Ch 8 Exam 1 a - Note for Level 2, EXAM 1 CHAPTER 8 PDF

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Note for Level 2, EXAM 1 CHAPTER 8...

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Chapter 8 Pain KEY POINTS MAGNITUDE OF PAIN PROBLEM • Pain is a complex, multidimensional experience that can cause suffering and decreased quality of life. • Millions of people suffer from pain, with a staggering effect on physical and psychosocial function and significant financial impact. • Inadequate pain management occurs across care settings and patient populations. Untreated pain can result in physical and psychosocial dysfunction, impaired recovery from acute illness and surgery, immunosuppression, and disturbed. • The reasons for under management may be: • Insufficient knowledge and skills to assess and manage pain. • Unwillingness of providers to believe patients’ reports of pain. • Inadequate reassessments resulting in failure to readjust treatments. • Inaccurate and inadequate information about addiction, tolerance, respiratory depression, and other side effects of opioids. • Fear that aggressive pain management may hasten or cause death. DEFINITIONS AND DIMENSIONS OF PAIN • Pain is defined as whatever the person experiencing the pain says it is, existing whenever the person says it does.

• Pain is a complex, multidimensional experience, with physiologic, affective, cognitive, behavioral, and sociocultural dimensions, which occurs in many patients and in all settings. • The emotional distress of untreated pain can cause suffering, which is the state of severe distress associated with events that threaten the intactness of the person. Pain Mechanisms • Nociception is the physiologic process by which information about tissue damage is communicated from the peripheral to the central nervous system (CNS). Nociception involves transduction, transmission, perception, and modulation: • Transduction is the conversion of a mechanical, thermal, or chemical stimulus into a neuronal action potential. • Transmission is the movement of pain impulses from the site of transduction to the brain. Increased sensitivity and hyperexcitability of neurons in the CNS is called central sensitization. • The first-order neuron extends the entire distance from the periphery to the dorsal horn of the spinal cord with no synapses. • The neurons in the spinal cord that project to the thalamus are called second-order neurons. • From the dorsal horn, nociceptive stimuli are communicated to the third-order neuron, primarily in the thalamus. • Peripheral sensitization refers to increased susceptibility to nociceptor activation due to injury, inflammation, and/or disease. • Perception occurs when pain is recognized, defined, and assigned meaning by the person experiencing the pain. The brain is necessary for pain perception.

• • Modulation involves the activation of descending neurochemical pathways that exert inhibitory or facilitatory effects on the transmission of pain. • Dermatomes are areas on the skin that are innervated primarily by a single spinal cord segment. CLASSIFICATION OF PAIN Pain is often categorized as nociceptive or neuropathic based on underlying pathology or as acute or chronic. • Nociceptive pain is caused by damage to somatic or visceral tissue, which activates peripheral nociceptors. It is further classified as somatic or visceral. • Somatic pain is characterized as deep, aching, sharp, or throbbing that is well localized and arises from bone, joint, muscle, skin, or connective tissue. • Visceral pain is often poorly localized and described as deep aching, cramping, pressure, or referred and resulting from stimuli, such as stretch, compression, or ischemia of the hollow or solid internal organs or organ coverings. • Neuropathic pain is caused by damage to peripheral nerves or CNS that results in the abnormal processing of stimuli. Patients typically describe neuropathic pain as a numbing, burning, shooting, stabbing, shock-like, or itchy sensation. There may be associated areas of decreased sensation (numbness) and/or areas of hypersensitivity. • A type of neuropathic pain is complex regional pain syndrome (CRPS). Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. • Acute pain and chronic pain are different as reflected in their cause, course, manifestations, and treatment.

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• Normally, acute pain decreases over time as healing occurs. • Chronic pain lasts for longer periods, often defined as longer than 3 months or past the time when an expected acute pain or acute injury should subside. PAIN ASSESSMENT

• The goals of a nursing pain assessment are to describe the patient’s multidimensional pain experience to identify and implement appropriate pain management techniques and the patient’s goal for therapy and resources for self-management. • A comprehensive assessment of pain includes describing the onset, duration, characteristics, pattern, location, intensity, quality, and associated symptoms, such as anxiety and depression. The patient’s beliefs, expectations, and goals for pain management are assessed. • Pain scales are useful tools to help the patient communicate pain intensity. A variety of scales are available based on developmental needs and cognitive function. • Ongoing documentation of findings and reassessments are key to providing optimal pain management. • Breakthrough pain (BTP) is transient, moderate to severe pain that occurs in patients whose baseline persistent pain is otherwise mild to moderate and fairly well controlled. • Patient and family beliefs, attitudes, and expectations influence responses to pain and pain treatment. PAIN TREATMENT Drug Therapy for Pain • Pain medications generally are divided into 3 categories: nonopioids, opioids, and adjuvant drugs. • Mild pain often can be relieved using nonopioids alone. • Moderate to severe pain usually requires an opioid.

