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Pain Power Point - Exam 2

Terms in this set (89)

What is pain?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
True or false - children do not feel pain to the same degree as adults.
False - it is often unrecognized, you must use different scales and assessment techniques
True or false - Physical manifestations are more important than self-reported measures
False - self reported pain is the gold standard, the patient's pain is what they say it is.
True or false - Pain without an obvious source is usually psychological.
False - there isnt always an obvious source. We have very advanced assessment techniques but we're not always able to see the cause
True or False - The same stimulus produces the same degree of pain in all individuals.
False - pain is an individual experience; two people could get the same injury and feel the pain differently.
True or false - use of opioids causes all patients to become addicted.
False - there is the potential for addiction, patients may become dependent or become pseudoaddicted.
What is the most common cause of lost work time and work absence?
Lost work time - headache
Work absence - chronic back pain, costs about $1500/year.
What is the nurses role in managing pain?
Accurately assess pain using a variety of methods and communicate findings verbally or through documentation.
Ensure implementation of pain relief measures.
Evaluate effectiveness of pain relief measures.
Advocate for patients with pain.
What is the sensory aspect of pain?
the physical response and activation of your sympathetic nervous system
What is the emotional aspect of pain?
the definition of pain has the word "emotional" in it, this is the person experiencing depression, anxiety or even joy.
What is the spiritual aspect of pain?
It asks "how does pain fit into the big picture of life" it may be viewed as a blessing or a curse and some people may use spirituality to deal with their pain.
What is the behavioral aspect of pain?
This is the outward expression of pain; crying/screaming/grimacing/somnolence
What is the cognitive aspect of pain?
Pain has an effect on cognitive abilities and generally it decreases our cognitive abilities.
What is the cultural aspect of pain?
Things that affect pain perception differently; age, gender, education level, socioeconomic status, ethnicity
What is the onset of acute pain?
Sudden
What is the duration of acute pain?
less than 3 months
What is the severity of acute pain?
mild to severe
What is the cause of acute pain?
There is generally an identifiable cause to the acute pain
What is the course of acute pain?
Decreases over time as the healing occurs
What is the typical behavior of acute pain?
It is a reflection of an activation of the sympathetic nervous system; increased heart rate, increased blood pressure ect.
What are the goals of acute pain?
Control/elimination of pain
What is the onset of chronic pain?
Gradual or sudden
What is the duration of chronic pain?
Greater than 3 months
What is the severity of chronic pain?
Mild to severe
What is the cause of chronic pain?
May or may not have an identifiable cause
What is the course of chronic pain?
Does not decrease over time, there is a pattern of increasing and decreasing. May depend on the day, time or season
What are the typical behaviors of chronic pain?
Reflects behavioral manifestations; flat affect, decrease in normal level of activity, may be withdrawn from family, may not participate in ADLs, may have chronic fatigue.
What is the goal of chronic pain?
The control of pain as best as possible and improved quality of life.
What are the two types of nociceptive pain?
Somatic - localized pain from acute injury, typically in bones/joints/subcutaneous tissues
Visceral - activation of nociceptors within internal organs. In response to inflammation, stretching or obstruction of internal organ.
What is neuropathic pain?
Pain r/t the damage to peripheral nerves or structures in the CNS. Pts will use words like "numbness, burning, shooting and/or electric shocks".
What is the physical exam portion of the pain assessment?
Look at the site!!! Do a neurologic and neuromuscular exam as well.
What is the psychosocial portion of the pain assessment?
Assess the emotional and behavioral reactions the patient displays towards the pain.
What are the diagnostics that help with pain
CT/MRI/X-ray and neurophysiology studies. It is important to remember that these show the anatomy but there may not always be something to physically see that can cause the pain.
What should be discussed during the interview portion of the pain assessment?
Onset/duration - When did it start, how long did it last
Location - where is it (point to it on the body). May be helpful to use pain map for them to mark an X. Is it referred pain? Example: in pts with gallbladder pain, they usually have pain that radiates up to their shoulder
Intensity - this is where you give a name to the pain; mild/moderate/severe and is a good starting point for assessment purposes
Quality - this is when the pain gets a description; throbbing, shooting, sharp
Associated symptoms - any n/v, diarrhea, fever, SOB, dizzy ect
Management Strategies - what have you used at home/what have you tried to help deal with the pain. Important to help determine what your next intervention will be
Impact of Pain - how are you sleeping at home, are you eating, are you able to work; how is this impacting your life
Patient Goal - what is the acceptable pain level for you? This is a good place to review any fears about narcotics also
What are the pro's and con's of the numeric pain intensity scale?
