Acute/chronic Pain

Front 1

Pain

Back 1

An unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage.
"Pain is basically whatever the patient says it is, existing whenever the patient says it does" (McCafferty, 1979).

Front 2

What is the Nature of Pain

Back 2

1. Subjective and highly individualized
2. Protective Mechanism

Front 3

The Four Processes of Nociceptive Pain

Back 3

Four Processes:
1. Transduction- the injury; pain not felt initially.
2. Transmission - pain travels from the peripheral nerve fibers (A-delta - send sharp, localized distinct sensations; C-send poorly localized, visceral , persistant pain) to the spinal cord.
3. Perception - patient becomes aware of the pain (brain stem, thalamus, and cortex); Neurotransmitters - send excitatory or inhibitory impulses; Neuromodulators modify neuron activity
4. Modulation - After binding to the spinal cord, the neurtransmitters are taken back up inthe cell, recycled and stored for future release.

Front 4

The Gate Control Theory

Back 4

suggests that pain impulses can be regulated or blocked by gating mechanisms along the CNS.
1. Pain impulses pass through when a gate is open and are blocked when the gate is closed.
2. closing the gates will provide pain relief.
3. Simulation of A-beta neurons (massage) will cause the gating mechanisms to close.
4. The endogenous ability to reduce or increase the degree of pain preceived.

Front 5

Acute Pain

Back 5

-Rapid onset with varying intensity.
-Identifiable cause and predictable ending
-It will eventually resolve with or without treatment after a damaged area heals.

Front 6

Types of Chronic Pain

Back 6

1. Chronic nonmalignant
2. Cancer Pain

Front 7

Chronic Pain

Back 7

Prolonged pain, usually lasts more than 6 months; endorphhins cease to function; there is a decrease in normal ADL's and physical activity

Front 8

Causes of Chronic Pain

Back 8

Arthritis, low back pain, peripheral neuropathy (non-life threatening)

Front 9

Signs and Symptoms of Chronic Pain

Back 9

May not show overt S/S; observed S/S are fatigue, insomnia, anorexia weight loss, depression, hoplessness, and anger

Front 10

Cancer Pain

Back 10

Due to tumor progression, invasive procedures, toxicities of treatment, infection, or physical limitation.

Front 11

Factors Influencing Pain

Back 11

1. Age
2. Gender
3. Culture
4. Meaning of Pain
5. Attention
6. Anxiety
7. Fatigue
8. Previous Experience
9. Coping Style
10. Family and Social Support

Front 12

Assessment of Pain

Back 12

"the 5th Vital Sign"
Pain Quality Region Severity Time

Front 13

Effects of pain on the patient

Back 13

1. Physical Signs and symptoms: V/S, physical exam, observe for autonomic other NS involvement - sympathetic/parasympathetic responses.
2. Behavioral Effects: Verbalization, vocal response (crying, moaning, gasping), facial and body movements, social interaction, Influence on ADL's, Behavoral Changes (nonverbal-confused patients)

Front 14

Non-Pharmacological Pain Relief Measures

Back 14

1. Accupressure
2. Relaxation
3. Guided Imagery
4. Distraction
5. Biofeedback
6. Self-hypnosis
7. Reducing Pain Perception
8. Cutaneous Stimulation

Front 15

Acute Pharmacological Pain Interventions

Back 15

1. Non-narcotic and Non-steroidal anti-inflammatory drugs (NSAIDs):
Mild Pain: Tylenol, ibuprofen, naproxen, Cox-2 inhibitor/Celebrex

Mild to moderate pain: ketorolac or Toradol inj.
Tylenol #3, Vicodin & Lortab, Percocet, Roxicet, & Tylox, ASA with Percodan.

Front 16

Narcotic Analgesics/Opioids

Back 16

For Moderate to Severe Pain:
Short-Acting: Morphine, Dilaudid & Fentanyl
Long-Acting: Oxycodone, MS Contin & Fentanyl patches

Front 17

Neuropathic Pain

Back 17

Cymbalta, Neurontin (Gabapentin), and Lidocaine 5% patch (Lidoderm)-write date, time, and inital on patch

Front 18

Adjuvants/Co-analgesics

Back 18

Enhance pain control or relieve other symptoms associated with pain.
Includes, sedatives, antianxiety agents, and muscle relaxants, tricylclic antidepressants, baclofen, anticonvulsants

Front 19

Patient Controlled Analgesia (PCA)

Back 19

Drug system that allows patients to administer pain medications when they want them without risk of overdose.

Front 20

Cancer Pain Approach

Back 20

3-step approach
1. nonopioid +/- adjuvant
2. weak opioid +/- adjuvant
3. strong opioid +/- adjuvant
Best to begin with higher dose and taper down.
Medication is to be given on a regular basis, not PRN.

