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192 Cards in this Set

  • Front
  • Back
Pain-Defined
Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does.
Margo McCaffery 1979
Purpose of Pain
 To signal ongoing or potential tissue damage.
 Can be protective mechanism to prevent further injury.
Categories of Pain
 Source of Pain
 Referred Pain
 Duration of Pain
Source of Pain
Nociceptive:
Neurogenic
Psychogenic:
Nociceptive
Pain that is acute and is transmitted after noxious stimuli.
Neurogenic
: Pain resulting form injury to or abnormal functioning of peripheral nerves or central nervous system.
Psychogenic pain:
Pain for which no physical cause is found. All pain may have a component of both physical and psychogenic origins.
3 types of Nociceptive Pain
 Cutaneous pain
 Deep Somatic Pain
 Visceral Pain
 Cutaneous pain
usually involves the skin or subcutaneous tissue. (A burn or paper cut)
 Deep Somatic Pain
is diffuse and scattered and originates is tendons, ligaments, vessels, and bones. ( a sprain or fracture would be an example)
 Visceral Pain
is poorly localized and originates in body organs or the thorax, cranium, and abdomen. (gall bladder attack, intestinal cramping)
Neuropathic Pain
Neuropathic pain results form injury to peripheral or central nervous system. Some common pain syndromes in this category are:
Neuropathic Pain types
 Causalgia:
 Postherpatic neuralgia
 Phantom Limb Pain:
 Trigeminal Neuralgia
 Diabetic Neuralgia
 Causalgia:
Pain in area of damage such as sciatic nerve.
 Postherpatic neuralgia
Follows CNS infection such as Herpes Zoster. Can last for months or years.
 Phantom Limb Pain:
Sensation in amputated limb.
 Trigeminal Neuralgia
Sharp pains of lips, mouth, gums, nose, cheek.
 Diabetic Neuralgia
Caused by vascular and nerve changes from diabetes mellitus.
Referred Pain
This is pain perceived in an area distant from where the point or origin. This travels along a nerve root.
This is the most common distinction or categorizing of pain that is done.
Duration of Pain
Duration of Pain two categories
Acute:
Chronic:
Acute:
: Rapid onset, varies in intensity form mild to severe. Usually resolves when source is eliminated.
Chronic:
: Pain that can be limited, intermittent, or persistent but lasts for more than 6 months and interferes with normal functioning.
Characteristics of Acute Pain
 Mild to severe
 Related to tissue injury-resolves with healing
 Client appears restless and anxious
 Pain behavior present
Characteristics of Chronic Pain
 Mild to severe
 Continues beyond healing
 Client depressed and withdrawn
 Pain behavior often absent
Acute pain nervous response
 Sympathetic nervous system responses
 increased pulse rate
 increased respiratory rate
 elevated blood pressure
 diaphoresis
 dilated pupils
Chronicpain nervous response
 Parasympathetic nervous system responses
 vital signs normal
 dry warm skin
 pupils normal or dilated
 Remission:
periods when pain is not experienced.
 Exacerbation:
Sudden worsening of chronic pain.
 Chronic Malignant Pain:
Associated with progressive diseases such as cancer or multiple sclerosis.
 Intractable:
Pain unrelieved by any intervention.
Four Stages
of the Pain Process
 Transduction
 Transmission
 Perception
 Modulation
Transduction
 The activation of pain receptors (aka: nociceptors)
 Electrical impulses travel from site of injury to brain via dorsal horn
 Activation can be by noxious stimuli and/or the release of body produced chemicals and enzymes such as histamine, prostaglandins, etc. that are released from the cells at the site of injury.
Transmission
 Pain signals travel as electrochemical impulses along the length of afferent nerve (ascending to brain) via dorsal horn of spine.
 The impulses reach the thalamus, a sensory center in the brain that detects heat, cold, pain, and touch.
 The impulses then go to the cerebral cortex where the more sophisticated sensory is interpreted influenced by prior pain experiences and memories.
 Phantom pain can exist because these impulses may still be remembered after the limb is gone.
Perception
Perception of pain involves the sensory process that occurs when painful stimuli is present.
Pain threshold is variable for different people but is generally similar.
Adaptation plays a role in this interpretation.
Gate Control Theory
This theory describes the message of the painful stimuli as held back at the spinal cord by opposing nerve fibers that are sending messages that block the pain. Not only the afferent fibers in the spinal column but also brain impulses can influence this gating mechanism and shut down or interrupt the pain process.
Gate Control Theory explains why
This could explain why pain is interpreted differently by people. This could explain why massage or warm compresses to the back could block painful impulses from that region by gclosing the gateh.
Modulation
The bodys response on a chemical level is the release of neuromodulators. These include endorphins and enkephalins that are released.
neuromodulators
These are endogenous opiods. They travel via neuro-fibers to the site of the pain producing an analgesic effect.
 Behavioral (Voluntary) Responses
Grimacing, withdrawing from pain, restlessness, protecting the painful area.
Three Responses to Pain
 Behavioral (Voluntary) Responses
 Physiologic (Involuntary) Responses
 Affective (psychological) Responses
 Physiologic (Involuntary) Responses to pain
Pupil dilatation, increased BP,RR, HR, pallor, nausea, increased blood glucose.
 Affective (psychological) Responses
Anorexia, fatigue, fear, stoicism, depression, anger, hopelessness, powerlessness.
Factors Affecting the Response to the Pain Experience
 Age
 Previous experience with pain
 Culture
 Religious beliefs
 Environment and support people
 Anxiety and stress
Nursing Process  Assessment
 Data collection
 Gathering subjective data
 Use of pain assessment tools
 Pain intensity scales
Pain- The Fifth Vital Sign!!!!
 New standards on pain management from JACHO took effect on January 1, 2001.
 Evidence must exist that all patients are assessed for presence of pain.
 Patients must be educated about pain and pain management.
Pain Assessment
 Frequency of pain assessment-depending on clinical circumstances-most hospitals and institutions will probably assess pain with vital sign assessment.
 Patient post-op-whenever vital signs are taken
 Pain reassessed 20-30 minutes after pain medication administration.
 Documentation on flow sheet or other form.
Pain Assessment is a Collection of
 Subjective Data
Pain Assessment
 Intensity
 numerical rating scale
 visual analog scale
 simple descriptive scale
Commonly Used Pain Scales
 Different forms of pain scales have been developed for use by clients.
 Each institution usually chooses one scale for adult use and one for pediatric use and incorporates this scale in pain assessment documentation materials.
Pain Assessment
More Questions
 Precipitiating Factors-What makes the pain worse?
 Alleviating Factors-What makes it better?
 Affect on A.D.L.fs
 Coping Resources
Objective Signs of Pain
Acute
 increased pulse, blood pressure,and respirations
 groaning,grimacing, crying, guarding
Objective Signs of Pain control Chronic
 vital signs return to baseline (autonomic nervous system adapts)
 sleeping, focus on activities that distract
Nursing Process: Planning
 Establishing goals appropriate to the situation.
 Select pain relief measures appropriate for the client.
Implementation Non-Pharmacological Interventions
 relaxation
 guided imagery
 biofeedback
 distraction
 Massage therapy
 Accupunture
 Reiki or energy therapy
Implementation
Pharmacological Interventions
 Use of Analgesics

