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Pain Lewis 10
Lewis Chapter 10 Pain
| Question | Answer |
|---|---|
| Complex, multidimensional experience, that causes suffering and reduces quality of life, and major reason that people seek health care | PAIN |
| What are the components of the nursing role in regards to pain (4)? | 1. Assess and communicate 2. Ensure adequate pain relief 3. Evaluate effectiveness of pain relief 4. Advocate for patient with pain |
| What are the consequences of untreated pain? | unnecessary suffering, physical and psychosocial dysfunction, impaired recovery from acute illness and surgery, immunosuppression , and sleep disturbances |
| What is the definition of pain according to Margo McCaffery? | “Whatever the person experiencing the pain says it is, existing whenever the person says it does.” |
| What is the definition of pain according to the International Association for the Study of Pain? | “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” |
| Who is the expert, most valid means of pain assessment? | the patient |
| What does the nurse do if the patient cannot verbally communicate their pain? | incorporate nonverbal information such as behaviors into their pain assessment |
| What are affective responses to pain? | Anger, fear, depression, anxiety |
| Studies have consistently demonstrated a link between __________ and __________. | Depression and Pain |
| Define suffering. | the state of severe distress associated with events that threaten the intactness of the person |
| What are some behavioral cues to pain? | grimacing, social withdrawal, less physical activity |
| What is the physiologic process by which information about tissue damage is communicated to the central nervous system? | Nociception |
| What the four processes of nociception? | transduction, transmission, perception, modulation |
| What is the conversion of a mechanical, thermal, or chemical stimulus into a neuronal action potential called? | Transduction |
| Where does transduction take place? | at the peripheral nerves, especially the free nerve endings/nociceptors |
| Give some examples of the chemicals that excite nociceptors to excitation? | prostaglandins, bradykinens, serotonin, substance P, histamine |
| How does the action potential get from the nociceptors to the spinal cord? | Via small, rapidly conducting, myelinated A-delta fibers and unmyelinated, slowly conducting C fibers |
| What is nociceptive pain? | Pain caused by the activation of peripheral nociceptors |
| What would a pain therapy need to do in order to prevent transduction and initiation of an action potential? | Decrease the effect of the chemicals released at the periphery or alter the sensitivity of the peripheral nociceptors |
| What drugs block the action of cyclooxygenase thereby blocking the production of prostaglandins? | NSAIDS |
| Name some common NSAIDS. | Advil, Motrin, Naprosyn, Aleve |
| What drugs block the action of phospholipase thereby blocking the production of prostaglandins and leukotrienes? | Corticosteriods |
| Name some drugs that block action potential on pain nerves by stabilizing the neuronal membrane and inactivating the sodium channels. | Local anesthetics like Lidocaine, bupivacaine (Sensorcaine) and antiseizure drugs like carbamazepine (Tegretol), oxcarbazepine (Trileptol), and lamotrigine (Lamictal) |
| What is transmission? | the movement of pain impulses from the site of transduction to the brain |
| What are the 3 parts involved in transmission? | 1. Peripheral nerves to spinal cord 2. Dorsal horn processing 3. Transmission to the thalamus and cortex |
| What are dermatomes? | Areas on the skin that are innervated primarily by a single spinal cord segment |
| Where are nocieptive signals first processed in the CNS? | the dorsal horn of the spinal cord |
| What kind of signal do these neurotransmitters produce? Glutamate, aspartate, substance P | Activation |
| What kind of signal do these neurotransmitters produce? Y-aminobutyric acid (GABA), serotonin, norepinephrine | inhibition |
| In the dorsal horn, how do opioids work to relieve pain? | They block the release of neurotransmitters, particularly substance P. |
| What are two kinds of opioids? | exogenous and endogenous |
| Morphine is an example of what kind of opioid? | exogenous |
| Enkephalin and Beta Endorphin are examples of what kind of opioid? | endogenous |
| What is central sensitization? | a state in which neurons activated by noxious mechanical and chemical stimuli are sensitized by such stimuli and become hyper-responsive to all subsequent stimuli delivered to the neurons' receptive fields (thefreedictionary.com). |
| What is it called when enhanced excitability in the spinal neurons occurs? | Central Sensitization |
