Copyright © 2017, Elsevier Inc. All rights reserved.

Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage A personal and individual experience Whatever the patient says it is Exists when the patient says it exists Copyright © 2017, Elsevier Inc. All rights reserved.

Nociception Pain results from stimulation of sensory nerve fibers called nociceptors. These receptors transmit pain signals from various body regions to the spinal cord and brain. Copyright © 2017, Elsevier Inc. All rights reserved.

Pain Tolerance The amount of pain a person can endure without it interfering with normal function Varies from person to person Subjective response to pain, not a physiologic function Varies by attitude, environment, culture, ethnicity Copyright © 2017, Elsevier Inc. All rights reserved.

Classification of Pain by Onset and Duration
Acute pain Sudden onset Usually subsides once treated Chronic pain Persistent or recurring Lasts 3 to 6 months Often difficult to treat Tolerance Physical dependence Copyright © 2017, Elsevier Inc. All rights reserved.

Classification of Pain
Somatic Visceral Superficial Deep Vascular Referred Neuropathic Phantom Cancer Central Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question
A patient with bone cancer tells the nurse that he is in pain. The nurse knows that bone pain is classified as which type of pain? Somatic pain Referred pain Visceral pain Neuropathic pain Answer: A Rationale: Somatic pain, which includes bone pain, originates from the skeletal muscles, ligaments, and joints. Referred pain occurs when visceral nerve fibers synapse at a level in the spinal cord close to fibers that supply specific subcutaneous tissues in the body. Visceral pain originates from organs and smooth muscles. Neuropathic pain usually results from damage to peripheral or CNS nerve fibers or injury, but may also be idiopathic. Copyright © 2017, Elsevier Inc. All rights reserved.

Gate Theory of Pain Transmission
Most common and well-described theory Uses the analogy of a gate to describe how impulses from damaged tissues are sensed in the brain Many current pain management strategies are aimed at altering this system Copyright © 2017, Elsevier Inc. All rights reserved.

Gate Theory of Pain Transmission (Cont.)
Copyright © 2017, Elsevier Inc. All rights reserved.

Pain Transmission Tissue injury causes the release of the following: Bradykinin Histamine Potassium Prostaglandins Serotonin These substances stimulate nerve endings, starting the pain process. Copyright © 2017, Elsevier Inc. All rights reserved.

Pain Transmission (Cont.)
The nerve impulses enter the spinal cord and travel up to the brain. The point of spinal cord entry or the “gate” is the dorsal horn. This gate regulates the flow of sensory impulses to the brain. Copyright © 2017, Elsevier Inc. All rights reserved.

Body has endogenous neurotransmitters Enkephalins Endorphins Produced by body to fight pain Bind to opioid receptors Inhibit transmission of pain by closing gate Copyright © 2017, Elsevier Inc. All rights reserved.

Treatment of Pain in Special Situations
PCA and “PCA by proxy” Patient comfort vs. fear of drug addiction Opioid tolerance Use of placebos Recognizing patients who are opioid tolerant Breakthrough pain Synergistic effect Copyright © 2017, Elsevier Inc. All rights reserved.

Adjuvant Drugs Assist primary drugs in relieving pain NSAIDs Antidepressants Anticonvulsants Corticosteroids Example: adjuvant drugs for neuropathic pain Amitriptyline (antidepressant) Gabapentin or pregabalin (anticonvulsants) Copyright © 2017, Elsevier Inc. All rights reserved.

World Health Organization Three-Step Analgesic Ladder
Step 1: nonopioids (with or without adjuvant medications) after the pain has been identified and assessed. If pain persists or increases, treatment moves to Step 2: opioids with or without nonopioids and with or without adjuvants. If pain persists or increases, management then rises to Step 3: opioids indicated for moderate to severe pain, administered with or without nonopioids or adjuvant medications. Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Drugs Synthetic drugs that bind to the opiate receptors to relieve pain Mild agonists: codeine, hydrocodone Strong agonists: morphine, hydromorphone, oxycodone, oxymorphone, meperidine, fentanyl, and methadone Meperidine: not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Analgesics: Mechanism of Action
Three classifications based on their actions Agonists Agonists-antagonists Antagonists (nonanalgesic) Copyright © 2017, Elsevier Inc. All rights reserved.

Agonists-Antagonists
Bind to a pain receptor Cause a weaker neurologic response than a full agonist Also called partial agonist or mixed agonist Copyright © 2017, Elsevier Inc. All rights reserved.

Antagonists Reverse the effects of these drugs on pain receptors Bind to a pain receptor and exert no response Also known as competitive antagonists Copyright © 2017, Elsevier Inc. All rights reserved.