 Use of Adjuvant Therapies
 Three general classes of analgesics
 NSAIDS
 non-opioid medications
 opioid medications
Types of Pain
Neuropathic Pain
Nocioceptive pain
Nocioceptive pain
 Results from mechanical, thermal, or chemical excitation or trauma to tissue
 Nocioceptors widely distributed in cutaneous tissue, bone, muscle, connective tissue, vessels, and viscera
 Pain described as dull or sharp, aching, throbbing.
 Opioid responsive
Neuropathic Pain
 Results from damage to or pathologic changes of the peripheral or central nervous system
 Pain described as burning, tingling, shooting, electric-like, lightning-like
 May exhibit resistance to opioids or require higher doss for effect
Medications for Nocioceptive pain
 NSAIDS
 Other analgesics
 Muscle relaxants
 Local anesthetics
 Opioids
Medications Neuropathic
 Antidepressants
 Anticonvulsants
 Antispasmotics
 Adrenergics
 Anesthetics
Non-steroidal
anti-inflammatory drugs
 relieve pain by inhibiting synthesis of prostaglandins.
 used for mild to moderate pain
Non-steroidal
anti-inflammatory drugs 3 effects include
analgesic, anti-pyretic, and anti-inflammatory.
Most common
Non-steroidal anti-inflammatory drugs (NSAIDS)
 aspirin
 ibuprofen (Advil)
 ketorolac (Toradol)
 celecoxib (Celebrex)
 rofecoxib (Vioxx)
Ceiling effect principle applies to these drugs-
Non-steroidal
anti-inflammatory drugs
Non-steroidal
anti-inflammatory drugs (NSAIDs)
MAJOR SIDE EFFECTS
 gastric irritation
 gastric bleeding
 renal problems
Main Non-Opioid Analgesic
Focus on: acetaminophen (Tylenol)
One of the most widely prescribed medications. Non-opiod but not anti-inflammatory. Reduces pain and fever. It is effective and relatively safe. Avoid use in presence of liver disease.
Caution: Liver damage in overdose. Children especially susceptible.
Often used in conjunction with opiods.
Opioid Analgesics
 Act by binding to receptor sites in the CNS
 Used for moderate to severe pain
 Fall into 3 classes
 pure opioid agonists
 partial agonists
 mixed agonists-antagonists
Opioid Agonists
 Opioid agonists-drugs that bind to specific opioid receptors to produce analgesia
 Strong Agonists
 morphine, meperidine, oxycodone, and hydromorphone
 Mild Agonists
 codeine, proproxyphene
Opioid Analgesics Major agents in this class
 Morphine
 Meperidine (Demerol)
 Hydromorphone (Dilaudid)
 Fentanyl Citrate (Sublimaze)
 Codeine
Dosages and Routes Morphine
Morphine
 PO-10-30 mg. Q4 hours prn.
 IM or SC-5-20 mg./70 kg. Q4 hours prn.
 IV infusion-0.1-1 mg/ml in D5W by controlled infusion pump
 Epidural infusion 2-4 mg/24 hours
Dosages and Routes  Meperidine (Demerol)
 PO,IM,SC,IV- 50-100 mg Q2-4 hours
Dosages and Routes  Codeine
 PO, IM,SC-15-60 mg Q4-6 hours prn
Dosages and Routes
 Sublimaze (Fentanyl)
 IV,IM-50-100 mcg
 Transdermal-25,50,75,100 mcg patch
 Onset 6 hours, duration 72 hours
 Addiction
-psychological dependence
 Physical dependence
-body adapts to the presence of opioid and suffers withdrawal symptoms if opioid is suddenly withdrawn
 Tolerance
-a larger dose of opioid is required to maintain same level of analgesia
Opioids-Side Effects CNS EFFECTS
 sedation
 dizziness
Opioids-Side Effects GI EFFECTS
 constipation
 nausea & vomiting
Opioids-Side Effects GU EFFECTS
 urinary retention
Opioids-Side Effects CV EFFECTS
 hypotension
 flushing
Opioids-Side Effects HISTAMINE-LIKE
 itching
 flushing
Opioids-Side Effects 1 more
RESPIRATORY DEPRESSION
 Ceiling effect vs No ceiling effect
as the dose of medication is increased above a certain level, the analgesic effect remains the same. Only the adverse effects tend to increase.

