High-Acuity Nursing, 6th Edition

Acute Pain in the High-Acuity Patient Objectives: 1. Explain the multidimensional nature of pain. 2. Discuss issues related to the under treatment of pain. 3. Describe potential sources and effects of pain. 4. Assess acute pain in the high-acuity adult patient 5. Demonstrate effective management of pain for the high-acuity adult patient. 6. Perform focused assessments of the patient receiving opioid drug therapy to prevent opioid-induced respiratory depression. 7. Identify considerations associated with pain management in special populations. 8. Discuss the nursing management of patients undergoing procedural sedation populations. I. The Multifaceted Nature of Pain A. A working definition of acute pain 1. The International Association for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” 2. Differentiating nociception and pain. a) Nociception (1) Physiological response to tissue damage or injury b) Pain (1) Involves psychosocial as well as physiological responses to injury (2) Pain is a subjective experience (3) There is no test to prove its presence. (4) Patient’s report of pain must be believed. (5) Pain is real to that patient 3. Defining acute pain (1) Acute pain continually changing and transient. (2) Rapid onset and relatively brief duration (less than six months) B. A multifaceted model of pain 1. The multifaceted conceptualization of pain is based on the theoretical model by Loeser and Cousins (1990), which consists of four overlapping spheres: nociception, pain, suffering, and pain behaviors 2. The First Facet: Nociception—refers to the activation of special pain sensory receptors called nociceptors. Noxious (pain causing) stimuli that are mechanical, thermal, or chemical, activate nociceptors in the affected tissue. a) Transduction (1) Transformation of a noxious stimulus to a nociceptive impulse. (2) Begins in the peripheral nervous system and initiates the exchange of sodium and potassium across the neuronal membranes, causing depolarization. b) Transmission (1) Pain transmission refers to conduction of the pain impulse through the nervous system once a noxious stimulus has been transduced. (a) Adelta fibers are small in diameter and are myelinated, conducting pain impulses rapidly along the myelin sheath, causing sharp, pinprick-like pain to be conducted. (b) Are small in diameter but are usually unmyelinated, which results in a slow conduction rate and transmission of deep aching, throbbing sensations (2) Role of the central nervous system in transmission (a) Body has its own analgesia system that influences how each person reacts to pain. (i) Periventricular and periaqueductal gray (PAG) areas (ii) Raphe magnus nucleus (iii) Pain inhibitory complex (3) Sensitization (a) Peripheral sensitization (i) Can decrease the patient’s pain threshold, causing a repeated painful stimulus to be more intense and to prolong the duration of pain. (b) Central sensitization (i) Is the increased excitability of neurons in the CNS and is a complex abnormal response to a barrage of prolonged nociceptive activation. c) Modulation (1) The body’s attempt to modulate (altering) pain transmission in response to specific physiologic events, such as pain and stress. (2) Analgesic substances (endogenous opioid peptides) modulate pain transmission: (a) Enkephalins (b) Beta-endorphins (c) Dynorphin (d) Perception (3) Pain perception refers to the patient’s subjective experience surrounding the pain. 3. The second facet: Pain a) Pain impulses are transmitted to the brain along multiple pathways (dual pathy). b) Neospinothalamic and paleospinothalamic tract (1) Delta pain fibers primarily transmit thermal and mechanical pain. (2) Pain impulses travel along first-order neurons. (3) Upon reaching the lamina marginalis in the dorsal horn, the impulse excites second-order neurons and immediately crosses to the opposite side of the spinal cord. (4) Primarily terminates in a broad area of the brainstem. c) Person perceives pain only when (1) Transmission of the noxious stimulus terminates within the brain. d) Unknown whether the patient’s ability to perceive pain remains intact: (1) When cortical function is compromised; (2) When cortical function has been chemically altered. 4. The third facet: Suffering a) Negative affective response generated in higher nervous centers of the brain. b) Closely connected to the personal meaning of the pain. c) Clinician’s assessment is restricted to observing pain behaviors. d) Suffering is particularly associated with chronic pain. 5. The fourth facet: Pain behaviors a) Pain-expressing behaviors (1) Those that are intended to communicate pain b) Pain-controlling behaviors (1) Those that are intended to lessen or control the pain PowerPoint Slides 1. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” 2. Differentiating nociception and pain Nociception Physiological response to tissue damage or injury Pain Involves psychosocial as well as physiological responses. A subjective experience. No test to prove its presence. Patient’s report of pain must be believed. Is real to that patient. 3. The first facet: Nociception Transduction Transmission Modulation Perception 4. Pain conduction Impulses are conducted more quickly over large, myelinated nerves. A delta fibers: Conduct impulses rapidly (sharp, pinprick-like pain) C fibers: Slow conduction rate (aching, throbbing sensations) 5. Body’s analgesia system influences person’s reaction to pain. Periventricular and periaqueductal gray areas Raphe magnus nucleus Pain inhibitory complex 6. Sensitization to persistent stimulation Persistent peripheral pain. Persistent central pain can result in neuroplasticity. 