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1) Define the concept of pain.
- a) Unpleasant sensory and emotional experiences associated with actual and potential tissue damage.
- b) Patient is authority on the pain and the only one who can describe the experience. In other words, self-report is always the most reliable indication of pain.
- c) Pain has an urgent and primitive quality, a quality responsible for the psychological, social, cultural, and cognitive aspects of the pain experience
- d) Useful purpose because it warns of impending tissue injury, motivating the person to seek relief.
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2) Identify populations at high risk for undertreatment of pain.
- a) Older adults, substance abusers, and those whose primary language differs from that of the health care professional
- b) Older adults in nursing homes are at especially high risk because many residents are unable to report their pain.
- c) There often is a lack of staff members who have been trained to manage pain in the older adult population.
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3) Discuss the attitudes and knowledge of nurses, physicians and clients regarding pain assessment and management.
- a) Patients rely on nurses and other health care professionals to adequately assess and manage their pain.
- b) Be sure to accurately document your assessments and actions, including patient and caregiver teaching
- c) Communication and collaboration between the patient and members of the interdisciplinary health care team about the patient's pain, expectations and progress toward control are equally important.
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4) Differentiate between addiction, tolerance and physical dependence.
- a) Physical dependence:
- i) normal response that occurs with repeated administration of an opioid for several days
- ii) It is manifested by the occurrence of withdrawal symptoms when opioid is suddenly stopped or rapidly reduced or an antagonist is given
- iii) Occurs in everyone who takes opioids over a long period of time
- iv) Withdrawal symptoms may be suppressed by the natural, gradual reduction of opioid as pain decreases or by gradual systematic reduction, referred to as tapering.
- v) Physical dependence is not the same as addictive disease
- b) Tolerance:
- i) Is a normal response that occurs when repeated use decreases the effect of drug over time
- ii) patients need increasing doses to achieve same pain relief
- iii) usually occurs in the first days to 2 weeks of opioid therapy but it is uncommon after that
- c) Addiction (chronic)
- i) Is a chronic neurologic and biologic disease
- ii) Influenced by genetic, psychosocial, and environmental factors
- iii) No single cause of addiction
- iv) It is characterized by one or more of these behaviors: impaired control over drug use, compulsive use, continued use despite harm, and craving
- v) The disease of addiction is a treatable disease; as for any other suspected disease, refer the patient to an expert for diagnosis and treatment
- d) Pseudoaddiction:
- i) “Addictive behaviors” because pain is under treated or a mistaken diagnosis of addictive disease
- ii) Anger/esculating demands for more meds, which results in suspicion and avoidance by staff
- iii) Common with chronic pain
- iv) Behavior resolved when pain is adequately treated
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5) Compare and contrast the characteristics of the major types of pain.
- a) Acute Pain
- i) Short Duration
- ii) Usually has a well-defined cause
- iii) Decreases with healing
- iv) Is usually reversible
- v) Initially serves a biologic purpose (warning to withdraw from painful stimuli)
- vi) When prolonged, sees no useful purpose
- vii) Mild - Severe intensity
- viii) When unrelieved, can increase morbidity and mortality and prolong hospital length of stay
- b) Chronic Pain (Peristent Pain)
- i) Lasts longer than 3 months
- ii) May or may not have well-defined cause
- iii) Usually begins gradually and persists
- iv) Serves no useful purpose
- v) Miled - Severe intensity
- vi) Often accompanied by multiple quality of life and functional adverse effects, including depression, fatigue, financial burden, and increase dependence on family, friends and the health care system
- vii) Can impact the quality of life of family member and friends
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6) Explain the transmission of pain.
- a) Pain receptors (nociceptors) in the skin are activated by tissue damage
- i) A signal travels up the peripheral nerve to the spinal cord
- ii) Within the spinal cord, chemical messengers (neurotransmitters) are released. These activate other nerves that pass signals to the brain.
- iii) The thalamus relays the signals on to the somatosensory cortex (sensation), frontal cortex (thinking) and limbic system (emotional response)
- b) 2nd Process to Nociception
- i) A-Delta Fibers: are lightly myelinated and faster conducting than unmyelinated C Fibers
- (1) They detect thermal and mechanical injuries
- ii) C Fibers: unmyelinated or poorly myelinated and slow conductors
- (1) Respond to mechanical, thermal and chemical stimuli
- (2) Activation after acute injury yields a poorly localized (more widely distributed) typically aching/burning pain.
- (3) Produces more continuous pain
- (4) Nociceptors have small diameter axons—either A-Delta & C-Fibers
- (5) Effective transduction generates an electric signal (action potential) this is transmitted in these nerve fibers form the periphery toward the CNS
- (6) The sensory perception accompanying A-delta fiber activation is sharp and well-localized and leads to an appropriately rapid protective response, such as reflex withdraw from painful stimuli
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7) Discuss the Gate Control theory.
- a) Pain transmission
- i) Exists in the spinal cord
- ii) When gate it closed, the impulses are blocked and pain is not perceived
- iii) When gates are opened, pain impulses ascend to the brain where the person perceives that pain is present
- iv) Proposes that only one pain pathway (gate) is open at one time. The brain therefore does not perceive pain while it is preoccupied with other sensory input.
