M1: PHARMACOLOGIC, NON PHARMACOLOGIC, NEUROLOGIC, & NEUROSURGICAL INTERVENTIONS

Nurse's Role in Management of Pain

1.Administering Pain relieving intervention

2.Assessing effectiveness of intervention

3.Monitoring for adverse effects

4.Advocate for the patient when the prescribed treatment is ineffective

• Allergies (1st to ask during \_____ assessment)

• Medication history

• Other health problems

Premedication Assessment

Approaches for using analgesic agents

1. Balanced Anesthesia

2. Pre Re Nata (PRN)- as needed

3. Preventive Approach

4. Individualized dosage

5. Patient Controlled Analgesia (PCA)

Refers to the use of more than one analgesia to obtain more pain relief and fewer side effects

Balanced Anesthesia

• For post-operative and chronic pain

• Allows patients to control administration of their pain medication with in predetermined safety limits

Patient Controlled Analgesia (PCA)

3 main groups of Analgesic Agents

1. Non-opioid (Paracetamol and NSAIDS)

2. Opioid (Inhibit CNS activity; pain reliever)

3. Adjuvants (Primary indication other than pain)

■ Decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)

■ decrease pain by inhibiting COX pathway; the rate limiting step in prostaglandin production

■ combined with opioids

■ nephrotoxic

NSAIDS

■ Mediates prostaglandin formation involved in maintenance of physiologic function

■ platelet aggregation and increase mucosal blood flow

COX-1

Mediates prostaglandin formation that results in symptom of pain, inflammation and fever

COX-2

Side effects of Opioid (Narcotic) Analgesic Agents

1. Respiratory depression and sedation (most serious)

2. Nausea and vomiting

3. Constipation

4. Inadequate pain relief

5. Tolerance and addiction

Preventive measure for Constipation (Opioiod)

• Increase fluid intake (eg, to 8 glasses daily).

• Increase fiber and bulk-forming agents to the diet (eg, fresh fruits and vegetables).

• Increase exercise regimen. If necessary, administer stool softeners and/or a mild laxative daily.

Preventive measure for Nausea & Vomiting (Opioiod)

• Inform client that tolerance to this emetic effect generally develops after several days of opiate therapy.

• Provide an antiemetic as required.

• Change the analgesic as indicated.

Preventive measure for Sedation (Opioiod)

• Inform client that tolerance usually develops over 3 to 5 days.

• Administer a stimulant, such as dextroamphetamine sulfate (Dexedrine) or methylphenidate hydrochloride (Ritalin) each morning to clients who receive opiate therapy for chronic pain and do not develop tolerance.

Preventive measure for Respiratory Depression (Opioiod)

• Administer an opioid antagonist, such as naloxone hydrochloride (Narcan) until respirations return to an acceptable rate. Administer the medication slowly by intravenous route with 10 mL of saline. Monitor the client, and repeat the procedure as required.

• If the client is receiving intravenous patient-con- trolled analgesia (PCA), stop or slow the infusion.

Preventive measure for Pruritus (Opioiod)

• Apply cool packs, lotion, and diversional activity. Administer an antihistamine (eg, diphenhydramine hydrochloride [Benadryl]).

• Inform the client that tolerance also develops to pruritus.

Use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects

Balanced Analgesia

Preventive measure for Urinary Retention (Opioiod)

• May need to catheterize client.

• Administer narcotic antagonist (naloxone hydro- chloride [Narcan]).

Routine administration for using Analgesic Agents

Around the clock (ATC) or preventive approach; medication acts before the pain becomes severe and before the serum opioid level falls to a subtherapeutic level.

The dosage and the interval between doses should be based on the patient's requirements rather than on an inflexible standard or routine

Individualized dosage

• Rapidly absorbed into bloodstream, resulting to ↓ availability at the surgical or injury site and an ↑ anesthetic level in the blood, increasing the risk of toxicity

• Blocks nerve conduction when applied directly to the nerve fibers.

• A vasoconstrictive agent (eg, epinephrine or phenylephrine)is added to the anesthetic agent to decrease its systemic absorption and to maintain its concentration at the surgical or injury site.

Local Anesthetic Agents

- Applied to the site of injury w/ a vasoconstricting agent

- EMLA (eutectic mixture of local anesthetic)

Topical Anesthetic Agent

Local anesthetic is directly applied to the nerve root through an Epidural catheter

Intraspinal (epidural) Anesthetic Agent

Purpose: Removal of a skin lesion; tooth extraction

Effects: Anesthetic that blocks nerve conduction (sensory) in a peripheral nerve

Example: Lidocaine

Local Anesthetic

Purpose: General surgery, no pain/awareness when combined with analgesic.

Effects: Affects brain-partial or total loss of consciousness.

Example: Intravenous - thiopental sodium

Inhalation (gas)- nitrous oxide

General Anesthetic

Purpose: General surgery, no pain/awareness when combined with analgesic.

Effects: Can respond

Example: Diazepam/Droperidol

Relative/Neuro-leptanesthesia

Purpose: Surgery on lower part of body: labor and delivery.

Effects: Blocks nerve conduction (sensation) at and below level of injection.

Example: Diazepam/Droperidol

Spinal Anesthesia

Name: ASA, Acetaminophen, NSAIDS

Action:

• Decreases pain at peripheral site.

• All are antipyretic.

• ASA and NSAIDs are anti-inflammatory.

Adverse Effects: Nausea, gastric ulcers, bleeding, allergies (various)

For MILD PAIN

Name: Codeine & Oxycodone

Action: Acts on central nervous system and affects perception

Adverse Effects: Narcotic (opium)-often combined with ASA/acetaminophen. High dose may depress respiration.

For MODERATE PAIN

Name: Morphine & Meperidine

Action: Acts on central nervous system; euphoria and sedation.

Adverse Effects: Narcotic-tolerance and addiction High dose depresses respiration; nausea, constipation common.

For SEVERE PAIN

Routes of Administration for Analgesics

1. Oral

2. Rectal

3. Topical & Transdermal

4. Parenteral

5. Transmucosal

6. Intraspinal

Act directly on opiate receptors in the dorsal horn of the spinal cord (quick)

- for persistent, severe, unresponsive pain

- may cause spinal h/a, respiratory depression, vomiting

Intraspinal Analgesics

Two commonly used medications are preservative-free

Morphine sulfate and Fentanyl

The major benefit of intraspinal drug therapy

Exerts a lesser sedative effect than do systemic opiates

For neurologic pain and unresponsive to opioids

Tricyclic antidepressants and anticonvulsants

Used in lower doses indicated for Pain of neurologic origin (causalgia, tumor impingement on a nerve, postherpetic neuralgia, dysesthesia (burning or cutting pain)

Antiseizure medications

• More likely to have adverse drug effects, drug interactions

• Increased likelihood of chronic illness

• May need to have more time between doses of medication due to decreased excretion, metabolism related to aging changes

Gerontologic Considerations

Proposes stimulation of fibers that transmit non-painful sensations can block or ↓ pain transmission impulses

Cutaneous Stimulation and Massage

Ice should be applied no longer than 20minutes at a time

Ice and Heat Therapies

Uses battery operated unit with electrodes applied to the skin to produce a tingling, vibrating or buzzing sensation in the area of pain

Transcutaneous Electrical Nerve Stimulation

Focusing the patient's attention on something other than the pain

Distraction

Abdominal breathing at a slow, rhythmic rate, rhythmic inhalation, and exhalation

Relaxation Techniques

Using one's imagination in a special way to achieve a specific positive effect; consist of combining slow, rhythmic breathing with a mental image of relaxation and comfort

Guided Imagery