Pain + death & dying + sleep

PVCC NUR152 Exam 4 Paradise Valley Community College

Margot McCaffrey

Margot McCaffrey

“pain is what the person says it is“

Nociception

Ability to feel pain

4 processes: transduction, transmission, perception, modulation

Neuropathic (pathophysiological) pain

Results from abnormal processing of sensory input by the CNS due to damage

Can be caused by stroke, chemotherapy, or tumors

Transduction

Cell damage at the injury site, the first step of the nociception process

Transmission

Message gets sent from an injury site through the spinal cord to the brainstem

Perception

The “ow” factor

Modulation

Neurons in the brainstem travel down the spinal cord and release hormones to counteract the pain. They inhibit pain impulses to mask or deal with pain. These pain inhibiting hormones are produced in the pituitary gland and the hypothalamus

Gate control mechanism

Creating a stimulus around or above a pain point so that the new stimulus can travel to the brain first and distract from the pain occuring

Best on mild to moderate pain

The “gate“ can be closed with competing impulses

Pain threshold

The point at which pain is felt

Pain tolerance

The amount of pain someone can withstand

Often on a scale of 1-10

Endogenous analgesia system

The body’s natural defense of producing analgesics in the pituitary gland and hypothalamus and diffusing that to the affect site to provide pain relief

Cutaneous (superficial) pain

A sensation of pain arising from the skin, can be a symptom of underlying issue

Visceral pain

Arises from the visceral organs, a well localized pain ex.tumor on the breast, appendicitis

Deep somatic pain

Related to parts of the body (like joints, muscles) where pain is made worse with movement occuring at the injury or infection site

Radiating pain

Pain that begins in one area but spreads

Referred pain

When the nerve fibers from one region of the anatomy transfer to the nerve fibers of another area

Phantom pain

Pain in a limb that isn't there, the reason for this is unclear but it's theorized that it could be due to increased neural activity and sensativity

Psychogenic

Caused by anxiety and other psychological issues

6

For pain to be classified as chronic it must be present for at minimum _ months

Intractable pain

Chronic and highly resistant to relief pain, requires multiple methods of releif

Acute pain

Rapid onset, short duration pain

Disappears as the tissue heals

Associated with injury/surgery

Loss

Undesired change or removal of a valued object, person, or situation

Grief

Physical, psychological, and spiritual response to a loss

Bereavement

State of grieving

Mourning

Actions and practices associated with grief. A person learns to deal with loss

Maturational loss

Losses that occur during the life cycle

Situational loss

Losses that are caused by unusual circumstances that are not expected to occur

Ex. Loss of a job

Psychological loss

emotional loss

Grief intensity factors

Individual personality

Nature of the relationship to the dead

Concurrent life crisis

Coping resources

Support system

Engles stages of grief

Shock and disbelief

Developing awareness

Restitution

Resolution of the loss

Idealization

Outcome

Kubler-Ross psych stages of grief

Denial

Anger

Bargaining

Depression

Accepting

Cheyne stokes, hearing

the first sign of dying is __________ _________ breathing and the last sense to stop functioning in death is ___________

clinical manifestation of dying

mottling

Cheyne stokes breathing

inability to clear secretions

sinking gazing of eyes

cold clammy skin

facial droop

accumulation of gas

T

T or F: the endogenous analgesic system can be simulated by accupuncture

ADL

chronic pain will interfere with a persons _______, it is considered a disease in itself

Pain assessment and history includes

precipitating factors

aggravation and alleviating factors

location of pain

character and quality of pain

duration

management

baseline

bowel sounds

L.O.C

death

the ultimate loss

occurs when all vital organs and systems cease to function

whole brain death, higher brain death, cardiac death (irreversible)

T

T or F: unrelieved pain will result in adverse psychological and physical effects

Pain assessment scales

WILDA: stands for words, intensity, location, duration, aggravating/alleviating factors. A subjective approach where the nurse asks questions to gauge the pain level.

visual analog scale: faces on a pg. depicting various pain states

Pain intensity scale: a number scale of 1-10 can be paired with the visual analog scale

Pain types

acute - short form, eases as damage to tissue heals

chronic - longer than 6 months

nociceptive - caused by injury trauma and inflammation

neuropathic - a repeated feeling of pain in the absence of a painful stimuli

intractable - pain that is highly resistant to relief

* these can overlap ex. chronic intractable pain or chronic neuropathic pain

2 key premises of hospice care

Those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families

The quality of life is as important as the length of life

Ex of advanced directive

Living will

Durable power of attorney

Health care surrogate law

Chronic pain

Considered a disease in itself. It can be influenced by environmental and psychological factors and is resistant to most medical treatment

Effects of unrelieved pain

Increase cardiovascular

Decrease respiratory

Decrease GU

Decrease GI

acupressure

___________ releases endorphins

message

_____________ increases the workload of the kidneys and liver

acupuncture

___________ stimulates the endogenous analgesic system

burning

heat application shouldn’t be mixed with menthol products because it could cause ____________

vasoconstriction

cold compresses causes ______________ of ones bv

numeric sedation scale

a measure of opioid drug tolerance and OD

1 = alert and awake

2 = occasional drowsiness but easy to arouse

3 = frequent drowsiness, will fall asleep during conversation, reduce pt dosage

4 = somnolent, minimal to no response, discontinue use and/or administer narcan

T

T or F: before assuming that a patient has built up a tolerance to a drug the nurse should assess and ensure that the disease isn’t progressing and there is no new infection occurring

narcan

RR less than 8 =

double effect

The rule of ________ ________ states that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. This is a practice supported by nursing association

