Study Guide 22: Pain (Ch. 36) PDF

Zeno Chat gpt ai chat Study Guide #22 Pain (Ch.36) Outcomes: I Define and discuss the nature of pain Identify causes of pain i State the functions of pain Discu...

Zeno Chat gpt ai chat Study Guide #22 Pain (Ch.36) Outcomes: I Define and discuss the nature of pain Identify causes of pain i State the functions of pain Discuss the reasons for potential undertreatment of pain or risk of injuries Describe the physical and emotional components of the pain pathway Discuss the gate control and neurochemical theories of pain transmission Differentiate between types and sources of pain ↳ Discuss factors that impact a person’s response to pain Describe the consequences of undertreated pain 10 Apply the nursing process to the care of patients experiencing pain Il Discuss pharmacological and non-pharmacological approaches to pain management at end ball answered Material: 1. Basic Concepts: a. Pain: unpleasant and emotional experience i. Whatever, wherever, and whenever the patient says that it is ii. Has both sensory and emotional components iii. The patient does not have to prove he is having pain to receive treatment iv. All pain is real v. Pain is subjective *You might be fooled by a drug seeker or malingerer, but you never fail to treat a patient who is having pain b. Pain process/pathway: i. Transduction 1. Stimuli→stimulation of nociceptors (transduction) a. Tissue damage b. Pressure  c. Heat 2. Transmission a. Pain impulses travel to spinal cord and brain b. Impulse transmission facilitated by pain producing neurotransmitters 3. Perception- sensory realization that pain is present (physical response) a. Physical component (sensation & physical reaction) i. Indicated an intact nervous system ii. Spinal reflexes→rapid physical response to limit tissue damage b. Emotional component (perception of pain) = suffering 4. Modulation- sensation reduced by neuromodulators (endogenous opioids) c. Functions of pain: protective mechanism i. Signal of tissue damage ii. Signal that something is wrong iii. Prevent further injury *People who cannot feel pain or communicate their pain are at risk for injury and undertreatment of pain iv. Risk of undertreatment or injury 1. Cannot feel pain: neuropathy, para/quadriplegia, 3rd degree burns 2. Cannot Communicate Pain: comatose, infants, children, aphasic, cognitive impairment (dementia/delirium), language barriers, endotracheal/tracheostomy tube d. Pain Theories: i. Gate Control 1. Spinal Cord a. Small nerve fibers carry pain impulses (slower) b. Large nerve fibers carry pleasure impulse (faster) and close chemical “gates” to block pain impulse transmission 2. Non-drug measures based on this theory (e.g., massage, heat & cold treatments) 3. Other factors thought to affect the “gates” (e.g., emotions, past experiences)  ii. Neurochemicals 1. Endorphins & enkephalins—endogenous (natural) opioids a. Attach to opiate receptors to block pain impulses b. Short duration of action c. Release caused by brief pain or stress, physical activity, sexual activity d. Release blocked by prolonged pain or stress iii. Pain Producing neurotransmitters promote transmission of pain impulses (prostaglandins and histamines) e. Types of Pain: i. Chronicity or duration (time) of Pain 1. Acute—usually less than 6 months a. Sudden onset b. Identifiable cause c. Relief with treatment of underlying cause 2. Chronic—usually longer than 6 months a. Gradual onset b. Cause often not identifiable c. Limited response to conventional treatment d. May be related to a previous injury or untreated pain e. Can lead to fatigue and depression f. Might have exacerbations (worsening/ recurrence) and remissions (improvement) ii. Sources of pain 1. Superficial (cutaneous) a. Skin or surface structures b. Localized to the site of stimulus 2. Deep—deeper body structures a. Somatic—connective tissue b. Visceral (organs) c. Referred—felt someplace other than origin ( d. Neuropathic- caused by nerve damage or irritation (e.g., shingles, phantom limb sensation, sciatic nerve pain) 3. Cancer a. Related to cancer or cancer treatments b. Pain increases as disease progresses 2. Patient Factors: a. Responses and Reactions to Pain i. Pain threshold—point where pain is first felt 1. Sensory (physical) component 2. Generally thought to be consistent (degree of stimuli to produce pain similar for everyone) 3. Endorphin levels account for some