NUR 135 Test #4

Pharmacological Interventions (Pain)

Non Opioid: - Aspirin - Acetaminophen - NSAID's Opioid: - Hydromorphone - Meperidine - Morphine - Fentanyl - Buprenorphine - Nalbuphine

Self awareness

- Examine own beliefs/behaviors - Recognize SA as a chronic illness with relapses and remissions - Strive to be objective and optimistic

Warning signs for Substance Abuse

- Sudden secrecy - Rapid disappearance of belongings - Rejection of old friends - Unable to hold a job/stay in school - Use of drug lingo - Loitering - Deterioration of health/appearance - Keeping odd hours - Spending unusual amount of time in bathroom - Frequent unexplained phone calls - Paraphernalia

Cage Questionnaire (Alcohol Assessment Tool)

C- Have you ever felt you should CUT down on your drinking? A- Have people ANNOYED you by critizing your drinking? G- Have you ever felt bad or GUILTY about your drinking? E- Have you ever had a drink first thing in the morning/to get rid of a hangover (EYE OPENER)? 2 or more affrimatives to these questions = probable diagnosis of Alchoholism/ 2 of 4 = a positive CAGE Drug: ALCOHOL (mg/DAY) MG CONVERSION 1 SHOT LIQUIOR = 1/2 OZ = 1 DRINK 1 GLASS OF WINE = 5 OZ = 1 DRINK 1 BOTTLE OF BEER = 12 OZ = 1 DRINK

Descriptors of Pain

Duration: - Acute - Chronic - Combination Location Intensity Frequency

What are some Primary Prevention activities a nurse can perform related to substance abuse? SATA

Education to prevent substance abuse Identification of risk factors for abuse Refer all to a self help group for stress relief and meditation

Which statement correctly describes a non pharmacological approach to pain control?

Imagery is the use of the pts imagination to help control pain

Pain Classification

Inferred pathology: - NOCICEPTIVE "normal pathway"- from receptor to brain ( Acute Pain mostly, but can be Chronic like w/ Osteoarthritis - NEUROPATHIC " nerve pain"- deep down (Chronic Pain- noncancer) - Mixed pain syndromes ( Cancer related- acute and chronic pain) Examples: - Acute: post op from incision, kidney stones, bone fractures, and childbirth ( its temporary and treatable) - Chronic: persists for more than 3-6 months, it may last a lifetime, interferes with sleep and function, PVD, traumatic injuries

Substance Abuse Definitions **

Intoxication: - use of substance that results in maladaptive behavior Withdrawal syndrome: - negative psychological and physical reactions that occur when use of a substance ceases/dramatically decreases Detoxification: - process of safely withdrawing from a substance, under medical supervision ** Substance Abuse: - using a drug in a way that is inconsistent with medical/social norms and despite negative consequences Substance dependence: - problems associated with addiction (tolerance, withdrawal, and unsuccessful attempts to stop using the substance)

A frail, older adult pt who is being cared for by her family at home says that she finds a heating pad soothing to stiff joints. What pt/family teaching in needed for safe and effective heat therapy? SATA

It is more effective to use the heating pad intermittently rather than continuously Do not apply heat to any areas that lacks normal sensation or circulation

Cannabis

Marijuana, hash, pot, weed, grass (synthetic cannabis- Spice) - Signs of Intoxication: sense of well being (high), relaxation, alterations in time/perception, laughter, incoordination, dry mouth - Signs of overdose: paranoia, panic, confusion , disorientation - Symptoms of withdrawal: insomnia, depression, carving for drug, decreased appetite, hyperactivity - Treatment Options: no drugs for withdrawal, therapy, addiction support group

Mr. A and Mr. B both had back surgery yesterday. Mr. A has used his PCA regularly. He says that he is " pretty comfortable" and he sleeps most of the time. Mr. B has used the maximal analgesic permitted by his PCA and has required an additional analgesic twice while continuing to complain of some discomfort. Of the following, which is the most likely explanation for the difference in the pain experience of these two patients?

