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Comfort and Pain NC3 2


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Seven Classifications and types of pain
Acute pain, cancer pain, chronic pain, somatic pain, superficial pain, vascular pain and visceral pain
Enzyme forms of cyclooxygenase
Cox-1 and Cox-2. Cox-1 protects the stomach lining & regulates blood platelets, promoting blood clotting, Cox-2 triggers pain & inflammation at the injured site.
Two groups of analgesics that block Cox I and II
Salicylates and NSAIDS
When Cox I is inhibited by an NSAID or Salicylates
Protection to the stomach is decreased, pain & fever reduced, blood clotting is decreased
Cox II inhibitor (new)
Celebrex, Vioxx and Mobic
Tylenol properties
Non-narcotic, not an NSAID (does not have the anti-inflammatory property), OTC, causes little or no gastric distress, does not interfere with platelet aggregation
Side effects of tylenol
Can be toxic to liver cells, early symptoms of liver damage include, N/V, diarrhea and abd. pain.
Action of Narcotics and Non-narcotics
Narcotics: acts on the CNS
Non-narcotics: acts on the peripheral nervous system
Narcotics action on the medulla
They not only suppress pain impulses but also suppress respiration and coughing by acting on the repiratory and cough centers in the medulla of the brain stem
Narcotic that suppresses respirations
Narcotic that suppress cough
Side effects of Opiods
N&V, constipation, slight decrease in BP, Orhtostatic hypotension, respiratory depresion, urinary retention and antitussive effect.
Narcotic without antitussive effect
Meperidine (Demerol)
These drugs tend to be more toxic in older adults
Meperidine (Demerol), pentazocone (Talwin), propoxyphene (Darvon)
Effective in relieving severe pain, acute MI, dyspnea related to PE, Preop med, acute pain
Side effects of morphine
respiratory depression, orthostatic hypotension, miosis, urinary retension, constipation, and cough suppression
Antidote for morphine
Most common post-op pain reliever
Meperidine (Demerol)
Drug of choice of pain relief during pregnancy
Demerol, does not cause uterine contractions to diminish
Contraindications for Demerol
Individuals with chronic pain, increased liver dysfunction, sickle cell disease, hx of seizures, CAD, and dysrythmias or low bps
Demerol displays neurotoxicity in older adults and CA pts
nervousness, tremors, agitation, irritability and seizures
Side effect of Meperidine
decreased bp, resp. depression, orthostatic hypotension, increased HR, drowsiness, mental fog, constipation and urinary retention
one sign of toxicity with Meperidine (Demerol)
pupillary constriction
Drugs developed to decrease abuse Combination of a narcotic agonist and antagonists
Narcan one ingredient, Pentazocine (Talwin), Butorphanol tartrate (Stadol), buprenorphine nalbuphine hydrochloride (Nubain)
Drugs safe during late pregnancy
Butorphanol tartrate (Stadol), buprenorphine nalbuphine hydrochloride (Nubain)
List of Narcotic antagonist
Naloxone (Narcan), nalmefene (Revex), Levallorphan tartrate (lorfan)
Action of Narcotic Antagonist
They reverse the respiratory and CNS depression brought on by narcotics.
