Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
86 Cards in this Set
- Front
- Back
What are the nine common myths about pain?
|
1. Too much pain medication too frequently constitutes substance abuse, causes addiction, will result in respiratory depression or will hasten death; 2.) Pain should be treated, not prevented; 3.) People in pain always report their pain to
their health care provider; 4.) People in pain demonstrate or show that they have pain - pain can be seen in the patient’s behavior; 5.) The level of pain is often exaggerated by the patient; 6.) Generally a patient cannot be relieved of all pain; 7.) Some pain is good so that the patient’s symptoms are not masked; 8.) Newborn infants do not have pain; and, 9.) It is expected that the elderly, especially the frail elderly, always have some pain. |
|
From the pain article: What is important for a nurse to know when assessing a client's pain?
|
She must know the physiological signs when a person isn't able to communicate their pain like: an infant, or comatose, or mental problem such as: tachycardia, hypertension, diaphoresis, bracing,and pallor. Nurse must know categories for pain: acute, chronic, breakthrough...and must know the types: Physical: musculo, skeletal, neurological, visceral. Emotional: depression, grief: and Spiritual and psychosocial: (person's perception)...the nurse knows there are different ways to treat: pharmacological/non-pharmacological. nurse is educated on opioids and side effects. Nurse will not lie to patient and give placebo. And nurse knows the difference between addiction/pseudoaddiction/ And DTs. Nurse checks biases at the door. Pain is what the patient says it is.
|
|
What is important in nursing goal/interventions and pain?
|
coming up w/individualized plan for the client/ educating client on side effects/ educating the family on how to deal with client's pain and on what they can do to help. Evaluating the response and outcomes and re-plan to manage client's pain efficiently.
|
|
Nurse needs to know that certain groups are at higher risk for pain such as:
|
Infants & children, women, the elderly, patients with cognitive dysfunction,patients with emotional or mental illness, patients with chronic pain, patients with neuro-pathic pain, substance abusers, minority populations, the homeless, and patients with terminal illnesses.In
addition, patients who speak a different language or who are from a cultural tradition different from that of the clinician pose a special challenge. |
|
Some common sources of pain for older adults:
|
Common sources of pain in older adults: (article from Nursing 2009)
Diabetes, contractures, arthritis, osteoporosis, etc. |
|
Pain management is all about getting rid of the pain. T/F
|
False. Pain management is beyond pain relief; related to quality of life, ability to work productively, to enjoy recreation, to function normally in family and society, and to die w/dignity.
|
|
Pain relief is a basic...
|
Human Need!
|
|
Remember Pain management isn't just up to the nurse. Who else could be involved?
|
Family, accupuncturist, masseuse, Accupressure, Meditation, hypnotist, P/T. O/T, Psychiatrist...
|
|
What is definition of pain?
|
1) Whatever the person experiencing the pain says it is, existing wherever the person says it does 2) An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP, 1979)
3) Multidimensional nature of pain includes physiologic, affective, cognitive, behavioral, and sociocultural influences on pain perception and expression. (see slide 9) |
|
What are the classifications of pain?
|
You can have these classifications: acute or chronic of any of the following classifications: 1) Nocioceptive (pain has a purpose, and it's good we have it. A signal that something is going on or that is related to something signifcant, like a hammer on a finger or post-op surgery. Neuropathic pain>Pain is altered because because of damaged sensory nerves that alter the processing of input, as with neuropathy like diabetics...Phantom pain is also this type. 3) Idiopathic pain: chronic pain w/out identifiable physical or psychological cause or pain that is perceived to be excessive for the linked pathology. (ex complex regional pain syndrome CRPS; chronic pain w/no known example.
|
|
6) Outline the mechanisms by which pain is perceived (4 mechanisms) Med Surge pg 127-130: Called the- Physiological process of Nociceptive pain:
|
oTransduction: conversion of mechanical, thermal, or chemical stimulus into a neuronal action potential. Level of peripheral nerves, particular the free nerve endings, or nociceptors. Injuries cause release of numerous chemicals into area surrounding peripheral nociceptors: Prostaglandins, Bradykinin, Serotonin, Substance P, Histamine, and ATP. Fast: A-Delta Fibers, Slow: C Fibers
oTransmission: movement of pain impulse from the site of transduction to the brain oPerception: point at which a person is aware of pain oModulation: release of inhibitory neurotransmitters, hinder transmission of pain…Serotonin, NorEpi, GABA, endogenous opioids Nociception is physicologic process by which information about tissue damage is communicated to CNS |
|
Explain the differences between nocioceptive and neuropathic pain.
