Mod 4: Pain (NS1P2)

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Mod 4: Pain (NS1P2)
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  1. Pain Def
    • Whatever the person experiencing pain says it is
    • Unpleasant sensory and emotional experience associated with actual or potential tissue damage You can feel pain before the pain receptors are even activated, like starting an IV   because it's unpleasant. Potential tissue damage.
  2. **MEDICATION THERAPY Three categories
    • Nonopioid
    • Opioids
    • Co-analgesic or adjuvant Therapy
  3. **NON-OPIOIDS
    Analgesic ceiling: doesn't matter how much medication you're going to get, you won't achieve any more pain managment

    Increasing dose above upper limit produces no greater analgesia

    • Do not produce tolerance or addiction!! Tylenol. Aspirin, Advil, Motrin, ve for mild
    • -no prescription
    • -effect

    • Many are OTC
    • Aspirin and other salicylates
    • Acetaminophen
    • NSAIDs
  4. **OPIOIDS
    • Binds to receptors in the CNS blocking conduction of pain pathways
    • Inhibition of transmission of nociceptive input Altered limbic activity: movement
    • Activation of descending inhibitory pathways: Read book!

    Classificaions: Pure agonists, mixed agonists-antagonists

    • =>Pure agonists
    • Morphine, oxycodone, and codeine
    • Potent, NO analgesic ceiling, and have several routes for administration: orally, injection, SubQ, IV.
    • Often combined with nonopioid analgesic for relief of moderate pain to maximize effects because they work on diff receptor sites

    • =>Mixed agonists-antagonists
    • Nalbuphine, pentazocine, butorphano

    lLess respiratory depression in regards to opioids. They DO have a ceiling

    • More dysphoria and agitation
    • Have an analgesic ceiling Can precipitate withdrawal; the long you're exposed to this and once we take away the meds you can have withdrawals: tremors, shaking, headaches..
  5. **Nocioceptive pain
    • Damage to somatic or visceral tissue; Surgical incision, broken bone, or arthritis
    • Usually responsive to Opioid and non-opioid medications

    -Nociception: Physiologic process that communicates tissue damage to the CNS-originates when the tissue is injured.

    • 1, Transduction occurs when there isrelease of chemical mediators;Conversion of noxious stimulus into neuronal action potential
    • Occurs at level of peripheral nerves

    • 2, Transmission involves the conduct of the action potential from theperiphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex.
    • Movement of pain impulses from site of transduction to brain

    Peripheral nerves -> spinal cord -> dorsal horn -> thalamus and cortex

    • 3,Perception is the conscious awareness of pain.
    • Recognition of pain by brain structures

    • 4, Modulation involves signals from the brain going backdown the spinal cord to modify incoming impulses.
    • Changes in pain signals and activation of descending pathways
  6. **NEUROPATHIC PAIN
    Damage to peripheral nerve or CNS-Numbing, hot-burning, shooting, stabbing, or electrical in nature-Sudden, intense, short-lived, or lingering
  7. **Central Sensitization: increased sensitivity and hyperexcitability or neurons in the CNS-allodynia: when ppl experience significant pain from touch or tactile stimulation in and around the areas of tissue or nerve injury-acute pain can become chronic thru central sensitivzation. -Neuroplasticity: processes that allow neurons in the brain to compensate for injury and adjust their respones to new situations or changes in their einvironment. -Referred pain: stiumulus may be distant from a pain location reported by the patient.
    increased sensitivity and hyperexcitability or neurons in the CNS

    -allodynia: when ppl experience significant pain from touch or tactile stimulation in and around the areas of tissue or nerve injury

    -acute pain can become chronic thru central sensitivzation.

    -Neuroplasticity: processes that allow neurons in the brain to compensate for injury and adjust their respones to new situations or changes in their einvironment.

    -Referred pain: stiumulus may be distant from a pain location reported by the patient.
  8. **Perception:
    Reticular activating system is responsible for warning the individual to attend to the pain stimulus.
  9. **Modulation:
    involves the activation of descending pathways that exert inhibior or facilitary effects on the transmission of pain.

