Harmful Effects of Unrelieved Pain
Endocrine
increase ACTH, cortisol, ADH, epinephrine, norepinephrine, growth hormone, renin, catecholamines, angiotensin II, aldosterone, glucagon, and interleukin-1
can decrease insulin and testosterone
Step 1
educate the patient about the pain scale you will be using. show them the scale and explain it's purpose
Morphine dose
30 mg PO
10 mg parenteral
first line opioid for multiple routes
nonpharmacological interventions
cutaneous stimulation, massage
thermal therapies
guided imagery/hypnosis
music therapy
distraction
relaxation
alternative therapies
Acute pain
is protective
temporary, self-limiting, goes away when the tissue heals
will see a sympathetic response; tachycardia, hypertension, etc.
usually specific and localized
responds well to medications
Metabolic
gluconeogenesis
hepatic glycogenolysis
hyperglycemia
glucose intolerance
insulin resistance
muscle protein catabolism
increased lipolysis
Step 2
explain the parts of the scale. if they do not understand it, switch to a different scale
Fentanyl dose
100 mcg IV
is the first line opioid for: IV, transdermal, and intraspinal
distraction interventions
ambulation
deep breathing
visitors
TV
Chronic Pain
not protective
ongoing/recurs frequently; lasts longer than 3 months
may not see vital sign changes, but you may see fatigue, depression, and decreased functional ability
Cardiovascular
increase in HR, cardiac workload, peripheral vascular resistance, systemic vascular resistance, hypertension, coronary vascular resistance, and myocardial oxygen consumption
hypercoagulation
deep vein thrombosis
Step 3
discuss pain as a broad concept that is not restricted to a severe and intolerable sensation
Hydrocodone dose
30 mg PO
not often recommended; has to be used in combination with acetaminophen
relaxation interventions
meditation
yoga
progressive muscle relaxation
Gerontologic pain considerations
more likely to have adverse drug effects; they take a lot of other meds so they might have drug reactions
increased risk of toxicity; may need more time between doses or a reduced dosage amount
they may choose to tolerate acute pain because they are used to chronic pain
often express concern about getting addicted or their meds affecting their breathing
Respiratory
decreases flows and volumes
atelectasis, shunting, hypoxemia, sputum retention, infection, decreased cough ability
Step 4
verify that the patient understands the broad concept of pain. Maybe have them come up with two other examples of pain that they have experienced rather than thinking about what they are currently experiencing
Hydromorphone dose
7.5 mg PO
1.5 mg parenteral
Alternative therapy interventions
cutaneous stimulation (TENS)
heat/cold
therapeutic massage
acupuncture
Naloxone administration
emergency use only when RR<8
effects last 1 hr
need continued monitoring because the drug may last longer than naloxone and need a second dose
GI/GU
GI: decreased gastric and bowel motility
GU: decreased urinary output, urinary retention, fluid overload, hypokalemia
Step 5
ask the patient to attempt using the pain scale on either their current pain or one of their examples that they gave you
Oxycodone dose
20 mg PO
short acting
available in twice-daily oral formulations
Pharmacologic pain relief interventions
PRN medications; IV or PO
routine administration: ATC/preventive
PCA
local anesthetics
topicals, patches
intraspinal
Tolerance
a patient is no longer getting they effects they were getting from the same dose; they may need a larger dose to achieve the same effects because their body is getting used to the drug
tolerance develops in all patients who take opioids for prolonged periods
Musculoskeletal
muscle spasms
impaired muscle function
fatigue
immobility
Step 6
set goals for comfort
ask them about an acceptable pain score
consider possibly recovery activities needed
Oxymorphone dose
10 mg PO
1 mg parenteral
PCA pump
the patient pushes the button to administer pain medication; the idea is that since the patient is aware enough to be pushing the button, they can tolerate another dose
need 2 nurses to set it up
only the patient can push the button; can sometimes designate one other person
Dependence
they may show physical symptoms when it is discontinued; AKA their body has come to depend on it
Cognitive/psychological
reduction in cognitive function and mental confusion
sleep deprivation, increased risk for depression
Explain the hierarchy of pain measures
Attempt to get self report from the patient first, making sure to give them plenty of time to think and give you a proper answer. You can take in their condition and assume they are in pain. Observe for signs and symptoms of pain; possibly try to find a pain signature that is unique to them because these behaviors can tell you about their pain even if they are not good at verbalizing it. evaluate physiologic indicators; like vitals. (these are not always reliable) conduct an analgesic trial by administering a low dose of a nonopioid/opioid and see their response. you can then adjust the dose as needed
Morphine times
onset: 30 minutes PO, 5 minutes IV
peak: 60-120 minutes PO, 20 minutes IV
duration: 4-12 hrs PO, 4-5 hrs IV
Fentanyl times
onset: 5-15 minutes OT, 1-2 minutes IV
peak: 20-30 minutes OT, 3-5 minutes IV
duration: 2-5 hrs OT, 0.5-1 hr IV
Hydromorphone times
onset: 15-30 minutes PO, 10-15 minutes IV
peak: 30-60 minutes PO, 15-30 minutes IV
duration: 4-5 hrs PO, 2-3 hrs IV
General Use of opioids
use a multi-modal approach
use the least invasive route
titrate dose slowly: 25% is a slight increase, 50% is a moderate increase, 100% is a considerable increase
consider the previous dose before giving this one
assess for adverse effects; monitor for withdrawals in case you need to taper the dose