as the dosage is increased, pain relief is increased.
Opiods  Limiting factor
the degree of side effects that may occur as dose is increased.
Managing Tolerance
 One mechanism of managing tolerance is to titrate the drug dosage, which is adjusting the dosage depending on the clientfs response.
 Another approach is to change to another drug in the same class or add a non-opioid drug, such as ibuprofen
Treatment for Respiratory Depression/Excessive Sedation
Administer Opioid Antagonists
Administer Opioid Antagonists
 Drugs that reverse the analgesic and depressant effects of opioid agonists by displacing the agonist from their receptor sites
 Antagonist drugs include
naloxone (Narcan) and naltrexone (Trexan)
Adjuvant Medications
: Medications developed for uses other than analgesia are added to pain relief regimen.
Adjuvant Medications Uses:
 enhance the analgesic efficacy of opioids
 treat concurrent symptoms that exacerbate pain
 provide independent analgesia for specific types of pain
Adjuvant Medications types
 Corticosteroids
 Anticonvulsants
 Antidepressants
 Antihistamines
 Benzodiazepines
General Principles for Pain Management
• Treat pain by combining analgesics based on WHO guidelines.
• Maintain therapeutic serum levels.
• Choose appropriate routes of administration.
WHO's guidelines are used for
Treat pain by combining analgesics
Pain Management meathods
 PRN dosing
 Round-the-clock dosing
 Patient controlled analgesia (PCA)
 Epidural analgesia
PRN Dosing
Intermittent dosing for pain usually means that the patient requires a larger dose, causing the patient to have a peak serum drug level in the sedation range.
Round-the-Clock Dosing
Maintains a relatively smooth analgesic level and few if any peaks and valleys.
Patient-Controlled Analgesia (PCA)
 Patient self administers medication intravenously using a computerized programmable pump.
 Pump can be programmed for a bolus initial dose, continuous infusion, and/or a booster dose as needed that the patient requests by pushing a button.
PCA Orders state
 Medication
 Loading Dose
 Continuous Dose
 PCA Dose
 Lockout Interval
 4 Hour Dose Limit
 Epidural analgesia
 catheter placed between spinal vertebrae and the dura mater to allow diffusion of the drug into the CSF.
 Drug then binds with opioid receptors in the dorsal horn of the spinal cord.
 Used for both acute and chronic pain.
Choose appropriate routes of administration which can be
 Oral route ( most preferred since it is most convenient and cost effective).
 Rectal route
 Transdermal route
 Intravenous and intramuscular.
Evaluation of Nursing Care for Patient in Pain
 Ongoing process in which the nurse listens to subjective reports of patient and observes objective data (vital signs, facial expressions, restlessness).

