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Pain Lewis 10

Lewis Chapter 10 Pain

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