Pain Management Strategies Quiz

Analgesic and Anti-inflammatory Medications

• Fall 2024 Nursing 488 course
• Instructors: Catherine Fox RN, MN, CON(C), Shelley de Boer, RN, MN, Bemi Lawal RN,MSN/ADM, Hillary Selkirk RN, MN, NP

Lesson Objectives

• Students will develop an understanding of the nursing process across the lifespan for individuals experiencing acute pain.
• Students will explore, discuss, and identify common pharmacological interventions for individuals experiencing acute pain, including anti-inflammatory medications and analgesics.

Pain Classification

• Acute pain: Sudden onset, short-term pain related to a specific injury or cause.
• Chronic pain: Long-lasting pain that often persists beyond typical healing time (over 3-6 months). Often difficult to treat. Pain is defined by the individual and is a complex sensory and emotional experience.

Pain Pathways

• Nociceptive Pain
• Neuropathic Pain
• Central Pain
• Psychogenic Pain
• Referred Pain

Inflammation and Pain

• Inflammation is a protective response to injury, serving to destroy, dilute, or wall off the injurious agent.
• Chemicals like prostaglandins and bradykinin are released, increasing pain sensation.
• Pain encourages rest and protection of the injured area, allowing healing.
• Anti-inflammatory agents reduce both inflammation and pain, making them key in pain management from inflammatory conditions like arthritis and injuries.

WHO Pain Management Ladder

• Presents a stepped approach to pain management for mild to severe pain starting with non-opioids, and progressing to stronger opioids.
• Includes adjuvant therapies to address psychosocial and spiritual issues.

Pain Assessment and Tools: Review

• PQRSTU method for evaluating subjective pain; Location, Provoking, Quality, Radiates, Severity, Time, Understanding/Impact
• Common scales include Numerical Rating Scale (NRS), Visual Analog Scale (VAS), and Wong-Baker FACES Scale.

Monitoring and Evaluating Pain Management

• Monitor response to medication(s) including vital signs and therapeutic/subtherapeutic responses.
• Give medication with meals to avoid gastrointestinal (GI) upset.
• Monitor adverse effects and treat accordingly.
• Consider dose reduction for the elderly and children to manage medication effects.

Pharmacological Management of Inflammation and Pain

• Anti-inflammatory Medications: NSAIDs, Corticosteroids
• Acute Pain Medication: Opioids, Non-Opioids, Adjuvant Analgesic Therapies

Anti-inflammatory Medications

• Mechanism of Action: Blocking the arachidonic acid pathway
• Types: Nonsteroidal or Corticosteroids

Anti-inflammatory Medications: NSAIDs

• Clinical Uses: Pain relief, anti-inflammatory uses, antipyretic, anti-arthritic effects, post-surgical or injury-related pain.
• Types: Salicylates (e.g., aspirin), Cyclooxygenase-2 Inhibitors (e.g., Celecoxib), Acetic Acid Derivatives (e.g., Diclofenac), Enolic Acid Derivatives (e.g., Meloxicam), Propionic Acid Derivatives (e.g., Ibuprofen, Naproxen)

NSAIDs: Contraindications

• Known drug allergy
• Conditions that place the patient at risk for bleeding such as epistaxis, vitamin K deficiency, or peptic ulcer disease.
• Children and teenagers with viral infections (risk of Reye's syndrome).
• Not recommended for breastfeeding mothers.
• Exercise caution during pregnancy and use.

NSAIDs: Adverse Effects

• Gastrointestinal Issues (most frequently reported): Include nausea, vomiting, abdominal pain, ulcers, and bleeding.
• Cardiovascular Risks: Increased hypertension, heart attack (MI), and stroke.
• Renal Impairment: Can reduce blood flow to kidneys, potentially leading to acute kidney injury (AKI) or fluid retention.
• Hematologic Effects: Altering blood clotting, increasing risk of bleeding, especially with concurrent anticoagulants..

NSAIDs: Drug Interactions

• Anticoagulants (e.g., Warfarin, Heparin)
• ACE Inhibitors, ARBs, and Diuretics
• Lithium
• Methotrexate
• Corticosteroids
• SSRIs and SNRIs (e.g., Sertraline, Venlafaxine)

NSAIDs: Important Lab Values

• Hemoglobin, Hematocrit, Platelets
• Creatinine and BUN
• AST and ALT
• Potassium

Anti-Inflammatory Medications: Corticosteroids

• Types: Mineralocorticoids, Glucocorticoids
• Actions: Anti-inflammatory, Immunosuppressive; Stabilizes blood vessels, Increases blood glucose, and Catabolic effects.

Glucocorticoids: Indications

• Inflammatory Conditions
• Allergy Reactions
• Autoimmune Disorders
• Respiratory Conditions
• Endocrine Disorders
• Oncology and Hematologic Disorders

Glucocorticoids: Contraindications & Drug Interactions

• Drug allergy
• Active infections
• Systemic fungal infections
• Live vaccinations
• Uncontrolled diabetes
• Hypertension and cardiovascular disease
• Osteoporosis
• Pregnancy
• Psychiatric conditions
• Glaucoma
• NSAIDs
• Antidiabetic medications
• Anticoagulants
• Diuretics
• Vaccines (especially live vaccines)

Glucocorticoids: Adverse Events

• Metabolic/endocrine effects
• Immune system effects
• Musculoskeletal effects
• Gastrointestinal effects
• CNS effects
• Other: cardiovascular, ocular, and integumentary effects

