Chapter 10 Pain

Anticonvulsants Treat neuropathic pain.

Examples carbamazepine (Tegretol) gabapentin (Neurontin) Nursing Implications Must be taken regularly to get full benefit.

Serotonin-Norepinephrine Reuptake Inhibitor Effective for nerve pain and depression.

Examples duloxetine (Cymbalta) Nursing Implications May take weeks before effect seen; teach patient to continue the medication even if it seems ineffective at first.

Benzodiazepines Treat anxiety or muscle spasms associated with pain

Examples midazolam (Versed) diazepam (Valium) Nursing Implications Can cause sedation, which limits the amount of opioid that can be safely given at the same time.

Adjuvant Agents *Corticosteroids* Toxic to some cancer cells; reduce pain by decreasing inflammation.

Examples prednisone prednisolone methylprednisolone dexamethasone Nursing Implications Administer with food. Benzodiazepines

9. A patient is started on gabapentin (Neurontin) 300 mg by mouth three times daily for chronic low back pain related to lumbar disc herniation. Which instruction should the nurse provide? 1."Take the medication at the first sign of any pain, up to three times daily." 2."Take one capsule every 8 hours continuously to keep the pain under control." 3."Take the medication only when you need it, to prevent becoming addicted." 4."Take one capsule three times a day, then stop it when the pain is under control."

"Take one capsule every 8 hours continuously to keep the pain under control."

Placebos

***the administration of an inactive substitute such as normal saline in place of an active medication. placebos were sometimes given in an attempt to determine whether a patient's pain was "real." **** -unethical and inappropriate unless the patient has given written consent - if it is ordered for a patient, discuss concerns with the HCP and nurse supervisor. -Placebos are only to be used in drug studies (clinical trials) to compare a new drug with an inactive substance.

Rectal May be used to provide local or systemic pain relief.

*Advantages -Can be used when patient cannot take oral medication. *Disadvantages -May be difficult for patient or family to self-administer.

Subcutaneous May be used if IV route is problematic.

*Advantages -Can deliver effective pain relief. -Some opioids may be given as continuous infusion. *Disadvantages -Injection may be painful.

Oral Preferred route in most cases.

*Advantages -Convenient. -Less expensive than other forms. -Immediate- and controlled-release forms available. *Disadvantages -Slower onset than intravenous (IV) form.

Transdermal Patch Used for chronic pain.

*Advantages -Easy to apply. -Delivers pain relief for several days without patch change. *Disadvantages -May take up to 3 days before maximum effective drug level reached; delay in excreting once removed. -Patient must be closely monitored; alternative routes may be needed when starting and stopping therapy.

Intraspinal (Epidural or Subarachnoid) -Catheter into epidural or subarachnoid space used for traumatic injuries or chronic pain unrelieved by other methods. -May also be used for orthopedic, chest, and abdominal surgical procedures.

*Advantages -May be able to control pain with lower doses of opioid because relief is delivered closer to site of pain. -Fewer systemic side effects. *Disadvantages -Requires single or continuous injection in back. -May be associated with intense itching. -Motor function must be assessed especially when local anesthetic is used.

Patient-Controlled IV Allows patient some control over administration schedule.

*Advantages -Patient pushes a button to administer a dose of opioid. *Disadvantages -Requires special training. -Pump must be programmed correctly.

IV Preferred route for postoperative and chronic cancer pain in patients who cannot tolerate oral route.

*Advantages -Provides rapid relief. -Continuous infusion to achieve steady drug level. *Disadvantages -Difficult to use in home health care setting. -Requires training and special equipment.

Intramuscular Acute pain.

*Advantages -Rapid pain relief, although slower than IV. *Disadvantages -Painful administration. -Inconsistent absorption.

APPLICATION OF COLD

- can reduce swelling, bleeding, and pain when used to treat a new injury -reduce the pain of an injection when applied prior to the injection, along with pressure, above the injection site. -Cold can be applied by cold wraps and cold packs as well as localized ice massage. -Patients choose heat over cold because cold can be uncomfortable -cold is better tolerated over a small area. -Alternating heat and cold therapies is most effective if not contraindicated.

