NURS 205 > Pain > Flashcards

Pain Flashcards

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1
Q

What is pain?

A

It’s subjective; it’s whatever the person experiencing it says it is occurring whenever he/she says it does.

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

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2
Q

What is the purpose of pain?

A

Warns us of imminent / actual tissue damage.

Elicits coordinated reflex and behavioural respes to keep injury to a minimumons.

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3
Q

As a nurse, what’s your role in pain assessment and management? (4)

A

Assess pain & document

Ensure delivery of effective pain relief measures

Evaluate the effectiveness of these interventions

Monitory the ongoing effectiveness

of pain management strategies.

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4
Q

How do we feel pain?

A

Nociception

  • A number of neurotransmitters are released into the body; Na&K channels open & close. Peripheral nerves fire & send to spinal cord
  • Peripheral nerve message goes to spinal cord then to brain. Pain is processed before it goes down the spinal cord to the motor nerves at the area w/ pain
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5
Q

What are the classifications of pain?

A

Acute pain: physiological response; sudden onset, avoids potential/actual tissue damage; tissue injury; few secs to many weeks; predictable outcome (ex: sprained ankle -> nociceptive)

Chronic pain: persistent pain that lasts long; no biological advantage (ex: amputation, arthritis, diabetes, shingles)

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6
Q

What is the prevalence of acute pain? Chronic pain?

A

Acute pain
- After surgery (moderate to severe pain weeks later); ER (78% have pain 8/10); primary care visit: family doctor (pain after surgery, new back pain, pain in throat, sprain/strain)

Chronic pain

  • W/o any known injury/disease (fibromyalgia)
  • 60% say it interferes w/ their daily life
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7
Q

What is the difference b/w allodynia and hyperalgesia?

A

Allodynia: pain due to a stimulus that does not normally provoke pain.

Hyperalgesia: increased pain from a stimulus that normally provokes pain.

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8
Q

What is nociceptive pain? What are the characteristics?

A

Caused by direct stimulation of peripheral nociceptors

Usually associated with tissue damage as well as inflammatory processes

Characteristics:

  • Well-localized
  • More diffuse if deeper structures or if viscera involved
  • Aching, sharp, dull
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9
Q

What is neuropathic pain? What is its prevalence? What are the characteristics?

A

Pain that is initiated or caused by a primary lesion or dysfunction in the nervous system

Sustained by abnormal processing of sensory input by the peripheral or central nervous system.

Characteristics:

  • Burning
  • Shooting
  • Numb/tingling
  • Electric shocks
  • Allodynia
  • Hyperalgesia
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10
Q

What is the prevalence or neuropathic pain?

A

Affects 2 to 3% of the population of the developed world

Affects 1 million Canadians

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11
Q

How often should you assess pain? (5)

A
  • During the initial assessment
  • At least once per shift for inpatients
  • At least once every visit for outpatients and homecare
  • Before, during and after procedures
  • Following treatment of pain
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12
Q

What information should you gather during a comprehensive pain assessment? (11)

A
  • Pain history & current pain experience
  • Physical exam
  • Medication use – past & present (addiction screening)
  • Functional status
  • Psychosocial impact
  • Meaning of pain to pt & family
  • Expectations for pain relief
  • Assess ADLs (walk through a day in the patient’s life; pain diary
  • Assess sleep
  • Identify goals (present & future)
  • Ask about how the pain interferes with lifestyle & limits daily living (Physical limitations? )Work?
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13
Q

What is OPQRSTUV?

A
  • Onset
  • Provocative/Palliative
  • Quality
  • Region/Radiating
  • Severity
  • Timing
  • Understanding (what do they think is causing the pain?)
  • Value (eg: religious/spiritual beliefs; personal/family experiences or beliefs)
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14
Q

What is the link b/w cultrual bias and pain?

A

As a HCP, don’t make stereotypical judgements based on a person’s ethnic heritage, however, do conduct a cultural assessment of the patient

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15
Q

What is the difference b/w how different cultures feel pain?

A

Ex: Chinese people may believe reporting pain is a sign of weakness so they only report it when it’s really bad. They may also be reluctant to discuss pain and believe it’s inappropriate to bother ppl w/ their problems. They may also be unwilling to take pain meds. This is not to say every Chinese person has these values, but it is something to watch out for.

