Pain Management

Describe the calculation process for converting medication between two opioids.

Calculate the current 24-hour drug dose, or the total amount given in a 24-hour period. Multiply the current 24-hour dose times the ratio of the 24-hour equivalent dose for the new drug over the 24-hour equivalent of the old drug. The calculation provides the equivalent 24-hour dose for the new drug. Divide the new dose amount by the number of doses to be provided during the day. This amount equals the new target dosage.

Discuss the common concerns surrounding use of pain medications with end-of-life patients.

Common concerns surrounding the use of pain medications with end-of-life patients include: Adequacy: Patients are often concerned that medication may not be adequate to control pain and the chronic or breakthrough pain will occur. Patients may be concerned that if they take adequate pain medication that it will be less effective later when pain may worsen. Sedation/Addiction: Some patients and family members are concerned about the risks of addiction and others may be concerned bout the effects of the medication on the patient's cogntion, as some patients may become confused, disoriented, or sedated, depending on he medication or dosage. Adverse effects: Nausea and vomiting may be almost as debilitating to patient as the pain it is intended to alleviate. Constipation, a common adverse effect may be very uncomfortable for a patient. Some medications may result in itching and others may cause myoclonus, both of which are uncomfortable for the patient.

Define and discuss conscious sedation.

Conscious sedation is identified as a minimally depressed state of awareness in which the patient maintains the ability to respond appropriately to verbal and physical stimulus and commands. Patients are also capable of maintaining their own airways, as well as continuing to protect themselves with reflexive responses. Conscious sedation is maintained with analgesics and sedatives in order perform various medical and surgical procedures. This procedure must be used with precaution in order to prevent loss of consciousness. In case of this type of emergency, health care personnel should have equipment on hand for airway management, resuscitation, and medications for sedation reversal, such as naloxone and benzdiazepines.

Define addiction and pseudoaddiction.

Addiction is primary and constant, neuro-biologic disease with genetic, psychosocial and environment factors that create an obsessive and irrational need or preoccupation with a substance. Addictive behaviors include unrestricted, continued cravings, compulsive and persistent use of a drug despite harmful experiences and side effects.. Pseudoaddiction is an assumption that the patient is addicted to a substance when in actuality the patient is not experiencing relief from the medication. It is prolonged, unrelieved pain that may be the result of under-treatment. This situation may lead the patient to become more aggressive in seeking medicated relief, thus resulting in the inappropriate "drug seeker" label.

Define and discuss adjuvants.

Adjuvant is defined as a complimentary treatment used in an effort to reduce and supplement current pharmacological responses. In immunology, chemicals such as aluminum hydroxide and aluminum phosphate are added to an antigen to cause a greater stimulation of the body's immunological responses by increasing the size of antigen. This process makes it easier for the body's B lymphocytes and phagocytes to recognize antigen. This process is not effective with all antigens and cannot stimulate T-lymphocyte activity. In the area of pain control, adjuvants are generally used in conjunction with opioids to reduce the amount of medication required and enhance the overall analgesic effects. Pharmacological choices for increased pain control include antidepressants, anticonvulsants, and corticosteroids. Nonpharmacological treatments can also be used as adjuvants, especially with pain control. The patient may gain better pain control with the addition of therapies, such as meditation, hot or cold application, or acupuncture.

Discuss cultural considerations for pain management.

American Indian and Alaskan natives are unwilling to show pain or request medications. Pain is a difficulty that must be endured rather than treated. Asian Pacific Islanders do not vocalize pain and may have an interest in pursuing nontraditional and nonpharmacological treatments, such as acupuncture, to help prevent pain. Black and African American cultures tend to openly express their pain but still believe that it is to be endured. They may avoid medication because of personal fears of addition or cultural stigmatism. Hispanic cultures value the ability to endure pain and suffering as a personal quality of strength. Expression of pain, especially for a male, id considered a sign of weakness. They may feel that pain is a form of godly punishment or trial.

Name the types of assessment tools available for use with cognitively impaired or nonverbal patients.

(a) Discomfort Scale for Dementia of the Alzheimer Type (DS-DAT): For use with elderly persons experiencing dementia, decreased cognition, and decreased verbalization. (b) Assessment of Discomfort in Dementia Protocol (ADD): Particularly designed for use with patients exhibiting difficult behaviors. (c) Checklist of Nonverbal Pain Indicators (CNPI): Pain measurement with cognitive impairment. (d) Noncommunicative Patient's Pain Assessment Instrument (NOPPAIN): Specifically for use by nursing assistants. (e) Pain Assessment for the Dementing Elderly (PADE): Assessing physical pain behaviors. (f) Pain Assessment Tool in Confused Older Adults (PATCOA): Focuses on the observation of nonverbal cues. (g) Pain Assessment in Advanced Dementia (PAINAD): Adapted from the DS-DAT (h) Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC): To assess common and subtle symptoms. (I) Abbey Pain Scale: For late-stage dementia in nursing home environments.

