Pain Assessment and Nursing Management Exam 203 Questions with Verified Answers
Define pain - CORRECT ANSWER An unpleasant sensory or emotional
... [Show More] experience
Associated with actual or potential tissue damage
Or described in terms of such damage (International Association for the Study of Pain)
whatever the person says it is, whenever the person says it is - McCaffery
complex, multidimensional experience that can cause suffering and decreased QOL
#1 symptom that brings individuals to health care professionals - CORRECT ANSWER pain
ideal characteristics of pain management - CORRECT ANSWER collaborative
individual and proactive (be aware of contextual issues/what pain is influenced by)
frequently assessed/reassessed (fifth vital sign)
use both drug and non-drug therapies
characteristics that influence pain - CORRECT ANSWER culture
genetic influence
anticipation and previous experience
emotional influence
cognitive influence
gender influence
clinician-related barriers to pain management - CORRECT ANSWER lack of pain training in medical school
insufficient knowledge
lack of pain assessment skills
rigidity or timidity in prescribing practices
fear of regulatory oversight
lack of patient education about the use/misuse of pain meds
patient-related barriers to pain assessment - CORRECT ANSWER Reluctance to report pain
Reluctance to take opioid drugs
Poor adherence
Inappropriate storage of unused medications
patient-perceived barriers to good management - CORRECT ANSWER Fear of opioids
Lack of provider communication
Lack of adequate non-pharmacologic tx options
Delay in delivery of pain interventions
system-related barriers to pain assessment - CORRECT ANSWER Low priority given to symptom control
Unavailability of opioid analgesics
Inaccessibility of specialized care
Lack of insurance coverage for outpatient pain medication
Diversion and non-medical use
the joint commission pain management standards - CORRECT ANSWER Recognizes patient's right to pain management
Requires regular pain assessment with follow-up
Requires staff competence
Examines policies and procedures for effective pain control
Necessitates patient education
four phases of pain processing - CORRECT ANSWER transduction
transmission
perception
modulation
transduction - CORRECT ANSWER conversion of a noxious mechanical, chemical, or thermal stimulus into an electrical signal called an action potential
stimuli cause release of chemicals like substance P and ATP into damaged tissues and chemicals released from mast cells and macrophages which activate nociceptors (specialized receptors or free nerve endings)
activation of nociceptors leads to an AP that is carried to spinal cord via A-delta fibers and unmyelinated C fibers
transmission - CORRECT ANSWER process by which pain signals are relayed from the periphery to the spinal cord and then to the brain
nerves are primary afferent fibers (A-delta and C fibers) that terminate in dorsal horn of spinal cord which integrates and modulates pain inputs from periphery
first order neuron - CORRECT ANSWER extends entire distance from periphery to dorsal horn with no synapses (AP travel up unless blocked by sodium channel inhibitor or disrupted by lesion)
A-delta - CORRECT ANSWER rapid
initial, sharp pain
C fibers - CORRECT ANSWER slowly
aching/throbbing
transmission to spinal cord - CORRECT ANSWER
dorsal horn processing - CORRECT ANSWER
transmission to thalamus and cortex - CORRECT ANSWER
perception - CORRECT ANSWER pain is recognized, defined, and assigned meaning by the individual experiencing pain
RAS (warn ind to attend to pain)
somatosensory (localization/characterization)
limbic (emotional/beh response)
modulation - CORRECT ANSWER activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain
can occur at level of periphery, spinal cord, brainstem, and cerebral cortex
descending modulatory fibers release chemicals that can inhibit pain transmission
pain classification systems - CORRECT ANSWER nociceptive
neuropathic
mixed
nociceptive pain - CORRECT ANSWER Activation of pain-sensitive afferent neural pathways in response to injury
Presumably related to ongoing activation of primary afferent neurons in response to noxious stimuli
