Februari 09, 2017
hi. welcome to the pain and alterations in comfort lecture. okay, we're gonna begin by discussing some definitions of what pain is. according to your book, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. then mccaffery who's really one of nurse experts on pain has defined it as "whatever the person
experiencing it says it is, existing whenever the experiencing person says it does." and that's a pretty popular definition in nursing theory up to this day. and american pain society encourages nurses to view pain as a fifth vital sign and so to assess it as frequent. okay and now we'll just discuss what pain isn't. pain really is not what the nurse or doctor determines a patient is feeling despite a
client's report. it's also not reliant primarily on changes in vital signs or deciding whether a person looks like they're not in pain or knowing how much a procedure or disease should hurt whether it's based on other clients or based on personal experience. it's not assuming that a sleeping or laughing client doesn't have pain or rather it doesn't mean that assuming
that the clients will tell you necessarily when they're having pain and i know all of you in your experiences, even as student nurses have probably been in situations where you worked with clients who have been requesting pain medication or maybe are reporting pain and you'll hear comments such as well they don't look like they're in pain, they said they're in pain i came back later, they're watching tv and laughing
so try to consider these statements when assessing pain. okay, what pain assessment is. pain assessment is asking and believing the patient. it is really the nurse's primary role in pain management is being the advocate for your client by believing the reports of pain because your client is really the only authority regarding the pain that they are experiencing.
it is a unique experience for them and one that we just have to have some trust in our clients and believe their report. okay, the gate control theory of pain was developed by melzack and wall and as i wrote here, it's the first theory to take a holistic view of pain and pain management. it was actually a pretty simple concept of a railroad switching station
where it opens to the favored area over the unfavored area. so for instance, the gate control theory is based upon the fact that nerve fibers transmit pain impulses from the periphery or from the body to the dorsal horn of the spinal cord and they normally travel through something called substantia gelatinosa and that's where this gating mechanism occurs so if the gait is opened then the pain impulse travels
to the brain where it's perceived as pain. but if it's closed, then the pain doesn't get perceived. an example of something that might close those gates are endorphins, they are thought to close the gates so they decrease the actual pain transmission. that's why a lot of non-invasive pain management techniques such as massage or relaxation or music therapy are thought to be effective because they release endorphins that can close those gates.
there are many factors that influence pain and pain perception and we're gonna go through all six of these. physical, psychosocial, social, spiritual, cultural, and then briefly look at age, gender, personality types. physical factors influence pain perception because basically every person has a different way of perceiving pain and you know when you ask your client "can you describe your pain
to me?" you get a whole variety of descriptors. everybody has little different pain threshold and pain tolerance can vary even within one patient from one experience to the next or from patient to patients so try not to superimpose your experiences again on a patient whether it's your personal experiences or your experience with patient or family member who's undergone a certain situation because physically everybody is
different with those. by the way, woman are at greater risk of undertreatment than men. and research is going on now actually to look at different treatment modalities between men and women and how they may actually respond differently to common treatment modalities. some other physical factors that influence pain are the type and severity of the pain. for instance, an acute or chronic type of pain and we're gonna
talk more about specific defining characteristics of those in just a bit. is there a presence of other symptoms such as nausea, anxiety, etc. or perhaps there's some adverse effects of the treatment of pain like post-anesthesia. post-anesthesia symptoms. here's a quote that i found. it says "we all have experienced a pain that we would call excruciating." it may be say a stubbed toe for some or wisdom
teeth extraction for others. in any case, we have all experienced the 'worst pain of our lives'. however, even in this statement is the implicit idea that we no longer experience this worst pain. the pain subsides, we eventually experience relief and that is kinda a good way to describe acute pain. now chronic pain is very different from acute pain. although it may start with an injury that causes pain, sometimes it doesn't. and unlike
acute pain, chronic pain persists. in chronic pain, the pain signals relentlessly fire the nervous system. perhaps continuing for years even perhaps a lifetime. and this is the sort of pain that emily dickinson had in mind when she wrote this verse that says, "pain has an element of blank: it cannot recollect when it began or if there were a time when it was not..."
