Nursing: Pain Management

theory exam 3

pharmacological and nonpharmacological

intractable cancer‑related pain.

60 min

cognitive impairment,

who speak a different language than the nurse, or who receive prescribed mechanical ventilation.

Acute/chronic

chronic pain syndrome

(acute or chronic) or by origin ( nociceptive or neuropathic)

Acute pain

(sympathetic nervous system)are fight-or-flight responses (tachycardia, hypertension,anxiety, diaphoresis, muscle tension).

grimacing, moaning,flinching, and guarding.

treatment of the underlying problem

chronic pain if unrelieved

protective

Chronic pain

Physiological responses to chronic pain

can lead to disability

aims at symptomatic relief. Pain does not always respond to interventions.

malignant or nonmalignant

chronic pain

Idiopathic pain chronic pain
Strategies specific for relieving chronic pain include the

Administering long-acting or controlled-release opioid analgesics (including the transdermal route).● Administering analgesics around the clock rather than PRN.

nociceptors and causes pain.

Nociceptive pain

Somatic
Visceral
Cutaneous

Somatic

Visceral

Cutaneous

Neuropathic pain

Neuropathic pain

Neuropathic pain

Neuropathic pain

-Transduction
-Transmission
-Pain threshold
-Pain tolerance
-Perception or awareness of pain
-Modulation

Transduction

Transmission

Pain threshold

is the amount of pain a person is willing to bear

occurs in various areas of the brain, with influences from thought and emotional processes.

Modulation

Substance P● Prostaglandins● Bradykinin● Histamine

Serotonin● Endorphins

sharp, dull, aching, burning, stabbing,pounding, throbbing, shooting, gnawing,tender, heavy, tight, tiring, exhausting,sickening, terrifying, torturing, nagging,annoying, intense, or unbearable.

7 years old

Specialized pain scales are available for use with

subjective data

cultural and societal attitudes, lack of knowledge, fear of addiction, exaggerated fear of respiratory depression

infants, children, older adults, and clients who have substance use disorder

1. Trauma
2. Surgery
3. Cancer
4. Arthritis
5. Fibromyalgia
6, Neuropathy
7. Diagnostic or treatment procedures (injection, intubation, radiation)

-Age
-fatigue
-genetic sensitivity
-cognitive function
-prior experiences
-anxiety and fear
-support systems and coping styles
-culture

increase sensitivity to pain.

pain

pain or reportit accurately.

adequate relief

pain

decrease sensitivity to pain.

the meaning they give to pain.

Allodynia

Cognitive-behavioral measures

Cutaneous (skin) stimulation

Distraction

Relaxation

Imagery

Acupuncture and acupressure:

Elevation of edematous extremities

Analgesics are the mainstay for relieving pain. The three classes of analgesics are nonopioids, opioids, and adjuvants.

The parenteral route

4 g/day acetaminophen

salicylism (tinnitus, vertigo, decreased hearing acuity

non-opioids

Difficulty in falling asleep or staying asleep

a sleep disorder characterized by temporary cessations of breathing during sleep and repeated momentary awakenings

A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times.

a sufficient lack of restorative sleep over a cumulative period so as to cause physical or psychiatric symptoms and affect routine performance or tasks

Abnormal behaviors such as nightmares or sleepwalking that occur during sleep. kids with bedwetting or night terrors. safety is a major concern

pacemaker
tells the heart when to beat

■Drugs and substances-simple as Benadryl use
■Hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants
■Lifestyle, Work schedule, social activities, routines
■Usual sleep patterns
■Emotional stress- Worry, physical health, death, losses
■Environment- Noise, routines
■Exercise- Moderate exercise and fatigue cause a restful sleep
■Food and calorie intake-Time of day, caffeine, nicotine, alcohol

Sources for sleep assessment = Patient, family
Tools for sleep assessment

Questions used to assess sleep, identify problem areas and plan appropriate interventions

-Think fluid overload- SOB, crackles, BLE edema, Weight gain, low sodium diet
-Clients should monitor weights every am before breakfast!
-Common treatments are diuretics to manage fluid

-Think Stroke risk And blood thinner use

-Surgery
-Regurgitation-fluid overload

Diuretic

weight gain

skin break down

pneumonia
FACTORS AFFECTING MOBILITY

-Metabolic Changes
■Decreased rate of metabolism- Weight gain
-Calcium resorption
-Weakness
-Cognitive decline
-Decreased GI function
Factors Affecting Oxygenation

Decreased Oxygen Carrying Capacity:
-Pregnancy
-Obesity
-Neuromuscular Disease
-Trauma
-COPD

