Complex 1C pt 1

Comfort and Tissue Integrity: Complex I

Priorities for Today

• Comfort: Focuses on pain management.
• Tissue Integrity: Concerns everything related to the skin. The skin is the body's largest organ; this topic is very broad, and the discussion will focus on critical points relevant to complex one and chronic problems.

Pain Management

• Acute vs. Chronic Pain:
  • Distinguishing the differences.
  • Understanding different treatments.
  • Setting different patient goals.
• Related conditions touched on:
  • Fibromyalgia.
  • Chronic Fatigue Syndrome.
    • A lot about these conditions is still unknown.

Module Objectives

• Posted in the course.
• Use as a guide when preparing for exams.

Approved Videos

• Videos for review, especially for auditory learners.
• LevelUp RN videos are closely aligned with ATI content; some videos have been removed due to legal issues.
• The videos present information in a slightly different way, which may help with understanding.

Pain: Acute vs. Chronic

• Goals for Pain:
  • Assess the goal of pain management.
  • Determine the patient's goal.
  • Evaluate if complete pain elimination is reasonable.
  • Realistic expectations are important (e.g., post-total knee replacement).
  • Everyone's pain tolerance is different.
• Assessing Pain:
  • Use PQRST (Provocation/Palliation, Quality, Region/Radiation, Severity, Timing) and additional questions.
  • What is your normal level of pain?
  • What level of pain are you okay with for functioning?
  • At what level does it really start to bother you?
• Goals for pain management:
  • Maximize independence.
    • Activities of daily living.
    • Mobility.
    • Toileting.
  • Maintain a good quality of life.
  • Quality sleep.
  • Management of anxiety and depression.
    • Anxiety, depression, poor sleep, and chronic pain form a triad.
      • If any of these are affected, pain is usually higher, or vice versa.
• Side Effects:
  • Assess patient tolerance of side effects.
    • Constipation with analgesics.
    • Drowsiness.
  • Manage nutrition and nausea.
    • Address barriers to pain management.
    • Educate the patient and family.
• Patient Understanding and Advocacy
  • Living with chronic pain can cause mental distress.
  • Patients may feel disregarded, leading to questioning their sanity.
  • Unsuccessful management of chronic pain leads to:
    • Substance use disorder.
    • Suicidal ideation.
• Important to know and communicate:
  • Patients are not "crazy" for feeling worse.
  • They deserve to be heard and have their treatment plan evaluated.
  • They should find a new provider if their needs are not met.
• Complications to Prevent
  • Addiction, infection, pressure injury/ulcer, or other skin breakdown.
  • In certain scenarios (e.g., hospice), addiction is not a concern.
• Interprofessional Referrals
  • Pain management specialists.
    • Offer various treatments beyond pills and patches (nerve blocks, implants).
  • Physical therapy, massage, acupuncture, and therapy.

Chronic Pain vs. Acute Pain

• Acute Pain:
  • Protective: signals potential harm (e.g., touching something hot).
• Chronic Pain:
  • Not protective: May not have a clear reason, leading to frustration.
  • Lasting longer than three months is generally considered chronic.
    • Significant abdominal pain for three months still needs exploration to rule out an acute illness.
  • Physiologic responses do not usually increase vital signs.
    • Acute pain typically elevates blood pressure, heart rate, and respiratory rate.
    • Chronic pain may not show these changes, which can lead to underestimation of pain.
  • Chronic pain can lead to depression, fatigue, decreased level of functioning, or disability.
    • Exhausting and can impair cognitive function.
    • Can affect emotional and psychological well-being.
    • Impacts quality of life and relationships (e.g., a mother unable to play with her children).
  • May not have a known cause or respond to expected interventions.
• Classifications of Chronic Pain:
  • Cancerous.
    • Often requires more medication to meet goals.
  • Non-cancerous.
    • Examples include osteoarthritis and neuropathy.

Risk Factors for Undertreatment of Pain

• Cultural Norms:
  • Some cultures value enduring pain, mixing cultural, societal, and religious beliefs.
  • Pain may be seen as punishment, influencing the desire for relief.
• Lack of Knowledge:
  • Thinking pain is a normal part of aging.
  • Patients need to be told it's not okay to be in pain.
• Fear of Addiction:
  • Exaggerated fear of respiratory depression, especially in the elderly.
• Populations at Risk:
  • Infants and children (communication issues).
  • Older adults (multiple pathologies, normalization of pain).
  • Clients with a history of substance use disorder (complex and scary for the patient).
    • Pain management specialists can be helpful in these cases.