7. Endogenous opioid peptides Analgesic substances modulate pain transmission: Enkephalins Beta-endorphins Dynorphins 8. The Second Facet: Pain: impulses are transmitted to the brain along multiple pathways Neospinothalamic tract Paleospinothalamic tract 9. The Third Facet: Suffering Negative affective response Closely connected to the personal meaning of the pain Clinician’s assessment is restricted Chronic pain 10. The Fourth Facet: Pain behaviors Pain-expressing behaviors Pain-controlling behaviors II. Acute Pain in the High-Acuity Patient A. Potential sources of pain 1. Potential sources of pain a) Acute pain of the initial insult. (1) e.g., traumatic injury, organ ischemia, surgical manipulation b) Invasive lines and tubes irritate delicate tissues. (1) E.g., chest tubes, intravenous lines, endotracheal and tracheostomy tubes c) Painful procedures. (1) E.g., lumbar puncture or endoscopic examinations d) Forced immobility can exacerbate chronic conditions. (1) E.g., back or arthritic pain B. Types of acute pain 1. Somatic pain a) Arises from stimulation of receptors in skin, muscle, joints, and tendons 2. Visceral pain a) Arises from stimulation of receptors in the viscera 3. Neuropathic pain a) Due to abnormal signal processing in the nervous system C. The effects of stress and pain on the body 1. Tissue injury, ischemia, metabolic, or chemical mediators, inflammation, or muscle spasm. 2. The stress response is crucial to self-preservation. It initiates events that increase the body’s chances of survival by minimizing organ damage. When the sympathetic nervous system is activated, blood vessels decrease perfusion in order to limit blood loss while optimizing circulation to vital organs. a) A high-stress response increases vascular shunting resulting in hypoperfusion of vital organs, b) Increases serum levels of endogenous opioid peptides resulting in counter-regulation of hormonal responses, 3. Immobility can cause stasis-related complications. a) Pulmonary complications (atelectasis and stasis pneumonia) (1) Source: thoracic surgery, abdominal surgery, or trauma b) Deep vein thrombosis (DVT) (1) Source: prolonged bed rest PowerPoint Slides 1. Potential sources of pain Acute pain of the initial insult Invasive lines/tubes irritate delicate tissues Painful procedures Forced immobility can exacerbate chronic conditions 2. The three major types of pain Somatic pain Visceral pain Neuropathic pain 3. Factors that can increase pain Anxiety that can accompany acute pain Stress associated with the hospital environment 4. A high-stress response Increases vascular shunting. Increases serum levels of endogenous opioid peptides. 5. Tissue injury is a strong stress response stimulus. Initial acute pain Prolonged pain 6. Immobility can cause stasis-related complications: Pulmonary complications Deep vein thrombosis (DVT) III. Pain Assessment A. Pain history 1. Pain history provides valuable information regarding: a) Preexisting pain experiences. b) Treatment modalities. c) Medication history. d) Usual pain behaviors. e) Usual pain relief methods used at home. B. Unidimensional and multidimensional pain assessment 1. Unidimensional Pain Assessment tools rate a single pain dimension (e.g., intensity), are especially useful in evaluating the effectiveness of interventions, are simple to use, and take little time to administer. a) Visual Analog Scale (VAS) (1) Effective measurement of pain intensity. (2) Line: one end labeled “no pain,” opposite end labeled “worst pain Imaginable.” (3) Patient self-reports the level of pain along this line (usually 10 cm). (4) The point is then converted to a numeric score. b) Numeric Rating Scale (NRS)) (1) Variation of the VAS. (2) Uses a sequence of numbers from which the patient chooses. (3) Most common and clinically proven NRS is the 0–10 scale. (4) 0 = “no pain” and 10 = “worst pain imaginable.” c) Verbal Descriptor Scales (1) Used to measure levels within any of the pain dimensions (2) Useful for older adults unable to rate their pain using numeric rating scales (3) Using a list, the patient chooses the adjective that best describes the pain: (a) E.g., sensory dimension adjectives—sharp, cutting, lacerating. (4) Potential disadvantages: (a) Careful choice of descriptor words is necessary. (b) Patients have a tendency to choose words from the middle. d) Wong-Baker Faces Scale (Faces) (1) Popular with both children and adults (2) Consists of six facial drawings ranging from smiling to crying (3) Each face is assigned a number from 0 to 5 or 0 to 10 (4) Patient points to the face that represents the current level of pain 2. Adapting the Unidimensional Pain Assessment Tool for the Severely Ill Patient Patients may be able to: a) Nod when a nurse points along a VAS to indicate the “point.” b) Point to the number on an NRS or to the location on the line of a VAS. c) Raise the number of fingers that indicate the level of pain: (1) 0 fingers = “no pain,” 10 fingers = “worst pain imaginable.” 3. Multidimensional Pain Assessment provides the patient with a means to expresses the affective and evaluative aspects of the pain experience. a) Most frequently used measurement of sensory and affective pain. b) Measures four aspects of pain experience: sensory, affective, evaluative, miscellaneous. c) Each pain category is measured using a cluster of descriptive words. d) Patient’s word choice determines from which category the pain is originating C. Assessment of pain in the adult with altered communication status 1. Assessing pain in adults with altered cognitive status: a) Use alternative pain assessment tools for those unable to self-report pain level. b) Patients rely on the nurse to advocate and intervene for them. c) Review of the patient’s medical history provides information. d) Sympathetic nervous system response also should be considered. e) Absence of physiologic indicators does not preclude pain. (1) Patients with chronic pain adapt to the stress response. (2) Pharmacologic interventions can prevent such change. 