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Stimulation of the sensory nerve endings that is harmful, injurious, or detrimental to physical health.

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Noxious

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- Mild or severe - Chronic or acute - Intermittent or intractable - Burning, dull, or sharp - Precisely or poorly localized - Referred

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Types of pain

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Pain that is felt at a site other than in the injured or diseased organ or part of the body. An example is the pain of coronary artery insufficiency that will in some cases be felt in the left shoulder or arm, or the jaw.

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Referred pain

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Intense, unpleasant sensation of short duration, lasting less than 6 months. It creates an autonomic response that originates within the sympathetic nervous system, flooding the body with epinephrine and commonly referred to as the fight-or-flight response.

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Acute Pain

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Pain lasting longer than 6 months; can be as intense as acute pain; can be continuous or intermittent. It does not serve as a warning of tissue damage in process. Because of the prolonged time, the patient often develops chronic low self-esteem, change in social identity, changes in role and social interaction, fatigue, sleep disturbance, and depression.

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Chronic Pain

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Action of two or more substances or organs to achieve an effect of which each is capable

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Synergistic

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Suggests that pain impulses can be regulated or even blocked by gating mechanisms located along the central nervous system

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Gate Control Theory

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The proposed location of the gates is in the dorsal horn of the

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Spinal Cord

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Gating mechanisms are also subject to alteration by

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Thoughts, feelings, and memories

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What have the capacity o influence whether pain impulses reach a person's conscious awareness

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Cerebral cortex and the thalamus

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Potent polypeptides composed of many amino acids found in the pituitary gland and other areas of the CNS

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Endorphins

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What activate endorphins

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Stress and Pain

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Absence of the sense of pain without loss of consciousness. This result when certain endorphins attach to opioid receptor sites in the brain and prevent the release of neurotransmitters, thereby inhibiting the transmission of pain impulses.

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Analgesia

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A type of pain control that is managed with a pocket-sized, battery-operated device that provides a continuous, mild electrical current to the skin via electrodes. It is typically used for patients suffering post-operative or chronic pain.

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Transcutaneous electric nerve stimulation (TENS)

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Health care providers are expected to be knowledgeable about pain assessment and management, and facilities are expected to develop policies and procedures supporting the appropriate use of analgesic and other pain control therapies.

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Under the new TJC standards

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- Patient have the right to appropriate assessment. - Patient is to be assessed and regularly reassessed. - Patients will be taught the importance of effective pain management. - Patients will be taught that pain management is part of treatment. - Patients will be involved in making care decisions. - Routine and prn analgesics are to be administered as ordered. - Discharge planning and teaching will include continuing care based on the patient's needs at the time of discharge, including the need for pain management.

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TJC Requirement for Pain control

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This suggestion comes from the American Pain Society (APS)

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Making pain the fifth vital sign

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Decrease the patient's perception of pain as well as improve the patient's sense of control

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The purpose of noninvasive pain relief techniques

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Cutaneous stimulation (heat, cold, massage, and TENS), the removal of painful stimuli, distraction, relaxation, guided imagery, meditation, hypnosis, and biofeedback

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Useful noninvasive approaches include

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Anything that enters the body. Examples are - Nerve blocks - Epidural analgesics - Neurosurgical procedures - Acupuncture

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Invasive

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1. Misunderstandings of insufficient knowledge of pharmacologic principles 2. Concerns about addiction 3. Anxiety over administering too large a dose of an opioid analgesic

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Nurses and physicians often undertreat patients and even administer less medication than is ordered because

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- Nonopioid analgesics - Use primarily for mild to moderate pain but are sometimes also used to relieve certain types of severe pain - Aspirin, ibuprofen (Advil, Nuprin, Motrin), and naproxen sodium (Aleve) - Aspirin blacks pain impulses in the CNS and reduces inflammation

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Acetaminophen and Nonsteroidal Antiinflammatory drugs (NSAIDs)

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The maximum recommended dosage of acetaminophen is

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4,000 mg (4g) in 24 hours

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All NSAIDs pose the risk of

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Gastrointestinal (GI) bleeding

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- Morphine, meperidine (Demerol), hydromorphone (Dilaudid), and fentanyl (Actiq, Duragesic) - It act on higher centers of the brain to modify perception and reaction to pain. It decrease the perceptiion of pain by binding to pain receptor sites in the CNS. - Manage moderate to severe acute pain - Often delay gastric emptying, slow bowel motility, and decrease peristalsis. They also tend to reduce secretions from the colonic mucosa. Gastrointestinal dysfunction can result in ilus, fecal impaction, and obstruction - Constipation is the most common side effect

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Opioids

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- hydromorphone HCI - levorphanol - oxycodone -fentanyl

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Substitutes if the patient has an unusual reaction or allergy to morphine

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Opiates cause respiratory depression by

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Depressing the respiratory center within the brainstem

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Clinically significant respiratory depression occurs less often when administering opioids by the epidural route (0.07% - 0.4%) or by IV patient-controlled analgesia (0.1% - 0.23%) than when the intramuscular (IM) route is used (0.9%)

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Respiratory depression on opioids

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Opiate analgesic, provide 24 hour pain relief with once daily administration. These medication are replacing the older MS Contin, which provides only 12 hours of pain relief.