Pseudoaddiction

- described in patients who are receiving opioid doses that are too low or spaced too far apart to relieve their pain. -Behavioral characteristics resembling psychological dependence, such as drug-seeking behaviors, develop in an attempt to get pain needs met. - stops drug-seeking behaviors when the pain is reduced to a tolerable level.

4. Define addiction

- is a disease of the brain that causes the compulsive pursuit of a substance or behavior to obtain reward or relief from craving. - Addiction is characterized by poor control over drug use, craving, reduced recognition of problem behaviors, and continued use despite harm.

physical dependence

- is a normal physiological response that most people experience after a week or more of continuous opioid use. -If an opioid is discontinued abruptly or if an opioid antagonist such as naloxone (Narcan) is administered, the patient experiences withdrawal syndrome. Withdrawal symptoms can include sweating, tearing, runny nose, restlessness, irritability, tremors, dilated pupils, sleeplessness, nausea, vomiting, and diarrhea. These symptoms can be prevented by decreasing the dose slowly over several days rather than stopping it suddenly.

1. What is the definition of pain?

-"Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does." -"an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."

Opioids and Opioid Combination Agents -codeine (in Tylenol #2, #3, #4)* -fentanyl (Sublimaze, Duragesic) -hydromorphone (Dilaudid, Exalgo) -methadone (Dolophine) -morphine (MS IR, MS Contin) -oxycodone (Oxy IR, OxyContin) -hydrocodone/acetaminophen (Norco, Lortab) -tapentadol (Nucynta, Nucynta ER)

-Bind to opioid receptors in the central nervous system to alter perception of pain -May be combined with nonopioid (e.g., acetaminophen). -Monitor vital signs, level of sedation, and respiratory status. -Avoid fentanyl patch in patient with fever; heat increases absorption. -Encourage fluids and fiber to prevent constipation. -Codeine is contraindicated in pediatric patients. -Never crush extended-release tablets.

Physical Agents

-Examples of physical agents include applications of heat or cold, massage, and exercise

APPLICATION OF HEAT

-Heat works to increase circulation, induce muscle relaxation, and decrease inflammation when applied to a painful area. -applied using dry or moist packs or wraps, or in a bath or whirlpool -worsened if used in an area of trauma, because of the possibility of increased swelling caused by vasodilation. -To prevent burns, heat should not be applied directly to the skin or over areas of decreased sensation.

Scheduling Options

-Intermittent, unpredictable pain may be best treated with as-needed doses. -Pain that is predictable can be more effectively treated, or prevented, with scheduled doses of medication. -Around-the-clock dosing is an effective way to schedule doses evenly over a 24-hour period to prevent pain from becoming unbearable. It is important to use around-the-clock dosing after surgery or trauma

analgesics

-Medications that relieve pain -encompass three main classes of medication: opioids, nonopioids, and adjuvants

BE SAFE!

-Never crush a controlled- or time-release tablet. Because the tablet is designed to deliver a dose of medication over time, crushing it could deliver the entire dose at once, resulting in overdose.

hyperalgesia in opioids

-Opioids alone have no ceiling effect to analgesia. This means that doses can safely be increased to treat worsening pain if the patient's respiratory status and level of sedation are stable. -However, inappropriate prescribing can lead to hyperalgesia, or increased sensitivity to pain. Patients with hyperalgesia have pain at the slightest touch, such as the moving of sheets, and require further medical intervention. -patients unaccustomed to opioids are sometimes called "opioid-naïve."

