Pain Management

nsaid therapeutic use

-inflammation suppression -analgesia for mild to moderate pain like OA, RA -fever reduction -dysmennorhea >>inhibit platelet aggregation protects against ischemic stroke and MI (aspirin)

Inova Sedation Scale (ISS)

1 alert 2 occasionally drowsy, easy to arouse 3 intermittent dosing 4 asleep, easy to awake 5 difficult to awaken 6 unresponsive

Use anatomical terminology and landmarks to describe pain location

1) are you feeling any pain or discomfort 2) does it hurt anywhere(ask them to point) 3) where does it hurt 4) does it spread anywhere else (radiating,localized)

epidural anesthesia/antiemetics

A patient with chronic cancer pain is usually administered epidural anesthesia for pain management. This patient has to be monitored for side effects every 15 minutes. Nausea and vomiting are common side effects associated with epidural anesthesia. To prevent such undesirable complications, the nurse administers antiemetics as ordered. To maintain catheter function, the nurse inspects the catheter for breaks. The nurse changes infusion tubing every 24 hours to prevent infection. To maintain urinary and bowel function, the nurse assesses for bladder and bowel distention.

ice therapy

Cold therapies are particularly effective for pain relief. Ice massage involves applying a frozen cup of ice firmly over the skin, which is covered with a lightweight cloth. When numbness occurs, remove the ice for usually 5 to 10 minutes.

NSAID Adverse effects

GI bleeding, renal dysfunction renal dysfunction includes: decreased output, fluid retention, increased BUN, CREATININE, increased risk MI, Stroke (not with asprin) salicylism may occur with asprin==>tinnutus, sweating, headache, dizzyness, respiratory alkalosis

barriers to effective pain management

Lack of money A difficulty in filling prescriptions A requirement of extensive documentation makes the process tedious

use opiods cautiously with

MI, kidney, liver disease, resp depression, head injury, physically dependent on opiods

antagonist opioids

Narcan-naloxone pharmacological action: interfere with opioid action by competing for opiod receptors --no affect in the absence of opioids -used for OD

pain sensation transmission in ascending order

Pain sensation is transmitted from afferent fibers to the spinal cord. From the spinal cord, the pain sensation is carried to medulla, pons, and midbrain. From here it continues through the spinothalamic tract to the thalamus and then to cerebrum.

misconceptions about pain and combating them

Regular administration of analgesics does not lead to addiction. Therefore, analgesics should be administered whenever the need arises. Although a client may suffer from minor illness, he may experience severe pain which should not be ignored. A common misconception is that chronic pain is often psychological. However, chronic pain may have a pathological origin. Another misconception is that only hospitalized clients experience pain. Clients who are not hospitalized may also experience pain which needs to be addressed. Another misconception is that psychogenic pain is not real.

reason to reassess naloxone after methadone od

The duration of action or half-life of naloxone is less than that of methadone. Therefore, recurrence of respiratory depression by the relatively long action of methadone can be prevented by reassessing the client every 15 minutes for 2 hours after naloxone administration. Methadone has a greater half-life than naloxone. Therefore, the effect of methadone is more prolonged than naloxone. Naloxone is an opioid-antagonist drug. Naloxone does not act as an agonist to morphine after 2 hours. Opioid-naïve clients are the clients who have not taken opioid medications for at least a week. Naloxone causes morphine withdrawal symptoms only in clients who are physically dependent on morphine and not the clients who are opioid-naïve. TEST-TAKING TIP: The most reliable way to ensure that you select the correct response is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the question, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled.

opioid agonist & antagonists

abstinence sydrome-withdrawal cramping, hypertension, vomit, fever, anxiety sedation, resp depression dizziness headache

antidote for tylenol OD

acetylcysteine (mucomyst) no alcohol take one med at a time containing acetimenophen

Diagnosis

acute pain chronic pain impaired comfort

sympathetic nervous system (fight or flight)

acute pain response causes; hypertension, tachycardia, anxiety, diaphoresis, muscle tension ALTERS VITALS

factors affecting pain

age, fatigue, genetic sensitivity, cognitive function

Opiods are classified as

agonists agonist-antagonists antagonists

sedatives, antianxiety agents, muscle relaxants have no

analgesic effect, but cause drowsiniess and impaired coordination

pharmacological interventions

analgesics-mainstay for relieving pain nonopiod analgesics- aspirin, ibuprofen opiod antagonists-morphine opiod agonists&antagonists-butorphanol(Stadol) adjuvant medications-amitryptaline/elavil miscellaneous pain medications-predisone

pharmacological action opioid agonist and antagonist

antagonist on MU receptors agonists on kappa receptors low potential for abuse causing little euphoria, high doses can cause anxiety restlessness and confusion less respiratory depression than opiod agonists