Mr. B has a lower pain threshold than Mr. A

Postoperative surgical patients should be given alternating doses of Acetaminophen and which medication throughout the postoperative course, unless contraindicated?

NSAID's

Opioids

Narcotic pain medicine, morphine, Hydromorphone, codeine, heroin - Signs of intoxication: euphoria, relief of physical/emotional pain, constricted pupils, drowsiness, alertness, high energy, constipation, lack of coordination, flushed face, and lightheaded - Signs of overdose: clammy skin, cyanosis, sedation, confusion, unconsciousness, death, over dose causes death from Respiratory Depression, reverse overdose with (naltrexone NARCAN) - Symptoms of withdrawal: AWFUL, very uncomfortable, body aches, cramps, N/V, watery eyes, runny nose, sleep disturbance, yawning, poor appetite, intense drug carving - Treatment options: Buprenorphine, methoadone, Suboxone, Clonidine, Lucemyra (lofexidine hydroclride)

CIWA ( Alcohol Withdrawal Assess Tool)

Nausea and Vomiting Tremor Paroxysmal Sweats Anxiety Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache, fullness in head Orientation and clouding of Sensorium They answer each question and you tally score at the end Max score possible is a 67

A 65 year old woman has fallen while sweeping her driveway, sustaining a tissue injury. She describes her condition as an aching, throbbing back. Which type of pain are these complaints most indicative of?

Nociceptive pain

When your cut your finger, which if the following represents the steps involved in your experiencing pain?

Nociceptors are stimulated, and afferent pathways send impulses to the spinal cord and then to the brain

Nursing measures when a pt has generalized seizure include which of the following? SATA

Turn pt to one side to maintain the airway Move objects away from pt to prevent injury Note the time the seizure began

A Post op craniotomy pt has an external ventricular drainage system. Proper management of the system includes, which of the following instruction?

Use strict aseptic technique to cleanse the insertion site Keep the zero point of the drip chamber at the level off the external auditory canal

Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way too evaluate the effectiveness of treatments. Pain should be reassessed at which minimum interval?

With report of new pain Before and after administration of narcotic analgesics

A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, " can I become addicted to this medication?" What is the nurses best response? SATA

You may develop a tolerance for the medication and need for more of it in order for it to be therapeutic Before stopping the medication, you may need to taper it so you do not suffer from withdrawal

The first step in treatment for substance abuse requires that the person recognize

the need for help

Fibromyalgia Risk Factors

- Age (diagnosed during middle age, more likely to get as you age) - Autoimmune Diagnosis ( Lupus/Rheumatoid Arthritis (RA) - Sex (women more than men) - Stressful/traumatic event (PTSD) - Repetitive injuries- stress on joints - Illness ( viral infections) - Family HX - Obesity

Long Term effects of Alcohol use

- (Brain and CNS) greatest affect - Liver - GI system _ Cardiovascular system - Musculoskeletal system - Endocrine/Reductive system- elevates blood sugar - Hematologic system- clotting, thins blood Tattoos sometimes cant get b/c of bleeding risk from drinking **

Alcohol Overdose

- Can result in vomiting, unconsciousness, and respiratory depression - Symptoms of withdrawal usually begin (4 to 12 hours) after cessation/marked reduction of alcohol intake - Alcohol withdrawal usually peaks on the (second day and is over in about 5 days)*** CNS depressant think airway **

Trigeminal Neuralgia

- Cause undetermined, various contributing factors ( trauma, infection, compression of nerve (Aneurysm, artery, or tumor)) - Diagnosis based on history, no specific tests exists - Treatment: ( Pharmacological management is preferred): > Phenytoin ( Dilantin) > Carbamazepine ( Tegretol) > Alcohol/Phenol injected in affected branch for pain relief (8-16 months) > Electrocoagulation- surgery performed for severe, debilitating pain

Fibromyalgia

- Cause unknown - DX- Patient History, Physical exam, xrays, and blood work - Treatment: managed with meds

Trigeminal Neuralgia (Pain)