Front 21

Cancer Pain Medication Routes

Back 21

Epidural infusion; intrathecal; long-acting oral meds (MSO4); transdermal patches; PCA; continuous drip MSO4

Front 22

Restorative Care

Back 22

1. Pain Clinics: interdisciplinary team approach for inpatient and outpatient care.

2. Hospices: programs for the care of the terminally ill, that allow the patient to remain at home in comfort and privacy. Pain control is a priority.

Front 23

Low Back Pain

Back 23

Affects 80% of adults at some point.
Lumbar pain is common.
1. the area bears most of the body's weight
2. most flixible region of spine
3. contains nerve roots that are vulnerable to injury

Front 24

Causes of Back Pain

Back 24

1. Degenerative disk disease
2. Lack of physical exercise
3. Prior injury
4. obesity
5. structural/postural abnormalities
f. systemic disease

Front 25

Clinical manifestations of Back Pain

Back 25

Radiating to buttock and leg
Depressed or absent reflexes
Paresthesia/muscle weakness in legs, feet, toes

Front 26

Diagnostic Studies of Back Pain

Back 26

X-Rays (structural defects)
MRI/CT, myelogram (to localize herniation)
EMG- (to determine severity of nerve irritation or to rule out other pathology)

Front 27

Collaborative Care for Chronic Pain

Back 27

PT, RICE
Surgery=only if conservative measures fail, if there is increased radiculopathy, or loss of bowel/bladder control.

Front 28

Addiction

Back 28

A strong physiological and/or psychological dependence on a drug or other psychoactive substance.

Front 29

Adjuvant Pain Therapy

Back 29

Therapy that is assisting or aiding another type of therapy. They include sedatives, antianxiety agents, muscle relaxants, PCA's, tricyclic antidepressants, baclofen, anticonvulsants

Front 30

Analgesic

Back 30

The most common mothod of pain relief. Include NSAIDs, opioids, narcotics

Front 31

Breakthrough Pain

Back 31

Pain that comes on suddenly that is not relieved by the patients' normal pain suppression management

Front 32

Distraction

Back 32

diversion of attention; with meaningful stimuli, a person can ignore or become unaware of pain. Stimuli triggers the release of endorphins. Music, singing, praying, reading, and playing games are examples.

Front 33

Endogenous

Back 33

produced within or caused by factors within the organism. Organisms are carried by the bloodstream from other areas of infection in the body

Front 34

Endorphins

Back 34

amino acid residues of B-lipotropin that bind to opiate receptors in various areas of the brain and have a potent analgesic effect

Front 35

Enkephalins

Back 35

pentapeptides occurring in the brain and spinal cord and also in the gastrointestinal tract; they have potent opiate-like effects and serve as neurotransmitters.

Front 36

Epidural

Back 36

area situated on or outside the dura mater

Front 37

Equianalgesic Dose

Back 37

Refers to the dose and route of administration of one drug that produces about the same degree of analgesia as the given dose and route of another drug.

Front 38

Narcotic

Back 38

drug that produces insensibility or stupor, especially an opioid

Front 39

Opioid

Back 39

synthetic narcotic that has opiate-like activities but is not derived from opium

Front 40

NSAIDs

Back 40

non-steroidal anti-inflammatory drug (Acetaminophen, ibuprofen, naproxen, Celebrex)
Effective analgesic for pain induced by inflammation.

Hint 40

Tylenol, Advil, Aleve

Front 41

Physical Dependence

Back 41

the adaptation manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreaseing blood level of the drug, and/or administration of an antagonist.

Front 42

Pain Tolerance

Back 42

the state of adaptation in which exposure to a drug induces changes that result in a decrease in one of more of the drug's effects over time. some of these changes include increaseing drug excretion and reducing the number of receptors to bind the drug.

Front 43

Pain Threshold

Back 43

the point at which a person first preceives a painful stimulus as being painful

Front 44

Referred Pain

Back 44

pain preceived in an area distant from the site of painful stimuli

Front 45

Somatic

Back 45

pain that arises from the skin and musculoskeletal structures

Front 46

Visceral

Back 46

pain that arises from organs

Front 47

Analgesia teams

Back 47

agencies who consult with staff and prescribers on how best to control the patient's pain. The team typically consists of one or more nurses, pharmacists, case managers, and physicians.

