Week 6 Study Guide PDF

lOMoARcPSD|36536331 Week 6 Study Guide practical nursing theory 2 (Centennial College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Abinaya Ravinderan (abinayara...

lOMoARcPSD|36536331 Week 6 Study Guide practical nursing theory 2 (Centennial College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE 1. Identify the factors that influence the pain experience.  Pain Experience = Its is the symptom most associated with describing oneself as “ill.” o Most common reason why people seek health care services. o Not well understood despite being a common issue. o Inconsistently and inadequately addressed. o Has both a physical and psychological nature of the experience.  Pain is "whatever the person experiencing it says it is, and existing wherever the person says it does."  Factors of the Pain Experience: o Age/Developmental stage  developmental differences determines how children and older adults perceive and react to pain o Gender  Women have higher threshold and experience more intense pain than men. o Previous experience with pain o Meaning of pain  affects the pain experience and how a patient adapts. Pain will be perceived differently if it suggests a threat, loss, punishment or challenge. o Heredity  generic disposition can influence our ability to metabolize pain med, pain threshold, pain tolerance and susceptibility to develop chronic pain. o Emotional status o Social Factors  Attention – more focus on pain can influence pain perception.  Experience - previous painful experience may determine how a patient responds to future painful events.  Family & Social Support – family and friends provide comfort, protection and support. o Absence of support can make the pain experience more stressful/unpleasant. o Culture / ethnic values  shapes individual responses, behaviours & attitudes about pain and how they react and cope.  Expectations and accepted behaviours about pain are learned.  Nurses may expect patients to act or behave in a particular manner when in pain. Some cultures are expressive about pain while others are not. 1 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE  Remember that pain has different meanings for different cultures (culturally sensitive care). o Environment & support person o Spiritual Factors  Religion & spirituality help some people to connect with nature/universe.  Pain may be viewed as retribution from God, chance to demonstrate inner strength with a reward to come after death.  Hope, prayer, attending church prayer, spiritual support have all been linked to less pain suffering.  Use of spiritual assessment tool (FICA) is helpful to explore patients' spirituality/pain relationship. o Anxiety & Stress  associated with many types of pain although cause and effect not established. If anxiety goes unnoticed, pain may not be managed effectively. o Sleep  disturbances including insomnia can increase pain perception & intensity, decrease coping abilities 2. Discuss the key strategies, barriers, and principles of pain management.  Definition of Pain o "An unpleasant subjective, sensory and emotional experience associated with actual or potential tissue damage." o Highly individualized. Personal experience. Can be accurately described only by the person experiencing it. o Pain also serves a protective role; a warning sign of potentially life- threatening condition. o Referred to as the: “Fifth Vital Sign”  Significance of Pain Problem o Unrelieved ongoing pain is an epidemic in Canada and other parts of the world. o Pain is the leading cause of disability among working aged Canadians. Up to 60% of pain sufferers in Canada lose their jobs or incur great income loss (back pain). o Global impact of pain has a major negative economic impact (estimated lost productivity ranging from US$297.4 -335.5 billion) o Prevalence of chronic pain increases with age (65% in community dwelling & 80% in long term care facilities) o Cancer patients (newly diagnosed, receiving active treatment, advanced stage) often receive inadequate pain treatment 2 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o Common surgical procedures leaves 5-50% of patients in pain (moderate –severe) o When left untreated, acute pain can progress to persistent/chronic pain  Reasons for Untreated Pain o Lack of knowledge and skills to adequately assess and treat pain o Misconceptions about pain o Inadequate and inaccurate information (patient & nurse) regarding addiction, tolerance, respiratory depression, and other adverse effects of opioids o Long wait times o No access for pain experts  Untreated pain results in: o Suffering (progress to persistent/chronic pain). o Physical dysfunction. o Psychological distress (manifests as anxiety or depression). o Impairment in recovery from acute illness and surgery o Immuno-suppression (increases risk of infection). o Pain causes sleep disturbances. o Unrelieved pain can cause increased morbidity d/t respiratory and cardiac dysfunction (for acutely ill patient).  