ATI FUNDAMENTALS PAIN Flashcards
(140 cards)
1
Q
REASONS CLIENTS EXPERIENCE PAIN
A
injury, surgery, acute or chronic diseases, and even as a response to emotional distress.
2
Q
WHAT DOES PAIN LIMIT
A
clients’ abilities to complete activities of daily living, participate in meaningful activities, work, and sleep. In fact, pain is often the reason clients seek care from their health care providers in the outpatient setting or report to an emergency care facility
3
Q
WHAT SYSTEMS PROCESS PAIN STIMULI
A
Both the central nervous system (CNS) and the peripheral nervous system (PNS)
4
Q
WHEN THE CNS AND PNS PROCESS PAIN STIMULI, WHAT HAPPENS
A
This processing mobilizes the nociceptors (the sensory receptors for noxious stimuli) and activates their pathways. Once the pathways are activated, the subjective response that a client experiences is described as pain.
5
Q
WHAT PART OF THE BRAIN CAN PAIN ARISE FROM
A
ain can also arise from the somatosensory cortex—the sensory system within the brain that receives impulses from areas throughout body.
6
Q
pain
A
Subjective and can be caused by stimuli that are actual or anticipated; official IASP definition: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
7
Q
pain threshold
SUBJECTIVE
A
The point at which a stimulus causes the client perceive pain.
8
Q
PAIN TOLERANCE
SUBJECTIVE
A
How much of a stimulus the client is willing to accept.
9
Q
The biopsychosocial model of pain suggests that three categories of factors form the experience of pain:
A
BIOLOGICAL
PSYCHOLOGICAL
SOCIAL
10
Q
PSYCHOLOGICAL FACTORS
A
MOOD/AFFECT
CATASTROPHIZING
STRESS
COPING
11
Q
BIOLOGICAL FACTORS
A
DISEASE SEVERITY
NOCICEPTION
INFLAMMATION
BRAIN FUNCTION
12
Q
SOCIAL FACTORS
A
CULTURAL FACTORS
SOCIAL ENVIRONMENT
ECONOMIC FACTORS
SOCIAL SUPPORT
13
Q
A nurse is caring for a postoperative client who states that he is worried about being discharged after surgery because he has no place to live. Describe how the biophysical model of pain, particularly the social factors, contributes to this client’s experience of pain.
A
The client is expressing concern that he has nowhere to live upon discharge. According to the biophysical model of pain, the client likely does not have anyone to care for him after discharge and may lack a social support system, which can lead to increased anxiety and perception of pain. Economic factors that may affect the client include that, if the client has no home, the client may not be employed, have insurance, or be able to pay for follow-up care, prescriptions, supplies, or therapies. These concerns can contribute to an increase in the client’s pain level and response to stimuli.
14
Q
WHAT IS PAIN
A
WHATEVER THE CLIENT SAYS THAT IT IS
Nurses should not impose their own opinions or perceptions of a client’s pain, but recognize that the client is the only person who can truly rate and describe their own pain.
15
Q
Descriptive Characteristics of Pain
A
ACHING, THROBBING, STABBING, POUNDING, SHARP, GRIPPING, DULL, TEARING, RADIATING, CUTTING, BURNING, SCALDING
16
Q
ACUTE PAIN
A
has a sudden or slow onset of any intensity and an anticipated or predictable end. By definition, acute pain is pain that lasts less than six months
17
Q
ACUTE PAIN CAN RESULT FROM
A
tissue damage caused by trauma or injury, incisional pain from surgery, and pain from environmental factors such as heat or cold
18
Q
CHRONIC PAIN
A
has a sudden or slow onset of any intensity and is constant or recurring without an anticipated or predictable end. By definition, chronic pain usually has a duration of lasting longer than six months.
19
Q
EXAMPLES OF CHRONIC PAIN
A
arthritis, back pain, and headaches. Chronic pain can be both physically and emotionally debilitating. If acute pain is not addressed, it can become chronic.