Methadone treatment program
Works by replacing the narcotics with methadone, a narcotic that is less addictive
Protective reflexes in pain
withdrawal of damaged limb, muscle spasm, autonomic responses
common sources of acute pain
trauma, surgery, labor, medical procedures and acute disease states. Acute pain is caused by chemical, thermal or mechanical stimuli
Pain behaviors when pain is severe
moaning, rubbing, splinting
Sympathetic responses with pain
tachycardia, hypertension, sweating, mydriasis (pronounced or abnormal dilation of pupils)
Chronic pain
Pain that extends beyong the healing period
Effects of chronic pain
disruption of sleep, degrades health and functional ability, causes irritability, social withdrawal, depressed mood, disruptio of work and social relationship
Words to describe pain
sharp/dull, throbbing or aching, continuous or intermittent
Verbal signs of pain
crying, moaning, groaning
Facial signs of pain
Grimace, Clencing teeth, biting lips and wrinkled forehead
Body movement in signs of pain
pacing, guarding, immobilization, restlessness, rhythmic rubbing a particular part of the body
Physiologic signs of acute pain
increased HR/force of heart, increased perspiration, dilated pupils, increased depth of respirations, elevated bp, decreased urine output, decreased peristalsis of GI tract, incrased bsal metabolic rate
ABCDE approach to pain
Assess pain frequently and systematically, Believe what the client tells you abut the pain and what relieves it, Choose pain control options that are appropriate for client, Deliver interventions in a timely, logical and coordinated manner, Empower clients and their families to control their pain experience to the greatest possible extent
Non-Pharmaceutical Measures to Control pain
Guided imagery, Transcutaneous Electrical Nerve Stimulation (TENS), Music Therapy, Relaxation, Massage therapy, Acupuncture, Biofeedback, basic comfort measures
Transcutaneous Electrical Nerve Stimulation (TENS)
Based on the Gate Control theory.. if nerve fibers closest to the spinal cord are stimulated then the pain signals from the same aea are blocked from reaching the brain. Endorphins are also released, promoting muscle relaxation and decreased inflammation
involves using electronic instrumentation to monitor specific, often unconscious physiological activities and habit patterns and then "feed back" the information
Comfort measures
Environmental considerations (temp, noise, light/darkness), Clean smooth linen, Positioning of whole body as well as individual body parts, back rub, cold and heat applications
Sedation levels
1=alert and awake- no action necessary, 2=occasional drowsiness- easy to arrouse, 3=frequently drowsy- drifts off to sleep during conversation- decrease opioid dose, 4= somnolent with minimal or no response to stimuli- discontinue the opoid and give naloxone if prescribed
Antidepressants that relieve pain (Tryciclic antidepressants)
amitriptyline (Amitril, Elavil, Endep), desipramine (Norpramin), doxepin (Adapin, Sinequan), Imipramine (Janimine, Tofranil), nortriptyline (Aventyl, Pamelor)
Antidepressants work in relieving pain by
increasing the levels of certain brain chemicals that improve mood and regulate pain signals.
Common side effects of Tricyclic antidepressants
constipation, dry mouth, blurred vision, drowsiness/fatigue, sedation or confusion, lowered blood pressure, Weight gain, tremors/sweating, inability to urinate, increased appetite, decrease in sexual function or ability, worsening of glaucoma
Other use of corticosteroids
used in control of inflammation with benefit of pain management
Side effects of corticosteroids
weight gain, stomach ulcers, sleeping difficulties, increased blood pressure, increased blood sugar, delayed wound healing, and reduced ability to fight infection, other problems include cataract formation, decreased blood flow to the hip joint that causes deterioration of the joint and osteoporosis
Trigeminal Neuralgia (TN)
tic douloureux, a condition that is characterized by intermittent, shooting pain in the face
Other pain relievers
Capsaicin, found in peppers cayenne, used topically to relieve pain
Trigger Point Injection (TPI)
procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax.
Contents of Trigger Point Injection (TPI)
Sometimes include corticosteroids.