 Nurse uses pain rating scales with patient to evaluate pain relief. Consistency is important in treatment.
 Interventional Level
 Use of nerve blocks, spinal (epidural and subarachnoid) adminstration of local anesthetics, spinal cord stimulation, and surgical interventions.
the most common reason that people seek medical advice.
 Pain (acute and chronic)
 Pain assessment and management skills
requires knowledge, understanding, and compassion.
Stress
A condition in which the human system responds to changes in its normal balanced state.
Stressor
Any situation,event, or agent that threatens a person’s security.
Stressor 2 types
* Internal
* Internal stressors
* e.g. headache,fear, illness
* External stressors
* e.g. difficult assignment-(care plans!!)
• loud noises-(child practicing tuba)
Common Stressors
* Physiologic
* Psychologic
* Cognitive
* Environmental
* Sociocultural
Homeostasis
* Physiologic


* Psychologic
Physiologic Responses to Stress 2 types
* General Adaptation Syndrome

* Local Adaptation Syndrome
General Adaptation Syndrome
Stage I
ALARM!!!
General Adaptation (cont.)
Stage II
Resistance
General Adaptation (cont.)
Stage III
Exhaustion
Local Adaptation Syndrome
* Involves only a body part
* Homeostatic and short term
* Examples
• Reflex Pain Response
• Inflammatory Response
Psychological Responses to Stress
Mind-Body Interaction
ANXIETY
Subjective response that occurs when a person experiences some threat to well-being- worry!
ANXIETY * Levels
* Mild
* Moderate
* Severe
* Panic
Anxiety vs. Fear
* Source may not be identifiable
* Related to future
* Vague
* Result of psychologic or emotional conflict
*
Source is identifiable
* Related to present
* Definite
* Result of discrete physical or psychologic entity
Coping Mechanisms
* Talking
* Crying
* Laughing
* Exercising
* Sleeping
Coping Mechanisms
* For moderate, severe, and panic anxiety and stress
* Task Oriented Behaviors
* Attack behavior
* Withdrawal Behavior
* Compromise Behavior
Defense Mechanisms
* Compensation
* Denial
* Displacement
* Introjection
* Projection
* Rationalization
* Reaction Formation
* Regression
* Repression
* Sublimation
* Undoing
Stress Management Techniques
* Exercise


