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What is pain?
- - Self report is the most reliable indication of pain
- - universal, complex, subjective experience.
- - Most common reason for pt's to seek med help
- - alters/diminishes quality of life
- - unrelieved/untreated remains major avoidable public health problem in the world
- - related to some type of tissue damage
- - serves as a warning signal
- - there is no single, universal treatment
- - unpleasant, sensory/emotional experience
- - whatever the experiencing person says it is whenever they say it happens
- - leading cause of disability
- - not adequately treated in all areas of health care.
Describe nociceptive pain and neuropathic pain
- - either visceral (arises from organs)
- - or somatic (arises from skin or
- musculoskeletal areas)
- Neuropathic - results from some type of nerve injury.
- - Described as "burning," "shooting," "stabbing," or "pins and needles"
Whats the difference between chonic cancer pain and chronic non-cancer pain?
- Chronic cancer pain
- Associated w/cancer
- Associated w/AIDs
- Cause is usually life threatening
- Chronic non-cancer pain
- Associated w/tissue injury that's healed
- Not associated w/cancer
- Associated w/arthritis or chronic back pain
What are characteristics of acute pain?
- Short duration
- Usually has a well-defined cause
- decreased with healing
- Serves as a biologic purpose (warning sign)
- Ranges from mild --> severe intensity
- May be accompanied by anxiety/restlessness
- Often results from sudden, accidental trauma, surgery or inflammation
- Easily localized
What are some biologic responses to acute pain?
- Similar to responses in "fight-or-flight" reactions
- Increase in HR, BP, & RR
- Dilated pupils
- Inability to concentrate
- Overall distress
What is preemptive analgesia?
- Designed to decrease postop pain
- Administering local anestetics, opioids, & others in preop, intraop and/or postop
- May inhibit changes in the spinal chord that can lead to central sensitization that results in chronic pain
What is the nurse's role in pain management?
- Advocate for pt's by believing pain reports
- Act promptly to relieve pain
- Respect pt's preferences and values
- Advocate for proper control of pain
- Legal/ethical responsibility to ensure pt's receive adequate pain control
What are characteristics of chronic pain?
- Lasts longer than 3 months
- May/not have well-defined cause
- Begins gradually and persists
- Exhausting and serves no biological purpose
- ranges from mild --> severe intensity
- May be accompanied by depression, fatigue, & decreased functional ability
- Most common cause of long-term disability
- Poorly localized (hard to pinpoint)
- Hard to describe
What are physiologic structures of somatic, visceral and neuropathic pain?
- Cutaneous or superficial: skin and subcutaneous tissues.
- Deep somatic: bone, muscle, blood vessels, connective tissues
- Organs and the linings of the body cavities
- Nerve fibers, spinal chord, and CNS
What are physiologic characteristics of somatic, visceral, and neuropathic pain?
- sharp, burning, dull, aching, cramping
- poorly localized, diffuse, deep cramping or splitting, sharp, stabbing
- NeuropathicPoorly localized, shooting, burning, fiery, shocklike, sharp, painful numbness
What are physiologic sources of acute postop somatic, visceral and neuropathic pain?
- Incisional pain, pain at insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms.
- Chest tubes, abdominal tubes and drains, bladder distension or spasms, intestinal distension.
- Phantom limb pain, postmastectomy pain, nerve compression
What are physiologic sources of chronic somatic, visceral and neuropathic pain syndromes?
- Bony metastases, osteoarthritis and rheumatoid arthritis, low back pain, peripheral vascular diseases
- Pancreatitis, liver metastases, coitis, appendicitis
- HIV-related pain, diabetic neuropathy, postherpetic neuralgia, chemotherapy-induced neuropathies, cancer-related nerve injury, radiculopathies
Describe addiction r/t pain management.
- Occurs over a long period of time.
- According to the American Society for Pain Management Nursing: "...a primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following impaired control over drug use, compulsive use, continues use despite harm, and craving."