*NONOPIOIDS Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) -ibuprofen (Motrin) -ketorolac (Toradol) -naproxen (Naprosyn, Aleve)

-Peripherally acting analgesics; reduce pain, fever, inflammation -Give with food - platelet aggregation; watch for bleeding -Do not give ketorolac for longer than 5 days

*NONOPIOIDS -Salicylates (aspirin)

-Peripherally acting analgesics; reduce pain, fever, inflammation -Give with food -Decrease platelet aggregation; watch for bruising or bleeding

NONOPIOIDS COX-2 Inhibitors -celecoxib (Celebrex)

-Reduce pain and inflammation; no effect on platelet aggregation -give with food

NONOPIOIDS -acetaminophen (Tylenol, Ofirmev)

-Relieves pain and fever; no anti-inflammatory or antiplatelet effect -Maximum safe dose is 4 g per day; less for those who use alcohol -Be aware of other drugs that contain acetaminophen, such as cold remedies, to prevent accidental overdose

risks of uncontrolled pain

-The body produces a stress response to pain that causes harmful substances to be released from injured tissue -breakdown of tissue, increased metabolic rate, impaired immune function, and negative emotions -pain prevents the patient from participating in self-care activities, such as walking, deep breathing, and coughing.

Morphine

-a full agonist -often the drug of choice for treating severe pain -standard against which all other analgesics -Morphine is long acting (4 to 5 hours) and available in many forms, making it convenient and affordable for patients -has a slower onset than many other opioids

Patient-controlled analgesia (PCA)

-an opioid on an IV controller -patient has a button on a cord that can be pushed to receive a dose of IV medication. -(RN) programs the pump to the dose and dosing interval ordered by the HCP. -A "lockout" mechanism prevents the patient from receiving the medication more often than ordered. - gives the patient some control over pain management * Teach the patient and family that only the patient should push the button, never the nurse or a family member. If the patient is too sedated to push the button, a dose of opioid is not likely needed and could even be dangerous.

Analgesic Adjuvants

-are classes of medications that are given in addition to other medications -Analgesic adjuvants can potentiate the effects of opioids or nonopioids, have analgesic activity themselves, or counteract the unwanted effects of other analgesics. -Some adjuvants are called off-label medications because they are being used in a way not specifically approved by the FDA; that is, they were not initially developed to treat pain

Adjuvants

-are different from opioid and nonopioids in that they include categories of medications that were originally approved by the Food and Drug Administration (FDA) for purposes other than pain relief (e.g., depression). -Some patients may require a combination of opioids, adjuvants, and NSAIDs to effectively manage their pain. Nurses should have a good understanding of these pharmacological treatment options.

Opioid Analgesics

-are drugs that have actions similar to those of morphine. -classified by how they affect receptors in the nervous system. -Full agonists have a complete response at the opioid receptor site -partial agonist has a lesser response -mixed agonist or an antagonist activates one type of opioid receptor while blocking another. -short list of "high-alert" drugs that can harm or even kill patients ***examples of opioids include controlled-release drugs such as oxycodone (OxyContin), hydromorphone (Dilaudid, Exalgo), and tapentadol (Nucynta ER)***

Opioids

-bind to opioid receptors in the brain, spinal cord, and other areas of the body, inhibiting the perception of pain.

Cognitive-behavioral

-can help patients understand and cope with pain and take an active part in its assessment and control

topical local anesthetics (lidocaine/prilocaine cream)

-decrease the pain of procedures such as venipuncture and lumbar puncture. -A lidocaine patch may be effective for patients with post-shingles or other nerve pain. -In patients with osteoporosis, drugs that promote calcium uptake by the bones can aid in pain relief. These may include hormonal agents and medications that decrease calcium reabsorption from bone.

suffering

-feelings of continuous distress, often accompanies pain -"Suffering is not synonymous with pain but is closely associated with it. Physical pain is closely related to psychological, social, and spiritual distress. Pain that persists without meaning becomes suffering"

Fentanyl

-given parenterally or intraspinally (Sublimaze) or by transdermal patch (Duragesic) -used via IV with anesthesia for surgery -used to relieve postoperative pain via IV, patient-controlled analgesia pump, or epidural - IV fentanyl has a short duration of action and must be given more often than other opioids to maintain an effective level of analgesia. -The transdermal fentanyl patch is useful for a patient with stable chronic pain. The patch lasts 48 to 72 hours after application.

