NSG 212 - Exam 4 KW

Acute pain

-Sudden onset

-Usually subsides when treated

-Protective, temporary

-May see patients flinch, guard, moan

-Examples: Headache, stub toe, etc.

-Pain is associated with tissue healing.

-Systemic: May also see other signs and symptoms such as tachycardia, increased respiratory rate, hypertension, anxiety, diaphoresis, muscle tension, pallor, dry mouth, nausea, increased blood sugar, and decreased urine output.

-Treatment: Treat the underlying cause.

treatment for acute pain

treat the underlying cause

Surgical Pain Management

-Pain is a normal part of the surgical experience.

-Pain must be assessed q 2 hours after surgery.

-Unresolved pain can increase length of recovery.

-Teach the patient to ask for pain meds while the pain is low to moderate intensity.

-Consider pharmacological and non-pharmacological treatment.

-Assess for sources of pain that may indicate surgical complications (DVT, dehiscence/evisceration, internal bleeding, etc.).

Chronic Pain

-Slow - Days to months

-Constant or intermittent

-1-6 months in duration

-Dull, persistent ache

-Ongoing, may have no known cause, could be malignant in nature

-Management is aimed at helping the symptoms NOT curing the cause.•Chronic pain may lead to depression/fatigue…May lead to disability.

-May have periods of remission where disease is present but NO symptoms

-Exacerbation…Symptoms are present…Example: rheumatoid arthritis

-Pain does not always respond to interventions.

-Treatment:

--Long acting or controlled release opioids (transdermal)

--Administer around the clock…NOT as needed (PRN).

treatment for chronic pain

-Long acting or controlled release opioids (transdermal)

-Administer around the clock…NOT as needed (PRN).

idiopathic pain

-Pain without a known cause

-Form of chronic pain

-OR pain that exceeds typical pain levels that we may expect based on the patient’s presentation.

nociceptive pain

-Responds well to meds

-Caused from damage or inflammation to normal tissues…throbbing, aching.

-Somatic: Originates from skeletal muscles, ligaments, tendons, bones, joints, blood vessels, and nerves

-Visceral: Originates from organs and smooth muscle; pain occurs as organs stretch abnormally and become distended/inflamed; GUARDING may occur as a protective mechanism.

-Superficial/Cutaneous: From the skin, cutaneous tissue, mucous membranes; example: paper cut

neuropathic pain

-Pain is caused by stimulation of the CNS; damage to nerve fibers

-Can include phantom pain, diabetic neuropathy

-People describe as burning, shooting, intense pain, and/or pins and needles.

-Typical pain meds usually do not relieve pain.

-Requires adjuvant medications

adjuvant analgesics

enhance the effects of non-opioids, help alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain

anticonvulsants

Carbamazepine, gabapentin

Antianxieity agents

Diazepam, lorazepam

Tricyclic antidepressants

Amitriptyline, nortriptyline

Anesthetics

infusional lidocaine

Antihistamine

Hydroxyzine

Glucocorticoids

Dexamethasone

Anti-emetics

Ondansetron

Bisphosphonates and Calcitonin

for bone pain

Types of pain

-physical
-psychogenic
-referred
-vascular
-breakthrough
-intractable

physical pain

cause of pain can be identified

psychogenic

cause of pain cannot be identified (phantom limb pain)

referred pain

moves from site

vascular pain

vasodilation-migraines

breakthrough pain

occurs between doses of pain meds

intractable pain

severe pain that is extremely resistant to relief measures

pain is whatever the pt

believes it to be

the pain process

transduction, transmission, perception, modulation

transduction

activation of pain receptors

transmission

conduction along pathways (A-delta and C-delta fibers)

perception of pain

awareness of the characteristics of pain

modulation

inhibition or modification of pain; occurs in the spinal cord and causes muscles to contract to move people away from pain

substances that increase pain

-stimulator of nociceptors or pain receptors (Nociceptors are NASTY)

-bradykinin

-prostaglandins

-substance P

-histamine

bradykinin

-a powerful vasodilator that increases capillary permeability and constricts smooth muscle

prostaglandins

-important hormone-like substances that send additional pain stimuli to the CNS
-Makes us feel or interpret pain
-many meds work by inhibiting prostaglandins

Substance P

-Sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves

-Makes us feel or interpret pain!

Histamine

-generation of pain hypersensitivity

substances that decrease pain response

good substances
-serotonin
-endorphines

serotonin

A neurotransmitter that affects hunger, sleep, arousal, and mood.

endorphins

-Some chemicals in the body act similarly to natural opioid medications, binding to the pain receptors. These chemicals are called endorphins. DECREASE PAIN RESPONSE.