2. Nurses rely on their observations of behavioral cues, rather than on self-report tools. a) Nurses frequently subjectively interpret the patient’s self-report of pain. b) Nurses’ attitudes frequently alter the assessment of pain. c) This is an inappropriate use of the self-report tools. d) The patient might be using coping skills. e) The patient’s use of distraction and relaxation techniques can be misinterpreted. 3. Behavioral pain scales use patient behaviors (cues) to indicate the presence of pain. a) Vocal: crying, moaning, and grunting b) Facial: grimacing, crying expression (tears might be noted) c) Body posturing: agitation, stiffening, rocking, and tapping 4. Acute pain is associated with stimulation of the sympathetic nervous system response. a) Of value in assessing short-term acute pain b) Loses validity over time PowerPoint Slides 1. Pain history provides valuable information regarding: Preexisting pain experiences. Treatment modalities. Medication history. Usual pain behaviors. Usual pain relief methods used at home. 2. Unidimensional pain assessment tools Patient rates a single pain dimension (e.g., intensity) Especially useful in evaluating the effectiveness of interventions Simple to use, and take little time to administer 3. Multidimensional assessment tools Patient expresses the affective and evaluative aspects of the pain experience. Work best for patients with more complex pain (e.g., unknown origin, chronic). 4. Visual analog scale (VAS) Effective measurement of pain intensity. Line: one end labeled “no pain,” opposite end “worst pain imaginable.” Patient self-reports the level of pain along this line. The point is then converted to a numeric score. 5. Numeric rating scale (NRS) Variation of the VAS. Uses a sequence of numbers from which the patient chooses. Most common and clinically proven NRS is the 0–10 scale. 6. Verbal descriptor scales Used to measure levels within any of the pain dimensions. Useful for older adults unable to rate their pain using numeric rating scales. Using a list, the patient chooses the adjective that best describes the pain. Potential disadvantages. 7. Wong–Baker Faces Scale Popular with both children and adults Consists of six facial drawings ranging from smiling to crying Each face is assigned a number from 0 to 5 or 0 to 10 Patient points to the face that represents the current level of pain 8. Adapt the scale for the severely ill patient. Patients might be able to: Nod when a nurse points along a VAS to indicate the “point.” Point to the number on an NRS or to the location on the line of a VAS. Raise up the number of fingers that indicates the level of pain. 9. McGill Pain Questionnaire (MPQ) Most frequently used measurement of sensory and affective pain. Measures four aspects of pain experience. Each pain category is measured using a cluster of descriptive words. Patient’s word choice determines from which category the pain is originating. 10. Assessing pain in adults with altered cognitive status Use alternative pain assessment tools for those unable to self-report pain level. Patients rely on the nurse to advocate and intervene for them. Review of the patient’s medical history provides information. Sympathetic nervous system response also should be considered. Absence of physiologic indicators does not preclude pain. 11. Behavioral pain scales use patient behaviors (cues) to indicate the presence of pain. Vocal: crying, moaning, grunting Facial: grimacing, crying expression Body posturing: agitation, stiffening, rocking, and tapping 12. Acute pain is associated with stimulation of the sympathetic nervous system response. It is of value in assessing short-term acute pain. Use of the sympathetic response criteria loses validity over time. IV. Management of Acute Pain A. Pharmacologic pain management 1. The World Health Organization (WHO) analgesic ladder a) An organized, systematic approach to effective pain management b) Suggests general pain management choices based on the level of pain: (1) Mild, mild-to-moderate, or moderate-to-severe c) Provides step-by-step approach to adjusting pharmacologic choices 2. Pharmacologic pain management modulates pain transmission at different levels. a) Opioids bind with opioid receptors. b) NSAIDs can relieve pain by working peripherally at the site of injury. 3. Nonopioid therapy a) Pain management can be enhanced by a combination of opioid and nonopioid therapy. (1) Better level of analgesia is often achieved in combination. (2) Nonopioids include acetaminophen, aspirin, NSAIDs. (3) Nonopioids are associated with fewer side effects than are opioids. 4. Adjuvant therapy a) Adjuvant therapy includes drugs that can assist in reducing certain types of pain: (1) Indirect assistance (decrease other symptoms) (2) Direct assistance (as a coanalgesic) (3) Generally used in addition to opioid and nonopioid analgesics (4) Examples of adjuvant drugs include: (a) Corticosteroids for cancer-related pain. (b) Antidepressants or anticonvulsants for treatment of neuropathic pain. 5. Opioid therapy a) First decisions: specific opioid drug, route of administration b) Next decisions: suitable initial dose, frequency, use of nonopioid analgesics c) Note: Dosing needs and analgesic response vary greatly among patients. 6. Multimodal therapy a) Multimodal therapy (balanced analgesia) is a balanced approach to pain treatment. b) Targets multiple pain-signaling pathways, matching treatment to type of pain. c) Preemptive pain treatment is treatment initiated prior to surgery. (1) Goal of reducing postoperative hypersensitivity (sensitization) d) Takes advantage of additive (synergistic) effects of different analgesics. e) Most likely required to reduce opioid-related adverse effects. 