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HCC 2008 Pain Manage

HCC 2008 Pain Management

QuestionAnswer
What are the three main types of pain? Acute, Chronic, and Cancer pain
Tell me about Acute Pain. Recent onset, usually associated with a specific injury, indicates damage or injury has occurred; draws attention to its existence, lasts from seconds to 6 weeks, stimulates the stress response which negatively affect health status
Effective pain relief may result in_________ faster recovery and improved outcomes
Tell me about Chronic Pain. Can be limited, intermittent, persistent; usually last 3-6 months or longer, can seldom be attributed to a specific cause or injury, may have poorly defined onset, difficult to treat because the cause or origin may be unclear
What are some adverse effects of chronic pain? Fatigue, depression, disability, withdrawal, dependency
Tell me about Cancer Related Pain. May be acute or chronic, most pain related to cancer is a direct result or tumor involvement
What are some other ways to classify pain? Location, Location, Location!!!! Etiology
Location classification? Headache, pelvic pain, chest pain Helpful in communicating and treating pain
Etiology classification? Burn pain and post-herpetic neuralgia Helps predict course of pain and directs plan for treatment Neuropathic eg phantom limb pain, diabetic neuropathy, trigeminal neuralgia
***BONUS**** What the heck is phantom pain? pain often referred to an amputated leg where receptors and nerves are clearly absent is a real experience for the patient
Harmful effects of pain Regardless of its nature, pattern, or cause, pain that is inadequately treated has harmful effects beyond the suffering it causes....so even if you think your patient isn't in pain......it still MUST be addressed!
What systems can acute pain affect? Pulmonary, Cardiovascular, GI, endocrine and immmune systems
How does acute pain affect those systems? Triggers stress response, increased metabolic rate, increased cardiac output, impaired insulin response, increased fluid retention
What are the effects of Chronic Pain? Suppress immune function (Physiologic response), may promote tumor growth, over time can cause depression, anger, fatigue, and disability, may result in high does of opioid medications to control chronic, progressive pain
What are some common misconceptions? Physiologic signs such as VS is a good indicator or pain; Clients taking pain medication will become addicted to the drug; The client is asleep or she or he is not in pain; If pain is ignored it will go away; The nurse is the best judge if the pts in pain
What if you think the patient is BSing when it comes to their pain It doesn't matter whether or not you believe the client is in pain. You have an ETHICAL and LEGAL obligation to act on what the client says, regardless of how you feel
Pain Categories include ___, ____, ____, _____, ______, Cutaneous, somatic, visceral, neuropathic, phantom pain
You better know cutaneous...moving right along to somatic...what is it? bone, muscle, ligaments, blood vessels
what is visceral pain occurs when organs are abnormally stretched and becomes inflamed: abdominal area an chest
What is neuropathic pain injury or abnormal functioning of peripheral nerves or the CNS, cause of chronic pain; burning, stabbing pain; Diabetic neuropathy: metabolic and vascular changes, sensory loss
What did you say phantom pain was? painful sensation perceived in a missing body part
Tell me what intractable means pain that is resistant to treatment
What is referred pain? pain perceived in an area distant from the point of origin....Think of when someone is having a heart attack....they are having referred pain up their neck and shoulders, and down their left arm
Threshold Smallest stimulus for which a person reports pain..Think of a sensation of pain that eventually occurs when your hand is immersed in water as it is gradually heated.
Tell me the 4 stages of the pain process transduction, transmission, perception, modulation (TTPM)
***Bonus**** What is transduction? activation of pain receptors; involves conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn.
***Bonus****What is transmission? pain sensations from the site of an injury or inflammation are conducted along pathways that have been rather clearly defined in certain areas but are still somewhat unclear in other areas to the spinal cord and then on to higher centers
***Bonus****What is Perception? involves sensory process that occurs when a stimulus for pain is present. Includes person's interpretation of the pain. (pain threshold)
***Bonus****What is modulation? process where the sensation of pain in inhibited or modified
What is the Gate Control Theory Area in dorsal horn acts as a gate that can increase or decrease the # of nerve impulses from the PNS to the brain
The gate is opened or closed depending on ____ input from large or small fibers
What allows pain to enter the brain? Increased activity in small fibers opens gate
What goes through the same gate and closes it? increased activity of large fibers
When stimuli to the brain surpass the threshold limit, ______ pain is perceived.
