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146 Cards in this Set

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American Pain Society
The APS defines pain as:
an unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage.
National Pain Care Act of 2003
A White House initiated national movement that requires the AHRQ(Agency for Healthcare Research and Quality) to collect EBP(evidence based practice) and to develop and disseminate pain protocols regarding pain and palliative care.
Pain is defined as applied to nursing is:
whatever the patient says it is, existing whenever the patient says it does.
Pain may be classified by its:
its location or source,
its mode of transmission,
its etiology(cause).
the study of the cause of a condition.
Acute pain is:
protective in nature warning of tissue damage or organic disease.
rapid in onset,
varies in intensity from mild to severe,
disappears after underlying cause is resolved,
ends once healing occurs.
Chronic pain is:
limited, intermittent, or persistent and lasts beyond the normal healing period.
when disease persists but symptoms are not experienced.
when symptoms reappear.
Chronic Malignant Pain
pain associated with cancer or other progressive disorders.
Chronic Nonmalignant Pain
pain associated with tissue injury that is nonprogressive or healed.
Patients have difficulty describing chronic pain because:
it is poorly localized, often perceived as meaningless.
Chronic, persistent pain may lead to:
Misconceptions and personal biases of caregivers regarding chronic pain may:
adversely affect the management of chronic pain,
label the patient as :
a malingerer,
a hypochondriac.
Location or Source:

Cutaneous pain
superficial pain usually involving the skin or subcutaneous tissue.
ex: a paper cut.
Location or Source:

Somatic pain
diffuse or scattered,
originating in:
blood vessels,
ex: a strong pressure on a bone or tissue damage resulting from a sprain.
Location or Source:

Visceral pain
poorly localized,
originates in body organs that stretch abnormally and become distended, ischemic or inflamed in the:
a reflex contraction or spasm of the abdominal wall that occurs as a protective mechanism to protect additional trauma to underlying structures.
patient automatically tenses his abdomen, preventing tissue organs from being palpated or touched.
Referred pain
pain that originates in one part of the body but is perceived in another area distant from its point of origin.
referred pain is transmitted to other areas innervated by the affected nerve root.
Neuropathic pain
pain resulting from an abnormal functioning or injury to peripheral nerves or the CNS.
its cause is unknown.
it can occur in many forms.
it can be of short duration.
it is often described as burning or stabbing.
appropriate treatment is often delayed as a result of misdiagnosis.
a characteristic feature of neuropathic pain that occurs after a weak or non-painful stimuli such as a light touch or a cold drink.
Neuropathic pain syndromes:

Complex Regional Pain Syndrome
pain occurs in the area partially injured peripheral nerve, most commonly the brachial plexus or median or sciatic nerve.
described as burning, severe, diffuse and persistant.
elicited by minimal movement or touch of the affected area.
it increases with repeated stimulation and continues after stimulation ceases.
Neuropathic pain syndromes:

Posterpetic Neuralgia
this pain syndrome follows an acute CNS infection, such as Herpes Zoster-shingles.
characterized by vesicular eruption and neuralgic pain, which is usually unilateral and encircles the body ib band-like clusters.
the pain may be mild to severe.
intractable pain may persist for months to years.
Intractable pain
pain that is resistant to therapy.
it persists despite a variety of interventions.
Neuropathic pain syndromes:

Phantom Limb Pain
pain that is referred to an amputated limb where receptors and nerves are clearly absent.
pain may be a severe, burning, fiery sensation; crushing; cramping;a sense that the limb is edematous; or a sensation that the limb is being twisted or distorted.
Neuropathic pain syndromes:

Trigeminal Neuralgia
paroxysms(sudden outbursts) of lightning-like stabs of intense pain in the distribution of one or more divisions of the trigeminal nerve(5th. cranial nerve).
pain is usually experienced in the mouth, gums, lips, nose, cheek, chin and surface of the head and may be triggered by activities like talking, eating, shaving, or brushing one's teeth.
Neuropathic pain syndromes:

Diabetic Neuropathy.
a common complication of long-term diabetes mellitus.
damage to the peripheral and autonomic nerves resulting from metabolic and vascular changes.
involvement of the peripheral nerves can result in sensory loss which can lead to injury progressing to infection and gangrene.
symptoms include sensations of numbness, prickling, or tingling(parasthesias)
Psychogenic pain
pain for which a physical cause cannot be identified.
pain from a mental event can be just as intense as pain that results from a phsiycal event.
The three types of responses to pain are:
the severity of pain and its duration affects responses to pain.
Common Responses to Pain:

Behavioral Responses(voluntary)
moving away from painful stimuli,
moaning and crying,
protecting the painful area and refusal to move.
Common Responses to Pain:
Physiological Responses(involuntary)
(moderate and superficial pain)
Increased blood pressure
increased pulse
increased respiratory rates
increased adrenalin output
increased blood glucose
pupil dilation
muscle tension and rigidity
pallor(peripheral vasoconstriction)
Common Responses to Pain:
Physiological Responses(involuntary)
(severe and deep pain)
decreased blood pressure
decreased pulse rate
rapid and irregular breathing
prostration(absolute exhaustion)
nausea and vomiting
fainting or unconsciousness
An increase in vital signs may
occur briefly in acute pain but
may not occur in chronic pain.
Common Responses to Pain:
Affective Responses(psychological)
exaggerated weeping and restlessness
The Process of Pain(mechanism) involves four stages:
The Process of Pain(mechanism)

the activation of pain receptors involving the conversion of painful stimuli into electrical impulses that travel from the peripheral nerve fibers(nociceptors) to the spinal cord at the dorsal horn.
the peripheral nerve fibers that transmit pain.
Pain Threshold
the lowest value of a stimulus that, once reached, allows the recognition of pain.
Gender may influence this threshold.
ADAPTATION has been described during the repeated torture of prisoners of war where it was reported that the pain was not as acute as it would have been under different circumstances; also seen when the toleration of pain from the immersion into hot water that is gradually heated is greater than that of being plunged into water of the same temperature.
the prolonged effect of pain stimuli on the CNS that leads to the lowering of the threshold for activation of pain, this can allow even harmless stimuli to trigger pain.
Injured tissues release neurotransmitters that excite nociceptors, they are:
Substance P.
a substance that can either excite or inhibit target nerve cells.

powerful vasodilator, increases capillary permeability,
constricts smooth muscle,
triggers the release of Histamine, resulting in the redness, swelling and pain typical of the inflammatory response.

hormone-like substances

Substance P
sensitizes nociceptors, increasing the rate of firing.