the transmission of pain
each acronym is given a number (0-2) 0/1/2
face, legs, activity, cry and consolability
Signs of pain in newborns
increased HR and RR, shallow respirations, crying (often with apneic spells), shrill cry, diaphoresis, palmar sweating, changes in sleep/wake cycles, changes in activity level, agitation or listlessness, furrowing or bulging of brow, quivering chin
Pain can be described as
Duration, location and etiology
Three Pain Syndromes
Peripheral pain syndrome, central pain syndrome and pain with underlying pathology syndrome
Another term for pain threshold
Pain Sensation
Peripheral pain syndrome
1.postherpetic neuralgia- severe pain persists for months or years, neuralgic pain is felt in areas where original eruptions were found 2. Phamtom limb pain- occurs in any body part amputated
phamtom limb pain can be described as
burning, severe, crushing, or a cramping sensation
Central pain syndromes
Trigeminal neuralgia: intense stablike pain, distributed by 5th cranial nerve, felt on gums, legs, cheek and surface of head
Pain with underlying pathology
headache: generally caused by intracranial or xtracranial problems
Pain with underlying pathology- Cancer pain syndrome:
results from progression of disease or from efforts to cure or control the disease
Pain with underlying pathology- Myofacial pain sundrome
occurs in the muscle and fascia. severe pain- characterized by muscle spasm, tenderness, stiffness, limitation of movement and weakness, severe and disabeling
receptors that transmit pain
Highly resistant to relief
Intractable pain, eg malignancy
Types of pain stimuli
Mechanical, thermal and chemical
a-delta fibers
associated with sharp, pricking pain
c-delta fibers
associated with slow, mediate long-lasting, burning pain
mechanical stimulus
trauma eg surgery, alterations in body tissue (edema), blockage of body duct, tumor, muscle spasm
thermal stimulus
extreme heat or cold
chemical stimulus
tissue ischemia (blocked coronary artery) muscle spasm
Pain perception
pain impulses stimulate regions of the midbrain, descending nerve fivers conduct impulses from the brain to the S.C. Spinal cord, where ascending impulses are inhibited at the first synapse in the dorsal horn by release of endogenus opiods
Endogenous opioids
enkephalins, dynorphins, beta endorphins (decrease or blocks pain)
Exogenous analgesia action
binds to opiate binding sites mu, kappa, and delta (morphine)
Gate control theory
blocking painful stimuli
Pain can be reduced at 4 sites
peripheral, spinal cord, brain stem and the cerebral cortex
Cultures and pain
No. European- stoic, middle east and african- self inflict pain- to show grief/mourning
Environment and pain
noise, lights and activity can compound pain
Past pain experiences
People who have personally experienced pain or who have been exposed to the suffering of someone close are often more threatened by anticipated pain than people without a pain experience
Meaning of pain
For a woman in childbirth: pain is beneficial, for someone with chronic pain: pain is dispair, someone who had surgery: pain is temporary, because of the benefit associated
Anxiety and pain
pain when relieved lessens anxiety
Pain assessment- severe/acute pain
focus on location, quality, severity and early intervention
Pain assessment- less severe/chronic pain
allow client to provide more detailed description
Frequency of pain assessment-initial post op
Assessed when initial vs are taken, Q15, then Q2-4
Freq. pain Assessment- administration of morphine
Severity of pain assessment reassessed Q 30min
Pain assessment consist of two major components
1) a pain history to obtain facts fr the client. 2) direct observation of behavioral and physiologic responses of the client
Pain History
*previous pain tx & effectiveness, * when & what analgesics were last taken, * other medications being taken now, * allergies to medications
Intensity in pain changes- investigate the cause
eg. the abrupt cessation of acute abdominal pain may indicate a ruptured appendix
Describing pts pain
A client's words are more accurate and descriptive than an interpretation in the nurses's words.
Alleviating Factors of pain
What helps to make it better, eg. home remedies such as herbal tea, medications, rest, application of heat or cold, prayer, distractions like TV
Associated Symtons of pain
nausea, vomiting, dizziness, diarrhea( may be onset of pain or the presence of pain)
ADL's affected by pain
sleep, appetite, concentration, work/school, interpersonal relationships, marital relations/sex, home activities, driving/walking, leisure activities, emotional status(mood, irritability, depression, anxiety)
Coping stratigies nurses can encourage for pain
use of distraction, prayer or other religious practices, withdrawal, support from significant other
Affective responses
anxiety, fear, exhaustion, depression or sense of failure
non-verbal (facial)expressions of pain (physiologic response
clenched teeth, tightly shut eyes, open somber eyes, lower lip and other facial grimaces
Vocal expressions of pain (physiologic response)
moaning, groaning, crying or screaming
Physiologic response to pain with body
Immobilization of the body or a part of the body eg, client with chest pain, holds left arm across the chest, person with abdominal pain positions with the greatest comfort, knees flexed. Purposeful body movements (tossing), Rythmic body movements (rubbing)