Describe pseudoaddiction r/t pain management.
It can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
"an iatrogenic syndrome created by the undertreatment of pain. It is characterized by behaviors such as anger and escalating demands for more or different medications, and results in suspicion and avoidance by staff.
Describe tolerance r/t pain management
"a state of adaptation in which exposure to a drug induces changes that result in a decrease in one or more of the drug's effects over time."
Describe physical dependence r/t pain management.
"adaptation manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist."
Describe withdrawal (or abstinence syndrome) r/t pain management.
results when a pt who is physically dependent on opioids abruptly ceases using them.
Physical dependence occurs in everyone who takes opioids over a period of time.
It's important to prevent physical withdrawal.
Abstinence syndrome may also occur if a pt on opioids receives a reversal agent, such as Narcan.
What is a placebo?
Any medical treatment on nursing care that produces an effect in a pt because of its therapeutic intent and not because of its actual physical or chemical properties.
**Because of the deception involved and the need for informed consent - NEVER - administer a placebo to your patient!! **
Remember the mnemonic PQRST??
P: Precipitating or palliative. What brings it on? What makes it better? Worse? When did you first notice it?
Q: Quality or quanity. How does it look, feel or sound? How intense/severe is it?
R: Region or radiation. Where is the pain? Does it spread anywhere?
S: Severity scale. How bad is it (scale 1-10)? Is it getting better or worse, or staying the same?
T: Timing. Onset - exactly when did it first occur? Duration - How long did it last? Frequency - How often does it occur?
Describe the 4 different categories of pain r/t its location.
- Localized pain: confined to the site of origin
- Projected pain: pain along a specific nerve(s).
- Radiating pain: diffuse pain around site of origin that's not well localized.
- Referred pain: perceived in an area distant from the site of painful stimuli.
Give a broad explanation of drug therapy for pain management.
Non-opioid analgesics: first line therapy for mild-moderate pain. Analgesic effect has a ceiling.
NSAIDs: ASA and other NSAIDs are effective for inflammatory-type pain, such as rheumatoid arthritis, mild-moderate postop pain, dental pain, menstrual pain, migraines and muscle pain.
Review Inspection of the cardiovascular system
Inspect chest from the side, at a right angle and downward over areas of the precordium where vibrations are visible.
Examine the entire precordium and note any prominent pulses.
Movement over the aortic, pulmonic and tricuspid areas is abnormal.
Pulses in the mitral area are normal (apical pulse).
Point of maximal impulse (PMI) is at the apex.
If the PMI appears in more than one intercostal space and has shifted lateral to the midclavicular line, the pt may have left ventricular hypertrophy.
Review modifiable risk factor for cardiovascular disease: smoking
- cigarette use
- - tar, nicotine and carbon monoxide found in cigarettes have been implicated in the development of CAV
- - Ask the pt about their desire to quit, past attempts to quit and the methods used to quit.
- - 3-4yrs after a patient has stopped smoking, their CVD risk is similar to those who have never smoked.
Review modifiable risk factors for cardiovascular disease: physical inactivity
- physical inactivity- regular physical activity promotes cardiovascular fitness and produces beneficial changes in BP, blood lipids and clotting factors.- 30 minutes of light-moderate exercise (such as a brisk walk) daily is recommended.
Review modifable risk factors for cardiovascular disease: obesity
- Obesity- defined as a BMI greater than 30.
- - Cultures at higher risk inclue: African American women, Mexican Americans, and native Hawiians.
- - Associated with hypertension, hyperlipidemia, and DM
- American Heart Association provides guidelines to combat obesity:
- - ingesting more nutrient-rich foods w/vitamins, minerals, fiber and other nutrients, but low in calories.