Identify and discuss the three basic types of breakthrough pain.

(a) Incident pain: Pain that can be specifically tied to an activity or event, such as dressing change or physical therapy. These events can be anticipated and treated with a rapid-onset, short-acting analgesic just prior to the event. (b) Spontaneous pain: This type of pain is unpredictable and cannot be pinpointed to a relationship with any certain time or event. There is no way to anticipate spontaneous pain. In the presence of neuropathic pain, adjuvant therapy may be useful. Otherwise a rapid-onset, short-acting analgesic is used. (c) End-of-Dose Failure: Pain that specifically occurs at the end of a routine analgesic dosing cycle when medication blood levels begin to taper off. Careful evaluation of end-of-dose failure can help prevent it sooner. It may indicate an increase dose tolerance and the need for medication dose alterations.

Discuss the core principles of pain assessment and management by the Joint Commission.

According to the Joint Commission, assessing pain should be a priority in patient care, and organizations must establish policies for assessment and treatment of pain and as well as educating staff members about these policies. The JC considers a plan of care regarding pain control as part of essential patient rights. Hospitals should be consistent in the use of the same assessment tools throughout the organization, specific to different patient populations (for example, pediatrics and geriatrics). Newly revised standards (2018), based on evidence-based practice, include: (a) Organizations must establish a clinical leadership team to oversee pain management and safe prescription of opioids. (b) Patients must be involved in planning and setting goals and should receive education regarding safe use of opioid and non-opioid medications. (c) Patients should be screened for pain in all assessments, including visits to the emergency department. (d) High risk patients for opioid misuse or adverse effects must be identified and monitored. (e) Healthcare providers should have access to prescription drug monitoring safety databases, such as the prescription databases provided by most states. (f) Organizations must provide performance improvement educational programs regarding pain assessment and management and must collect and analyze data on its pain assessment and management.

Discuss the advantages and disadvantages to acetaminphen use.

Acetaminophen(APAP) remains one of the safest analgesics for long-term use. It can be used to treat mild pain or as an adjuvant with other analgesics for more severe pain. Nonspecific musculoskeletal pain and osteoarthritis are particularly responsive to APAP therapy. Acetaminophen also has a limited anti-inflammatory nature. Acetaminophen should, however, be used cautiously in persons with altered liver or kidney function, as well as those with a history of significant alcohol use, regardless of liver function compromise. It should be dosed separately from any opioid analgesic, which should be given separately as well. This allows for individual titration of each drug to assess the individual needs and side effects separately.

Discuss the importance of pain assessments in the non-verbal patient.

As many as 90% of all advanced disease patients will experience some level of pain. The hospice and palliative care philosophy focuses on the relief of pain and provision for comfort measures for all patients who desire it to improve quality of life. Each patient has the right to accept or refuse treatment for their pain. This becomes difficult when the patient is unable to communicate their desires and pain level. It can be assumed that if a patient was experiencing pain when able to communicate, they will continue to experience pain when the ability to communicate has been compromised - pain will be present even in an unconscious state. Changes from previous behavioral, psychological and subjective and objective assessment data provide the supporting information for continued pain assessment in the non-verbal patient.

Discuss measures that can be taken when faced with a pain crisis.

Assess for a change in the mechanism or location of the pain, and attempt to differentiate between terminal anxiety or agitation and the physical causes of pain. Begin with a rapid increase in opioid treatment. If the pain is unresponsive to opioid titration, switching to benzodiazepines, such as diazepam and lorazepam, may produce a more effective response. If terminal symptoms remain unresponsive, assess for drug absorption. While invasive routes of medication delivery are generally avoided unless necessary, the only guaranteed route of drug delivery is the IV route. If there is any question about absorption, it is appropriate to establish parenteral access. IM delivery should be considered as a last resort. When all accessible resources have been exhausted, seek a pain management consultation as quickly as possible. Alternative methods of terminal pain control include radiotherapy, anesthetic, or neuroablative procedures.

Discuss opiod use during the last few hours of life.

Assessment of pain continues in the last few hours of life and medication is adjusted according to assessment. Pain does not necessarily increase as death approaches. It can be assumed that if pain was present prior to loss of consciousness it will continue in the patient's unconscious state. It should be assessed for and treated accordingly. Research has confirmed that administering opioids at the end of life does not hasten nor prolong the dying process. The patient's prior medication regimen should be continued. However, adjustments may be made in consideration of reduced renal or hepatic clearance. The route of administration should also be assessed for appropriateness and adjusted as needed (eg, loss of consciousness, inability to swallow).

Discuss patient, family and social barriers to optimal pain assessments.