Cognitive-Behavioral Interventions

-include educational information, relaxation exercises, guided imagery, distraction (e.g., music, television), and biofeedback. -require extra time for detailed instruction and demonstration -Educating patients about what to expect and how they can participate in their own care has been shown to decrease patients' reports of postoperative pain and analgesic use.

3. Define tolerance

-is a normal biological adaptation to long-term use of a drug, the drug becomes less effective. Therefore, a larger dose is required to provide the same level of pain relief.

Opioid Antagonists Naloxone (Narcan)

-is a pure opioid antagonist that reverses, or antagonizes, the effect of opioids. -used in emergency departments for treating the effects of opioid overdose, such as sedation and respiratory depression. ***Caution must be used when giving naloxone to a patient who is receiving opioids for pain control. If too much naloxone is given too fast, not only can it reverse the unwanted effects—such as respiratory depression and sedation—but the pain may return as well.****

Perception

-is actually feeling pain. During perception, the hypothalamus activates, which controls emotional input and generates purposeful goal-directed behavior. Meanwhile, the cerebral cortex receives the pain message.

Neuropathic pain

-is associated with injury to either the peripheral or central nervous system. -Unlike nociceptive pain, neuropathic pain is poorly localized and may involve other areas along the nerve pathway. -Neuropathic pain is common in cancer patients following chemotherapy or radiation therapy. It also occurs in patients who have fibromyalgia, diabetic neuropathy, and shingles. The pain is often described as numbing, tingling, sharp, shooting, or shocklike

Somatic pain

-is localized in the muscles or bones. -Patients can often point to the exact location of pain and will describe it as throbbing or aching. -Cancer patients may experience somatic pain when the cancer has spread to the bone or a tumor has invaded soft tissue.

Visceral pain

-is not well localized and is often described as cramping or pressure. -Bowel obstructions and tumors in the lung can cause visceral pain symptoms. -Pain may also be felt in parts of the body away from the pain source, such as low back/flank pain that often accompanies a bladder infection. This is called referred pain

Modulation

-is the body's attempt to interrupt pain impulses by releasing endogenous (naturally occurring) opioids. -Endorphins are endogenous chemicals that act like opioids, inhibiting pain impulses in the spinal cord and brain. Endorphins are the chemicals that stimulate the long-distance runner's "high." Unfortunately, they degrade too quickly to be considered effective analgesics. Enkephalins are one type of endorphin.

Transmission

-is the process of moving a painful message from the peripheral nerve endings through the dorsal root ganglion and the ascending tract of the spinal cord to the brain.

physical agents

-may include providing comfort, correcting physical dysfunction, or altering physiological responses.

Nonopioids

-nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol) -are typically the first class of drugs used to treat mild pain -causes, such as surgery, trauma, arthritis, and cancer. -These drugs are limited because they have a ceiling effect to analgesia. -A ceiling effect means that there is a dose beyond which there is no improvement in the analgesic effect, but there may be an increase in adverse effects. When used with opioids, the nonopioid dose must not exceed the maximum safe dose for a 24-hour period.

Relaxation

-patient may prefer a scripted relaxation exercise that can be practiced and used the same way each time or simply the use of a favorite piece of music that allows a state of muscle relaxation and freedom from anxiety

2. What is the difference between acute and chronic pain?

-prompts an inflammatory response -Acute pain is short term, objective, physical signs such as increased heart rate and blood pressure -Chronic pain is typically diagnosed after a patient experiences 3 months or more of persistent pain -suffering can occur if not treated *malingerer (someone who pretends to be in pain) or drug seeker

Nociception

-refers to the body's normal reaction to noxious stimuli, such as tissue damage, with the release of pain-producing substances. Nociceptive pain may be somatic or visceral.

Transduction

-represents the initiation of the stimulus and conversion of that stimulus into an electrical impulse at the time of the injury. Chemical neurotransmitters are released from damaged tissue. These substances include prostaglandins, bradykinin, serotonin, and substance P.