- - choose foods like vegetables, fruits, whole-grain products, & ff dairy products most often
- - teach pts to not eat more calories than they can burn every day
Review modifiable risk factors for cardiovascular disease: psychological variables
- psychological variables- highly competitive
- - overly concerned about meeting deadlines
- - often hostile or angry
- - psychological stress, anger, depression and hostility are all closely associated w/risk for developing heart disease.
Review blood pressure: hypertension and hypotension
- - 140+/90+
- - taking drugs to control BP
- - a BP that exceeds 135/85 increased the workload of the left ventricle and O2 consumption of the myocardium.
- - -90/-60
- - may not be adequate for providing enough O2 and sufficient nutrients to body cells.
Review BP: orthostatic hypotension
Occurs when the BP is not adequately maintained while moving from a lying to a siting/standing position. Defined as a decrease of more than 20mm Hg of the systolic or more than 10mm Hg of the diastolic pressure as well as a 10%-20% increase in HR.
Review BP: pulse pressure
the difference between the systolic and diastolic values.
an increased pulse pressure may occur in patients with slow HR, aortic regurgitation, atherosclerosis, hypertension and aging.
Review intermittent claudication
moderate-severe cramping sensation in the legs or buttocks associated with an activity such as walking.
Claudication pain is usually relieved by resting or lowering the affected extremity to decrease tissue demands or to enhance arterial blood flow.
Review venous pulses
- -Assess for JVD
- - causes include:
- - tricupsid regurgitation or stenosis
- - pulmonary hypertension
- - cardiac tamponade
- - constrictive pericarditis
- - hypervolemia
- - superior vena cava obstruction
Review arterial pulses
- in pt's with suspected (or actual) arterial disease - all major peripheral pulses should be assessed for presence or absence, aplitude, contour, rhythm, rate, and equality.
- Palpate the peripheral arteries in a head-to-toe approach with a side-to-side comparison.
- Hypokinetic pulse = weak pulse indicative of a narrow pulse pressure.
- Hyperkinetic pulse = bounding pulse caused by an increased ejection of blood.
Review heart rate
- # of times the ventricles contract each minute
- normal HR for adult = 60-100 bpm
- increased HR = increase myocardial O2 demand.
- HR is controlled by the ANS
- Parasympathetic (vagus nerve) slows the HR whereas the sympathetic stimulation increases the HR.
Review stroke volume
The amount of blood ejected by the left ventricle during each contraction.
Variables affecting stroke volume: HR, preload, afterload, contractility
The nail straightens out to an angle of 180 degrees and the base of the nail becomes spongy.
Caused by chronic O2 deprivation in body tissues.
Common in pts w/advanced chronic pulmonary disease, congenital heart defects, and cor pulmonale.
Review auscultation major arteries
- Aortic - 2nd intercostal space right of the sterum.
- Pulmonic - 2nd intercostal space left of the sternum
- epigastric - lower right sternal border
- right ventricular area - lower half of the sternum and the left parasternal area.
- tricuspid - 5th intercostal space at the lower left of the sternal border
- mitral - 5th intercostal space at the apex of the heart.
Describe grading of heart murmurs
- Grade I - very faint
- Grade II - faint but recognizable
- Grade III - Loud but moderate in intensity
- Grade IV - Loud and accompanied by a palpable thrill
- Grade V - Very loud, accompanied by a palpable thrill, and audible w/the stethescope partially off the patient's chest.
- Grade VI - Extremely loud, may be heard with the stethoscope, slightly above the patient's chest, accompanied by a palpable thrill.
Describe normal heart sounds
The first sound (S1) is created by the closure of the mitral and tricupsid valves. It's softer and longver - a low pitch - and is best heard at the lower left sternal border (apex)
The second sound (S2) is caused by the closing of the aortic and pulmonic valves. It's higher pitched and is heard best at the base of the heart at the end of systole.