hormone that stimulates smooth muscle, vasoconstricts and inhibits gastric secretions.
The four stimulant agents that stimulate skin and superficial organs are:
MECHANICAL stimulants- such as friction from bed liners or pressure from a cast,
THERMAL stimulants- sunburn or cold water on a tooth carrie,
CHEMICAL stimulant- acid burn,
ELECTRICAL stimulant- the jolt of a static charge.
Afferent nerve fibers associated with pain transmission are:
A-delta fibers &
C- fibers.
these carry impulses from pain receptors to the CNS.
A-delta fibers
fast conducting fibers that transmit acute, well localized pain.
smaller, slower fibers that conduct diffuse, visceral pain.
pain is often described as burning and aching.
Pain Reflex.
protective, responsible for withdrawal of endangered tissue from a damaging stimuli.
impulse travel via the (afferent) A-delta fibers through the dorsal root ganglia to the dorsal horn of the spinal cord.
synapsing with an (efferent) motor neuron, the impulse carried is back to the site of the stimulus resulting in an immediate muscle contraction.
Thalamus and Cortex of the brain
The Thalumus is the sensory center of the brain where sensations such as heat, cold, pain and touch first become conscious.
it receives the impulse from the pain stimuli via the spinal cord soon after it is processed through the pain reflex.
The impulse is then directed to the cortex where the PERCEPTION of intensity and location of the pain are determine.
The cortex then sends a signal back via the spinal cord to the dorsal horn where the pain is MODULATED with the release of chemicals such as endorphins.
occurs in the cortex.
the recognition and interpretation of the pain stimuli.
the process by which the sensation of pain is inhibited or modified by substances called neuromodulators.
Endogenous opioid compounds(naturally present morphine-like chemical regulators) in the spinal cord and brain.
Possess analgesic activity and alter the perception of pain.
They bind to specific opioid receptor sites throughout the CNS, blocking the release or production of pain-transmitting neurotransmitters.
Pain and Stress are capable of activating this endogenous opiate system.
Endorphins and Enkephalins are opioid neuromodulators.
The Endorphins
produced at neural synapses at various points along the CNS pathway.
powerful pain blockers with prolonged analgesic and euphoric effects.
May be released when pain-relieving drugs are used and during the application of skin stimulation and relaxation techniques.
possess the most potent analgesic effect of all the endorphins.
The Enkephalins
found widespread throughout the brain and dorsal horn of the spinal cord.
less potent than the endorphins.
believed to reduce pain sensation by inhibiting the release of Substance P from the terminals of afferent neurons.
The Gate Control Theory of Pain
the theory states:
small diameter afferent nerve fibers conduct excitatory pain stimuli toward the brain.
large diameter afferent nerve fibers inhibit the transmission of pain impulses from the spinal cord to the brain.
a gate mechanism exists in the dorsal horn of the spinal cord.
the inhibitory and excitatory signals at the gate determine the impulses that go to and from the brain.
the brain regulates the gate through learned past experiences & behaviors. this explains how similar painful stimuli are interpreted differently by different people.
this theory may explain why mechanical(massage),thermal(hot/cold compresses), and electrical interventions can bring relief to a painful lower back area or a soothing voice can ease pain all by stimulating the large fibers to close the gate.
Terms used to describe the Quality of pain:
intense, sticking
Terms used to describe the Quality of pain:
more diffuse and not as intense as sharp pain, possibly more annoying tha painful.
Terms used to describe the Quality of pain:
pain that covers a large area.
patient is often unable to point to a specific area, usually moves hand over a large area, such as the entire abdomen.
Terms used to describe the Quality of pain:
pain that moves from one area to another, such as the lower abdomen to the area over the stomach.
Other Terms used to describe the Quality of pain:
vise-like pressure.
Terms used to describe the Severity of pain:
Severe or Excruciating
Slight or Mild.
Patient's interpretation of pain is important.
Behavioral and Physiological signs help the nurse assess the severity.
On a scale of 1 to 10:
mild = 1 to 3
moderate = 4 to 7
severe = 8 to 10.
Terms used to describe the Periodicity of pain:
pain that does not stop.