|
Nociception: Normal processing
Damaged non-neuronal tissue Localized to where injury is Opioids, NSAIDS, steroids Post-operative, acute fractures, smash fingers, etc. Neuropathic: Abnormal processing Damaged neuronal tissue Non-localized Adjunctive meds: Anti-depressant, anti-seizure, muscle relaxants, anesthetics, a2-adrenergics Diabetic neuropathy, spinal compression, neuralgia Noxious stimuli-induced activation of the free nerve endings Releases chemical mediators that activate nociceptors Function primarily to sense and transmit pain signals; but if problem w/pathways, they may not transmit the signals right. Neuropathic Abnormal processing of noxious stimuli by nervous system For example: when nerves are damaged, the CNS no longer processes pain. Before nerves are totally dead, nerve pain is intense pain (hot poker pain); diabetic neuropathy (nerve is damaged but not dead, so still having pain). |
|
What kind of pain is this describing? Acute or Chronic?
Ends when problem is healed Generally diminishes Initiating event (what has caused the pain) directly associated with pain mechanisms Physiologic manifestations ↑HR, ↑RR, ↑BP, diaphoresis/pallor, anxiety,agitation, confusion, urine retention Opioids & NSAIDS Goal: Elimination of the pain |
Acute.
|
|
What are the symptoms and signals that someone is in chronic pain?
|
Continues past healing
Peaks & valleys Pain mechanisms different from initiating event Behavioral manifestations Flat affect Decreased physical activity/movement Fatigue Withdrawal from others and social interaction. Adjuvant therapy Goal: Functionality/can’t eliminate it, but can treat it to get a better quality of life. |
|
Name the different dimensions of pain?
|
Physiologic (the physical determinants of pain), sensory (recognition of painful stimuli), affective (emotional response to pain), cognitive (beliefs, attitudes, memories regarding pain), behavioral (observable actions like grimacing in response to pain) sociocultural (demographics, culture...support system).
|
|
Explain the physiologic dimension of pain.
|
Physiologic: cause suffering systemically; includes the genetic, anatomic, & physical determinants of pain; these physical components influence how painful stimuli are recognized and described.
These are the 4 major neural mechanisms by which nocioceptive pain is perceived: Transduction, Transmission, Perception, Modulation. |
|
Explain the sensory dimension of pain.
|
Sensory: recognition of painful stimuli (see next slide for area, pattern, nature, and intensity of pain for assessment) Perception "i'm in pain"
|
|
Explain the affective dimension of pain
|
Affective: refers to emotional response to pain; fear, anxiety, depression, anger (all associated with affective dimensions; the feelings that ppl experience)
Negative emotions impair the patient’s quality of life; There is a link between depression and pain! Treating depression & anxiety in patients w/chronic pain can help relieve the depression symptoms AND the pain; be aware of the cycle as a nurse! Cancer therapy |
|
Explain the cognitive pain.
|
Cognitive: refers to beliefs, attitudes, memories from past painful experiences; meaning to pain influences the ways they respond to pain.
Pain-related beliefs and coping strategies people may use: distraction, others convince themselves that the pain is permanent and untreatable; those that believe the pain is uncontrollable and overwhelming are more likely to have poor outcomes. Dementia, dilirium, sedation, and mental disability alter responses to pain. |
|
Explain the behavioral dimension to pain.
|
Behavioral: refers to observable actions used to express or control pain (grimacing, posture, change of daily activities in response to pain)
People who cannot communicate verbally (ie dementia) may demonstrate changes in behavior (becoming less active/withdrawn socially; can be combative). |
|
Explain the sociocultural dimension of pain.
|
Sociocultural: factors like demographics, support systems, culture (think about how this influences pain/ rituals around pain), social roles, gender, age, and education all influence pain perception, beliefs and coping.
L&D example: mother scared of pain, but father says she can’t have epidural (cultural influence); have to follow what they want, and honor those cultural differences. |
|
You can use PQRST, but what is the other acronym and its parts that we can use to assess pain in babies (they can't talk)?
|
Called NPASS(neonatal pain agitation sedation scale) a lot of this is physiological (HR, RR) or behavioral (crying/irritability, facial expression, extremities and tone/ flaccid or tense) to determine pain level; if babies are sedated the physiological side may be depressed;this type of assessment would be the same as someone who is cognitively impaired (curled up in ball, rocking, flailing, etc).