Nature of Pain o Pain is more than a physical sensation caused by a specific stimulus. o A person's perception of pain includes affective (emotional), cognitive, behavioural and sensory components. o Past experiences, culture and situational factors impact the pain perception. o Nature of pain stimulus can be physical or psychological or a combination of both.  Physiology of Pain  o Nociception has four (4) process: o Transduction – damaged (thermal, mechanical or chemical) tissue cells 3 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE releases pain-sensitizing/inflammatory substances that activates nociceptors. o Transmission – pain sensitizing/inflammatory substances surround pain nerve fibers in the extra cellular fluid, creating spread of pain messages/impulses from site of transduction to the brain. o Perception – Conscious awareness/experience of pain. The recognition, definition & response of pain by the individual experiencing it. o Modulation – Increase or decrease in pain intensity that can take place before, during and after pain is perceived. Types of Pain  Acute Pain o Sudden onset (e.g., post-op, trauma, labour, angina, fracture, dysuria) o Usually has an identifiable cause (somatic, visceral, nociceptive) o Usually within the normal time of healing o Mild to severe o Short duration (6 months or less) o Predictable ending o Eventually resolves with or without treatment after damaged area heals o Physical & Behavioural Manifestations:  Manifestations reflect sympathetic nervous system activation  Increased heartrate  Increased respiratory rate  Increased blood pressure  Diaphoresis  Pallor  Anxiety  Agitation  Confusion  Response normalize quickly owing to adaptation  Usual goal of treatment: Pain control and eventually elimination.  Persistent/Chronic Pain o Gradual or sudden onset (e.g., o Pain that persists past normal time of healing o Mild to severe o May be experienced at any age in life including early childhood 4 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o May be intermittent (occurs in a pattern) or persistent (lasting more than 12 hours daily) o Result in great personal suffering o Malignant or non-cancer related o Physical & Behavioural Manifestations:  Predominantly behavioural manifestations  Changes in affect  Decreased physical movement and activity  Fatigue  Withdrawal from people and other social interaction  Usual goal of treatment: Minimizing pain to the extent possible, focusing on enhancing function and quality of life. Role of the Nurse in Pain Management  Nurses need understanding of many dimensions of pain to do proper assessment and management.  Nurses act as planners, educators, patients advocates, interpreters, supporters (of patient, family and care givers).  Goals of pain assessment are: o To describe the patient’s pain experience (sensory, behavioural, sociocultural) for the purpose of implementing pain management techniques. o To identify the patient’s goal for therapy (resources & strategies for self- management). o To conduct accurate assessment.  Nursing roles regarding pain management includes: o Assessing, documenting, and communicating findings to the other members of the health care. o Ensuring delivery of effective pain relief measures/therapies. o Monitoring of adverse effects. o Teaching patients and caregivers. o Addressing concerns of clients regarding pain and treatment. Nursing Process for Pain  Knowledge of pain physiology & factors that influence pain will help the nurse to manage the patient's pain more effectively.  The NP provides nurses with a systematic approach to understanding and treating a patient's pain. 5 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE  Pain management goes beyond pain relief to include the patient's quality of life including work, play and family involvement.  