Pharmville

• Pain is a protective mechanism
• -Can continue long after the tissue damage is repaired
• -Serves no useful purpose
• -Can result in chronic pain BUT if no mechanism in place to identify pain then (ie pain has no obvious cause), if left uninvestigated it can lead to...
• --extensive tissue damage
• --more disability, morbidity and mortality

Varies from one individual to another related to physiologic and psychosocial factors

• Psychosocial factors
• cultural background, values, environment, past pain experiences, support persons, anxiety/stress,locus of control

• Physiologic factors
• age, gender, intactness of the CNS, physical pain stimulus itself, fatigue

• Physiologic Response
• Involuntary responses: withdraw from source of pain, fetal position, pressure on site (gate control)
• Sympathetic response comes first, but as pain continues the parasympathetic predominates
• May actually precipitate a shock-like state
• Behavioral Response
• Related to pain tolerance
• Clenching teeth, holding painful part, bending over, grimacing, tensing muscles, crying, moaning, calling nurse often

• ASK about pain
• Patient’s self report is primary source (even for cognitively impaired)
• Use rating scales
• -Document at regular intervals and with changes in symptoms and interventions
• -Teach patients and families to use
• -Be sure to ask what the acceptable level of discomfort is

• Ask. Every 2 hrs with documentation
• Believe
• Chose appriopriate pain control option
• Deliver in timely fashion
• Empower pts and their families.
• Enable pts to control their course to the greatest extent possible.

• Medication used primarily for other indications--but also produce pain relief
• Can be used in conjunction with opioids, or as primary therapy
• Especially helpful for neuropathic and bone pain, ie NSAIDS, antidepressants, anticonvulsants, benzodiazapenes, muscle relaxants, local anesthetics
• In many ways, adjuvants are the ideal Rx for analgesia.

• Less fluctuations in analgesia level
• Less total drug requirements
• Less sedation and nausea due to less opioid
• Improved post-op pulmonary function --> decreased chance of postop pneumonia.
• Earlier ambulation
• Patient control of analgesia with less anxiety
• Patient preference over IM injections
• Less nocturnal awakening
• Less cost
• Increased patient satisfaction
• Reduced hospitalization
• Patient Controlled Analgesia
• Refers to a process
• Uses a computerized pump connected to IV to administer Rx. Has cap on times/hr can be activated.

• Opioid
• Prescribed dose (Demand bolus)
• Dose interval (usually 6-8 minutes)
• Lockout interval (1 hour or 4 hours)
• If attempts to activate are 2x # of doses prescribed –need to request an increase in dose.
• Two RN’s verify PCA settings when working with narcatics.
• Initial PCA set-up
• -At the beginning of each shift
• -Upon transfer
• -Change of order (rate, mode, lockout or medication)

• Discuss pain experience with patient
• Demonstrate PCA pump usage
• Describe safety features of PCA
• Discuss potential for adverse effects
• NO ONE other than the patient should activate the PCA pump
• Encourage communication about pain

• Monitor and document respirations, sedation scale and pain intensity q 1 hour x 4, then q 2h x 4, then q 4h
• Initiate the “stir-up regimen” (shake'em'n'wake'em) if R (respirations) are 6-8/minute and/or sedation scale is 2
• Administer Narcan (opiod antidote) if R < 6 --> to neutrilization of opiod and pt will be in lots of pain.
• If pulse ox < 89, administer oxygen

• Must be able to understand concept and physically able and willing to follow instructions
• Infants and young children: must be assessed for ability to operate and understanding.
• Confused older adults: ditto
• Obesity: unpredictable metabolism of narcotics
• Asthma: Opiods disrupt sleep, so no.
• Sleep apnea: ditto
• Taking other drugs that would potentiate opioids, ie muscle relaxants, antiemetics, sleeping meds

• 0 Awake and alert
• 1 Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound
• 2 Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation or simple verbal command
• 3 Deep sedation: deep sleep, arousable only with deep or significant physical simulation
• 4 Unarousable
• 5 Patient is sleeping. If you're there to assess, you MUST assess. Can still assess respiration, HR, rousability (have to know if they can be roused).

• Catheter placed in the epidural (in spine) space in which either bolus or continuous medications may be administered for pain control. Blocks pain from that point down.
• Nurse must:
• Monitor site
• Check infusion rate
• Monitor for desired effect
• Monitor for potential complications, ie epidural analgesia. Expect pt to have loss of sensation everywhere distal to site of infusion

• Urine Retention:
• -Monitor I and O
• -Palpate for bladder distention, just above pubis.
• -Provide for privacy
• -Use nursing measures as appropriate, ie peppermint oil relaxes sphincter muscles, move to urination position over bed pan.
• Pruritus
• Be alert for S and S (signs and symptoms)
• Use comfort measures like:
• -soft linen cool, light clothing
• -Diversion
• -Assess for potential allergic reaction
• -Increased temp, dyspnea, edema, itching

• Possible causes:
• Insufficient dose of analgesia
• Displaced catheter
• Kinked or disconnected tubing
• Catheter placement below site of pain innervation
• Increase in patient’s activity
• Assessment Criteria

• Pain level?
• Note site and quality of pain
• Check for leakage at insertion site --> severe HA.
• Look for any obvious breaks, knots or kinks

• Increase fluid intake
• Keep flat for 12-14 hours
• Anesthesiologist may do “autologous blood patch.” Small amount of blood taken from pt and inserted through epidural. to plug leak.

Relieves pain without loss of consciousness

• Derived from opium
• similar to morhphine

• Mu: Mediates central analgesia, euphoria, respiratory depression, and physical dependence (primary site of stimulation with opioids)
• Kappa: Mediate spinal analgesia, miosis, sedation, disorientation and appetite regulation
• Delta: Both spinal and in brain structure; primary receptors for endogenous endorphins

• Abstinence syndrome occurs if drug abruptly stopped
• Abstinence syndrome is dependent on
• -Half-life of drug
• -Degree of physical dependence
• Adverse Effects
• HA
• Lethargy
• "feeling sick"
• can actually reach shock-like state.

• Classic triad (toxic levels will depend on how naive/wise pt is to Rx)
• -Coma
• -Respiratory depression
• -Pinpoint pupils
• Treatment
• Ventilatory support when R depression gets too low.
• Opioid antagonists like
• -Naloxone (Narcan)
• -Nalmefene (Revex)

• D/C the PCA – or other dose forms of Opioid
• D/C all other infusions that could be contributing to sedation
• Maintain IV site
• Attempt to rouse the patient
• Call Rapid Response Team (group of nurses, ER Dr., respiritory therapist, to advise or assist with pt.)
• If apneic: administer bag & mask ventilation with 100% oxygen
• Capnography is used in many facilities
• -Co₂ levels > 45% cause for concernIf breathing: maintain airway, monitor oxygen saturations and capnography and administer oxygen via face mask at 8 L/min
• Check circulation. If pulseless: commence chest compressions
• Be prepared to administer naloxone if opioid toxicity is suspected

• 1. obtain an accurate Hx of all medicaiton taken in the last 6 months
• -Time for alst doses of Rx in the last 24 hrs.
• 2. Use smaller amount and titrate for effect instead of giving a rapid bolus of the total amount the physician will allow to be given.
• 3. Know which pt are at high risk for problems
• -older
• -younger
• -pt with allergies
• -Hx of prior use
• -hypotensivion, dehydration, liver and kidney disease (all because narcs will not circulate well.)
• 4. Prevent falls.
• 5. Have analgesic reversal Rx readily available. (look for narcan)