Unit 5

What is the primary difference between acute and chronic pain regarding duration?

Chronic pain persists for longer than 3 months, whereas acute pain is immediate and transient.

Which type of pain is characterized by burning, shooting, or 'pins and needles' sensations due to nerve damage?

Neuropathic pain.

What is the clinical term for pain resulting from the compression or entrapment of a spinal nerve root?

Radicular pain.

Which type of pain arises from direct stimulation of intact nociceptors in response to tissue injury or inflammation?

Nociceptive pain.

Define 'nociplastic pain' as described in the material.

Pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, such as fibromyalgia.

What physiological stress response is triggered by the autonomic nervous system during acute pain?

Increased heart rate, respiratory rate, and blood pressure.

What is 'multimodal analgesia'?

The use of multiple medication classes and nonpharmacological treatments to manage pain while minimizing opioid doses.

Drug Class: Opioid Agonists. What is the prototype medication?

Morphine.

Mechanism of Action: How do opioid agonists like morphine alter pain perception?

They bind to mu receptors at opioid receptor sites in the CNS to inhibit pain-signaling pathways.

Indications: Name the therapeutic use for morphine.

Management of moderate to severe pain, palliative care, and pain crises.

Contraindications: Why is morphine contraindicated in clients with head injuries?

It can increase intracranial pressure due to carbon dioxide retention from decreased respiratory drive.

Side Effects: What is the most common gastrointestinal side effect of chronic opioid use?

Constipation due to decreased intestinal motility.

Adverse Effects: Which life-threatening complication must nurses monitor for in clients receiving opioids?

Respiratory depression.

Nursing Assessment: What is the minimum respiratory rate required before safe administration of an opioid?

A respiratory rate of at least $12/\text{min}$.

Nursing Assessment: When should a nurse reassess pain after IV morphine administration?

Within 20 minutes.

Client Education: What should the nurse instruct a client regarding position changes while taking opioids?

Rise from sitting or lying positions slowly to avoid dizziness and falls.

High-Yield Exception: Why is meperidine generally not recommended for use in older adults?

It carries an increased risk of adverse effects due to physiological changes and comorbidities in the elderly.

Drug Class: Opioid Agonist-Antagonists. What is the prototype medication?

Butorphanol.

Mechanism of Action: What are the mixed receptor actions of opioid agonist-antagonists?

They act as mu receptor antagonists and kappa receptor agonists.

Indications: What is a specific clinical use for butorphanol?

Analgesia for clients in labor or as a preoperative sedative.

Contraindication: Why should butorphanol be avoided in clients with physical dependence on opioids?

It can precipitate immediate opioid withdrawal manifestations.

Adverse Effects: Compared to pure agonists, what is the benefit of the 'ceiling effect' in agonist-antagonists?

They produce fewer mu-related adverse reactions like severe respiratory depression and euphoria.

Nursing Assessment: How soon should pain be reassessed after intranasal administration of butorphanol?

Within 90 minutes.

Client Education: What is a unique side effect of butorphanol that clients should be warned about?

Dysphoria or hallucinations.

Drug Class: Dual-Mechanism Agents. What is the prototype medication?

Tramadol.

Mechanism of Action: What two pathways does tramadol affect to relieve pain?

It binds to mu receptors and inhibits the reuptake of serotonin and norepinephrine.

Indications: When is tramadol typically indicated?

For moderate to moderately severe acute or chronic pain.

Contraindication: Tramadol is contraindicated in pediatric clients under what age?

Under the age of 12.

Adverse Effects: Which neurological adverse effect is associated with tramadol lowering the seizure threshold?

Seizures.

Adverse Effects: What life-threatening syndrome can occur if tramadol is taken with other serotonergic medications?

Serotonin syndrome.

Nursing Assessment: What electrolyte imbalance should the nurse monitor for in clients taking tramadol?

Hyponatremia.

Client Education: How should a client take extended-release tramadol tablets?

Swallow them whole; do not crush, chew, or split the tablet.

Drug Class: Opioid Antagonists. What is the prototype medication?

Naloxone.

Mechanism of Action: How does naloxone reverse opioid toxicity?

It competitively binds to opioid receptors, blocking agonists from exerting their effects.

Indications: What is the primary therapeutic use for naloxone?

Rapid reversal of opioid-induced respiratory and CNS depression.