Front 48

Withdrawal/Abstinence syndrome

Back 48

Patient who is physically dependent on opioids abruptly ceases using them. Can also occur if the patient receives a reversal agent such as naloxone/Narcan

Front 49

Localized pain

Back 49

pain confined to the site of origin

Front 50

Projected Pain

Back 50

pain along a specific nerve or nerves

Front 51

Radiating pain

Back 51

diffuse pain around the site of origin that is not well localized

Front 52

Mu Opioids cause:

Back 52

cause side effects that include constipation, nausea, and vomiting, urinary retention, pruritis, sedation, and respiratory depression. Often viewed as allergies

Front 53

Intractable pain

Back 53

chronic pain that cannot be managed using standard therapies

Front 54

Additives

Back 54

drugs that add an effect, either harmful or beneficial. Phenergan is a an example that gives additive effects to enhance opioid effects, yet don't contain any analgesic or analgesia-potentiating properties.

Front 55

radiofrequency ablation

Back 55

heat therapy

Front 56

cryoanalgesia

Back 56

cold therapy

Front 57

Time Required for respiratory depression effects with opiod analgesics (IV/IM/SubQ)

Back 57

IV: 7 minutes
IM 30 minutes
SQ: 90 minutes
*times are approximate

Front 58

What is the nurse's role in the administration of opioid antagonists?

Back 58

Opiod antagonists are administered as emergency For treatment of opioid overdose and as maintenance thereapy for former opiod-addicted individuals

Front 59

What are some patient education that a nurse would educate on NSAIDs?

Back 59

Name, dose, frequency, route, indication
Notify MD for GI distress, edema.
Do not double doses if there is a missed dose
Adverse effects: skin rash, itching, visual disturbances, edema, h/a, heartburn, CP, dark stools. Some NSAIDs may cause drowsiness and dizziness and should be cautioned about performing tasks with which the NSAID would interfere.
No Concurrent use with any OTC analgesics, photosensitivity with ibuprofen

Front 60

Bouchard's Nodes

Back 60

Nodules in the proximal interphalangeal joint. Less common in OA (Osteoarthritis)
May cause redness, swelling, tenderness, & aching. More common in degenerative joint disease.

Front 61

Gout
Primary & Secondary

Back 61

acute attacks of arthritis in association with increased serum uric acid levels.
Primary: Hereditary error of purine metabolism
Secondary: may be R/T another disorder (alcoholism, DM, HTN, obesity, etc. or medications-chemotherapy)

Front 62

Heberden's Nodes

Back 62

reactive bony overgrowths at the distal interphalangeal joints; palapable protuberances associated with flexion & lateral deviation of the distal phalanx. More common in women. Can be found in both osteoarthritis and degenerative joint disease

Front 63

Occupational Therapist (OT)

Back 63

Therapy that works on fine motor skills associated with ADL's and the skills related to coordination and cognitive retraining.

Front 64

Osteoarthritis

Back 64

A slowly progressive disorder of articulating joints (esp. weight-bearing) and is characterized by degeneration (destruction) of articular cartilage.

Front 65

Causes of Osteoarthritis (OA)

Back 65

exact mechanism is unclear
Prolonged and excessive use of joints
Inadequate cartilage nutrition resulting in degeneration
Digestion of proteohlycans via cracks in the surface of articular cartilage by the enzyme hyaluronidase (normally in synovial fluid)

Front 66

Predisposing Factors of OA

Back 66

Excessive use of or stress on a joint
Genetic factors influence the development of some clinical manifestations
Congenital structural defects, metabolic disturbances (DM), repeated intraarticular hemorrhages (hemophilia)
women > men; over the age of 60

Front 67

Clinical presentations of OA

Back 67

no systemic manifestations; other organ involvement also absent
Joints involved: most frequently involves the distal and proximal interphalangeal joints of the finger, first carpometacarpal joint, knees, 1st metatarsophalangeal joing (big toe), joint pain, joint stiffness, crepitation, mal-alignment of extremity

Front 68

Diagnostic Studies of OA

Back 68

X-rays: show joint space narrowing. They do not always correlate with pain experienced
ESR (sed rate): may be moderately elevated in erosive OA
Synovial fluid: may be increased in volume, but free of signs of inflammation (clear yellow & viscous)

Front 69

First-line therapy pharmacological Agents for OA

Back 69

Acetaminophen 1000 mg up to QID (Tylenol NTE 4g/24 hours)
Topical agents
Low-dose ibuprofen 400 mg up to QID or 800 mg TID Q8H

Front 70

Second-line Therapy pharmacological agents

Back 70

NSAIDs
Cox-2 inhibitors (Celebrex)
Intra-articular injections of corticosteroids-less likely
Glucosamine sulfate & chrondroitin sulfate
Intra-articular injections of synthetic & naturally occurring hyaluronics (anti-inflammatory effort, short term lubricant effect-no additional medications are required with this treatment)

Front 71

Non-pharmacological Treatments

Back 71

Rest, joint protection
Heat
Exercise
Assistive Devices
Stress management
Surgery-debridement, arthodesis, arthroplasty osteotomy, total joint replacement

Front 72

Chronic complications of OA

Back 72

Generally not crippling; surgery may become an option if destruction is extensive and pain is severe

Front 73

Rheumatoid Arthritis (RA)

Back 73

Chronic systemic disease characterized by recurrent inflammation of the diathrodial joints & related structures; characterized by remissions and exacerbations (75% are women)

Front 74

Causes of RA

Back 74

Infection: Epstein-Barr virusparovirus, mycobacterium

Autoimmunity: an antigenic stimulus, such as a virus, leads to the formation of an abnormal immunoglobulin G (IgG). Will show an increased Sed Rate.