• • Neuropathic pain often requires adjuvant drug therapy alone or in combination with an opioid or another class of analgesics. Treatment is typically augmented with adjuvant therapies, including tricyclic antidepressants, antiseizure drugs, and α2-adrenergic agonists. Nonopioids are often used in conjunction with opioids because they reduce the amount of opioid needed for pain relief. This phenomenon is called the opioid-sparing effect. • Multimodal analgesia employs the use of 2 or more classes of analgesic agents to take advantage of the various mechanisms of action. Nonopioids • Nonopioids are characterized by an analgesic ceiling, lack of ability to produce tolerance or dependence, and availability without a prescription. • An analgesic ceiling means that increasing the dose beyond an upper limit provides no greater analgesia. • Nonopioid pain medications include acetaminophen, aspirin, and NSAIDs. • NSAIDs are associated with several side effects. These include bleeding tendencies, gastrointestinal (GI) ulcers and bleeding, and renal and CNS dysfunction. Opioids • Opioids are the strongest analgesics available. Opioids produce their pain-relieving effects by binding to receptors in the CNS, inhibiting the transmission of nociceptive input from the periphery to the CNS. • Common side effects of opioids include constipation, nausea, vomiting, sedation, respiratory depression, and pruritus.

• • Concerns about sedation and respiratory depression are 2 of the most common fears associated with opioids. • Sedation is usually seen in opioid-naive patients in the treatment of acute pain. Patients at most risk for respiratory depression and renal insufficiency include those who are opioid naive, are elderly, have underlying lung or renal disease, have a history of sleep apnea, or are receiving other CNS depressants. • Patient-controlled analgesia (PCA) or demand analgesia is a method that allows the patient to self-administer preset doses of an analgesic within a prescribed time period using activation of an infusion pump. • Patient-controlled epidural analgesia (PCEA) is an electronically controlled infusion pump that delivers the medication by an epidural route. Adjuvant Analgesic Therapy • Adjuvant analgesic medications are used alone or in conjunction with opioid and nonopioid analgesics. They include antidepressants, antiseizure drugs, α-adrenergic agonists, and corticosteroids. • Tricyclic antidepressants enhance the descending inhibitory system and are effective for a variety of pain syndromes, especially neuropathic pain syndromes. • Antiseizure drugs affect peripheral nerves and the CNS and are effective for neuropathic pain and preventative treatment of migraine headaches. • Clonidine and tizanidine (Zanaflex) are 2-adrenergic agonists that may be used for chronic headache and neuropathic pain.

• • Corticosteroids, including dexamethasone, prednisone, and methylprednisolone, are used for management of acute and chronic cancer pain, pain resulting from spinal cord compression, and inflammatory joint pain syndromes. • Ketamine (Ketalar) is an NMDA receptor antagonist that is potentially useful for blocking mechanisms that lead to or sustain central sensitization.

Administration • Appropriate analgesic scheduling focuses on prevention or control of pain rather than the provision of analgesics only after the patient’s pain has become severe. • Analgesic titration is dose adjustment based on assessment of the adequacy of the analgesic effect versus the side effects produced. • The term equianalgesic dose refers to a dose of one analgesic that is approximately equivalent in pain-relieving effects compared with another analgesic. • Opioids and other analgesic agents can be delivered via several routes, allowing flexibility in achieving pain control. • Oral administration is the route of first choice when the patient has a functioning GI tract. • Transmucosal and buccal medications are absorbed more directly into systemic circulation, which exempt them from the first-pass effect. • Transdermal fentanyl (Duragesic) diffuses across the skin to form a depot of drug in the subcutaneous fat from where it is then absorbed into the systemic circulation. • Intranasal administration allows delivery of medication to highly vascular mucosa and avoids the first-pass effect. An example is butorphanol (Stadol). • Rectal preparations are useful when a patient cannot take medications orally. • IV administration is the best route when immediate analgesia and rapid titration are necessary. • Intraspinal (epidural or intrathecal) analgesics are highly potent because they are delivered close to the receptors in the spinal cord dorsal horn. • Topical administration delivers the drug through the skin to local tissue with reduced absorption into the bloodstream and low risk of systemic side effects. Examples are topical NSAIDs and aspirin creams.