    -SNRI (seriotonin norepi reuptake inhibitors), Tricclic atnideprssants (amitriptyline) interphere with modulatory systems and inhibit noxious stimuli.
  10. **Types of Pain Management
    Recognize the differences so you can help pt in regards to adequate therapy to manage the pain.

    CHRONIC
    CANCER
    NEUROPATHIC
    ACUTE
    PCA
    • =>Chronic pain-those individuals live with the pain life long; life term. Manages with medication: right amt (minimal dose to maximum benefit)
    • -person can get acute exacerbation of that chronic condition or they can get break through pain. Know so you can initiate pain management.
    • Maintenance therapy
    • Breakthrough
    • Can use Demerol (Meperidine)? NO!! One of the drugs not currently used for chronic pain due to neurological effects like seizures that it causes.

    =>Cancer pain-responds well to antiinflammatory, non steroidals. Antidepressants (Adjunct)

    NSAIDS Opioids antidepressants

    • =>Neuropathic pain
    • -specific meds that work well on neuro pathwayAdjuvant
    • -Anesthesia and Anatiseizures: stabilize the neuronal membrane and inactivate peripheral Na Channels.

    • =>Acute pain-works best will opioids, NSAIDs PRN: first 28-48 hrs are the most, be on top of it, don't wait for pt to tell you they're on excruciating pain.
    • ATC option (Acute traumatic coagulopathy)
    • Different routes 

    • =>PCA-when pt feels they're in pain, they have capability based on med admin to push for that dose.. depend on drug order for pt controlled dose. Q6,10 or 15 minutes. There's also an hour limit meaning the machinewill only deliver a threshold amount of medication within an hour despite how many times they hit that button.
    • -dose, how often and hourly max.-pure PCA: drug amt, how often they can receive it, and hrly max.
    • -PCA and basal: basal hourly rate PLUS drug amt, how often they can receive it, and hrly max.
    • -You still must assess and talk to doc maybe they want more pain medication.
    • -continuous puls ox to see if they're getting they're oxygen
    • -side effects: resp depression, constipation, decreased neuro response and n/v.
  11. **ADJUVANCT THERAPY-
    Another type of medication added to a drug to increase or aid in its effect-if resp depression doesn't support opioids

    • Antidepressants
    • Antiseizures
    • Gaba receptors
    • Local Anesthetics
    • Mixed Mu Agonists
  12. ==>Corticosteroids
    -decrease inflamm response in a higher response for acute pain of surgery (usually)

    -SE: Immunosuppression: look at WBC labs, Increased Blood Sugar!

    !-From high levels, tapered to avoid metabolic shock
  13. ==>Antidepressants
    • Tricyclics
    • SNRI’s-inhibiors-because of the response to pain (chronic and cancer especially) tend to be depressed from pain causing limitations on their usual lifestyle
  14. ==>Antiseizure drugs
    Gabapentin [Neurontin]

    lamotrigine [Lamictal]

    Pregabalin [Lyrica]'

    -all work on neuropathic pain: diabetics, fibromyaligia, amputation individuals.
  15. ==>GABA receptor agonists
    Baclofen [Lioresal]α2

    -Adrenergic agonists-blood pressure usually, found that utilizing it seems to have an effect on the sensory pathway for pain

    Clonidine [Catapres] *big one* why are you taking this? ask.

    Tizanidine [Zanaflex], and dexmedetomidine
  16. ==>Local anesthetics (‘caines)
    -patches, put it closest to pain site duuur.
  17. ==>Mixed mu agonist opioid and NE/5-HT reuptake inhibitors
    Tramadol [Ultram]Tapentadol [Nucynta]
  18. ==>Cannabinoids
    Dronabinol [Marinol]
  19. ADMINISTRATION 
    -Titration
    SchedulingFocus on prevention or control. Harder to chase down pain than to prevent it.Do not wait for severe pain.Constant pain requires around-the-clock administration (not PRN!); that first 24-48 hour, tell pt to set alarm and take that pain med in the morning whether you're in pain or not.-know diff between onset and duration of each drug therapy, how fast acting, which are quick acting or longer acting opioids (not for acute, but chronic!).Fast-acting drugs for breakthrough and acute: IV. SubQ, IM. Slow: oral!