Nsaid interactions

anticoagulants-heparin, warfarin increase risk of bleeding glucocorticosteroids-increase risk of GI bleed alcohol-increase risk of bleeding ibuprofen-decreases antiplatelet effects of low dose aspirin

The pharmacologic pain management therapies that would be beneficial to a patient with neuropathic pain include

anticonvulsants such as gabapentin (Neurontin) and antidepressants such as nortriptyline (Pamelor). Gabapentin (Neurontin) acts on the supraspinal region to stimulate noradrenaline-mediated descending inhibition to reduce neuropathic pain. Nortriptyline (Pamelor) alleviates neuropathic pain by altering neurotransmitter levels.

Neuropathic pain

arise from abnormal or damaged pain nerves Includes: phantom limb pain, diabetic neuropathy intense, shooting, burning, tingling, pins & needles treated with: adjuvant medications (elavil/amitryptaline)

Pain impulses

ascend the spinal cord to thalamus, which transmits information to higher brain centers that perceive pain

non opiod analgesics

aspirin, ibuprofen, nsaids, aleve acetimenophin (not an nsaid) antiinflammatory, antipyretic, analgesic

before medication administration it is required that you

assess for pain and reassess post admin

student RNs are accountable for

assessing pain before and after pain medication administration continual assessment of pain level providing individual interventions assess effectiveness of interventions 30-60mins after implementation legally ethically responsible for managing pain and relieving suffering

opioids reduce pain by

attaching to a receptor in the CNS altering perception and response to pain

The nurse checks the patient's history for drug allergies to

avoid placing the patient at risk for allergic reactions.

document their pain when?

before you adminster the med, pain was 8/10 now 30min later it is 2/10

agonist-antagonist

binds to one receptor causing a response and binds to another receptor to prevent a response

common adjuvants

biphosphonates and calcitonin given for bone pain

transmucosal fentanyl can be given how many times per episode of breakthrough pain?

breakthrough pain. It is swabbed over the buccal mucosa and gums to be dissolved in the mouth. It should not be chewed. The nurse has given one unit of Fentanyl already; if the pain still persists, the nurse can administer one more unit of Fentanyl. A client can be given a total of two units of transmucosal Fentanyl per episode of breakthrough pain. If the client is not relieved of the pain, then the nurse should notify the primary health care provider.

opioid agonist and antagonist

butorphanol (Stadol) nalbuphine (Nubain) buprenorphine(Buprenex) pentazocine (Talwin) subutex suboxone treatment of opioid dependence (buprenex) relief of labor pain (butorphanol)

physiology of pain includes

cellular damage by thermal, mechanical, chemical stimuli causing the release of neurotransmitters

To ensure that the patient receives the correct medications,

checks the patient's prescription.

Risk factors for under treatment of pain

cultural, societal, lack of knowledge, fear of addiction, exaggerated fear of resp depression

Nonpharmacological Pain Mgmt

cutaneous skin stimulation (ice/heat) distractions relaxation acupuncture reduce environmental stimuli like light and noise

glucocorticosteroids (adjuvant medications cont)

dexamethasone (Decadron) NSAIDS: ibuprofen (motrin)

If the patient is unable to manipulate a PCA pump to control pain, the nurse should

discuss a possible basal (continuous) dose with the PHP or consult with the PHP regarding an alternative medication route.

essential to achieve adequate pain relief

effective communication providing pain relief is a basic human right pain is the fifth vital sign

During the process of pain modulation, which inhibitory neurotransmitters are released to inhibit the pain impulse.

endogenous opioids, serotonin, norepinephrine, and gamma aminobutyric acid (GABA) are some of This happens in the fourth and final phase of the nociceptive process. Histamine and substance P have no role in pain modulation. Histamine is released by mast cells and plays a major role in the inflammatory process. Substance P transmits pain impulses from periphery to higher brain centers.

purpose of NSAIDS

expected action: inhibit cooxygenase, inhibit cox 1 can result in platelet aggregation decrease and kidney damage

nonverbal cues to assess for in patients

facial expressions behavior changes from baseline moaning crying decreased attention span blood pressure, pulse, respiratory rate

2 types of sensory nerve fibers are

fast myelinated A-delta fibers: send sharp localized distinct sensations Slow, small unmyelinated C fibers- send poorly localized burning persistant pain

document associated symptoms such as

fatigue, depression, nausea, anxiety "what other symptoms do you have when you are feeling pain?" what makes the pain better or worse are you currently taking any perscription medications herbals or OTCS?

