73 terms

Kozier Chapter 46- Pain Management

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Acute pain
pain that lasts only through the expected recovery period (less than six months), whether it has a sudden or slow onset and regardless of the intensity
Adjuvant analgesic
medication that may enhance the effects of other analgesics or have its own analgesic properties
Agonist analgesic
full agonists which are pure opioid drugs that bind tightly to mu receptor sites, producing maximum pain inhibition, an agonist effect
Agonist-antagonist analgesic
mixed agonists-antagonists drugs that can act like opioids and relieve pain (agonist effect) when given to a client who has not taken any pure opioids
Chronic pain
prolonged pain, usually recurring or persisting over six months or longer, and interferes with functioning
Cordotomy
surgical severing which obliterates pain and temperature sensation below the level of the spinothalamic portion of the anterolateral tract severed, and is usually done for pain in the legs and trunk
Cutaneous pain
pain that originates in the skin or subcutaneous tissue
Deep somatic pain
pain that arises from ligaments, tendons, bones, blood vessels, and nerves
Equianalgesia
equal analgesia, is used when referring to the doses of various opioid analgesics that provide approximately the same pain relief
Fifth vital sign
pain assessment
Hyperalgesia
extreme sensitivity to pain
Intractable pain
pain that is resistant to cure or relief
Neurectomy
surgery in which peripheral or cranial nerves are interrupted to alleviate localized pain
Neuropathic pain
the result of a disturbance of the peripheral or central nervous system that results in pain that may or may not be associated with an ongoing tissue-damaging process
Nociception
the physiologic processes related to pain perception
Nociceptor
a pain receptor
Nonsteroidal anti-inflammatory drugs (NSAID)
drugs that relieve pain by acting on the peripheral nerve endings to inhibit the formation of the prostaglandins that tend to sensitize nerve to painful stimuli; have analgesic, anti-pyretic, and anti-inflammatory effect; include aspirin and ibuprofen
Pain
whatever the experiencing person says it is, existing whenever he (or she) says it does
Pain reaction
the autonomic nervous system and behavioral responses to pain
Pain sensation
can be considered the same as pain threshold
Pain threshold
the amount of pain stimulation a requires before feeling pain
Pain tolerance
the maximum amount and duration of pain that an individual is willing to endure
Patient-controlled analgesia (PCA)
a pain management technique that allows the client to take an active role in managing pain
Phantom pain
pain that remains after the perceived location has been removed, such as pain perceived in a foot after the leg has been amputated
Placebo
any form of treatment (e.g., medication) that produces an effect in the client because of its intent rather than its chemical or physical properties
Preemptive analgesia
the administration of analgesics prior to an invasive or operative procedure in order to treat pain before it occurs

prevents the windup and sensitization that spreads, intensifies, and prolongs pain.
Radiating pain
pain perceived at the source and in surrounding or nearby tissues
Referred pain
pain perceived to be in one area but whose source is another area
Rhizotomy
interruption of the anterior or posterior nerve root between the ganglion and the cord; generally performed on cervical nerve roots to alleviate pain of the head and neck
Spinal cord stimulation (SCS)
involves the insertion of a cable that allows the placement of an electrode directly on the spinal cord and is used with nonmalignant pain that has not been controlled with less invasive therapies
Sympathectomy
severence of the pathways of the sympathetic division of the autonomic nervous system; eliminates vasospasm, improves peripheral blood supply, and is effective in treating painful vascular disorders
Transcutaneous electrical nerve stimulation (TENS)
a noninvasive, nonanalgesic pain control technique that allows the client to assist in the management of acute and chronic pain
Visceral pain
results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax (organs and/or hollow viscera.) Tends to be characterized by cramping, throbbing, pressing, or aching. Sometimes associated with feeling sick (nausea, vomiting, sweating), such as labor pain, angina pectoris, or irritable bowel.
Diffuse Pain
Pain that is all over or in many areas.
Psychogenic or Functional Pain
Pain that does not have any known organic cause. Pain that cannot be linked to physical origin.
Perception
When the client becomes conscious of pain.
Modulation
Often described as the "descending system," this final process occurs when neurons in the thalmus and brainstem send signals back down to the dorsal horn of the spinal cord.
Transmission
The second process of nociception. During this stage pain impulses travel to the spinal cord, ascend via the spinothalamic tracts to the brainstem and thalmus, and then to the somatic sensory cortex where pain perception occurs.
Transduction
The first stage of nociception during which noxious stimuli trigger the release of biochemical mediators that sensitize nociceptors, and cause movement of ions which excite nociceptors. Pain meds can work by blocking prostoglandins or decreasing movements of ions across cell membrane, or the depleting of substance P.
Gate Control Theory
Peripheral nerve fibers can have their input modified at the spinal cord level before transmission to the brain. This is the basis of many pain intervention strategies, especially nonpharmacologic interventions.
Infant (pain perception and behavior/ selected nursing intervention)
Perceives pain. Responds to pain with increased sensitivity. Older infant tries to avoid pain.