    =>Titration-Dose adjustment based on assessment of analgesic effect versus side effects-Use the smallest dose to provide effective pain control with fewest side effects!-what is their pain level goal? are you okay with a 2?
  20. **INTERVENTIONAL THERAPY

    =>Nerve blocks-
    =>Neuroablative techniques
    =>Neuroaugmentation-
    • =>Nerve blocks-nerve roots flooded (extermity surgeries) with one of those local anesthetics ('caines); done a lot in PACU.
    • -but start antiinflammatory and opioids once they feel the nerve block waring off.
    • Interrupt all afferent and efferent transmission, not only nociceptive input Used during and after surgery to manage pain

    • =>Neuroablative techniques For severe pain unresponsive to other therapy
    • Destroy nerves to stop transmission
    • -sever/caurderize the entire nerve root-sensitivity to cold, heat, touch just in that area..

    • =>Neuroaugmentation-put in "TENS" units or neuro stim devices that go into that area and stimulus blocks pain area in that pathway.
    • Electrical stimulation of brain and spinal cordCommonly used for chronic back pain

    -*TENS: TENS stands for (Transcutaneous Electrical Nerve Stimulation). which are predominately used for nerve related pain conditions (acute and chronic conditions). It works by sending stimulating pulses across the surface of the skin and along the nerve strands. The stimulating pulses help prevent pain signals from reaching the brain. They also help stimulate your body to produce higher levels of its own natural painkillers, called "Endorphins".
  21. **BARRIERS TO PAIN MANAGEMENT
    Common concerns:
    ==>Tolerance Need for increased dose to maintain same degree of pain control-rotate drugs instead of increasing dose.-not indicators of addiction

    • ==>Physical dependence
    • Expected response to ongoing exposure to pharmacologic agents manifested by withdrawal syndrome when blood levels drop abruptly
    • -no pain but their body still dependent to level of drug in their system and taking away may cause harm.
    • -not indicators of addiction

    • ==>Addiction
    • Neurobiologic condition with drive to obtain and take substances for other than prescribed therapeutic value
    • -Now you HAVE to have this substance in your body to function.
    • -use adjuct therapy for antiinflammatories
    • -taper off for accute pain.
    • -chronic pain: antidepressants, alpha adrenergics, gaba receptors.
  22. **GERONTOLOGICAL CONSIDERATIONS
    50% to 80% of older adults are estimated to have chronic pain problems

    • Most common painful conditions
    • Musculoskeletal Osteoarthritis Low back pain

    Previous fracture sites: can press on nerve sites and cause pain.Chronic pain often results in Depression. Sleep disturbance, Decreased mobility . Decreased health care utilization (can't get around to doctor's office), Physical and social role dysfunction (changing role)

    • =>Barriers to pain:Belief that pain is inevitable for aging, they don't have to be in pain, can help through physical pain
    • Greater fear of using opioids
    • Use words like aching, soreness, or discomfort instead of pain. Identify specific terms
    • High prevalence of cognitive, sensory-perceptual, and motor problems
    • Fear of analgesics because it will hasten death..