Factors affecting the pain experience culture, ethnicity, family, gender, age, religious beliefs, environmental and support, anxiety, and other stressors, past experience
Behavioral responses to pain? (What do you do when you're in pain?) Moving away, grimacing, moaning, crying, restlessness, protecting (guarding) painful area
Physiologic responses to pain? Tachycardia, hypertension, tachypnea, dilated pupils, muscle tension
When giving medications to a child as far as pain guidelines go, what are you going to avoid and give instead? AVOID IM, you know those kids are scared as hell of those needles.....if you can give it to them PO, IV, or epidurally
Calculation of dosage for children milligrams of medication per kilograms of weight
Can children take same medications as adults. No, some medications are contraindicated in children due to safety or dosage issues
Instruments for assessing pain visual analogue scale; faces pain scale
What myth is assumed when it comes to elderly in pain pain is an expected outcome of aging
What are the facts when it comes to elderly and pain? pain is often under reported- fear of not being seen as a good patient
What are the elderly sensitive to? respiratory depression, excessive sedation, confusion. Use cautiously if debilitated or if there is hepatic, renal, or respiratory impairment
Pain Diagnosis Look at the cause: acute or chronic. What are the symptoms? What are the factors influencing pain?
What is the major goal of pain management? Relieve pain and suffering; improve the quality of life
What are some things to think about when planning pain management? Determine the client's need, strengths, and resources. Discuss where the nearest pain center is located. Remember to document the plan on the client's record
You know about implementing and evaluating....i'll put it on here anyways after plan developed, implement actions..duh evaluate attainment of goals and effectiveness of actions. revise plan of care, or terminate plan or care, or alter plan of care
What are analgesics? drugs used to relieve pain. Reduce an individual's perception of pain and alters the person's discomfort.
Give me the categories of analgesics Opioids (narcotics), non opioids, and adjuvant drugs
What is used to treat moderate to severe pain? Opioids
What do opioids do? Inhibit the release of substance "P" in the peripheral and central nerves by reducing the perception of pain sensation in the brain. Provide a sense of euphoria by binding to opiates receptors. Binds to opiate receptors in the CNS
What do opioids produce? generalized CNS depression
Schedule I of controlled narcotics Unacceptable potential for abuse: heroin, cocaine, LSD
Schedule II of controlled narcotics High potential for abuse and dependence: opioids, amphetamines
Schedule III of controlled narcotics Intermediate potential for abuse: codeine+acetaminophen, hydrocodone+acetaminophen
Schedule IV of controlled narcotics Less abuse potential than schedule III, minimal dependence: lorasepam alprazolam, diasepam (valium)
Schedule V of controlled narcotics minimal abuse potential: codeine cough syrup, lomotil
Morphine Prototype: given PO, IM, SC, IV; Do not crush extended relief, has no ceiling (no max dose)
Fentanyl May be given IV, IM, via PCA pump, tansdermally (patch), transmucosal (lollipop)
Meperidine (Demerol): PO, IM, IV, SC (not reversed by Narcan ***nasty metabolite- normaperidine causes seizures****
Routes of Analgesic Administration Oral (PO), IM, IVP, PCEA (epidural analgesia), duragesic (transdermal patch fentanyl, nasal (stadol), Rectal
What to remember for routes of opiate delivery. When the route of a drug is changed the dose must also be changed to prevent over or under-dosage
Common side effects of Opioid narcotics respiratory depression, sedation, hypotension, nausea and vomiting, constipation, pruritis, urinary retention
What are some nursing implications? Monitor VS, respiratory status, LOC Assess effectiveness of pain management Assess catheter insertion site Narcan availability; Prevent constipation
What are some opioid antagonists (antidote) Naloxone (Narcan)- drug of choice for opioid overdose Naltrexone (ReVia)- used for opioid and alcohol dependence Nalmefene (Revex)- similar to narcan but longer lasting action. Used mainly in tx of methadone overdose
What are opioid antagonists (antidote)? derugs that are used to reverse the effects of opioid agonists: they block or reverse analgesia, CNS and respiratory depression. Compete for opiate receptor site in the brain
Adjuvant Drugs Does not provide analgesia by itself. It is usually used in conjunction with another drug to enhance its medical effectiveness.
What are some adjuvant drugs? Anticonvulsants - dilantin, tegretol Corticosteroids - Decadron, medrol (reduce swelling) Antidepressants - Elavil, Tofranil (nerve pain) SSRI - prozac, Paxil
What is addiction? behavioral patterns of substance use characterized by a complusion to take the drug primarily to experience its psychic effects
What is Tolerance? The maximum amount of pain a person can tolerate
What is dependence? Withdrawal symptoms may occur if medication is stopped. Withdraw slowly to avoid.