It is best for patients who are adult, alert and oriented x3, and verbal.
Pros - measurable, objective
Cons - needs some understanding, may need to do pt education.
What are the pro's and con's of the Wong-Baker FACES pain rating scale?
It is best for children but can also be used for patients with cognitive impairment.
Pros - gives a visual/objective measurement to a subjective feeling.
Cons - requires a certain level of emotional intelligence; what the happy vs the crying face means. For some pts the differences in the faces may be difficult for them to see.
What are the pros and cons of the lego pain assessment tool?
It is best for children.
Pros - it is familiar to kids and the descriptions can be helpful in explaining to parents and children
Cons - the pt needs to be at a level where they understand the facial expressions and vocabulary as well as some patient education.
What are the pros and cons of the nips scale pain assessment tool?
It is best for non-verbal adults, children, and infants; anyone who may have had a stroke or have aphasia.
Pros - very objective in that it is behavior based and correlates with a point value and then determines the intensity.
Cons - we don't get a self-reported pain description which is the gold standard.
When do you use the Richmond agitation and sedation score and what are the benefits?
It is used for pain assessment and with opioid or CNS depressant administration.
Benefits - it is a continuum; this gives us an objective measurement of their level of alertness. There is a continuity of care so a variety of nurses can use this and come up with a similar score. This allows us to have a common ground/common language between care givers.
What are the pain management planning goals?
Follow principles of pain assessment.
Every pt deserves adequate pain management.
Base treatment plan on pts goal.
Use both drug and non-drug therapies.
Use multimodal approach to analgesic therapy.
Implement interdisciplinary plan.
Evaluate effectiveness.
What are pain management considerations for drug administration?
Scheduling - think about prevention; don't only give PRN meds, be on top of it and keep the pt on a schedule. Pts also have pain when they sleep so ask if they want to be woken up for a pain med if they have been taking them on a schedule.
Titration - give the smallest dose possible to alleviate pain - rationale is that the smaller doses have less side effects.
What are the different routes for pain management medications?
Oral - sustained/extended/immediate release available; will possibly need higher doses with oral as opposed to IV.
Transmucosal - fentanyl usually only given this way and is effective in 10 minutes
Intranasal - nose is highly vascular and is good for pts who are agitated
Rectal - good for pt's with N/V or are NPO
Transdermal - Good for delayed release; may have systemic effects or just local effects.
Intraspinal - can be given as epidural for OB or cervical for thoracotomy or GI surgery.
What are the four classifications of pain management medications?
Non-opioids - used for mild to moderate pain. Example: Tylenol, NSAIDs, Aspirin
Opioids - used for moderate to severe pain. Example: morphine, hydrocodone
Adjuvant - used alone or with other analgesics, great for neuropathic pain. Example: corticosteroids, antiepileptics, antidepressants
Non-Pharmacologic - used anytime but people with chronic pain usually like these. Example: heat, ice, massage therapy
What are some features of non-opioid pain medications?
They all have an analgesic ceiling meaning an increase in dose does not create further pain relief. They do not produce tolerance or dependence. They are commonly available OTC. They should be used for mild to moderate pain. Examples: tylenol, aspirin, NSAIDs.
What is the mechanism of action for acetaminophen-Tylenol?
Inhibits pain impulses at the peripheral nervous system receptor sites. Blocks prostaglandin synthesis. It is used as an antipyretic.
What are the potential side effects for acetaminophen-Tylenol?
They are rare - potential hypersensitivity and hepatotoxicity.
What are the nursing considerations for acetaminophen-Tylenol?
daily maximum dose is 4,000 mg or if you have liver impairment, 3,000 mg. There are no anti-inflammatory effects. Used in many OTC preparations, so be aware that a pt may have ingested more tylenol than they realize. Available as an oral or rectal medication nd can be given IVPB over the course of 10 minutes. Commonly mixed with hydrocodone; you'll see it abbreviated as APAP.
What is the mechanism of action for NSAIDs?
Inhibits the cyclooxygenase enzyme (COX). If we don't have the COX enzymes we don't have prostaglandins or thromboxane's and without those there is no inflammation or fever or pain. May be COX 1 or COX 2. Used for mild to moderate pain r/t inflammation, bone pain or cancer.
What are the side effects for NSAIDs?
GI upset, GI bleed, sodium retention, nephrotoxicity.
What are the nursing considerations for NSAIDs?
If one doesn't work, try another one. Do not use with aspirin (ASA) since they have similar effects and side effects. If a pt has any renal impairment, they shouldn't be taking these medications.
What are some examples of COX-1 NSAIDs?
Ibuprofen, naproxen, ketorlac (Toradol), aspirin.