*Restlessness
*Agitation
*Confusion
*Dyspnea
*Increased HR
*Increased BP
*Diaphoresis
*Cyanosis
late stage:lathorgic

-positioning
-ambulation
-TCDB (turn, cough, deep breath)
-hydration
-suction
-incentive spirometry
-medications

-Purpose is to maintain a positive airway pressure and improve alveolar ventilation
-Continuous positive airway pressure (CPAP)
Bilevel positive airway pressure (BiPAP

-Think Safety! Open flames? Wool clothing with synthetic fibers?
-Tanks or wall-piped system, secure, tubing correct?
prevent or relieve hypoxia

Nasal cannula
Oxygen mask

immobility blood cots

blood clots

compression socks

ambulation

bipap
ambulation
cpap
exercise
deep breathing
pnumonia pt or respitory complication pts

sleep apnea

Immobilization can result from decline in medical or physical status due to illness, injury or surgery or can be used therapeutically to limit movement of body or part or restrict ambulation
-Muscleone atrophy/contractures
-Contractures
-Decubitus ulcers
-Constipation
-UTI
-Disuse osteoporosis
-Insomnia
-Renal calculi
-Deep vein thrombosis
-Pulmonary embolism
-Postural hypotension
-Pneumonia

provocative/palliative, quality, regionadiation, severity, timing

Used for direct and indirect contact with patients and their environment. Direct contact refers to the care and the handling of contaminated body fluids; Contact Precautions require a gown and gloves. An example includes blood or other body fluids
From an infected patient that enter the health care workers body Through direct contact with compromised skin or mucous menbrans. Indirect contact involves the transfer of an infectious agents
through a contaminated intermediate object such as contaminated instruments or hands of health care workers. The health care worker may transmit microorganisms from one patient site to another if
hand hygiene is not performed between patients.

Focus on diseases that are transmitted by large
droplets (greater than 5 microns) expelled into the air and by being
within 3 feet of a patient. Droplet Precautions require the wearing
of a surgical mask when within 3 feet of the patient, proper hand
hygiene, and some dedicated-care equipment. An example is a
patient with influenza.

Focus on diseases that are transmitted by
smaller droplets, which remain in the air for longer periods of time. Airborne Precautions require a specially equipped room with a negative airflow referred to as an airborne infection isolation
room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. For example, all health care personnel wear an N95 respirator every time they enter the room of a
patient with TB.

: Focuses on a very limited patient population, all of whom are highly susceptible to infection. This form of
isolation requires a specialized room with positive airflow. The air flow rate is set at greater than 12 air exchanges per hour, and all air is filtered through a HEPA filter. One example of a patient requiring a protective environment is a patient who received a kidney transPlant: The patient wears a mask when out of his or her room during transportation to x-ray.

diurectic

stroke on blood thinners is a possiblity

a) applies to all body fluids (except sweat), nonintact skin, and mucous membranes.
b) Hand hygiene using alcohol based waterless product is recommended after contact with client, body fluids, and contaminated equipment.
c) Alcohol-based waterless antiseptic is preferred unless hands are visible dirty, because alcohol based product is more effective in removing micro-organisms.

d) Clean gloves are worn when touching body fluids, nonintact skin, mucous membranes, and contaminated equipment
e) Gloves are removed and hand hygiene performed between each client.
f) Masks, eye protection, and/or face shield are required when care may cause splashing or spraying of body fluids.

g) Hand hygiene is required after removal of the gown. A sturdy moisture-resistant bag should be used for soiled items and the bag should be tied securely in a knot at the top.
h) All equipment used for client care is to be properly cleaned, one time use should be disposed accordingly.
i) Contaminated laundry should be bagged and handled to prevent leaking or contamination of clothing or skin

j) Safety devices on all equipment/supplies must be enabled after use; sharps must be disposed of in a puncture-resistant container
k) A private room is not needed unless the client is unable to maintain appropriate hygiene practices.