differences ii. Pain tolerance—degree of pain a person is willing to endure 1. Emotional component 2. Considers the role of the limbic system (responsible for the emotional response to pain) 3. Variable– different for each person *There are factors that can raise or lower the patient’s threshold or tolerance for a person b. Types of Pain Responses i. Behavioral/ voluntary– observable physical reactions to sensation of pain ii. Physiological/ involuntary)– predictable sympathetic and parasympathetic responses to pain iii. Affective/ psychological– emotional responses to pain c. Factors that Influence Pain Response i. Acuity of pain receptors 1. Accounts for some of the decreased sensation with neuropathies 2. Cannot assume that elderly people have dulled receptors ii. Variations in endorphin release iii. Past experience with pain iv. Perception of what pain means– possible known or unknown causes v. Cultural/ religious beliefs 1. Might be learned behavior (e.g., some cultures tend to be stoic other demonstrative; in family– son sore after playing sports told to “suck it up” while his sister learns that menstrual cramps earn sympathy) 2. Religious beliefs can be a source of comfort or contribute to suffering d. Experience with Opioids i. Opioid-naïve patients 1. Expected effects at usual dosage ranges  2. More likely to have side effects (e.g., sedation & respiratory depression ii. Opioid-experienced patients (e.g., chronic pain, cancer pain) 1. Able to tolerate higher doses 2. Can increase dose when no longer effective 3. Must wean off when changing to non-opioid management of pain (chronic pain) iii. Opioid-addicted patients 1. Tolerate higher doses 2. Individualized approach to pain management iv. Recovering opioid addicts 1. Might refuse opioids due to fear of relapsing 2. Opioid will be ineffective if taking a long-acting opioid antagonist (e.g., naltrexone) e. Consequences of Undertreated Pain i. Stress response → VS changes, increased metabolism ii. Immunodeficiency iii. Negative emotional responses iv. Limited mobility → limitations in ADLs & complications of inactivity v. Difficulty coughing & deep breathing → pulmonary complications 3. Nursing Process: *Pain is a challenge to manage! Most health care providers are poorly educated to manage pain Many fear that they will promote addiction, hasten death or face legal action for too many narcotic Rxs. Strides have been made in pain management in terminal care, but less so in other types of pain. It is important to approach pain management in a systematic manner and to include the patient. It is important to manage pain before it gets out of control a. Joint Commission Standards, effective 2018 i. Identify pain assessment & management as a facility-wide priority ii. Active involvement of medical staff as leaders in developing policies, protocols and metrics  iii. Assess & manage patient’s pain to minimize complications 1. Screening and assessment tools 2. Evidence-based practice & interventions 3. Assessment includes functional impact and effect on quality of life 4. Involve patient in setting realistic goals and determining interventions (drug and non-drug) 5. Offer at least one complimentary pain treatment method (non- drug) 6. Monitor for adverse effects of medications, especially opioids 7. Teaching related to safe use, storage, handling and disposal of opioids iv. Monitor effectiveness of interventions (data collection) v. Analyze data to improve safety and effectiveness of pain management b. Pain Assessment i. Pain is the “5th VS” & should be part of every assessment- the historic “don’t ask, don’t tell” approach is gone! ii. Required for adequate management iii. Whatever you find must be addressed iv. Methods of Assessment 1. Subjective a. Patient description b. Pain scales– 0- 10 c. Numeric/ analog d. Faces scale 2. Objective a. Simple observation b. Pain behaviors c. Sympathetic response 3. Special Situations a. Infants & young children (see handout packet) i. FLACC scale ii. Faces scale b. Cognitive impairment– PAINAD scale ** The patient is an expert about their own pain v. Barriers to Pain Assessment 1. Cannot communicate pain (see previous list) 2. Fear  a. Injections (especially children) b. Elderly– being labeled a “complainer” c. Overmedication d. Addiction 3. Caregiver attitudes (including family members as well as professionals) 4. Cultural differences c. Nursing Diagnoses