Pain is consistent with the degree of tissue injury
four processes*
caused by damage to somatic or visceral tissue
subtypes of nociceptive pain - CORRECT ANSWER somatic vs visceral
somatic pain - CORRECT ANSWER well localized, described as sharp,
aching, throbbing
superficial: arises from skin, mucus membranes, SQ tissues
deep: bones, joint, muscle, skin, CT
visceral pain - CORRECT ANSWER more diffuse, described as
gnawing or cramping
organs and lining of body cavities
inflammation, stretching, ischemia
neuropathic pain - CORRECT ANSWER Abnormal pain processing due to lesions in the PNS, CNS or both
Pain believed to be sustained by aberrant somatosensory processing in the peripheral or central nervous system
numbing, hot, burning, shooting, stabbing, sharp, electric-like
no single sign or symptom is diagnostic
causes = trauma, inflam, met disease, alcoholism, neuro disease, etc
subtypes of neuropathic pain - CORRECT ANSWER central generator vs peripheral generator
central generator - CORRECT ANSWER Deafferentation pain (central pain, phantom pain)
Sympathetically-maintained pain
deafferentation pain - CORRECT ANSWER results from loss of or altered afferent input secondary to peripheral nerve injury or CNS damage
sympathetically-maintained pain - CORRECT ANSWER associated with dysregulation of ANS
peripheral generator - CORRECT ANSWER Originate in the nerve root, plexus, or nerve
Polyneuropathies, mononeuropathies
examples of nociceptive pain - CORRECT ANSWER post op
mechanical low back
pain from injuries
sickle cell
pancreatitis
arthritis
examples of neuropathic pain - CORRECT ANSWER postherpetic neuralgia
neuropathic low back
distal polyneuropathy
central post-stroke pain
trigeminal neuralgia
CRPS
CRPS - CORRECT ANSWER complex regional pain syndrome (page 107)
mixed pain - CORRECT ANSWER specific pain syndrome such as fibromyalgia, headache syndromes, and low back pain
specific disease states such as cancer or AIDS
presentations of pain caused by multiple etiologies, e.g., cancer-related pain and post-herpetic neuralgia
Mixed neuropathic pain is characterized by both peripherally and centrally mediated pain, e.g., stump pain from amputation and phantom limb pain
acute pain - CORRECT ANSWER recent, well-defined onset
essential warning; rest/avoid further harm
anxiety when severe or cause is unknown
pain behaviors common when severe or when cause is unknown
may have signs of sympathetic hyperactivity when severe
post-op trauma, burns, HA, IBS
manifestations of acute pain - CORRECT ANSWER reflect sympathetic nervous system activation:
increase HR, RR, BP
diaphoresis
pallor
anxiety/agitation/confusion
urine retention
chronic pain - CORRECT ANSWER remote, ill-defined onset; duration is unpredictable
no biologic function
variable intensity
irritability/depression
behavior may/more not give indication of pain
may have vegetative signs
AIDs, cancer, osteoarthritis, neuropathic pain
manifestations of chronic pain - CORRECT ANSWER behavioral:
flat affect
decrease physical activity
fatigue
withdrawal from social interaction
nursing tools to define pain - CORRECT ANSWER history
assessment
measurement
goals of assessment - CORRECT ANSWER describe pt's pain experience to identify/implement appropriate pain management
identify pt's goal for therapy and resources for self-management
nursing history - CORRECT ANSWER Chronology of events - location, quality, intensity
Precipitating factors
Cause of pain
Onset of pain - duration, time course and pattern
Association with activities, food, environmental factors
Aggravating factors
Impact on Functional status
Personal meaning
Pain management regimen
principles of pain assessment (page 108) - CORRECT ANSWER
breakthrough pain (108) - CORRECT ANSWER
end-of-dose failure - CORRECT ANSWER
incident pain - CORRECT ANSWER
nursing assessment - CORRECT ANSWER phsyiologic
behavioral
social
spiritual
cultural
physiologic assessment - CORRECT ANSWER genetic, anatomic, and physical determinants of pain influence how painful stimuli are processed, recognized, and described