When you touch them, the sats drop (indicates that they cannot handle the pain from touching) With babies in hospital: have to treat anything 4 or greater on pain scale (as determined by NPASS scale); 3 would indicate bundling, comfort measures (touch, pacifiers). * |
|
When you are assessing pain, what 4 areas and there parts, are you assessing?
|
Pattern:Onset, Duration, Constant,
Intermittent; Area:General, Localized Referred, Radiating; Nature:Quality Throbbing,Aching, Dull, Sharp, Burning, Cramping; Intensity: Quantify (0-10),Numeric,Verbal, Visual. |
|
Explain transduction.
|
1) Transduction: the conversion of a mechanical, thermal, or chemical stimulus into a neuronal action potential. Transduction of pain happens @ the level of peripheral nerves, in particular the free nerve endings (nociceptors).Pain produced form activation of peripheral nociceptors is called nociceptive pain.
Second source of pain-related action potentials arising form abnormal processing of stimuli by the nervous system called neuropathic pain. |
|
Explain transmission in nocioceptive pain.
|
Transmission: the movement of pain impulses from the site of transduction to the brain (includes transmission along peripheral nerves to spinal cord, dorsal horn processing, transmission to thalamus & cerebral cortex)
once the signal arrives in the CNS it is processed w/in the dorsal horn of the spinal cord; this processing includes the release of neurotransmitters from afferent fibers into synaptic cleft; the neurotransmitters can bind to nearby cell bodies and can activate or inhibit the signal continuing on. |
|
Explain the perception part of pain
|
Perception: occurs when pain is recognized, defined, and responded to by the person experiencing the pain. In the brain, nociceptive input is perceived as pain (involves several brain structures like RAS, limbic, & somatosensory system).
|
|
Explain modulation part of physiologic nociceptive pain.
|
Modulation: involves the activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain; signals from the brain going back down spinal cord modify incoming impulses; modulation of pain signals can occur @ the level of the periphery, spinal cord, brainstem, & cerebral cortex.
Neurons originating in brainstem descend to spinal cord and release substances (endogenous opioids, serotonin, norepinephrine) that inhibit nociceptive impulses/pain transmission). |
|
Where do these certain places of pain radiate or refer to: i.e. lungs & diaphrgm, liver, gall bladder, heart, kidneys, bladder, stomach, ovaries, appendix, and ureters.
|
Lungs and diaphragm refer to: front and back of neck (necklace), liver radiates to right side of neck, gall bladder refers to right shoulder, heart: left side of chest down left arm and mouth or face; kidneys hurt on back side of kidney area and right flank; bladder refers to lower back to sacral to inner thighs; stomach refers to front and back side of stomach; ovaries-pain refers to front and back of ovaries; appendix: right over top of appendix-lower right side; ureters hurt right over the top of the bladder.
|
|
What type of pain must be considered when evaluating or doing a pain location report?
|
Must consider Referred pain or pain happening in uninjured tissue that has radiated from another location. Must consider this type of pain or therapy could be misguided.
|
|
What is central sensitization of the dorsal horn and its results?
|
It is enhanced excitability that occurs in spinal nerves) results in 4 types of pain. 1) Increased responses to noxious stimuli (hyperalgesia). 2) Painful responses to normally innocuous stimuli (allodynia) 3) Persistent pain. 4) spread of pain to uninjured tissue (referred pain)
|
|
What are the drug treatments used to interrupt the transmission part of nociceptive pain?
|
Transduction: therapies that alter either the local environment or sensitivity of the peripheral nociceptors can prevent transduction and initiation of action potential. Decreasing the effects of chemicals released @ the periphery is the basis of several drug approaches to pain relief. Examples are below:Non-steroidal anti- inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) & corticosteroids exert their analgesic effects by blocking pain-sensitizing chemicals. NSAIDS interfere w/prostaglandin production
(ibuprofen is classic; teach elderly that ibuprofen can burn up kidneys if overused). Bleeding tendencies due to decreased platelet aggregation Ulcers, Renal problems, Drugs that stabilize the neuronal membrane and inactivate the peripheral sodium channels inhibit production of the nerve impulse; examples of these meds are: Local anesthetics, Anti- seizure agents, Corticosteroids : prednisone is classic example Function to reduce the production of both prostaglandins and leukotrienes. |
|
What are drug treatments that can interrupt transmission part of nociceptive pain?
