Exam 1: Pain and ABCs Flashcards
(111 cards)
1
Q
NSAIDS - pain pathway
A
Block PG production
2
Q
Opioids - pain pathway
A
activate opioid receptors on nerves that inhibit firing and in the brain cause euphoria
3
Q
NMDA antagonists - pain pathway
A
Ketamine
Memantine
Block Ca++ channels on first order neuron so doesn’t allow first order neuron to depolarize (BEGINNING)
Good for neuralgia/neuropathic pain
4
Q
Gabapentinoids - pain pathway
A
Block Ca++ channels and prevent first order neuron from firing
Good for neuralgia/neuropathic pain
5
Q
Lidocaine/Bipuvicaine - pain pathway
A
Local anesthetic
Block NA+ channels and prevent first order neuron from firing
6
Q
Serotonin and NE - pain pathway
A
They inhibit the first order nerve from firing and second from depolarizing
7
Q
How do SSRIs work for pain
A
Serotonin reuptake inhibitors
8
Q
An older adult client with postherpetic neuralgia reports deep tissue pain. Which skin infection does the nurse expect to observe in the client’s electronic medical record?
A
Herpes Zoster. Herpes Zoster can leave the client with deep pain after the lesions have resolved.
9
Q
Cellulitis is associated with
A
Lymphadenopathy and fever
10
Q
Candidiasis is associate with
A
oral whitish lesions
11
Q
Herpes simplex is associated with
A
vesicles that evolve to pustules that rupture, weep, and crust
12
Q
A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take?
A
Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site.
13
Q
Drug habituation
A
a mild form of psychologic dependence on a drug - individual developed a habit of taking the substance
14
Q
Physical addiction
A
related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance fo usual function.
15
Q
Psychological dependence
A
emotional reliance on the substance to maintain a sense of well-being
16
Q
intractable pain
A
Neuropathic pain that is severe, constant paint that is not curable
Chronic pain
17
Q
Somatic pain
A
Arises from bone, joint, muscle, skin or connective tissue
Usually aching or throbbing in quality and is well localized
18
Q
Referred pain
A
Experienced in clients with tumors
Pain is felt in a part of the body other than its actual source.
19
Q
Methadone therapy
A
substitutes a legal drug for an illegal one
20
Q
Acetaminophen
A
(Tylenol)
Hepatotoxic
21
Q
NSAIDs
A
(ibuprofen)
Renal-toxic
22
Q
Diphenhydramine
A
Benadryl
23
Q
What are nociceptor fibers that connect to the dorsal horn comprised of?
A
A-delta and C-fibers
24
Q
What pain are A-delta nerve fibers responsible for
A
sharp, discriminatory pain
25
What are C-fiber nerves responsible for?
mechanical and thermal (less pain)
This is why if you have muscle pain and you rub your muscle, the c fibers override the transmission of pain - overriding before getting to the brain
26
Why is caring and empathetic behavior important when caring for someone in pain?
Thalamus acts as the "relay station" in the brain and can decrease or amplify these pain signals based on a variety of contextual signals
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What are some caring and empathetic behaviors we use with
- creating therapeutic environment
- providing meaning behind painful stimuli/explaining everything you are doing
- identifying maladaptive beliefs/CBT
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Pain cannot be measured objectively
Pain is a complicated biopsychosocial phenomenon. Genetics influence how frequently peripheral nerves fire and how robust descending pain pathway is.
Also, everyone has different past experiences that influence how thalamus reacts to pain signal
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ACEs in pain
Adverse Childhood Experiences
Need to treat underlying psychosocial trauma too
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Central Sensitization
A state in which the CNS (thalamus) amplifies sensory input across many organ systems so you are having enhanced response to that sensation.
Any nerve that constantly fires, b/c neural plasticity, that nerve pathway will get stronger - learned response
increased excitation --> neural plasticity encouraging nerve to continue to fire --> predisposing people to future stimulation (benign sensations in the body that are amplified and become painful)
31
Allodynia
Pain due to a stimulus that does not normally provoke pain
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Physiologic responses to pain
1. tachypnea
2. tachycardia
3. hypertension
4. fight/flight responses
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Behavioral responses to pain
1. vocalizations (groaning, moaning)
2. Facial expressions (grimaces, etc.)
3. Body movements (restless, unable to "sit still")
4. Guarding
5. Tensing of muscles
6. Agitation is pain is severe
34
Objective pain assessment
Physiologic Responses to Pain
Behavioral Responses to Pain
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Subjective pain assessment
Nursing History
Onset and duration
Location and pattern
Quality and intensity - pain scales
aggravating/alleviating factors
associated/contributing symptoms
effect on patient function
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Nursing History - Subj Pain Assessment
- life stressors
- history of chronic pain
- usual level of pain (important because level 6 could be horrible for one person and great for another - usually won't get person to a 0)
- what level of pain they consider tolerable
- pain meds currently?