-Powerful pain blocking chemicals

--Dynorphins: Most potent endorphin; “natural” pain relief

neuromodulators

endogenous opioid compounds, "natural" pain relief

enkephalins

inhibit the release of substance P

gate theroy of pain

-Describes the transmission of painful stimuli and recognizes a relationship between pain and emotions.
-Small- and large-diameter nerve fibers conduct and inhibit pain stimuli toward the brain.
-Gating mechanism determines the impulses that reach the brain.

The student nurse is reviewing information for a Fundamentals exam. The student is reviewing the theory behind pain response. The student would know that which of the following substances are responsible for the perception of pain? SELECT ALL THAT APPLY:

substance P, Prostaglandins

pain response

-mild
-severe deep pain
-behavioral
-affective responses

mild pain response

-Increased RR rate, HR, BP, and blood glucose; dilation of bronchial tubes; pallor; release of adrenaline; diaphoresis; muscle tension; decreased GI motility

severe deep pain response

-Pallor; rapid, irregular breathing; N/V; weakness, fatigue; fainting, LOC; decreased HR and BP

behavioral pain response

-Moving away from painful stimuli, clenching of teeth, holding painful part, grimacing, bending over, tensing abdominal muscles, crying, moaning, refusing to move, restlessness

affective pain response

-Withdrawal, anxiety, fear, depression, anger, anorexia, hopelessness, powerlessness

pain influences

•Cultural beliefs
•Healing
•Environment
•Belief that comfort will come
•Anger
•Anxiety
•Control
•Sleeplessness
•It exists whenever the patient says it exists.
•It's an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
•Pain is a personal and individual experience.

threshold

-The level of stimulus needed to produce the perception of pain.
-A measure of the physiologic response of the nervous system.

tolerance

-The amount of pain a patient can endure without its interfering with normal function.
-Varies from person to person
-Subjective response to pain, not a physiologic function
-The point beyond which pain becomes unbearable

physical dependence

-The physiologic adaptation of the body to the presence of an opioid

CRIES pain scale

0-6 months
-crying, requires 02, vital signs(BP+HR), expression, sleepless

FLACC pain scale

-2 months to 7 years old
-Faces, Legs, Activity, Cry, Consolability

pain assessment

-O – Onset: When did it start?

-P – Provoked: What causes the pain; makes it better, worse

-Q – Quality: What does it feel like? Dull, sharp…

-R - Region/Radiation: Where is it? Does it spread?

-S – Severity (Intensity): Use scale.

-T – Timing: When does it occur? Consistent?

faces pain scale

"oucher"

objective (non-verbal) pain assessment

•Facial grimacing
•Moaning, crying
•Guarding
•Decreased attention span
•Physiologic measures: Increased blood sugar, change in vital signs. Over time, these measures will "stabilize" even if the patient is experiencing pain.

subjective (verbal) pain assessment

•Location

•Intensity: Visual scale (7 and older)

•Quality: Sharp, dull, piercing. Use the patient’s exact words.

•Pattern: Onset, duration, frequency, intervals without pain

•Setting: In a particular place/area, such as driving in a car or sitting in hard chair

•Precipitating/ alleviating factors

•Associated symptoms

•Effects on daily living

•Coping strategies

•Affective/behavioral responses: Anxiety, depression, grimacing, moaning, change in vital signs

how to assess there pain?

-A: Ask about pain regularly; assess pain systematically.

-B: Believe the patient and family.

-C: Choose the appropriate pain control options.

-D: Deliver interventions in a timely manner.

-E: Empower the patient and family.

The nurse would know that the FLACC pain scale would be an appropriate pain scale to be used to assess pain in which of the following patient populations?

3-month-old admitted for abdominal surgery

non-pharmacologic pain relief

•Distraction: Includes ambulation, deep breathing, visitors, television, games, prayer, and music. Decreased attention to the presence of pain can decrease perceived pain level.

•Relaxation: Includes meditation, yoga, and progressive muscle relaxation.

•Humor

•Music

•Imagery: Focusing on a pleasant thought to divert focus from pain.

•Massage

•Cutaneous stimulation: Heat/cold application. (Cold for inflammation or heat to increase blood flow and to reduce stiffness.) TENS unit (Transcutaneous Electrical Nerve Stimulation)

•Cognitive-behavioral measures: Changing the way a client perceives pain and physical approaches to improve comfort.

•Acupuncture and acupressure: Stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure). Reduction of pain stimuli in the environment.

•Elevation of edematous extremities to promote venous return and decrease swelling.

