Pain Management Lecture

What is Pain?
Subjective, whatever the patient says it is.
Pain Should Be?
At an acceptable, tolerable level for the patient. Ask the patient what is the patients acceptable pain level. When they reach that the goal has been met.
Patients May…
Complain all the time or be reluctant to complain.
Nurses Need To…
Educate patients beforehand about medications, when they can take them, how they are going to effect the patient, how long it will take to take effect.
Offer…
Alternative methods of pain control.
What to do 15 min – 1 hr Before Having Patient do Anything Strenuous.
Medicate them
Nature of Pain
– Involves physiccal, emotional, and cognitive components
– Results from physical and/or mental stimulus
– Reduces quality of life
– Not measurable objectively
– Subjective and highly individualized component
How To Explain Why They Cannot Have Any More Medication
Because we don’t want to over medicate them. If we give them too much it can slow down their heart rate and stop breathing all together.
Physiology of Pain
Cellular damage by thermal, mechanical, or chemical stimuli causes release of neurotransmitters.
If Pain Does Not Go To Brain…
Patient feels no pain
Good grad school research
Phantom limb pain
Types of Sensory Nerve Fibers
A-delta Fibers and C-Fibers
A-delta Fibers:
Fast, myelinated, send sharp, localized, distinct sensations

Close Gates (Stops Pain)

Idiopathic
Pain that cannot be located
C Fibers:
Slow, small, unmyelinated, send poorly localized, burning, persistent pain

Open Gates (Pain)

Non-Pharm ways to Help with Pain
Messages, compresses, music, distract them, tea, herbs
Sources of Pain
– Nociceptive Pain: mechanical stimuli, themal stimuli, chemical stimuli, electrical stimuli
– Neuropathic Pain
Thermal Stimuli
Hypothermia, Hyperthermia
Chemical Stimuli
Tissue eschemia
Electrical Stimuli
Electrical pulses (not AED)
Neuropathic Pain
Nerve pain – generally cannot directly pinpoint location
Types of Pain
Acute/Transient, Chronic/Persistent, Chronic Episodic, Cancer, Inferred Pathological, Idiopathic
Acute/Transient Pain
Protective, identifiable, short duration; limited emotional response
Chronic/Persistent Pain
Is not protective, has no purpose, may or may not have an identifiable cause
Chronic Episodic Pain
Occurs sporadically over an extended duration
Cancer Pain
Can be acute or chronic
Inferred Pathological Pain
Musculoskeletal, visceral, or neuropathic
Idiopathic Pain
Chronic pain without identifiable physical or psychological cause
Other Types of Pain
Deep somatic, visceral, lancinating, referred, phantom
Acute Pain
– Short duration
– Cause usually well defined
– Act as a warning sign
– Activates SNS
– Decrease with healing
– Reversible
– Mild to severe
– May be accompanied by anxiety
Chronic Pain
– Lasts more than several months (usually 5-6)
– Cause may or may not be well-defined
– Begins gradually and persists
– Poorly localized (hard to pinpoint)
– Mild to severe
– May be accompanied by depression & fatigue
Endorphins
– Opiate-like substances
– Bind with opioid receptors in CNS
– Inhibit release of neurotransmitters such as Substance P
Factors influencing pain (Slides)
Pain Perception (Slides)
Management of Pain
Get patient involved, needs to be systemic, consider patients quality of life.
Assessment
Expressions of pain
Characteristics of pain
Is baseline
Characteristics of Pain
Onset and duration
Location (have them point to exactly where)
Intensity
Quality
Pattern
Relief measures (What would you do at home)
Contributing symptoms
Effects of pain on the patient
Assess Pain
At least every 4hrs, PRN, With pain meds, with vitals
PQRSTU Pain Assessment Tool
P: Precipitating or palliative
Q: Quality or quantity
R: Region or radiation
S: Severity scale
T: Timing
U: other
Comatose Patients in Pain
Assess vitals, facial expressions
Behavioral Assessment
Pains Scales
Numeric, color, faces, behavioral
Pain Assessment and Management – A.B.C.D.E.
PRN Pain Meds
IV – immediate
PO – hours later
Good idea to give both so that they continue to have relief
1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient’s pain. Which of the following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judges of their pain.
C. Regular use of narcotic analgesics leads to drug addiction.
D. Amount of pain is reflective of actual tissue damage.
B
VERY IMPORTANT TO KNOW DRUGS – WILL BE SENT HOME IF DO NOT KNOW
KNOW ALL OF PATIENTS DRUGS WHETHER THEY ARE RECEIVING THEM OR NOT
Planning/Goals (Slides)
Acute Pain Management Medications
PRN, ATC, PCA
PRN
As needed
ATC
Around the clock
PCA
Patient controlled analgesic (they get the button and give themselves the medication)
PRN Meds: How to Evaluate Which to Give
– Set goals with patient
– Check previous dose and response
– What is patient about? (What is going on with your patient, talk to them, have they always had that pain)
– Anticipate rather than react to pain
– Watch for adverse effects
– Can combine different meds if pain does not change (Class example)
If Patient Wants Only 1 out of 2 Tablets
Can downgrade but not upgrade
Analgesic Types
Nonopioids
Opioids
Adjuvants/co-analgesics
Delivery Systems (Routes)
Patient-controlled analgesia (PCA)
Local/regional anesthesia
Topical agents
Analgesic Classification and Action Sites
Nonopioids – NSAIDS (Acetaminophen) – PNS (Peripheral Nervous System)