NANDA for pain
* Pain, * Chronic pain, * Altered comfort
Eg of nursing diagnosis for pain
Ineffective Airway Clearance, Anxiety, Ineffective individual coping, Altered Health Maintenance, Knowledge Deficit, Impaired Physical mobility, sleep pattern disturbance
pain management
the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client
Two types of intervention for pain
Pharmocological- requires a physicians order and Non-pharmocological (independent nursing judgement)
preemptive analgesia
administration of analgesics prior to an invasive or operative procedure
agonist analgesia
pure opioid drugs bind tightly to mu receptor sites producing maximum pain inhibition (an agonist effect)
examples of agonist analgesia
morphine, codeine, meperidine (Demerol), propoxyphene (Darvon), hydromorphine, Dilaudid)
Mixed agonist-antogonist
Agonist-antagonist analgesic, drugs act like opioids and relieve pain
Eg of mixed agonist-antogonist
dezocine (Dalgan), pentazocine Hydrochloride (Talwin), butorphanol tartrate (Stadol), nalbuphine hydrochloride (Nubain)
Adjuvant Analgesia
medications that were developed for uses other than nalgesia but have been found to reduce certain types of chronic pain in addition to their primary action
Examples of Adjuvant analgesia
diazepam (Valium), amitriptyline hydrochloride (Elavil), carbamazepine (Tegretol), clonazepam (Klonopin)
contralateral stimulation
stimulating the skin in an area opposite to the painful area (eg, opposite knee, if pain is felt in the L knee, stimulate the R knee
Postmastectomy pain syndrome
PMP occurs after mastectomy with node dissection but is not necessarily related to the cntinuation of disease.This pain is described as a sensation of constriction, with burning, pricking, or numbness in the poterior arm, axilla, or ches wall
Post traumatic headache disorder
occurs after trauma to the head and is characterized by daily and persistent headache
chronic pain syndrome characterized by generalized musculoskeletal pain, trigger points, stiffness, fatigability and sleep distrubances, aggravated by stress and overexertion
Hemiplagia-Associated shoulder pain
seen in stroke patients, May result form stretching of the shoulder joint due to the uncompensated pull of gravity on the impaired arm
Pain associated with Sickle Cell disease
pain results from venous occlusion, caused by the sickle shape of the blood cells, impaired circulation to a muscle or organ, ischemia and infarction.
Aids related pain syndrome
aids patience develope problems with increasing pain from neuropathy, esophagitis, headaches, postherpetic pain, abdominal, bone, back and joint pain
Guillain-Barre syndrome and pain
Inflammatory disorder of the peripheral nerve characterized by presthesia and pain-muscle pain and severe unrelenting burning pain
pain causing substances that affect the sensitivity of nociceptors
increase the sensitivity of pain
parts of the body that respond to painful stimuli (nociceptors)
joints, skeletal muscle, fascia, tendons, cornea.
organs that do not respond with painful stimuli from nociceptors
internal organs (visceral)
Pain in the visceral organs respond with pain by
inflammation, stretching, ischemia, dilation and spasm of the internal organs.
a person's pain experience is influenced by a number of factors
past experiences with pain, anxiety, culture, age, gender and expectations about pain relief
Nurses tip on pain mgt and anxiety
Treat pain before anxiety, treating anxiety with anti-anxiety meds could cause respiratory depression, inability to participate in treatment (inability to deep breath),
The main issues to consider with culture and pain
~Find out what pain means to the candidate, Investigate if there are culturally based stagmas related to pain, What is the role of the family in health care decisions?, Are there traditional pain-relief remedies use?, What is the role of stoicism in that culture?, Are ther culturally determined ways of expressing communicatin pain? Does the pt. have any fears about pain, Has the pt seen or wants to see a traditional healer?
Unrelieved pain contributes to the problems of
depression, sleep disturbances, delayed rehabilitation, malnutrition, and cognitive dysfunction
Factors to consider in a complete pain assessment
intensity, timing, location, quality, personal meaning, aggravating and alleviating factors and pain behaviors
Intensity of pain
none, mild discomfort, excrutiating
Timing of pain
onset, duration. (suddenly-sudden pain is indicative of tissue rupture; gradually, pain from ischemia gradually increases and becomes intense over a longer time
Pain and the unconscious
pain in an unconscious person should always be assumed that pain is present
balanced analgesia
refers to the use of more than one form of analgesia, to obtain more pain relief with fewer side effects. eg opioids and NSAIDS
The most serious side effects of opioids analgesic agents administered by IV, SC or Epidural route is
Respiratory Depression
Side effects of opioid analgesics
respiratory depression and sedation, n&v and constipation
Effects of opioid and pts with liver and kidney compromise
Opioids are primarily metabolized by the liver and excreted by the kidneys, compromised pts are at risk for toxicity eg, normeperidine in kidney impaired pts can cause seizures
Opioids and pts with untreated hypothyroidism.