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Onset and duration - subj pain assessment
- acute (usually result of focal, tissue damage)
- chronic - usually define as pain lasting more than three months (patient's body can more efficiently send pain signals)
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Location and pattern - subj pain assessment
Location:
- Anatomical location
- "referred pain" is pain that is caused by tissue damage elsewhere (usually visceral pain)
Pattern: (inform treatment approaches)
- constant
- intermittent
- occasional
39
When you should evaluate pt for heart attack
If patient present with:
- crushing, sub-sternal pain or pressure
AND/OR
- pain radiating to the left arm or jaw
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quality - subj pain assessment
Quality can help us identify source
1. neuropathic pain
2. somatic pain
3. visceral pain
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neuropathic pain
typically
- burning
- aching
- radiating
- shooting
Usually arising from direct damage to nerve or central sensitization --> aberrant (random) nerve firing
Could have to do with virus living in nerve, but not usually
42
somatic pain
superficial somatic pain - well localized, sharp (small hand burn)
- deep somatic pain: deeper aching (sprained ankle)
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visceral pain
- typically deep
- poorly localized
- arising from internal organs
(abdominal cramping - hard to say where pain is coming from)
44
Wong-Baker FACES pan scale - who for?
pediatric patients who can't grasp underlying numerical value of
children look at faces and they tell you what they feel - so still patient reported
also nonverbal adults
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Neonatal Infant Pain Scales (NIPS) - who for?
Neonates
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FLACC Scale - who for?
Altered mental status
| patient with advanced dementia who broke her femur
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AMS
Altered mental status
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Malingering
exaggerating symptoms to acquire time off/disability benefits/pain medication
FAIRLY RARE
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Pseudo-addiction
Pseudo-addiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated
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Pseudo-addiction
Not getting adequate dosage of pain meds - might go to multiple providers to get the right dose
"drug seeker" on chart
Pseudo-addiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated
51
Physical dependence
a state of physiologic adaptation manifested specific withdrawal symptoms caused by abrupt cessation of drug
opioids - diarrhea, dysphoria/anxiety
alcohol - delirium tremens, seizures
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Physical dependence
a state of physiologic adaptation manifested specific withdrawal symptoms caused by abrupt cessation of drug
opioids - diarrhea, opioids cause euphoria so when go off - dysphoria/anxiety
alcohol - delirium tremens, seizures
53
Opioid dependence/hyperalgesia
The inability of the endogenous opioids to react appropriately to outside stressors will cause the users to ultimately become dependent on exogenous opioids to mimic the action elicited by the exogenous opioid system.
Henceforth, this propels the increased risk of hyperalgesia, dependence, and when unchecked, eventually leading to addiction
54
Aggravating/alleviating factors - subj pain assessment
- "aggravated by palpitation" or "aggravated by bending over"
- "relieved by rest;" "relieved by elevation"
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Aggravating/alleviating factors - subj pain assessment
aggravating factors can help us see if they don't need pharmacologic interventions
- "aggravated by palpitation" or "aggravated by bending over"
- "relieved by rest;" "relieved by elevation"
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Associated/contributing symptoms
"Headache pain with associated photophobia"
"Pain accompanied by nausea"
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ADLs
1. Bathing
2. Dental Hygiene
3. Toileting
4. Eating
5. Dressing
6. Transfer and Mobility
Must be able to carry out ADLs before sent home
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Nursing Diagnoses
- acute pain
- ineffective coping
- fall risk (from pain or meds that could cause ortho hypotn)
- impaired mobility
- self care deficit/impaired ADLs
- impaired nutrition
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Pain Score Rating
Hard to put numbers to such a subjective experience - esp in middle
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Diabetic Neuropathy
hyperglycemia (high blood sugar) causes damage to peripheral nerves, usually in feet.
May cause burning pain, numbness and tingling, or complete absence of sensation
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Ischemic Pain
Lack of oxygen/perfusion to tissue causes pain
ischemia of heart --> Chest pain can represent MI
Sick cell crisis: RBCs sickle and clog arteries and capillaries --> pain
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Non-pharmacologic Nursing Interventions
1. fixing underlying cause
2. framing things positively (but truthfully)
3. distraction
4. position for comfort
5. PT
6. Heat/cold application
7. Cutaneous stimulation (TENS units, massage)
8. Acupuncture
63
Physical Therapy
Often is it the maladaptive response to pain that causes more pain (guarding)
Physical therapy can help correct postural problems
Often more effective than any other intervention
Buy-in can be difficult b/c pain may initially be worse
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Causes of COPD
Long-term exposure to irritants that
damage the lungs and airways is the
most common cause of COPD.