Barriers to optimal pain assessment include: Patient: For personal or cultural reasons, patients may minimize or overstate the degree of pain, interfering with assessment. Some patients may be concerned about addiction or the effects of drugs on cognition (confusion, disorientation, lethargy)or other side effects (constipation, nausea, itching). Some may want to protect family from knowing the extent of pain. Family: Cultural biases may influence how the family responds to a patient's pain, and this can influence the patient's response as well. Families may lack understanding of the role of pain assessment and management. Some lack understanding about the difference between addiction and pain control at the end of life. Society: Concerns about drug abuse and addiction often permeate society and influence societal attitudes toward pain control and appropriate drugs to use. Laws and regulations may make access to certain drugs, such as those derived from marijuana, difficult or impossible to obtain.

Discuss health care professional and system barriers to optimal pain assessments.

Barriers to optimal pain assessment includes: Professional: Health care providers may lack knowledge about pain assessment and management of different patient populations or may carry out assessments based on personal perceptions rather than validated pain assessment instruments. Some may be concerned about managing adverse effects or the patient's suffering. Lack of cultural awareness may affect interpretation of pain. For examples, patients in cultures that encourage expression of pain may be assessed as having more pain that patients from cultures that value stoicism. System: The organization may lack clear policies regarding pain assessment and management and may not have established clear guidelines for consistent use of pain assessment instruments. Additionally, supervision and accountability may be inadequate, and the organization may be concerned about costs and reimbursement for treatment.

Discuss outcome indicators for pain control in the palliative care setting.

Effective pain control in the palliative care setting begins with the initial evaluation, The goal of palliative care is to bring any pain that is not well controlled within the patient's own omfort level within the first 48 hours. From his point, pain control should be maintained within these parameters with provisions for breakthrough pain apisodes and changes in overall pain levels. Pain that is out of control should be managed by active interventions within a predetermined time limit. It is the mission of palliative care to improve the overall quality of the patient's life. In turn, no patient should face death or die in the presence of uncontrolled pain. Adverse effects should be anticipated and prevented whenever possible. When adverse effects occur, they should also be treated in the same timely manner.

Discuss factors that can influence the perception of pain.

Factors that can influence the perception of pain include: Emotional state/Attitude: Patients who are extremely upset or anxious may be so overwhelmed they don't feel pain or they may experience pain as more severe than those who are more relaxed and calm. If patients expect to suffer from pain, they are also more likely to report severe pain than patients who expect that their pain will be controlled. Cultural expectations: Perception may vary according to cultural beliefs about pain. For example, if a patient believes that pain is punishment, the patient may agonize over past sins. If a patient believes that pain is fate and reflects karma, then the patient may feel that bearing pain is necessary. Pain threshold: Different patients simply perceive and experience pain to different degrees. What may be minor pain to one individual may be severe to another.

Discuss how gender can affect the patient's pain experience.

Gender can affect pain sensitivity, tolerance, distress and exaggeration of pain, and the patient's willingness to report pain, as well as displayed nonverbal cues concerning the pain experience. Studies indicate that women generally have lower pain thresholds and less tolerance for noxious stimuli or pain factors that hinder them from doing things they enjoy. Women seek help for pain-related problems sooner than men and respond better better to therapy. Women also experience more visceral pain than men. Men are more prone to experience somatic pain and show more stoicism regarding pain experiences than women. Neuropathic pain seems to be experienced equally between men and women. Nurses need to be careful that biases concerning gender experiences with pain do not skew their assessments of pain. However, they need to be aware that pain experiences are always individual and may differ between the sexes.

Discuss the advantages and disadvantages of hydromorphone use.

Hydromorphone is available as tablet, liquid, suppository, and parenteral formulations. It offers the advantage of being synthetic, allowing for its use in the presence of a true morphine allergy. It is also helpful when significant side effects have occurred in the past or pain has been inadequately controlled with other medications. It may also be useful for controlling cough. However, neurotoxicity may occur, particularly myoclonus, hyperalgesia, and seizures. It should also be used cautiously in the presence of kidney, liver, heart, and thyroid disease, seizure disorders, respiratory disease, prostatic hypertrophy, or urinary problems. Common side effects include dizziness, lightheadedness, and drowsiness, upset stomach if taken without food, vomiting, and constipation.

Discuss the basic principles of prescribing controlled substances to patients with advanced illness and addiction challenges

In the presence of addiction challenges it becomes important to choose a long-acting opioid that can facilitate around the clock dosing and minimize the need for short-term medications used for "breakthrough" doses. Short-term medications use should be v1ery limited or eliminated entirely if possible. Whenever possible nondrug adjuvants such as relaxation techniques, distraction, iofeedback, TNS, and therapeutic communication in place of short-term medications. When short-term medication therapy is needed, a nonopioid is best. Limit the amount of medication available to the patient at any given time and monitor for compliance with pill counts and urine toxiology screens as necessary. In some instances, a referral to an addictions specialist is recommended.

Describe the calculation process for converting medication regimen between two opioids.