Principles for Administering Analgesics Goal: to relieve pain; frequent and ongoing pain assessment, nurse must review pain scale; discuss benefits of using a pain scale with patient; try various pain control measures; be open minded about alternative pain relief measures
Pharmacologic Measures Ongoing assessment, Nurse must evaluate whether medication is working or not- if not get changed, monitor for adverse effects; timing: need to know peak action of drug; administer in timely fashion at regular intervals
When should you remind clients to ask for pain meds? Before pain becomes severe
Acute Pain Management - Surgery Discuss pain control alternatives w/ clients b4 surgery; assist post op pts by helping to maintain a steady serum level. (PCA Pump); be advocate for client; individualize tx; medicate prior to anticipated pain: dressing change, ambulation,physical therapy
Post operative pain management frequent regular dosing intervals in early post op period, then PRN
Advantages of Post op pain management shorter hospitalization, reduced cost, early mobilization
Chronic Pain Management Goals maximize function, enhance quality of life
Chronic Pain Management Medicate client around the clock rather than PRN; If possible, give meds orally. Allow client control of med regimen whenever possible.
Steps in pain control 1. NSAID or acetaminophen 2. Add opioid analgesic to above 3. Increase potency of opioid
PCA pumps are designed with what? A safety mechanism to prevent overdose and narcotic theft
What is the most frequently prescribed analgesic? Morphine
What is the most frequent route when using a PCA pump? Via the IV route, however, it may be, via an epidural catheter, or sub Q
Advantages of PCA Pump Consistent analgesic blood level maintained; the client decides when doses of opioid is needed. Medication is administered IV, therefore, absorption is faster and more predictable. The client tends to USE LESS medication.
Why does the client use less medication when on a PCA pump? he or she can administer the medication before they are in severe pain
Bolus Dose Initial loading dose
Contiuous dose maintenance dose
lockout interval every 10 minutes; prevents pt from overdosing
Nursing Responsibility for Pts with PCA pump Check for allergy; monitor VS, sedation level, pain control, s/e, verify correct settings on pump with other RN, observe IV site for infiltration, monitor the client q2h for 1st 24 hrs. Have benadryl and narcan available, teach pt and fam how to use pump.
Other pain relief measures may be administered topically or mucous membranes; sub q into or near surgical site to relieve post op pain; via epidural catheter
Who administers an epidural cathether? ACP - Anesthesia care practitioner
How is the epidural administered? As a bolus or intermittently via a continuous pump The drug is usually a preservative free morphine or fentanyl.
Nursing Responsibilities for Epidural catheter Properly fasten catheter w/ tape. No not use alcohol @ insertion site. Elevate HOP 30 degrees. Observe for urinary retention. Monitor site for infection
What complications/ side effects do you look for with an epidural catheter? Hypotension, urinary retention, headache, infection
Non-Opioid Analgesics Acetaminophen; prostaglandin inhibitor, antipyretic (reduces fever), analgesic (controls pain)
Adverse effects of non-opioid analgesics liver toxicity, rash; antidote mucomyst; precautions; do not exceed 4 grams per day
NSAIDS Ibuprofen, naproxen, ketorolac, celecoxib, anti-inflammatory, antipyretic, aspirin
What are NSAIDS used for? Analgesic; tx of mild to moderate pain, reduce inflammation, adjunct to opioids in severe pain; anti-inflammatory, reduce inflammation, antipyretic
NSAID effects anti-inflammatory, antipyretic, analgesic: prostaglandin inhibitor, Cox-2 inhibitor (celebrex)
NSAID s/e GI irritation, GI bleed, platelet dysfunction, kidney dysfunction, worsening of heart failure, liver dysfunction
Contraindications and precautions of NSAIDS Aspirin hypersensitivity/allergy History of bleeding disorders, ulcer, severe kidney, liver, or heart disease
Nursing Implications: NSAIDS administer with food or milk, avoid if history of ulcer, GI bleed, etc., risk of bleeding:surgery, drug interactions, pt education
Older adults Medicate with 50-75% of the normal average adult dose then increase as necessary Observe closely for over medication Discourage self medication Monitor for behavioral changes that may be due to Meds
Non Pharmological measures imagery, relaxation, distraction, humor, music therapy, cutaneous stimulation, Tens unit, hypnosis, accupressure, therapeutic touch, biofeedback, heat and cold
Ethical issues regarding Pain Management Clients must be medicated in a timely manner. The have a right to have their pain controlled no matter the cause and your feeling regarding their pain. They have a right to be treated with respect. Clients should not be treated like a drug abuser.
Created by: lcano2288