Terms used to describe the Periodicity of pain:
pain that starts and stops again.
Terms used to describe the Periodicity of pain:
Brief or Transient
pain that passes quickly.
Factors Affecting the Pain Experience:
Culture & Ethnicity.
cultural norms dictate patient's behavior, attitudes and values.
Do not stereotype responses to pain.
be knowledgeable about cultural variations and alternative practices used to manage pain.
Factors Affecting the Pain Experience:
Family, Gender and Age variables
nurses must increase their respect for diversity.
these variables make pain assessment a complex task for nurses.
Factors Affecting the Pain Experience:
Environment and Support
a healthcare environment may decrease an individual's ability to cope with pain.
some require the presence of a loved one or friend, others prefer to be alone.
intervening and attempting an honest discussion is important
Factors Affecting the Pain Experience:
Anxiety and other Stressors
anxiety tends to increase the perceived intensity of pain.
pain may be aggravated with anxiety, tension and fatigue.
the threat of the unknown increases anxiety. teaching patients what to expect about what to expect tends to decrease the need for pain medication.
Factors Affecting the Pain Experience:
Past Pain Experiences
an individual's experience of pain in the past and the qualities of that experience profoundly affect new pain experiences.
those that have received adequate pain relief in the past are generally unafraid.
some memories are virtually unerasable.
Pain Assessment:
Pain as the Fifth Vital Sign.
pain is a vital sign along with:
body temperature
respiratory rate
blood pressure.
The TJC has accreditation standards that include emphasis on patient's rights to effective assessment and treatment of pain.
Components of a Pain Assessment:
Data Collection
patient's verbalization and description.
report from family and caregiver familiar with patient.
duration of pain.
quantity and intensity-pain scale.
aggravating factors.
alleviating factors.
physiological indicators -vitals.
behavioral responses- nonverbal ques included.
effect of the pain on activities and lifestyle.
patient's expectation for pain relief.
Questions and Factors Used to Assess Pain's Characteristics
where is your pain?
is it internal or external?
in acute pain,ask patients to point to painful area.
in chronic pain patient may have difficulty trying to localize it.
Questions and Factors Used to Assess Pain's Characteristics
how long have you been experiencing pain?
how long does the pain last?
how often does it occur?
Questions and Factors Used to Assess Pain's Characteristics
ask patient to rate scale on a 1 to 10 scale( 1 to 5 for older adults).
rate the pain at its least and at its worst.
Questions and Factors Used to Assess Pain's Characteristics
what words would you use to describe your pain?
Questions and Factors Used to Assess Pain's Characteristics
how does the pain develop and progress?
has the pain changed since it first began?
if so, how?
Questions and Factors Used to Assess Pain's Characteristics
Aggravating Factors
what makes the pain occur or increase in intensity?
Questions and Factors Used to Assess Pain's Characteristics
Alleviating Factors
what makes the pain lessen or go away?
what methods of relief have you tried in the past?
how long were they used?
how effective were they?
verify current orders and their effectiveness.
ask outpatients to record a medication profile-all the medications they are taking.
Questions and Factors Used to Assess Pain's Characteristics
Associated Phenomena
are there factors that relate consistently to your pain?
are there any other symptoms that occur just before, during or after your pain?
Questions and Factors Used to Assess Acute Pain's Characteristics
Physiological Responses
increased vital values
skin color
pupil size
signs of sympathetic stimulation may occur with acute pain but need not be present to verify pain.
Questions and Factors Used to Assess Chronic Pain's Characteristics
Physiological Responses
decreased pulse and BP,
rapid, irregular respirations,
pupil constriction,
nausea and vomiting,
warm,dry skin
signs of parasympathetic stimulation may occur, especially in prolonged, severe,visceral or deep pain.
Questions and Factors Used to Assess Pain's Characteristics
Physiological Responses
muscle tension
ask patient if he is aware of any tight, tense muscles.
Questions and Factors Used to Assess Pain's Characteristics
Physiological Responses
are signs of anxiety present?
decreased attention span or an inability to follow directions,