7. Routes of administration a) Oral route is most commonly used for opioids (inexpensive, convenient) (1) Might not be available due to nothing-by-mouth status (2) Feeding tubes that act as an alternate medication route b) IV: When IV access is not possible, use rectal or sublingual routes (AHCPR guidelines). (1) Intravenous patient-controlled analgesia (PCA) (a) Patient can self-dose intravenously (push a button attached to infusion device). (b) Other forms: subcutaneous, intra-muscular, epidural. (2) Repeated use of subcutaneous and intramuscular routes is painful. (3) Avoids lag time between injection and absorption. c) Intraspinal opioids can be administered in a variety of ways: (1) Single-dose epidural or intrathecal (2) Intermittent scheduled-dose epidural or intrathecal (3) Intermittent patient-controlled epidural (PCEA) or intrathecal (4) Continuous infusion of opioid alone or in combination (5) Continuous infusion plus patient-controlled opioid alone or in combination (6) The epidural route (a) Insertion of a small catheter into the space located just before the dura mater. (b) An opioid, or a combination, is delivered using an infusion device. (c) Requires low doses of analgesic, whether administered alone or in combination. (d) Minimizes the potential for side effects. d) Intrathecal route (1) Passage of a small catheter into the cerebrospinal fluid (CSF) space. (2) Opioid flows through the CSF and rapidly binds to opioid receptors. (3) Smaller amounts of drug required to achieve same effects as epidural. (4) Methods: percutaneous catheters, implanted ports, implanted pumps. e) Peripheral Nerve Block (peripheral nerve path transmitting the pain is located) (1) Local anesthetic is injected medial to the point of pain origin. (2) Duration of the analgesia depends on the half-life of the local anesthetic. (3) Example: intercostal nerves medial to the insertion site of chest tubes. (4) Example: femoral nerve prior to total knee arthroplasty. f) Pleural infusion route used primarily when multiple rib fractures are present (1) Small catheter is placed into the pleural space, and a local anesthetic injected. (2) Multiple intercostal nerves can be blocked without repeated needle sticks. B. Nonpharmacologic interventions 1. Nonpharmacologic (complementary) interventions can be used concurrently. a) Identify effective alternative interventions to incorporate into the care plan. b) Patients respond individually to nonpharmacologic interventions to pain. PowerPoint Slides 1. World Health Organization (WHO) analgesic ladder An organized, systematic approach Choices based on the level of pain Provides step-by-step approach 2. Modulating pain—pharmacologic pain management Opioids bind with opioid receptors. NSAIDs working peripherally. 3. Combination therapy—pain management enhanced by combining opioid and nonopioid Better level of analgesia in combination. Nonopioids: acetaminophen, aspirin, NSAIDs. Nonopioids have fewer side effects than do opioids. 4. Adjuvant therapy drugs assist in reducing pain Indirect assistance (decrease other symptoms) Direct assistance (as a coanalgesic) Used in addition to opioids and nonopioids 5. Opioid therapy First decisions: specific opioid drug, route of administration Next decisions: initial dose, frequency, nonopioid analgesics Note: Dosing needs and analgesic response vary greatly 6. Multimodal therapy (balanced analgesia) Targets multiple pain-signaling pathways Preemptive pain treatment initiated prior to surgery Takes advantage of additive (synergistic) effects Reduces opioid-related adverse effects 7. Oral route is most commonly used for opioids. Might not be available due to NPO status. Feeding tubes act as alternate medication route. 8. Alternative routes of administration If IV access is not possible —> Use rectal or sublingual routes. Repeated use of sc and intramuscular routes is painful. Avoids lag time between injection and absorption. 9. Intravenous patient-controlled analgesia (PCA) Patient can self-dose intravenously. Other forms: sc, intra-muscular, epidural. 10. Intraspinal opioids can be administered: Single-dose epidural or intrathecal Intermittent scheduled-dose epidural or intrathecal Intermittent patient-controlled epidural or intrathecal Continuous infusion of opioid alone or in combo Continuous infusion plus patient-controlled opioid alone or in combo 11. Epidural route of administration Insertion of a small catheter. An opioid, or a combination, is delivered. Requires low doses of analgesic. Minimizes the potential for side effects. 12. Intrathecal route of administration Small catheter into the CSF space. Opioid flows through the CSF, binds to opioid receptors. Smaller amounts of drug to achieve same effects as epidural. Methods: percutaneous catheters, implanted ports, implanted pumps. 13. Peripheral nerve block Local anesthetic injected medial to point of pain origin. Duration depends on the half-life of the local anesthetic. 14. Pleural infusion route of administration used for multiple rib fractures Small catheter placed in the pleural space. Local anesthetic injected. Multiple intercostal nerves can be blocked. 15. Nonpharmacologic (complementary) interventions—used concurrently Identify effective alternative interventions. Patients respond individually. V. Issues in Inadequate Treatment of Acute Pain A. Undertreatment of pain 1. Undertreatment problem is multifactorial (social and health care system issues) a) Inadequate attention to pain education in many medical programs b) Clinical, human, and economic consequences of this shortcoming: (1) Altered immune system functioning (2) Diminished ability to function (3) Increased risk for chronic pain (4) Needless suffering (5) Higher health care costs B. Definitions 1. Definitions from AHCPR guidelines remain current. a) Tolerance: larger dose of opioid required to maintain same level of analgesia b) Physical dependence: physical adaptation of the body to the presence of opioids c) Psychological dependence (addiction): continued craving for an opioid d) Opioid pseudoaddiction: behaviors that mimic those associated with addiction (1) Results from inadequate pain management, not psychological Dependence. (2) Undertreated pain behaviors frequently are misread as drug seeking. (a) Demands for different or