Equianalgesia Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia Hydromorphone (Dilaudid): seven times more potent than morphine Example: if morphine 10 mg was given to a patient followed 1 hour later by hydromorphone 1 mg, then the patient would have received an equivalent of 17 mg of morphine. Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Analgesics: Indications
Main use: to alleviate moderate to severe pain Often given with adjuvant analgesic drugs to assist primary drugs with pain relief Opioids are also used for: Cough center suppression Treatment of diarrhea Balanced anesthesia Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Analgesics: Contraindications
Known drug allergy Severe asthma Use with extreme caution in patients with: Respiratory insufficiency Elevated intracranial pressure Morbid obesity or sleep apnea Paralytic ileus Pregnancy Copyright © 2017, Elsevier Inc. All rights reserved.

A patient is recovering from an appendectomy. She also has asthma and allergies to shellfish and iodine. To manage her postoperative pain, the physician has prescribed patient-controlled analgesia (PCA) with hydromorphone (Dilaudid). Which vital sign is of greatest concern? Pulse Blood pressure Temperature Respirations Correct answer: D Rationale: This patient has a history of asthma and allergies, and she will be receiving a drug that can depress respirations. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Opioid Analgesics: Adverse Effects
CNS depression Leads to respiratory depression Most serious adverse effect Nausea and vomiting Urinary retention Diaphoresis and flushing Pupil constriction (miosis) Constipation Itching Copyright © 2017, Elsevier Inc. All rights reserved.

Opioids: Opioid Tolerance
A common physiologic result of chronic opioid treatment Result: larger dose is required to maintain the same level of analgesia Copyright © 2017, Elsevier Inc. All rights reserved.

Opioids: Physical Dependence
Physiologic adaptation of the body to the presence of an opioid Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychologic dependence (addiction) Copyright © 2017, Elsevier Inc. All rights reserved.

Opioids: Psychologic Dependence
A pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief Copyright © 2017, Elsevier Inc. All rights reserved.

A patient who has metastasized bone cancer has been on transdermal fentanyl patches for pain management for 3 months. He has been hospitalized for tests and has told the nurse that his pain is becoming “unbearable.” The nurse is reluctant to give him the ordered pain medication because the nurse does not want the patient to get addicted to the medication. The nurse’s actions reflect appropriate concern for the patient’s best welfare. appropriate caution for a patient who is already on a long-term opioid. an uncaring attitude toward the patient. a failure to manage the patient’s pain properly. Correct answer: D Rationale: Patients with severe pain, including metastatic pain or bone pain, may need higher and higher doses of analgesics. The nurse is responsible for ensuring that the patient experiences adequate pain relief. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Opioid Analgesics: Toxicity and Management of Overdose
Naloxone (Narcan) Naltrexone (ReVia) Regardless of withdrawal symptoms, when a patient experiences severe respiratory depression, an opioid antagonist should be given. Copyright © 2017, Elsevier Inc. All rights reserved.

Toxicity and Management of Overdose (Cont.)
Opioid withdrawal or opioid abstinence syndrome Manifested as: Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Analgesics: Interactions
Alcohol Antihistamines Barbiturates Benzodiazepines Monoamine oxidase inhibitors Others Copyright © 2017, Elsevier Inc. All rights reserved.

Codeine Sulfate Codeine sulfate Natural opiate alkaloid (Schedule II) obtained from opium Less effective Ceiling effect More commonly used as an antitussive drug GI disturbance Copyright © 2017, Elsevier Inc. All rights reserved.

Fentanyl Synthetic opioid (Schedule II) used to treat moderate to severe pain Parenteral injections, transdermal patches (Duragesic), buccal lozenges (Fentora), and buccal lozenges on a stick (Actiq) Fentanyl in a dose of 0.1 mg intravenously is roughly equivalent to 10 mg of morphine intravenously Copyright © 2017, Elsevier Inc. All rights reserved.

Dilaudid Hydromorphone (Dilaudid): very potent opioid analgesic; Schedule II drug One milligram of IV or IM hydromorphone is equivalent to 7 mg of morphine Copyright © 2017, Elsevier Inc. All rights reserved.

Methadone Hydrochloride (Dolophine)
Synthetic opioid analgesic (Schedule II) Opioid of choice for the detoxification treatment of opioid addicts in methadone maintenance programs Renewed interest in the use of methadone for chronic (e.g., neuropathic) and cancer-related pain Prolonged half-life of the drug: cause of unintentional overdoses and deaths Cardiac dysrhythmias Copyright © 2017, Elsevier Inc. All rights reserved.

Morphine Sulfate Naturally occurring alkaloid derived from the opium poppy Drug prototype for all opioid drugs; Schedule II controlled substance Indication: severe pain High abuse potential Oral, injectable, and rectal dosage forms; also extended-release forms Copyright © 2017, Elsevier Inc. All rights reserved.

