Chapter 43 Pain Management

Pain Experience

involves physical emotional and cognitive components

palliative care

provided with the goal is to live life fully with an incurable condition

to adequately assess quality of a patients pain which question would be appropriate

"tell me what your pain feels like"

Nonpharmacologic intervention that lessen pain: Cutaneous stimulation

(including massage, warm bath, ice bag, and TENS) reduces pain perception by the release of endorphins, which block the transmission of painful stimuli

ABCDE clinical approach to pain assessment and management

1. Ask about the pain regularly. Assess pain systematically 2. Believe the patient and family in their report of pain and what relieves it 3. choose pain-control options appropriate for the patient, family, and setting 4. deliver interventions in a timely, logical, and coordinated fashion 5. empower patients and their families. enable them to control their course to the greatest extent possible

patient outcomes appropriate for the patient experiencing pain

1. Patient reports that pain is a 3 or less on a scale of 0-10 does not interfere with ADLs or personal pain intensity goal attained 2. patient identifies factors that intensify pain and modifies behavior accordingly 3. patient uses pain-relief measures safely

Physiological factors that influence pain

1. age 2. fatigue 3. genes 4. neurological function

psychological factors that influence pain

1. anxiety 2.coping styles

cultural factors that can influence pain

1. meaning of the pain 2. ethnicity

Three analgesics used for pain

1. nonopioids 2. opioids 3. adjuvants or coanalgesics

common characteristics of pain that the nurse would assess

1. onset and duration 2. location 3. intensity 4. qaulity 5. pain pattern 6. relief measures 7. contributing symptoms 8. effects of pain on the patient 9. behavioral effects 10. influence on activities of daily living

Goals for care of a patient with epidural infusions describe one action for each goal

1. prevent catheter displacement: secure the catheter (if not connected to an implanted reservoir) carefully to outside skin 2. Maintain catheter function: check the external dressing around catheter site for dampness or discharge (leak of cerebrospinal fluid may develop) 3. prevent infection 4. monitor for respiratory depression 5. maintain urinary and bowel function

social factors that influence pain

1.attention 2. previous experience 3. family and social sport 4. spiritual factors

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when A. You compare assessed pain w/baseline pain. B. Body language is incongruent with reports of pain relief. C. Family members report that pain has subsided. D. Vital signs have returned to baseline.

A

potential or actual nursing diagnosis related to patient in pain

Activity intolerance Anxiety Hopelessness Powerlessness Chronic low self-esteem Insomnia Fear Impaired social interaction Impaired physical mobility Fatigue Spiritual distress Imbalanced nutrition: less than body requirements Ineffective coping

When using ice massage for pain relief, which of the following are correct? (Select all that apply.)

Apply ice using firm pressure over skin. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes.

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient' s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action:

Assess patient's vital signs every 15 minutes for 2 hours Reassess patients who receive naloxone every 15 minutes for 2 hours following drug administration because the duration of the opioid may be longer than the duration of the naloxone and respiratory depression may return.

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to:

Assess the characteristics of the pain. It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number.

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.

B

A health care provider writes the following order for an opioidnaive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action:

Calls the health care provider, and questions the order Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.

A patient has just undergone an appendectomy. When discussing with the patient several pain relief interventions, the most appropriate recommendation would be A. Adjunctive therapy. B. Nonopioids. C. NSAIDs. D. PCA pain management.

D

Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?

Difficulty arousing the patient Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine?

Only the patient should push the button.

what is patient controlled analgesia (PCA) what is the goal of PCA

PCA allows patients to self administer opioids with minimal risk of overdose; the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing

breakthrough pain: end of dose pain

Pain that occurs toward the end of the usual dosing interval of regularly scheduled analgesic

Barries to effective pain management

Patient fear health care provider health care system

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:

Physical dependence.

teaching a child about painful procedures is best achieved by

Relevant play directed toward procedure activities

A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads as follows: "Vicodin 1 tab, per tube, q4 hours, prn." Which action by the nurse is most appropriate?

Request to have the ordered changed to ATC for the first 48 hours. The American Pain Society (2003) states that, if you anticipate pain for most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication?

Stimulant laxative Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation.

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include?

TENS electrodes are applied near or directly on the site of pain. TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain.

The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most?

The amount of daily acetaminophen The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successful pain control.

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain?

The patient's report of pain is the best method for assessing the pain.

A postoperative patient is currently asleep. Therefore the nurse knows that:

The sedative administered may have helped him sleep, but assessment of pain is still needed. Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness and impaired coordination, judgment, and mental alertness and contribute to respiratory depression. It is important to avoid attributing these adverse effects solely to the opioid. You need to conduct a thorough reassessment.

A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question?

The time interval Controlled- or extended-release opioid formulations such as OxyContin are available for administration every 8 to 12 hours ATC. Health care providers should not order these long-acting formulations prn.