Biggest Causes of Chronic Pain

• Cancer.
  • Tumor growth putting pressure on nerves, organs, and causing bone pain.
  • Associated infections and immobility.
• Arthritis.
  • Affecting the back, knees, and hips.
• Fibromyalgia.
• Neuropathy.

Factors Affecting the Pain Experience

• Age:
  • Infants cannot verbalize pain, so use scales with pictures (faces scale).
  • Older adults may have multiple conditions causing pain and limiting function.
• Fatigue:
  • Increases sensitivity to pain.
• Genetic Sensitivity:
  • Can increase or decrease pain tolerance.
  • Higher testosterone levels may increase pain sensitivity.
• Cognitive Function:
  • Impaired patients may not be able to communicate pain effectively.
• Prior Experiences:
  • Can increase or decrease sensitivity.
  • Assess their experience to manage expectations.
• Anxiety and Fear:
  • Increase sensitivity to pain; anti-anxiety medications can help.
• Support Systems:
  • Decrease sensitivity to pain.
• Culture:
  • Influences how clients express pain.
• Veterans:
  • Increased sensitivity to pain, especially those who served in Iraq and Afghanistan.
  • May be related to anxiety, depression, poor sleep, or PTSD.

Pain Assessment

• Don't rely solely on PQRST; use basic humanity.
• Visually inspect the affected area.
• For complaints of back pain:
  • Look at their back.
  • How painful is their back?

Basics of Pharmacology for Pain.

• Oral Route:
  • Preferred due to being less invasive and providing longer-lasting relief.
  • Has a smoother drop-off compared to IV medications.
  • Example: MS Contin (oral morphine) may take 30 minutes to start working but lasts 4-6 hours.
  • Goes through the first pass effect through the stomach and liver.
  • IV morphine will hit quickly but also leave faster.
• Reassessment:
  • Always reassess pain levels after medication administration.
  • Reassessment should occur more than once.
• Transdermal:
  • Fentanyl patches, lidocaine patches, and capsaicin patches.
• Capsaicin:
  • Comes from chili peppers and is effective for nerve pain.
  • Use gloves when applying to avoid irritation.
• Dosage:
  • Ask patients what dose usually works for them at home.
  • Advocate for the patient with the doctor if needed.
• Nonverbal Patients:
  • Use scales like the FLACC scale (Face, Legs, Activity, Cry, Consolability).
  • Look for changes like sweating, shaking, and muscle tension.
  • Reposition the patient and ensure comfort before administering medication.

Classes of Medications

• Nonopioid Analgesics:
  • Acetaminophen, ibuprofen, ketorolac.
• Opioid Analgesics:
  • Morphine, codeine, hydrocodone, oxycodone, fentanyl, methadone.
• Coanalgesics:

Coanalgesics in detail.

• Local Anesthetics:
  • Lidocaine.
• Systemic Anesthesia:
  • Propofol (helps with anxiety).
• Anticonvulsants:
  • Gabapentin (for neuropathy).
  • Topamax (topiramate).
• Antidepressants:
  • SSRIs (fluoxetine, citalopram/Lexapro).
  • SNRIs (Cymbalta).
  • Tricyclic antidepressants (amitriptyline, imipramine).
• Muscle Relaxants:
  • Cyclobenzaprine.
  • Benzodiazepines for muscle spasms.
• Ketamine:
  • Low doses can be given orally, IV, or intranasally for opioid-resistant chronic pain.
• Bisphosphonates:
  • Given for bone problems like bone cancer or Paget's disease.
  • May cause worse pain initially.
• DMARDs (Disease-Modifying Antirheumatic Drugs):
  • Methotrexate (for rheumatoid arthritis).
  • Glucocorticoids.
  • Enbrel, Remicade, Humira (for autoimmune-related pain).

Medication Management

• Most people with chronic pain are on a combination of medications.
• Trial and error is often used to determine the best medication combinations.