* Rest and Sleep

* Nutrition
Stress Management Techniques
* Relaxation
* Guided Imagery
* Meditation
* Anticipatory Guidance
Anti- anxiety medications
* Reduce anxiety by reducing over activity in the CNS
* Diazepam, valium
* Lorazepam- ativan
* Alpraazolam- xanax
* Benzodiazepines
- largest and most commonly prescribed anxiolytic, first line drug treatment for anxiety
* Little effect on consciousness
* Safe- low side effects
* Little interactions with other drugs
Crisis
Acute state of disorganization
 Occurs when usual coping mechanisms are no longer effective
 Immediate intervention is needed
Types of Crises
* Developmental


* Situational

* Adventitious
Balancing Factors of a Crisis
Perception
CopingMechanism
Situational
Support
Stress and the Nurse
* Proper nutrition
* Regular exercise
* Adequate sleep and rest
* Avoid unhealthy coping
* mechanisms-e.g. drugs, alcohol, nicotine
* Learn to say “no” without guilt
* Relaxation techniques
How to avoid Burnout
* Use time management methods.
* Focus on accomplishments,not uncompleted tasks.
* Don’t assume responsibility where you have none.
* Know your limits.
* Remove yourself from stressors that have negative impact.
The Patient with Stress and Anxiety
NANDA Nursing Diagnoses
* Ineffective Coping
* Ineffective Denial
* Decisional Conflict
* Anxiety
Anxiety as Etiology
* Stress and Anxiety
* Part of etiology
Planning-Setting Goals help to
* Decrease level of anxiety
* Develop effective coping skills
Implementation * Anxiety Reduction
* Clearly state expectations
* Use calm approach
* Listen attentively
* Help patient identify anxiety producing situations
Evaluating Anxiety Reduction
* Use problem solving to respond to stress