behavioral assessment - CORRECT ANSWER with non-verbal critically ill patients you can use the Critical Care Pain Observation Tool and the Behavioral Pain Scale - both incorporate facial expressions, body movements and ventilator compliance
social assessment - CORRECT ANSWER one sturdy of US veterans with pain found that significant others of veterans who had pain and PTSD perceived that their significant other had more negative ("Punishing" )responses to their pain than those without PTSD (versus solicitous and distracting - with distracting being the best response). Punishing responses my make the pain sufferer feel an unintentional need to prove he or she truly is suffering and are associated with more depressive symptoms and decreased marital satisfaction but not greater disability or pain severity
also consider caregiver burden; social costs e.g. decreased opportunities for social interaction and leisure activities
measuring pain - CORRECT ANSWER Self-report
Quality and/or pattern
Location
Pain intensity
(Numerical rating scale
Visual analog scale)
Pain Relief
Other
basic principles of pain treatment (110) - CORRECT ANSWER
clinical goals of pain management - CORRECT ANSWER reduce incidence and severity of pain
enhance recovery
prevent development of chronic pain syndromes
acute pain as an issue - CORRECT ANSWER More than half of post-operative patients report moderate pain, and more than one-third report serious or extreme pain1
Certain procedures are predictably associated with pain2
most common cause of readmission after same-day surgery - CORRECT ANSWER pain
how to reduce incidence and severity of pain - CORRECT ANSWER Produce clinically meaningful pain relief1,2
(Pain cannot be eliminated or always reduced to a low level)
Achieve balance between maximum pain relief and minimum side effects2
(Enhance consistency of effect/reduce analgesic gaps
Avoid unnecessary sedation
Mitigate serious risks
Reduce effects that compromise patient comfort/compliance)
Individualize treatment based on patient's current response and past medical history2
(Avoid dosing to a specific pain rating number)
how can inadequately controlled pain impair healing - CORRECT ANSWER Stress response can lead to hemodynamic and metabolic abnormalities with associated clinical consequences
(Impaired immune function and postop infections1,2
Impaired glucose metabolism, producing insulin resistance and hyperglycemia3,4)
May also lead to mechanical complications
(Constricted respiration and impaired
lung clearing5
Delayed return of normal gastrointestinal (GI) function6
Delayed mobilization, increasing risk of thromboembolism and delaying rehabilitation7)
what can predict chronic pain - CORRECT ANSWER severity of acute pain via hyper sensitization and persistent pain syndrome
peripheral sensitization - CORRECT ANSWER tissue damage leading to inflammatory response which sensitizes active neurons and activates dormant neurons leading to amplification of noxious process leading to peripheral sensitizataion
inflammation and release of chemical mediators lower nociceptor thresholds leading to firing during non-noxious or lower threshold stimuli
involves leukotrienes, prostaglandins, cytokines, COX, and substance P
example is sunburn
what does sensitization of STT neurons lead to - CORRECT ANSWER increased spontaneous impulse activity and enhanced responsiveness to impulses in nociceptive and non-nociceptive primary afferents
central sensitization - CORRECT ANSWER sustained neuronal firing in C nociceptive neurons producing sensitization of STT neurons over time leading to released excitatory amino acids leading to increased sensibility to pain leading to central sensitization
caused by peripheral tissue damage or nerve injury and maintained by continued nociceptive input from periphery
how does acute/unrelieved pain lead to chronic pain - CORRECT ANSWER central sensitization
windup (105) - CORRECT ANSWER
what kind of pain does central sensitization cause - CORRECT ANSWER hyperalgesia, allodynia, spontaneous pain
how to prevent central sensitization - CORRECT ANSWER aggressive perioperative pain management
what does optimizing analgesic therapy require - CORRECT ANSWER individualized approach to each patient; treatment should be based on comprehensive assessment of patient's needs