Individual patient needs, including cost, practicality, and convenience, should be taken into account with every prescription. Monitor the patient status frequently and adjust analgesics based on patient goals and the results of full pain assessments, including needs for supplemental analgesics, sleep, emotions, and quality-of-life factors. Arount-the-clock pain relief should be provided in the form of sustained-release preparations and consistent dosing schedules. Immediate-release options should also be provided to accommodate for episodes of breakthrough pain. Avoid mixing agonist-antagonist opioids. Monitor for drug-drug and drug-disease interactions. Actively manage known side effects. Be familiar with the additional resources of pain management experts in your care community and make referrals as needed when pain cannot be adequately controlled using standard, reasonable guidelines and interventions.

List the areas that should be addresses when assessing pain.

Information concerning a patient's pain can be gathered from a variety of sources including observations, interviews with the patient and family, medical records and observations of other health care providers. However, it is important to remember that each patient's pain is subjective and personal. Pain is defined as whatever the patient says it is. Having the patient give parameters of location, duration or length of the pain, onset or when it begins, and intensity as defined by pain assessment can all be beneficial in forming a treatment plan based on the patient's needs. Pain is also influenced by psychological, social, and spiritual factors. Behavioral, psychological and subjective assessment information such as physical demeanor and vital signs can be helpful in further defining a patient's pain parameters.

Discuss the protocol for using ketamine to treat a pain crisis.

Ketamine treatment begins with an initial bolus of 0.1 mg/kg IV. If there is no improvement, a second bolus, with double the dosage, is provided in 5 minutes. This can be repeated as needed. Boluses should be followed by a decrease in the patient's current opioid dose by 50% and an infusion of ketamine. Infusing dosing for ketamine is 0.015 mg/kg/min, or about 1 mg/min for a 70 kg person. If IV access cannot be attained, subcutaneous infusion is a possibility with dosing of 0.3 to 0.5 mg/kg. Consider concurrent treatment with a benzodiazepine to prevent hallucinations or frightful dreams and observe for increased secretions. These secretions may be treated with glycopyrrolate, scopolamine, or atropine as needed.

Discuss the usefulness of Ketorlac.

Ketorolac is an NSAID often used for its analgesic, antipyretic, and anti-inflammatory properties. It acts by inhibiting the synthesis of prostaglandins within the body. Though its therapeutic use is generally limited to short-term therapy of 5 days or less, it is the only NSAID available in oral, nitramuscular, and ophthalmic solutions. The ophthalmic solution is effective in treating general eye pain as well as irritation related to seasonal allergies. Like most NSAIDs, it is used cautiously, or contraindicated in the patient with renal disease or dysfunction. The most common side effects include edema, hypertension, rash, nausea, constipation, diarrhea, vomiting, drowsiness, dizziness and headache. The following serious risk factors are related to ketorolac: stomach ulcerations, bleeding, and perforation., renal damage, and hemorrhage.

Discuss the advantages and disadvantages of methadone use.

Methadone is useful for treating severe or chronic pain and may be particularly helpful in the presence of neuropathic pain. It has a long-acting pain relief factor for a lower cost than many comparable medications. However, the exact dosing ratios with morphine remain unclear within the available research. Metabolism of methadone can also be swayed (either increased or decreased) be many other medications normally taken by patients with chronic conditions. Methadone can be used to treat opioid addiction. US law for the prescription of methadone for addition in detoxification or maintenance programs requires a special license and patient enrollment. The words "for pain" need to be clearly stated in the prescription. Methadone can cause drowsiness, weakness, headache, nausea, vomiting, constipation, sweating, and flushing, as well as sedation, decreased respirations, or an irregular heart rate.

Compare the dosage of both the enteral and parenteral routes of morphine, codeine, hydromorphone, and levorphanol

Morphine: Enteral dosage is 30 mg (available as continuous and sustained-release formulations to last 12 to 24 hours); parenteral dosage is 10 mg. Codeine: Enteral dosage is 200 mg ( not generally recommended); prenteral dosage is 130 mg. Hydromorphone: Enteral dosage is 7.5 mg (available as a continuous-release formula lasting 24 hours); parenteral dosage is 2 mg. For chronic pain, dosage is equivalent for both enteral and parenteral at 1 mg. Leverphanol has a long half-life, increasing of dosage accumulation over time. Adhering to the statement "If the gut works, use it," as much as 90 percent of all patients will at least start out able to use oral medications instead of other routes.

Identify multidimensional tools used for pain assessment.