•Hypnosis

•Biofeedback

•Therapeutic touch

•Animal-facilitated therapy

heat and cold therapy

•Both may be used as non-pharmacological pain interventions.

•A provider’s order is needed for both (dependent nursing intervention).

•Increases blood flow

•Increases tissue metabolism

•Relaxes muscles

•Eases joint stiffness and pain

•MOIST

oWarm compresses: Towel, bath thermometer, hot water, plastic covering, hot pack or aquathermia pad (with distilled water), tape

oWarm soaks: Water, bath thermometer, basin, waterproof pads

oSitz baths: Specific chair, tub, or basin (disposable or built-in), bath thermometer, bath blanket, towels

•DRY

oHot pack (disposable or reusable) or an aquathermia pad (with distilled water), and a pillowcase

oWarming blanket

Document the following:

•Location, type, and length of the application

•Condition of the skin before and after the application

•Patient’s tolerance of the application

Nursing interventions fo heat therapy

•Follow provider’s order: Location, duration, and frequency; specific type (moist or dry); temperature to use

•Monitor bony prominences carefully, because they are more sensitive to heat applications.

•Avoid the use of heat applications over metal devices (pacemakers, prosthetic joints) to prevent deep tissue burns.

•Do not apply heat to the abdomen of a patient who is pregnant to prevent harm to the fetus.

•Do not place a heat application under a patient who is immobile because this can increase the risk of burns.

• Do not use heat applications during the first 24 hr after a traumatic injury, for active bleeding, for non-inflammatory edema, or for some skin disorders.

•Use extreme caution with patients who are very young or fair-skinned, and older adults because they have fragile skin.

•Patients who are immobile might not be able to move away from the application if it becomes uncomfortable. They are at risk for skin injuries.

•Patients who have impaired sensory perception might not feel numbness, pain, or burning.

•Use minor temperature changes and short-term applications of heat or cold for best results.

•Discontinue the application if any of the above occur, or remove the application at the predetermined time (usually 15 to 30 min).

cold therapy

•Do not use cold applications for patients who have cold intolerance, vascular insufficiency, open wounds, and disorders aggravated by cold, such as Raynaud’s phenomenon.

•Avoid long applications of either heat or cold, because this can result in tissue damage, burns, and reflex vasodilation (with cold therapy).

•MOIST

oCold water compresses

oCold soaks

•DRY

oIce bag, ice collar, ice glove, or a cold pack

oCooling blanket

•Decreases inflammation

•Prevents swelling

•Reduces bleeding

•Reduces fever

•Diminishes muscle spasms

•Decreases pain by decreasing the velocity of nerve conduction

•Apply to the area.

•Make sure the call light is within reach, and instruct patients to report any discomfort.

•Assess the site every 5 to 10 min to check for the following:

oRedness or pallor

oPain or burning

oNumbness

oShivering

oBlisters

oDecreased sensation

oMottling of the skin

oCyanosis

oDiscontinue the application if any of the above occur, or remove the application at the predetermined time (usually 15 to 30 min).

pharmacologic pain relief measures

•Non-opioid analgesics
•Opioids or narcotic analgesics
•Adjuvant drugs

PCA

patient controlled analgesia

•Only the patient should push the button!

•Pain assessment/pain reassessment

•Treat the pain before it becomes too severe!

•Reassess 30 -60 minutes after pain medication/intervention.

•PRN: Not automatic. Explain this to your patient.

•Constant plasma levels are maintained by small frequent doses.

•Less lag time between need and delivery

•Increases patient sense of control

•May decrease amount of medication needed

•Morphine sulfate and hydromorphone are commonly used.

•Patients need educated – only they should push button!

Patient determines when analgesia is administered (with predetermined safety limits).

•Loading dose

•Demand dose

•Basal dose

•Rescue dose (bolus)

•Lockout interval (pt can push button, but no med delivered)

•Can go into IV, SQ, epidural cath

•Nurses must assess RR.

