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Describe neuropathic pain
The damage to nerve cells, peripheral or CNS pain. Can be phantom limb pain
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What is cutaneous pain?
- Superficial pain, easily localized, just below the skin between high concentration of nerve endings that produce a well-defined pain.
- Abrupt onset and a burning quality depending on type of nerve fiber involved
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What is somatic pain and where does it originate?
Deep pain that originates from ligaments, tendons, bones, blood vessels, and nerves. Poorly localized, accompanied by inflammation, such as a sprained ankle
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What is visceral pain?
Originates from viscera or organs, such as appendicitis, kidney, liver pain. Difficult to localize more aching and longer duration than somatic pain. May cause referred pain
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Describe psychogenic pain
mental or emotional problems that can cause, increase or prolong pain. Diagnosed when other causes of pain are ruled out
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What is the difference between pain threshold and pain tolerance
Threshold is where they can start to feel the pain and tolerance is how much pain they can take
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What are some sociocultural factors affecting pain?
Age, gender, meaning of pain, anxiety, past experiences with pain, expectation and placebo effect
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What do local anesthetics do and what are some examples
- Temporarily block nerve impulses between peripheral structures and higher centers. Causes loss of feeling and sensation, no LOC, used in minor surgery, reversible, works in minutes to hours
- Lidocaine-topical and intravascular block works within 5-10 minutes.
- Bupivacaine-slow onset, lasts 4-8 hours 4X more potent than lidocaine, blocks sensory nerves as opposed to motor nerves
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What do nerve blocks do?
Reversible or irreversible interruption of nerve pathways, blocks conductivity, given for pain relief
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Describe topical local anesthetics
Sprays, pastes that may reduce pain, EMLA is a commonly used cream with lidocaine and prilocaine applied before venipuncture
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Describe the first tier/step of WHO pain ladder
Non-opioid analgesics (pain medications) that have a ceiling effect but do not cause physical dependence or tolerance, can have anti-inflammatory effects
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List the medications onthe first tier of the WHO pain ladder
- Aspirin-most effective non-opioid analgesic, can cause GI upset and anti-clotting effect
- Salicylate salts-similar to aspirin but without the GI upset. Examples include: Trilisate (trisalicylate) & Dolobid (diflunisal)
- Acetaminophen-no GI effects, no anti-inflammatory effects, drug of choice for viral infections, metabolized in liver, do not exceed daily dose of 4000 mg
- NSAIDS-non-steroidal anti-inflammatory drugs that decrease inflammation and block prostaglandin synthesis, helpful for cancer or post-op patients, Ibuprofen (motrin) and ketorolac (Toradol), can cause GI upset and bleeding
- COX-2 inhibitors such as celecoxib (Celebrex)
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What is the Second & Third step/tier on the WHO ladder and describe
- 2nd Opioids to treat mild to moderate pain
- 3rd Opioids t treat moderate to sever pain
- Opiod agonists bring about pain relief by producing the maximum degree of receptor binding with no ceiling effect
- Opioid Antagonist-reverse the side effects and analgesia of opioids, produces no pain relief such as naloxone (Narcan)
- Opioid Agonist-Antagonist-engage one receptor type while inhibiting receptor bidning of another
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What are the adverse effects of analgesics?
- #1 Constipation
- Nausea Vomiting
- Respiratory depression
- Circulatory depression
- Cutaneous effects-itching, sweating, flushing
- Urinary retention
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What are adjuvant medications?
- Meds developed for other problems that may have pain-reducing properties
- Tricyclic antidepressants-neuropathic pain, amitriptyline (Elavil)
- Anti-Anxiety-muscle relaxant-spasm associated with pain, diazepam (Valium)
- Anticonvulsants-neuropathic pain, phenytoin (Dilantin), gabapentin (Neurontin), pregabalin (Lyrica)
- Corticosteroids-reduces edema and the inflammation in the periphery, reducing compression caused by swelling and the availability of chemical medicators of nociception, predinsone, dexamethasone (Decadron), methylprednisolone (Solu-Medrol)
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What influences the effectiveness of analgesics?
- Relative potency-ratio of doses of 2 analgesics required to produce the same effect, which one is stronger
- Duration of action-how long it lasts
- Oral potency v. SQ, IV routes-opioids are absorbed from the intestine and pass through the liver and into the systemic circulation then differ in the degree to which they are active
- Ceiling effect-occurs when a medication has a max effective dose, increasing the dose cannot increase pain relief but may increase side effects
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What is the difference between tolerance and physical dependence?
- Tolerance is a physiologic phenomenon and ocurs when larger doses of medications are needed to provide the same amount of pain relief as the previous smaller dose, opiate receptors become less sensitive
- Dependence occurs when meds are taken over a long period of time, physical manifestations asociated with sudden termination of the med and symptoms may include anxiety, irritabililty, chills/hot flashes, N/V, etc.
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List the common opioids
- morphine sulfate-IV/PO
- hydromorphone HCL (Dilaudid)-IV/PO
- oxycodone (OxyContin)-PO
- oxycodone with acetaminophen (Percocet)-PO
- oxycodone with aspirin (Percodan)-PO
- hydrocodone with acetaminophen (Vicodan)-PO
- codeine-PO
- fentanyl (Duragesic/Sublimaze)-IV, Transdermal, transmucosal
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How and what needs to be assessed before giving pain medication?
- How-facial expressions, body movements, sleep, mood, asking OPQRSTI
- What-medication allergies, time of last dose and response, other meds, weight, pain experience, cardiac, respiratory, renal hepatic, CNS status
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What are the methods of administration
PCA, oral, intramuscular, intravenous, rectal, transdermal, transmucosal, continuous subcutaneous pump, intraspinal/epidural pump
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What are some cognitive or biobehavioral intervention?
deep breathing, progressive relaxation, rhythmic breathing, music, guided imagery, biofeedback, distraction, therapeutic touch, meditation, hypnosis, humor, magnets
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What is the FLACC scale?
Pain scale using a scoring system looking at Face, legs, activity, cry, consolability
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What age is a 0-10 scale used?
Ages 7+
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How do the different age groups react to pain?
- Infants-crying
- Toddlers/Preschoolers-cry, expressions, start to anticipate pain
- School-age-vocal protest, stalling, muscle rigidity
- Adolescent-less vocal protest, increased muscle tension
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