↑ ↓ Exam 2 content

Chronic Pain Management

nociceptive: cut or bun something physical like a punch

neuropathic: from nervous system ( tingling, shooting)

Pain medication principles:

• start with non-opioids; use opioids short-term if needed.

• Give meds on schedule, adjust dose to patient, treat breakthrough pain, taper opioids slowly, manage side effects, and prevent constipation early.

  • Dietary fiber (up to 40 grams/day)

  • Fluids: at least 2 liters/day

  • Increase activity

Pure opioid agonists (full opioid agonists)

• Morphine, fentanyl, oxycodone, oxymorphone, hydrocodone

Agonist-Antagonist opioids (mixed opioids)

• Butorphanol, nalbuphine

Opioid antagonists

• Naloxone

Short-acting/IR: works in ~30 min, lasts 3–4 hr

ER/SR/CR: slowly over time

Long-acting: long half-lives for prolonged effect

Equianalgesia: approximately equal pain relief. Equianalgesic charts help compare opioid doses, especially when switching drugs/routes; doses are adjusted based on patient response.

• 10 mg IV morphine may relieve pain about the same as 30 mg oral morphine.

• Different dose, same effect = equianalgesic.

Suspected Opioid Addiction

• Excessive craving

• Compulsive use and Continued use despite known harm

• Track marks, swelling along veins; erosion of nasal septum, constricted pupils, sedation, slurred speech

• Changes in personality, social habits, or role functioning

Opioid Withdrawal

• Yawning

• Sweating

• Dilated pupils

• Tachycardia

• Abdominal pain

Cognitive-Behavioral Modalities

Simple: Prayer, relaxation breathing, artwork,

More Complex: Mindfulness, meditation, guided imagery

HIV/AIDS 

HIV infection leads to ↓ # leukocytes, ↑ production of incomplete/nonfunctional antibodies, Abnormally functioning macrophages

HIV = rapidly replicating retrovirus that Targets CD4 (T4 helper) cells

• CD4 receptors + chemokines help HIV enter cells

• HIV inserts into host RNA and replicates

• CD4 destruction weakens immune system → AIDS

• Some people have genetic resistance to HIV entry

• HIV = retrovirus that inserts genetic material into host DNA

• Uses enzymes:

  • Reverse transcriptase

  • Integrase

  • Protease

• Targets CD4 (T-helper) cells

• Causes ↓ lymphocytes, abnormal antibodies, dysfunctional macrophages

• Weakens immune system over time

screening: One-time testing ages 18–65

• Prenatal screening

• Annual testing if high risk

  • STIs

  • Injection drug use

  • Multiple partners

  • Incarceration

  • sex workers

dx. HIV positive + CD4 <200 OR Opportunistic infection (OI)

s/s.

Initial: Acute: Flu-like symptoms, very contagious (Fatigue, fever, night sweats* Headache, muscle aches*)

• Massive replication- high levels- highly transmissable

• Immune system counterattacks- levels fall

Middle: Latent/Chronic: Few symptoms, virus still active

• Prolonged clinical latency 10 years

• CD4 cells decline

Late: AIDS: CD4 < 200 and opportunistic infections

tx. No cure, but Combination antiretroviral therapy cART slows progression

• HIV can mutate → drug resistance

OA: More older adults living with HIV; Watch for: Polypharmacy, Depression, and Isolation → Safe sex still important!!!

Head injury

Spinal cord injury ndylosis, tumors, osteoporosis, fracture 

Concussion: dysfunction, resolves in 24-48 hours 

Contusion: bleeding into cord à edema 

Laceration: tear in corn (permanent injury) 

Transection: complete/incomplete severing of cord, loss of function below 

Acute care: 

Transport to ED: airway/resp. support, XR, CT, MRI, foley, high dose steroids, PPI 

Neuro assessment: collar, Gardner-wells/Crutchfield tongs for cervical, surgical stabilization/halo application 

Determine: location of injury, immediate symptoms, changes since, type of immobilization device, treatment at scene, PMH (H/O previous injury, surgery, resp. problems) 

Stabilize to prevent further damage from bone fragments 

SCI interventions:  

Surgery to stabilize/prevent further damage, prompt w. wiring, rods, TLSO brace post-op (lumbar-thoracic-sacral) 

Procedures: decompressive, spinal fusion, internal fixation 

Post-op: monitor vs/neuro q 1 hr, maintain spinal alignment 

Halo fixator/crown: for cervical spine immobilization, worn for 6-12 weeks 

• 4 pins in outer skull connected to jacket 

• Also helps reduce fracture 

• Fixator care: keep wrench for emergency, never move y rods, assist w/ moving, check pins for moving, leaking, keep clean, report redness/swelling, was under vest w/ alcohol, use straws, cut food small 

SCI assessment: 

Neuro: determine baseline sensory perception/mobility, lowest – intact/normal function 

• Quadriplegia: paralysis of 4 extremities 

• Paraplegia: paralysis of 2 extremities 

• Paresis: weakness in 2 or 4 extremities 

• Determine extent of injury, may improve as swelling goes down 

CV: brady cardia/dysrhythmia, hypotension, hypothermia, SBP <90 = decreased perfusion to cord, monitor for neurogenic shock 

• Spinal shock: not circulatory in nature IVF, TEDS, pressors, keep warm, monitor VS 

Respiratory: maintain airway at all times, assess need for ventilator, pulse ox, ABGs, O2 

GI/GU: abdominal distention/pain, bowel sounds (gastroparesis/paralytic ileus), GI hemorrhage (slow due to stress ulcers), urinary retention 

• Cervical – spastic bowel/bladder 

• Thoracic/lumbar – flaccid bowel/bladder 

SCI Rehab 

Mobility:  

Positioning: frequent changes in including prone, upper extremities away from body, knee flexed 15 degrees when supine 

Muscle strength: active/passive ROM, aqua-therapy, tilt table, TEDs to prevent orthostatic changes, meds to control spasms 

Wheelchair, splints, braces, splints, high-top sneakers 

Bladder control: 

Upper motor neuron spastic/reflex: injury above T12 

• Intact reflex for voiding = spontaneous in low volumes and incomplete emptying 

• Intermittent cath. q 4-6 hrs 

• Post-void residuals 

• Monitor for UTI 

Lower motor neuron flaccid/non-reflex: injury below T12 

• Valsalva maneuver + tightening of abdominal muscles 

• Self-cath.  

• Post-void residual 

• UTI 

Bowel Control: 

Reflex bowel: affects external sphincter 

• Constipation 

• Can trigger AD 

• Use reflexes: suppository, digital stimulation (vagal response) 

Flaccid bowel: loss of peristalsis and anal sphincter control 

• Incontinence 

• Stool softeners, bulk laxatives 

Teach when to go, high fiber diet, 2L water/day, create schedule/routine 

Can take 30-60 mins 

Sit upright, stimulate anus, wait 15 mins, reassess 

Sexuality: 

Women: continue contraceptives, foley common, positioning, KY gel, non-genital orgasm 

Men: reflex erection w/ genital stim, rectal stretch, manipulation of catheter, sperm counts can be low, PDE 5i, implants