- Characterized by intense pain in the face, along trigeminal nerve ( Cranial Nerve 5, ophthalmic (eye), mandibular (down jaw), and maxillary (to nose) - Abrupt onset - Usually unilateral - Lasts from seconds to a few mins - No motor or sensory deficits exists - Triggers (drinking hot/cold liquids, chewing, shaving or washing face) - Between episodes - dull ache or pain free ** pain may be crippling, restricting patients daily routine

Fibromyalgia Pain

- Characterized by widespread muscle pain and tenderness - Chronic in nature - S/S: all over pain/stiffness, fatigue/tiredness, depression/anxiety, sleep problems,problems with thinking/memory/concentration, tingling/numbness in hands/feet, pain in face/jaw, TMJ, digestive problems (abd. Pain/bloating/constipation and IBS)

Types of Substances Abused

- Classes of substances abused: > alcohol > amphetamines/sympathomimetics > caffeine > cocaine > hallucinogens > inhalants > nicotine > opioids > Phencyclinidine (PCP) > sedative/hypnotics/anxiolytics

Dual Diagnosis

- Client with both substance abuse and another psychiatric illness - Successful Treatment and relapse prevention strategies include: > healthy, nurturing, supportive living environment > assisting with fundamental life changes, (finding a job and abstinent friends) > connections with other recovering people > treatment of their co-morbid conditions

Alcohol withdrawal syndrome

- Course hand tremors - Sweating - Elevated. HR and BP - Insomnia - Anxiety - Nausea/Vomiting - Elevated temp - Delirium Tremors (DT's)- hallucinations, Delirium, and seizures ** Symptoms begin 4-12 hours after last drink or marked reduction in intake ** DT's require ICU care as it is a medical emergency! High fatality rate (20%) even with treatment

Factors Affecting Pain

- Culture, ethnicity, and gender - Religious beliefs - Past experiences and anxiety - Situational Factors Be aware of the different ways of expressing pain and respect Use of prayer Punishment for sins Views of suffering Development of positive coping strategies to deal Chronic illness (Cancer) vs Pain associated with less serious condition or pain like childbirth is short lived and results in beautiful outcomes

Relapse Prevention involves

- Disulfiram ( Antabuse)> aversion therapy - Acamprosate ( Camparil) > lessens the sleepiness and anxiety associated with Alcohol withdrawal - Methadone> replacement therapy for Heroine addicts - Naltrexone ( ReVia)> indicated in alcohol/opiate addiction, reduces high and the carving , also an opiate antagonist, completely blocks the effects of an opioid - Clonidine (Catapres)> antihypertensive, unlabeled use ( management of opioid withdrawal) - Ondansetron ( Zofran)> antiemetic (methamphetamine Addiction) - Buprenorphine ( Subutex/Suboxone)> blocks effects of opioids, suppresses withdrawals symptoms in opioid detox - Propanolol ( Inderal)>beta blocker, unlabeled use alcohol withdrawal, reduces anxiety and lessens withdrawal symptoms - Topramate (Topamax)> anticonvulsant, off label use in alcohol withdrawal

Alcohol

- ETOH = chemical compound (ethyl alcohol) - Anesthetic and CNS depressant *** (what it means) - Absorbed from stomach and small intestines - Liver metabolizes alcohol at a rate of one drink per hour (12 oz beer, 5 Oz wine, 1 oz distilled spirits)

Nursing management of Alcohol Withdrawal

- Follow standards of care protocol- CIWA scale** (know 10 areas for observation) - Administer benzodiazepines as ordered - Encourage PO fluids - Administer vitamin replacements ( vitamin B1, B12, and folic acid) - Administer Magnesium Sulfate - Educate on Treatment options - Privide education/support to families- maintain normal home environment and offer support, discourage family from enabling/making excuses/exclude them when drinking is around ** watch the emergency post op patient ( bowel obstruction, appendectomy) for acute withdrawal

Acute Intoxication/Toxicity treatment ( Alcohol Overdose)

- ICU (medical emergency) - Gastric lavage or dialysis - Respiratory support (CNS depressant) - Cardiovascular support ** Monitoring vital signs (temp regulation-increased) IV fluids for possible Dehydration, electrolytes,vitamins, minerals Prevention of aspiration pneumonia Prevention of cardiovascular shock ( from alcohol induced hypotension)