so when you have a client who is experiencing chronic pain consider this statement. i know i do and it's true. it's hard for them to recollect when they actually were free of pain. okay, there are psychological factors that influence pain. for instance, a patient may be experiencing anger. perhaps they're angry about the delay in diagnosis or a treatment failure. pain can be influenced by the fear
of the disease, fear of pain or death. disfigurement. feeling of helplessness, whether it's helplessness to get pain relieved or maybe a family member feeling helpless to fix the problem. a person or client could experience fear of being a burden to society. burden to relatives. i know sometimes patients, they'll come on the next slide, but they could actually develop a fear of being a burden to a healthcare provider,
their physician, or interdisciplinary team. patients may experiences worries whether they're financial or about the future or concerns that can affect their pain experience. they may appear hostile or desperate in nature. social factors that could influence the pain experience. worrying about a family or finances, loss of a job, prestige or income that kind of
fall in the area of role function as would be loss of a social position or loss of role in a family. clients could experience feelings of isolation and abandonment and i think especially of those of our patients who are in contact precautions, how they must doubly experience those feelings of isolation. and finally as i talked about before fear of bothering healthcare providers especially the nurses. i've heard patients so many times
say "i was gonna call but i know you guys are busy." and so just encourage them to call whenever they have pain. make sure to keep reinforcing that and when you say you're gonna do something, do it. it could also be spiritual factors which influence the pain experience. questions about meaning or purpose in life, about suffering or the meaning in suffering. some may experience
fears about the past wrongs catching up with them or even questions about god or a higher power. now in our role as nurses, sometimes we would be comfortable intervening this area or offering support or just listening. or there are times you could refer to the pastoral services in your agency if there's such a thing or at least check their chart or ask them if they have a spiritual
leader or somebody who could give some kind of guidance in this situation. and of course there are cultural factors which can influence the pain experience, ranging from the demographic variables such as age, sex, or religion and then also the cultural background or even race can affect how the person expresses how much pain they're having or their pain medication
needs. and also they may have a different view of the meaning of pain. so i guess i would just encourage you when you're working in the community with, no matter where you work in the future with certain cultures that you would investigate. find out how you could be an advocate for that set of the population. okay, next we're gonna look at the simple difference between acute and chronic pain.
okay, acute pain is generally caused by an injury, disease, or surgery. the amount of pain usually decreases with healing and is reversible. so patients may interpret the pain as necessary or even expected and because they know there is a certain duration of the pain this many times is easier for the patient to deal with this than with chronic pain. okay it is estimated that about 250 million
americans have chronic pain. chronic pain is defined as long term in nature, usually more than 3 months. many times it is accompanied by depression and there's kind of a classification of chronic pain into cancer pain and non-cancer pain. cancer pain would obviously is the pain is result of the life threatening process of cancer. you know examples of that might be say a tumor invasion, nerve compression, bone metastasis is
very painful. and chronic non-cancer pain is actually more common. it affects people over the age of 65 years old of age and is a type of pain where the pain really serves no biological purpose. it is just something that is, has to be dealt with for months, years, or even a lifetime. some real common examples of that in our elderly population would be say rheumatoid arthritis, chronic back injuries, or osteoarthritis.
types of pain can also be divided into three categories known as somatic, visceral, and neuropathic pain. your book does talk about this a little bit so go into depth just looking at them one slide each. okay, we'll start with somatic pain. somatic pain is caused by activation of nociceptors in the cutaneous, deep tissues, and musculoskeletal system. now a nociceptor is the sensory receptor
that responds to potentially damaging stimuli. it sends nerve signals to the spinal cord into the brain and actual process is called nociception and it's really what causes the perception of pain. so somatic pain is caused by the activation of these devices if you will and the cutaneous, deep tissues, and musculoskeletal system. as far as assessment you will see pain with movement or a client might say "i'm fine if i don't move, if i
just lay still." descriptors patients may use when you ask them if they can describe the pain, they might say aching, gnawing, constant, well-localized in a certain area, a dull ache, or throbbing. some specific examples post-surgery bone fractures, bone metastasis, infection, inflammation of soft tissues, muscle spasms, or inflammation. i also had in my notes like a sprained ankle as an example of a somatic
type of pain. okay, so the second type of pain is visceral pain and visceral pain is caused by an activation of the nociceptors, from situations such as infiltration, compression, distention, or stretching of thoracic or abdominal viscera. when you think of abdominal viscera, think organs in your mind. as far as nursing assessment you may discover patients are experiencing either dull or sharp
pain, deep and constant, could be a vague type of discomfort or difficult to localize or even difficulty describe. as far as descriptors clients may use when we ask them to describe their pain, they may say deep and squeezing, pressure, cramping, also associated with nausea, vomiting, diuresis many times because it does involve the organs and the viscera. some examples i've listed here are bowel obstructions, pleural
effusion, pneumonia, menstrual cramps. i'd also like you to keep in mind that visceral pain can also and many times is referred and that is where there's a sensation of pain located in an area that's distal from or distant from the actual area of injury. i'm just trying to think, probably the most common type of referred pain is the type of pain associated with myocardial damage which as you know is angina. angina sometimes
they can feel it in the chest or epigastric area but many times it's radiating to the jaw, down the left arm, even to the wrist or elbows. i think last semester you probably learned about gall bladder pain which many times is manifested by scapular pain in the right side of the body. and if you've ever eaten ice cream really fast, you've experienced something called brain freeze. i think everybody's experienced that. that's a perfect example of referred pain.