While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends:

Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids. The WHO analgesic ladder transitions from the use of nonopioids (NSAIDS) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recommended for lesser levels of pain. Side effects related to the use of opioids may be unavoidable but are treatable. Treatment for severe pain may result in some level of sedation.

addiction

a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its developmental and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

drug tolerance

a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effects over time

Physical dependence

a state of adaptation that manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, or administration of an antagonist

Neuropathic pain

abnormal processing of sensory input by the peripheral or CNS; treatment usually includes adjuvant analgesics

Define adjuvants or coanalgesics

are a variety of medications that enhance analgesics or have analgesics properties that were originally unknown

Nonpharmacologic intervention that lessen pain: Herbals

are not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements

opioids (narcotics)

are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opioids that always precedes respiratory depression.

Visceral Pain

arises from visceral organs such as the GI tract and pancreas

sympatheically maintained pain

associated with dysregulation of the autonomic nervous system. ex: pain associated with reflex sympathetic dystrophy or causalgia (complex regional pain syndrome, type one and type two)

Bradykinin

binds to receptos on peripheral nerves increasing pain stimuli

Neuromodulators

bodys natural supply of morphinelike substances

Substance P

causes vasodilation and edema

Somatic Pain

comes from bone joint muscle skin or connective tissue. it is usually aching or throbbing in quality and is well localized

Nonpharmacologic intervention that lessen pain: Distraction

directs a patients attention to something other than pain and thus reduces the awareness of pain

Nonpharmacologic intervention that lessen pain: Music

diverts the person attention away from the pain and creates a relaxation response

A substance that can cause analgesia when it attaches to opiate receptors in the brain is

endorphin

some principles to evaluate related to pain management

evaluate the patient for the effectiveness of the pain management after an appropriate period of time; entertain new approaches if no relief; evaluate the patients perception of pain

Nonpharmacologic intervention that lessen pain: Relaxation

in mental and physical freedom from tension or stress that provides individuals with a sense of self control

nonopioids (acetaminophen and nonsteroidal antiinflammatory drus NSAIDS)

include acetaminophen and nonsteroidal anti-inflammatories (NSAIDs). Acetaminophen has no anti-inflammatory or antiplatelet effects. NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli. Long-term use is associated with GI bleeding and renal insufficiency.

Prostaglandins

increase sensitivity to pain

Modulation

inhibition of the pain impulse of the nociceptive process

Serotonin

inhibits pain transmission

deafferentation pain

injury to either the peripheral or CNS. Ex: phantom pain reflects injury to the peripheral nervous system; burning pain below the level of the spinal cord lesions reflects injury to CNS

Transdermal fentanyl

is 100 times more potent than morphine in predetermined doses that provide analgesic for 48-72 hours; useful when unable to take oral medications

define placebo

is a medication or procedure that produces positive or negative effects in patients that are not related to the placebos specific physical or chemical properties.

Local anesthesia

is intended for local infiltration of an anesthetic medication to induce loss of sensation to a body part

Acute Pain

is protective, has a cause, is of short duration and has limited tissue damage and emotional response

hospice

is provided at the end of life; it emphasizes quality of life over quantity.

regional anesthesia

is the injection of a local anesthetic to block a group of sensory nerve fibers

transmucosal fentanyl

is used to treat breakthrough pain in opioid-tolerant patients; the unit is place in the mouth and dissolved not chewed

Chronic Pain

last longer than anticipated, does not always have a cause, and leads to great personal suffering

Pain Tolerance

level of pain a person is willing to put up with

Complications of opioid epidural analgesia are

nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus.

breakthrough pain: spontaneous pain

pain that is unpredictable and not associated with any activity or event

Nociceptive Pain

normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids or opioids

Nonpharmacologic intervention that lessen pain: Reducing pain perception

one simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback.

Idiopathic Pain

pain is chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for for the extent of an organic pathological condition.

Chronic Episodic Pain

pain the occurs sporadically over an extended duration of time.

breakthrough pain: incident pain

paint that is predictable and elicited by specific behaviors such as physical therapy or wound dressing changes

polyneuropathies

patient feels pain along the distribution of many peripheral nerves. ex: diabetic neuropathy, alcohol nutritional neuropathy, guillain barre syndrome

epidural analgesia

permits control or reduction of severe pain and reduces the patients overall opioid requirement; can be short or long term.

Nociceptor

sensory peripheral pain nerve fiber

Pain is protective mechanism warning of tissue injury and is largely an

subjective experince

Pain threshold

the point at which a person feels pain

Perception

the point at which a person is aware of pain

explain the purpose of perineural local anesthetic infusion

the purpose is to manage pain from a variety of surgical procedures with a pump that is set as a demand or continuous mode and left in place for 48 hours

the use of patient distraction in pain control is based on the principle that

the reticular formation can send inhibitory signals to gating mechanisms

Pain clinics

treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain-relief measures.

mononeuropathies

usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. ex: nerve roo compression, nerve entrapment, trigeminal neuralgia