•Families, RNs, CAs, and students should not push the button for pts!

analgesics - non-opioid

•Acetaminophen

oAdverse effect: Liver dysfunction

•NSAIDS

oAct peripherally

oDecrease inflammation/inhibit prostaglandins

oExamples: Aspirin, Ibuprofen, Naproxen, Indomethacin, Toradol

oAdverse effects: GI upset, bleeding, renal dysfunction

oCOX-2 inhibitors (Celebrex, Vioxx) -- Less chance of GI upset (We now have safety concerns with this class of meds!)

analegsics -opioid(narcotic)

•Act on CNS

oBlock release of neurotransmitters that promote transmission of pain pathways

•Examples: Morphine, codeine, hydromorphone, fentanyl, oxycodone, meperidine

•Opioid Antagonist - Naloxone (Narcan)

oReverses effects of opioids, both side effects & analgesia. Used only to counteract an overdose of opioid. IM and intranasal versions available for purchase at pharmacies and carried with all first responders

adverse effects of opiods

•Respiratory Depression - Increased with age, other CNS meds

•Circulatory Depression

•Constipation - Dose related, occurs frequently with long term use, ^ after surgery secondary to immobility and decreased fluid intake

•Nausea & Vomiting - Try to increase hydration, can administer anti-emetics

•Urinary retention – Especially with epidural

•Pruritus - Does not = allergy, can give antihistamines

•Physical Dependence - W/d symptoms

•Tolerance - Need increased dosing pattern for same effect

•Addiction - Psychological/behavioral pattern, taking drug for euphoric effects

•Inadequate pain relief - May be due to changing route, i.e. If switch from IV to PO will need 3x dose

pain management in pt with opioid use disorder

-Understand the difference between medication dependent and medication addicted.

-Dependence: Experience improved quality of life and increased functioning with treatment

-Addiction: Exhibit a lack of control and compulsive need for medication

management for opioid use disorder

•Effective medications exist to treat opioid use disorder, but only a fraction of people with addiction have access to them (buprenorphine, methadone, naltrexone).

•Lots of research going on right now looking for newer, longer lasting, safer ways to treat opioid use disorder.

oDepot formulation injections (Vivitrol – blocks effects of opioids in body for 4 weeks)

oImplants (Probuphine)

A patient who has bone cancer is most likely experiencing which of the following types of pain?

somatic

Which modulator of pain is thought to reduce pain sensation by inhibiting the release of substance P from the terminals of afferent neurons?

enkephalins

The best judge of the existence and severity of a patient's pain is the physician or nurse caring for the patient. T or F

False - The best judge of the existence and severity of a patient's pain is the patient.

Which following pain assessment tools is recommended for use with neonates ages 0 to 6 months?

CRIES pain scale

A sedated patient is frequently drowsy and drifts off during his conversation with the nurse. What number on the sedation scale best describes this patient?

3

A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

"I should tell the nurse if the pain doesn't stop while I am using this device."

Cutaneous stimulation (TENS) for pain control

a method of pain relief involving the use of a mild electrical current. A TENS machine is a small, battery-operated device that has leads connected to sticky pads called electrodes. You attach the pads directly to your skin

factors affecting safety

-Falls

•Older adults

-Fires (later slide)

-Poisoning

•Call poison control.

-Suffocation and choking

-Firearm injuries

•Keep firearms unloaded, locked up, and out of reach.

•Teach to never touch a gun or stay at a friend’s house where a gun is accessible.

•Store bullets in a different location from guns.šDevelopmental considerations

-Lifestyle

-Social behavior

-Environment

-Mobility

-Sensory perception

-Knowledge

-Ability to communicate

-Physical and psychosocial health state

Safety considerations through lifespan

See Taylor Page 765 (Please see this page.

restraints

-Chemical Restraints (Medications)

•Used only at LAST resort

•Confusion, disorientation

•May lead to additional falls and injury

-Physical Restraints

-Safety Measures When Using Restraints:

-Pad boney prominences under or near the restraint.

-Allow enough slack for patient to perform ROM.

-Use slip knots; can be untied with one hand.

-2 fingers between the restraint and the person.

-NEVER tie restraints to the side rails; tie to portion of the bed that moves with the patient - bed frame

-Explain need to patient, family; continually evaluate need; DC when no longer required;

Hazards to Using Restraints:

-Older patients are 8 x’s more likely to die while restrained than when non-restrained.

-Suffocation and/or entrapment; impaired circulation, altered skin integrity, pressure ulcers, and contractures, diminished muscle and bone mass, fractures, altered nutrition and hydration, aspiration and breathing problems, incontinence

Least restrictive restraints

-Least restrictive!

-Vest restraints are least restrictive. Good for patients who frequently get up out of the bed or chair. They still have use of arms and can still eat, drink, etc.

-Side rails - Restraint unless patient requests

-The patient must be able to raise/lower them.

alternatives to restraints

-Remember, restraints are LAST option.
-Used when all other less restrictive means have failed.
-May also use:
•Orientation to the environment
•Supervision of a family member or sitter
•Diversional activities
•Electronic devices

factors that contribute to falls

-Lower body weakness

-Poor vision

-Gait and/or balance issues

-Problems with feet and/or shoes

-Use of psychoactive medications

-Postural dizziness

-Hazards in the home (and community)

-Interventions in the home

•Remove small items that can cause falls.