it's referred because the pain's caused by you know ingestion of very cold substance and there's vasoconstriction and dilation of the capillaries and actually the trigeminal vagus nerves are stimulated but the pain sensation is felt in kinda the upper head or the brain area. and finally the last example of referred pain i'd like to mention is phantom limb pain. this is the pain where clients who have had
an extremity removed may continue to experience pain in that extremity even though it's no longer there and it generally goes away after quite a long time but it can be very severe and debilitating. third type of pain i'd like to discuss is neuropathic pain. neuropathic pain is caused by spontaneous discharges in the central or peripheral nervous system
and as far as the assessment you could probably be assessing the kind of continuous or intermittent tingling type pain which is also known as parasthesia. hypersensitivity to the skin, nerve compression, or damage. if you would ask the client to describe this type of pain they would probably describe it as burning, aching, shooting, maybe pain or numbness, tingling would be in there.
examples would include in this would be peripheral neuropathy, many times experienced by diabetic clients. those experiencing trauma to nerves or nerve endings could be for instance motor vehicle accident, patient, or even somebody who has say lumbar disease or lumbar disvulging where those nerves are compressed and you know they'll experience a tingling and numbness down their leg and herpetic neuralgia is considered a
neuropathic type of pain. herpetic neurolgia is what occurs after a person's had shingles. as you know shingles is a herpes type disease, skin rash and it'll be resolved but they could experience very severe pain for quite a long time after that. and then finally, trigeminal neuralgia also known as tic douloureux is caused by damage to the trigeminal nerve. it can actually cause very relentless facial
pain and if you ever google this or wanna look it up, you'll see that it's coined actually the suicide disease because it's very difficult to deal with. i've cared for patients in acute care who are, they are on trials for different medications trying to get control of this neuropathic type of pain known as trigeminal neuralgia. okay, now we're gonna take a bit of time to look
at pain assessment across the lifespan. okay, so this is a review from i'm sure a couple of semesters now but when you assess client's pain you wanna certainly assess the location, duration, quality, and type of the pain and i know you guys are doing that. i see you doing it routinely in clinical. factors that relieve or increase the pain, the impact of the pain on their quality of life and the patient's
previous response to treatment and their preferences. many times you look at the prns and they'll be a whole page of them and i'll frequently ask you know "what works best for you and what do you prefer?" so we are going to be looking at some pain scales. we're gonna be looking at the zero to ten scale which you're all very familiar with, visual analogue, faces,
flaac, and then the newborn and young infant scale and i think i included those all on your powerpoint so you can follow along. zero to ten scale you're very familiar with the worst possible pain to no pain at all. however, the faces scale on the right side of this screen is appropriate for children maybe starting right around two years up to about 7-8 years of age. after that they can
usually respond to the numerical rating so to ask them which face corresponds to how they're feeling. here's another interesting pain scale that i haven't seen used a lot but boy you're thinking wisconsin we could really get a lot of use out of this. what is your weather today? take just a minute and look at this and tell me how are you feeling today? are you experiencing any pain? are you sunny with no pain? or maybe just some intermittent pain, showers?