include patient and practice factors
patient factors that help individualize pain therapy - CORRECT ANSWER general health status and predisposing risk factors
pre-existing pain syndromes
injury/surgery type
medication history
practice factors that help individualize pain therapy - CORRECT ANSWER systematic assessment and monitoring
implementation of protocols
formulating initial pain plan
reassessment and adjustment of pain plan
multimodal pain management step therapy - CORRECT ANSWER step 1: mild postop pain
step 2: moderate postop pain
step 3: severe post op pain
mild postop pain (step 1) - CORRECT ANSWER nonopioid analgesic (acetaminophen, NSAIDs, COX2 selective inhibitors) and local anesthetic infiltration
moderate postop pain (step 2) - CORRECT ANSWER step 1 strategy and intermittent doses of opioid analgesics
severe postop pain (step 3) - CORRECT ANSWER steps 1 and 2 strategies and local anesthetic peripheral nerve block and use of sustained release opioid analgesics
how does multimodal therapy target pain throughout the pathway - CORRECT ANSWER Different classes of agents act on different parts of the pain pathway based on their receptor targets
Multimodal regimens use these differences to improve pain control
Result is a more rational approach to pain therapy
clinical advantages of multimodal therapy - CORRECT ANSWER Multimodal therapy provides a way to achieve balanced, safer pain therapy
(Improved quality of analgesia,
Fewer adverse effects,
Better functional status)
Distinct from polypharmacy
multimodal peripheral - CORRECT ANSWER local anesthetics
anticonvulsants
TCAs
opioids
anti-inflam agents
multimodal central - CORRECT ANSWER anticonvulsants
opioids
tricyclic/SNRI antidepressants
a2-agonist
local anesthetics
multimodal descending - CORRECT ANSWER anticonvulsants
opioids
tricyclic/SNRI antidepressants
a2-agonist
benefits of multimodal analgesia - CORRECT ANSWER Reduced doses of each analgesic are needed to achieve pain control
Improved pain relief secondary to synergistic or additive effects of particular agents
Side effects of individual medications may be reduced
Outcomes of acute pain are improved
pharmacotherapy*** - CORRECT ANSWER analgesics
types of analgesics - CORRECT ANSWER nonopioids
opioids
adjuvant analgesics
action of opioids - CORRECT ANSWER agonistic effect, acts at the mu receptor
inhibit transmission of nociceptive input from periphery to spinal cord, alter limbic system act, activate descending inhibitory pathways that modulate transmission
side effects of opioids - CORRECT ANSWER resp depression, GI irritation
types of nonopioids - CORRECT ANSWER acetaminophen, aspirin, NSAIDs
acetaminophen - CORRECT ANSWER antipyretic effects/analgesic
metabolized by liver
opioid sparing effect
aspirin - CORRECT ANSWER mild pain
GI bleed
antiplatelet/antiinflam effects
NSAIDs - CORRECT ANSWER all inhibit COX (1 = all tissues, 2 = sites of injury)
inhibiting 1 = side effects (renal function, bleeding, GI irritation, ulceration)
inhibit 2 = antiinflam
ibuprofen = nonselective
pts vary in response to different NSAIDs
shouldnt be given with aspirin
action of nonopioids - CORRECT ANSWER principle mechanism of action is prostaglandin synthesis; have analgesic ceiling and don't produce tolerance
side effects of nonopioids - CORRECT ANSWER Impaired hemostasis, GI irritation/bleeding, cardiovascular risk, renal toxicity
action of dual-mechanism - CORRECT ANSWER Target multiple pain mechanism
side effects of dual-mechanism - CORRECT ANSWER Similar to opioids with better GI tolerability
action of anticonvulsants - CORRECT ANSWER Decrease excitability of neurons by modulating sodium channels
side effects of anticonvulsants - CORRECT ANSWER Sleepiness, dizziness, fatigue
action of antidepressants - CORRECT ANSWER Inhibit both NE and serotonin reuptake
side effects of antidepressants - CORRECT ANSWER Vary by class, include, dry mouth, blurred vision, nausea, constipation
action of local anesthetics - CORRECT ANSWER Modulate sodium channels; interrupts some nerve conduction
side effects of local anesthetics - CORRECT ANSWER Local reactions at application site
