Card Set Information
Nursing considerations for pain
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
Things to know about Pain Threshold
Varies from one individual to another related to physiologic and psychosocial factors
cultural background, values, environment, past pain experiences, support persons, anxiety/stress,locus of control
age, gender, intactness of the CNS, physical pain stimulus itself, fatigue
Reactions to pain
: 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
Related to pain tolerance
Clenching teeth, holding painful part, bending over, grimacing, tensing muscles, crying, moaning, calling nurse often
Principles of Pain Assessment
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
ABC's of Pain
sk. Every 2 hrs with documentation
hose appriopriate pain control option
eliver in timely fashion
mpower pts and their families.
nable 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.
Pt controled analgesics (PCA pumps)
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.
Patient control of analgesia with less anxiety
Patient preference over IM injections
Less nocturnal awakening
Increased patient satisfaction
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.
Important points concering PCA
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
-Change of order (rate, mode, lockout or medication)
Pt teaching points with PCAs
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
Stuff nurses should know about PCAs
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
PCA pt selection
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
: unpredictable metabolism of narcotics
: Opiods disrupt sleep, so no.
Taking other drugs that would potentiate opioids, ie muscle relaxants, antiemetics, sleeping meds
University of Michigan Sedation Scale
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
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).
Epidural Pain Control
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.
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
Potential complications with epidural analgesia
-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.
Be alert for S and S (signs and symptoms)
Use comfort measures like
-soft linen cool, light clothing
-Assess for potential allergic reaction
-Increased temp, dyspnea, edema, itching
Potential complications with epidural analgesia and
Insufficient dose of analgesia
Kinked or disconnected tubing
Catheter placement below site of pain innervation
Increase in patient’s activity
What is the epidural pain assessment?
Note site and quality of pain
Check for leakage at insertion site --> severe HA.
Look for any obvious breaks, knots or kinks
Epidural complications, Spinal HA
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.
What is the main benefit of using opioid analgesics?
Relieves pain without loss of consciousness
What is an opioid?
Derived from opium
similar to morhphine
: Mediates central analgesia, euphoria, respiratory depression, and physical dependence
(primary site of stimulation with opioids)
: Mediate spinal analgesia, miosis, sedation, disorientation and appetite regulation
: Both spinal and in brain structure; primary receptors for endogenous endorphins
SnSs of Opioid Physical Dependence
Abstinence syndrome occurs if drug abruptly stopped
Abstinence syndrome is dependent on
-Half-life of drug
-Degree of physical dependence
can actually reach shock-like state.
(toxic levels will depend on how naive/wise pt is to Rx)
Ventilatory support when R depression gets too low.
Opioid antagonists like
IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:
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
Rapid Response Team
(group of nurses, ER Dr., respiritory therapist, to advise or assist with pt.)
: administer bag & mask ventilation with 100% oxygen
Capnography is used in many facilities
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
if opioid toxicity is suspected
5 must do steps for IV Narcotis
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
-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)