| What is necessary to maintain central sensitization? | continued nociceptive input from the periphery |
| What causes firing of specialized dorsal horn neurons to gradually increase? | ongoing stimulation of c-fiber (slow) nociceptors |
| What is “windup”? | gradually increased firing of specialized dorsal horn neurons in response to ongoing stimulation of c-fiber nociceptors |
| What are NMDA receptor antagonists promising agents for treating central sensitization? | because windup is dependent on the activation of NMDA |
| What kind of cells are thought to play a role in central pain modulation? | glial cells |
| What are 4 clinical results of central sensitization? | Hyperalgesia, allodynia, persistent pain, referred pain |
| What is hyperalgesia? | Increased response to noxious stimuli- what used to hurt, now really hurts. |
| What is allodynia? | painful response to normally innocuous stimuli – what used not hurt, now hurts! |
| What is persistent pain? | prolonged pain after the original noxious stimulus is gone – It shouldn’t hurt, but it does. |
| What is referred pain? | the spread of pain to uninjured areas – That spot shouldn’t hurt, but it does. |
| What is a first order neuron? | a neuron that conducts impulses from a somatic receptor into the brainstem or spinal cord |
| What is a second order neuron? | a neuron that conducts impulses from the brain stem and spinal cord to the thalamus |
| What do third order neurons do? | conduct impulses from the thalamus to the cortex |
| Where does nociceptive stimuli go from the dorsal horn? | to third order neurons primarily in the thalamus and to several other areas of the brain |
| What is it called when pain is recognized, defined and responded to by the individual experiencing the pain? | perception |
| In what area of the brain does pain perception occur? | There is no single area in the brain for pain perception |
| What area of the brain is believed to be responsible for warning the individual to respond to the pain stimulus? | the reticular activating system (RAS) |
| What area of the brain is believed to be responsible for localization and characterization of pain? | Somatosensory system |
| What area of the brain is believed to be responsible for the emotional and behavioral responses to pain? | Limbic system |
| What area of the brain is believed to be responsible for constructing the meaning of the pain? | cortical structures |
| What is modulation? | Modulation involves the activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain. |
| The degree of __________ determines the amount of nociceptive stimulation that may or may not be perceived as pain. | Modualtion |
| Name some drugs that use modulation to relieve pain by blocking the reuptake of serotonin and norepinephrine so that there is more available to inhibit noxious stimuli. | Cymbalta, Elavil, Effexor (used for cancer pain) |
| What are the two categories of pain based on the underlying pathology? | nocicpetive and neuropathic |
| Pain caused by damage to somatic or visceral tissue is _________ ________. | Nociceptive Pain |
| Somatic and visceral pain are types of ______ ______. | Nociceptive pain |
| Where does somatic pain come from? | Bone, Muscle, Joint, Skin, Connective tissue |
| What is the usually quality of somatic pain? | fairly localized , usually aching or throbbing |
| Where does visceral pain come from? | visceral organs |
| Which type of pain is often not well controlled by opioid analgesics alone? | Neuropathic pain |
| The fifth vital sign | Pain |
| Name 7 pain characteristics that should be assessed. | onset, duration and pattern of pain, location, intensity, quality, associated symptoms, and factors that increase or relieve pain |
| Patients typically describe ________ pain as burning, numbing, shooting, stabbing , or itchy sensations. | neuropathic |
| Patients typically describe _________ pain as sharp, aching, throbbing, and cramping. | nociceptive pain |
| What are the non opioids? | acetaminophen, aspirin and other salicylates, and NSAIDS |
| Name 3 things that characterize non opioids. | 1) analgesic ceiling 2) No tolerance or dependence 3) usually OTC |
| What kind of pain is caused by damage to peripheral nerves or the CNS? | Neuropathic |
| Name 3 adverse affect associated with aspirin. | gastric upset, platelet dysfunction, and bleeding |
| How is acetaminophen (Tylenol) like aspirin and how is it different? | Like: analgesia and antipyretic effects Different: no anti-platelet or anti-inflammatory effects |
| Where is acetaminophen metabolized? | In the liver |
| Which patients are in danger of hepatotoxicity with acetaminophen? | Patients with liver disease or alcoholism |
| What is the daily maximum dose for acetaminophen especially for older adults? | 3 g |
| Cox inhibitors | NSAIDs |
