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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.
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.
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.
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
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
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
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
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
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
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
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
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
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.
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
15) Program a patient controlled analgesia (PCA) pump correctly.
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
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
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.
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.
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.