Ketorolac (Toradol) is the ONLY IV push NSAID and can be given topically or as an eye drop.
What is an example of COX-2?
Celecoxib (Celebrex). It is the only NSAID that is strictly a COX-2 inhibitor, it reduces inflammation without GI effects but all other COX-2 inhibitors have been pulled off the market because they were causing blood clots so pts were experiencing MI's and strokes. Always make sure if your pt is on these so you can assess for s/sx of clotting. If a pt has any renal impairment they shouldn't be taking these medications
What is the use and route of aspirin (ASA)?
used for mild to moderate pain. The use is dose dependent; this is an anti-inflammatory and antiplatelet (prevents aggregation of platelets). So an 81 mg (low dose adult chewable) dose has cardiac related uses. Higher doses are used for pain. The route can either be oral or rectal.
What are the potential side effects of aspirin (ASA)?
GI bleed, tinnitus
What are the nursing considerations for aspirin (ASA)?
Enteric-coated useful with GI distress.
Stop taking 1 week minimum prior to procedure.
What is the mechanism of action for opioids?
Binds with opioid receptors in CNS and interferes with transmission of pain impulse. There is no analgesic ceiling. The more you give the less pain the pt will feel but at some point they will go into respiratory depression.
What are the side effects for opioids?
Respiratory depression, GI issues such as n/v and constipation, sedation, pruritus.
What are the routes for opioids?
PO, IV, subQ, transdermal, rectal, epidural, intrathecal, transmucosal, and nasal.
What are the nursing considerations for opioids?
This is used for moderate to severe pain, and acute or chronic pain. Start low and go slow. Monitor for LOC, RR. The frequency of administering doses are always x-amount of hours from the last dose given. Encourage fluids to help with the GI issues. Use caution with geriatric patients; this has to do with the liver and kidney impairment, the potential cognitive decline, and their ability to express pain and slip into respiratory depression. Use with caution if pt is taking other CNS depressants.
What is the antidote for opioids?
naloxone (Narcan) - Respiratory depression is usually seen when the RR starts to get to 8 breaths per minute or less or their O2 sats drop. Narcan competes with the same receptors as opioids, so it can reverse actions of opioids. most common use is for respiratory depression. Can be given IV, IM, subQ, and nasal. Opioids last longer than narcan does so may have to give more than one dose. Pts may come out of respiratory depression delusional or swinging r/t the severe pain.
What are different dosing options for PCA?
Continuous dose - set dose is given every hour
Loading dose - a one time dose on initiation
Patient bolus dose - patient controls the bolus every X-minutes (example: 1 mg every 8 minutes).
What are ways PCA prevents the patient from danger?
You can see how many times the pt hit the button compared to how many doses the pt actually got; this is a good way to see how well controlled the pts pain is. There is end-tidal CO2 monitoring (EtCO2 monitoring) which looks like a nasal cannula with a larger bulb ovver the top lip. It monitors the respiratory rate second by second and the end oxygen or end CO2 levels. It will sound an alarm when oxygen and CO2 levels are above or below a certain limit then the analgesia will turn off. This can be life saving as it alerts for potential respiratory depression.
What is the use and route of adjuvant pain medications?
Use - can be used alone or in conjucntion with opioids. They are appropriate for all categories of pain.
Route - depends on each medication. They are all available PO. The goal is long-term therapy, many have a long half-life. Opioids have a really short half-life so you may have to give every 2 hours or so, but with adjuvants you may only have to give once or twice a day.
What are examples of adjuvant pain medications?
You cannot stop these medications abruptly!!
Corticosteroids, antidepressants (TCAs, SSRIs, SNRIs), GABA receptor agonists (Baclofen), anti-epileptics (gabapentin), alpha-adrenergic agonists (clonidine), local anesthetics, cannabinoids
What are examples of non-pharmacologic pain management techniques?
Every pain appproach should have a pharmacologic and non-pharmacologic measure instituted. Examples: massage, exercise, TENS (transcutaneous electrical nerve stimulation, elicits a tingling in painful area and is usually done for acute pain but can be used for chronic pain as well), acupuncture, heath or cold therapy, distraction, hypnosis, relaxation
What are interventional pain managments?
Therapeutic nerve blocks - may be given once or continuously, also called regional anesthesia, side effects are dysrhythmias, confusion, tinnitus, and respiratory depression
Neuroablative techniques - used for severe pain that is unresponsive to all other methods and it destroys the nerve
Neuroaugmentation - this is the electrical stimulation of the brain and spinal cord and is used when other treatment options have been unsuccessful. Commonly used for back pain.
What are the benefits to PCA?