Nursing management of DT's

- ICU care - Follow medical protocol for safe pt care (vital signs Q1 to 2 hours 4 at most) restraints possible for safety - Restrict visitors - Decrease stimulation - Use lights in room to prevent illusions - Restrain as necessary to prevent injury - No whispering - Convey calm, caring attitude (keep comfortable)

Cultural Considerations ( Addiction)

- Muslims DO NOT drink alcohol - Wine is an integral part of Jewish religious rites - Some Native American tribes use Peyote ( hallucinogen), religious ceremonies - Japanese do not regard Alcohol as a drug, there are no religious prohibitions against drinking - Variations have been found in enzymatic activities among Asians, African Americans, whites - Alcohol abuse plays a part in the 5 leading causes of death for Native Americans - in Russia, high rates of alcohol abuse, suicide, cigarette smoking, accidents, violence, and cardiovascular disease are found in the male population

Opioid Analgesics Misconceptions

- Patients, families, nurses, and physicians have misconceptions about Addiction. The term must be defined and differentiated from the terms tolerance and physical dependence - Tolerance and physical dependence are normal responses to continued opioid administration for pain relief, they DONT lead to a craving for the drug for its mind altering effects - Fear of Addiction greatly exaggerated, rare (<1%) in patients taking opioid for pain relief *** Risk of Addiction is not a concern in treating acute pain or cancer pain ** Be preventative, Not reactive The pt who is tolerant requires higher doses of a drug to achieve an analgesic effect The pt who is physically dependent on an Opioid will experience unpleasant withdrawal symptoms when the opioid is stopped.

Interventions for Pain

- Physical comfort measures - Educational instructions - Comfort measures - Environment - Analgesic administration - Stimulation techniques - Psychologic techniques

Six major categories of Substance Abuse

- Sedatives, hypnotics, anxiolytics - Narcotics - Stimulants - Hallucinogens - Cannabis - Inhalants

Substance Abuse

- The actual prevalence of substance abuse is DIFFICULT to determine - Detrimental effects of substance abuse include: workplace injuries, motor vehicle accidents/fatalities, domestic abuse, homicide, and child abuse/neglect 14% adults have alcohol related disorder 6.2% have substance related disorder (excluding nicotine) Adolescent substance abuse is rising Increasing number of babies born addicted to substance abuse mothers Children of alcoholics are 4 times more likely that the general population to develop problems with alcohol

Substance Abuse Treatment

- Treatment is based on the concept that Alcoholism and Drug Addiction are Medical illnesses: chronic, progressive, characterized by remission and relapses - Treatment models for the addict include: > The Hazelden Clinic Model > 12 step program for Alcoholics Anonymous (AA) > Individual and group counseling

Signs on Pain

- increase in BP, HR, and RR - dilated pupils - perspiration - pallor - facial expressions - restlessness - change in activity - crying - assessment tool Assessment Tools: Numeric, Wong-Baker FACES, FLACC

Pain

- is WHATEVER the patient is experiencing says it is, existing whenever he says it does ** the pt report is the MOST reliable indicator of pain

Assessment (PAIN)

- should be done on admission and on a regular basis - pain is called the 5th vital sign ** Assessment is the first step in Pain Management - Visual, speech, hearing, and motor impairments may limit the ability of older patients to communicate pain or to use the scales to rate pain - When a pt cannot report pain, the nurse may need to perform a different assessment, which includes observing for usual or unusual behaviors that may indicate pain

Every chemical ingested by a pregnant woman poses a potential danger to her unborn child. This is especially true during the

1 trimester of pregnancy

Pharmacological Treatment

2 main purposes - To permit share withdrawal from Alcohol, sedatives.hypnotics, and benzodiazepines - Prevent relapse

the client drinks at least 12 colas every day. Today, he is unable to obtain his cola and is becoming more irritated and physically uncomfortable with each hour. The client is experiencing signs of: 1.relapse 2.addiction 3.crankiness 4.intoxication