action of alpha-2 agonists - CORRECT ANSWER Inhibition of NE release
classes of opioids - CORRECT ANSWER pure/full agonists
agonist-antagonists
antagonists
pure/full agonist opioids - CORRECT ANSWER Bind to opioid receptor(s)
No antagonist activity
No ceiling effect
morphine-like
morphine, oxycodone, hydrocodone, codeine, methadone, hydromorphine, oxymorphone, levorphanol
agonist-antagonist opioids - CORRECT ANSWER Ceiling effect for analgesia
Can reverse effects of pure agonists
mixed agonist-antagonists (butorphanol,
nalbuphine, pentazocine, dezocine) produce less resp depression but cause more dysphoria and agitation
partial agonists (buprenorphine) bind tightly to mu and can block effects of other drugs
antagonist opioids - CORRECT ANSWER Reverse or block agonist effects of pure opioids
Naloxone has been used to treat opioid overdose, addiction
short-acting opioids - CORRECT ANSWER Hydrocodone/APAP
Hydromorphone
Morphine
Oxycodone w or w/o
APAP
Oral transmucosal fentanyl
Tramadol
long-acting opioids - CORRECT ANSWER Transdermal Fentanyl
Methadone
Extended-release morphine
Oxycodone CR
Cip-Tramadol ER
side effects of opioids (systems) - CORRECT ANSWER CNS
CV
GI
other
CNS side effects of opioids - CORRECT ANSWER Sedation (first sign), Respiratory Depression
POSS - CORRECT ANSWER
CV effects of opioids - CORRECT ANSWER Vasodilatation/drop BP
GI side effects of opioids - CORRECT ANSWER Nausea, vomiting, constipation (long-term) (constipation is most common and only side effect that doesnt diminish with use)
other side effects from opioids - CORRECT ANSWER Itching (inform pt of possibility)
opioid-induced hyperalgesia - CORRECT ANSWER
adjuvant analgesic therapy - CORRECT ANSWER Enhance the effects of opioids and nonopiods
Possess analgesic properties of their own
Counteract side effects of other analgesics
adjuvant analgesics - CORRECT ANSWER anticonvulsants
antidepressants
corticosteroids
NMDA-receptor antagonists
common characteristics of anticonvulsants - CORRECT ANSWER Most clinical experience: gabapentin, pregabalin, lamotrigine
Limited data on efficacy of newer anticonvulsants
Used as an analgesic, dosing schedule is similar to anticonvulsant indication
Large inter-/intra-individual variability in analgesic response
sodium/calcium channel modulation and changes in excitatory AA and other receptors
gabapentin - CORRECT ANSWER Usual first-line drug for neuropathic pain
Favorable safety profile
Positive controlled trials in PHN/diabetic neuropathy
No controlled studies in cancer patients
Usual starting dose 100-300 mg/day
Titration to identify responders/nonresponders
Usual effective dose 600-3600 mg/day; higher doses sometimes beneficial
antidepressants - CORRECT ANSWER Evidence is best for tricyclics
SSRI/atypical antidepressants better tolerated
Proven efficacy for all types of neuropathic pain, but often preferred for continuous dysesthesias
Analgesic doses for tricyclics is usually less than the antidepressant dose
prevent reuptake of NE and serotonin, modulate sodium channels, a1-adrenergic antagonistic effects, weak NMDA receptor modulation
corticosteroids - CORRECT ANSWER Shown to improve pain, appetite, nausea, malaise, quality of life in cancer patients
In the cancer population, indicated for refractory neuropathic pain, and other indications: bone pain, bowel obstruction, capsular pain, lymphedema, headache
In non-cancer pain, long-term use is limited to inflammatory conditions
Usual drugs are prednisone and dexamethasone
dont give with NSAIDs (act through same pathway)
side effects of corticosteroids - CORRECT ANSWER hyperglycemia, fluid retention, dyspepsia, GI bleeding, impaired healing, muscle wasting, osteoporosis, adrenal suppression, susceptibility to infection
NMDA-receptor antagonists - CORRECT ANSWER N-methyl-D-aspartate receptor involved in neuropathic pain
Commercially-available drugs in the U.S.: ketamine, dextromethorphan, amantadine
ketamine - CORRECT ANSWER dissociative anesthetic; can be used p.o. or IV/SC infusion
dextromethorphan - CORRECT ANSWER antitussive; starting dose 120 mg/day; maximum daily dosage one gram
amantadine - CORRECT ANSWER starting does 100 mg b.i.d.