frequent asking of questions,
changing the subject,
avoidance of discussion of feelings,
acting out,
somatizing(expressing a mental condition as a bodily function).
Questions and Factors Used to Assess Pain's Characteristics
Behavioral Responses:
Posture, gross motor activities-
does patient rub or support a particular area or make frequent position changes?
does patient protect an area from stimulation?
lie quietly?
Questions and Factors Used to Assess Pain's Characteristics
Behavioral Responses:
Facial features-
does patient show facial grimaces, knotted brow, or an overall taut, anxious appearance?
Questions and Factors Used to Assess Pain's Characteristics
Behavioral Responses
does patient moan,sigh, scream, cry,repetitively use the same words?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
do you feel anxious?
are you afraid?
if so, how bad are these feelings?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
do you feel depressed, down or low?
if so, how bad are these feelings?
are your feelings about yourself mostly good or bad?
do you have feelings of failure?
Do you see yourself or your illness as a burden to those that care about you?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
Interactions with others
how does patient act when he is pain in the presence of others?
how does patient act when not in pain?
how do significant others respond to the patient when he is in pain and when not in pain?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
Pain's interference with patient's life
does pain interfere with sleep?
if so, to what extent?
is fatigue a major factor in the pain experience?
are your relationships affected by your pain?
is work affected?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
Perception and meaning of pain to patient
are you worried about your illness?
do you see a relationship between your pain and your illness?
if so, how do you see them related?
do you find any meaning in your pain?
is this helping or hurting you?
are you struggling to find some meaning in your pain?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
Adaptive mechanisms used to cope
what do you usually do to relieve stress?
how well do these things work?
what techniques do you use at home to help cope with the pain?
how well have they worked?
do you use these in the hospital?
if not, why not?
Questions and Factors Used to Assess Pain's Characteristics
Affective Responses:
what would you like to be doing right now if the pain were better controlled?
how much would the pain have to decrease(on a 1 to 10 scale) for you to begin to accomplish these goals?
Pain Assessment Scales:
NRS - Numerical Rating Scale
a 1 to 10 rating scale with 10 being severe pain
Pain Assessment Scales:
infants,children,and adults who are unable to use the NRS or Wong-Baker FACES scale
Pain Assessment Scales:
CRIES scale
neonates(0 to 6 months)
Pain Assessment Scales:
FLACC scale
infants and children(2 months to 7 years) who are unable to validate the presence or quantify the severity of pain.
F- faces
L- legs
A- activity
C- cry
C- consolability
Pain Assessment Scales:
Wong-Baker Faces Pain Rating scale
adults and children(>3 years old) in all patient care settings.
Pain Assessment Scales:
Beyer Oucher Pain scale
young children who can point to a face to indicate their level of pain.
Pain Assessment Scales:
WILDA scale
widely used scale.
use words to describe pain(stabbing, etc.)
Intensity(1 to 10 or 1 to 5 )
location(pointing to area of pain)
duration(how long?)
aggravating or alleviating factors.
Pain Assessment Scales:
PAINAD scale
behavioral pain scale for use with the critically ill and those with dementia.examines 5 items:
facial expression
body language
Pain Assessment Scales:
Payen Behavioral Pain scale
useful with intubated, critically ill patients which measures bodily indicators of pain and tolerance of intubation.
Nursing Diagnosis of Acute or Chronic Pain should identify the following:
type of pain.
etiological factors, to the extent that they are known and understood.
patient's behavioral, physiologic, and affective responses.
factors affecting pain stimulus, transmission,perception and response.
Pain Tolerance
the point beyond which a person is no longer willing to endure pain.
Nonpharmacologic Relief Measures
complementary and alternative
cutaneous stimulation-accupressure and TENS unit
therapeutic touch.
a pharmaceutical agent that relieves pain.
Three general classes of drugs-analgesics- used for pain
Nonopoid analgesics:
NSAIDS - nonsteroidal anti-inflammatory drugs - motrin.