Pain assessment DATA COLLECTION

first find out if they are in any pain

Medication Classification: NSAID

first generation-COX 1 COX 2 inhibitors -aspirin -ibuprofen (motrin, advil) -naproxen (naprosyn) -naproxen sodium (aleve) inhibit prostaglandin production Second generation NSAID COX 2 INHIBITOR celecoxib- (celebrex)

substance P

found in pain neurons of dorsal horn excitatory peptide needed to transmit pain impulses from the periphery to higher brain centers causes vasodilation and edema

behavioral responses for acute pain

grimacing, moaning, flinching, guarding

measures of pain: intensity, strength, severity

how much pain do you have now what is the worst/best the pain has been

acute pain components

identifiable cause, limited tissue damage, and an emotional response. Acute pain results in prolonged hospitalization as it seriously threatens a client's recovery, so the health team members treat it aggressively. Acute pain is protective, unlike chronic pain which is not protective.

reasons for effective pain management include

improved quality of life reduced physical discomfort early mobilization fewer hospital clinic visits decreased lenght of state

Specific Chronic Pain Management Strategies

include proactive interventions administer long acting or controlled release opioid analgesics ( including transdermal-fentynal patch) adminster around the clock analgesics

who is at risk for under treatment of pain

infants, children, older adults, substance abuse clients

Corticosteroids relieve pain associated with

inflammation and bone metastasis. *Muscle relaxants have no analgesic effect. Bisphosphonates are prescribed for bone pain.

needless adapter for PCA pump

inserted into the injection port nearest the patient to establish the route of medication and facilitate continuous delivery of the medication. The nurse administers the loading dose of analgesia as prescribed by giving one-time doses manually or programming it into the PCA pump. Attaching the drug reservoir to the infusion device and prime tubing locks the system and prevents air from infusing into the intravenous (IV) tubing. Attaching a needleless adapter to the tubing adapter of a patient-controlled module is done to connect with the IV line. It does not facilitate continuous delivery of the medication.

If the patient verbalizes continued or worsening discomfort or displays nonverbal behaviors indicative of pain suggesting the underlying condition has changed, the nurse should

inspect the IV site for possible catheter occlusion or infiltration.

massage technique

knead upward along one side of the spine from buttocks to shoulders, not downward from the shoulders to the buttocks. The nurse should massage each body part for at least 10 minutes and use long, gliding strokes along the muscles of the spine. The massage should begin at the sacral area and progress in a circular motion while moving upward from the buttocks to the shoulders. The nurse should knead the skin by gently grasping tissue between the thumb and fingers.

PCA- Patient controlled Analgesia

medication delivery system, small frequent doses, patient should be only one touching button

opiod agonists

morphine fentanyl- (Sublimaze, Duragesic) meperidine- (Demerol) methadone- (Dolophine) codeine oxycodone (OxyContin)

typical opiod PCA medications include

morphine, hydromorphine (dilaudid) let nurse know if pump does not control the pain to prevent adverse OD-patient only one touching pump

neuromodulators (inhibitors)

natural supply of morphine like substances in the body activated by stress and pain located in brain, spinal cord and GI tract causes analgesia when attach to opiate receptors in brain present in higher levels in people who have less pain than others when injured

wong baker faces scale

no hurt to hurts worst

Do people experience pain the same

no two people experience pain in the same way and no two events create the same response

chronic pain

not protective ongoing, occurs frequently longer than 6months (3-6months) persists beyond tissue healing does NOT alter vital signs clients may have depression, fatigue, decreased level of functioning

If the patient who is on a PCA pump is not readily arousable, the nurse should

notify the PHP and prepare to administer an opioid-reversing agent.

chronic pain seeks numerous hcp because

of its unknown cause.

Timing of pain:

onset, duration, frequency when did it start? how long does it last? How often does it occur? Is it constant, does it come and go?

Look at your values when

pain medication views differ from your own

Medication classification-Acetaminophen

patients who cant take NSAID can take 4000mg=4g/day of tylenol with normal LFTS Pharmacologic Action: slows production of prostaglandins in CNS therapeutic: analgesic, antipyretic

purpose of opiods

pharmacological action: opiod agonists like morphine,codeine, meperidine, fentynal, act on MU RECEPTORS and KAPPA receptors MU receptors: produces analgesia, resp depression, euphoria, sedation kappa receptors: analgesia, sedation, decrease gi motility

nsaid contraindications

pregnancy (cat. d) peptic ulcer disease bleeding disorders (hemophilia, vit k deficient) hypersensitivity children with viral infections older adults who smoke, helobacter pylori, hypovolemia, asthma, chronic urticaria, alcholism

A second registered nurse confirms the PHP's order and correct setup of the PCA pump to

prevent medication errors.