tapentadol - CORRECT ANSWER
opioids to avoid - CORRECT ANSWER
tramadol - CORRECT ANSWER dual-mechanism analgesic
may be associated with less tolerance and useful in patients with opioid sensitivity
what does tramadol act on - CORRECT ANSWER mu opioid receptors and inhibits reuptake of NE and serotonin
how is tramadol given - CORRECT ANSWER IR formulation
tramadol in clinical trials - CORRECT ANSWER Comparable to oxycodone in acute pain (bunionectomy)2
and in more chronic pain (up to 90 days in joint or
back pain)3
Comparable or better pain relief than morphine in dental surgery4
side effects of tramadol - CORRECT ANSWER Main adverse effects similar to conventional opioids
(GI, CNS), but significantly better GI profile, including
lower rate of constipation
lowers seizure threshold
effective and safe practices with multimodal strategies requires that nurses: - CORRECT ANSWER Understand the rationale for combining analgesics1,2,4
Be knowledgeable about classes of analgesics1,2,4
(Mechanisms of action and pharmacodynamics
Synergistic and AEs)
Ensure timely administration of all analgesics, avoiding gaps in analgesia2-4
Institute proper assessment and monitoring practices2,3
Aggressively manage AEs of analgesics1,2,4
Remain informed about novel dual-mechanism analgesics and drug delivery systems1,2,4
barriers to pain management - CORRECT ANSWER drug tolerance
physical dependency
psuedoaddiction
drug tolerance - CORRECT ANSWER Gradual resistance of body to effects of drug; same relief = need more meds
physical dependency - CORRECT ANSWER Physiologic adaptation of body tissues so that continued administration of drug is necessary for normal tissue function
psuedoaddiction - CORRECT ANSWER Aberrant drug-related behaviors driven by uncontrolled pain; if you treat that pain well, the pain will disappear
early response opioids withdrawal symptoms - CORRECT ANSWER Anxiety, diaphoreses, yawning, dilated pupils
late response opioid withdrawal symptoms - CORRECT ANSWER Nausea, vomiting, abdominal cramping, delirium, convulsions
addiction - CORRECT ANSWER Disease with pharmacologic, genetic, psychosocial elements
Persistent drug craving and abuse
chief features of addiction - CORRECT ANSWER loss of control, compulsive use, use despite harm
low addiction risk - CORRECT ANSWER Acute pain
Cancer pain
Patients without abuse background or psychopathology
probability of addiction with chronic noncancer pain - CORRECT ANSWER small (surveys that include patients with abuse or psychopathology show mixed results)
predictors of addiction - CORRECT ANSWER history of substance abuse
Age
personality factors
family dynamics and social factors
predictive behavior of addiction - CORRECT ANSWER Selling prescription drugs
Prescription forgery
Stealing or "borrowing" drug from another person
Injecting oral formulation
Obtaining prescription drugs from non-medical source
Multiple episodes of prescription "loss"
Concurrent abuse of related illicit drugs
Multiple dose escalations despite warnings
Repeated episodes of gross impairment or dishevelment
less predictive behavior of addiction - CORRECT ANSWER Aggressive complaining
Drug hoarding when symptoms milder
Requesting specific drugs
Acquisition of drugs from other medical sources
Unsanctioned dose escalation once or twice
Unapproved use of the drug to treat another symptom
Reporting psychic effects not intended by the clinician
Occasional impairment
general management principles for addressing drug-related behavior - CORRECT ANSWER know laws and regulations
structure therapy to match perceived risk
proactive strategies for addressing drug-related behavior - CORRECT ANSWER communicate goals of therapy
provide written guidelines (treatment contract)
assess often
reactive strategies for addressing drug-related behavior - CORRECT ANSWER require frequent visits and small quantities of drug
use of urine toxicologies
long-acting drugs with no rescue doses
relate to addiction-medicine community (sponsor, program, addiction-medicine specialist, psychotherapist)
what is good about having multiple routes to administer analgesics - CORRECT ANSWER allow HCP to target particular anatomic source of pain, achieve therapeutic blood levels rapidly, avoid certain side effects through localized administration, provide analgesia when patients are unable to swallow
administration routes of pharmacologic pain management - CORRECT ANSWER Oral
Transmucosal
(Sublingual, transnasal -avoid first pass effect -, rectal, buccal)
Transdermal
Surgical site infiltration
Infusions
(SC, IM (not recommended), IV, intraspinal)
Patient controlled Analgesia (PCA)(
oral routes - CORRECT ANSWER route of choice for person with functioning GI
include immediate, extended, sustained release
first pass effect/opioids - CORRECT ANSWER oral opioids are absorbed from the GI tract into the portal circ and shunted to the liver; partial metabolism occurs before drug enters systemic circ and becomes available to peripheral receptors or can cross BBB and access CNS receptors
transmucosal - CORRECT ANSWER allows drug to enter bloodstream and travel directly to CNS; relief within 5-7 minutes
intranasal - CORRECT ANSWER absorb through highly vascular mucosa
avoid first pass effect
transdermal route - CORRECT ANSWER useful for patient who can't tolerate oral drugs
12-17 hours
