Pain
Dexamethasone (Decadron), prednisone, and methylprednisolone (Medrol)
are used for management of acute and chronic cancer pain, pain secondary to spinal cord compression, and inflammatory joint pain syndromes.
Nursing roles for pain
assess, initate, evaluate, advocate
Treatment goals of chronic pain
Control to the extent possible and Focus on enhancing function and quality of life
Another definition of pain
"Unpleasant sensory and emotional experience associated with actual or potential tissue damage." IASP
Definition of pain
"Whatever the person experiencing pain says it is, existing whenever the person says it does." Margo McCaffery
Side effects of Corticosteroids
(especially when given chronically in high doses) hyperglycemia, fluid retention, dyspepsia and GI bleeding, impaired healing, muscle wasting, osteoporosis, adrenal suppression, and susceptibility to infection
Magnitude of pain problem
25 million people experience acute pain from injury or surgery, Chronic pain affects over a million American adults, 60% of cancer patients experience pain during treatment
Routes: Patient-controlled analgesia (PCA)
A dose of opioid is delivered when the patient decides a dose is needed, Patient pushes a button to deliver a bolus dose of opioid IV, Teach patient that they cannot "overdose"
Nonopioid examples
Acetaminophen, aspirin and other salicylates, and NSAIDs (GI bleeding)
Visceral Pain
Activation of nociceptors in the internal organs and lining of the body cavities, Tumor involvement or obstruction, Arises from internal organs such as the intestine and bladder
Opioid
Bind to receptors in the CNS, Inhibition of transmission of nociceptive input , and Activation of descending inhibitory pathways
Common side effects of opioids
Constipation (most common), Nausea/vomiting, Sedation, Respiratory depression, and Pruritus
Combined with nonopioids for moderate pain
Codeine plus acetaminophen (Tylenol #3) and Hydrocodone plus acetaminophen or ibuprofen (Vicoprofen)
Pain reassessment
Critical to reassess at appropriate intervals, guided by Pain severity, Physical and psychosocial condition, Type of intervention, Risks of adverse effects, Institutional policy
Neuropathic pain
Damage to peripheral nerve or CNS
Nociceptive pain
Damage to somatic or visceral tissue
Behavioral manifestations of chronic pain
Decreased physical movement/activity, Fatigue, and Withdrawal from others and social interaction
TENS
Delivery of an electrical current through electrodes on the skin
Adjuvant: Corticosteroids expamles:
Dexamethasone (Decadron), prednisone, and methylprednisolone (Medrol)
Cognitive therapies
Distraction, Hypnosis, Relaxation
Non-opioid
Do not produce tolerance or addiction, Many are OTC, Acetaminophen has analgesic and antipyretic effects, It does not have anti-inflammatory effects
Pain assessment documentation
Documentation is critical to ensure effective communication pain assessment tools
Administration: Scheduling
Focus on prevention or control, Do not wait for severe pain, Constant pain requires around-the-clock administration (not PRN), Fast-acting drugs for breakthrough
Pain treatment principles
Follow principles of assessment, Use a holistic approach, Every patient deserves adequate pain management, Base treatment plan on patient's goals, Use both drug and nondrug therapies, Use multimodal approach when appropriate, and Address pain using an interprofessional approach
(TCAs)
Higher levels of serotonin and norepinephrine in the synapse inhibit the transmission of nociceptive signals in the CNS.
Manifestations reflected in sympathetic nervous system for acute pain
Increased heart rate, respiratory rate, and blood pressure
Pain management strategies
Inquire about strategies used (Effective and ineffective) like prescription drugs, OTCs, nondrug therapies
Addiction
Neurobiologic condition with drive to obtain and take substances for other than prescribed therapeutic value
NMDA receptor antagonist
Ketamine
Nalbuphine, pentazocine, butorphanol
Less respiratory depression, More dysphoria and agitation, Have an analgesic ceiling, Can precipitate withdrawal
Somatic pain
Localized and Arises from bone, joint, muscle, skin, or connective tissue
Example of location
Localized, All over, and Referred or radiated from origin to different site
Pain assessment: Location
Location assists in identifying cause and treatment
Non-drug therapy for pain
Massage, Exercise, TENS or PENS, acupuncture, heat/cold therapy, cognitive therapies
Examples of opioid
Morphine, oxycodone, and codeine
Pruritus
Most common with epidural or intrathecal routes
Examples Mixed agonists-antagonists:
Nalbuphine, pentazocine, butorphanol
Pain assessment: Quality
Nature or characteristics (stabbing, electric shock-like, throbbing)
Tolerance
Need for increased dose to maintain same degree of pain control and Rotate drug if tolerance develops, as increasing dose could result in opioid-induced hyperalgesia (OIH)
Are Tolerance and physical dependence indicators of addiction?