Give glucose pacifier. Use tactile stimulation. Play music or tapes of a heartbeat.
Toddler and Preschooler (pain perception and behavior/ selected nursing intervention)
Develops ability to describe pain and its intensity and location. Responds with tears and anger. Reasoning is unsuccessful. May consider pain a punishment. May learn of gender differences in pain expression.

Distract child with toys, books, pictures, etc. Appeal to childs belief in magic by using a "magic" blanket or glove to take pain away. Hold child to provide support. Explore misconceptions about pain.
School-age child (pain perception and behavior/ selected nursing intervention)
Tries to be brave. Rationalizes. Responsive to explanations. Can identify location of pain and describe it. With persistent pain, may regress to earlier stage of development.

Use imagery to turn off "pain switches." Provide behavioral rehearsal of what to expect and how it will look and feel. Provide support and nurturing.
Adolescent (pain perception and behavior/ selected nursing intervention)
May be slow to acknowledge pain. Recognizing pain may be considered weakness. Wants to appear brave in front of peers and not report pain.

Provide opportunities to discuss pain. Provide privacy. Present choices for dealing with pain. Encourage music or TV for distraction.
Adult (pain perception and behavior/ selected nursing intervention)
May exhibit gender-based behaviors learned as a child. May ignore pain because to admit is is perceived as a sign of weakness or failure. Fear of what pain means may prevent some from taking action.

Deal with misconceptions about pain. Focus on the client's control in dealing with the pain. Allay fears and anxiety when possible.
Older Adult (pain perception and behavior/ selected nursing intervention)
May have multiple conditions with vague symptoms. May perceive pain as part of aging process. May have decreased sensations or perceptions of pain. Lethargy, anorexia, fatigue may be indicators. May withhold statements of pain for fear of treatment or lifestyle change, of becoming dependent. May call pain and "ache," "hurt," or "discomfort." May think it unacceptable to admit or show pain.

Thorough history and assessment. Spend time with client, listen carefully. Clarify misconceptions. Encourage independence whenever possible.
dysesthesia
An unpleasant or abnormal sensation that can be either spontaneous or evoked.
Windup
Progressive increase in excitability and sensitivity of spinal cord neurons, leading to persistent, increased pain.
allodynia
Sensation of pain from a stimulus that normally does not produce pain (e.g., light tough).
What are the different types of mechanical pain?
-Trauma to the body tissues (ie, surgery)
-Alterations in body tissue (ie, edema)
-Blockage of a body duct
-Tumor
-Muscle spasm
What is assessed in a pain assessment?
Pain History (OLDCART & ICE)
-and-
Observation of clients behavior and physiologic responses
OLDCART & ICE
Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment, Impact on ADL, Coping strategies.
Characteristics of acute pain
-mild to severe
-Sympathetic NS responses: increased pr, increased rr, increased bp, diaphoresis, dilated pupils
-related to tissue injury; resolves with healing
-may be restless and anxious
-may exhibit behavior indicative of pain: crying, rubbing area, holding area
Characteristics of chronic pain
-mild to severe
-Parasympathetic NS responses: normal vital signs, dry, warm skin, pupils normal or dilated
-pain continues beyond healing
-client depressed and withdrawn
-client does not mention pain unless asked
-pain behavior often absent
Factors affecting the pain experience
ethnic and cultural values, developmental stages, environment and support people, previous pain experience, and the meaning of the current pain.
what is the single most important indicator of the existence and intensity of pain?
the clients report of pain.
pseudoaddiction
A condition that results from the undertreatment of pain where the client may become so focused on obtaining medications for pain relief that they become angry and demanding, may "clock wacth," and may otherwise seem inappropriately "drug seeking,"

Nurses candifferentiate between pseudoaddiction and addiction if the client's negative behaviors resolve when the pain is treated effectively.
True or False. Patients with addictive disease and pain should withhold medication to treat the addictive disorder.
False.

It is important to first treat the pain. A myth held by nurses is that if they treat the pain, they are contributing to the addiction, but this is not true. Undertreating pain may cause clients with an addictive disorder to increase their drug use.