- v) Explains how massage, vibration, heat, and cold reduce pain sensations
- vi) Melzack and Wall suggest that this process explains why we tend to rub injuries after they happen. When you bang your shin on a chair or table, for example, you might stop to rub the injured spot for a few moment. The increase in normal touch sensory information helps inhibit the pain fiber activity, therefore reducing the perception of pain
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8) Describe the components of a comprehensive pain assessment.
- a) Location
- i) Ask patient to state or point to the area(s) of pain on the body
- ii) Pain may be described as belonging to one of four categories r/t its location
- iii) Localized pain is confined to the site of origin
- iv) Projected pain is diffuse around the site of origin and is not well localized
- v) Referred pain is felt in an area distant from the site of painful stimuli
- vi) Radiating pain is felt along specific nerve or nerves
- b) B. Intensity
- i) Ask patient to rate the severity of the pain
- ii) Numeric Rating Scale (NRS)
- iii) “On a scale of 0-10…”
- iv) Wong-Baker FACES Pain Rating Scale
- v) J -_- L
- c) Quality
- i) Have them describe how the pain feels
- ii) Descriptors help identify the presence
- iii) Pain involving superficial or cutaneous can often localize pain to specific area
- d) Onset and Duration
- i) When did the pain start
- e) Aggravating and Relieving Factors
- i) What makes the pain worse and what makes it better
- f) Effect of Pain on Function and Quality of Life
- i) Patients with persistent pain about how it has affected their lives
- g) Comfort-Function
- h) Other Information
- i) Consider patient’s culture, past pain experiences, medical hx
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9) 9. Describe the use of non-opioid analgesics in pain management.
- a) Non-Opioid
- i) Acetaminophen and NSAIDs make up the group
- ii) May be given together
- iii) Appropriate alone for mild to moderate nociceptive pain
- iv) Added to opioids, local anesthetics, and/or anticonvulsants as part of multimodal analgesic regimen
- v) Not appropriate for severe pain bc maximum dose of non-opioid limits escalation of the opioid dose
- b) Acetaminophen
- i) Tylenol, Abenol
- ii) First-line for musculoskeletal pain
- iii) Relieve pain by underlying mechanisms in CNS
- iv) Has analgesic and antipyretic properties
- v) NO inflammatory properties so less effective than NSAIDs for chronic inflammatory pain
- vi) Most serious complication is hepatoxicity as a result of overdose
- vii) Does NOT increase bleeding time and has low incidence of GI adverse effects
- c) NSAIDs
- i) Administration by noninvasive routes
- ii) More adverse effects than acetaminophen with gastric toxicity and ulceration
- iii) Risk factors:
- iv) Older than 60 years
- v) Hx of peptic ulcer or cardio disease
- vi) Administer lowest dose for shortest time necessary
- vii) Carry a risk for cardio adverse effects through prostaglandin inhibition
- viii) Keep patient adequately hydrated when administering to prevent acute renal failure
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10) Discuss and compare opioid analgesics.
- a) Moderate to severe nociceptive types of pain
- b) Interacts with opioid receptor sites located throughout the body
- c) Produces analgesia as well as unwanted effects
- i) Constipation
- ii) Sedation
- iii) Nausea
- iv) Respiratory depression
- d) Three classifications of opioids
- i) Full or Mu Agonists (“morphine-like”)
- (1) Bind primarily to mu type opioid receptors in the CNS
- (2) Block release of neurotransmitter substance P, which prevents transmission of pain
- (3) No ceiling effect on analgesia
- ii) Increase in dose produce increases in pain relief and no maximum dose
- (1) First-line opioid analgesics for moderate to severe nociceptive pain
- iii) Mixed Agonists Antagonists
- (1) Bind to more than one type of opioid receptor
- (2) Bind as agonists to the kappa opioid receptors to produce analgesia
- (3) Trigger severe pain and opioid withdrawals characterized by:
- (a) Rhinitis
- (b) Agitation
- (c) ABD cramping
- (d) Restlessness
- (e) Nausea
- (4) Produce dose-ceiling effect
- (a) Increases in dose will not produce further relief
- (5) Risks reversing analgesia – assess patient to ensure adequate pain control is maintained
- iv) Partial Agonist
- (1) Produce an analgesia plateau and are not easily reversed by opioid antagonists
- (2) Limit their role in pain management
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11) Discuss the adverse effects of Meperidine.
- a) CNS: Increased ICP, Seizures, drowsiness, dizziness, confusion, headache, sedation, euphoria, serotonin syndrome
- b) CV: Tachycardia (IV), palpitation, bradycardia, hypotension, change in B/P,
- c) RESP: Respiratory depression (hypoventilation)
- d) SYST: anaphylaxis (allergic reaction; can include shock.)
- e) EENT: Tinnitus, blurred vision, miosis, diplopia, depressed corneal reflex
- f) GI: nausea, vomiting, anorexia, constipation, cramps, biliar spasm, paralytic ileus
- g) GU: Urinary retention, dysuria
- h) INTEG: rash, urticarial
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12) 12. Define equalanalgesic dosing.