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16
Q

When assessing for pain, what should you be looking for in your physical exam?

A

Review of the systems / vital signs

Physical appearance

Musculoskeletal exam and neurological exam

  • Gait
  • Examine the painful body locations
  • Consequences (stiffness and atrophy
  • Signs of neuropathic pain (hyperalgesia, allodynia, parasthesia, skin changes)
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17
Q

What tests should you run? (5)

A
  • Blood tests
  • X Rays
  • CT/MRI
  • Bone scan
  • EMG
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18
Q

When do we need to intervene?

A

Pain Score of 4/10 or greater

Patient unable to do ADL’s due to pain

Patient unable to mobilize/deep breath and cough due to pain

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19
Q

What is the pharmacological approach to treat pain?

A

Non-Opioids:

  • Acetaminophen
  • Non-Steroidal Anti-inflammatory Drugs (NSAIDS)

Opioids

  • Morphine
  • Hydromorphone (dilaudid)
  • Meperidine (demerol)
  • Codeine
  • Oxycodone (found in percocet/percodan)
  • Fentanyl
  • Tramadol
  • Methadone
  • Bupinorphine

Adjuvant drugs:

  • Anticonvulsants
  • Antidepressants
  • Anxiolytics
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20
Q

How do opioid agonists work? What is the indication? What is the ceiling? What is the peak/duration?

A

Action:
- Bind to receptors (in the central nervous system, on nerve terminals in periphery and on cells of the gastrointestinal tract) and activate cellular changes to decrease the amount of pain transmissions to the brain

Indication:
- Useful in both nociceptive and neuropathic pain

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21
Q

What is the ceiling of opioid agonists? What is the peak/duration?

A

Ceiling:
- Dosage titration is limited by side effects
Watchful dose 90mg/day morphine equivalents

Peak/Duration:

  • Oral (recommended route)
  • IV
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22
Q

What is the pharmacokinetics of opioids?

A

Absorbed in the upper small bowel

Significant first pass effect

Liver metabolism

  • Certain opioids have active metabolites (ex: Morphine-6-glucuronide, morphine 3-glucuronide, normeperidine)
  • Usually maintained even in situations of severe liver disease

Renal excretion
- Renal dysfunction may affect metabolite clearance leading to increased toxic and analgesic effects

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23
Q

What are the side effects of opioids? (9)

A
  • Nausea and Vomiting
  • Sedation
  • Constipation
  • Pruritus
  • Mental Clouding
  • Hallucinations
  • Urinary Retention
  • Respiratory Depression
  • Myoclonus
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24
Q

What is respiratory depression?