20
Q
NOCICEPTORS
A
Found in multiple parts of the body (skin, joints, muscles, viscera) and activated by many different chemical substances, extreme temperature and pressure changes, and tissue damage
21
Q
NOCICEPTIVE PAIN
A
Pain that is felt in the tissue, an organ, a damaged part of the body, or a referred pain.
22
Q
SOMATIC PAIN
A
pain occurring in the skin, bones, joints, muscles, or connective tissues
23
Q
VISCERAL PAIN
A
with pain occurring in the internal organs and referring to other locations of the body
24
Q
CUTANEOUS PAIN
A
pain occurring in the skin or subcutaneous tissue
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NOCICEPTIVE PAIN IS USUALLY
LOCALIZED
DESCRIBED AS THROBBING OR ACHING
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NEUROPATHIC PAIN
Nerve pain that arises from the somatosensory system, described as intense, burning, and shooting.
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EXAMPLE OF NEUROPATHIC PAIN
diabetic neuropathy, phantom limb pain, and pain associated with a spinal cord injury.
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NEUROPATHIC PAIN IS DESCRIBED AS
INTENSE, SHOOTING, BURNING, INTENSE ITCHING, PINS AND NEEDLES
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Match the client condition with the type of pain
1. NEUROPATHIC
2. NOCICEPTIVE
A. BACK PAIN
B. TRIGEMINAL NEURALGIA
C. BROKEN RIB
D. SCIATIC PAIN
E. BELOW THE KNEE AMPUTATION
1: B, D, E
2. A, C
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CANCER PAIN
A newly recognized category of pain that can involve tumor pain, bone pain, and treatment-associated pains such as chronic post-surgical pain.
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CHILDREN
| Age-Related Considerations
1. HIGH RISK OF UNDERTx
2. DISPLAY PAIN DIFFERENTLY
3. behaviors, physiological measurements such as blood pressure and pulse, physical assessment, and parental or guardian reports must be considered when assessing pain in the child.
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PAIN SCALE FOR CHILDREN
WONG-BAKER FACES SCALE
FLACC SCALE
CRIES SCALE
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Clients in their 30s, 40s, and 50s have more complaints of
headaches, abdominal and back pain, and temporomandibular problems
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As age increases, pain seems to
increase in conjunction with neuropathic conditions, as well as for joint and lower extremity conditions.
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DOES PAIN TOLERANCE CHANGE AS A PERSON AGES
NOT SIGNIFICANTLY
36
List facts you have learned about age-related considerations and pain management.
As age increases, pain seems to increase for neuropathic conditions, as well as for joint pain and pain in the lower extremities. Many clients live with more than one chronic condition and experience pain on a daily basis. Pain tolerance does not change significantly as a person ages. Older adult clients who have cognitive impairment and/or communication challenges (e.g., expressive aphasia) require careful nursing assessment. These clients may not report pain effectively, so the nurse should look for behaviors that suggest pain is present.
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MALPRACTICE
A negligent act that has been performed by a professional or trained person.
CAN BE CHARGED WITH MALPRACTICE IF WE ARE NOT ADHERING TO STANDARDS OF CARE FOR PAIN MANAGEMENT
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negligence
Failing to perform in a manner that a reasonable and prudent person should perform.
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ETHICS
The application of principles that guide moral behavior of an individual or group.
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WHEN CAN ETHICAL DILEMMAS OCCUR
when there are no clear right and wrong solutions for a problem.
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WHAT DOES THE ANA OFFER IN REGARDS TO ETHICS
guidance to nurses in the form of a position statement on nurses’ ethical responsibility to alleviate the pain and suffering that clients may experience.
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WHAT ETHICAL CONCEPTS GUIDE PAIN MANAGEMENT
beneficence, nonmaleficence, autonomy, and justice
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beneficence
acts of doing good and acting in the best interest of clients by providing care that benefits them
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nonmaleficense
working to do no harm
Failing to manage a client’s pain can indeed cause harm, and it is each nurse’s ethical responsibility to avoid this outcome.