Front 75

Clinical presentations of RA

Back 75

Joints: ALWAYS AFFECTED SYMMETRICALLY
small joints of hands and feet, larger peripheral joints of the wrists, elbows, shoulders; hips, ankles, and jaw
Joint Pain and Stiffness: increased pain with motion
Stiffness on arising and after periods of inactivity
joints are tender, painful, and warm to touch
Deformities of the hand:
Ulnar drift
Boutonniere deformity
Hallux valgus
Swan-neck deformity
Extra-articular Manifestations
rheumatoid nodules
vasculitis
Other: heart disease, myositis, peripheral edema, pleuritis, Raynaud's, peripheral neuropathy

Front 76

Ulnar drift

Back 76

occurs secondary to stretching of articular capsul and muscular imbalance

Front 77

Boutonniere deformity

Back 77

Flexion of proximal interphalangeal with compensatory hyperextension of distal interphalangeal joint

Front 78

Hallux Valgus

Back 78

aka bunion

Front 79

Swan-neck deformity

Back 79

flexion contracture of metacarpophalangeal joint & hyperextension of proximal interphalangeal joint & flexion of distal interphalangeal joint

Front 80

Rheumatoid Nodules

Back 80

Raised, firm, nontender SQ nodules; usually found on the olecranon bursae or extensor surface of forearm

Front 81

Vasculitis

Back 81

inflammation of blood vessels; may be responsible for SQ nodules and other extra-articular manifestations of RA

Front 82

Physical Therapy

Back 82

helps the patient achieve mobility and teaches techniques for performing certain activities of daily living.

Front 83

Rehabilitation

Back 83

The process of learning to live with chronic and disabling conditions by returning the patient to the fullest possible physical, mental, social, vocational, and economic capacity.

Front 84

Diagnostic Studies of RA

Back 84

ESR (Sed Rate)
Serum rheumatoid factor
Arthrocentesis
X-ray

Front 85

Arthrocentesis

Back 85

synovial fluid analysis

Front 86

Pharmacological agents of RA

Back 86

Disease modifying drugs: Plaquenil
Gold salts therapy
Immunosupressants: Imuran
Cytoxic Drugs: Methotrexate
Minocycline

Front 87

Clinical presentations of Gout

Back 87

Onset is rapid, pain, swelling within hours with a low grade fever.

Front 88

Acute S/S of Gout

Back 88

Great toe typically initial site
midtarsal, ankle knee, and wrist
attacks subside (with/without treatment) in 2-10 days
no symptoms between attacks

Front 89

Chronic S/S of Gout

Back 89

multiple joint involvements
Tophi- deposits of sodium urate crystals in the olecranon bursae, vertebrae, along tendons, and in skin and cartilage; typically not noted until many years afte onset of disease

Front 90

Diagnostic Studies of Gout

Back 90

Synovial fluid
Serum Uric Acid Levels
Urine uric acid levels

Front 91

Management plans of Gout

Back 91

Supportive care of inflammed joints-bed rest, splinting, careful handling, cradle to keep bedclothes off feet
Education to control; some precipitating factors are starvation, overindulgence of calories, alcohol, or purines

Front 92

Pharmacological Agents for Gout

Back 92

Cochicine
Allopurinol
Probenecid
NSAIDs
Corticosteroids-last resort

Front 93

Nutritional Therapy for Gout

Back 93

Limit alcohol and foods high in purines

Front 94

Purine rich foods

Back 94

anchovies, sardines, roe, scallops and mussels, broth, bullion, consomme, game meats, gravy, dark leafy greens

Front 95

Chronic Complications of Gout

Back 95

deformity of joints
Secondary OA
Renal disease (kidney or UT stone formation; pyelonephritis

Front 96

Hip Fracture Classification

Back 96

Intracapsular-within the joint capsule

Extracapsular-outside the joint capsule

Front 97

Short-term Rehabilitation Goals (4 day stay) for Hip Fractures

Back 97

Prevention of complications
Prevention of dislocation
S/S of prosthesis dislocation
Prevention of hip pining complications

Front 98

Five "P's" of musculoskeletal post-surgical assessment

Back 98

Pain
Pulses
Pallor
Parasthesia
Paralysis