ATI, CH4: Pain Management

Physiology of Pain
– the following is known as the physiology of what??
– Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors).
– Transmission occurs as the electrical impulse travels along the nerve fibers & is regulated by neurotransmitters.
– point at which one feels pain is known as the pain “Threshold”.
– the amount of pain one is willing to bear is known as a pain “Tolerance”.
Substances that Increase Pain Transmission & Cause an Inflammatory Response
– the following substances do what in regards to pain??
*Substance P
*Prostaglandins
*Bradykinin
*Histamine
Substances that Decrease Pain Transmission & Produce Analgesia
– the following substances do what in regards to pain??
*Serotonin
*Endorphins
Paint Categories
– study Pg 49 for (Pain Categories):
*Acute Pain
*Chronic Pain
Nociceptive Pain
– what type of pain arises from damage to or inflammation of tissues other than that of the peripheral & central nervous systems??
– usually throbbing, aching & localized.
– this pain typically responds to opioids & nonopioid medications.
– Types:
*Somatic – in bones, joints, muscles, skin or connective
tissue.
*Visceral – in internal organs such as stomach/intestines.
It can cause referred pain in other body
locations not associated w/ the stimulus.
*Cutaneous – in the skin or subcutaneous tissue.
Neuropathic Pain
– what type of pain arises from abnormal or damaged pain nerves??
– it includes phantom limb pain, pain below the level of the spinal cord injury, & diabetic neuropathy.
– Usually intense, shooting, burning, or described as “pins & needles”.
– this pain typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).
Nonpharmacological Pain Mgmt
– the following fall under what type of pain management??

*Cutaneous (Skin) Stimulation – transcutaneous electrical
nerve stimulation (TENS), heat, cold, therapeutic touch
& massage.
Interruption of pain pathways.
Cold for Inflammation.
Heat to increase blood flow & reduce stiffness.
*Distraction – includes ambulation, deep breathing, visitors,
TV, &/or music.
*Relaxation – includes meditation, yoga, &/or progressive
muscle relaxation.
*Imagery – focuses on a pleasant thought to divert focus.
requires an ability to concentrate.
*Acupuncture – vibration or electrical stimulation via tiny
needles inserted into the skin & subcutaeneous tissues
at specific points.
*Elevation of Extremities that are edematous help to promote venous return & decrease swelling.

Pharmacological Interventions for Pain Mgmt
– the following fall under what type of pain management??

*Analgesics are the mainstay for relieving pain. the three classes of analgesics are Nonopioids, Opioids, & Adjuvants

Non-Opioid Analgesics
– these type of analgesics include:
*Acetiminophen
*Ibuprofin
*Aspirin
– appropriate for treating mild – moderate pain.
– acetiminophen has analgesic & antipyretic effects. NSAIDS have analgesic, anti-inflammatory, antiplatelet, & antipyretic effects.
– Be aware of Hepatotoxic effects of Acetiminophen. Pt w/ a
healthy liver should take no more than 4g/day.
– prevent GI upset in pt by admin the Rx w/ food or antacids.
– Monitor pt for bleeding w/ long term NSAID use.
– Monitor pt for “Salicylism” (tinnitus, vertigo, decreased hearing acuity).
Opioid Analgesics
– these type of analgesics include:
*Morphine Sulfate
*Fentanyl (Sublimaze)
*Codeine
– appropriate for treating moderate – severe pain (post-op pain, MI pain, cancer pain)
– Parenteral route preferred for immediate, short-term relief of acute pain. Oral route preferred for chronic, nonfluctuating pain.
– Essential to monitor for adverse effects:
#Constipation – use a preventative approach (monitoring
of bowel movements, fluids, fiber intake, exercise,
stool softeners, stimulant laxatives, enemas).
#Orthostatic Hypotension – advise pt to sit or lie down if
sxs of dizziness occur. Instruct pt to avoid sudden
changes in position by slowly moving from lying to a
sitting position or standing position.
#Urinary Retention – monitor the pts I&O, assess for
distention, admin “Bethanechol (Urecholine), &
catheterize as prescribed.
#N&V – admin Antiemetics, advise pt to lie still &/or move
slowly, & eliminate odors.
#Sedation – monitor the pts LOC & take safety precautions
usually precedes respiratory depression.
#Respiratory Depression – monitor the pts RR prior to &
following admin of opioids. Initial txt of respiratory
depression & sedation is generally a reduction in
opioid dose. If necessary, slowly administer diluted
“Naloxone (Narcan)” as presribed to reverse opioid
effects.
Adjuvant Analgesics
– these type of analgesics enhance the effects of nonopioids, help alleviate other sxs that aggravate pain (depression, seizures, inflammation) & are useful for txt of neuropathic pain??
– these type of Analgesics include:
*Anticonvulsants – carbamazepine (Tegretol)
*Antianxiety Agents – diazepam (Valium)
*Tricylcic Antidepressants – amitriptyline (Elavil)
*Antihistamine – hydroxyzine (Vistaril)
*Glucocorticoids – dexamethasone (Decadron)
*Antiemetics – ondansetron hydrochloride (Zofran)
Other Strategies for Pain Mgmt
– other strategies for effective Pain Management:
*Take a proactive approach by giving the pt analgesics
before pain becomes severe. It takes less Rx to prevent
pain than to treat pain.
*Instruct the Pt to report developing or recurrent pain & to
not wait until pain is severe.
*Assist pt to reduce fear & anxiety.
*create a txt plan that includes both nonpharmacologic &
pharmacologic relief measures.
Complications & Nursing Implications
– Undertreatment of pain is a serious complication & may lead to increased anxiety w/ acute pain & depression w/ chronic pain. Assess/monitor the pt for pain frequently & intervene as appropriate.
– Sedation, Respiratory Depression, & Coma can occur as a result of overdosing. Sedation “always” precedes respiratory depression:
*ID pts who are High-Risk (older adult pts, clients who are
Opioid Naive).
*carefully titrate doses while monitoring respiratory status.
*STOP the opioid & give the antagonist “naloxone (Narcan)
if the pts respirations are less than 8/min & shallow, or if
the pt is difficult to arouse.