Opioid analgesics:
controlled substances e.g.

Adjuvant Drugs:
multipurpose drugs.
Administering analgesics requires a thorough knowledge of the:
mechanism of action,
side effects,
administration guidelines.
The prototype opioid is
tolerance to the drug and its respiratory depressant effects occurs.
side effects are:
Numeric Sedation Scale
determines patient's risk for respiratory depression.
1- awake
2- -occasionally drowsy but easily aroused- no action required.
3 - frequently drowsy, drifts off to sleep during conversation-decrease opioid use
4 - somnolent with minimal or no response to stimuli - dicontinue use of opioid and consider naloxone.
Naloxone (Narcan)
if respiratory depression is suspected,
an opioid antagonist(Narcan) will reverse the respiratory depressant effect of an opioid.
Physical Dependance
when body becomes physiologically accustomed to the opioid and suffers withdrawal symptoms if the opioid is suddenly removed.
occurs when the body becomes accustomed to the opioid and needs a larger dose for pain relief.
a pattern of compulsive use for means other than pain control.
4 characteristics for an addiction:
compulsive use
lack of control over the drug
continued use despite harm.
Range Orders
a medication order in which the dosage or time period or both are specified according to a range.
ex: Morphine 2 to 8 mg IV every 2 hours as needed.
Which is the major class of analgesics used to manage moderate to severe pain?
opioids, formerly called narcotic analgesics.
The drugs of choice for mild to moderate pain are:
nonopioid analgesics such as acetaminophen and NSAIDS.
Besides their analgesic effect, NSAIDS also have an
anti-inflammatory effect.
NSAIDS are contraindicated in patients with
bleeding disorders(their action may interfere with platelet formation) and probable infections(they can mask the inflammatory signs of an infection).
Nonopioid analgesics such as the COX-2 inhibitors, a class of NSAIDS, have a lower risk if GI bleeding but are thought to significantly increase
cardiovascular risks.
drugs typically used for other purposes but are also used to enhance the effects of opioids.
ex: antidepressants and anticonvulsants.
Timing is an important consideration when administering analgesics. To time analgesics properly, you need to know:
average duration for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense.
ex: before ambulating a patient postoperatively.
as needed
around the clock.
Breakthrough Pain
a temporary flare-up of moderate to severe pain that occurs even when the patient is taking ATC medication for persistent pain.
Breakthrough Pain can be classified as:
Incident pain- e.g., pain caused by movement.
Idiopathic pain- spontaneous pain due to an unknown cause.
End-of-Dose pain- where the pain occurs before the next dose of analgesic is due.
Effective management of BTP requires:
a medication with rapid onset and short duration.
assume pain present.
The major principles that guide treatment for cancer or chronic pain include:
give medication orally, if possible.
administer medication ATC rather than on a p.r.n. basis.
adjust dosage to achieve maximum benefits with minimal side effects.
allow patients as much control as possible over their medication regimen.
The WHO 3 Step Analgesic Ladder.
devised by the World Health Organization.
the 3 step ladder is a progression of drugs that manages chronic pain.
this provides relief to 70-90% of patients with cancer pain.
Patient Controlled Analgesia
computerized infusion pump containing a chamber prefilled with the prescribed opioid analgesic.
the patient presses a button to self-administer a preset bolus dose.
can be programmed to deliver only a specified amount within a given time interval.
allows patient control over his pain.
decreases dependency on the nurse.
allows stabilization of blood serum levels-determined by patient's pain level.
must include client education and an alert & intact mental status.
Loading Dose
an initial dose administered to raise blood levels to a therapeutic level.
The most frequently prescribed drugs for a PCA are:
The most common human error associated with PCA therapy is:
improper programming of the pump.
another nurse needs to check:
patient's ID
drug dose and concentrations
PCA pump settings
infusion tubing
infusion site.
Epidural Catheter
used to provide pain relief during the immediate postoperative phase, particularly after thoracic, abdominal, orthopedic and vascular surgery.
anesthesiologist inserts the catheter in the midlumbar region into the epidural space between the walls of the vertebral canal and the dura mater.(outermost connective tissue membrane surrounding the spinal cord).
Monitoring for respiratory rate and pattern is very important.
Drug of choice for an Epidural Catheter is
preservative-free morphine or fentanyl.
Fentanyl is lipid soluble so it is readily dissolved and has a rapid onset of action(5 minutes) but short duration( 2 hours).
morphine is a hydrophilic opioid with a high affinity for water with a slow onset but a long duration(24 hours) so it remains longer in the CFS and spinal tissue.
Local Anesthetics
aka Nerve Blocks.
may be applied topically to the skin or mucous membranes or injected into the body to produce a temporary loss of sensation and motor and autonomic function in a localized area.they chemically block the nerve pathways involved in pain sensation and response.
any medication or procedure that may produce an effect because of its implicit or explicit intent and not because of its specific or chemical properties.
Pure Opioids
Therapeutic Goal
relief of moderate to severe pain while causing minimal respiratory depression, constipation, urinary retention and other adverse effects
Pure Opioids
premature infants-both during and after delivery.
morphine-following biliary surgery.
meperidene- for patients taking MAO inhibitors.
Pure Opioids
Use With Caution
head injury-ICP
profound CNS depression
respiratory depression
pulmonary disease
cardiovascular disease
reduced blood volume
prostatic hyperthrophy
urethral stricture
liver impairment
treating infants,elderly,debilitated patients
patients receiving MAO inhibitors, CNS depressants, anticholinergics and hypotensive drugs.
Pure Opioids
Adverse Effects
respiratory depression-12 breaths per minute or less.
orthostatic hypotension
urinary retention
cough suppression
dependence in the neonate.