more pain medications that escalates (b) Clock watching (c) Preoccupation with obtaining pain medications (d) Anger (3) Resolution of aberrant behaviors when pain is relieved. C. Reasons for opioid undertreatment of pain 1. Oligoanalgesia—practice of treating pain with minimal drug use a) Physicians underprescribe opioids. (1) Prescribing subtherapeutic doses (2) Prescribing time intervals that are less than the duration of action b) Nurses undertreat pain. (1) Administering less than the physician orders (2) Administering at longer intervals than prescribed c) Patients contribute to their own undertreatment of pain. (1) Not requesting as-needed (PRN) pain medications (2) Taking medication at longer-than-ordered intervals (3) Taking less than the amount prescribed (4) Refusing to take the drug at all 2. Fear of addiction (psychological dependence). a) Probably the major cause of undertreatment of pain. b) Opiophobia: fear of prescribing/consuming adequate amounts of opiates. c) Very few hospitalized patients who receive opioids become addicted. d) Few patients who do develop addiction have a history of prior substance abuse. 3. Fear of physical dependence a) Fear associated with physical dependence. b) Many believe addiction is natural progression of dependence. c) Truth: some degree of withdrawal symptoms if opioid is suddenly stopped. d) These symptoms can be effectively managed. 4. Fear of tolerance a) Patients, physicians, nurses fear that opioids lose their effectiveness over time. b) Belief in an imaginary dose ceiling. (1) This feared dose ceiling does not seem to exist. c) Tolerance is treated by decreasing dose interval or increasing the dose. 5. Fear of respiratory depression a) Physicians and nurses fear respiratory depression. b) In the majority of hospitalized patients, it is not a significant problem. c) Nursing management: Focus on close observation of the patient’s response. (1) Sedation develops before respiratory depression. D. Nursing approach in acute pain management 1. Preventive approach- a) Analgesics are administered before the patient complains of pain. b) Maintain a consistent therapeutic level of analgesic in the bloodstream. c) Diminishes the likelihood of undertreatment of pain. 2. Titration approach a) Adjusting/individualizing therapy based on effects the drug is having (1) Rather than based on the milligrams being administered b) Goal: Gain the desired level of pain relief with minimum side effects c) Consider: dose, interval between doses, route of administration, and choice of drug PowerPoint Slide 1. Undertreatment of pain—a persistent challenge Multifactorial (social and health care system issues) Inadequate attention to pain education Consequences 2. AHCPR guideline definitions Tolerance Physical dependence Psychological dependence (addiction) Opioid pseudo addiction 3. Pseudo addiction Results from inadequate pain management, not psychological dependence. Undertreated pain behaviors are frequently misread as drug-seeking. Resolution of aberrant behaviors when pain is relieved. 4. Oligoanalgesia—practice of treating pain with minimal drug use Physicians underprescribe opioids. Nurses undertreat pain. Patients contribute to their own undertreatment of pain. 5. Fear of addiction (psychological dependence) Major cause of undertreatment of pain. Opiophobia. Very few become addicted. 6. Fear of physical dependence Fear associated with physical dependence. Many believe dependence leads to addiction. Truth: some degree of withdrawal symptoms 7. Fear of tolerance Patients, physicians, nurses fear opioids lose effectiveness. Belief in an imaginary dose ceiling. Tolerance treated by decreasing dose interval or increasing dose. 8. Fear of respiratory depression Physicians and nurses fear respiratory depression. In the majority, it is not a significant problem. Nurses should closely observe patient’s response. 9. Effective pain management—preventive approach Analgesics are administered before pain. Maintain a consistent therapeutic level. Diminishes likelihood of undertreatment of pain. 10. Effective pain management—titration approach Adjusting therapy based on effects the drug is having. Goal: Gain pain relief with minimum side effects. Consider: dose, interval, route, and choice of drug. VI. Monitoring for Opioid-Induced Respiratory Depression A. Assessment 1. Patient variables a) Age and disease or compromise b) History of obstructive sleep apnea (OSA) c) Body mass index (BMI) of greater than 30 kg/m2 d) Neck circumference of greater than 17.5 inches e) Impaired renal or hepatic function f) Neurologic disorder resulting in muscle weakness 2. Iatrogenic (therapy) variables a) Modality and level risk: (1) Lowest risk: Continuous epidural infusion (2) Moderate to high risk: Basal or continuous intravenous infusion b) Hospital environment variables: (1) Night shift patients admitted to units where nurses are unfamiliar with the patients’ needs. (2) A poor environment of care, such as poor nursing/management or nursing/physician communication, poor staffing and less education of nursing staff providing care. 3. Sedation assessment a) The nurse’s recognition of advancing sedation is a sensitive indicator of impending respiratory depression. b) Opioid analgesia depresses both respiratory effort and rate, relaxes pharyngeal tone and depresses the response to hypoxia and hypercarbia. (1) POSS and the RASS are valid and reliable tools for monitoring sedation assessment. 4. Use of technology in assessment a) Pulse oximetry: (1) Measures oxygen saturation in arterial blood and pulse rate. (2) Continuous monitoring of oxygen saturation has been recommended when initiating opioid analgesia for patients at high risk for opioid-induced respiratory depression in order to facilitate the identification of trends. b) Capnography: (1) EtCO2 monitoring has been shown to detect changes in ventilation (the exchange of air between the lungs and the atmosphere) earlier than pulse oximetry, which simply measures the oxygen saturation of hemoglobin. (2) Oximetry only measures oxygenation and EtCO2 only measures ventilation; therefore, to adequately reflect patient status, monitoring of both is necessary. B. Nursing interventions 1. The plan of care for patients at a higher risk for respiratory depression should include a greater frequency and intensity of monitoring. 