• Standard Precautions apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes.
• Perform hand rigiene before direct contact with patients, between patient contacts; after contact with blood, body fluids, secretions, and excretions and wit
equipment or articles contaminated by them; and immediately after gloves are removed.
• When hands are visibly soiled or contaminated with blood or body fluids, wash them with either a nonantimicrobial soap or antimicrobial soap and water.
• When hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub to perform hand hygiene.
• Wash hands with nonantimicrobial or antimicrobial soap and water if contact with spores (e.g., Clostridium difficile) is likely to have occurred.
• Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes.
• Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces. Remove and disr
of gloves and perform hand hygiene between patient care encounters and when going from a contaminated to a clean body site
• Wear PPE when your anticipated patient interaction is likely to involve contact with blood or body fluids.
A private room is unnecessary. Check with the infection prevention and control professional of your agency.
• Discard all contaminated sharp instruments and needles in a puncture-resistant container. Health care facilities must make needleless devices available. Activate
the mechanical safety device, if present. If needle recapping is necessary, use the one-handed scoop method and dispose of the capped needle as soon as possible
• Respiratory hygiene and cough etiquette: Have patients cover the nose or mouth when sneezing or coughing; use tissues to contain respiratory secretions and
dispose in nearest waste container; perform hand hygiene after contact with respiratory secretions and contaminated objects or materials; contain respiratory
secretions with procedure or surgical mask; sit at least 3 feet away from others if coughing.

Measles, chickenpox (varicella), disseminated herpes zoster,Mycobacterium tuberculosis, rubeola
Droplet Precautions(Droplets >5 um; being within 3 feet of

Influenza, adenovirus, group A streptococcus, Neisseria
meningitides, pertussis, rhinovirus, mycoplasma pneumoniae, pertussis, diphtheria, pneumonic plague, rubella, mumps, respiratory syncytial virus

Private room; negative-pressure airflow of at least
6-12 exchanges per hour via HEPA filtration; mast a
respiratory protection device, N95 respirator
Private room or cohort patients; mask or respirator

*private room or cohort client
*use a surgical mask when within 3 ft of client
*surgical mask on client when out of room.
mask or respirator
Contact Precautions
(Direct patient or environmental

Colonization or infection with multidrug-resistant organisms,
such as VRE and MRSA, Clostridium difficile, shigella and
other enteric pathogens, major wound infections, herpes
simplex, scabies, varicella zoster (disseminated), respiratory
syncytial virus

*private room or cohort client
*use of gloves and a gown whenever entering a client's room
*standard precautions as necessary

Allogeneic hematopoietic stem cell transplants

Private room; positive airflow with 12 or more air exchanges per hour; HEPA filtration for incoming air; mask to be worn by patient when out of room during times of construction in area

(Staphylococcus aureus, Escherichia coli,Mycobacterium tuberculosis)

Organisms that use the host's genetic machinery to reproduce (HIV, hepatitis, herpes zoster,herpes simplex virus [HSV])

Protein particles (new variantCreutzfeldt-Jakob disease)

Protozoa (malaria, toxoplasmosis) and helminths (worms [flatworms, roundworms], flukes [Schistosoma])

is the ability of a pathogen to invade andinjure a host

is a common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract.

restricts entry or immediately responds to a foreign organism (antigen) through the activation of phagocytic cells, complement, and inflammation. This occurs with all micro-organisms, regardless of previous exposure

Antibodies are produced by an external source.● Temporary immunity that does not have memory of past exposures● Intact skin, the body's first line of defense● Mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins● Inflammatory response with phagocytic cells, the complement system, and interferons to localize the invasion and prevent its spread

allows the body to make antibodies in response to a foreign organism (antigen). This reaction directs against an identifiable micro-organism.

antibodies that are produced in response to an antigen
-requires time to react to antigens
-provides permanent immunity
-involves B-and T-lymphocytes
-produces specific antibodies against specific antigens (IgA,IgD,IgE,IgG,IgM)

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

bacteria, virus, fungus, prion, parasite

(human, animal, food, organic matter on inanimate surfaces, water, soil, insects

from (means for leaving) the host● Respiratory tract (droplet, airborne): Mycobacteriumtuberculosis and Streptococcus pneumoniae● Gastrointestinal tract: Shigella, Salmonella enteritidis,Salmonella typhi, hepatitis A● Genitourinary tract: Escherichia coli, hepatitis A, HSV, HIV● Skin/mucous membranes: HSV and varicella● Bloodody fluids: HIV and hepatitis B and C● Transplacental

contact, droplet, air, vehicles, or vectorborne

Direct physical contact: Person to person◯ Indirect contact with an inanimate object:Object to person◯ Fecal-oral transmission: Handling food after using a restroom and failing to wash hands

Sneezing, coughing, and talking

sneezing and coughing

Animals or insects as intermediaries (ticks transmit Lyme disease, mosquitoes transmit West Nile and Malaria)

to the host: Might be the same as the portal of exit

Compromised defense mechanisms(immunocompromised, breaks in skin), leaving the host more susceptible to infections