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to do good, requires that nurses decrease the suffering of their clients. how does this relate to pain
Controlling and alleviating pain is one way in which nurses can minimize suffering
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autonomy
granting client the right to self determination
allows them freedom of choice, but that choice must be based on informed decisions
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what is the nurse's responsibility in autonomy
provide clients with the education they need to make such informed decisions.
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justice
requires that all clients be treated equally. The relief of pain should be available to all, regardless of age, race, background, or history.
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nightingale pledge
| in relation to ethics and pain management
“I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug.”
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morality
an individual’s sense of right and wrong or their personal values. Every client has the right to pain management as a basic human right.
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provider assisted suicide and ethics
illegal in most of us.
if you feel it is immoral, you have the right to refuse to provide care that violates the nurse’s own moral or ethical beliefs, and can ask that someone else provide this care.
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barriers to end of life Tx
can be from client, family, providers or health care system itself.
fear of addiction, intellectual abilities, belief that pain is part of the process, inadequate pain assessment, uninformed individuals, lack of education
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how can the health care system be a barrier to end of life pain management
1. cost of meds
2. lack of insurance coverage
3. shortage of palliative care providers
4. shortage of education resources
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American Society for Pain Management Nursing (ASPMN) and the Hospice and Palliative Nurses Association (HPNA) created a joint position statement that identifies effective pain management as a basic human right. This statement also calls for
education on pain management for providers and the public, and greater accessibility of treatments, both pharmacological and nonpharmacological. Such treatments include palliative care as well as hospice care for clients who are experiencing pain as they near the end of life.
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subjective descirptors
pain scale, location, length of time, what precipitated, what relieves, radiation of pain, how pt characterizes
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objective indicators
manifestations that we can observe and measure by sight, hearing, smell, and touch
crying, sweating, restlessness, grimacing, guarding, vs, physical assessment, lab tests, imaging reports, diagnostic info
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PQRST
PRICIPITATING CAUSE
QUALITY
REGION
SEVERITY
TIMING
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QUESTIONS FOR PQRST
P: “What were you doing when the pain started?”
Q: “Describe what your pain feels like.”
R: “Show me the location where you are experiencing pain.”
S: “On a scale of 1 to 10, how would you rate your pain?” (Use one of the pain scales discussed in the next section.)
T: “When did your pain first begin? Have you experienced this pain before?”
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NUMERIC RATING SCALE
NRS
The most frequently used pain scale where the client is asked to rate the intensity of their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain the client can imagine.
60
WHEN CAN THE NRS BE USED
CHILDREN OLDER THAN 8
GOOD FOR CANCER RELATED PAIN
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VISUAL ANALOG SCALE
The VAS consists of either a vertical or horizontal single line, with one end representing no pain, and the other end representing the worst pain imaginable. The nurse asks the client to select a point along the line that represents the intensity of their pain.
62
WONG BAKER FACES PAIN RATING SCALE
appropriate to use in children ages 3 and older. This scale is intended only for clients to rate their own pain—not for others to rate the pain experienced by the client.
3 SCALES IN ONE WITH FACES, WORDS, AND NUMBERS
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Face, Legs, Activity, Cry, Consolability (FLACC) Scale
observational pain measurement tool designed to be used with children ages 2 months to 7 years, and clients who are cognitively disabled.
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HOW TO USE THE FLACC SCALE
he nurse observes the client for 1 to 5 minutes (if awake) or for 5 minutes or longer (if asleep), and gives a numeric score of 0 to 2 for each behavior: facial expression, leg movement, bodily activity, cry or verbalization, and consolability. Total scores can range from 0 to 10.
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Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) Scale
1. INFANTS BORN AT 38+ WEEKS
2. POSTOPERATIVE NEONATES
3. COGNITIVELY DISABLED
4. EACH IS RATED FROM 0-2
5. 4+ FURTHER ASSESSMENT
6. 6+ ADMIN ANALGESICS
66
Nonverbal Pain Scale (NVPS)
Designed for clients who are unable to verbalize their pain level.