2. Working collaboratively with the prescribing health care provider to consider the omission of, or dose decreases of other sedating agents may also be effective in reducing the risk of advancing sedation and respiratory depression. 3. Opioid Reversal Agent a) Naloxone (Narcan®), may be required if the patient develops severe respiratory depression. b) The half-life of naloxone is 30–81 minutes, which can result in an extended time during which the patient may be in extreme pain. c) The exact PCA opioid reversal protocol will be specified by the prescribing health care provider or agency policy. d) Sedatives and analgesics in large doses are frequently administered in the ICU and contribute to delirium, which is subsequently associated with longer hospital stay and decreased quality of life after discharge from the ICU. e) Decreasing the mean doses of opioids and sedative use was accomplished by individualizing the care of each patient. PowerPoint Slides 1. Assessment Patient variables Iatrogenic (therapy) variables Hospital environment variables 2. Sedation assessment. Nurse’s recognition Opioid analgesia POSS and the RASS 3. Use of technology in assessment Pulse oximetry. Capnography. EtCO2 monitoring. Oximetry only measures oxygenation, and EtCO2 only measures ventilation. 4. Nursing Interventions Greater frequency and intensity of monitoring Working collaboratively with the prescribing health care provider 5. Opioid reversal Agent Naloxone (Narcan®) PCA opioid reversal protocol Sedatives and analgesics in large doses Decreasing the mean doses of opioids and sedative use VII. Pain Management in Special Patient Populations A. Pharmacology and aging 1. Several important patient-focused factors influence acute pain management: a) Age b) Concurrent medical disorders c) History of substance abuse 2. Pharmacology and aging: a) Aging individuals vary greatly in capacity to absorb, metabolize, and excrete drugs. b) As a group, older adults are at greater risk for drug toxicity than are younger adults. c) Older adults tend to take more drugs—drugs might interact, producing symptoms. d) Older adults tend to have less body water and increased body fat. (1) Less body water causes high blood levels of water-soluble drugs. (2) Increased body fat causes prolonged effects of fat-soluble drugs. 3. Other age-related complicating factors. a) Short-term memory impairment can cause incorrect/missed/multiple doses. b) Impaired vision can lead to overdosage. c) Impaired agility in opening containers can cause missed doses. d) Financial factors and limited transportation can prevent filling prescriptions. 4. Considerations in obtaining a medication history—Ask about: a) Prescription and OTC preparations, OTC supplements. b) Alcohol, caffeine, and tobacco use. c) Home remedies B. Patients with concurrent medical disorders 1. Impaired function of liver and kidneys has serious implications for analgesic therapy. a) Analgesics are metabolized primarily in the liver. b) Kidneys have the major responsibility for opioid excretion. c) If either has decreased functioning, serum drug levels increase. d) Results: severe respiratory depression, deep sedation, and intractable nausea. e) Doses of most opioids must be reduced and the patient monitored closely. C. Management of the tolerant patient with superimposed acute pain 1. Management of the tolerant patient with superimposed acute pain. a) Long-term opioid therapy for chronic pain can result in opioid drug tolerance. b) Consider a patient’s home routine opioid dose as a baseline. c) Additional opioid is titrated to manage the incidence of acute pain. d) The continuous dose and the incremental dose can be slowly titrated upward. 2. Hyperalgesia a) Both the use of high dose opioids over a prolonged time and the effects of chronic pain on the CNS can produce a condition known as hyperalgesia. b) Characterized by increasing pain despite repeated upward titration of opioids. c) Increasing opioids only makes the pain worse. d) Treatment for hyperalgesia requires careful and appropriate detoxification when appropriate. D. The known active or recovering substance abuser as patient 1. An ethical code a) Pain management of an active/recovering substance abuser is a challenge. b) Treating pain in this population poses an ethical dilemma (“do no harm”). c) Should pain be treated using potentially addicting substances? (1) Experts in the fields of pain and addiction answer “Yes” d) All people, even substances abusers, have the right to pain relief. e) Relief of pain temporarily overrides the problem of addiction. f) Employ recommendations of experts, such as those developed by ASPMN. 