or severe pain where you're not really able to participate in activities, you're snowed in, and most activities are cancelled for the day and that would correlate to a ten on the pain scale. this pain scale by mosby is just another variation of the faces. it's horizontal as opposed to vertical and it uses different words as opposed to just numbers which the original faces pain scale has, it has words. no hurt, hurts a little bit,
hurts little more, could be nice for people who do not speak english or again for those about 7 years old and under. maybe like 2 years to 7 or 8. and finally this flacc scale is very commonly used in our region. it's used for children under 2 years of age and older than about 2 months. so 2 months to about 2 years and you'll be assessing five things. one is the face whether
there's expression or smile, grimace, or frown, clenched jaw, quivering. legs you would assess whether they're normal position or relaxed, uneasy, restless, or tense or kicking or drawn up. i think of a child who's experiencing colic say a 6 month old who's pulling their legs up in severe pain. as far as activity, are they lying quietly, squirming, arched or rigid, is there crying either absent, no cry, moans, or whispers or
steady cry and finally consolability. whether they're content and relaxed or one would be they're able to be reassured by picking them up, hugging them, talking to them, and number two would be difficult to console or even impossible to console. now as far as a flacc scale, i don't want you to memorize what each number stands for but i'd like you to know who it's best used for, kind of the five categories and how they all work together
to interpret the patient's experience of pain. okay and this is a newborn/young infant pain scale as you can see is a little less discriminatory as either 0, 5, or 10 and you can see that just defining characteristics under each number. some of them are similar to the flacc scale. for instance difficult to settle, grimacing, but they will use this on the newborns in order to determine the amount of pain they are
most likely experiencing. finally you wanna of course document what you have assessed and done. you wanna document the client's report of pain, the patient's goal for pain relief, on a scale of 1-10. that should be clearly identified wherever the agency requires it to be. to plan for pain management, interventions by the nurse, and the client's responses to those interventions. i know at aspirus patient must be reassessed within
2 hours or less of interventions. now the following slides are going to talk about nursing interventions for a patient in pain. okay so now we're gonna be looking at nursing interventions for a client in pain. we're going to focus on medications, medication delivery systems, and at the end of this handout there are just a few slides on nonpharmacological approaches. we won't really be discussing them in depth but it's something
for you to consider. okay so non-opioid analgesics, the primary one i'd like to talk about is tylenol or acetaminophen. if you look under most drug books it'll say the action is unknown but tylenol is thought to block the peripheral pain receptors and to simply increase the client's pain threshold. it has great analgesic and antipyretic properties which means it treats the pain and brings temperature
down. in fact, antipyretic properties of tylenol are just as good as those of the nsaids or non-steroidals. there's no antiplatelet aggregation as you would say in say aspirin and there are few anti inflammatory properties that you would see in aspirin and the nsaids. however there's a lot less side effects than the nsaids. you won't see the gi upset that aspirin causes for instance and remember how asthmatics should really avoid aspirin.
tylenol or acetaminophen is a great alternative for them. however, acetaminophen can cause hepato nephrotoxicity that's liver and kidney with long term use or with overdose. and tylenol unfortunately is a substance used, i'm not gonna frequently, but it is used upon occasion for overdose. the maximum dose of tylenol is 4 grams in 24 hours. sometimes prescribers will write for 2 grams in 24 hours. so always make sure
you look back and count how much the patient has received and kind of project for the next 24 hours so you know if you're reaching that limit or coming close to that limit or not. okay, so now we'll begin a discussion regarding nsaids or non-steroidal anti inflammatories. they are very popular. as you know, they have anti inflammatory properties. generally from inhibiting
prostoglandin synthesis. nsaids are useful in management or acute inflammation caused by tissue destruction, trauma, post surgery, back and arthritic pain. examples ketorolac or toradol is given. it can be given iv or po and probably the most common is ibuprofen which has a lot of brand names as you know. general dosing for that the maximum 3200 mg in 24 hours generally divided up in 800 mg doses. so 800 mg
tid. the next slide we'll talk about side effects. side effects of nsaids are similar to side effects of aspirin of course and those are gastric upsets probably first and foremost. it can actually progress to gi or gastrointestinal bleeding so make sure it's taken with food. of course a client should know to report any bloody emesis or stools. can cause renal toxicity, decrease clotting so when a person is on coumadin they should not be taking nsaids
at the same time cause those can work together. and nsaids can also cause sodium and water retention so it can be a problem for those obviously who are experiencing heart failure so watch it with older adults. those with renal or hepatic elimination problems really wanna be sure you're watching bun and creatinine and watching for fluid volume overload. okay then finally we're onto the opioid analgesics which i know you learned about in
pharmacology. this is just a real quick review of those. also known as narcotic medications. the action i've just written up on top: binds to opioid receptors in the central nervous system and spinal cord and it blocks the transmission of the pain impulse. so just some reminders about opioid or narcotic analgesics, there is no ceiling or maximum dose as there are with the other medications.
and most of these opioid analgesics are similar so they should only be on one so when you get a client in the hospital say who's on vicodin or a large amount of oxicodone there is something called an equianalgesic chart that compares it to 10 mg of morphine. so providers use that to determine how much medication of whatever type they choose, the client should be on. a general rule of thumb
with the elderly are to start slow and go slow as far as increasing the dosing. so if they're on a medication say one or two tabs or 2-4 mg that you would start with the lowest and increase very slowly. okay, some examples of common opioids. the number one would be morphine and simply the gold standard of all narcotics, it's inexpensive, and there's many types and forms of long and short acting.
