates (anti-convulsants, anaesthesia)
phenobarbital - (po)
pentobarbital - (IV IM)
thiopental - (IV)
what are some cons for barbiturates?
too many side effects, addictive, respiratory depression. too much drug drug interactions
name the drug - commonly prescribed drug class, minimal tolerance or physical dependence
Benzodiazepines
what part of the anatomical systems does Benzodiazepines affect?
hypothalamic, thalamic and limbic systems
what happens when someone withdraws from Benzodiazepines?
Insomnia, anxiety, agitation, tremor, tachycardia, anorexia
does Benzodiazepines increase metabolism of other drugs?
NO
true of false: Benzodiazepines causes less REM sleep suppression
true
which one of these Benzodiazepines drugs are long acting, intermediate acting or short acting?
diazepam - long
lorazepam - inter
midazolam - short
DRUG CARD: Diazepam (Valium)
long acting
route: po
dose: 0.5-2mg/h
half life of 100h
usually used for alcohol withdrawal
someone used to alcohol in body: used to CNS being depressed
DRUG CARD: Iorazepam (Ativan)
intermediate
Route: po
Dose:2-4mg/h
route and frequency: sl 1 h, IV 5-10 min
half life of 10-20hours
DRUG CARD: midazolam(Versed)
short acting
route:IV
dose: 1.5-5mg/min
half life 1-4 hours
temazepam (Restoril), alprazolam (Xanax), triazolam (Halcion)
why is PO/SL route preferred for Benzos?
IV may have a profound BP drop (cardiac arrest) or respiratory depress, have emergency equiptment nearby
what does a mild OD look like for Benzos
drowsiness, impaired coordination confusion, lethargy
What does a serious OD look like for Benzos?
ataxia, hypotonia, hypotension, respiratory depression, coma
What does a rare OD look life for Benzos?
cardiac arrest when combined with alcohol/other CNS depressants
what drug is used as an antidote for Benzos?
Flumanzenil - effect fades in 1hr (repeat may be necessary)
if no long term use of BZD - otherwise withdrawal occurs
select all that is true: Benzodiazepines do not induce hepatic drug-metabolizing enzymes
Additive with other CNS depressants such as alcohol, opioids
Enzyme inducers can reduce effect of Benzo by speeding its breakdown such as Carbamazepine, phenobarbital, phenytoin, St John’s wort
Enzyme inhibitors can increase effect of Benzo by delaying breakdown ex. Grapefruit (diazepam), diltiazem, verapamil, macrolide antibiotics, fluconazole, omeprazole, oral contraceptives
true
what is the drug: short term use, po, short term use for insomnia
Zopiclone (Immovane)
can sedative drugs increase risk for falls?
yes
what are some things to monitor while a patient is taking sedative drug
Monitoring patients we have been sedating with drugs
Monitor during sedation – and to track recovery
Respiration (Deep/cough, dyspnea/ shallow, apnea)
Oxygen Saturation (O2 Sats)
Consciousness/Communication (awake/
rouseable/no response)
Circulation (BP – full VS generally assessed)
Activity (Moving extremities) – Risk for Falls
does sleep enable physiological restoration?
yes
what is a normal physiological process(sleep)
period of wakefulness
period of rest and sleep the enables physiological restoration
sleep - 4 stages and REM
what are the stages of sleep?
stage 1 - N1 (light sleep)
Stage 2 - N2 (no eye movement)
Stage 3 - N3 (deep sleep) - slow delta waves and small fast waves
Stage 4 - N4 (deep sleep) - mostly slow delta waves
Rapid eye movement (REM) - 90 mins
what are some other concepts sleep is connected to?
cognition
gas exchange
perfusion - (to brain)
hormonal reguation
pain
elimination
stress and coping
fatigue
what is insomnia?
impaired sleep, inability to sleep well
short term for some, chronic for others
could be result of medical condition
common causes: Psychiatric disorders and pain are two common causes
treatment: depends on cause
what are some consequences of not sleeping?
too much daytime sleepiness
Psychological and emotional impacts
Reguatory mech of body impaired (hypertension, heart disease, stroke, obesity)
reproductive disorders
increased mortality
developmental and behaviour abnormal in children
what are some clinical management for sleep
primary prevention - sleep hygiene strategies
secondary prevention: screening
common pharmaceuticals: melatonin, zopiclone, zolpidem
explain the concept of pain
AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE
what is one important thing to remember about pain?