Review symptoms of chronic heart failure
Shortness of breath (dyspnea) when you exert yourself or when you lie down
Fatigue and weakness
Swelling (edema) in your legs, ankles and feet
Rapid or irregular heartbeat
Reduced ability to exercise
Persistent cough or wheezing with white or pink blood-tinged phlegm
Swelling of your abdomen (ascites)
Sudden weight gain from fluid retention
Lack of appetite and nausea
Difficulty concentrating or decreased alertness
Review symptoms of acute heart failure
Symptoms similar to those of chronic heart failure, but more severe and start or worsen suddenly
Sudden fluid buildup
Rapid or irregular heartbeat (palpitations)
Sudden, severe shortness of breath and coughing up pink, foamy mucus
Chest pain, if your heart failure is caused by a heart attack
Review risks for PVD
- Obesity (BMI 30+)
- High BP
- High Cholesterol
- Age (50+)
- family Hx.
Review treatments for pain
Non-Opioid Analgesics - first line therapy for mild-moderate pain.
NSAIDs - good for inflammatory-type pain such as early rheumatoid arthritis, mild-moderate postop pain, dental pain, menstrual pain, migraines, and muscle pain
Opoid analgesics - the mainstay in the management of all types of moderate-severe pain.
What are some nursing interventions to prevent constipation resulting from opioid use?
(Use measures to prevent this problem bc constipation is the most common side effect)
- -Assess previous bowel habits
- -Push fluids
- -Encourage activity
- -give foods high in bulk and roughage
- -Keep a record of bowel movements
- -Administer stool softeners and stimulant laxatives
- -if stool softeners/laxatives are ineffective, try suppository or Fleet's enema.
What are some nursing interventions to prevent nausea & vomiting resulting from opioid use?
(Recognize that N/V may be only an initial, temporary side effect for the first 24-48 hrs bc tolerance seems to develop quickly to this side effect)
- - Assess actual cause of nausea
- - Try an antiemetic prophylactically before administering as prescribed
- - Administer an antiemetic as prescribed
- - Give metoclopramide (Reglan) 10mg before meals and at bedtime, or ondansetron (Zofran) 4mg IV.
What are some nursing interventions to prevent sedation and confusion resulting from opioid use?
(Remember that tolerance to this side effect generally occurs after 2-3 days)
- - Assess actual cause of sedation because the patient may also be on hypnotics and antianxiety agents
- - eliminate unnecessary sedating medications
- - Be aware that stimulants such as caffeine may counteract opioid-induced sedation.
- - Consider opioid rotation using an equianalgesic chart.
What are some nursing interventions that prevent respiratory depression resulting from opioid use?
(Recognize that pain and stress seem to counteract the respiratory depression effects of opioids.)
- - Be aware that clinically significant respiratory depression is rarely seen in pt's w/severe pain caused by cancer, even when large doses of opioids are given.
- - Recall that respiratory depression occurs before sedation and possible lethal overdose.
- - Monitory sedation level and respiratory status frequently for the first 24-48hrs, especially in opioid-naive pt's.
- - If increased sedation occurs, decrease opioid dose and attempt to stimulate the pt.
- - Be aware that respiratory rate alone is not indicative of respiratory status.
- - If absolutely necessary in an unresponsive pt, admin 4mg Narcan diluted in 10mL of normal saline, push 0.5mL IV slowly for 2 minutes and observe the pt.
What are some common examples of non-opioids?
- Acetaminophen (Tylenol)
- NSAIDs - Aspirin, Ibuprofen, Naproxen, Ketoprofen, Celebrex
Review lifestyle contributions related to osteoporosis.
30 minutes of walking is the most effective preventative action against osteoporosis.
- high-impact sports can cause musculoskeletal injury to soft tissues and bone.
- Tobacco use slows the healing of musculoskeletal injuries.
- Excessive alcohol intake can decrease vitamins/nutrients the person needs for bone and muscle tissue growth.
- A person's occupation can cause/contribute to an injury.
- Allergy to dairy products could cause decreased calcium intake.