* Practices healthy lifestyle habits and anxiety reducing techniques

* Decrease in anxiety is verbalized
Stress can
interfere with homeostasis but can also promote health and learning if level is not too high.
* Mechanisms exist to
help persons with stressful events.
Leader / Leadership
The ability to direct or motivate an individual or group to achieve set goals.”
Leadership  Qualities:
 Positive self image
 Role model
 Energizing vision
 Critical thinkers
 Responsible decision makers
 Value learning and are
knowledgeable
 Flexible
Leaders:
 3 tasks:
 Develop a sense of direction and purpose
 Build commitment to goals
 Face challenges that arise
When power used properly can effect change in:
 Health patterns
 Healthcare agency
 Community
 Nursing profession
 Healthcare system
Leadership / management styles:
 Autocratic
 Democratic
 Laissez-faire
 Transformational
 Situational
 Quantum
Autocratic
 Directive
 Complete control
 No thought to employee desire
 Bears responsibility for outcomes
 Stifles creativity
 Inhibits motivation
Democratic
 Participative
 Equality among leader and participants
 Work together / Share responsibility
 Fosters motivation and creativity
 Guidance rather than control
Laissez-faire
 Non-directive
 Permissive
 Gives power to the group
 Participants usually confused / frustrated
 No goal, No guidance, No direction
Transformational
 Charismatic
 Able to inspire and motivate others
 Challenge to grow personally / professionally
 Need a sense of mission
 In nursing our mission is to care for others
Situational
 Look at multiple factors
 Leadership style
 Group maturity
 Situation at hand
 Adaptability
 Understand all factors that affect a particular group of people
Quantum
 Quantum age
 Change is dynamic, ever present, and continuously unfolding
 Experience it as we perceive it
Manager
 Plan
 Identify problems, develop goals and strategies
 Organize
 Acquire, manage, mobilize resources to meet goals
 Direct
 Lead others to meet goals
 Control
 Implement ongoing evaluation
Dirty Dozen
• Isolation
• No feedback / recognition
• Only negative feedback
• Favoritism
• Mixed messages
• Talking down to
• Unrealistic deadlines
• Passive aggression
• Personal put down
• Breaking promises
• Threatening
• Attacking
• Functional Nursing care models
o Specific tasks for a group of patients
Nursing care models
• Team
• Functional
• Total care
• Primary
• Case Management
• Patient-centered / focused
• Collaborative
Nursing care models Team
o RN and other members provide care to a group of patients
Nursing care models • Total care
o Nurse does it all for her team
Nursing care models • Primary
o Nurse is responsible 24/7
Nursing care models • Case Management
o Quality / financial end of patient care
Nursing care models • Patient-centered / focused
o Multiple team members from multiple departments and different levels
Nursing care models • Collaborative
o Nurse and physician
Factors promoting change:
 Increased number of chronically ill / older people
 Increased role of government and industry in healthcare
 Rising cost of healthcare
 Changing patterns of healthcare delivery
 Number of RN’s staying in field / delaying retirement
Resistance to change:
• Threat to self
• Lack of understanding
• Limited tolerance for change
• Disagreements about the benefits
• Fear of increasing responsibility
• Active or Passive resistance:
• Active or Passive resistance
o _______ Active ___________: attacks, refusal to do, emails
o _____ Passive _____________: cancel meetings, too busy, ignore / avoid
Overcome resistance:
• Explain
• List advantages
• Relate to existing beliefs / values
• Open communication / feedback
• Be clear
• Introduce gradually
• Involve all parties
• Provide incentives
• Patient Care Coordinator
o Organize the care for your team of patients
• Considerations when delegating:
o Patient condition
o Complexity of the activity
o Potential for harm
o Degree of problem solving needed
o Level of interaction needed by the patient
o Capabilities of the staff being assigned the duty
o Availability of staff to accomplish the task
ANA’s position on Delegation:
• Nursing profession determines nursing’s scope of practice.
• Nursing profession defines and supervises personnel providing direct care.
• RN is responsible and accountable for their practice.
• RN supervises any assistant providing direct care.
• Assistive personnel work in a supportive role to the RN.
The Joint Commission
 Set the goals and standards for patient / family education.
 Speak Up Initiative
 Patient Education: Purpose
maximize or develop their self care abilities
 Patient Education: Influence their behavior to effect change in
 Knowledge
 Attitude
 Skills
4 key aspects of patient education:
 Maintain / Promote health
 Prevent Illness
 Restore Health
 Facilitate Coping
 Culture
 Beliefs, values, rituals
 Language / translation
 Literacy
 Can they function in society using written / printed material?
 20% can not!
Teaching Process
 Assess
 Diagnose
 Identify Outcomes / plan
 Implement
 Evaluate
 Document
Assessment:
 What are the learning needs and is the client ready to learn?
 Motivation:
 What is their internal trigger that will change the behavior?
 Compliance:
 Will they follow the plan or ignore it?
Diagnose:
 Problem related to etiology as manifested by signs and symptoms.
 Your problem is going to be what they are deficient in.
Outcome identification and planning
 Be thoughtful, put time into this process
 Learner outcomes are similar to patient outcomes in your nursing care plan.
 Box 22-9 verbs for writing outcomes.
 Content: what you need to give them for them to be able to meet the goal.
 Evidenced Based
 CINAHL (Cumulative Index to Nursing and Allied Health Literature)
 Technique you will use to deliver the content
 Role modeling
 Lecture
 Discussion
 Panel discussion
 Role playing
 AV material
 Printed material
 Web based instruction
  Teaching Strategies Keep in mind:
 Time constraints
 Schedule
 Group vs Individual
 Formal vs Informal
Teaching Implementing
 Effective communication
 Interpersonal skills
 Avoid technical / medical terms
 Adequate space / lighting
 Be prepared
 Be positive
 No distractions / interruptions
 Patient / learner responsibility:
 Listen
 Observe
 Attempt to understand
Evaluate
 Need proof / feedback that learning has occurred
 Cognitive: oral questioning
 Affective: their response
 Psychomotor: return demonstration
Document
 Summary of the need
 The plan
 Implementation
 Evaluation
 If outcome not met, how did you adjust?
Counselor
 Interpersonal process of helping patient make decisions that promote overall wellbeing
 Warm, friendly, open, caring
 Listen: guide in finding solutions, don’t solve
 Short term
 Long term
 Motivational
 Health Literacy:
“Health literacy is the ability of an individual to access, understand, and use health-related information and services to make appropriate health decisions. “
 Low health literacy is
a threat to the health and well-being of Americans and to the health and well-being of our medical system.
Low health literacy Costs the health care industry
$73 billion a year in misunderstood / misused health care services. More than 90 million Americans cannot adequately understand basic health information.