Pain is whatever the experiencing person says it is, existing whenever they say it does - ONLY an individual can determine where the pain is and how severe it is
what are some concepts that connect to pain
sleep
fatigue
tissue integrity
mobility
functional ability
development
culture
spirituality
mood affect
true or false: chronic pain is the most common cause of long term disability
true
true or false: as the population ages, the number of people who will need treatment from pain is expected to decrease
false; increase
true of false: pain
Most common reason individuals seek health care
Major cause of absenteeism, underemployment and unemployment
Significant physical, psychological, emotional, social, spiritual, and financial consequences
true
true of false: pain is universal but is also individual and subjective
true
which one resonates with pain:
It is a normal physiologic response to tissue injury
It is a symptom of pathology associated with a disease
process
Is a result of an alteration of the somatosensory system
all of them
is pain normally protective?
yes it is
is pain often referred to as the 6th vital sign?
yes it is
no pain - minimal pain back and forth from acute to chronic?
true
minimal pain to moderate pain back and forth from localized to generalized
true
moderate pain to severe pain back and forth from intermittent to constant
yes
what are the four categories that fall under neurological system and pain?
transduction, transmission, perception and modulation
can you explain what transduction consists of?
this is when noxious stimuli causes cell damage with the release of chemicals such as: prostaglandins, bradykinin, serotonin, substance P, Histamine - activate nocireceptors and lead to generation of action potential
AWARENESS OF PAIN
can you explain what transmission consists of?
Action potential continues from - the site of injury to spinal cord, spinal cord to brain stem and thalamus, thalamus to cortex for processing
PNS - sends neurons out to our bodies, A fibers - sharp fast pain (myelinated) and C fibers (slow acting burning sensations) (unmyelinated), pain then transmits to CNS
can you explain what perception consists of?
this is where the understanding that the stimulus is painful
the conscious experience of pain - brain
can you explain what modulation consists of?
internal treatment - body will release chemicals to protect/block the CNS from receiving this action potential
neurons originating in the brain stem descend to the spinal cord and release substances (ex. endogenous opioids) that inhibit nociceptive impulses
how to treat pain?
to block the dermatomes - C 2-8, T1-12, L1-5, S1-4
what are some sources of nociception?
somatic: joints, muscles, bone, tissue pain
visceral: from the organs, leading to dull, cramping pain (difficult to pinpoint)
referred: from an organ but felt elsewhere
Neuropathic: damage to nerve cells (ex. diabetic neuropathy - nerve endings are damaged, burning shooting)
what are some nociceptive pain that is normal?
somatic pain - arises from nerve receptors in the skin or close to the surface (bones, muscles, joints or CT)
Visceral pain and Referred pain
what are some neuropathic pain (pathologic)
abnormal processing of the sensory input as a result of injury of the PNS or the CNS
centrally generated pain - Deafferentation Pain- injury to either the peripheral or CNS (e.g., Phantom Pain)
Sympathetically maintained pain-associated with dysregulation of the Autonomic Nervous System
Peripherally Generated Pain - Painful polyneuropathies-pain is felt along the Peripheral Nerves (e.g., Diabetic Neuropathy)
Painful mononeuropathies- associated with peripheral nerve injury (e.g., nerve root compression, trigeminal neuralgia)
biggest difference between acute and chronic pain?
acute - abrupt sudden onset
chronic - pain over 3-6 months to years
what is acute pain
abrupt sudden onset
SNS response (HR, BP, diaphoresis)
■ Cause/source can be determined
■ Time-limited (brief)-dissipates with time
■ Variations in the intensity, frequency, and duration of pain between individuals
■ Can be associated with acute anxiety
■ Hope of recovery
what is chronic pain?
Ongoing pain > 3-6 months to years No effect on SNS
Cause difficult to pinpoint Depression, anxiety
Behaviour is adapted to modify pain
Sense of hopelessness and helplessness Interferes with quality of life, ADL
Varies in intensity, frequency, and duration
People with chronic pain can experience acute pain at the same time
true or false: People with chronic pain can not experience acute pain at the same time
FALSE; they can!!
what are some normal and abnormal clinical manifestations of acute pain?
Normal:
Mild to moderate severity
▪ Should be able to identify how much they can tolerate
▪ Assess for nausea, vomiting and pruritis
▪ Consider medications for pain before painful procedures
Abnormal:
Increased heart rate and/or blood pressure
■ May have hypoventilation or hypoxia
■ May report joint stiffness
what are some normal and abnormal clinical manifestations of chronic pain?
Normal:
Pain present for extended time after acute phase
▪ Should be manageable
▪ Should be able to participate in ADLs
▪ Social supports in place
▪ Financial and psychological supports in place
Abnormal:
Fear, anxiety, depression
■ Isolation
■ Limited mobility
■ Family distressed
■ Decreased quality of life
■ Hard time completing tasks
■ Reports increased levels of fatigue
what are some normal and abnormal clinical manifestations of neuropathic pain?
