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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
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Things to know about Pain Threshold
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
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Reactions to pain
- 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
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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
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ABC's of Pain
- 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.
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Adjuvant Analgesics
- 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.
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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.
- 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.
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Important points concering PCA
- 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)
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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
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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
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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: 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
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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
- 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).
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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.
- 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
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Potential complications with epidural analgesia
- 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
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Potential complications with epidural analgesia and
Breakthrough Pain
- 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
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What is the epidural pain assessment?
- Pain level?
- Note site and quality of pain
- Check for leakage at insertion site --> severe HA.
- Look for any obvious breaks, knots or kinks
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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.
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What is the main benefit of using opioid analgesics?
Relieves pain without loss of consciousness
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What is an opioid?
- Derived from opium
- similar to morhphine
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Opioid Receptors
- 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
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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
- Adverse Effects
- HA
- Lethargy
- "feeling sick"
- can actually reach shock-like state.
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Opioid Overdose
- 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)
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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
- 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
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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
- -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)
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