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What is the Definition of Pain?

"Whatever the experiencing person says it is existing whenever she/he says it does"

What are five misconceptions about pain

1. All real pain has an identifiable physical cause
2. Pts in pain always have observable signs
3. Comparable physical stimuli produce comparable pain in different people
4. If a pt doesn't complain of pain then it is not a problem (don't let pain get out of control)
5. Addiction is a common problem among pts taking opioids - addiction, physical dependence & tolerance

What is Addiction (3)?

- physiological need for the drug
- compulsive opioid use for means other than pain control.
- craving, compulsive use, lack of control, continued use despite harm
ex: watching the clock for next dose

What is Physical Dependence (2)?

- S/S of withdrawal if you stop the drug
- the body physiologically becomes accustomed to the opioid & suffers withdrawal symptoms if the opioid is suddenly removed or dose is rapidly decreased.
- could be any kind of drug. Ex. cardiac meds

What is tolerance?

- More to get same response (Rx & street drugs)
- occurrence of the body's becoming accustomed to an opioid & needing a larger dose each time for pain relief

What is Gate Control Theory?

Goes from PERIPHERAL STIMULI → SPINAL CORD → BRAIN

- if we bombarde the gate with a lot of stimuli the gates will close and no pain will get through to the brain (GATES CLOSE)

What are Neuromodulators & what are 3 examples?

• Chemicals in the body that inhibit pain
- Endorphins (once secreted block pain, they use receptors so pain can't)
- Enkephalins (once secreted block pain, they use receptors so pain can't)
- Certain activities increase the release of these chemicals. Ex. Exercise will help release these

What are 3 kinds of nociceptive Pain?

1. Cutaneous - skin (paper cut)
2. Somatic - tendons/ligament (sprained ankle)
3. Visceral - organs (deep pain)

What are 2 kinds of Neuropathic Pain?

= sensations (ex. burning, numbness, tingling)
1. Allodynia - nerve pain (numbness/tingling)
2. Phantom Limb - after amputation (type of nerve pain)

What is Referred Pain?

pain comes from a different area than where the problem of pain actually is

ex: typically heart attack=pain in arm & jaw

What is Psychogenic pain (3)?

- psychological form of pain
- no physical cause can be identified
- rule out everything else 1st

What is chronic pain (3)?

- pain will last over the expected time frame
- greater than 6 months
- can be either persistent or intermittent

What is acute pain?

- abrupt onset
- episode of pain that lasts from seconds to less than 6 months

What are 2 physiologic responses to acute pain?

1. Stress response
a. Increased HR, RR, BP
b. Pallor or flushing
c. Diaphoresis
2. Psychological response =Crying/Screaming/Yelling
*These are use to distinguish btw acute & chronic

What is Intermittent pain?

- Comes & goes
- may be same physiologic response as acute pain
- same pain, but at different times. a flare up is still considered chronic

What is persistent pain & what are manifestations?

- 24/7
- No change in HR, RR, or BP - b/c it is continuous
- psychological response

what are four factors affecting the pain experience?

1. Culture = Ethnic variations, Stoic & controlled, Expressive, Family (what is learned), gender, age, Religious beliefs & Medical culture (must believe, even is pain doesn't match injury or surgery)
2. Environment = Hospital vs home
3. Mental stressors = Anxiety & fatigue (fatigue = ⬆ anxiety & ⬆ pain)
4. Past experience = Good pain control, Poor pain control, Chronic pain

Pain assessment: how to do it (4)?

1. 5th Vital Sign = pain score
2. Reassessment after intervention
a. 30 minutes after IV med (MUST document)
b. 60 minutes after PO med (MUST document)
3. Physical exam
a. Vital signs
b. Appearance = General & Site
4. Functional exam = what can the patient do or not do because of this pain?

What questions do you ask to assess pain (6)?

- Location = don't assume pain is in the obvious place
- Quality (somatic, visceral, neuropathic) = have them describe
- Quantity = pain scale (1-10)
- Duration = how long lasting
- Aggravating Factors
- Alleviating Factors

How long until you reassess after giving a pain med IV?

30 minutes

How long until you reassess after giving a pain med PO?

60 minutes

What things do you ask during your functional exam?

Do you have any pain?
What would you score your pain 1-10?
What is you acceptable pain level? (A level of 0 may not be a realistic goal)
What do you do at home to alleviate pain?
What is the pain preventing you from doing (ADL)?

What number pain on a 1-10 scale would you treat?

treat 5 or above

What is FLACC scale (2)?

- used for patients who are unable to give pain score
- ratings from 0-2 in five categories. It they have a 2 in each category it is the equivalent of 10 on the pain scale

What are six special issues with older patients regarding pain?

- multiple sources of pain (what's different?)
- multiple medical problems
- potential drug interactions
- underreporting pain
- cognitive/psychomotor impairment
- altered pharmacokinetics (meds eliminated slower)

What are 12 non pharmacologic ways to relieve pain?