Effective strategies for effective pain mgmt include

proactive approach create treatment plan with pharm & non pharm interventions instruct patient to report developing recurrent pain and dont wait until pain is too severe educate the patient

histamine

produced by mast cells causing capillary dilation and increases capillary permeability

substances that increase pain transmission and inflammatory response

prostaglandins histamines substance p bradykinin nsaids, acetimenophin treat this

neurotransmitter (excitatory) prostaglandins

prostaglandins: generated from breakdown of phospholipids in cell membranes -increase sensitivity to pain

Acute pain is

protective, temporary, resolves with tissue healing

use visual analogs to measure and monitor pain and evaluate effectiveness of interventions such as

rate your pain on a scale from 0-10

nsaid expected outcomes

reduce inflammation reduce fever relief from mild to moderate pain absence of injury

desired outcome of opioids

reduce pain and increase activity with few adverse effects

The nonpharmacologic interventions that are usually recommended for pain relief in a patient with neuropathic pain include

relaxation and guided imagery. This allows patients to alter affective-motivational and cognitive pain perception.

serotonin

released from brainstem and dorsal horn to inhibit pain transmission

bradykinin

released from plasma that leaks from surrounding blood vessels at site of tissue injury binds to receptor on peripheral nerves increasing pain stimuli binds to cell that cause chain reaction producing prostaglandins

therapeutic uses for opioids

relief of moderate to severe pain, sedation, reduction of bowel motility, codeine used as cough suppressant

corticoteroids

relieve pain assoicated with inflammation and bone metastisis

opioid complications

respiratory depression, constipation, urinary retention, orthostatic hypotension, cough suppression, abstinence sydrome, sedation, biliary colic, nausea, vomiting, OD: coma, respiratory depression, pinned pupils

substances that decrease pain transmission and produce analgesia

serotonin endorphines

opioid analgesics are used to treat

severe pain

3 types of nociceptive pain are

somatic- bones, joints, muscles, skin, connective tissue visceral- stomach, intestines, can cause referred pain cutaneous- in the skin

nsaid nursing administration

stop 1 wk prior surgery take with milk, water, food dont crush enterics KETEROLAC has MANY INTERACTIONS administer IV ibuprofen as infusion over 30 mins to PREVENT kidney damage

If respiratory rate is <8/min

stop opioid treatment and give antagonist naloxone (narcan) id cause of sedation, if client is difficult to arouse, use sedation scale in addition to pain rating scale

celebrex (celecoxib) -2nd generation nsaid contraindication

sulfonimide allergys (sulfa drugs) dont use heparin, warfarin, coumadin- ibuprofen decreases low dose aspirin therapetic effect

Neurotransmitters

surround pain fibers, spreading the pain message causing an inflammatory response

The nurse checks the computer printout with the PHP's order for patient name, name of medication, dose, frequency of medication, and lockout period to ensure

the medication is administered safely.

NOCICEPTIVE Pain

throbbing, aching, localized responds to opiod & nonopiod

agonists attach:

to receptor and produce a response

Nerve impulses

travel along afferent sensory nerve fibers to the spinal cord

interventions for acute pain

treatment of underlying problem

adjuvant drugs that treat neuropathic pain

tricyclic antidepressants-nortriptyline(Pamelor) anticonvulsants-gabapentin(Neurontin) infusional lidocaine

Pain complications/Nursing Interventions

undertreatment leads to anxiety with acute pain and depression with chronic pain sedation, respiratory depression, coma can be from OD ID high risk patients (older, opiod naive)

Describe pain

unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage

NSAID nursing interventions

use cautiously with older patients, clients with heart failure use smallest effective dose advice patient who take asprin to tell their provider dont give ASPIRIN to children after viral infection (reyes syndrome) aspirin toxicity is an EMERGENCY

adjuvant medications for pain

used with primary pain medications usually opioid agonist to increase pain relief while reducing dosage of opiod agonist tricyclic antidepressant- amitryptaline (Elavil) anticonvulsant- carbamazepine (Tegretol) and gabapentin (Neurotonin) CNS stimulants: methylphenidate (Ritalin) antihistamine: hydroxyzine (Vistaril)

setting of pain: how it affects ADLS

what are you doing when the symptoms occur how does the pain affect your sleep how does it affect your ability to work and do your job

quality or how the pain feels

what does the pain feel like? is it burning, throbbing, dull, aching, sharp, stabbing?