Normal:
May have increased or decreased sensation over affected area
▪ Inspect skin and tissue for colour, warmth, deformity or masses
▪ May have increased neuropathic pain during night
Abnormal:
Lesions
■ Open wounds
■ Changes in hair distribution
■ Tissue damage
state if this is true about tolerance of drug: In the tolerant user, doses must be increased to produce the same intensity of response that could formerly be achieved with smaller doses.
true
true of false: Individuals who are physically dependent on barbiturates exhibit cross- dependence with other general CNS depressants. Because of cross-dependence, a person physically dependent on barbiturates can prevent withdrawal symptoms by taking any other general CNS depressant (e.g., alcohol, benzodiazepines).
true
true of false: Abrupt withdrawal from general CNS depressants is less dangerous than withdrawal from opioids
false: more
what is the goal for a pain assessment?
Describe the patient’s sensory, affective, behavioural, and
sociocultural response to pain
Identify the patient’s goal for therapy and resources and strategies for self-management
what is the GOLD standard of pain assessment?
the patients subjective report of their pain experience
what is the primary role for the nurse within pain assessment?
to ADVOCATE for the patient by accepting their reports of pain and acting quickly to relieve it while respecting their values and preferences. start by ASKING the patient
what is one pain assessment that we have previously learned?
OPQRSTUV
onset, provoking/palliative factors
quality and quantifying intensity
region and radiation
signs and symptoms associated
timing: duration, recurrence, pattern
understanding of cause and impact
VALUES - expect to have no pain, cause of pain etc.
what assessment expands on OPQRSTUV and that can be helpful for chronic pain?
Brief pain inventory-In the past 24 hours, how has pain impacted the patient’s general activities, mood, walking ability, work, and sleep
is there another ways where subjective information can not be documented verbally (in terms of pain assessment)?
yes - through the FLACC pain assessment for infants and toddlers (facial expression, leg movement, activity, crying, consolability)
true of false: pain is a sign of aging
false; nope but the incident is higher in older adults
true or false: many older adults are reluctant to report pain (some believe is as normal)
sadly true
what are some challenges in assessment ?
people that cant report their pain using a self assessment tool
cognitively impaired
critically ill
comatose (decrease LOC)
Imminently dying
language
sedated
too young
what are some things you would observe in a patient ?
position of comfort
guarding areas of pain
facial expression(stress)
movement/gestures
behaviour
vital signs (HR, BP, pupils)
what are some questions we can ask the patient, during a social determinants of health- cultural assesment? ( give at least 5 on the list)
do you have any fears about pain and pain management ?
what traditional remedies have you tried to help with your pain?
how do you usually behave while your in pain?
why do you think you’re having pain?
how would people recognize pain in you?
Consequences of unrelieved pain give the stress responses of the following functional domain:
Endocrine/Metabolic
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Immune
Genitourinary
altered release of hormones
increased in HR, BP, and oxygen demand, and clotting
decreased in airflow limited respiratory effort
decreased rate of emptying and motility
muscle spasm, impaired muscle mobility
impaired immune function
abnormal release of hormones
Consequences of unrelieved pain give the clinical manifestations of the following functions:
Endocrine/Metabolic
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Immune
Genitourinary
weight loss , fever, increased respiration rate and heart rate, shock
unstable angina, MI DVT ( CLOTTING)
atelectasis, pneumonia
decreased in gastric emptying and motility , ileus ( lack of movement in the intestine), anorexia, constipation,
immobility, weakness, fatigue
infection
decreased in urinary output, hypertension, electrolyte imbalances
What are the psychological consequences of unrelieved pain?
chronic pain may be associated with pyschological and social consequences
underrated or untreated pain can negatively impact nearly every aspect of a person’s life
treating pain with opioids can have pyschosical consequences, including opoid use disorder
addiction can impact every aspect of a person’s life
Hierarchy of pain assesment
A
C
O
E
C
attempt= attempt to obrain self- report
consider= consider underlying pathology/condtion that might be painful-assume pain present
observe= observe behaviour
evaluate= evaluate physiologic indicators
conduct = conduct an analgestic trial
true or false. Pain management is much more complex than pharmaceuticals?
yes, that is true
define if the characteristics amongst multimodal therapy is true or false.
there is no single, universal treatment for pain
using two or more classes of analgesis or interventions to target pain mechanims in the PNS or CNS.
purposeful combination of pain medication to maximize relief, and prevent gaps in treatment if effective
may allow higher doses to each of the drugs. Higher doses may lead to few side effects.
offers promise of reducing the incidence of pronlonged or persistant post-surgical pain
for complex chronic pain, combining analgesics such as anticonvulsants, antidepressants, and local anesthetics to target differing underlying mechanism
all true except 4th one, it’s lower dose not higher.