there's po, iv, rectal. ms contin is a po form, it's very common. as you know, we give morphine intravenously on the floor quite a bit. rectal it is available per suppository, not as frequently used. codeine is another common example. i guess what i'd like you to know about codeine is it may not work in about 5-10% of the population in fact, 7% of caucasians are missing an enzyme that is necessary to make codeine work. so if you're
giving or administering codeine and you that the patient's pain is not improving, you may ask them if they have an insensitivity to codeine or request that other medications would be investigated. opioids are commonly presented as combinations with acetaminophen or ibuprofen and many times they'll have long acting and short acting opioids together in one compound. okay, so some common side effects of
opioid analgesics, probably one of the most common is constipation and even though that may seem minor to healthcare providers, it can be very major to clients. so encourage them to increase their fiber intake, fluid intake, etc. patients may experience nausea and vomiting, especially of course when they're taking the medications orally so it's good to take it with some food if permittable. watch for urinary retention, watch for a itchy rash or
pruritis. a common side effect of opioids and sometimes almost a desired effect is sedation but it can also cause confusion so you wanna monitor their level of consciousness and finally a respiratory depression. i listed it last but it really is the top priority as you know. so you really need to monitor their respiratory rate and their o2 saturations. now you would expect that their
respiratory rate would go down and what i would suggest is when you count their respirations, say they get down to 12 or 10 per minute, go make sure they're arousable, check their o2 saturations. many times their rates will go down, that is expected but if their saturations are okay and if they're arousable than they're probably tolerating that amount of medication just fine.
and i apologize for this light writing here but a couple other things i'd like you to consider is the reversal and synergism of medications. so these are terms i'm sure you've learned in pharmacology but synergism is when mixing drugs with other drugs to potentiate or enhance the analgesic effect so iggy your book describes this as a juven analgesic activity. in other words, something that you would use in combination
with. and i wrote a note here, what is a drug that reverses the effects of opioids? if we were in class we could discuss that this drug is narcan. most commonly, there are other reversal agents but i think narcan is the most common. what you would do as a nurse is mix the 0.4 mg diluted in about 10 ml of normal saline and push over about 2 minutes. now i think your handout may have a few extra words on it there, possibly.
but you would push the whole 0.4 mg in over about 2 minutes and observe the client. now it takes about 2 minutes for narcan to it's effect and the effect of narcan is about 45 minutes to an hour so if the person is still depressed and you don't see a change in their symptoms or desirable change after a few minutes you can go ahead and repeat it. currently this adjusted top limit is about
2 mg so that'd be about 5 doses of the 0.5 mg. i just wanna also point out that as a nurse it's always good to know how you would have access to the narcan. it used to be that when people are on large doses of analgesics you would have the narcan in the drawer, near the room but now with automated delivery systems most patients have that as
an override so just be sure you would know how to get ahold of it before you would actually have to get ahold of it. and finally, i'd just like to put a plug in here for considering the medication administration across a lifespan. when working with a pediatric and geriatric populations think about how are the meds absorbed, distributed, metabolized, and eliminated. cause really if your client has
any renal or liver considerations you may have to consider changing or requesting to change a medication, dosages, increasing the dosages more slowly or even changing the medications because most pain medications are metabolized through one of those two systems. so just something to keep in mind as you care for either pediatric or geriatric clients. okay, so now we're gonna talk about pain
medication delivery systems. the first one you are hopefully familiar with, we've talked about it in skills and a lot of you have seen it in the acute care setting that's a pca or a patient controlled analgesia. this is where the patient actually determines how much medication to take. research has demonstrated that it provides for more steady coverage, smaller more frequent dosing, and it enhances a client's
sense of control reducing anxiety. it's been demonstrated that patients who have patient controlled analgesisa actually consume less medication than patients who have just a prn iv push type of medication. okay, patient controlled analgesia involves setting the pump in a certain way that reflects the providers orders. the providers orders, very much like a recipe. one of the
things that may be ordered is a loading dose and this is a certain amount of medication that is delivered on the onset of the pca. so when you set up the patient controlled analgesia pump, it'll actually ask you "is there a loading dose?" and you can hit yes or no. and if you hit yes you have to put in how many milligrams is ordered. you'll have the option of instituting a basal or continuous rate and that
would be a very small amount of medication that's being continuously delivered. we don't see that very often although once in a while you'll have a provider that orders the basal or continuous rate at night. so that would mean the evening shift would have to change the settings on the pca pump every night and then of course in the morning have to change them back. the provider will also order prescribed doses
and lockout intervals. for instance, when they push the button how much will be delivered of the medication common dose for instance of dilaudid would be 0.1 mg and then the lockout interval would be how much time inbetween dosages would be preset. for instance, you have 0.1 mg every fifteen minutes. fyi, the three common medications used for pca pumps are dilaudid, morphine, and demerol.