| What have NSAIDs (except aspirin) been linked to? | increased cardiovascular events such as stroke and myocardial infarction |
| Patients who have just had heart surgery should not have _______. | NSAIDs |
| What does COX 1 do? | promotes gastric and renal blood flow and platelet adhesion |
| What does COX 2 do? | promotes inflammation |
| What kind of drug was Vioxx and why was it pulled from the market? | selective cox 2 inhibitor, Vioxx was pulled from the market along with Bextra due to concerns about adverse cardiovascular events (MI). |
| Use of what non opioid should be limited with elderly patients and patients with a history of PUD? | NSAIDs |
| What is the same about Morphine, Oxycontin, hydrocodone, codeine, methadone, Dilaudid and Levo-Dromoran? | They are pure opioid agonists |
| What kind of pain are pure opioid agonists used for and why? | moderate to severe because they are potent and have no analgesic ceiling |
| What vital sign is very important to monitor when our patient is on Morphine and why? | Respirations because morphine can cause respiratory depression |
| If we are going to administer morphine to our patient but their respirations are > 12, what do we do? | We withhold the medication and alert the physician. |
| When opioids are prescribed for moderate pain, what other analgesic is often included? | Acetaminophen or NSAIDs |
| Give some examples opioids mixed with nonopioid analgesics. | Tylenol 3= codeine plus acetaminophen, Vicodin = hydrocodone plus acetaminophen, Vicoprofen = hydrocodone plus acetaminophen |
| What are the five deminsions of pain? | physiologic, affective, behavioral, cognitive, sociocultural |
| What is the physiologic dimension of pain? | the genetic, anatomic, and physical determinants of pain |
| What is the affective dimension of pain? | emotional response to pain including anger, depression, fear, and anxiety |
| What is the behavioral component of pain? | the observable actions used to express or control the pain like grimacing or becoming less physically active or socially withdrawn |
| What does the cognitive component of pain refer to? | the beliefs, attitudes, memories, and meaning attributed to pain |
| What does the sociocultural dimension of pain encompass? | factors like demographics (age, gender, education, socioeconomic status) support systems, social roles, and culture |
| Name some modulating chemicals sent down by the brain to tone down pain signals. (SON GABA) | Serotonin, Opioid, Norepinephrine, GABA |
| Name three antidepressants that work for pain modulation in cancer by blocking the reuptake of serotonin and norepinephrine. | Elavil, Effexor, and Cymbalta |
| If the patient describes describes deep,cramping, sharp, aching, or throbbing pain, what kind of pain is he likely to be experiencing? | Nocioceptive pain |
| If the patient describes pain that is numbing, burning, shooting, stabbing or electirical in nature, what kind of pain is he experiencing? | Neuropathic pain |
| What is the definition that quantifies pain as chronic? | lasting 3 months or past the time when acute pain is expected to should subside |
| What are the characteristics of pain that we need to assess? | onset, duration, pattern, location, intensity, quality, associated symptoms, what makes it better or worsens it |
| What are the three categories of pain drug therapy? | nonopioid, opioid, and co-analgesic/adjuvant drugs |
| What pain medications are included in the nonopioid category (4)? | acetaminophen, aspirin, salicylates, and NSAIDs |
| What characteristics are shared by nonopioid analgesics? | analgesic ceiling (more drug does not equal more pain relief after reaching the ceiling), no tolerance/physical dependence, often OTC/no RX required |
| What level of pain is aspirin for and what are its drawbacks? | aspirin is for mild pain, drawbacks=gastric upset, platelet dysfunction, and bleeding |
| How is acetaminophen like aspirin and how is it different (2 sames/2 differents)? | Has analgesic and antipyretic like asa. Does not have anti-inflammatory or anti-platelet |
| What organ could suffer from doses greater than 3 to 4 g/day of acetaminophen? | acetaminophen is metabolized in the liver/hepatotoxicity |
| What kind of analgesic works by inhibiting the enzyme that converts arachidonic acid into prostaglandins? | NSAIDs (Cox inhibitors) |
| ¬¬¬Inhibition of _________ causes renal function impairment, bleeding tendencies, GI upset and ulceration, the bad side effects of NSAIDs. Inhibition of__________ reduces inflammation in injured tissues. | Cox 1 cox 2 |
| Why were Vioxx and Bextra pulled from the market? | Concerns about increased risk of adverse cardiovascular effects: MI, strokes, and Heart failure |
| What intensity of pain are opioids for? | Moderate to severe |