May require larger doses of pain relief, they are more susceptible to the side effects
Opioids and pts with untreated hyperthyroidism.
May require larger doses of pain relief
opioid effects and hypothyroidism
they are more susceptible to opioid effects
opioid effects and respiratory disease
pts with a decreased respiratory reserve from a disease or aging may be more susceptible to the depressant effects of opioids. Respiration must be monitored
opioid effects and patients taking MAO inhibitors
pts taking MAO inhibitors or tricyclic antidepressants should receive small doses and monitored closely
The need for increasing doses of opoids to achieve the same therapeutic effect
When Cox1 is inhibited
gastric ulceration, bleeding and renal damage occurs
When cox 2 is inhibited
mediates prostaglandin formation that resuls in symptoms of pain, inflammation and fever.
breakthrough pain
a sudden increase in pain despite the administration of pain-relieving medications
absorption and metabolism of opioids in the elderly
absorption and metabolism are altered in the elderly because of decreased liver, renal and GI function. This causes slow metabolism of drungs and prolonged increased levels in the blood
merepidine in the elderly
This drug should be avoided in the elderly, it is neurotixic, and blood levels are twice that of younger patients
tumor impingement on a nerve, postherpetic neuralgia
burning or cutting pain
parental administration
intramuscular, intravenous or subcutaneous
best rout of adminstration for hemophillas is
the rectal route
When should care be taken in the administration of fentanyl (Duragesic)
a heating pad should never be applied to a fentanyl patch, increased absorption occurs, as with the febrile pt
Withdrawal symptoms of morphine
shivering, feeling of coldness, sweating, headache and presthesia
affinity to body fat
What opioid analgesic is lipophilic?
Adverse effect of intraspinal administration
What opioid analgesic is hydrophilic?
Treatment for patient after intraspinal injection
monitor headaches, if headaches occure they should remain flat in bed and should be given large amounts of fluid (if medically allowed)
nursing responsibility in cardiovascular effects of intraspinal administraton of opioids
hypotension and decreased heart rate may result from relaxation of the vasculature in the lower extremities. The nurse assesses frequently for decreases in blood presure, pulse rate and urine output.
Pts experiencing urinary retention and prutirus.
Drs. order may include naloxone, the nurse administers small doses to reverse the side effect of the opioids without reversing the analgesic effect, benadryl to relieve opioid related pruritus
The gate control theory
The gate control theory of pain proposes that the stimulation of fivers that transmit nonpainful sensations can block or decrease the transmission of pain impulses
Nonpharmacological pain relief strategies
rubbing the sking, and using application of heat or cold
Ice Therapy
For greatest effect, ice should be applied on the injury site immediately, no longer than twenty minutes
Distraction in pain
distraction involves focusing the pt's attention on something other than the pain
Relaxation techniques in pain
skeletal muscle relaxation reduces pain by relaxing tense muscles that contribute to pain (good for chronic low back pain, not good for postoperative pts)
How is relaxation done?
slow rythmic breathin and closing eyes
Guided imagery
using one's imaginatin in a speical way to achieve a specific positive effect
Intractible pain
Pain that cannot be relieve satisfactorily by the usual approaches, including medications
disorders that produce intractible pain
malignancy of the bladder, cervix, bladder, prostate, lower bowel, potherpetic neuralgia, trigeminal neuralgia, spinal cord arachnoiditis and uncontrolable ischemia as well as other tissue distruction
Sensory nerve roots are dwstroyed where they enter the spinal cord. Used for severe chest pain in lung CA
division of certian tracts of spinal cord. Performed to interrupt the transmission of pain. Pain is alleviated but motor function is intact
those events that produce stress
separation anxiety
anaclitic depression, principal behavioral responses to the stressor anxiety during early childhood
phase of protest
children react aggressively to the separatio from the parent
phase of despair
crying stops and depression is evident
detachment phase
also called denial, superficially appears that the child has adjusted
Children's fear and hospitalization
being away from family ranked higher thatn any other fear associated with hospitalization
Middle and late school-age children may react more to separation (hospitalization & illness)
high level of mental and physical ability, experience loneliness, boredom, isolation and depression
Separation of adolescence with hospitalization
separation from home and parents may be a selcomed and appreciated event. Loss of peer group is not.