Glucocorticoids: Patient Teaching and Nursing Management

• Do not stop abruptly.
• Take with food.
• Surgery considerations
• Recognize signs of infection
• Monitor blood glucose
• Support bone health if on long-term therapy
• Administration routes: oral, IM, IV, intranasal, and inhalational.
• Tapering
• Avoid concurrent NSAIDs and Aspirin.
• Administer with food or milk
• Monitor for therapeutic and adverse effects

Acute Pain Medication

• Opioids and Non-opioids

Opioids

• Mechanism of Action: Bind to specific receptors (mu, delta, kappa) in the CNS and PNS. They can act as agonists, partial agonists, antagonists, or mimic natural endorphins.
• Types: Strong (full agonists), Moderate (full agonists), Mild (weak agonists or partial agonists).

Opioids: Examples

• Fentanyl
• Morphine
• Hydromorphone (Dilaudid)
• Methadone
• Oxycodone
• Tramadol
• Codeine

Opioids: Adverse Effects

• CNS: Sedation, dizziness, euphoria/dysphoria, respiratory depression
• GI: Constipation, nausea/vomiting
• Cardiovascular: Hypotension, bradycardia
• Urinary: Urinary retention
• Other: Pruritus, tolerance, dependence, anaphylaxis

Opioids: CNS Depression

• Mechanism: Binding to opioid receptors, slowing down brain activity, leading to sedation, slowed breathing, and loss of consciousness in severe cases.
• Overdose treatment: Naloxone, administered intranasally, intravenously, or intramuscularly.

Opioids: Drug Interactions

• CNS Depressants
• Monoamine Oxidase Inhibitors (MAOIs)
• Anticholinergics
• Serotonergic Drugs
• CYP3A4 Inhibitors and Inducers
• Other Opioids and Mixed Agonists/Antagonists

Opioids: Lab Values to Monitor

• Liver Function (ALT, Alk Phos, Bilirubin)
• Renal Function (Creatinine, BUN)

Patient Controlled Analgesic (PCA)

• Method allowing patients to self-administer small doses of opioids through an IV pump
• Programmed variables include concentration of opioid solution, dose size (amount opioid per dose), lockout intervals (minimum time between doses), and total drug dose limit (max amount of drug over period of time).

Non-Opioids

• Pain-relieving medications that work through mechanisms other than opioid receptors. Effective for mild to moderate pain.
• Commonly used for pain associated with inflammation, headaches, minor injuries, and musculoskeletal conditions.
• Types: Acetaminophen, Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Non-Opioids: Acetaminophen

• Mechanism of Action: Blocks peripheral pain impulses, inhibits prostaglandin synthesis, antipyretics effects.
• Indications: Mild to moderate pain, alternative to aspirin, antipyretic effect.
• Contraindications: Drug allergy, severe liver impairment or liver disease.
• Adverse Effects: Hepatotoxicity, gastrointestinal distress, renal impairment (high, prolonged doses), rash, urticaria
• Overdose/Toxicity: Life-threatening, acute ingestion results in liver toxicity, long-term ingestion in nephrotoxicity, major cause of serious liver injury. Use activated charcoal, N-acetylcysteine (NAC), and liver function monitoring to manage.
• Drug Interactions: Alcohol-increased risk of hepatotoxicity; Warfarin- enhanced bleeding risk; Phenytoin, Rifampin, Barbiturates-potential interactions.

Acetaminophen: Monitoring and Patient Education

• Regularly assess liver function tests (e.g., ALT, Alk Phos, bilirubin) for patients on acetaminophen, especially those with existing liver conditions.
• Watch for signs of gastrointestinal distress and renal impairment during therapy.
• Advise patients to not exceed a maximum daily dose (4 grams).
• Encourage reporting of unusual symptoms, especially signs of liver distress and gastrointestinal issues.

Adjuvant Analgesic Therapy

• Definition: Drugs added to enhance existing pain management for types of pain that don't respond well to traditional analgesics.
• Examples: Antidepressants, Antiseizure agents, Glucocorticoids, Muscle relaxants, Local anesthetics, NSAIDs, Bisphosphonates

Non-Pharmacological Management of Pain

• Physical Therapies: Hot or cold packs, massage, transcutaneous electrical nerve stimulation (TENS), physiotherapy.
• Mind-Body and Psychological Therapies: Cognitive behavioral therapy (CBT), biofeedback, relaxation techniques, mindfulness and meditation.
• Complementary Therapies: Acupuncture and acupressure, yoga.
• Distraction and Sensory Techniques: Distraction, music therapy, art therapy, pet therapy, therapeutic exercises and communication.
• Comfort: Frequent repositioning, cold/ice, warm blanket, verbal reassurance, deep breathing( exercises), and presence by the nurse.

Understanding Tolerance, Dependence, and Addiction

• Tolerance: Body requiring higher doses of medication to achieve the same effect over time.
• Dependence: Body adapting to the drug, resulting in withdrawal symptoms if the drug is suddenly stopped.
• Addiction: Psychological condition characterized by compulsive drug-seeking behavior, despite harm.

Why Things Hurt

• Pain as protection
• Brain constructs pain
• Neuroplasticity and chronic pain
• Education and perspective on pain helps

WHO Pain Management Ladder

• Steps for pain management (mild to severe)
• Includes non-opioid, opioid analgesics, and adjuvants