| Why is it that opioids can treat moderate to severe pain when nonopioids can not? | opioids have no analgesic ceiling, increase dose=increase pain relief |
| Name 6 common opiods. | oxycodone (Oxycontin), hydrocodone, codeine, methadone, hyromorphone (Dilaudid), and levorphanol (Levo-Dromoran) |
| Which opioid is the standard of comparison for all other opioids? | Morphine |
| Which opioid should not be used in doses more than 600mg per 24 hours, for more than 2 days, for chronic pain, nor for patients on Monoamine oxidase inhibitors because its metabolites are neurotoxic? | meperidine (Demoral, Pethidine) |
| What are the common side effects of opioids (5 )? | constipation, sedation, N&V, respiratory depression, pruritus |
| Which opioid side effect is not likely to improve with time? | constipation |
| Why are patients who are on an opioid often also taking Reglan-metocloparmide? | helps with nausea and vomiting/ antiemetic |
| Which patients would be at an increased risk for respiratory depression on an opioid? | opioid naive, elderly, underlying lung disease, receiving other CNS depressants (sedatives, benzodiazepines, antihistamines) |
| What drug will be carefully employed if you cannot rouse your patient from a opioid induced somnolence? | Narcan-Naloxone 0.4mg in 10mL saline in 0.5mL increments every 2 minutes IV or subcut |
| What drug class, also used as an adjuvant drug, works by preventing reuptake of serotonin and norepinephrine? | Tricyclic antidepressants |
| What side effects should we monitor for if our patient is taking an antidepressant for pain relief? | anticholinergic side effects like dry mouth, urinary retention, sedation, orthostatic hypotension, weight gain and sexual dysfunction |
| Amitriptyline, doxepin, imipramine, and nortriptyline are all what type of drugs? | antidepressants |
| Carbamazepine (Tegretol), and Gabapentin (Neurontin) are what kind of drugs? | antiseizure |
| What kind of drug is baclofen (Lioresal)? | muscle relaxer - particular useful for neuropathic pain and muscle spasms |
| What kind of drugs are clonidine (Duraclon, Catapres) and tizanidine (Zanaflex)? | Alpha two andrenergic antagonists |
| Which group of adjuvant drugs is good for neuropathic pain as well as prophylaxis of migraine headaches? | antiseizure drugs |
| What kind of drugs are dexamethasone (Decadron), prednisone, and methylprednisone (medrol)? | corticosteroids |
| Which group of adjuvant drugs is good for neuropathic pain as well as chronic headache? | alpha two adrenergic antagonists |
| What are the common side effects of the alpha two adrenergic antagonists? | sedation, dry mouth, othostatic hypotension |
| Which kind of adjuvant drugs are especially useful when injected epidurally for acute and subacute disk herniation because they can decrease activation of an inflamed neuron? | corticosteroids |
| What class of adjuvant drugs is used for acute and chronic cancer pain, pain secondary to spinal cord compression and inflammatory joint pain syndromes? | corticosteroids |
| What are the side effects associated with corticosteroids? | hyperglycemia, fluid retention, dyspepsia, GI bleeding, impaired healing, muscle wasting, osteoporosis, adrenal suppression, and immunosupression – eeesh! |
| What class of drugs should not be administered at the same time as corticosteroids because they work through the same final pathways? | NSAIDS |
| Which type of adjuvant drug works by interfering with nociceptive impulses, and is mainly used for muscle spasms? | GABA receptor agonist like Baclofen (Lioresal) |
| What is analgesic titration? | dose adjustment based on assessment of pain relief vs. side effects |
| What is the goal of analgesic titration? | to use the smallest dose of analgesic that provides effective pain relief and with the fewest side effects |
| Give 8 guidelines we follow when treating pain. | everybody deserves pain relief, treatment based on patient goals, combine drug and nondrug therapy, manage side effects, collaborate, Evaluate, educate |
| Name two opioids that we don’t use often because of limited efficacy or toxicities. When we do use them, it is definitely not for long term. | propxyphen (Darvon) and meperidine (Demerol, Pethidine) |
| Therapies that alter either the local environment or sensitivity of the peripheral nociceptors can prevent ____________ and initiation of an action potential. | transduction |
| Give some examples of drugs that prevent transduction. | By blocking pain sensitizing chemicals: NSAIDs like ibuprofen (Advil, Motrin), naproxen (Naproyn, Aleve); corticosteroids like dexamethasone (Decadron)- By changing the sensitivity of peripheral nociceptors: local anesthetics and antiseizure drugs. |
| What kind of opioid is administered transmucosally and approved for before surgery and procedures and cancer break through pain? | Fentanyl citrate (Actiq) |