|
Transmission
Opioids : interrupts transmission and perception of pain Once generated, an action potential travels all the way to the spinal cord unless it is blocked by sodium channel inhibitor (local anesthetic)Transmission interruption: in the area of neurotransmitter release (synaptic cleft), exogenous and endogenous opioids play important role by binding to opioid receptors abd blocking the release of neurotransmitters; endogenous opioids (secreted by the body) are capable of producing analgesic effects similar to exogenous opioids like morphine. |
|
What are the drug treatments that can be used to treat the perception part of nociceptive pain?
|
Perception: because pain perception involves several brain structures (RAS, somatosensory system, limbic system), there is no precise location for pain perception; corticol structures are also thought to be critical in constructing the meaning of pain (this explains why behavioral strategies like distraction and relaxation techniques are effective @ pain reduction for many people; by directing attn away from pain sensation, patients can reduce the sensory & affective components of pain.OpioidsNon-steroidal anti- inflammatory drugs (NSAIDs)
Adjuvants (e.g., antidepressant, antiseizure) |
|
What are the drug treatments that can be used to treat the modulation part of nociceptive pain?
|
Modulation: several anitdepressants exert their effects through the modulatory systems. Tricyclic antidepressants (increase serotonin in brain and NE levels by preventing cellular reuptake to keep levels high; increasing their availability to inhibit noxious stimuli.). Higher levels of serotonin and NE in the synaptic cleft inhibit the transmission of nociceptive signals in the CNS.
Especially helpful for neuropathic pain syndromes. |
|
What are the consequences of untreated pain?
|
Unnecessary suffering, Physical & psychosocial dysfunction, Impaired recovery from acute illness & surgery, Immuno suppression, Sleep disturbances. In the acutely ill person, unrelieved pain can result in increased morbidity as a result of :
Respiratory dysfunction, increased heart rate & cardiac workload, Increased muscular contraction & spasm, decreased GI motility & transit, & increased catabolism (lewis, 126) Among patients, attitudes toward pain & opioids play major role in underreporting and undertreatment of pain. Fear of addiction, tolerance & side effects often make patients reluctant to report pain or comply w/regimen that involves opioid drugs.Others may be hindered due to beliefs that pain is inevitable & the result of worsening disease; my belief that pain cannot be relieved by drugs; Older adults: may believe that pain is inevitable & they desire to be a “good patient” who doesn’t want to complain, so doesn’t ask for meds; this is common among older adults. Untreated pain is harmful; can be systemic! *Notes from table that were mentioned in class:Endocrine: increased cortisol, increased glucose intolerance, increase blood sugar; GU effects of F&E disturbances (diabetics are @ high risk for these problems if pain is untreated) Chronic pain in diabetic person (lots of potential problems) Hyperglycemia occurs w/stress, & unrelieved pain causes more stress; vicious cycle. |
|
According the following core principle of pain assessment: Patients have the right to appropriate assessment and management of pain....What is the nursing implication?
|
Pain should be assessed in all patients.
|
|
According the following core principle of pain assessment: Pain is always subjective....What is the nursing implication?
|
The patient's self-report of pain is the single most reliable indicator of pain. The nurse needs to accept and respect this self-report unless there are clear reasons for doubt.
|
|
According to the core principle of pain assessment: Physiologic and behavioral (objective) signs of pain (tachycardia, grimacing,) are not sensitive or specific for pain....What is the nursing implication?
|
Observations should not replace patient self-report unless the patient is unable to communicate.
|
|
According to the following core principle of pain assessment: Pain is an unpleasant sensory and emotional experience....what is the nursing implication?
|
Assessment should address physical and psychologic aspects of pain.
|
|
According to the following core principle of pain assessment: Assessment approaches, including tools, must be appropriate for the patient population...what is the nursing implication?
|
Special considerations R needed for obtaining assessment data for patients w/ difficulty communicating. Family members should be included in the assessment process, when possible.
|
|
According to the core principle of pain assessment: Pain can exist even when no physical cause can be found...what is the nursing implication?
|
Pain without an identifiable cause should not be attributed to psychologic causes.
|
|
According to the core principle of pain assessment: Different patients experience different levels of pain in response to comparable stimuli...what is the nursing implication?
|
A uniform pain threshold does not exist.
|
|
According the core principle of pain assessment: Patients w/ chronic pain may be more sensitive to pain and other stimuli...what is the nursing implication?
|
Pain tolerance varies among and within individuals depending on various factors (heredity, energy level, coping skills, prior experience w/pain)
|
|
According to the core principle of pain assessment: Unrelieved pain has adverse physical and psychologic consequences...what is the nursing implication.