2. Assessing opioid misuse or abuse a) Extremely difficult to differentiate drug-seeking from pain relief–seeking behaviors. (1) Pain relief–seeking and drug-seeking behaviors often are interchangeable. (2) Pseudoaddiction behaviors cease when pain relief is achieved. (3) Crucial to observe changes in behavior during pain relief interventions closely. b) Tools exist to determine the level of monitoring required preventing opioid abuse. (1) Opioid Risk Tool (ORT) (2) Screener and Opioid Assessment for Patients with Pain (SOAPP) E. Major considerations in pain management  1. Clinical management considerations a) Involve a multidisciplinary team b) Set realistic goals for therapy c) Evaluate and treat comorbid psychiatric disorders d) Prevent or minimize withdrawal symptoms e) Consider the impact of tolerance f) Apply appropriate pharmacologic principles to treat chronic pain g) Use a multimodal approach to treatment when possible h) Recognize specific drug abuse behaviors i) Use nondrug approaches as appropriate 2. Other clinical suggestions for treating an active/recovering substance abuser: a) Avoid analgesics that have the same pharmacologic basis as the abused drug. b) Choose extended-release and long-acting analgesics rather than short-acting. c) Restrict short-acting opiates for breakthrough pain. d) Avoid naloxone (will precipitate immediate opiate withdrawal). e) Administer analgesics orally rather than intravenously when possible. PowerPoint Slides 1. Several important patient-focused factors influence acute pain management: Age Concurrent medical disorders History of substance abuse 2. Pharmacology and the effect of aging Aging individuals vary greatly in capacity to absorb, metabolize, and excrete drugs. Older adults are at greater risk for drug toxicity. Older adults tend to take more drugs—might interact, producing symptoms. Older adults tend to have less body water and increased body fat. 3. Other age-related complicating factors Short-term memory impairment. Impaired vision can lead to overdosage. Impaired agility in opening containers can cause missed doses. Unfilled prescriptions. 4. Considerations in obtaining a medication history—Ask about: Prescription and OTC preparations, OTC supplements Alcohol, caffeine, and tobacco use Home remedies 5. Impaired function of liver and kidneys has serious implications for analgesic therapy. Analgesics are metabolized primarily in the liver. Kidneys have the major responsibility for opioid excretion. If either has decreased functioning, serum drug levels increase. Doses of most opioids must be reduced and the patient monitored closely. 6. The opioid-tolerant patient—management of the tolerant patient with superimposed acute pain. Long-term opioid therapy for chronic pain can result in drug tolerance. Consider a patient’s home routine opioid dose as a baseline. Additional opioid is titrated to manage the incidence of acute pain. The continuous dose and the incremental dose can be slowly titrated upward. 7. Pain management of an active/recovering substance abuser is a challenge. Treating pain in this population poses an ethical dilemma. Should pain be treated using potentially addicting substances? All people, even substances abusers, have the right to pain relief. Relief of pain temporarily overrides the problem of addiction. Employ recommendations of experts. 8. Extremely difficult to differentiate drug-seeking from pain relief–seeking behaviors. Pain relief–seeking and drug-seeking behaviors often are interchangeable. Pseudoaddiction behaviors cease when pain relief is achieved. Crucial to closely observe changes in behavior during pain relief interventions. 9. Tools exist to determine the level of monitoring required to prevent opioid abuse: Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients with Pain (SOAPP) 10. Clinical management considerations for treating active/recovering substance abuser: Involve a multidisciplinary team Set realistic goals for therapy Evaluate and treat comorbid psychiatric disorders Prevent or minimize withdrawal symptoms Consider the impact of tolerance Apply appropriate pharmacologic principles to treat chronic pain Use a multimodal approach to treatment when possible Recognize specific drug abuse behaviors Use nondrug approaches as appropriate 11. Other clinical suggestions for treating an active/recovering substance abuser Avoid analgesics that have the same pharmacologic basis as the abused drug. Choose extended-release and long-acting analgesics rather than short-acting. Restrict short-acting opiates for breakthrough pain. Avoid naloxone. Administer analgesics orally rather than intravenously when possible. VIII. Moderate Sedation/Analgesia A. Conscious sedation 1. Conscious (moderate) sedation is classified as “sedation level 2” (ASA). a) Used to induce relaxation with minimal variation in vital signs. b) Used when patient cooperation is needed for a procedure. c) Produced by administering pharmacological agents (IV). d) Patient has an altered level of consciousness. e) Patient maintains a patent airway and responds to stimuli. 2. Important to have a clear understanding of the different stages of consciousness. a) Clarification of terms leads to increased patient safety. b) Ramsey Sedation Scale assesses sedation in the intensive care unit. c) Sedation definitions have been outlined by JCAHO. B. Purpose of moderate sedation/analgesia 1. Purpose of conscious sedation a) Patient who is moderately sedated can tolerate uncomfortable procedures. b) Patient can breathe spontaneously, maintain airway, cough, swallow, etc. c) More types of procedures are being performed outside the operating room. C. Nursing management of the patient undergoing moderate sedation 1. Institutions providing conscious sedation abide by strict policies, guidelines, and protocols. a) Age-appropriate considerations b) Necessary equipment and supplies c) Mandatory education requirements d) Process for validating competency e) Interface with risk management and quality improvement f) Required documentation g) Rescue training (rescue patients who become unstable) 2. Before the procedure a) Before the conscious sedation procedure: b) Verify that the patient has given informed consent. c) Verify that the physician has explained the procedure to the patient. (1) E.g., medications, risks, benefits, adverse reactions, alternative treatments d) Do not leave the patient unattended or compromise continuous monitoring. e) Have knowledge of the legal liability of administering conscious sedation. f) Understand the principles of respiratory physiology. g) Have required equipment available. h) Have trained backup personnel readily available. 