What are the 3 analgesic groups?
nonopoid
opoid
adjuvant
true or false. the broad categories of medications of the 3 analgesic group works to block the transmission of noireception into the cns , in other words they block the noiception from being perceived.
true
true or false: lower doses may lead to more side effects
false; fewer
what drugs were placed on the 1-3 mild WHO step ladder?
Acetaminophen
NSAID’s - ibuprobin, ASA (aspirin)
naproxen
+- adjuvants
what drugs were placed on the 4-6 moderate WHO step ladder?
Codeine
Hydrocodone
Oxycodone
Dihydrocodeine
Tramadol
+-adjuvants
what drugs were placed on the 7-10 severe WHO step ladder?
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
+-Adjuvants
what class of drugs would be given if the pain is mild?
non-opioids such as Acetaminophen
what’s an example of a selective COX 2 inhibitor?
celecoxib
what pathway specifically does the NSAIDS such as ASA and ibuprofen block?
blocks arachidonic acid to Cyclooxygenase 1 and 2 pathways
what pathway specifically does the COX 2 inhibitors block?
Cyclooxygenase 1 and 2 pathways to prostaglandins 1 and 2
if COX 2 inhibitors block prostaglandin 1, what are some side effects that can take place?
side effects - GI upset, kidney problems (decrease renal perfusion)
clotting
by mixing opioids with non opioids, what can we decrease?
the use of opioids (less addict risk)
what is the difference between physical dependence and addiction?
physical dependence: increase in Tolerance and Dependence in which negative consequences occur despite continued use
addiction: use of drugs or alcohol to the point where it causes problems in your life.
which kind of drug does not have a ceiling?
pure opioid agonists, it is subject to abuse!!
what are some examples of pure opioid agonists?
Morphine, Fentanyl, hydromorphone
true or false: opioids are not designed for long term use - unless palliative care
true
true or false: opioids are different from other drugs because they are treating the pain rather then masking the clinical manifestation
false; just masking aint no healing
what the antidote for morphine?
naloxone - competing for the same binding site
under the category of 2 analgesic groups :
name the following medications that
nonopiod analgesics
opioid analgesics
adjuvant analgesics
nonopiod analgesics :
acetaminophen
nonselective NSAIDs ( e.g, ibuprofen, naprofen, ketorolac)
COX-2 selective NSAIDS ( e.g, celecoxib)
opiod analgesics
- morphine
-fentanyl
-hydromorphone
-oxycodone
Adjuvant analgesics
-local anesthethics ( e.g bupivacaine, ropivacaine, lidocaine)
- anticonvulsants ( e.g, gabapentin, pregabalin)
- antidepressants ( e.g desipramine, nortiptyline, duloxetine)
true or false.Opioids with non-opioids. you wanna combine these, in order to treat that pain in two different ways.
true
True or false. With any opioids any body can develop a tolerance meaning any time that medication is not going to be effective for treating that patients pain.
true
determine if the following are true or false.
opioids with non opioids:
is the second rung on the pain ladder
less effective and primary drugs for moderate to severe pain
weak opioids with acetaminophen
can not cause sedation, euphoria but can cause constipation, respiratory depression, and urinary retention
with continuous use, tolerance does not develop
can also result in physical dependance
physical dependance is not the same as addiction
true
false ( it is most effective)
true
false, it can cause all of them
true
true
true
opioid analgesics are used for acute, and are not intended for long term use for abuse, addiction, and effects. true or false
true
this is mainstay in management of moderate to severe nociceptive types of pain (postoperative, surgical, trauma, and burn pain).
opioid analgesics
what produces effects by interacting with opioid receptor sites located throughout the body ( peripheral tissues, GI system, spinal cord, and brain).
opioid analgesics
true or false. _____ binds to receptor sites, produces analgesia and unwanted side effects.
opioid analgesics
true or false.
opioid analgesics. produce effects by interacting with opioid receptor sites located throughout the body ( peripheral tissues, GI system, spinal cord, and brain).
the biggest one is in Gi they causes constipation, and the other one is respiratory depression.
true
This is not for long term use unless it’s a palliative care patient who has terminal cancer but back pain or knee pain, we do not use opioids.
pure opioid analgesics
true or false. pure opioid analgesics is a pure opioid antagonist.