now these settings, loading dose, basal or continuous rate, prescribed dose, and lockout you could actually add to that four hour limit. most pumps have that as well so maybe the physician will say "no more than three milligrams of dilaudid every 4 hours". now that's just a random example but those will need to be checked by two nurses. okay, here is a common pca pump. this is i think the same kind of pump we have at our lab at ntc
and the ones that are at our facilities here in wausau and as you can see there is a key that keeps the medication secure and also the key needs you need to unlock the machine is order to change the settings. again which needs to be verified by two nurses. and as you're aware the patient will need to press the button. they can press the button as many times as they want and the medication
will only be delivered as often as the lockout is set. for instance, if the lockout is fifteen minutes and the patients pushing the button say 8 or 9 times in that fifteen minute period, they'll only get their medication after fifteen minutes has expired. what i have noticed is there's a different sound or beeping when the patient pushes it and they actually get the medication delivered
as when the medication isn't delivered and you'll have clients who become very savvy to it and they will know exactly when medications been delivered or not. so when setting up a pca pump not only do you have to consider the legal ramifications such as checking the settings with two nurses and making sure it's locked, etc. but think about, is your patient a good candidate for a pca analgesia? very confused or weak patients are not good candidates. they're
not able to push the button or if they're paralyzed obviously they're not able to push the button. now with children, this mode of medication delivery is found to be effective with children as young as 7 years of age. but really any younger than that, it would probably be inappropriate. but i wonder how many of our pediatric clients who are say 8 or 9 years of age have got to use a pca modality. so make sure your clients appropriate and that you've
educated them, that they can push the button as much as they want and they will not get overdosed or receive too much pain medication. okay now i'd like to talk about medication delivery methods that are delivered in the spinal cavities. the first one is epidural analgesia which is delivered within the epidural space and i believe i put a picture of that in your handout on the next slide. this can be either short or long term pain control.
the second we'll talk about briefly is the inthrathecal analgesia and this is within the spinal canal. it's generally used for more long term control and there are some more cns risks associated with inthrathecal medication. so again, the epidural analgesia is administered via a catheter that is inserted within the epidural space. okay and the intrathecal analgesia is actually
administered via a catheter that's inserted into intrathecal space and this space is really the actual space it's surrounding the spinal cord. it's also called a subarachnoid space, you may recognize that term. and just a word about intrathecal medication is becoming more and more popular that these are placed usually during surgery and attached to a pump. the pump can be internal or it can be external and many times when it's
internal it's kinda placed in the abdominal region and there's a diaphragm in it that when it's empty it can be refilled so it's used for chronic pain. before a patient is placed on intrathecal medication they usually go through a type of trial to make sure they can tolerate it. common types of pain that this is used for would be cancer pain, real chronic back pain, say any patients who have had failed back
surgeries or chronic pacreatitis, spinal cord injuries, etc. okay and as i said before, many times these catheters are surgically placed. now some of you may be thinking about epidural catheters that are placed for anesthesia purpose and very short they might be placed say at the bedside but if they're gonna be cannulated in the epidural or intrathecal space, many times
are surgically placed. again there are pumps used to infuse the medication. it could be an external pump which i have a picture of on the next slide. it could be patient control pump. more recently i know they use a lot of these on the orthoneural floor and there are orders similar to the pca orders where the nurses have to go through step by step for the epidural pump settings and they can actually increase or decrease the settings based upon the
patient's needs. so pain assessment is so important here. with epidural and intrathecal analgesia they may have an implanted cord as i talked about before. usually it's placed in the abdomen near the subcutaneous tissue so when it is completed there's a port where it can be accessed subcutaneously and refilled. they could have an implanted pump which is kinda prefilled and preset to deliver certain amount of medication at a steady rate. what they have found
with this type of pain medication delivery system there's better pain control and client's actually require less medication and have better outcomes. here is a simple picture of intrathecal analgesia where the catheter be placed surgically running along the spinal cord there in the subarachnoid space. catheter tip is up here and this is kind of a posterior view but the pump would be facing forward to the abdomen with the port facing
forward so it can be refilled when needed. okay so side effects of these medications they're very similar to the iv push medications. pruritus, nausea, vomiting, respiratory depression again number one. gotta watch o2 saturations, arousability, urinary retention. lower motor weakness if an anesthetic is used or even partial anesthetic is used so make sure you assess that before a client gets up on their own and then the nurses
role besides the pain assessment and adjusting the pump as needed per order would be to monitor the site, prevent dislodgement, and infection. so also because it's in the back you know make sure when they're repositioned that the tubing catheter isn't kinked behind them. okay, so as i said there are pre-loaded pain pumps that are frequently used. we see a lot of these with the orthopedic surgeries. they're placed during
surgery and filled with a local anesthetic agent. bupivacaine and lidocaine are probably the most common anesthetic agents used. a common example is a stryker pain pump. i think i have a picture or a youtube video on blackboard of a pain pump that's being discontinued at home. it's not unusual and i do have a bullet below that says removal that this would be removed by the patient or a family member in the home setting.