Multidimensional tools used for pain assessment include: Multi-dimensional Pain Inventory: The patient begins by identifying a significant other and then answering 20 questions(rating scale 0-6) about the current rate of pain, the degree of interference in daily life, the ability to work, satisfaction from social/recreational activities, support level of the significant other, mood, pain during previous week, changes brought about by pain, concerns of significant other, ability to deal with pain, irritability, and anxiety. Brief pain inventory: The patient marks area of pain on the body diagrams, rates (1-10 scale) the degree of pain at present, at its worst and least in 24 hours, average pain as well as treatments and the degree of relief obtained and how the pain interfered with activities, mood, walking, normal work, interpersonal relations, sleep, and enjoyment of life. McGill pain questionnaire: The patient marks areas of internal and external pain on body diagrams and select appropriate adjectives for 20 different sections regarding sensory, affective, and evaluating perceptions. For example, #1 includes "Flickering, quivering, pulsing, throbbing, beating, and pounding." The patient also rates present pain intensity (PPI) from 0 (none) to 5 (excruciating).

Discuss non-pharmacologic interventions that may be appropriate for assisting in pain control.

Multiple factors contribute to pain, so nondrug therapies such as cognitive-behavioral techniques and physical measures can serve as supplemental pain control measures, in turn reducing the amount of analgesic required by the patient. Cognitive-behavioral therapies are used to imprve coping and relaxation techniques. These can include guided imagery, hypnosis, biofeedback, distraction with music or humor, prayer or other spiritual routines, simple exercises, rest, breathing exercises, and meditation. Even simple patient education about the nature and causes of pain can help patients feel more in control and less anxious in dealing with that pain. Physical measures include heat and cold, massage, reflexology, acupuncture, chiropractic, transcutaneous electrical nerve stimulation (TENS). In cases of refractory pain, nerve blocks and cordotomy may also be surgical options for pain management.

Describe neuropathic pain.

Neuropathic pain results from injury to the nervous system. This can result from cancer cells compressing the nerves or spinal cord, from actual cancerous invasion into the nerves and spinal cord, or from chemical damage to the nerves caused by chemotherapy and radiation. Other causes include diabetes- and alcohol-related damage,trauma, neuralgias, or other illnesses affecting the neural path either centrally or peripherally. When the nerves become damaged, they are unable to carry accurate information. This results in more severe, distinct pain messages. The nerves may also relay pain messages long after the original cause of the pain is resolved. It can be described as sharp, burning, shooting, shocking, tingling, or electrical in nature. It may travel the length of the nerve path from the spine to a distal body part such as a hand, or down the buttocks to a foot. NSAIDs and opioids are generally ineffective against neuropathic pain, though adjuvants may enhance the therapeutic eefect of opioids. Nerve blocks may also be used.

Define nociceptors.

Nociceptors are the primary neurons, or sensory receptors, responding to stimulus in the skin, muscle, and joints, as well as the stomach, bladder, and uterus. These neurons have specialized responses for mechanical, thermal, or chemical stimuli. The neurons stimulation is a direct result of tissue injury and follows four stages: transduction where a change occurs, transmission where the impulse is transferred along the neural path, modulation or translation of the signal, and perception by the patient. When injury occurs, the nociceptors initiate the process that begins depolarization of the peripheral nerve. Nociceptors may consist of either A axons or C axons. The message passes along the neural pathway and creates a perception of pain. A axons carry these pain messages at a much faster rate than C axons.

Explain the advantages and disadvantages of using morphine for chronic cancer pain.

One advantage of morphine for chronic cancer pain is that it has no ceiling dose. As tolerance to the medication increases or the disease progresses in severity, the dose can be gradually increased to an infinite level. It is also available in many different forms for administration, including intravenous, intramuscular, immediate release, sustained release, long-acting, liquid oral preparations, and suppositories. Morphine is often used as the equivalency standard for other opioid analgesics. Common side effects of morphine include sedation, respiratory depression, itching, nausea, chronic spasms or twitching of muscle groups, and constipation. Constipation is experienced by all patients receiving opioids. This inevitability should be planned for and treated aggressively. Hallucinations are common when morphine is initiated. After the first few days, most patients will overcome the respiratory depression, nausea, itching, and extreme sedation.

Discuss guidelines for the use of opioids.

Opioid analgesic therapy is a widely used method of chronic pain control. By adhering to clinical guidelines, pain control can be safely optimized. Intramuscular administration should be used as a last resort except in the presence of a "pain emergency" when no other treatment is readily available. Such cases are rare since subcutaneous delivery is almost always an alternative. Noninvasive routes such as transdermal and transmucosal, which bypass the enteral route, are optimal for continuous pain control and are often effective in eliminating breakthrough pain as well. Changing from one opioid to another, or altering the delivery method, may become necessary under the assumption that incomplete cross-tolerance among opioids occurs. Changing analgesics or method of delivery may result in a decreased drug requirement. When altering opioid delivery regimens, use morphine equivalents as the common factor for all dose conversions. This method will help reduce medication errors. Side effects such as sedation, constipation, nausea, and myoclonus should be anticipated in every care plan, and requireboth prevention and treatment methods.

Discuss the uses of oral transmucosal citrate.