Opioids – Narcotics – CNS (Central Nervous System)

Adjuvant Analgesics – Antidepressants, Anticonvulsants – Neuropathic, chronic pain

Opioid Analgesic Side Effects
Depresses cough center
Respiratory depression
Miosis
Nausea & vomiting
Constipation
Sedation
Vasolidation / hypotension/ Increased ICP
Synthetic Opioids
Fentanyl
Methadone
Demerol
Semi-Synthetic Opioids
Hydromorphone
Oxymorphone
Hydrocodone
Oxycodone
Heroin
Opioid Withdrawl
Sign and Symptoms:
Agitation
Insomnia
Diarrhea
Diaphoresis
Tachycardia
If patient has cerosis
do not give tylenol
If having chest pain
Chew on a baby aspirin ( chewing has a different affect)
Tylenol is best to give if
they are on Warfrin (Cumaden)
No whether it is an
allergic reaction or a side effect
Best to give BP before
giving opioid
The patient is receiving his first dose of an opioid analgesic for pain. The nurse expects that another medication that will probably be ordered concurrently for this patient will be a(n):

A) Antacid agent
B) Laxative or stool softener
C) Anti-anxiety agent
D) Breakthrough pain reliever

B
KNOW WHY WE WOULD GIVE ONE TYPE OF MEDICATION OVER ANOTHER
WHEN THEY DO THE SAME THING
Routes of Administration
Transmucosal
Under tongue, in the cheek
If taking drug test do not eat anything with poppy seeds
because the drug test will be positive for opioids
Start low and go slow
for opioids, especially in older adults
Stopping opioids cold turkey
will go through withdrawal

Will have to ween them off, to give them a little something in the meantime

Hydromorphone
Dilauded
Patient-Controlled Analgesia (PCA)
Goals:
is to maintain a constant plasma level of analgesic
Give patient control with low risk of overdose

Meds used:
Morphine Sulfate
Hydromorphone

Settings:
PCA dose
Lockout time
Basal rate

Narcotic Opioid Reversal Agent
Narcan
Mixed Agonist/Antagonist
Will prevent from overdoing it on the opioids
Morphine
Slows down the breathing
Adjuvant Drugs
Antidepressants
Anticonvulsants
Steroids
Benzodiazepines
Evaluation
Is goal met
WHO Analgesic Ladder for Cancer Patients
Three Step Ladder:
1. By the Mouth
2. By the Clock
3. By the Ladder
2. A patient has just undergone an appendectomy. When discussing with the patient several pain relief interventions, the most appropriate recommendation would be
A. Adjunctive therapy.
B. Nonopioids.
C. NSAIDs.
D. PCA pain management.
D
Assess to see if the patient needs their medication
a little before you would actually give it
True or False: A patient who has a history of chronic pain is in danger of experiencing respiratory depression when taking opioids as long-term therapy.
False
EQUIANALGESIC CHARTS
WILL BE ON TEST
“”
WILL HAVE A CHART
“”
DOSES: EVERYTHING ON THE CHART IS EQUAL
“”
USE PROPORTIONS TO ANSWER
Ms
Morphine
The patient is recovering from exploratory abdominal surgery for pancreatic cancer. Her pain has been well controlled with morphine sulfate 10 mg IV every 4 hours. When she began to take liquids, her surgeon prescribed morphine elixir 30 mg PO q 4h. Based on the change in orders, what is the nurse’s best action?
A) Administer the new drug as ordered.
B) Question the new order because the patient will be receiving too little medication
C) Question the new order because the patient will be receiving too much medication.
D) Try non-pharmacological measures to relieve pain.
A
The patient has been from bony lesions as a result of multiple myeloma. His pain has been well controlled at home on Morphine elixir 40 mg p.o. q 3h. While in the hospital he is NPO in preparation for an x-ray. The physician prescribes Hydromorphone 4 mg IV q 3h until the diagnostic test is completed. Based on the change in orders, what is the nurse’s best action?
A) Administer the new order because the patient will be receiving too little medication.
B) Question the new order because the patient will be receiving too little medication.
C) Question the new order because the patient will be receiving too much medication.
D) Use anticipatory guidance instead of p.o. morphine to relieve pain
C