These work on gate-control therapy
- aromatherapy
- humor
- music
- imagery
- relaxation
- distraction
- acupuncture
- hypnosis
- biofeedback
- therapeutic touch / massage
- cutaneous stimulation
- heat / cold therapy

What is the Controlled Substance Act (3)?

1. Enacted to control the distribution and use of all depressant and stimulant drugs and other drugs of abuse or POTENTIAL ABUSE as designated by the Drug Enforcement Administration
2. Specifies record keeping by the pharmacist (and nurse)
3. Centrally acting drugs are divided into five classes call schedules.

What are Schedule 1 Drugs & what are 3 examples?

- High abuse potential & no/minimal accepted medical use.
- usually experimental

- HEROINE
- COCAINE
- MARIJUANA

What are Schedule 2 Drugs & what are the 3 groups?

- High abuse potential w/severe dependance liability

- AMPHETAMINES
- BARBITURATES
- NARCOTICS =
• Morphine sulfate
• Hydromorphone (Dilaudid)
• Oxycodone (Oxycontin, Percocet)
• Oxymorphone (Opana)
• Codeine (individual form)
• Fentanyl (sublimaze, duragesic)

What are Schedule 3 Drugs & what are the 3 groups?

Less abuse than Schedule 2 / moderate dependence liability

- NONBARBITURATE SEDATIVES
- NONAMPHETAMINE STIMULANTS
- NARCOTICS =
• Codeine (tablet form w/other drug Ex. Tylenol #3)
• Hydrocodone in combination (Vicodin, Lortab, Norco)

What are Schedule 4 Drugs & what are the 3 groups?

Less abuse than Schedule 3 & limited dependence liability

- OPIOID ANALGESICS
(Codeine liquid form & Propoxyphene/Darvocet)
- ANTIANXIETY AGENTS
(Diazepam/Valium & Alprazolam/Xanax)
- ANTICONVULSANTS/SEDATIVES
(Phenobarbital (seizure control) & Clonazepam/Klonopin)

What are Schedule 5 Drugs & what are the 2 groups?

Limited abuse potential

- NARCOTICS (contain small amounts)
• Antitussives=Codeine=cough syrup
- Pregalain (LYRICA)

What are the 8 routes of administration?

1. Oral
2. IV
3. Transdermal
4. PCA
5. Epidural
6. IM = don't see very much
7. SQ = don't see very much
8. Rectal

What are Patient controlled analgesia (4)?

1. patient pushes a button when sensation of pain occurs (after initial dosing) & a preset bolus dose of analgesic is administered
2. Ordered as basal (continuous- helps when patient is sleeping), PCA, or basal + PCA.
3. Common drugs are hydromorphone (dilaudid) and morphine sulfate
4. Nurse must validate settings = its as if you are giving meds. make sure pump is what was ordered

What does the nurse need to know for PCAs (5)?

- Medication,
- dose
- lock out (when patient can get next dose, may or may not have 4 hour limit
- pain scores
- how much is patient actually using

What are the two common drugs used for PCA?

Dilaudid

Morphine Sulfate

usually 24-48 hours only

What is an EPIDURAL ANALGESIA & what are 2 common drugs used? (4)

1. usually combination of narcotic & anesthetic
2. May be delivered via basal (continuous) or PCA mode
3. Common narcotics used are fentanyl and morphine sulfate
4. assess lower extremities q4h

FENTANYL
MORPHINE SULFATE

What is acute pain pharmacological management (4)?

1. Combination of medications allow for lower dosing and better control
2. Use PO whenever possible = tends to last longer, not as many peaks & valleys, if patient has BTP then you can give IV meds
3. IV routes used:
a. When pt. NPO, vomiting
b. Breakthrough pain (BTP)-after PO dose given and it is ineffective
c. Severe pain
4. May benefit from ATC dosing (even when ordered prn)
a. Give ATC first 24-72 hours, then prn

What is chronic pain pharmacological management (4)?

1. Oral route preferred
2. ATC dosing adjusted to pt. response
a. Use sustained release forms
3. IMMEDIATE RELEASE PO forms used for BTP
4. Optimize adjuvants and non-pharmacological approaches

What is World Health Organization (WHO) analgesic ladder (2)?