    =>Treatment cautions

    • Metabolize drugs more slowlyRisk of GI bleeding with NSAIDs
    • Multiple drug use (interactions)
    • Cognitive impairment, ataxia can be exacerbated by analgesics
  23. Pain Defn, Dimensions
    Pain is whatever the person experiencing the pain says it is, existing whenever the person says it does-Margo McCaffrey

    => Definition of Pain: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage

    • **Dimensions of Pain:
    • Physiologic
    • Sensory: sensation
    • Affective: how it affects behavior
    • Cognitive: how are they thinking about it, feeling about it?
    • => pain untreated: causes physical and emotional suffering, depression, anxiety, impaired immune function, reduced healing. Depression and anxiety have chronic pain tolerance.
  24. **Chemicals that activate PAIN

    -Pain Facts
    -Nursing Role
    =>Tissue trauma: Prostaglandins, veterans/car trauma

    =>Injured cells: release K+, histamines, bradykinins, activate platelets serotonin activate PAN, substance P, dilate blood vessels, edema, more histamines (Inflammation and injury that causes the pain)

    => Fear, anxiety, anger activates ANS: Releases norepinephrine, prostaglandins, activates on contact, pain impulse to brain. Pain is amplified by emotional state. animals are frightened because they experience pain.

    • **Facts
    • -99% of hospitalized patient will have pain
    • -Opioid is the best pain relief: they don't always work the same for each person
    • -1% will have respiratory depression from opiod (decreased respiratory rate or very shallow breathing, don't overdose them)
    • -Treat the underlying cause or assist in other ways to avoid any respiratory depression
    • -Be creative: distraction

    • => Nursing Role“ RN provides direct and indirect patient care serves that insure the …comfort of patients”
    • Nursing practice Act, section 2725. We are patient advocates, we are in charge of the patient's pain. If orders we have are not enough, it's up to us to collaborate with physicans to try to get their pain managed better. Nurse Practice Act. Proper management of patient’s pain is incorporated in the RN’s role as a patient advocate Section 1443.5
  25. **Types of Pain & Quality
    • Cutaneous
    • Somatic
    • Visceral
    • Referred: some place else
    • Radiating: starts in one spot and leaches off to another
    • Ischemic: Pain comes from poor blood flow
    • Neuropathic: Neurological
    • Psychogenic: In your mind. Not a real injury but brain tells you that there is pain so to the person, it IS very real. Ex. Phantom pain.

    • Quality of Pain: "what is it like? stabbing or just throbbing?"
    • Cutaneous: localized, sharp
    • Somatic: localized aching, throbbing
    • Visceral: diffuse,squeezing, crampingNeuropathic: burning, electric
  26. **Classification of Pain: Acute vs. Chronic
    • Acute: < 3 months or until tissue heals. It is expected to resolve because it's coming from an issue. You're waiting for a bone or tissue to heal.
    • -post operative pain, labor, pain from trauma (lacerations, fracture), pain from infection or acute ischemia.
    • -treatment: analgesic, postherapic neuraligia: development into a chronic pain.
    • -course of pain: decreases over time and goes away as recovery occurs
    • -Typical Physical behavior: Manifestiations vary but reflect sympathetic nervous system activation: increased HR, Resp, BP, Diaphoresis, pallor, anxiety, agitation, confusion, urine retention.
    • -Goal: Pain control with eventual elimination.

    Chronic: (Intractable-hard to manage and keep away) >3 months

    • - Severity and functional impact of chrnoic pain often are disproportionate to objective findings because of changes in NS
    • -accompanied by anxiety and depression
    • Malignant Pain: pathology
    • Non-malignant Pain: some tension, but nothing is falling apart or being damaged inside your body.
    • -Predominantly behavioral manifestations: Flat affect, decreased physical activity, fatigue, withdrawal from social interaction.
    • -Goal: pain control to the extend possible. Focus on enhancing function and quality of life.
  27. Pain Assessment
    => Pain Intensity
    => PQRST
    • **Pain Intensity:
    • pain meds are ordered by pain intensity, for how bad a pain to the prescriber.
    • 0 No pain
    • 1,2,3 Mild
    • 4,5 Moderate
    • 6,7 Severe
    • 8,9 Very severe
    • 10 Worst Possibe

    • **Pain Assessment-
    • 0-10 scale
    • -Behavior Scales: F/ACC,
    • Payen-ICU
    • -restlessness, grimacing
    • -body tension
    • -vocalization changes
    • -resistance to ventilation: biting(assess q contact, med,when turn)