| Name some long acting forms of morphine (12-24 hours). | Kadian, Avinza, MSContin |
| Name some sustained release formulations of oxycodone. | OxyContin, Oxycodone SR |
| What opioid is administered intranasally for acute headache and other intense, recurrent types of pain? | Butorphanol (Stadol) |
| What is an alternative GI route for a patient who needs pain relief but nauseous and vomiting? | rectal |
| Name the analgesics that are available in rectal formulations (4 PHs). | hydromorPHone, oxymorphPHone, morPHine, acetaminoPHen |
| What could we do for a patient with a fetanyl patch if they continually get rashes from the adhesive on the patch? | prepare the skin one hour before placement with a corticosteroid cream. |
| What kind of patch can be used to help with postherpatic pain (if the skin is unbroken)? | Lidoderm patch (5% lidocaine impregnated) good for up to 12 hours few side effects |
| What are Aspercream and Myoflex used for? | joint and muscle pain |
| Which aspirin side effect is avoided with Aspercream and Myoflex? | GI upset |
| Name a topical pain relief drug derived from red chilli peppers. | Capsaicin (ICY-HOT, Zostrix) |
| What kind of topical pain relief is covered with plastic for 30 to 60 minutes before a painful procedure? | EMLA (eutectic [melty] mixture of local anesthetics) |
| What administration route is best for immediate analgesia, rapid titration, and maintaining steady analgesia and blood levels of drug ? | IV |
| What administration route is not recommended, although frequently used, because it hurts, absorption is unreliable, and chronic use can result in fibrosis and abcesses? | IM |
| Why does it only take a little bit of drug if it delivered intraspinally? | because it is delivered close to the receptors in the spinal cord dorsal horn |
| 1mg of intrathecal morphine is equal to ____mg of epidural morphine is equal to _____mg of IV morphine is equal to _____mg of oral morphine. | 10mg,100mg, 300mg |
| Name 6 drugs that are administered intraspinally. | morphine, fentanyl, sufentanil (Sufenta), hydromorphone (Dilaudid), ziconotide (Prialt) (a calcium channel receptor modulator for use in neurpathic pain syndromes) and clonidine. |
| What are the common side effects with intraspinal anesthesia? | Nausea, itching, urinary retention; clonidine- hypotension; ziconotide dizziness, ataxia, nausea, confusion, headache |
| What’s a “Wet tap”? | Oops, we missed and a little CSF leaked out. Results in severe headache that only hurts when the patient is sitting or standing |
| How do we check if a intrathecal catheter is correctly placed (hasn’t migrated)? | we aspirate CSF |
| Give three types of areas that should not be treated with cold therapy. | areas being treated with radiation therapy, open wounds, and areas with poor circulation |
| Give four types of areas that should not be treated with heat therapy. | areas being treated with radiation therapy, bleeding areas, recently injured (within the past 24 hours), or areas with decreased sensation |
| What are six things we want our patients to know when we educate about pain? | Negative consequences if unrelieved, maintain a record of level and relief, don’t wait till pain gets bad to ask for pain relief, dosage can be adjusted if loses effectiveness, side effects, report when not relieved |
| What is the formula for tapering a patient off an opioid to which they have developed dependence. | daily dose x 50%= New daily dose give 1/4 q6hrs for 2 days. New daily dose x 75% give 1/4 q6hrs for 2 days. Repeat till daily dose is 30mg per day for 2 days. Then stop. |
| Give 10 early (6-12hrs) manifestations of opioid withdrawal. | Anxiety, tears, runny nose, sweating, yawning, piloerection, shaking chills, dilated pupils, anorexia, tremor |
| Give 9 late (48-72 hrs) manifestations of opioid withdrawal. | excitation, diarrhea, restlessness, fever, nausea and vomiting, cramping abdominal pain, hypertension, tachycardia, insomnia |
| What is the rule of double effect teach us? | The rule states that if an unwanted consequence (hastened death) occurs as a result of an action taken to achieve a moral good (pain relief), the action is justified because the nurse’s intent is to relieve pain. |
| What age group is the adage “start low and go slow” relevant for and why? | for older patients because they metabolize drugs more slowly so are at greater risk for high blood levels and side effects |
| Why is acetaminophen preferred to NSAIDs in older adults? | because NSAIDs are associated with a high frequency of serious GI bleeding |
| what are the components of the nursing role in regards to pain the rhyming way(4)? | assess and comminicate, ameliorate, evaluate, advocate |
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Perseverandovercome
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