BE SAFE!

-respiratory rate should be monitored, especially when beginning opioid use or with dose increases. Always check the respiratory rate before administering an opioid and report any respiratory rate that is lower than 12 per minute or lower than normal for that patient. An additional sign of opioid overdose is pinpoint (very small) pupils.

Balanced Approach to Analgesia

-should be used, combining analgesics and adjuvants from different classes to minimize the adverse effects of opioids, such as nausea and vomiting or sedation, while maximizing pain relief. -additional sedating medications such as antiemetics and antihistamines (to treat side effects) may not be needed

distraction

-used by patients to focus their attention on something other than the pain. They may watch a favorite television program or laugh with visitors when they are in pain. When the program is over or the visitors leave, the patient may focus on the pain again and ask for a dose of pain medication.

Biofeedback

-used in chronic-pain programs to teach patients how to train their bodies to respond to different signals. Biofeedback has been very useful in patients with migraine headaches. When an aura (a warning sign) occurs before a migraine headache, patients are prompted to begin the exercise that relaxes them, maybe allowing them to prevent the headache.

Meperidine

-used synthetic opioid but is no longer recommended -is an opioid agonist -when broken down in the body, it produces a toxic metabolite called normeperidine. -Normeperidine is a cerebral irritant that can cause adverse effects, ranging from dysphoria and irritable mood to seizures. -should be avoided in patients over age 65, patients with impaired kidney function, and patients taking a monoamine oxidase inhibitor (MAOI) antidepressant -should be limited to young, healthy patients who need an opioid for a short period and to those who have unusual reactions or allergic responses to other opioids -three to four times the parenteral dose

MASSAGE AND EXERCISE

-used to stretch and regain muscle and tendon length and to relax muscles. -Immobilization is used after a variety of orthopedic procedures as well as fractures and other injuries worsened by movement. -Acupressure has also been shown to be beneficial for pain reduction - it is important to use nonpharmacological treatments as an enhancement of appropriate drug treatments, not as a substitute.

Guided imagery

-uses the patient's imagination to take the patient away from the pain to a favorite place, such as a beach in Tahiti. The success of guided imagery does not mean that the pain is in any way imaginary.

11.A nurse needs to administer morphine 10 mg intramuscularly. It is supplied as grains 1/4 per mL. How many milliliters should the nurse prepare for injection? Answer: ______________ mL

0.7 mL

5. What are the 4 mechanisms of pain transmission?

1. Transduction 2.Transmission 3.Perception 4.Modulation

6. Which of the following methods is the most reliable way to assess the severity of a patient's pain? 1.Ask the patient to describe the pain. 2.Observe the patient for physical signs of pain such as moaning or grimacing. 3.Ask the patient to rate his or her pain using a valid assessment scale. 4.Ask a family member to rate the patient's pain.

Ask the patient to rate his or her pain using a valid assessment scale.

10. A nurse receives an order to administer 1 mL of sterile normal saline solution intramuscularly to a patient suspected of opioid abuse. Which response by the nurse is appropriate? 1.Administer the saline and document the patient's response in the medical record. 2.Inform the patient that the saline was ordered instead of an opioid. 3.Discuss concerns about the order with the supervisor and health care provider. 4.Administer an appropriate dose of opioid instead of the saline.

Discuss concerns about the order with the supervisor and health care provider.

8. An 88-year-old patient is admitted with a broken hip after a fall. An order is written for meperidine 50 to 75 mg intramuscularly every 4 hours as needed for pain. Which of the following actions should the nurse take first? 1.Give the meperidine every 4 hours around the clock. 2.Offer the meperidine every 4 to 6 hours as needed. 3.Administer a nonsteroidal anti-inflammatory drug with the meperidine for added pain relief. 4.Discuss the order with the registered nurse or health care provider.

Discuss the order with the registered nurse or health care provider.