    • Pain Assessment - PQRST
    • P = Precipitating factors: what brought the pain on
    • Q = Quality of pain: descriptive words. Feels "heavy, tight, hot"
    • R = radiation: where is pain going to
    • S = Severity: number, how bad
    • T = Timing: How long does it last.
  28. Nursing Managment of Pain
    -pseudoadiction
    -addiction
    -Barriers to Pain Managment
    • -Effective communication: pts need to feel confident that their reporting of pain wiell be believed and will not be perceived as complaning.
    • =>Challenges to effective pain managment:
    • -tolerance (opiodis) charactarized by the need for an increased opioid dose to maintain the same degree of analgesia. Opioid rotation considered, though increased opioid levels can increase pain levels (hyperalgesia)
    • -physical dependence: withdrawal symptoms (anxiety, diaphoresis, shaking, dilated pupils, tremors, restlessness, fever, tacycardia, insomnia). Tapering schedule should be used with careful monitoring. Calculate 24 hour dose divide by 2, of this amount, 25% given evenry 6 hours..
    • -pseudoaddiction: Inadequate treatment of pain--> pt exhibts wanting more drugs; occurs in a mistrust b/w patient and prvidder.
    • -Addiction: complex neurobiologic condition characterized by aberrant behavior. Hallmarks: compulsive use, loss of control of use, continued use despite ris of harm

    => Reducing Barriers to pain managment:

    -Fear of addiction, tolerance, concern about side effects, fear of injections, Desire to be "good" patient, to be stoic, forgetting to take analgesic, concern taht pain indicates disease progression, sense of fatalism, ineffective medication.

    • => Pain managment (teaching guide)
    • -Self managment technqiues, realistic goals for pain control, negative consequences of unrelieved pain, need to maintain a record of pain level and effectiveness of treamtne, pain should be treated with drugs before it becomes severe, meds may stop working after it is taken for a period of time so dosages must be readjusted, potential side effects/complications associated with pain therapy, need to report when pain is NOT relieved to tolerable levels.
  29. Pain => Gerontological Considerations:
    • -persistent pain associated with physical disability/psychosocial problems
    • - chronic pain is prevalent: musculoskeletal condtions
    • -osteroarthritis, low back pain. Results in depression, sleep distrubance, decreased mobility, increased health care utilization and physical/social role dysfunction.
    • -barrier to pain assessment: providers think pain is normal part of aging
    • may not repot pain for fear of being a "burden" or a "complainer", use "aching, soreness, discomfort" rather than pain. Carry out assessment in an unhurried manner. they have increased prevalance of cognitive, sensorty perceptual and motor problems that interfere with a person's ability to process info and to communicate.
    • Ex: demential, delirium, postroke, aphasia and other communication barriers. Use other assessment tools: large print pain intensity scale.

    -Assess depression and functional impairments.

    -Treatments: older adults metabolize drugs more slowly than younger people and are at greater risk for higher blood levels and adverse effects. "start low and go slow". Second: use of NSAIDs is associated wtih high frequency GI bleeding. Third, older adults often are taking many drugs for one or more chronic conditions. Dangerous drug interactions. Fourth: cognitive impairment and ataxia are exacerabated by analgesics such as opioids, antidepressants, and antizeizures.
  30. **Nursing Interventions
    • Informed consent: Diagnostics, IV line meds
    • Assess and evaluate response: evaluate the pain med, know onset of medication and how long it's been so you know when it's supposed to kick in and if it's working. Some meds don't work on a few people.
    • Instruct
    • Cultural sensitive: mom and son having pain, secret?
    • Est. therapeutic relationship: your patient knowing that you care about them helps them deal with it more
    • Use distraction
    • Touch
    • Relaxation techniques
    • Breathing, imagery, music
    • Massage: as long as you don't damage anything.
    • Transcutaneous stimulation: chronic pain, tens unit, neurostimulaton around the area that hurts to distract the nerves.
    • Exercise: chronic back piain
    • Administer Medications
  31. 1.Describe the origins of pain
    => Nociceptive Pain: 
    => Neuropathic Pain
    • -Normal processing of stimulus that damages normal tissue or has the potential to do so if prolonged.
    • -Treatment: usuall responsive to nonopioid and or opioid drugs
    • ->Types: Superficial somatic pain, Deep somatic pain, visceral pain
    • 1. Superficial Somatic: pain arising from skin, mucous membranes, subcutaneous tissue. Tends to be well localized. Examples: Sunburn, skin contusions.
    • 2. Deep Somatic Pain: Arseing from muscles, fasciae, bones, tendons. Localized or diffuse and radiating. Examples: arthritis, tendonititis, myofascial pain
    • 3. Visceral pain: activation of nociceptors in interal organts, respond to inflmmation, streching and ischemia. Distension produces cramping pain. Pain arising from visceral organs, such as GI tract and bladder. Well or poorly localized. Often referred to cutaneous sites. Ex: appendicitis, pancreatitis, cancer affecting internal organs, irritable bowel and bladder syndromes.