- a) The quantitative ratio between actual milligram potency of comparable analgesics required to achieve the equivalent therapeutic effect.
- b) Equianalgesic dose: a dose of one analgesic that is equivalent in pain-relieving effects to that of another analgesic.
- i) This equivalence permits substitution of medications to prevent possible adverse effects of one of the drugs.
- ii) This term is also applied to equivalent alternative dose sizes and routes of administration
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13) 13. Explain the purpose of adjuvant medications in pain management.
- a) Medications that are not typically used for pain, but may be helpful for its management.
- b) Can include:
- i) antidepressants,
- ii) anti-seizure medications
- iii) muscle relaxants
- iv) Sedatives
- v) anti-anxiety medications
- vi) botox.
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14) Differentiate four routes of analgesic administration. (http://www.rnceus.com/ages/routes.htm, pg. 1180 Taylor)
- a) Oral: Preferred route of administration; least expensive, best tolerated, easiest to administer
- b) Intramuscular: Drug is injected into the muscle; most often the deltoid or vastus lateralis muscles; THIS ROUTE IS NOT RECOMMENDED FOR PAIN MANAGEMENT, because IM injections are often painful and drug absorption is variable and unpredictable
- c) Intravenous: Drug is given directly into the vein; almost all opiods can be given by IV route; PROVIDES THE MOST RAPID ONSET OF PAIN RELIEF; Needs to be done slowly to limit any adverse effects
- d) Transdermal: Drug is absorbed through the surface of the skin; ex: Fentanyl is available as a transdermal drug; contraindicated for use in acute post-op pain or in opiod naïve pats, due to risk of respiratory depression; DIFFICULT TITRATE AN OPTIMUM DOSE, this requires additional short acting oral opiods to manage breakthrough pain (BTP)
- e) Rectal Suppository: Used for pts who cannot swallow or when IV sites are not available; opiods are absorbed rapidly
- f) Sublingual/ Buccal: Sublingual - Placed under the tongue; buccal - placing a tablet between the teeth and mucous membranes of the cheek: opiods absorb rapidly
- g) Intranasal: drug administered through the nose
- h) PCA (Patient controlled analgesic): allows pts to treat their pain by self-administration; pts must be able to understand the relationships between pain, pressing the PCA button and taking the analgesic and pain relief; pts must also be cognitively and physically able to use any equipment that is used to administer the therapy; most commonly used to deliver analgesics intravenously, SQ, or via the epidural route
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15) Program a patient controlled analgesia (PCA) pump correctly.
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16) Identify special considerations for older adults related to pain assessment and management. (From Pain Management Ppt.)
- a) Pain is prevalent in the elderly
- b) At risk for under treatment
- c) May not describe the pain as “pain” but may call it discomfort, or soreness
- i) Tend to report less often
- ii) May view as sign of weakness or
- iii) something to be lived with
- iv) Don’t want to be a bother
- d) Assessment
- i) ASSUME PAIN IS PRESENT
- ii) Use a standard scale
- iii) Use a variety of descriptors
- e) Management
- i) Use round the clock dosing
- ii) Start low and go slow
- iii) Monitor for adverse effects
- iv) Drug interactions
- v) Avoid use of meperidine (Demerol)
- vi) Use nondrug therapies
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17) 17. Identify physical and cognitive-behavioral therapies for clients experiencing pain.
- a) Physical have the best evidence for reducing pain. Low impact exercises, in combination with analgesics improve outcomes.
- b) Physical theory, Occupational therapy, Aqua therapy, Functional restoration, Acupuncture and low impact exercise programs such as slow walking and yoga
- c) Cognitive behavior strategies
- d) Less effective in relieving pain than physical modalities. They are useful in reducing the patient’s focus on pain but do not physiologically block pain.
- e) They range from prayer, relation breathing, artwork, reading, and watching tv
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18) Develop a teaching/learning plan for managing pain.
- a) Teach the patient and the family about analgesics the purpose and action of various drugs, their side effects and complications; and the importance of correct dosing and dosing intervals.
- b) Explain to them how to prevent or treat constipation associated with taking opioids analgesics and other medications. Establish sleep schedule that will not be interfered due to analgesics medications.
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19) Describe the role of the nurse in pain management.
- a) Try your best to have direction in providing maximum relief. Teach the patient how to treat breakthrough pain.
- b) Encourage the patient to speak to his or her primary provider before a painful treatment or procedures.
- c) Evaluate the family support system in assisting the patient in adhering to and continuing the proposed medical treatment.
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20) Discuss the harmful effects of untreated pain.
- a) Physiological Impacts: stress response, Increased HR, BP, AND O2 demand, Decreased GI, Immobility, Decreased in immunize response, delay in healing, may develop chronic pain.
- b) Quality of life: Interferes with ADL, Causes anxiety, depression, hopelessness, fear, anger, sleepless nights impairs family, work, social relationships.
- c) Financial Impact: Costs Americans billions of dollars, Increases hospital length of stay, Leads to lost income and productivity.
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