Addicted clients often require more pain meds than usual, often more than the nurse is comfortable giving. Consult w/ pain management specialist and addiction specialist.
WHO three-step analgesic ladder
Focuses on aligning the proper analgesic with the intensity of pain. This has eveolved into "rational polypharmacy." Demands health professionals be aware of all ingrediants of meds that alleviate pain.

Combo's reduce need for high doses of any one med, thus maximizing pain control while minimizing side effects or toxicity.

For mild pain (1-3 on a 0-10 scale), step 1 of the analgesic ladder, nonopiod analgesics

For mild pain that persists or if pain is moderate (4-6 pn a 0-10 scale), then step 2, an opioid for moderate pain or combo of opiod and nonopioid med is provided with or without coanalgesic meds.

For moderate pain that persists or increases or if pain is severe (7-10) then step 3, an opioid for severe pain is administered and titrated in ATC and scheduled doses until the pain is relieved.
rational polypharmacy
demands that health care professinals be aware of all the ingredients of medications that alleviatepain.

COmbinations reduce the need for high doses of any one medication, thus maximizing pain control while minimizing side effects or toxicity.
Physiological response to pain in the nonverbal client
clenched teeth, tightly shut eyes, open somber yes, biting of the lower lip, facial grimaces, moaning, groaning, screaming, crying, immobilization of the body or a body part, client with chest pain hold left arm across chest, client with abdominal pain may assume position of greatest comfort often with knees and hips flexed and reluctant movement, purposeless body movement (tossing and turning in bed, flinging arms), involuntary movements (reflexive jerking away from needle inserted through skin), behavioral changes such as confusion and restlessness, agitation or aggressiveness, phythmic body movements or rubbing.
Small diameter (A-delta or C)
Peripheral nerve fibers carry signals of noxious stimuli to the dorsal horn to send pain signal to the thalmus.
Large diameter (A-beta)
Peripheral nerve fibers which typically send messages of touch or warm or cold temperatures, have an inhibitory effect on the substantia gelatinosa, and may activate descending mechanisms that can lessen the intensity of pain perceived or inhibit the transmission o9f those pain impulses- closing the (ion) gates.
Addiction
A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestation. It is characterized by behaviors that include one or more of the following: impaired control over drug use, continued use despite harm, and craving.
Physical dependence
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
Tolerance
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effect over time.
nerve block
A chemical interruption of a nerve pathway, effected by injecting a local anesthetic into the nerve. Injected drug blocks nerve pathways from the painful areas, thus stopping the transmission of pain impulses to the brain.
ceiling effect
once the maximum analgesic benefit is achieved. more drug will not produce more analgesia; however, more toxicity may occur.
narrow therapeutic index
indicates that there is not much margin between the dose that produces a desired effect and the dose that may produce a toxic, even lethal effect.
partial agonists
Have a ceiling effect in contrast to a full agonist. Block th emu receptors or are nuetral at that receptor but bind at a kappa receptor site. The safety and favorable side effect profile make it an increasingly popular choice.
Common Opiods
Opiod analgesic for moderate pain
Hydrocodone (Lortab, Vicodin)
Codeine (Tylenol No. 3)
Tramadol (Ultram, Ultracet)
Pentazocine (Talwin)

Opiod analgesic for severe pain
Fentanyl citrate (Sublimaze, transdermal patches, Actiq lozenges)
Hydromorphone hydrochloride (Dilaudid)
Oxycodone (OxyContin)
Morphone (Opana)
Methadone (Dolophine)
Morphine
Meperidine (Demerol)

Three types of opiods (full agonists, mixed agonist-antagonists, partial agonists)
Common NSAIDS
Acetaminophen (Tylenol, Datril)
Acetylsalicylic acid (aspirin)
Choline magnesium trisalicylate (Trilisate)
Ibuprofen (Motrin, Advil)
Indomethacin sodium trihydrate (Indocin)
Naproxen (Naprosyn), naproxen sodium (Anaprox)
Ketorolac (Toradol)
Piroxicam (Feldene)
Meloxicam (Mobic)
Celecoxib (Celebrex) Cox II NSAID
Adjuvant therapy (coanalgesic)
A coanalgesic.
A medication that is not classified as a pain medication, but has properties that may reduce pain alone or in combination with other analgesics, relieve other discomforts, potentiate the effect of pain medications, or reduce the pain medication's side effects.

Ex, antidepressants (increase pain relief, improve mood, and improv sleep), anticonvulsants (stabilize nerve membranes, reducing excitability and spontaneous firing), and local anesthetics (block the transmission of pain signals).

Coanalgesics appear to be beneficial for managing neuropathic pain.

Growing scientific and clinical basisfor the use of these meds in relieving pain, esp for persistent ain that is not relieved by the analgesic classes of medication alone.