Naloxone Hydrochloride (Narcan)
Pure opioid antagonist Drug of choice for the complete or partial reversal of opioid-induced respiratory depression Indicated in cases of suspected acute opioid overdose Failure of the drug to significantly reverse the effects of the presumed opioid overdose indicates that the condition may not be related to opioid overdose. Copyright © 2017, Elsevier Inc. All rights reserved.

Nonopioid Analgesics: Acetaminophen (Tylenol)
Analgesic and antipyretic effects Little to no antiinflammatory effects Available over the counter (OTC) and in combination products with opioids Copyright © 2017, Elsevier Inc. All rights reserved.

Acetaminophen: Dosage
Maximum daily dose for healthy adults is being lowered to 3000 mg/day. 2000 mg for older adults and those with liver disease Inadvertent excessive doses may occur when different combination drug products are taken together. Be aware of the acetaminophen content of all medications taken by the patient (OTC and prescription). Copyright © 2017, Elsevier Inc. All rights reserved.

Acetaminophen: Contraindications and Interactions
Should not be taken in the presence of: Drug allergy Liver dysfunction Possible liver failure G6PD deficiency Dangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic. Copyright © 2017, Elsevier Inc. All rights reserved.

Acetaminophen: Toxicity and Managing Overdose
Even though available OTC, lethal when overdosed Overdose, whether intentional or resulting from chronic unintentional misuse, causes hepatic necrosis: hepatotoxicity Long-term ingestion of large doses also causes nephropathy Recommended antidote: acetylcysteine regimen Copyright © 2017, Elsevier Inc. All rights reserved.

A patient with a history of heavy alcohol use needs a medication for pain. The recommended maximum daily dose of acetaminophen for this patient would be 1000 mg. 2000 mg. 3000 mg. 4000 mg. Correct answer: B Rationale: Chronic heavy alcohol abusers may be at increased risk of liver toxicity from excessive acetaminophen use. For this reason, a maximum daily dose of 2000 mg is generally recommended for these persons. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Herbal Products: Feverfew
Related to the marigold family Antiinflammatory properties Used to treat migraine headaches, menstrual cramps, inflammation, and fever May cause GI distress, altered taste, muscle stiffness May interact with aspirin and other NSAIDs, as well as anticoagulants Copyright © 2017, Elsevier Inc. All rights reserved.

Analgesics: Nursing Implications
Before beginning therapy, perform a thorough history regarding allergies and use of other medications, including alcohol, health history, and medical history. Obtain baseline vital signs and I&O. Assess for potential contraindications and drug interactions. Copyright © 2017, Elsevier Inc. All rights reserved.

Analgesics: Nursing Implications (Cont.)
Perform a thorough pain assessment, including pain intensity and character, onset, location, description, precipitating and relieving factors, type, remedies, and other pain treatments. Pain is now considered a “fifth vital sign” Rate pain on a 0 to 10 or similar scale Copyright © 2017, Elsevier Inc. All rights reserved.

Be sure to medicate patients before the pain becomes severe so as to provide adequate analgesia and pain control. Pain management includes pharmacologic and nonpharmacologic approaches; be sure to include other interventions as indicated. Copyright © 2017, Elsevier Inc. All rights reserved.

Patients should not take other medications or OTC preparations without checking with their physicians. Instruct patients to notify physician about signs of allergic reaction or adverse effects. Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Analgesics: Nursing Implications
Oral forms should be taken with food to minimize gastric upset. Ensure safety measures, such as keeping side rails up, to prevent injury. Withhold dose and contact physician if there is a decline in the patient’s condition or if vital signs are abnormal, especially if respiratory rate is less than 10 to 12 breaths/min. Copyright © 2017, Elsevier Inc. All rights reserved.

Opioid Analgesics: Nursing Implications (Cont.)
Check dosages carefully. Follow proper administration guidelines for IM injections, including site rotation. Follow proper guidelines for IV administration, including dilution, rate of administration, and so on. Copyright © 2017, Elsevier Inc. All rights reserved.

Constipation is a common adverse effect and may be prevented with adequate fluid and fiber intake. Instruct patients to follow directions for administration carefully and to keep a record of their pain experience and response to treatments. Patients should be instructed to change positions slowly to prevent possible orthostatic hypotension. Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for adverse effects Contact physician immediately if vital signs change, patient’s condition declines, or pain continues. Respiratory depression may be manifested by respiratory rate of less than 10 breaths/min, dyspnea, diminished breath sounds, or shallow breathing. Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for therapeutic effects Decreased complaints of pain Decreased severity of pain Increased periods of comfort Improved activities of daily living, appetite, and sense of well-being Decreased fever (acetaminophen) Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved.

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