1. Type of pharmacological agent used based on severity of pain
2. 3 steps

What is STEP 1 (WHO)? (2)

1. Mild Pain
2. NON-OPIOID ANALGESIC:
- ASA, Acetaminophen (Tylenol, APAP), NSAIDS

What is STEP 2 (WHO)? (4)

1. Moderate Pain
2. LOW DOSE OPIOID (usually combined w/ non-opiod)
3. ACETAMINOPHEN COMBINATIONS, Propoxyphene (Darvocet)

*no additional Tylenol

What is STEP 3 (WHO)? (5)

1. Severe Pain (BTP=episodic/Continuous=PCA, epidural)
2. O/P/D dependent on route
3. OPIOIDS used:
- Morphine sulfate
- Oxycodone (Oxycontin)
- Hydromorphone (Dilaudid)
- Fentanyl (Sublimaze, Duragesic)
- Methadone
- Meperdine (Demerol)

IV asap / ↓ duration
PO onset 45 min / ↑ duration

Aspirin (non-opioid) (3)

1. effects: Antiplatelet (single dose =Hx of stroke or MI), Analgesic, Antipyretics
2. may cause bleeding - look for blood in urine
3. should not be taken w/ NSAIDS, Anticoagulants or other Antiplatelets agents unless directed

NSAIDs (non-opioid) (2)

= Non-steroidal Anti-Inflammatory Drugs
1. Medications =
Ibuprophen (Motrin/Advil)
Naproxen (Aleve)
Ketorolac (Toradol)
2. Contraindicated:
PUD
**Bleeding
**Renal Impairment (kidney failure)
When on Anticoagulant or Antiplatelet (ASA or Plavix) agents
3. if taking steroids should not take NSAIDs

Acetaminophen (non-opioid) (2)

1. No more than 4g/24hr or 1g/4hr
2. causes liver failure (hepatic toxicity)

ex: Tylenol / APAP

Acetaminophen Combinations (3) & other general information (3)

1. Plus Codeine (Tylenol 3 & 4)
2. Plus Hydrocodone (Vicodin/Lortab/Norco)
3. Plus Oxycodone (Percocet)
4. MUST know combination of drug!!
5. Patient teaching regarding acetaminophen dose
6. Side effects = Constipation, Respiratory depression

What are seven Opioid Adverse Effects?

- adverse effects may be route dependent (IV=peak & onset are quick; PO=peak & onset are delayed)
- HYPOTENSION (w/IV) Orthostatic hypotension
- respiratory depression (usually not if dose is right)
- flushing
- pruritus (esp. w/IV morphine)
- Constipation = slows things down
- Physical Dependence, tolerance

What is Narcotic Antagonist? (7)

1. Naloxone (Narcan) = usually for low RR, usually IV
2. used for narcotic OD
3. usually given IV (IM if no IV access)
4. reversal occurs immediately w/ IV route
5. short half life (5min/watch for resedation)
6. binds to receptor sites and doesn't allow pain meds to get through (so now patient feels pain)
7. may give 2nd dose if needed

What do Adjuvants do? (2)

- drugs that enhance the effect of opioids

- drugs that ↓ side effects of opioids

What types of drugs are Adjuvants?

- Antidepressants
- Anticonvulsants
- Corticosteriods
- Muscle Relaxants
- Antihistamines
- Topical Anesthetics

What do Antidepressants do & what are 3 types?

= help potentiate & may have some pain remedies themselves
1. Tricyclics- Amitriptyline (Elavil)
2. Atypicals- Buproprion (Wellbutrin), duloxetine (Cymbalta)
3. SSRIs- Fluozetine (Prosac), Sertraline (Zoloft)

What do Anticonvulsants do & what are two types?

= usually used for neuropathic pain "burning"
1. Gabapentin (Neurontin)
2. Pregabalin (Lyrica)

What are Corticosteriods & what are three examples? (5)

1. Anti-inflammatory effect
2. DO NOT use with NSAID
3. Prednisone
4. Dexamethasone (Decadron)
5. Methylprednisolone (Medrol)
- once you complete the course of steroids you can start taking NSAIDs

What are two types of Muscle Relaxants?

Diazepam (Valium)

Methocarbamol (Robaxin)

- motor vehicle accidents / falls/ tight muscles

What are two types of Antihistamines & what do they do?

Diphenhydramine (Benadryl)
Promethazine (Phenergan)

- helps to control side effects Ex. itching, nausea

What is Topical Anesthetic (6)?

- Lidocaine (Lidoderm patch)
- Usually on for 12 hrs, then removed for 12 hrs
- placed directly on painful site
- up to 3 patches daily
- can cause skin irritation
- numbs area

-ex: rib fractures, muscle strain

Controlled Substance Act

Scheduled 1-5

to control distribution of depressant & stimulant drugs

What is a nursing diagnosis?

Impaired Comfort
- Acute pain related to tissue trauma and reflex muscle spasm secondary to fractured femur AEB patient rates pain 8/10
- Chronic pain related to tissue trauma and reflex muscle spasm secondary to left hip arthritis AEB patient rates pain 7/10

What are outcomes for acute and chronic pains?

1. Acute Pain
- Patient will have relief of pain AEB pt. rates pain 3/10 (acceptable pain level) or less within 1 hour after receiving pain medication
2. Chronic Pain
- Patient will have adequate pain control AEB
Pt. rates pain 3/10 or less for the entire shift
Pt. is able to perform ADL's independently

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