Oral transmucosal fentanyl citrate cinsists of fentanyl on an oral applicator. The patient applies the dosage (starting at 200 mcg) to the buccal mucosa between the cheek and gum for rapid absorption and subsequent pain relief. This makes transmucosal fentanyl particularly useful for managing breakthrough pain. Pain relief generally begins within 5 minutes; the patient should be instructed to wait 15 minutes after the previous dose has been completed before taking another dose. Swallowing even part of the dose rather than having it completely absorbed through the oral mucosa can affect the timing of pain relief onset. Peak effect occurs in 20 to 40 minutes with the total pain relief duration lasting 2 to 3 hours. Side effects can include somnolence, nausea, and dizziness. Consuming drinks such as coffee, tea, and juices that alter the oral secretion pH can also alter the absorption rate of transmucosal fentanyl.

Discuss the advantages and disadvantages of oxycodone use.

Oxycodone, a synthetic formulation, is a long-acting opioid for moderate to severe pain relief. Side effects are similar to those of morphine. It has a similar pain relief ratio, with the possibility of less nausea and vomiting. Because if its extended-release nature, the medication cannot be cut or crushed for administration. Oxycodone does not carry any greater addiction risk than other types of opioids; however, public sensationalism related to this formulation may create hesitation for use among patients. Pharmacies may also limit the amount of this medication they will make available to an individual. Oxycodone should be used cautiously in patients with a history of hypothyroidism, Addison'sdisease, urethral structure, prostatic hypertrophy, or lung or liver disease.

Describe the benefits and adverse side effects that may occur as a result of NSAID use.

Patients may benefit from NSAID use because of the anti-inflammatory, analgesic, and antipyretic properties. NSAIDs tend to be the first line of defense against pain caused by inflammatory conditions. They may also be used in conjunction with opioid therapy to reduce the amount of opioid needed. Adversely, gastrointestinal bleeding or ulceration, decreased renal function, and impaired platelet aggregation may occur. Studies have also indicated that the therapeutic affects of NSAIDs may not extend beyond six to twelve months of use. Short-term memory loss may occur in older patients. There may be an increased cardiovascular risk with prolonged use. Patients allergic to sulfa drugs can also experince a cross-sensitivity to come types of NSAIDs.

Discuss physical dependence.

Physical dependence occurs when the body adapts to a drug, requiring increasing dosages over time to gain the same effect, and withdrawal of that drug then will result in an abstinence syndrome (withdrawals). Physical dependence can be described as a form of addiction. While physical dependence was commonly thought of as being related to narcotic drugs (such as morphine, methadone, fentanyl), many different types of drugs may cause some degree of physical dependence. For example, abruptly stopping a beta blocker may result in cardiac arrhythmias or cardiac arrest. Abruptly stopping SSRIs may result in severe depression and anxiety. Thus, when considering stopping a patient's drugs near end of life, physical dependence must be considered as many drugs should be tapered to avoid withdrawal effects. Drugs that effect the central nervous system, such as ethanol, barbturates, and benzodiazepines, pose considerable risk of dependence, and may result in severe withdrawal symptoms.

Identify and discuss the QUESTT pediatric pain assessment tool.

QUESTT is designed to focus on assessment, action, and consequent reassessment for results. Q- Question both the child and parent about the pain experience. U - Use assessment tools and rating scales that appropriate to the development stage and situation and understanding of the child. E - Evaluate the patient for both behavioral and physiological changes. S - Secure the parent's participation in all stages of the pain evaluation and treatment process. T - Take the cause of the pain into consideration during the evaluation and choice of treatment methods. T - Take action to treat the pain appropriately, and then evaluate the results on the regular basis.

Discuss recommendations for pain documentation in the medical record.

Recommendations for pain documentation in the medical record include: (a) Describe the time of onset, the location of pain, the character of the pain, and the degree of the pain, using a validated pain assessment instrument (either a self-reporting instrument, such as the visual analog sclae, or one based on observation, such as PAINAD). (b) Doument all interventions, including non-pharmacological(positioning, massage, relaxation exercises) and pharmacological (opioids, aduvants), including the time, the dosage, and the method of administration. (c) Assess and document the initial response to the medication based on the expected response time. For example, an IV medication should take effect almost immediately, but oral medications may take up to 20 minutes to take effect. (d) Assess and document the duration of response based on the expected duration of the medication. For example, if a medication response is expected to last 6 hours, the patient's pain level should be assessed at least every 2 hours and more frequently if the rate of pain increases. (e) Describe any adverse effects, such as itching or nausea.

Describe somatic pain.

Somatic pain refers to messages from pain receptors located in the cutaneous or musculoskeletal tissues. When the pain occurs within the musculoskeletal tissue, it is referred to as a deep somatic pain. Metastasizing cancers commonly cause deep somatic pain. Surface pain refers to pain concentrated in the dermis and cutaneous layers such as that caused by surgical incision. Deep somatic pain is generally described as a dull, throbbing ache that is well focused on the area of trauma. It responds well to opioids. Surface somatic pain is also directly focused on the injury. It is frequently described as sharper than deep somatic pain. It may also present as a burning or pricking sensation.