OR, WA, MT

assissted suicide is only allowed in ___, ____, ___

NSAIDs

inhibit prostaglandin production/release

selective and non-selective

available over the counter

an anti-inflammatory

for mild to moderate pain

NSAID nonselective

blocks Cox-1 and Cox-2 enzymes

ex. Indomethacin(Indocin), Ibuprofen (Motrin, Advil), Ketorolac (Toradol), Naproxen (Aleve)

because it blocks both Cox-1 and Cox-2 enzymes the side effects are GI upset, renal impairment and bleeding

NSAID selective

blocks only Cox-2

ex. celebrex

Celebrex come with and increase risk of CV incidences (MI, heart failure, etc.)

arachidonic acid

_____________ _______ is released upon injury

Tylenol, antiinflammatory

Although _________ inhibit prostaglandin synthesis like NSAIDs they have no _______________ properties so they are classified as acetomephens

asprin

_________ is both an NSAID and Salicylate

Salicylate Asprin

inhibit prostaglandin synthesis

inhibits platelet aggregation for a longer period of time than NSAIDs

increases blood flow during MI and is anticlotting after

SE: Epigastric distress, GI bleed, tinnitus, platellet dysfunction

NSAID and Salicylate consideration

give w/ food

immediately report GI bleeding

Discontinue during the last trimester of pregnancy and/or 5-7 days before surgery

decrease ETOH usage

Acetaminophens (Tylenol)

Analgesic with Antipyretic effects

inhibit prostaglandin synthesis

potential for overdose (Aceylsystine/mucomyst is antidote)

Monitor ALT and AST for liver function

Avoids the bleeding risk of NSAIDs and Salycilates

acetylcysteine (mucomyst)

______________ is the antidote for Acetaminophen( Tylenol)

3-4

a pt can OD if they ingest ____-___g of tylenol

Opioids

can be natural, synthetic, semi-synthetic

attaches to the bodies MU receptors

SE: constipation, N/V, Drowsiness

pt baseline, drugs they’r taking (CNS & RR depressants), presences of brain injury

prior to administering an opioid a nurse should know

Opioid types

Opioid agonists, mixed agonist antagonists and partial agonist

Opioid + MAOIs

hypotension, seizure, RR depression

ETOH, Antihistamines, Benzodiazepines, CNS

opiods don’t mix well with ________, ______________, _____________,& other _____ depressants

Opioids

__________ shouldn’t be given to pt who;

have sleep apnea

are morbidly obese

severe asthmatics

have a head injury

pregnant

paralytic ileus

slowly

discontinuation of opioid use should be done ___________

strong, MU

partial agonist opioids aren’t as ___________ as full opioid agonist and shouldn’t be used together because partial agonist block the ____ receptor

acetaminophen, opioids

being cautious about their OTC Tylenol use and use of any other CNS/RR depressants

A pt on Percocet is taking ____________ in the form of Tylenol and ___________ in the form of codeine. Before discharging they should be educated on ______

antagonist

Reduces the physiological activity of other substances

ex narcan

2

IV morphine should be administered over the course of __ minutes (minimum)

treating pain in older adults

Older adults are more at risk for undertreatment due to cognitive impairment and increased risk of NSAID caused GI bleed.

They are also at risk for overtreatment because due to higher peak effects and the drug lasting longer in their system

T

T or F: sleep is variable, different age groups can function on different amounts of sleep but the standard amount of sleep per night is 8 hours

75

REM sleep decreases after the age of ___

T

Tor F: biorhythms/biological clocks are synchronized with gravity, light/darkness, eating patterns

ICU psychosis

a disorder in which patients in an intensive care unit (ICU) or a similar setting experience psychosis due to not being able to tell time

hypothalamus

the _____________ regulates circadian rhythm

T

T or F: a sleep cycle last 90-100 minutes

5

which stage does REM sleep occur in

dyssomnias

insomnia or excessive sleepiness

Parasomnias

waking behaviors that appear during sleep ex. sleep walking

Co2

a sleep apnea patient involuntarily wakes to breath because their ______ levels got to high

sleep apnea treatments

CPAP

Weight loss

Surgery: tonsilectomy

sleep aids pt precaution

use caution when doing their morning activities until they know how the medication affects them

sleep aids

benzodiazepines

are also classified as selective hypnotic or anxiolytic

with less dependancy rate than barbituates

ex. valium, Xanax, Ativan, klonopin

benzodiazepine

______________ have less dependency rate than barbituates which is why they are the better sleep aid choice

benzodiazepines (Ativan)

class of sleep aid drugs that can also be used to treat alcohol withdrawal

lunesta

__________ is a benzodiazepine that can be used to treat insomnia due to it long half life

ambien

a short-term insomnia treatment

do not prescribe more than 5-10mg

rapid onset of minutes

T

T or F: Tricyclic antidepressants and SSRIs can also function as sleep aides

ex. lexapro, Prozac, Zoloft, Celexa

rebound insomnia

can occur when pt cease sleep aid medications