|
Nurses should encourage patients to report pain, especially those who are reluctant to discuss pain, deny pain when it is likely present, or fail to follow through on prescribed treatments.
|
|
What is the most valid indicator in regard to pain management?
|
Patient report (subjective)
|
|
T/F pain is never good.
|
In some circumstances pain is necessary or a good sign as like in child labor, means normal progression is happening and a baby will soon arrive, or in after labor pains for the uterus to contract and stop bleeding.
|
|
what are the 4 main roles/interventions of the nurse in regards to pain?
|
1) Assess for pain and communicate the information to other health care providers/collaboration, 2) Base treatment on client’s goals; reassessing goals over course of treatment.
3) Ensure the initiation of adequate pain relief measures-Giving meds when needed; not waiting for pain to severe before giving meds. 4) Evaluate the effectiveness of the interventions. Evaluate impact of pain on physical and social functioning. |
|
What are the important things a nurse needs to remember in administering pain treatment?
|
8 Underlying principles that guide all
pain treatment : 1)The patient must always be believed 2) Every patient deserves adequate pain management 3) Treatment must be based on the patient’s goals not ours 4) Treatment includes a combination of drug and nondrug therapies. 5) The multidisciplinary approach addresses all dimensions of pain (collaboration w/others) 6) All therapies must be evaluated to ensure they are meeting patients’ goals (have to make sure it is working; may have to re-plan) 7) Drug side effects must be prevented and/or managed Nausea is common side effect 8)Patient and family teaching: the cornerstone of a treatment plan |
|
Name the common non-opioid analgesics and the nursing considerations regarding these pain killers.
|
1) Acetaminophen (Tylenol): antipyretic and analgesic effects, but no antiplatelet or antiinflammatory effects like aspirin has. (not an NSAID) . It is Metabolized by the liver, so while usually well tolerated, if doses over 3-4 g/day are taken, acute overdose or alcoholics/liver disease can result in hepatoxicity.
2) Salicylates: Aspirin: effective for mild pain, but is limited by its common side effects (gastric upset, platelet dysfunction and bleeding); has antiinflammatory effects Nonselective NSAIDS: 3) Ibuprofen (Advil): an NSAID 4) Naproxen (Naprosyn): an NSAID, antipyretic, analgesic effects; prototype is ibuprofen (drug book) 5) Ketorolac (Toradol) (the only IV NSAID) Selective NSAID 6) Celecoxib (Celebrex)COX-2 enzyme inhibitor (see lewis, p 135-136) COX -2 enzyme is responsible for converting arachidonic acid into prostaglandins; enzyme is found mostly @ site of injury where it mediates inflammation; if COX-2 is inhibited (w/celbrex or ibuprofen, it will have antiinflammatory effects). |
|
Explain Opioids and their mechanism of effect.
|
Opioids produce effects by binding to receptors in the CNS; this results in: 1) Inhibition of transmission of nociceptive input from periphery to the spinal cord 2)Altered limbic system activity and 3) Activation of the descending inhibitory pathways that modulate the transmission in the spinal cord. Overall, opioids act on several nociceptive processes.
Opioids are categorized according to their physiologic action (ie agonist and antagonist) & binding at specific opioid receptors. Nociceptive pain appears to be more responsive to opioids than neuropathic pain, although opioids are used in both types of pain. |
|
What are some of the most common opioids, their route, and their mechanism of effect?
|
Types of opioids:1) Codeine (Tylenol #2, #3, #4); tylenol w/amount of codeine in itN/V (nausea/vomiting) common2) Hydrocodone (Vicodin): tylenol and hydrocone mixture; used for moderate to moderately severe pain. Quicker onset, longer acting
3) Oxycodone (Percocet): tylenol w/oxycodone; for acute moderate pain; can be used also like oral morphine for severe pain. Similar to hydrocodone. 4) Morphine sulfate (Duramorph, MS Contin). Prototype narcotic: IV, IM, SQ, PR (per rectum; suppository given to avoid nausea and vomiting; or not functional GI system, so give it this way), PO Can bypass 1st pass by doing others than PO. Anytime direct absorption into blood stream, you are bypass- ing liver (which will diminish thru 1st pass effect). Comotose patients (good to give suppositories to; they cannot communicate, but you know they are in pain w/source of pain). 5) Meperidine (Demerol) (has a toxic metabolite, normeperidine, that may cause seizures; associated w/neuro-toxicity)IV, IM. Shorter acting; contraindicated for acute pain lasting longer than 2 days & for those that require larger doses (more than 600mg per 24hrs.) Should NOT be used to treat chronic pain. 6) Fentanyl (Sublimaze) IV. Quick onset, very short acting. Great for post-op pain in PACU & procedures. |
|
What do you give a person who is showing signs of respiratory depression, like RR of 8, from overdosing opioids?