Identify and discuss sources of pain that may be present for the HIV/AIDS patient.

Sources of pain that may be present for the HIV/AIDS patient: (a) Aphthous ulcer and oral candidiasis produce painful sores within oral cavity; dysphagia may also be experienced. (b) Arthralgia is joint pain with heat, redness, tenderness, loss of motion, and swelling. Cryptococcal meningitis is a life-threatening fungal infection resulting in headache, dizziness, and stiff neck. Coma and death can occur. (c) Hepatoxicity is liver damage resulting in nausea, vomiting, abdominal pain, loss of appetite, diarrhea, fatigue and weakness, jaundice, swelling, and weight gain. (d) Herpes simplex virus 2 (HSV-2) produces painful sores around the anus or genitals. (e) Isosporiasis is a gastrointestinal infection. Diarrhea, fever, headache, abdominal pain, vomiting, and weight loss result. (f) Myalgia is the condition of muscle pain and tenderness, general discomfort, and weakness throughout the entire body. (g) Neuralgia and peripheral neuropathy are sources of chronic nerve pain. (h) Stevens-Johnson syndrome (SJS) is a reaction to medications and creates a severe to fatal skin rash with red, blistered, and painful spots on skin, mouth, eyes, genital, and moist areas of the body, or internal organs.

Discuss the ABCDE mnemonic approach to pain assessment.

The Agency for Halthcare Policy and Research recommends use of the ABCDE method for assessing and managing pain: Asking patient about the extent of pain and assessing systematically. Believing that the degree of pain the patient reports is accurate. Choosing the appropriate method of pain control for the patient and circumstances. Delivering pain interventions appropriately and in a timely, logical manner. Empowering patients and family by helping them to have control of the course of treatment. The 5 key elements of pain assessment include: (1) Words: Used to describe pain, such as burning, stabbing, deep, shooting, and sharp. Some may complain of pressure, squeezing, and discomfort rather than pain. (2) Intensity: Use of 0-10 scale or other appropriate scale to quantify the degree of pain. (3) Location: Where patient indicates pain. (4) Duration: Constant or comes and goes, breakthrough pain. (5) Aggravating/alleviating factors: Those things that increase the intensity of pain and those that relieve the pain.

Identify the Neuropathic Pain Scale.

The Neuropathic Pain Scale (NPS) is the first tool designed specifically to assess the types of pain associated with neuropathy. The NPS comprises 10 sections with 9 assessed with a 0 to 10 (not unpleasant to intolerable) scale: (a) Intensity of pain. (b) Sharpness of pain. (c) Heat of pain. (d) Dullness of pain. (e) Coldness of pain. (f) Skin sensitivity to touch,clothing. (g) Itchiness. (I) Overall unpleasantness of pain. (j) Intensity of deep and surface pain. One question asks for narrative descriptions of the time quality of pain. The patient chooses from three options: (1) feeling background pain all of the time with occasional flare-uos, (2) feeling a single type of pain all the time, and (3) feeling a single type of pain sometimes while having some pain-free periods. The patient is then asked to describe the pain experienced.

Discuss physical signs that can indicate pain.

The best assessment of the patient's pain is his own report. All other information is assessed as supporting this report. However, when this method is restricted or unavailable, physical signs and symptoms can help the nurse's assessment capabilities. It is important to be familiar with the patient's baseline or resting information to give a clear picture of the changes the body may go through when experiencing significant pain. Systolic blood pressure, heart rate and respirations may all increase above the patient's normal parameters. Tightness or tension may be felt in major muscle groups. Posturing can also occur: the patient may guard areas of the body, curl around themselves in a "fetal" position or hold only certain body portions rigid. Calling out, increased volume in speech and moaning can also be indicators. Facial expressions such as flat affect or grimacing and distraction from their surroundings also indicate a significant increase in stressful stimulus.

Discuss the shortcomings or meperidine use as a chronic pain relief.

The clinical practice guidelines from the American Pain Society strongly discourage the use of meperidine, especially in the long-term palliative care setting. Meperidine does not have a long-lasting analgesic effect; it only lasts 2 to 3 hours. Repeated doses may also lead to central nervous system toxicity. The toxicity is a result of ineffective metabolite clearance. Individuals with renal insufficiency are unable to excrete the byproduct, normeperidine, in the body results in chronic muscle twitching or new-onset seizures. The metabolites of meperidine have also recently been linked with an increased pain perception and intensity. Normeperidine toxicity is not easily reversed and down not respond to naloone.

Discuss reasons for use of complementary and alternative medicine in palliative care.