•Place cords/wires out of walking areas.

•Ensure steps and sidewalks are in good repair.

•Grab bars by toilets/bathrooms.

•Non-skid backing to mats/rugs in the home.

•Use a shower chair.

•Use of adequate lighting.

•Infants

seizures

-A seizure is a sudden surge of electrical activity in the brain. It can occur at any time due to epilepsy, fever, or a variety of medical problems.
-Partial seizures (also called focal seizures) are due to electrical surges in one part of the brain, and generalized seizures involve the entire brain.
-Status epilepticus (a prolonged seizure) is a medical emergency.
-Seizure precautions (measures to protect patients from injury during a seizure) are imperative for patients who have a history of seizures that involve the entire body and/or result in unconsciousness.

seizure precautions

-Make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails.
-Patients at high risk for generalized seizures should have a saline lock in place for immediate IV access.
-Ensure rapid intervention to maintain airway patency.
-Inspect the patient's environment for items that could cause injury during a seizure, and remove items that are not necessary for current treatment.
-Assist patients at risk for seizures with ambulation and transferring to reduce the risk of injury.
-Advise all caregivers and family not to put anything in the patient's mouth (except an airway for status epilepticus) during a seizure.
-Advise all caregivers and family not to restrain the patient during a seizure but to lower them to the floor or bed, protect their head, remove nearby furniture, provide privacy, put them on their side with their head flexed slightly forward if possible, and loosen clothing.

during/after a seizure

-Stay with the patient, and call for help.
-Maintain airway patency and suction PRN.
-Administer medications.
-Note the duration of the seizure and the sequence and type of movements.
-After a seizure, determine mental status and measure oxygen saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery.
-Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider.

fire safety

All staff must:

-Know the location of exits, alarms, fire extinguishers, and oxygen shut‑off valves.

-Make sure equipment does not block fire doors.

-Know the evacuation plan for the unit and the facility.

RACE

-R - Rescue anyone in immediate danger.
-A - Activate the fire code and notify appropriate person.
-C - Confine the fire by closing doors and windows.
-E -Extinguish the Fire/Evacuate

PASS

To use a fire extinguisher, use the PASS sequence.
-P: Pull the pin.
-A: Aim at the base of the fire.
-S: Squeeze the handle.
-S: Sweep the extinguisher from side to side, covering the area of the fire.

ABC fire extinguishers

•A: Paper, woods, upholstery, rags,
•B: Flammable liquids and gas
•C: Electrical Fires

The nurse is completing a continuing education program concerning fire safety in a hospitalized setting. The nurse is reviewing the concepts of RACE and PASS. The nurse would understand that the "A" in PASS stands for :

Aim

The nurse is caring for a patient who continually attempts to climb out of bed and stand up from a seated position in a chair. The patient underwent a total knee surgery 2 days ago. The patient's actions are preventing proper wound healing and placing him at a very high risk for falls. After considering all of the other alternatives to restraints, the nurse consults the provider to ask for an order for restraints. Which of the following type of restraint would be most appropriate and least restrictive for this older adult patient?

vest restraint

Among older adults, fires are the leading cause of injury fatality. T or F

False - Among adults older, falls are the leading cause of injury fatality.

A nurse whose behavior is reasonable and prudent and similar to the behavior that would be expected of another nurse in similar circumstances is still likely to be found liable if a patient falls. T or F

False - A nurse whose behavior is reasonable and prudent and similar to the behavior that would be expected of another nurse in similar circumstances is unlikely to be found liable if a patient falls, even if injury occurs.

Which action is a priority emphasized in the RACE acronym guide to fire safety?

Extinguish/Evacuate patients and other people to a safe area

A side rail is considered a restraint even if the patient asks for it to be raised to assist in getting into and out of bed. T or F

False - A side rail is not considered a restraint if the patient requests that it be raised to aid in getting in or out of bed. Some patients may request that side rails be used at night while they sleep so that they may feel more secure. The patient must be able to raise and lower the side rail on one's own.

Preoperative

-before surgery

Begins with decision to have surgery, lasts until patient is transferred to operating room or procedural bed

Intraoperative

-during surgery
Begins when the patient is transferred to the OR bed until transfer to the post-anesthesia care unit (PACU)

postoperative

-after surgery
Lasts from admission to the PACU or other recovery area to complete recovery from surgery and last follow-up health care provider visit

elective surgery

Performed when surgery is the preferred tx; may IMPROVE the patient's life, but is NOT essential for the person's health; breast reduction, tonsillectomy