DEVELOPED FOR BURN UNITS, BUT NOW IN CRITICAL CARE AREAS WHERE ILLNESS, SEDATION, OR MECHANICAL VENTILATION DOESN'T ALLOW THEM TO REPORT PAIN
67
A nurse working in the emergency department admits a client who reports chest pain. Using the PQRST mnemonic and a pain scale, develop specific questions that you should ask the client to assess their pain.
The nurse should ask questions directed to the client’s chest pain, asking more probing questions if complete answers are not given by the client
68
A nurse is discussing the challenges of assessing pain in children with a group of parents. Which of the following statements should the nurse include?
A
The presence of the child’s parent can make it more difficult to assess a child’s pain.
B
Children may deny pain to avoid IM injection or bad tasting oral medicine.
C
Children often cannot identify where the pain is located.
D
Young children do not exhibit pain.
B
69
In addition to using an age-appropriate pain scale, the nurse should also note and document additional subjective data. Which of the following subjective data should the nurse have assessed and documented for the client?
A
Withdrawn
B
Palmar sweating
C
Crying
D
Increased heart rate
A
70
WHY SHOULD PAIN BE VIEWED HOLISTICALLY
because pain impacts the physical, mental, social, environmental, and spiritual aspects of the client.
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WHAT PARTS OF A PT HISTORY SHOULD THE NURSE ASSESS
(both personal and family) related to trauma and previous substance abuse disorders, as well as mental health history. The nurse should also assess the support systems that the client has in place—for example, family and friends.
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opioids carry a high risk for
sedation and respiratory depression; therefore, frequent monitoring of clients receiving such medications is needed.
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Clients who are experiencing sedating adverse effects of medications may not
accurately rate their pain; therefore, nurses should be vigilant to not only use a pain scale, but also consider nonverbal cues to assess pain.
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A nurse is caring for a client who is experiencing pain. Which of the following are influencing factors of pain? (Select all that apply.)
A
Client risk factors
B
Client trends
C
Anxiety
D
Type of pain medication used
E
Moral considerations
F
Socioeconomic status
A, B, C, D
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Nurses will frequently encounter clients from
a variety of ethnic backgrounds, cultural variances, socioeconomic status, literacy levels, and religious preferences. Language barriers can also exist.
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To provide culturally sensitive care, the nurse must
understand that such differences may influence the way in which clients react to and report their pain. Also, these influences can lead a nurse to underestimate, and therefore undertreat, the client’s pain.
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As opioids remain one of the leading pharmacological treatments for pain, the nurse may need to
provide education to clients and family members on the advantages of having pain relieved through the administrations of opioids.
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ALTERNATIVE THERAPIES INSTEAD OF OPIOIDS
medicinal herbs, acupuncture, and cupping can be helpful when caring for clients. Clients should be allowed to utilize traditional practices as long as they are not harmful to the client.
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The goal of providing compassionate care and improving a client’s quality of life by relieving their pain remains
the same, regardless of the client’s cultural or religious beliefs.
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Nonpharmacological Pain Interventions
positioning, cutaneous stimulation, cognitive strategies, and therapeutic touch.
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HOW OFTEN SHOULD A PATIENT BE REPOSITIONED
Q2H
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Proper client positioning is key to
preventing injury and subsequent pain.
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Clients should move and be positioned off
of bony prominences to avoid painful pressure injuries, and care should be taken when moving clients to avoid shear injuries.
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CUTANEOUS STIMULATION
Therapy applied to the skin such as heat and cold, touch, massage, acupuncture, acupressure, or TENS.
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Heat, in the form of a heating pad or hot water bottle, is typically used for
muscular pain relief, such as back pain or menstrual pain.
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Cold is used to decrease swelling, such as in
an orthopedic injury like a sprain.
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Cold therapies should be applied for no more than
15-30 minutes at a time and up to 2-3 times per day
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Massage and acupressure have been shown to decrease pain scores in clients with
various ailments, including neuropathic pain from diabetes.
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The nurse should be sure to assess for any allergies to
essential oils prior to use, and should be aware of the individual and combined effects of the oils.