effective is pain is stable/amt of medicine needed is unknown
patches may have to be changed 48-72 hours
rashes can be reduced by using corticosteroid cream
ones used for systemic vs topical/local delivery
parenteral routes - CORRECT ANSWER SQ is rather slow
IV is best for immediate use
continuous IV is good for steadying pain
continuous SQ are helpful with end of life care
IM injections can result in abscesses and fibrosis
rectal - CORRECT ANSWER good for those who can't take oral med by mouth
many oral meds can be taken rectally
goal of intrapsinal pain management - CORRECT ANSWER Interrupt pain conduction at point where sensory fibers exit from spinal cord
intermittent bolus or continuous
smaller doses needed
side effects of intraspinal - CORRECT ANSWER urinary retention, nausea, itching
epidural - CORRECT ANSWER epidural space
Local anesthetic or opioid can be used
Pain relief 5 - 16 hours
VS - frequency depends on hospital protocol
lumbar region is most common
side effects of epidural - CORRECT ANSWER Paresthesia, muscle weakness and paralysis, urinary retention
complications of intraspinal - CORRECT ANSWER catheter displacement, accidental infusions of neurotoxic agents, epidural hematomas, infection
depend on location and drug being used
complications of epidural - CORRECT ANSWER Infection, technical difficulties (migration of catheter), infusion of neurotoxic drugs
intrathecal - CORRECT ANSWER Smaller dose required than epidural
Up to 36 hours of pain reliefCan be used for chronic pain with the implantation of an intrathecal catheter and subcutaneous programmable pump
side effects of intrathecal - CORRECT ANSWER similar to epidural although more allergic reactions and increased risk of infection
implantable pumps - CORRECT ANSWER
PCA benefits for patients - CORRECT ANSWER Decreased sedation and respiratory depression from self- titration
Improved pain control
Decreased time between pain and drug delivery
Ability to adjust medication use to individual need
Increased sense of control
Better sleep quality
Avoidance of pain from IM injections
Greater patient satisfaction
Control of devise is restricted to patient
benefits of PCA (not specifically for patient) - CORRECT ANSWER less drug utilization
lower complication rates
shorter hospital stays
decreased nursing time
maximized resources while reducing human suffering
caveats to nonpharmacologic relief of pain - CORRECT ANSWER Relief only as long as stimulation
Benefits unpredictable
Stimulation may cause more pain
physical strategies for nonpharmacologic treatment of pain - CORRECT ANSWER Application of heat/cold, massage, exercise, physical therapy, therapeutic ultrasound, aromatherapy
heat vs cold therapy - CORRECT ANSWER
neurostimulatory approaches to pain - CORRECT ANSWER Transcutaneous electrical nerve stimulation (TENS) (gate control theory), acupuncture, dorsal column stimulation
TENS - CORRECT ANSWER Patient can wear unit doing ADL
Unit can be worn several hours
Skin at electrode site may become irritated
pain suppressor - CORRECT ANSWER Used for diffuse pain
10 to 20 minute treatments given several times a day
goals of psychologic/cognitive strategies for pain - CORRECT ANSWER Change patients' perceptions of pain
Alter pain behavior
Provide patients a greater sense of control over pain
types of psychologic/cognitive strategies - CORRECT ANSWER Visual
Auditory
Environmental (ex of taking older women outside/to gift shop)
Guided Imagery
Relaxation techniques
Mindfulness meditation
Prayer
Behavioral treatment
Biofeedback
Cognitive-Behavioral treatment
Other - e.g. peer support
change the consequences of pain behavior - CORRECT ANSWER Medications administered "on the clock" rather
than "as needed"
Social responses, particularly spouses and families,
shift from pain-related to activity- and wellness-related; communication training often integrated
Pacing of daily activities diminishes both aversive consequences of being active and positive consequences of rest; record keeping, daily logs often critical
biofeedback intervention - CORRECT ANSWER Learning to influence physiologic parameter
Electromyography
Galvanometry (electrodermal)
Temperature
Shaping of behavior
Typically includes training in relaxation techniques
Used with tension and migraine headaches, Raynaud's
cognitive-behavioral treatment - CORRECT ANSWER Affect and behavior are largely determined by cognitive processes
Behavior results from a complex interaction between cognitive structures (eg, beliefs), cognitive processes (eg, automatic thoughts), overt responses, and the intrapersonal and interpersonal consequences of these multiple components
Integrates behavioral and biofeedbackFocuses on cognitive structures and processes
Sessions focus on identifying and challenging maladaptive cognitive structures and processes
"Homework" focuses on personal experiments designed to test the validity of cognitive structures and processes
energy therapies - CORRECT ANSWER Qigong
Reike
Therapeutic Touch
Other
Traditional Health Practices, e.g. native American use of smudging, sweat lodge, sema (ceremonial tobacco), feasting (strengthening process), pipes (ceremonial herb and tobacco) story telling (non-hierarchical environment for verbal communication), and contact with a traditional healer (elder spiritual leader).