    • => Neuropathic Pain: Abnormal processing of sensory input by the peripheral or central nervous system. Typically described as numbing, hot, burning, shototing, stabbing, sharp, or electric shock like pain. Intense, short lived or lingering.
    • -Treatment: usually includes adjuvant analegesics
    • => Types: Central, Peripheral nerupathies, Deafferentation pain, Sympathetically maintained pain.
    • 1. Central : Caused by primary lesion or dysfunction in the CNS. Ex: Poststroke pain, pain associated with multiple sclerosis.
    • 2. Peripheral Neruopathies: pain felt along the distribution of one or many peripheral nerves caused by damage to the nerve. Ex Diagetic neruopathy, alchohol nutritional neuropathy, trigeminal nerualigia, postherpetic neuraliga
    • 3. Deaffernetation pain: resutls from a loss of afferent input. Ex: Phantom limb pain, postmastectomy pain, spinal cord injury pain. 4. Sympathetically Maintained Pain: associated with dysregulation of the autonomic ns and central pain is caused by CNS lesions or dysfunctions. persists secondary to sympathetic nervous system activity. Ex: phantom limb pain, complex regional pain syndrome.

    **Complex Regional Pain Syndrom: debilitating type of neuropathic pain, dramtic changes in color and temp of skin over the affectedd limb or body part accompanied by insense purning pain, skin sensitivity, sweating and swelling. Trigged by tissue injur, surgery or vascular event such as stroke. Or peripheral nerve lesion (type 2)
  32. => Core Principles of Pain Assessment and Nursing Implications:
    • 1. Patients have the right to appropriate assessment and managment of pain (assess in all patients)
    • 2. Pain is subjective (pt's self report of pain the the single most reliable indicator of pain.)
    • 3. Physiologic and behavioral signs of pain (tachycardia, grimacing) are not reliable or specific for pain (don't rely primary on onservations and objective signs unless pt can't tell you)
    • 4. Pain is unpleasant sensory and emotial experience (address both physical and spychological aspects when assessing)
    • 5. assessment appropatches, including tools must be appropriate for the pt population (special considerations are needed for assessing pain in patient's with difficulty communication, included family members when appropriate)
    • 6. Pain can exist without a physical cause (don't attribute pain that doesn't have an identifiable cause to psychological causes)
    • 7.Diff pts experience diff levels of pain in comparable stiuli (no uniform threshold for pain exists)
    • 8. Pt with chronic pain may be more snesitive to pain and other stimuli (pain tolderance varies)
    • 9. Unrelieved pain has adverse consequences. Acute pain that is not adequately controlled can result in physiologic changes that increase the likelihood of developing persisten pain (encourage pt to report pain and follow through with pain meds.)
  33. => Goals of Nursing pain assessment:
    diescribe pt pain experience in order to identifiy and implement appropriate pain management techniques and identify the pt's goal for therapy and resources for self management.

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