|
Give them narcan or naloxone to reverse it. Narcan is given to reverse respiratory depression; short half-life, and short acting; might have to give it more than once.
|
|
What are adjuvant drugs?
|
Adjuvant drugs are used in conjunction w/opioid and nonopioid analgesics. They were originally developed for other purposes (antiseizure, antidepressants) but were found later to be effective for pain.
|
|
Explain antidepressants as adjuvant drugs.
|
Antidepressants: prevent reuptake of serotonin and NE (higher levels left in synaptic cleft inhibit transmission of nociceptive signals to the CNS; especially good for neuropathic pain. Nursing considerations: monitor for anti- cholinergic adverse effects (side effects=dry mouth, urinary retention, sedation, & orthostatic hypotension) & monitor blood levels during chronic therapy. amitriptyline (Elavil).
|
|
Explain antiseizure meds and muslce relaxants as adjuvant therapy.
|
1) Antiseizure agents: effective for neuropathic pain & migraine headaches: gabapentin (Neurontin) and (Tegretol) carbamazepine.
2) Muscle relaxants:cyclobenzaprine (Flexeril):muscle spasm relief |
|
Explain corticosteroids as adjuvant therapy.
|
Corticosteroids : used for manage- ment of acute & chronic cancer pain, pain secondary to spinal cord compression and inflammatory joint pain syndromes;Adverse effects of corticosteroids: hyperglycemia, fluid retention, dyspepsia & GI bleeding, impaired healing, muscle wasting, osteoporosis, adrenal suppression, & susceptibility of infection.
Should NOT be given @ same time as NSAIDS cuz work on same final pathway. Prednisone (Deltasone): work w/ inflammation. |
|
Explain anesthetics as adjuvant therapy.
|
There are oral, parenteral, and topical local anesthetics. They can be given IV, subcut, IM). They interrupt transmission of pain signals to the brain.Side effects of systemically delivered local anesthetics include dizziness, paresthesia (especially around mouth) & seizures (@ high doses); may also cause dysrhythmias and myocardial depression due to their effect on cardiac conductivity.
“caines” (Lido, Bupivi, Mar, Sensor) Lidocaine, bupivicaine, marcaine, sensorcaien. |
|
Name the 10 various routes that opioids can be given.
|
Oral, sublingual, buccal, intranasal, transdermal, subq, IM, IV, Rectal, and Epideral.
|
|
What is important to know about the oral route of administration of opioids?
|
Oral : 1) have slower onset of action & more prolonged effect than parenteral meds. 2) Larger doses may be required due to the 1st pass; this means that oral opioids are absorbed from the GI tract into the portal circulation and shunted to the liver; partial metabolism in the liver occurs before it enters systemic circulation. 3) Oral opioids are as effective as parenteral opioids if dose is large enough to compensate for 1st pass metabolism.
|
|
What is important to know about the sublingual route of administration of opioids?
|
Sublingual:1) Meds that are absorbed into circulation after being placed under the tongue (exempts them from 1st pass effect); should not be swallowed (will not have desired effect); 2) morphine is commonly given to cancer patients via sublingual route, but little of the drug is absorbed from sublingual tissue (most gets dissolved in saliva & swallowed, making its metabolism the same as oral morphine.
|
|
What is important to know about the buccal route of administration of oioids?
|
Buccal: 1) Dissolving solid med in mouth against the cheek & gets released to systemic circulation (exempts from 1st pass effect); 2) alternate cheeks to avoid mucosal irritation; 3) do not chew or swallow this type or take liquids w/it.
|
|
What is important to know about the intranasal route of administration of oioid drugs.
|
Intranasal: delivers meds to highly vascular mucosa avoiding the 1st pass effect; Stadol (for acute headaches ). Note: has been used lately flu vaccine.
|
|
What is important to know about transdermal route of administration of opioids?
|
Transdermal: type of topical application; has systemic effects; patch that goes on skin to deliver meds; 2) lidocaine patches put @ site of pain (this is a numbing agent)
Useful for those that cannot tolerate oral analgesic meds; absorption is slow w/1st application, it may take 12-17 hrs to reach full effect. |
|
What is important to know about subq route of administration of opioids?
|
Subcutaneous:1) injection into tissues just below dermis of skin (into fat). 2)Onset of analgesia w/this route is slow and so is rarely used for acute pain management.