2. Addiction

Roxie had been sober for 6 months. Last week, her best friend came to visit, and they celebrated with five gin and tonic. Roxie has experienced: 1.repose 2.relapse 3.withdrawal 4.detoxification

2. Relapse

Assessment Continued (Pain)

6 steps: - accept pts report - determine the status of the pain - describe the pain (location/quality/intensity/ aggravating/alleviating factors) - examine the site of pain - identify coping methods - document assessment findings and evaluate interventions (follow up after/reassess always) Obtain specific details about pain and respond positively that action will be taken to relieve the pain Ask pt if he/she had has pain before and whether it was diagnosed by a physician Assess the area for (heat/redness/swelling/tenderness/abnormal position/ or other factors that may be causing local irritation ) Record location, quality, and intensity of pain, related factors, and how the patient copes with pain

A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? SATA

A motivational interview Observing for stress reaction Encouraging involvement in Narcotics Anonymous

A patient says that she has pain whenever she bends over. Which aspect of the pain assessment is she describing?

Aggravating factor

Factors that may trigger migraine headaches include which of the following? SATA

Alcohol Menstruation Certain foods

The medication nurse has several pts who take NSAID's in addition to the drugs listed subsequently. The nurse should question the NSAID order for a pt who is also taking.

Anticoagulants

Trigeminal Neuralgia Nursing Care

Assessment: - Description of pain - Factors that trigger - Treatments used, what worked, what didnt Interventions: - Pain assessment and management is the focus - Help pt develop alternative strategies for pain relief - Encourage and assist pt in performing ADL's - Nutrition if chewing is a trigger - Prevent social isolation - Pt teaching- avoidance of triggers ** Fibro-Aerobic exercise and muscle strengthening, stress management, good sleep habit to improve quality of sleep, Cognitive Behavioral Therapy (CBT)

Key interventions for clients with substance-related problems include:

Assisting the client's family by encouraging them to become involved in the treatment process and in group counseling

Which one of the following is a nursing measure used to decrease ICP?

Avoid flexing the neck and hips

Stephanie is a 70-year-old retired schoolteacher who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Which of the following options should you suggest for her plan of care, considering her expressed wishes? A. Using a stationary exercise bicycle and free weights and attending a spinning class. B. Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy. C. Drinking chamomile tea and applying icy/hot gel. D. Receiving acupuncture and attending church services. (Giddens: Concepts for Nursing Practice, Concept 26)

B. Mind body therapies

Stimulants

Bath salts, caffeine, diet pills, meds fo ADHD, crystal meth, cocaine, crack - intoxication: energy!!, high sex drive, high sense of well being, low appetite, high HR/RR, dilated pupils - Overdose: panic, paranoia, confusion, dilated pupils, chest pain, cardiac arrhythmias, seizures, coma - withdrawal: crashing, depression, suicide potential, intense drug carving, low energy, hypersomnia, irritability, vivid nightmares/dreams - Treatment options:withdrawal is not life threatening, antidepressants

Autonomic nervous system responses to pain include which of the following? SATA

Constipation Increased heart rate

Alcohol/ETOH

Beer/liquor/wine - Signs of intoxication: CNS depressant, relaxation, decreased inhibitions, impaired judgement, slurred speech, ataxia, poor attention span, mood changes,poor memory and blackouts - Signs of overdose: stupor, unresponsive, LOw HR/BP/RR, comatose, death from respiratory depression, need ICU care -Symptoms of withdrawal: VERY DANGEROUS!! Tremors, diaphoresis, high HR/BP, anxiety, insomnia, N/V, high temp - Treatment options: detox( use decreasing doses of benzodiazepines), AA, Antabuse

Etiology ( Addiction)

Biologic Factors: - genetic vulnerability - children with addicted parents - neurochemical influences Psychological Factors: - familial dynamics - dysfunction, communication is key , take responsibility for behavior - coping styles - maladaptive Social/environmental factors - who they hang with

Onset and Clinical Course

Blackout: - drinking and person continues to function but has no conscious awareness of his/her behavior at time nor any alter memory of behavior - As the person continues to DRINK, he/she often develops a TOLERANCE for alcohol, he/she needs more alcohol to produce the same effect - After continued heavy drinking, person experiences a TOLERANCE BREAK, means that very small amounts of alcohol will intoxicate the person - During later course of alcoholism, when the person functioning definitely is affected, periods of abstinence or temporarily controlled drinking occurs

Which of the following is a priority for a nurse to include in a teaching plan for a patient who desires self management and alternative strategies?