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Avinza and Kadian

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Contain 5 mg of oxycodone and 400 mg of ibuprofen, is now often prescribed for pain relief

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Combunox

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Because of its potential for inducing seizures, it is no longer the drug of choice for.

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meperidine (Demerol)

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The active metabolite is normeperidine. Because normeperidine is eliminated by the kidneys, do not use it in patients with decreased renal function. It is a poor choice in the older adult and patients with sickle cell disease because most have some degree of renal insufficiency. Repeated administration increases the risk of accumulation of normeperidine, so meperidine is not generally prescribed for patients requiring long term opioid treatment, such as those with cancer or chronic nonmalignant pain. Meperidine administration is contraindicated in patient receiving monoamine axodase (MAO) inhibitors and in patients with untreated hypothyroidism, Addison's disease, benign prostatic hypertophy, or urethral stricture. Meperidine is more likely than other opioid drugs to cause delirium in postoperative patients of all ages.

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meperidine

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Inflammatory mediator, released when cells are damaged, that sensitizes nerves that carry information about pain

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Prostaglandin

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Opioid antagoinst

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naloxone (Narcan)

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composed of diverse classes of drugs that relieve pain by a variety of mechanisms. Example, antidepressants appear to relieve pain by blocking the reuptake of serotonin, resulting in the presence of greater amounts of serotonin.

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Adjuvant analgesics

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It is the best administration after major surgery. They are suitable for bolus administration and continuous infusion, including patient-controlled analgesia.

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IV route for opioid analgesics

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Fluctuations in absorption, including delayed absorption in postoperative patients, making it an ineffective and potentially dangerous method of managing pain. Repeated IM injections are often painful and traumatic, deterring patients from requesting medications of relief of pain; they also have the potential to cause fibrosis of muscle and soft tissue and sterile abscesses

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IM route for opioid analgesics

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Optimal route, especially for chronic pain. It is convenient, flexible, and relatively steady blood levels. It use is appropriate as soon as the patient can tolerate oral intake and is the mainstay of pain management for ambulatory surgical patients.

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Oral route for opioid analgesics

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Allow patients to self-administer analgesics whenever needed. Each dose may be as small as 1 mL or 1 mg of morphine every 6 to 12 minutes. Assess the patient for signs of oversedation and respiratory depression

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Patient-controlled analgesia (PCA)

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Teach the use of PCA before surgery so that patients will know how to use it after awakening from anesthesia. (Confused and unresponsive patients, patients with neurologic disease, patients with impaired renal, hepatic or pulmonary function, and those unable to press the delivery button are not candidates for PCA)

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Preparation for Patient-Controlled Analgesia

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If someone other than the patient pushes the button on a PCA pump

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PCA by proxy

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- PCA bolus doses with a continuous infection (also called a basal rate) or PCA bolus doses alone

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PCA is delivered by one of two modes

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Insertion of an epidural catheter and the infusion of opiates into the epidural space. Containing blood vessels, fat, and nerves, the epidural space is a "potential" space (there is no free-flowing fluid in it) between the walls of the vertebral canal and the dura mater of the spinal cord. It surrounds the spinal meninges and extends from the foramen magnum to the sacral hiatus. The epidural medication diffuses slowly from the epidural space across the dura and arachnoid membranes into the cerebrospinal fluid. Monitor respiratory rate carefully every 15 minutes during infusion. Is beneficial for controlling acute pain during labor and for relieving chronic pain, such as that seen in patients with advanced cancer. Nursing staff members are responsible for monitoring the patient's level of consciousness, pain intensity, respiratory rate, and the infusion rate and volume on the pump. Also examine the dressing site for signs of infection or leakage of medication around the catheter.

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Epidural Analgesia

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- Bolus doses - Continuous infusion - Patient-controlled epidural analgesia

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Three methods of administering epidural analgesia

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Morphine, fentanyl, and hydromorphone

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Drugs used for epidural analgesia

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Urinary retention, postural lyotension, pruritus, nausea, vomiting, and respiratory depression

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Side effects of epidural opioids

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- Prevent catheter displace - Maintain catheter function - Prevent infection - Monitor for respiratory depression - Prevent undesirable complications - Maintain urinary and bowel function

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NI for Patients with Epidural Infusions

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An objective means of assessing pain severity; it consists of a straight line, representing a continuum of intensity, and has visual descriptors at each end.