false, it is pure opioid agonists
Pure opioid analgesics : name characteristics
binds primarily to the mu- type receptors in the CNS. First line for mild- moderate. ( stoping that transmission process from occurring )
No ceiling - increasing dose produces increased pain relief
can adjust based on pain severity
subject to abuse
- rare when used appropriately
pure opioid analgesics : name the mediation under the category
morphine, fentanyl , hydromorphone
true or false. opioids is not treating the underlying cause of the pain they are simply making the symptom/ clinical manifestation.
true
what is the antidote for morphine ?
naloxene
what does naloxene do to morphine?
naloxene is the antidote for morphine and what it’s going to do is that it’s going to compete for the same binding site
Morphine : contraindications and adverse effects
contraindications
known drug allergies
severe asthma
caution in patients with
-respiratory insufficiency
-elevated intracranial pressure
-morbid obesity
-sleep apnea
adverse effects
-cns-sedation , disorientation , euphoria
-cvs- hypotension, palpitations, flushing
-resp- respiratory depression, asthma exacerbation
-GI- Nausea, vomiting, constipation , biliary tract spasm
-GU- Urinary retention
-Integumentary ( skin ) - itching, rash
other strong opioid agonists :
true or false.
morphine is the least potent out of all the three ( out of morphine, fentanyl , hydromorphone ).
true
other strong opioid agonists
fentanyl ( duragesic )
- 100 times the potency of morphine
- formulations given via three routes
- parenteral
- surgical anesthesia
Transdermal ( duragesic )
- Patch : Heat acceleration
Transmucosal
- Lozenge on a stick
true or false. morphine has been done by a path.
true
true or false ( lozenge on a stick can be absorb)
primarily for cancer patients.
true
this act as antagonists at mu and kappa receptors
opioid antagonists
this bind to opioid receptors but produce no analgesia ( naloxene)
opioid antagonists
true or false.
Opioid antagonists :
If an antagonist is present, it competes with opioid molecules for binding sites on the opioid receptors
true
true or false.
Opioid antagonists : has no potential to block analgesia and other effects
false; they have potential to block analgesia and other effects
used most often to reverse opioid effects like sedation and respiratory depression
opioid antagonists
this is using other medication that are not analgesic to help treat a patients pain.
adjuvant theraphy
Those on the second step should also receive adjuctive therapy with :
acetaminophen
anti- inflammatory medications
both
true or false. pain is something that is perceived
true
Those with chronic pain may also take other adjunctive therapy :
gabapentinoids
pregabalin ( lyrical)
tricyclic antidepressants ( amitriptyline)
benzodiazepines
other opioids
- cannabinoid
-methadone
cannabis is increasingly used for a various reasons : name the reasons :
including persistent and neuropathic pain management
cannabis contains numerous cannabinoids : what are they ?
the most common is THC ( Tetrahydrocannabinol), cannabidiol ( CBD) , Cannabinol ( CBN)
cannabis : evidence exists that it can effective for persistent : what?
persistent cancer pain
rheumatoid arthritis
fibromyalgia
as well as neuropathies associated with MS
cannabis : can be inhaled via smoking, vaporization, ingestion?
true yes it can be
what are the side effects of cannabis ?
side effects increased heart rate, increased appetie, dizziness, decreased blood pressure, dry mouth, hallucination, paranoia, alteration in motor function, and impaired attention
Tolerance
Tolerance with prolonged opioid use…
develops to come pharmacologic effect but not to others ( euphoria. respiratory depression, and nausea)
No tolerance develops to constipation and constricted pupil. the longer you take that medication, you build tolerance
true
Long-term use ( medication) produces physical dependance
true
Physical dependance can develop acute abstinence syndrome- withdrawal that can last up to 10 days, It is unpleasant but not dangerous.
true
Addiction : what are the five terms we have to know
substance- induced disorders
substance use disorder
craving
tolerance
withdrawal
describe these five terms :
substance induced disorders
substance use disorders
craving
toelrance
withdrawal
temporary and reversible caused by immediate use of substance and the immediate effect that occurs when subtance is stopped
as a result from continued, frequent use of substance. combines abuse and dependance
describes the desire to use a substance and is a symptom of SUD
another symptom of SUD increasing need for the substance to achieve its reward
syndrome of symptoms that occurs from a sudden cessation of the substance
non pharmacological interventions - pain
heat-ice
massage
TENS - electrical treatment
physiotherapy
imagery
distraction
deep breathing
cultural practices
what should we consider as nurses?
10 rights of medications administration
accurate assessment
knowledge safe dose, side effects, contraindications
anticipate adverse effects
evaluate patient
patient teaching
patient safety, start low, go slow