again usually it's for orthopedic surgeries, they're pre-programmed so there's not a lot of settings that have to be confirmed with the nurse. as far as teaching you know, the client if they're going home the day after surgery they'll have to know how to clean with soap and water or however the provider has prescribed around the pump. the pump itself, the tube, looks
a lot like a jackson-pratt. here i will just hop forward in a moment you'll be able to see. some benefits of this are the patients feel more comfortable post-operatively, they can resume earlier ambulation, generally the hospital stay is shorter, and the patients perceive and they are in more in charge of their pain management. again removal, whether it's out patient in a clinic or if it's at home with take home instructions, there needs to be education that goes
home with the patient and family members. okay here's just a picture of a common example of a preloaded pain pump. here's a reservoir where the medication is put and real common combination of medication that's used today or at least at aspirus is a combination or toridol, lidocaine, morphine, and maybe something else. so it's kind of a drug cocktail that is and again put in during surgery. and it is delivered at a certain rate and has very
little maintenance really for the nurse except for make sure the tubing is not kinked and that it stays clean, dry, and intact. patient should be given discharge information as far as again whether they'll go to an out patient clinic to have it removed or perhaps will be given written instruction in how to remove it on their own. one thing that i've read is because this is delivering pain medication at kind of a consistent rate, that the patient should expect some
clear drainage or leakage at the surgical site because the medication will naturally kind of seep out eventually so they shouldn't be real surprised to see that. obviously if they're having purulent drainage or it becomes more sanguinous in nature they should report that. okay another pain delivery method is iv concious sedation. this is a common methodology that's used today. i think we've talked about tees,
endoscopies, colonoscopies, cardiumversion, all of those procedures require iv conscious sedation. so what is iv conscious sedation? it's administration of iv medication that produces optimumally just a light sedation. it controls pain and actually produces amnesia. the unique thing about iv conscious sedation is that the patient is able to respond to commands and maintain their own airway. so for instance,
during a colonoscopy when the patient has to turn from one side to the other, they're able to follow that command. it's an increasingly popular option for many surgical and endoscopic procedures. it shortens recovery time, it reduces the risks associated say with general surgery or general anesthesia. and probably the most important thing for you to know is a patient really shouldn't
lose their protective and deep tendon reflexes. for instance, under this type of iv conscious sedation they would be able to respond to verbal stimuli. example, in the cath lab they might be somewhat sedated but if asked to cough or hold their breath or turn their head or report angina they could do so. also their protective reflexes such as a gag reflex should remain intact. even though they're lathargic they can be aroused and now it's a fine line
between that and being too sedated. so the next slide i'll talk about how it's important to monitor their heart rhythm, o2 saturations, etc. also even though they should have their gag reflex throughout this, before feeding them or giving them something to drink i would make sure that their gag reflex is intact. okay so to administer iv conscious sedation you need to gather the right equipment, cardiac monitor if they're not already on that, o2 saturation machine,
blood pressure cuff, respiratory emergency equipment and by this i mean i always know where the airway is the artificial airway and i'll have an ambu bag with oxygen present. usually the patient is already on nasal o2 but make sure you have the ambu bag present and you can always hook the oxygen up to the ambu bag if needed. nursing assessment throughout the whole process is crucial. their history, including concurrent illnesses,
allergies, base line vital signs, make sure you have iv access usually there's an iv running it. tko that medication can be administered through. tko again means 'to keep open' unless the rate is more. more than tko but tko for an adult is usually about 20-30 ml per hour. you'd make sure you know their baseline respiratory status, inform consent must be signed for the procedure that's gonna be done, client should be npo before iv conscious sedation and
whatever procedures gonna happen. and as far as nursing ongoing assessments make sure watch your respiratory status, which includes o2 saturation definitely and vital signs. and the goals again iv conscious sedation are to maintain the ability to follow commands, to breath spontaneously they should keep their gag reflex. however, you don't want the patient to remember what's going on and i always kinda joke around because
when you use this type of iv conscious sedation even though they're talking to you throughout it and they can follow commands and respond somewhat, when they're all done when they wake up they'll usually say something like "well, when are we gonna get started?" because it's very hypnotic in nature especially if something like phentinol or versed is used is the drug of choice. also as i said, we really want them to be able