A

Less than 10 breaths/min

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25
What kind of medication can cause resp depression?
It rarely occurs in patients who have been receiving stable doses of opioids over a period of months
26
What is the main sign/symptom of resp depression?
Decreased level of consciousness
27
How is resp depression treated?
Reverse respiratory depression with Naloxone (an opioid antagonist)
28
What are the pharmacogenetics of pain for pts taking codeine?
Codeine requires conversion to active metabolites (morphine, C-3-G, C-6-G) to have any analgesic effect 3-10% of the Caucasian population are poor metabolizers at the Cytochrome P-450 2D6 enzyme Poor metabolizers will have no analgesic effects but all of the side effects when taking codeine for pain Some people are super metabolizers and metabolize codeine into morphine too quickly
29
Where is codeine metabolized?
Codeine is metabolized into its active form - morphine - by the liver
30
What is Meperidine (Demerol)?
Synthetic opioid analgesic Active metabolite - normeperidine
31
What occurs after repeated administration of Demerol?
Repeated administration can lead to CNS stimulation
32
What pts are not recommended to use Demerol?
- Pts w/ renal failure - Long term or chronic pain (greater than 48 hours) - Elderly
33
What is methadone? What is it used for?
It's a blocking agent A long-acting  and Δ opioid agonist with NMDA blocking properties - A good option in neuropathic pain - Opioid of choice in pregnancy
34
True or false: NMDA requires more careful initial titration.
True
35
Are there many drug interactions w/ CYP450 3A4?
Yes
36
What is Equianalgesia?
It's the dose of one analgesic drug that's equivalent in pain relieving potential to another analgesic drug The standard equianalgesic conversion is based on the pain relieving potential of 10 mg of parenteral morphine.
37
How do you convert from the oral route to another route? Give examples.
To convert from the oral route to another route, or from one opioid to another, find the equianalgesic dose of the present opioid and the opioid you wish to convert in using an equianalgesic table Ex: 15 mg (oral morphine) = 7.5 IV morphine Ex: 1mg IV hydromorphone would be equivalent to 10 po morphine
38
Show an example of how to convert one drug type to another.
Ex: 1mg IV hydromorphone would be equivalent to how many PO morphine 4mg IV hydromorphone / 2 = 2mg IV Thus, 1mg IV = 2mg PO 1mg IV hydromorphone = 5mg IV morphine (20 / 4 =5) 5mg IV morphine = 10mg PO morphine (20 / 2 = 10)
39
What are special considerations for older adults in terms of prescribing meds?
Alterations in cardiac output and renal and hepatic clearance occur as we get older - These alterations may change the drug plasma concentration and duration of action of medications The older adult is more vulnerable to the physiologic consequences of inadequate analgesia and the adverse effects of analgesics
40
True or false: Both pain and addiction can co-exist in the same patient
True
41
How can you prevent concurrent pain and addiction? (3)
- Complete a thorough assessment (physical, psychological, diagnostic testing) - More controlled prescribing - More controlled monitoring
42
What is physical dependence?
It's a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence does not equal addiction
43
What are the symptoms of withdrawal? (9)
- Muscle pain - Sweating - Diarrhea - Vomiting - Abdominal cramps - Chills - Anxiety - Insomnia - Tremor
44
How long do withdrawals last?
Can last for 3-10 days with immediate release opioids 10-20 days with control release/slow release opioids
45
What is addiction?
It's a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.
46
What are the 4C's of addiction
Control (loss of) Compulsive use Consequences (use despite harm) Craving
47
How do you screen for an opioid misuse risk?
Take a history around drug and alcohol use - Age of first use, routes of use, current use EtOH and other drugs History of adverse consequences of EtOH/drug use - DWI, “black outs”, medical / social / legal complications Previous treatment history - Residential vs outpatient, mutual support (i.e. AA,NA) 3rd party corroboration (old charts, primary health care provider, spouse)
48
What are the 5 questions asked during the opioid risk assessment?
1) Family History of Substance Abuse - Alcohol - illegal Drugs - Prescription Drugs 2) Personal History of Substance Abuse - Alcohol - illegal Drugs - Prescription Drugs 3) Age (between 16 and 45 years) 4) History of Preadolescent Sexual Abuse 5) Psychological Disease - Attention Deficit Disorder - Obsessive-Compulsive - Disorder - Bipolar, Schizophrenia - Depression
49
What are NSAIDs and what is their MoA?
They are Non-Steroidal Anti-inflammatory Drugs Tissue trauma -> neurotransmitters released (histamine, serotonin, bradykinin, prostaglandins) - Sensitization of peripheral nerve which transmit pain to spinal cord then to brain = pain NSAID’s inhibit the synthesis of prostaglandins therefore preventing their contribution to the sensitization of nociceptors
50
Give examples of non-selective NSAIDs. (6)
- ASA - Indomethicin - Ketorolac - Ibuprofen - Naproxen - Advil