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Acupuncture is a therapy that involves
inserting small, sterile needles into the skin to minimize pain, both acute and chronic, as well as for complex regional pain syndrome.
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HOW DOES ACUPUNCTURE WORK
“Acupuncture points are believed to stimulate the central nervous system. This, in turn, releases chemicals in the muscles, spinal cord, and brain. These biochemical changes may stimulate the body’s natural healing abilities and promote physical well-being”.
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TENS unit
emits low-voltage electrical impulses to the skin over painful areas. The care provider or the trained client attaches electrodes to the skin and can program the unit to deliver various intensities, pulse rates, and widths
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extracorporeal shock-wave lithotripsy (ESWL).
treating soft-tissue injuries by applying shock waves to the area of pain. effective in managing common sports-related injuries such as tennis elbow, Achilles tendon pain, and plantar fasciitis and other tendinopathies.
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ESWL is applied to clients who
have not received relief from other treatments but are not ready to undergo more invasive procedures.
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The side effects of ESWL can include
localized bruising, swelling, pain, or numbness to the area of application.
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cognitive behavioral therapy (CBT)
Therapy to help clients learn to manage and target negative thoughts to help reduce pain, especially chronic pain.
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Examples of CBT include
distraction, relaxation, imagery, and music therapy. Such interventions do not require a health care provider’s prescription, and nurses can advocate for using these therapies for their clients.
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Therapeutic touch
is a modality in which the nurse utilizes the hands either on or near the body of the client to balance the client’s energy and thereby promote healing.
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THERAPEUTIC TOUCH HELPS
alleviate or reduce pain and alleviate psychological symptoms for patients with cancer or fibromyalgia.
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CLIENTS HAVE REPORTED BENEFITIS INCLUDING
| THERAPEUTIC TOUCH
improved mood, better sense of well-being, decreased pain, decreased nausea, decreased anxiety, and decreased fatigue.
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Opioids
are the medications most commonly prescribed for the relief of pain. These agents suppress pain by activating opioid receptors in the brain, spinal cord, and central nervous system.
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Because opioids can lead to addiction if misused WHAT IS REQUIRED
careful titration and monitoring are required.
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Opioids can cause
both sedation and depression of the respiratory system
must assess rr, respiratory depth, hr, bp
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Clients who receive opioids are also at risk for
orthostatic hypotension and syncope
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Opioids also can cause
nausea and vomiting as well as constipation, itching, rashes, and flushing.
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3 classes of opioids
natural
semisynthetic
synthetic
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opiates
natrual opioids
directly from the opium poppy
6 of them
most common are codeine and morphine
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Semisynthetic opioids
are created from the naturally occurring opiates; they include heroin, hydrocodone, oxycodone, and hydromorphone.
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Synthetic opioids
are manufactured products that include fentanyl, fentanyl analogs, and tramadol.
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routes to receive opioids
mouth (PO), intramuscular (IM) injection, intravenous (IV) injections given intermittently or as continuous drips (i.e., for comfort care), per rectum (PR), and topically (TOP).
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patient-controlled analgesia (PCA)
A computerized pump controlled by the client capable of delivering pain medication through a syringe to their IV line.
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Naloxone
given intravenously, works quickly to reverse the adverse effect of opioids. the need for naloxone usage can be decreased if respiratory assessments, including capnography, are used effectively while monitoring the client.
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Opioids such as morphine, hydromorphone, and fentanyl, as well as local anesthetic medications such as lidocaine, mepivacaine, ropivacaine, and bupivacaine, can also be delivered where
in the epidural space via an epidural pump to be used for intraoperative and postoperative use in controlling pain
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nonopioid analgesics include
local anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen
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nsaids
effective for both acute and chronic pain
In addition to having analgesic properties, NSAIDs reduce inflammation and fever. work through a complex process of inhibiting prostaglandin synthesis by blocking two cyclooxygenase enzymes (COX 1 and COX 2). Prostaglandins play a major role in the inflammatory process.
116
NSAIDs are available in numerous forms, such as
PO, IV, IM, PR, and TOP (by patch or ointment).