neuroablative techniques - CORRECT ANSWER
neuroaugmentation - CORRECT ANSWER electrical stimulation of the brain and spinal cord
complications =
surgical pain management - CORRECT ANSWER nerve blocks
Spinal cord stimulation (similar to tens)
Neurectomy, rhizotomy, sympathectomy (neuroablative interventions that destroy sensory division of nerve)
Chordotomy (tract is interrupted in spinal cord), tractotomy (interruption is in medulla or midbrain) (neurosurgical procedures that ablate the lateral spinothalamic tract)
nerve block - CORRECT ANSWER regional anesthesia
interrupt all afferent and efferent transmission to area
can be one time or continuous
local infiltration into surgical area or nerve plexus
nerve blocks (three types) - CORRECT ANSWER Diagnostic, short term therapeutic, neurolytic
side effects of nerve blocks - CORRECT ANSWER Decreased sensation in area
With lumbosacral application: impaired bowel, bladder, sexual function
placebos - CORRECT ANSWER Any medical or nursing intervention that produces effect because of its intent not because of its specific nature
McCaffery
manifestations of pain - CORRECT ANSWER
sign vs symptom (general) - CORRECT ANSWER
sign vs symptom (pain) - CORRECT ANSWER
short/long-term outcomes of pain management - CORRECT ANSWER
negative consequences of unrelieved pain (page 103) - CORRECT ANSWER
suffering (page 103) - CORRECT ANSWER
dimensions of pain/pain differences (page 103) - CORRECT ANSWER
drugs that act on four different processes of nociceptive pain transmission - CORRECT ANSWER
dermatomes (page 105) - CORRECT ANSWER
dorsal horn processing (105) - CORRECT ANSWER
neural plasticity - CORRECT ANSWER
referred pain - CORRECT ANSWER
managing side effects of pain meds (111) - CORRECT ANSWER
administration (117) - CORRECT ANSWER scheduling
titration
equianalgesic dosing
administration routes
why are nondrug strategies important in pain management - CORRECT ANSWER
gerontologic considerations - CORRECT ANSWER most common painful conditions are musculoskeletal
associated with physical disability and psychosocial probs
results in depression, sleep disturbance, decreased mobility, increased use of healthcare, role dysfunction
pain is often inadequately assessed and treated
exercise/teaching
caregiver support
barriers to pain assessment in older adult - CORRECT ANSWER believe pain is normal
fear of complaining/being burden
fear taking opioids
use of words other than pain
cognitive/sens-perceptual/motor probs interfere
hearing/vision deficits
metabolize drugs more slowly
use of NSAIDs is correlated to GI bleeds
already taking lots of drugs
cognitive impairment/ataxia can be exacerbated on pain meds
assessing pain in nonverbal patients - CORRECT ANSWER obtain self-report when possible
never assume a nonverbal person is unable to communicate in some manner
investigate causes
observe behaviors
obtain surrogate reports from family members/caregivers
use analgesics and reassess
treating patient with substance abuse - CORRECT ANSWER no evidence showing opioid analgesia worsen's disease
stress of no pain management may worsen disease
avoid exposing pt to drug of abuse
suspect abuse when norm amounts of drug are not effective
use single opioid
IV/PCA
use supplemental doses when needed [Show Less]