```
Cigarette smoke (from smoking or
secondhand smoke) is the most common irritant.
```
```
Other irritants:
- particles from fires used in the home
for cooking or heating
- workplace exposure to chemical fumes,
dust, and particles.
```
65
Signs and symptoms of COPD
1. cough with sputum
2. dyspnea
3. wheezing or rhonci
4. chest pain (muscle strain from breathing)
5. fatigue
6. orthopnea
7. depression
8. constant SOB
9. later - may have diminished breath sounds in both lower lobes of lungs
10. barrel chest - hyperinflation of lungs
11. malnutrition - (work of breathing more difficult, caloric requirements increase, but not fulfilling that demand)
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Systolic HF
Ventricles can't pump hard enough
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Diastolic HF
Ventricles aren't filling enough
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Signs of decreased perfusion to brain
Mild: restlessness, confusion, altered mental status (completely out of it)
Severe: TIA (mild/temporary stroke) or Stroke (infarction of brain tissue)
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What would you measure if you thought a patient had decreased perfusion to brain
Check for low BP and/or low oxygenation
70
Signs of decreased perfusion to heart
Mild: chest pain s/t ischemia (crushing substernal chest pain radiating through left arm)
Severe: MI
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Signs of decreased perfusion to kidneys
Mild: decreased UOP (one of first signs of decreased CO_
Severe: increasing creatinine s/t acute kidney injury (specifically Acute Tubular Necrosis)
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Causes of hypoperfusion
1. conduction system failure (electrolyte abnormality or scar tissue after MI causes disruption in conduction)
2. pump failure (s/t MI or CHF)
3. Vascular failure (usually some sort of blockage)
4. Hematologic Failure (anemia, hypovolemia)
73
Causes of hypovolemia
1. dehydration
2. hemorrhage
3. third-spacing (fluid moves out of the vessels into the tissues or pools in the periphery - weight the same - no new fluid)
74
Assessing for Hypovolemia
1. nausea and vomiting
2. diarrhea
3. decreased thirst (common in older adults)
4. lack of access to water
5. disease like stomatitis, head and neck cancer, or sore throat
6. O>I
75
Physical Assessment findings related to dehydration
1. Low BP (below 90 systolic)
2. weak, thready pulses
3. tachycardia
4. dry mucous membranes
5. poor skin turgor
6. Cool extremities (due to blood being shunted back to organs where it is most needed)
7. decreased cap refill (same reason as cool extremities - vasoconstriction and shunting blood to more important areas) - also low blood volume
8. urine findings (decreased UOP and concentrated urine)
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Systemic vascular resistance
how narrow or dilated arteries are
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Body's compensation mechanism to hypotension
1. Compensate via SNS - release hormones that will trigger two receptors: alpha 1 and beta 1
2. RAAS
78
What does SNS response to hypotension do?
Stimulates:
1. alpha 1 receptors - constricts vessels (increases resistance)
2. beta 1 receptors - increases strength of each heart contraction (increases amt of blood ejected)
79
RAAS response to hypotension
1. angiotensin constricts vessels (increasing resistance)
| 2. Aldosterone retains salt --> retains water
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What does SNS release
Epinephrine and NE
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Epi and NE effect on lungs
stimulate B2 receptors --> dilate airways
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Epi and NE effect on heart
stimulate B1 receptors --> increased strength of contraction (increases ejection fraction - amt of blood ejected) and HR
pumping faster and more blood
83
Epi and NE effect on blood vessels
stimulate A1 receptors --> vasoconstriction and increased SVR
84
What does angiotensin do?
tenses (constricts) blood vessels (angio)
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What does aldosterone do?
causes you to retain fluid
86
Lab tests for Hypovolemia
Acute blood loss/hemorrhage: check your hemoglobin and hematocrit (part of Complete Blood Count = CBC)
Dehydration: elevated Na- levels due to decreased water levels (not because Na- is high, b/c water low)
87
Treatment for Hypovolemia
Treatment:
Dehydration:
1. Oral rehydration (Pedialyte or other electrolyte fluids if there are electrolyte abnormalities)
2. IV fluid
Acute blood loss:
1. Hold pressure
2. Blood transfusion
Third Spacing
1. If anaphylactic shock, giving epinephrine exogenously will activate those alpha and beta adrenergic receptors, correcting any hypotension
2. Still need to give IV fluids
88
Risks of Hypovolemia
Ischemia --> infarction --> death
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What causes CHF?
previous MI, chronic hypertension, COPD
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Why is adding too much fluid to a pt with hypovolemia bad?