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when are nsaids contraindicated
in surgery and labor, and they enhance bleeding if given concurrently with anticoagulants or antiplatelets.
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Topical medications
lidocaine and diclofenac are typically safe, but can cause mild skin reactions in some clients. .
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Capsaicin (topical) is available to clients as an OTC product and is useful for
arthritis, myalgias, arthralgias, and neuralgias, but not for musculoskeletal or neuropathic pain
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Adjuvant medications are not
specifically labeled as a separate class of pain medications.
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adjuvant analgesics
Aid in pain relief by working on underlying pain generators, such as antidepressants, corticosteroids, and botulinum toxin.
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Corticosteroids that are used as adjuvants for the relief of pain include
hydrocortisone, cortisone, and prednisone.
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adverse effects of corticosteroids
increased blood glucose levels, suppression of immunity, weight gain, mood swings, fluid retention, and elevated blood pressure.
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antidepressants
work well for nerve-related pain, migraines, and arthritis. Scientists are unsure of their mechanism of action in pain relief, but suspect that these medications increase the number of neurotransmitters within the spinal cord.
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examples of antidepressants used as adjuvants.
Tricyclic antidepressants (e.g., amitriptyline, doxepin, imipramine), serotonin and norepinephrine reuptake inhibitors (e.g., venlafaxine, duloxetine), and selective serotonin reuptake inhibitors (e.g., paroxetine, fluoxetine)
126
con of antidepressants for adjuvant therapy
Relief from pain may not be instantaneous; instead, clients may need to take medication for several weeks before noticing an improvement in their pain.
127
Antidepressants can cause
sedation, cardiac problems, and dry mouth, and should be used cautiously. Nurses should educate clients that consistent use, as prescribed, may produce positive results in time.
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One major nursing consideration and teaching point for antidepressants is that
clients may experience an increased risk of suicidal thoughts or actions. Clients must be advised to speak immediately with a counselor or health care provider if this occurs.
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cannabis (medical marijuana)
minimal evidence-based practice research has been conducted to confirm that cannabis is effective for pain management. Cannabis is not FDA approved and has not been legalized in all states.
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Clients with chronic pain are frequently prescribed
anticonvulsants (e.g., carbamazepine), which may cause sedation, nausea, and vomiting. Gabapentin may also be utilized, as it lacks these troubling side effects.
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Opioid addiction is
a chronic condition and a chronic disease that some may associate with illegal or immoral behaviors. However, clients can become addicted to either illegal or legal (prescribed) opioids.
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The nurse must remember that chronic diseases are
managed rather than cured, and that any client who has been addicted to opioids has experienced a pathophysiologic brain change and needs consistent assessment, guidance, and support.
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SBIRT
stands for Screening, Brief Intervention, and Referral to Treatment.
screening tool for opioid addiction
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Barriers to Effective Pain Management
client’s unwillingness to take pain medications or unwillingness to use nonpharmacological pain interventions.
different language
history of substance abuse
lack of communication
confusion
nurse may use discomfort and client may not think they mean pain
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All clients receiving pharmacological pain interventions require
a client-centered plan of care and frequent monitoring, including a complete baseline and ongoing assessment of their respiratory rate, quality, and oxygen levels obtained by pulse oximetry, as well as the level of sedation.
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first hours after surgery
Although the first 4 hours after release from the postanesthesia care unit (PACU) are the most critical, close monitoring needs to occur for the first 24 hours following surgery.
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Newer modalities for early identification of opioid-induced ventilatory impairment (OIVI)—another name for respiratory depression—include
using a combination of capnography (monitoring of carbon dioxide levels) along with respiratory assessment and pulse oximetry to improve identification of OIVI.
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If the client is using medications for pain management, then education should include
information on the name, dosage, and side effects; special considerations regarding administration (e.g., if a non-oral route is used, the client must be instructed on how to administer the medication safely); and safe storage of the medication.
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Keeping a pain diary or a pain log
can be helpful for clients to determine if medications or treatments are helping over time, and it may assist in reinforcing adherence to the pain regimen.
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