Infants- development
They are developing the most important attribute of a healthy personality-trust
Striving for autonomy
Loss of control when hospitalized-infants
inconsisten routines are not taken well (trusting age)
Loss of control when hospitalized-toddlers
toddlers rely on consistency, hospitalization severely limits there expectations
loss of control toddlers can lead to negative
Regression to earlier stages, eg req bottle instead of autonomy with feeding
Preschool and loss of control
they feel fear and shame, they associate one negative with all, nurse gives shot, all nurses inflict pain
Loss of control and schoolage (hospitalization & illness)
being told what to do is very limiting, they now also have to act grown up, allowing some control this group responds well.
Adolescence and loss of control
In their struggle for independence, self assertion, liberation, quest for personal identity, anything that interferes, results in loss of controll
Infants and pain expression
Facial expression -the best indicator of discomfort
Toddlers and pain
they react with intense emotional upset and physical resistance to any actual or percieved painful experience
Preschoolers with pain and procedures
The respond well with explanation that are not goary, they also get upset with any painful interventions
Children and the pain scale
preschoolers can locate their pain and can use appropriate pain scales. Children as yound as 3 years can use assessment tools that employ facial expression
School age children and illness (pain)
Girls express more than boys, both gender are very concerned about injury or loosing a body part. The truth is very important. They are very good about describing their pain, eg "hurt, sore, burning"
Fears of school age children with illness
they are more fearful of an actual procedure eg, anesthesia while a younger child (preschooler) would be more concerned about the mask
Adolescense and pain
much self control is noted, they want to be in control, embarrassed if they loose control
signs of pain in adolescents
limited movement, excessive quiet or iritability
typical reaction of a parent when a child suddenly turns ill
first disbelief, then anger, and or guilt as well as fear anxiety, frustration and depression
preparation for hospitalization
fear of the unknown (fantasy) exceeds fear of the known
a traumatic care
atraumatic care is therapeutic care in settings by personnel, through the use of inteventions that eliminate or minimize the psychologic, physical distress experienced by children and their families in the health cre system
Assessment of the pediatric on hospitalization
evaluate- child' growth and development, psychosocial needs, educational needs, cultural background, and the effects of the illness on the child's family or guardian
Physical assessment of a pedi
look for bruises, rashes, signs of neglect, deformities or physical limitations, listen to lungs and heart
family-centerd care
families allowed to room in, often a bed, chair or mini-kichinette is provided
Important things for a child when families are not able to room in
blanket, toy, bottle, feeding utensil or article of clothing
minimizing loss of control (hospitalization & illness)
promoting freedom of movement, maintaining child's routine, encouraging independence, promoting understandin
Pain assessment in children (QUESTT)
Q-question the child, U-use a pain rating scale, E-evaluate behavioral and physiologic change, S-secure the parents involvement, T-take the cause of patient into account, T-take action and evaluate results
Physiologic response in pain for children
flushing of the skin, increases in sweating, blood pressure, pulse and restlessness; and dilation of the pupils
describes a type of medication that alleviates pain without loss of consciousness
substance that dulls pain: a substance that reduces sensitivity to pain and may cause unconsciousness, especially a drug used in medicine
methadone use can also include
post op management for pain as well as used for treatment for intractible pain
ceiling effect of nonopioids
doses higher than the recommended dose will not produce greater pain relief
celing effect on opioids
no celing effect, other than that from side effects
first past effect
an oral opioid is rapidly absorbed from the GI tract and enters the protal circulation where it is partially metabolized before reaching the central circulation (partial loss of analgesia occurs)
equal analgesic effect
typical use of PCA pump
controlling peroperative pain, sickle cell crisis, trauma and cancer
Eutectic mixture of local anesthesia (lidocaine 2.5%, prilocaine 2.5%)

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