Side Effects: What symptoms are typically seen as a result of naloxone administration in an opioid-dependent client?

Acute withdrawal manifestations like nausea, vomiting, tachycardia, and sweating.

Adverse Effects: What is a significant, fast heart rhythm complication associated with naloxone?

Ventricular arrhythmia.

Nursing Assessment: For how long should the nurse monitor respirations after naloxone administration?

At least 3 hours to ensure manifestations of toxicity do not return as naloxone wears off.

Emergency Procedure: How often can intranasal naloxone doses be repeated if there is no response?

Every 2 to 3 minutes, alternating nostrils.

High-Yield Exception: Which opioid antagonist is used specifically for opioid-induced constipation without crossing the blood-brain barrier?

Methylnaltrexone.

Drug Class: Nonopioid Analgesic (Antipyretic). What is the prototype medication?

Acetaminophen.

Mechanism of Action: Where does acetaminophen primarily interfere with prostaglandin production?

In the Central Nervous System (CNS).

Indications: What are the two primary therapeutic effects of acetaminophen?

Analgesia (pain relief) and antipyresis (fever reduction).

Contraindication: Acetaminophen is contraindicated in clients with which chronic condition due to liver risk?

Severe hepatic disease or chronic alcohol use disorder.

Adverse Effects: What is the primary organ system at risk for toxicity during an acetaminophen overdose?

The liver (Hepatotoxicity).

Nursing Assessment: What is the maximum daily dose of acetaminophen for a healthy adult?

$4\text{ g}$ per day.

Antidote: What is the reversal agent for acetaminophen toxicity?

$N$-acetylcysteine.

Client Education: Why should clients read labels of OTC cold medications while taking acetaminophen?

To avoid accidental toxicity from combination products that also contain acetaminophen.

Drug Class: Nonselective NSAIDs. What are the prototype medications?

Aspirin and Ibuprofen.

Mechanism of Action: How do first-generation NSAIDs work?

They nonselectively inhibit both COX-1 and COX-2 enzymes.

Indications: What are the three primary therapeutic actions of NSAIDs?

Reduction of inflammation, fever, and pain.

Contraindication: Why is ketorolac contraindicated in clients with active peptic ulcer disease?

It inhibits COX-1, which is essential for protecting the gastric mucosa, increasing the risk of perforation.

Adverse Effects: What is a serious skin reaction associated with NSAIDs like ketorolac?

Stevens-Johnson syndrome or Toxic Epidermal Necrolysis.

Nursing Assessment: What is the maximum recommended duration for ketorolac therapy?

5 days (due to high risk of renal and GI complications).

High-Yield Exception: Which NSAID is a selective COX-2 inhibitor?

Celecoxib.

Contraindication: Clients with an allergy to which drug class should avoid celecoxib?

Sulfonamides (Sulfa drugs).

Drug Class: Local Anesthetics. What is the prototype medication?

Lidocaine.

Mechanism of Action: How does lidocaine produce a numbing effect?

It blocks sodium ion channels, preventing the initiation and conduction of nerve impulses.

Indications: Name a common use for lidocaine patches.

Relief of muscle aches in joints like the back, shoulders, or knees.

Adverse Effects: What are manifestations of systemic lidocaine toxicity?

Confusion, seizures, arrhythmias, and cardiac arrest.

Nursing Assessment: What reflex must the nurse assess before a client eats or drinks after using oral lidocaine spray?

The gag reflex.

Client Education: What should a client avoid applying over a lidocaine patch?

External heat sources like heating pads (which increase absorption and toxicity risk).

Drug Class: Adjuvant Analgesics (SNRIs). What is the prototype medication?

Duloxetine.

Mechanism of Action: How does duloxetine act as a centrally mediated pain inhibitor?

It inhibits the reuptake of serotonin and norepinephrine in the CNS to dampen pain signal transmission.

Indications: What chronic pain conditions is duloxetine indicated for?

Diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain.

Adverse Effects: What psychological adverse effect requires close monitoring in clients taking antidepressants for pain?

Suicidal thoughts or behaviors.

Nursing Assessment: What vital sign should be monitored closely during duloxetine therapy?

Blood pressure (risk of dose-related hypertension).

Client Education: Why should duloxetine not be stopped abruptly?