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

incubation, prodromal, illness, convalescence

Inadequate hand hygiene (client and caregivers)● Individuals who have compromised health or defenses against infection, which include:◯ Those who are immunocompromised◯ Those who have had surgery◯ Those with indwelling devices◯ A break in the skin (the body's best protection against infection).◯ Those with poor oxygenation◯ Those with impaired circulation◯ Those who have chronic or acute disease (diabetesmellitus, adrenal insufficiency, renal failure, hepatic failure, or chronic lung disease)● Caregivers using medical or surgical asepsis that does not follow the established standards (11.2)● Clients who have poor personal hygiene or poor nutrition, smoke, or consume excessive amounts of alcohol, and those experiencing stress● Clients who live in a very crowded environment

Often occur in the intensive care unit.● The best way to prevent HAIs is through frequent and effective hand hygiene.● A common site of HAIs is the urinary tract and these are often caused by Escherichia coli, Staphylococcusaureus, and enterococci. Other sites of HAIs are surgicalwounds, the respiratory tract, and the bloodstream.● An iatrogenic infection is a type of HAI resulting from a diagnostic or therapeutic procedure.● HAIs are not always preventable and are not always iatrogenic.● Use current evidence‑based practice guidelines to prevent HAIs due to multidrug‑resistant organism

Fever◯ Presence of chills, which occur when temperature is rising, and diaphoresis, which occurs when temperature is decreasing◯ Increased pulse and respiratory rate (in response to the high fever)◯ Malaise◯ Fatigue◯ Anorexia, nausea, and vomiting◯ Abdominal cramping and diarrhea◯ Enlarged lymph nodes (repositories for "waste")

agitation, confusion, or incontinence) can be the only manifestations

redness (from dilation of arterioles bringing blood to the area)■ Warmth of the area on palpation■ Edema■ Pain or tenderness■ Loss of use of the affected part

In the second stage, the micro-organisms are killed. Fluid containing dead tissue cells and WBCs accumulates and exudate appears at the site of the infection. The exudate leaves the body by draining into the lymph system. The types of exudate are:■ Serous (clear).■ Sanguineous (contains red blood cells).■ Purulent (contains leukocytes and bacteria).

damaged tissue is replaced by scar tissue. Gradually, the new cells take on characteristics that are similar in structure and function to the old cells.

2 hr, or as prescribed

decreases the growth of organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movements and clearance and expanding lungs. exercises include turning, coughing, deep breathing, incentive spirometry.

Covering the mouth and nose when coughingand sneezing.◯ Using facial tissues to contain respiratory secretions and disposing of them promptly into a hands-free receptacle.◯ Wearing a surgical mask when coughing to minimize contamination of the surrounding environment.◯ Turning the head when coughing and staying a minimum of 3 ft away from others, especially incommon waiting areas.◯ Performing hand hygiene after contact with respiratory secretions and contaminated objects/materials

Isolation guidelines

isloation clients

-applies to all body fluids (excluding sweat), non-intact skin, and mucous membranes
-hand hygiene recommended after all contact and alcohol-based waterless product is preferred unless hands are visibly dirty; also required after removal of gown
-clean gloves are worn when touching all body fluids, non-intact skin, mucous membranes, and contaminated equipment/articles
-gloves removed and hand hygiene completed between each client
-masks, eye protection, and shields required when splashing or spraying of body fluid may occur
-gloves worn whenever touching anything that has potential to contaminate hands of the nurse
-sturdy, moisture resistant bag used for soiled items; contaminated laundry to be bagged and handled to prevent leaking; equipment for client care properly cleaned and one time use items disposed of
-safety devices on all equipment/supplies enabled after use and sharps disposed of properly
-private room not needed unless client is unable to maintain appropriate hygienic practices

Use airborne precautions to protect against

Private room
Masks and respiratory protection
Negative pressure airflow exchange in the room of at least 6 to 12 exchanges per hour. Examples: Measles, varicella, Turburculosis

Droplet precautions protect

A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment.● Masks for providers and visitors.● Clients who have a droplet infection should wear a mask while outside of the room/home

Contact precautions

Protective environment

- private room
- positive airflow 12 or more air exchanges/hr
- HEPA filtration for incoming air
- mask for client when out of room

Antipyretics (acetaminophen and aspirin

Antimicrobial therapy

educed fever,increase in the level of comfort, decreasing WBC count)

consistent therapeutic blood levels of the antibiotic.

the nurse takes precautions to ensure that the environment is not contaminated. For example, a surgical mask is placed on the client who has an airborne or droplet infection, and a draining wound is well covered.

-ensure appropriate medical treatment of disease
-monitor for common source outbreaks
-plan and evaluate control and prevention plans
-identify outbreaks and epidemics
-determine public health priorities based on trends