2. A patient with terminal cancer has been requiring 5 mg of intravenous morphine every 1 to 2 hours to control pain. Yet, the patient is engrossed in a movie on television and appears to be in no pain. Which of the following explanations of this behavior is most likely correct? 1. Denial of pain is common in patients with cancer. 2.The cancer treatment is working and the pain is improving. 3.The patient is hiding the pain to finish watching the movie undisturbed. 4.Distraction can be an effective treatment for pain when used with appropriate drug treatments.

Distraction can be an effective treatment for pain when used with appropriate drug treatments.

Tricyclic Antidepressants Help relieve neuropathic pain.

Examples amitriptyline imipramine desipramine doxepin Nursing Implications Often cause anticholinergic side effects (e.g., sedation, constipation, blurred vision, dry eyes, urinary retention).

7.A patient is hospitalized following a motor vehicle accident with multiple orthopedic injuries. The patient reports acute pain at an 8 on a 0 to 10 scale. An order is written for morphine 6 mg intravenously every 4 hours as needed as well as a nonopioid oral analgesic every 4 hours as needed. To reduce the risk of adverse effects and maintain an acceptable level of sedation and pain control, which of the following analgesic schedules will be most effective? 1.Offer the opioid every 4 hours. 2.Tell the patient to call when pain becomes severe and then give the drugs immediately. 3.Give both the intravenous opioid and the oral nonopioid every 4 hours around the clock. 4.Alternate the intravenous analgesic with the nonopioid oral analgesic as needed.

Give both the intravenous opioid and the oral nonopioid every 4 hours around the clock.

4. A patient has surgical site pain 24 hours after a total hip replacement. All the following medications are ordered. Which would be the most appropriate choice for the patient at this time? 1.Ibuprofen (Motrin) 2.Hydromorphone (Dilaudid) 3.Acetaminophen (Tylenol) 4.Gabapentin (Neurontin)

Hydromorphone (Dilaudid)

3. What action should the nurse take when a patient with cancer pain develops tolerance to opioid analgesics? 1. Slowly wean the patient from opioids. 2. Request a referral to an addiction specialist for the patient. 3. Talk to the registered nurse or health care provider about increasing the dose of analgesic. 4. Offer the patient nonopioid alternatives for pain control.

Talk to the registered nurse or health care provider about increasing the dose of analgesic.

1. A patient is walking up and down the hall and visiting and laughing with other patients. When the nurse approaches, the patient reports a pain level of 6 on a scale of 0 to 10. Based on McCaffery's definition of pain, which of the following assumptions by the nurse is most likely correct? 1.The patient is not really in pain but just wants medication. 2.The patient is having pain at a level of 6 on a scale of 0 to 10. 3.The patient is in minimal pain and should receive an oral analgesic instead of an injection. 4.The patient is in pain but does not need pain medication yet.

The patient is having pain at a level of 6 on a scale of 0 to 10.

5. A patient is receiving duloxetine (Cymbalta) for neuropathic pain related to diabetes. Which symptoms of neuropathic pain should the nurse assess? 1.Tingling, shocklike pain 2.Dull, aching pain 3.Deep, cramping pain 4.Throbbing, aching pain

Tingling, shocklike pain

WHAT'S UP?

Where is the pain? Be specific. Use a drawing of the body if needed. How does the pain feel? Is the pain shooting, burning, dull, sharp, aching? Aggravating and alleviating factors What makes the pain better? What makes it worse? Timing When did the pain start? Is it intermittent? Continuous? Severity How bad is the pain on a scale of 0 to 10? Use a different tool, such as the FACES Pain Scale-Revised (see Fig. 10.2) or PAINAD Scale (see Fig. 10.3), if needed. Useful other data Are any other symptoms associated with the pain or pain treatment? Itching, nausea, sedation, constipation? How does the pain affect lifestyle (e.g., inability to eat, sleep, work, enjoy sex)? Patient's perception What is the patient's perception of what caused the pain? Is the patient experiencing suffering? Is the patient satisfied with pain control?