The patient may choose to explore complementary and alternative medicine for a variety of reasons. Given a poor prognosis, patients may attempt to focus on ways to improve their overall health, reduce side effects or medical treatments or the disease process, and improve the quality of their life. Approaches they feel are more in their control than helplessness or hopelessness. It allows them to feel they are takaing an active role in their care. Exploration of complementary and alternative medicine may also volve from suggestions from friends and family; philosophical and cultural factors may also come into play. There is a desire to be sure that they have "tried everything", hoping to alter the course of disease progression. At times, there may be a mistrust or lack of faith in traditional medical treatments and a desire to treat the disease process in more "natural" ways. The patient may also feel that alternative medicine is less expensive and more accessible than traditional physicians and medical care.

Define tolerance and pseudo tolerance.

Tolence is the adaptation of the body to continued exposure to a drug or chemical. The effects of the drug at the same level of exposure are minimized over time. Additional dosing is required to maintain the same outcomes. Pseudotolerance is the misguided perception of the health care provider that a patient's need for increasing doses of a drug is due to the development of tolerance when in reality disease progression or other factors are responsible for the increase in dosing needs.

Discuss types of medications that may be useful in treating neuropathic pain.

Treatment options for neuropathic pain are often different from the methods used to treat other types of pain. The three drug classes most commonly used and proven effective for treating neuropathic pain are anticonvulsants, anesthetics, and antidepressants. Some are given on an as-needed basis but most require consistent dosing with 24-hour symptom control. Examples of the most common medications include amitriptyline, nortriptyline, duloxetine, gabapentin, topical lidocaine, opioids,and pregabalin. Medication choice is dependent on factors such as the type and progression of the disorder and the associated physical and emotional problems, such as nerve injury, muscle weakness, or spasms, anxiety, depression, or sleep disturbances.

Identify treatments for bone pain.

Treatment options may depend on the causative agent related to the pain, such as the primary cancer site, severely weakened bones, or fractures. Systemic treatment choices include chemotherapy, radiation, and hormone therapy. Hormone therapy is used in the presence of estrogen and adrogen receptors within the cancer cells. Bisphosphonates, such as ibandronate, zoledronate, and alendronate, may help strengthen the bones, slow damage and prevent fractures; they can also help reduce pain. However, side effects can include fatique, fever, nausea, vomiting, and anemia. Surgery may also be considered to remove cancerous cells or reinforce weakened areas of bone. Opioids and NSAIDs/COX-2 inhibitors are most often used for pain relief and need to be provided on a consistent basis. Morphine combined with ibuprofen provides the benefit of a centrally acting opiod with a peripherally acting NSAID.. Ibuprofen also acts as an effective adjuvant analgesic agent to enhance the relief provided by the opioid without increasing opioid side effects.

Identify the following unidimensional tools for pain assessment: Visual analog/Numeric rating, Descriptive, and FACES

Unidimensional tools for pain assessment focus on one aspect only, the patient's level of pain. Tools include: Visual analog/Numeric rating scale: A 1-to-10 rating scale presented visually or verbally from which the patient chooses a number to describe the degree of pain the patient is experiencing. Zero represents no pain, 1 very mild pain, and 10 the most severe pain the patient can imagine. Descriptive: Pain is described in simple terms that a patient can choose from: Mild, moderate, severe. This may be especially helpful for patients from cultures, such as Mexican, in which the 1-10 is not generally used. FACES: A chart shows facial expression scale of simple drawings showing faces with different emotions, such as happiness, fear, and pain. Used primarily for children over age 3 and for non-verbal adults, although both a child's and an adult's version are available. A revised version applies numeric values to expressions so that pain can be assessed according to a numeric scale as well.

Describe Visceral pain.

Visceral pain is associated with the internal organs. It can be very different depending on the affected organ. Not all internal organs are sensitive to pain (some lack nociceptors, such as the spleen, kidney, and pancreas), and may withstand a great deal of damage without causing pain. Other internal organs, such as the stomach, bladder, and ureters, can create significant pain from even the slightest damage. Visceral pain generally has a poorly defined area. It is also capable of referring pain to other remote locations away from the area of injury. It is described as a squeezing or cramping, a deep ache within the internal organs. The patient may complain of a generalized "sick" feeling or have nausea and vomiting. Visceral pain generally responds well to treatment with opioids.

Discuss unique aspects of assessing pain in the pediatric patient.

When assessing the pediatric patient, the nurse must take into consideration the chronological and developmental age of the child. These help determine which measure the child might use to express pain, as well as treatments that might prove most successful. Assessment parameters must also include the presence of and parameters surrounding chronic illness, as well as neurological impairment. Identify the underlying cause of the pain, what nonpharmacological measures have been tried for pain control, and what methods can be used to deliver pharmacological interventions. The weight of the child in kilograms determines the appropriate dosages of medications. If the child is able to speak, do the child and parents speak the same language as the health care provider, and are there any other obvious barriers to communication or pain relief measures?