3) Continuous infusions are effective for end of life pain management. |
|
What is important to know about the IM route of administration of opioids?
|
Intramuscular: 1) (IM) injection into muscle. 2) Injections can cause significant pain, result in unreliable absorption, and w/chronic use can result in abscessess and fibrosis (so not recommended as much as other parenteral routes).
|
|
What is important to know about IV route of administration of opiods?
|
Intravenous: injection into vein; best parenteral route when immediate analgesia are necessary.
|
|
What is important to know about the rectal route of administration of opioids?
|
Rectal route is oftenoverlooked but is useful when patient can't take analgesic by mouth like when they are vomiting...Options are hydromorphone, oxymorphone, morphine and acetaminophen. Note: some opioids cause nausea and anti nausea drugs like phenergan can be given to offset nausea to allow opioid to be given.
|
|
What is important to know about the epidural route of administration of an opioid?
|
Epidural: 1) administered in the epidural space via a catheter. 2) Catheter is placed as close to the nerve supplying the painful dermatome as possible; 3) intraspinally delivered analgesics are highly potent (they are delivered close to receptors in the spinal cord dorsal horn), so less is needed for effect. 4) s/s of an intraspinal infection due to epidural: diffuse back pain, pain or paresthesias during bolus injection, & unexplained sensory or motor deficits in lower limbs; fever may or may not be present. 5) Nursing Implications for managing epidural analgesia: Fundies, p. 1078/table 43-6
Monitor VS, especially respirations q15 for epidural analgesia (including skin color and respiratory effort monitoring); once stablized, monitoring occurs qhr. |
|
What are some of the common side effects of opioids that nurses need to monitor?
|
Avoid supplemental doses of opioids due to possible additive CNS adverse effects.
Monitor for effects of meds; complications include nausea and vomiting, urinary retention, constipation, respiratory depression and pruritus |
|
What are the great things about having the various routes for opioid administration?
|
Flexibility of administration routes allows health care providers to:
1) Goal is to target the source of the pain 2) Achieve therapeutic blood levels rapidly (use IV if this is the desire) 3) Avoid certain side effects Example, don’t want to risk nausea and vomiting by PO, give rectal suppositories. 4)Provide analgesia to patients who are unable to swallow,- use sublingual route or rectal suppositories. |
|
What do the initials PCA stand for?
|
Patient Controlled Analgesia
|
|
How is PCA administered?
|
Epideral or IV, in Intermittent delivery or continuous delivery; patient pushes button when they decide the dose is needed and machine delivers a bolus infusion of analgesic
Used for management of acute pain, including post-op and cancer pain. Continuous infusion may improve nighttime pain relief and promote sleep |
|
What is important to educate the client PCA?
|
1) Client education CRITICAL; they are afraid of overdose.
2)Teach them that machine is on “lock-out” and won’t allow them to get more than they need; pushing the button after this period will NOT deliver more meds. 3)Teach them push button before pain intensity is greater than the patient’s desired pain intensity goal. |
|
T/F the nurse and family can control the pca.
Also If you a person switches to other methods of opioids after pca what is important to know? |
Not “nurse or family” controlled, but rather patient controlled. However through authorized agent controlled analgesia guidelines a family member could be authorized to push the button. Taper/ transition to oral medications
Change setting to taper down as patient transitions to PO meds. To transition, patient should receive increasing doses of oral drug as the PCA analgesic is tapered. |
|
What are some non-pharmacologic therapies for pain?
|
Physical pain relief strategies: 1) Application of heat/cold
2) Exercise 3) Massage 4) Acupuncture 5) Transcutaneous electrical nerve stimulation (TENS) Not as effective for chronic pain; May be used for acute pain including post-op pain and pain associated w/physical trauma.Delivery of electric current through electrodes applied to the skin over painful areas, @ trigger points, or over a peripheral nerve 6) Percutaneous electrical nerve stimulation (PENS) Lewis, p 144. Stimulates deeper peripheral tissues through insertion of a needle that is connected to a stimulator located near a large peripheral or spinal nerve. Amount of electric current is regulated for max pain relief. Helpful w/some types of musculoskeletal pain. |
|
Closing the Gate from the Gate-Control theory of pain is the basis for what type of treatment for pain?