51
What are some NSAID COX 2 inhibitors? (2)
- Celecoxib | - Mobicox
52
What are the indications of NSAIDs? (4)
- Muscle pain - Bone pain - Headache - Mild-moderate nociceptive pain
53
What are some adverse effects of NSAIDs?
- GI (breakdown stomach lining) - Renal - Platelets (don't give it to someone who is actively bleeding) - CV (COX2 -> increase in heart disease)
54
What is acetaminophen? What is it used for?
Advil Unknown how it works. Used for mild-moderate nociceptive pain Used to treat post-op pain. May use in combination with opioids for more severe pain
55
What are some concerns regarding acetaminophen?
Hepatic toxicity | Renal toxicity
56
What is the recommended dosing for Acetaminophen?
- 4 gm/day (short-term use in healthy patients) - 3.2 gm / day (chronically in healthy patients) - 2.6 gm / day (chronically in at risk patients) * Daily alcohol consumption, warfarin, fasting, a low protein diet, cardiac or renal disease increase the risk of hepatotoxicity
57
How do anticonvulsant drugs work?
Unclear reason for analgesic efficacy - Reduce membrane excitability - Suppress abnormal discharges in pathologically-altered neurons
58
What are the indications for anticonvulsant drugs?
Acute and chronic neuropathic pain from peripheral nerve syndromes - Trigeminal neuralgia - Diabetic neuropathy - Postherpetic neuralgia - Efficacy with both lancinating and burning pain
59
What are some examples of anticonvulsant drugs? What are their side-effects and drug interactions?
Gabapentin / Pregabalin - Few drug interactions - Common adverse effects: somnolence, dizziness, fatigue Carbamazepine - Common adverse effects: sedation, mental clouding, dizziness, nausea, unsteadiness - Multiple drug interactions - Potential for liver damage and aplastic anemia require regular monitoring of CBC, liver enzymes, PT/INR, and serum drug levels
60
How do Tricyclic Antidepressants work? What are the indications?
``` Nociceptive, inflammatory and neuropathic pain - Diabetic neuropathy - Postherpetic neuralgia - Atypical facial pain Central pain ``` Other indications: - Low back pain - Cancer pain - Headache Relieves lancinating as well as burning pain
61
What are some examples of Tricyclic Antidepressants?
- Amitriptyline | - Nortriptyline
62
How do local anesthetics work?
Work by blocking Na+ channels so nerve conduction is inhibited Block sensation and motor function of nerves Block the transmission of pain sensation Does not cause constipation
63
What are some examples of local anesthetics?
- Local infiltration - Epidural/Intrathecal (Spinal) - Peripheral Nerve Blocks - Topical
64
What are some other medications for pain? (6)
Muscle relaxants/anti-spasmodics - Cyclobenzaprine, methocarbamol, baclofen, magnesium supplement NMDA blockers - Ketamine Alpha-2 agonists - Clonidine Botulinum toxin Steroids “Medical” marijuana
65
What is a multimodal approach? What are some examples?
Different types of analgesia can be used to treat different types of pain Frequently an opioid plus another type of analgesic is used Examples: - Post-op pain -> using an anti-inflammatory in conjunction with an opioid - Neuropathic pain -> anticonvulsant plus an opioid - Epidural analgesia -> local anesthetic plus an opioid
66
What are some examples of non-pharmacological interventions/modalities? (10)
- Deep breathing - Distraction - TENS - Hot/Cold - Positioning - Exercise - Acupuncture - Massage - Music Therapy - Dance
67
What are the benefits of non-pharmacological interventions?
- May reduce the need for analgesics - Improve mood, reduce anxiety - Strengthen coping skills - Improved sleep - Muscle relaxation - Few, if any side effects
68
True or false: Non-pharmacologic treatments are usually a supplement, not a replacement for pharmacotherapy
True
69
When should heat or cold NOT be used?
- With patients who have a medical condition that effects circulation including: Raynaud’s Disease, systemic lupus erythematous (SLE), sickle cell disease, peripheral vascular disease (PVD), or scleroderma. By patients who have decreased or impaired sensation such as: with diabetic neuropathy, stroke, head injury, and nerve damage. Over malignant tumors, over open wounds or areas of suspected infection
70
What are the nursing implications w/ cold or heat applications?
Assess the effectiveness of cold or heat in patients who are using this modality to manage pain. Assess appropriateness of using cold or heat to manage pain in consideration of the patient’s overall health and reason for the heat or cold application. Assess the patient’s understanding of how to use heat or cold and provide education.
71
How do you evaluate pain treatment?
Pain Rating Scales (0-10), faces scale Verbal Descriptors Side effects of therapy Our objective evaluation Pain is reassessed on a regular basis according to the type and intensity of pain and the pain treatment - New report of pain - New procedure - Pain intensity increases - After the administration of pain treatment
72
What does the nursing process consist of?
Assess -> Plan & Implement -> Evaluate
NURS 205
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