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Visual analog scale

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- Many Latino men believe that men are supposed to endure pain without complaining and that alleviating it would be "unmanly" and demeaning in the eyes of their children. - Many Chinese people avoid eye contact, making pain assessment more difficult. - Italian, Jewish, African-American, and Spanish-speaking people often smile readily and use facial expressions and gestures to communicate pain or displeasure. - Irish, English, and northern European people tend to show fewer facial expressions and are less responsive, especially to strangers such as professional caregivers.

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Cultural Consideration for Pain Management

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- Use different types of pain relief measures - Provide pain relief measures before pain becomes severe - Use measures the patient believes are effective - Consider the patient's ability or willingness to participate in pain relief measures - Choose pain relief measures appropriate to the severity of the pain as reflected by the patient's behavior - If a therapy is ineffective at first, encourage the patient to try it again before abandoning it. - Keep an open mind about what has potential to relieve pain. - Keep trying. - Protect the patient.

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Guidelines for Individualizing Pain Therapy

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The biological clock; regular bodily rhythms (for example, of temperature and wakefulness) that occur on a 24-hour cycle

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circadian rhythm

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- Physical illness - Anxiety and depression - Drugs and substances - Lifestyle - Sleep patterns - Stress - Environment - Exercise and fatigue - Nutrition

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Factors Affecting Sleep

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One of the two highly individualized sleeping states that follows NREM state. May last from a few minutes to a half an hour and alternate with NREM periods; dreaming occurs during this time

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Rapid eye movement (REM)

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One of two highly individualized sleeping states divided into four stages through which a sleeper progresses during a typical sleeping cycle; represents three fourths of a period of typical sleep

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Non-rapid eye movement (NREM)

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-Lightest level of sleep - Lasts a few minutes - Decreased physiologic activity beginning with a gradual fall in vital signs and metabolism - Person easily aroused by sensory stimuli such as noise - If person wakes, feels as though daydreaming has occurred - Reduction in autonomic activities (eg, heart rate)

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NREM Sleep - Stage 1

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- Period of sound sleep - Relaxation progresses - Arousal still easy - Lasts 10 to 20 minutes - Body functions still slowing

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NREM Sleep - Stage 2

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- Initial stages of deep sleep - Sleeper difficult to arouse and rarely moves - Muscles completely relaxed - Vital signs decline but remain regular - Lasts 15 to 30 minutes - Hormonal response includes secretion of growth hormone

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NREM Sleep - Stage 3

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- Deepest stage of sleep - Very difficult to arouse sleeper - If sleep loss has occurred, sleeper will spend most of night in this stage - Restores and rests the body - Vital signs significantly lower than during waking hours - Lasts approximately 15 to 30 minutes - Possible sleepwalking and enuresis - Hormonal response continues

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NREM Sleep - Stage 4

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- Stage of vivid, full-color dreaming (less vivid dreaming sometimes occurs in other stages) - First occurs approximately 90 minutes after sleep has begun, thereafter occurs at end of each NREM cycle - Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure - Loss of skeletal muscle tone - Responsible for mental restoration - Stage in which sleeper is most difficult to arouse - Duration increasing with each cycle and averaging 20 minutes

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REM Sleep

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As adults fall asleep, they progress through the four stages of NREM sleep. At the end of the fourth stage, they come out of a sleep, go back to stage 2, and then enter a period of REM. A person reaches REM sleep in about 90 minutes (average).

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Sleep Cycle

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Is necessary for body tissue restoration and healthy cardiac function. A person's biologic functions slow during NREM sleep. Example: a healthy adult has a heart rate 70 to 80 beats per minute during the day; however, during sleep the heart beats at 60 beats per minute or less. Respirations and blood pressure also also decreased during sleep

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Importance of NREM

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Is important for brain and cognitive restoration. During REM sleep there are changes in cerebral blood flow and increases in cortical activity, oxygen consumption, and epinephrine release, which are beneficial to memory storage and learning

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Importance of REM

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Possible physiologic signs and symptoms include: - Head tremors - Decreased reflexes - Slowed response time - Reduction in word memory - Decreased reasoning and judgement - Cardiac dysrhythmias Possible psychological signs and symptoms include: - mood swings - Disorientation - Irritability - Decreased motivation - Fatigue - Sleepiness - Hyperexcitability

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Sleep Deprivation

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- Encourage patient to ambulate in the early evening, if permitted - Provide glass of milk 30 minutes before bedtime unless contraindicated - Perform all necessary procedures before bedtime to ensure uninterrupted sleep - Massage back, freshen linens, reduce noise, and dim lights - Administer hypnotic as order

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NI for Disturbed sleep pattern

FON Ch. 16 – Pain Management, Comfort, Rest, and Sleep – Flashcards

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