Muscles get stretched out and floppy/weak
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What is body's response to hypovolemia? Why is this bad for a pt with systolic HF?
1. Body designed to respond to all low-blood flow states as though it is hypovolemia
2. HF triggers alpha and beta stimulation (in an already overworked heart) AND encourages fluid retention
3. Fluid retention is already a big issue with HF patients
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Associated diseases for HF
1. Prior MI
2. Chronic HTN
3. CAD (cronary artery disease decreases O2 supply ot heart, which decreases its effectiveness)
4. many other causes
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HF Assessment Findings
1. PMH, fam hx
2. SOB
3. Weight gain (quick) - edema
4. fatigue/activity intolerance - can interfere with ADLs
5. Paroxysmal nocturnal dyspnea and pillow orthopnea (most often seen with left sided HF)
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General HF physical assessment findings
fluid overload can cause atrial fibrilation by "stretching" the atria and causing irritability and fast, irregular hearbeat
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Right-sided HF physical assessment findings
AW HEAD
Anorexia and nausea
Weight gain
Hepatomegaly - (venous engorgement of the liver; increased pressure may interfere with liver's ability to function)
Edema (Bipedal)
Ascites - (accumulation of fluid in peritoneal cavity; increased pressure within portal vessels forces fluid into abd. cavity)
Distended jugular vein
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Left-sided HF physical assessment findings
DO CHAP
```
Dyspnea
Orthopnea
Cough
Hemoptysis
Adentitious Breath Sounds - fine crackles in lungs
Pulmonary Congesiton
```
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Tests for HF
BNP (increased = atrial enlargement = HF)
Chest x-ray will show enlarged heart and can show fluid on the lungs
Echocardiogram will reveal ejection fracture
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Treatment for HF
1. drugs that block the maladaptive activation of RAAS pathway (Ace inhibitors, beta adrenergic blockers)
2. diuretics
3. luid restrictions
4. low Na+ diet
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Improvement in Myocardial Contractility can be aided by
1. Inotropic agents (not first line) (digoxin, milrinone)
| 2. Surgery: ventricular assist device
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Education for HF
1. rest periods
2. screen for depression
3. preventing readmission/exacerbation: when to call the provider
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Where does acetaminophen act?
Centrally
102
Where do NSAIDs act?
peripherally
103
Background pain and med used
pain that is present even when you are completely at rest - cancer/burn pain
long acting opioid
104
Breakthrough pain and med used
Most common at hospital
flare up of pain randomly or as a result of normal daily activities (getting on bedpan)
PRN short acting PO or IV opioid
105
Procedural pain and med used
pain as a result of a dressing change, chest tube insertion, etc.
1. Premedication with PO opioid + PRN IV opioids during procedure
2. local anesthetics
106
Adverse effects of NSAIDs
1. stomach ulcers/GI bleeds
2. NEPHROTOXICITY
3. Clinical judgment: avoid NSAIDs in pts with a hx of or chronic kidney disease
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Adverse effects of acetaminophen
1. HEPATOTOXICITY
2. Clinical judgment (generally) avoid acetaminophen in pts with hx of liver disease
3. pay attention when using combo products that could contain acetaminophen
4. acetaminophen overdoses can be v severe
108
Nursing interventions to prevent skin breakdown
Understanding that very young and very old are more at risk (thinner skin) and those with poor circulation - diabetic - (circulation acts as a natural radiator)
1. use commercial products instead of "homebrew" solutions
2. don't apply ice directly - use pillow case or other cloth to guard skin
3. Typically only use for 15-30 min at a time
4. frequently reassess skin
109
TENS unit
Generates non-painful electrical stimulation that overrides pain signals (C fibers)
can be used at home
relatively effective
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Pharmacologic interventions for pain
1. local anesthetics (lidocaine)
2. Non-opioid analgesics
- NSAIDs (peripherally)
- acetaminophen (centrally)
- ketamine
3. opioid analgesics
a. short acting
- scheduled (usually q4h or q6h)
- PRN
b. long acting opioids (don't crush XR tablets)
c. PCA (patient controlled analgesia)
4. Adjuvant medications:
- gabapentinoids
- muscle relaxers
- tricyclic antidepressants
- SSRIs/SNRIs
111
Opioid side effects
1. impaired gas exchange - low resp rate (check vitals to begin with and every 4 hours)
2. At risk for constipation
- ambulate
- hydration
- stool softeners
- know last bowel movement compared with normal patterns
3. Hypotension and ortho hypotension - dangle at bedside and frequently monitor BP
4. Itching - histamine release - antihistamine
5. Opioid-induced hyperalgesia - opioids can actually worsen pain for a bit after cessation of use
6. nausea