To prevent withdrawal manifestations such as nausea, dizziness, and anxiety.

Drug Class: Adjuvant Analgesics (Anticonvulsants). What is the prototype medication?

Gabapentin.

Mechanism of Action: Though the exact mechanism is unknown, how is gabapentin thought to stabilize neurotransmitters?

By binding to calcium channels in the brain to inhibit the release of excitatory neurotransmitters.

Indications: Gabapentin is specifically approved for pain following which viral infection?

Herpes zoster (Postherpetic neuralgia/shingles).

Adverse Effects: What serious muscle-related adverse effect can occur with gabapentin?

Rhabdomyolysis.

Side Effects: What is a common metabolic side effect of gabapentin?

Weight gain.

Client Education: What is the instruction regarding the timing of gabapentin and antacids?

Separate doses by at least 2 hours to avoid interference with absorption.

Drug Class: Cannabis. What are the two main chemical compounds used in pain management?

Tetrahydrocannabinol (THC) and Cannabidiol (CBD).

Mechanism of Action: What is the network of receptors that cannabis interacts with in the body?

The endocannabinoid system (CB1 and CB2 receptors).

Indications: Cannabis is especially helpful for which type of pain where opioids might be avoided?

Chronic neuropathic pain.

Adverse Effects: Describe 'Cannabis Hyperemesis Syndrome'.

A condition of persistent nausea and vomiting relieved by hot showers and stopping cannabis use.

Nursing Assessment: Why should nurses check for a 'Certificate of Analysis' for cannabis products?

To ensure the product is free from contaminants like micro-organisms and heavy metals.

Client Education: What is the 'start low and go slow' rule in cannabis therapy?

Begin with a low dose and increase incrementally to find the minimum effective dose with the fewest side effects.

Pain Pathway. What are 'unmyelinated C-fibers' responsible for?

Transmitting slow, dull, aching pain signals.

Opioid Naïve. Define this term in a nursing context.

A client who has not recently or ever taken opioid medications and is at higher risk for adverse effects.

Common Drug Stem: -profen

NSAIDs (e.g., Ibuprofen).

Common Drug Stem: -oxetine

SNRIs/Antidepressants (e.g., Duloxetine).

Common Drug Stem: -caine

Local Anesthetics (e.g., Lidocaine).

Common Drug Stem: -coxib

Selective COX-2 Inhibitors (e.g., Celecoxib).

Recognition: Which medication is identified by the stem '-codone' or '-morphone'?

Opioid Agonists.

Recognition: What is the classification of a medication ending in '-nax' or '-lam' used as a CNS depressant interaction with opioids?

Benzodiazepines.

Safety: What are the 'ABCs' of a primary survey for a trauma client in pain?

Airway, Breathing, and Circulation.

Safety: What is the most critical assessment to perform before administering any opioid?

Respiratory rate.

Emergency: What should a nurse prioritize if a client's respiratory rate drops below $8/\text{min}$ after an opioid dose?

Administration of naloxone and providing ventilatory support.

Interactions: Why is the combination of acetaminophen and alcohol particularly dangerous?

Both are metabolized by the same enzyme, leading to an increase in the toxic metabolite NAPQI and potential liver failure.

Summary: Drug Class: Opioid Agonist | Prototype: Morphine | Adverse Effect: _____ | Antidote: Naloxone.

Respiratory Depression

Summary: Drug Class: Nonopioid Analgesic | Prototype: Acetaminophen | Adverse Effect: Hepatotoxicity | Antidote: _____.

N-acetylcysteine

Summary: Drug Class: NSAID | Prototype: Ketorolac | Major Risk: _____ | Limit: 5 days.

GI Bleed or Renal Failure

Summary: Drug Class: Dual-Mechanism | Prototype: Tramadol | Major Risk: _____ and Serotonin Syndrome.

Seizures

Summary: Drug Class: SNRI Adjuvant | Prototype: Duloxetine | Indication: _____ Pain.

Neuropathic

Summary: Drug Class: Anticonvulsant Adjuvant | Prototype: Gabapentin | Indication: _____ Neuralgia.

Postherpetic

Which headache type is characterized by a bilateral 'tight band' sensation and a gradual onset?

Tension-type headache (TTH).

What is the typical duration of a migraine headache episode?

4 to 72 hours.