3. During the procedure. a) Continuously monitor oxygen saturation using pulse oximetry (SpO2). b) Monitor respiratory rate, BP, heart rate, rhythm, and level of consciousness. c) Capnometry is recommended, but is not mandated. 4. Post-procedure a) Post-procedure (after the conscious sedation procedure): b) Monitor the patient’s level of consciousness and vital signs. c) Assess pain, wounds, nausea, vomiting, intake/output, and neurovascular status. d) Patient might report amnesia, headache, hangover, or unpleasant memories. e) No patient should be sent to unsupervised area (e.g., X-ray) until recovered. (1) If it’s necessary for the patient to go, the nurse must accompany. D. Drugs used for moderate sedation 1. A wide variety of drugs is available for use to attain a state of conscious sedation. a) Etomidate b) Propofol c) Ketamine d) Fentanyl e) Midazolam 2. Medications that produce a state of sedation might not control pain. a) Often a combination of analgesics and sedatives is selected. b) These medications should be administered through separate intravenous lines. c) The patient’s level of pain should be assessed using a behavioral pain rating scale. d) Analgesics should be administered as indicated by the patient’s condition. E. Possible complications of moderate sedation 1. Deep sedation a) Deep sedation is a possible complication of conscious sedation. b) The nurse must be prepared to rescue a patient who progresses to deep sedation: (1) Manage a compromised airway. (2) Provide ventilation. c) Placing a call to the Rapid Response Team does not meet the standard. d) It is not acceptable to continue the procedure if the patient is oversedated. 2. Other possible complications a) Cardiopulmonary arrest b) Airway compromise c) Hypoxemia d) Aspiration e) Significant hypotension f) Significant brady-/tachycardia g) Prolonged sedation h) Death PowerPoint Slides 1. Conscious sedation is “sedation level 2” (ASA) Used to induce relaxation. Used when patient cooperation is needed. Produced by administering pharmacological agents. Patient has an altered level of consciousness. Patient maintains patent airway, responds to stimuli. 2. Different stages of consciousness Clarification of terms leads to increased patient safety. Ramsey Sedation Scale assesses sedation in the ICU. Sedation definitions. 3. Purpose of conscious sedation Patient can tolerate uncomfortable procedures. Patient can breathe, cough, swallow, etc. These types of procedures are increasing. 4. Institutions providing conscious sedation abide by strict policies, guidelines, and protocols. Age-appropriate considerations Necessary equipment and supplies Mandatory education requirements Process for validating competency Interface with Risk Management and Quality Improvement Required documentation Rescue training 5. Before the conscious sedation procedure: Verify the patient has given informed consent. Verify the physician has explained the procedure. Do not leave the patient unattended. Have knowledge of the legal liability. Understand the principles of respiratory physiology. Have required equipment available. Have trained backup personnel available. 6. During the conscious sedation procedure: Continuously monitor oxygen saturation. Monitor respiratory rate, BP, heart rate, LOC. Capnometry is recommended, but not mandated. 7. Post-procedure (after the conscious sedation procedure): Monitor the patient’s LOC and vital signs. Assess pain, wounds, nausea/vomiting, intake/output, and neurovascular status. Patient might report amnesia, headache, hangover, memories. No patient should be sent to unsupervised area until recovered. 8. A wide variety of drugs are available for conscious sedation Etomidate Propofol Ketamine Fentanyl Midazolam 9. Pain medication is also necessary. Medications that produce a state of sedation might not control pain. Often a combination of analgesics and sedatives needed. Medications administered through separate IV lines. Patient’s level of pain should be assessed. Analgesics should be administered. 10. Deep sedation is a possible complication of conscious sedation. Rescue a patient who progresses to deep sedation. Placing a call to 911 does not meet the standard. Do not continue procedure if patient is oversedated. 11. Other possible complications of conscious sedation Cardiopulmonary arrest Airway compromise Hypoxemia Aspiration Significant hypotension Significant brady-/tachycardia Prolonged sedation Death IX. Chapter Summary X. Clinical Reasoning Checkpoint XI. Post-Test XII. References Suggestions for Classroom Activities Read the original AHCPR guideline definition document. Discuss the AHCPR guideline definitions in detail for tolerance, physical dependence, psychological dependence (addiction), and opioid pseudoaddiction. Ask students if they have other ideas or thoughts on the undertreatment of pain, other than what was presented in this section. Ask students if any have personally experienced the undertreatment of pain—and who they believed was responsible (physician, nurse, themselves). Ask each student to take a few moments and write their definition of pain and then of pain management. Ask for student volunteers to discuss their impressions. What similarities and differences are found within the class? Suggestions for Clinical Activities Meet with a clinician who regularly treats pain. Ask about the four common misconceptions regarding opioid use that contribute to inadequate treatment: fear of addiction, of physical dependence, of tolerance, and of respiratory depression. Discuss how these fears play out in the actual clinical setting—how they present, how they are handled, how they are avoided, etc. Obtain the pain management policies for the clinical facility. Discuss the policy with the clinical group. What are the specific nursing responsibilities? Do the students feel they are seeing the guidelines in the policy upheld on a regular basis on the clinical unit? Wagner et al., Instructor’s Resource Manual for High-Acuity Nursing, 6th Edition ©2014 by Education, Inc.