Allows pt control over their pain management.
Decreases time between need and administration.
Can administer basal (continuous) dose and/or demand dose
What are safety considerations r/t PCA?
Settings need to be verified every shift. Often paired with a CO2 monitor. Often administers an opioid medicaiton; sedation and respiratory depression can occur. Have narcan readily available. Administration button is for patient only, not family.
What are nursing considerations r/t PCA?
Patient needs to be able to understand administration as well as potential side effects. Patient must have physical and mental capabilities to self-administer.
What are the benefits of naloxone?
It is the antidote for opioid induced respiratory depression. Competes with the same receptors as opioids.
What are the safety considerations of naloxone?
Has a short half-life, may need repeat doses. Frequently monitor respriatory status after reversal.
What are the nursing interventions r/t naloxone administration?
Can be administered IV, IM, subQ, and nasal. Do the math calculations prior to your pt needing this drug. Consider benzodiazepine reversal agent as well - flumazenil (Romazicon). Pts pain will return, consider alternative therapies for pain management.
What are the benefits of EtCO2 monitoring?
First line indicator of respiratory depression - will alert sooner than O2 sats
What are the safety considerations for EtCO2 monitoring?
Applied similar to nasal cannula but includes pieces to capture CO2 exhaled via mouth. Can be used in code situations to measure effectiveness of chest compressions and return of spontaneous circulation. Can be linked directly to PCA, will turn off basal rate if CO2 gets too high.
What are the nursing interventions r/t EtCO2 monitoring?
Requires patient education to increase compliance. Alarm fatigue; will often alarm for apnea or when pt is talking, be sure to correct settings if needed.
What are the benefits of intraspinal pain management?
Small amount of opioid or other medication can be administered directly to CNS. There are fewer systemic side effects.
What are the safety considerations r/t intraspinal pain management?
May have loss of sensory/motor function. Special color coded tubing. Locked box for medication, keep keypad of IV pump locked
What are the nursing interventions r/t intraspinal pain management?
Risk for infection - epidural sites should be assessed frequently and be covered with a sterile dressing.
Catheter migration can occur - frequent neuromuscular assessment indicated.
What is "tolerance" and the nursing considerations related to it?
Tolerance - need for increased opioid dose to maintain degree of analgesia.
Considerations - with increased dose comes potential increased side effects.
What is "physical dependence" and the nursing considerations related to it?
Physical dependence - ongoing exposure creates withdrawal symptoms when decreased.
Considerations - can develop withdrawal symptoms, tapering dose when decreasing medication
What is "pseudoaddiction" and the nursing considerations related to it?
Pseudoaddiction - attempt to compensate for tolerance or worsening pain.
Considerations - patients display drug seeking behaviors that stop when adequate control is achieved, leads to distrust in pt-caregiver relationship
What is "addiction" and the nursing considerations related to it?
Addiction - drive to take substances for reasons other than they are prescribed
Considerations - most common in younger pts, those with history of substance abuse or mood disorders
What is the clinical opioid withdrawal scale (COWS)?
Autonomic nervous system is activated in opioid withdrawal. These are typically sympoms that a patient cannot control such as goosebumps, GI upset, pupil size, tremors, bone and joint aches and runny nose. The COWS is a withdrawal scale utilized by health professionals. The patient is scored and given prescribed intervention/medication based on their score.
What are the barriers to treating pain in geriatric patients?
80% of nursing home patients report chronic pain. They believe it is an inevitable part of aging. They will use different words to describe pan. Cognitive problems such as dementia, post stroke aphasia, parkinsons are barriers.
What are nursing considerations r/t treating pain in geriatric patients?
They metabolize drugs slowly, giving them a higher risk for adverse effects. Polypharmacy - use many other medications for chronic conditions, puts at risk for interactions. High coincidence of GI bleed with NSAIDs. Should always consider non-drug therapies.
What are barriers to treating pain in non-verbal adults?
Gold standard is self-report of pain, relief, so how can we care for those who are non-verbal.
what are nursing considerations to treating non-verbal adults?
Behavioral and physiological changes are only indicators. Never assume anything. Use a different scale.
What are barriers and nursing considerations to treating substance abuse patients?
Fear of promoting addictive behaviors. May require higher doses of opioids. avoid using opioid that was abused. Withdrawal symptoms may occur. Avoid mixing opioids. Reflect on your own views regarding this population.
What are barriers and nursing considerations to treating patients during the end of their life?
Fear of hastening death. Choose the correct and appropriate route. Provide the dose to met the patient's needs (if they want to be alert, titrate appropriately), provide emotional/spiritual care, patient education is key, clarify pain management goals and address any fears.
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