The NP along with evidence-based practice will frame guidelines for effective pain management Assessment  must be initiated by the nurse  often considered the fifth vital sign  frequency of assessment depends on client situation  It is the basis of pain management  Ongoing pain assessment is necessary along with other vital signs  Effective and timely pain assessment is best achieved by using a validated pain assessment tool that is best suited for the patient  When choosing a pain assessment tool, consider the patient's age & development, condition, type of pain, culture, cognitive ability, preference and ease of use (for patient and nurse)  Assessment should include obtaining information about pain intensity, pain location, pain descriptors, effects of pain on function and mood  Factors that increase /decrease pain response  Cultural variations in how pain is expressed  Knowledge on non-verbal communication  Types of error when assessing pain: o Bias – leads to nurse overestimating or underestimating pain. o Unclear assessment questions. o Use of unreliable assessment tools. o Lack of ability to self-report pain due to inability to use scale or to verbalize pain. o No consideration of patient's present pain or changes in patient's expression of pain (gold standard) Subjective  Initial Pain Assessment: PQRASTUV  What other questions should you ask that are not covered by “PQRASTUV”? 6 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE  Patterns of Pain o Pain onset (when it starts) and duration (how long it lasts) comprises the pain pattern. o Pain from surgery or injury diminishes overtime, gets better as healing occurs. o Arthritic pain is more severe in the morning as joints are stiffer, pain diminishes as joints become more mobile during the day. o Pain maybe constant (round the clock) or separate periods of intermittent pain. o Breakthrough pain: Moderate to severe pain that occurs despite treatment.  Areas of Pain o Area of pain helps to determine cause and treatment. o Some patients may describe specific locations, others may not (all over). o Pain maybe referred from original site to another (felt in site separate from pain source; Chest pain radiates to jaw, shoulder, left arm). o Pain may radiate from origin to another site (radiate down leg from sciatica nerve irritation). o Sciatica pain originates from compression or damage to sciatica nerve or spinal cord (causes painful shooting sensations down the back of the thigh & inside the leg)  Description of Pain o Pressure o Dull o Cramping o Tender o Aching o Burning o Discomfort o Squeezing o Stabbing  Intensity of Pain o Assessment of intensity/severity gives accurate measurement to decide type of treatment & evaluation of treatment. o Pain scales help patients to communicate the intensity of the pain. 7 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o Pain scales must be adjusted to age & cognitive develop. Objective/Physical  Physiological  Behavioural/Nonverbal Indicators of Pain o State/vocalize - moaning, crying, gasping, burning o Facial expressions – grimacing, clenched fist, wrinkled forehead, tightly closed or widely opened eyes, lip biting o Body Movement – restlessness, immobilization, muscle tension, pacing, guarding, rubbing, rhythmic movement o Social Interaction – avoidance of conversation, focused only on activities for pain relief, reduced attention span, withdrawn  Chronic or acute pain 3. Identify best practices for relieving symptoms using pharmacological and non-pharmacological nursing interventions to manage pain.  Pharmacology – know the WHO Step Ladder Approach  Physical o Cutaneous stimulation  massage  application of heat / cold – also refer to readings for PNUR125 r/t heat and cold application  acupressure  contralateral stimulation  reflexology o Immobilization  Splints  Supportive devices o Transcutaneous electrical nerve stimulation 4. Discuss the lived experience of a client living with acute and/or chronic pain.  Types of pain – define & give an example for each type:  Origin o Visceral 8 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o Cutaneous o Somatic  Location o Referred o Radiating o Neuropathic o Phantom o Intractable o Syndromes  Nature o Acute o Chronic o Breakthrough  Differentiate (PATH 122) o Pain threshold o Pain sensation o ain reaction o Pain tolerance NURSING DIAGNOSES  Pain (indicate where, type) r/t (factors) s/b (symptoms)  Pain-Related Nursing Diagnoses Activity intolerance Anxiety Body image disturbance Coping difficulties Hopelessness/Powerlessness Sleep pattern disturbance Social interaction changes Sexual practices alteration Thought process alteration Knowledge deficit  Nursing Diagnosis: o Should be done after a thorough pain assessment is completed. o Careful consideration of procedures or pre-existing pain will help to determine/diagnose pain. o Focus on nature or origin of pain so the nurse can intervene to alleviate pain and its impact. o Ensure that the related factors are accurately identified so the nurse can intervene appropriately. o For example, pain related to recent surgery is different from pain related recent fall - (need to assess vital signs). PLANNING  Includes both pharmacology & nonpharmacological methods 9 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE  Know the how, what & when each one will be used  Actively involve HTC in improving assessment and management of pain (including strategies to decrease opioid use).   