i. Acute pain ii. Chronic Pain *Pain is the most commonly used nursing diagnosis and the most common reason people seek health care d. Planning & Outcomes i. Individualized pain relief ii. Establish goals with patient for acceptable pain level 1. Rating 2. Level of functioning iii. Include drug and non-drug approaches iv. Planning depends on whether pain is acute or chronic and the patient’s response to it v. Always include the patient! vi. Mention the role/use of Pain Clinics in managing chronic pain e. Implementation i. Pharmacological Approaches—require order from authorized prescriber 1. WHO Analgesic Ladder- Explain ladder; a. using more than one types of drug attacks pain from different angles– originally developed to manage cancer pain; there are some adapted models for acute and chronic, non-cancer pain 2. Non-opioids- block pain in periphery &/or reduce prostaglandin production a. Mild to moderate pain (rating of 1- 5) b. NSAIDs & salicylates (ibuprofen, aspirin) i. Block prostaglandin formation ii. Predominate adverse effect– GI distress c. Acetaminophen i. Blocks peripheral pain impulses  ii. Predominate adverse effect– liver damage d. “Ceiling” effect—cannot escalate doses—higher doses will provide no further pain relief, but side effects may continue to worsen (dose related) 3. Opioids—block pain impulses in CNS a. Indications i. Moderate to severe pain (5-10 rating) ii. Breakthrough pain– small doses of short-acting opioid b. Actions i. Attach to opiate receptors to block pain impulses ii. Affect limbic system to reduce emotional response to pain iii. Be alert to extended action forms of drugs— longer action= potential for longer or delayed adverse effects c. Adverse Effects i. Sedation—important to monitor effect (LOC and respirations) in opiate-naive patients ii. Respiratory depression 1. Can take deep breath if instructed a. Respiratory depression + sedation → dangerous situation iii. Pruritis—(due to histamine release)—change drugs iv. Constipation 1. Tolerance does not develop 2. Need measures to prevent (usually stool softeners) v. Addiction potential (controlled substances) 1. Follow prescribing and administrative guidelines 2. Monitor use and response to medications 3. Use only as long as necessary 4. Transition to non-opioid drugs & non-drug measures  d. Routes—po, IM, SC, IV, rectal, intrathecal (intraspinal), transdermal i. Intrathecal 1. Given directly into CSF—very effective at lower doses 2. May combine w/ local anesthetic lower doses & less adverse effects (but might be SE from both drugs) 3. Usually managed by anesthesia ii. PCA—IV or intraspinal e. Equianalgesic doses– opioid doses that provide equal pain relief (see Lilley, p. 144, Box 10.2) 4. Adjuvants—affect limbic system or reduce nerve impulse transmission a. Usually for chronic pain b. Generally classified as analgesics (used for pain management rather than their usual purpose) c. Action i. Combat analgesic SE ii. Enhance analgesic effects d. Examples i. Antidepressants ii. Anticonvulsants iii. Anesthetics 5. General Guidelines a. Give around the clock for expected pain—post-op, cancer, acute injury b. Be aware of onset, peak and duration times– guides evaluation of effects and frequency of dosing c. May combine opioids and non-opioids i. Might be combined in same tablet (e.g., Vicodin= hydrocodone & acetaminophen) ii. Be aware of total acetaminophen dose 1. Maximum dose= 3- 4 Gm/day & 1 Gm/ dose (per McNeil website— recommendation recently reduced from 4 Gm to 3 Gm/ day; 325 mg tabs is 2350  mg; professionals can use their discretion and recommend up to 4 Gm/ day) 2. Lower recommendation for patient’s w/ existing liver damage 3. Risk of hepatotoxicity increased with alcohol consumption iii. Monitor response 1. Therapeutic and adverse effects 2. Be alert to adverse reactions from both drugs with combination drug **Research shows that nurses do not often follow the research-based guidelines leaving patients with poorly managed pain. Example—Demerol is not better than morphine because of the metabolite, but nurses continue to promote its use 6. Patient-controlled Analgesia (PCA) Safety a. Only patient should push button unless unable to do so b. Teach patient, family members & visitors about safe PCA use c. Post tags on pumps instructing that “only patient should press button” d. Safety feature i. If the patient is not alert enough to push the button, opioid