|
Theory that pain impulses that travel along the CNS will only be able to travel through if the gate is open, but nonpharmacological treatments like: massage, or other influences like stress can release endorphins that raises a person's pain threshold will all have an effect on the various gates: physiological, emotional or cognitive.
|
|
What are some cognitive, affective, and behavioral non-pharmacological pain relief strategies that can be used?
|
1)Distraction: redirection of attn away from pain. 2) Music
3) Imagery: “happy place” find a relaxing place to imagine. 4) Talking, watching TV, playing games. 5)Relaxation 6) Hypnosis 7) Just being present,(nurse and family). |
|
What are the barriers in treating the elderly for pain or diagnosing pain?
|
see lewis, p. 146/table 10-15 & p. 147/gerontologic considerations.
1) Often believe pain is normal, inevitable part of aging & may think nothing can be done about it. 2) May not report pain for fear of being a burden.3) Have fear of taking opioids.4) More likely to use words like “aching, soreness, or discomfort” rather than “pain”; so nurses have to be persistent in asking about pain in older adults. 5) Communication barriers due to prevalence of cognitive, sensory-perceptual, and motor problems that interfere w/a person’s ability to process info and communicate (dementia, delirium, post-stroke aphasia & paraplegia, and language barriers). 6) Hearing and vision deficits may complicate assessment. |
|
Is chronic or accute pain most common in the aging and what is important to know about this type of pain?
|
Chronic pain is common among older adults; often associate w/physical disability & psychosocial problems. 2) Most common painful conditions are musculoskeletal (osteoarthritis, low back pain, previous fracture sites)3) Chronic pain results in depression, sleep disturbance, decreased mobility, increased health care utilization, and physical and social role dysfunction.
4) Pain is often inadequately assessed & treated in this population. |
|
What are important thing to know the aging and pain treatment?
|
Treatment concerns: 1) metabolize drugs more slowly so 2) are @ greater risk for higher blood levels and adverse effects. 3) Use of NSAIDS associated w/GI bleeding; acetaminophen should be used whenever possible.4) Polypharmacy due to other chronic issues; addition of analgesics can result in dangerous drug interactions and increased side effects.5) Cognitive impairment can be exacerbated when analgesics like opioids, antidepressants and antiseizure meds are used (titrate slowly and monitor carefully for side effects)
6) Must incorporate nonpharmacologic techniques 7) Exercise and patient teaching are very important in this population. |
|
What are some common myths about pain?
|
1) The patient exaggerates pain.
2) Generally pain cannot be relieved entirely. 3) Pain is good to avoid masking symptoms.3) The elderly always have some pain.4) Frequent pain medication constitutes substance abuse, addiction, results in respiratory depression, or hastens death. 5) Pain should be treated, not prevented. 6) Pain is always reported to health care providers 7) Pain always shows |
|
What are the pain related nursing diagnoses?
|
Activity intolerance
Acute pain Anxiety Chronic pain Constipation Disturbed sleep pattern Disturbed thought process Fatigue Fear Hopelessness Ineffective coping Ineffective role performance Powerlessness Social isolation |
|
What organizations have highlighted the ethics and legalities regarding pain?
|
1) A basic human right (Amer. Pain Foundation)
2)Pain care “Bill of Rights” (2001) 3) A basic legal right (Amer. Bar Assoc.) 4) ANA Code of Ethics 5) TJC Guidelines |
|
What are some of the important summary reminders that Ms. Meredith gave during class?
|
1) Pain management is a basic human need! 2) Pain is “What the client says it is!” 3) Pain manage- ment applies to ADN concepts. 4) It is nociceptive/ neuropathic, acute/chronic 5) It is multi-dimensional. 6) Unrelieved pain is systemically damaging. 7) The RN plays a central role in pain care.
8) Assessment: subjective/objective/comp. 9) Pain management is multidisciplinary. 10)Pain management has ethical/legal issues 11) Pain relief may be Rx or non-Rx 12) Special groups have unique needs.13) RN attitudes affect pain management. |
|
What is cutaneous stimulation for pain treatment?
|
Stimulation of the skin that relieves pain: massage, warm bath, ice bag, Tens unit...
|
|
Which painkillers are derivatives of acetamenophen? How much acetomenophen is allowed per 24 hour period?
|
4 gms of acetomenophen is allowed in a 24 hr period. Can cause hepatotoxicity. Derivatives are: percocetn, vicodin, lortab, and ultracet. Overdoses are treated w/ acetylcysteine (mucomyst).
|