Offer complimentary therapy pain treatment modality (to supplement health care practices, CNO, 2022).  Facilitate access to prescription monitoring programs.  Engage patients in treatment decisions about pain management.  Provide referrals to treatment programs for patients with addiction.  Plan of care involves assesment data, critical thinking, professional standards and evidence to determine the best interventions.  Consider organizational policies and professional standards (RNAO); Canadian Pain Society for resources.  Practice with caring approach (may help patient to accept therapies).  Consider interventions like positioning, hygiene & rest (promote comfort).  Involve other member of the HCT in pain management plan.  Use adult learning principles when educating patient and families.  Interventions should be aimed at relieving patient's pain in Health care or home setting.  Prioritize interventions based on level of patient's pain.  Provide skills and knowledge to help the patient and the family to manage and understand the pain.  Consider previous patient experiences and responses to pain.  Be confident when selecting therapies (lessen patient anxiety level).  Always apply ethical principles (beneficence and non-maleficence).  Implementation: o Pain nature and impact on well-being determine interventions. o Pain therapy needs individualized treatment approach. o MD, nurse, patient, family and health care team collaborate to relieve patient’s pain. o Least invasive therapy should be tried first. o Patient remedies often work (especially if they have experience pain before).  Pain Therapy – Basic Principles o Routine assessment is necessary to manage pain well o Unrelieved pain complicates recovery o Health care providers are responsible for proper assessment, intervention and documentation o Pain relief is a basic human right, HCP must be aware of personal biases and misinformation 10 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o Collaborative effort including HCT, patient, and family o Treatment based on patient and family goals. o Treatment plan must include non-pharmacological & pharmacological therapies o Therapies must be evaluated o Adverse effects of medications must be prevented/managed o Patient and family teaching must be done GOAL  High priority is to control & manage pain at a level that is acceptable to pt.  Individualized approach should be used  Multidisciplinary approach is best  Break down the barriers & reduce misconceptions  Pre-emptive Analgesia = a treatment that is initiated before the surgical procedure in order to reduce this sensitization. Key Terms Related to Pain Management  Equianalgesic Dose: - dose of one analgesic that produces pain-relieving effects equivalent to those of another.  Titration: - dosage adjustment based on assessment of effectiveness of analgesic effect.  Adjuvant therapy: - Meds originally developed to treat other conditions but have shown analgesic properties so they are used in conjunction with analgesics. o Classes of drugs considered as adjuvant therapy includes:  Anticonvulsants such as gabapentin, for neuropathic pain  Antidepressants such as amitriptyline for neuropathic pain  Corticosteroids (alpha adrenergic antagonists) such as clonidine for dysmenorrhea  Pain tolerance – Amount (duration and intensity) of pain an individual can endure before outwardly responding to it.  Addiction – Strong psychological and physical dependence on a drug, usually resulting from habitual use, that is beyond normal voluntary control.  Opioid withdrawal – The signs and symptoms associated with abstinence from, withdrawal of, or reduction of an opioid analgesic when the body has become physically depend on the substance.  Tolerance – A progressive decrease responsiveness to a drug resulting in the need for a larger dose of the drug to achieve the effect originally obtained by a smaller dose. 11 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE INTERVENTIONS  Non-Pharmacological Pain Relief Interventions o Can reduce doses of pain medication& minimize side effects. o Some can be initiated by nurses without MD’s order. o Not to be used instead of pharmacological agents but in addition to. o Physical  Massage  Exercise  Turning & repositioning  Heat/Cold Therapy  Acupuncture o Cognitive  Distraction  Relaxation/guided imagery  Self-management  Pharmacological Therapy for Pain o World Health Organization (WHO): Proposed Analgesic Ladder.  