to breath spontaneously, maintain the gag reflex, plan for the worst case scenario, that's why i always have the ambu bag present, i don't leave the patient's side during the whole procedure and make sure the ongoing assessments are done frequently and continuously. okay so the remainder of the presentation i'll probably let you go through on your own but i just want to talk about a couple things that are out there on the horizon. these are only fyi things so i'm not gonna be covering them
on the exam necessarily but i wanted to peak your curiosity as far as to what the future might hold with pain management, what you may be working with in your career. and the first thing on the horizon is medication implanted during a surgical procedure that dissolves over time. imagine you were gonna go in to have say hip replacement or a back surgery and medication is implanted during that surgical procedure, it would normally be very painful recovery but because of these you experience very little pain, there's
no out patient visit or drain or pump that has to be dealt with. well that's what's kinda being worked on with the medication that is an anesthetic agent bupivacaine and this actually being imbedded in a collagen material that is implanted during surgery. so it totally avoids the need for removal of a catheter by healthcare professional or by the patient or family member. and it increases the ability of the patient to resume ambulation or activities of daily living. so that's something that's out there
in the future. here's some examples of collaborative interventions for clients experiencing pain beyond the administration of medications. okay the first one i really and the only one i'm really gonna talk at length about is the use of the tens therapy because we do see transcutaneous electrical nerve stimulation therapy used every once in a while even in acute care and it's also used
out patient therapy and i know a lot of say physical therapy companies may use a tens machine. it is a use of electrical current produced by a device to stimulate the nerves for a therapeutic response or therapeutic purpose. just an interesting story, i looked into this and found out that it was actually discovered or used in ancient greece. now i'm talking 63 a.d. it was reported that pain was relieved by standing on an electric fish or an electric eel at the seashore.
so then in the 16th through the 18th century, various devices were used for headache and other pain, types of pain to relieve them. and interestingly enough benjamin franklin was a huge proponent of this method for pain relief and promoted its' use. so i guess it goes back a long way, i don't suggest standing on any electric eels but it is commonly used in out patient and physical therapy rehabilitation as i said. by the way, the use of tens from different
patients just personally that i've talked to some say when it's used it just has a tingling feeling, a burning feeling, some enjoy it. they say it feels warm and relaxing. others have said it's a painful experience so there you go with different perceptions of pain or pain threshold. okay, i've included in your hand out a bunch of ideas for non-pharmacological pain management strategies that you may and should be using with your patients. not that you would use all of these but
certainly pick out certain ones that might be helpful. distraction is a huge, hugely helpful technique especially with the pediatric population and with elderly. and with the distraction i would include reminiscence therapy is very helpful. just remember all of these techniques although they don't actually influence the cause of the pain can alter the perception of pain. here are some examples of complimentary and alternative
therapies that patients may use or they may be referred to. again, i'm not gonna test you on these but there are certain areas in our community that deal with a variety of these techniques. in case you are not familiar with them you can certainly look them up individually. i know for me i wasn't sure was shiatsu was but it's actually a finger pressure technique where includes massage of the fingers that's supposed to stimulate
referred pain relief. and as i was reviewing all of the herbal therapies out there, i got a little overwhelmed. i mean there are entire textbooks dedicated to herbal therapies. i put down the ones i felt were most common. i think the most important things for a nurse to know is we need to assess for our client's use of these medications. clients should know or be educated about their relationship or interaction with
other medications or conventional medications. they need to know to report them to their healthcare providers cause they can have interactions or even contraindications with some medications. other thing to know is for the most part even though these indications for use they are not fda approved and just something to keep in mind. so in conclusion as i said clients should always discuss the use of herbal medications or supplements
with physician or practitioners. and if they do have a planned procedure or surgery many times they'll be stopped before hand however if you have a patient who's coming in before a procedure or surgery who is on an unreported herbal medication i would certainly make sure the provider knows about that before they go into that procedure. so i hope this recording was helpful. if you have any questions, please give me a call and i hope you
all have a wonderful week. good bye.
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