Interventional Therapies • Interventional nerve therapies include regional anesthesia, neuroablative interventions, and neuroaugmentation. • Regional anesthesia includes nerve blocks and epidural or intrathecal infusions. • Neuroablative interventions involve cutting or destroying nerves and are done for severe pain that is unresponsive to all other therapies. • Neuroaugmentation involves electrical stimulation of the brain and spinal cord. Non-Drug Therapies • Non-drug therapies include physical or cognitive behavioral strategies. Physical methods include superficial and deep massage, exercise, transcutaneous electrical nerve stimulation (TENS), acupuncture, and thermal treatment. Cognitive-behavioral techniques alter the affective, cognitive, and behavioral components of pain. They include distraction, hypnosis, and relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation. • TENS involves the delivery of an electric current through electrodes applied to the skin surface over the painful region, at trigger points, or over a peripheral nerve. • Trigger point is a circumscribed hypersensitive area within a tight band of muscle. It is caused by acute or chronic muscle strain and can often be felt as a tight knot under the skin. • Acupuncture is a technique of Traditional Chinese Medicine in which very thin needles are inserted into the body at designated points to reduce pain. • Thermal therapies are the application of moist or dry heat or cold to the skin. NURSING AND INTERPROFESSIONAL MANAGEMENT: PAIN

• In your role as a nurse, provide input into the comprehensive assessment and reassessment of pain. Help in the planning and implementation of pain treatment including education, advocacy, and support of the patient and family. • Your beliefs and attitudes may hinder appropriate pain management. Challenges to Effective Pain Management • Tolerance occurs with chronic exposure to a variety of drugs. It is characterized by the need for an increased opioid dose to maintain the same degree of analgesia. • Physical dependence is an expected physiologic response to ongoing exposure to pharmacologic agents, manifested by a withdrawal syndrome that occurs when blood levels of the drug are abruptly decreased. • Addiction is a complex neurobiologic condition characterized by loss of control, craving, and compulsive use of a drug that may be associated with aberrant behaviors and harm arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value. • There is no evidence that giving opioid analgesia to substance-using patients worsens their addictive disease. In fact, the stress of unrelieved pain may contribute to relapse in the recovering patient or increased drug use in the patient who is actively using or abusing drugs. • Pseudoaddiction occurs when patients have behaviors associated with addiction (frequent requests for analgesic refills and/or higher doses), but the behaviors resolve with adequate pain treatment. INSTITUTIONALIZING PAIN EDUCATION AND MANAGEMENT • Under regulatory standards, health care facilities must recognize the patient’s right to appropriate assessment and management of pain and provide education to HCPs, patients, and their families about pain management.

ETHICAL ISSUES IN PAIN MANAGEMENT • A common concern is that providing sufficient opioids to relieve pain will precipitate the death of a terminally ill person. • The use of placebos in clinical practice to assess or treat pain outside of the situation of informed consent in research studies is unethical. GERONTOLOGIC CONSIDERATIONS: PAIN • Persistent pain is a common problem in older adults and is often associated with significant physical disability and psychosocial problems. • Treatment of pain in the older adult is complicated by changes in drug pharmacokinetics (absorption, distribution, metabolism, and excretion) and increased risk for adverse events because of the potential for higher blood levels and drug-to-drug interactions. • HCPs should titrate drugs slowly and monitor carefully for side effects in the older patient. • The use of NSAIDs in the older adult is associated with a high frequency of serious GI bleeding. • Cognitive impairment and ataxia can be worsened when analgesics, such as opioids, antidepressants, benzodiazepines, and antiseizure drugs, are used. MANAGING PAIN IN SPECIAL POPULATIONS • In those who are unable to self-report, behavioral and physiologic changes may be useful in the assessment of pain. A variety of behavioral pain assessment scales are available for patients who are cognitively impaired. • Assessing and treating pain in persons with current, or a history of drug and/or alcohol use is challenging, particularly when therapy involves medications that may, themselves, be abused (e.g., opioids). Opioids may be used effectively and safely in patients with substance dependence when indicated for pain control....