Medications are given based the intensity/severity of the pain.  If pain incre ases, meds from higher step are given to control pain.  Not meant to be sequential (a pt. with severe pain would get the strongest analgesic in level 3). o Step 1 - Mild pain (Nonopioid Analgesics)  Acetaminophen – maximum daily dose of 4 grams  Salicylates: Acetylsalicylic acid – possibility of upper GI bleed.  Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)  Ibuprofen (Motrin, Advil) – usually well tolerated despite risk of GI bleed.  Ketorolac (Toradol) – Treatment should not exceed 7/day; may cause renal failure in dehydrated patients.  Naproxen Sodium (Aleve, Naprosyn)– To reduce GI upset, take with food, milk or antacid; risk of GI bleed.  Celecoxib (Celebrex) – Assess patients who are taking other anticoagulants, NSAIDs will increase risk of bleeding. o Step 2 - Mild to moderate pain (Opioid Analgesics)  Morphine-Like Agonist – Codeine 12 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE  Fentanyl (Duragesic patch)  Regulated by Federal law  Evaluate pain status before administration and 1 hour after  Administer on a fixed schedule  Taper down slowly if physically dependent  Do not drink alcohol while taking these drugs.  Increase fluid and fiber  Do not take OTC drugs as well o Step 3 - Moderate to severe pain (Nonopioid Analgesics)  Morphine  Morphine-Like Agonists  Hydromorphone (Dilaudid)  Fentanyl  Oxycodone  Methadone  Morphine Antagonist e.g. naloxone (Narcan), naltrexone (should be readily available).  INDICATION: emergency situations when acute opioid overdose is suspected (coma, respiratory depression, pinpoint pupils). Given IV for a respiratory rate under 10 bpm  Side Effects of Opioid Agonists o Central Nervous  Sedation, disorientation, euphoria, tremors, lightheadedness, lowered seizure threshold, delirium, agitation, pupil constriction, dependence o Respiratory  Respiratory Depression, asthma exacerbation, cough suppression o Cardiovascular  Hypotension, palpitations, flushing o Gastrointestinal  Nausea, vomiting, constipation, biliary tract spasm o Genitourinary  Urinary retention o Integumentary  Itching rash, wheal formation Patient & Caregiver Teaching  Goals of patient & caregiver teaching r/t pain management includes: o The need to keep a record of pain intensity and effectiveness of treatment. 13 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o Do not wait until pain intensifies to treat (pharmacological & non- pharmacological) o Pain medications may need adjustment overtime to ensure effectiveness. o Potential side effects of Opioids include – nausea, constipation, sedation & drowsiness, itching, & sweating. o Tell your HCP if pain is not relieved by current treatment plan.  Barriers to Pain Management o Fear of addiction or tolerance o Concern about adverse effect o Fear of injections o Desire to be a good patient o Desire to be stoic o Forgetting to take analgesic o Fear of disease progression (pain as an indicator) o Sense of fatalism o Ineffective treatment o Inadequate HCP education o Lack of institutional support  Age-Related Considerations & Pain o Persistent pain is common, associated with physical disability and psychosocial problems. o Musculoskeletal conditions such as osteoarthritis, back pain, old fractures most common source. o Although prevalence is high, pain in the older population is inadequately assessed and treated. o Perceive pain as “normal”. Does not want to be a bad person” or “burden.” o Barriers – cognitive changes, hearing changes, vision changes. o Metabolize drugs slower so at increased risk of toxic/adverse effects (start low and go slow). o NSAIDs has high frequency GI bleeds. o Older people take multiple drugs, analgesic may cause interactions. o Cognitive impairment and ataxia can get worse with analgesic use. o Include non-pharmacological therapies in treatment plan. o Encourage exercise and do patient teaching. o Identify/Support roles of family and paid caregivers.  Ethical Issues in Pain Management 14 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])  lOMoARcPSD|36536331 PNUR124 WEEK 6 STUDY GUIDE o Fear of hastening death by administering analgesics. o Use of placebos in pain assessment and treatment. Evaluation  Need to continually evaluate and re-evaluate when you provide interventions for pain management – Are the interventions effective? What changes need to be made? Alternative options? 15 PNUR124 Downloaded by Abinaya Ravinderan ([email protected])