administration is probably not safe ii. Based on the principle that sedation precedes respiratory depression iii. Well-meaning visitors will push the button for a sleeping patient if they are not aware of this safety feature e. Family Controlled Analgesia i. Patient is unable to manage PCA (e.g., children, confused, or simply don’t want to manage their own pain) ii. Designate and teach one family member to push the button iii. Teach to monitor the patient for signs of pain, level of consciousness and to push the button  iv. Respite caregivers can take over, but only one pain manager at a time! f. Nurse Activated Analgesia i. Nurse has primary responsibility for managing the PCA (usually when no one else is willing or able to assume the role of pain manager) ii. Again, only one person can manage at a time. 7. Placebos a. No role in pain management b. Expectation might endorphin release (placebo itself has no pharmacological action) c. Ethical consideration—trust not only of individual nurse or prescribe but also of professions and health care system ii. Non-pharmacological Approaches 1. Supplement to medications for acute/ expected pain a. Holistic approach to manage chronic pain b. Examples i. Basic care measures- e.g., backrub, hygiene, positioning ii. Heat & cold treatments iii. Comfort measures iv. Distraction– reading, TV, music v. Relaxation vi. Support usual coping mechanisms vii. Spiritual care 2. Patient Education a. Promote control and autonomy b. Improves ability to manage pain c. Teach prevention and early management d. Pain free is not always realistic or desirable 3. Transcutaneous Electrical Nerve Stimulation (TENS) a. Electrical stimulation of cutaneous nerves → endorphin release and closes gates b. Able to control degree of electrical stimulation c. Relies on endorphins and gate control theory 4. Measures Requiring Specialized Training a. Physical therapy  b. Massage therapy c. Art/ music therapy d. Acupuncture e. Acupressure f. Biofeedback Hypnosis g. h. Neurosurgical measures—last resort—involves cutting nerves to stop impulse transmission f. Evaluation of Management Measures i. Acceptable level of pain (on scale) after intervention ii. Degree of adverse effects of medications iii. Functional level– can patient do what he/she desires? g. How do opioids differ from non-opioids? i. Action, pain level, side effects ii. Non-opioids-- limited routes; ceiling THERE ARE REVIEW QUESTIONS utcomesan unpleent and emotional , Whatever , wherever , t whenever the patient lay itis concepts. 6 Gate control theory sensory demotional : nerve fibers carry pain that small be addressed - suggests pleasure must fibers carry -all pain is real + impulses while large transmission be caused by : tissue damage pressure, heat impulses , inflorencing pain 2. Pain can , leading to transduction Theories : ↳ these stimulate nociceptors Neurochemical like 3. Functions of pain are: - involve endogenous opioids encephaling that block Mechanism endorphins + - protective tissue damage pain impulses at Opiate receptors - signaling is wrong - indicating something 7. Types of Pain : further injury acute (short term identifable cause preventing - when : , term ; Unidentifable ( occurs 4 under treating pain. feel pain - Chronic (long cannot - patients - cannot communicate pain treatment t injuries Source of Pain : risk for under Aboth higher Superficial (cutaneous at - deep (somatic visceral & Components : 5. Physical - - transduction - referred pain - transmission - neuropathiz pain perception. Response 8 Pain Factors : - to - modulation components : threshold - individual Emotional pain - differences to the - pain tolerance endorphin - related like of suffering responses levels perception - emotional experiences with pain past - - cultural beliefs  1) Pharmacological vs Non-pharmacological 9 consequences :.. undertreated pain. - Stress responses (vital Sign Changes - Pharmacological WHO analgesic · ladder - immunodeficiency for mild-moderate · using non-opioids emotional effects pain - negative pain f for moderate-severe - limited mobility - Non pharmacological the - difficulties in breathing o techniques that align with gate control theory Process : 10. Pain in the Nursing ↳ ex-massage/heat assessment - systemic application - involve patient in pain management 5th vital sign pain - = various tools - accessing using individualized for pain - Letting goals relief