No
Pain mechanisms
Nociception
Pain assessment: Characteristics
Onset, Duration, Factors increasing or relieving pain, Pattern
what is pain
Pain is a complex, multidimensional experience that can cause suffering and decreased quality of life
Chronic pain
Persistent pain, Gradual or sudden onset, Longer than 3-month duration; may start acute but continues past normal recovery time, Cause may be unknown, Does not go away; characterized by periods of waxing and waning, Can be disabling and accompanied by anxiety and depression
Nociception
Physiologic process that communicates tissue damage to the CNS
Signs of respiratory depression
Pinpoint pupils, coma
Morphine, oxycodone, and codeine
Potent, no analgesic ceiling, and have several routes for administration and Often combined with nonopioid analgesic for relief of moderate pain
Pain assessment: Intensity
Reliable measure for determining treatment, Rated using scales (0 to 10)
Withdrawal symptoms
Shakes, seizures, stroke, N/V, anxiety
Description of pain
Subjective: Patient's experience and self-report are essential
Acute pain
Sudden onset, Less than 3 month's time for normal healing to occur, Mild to severe, a precipitating event or illness can be identified, Course of pain decreases over time and goes away as recovery occurs, Pain control with eventual elimination
Example of Nociceptive pain
Surgical incision, broken bone, or arthritis
What does the definition of pain emphasize?
The subjective nature
Benefits of (TCAs)
They are effective for a variety of pain syndromes, especially neuropathic pain syndromes.
Dual mechanism agents (non- habit forming)
Tramadol (Ultram) is a weak mu agonist and also inhibits the reuptake of norepinephrine and serotonin and Tapentadol (Nucynta) works at mu receptors and inhibits norepinephrine reuptake.
Antiseizure drugs
Transdermal lidocaine and α2-adrenergic agonists
Pain assessment: Breakthrough pain
Transient, moderate to severe, Occurs beyond treated pain, and Usually rapid onset and brief duration with variable frequency and intensity
Adjuvant: Antidepressants
Tricyclic antidepressants (TCAs) enhance the descending inhibitory system by preventing the cellular reuptake of serotonin and norepinephrine
Adjuvant analgesics (not originally intended to treat pain)
Tricyclic antidepressants and Serotonin norepinephrine reuptake inhibitors (SNRIs)
Consequences of untreated pain
Unnecessary suffering, Physical and psychosocial dysfunction, Immunosuppression, Sleep disturbances
Adjuvant
Used alone or in conjunction with opioids and nonopioids and Generally developed for other purposes, but also effective for pain
Who was Margo McCaffery?
a nurse and pioneer in pain management.
Adjuvant: Antiseizure drugs
affect both peripheral nerves and the CNS in several ways, including sodium channel modulation, central calcium channel modulation, and changes in excitatory amino acids and other receptors.
MOA of Corticosteroids
are may be related to the ability of corticosteroids to decrease edema and inflammation.
Superficial somatic pain
arises from skin, mucous membranes, and subcutaneous tissues and often is described as sharp, burning, or prickly
Adjuvant: GABA receptor agonists (muscle- relaxer)
baclofen an agonist at of GABA receptors, can interfere with the transmission of nociceptive impulses and is used for muscle spasms and neuropathic pain and It crosses the blood-brain barrier poorly and is much more effective for spasticity when delivered intrathecally
Description of pain of nonverbal patients (autistic, dementia, coma patients)
behaviors aids the assessment of pain such as crying, postures of body
Pain assessment: Associated symptoms
can worsen pain (anxiety, fatigue, depression)
Deep somatic pain
characterized as aching or throbbing and originates in bone, joint, muscle, skin or connective tissue
Examples Visceral nociceptors:
contraction of uterus, gallbladder removal, appendix removal
Nociceptive
everything visceral, organ, anything other than nerves
Examples of Antiseizure drugs
gabapentin (Neurontin), lamotrigine (Lamictal), and pregabalin (Lyrica)
Stretching of viscera nociceptors
hollow viscera in the intestines and bladder that occurs from tumor involvement or obstruction can produce intense cramping pain.
Example of end- of- dose failure
in a patient on transdermal fentanyl (Duragesic patches), the typical duration of action is 72 hours and An increase in pain after 48 hours on the medicine would be characterized as end-of-dose failure
Analgesic ceiling
increasing the dose beyond an upper limit provides no greater analgesia
Hepatotoxicity of Acetaminophen
may result from chronic dosing of more than 3 g/day, acute overdose
Neuropathic Pain Treatment
multimodal (adjuvant, antiseizure, NMDA)
Neuropathic
nerve pain
Three categories of Drug therapy
non-opioid, opioid, adjuvant
Pain assessment: End-of-dose failure
occurs before the duration of pain relief that is expected with a specific analgesic, and failure signals the need for changes in the dose or scheduling of the analgesic
what is the major reason people seek health care
pain
Morphine may cause what?
respiratory depression
Visceral nociceptors
respond to inflammation, stretching, and ischemia.
What is Nociceptive pain Divided into?
somatic and visceral
Somatic pain division
superficial and deep
What does Nociceptive pain respond to?
to opioids and nonopioid medications
Nociception process
transduction, transmission, perception, modulation
Common causes of neuropathic pain
trauma, inflammation, metabolic disease such as diabetes mellitus, infections of the nervous system, tumors, toxins, and neurologic disease such as multiple sclerosis
Classification of pain
underlying pathology (nociceptive and neuropathic) and duration (acute and chronic)
Physical dependence
Normal response to ongoing exposure to pharmacologic agents manifested by withdrawal syndrome when the drug is abruptly decreased
Quality of pain for neuropathic pain
Numbing, hot/burning, shooting, stabbing, or electrical in nature, Sudden, intense, short-lived, or lingering
Examples of neuropathic pain conditions
phantom limb sensation, diabetic neuropathy, and trigeminal neuralgia, shingles, MS, sciatic