Body alignment and superficial heating/cooling

What Alcohol can do to your body!

Brain: depresses nerve cells impairing brain function Lungs: lowers resistance to infection/ can cause breathing to stop Heart:impairs heart muscle to pump blood, abnormal heart function and irregular heart beat Liver: alcoholic hepatitis, cirrhosis Stomach: irritates stomach, peptic ulcers, bleeding lesions, cancer Intestines/Pancreas: inflammation in colon, ulcers/cancers in intestines/colon, pancreases inflamed leak digestive enzymes Bones/muscles: interferes ability to absorb calcium, muscles become weaker and uncoordinated

When preparing to give a non opioid analgesic the nurse notes that the pt also takes drugs for HTN. The nurse knows that non opioid analgesics must be used cautiously in pts with HTN because the drugs cause

Fluid retention

Hallucinogens

PCP, LSD, mushrooms, designer/club drugs - Signs of Intoxication and overdose: alterations in realty (tripping), warped sense of time, seeing vivid colors, seeing visions, feeling separated from one's body/environment, hypersensitivity, enhanced awareness, unpredictable behavior, dilated pupils, dizziness, nausea, high heart rate, weakness seizures, deaths, some have flashbacks - Symptoms of withdrawal: stiff muscles, tremors, high HR/BP/RR, alterations in body temp, seizures - Treatment Options: no drugs for withdrawal, therapy addiction support group

Pain is Best defined by the:

Patient

Elements of Pain Assessment

Patient self report of pain: - location - intensity - quality - onset and duration - alleviating or relieving factors - effect of pain on quality of life and functional status - comfort and function goal

A nurse is interviewing a patient and assessing the patients readiness to change. Which statements by the patient in the motivational interview reflect this willingness? SATA

Patient states " i. Will watch the game at my friends house instead of at the bar" Pt states " i now realize that the drinking has affected by family life" Pt states "i have been attending one meeting a day"

The nurse is assessing a patient using the CAGE questionnaire. The nurse suspects possible alcoholism when the patient makes which of the following statements ? SATA

Pt states " My wife keeps nagging me about my drinking" Pt states " i am going to try to cut down on drinking. I have been partying too much" Pt states " i usually have a Bloody Mary/Mimosa for breakfast" Pt states " i am ashamed of how much i have been drinking lately"

Sedatives/Hypnotics/Anxiolytics

Quaalude, Xanax, Valium, Sleeping pills, phenobarbital - Signs of Intoxication: same as for alcohol - Signs of overdose: same as alcohol - Symptoms of withdrawal: VERY DANGEROUS! Similar to alcohol - Treatment options: detox decreasing doses of benzodiazepines, narcotics anonymous

When pts take opioid analgesics, the nurses first priority is to monitor which of the following?

Respiratory system

Opioid Analgesics

Routes of administration: - Oral - IM (intramuscular) - Sublingual - IV, intermittent bolus injections, continuous infusions, or PCA Epidural or intrathecal route A limited number of Opioids (morphine, Hydromorphone, oxymorphone may be administered rectally) PCA- regularly a patient will push a button to get the scheduled medicine through their IV, now because on shortage it's regulated by a Pump and they do not push a button)

Inhalants

Solvents, gasoline, paint/thinner, hairspray, glue - Intoxication: dizziness, giddiness, ataxia, nystagmus, tremor, muscle weakness - Overdose: medical emergency, respiratory depression, coma, death - Withdrawal: crashing, depression, carvings, irritability, sleep disturbance - Treatment Options: no drug for withdrawal, therapy, addiction support group