Review risk factors for osteomalacia
- Vitamin D disturbance -
- - inadequate production
- - lack of sunlight exposure
- - dietary deficiency
- - Abnormal metabolism
- - Drug therapy (Phenytoin, Flouride, Barbiturates)
- - Liver disease
- - Renal disease
- - inadequate absorption
- - IBS
- Kidney disease
- - Chronic kidney diseases
- - Acute tubular disorders (acidosis, hypophosphatemia)
Review lab tests for Ewing's sarcoma
- typically show elevated serum alkaline phosphatase levels (body is trying to form new osteoblasts to form new bone)
- often has anemia
- elevated serum lactic dehydrogenase (LDH) levels
- leukocytosis is commonly found.
Review acute osteomyelitis S/S.
- - Fever, temp usually above 101 (remember that older adults may not have an extreme temp bc of a lower core body temp and compromised immune system)
- - Swelling around affected area
- - Erythema of affected area
- - Tenderness of affected area
- - Bone pain that is constant, localized, and pulsating (intensifies w/movement)
review chronic osteomyelitis S/S
- - Ulceration of the skin
- - sinus tract formation
- - Localized pain
- - Drainage from affected area
Review plantar fascitis
- - inflammation of the plantar fascia (arch of the foot)
- - seen in middle aged/older adults
- - seen in athletes, especially runners
- - obesity is a contributing factor
- - pt's report severe pain that's worsened w/weight bearing.
- - possible to affect both feet.
- - mostly cured w/rest, ice, supportive shoes and orthotics.
- - NSAIDs or steroids for pain control/inflammation.
- - If conservative methods are unsucessful, endoscopic surgery may be required to remove the inflamed tissue.
- - Teach the pt the importance of adhereing to the treatment plan and coordinating care w/the physical therapist for instruction/exercise.
- - used to evaluate diffuse or localized muscle weakness.
- - accompanied by nerve conduction studies for determining the electrical potential generated in an infividual muscle.
- - aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders.
- - contraindicated in pts undergoing anticoagulant therapy.
Review Paget's disease
- - chronic metabolic disorder in which bone is excessively broken down and reformed. (this results in structurally disorganized bones that are weak, causing an increased risk for fractures.
- - usually seen in ppl 50+ years and of European heritage.
- - Most pt's are asymptomatic.
- - May be accidentally discovered during a routine lab or x-ray exam.
- - pt experiences mild-moderate bone pain.
What are some key "manifestations" of Paget's Disease?
- Musculoskeletal Manifestations:
- - Bone and joint pain that's aching, poorly described and aggrivated by walking
- - low back & sciatic nerve pain
- - Bowing of long bones
- - Loss of normal spinal curvature
- - Enlarged, thick skull
- - pathologic fractures
- - osteogenic sarcoma (bone cancer)
- Skin Manifestations
- - Flushed, warm skin
- Other Manifestations:
- - Apathy, lethargy, fatigue
- - Hyperparathyroidism
- - Gout
- - Urinary/renal stones
- - Heart failure from fluid overload
Review nursing care for the cardiac cath patient.
- - Assess the pt's physical/psychosocial readiness/knowledge about the procedure.
- - Review purpose of procedure w/patient
- - Inform pt about the length of the prcedure
- - State who will be present during the procedure
- - tell pt about the sensations they'll experience during the procedure (palpitations, hot flash, & a desire to cough).
- After the procedure:
- - restrict the pt to bedrest for 2-6 hrs (depending on the type of vascular closure device used) and keep insertion site extremely straight. (a soft knee brace can be applied to prevent bending of the affected extremity).
- - Some cardiologists allow the bed to be elevated 30 degrees during the period of bedrest, whereas other cardiologists prefer that the pt remain supine.
- - monitor vital signs q15 minutes for the first hour, then q30 minutes for 2 hours or until vital signs are stable.
- - Assess insertion site for bloody drainage or hematoma formation.
- - Assess peripheral pulses in the affected extremity as well as temperature & color w/every vital sign check.