COMPETENCY

APPRAISAL 2
RHENIER S. ILADO, RN, MNC
OUTLINE OF TOPICS
• PAIN
• PERIOPERATIVE NURSING
• FLUIDS AND ELECTROLYTE IMABALANCES
• RESPIRATORY DISORDERS
• CARDIOVASCULAR DISORDERS
• GASTROINTESTINAL DISORDERS
• ENDORCRINE DISORDERS
• HEMATOLOGIC DISORDERS
GRADING SYSTEM
• 35% QUIZZES
• 25% REPORTING
• 40% TERM EXAM
REPORTING ASSIGNMENT
CONTENT OF REPORT
• Descriptions
• Etiology & risk factors
• Simplified pathophysiology
• Diagnostic/laboratory findings
• Assessment findings & complication
• Collaborative management – Nursing, medical/surgical management
• references
PAIN MANAGEMENT
RHENIER S. ILADO, RN, MNC
LEARNING OBJECTIVES
• Differentiate between acute pain, chronic pain, and cancer pain.
• Describe the negative consequences of pain.

• Describe the pathophysiology of pain.

• Describe factors that can alter the perception of pain.

• Demonstrate appropriate use of pain measurement instruments.

• Explain the physiologic basis of pain relief interventions.

LEARNING OBJECTIVES
• Discuss when opioid tolerance may be a problem.

• Identify appropriate pain relief interventions for selected groups of

patients.
• Develop a plan to prevent and treat the adverse effects of opioid analgesic
agents.
• Use the nursing process
PAIN
• Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage (Merskey
& Bogduk, 1994)
• “Pain: The 5th Vital Sign” (Campbell, 1995)
• Calling pain the fifth vital sign suggests that the assessment
of pain should be as automatic as taking a patient’s blood
pressure and pulse.
TYPES OF PAIN
ACUTE PAIN
• Usually of recent onset and commonly associated with a
specific injury, acute pain indicates that damage or
injury has occurred.
• can be described as lasting from seconds to 6 months.
CHRONIC (NONMALIGNANT)
PAIN
• Chronic pain is constant or intermittent pain that
persists beyond the expected healing time
• seldom be attributed to a specific cause or injury.
• may be defined as pain that lasts for 6 months or longer
CANCER-RELATED PAIN
• Pain associated with cancer may be acute or chronic
• the second most common fear of newly diagnosed
cancer patients (Lema, 1997).
• can be directly associated with the cancer, a result of
cancer treatment (eg, surgery or radiation)
• a direct result of tumor involvement
PAIN CLASSIFIED BY LOCATION
• Pain is sometimes categorized according to location,
such as pelvic pain, headache, and chest pain.
• helpful in communicating and treating pain.
HARMFUL EFFECTS OF
PAIN
EFFECTS OF ACUTE PAIN
• Unrelieved acute pain can affect the pulmonary, cardiovascular,
gastrointestinal, endocrine, and immune systems
• The stress response (“neuroendocrine response to stress”)
occurs
• The stress response generally consists of
increased metabolic rate and cardiac output,
impaired insulin response,
increased production of cortisol, and
increased retention of fluids
EFFECTS OF CHRONIC PAIN
• Suppression of the immune function associated with
chronic pain may promote tumor growth
• often results in depression and disability
• Patients with a number of chronic pain syndromes
report depression, anger, and fatigue
• The patient may be unable to continue the activities and
interpersonal relationships
WHO three-step ladder approach to
relieving cancer pain.
PATHOPHYSIOLOGY OF
PAIN
PAIN TRANSMISSION
Nociceptors
• pain receptors
• involved in the transmission of pain perceptions to and
from the area of the brain
• free nerve endings in the skin that respond only to
intense, potentially damaging stimuli
Peripheral Nervous System
• Nociception - the transmission of pain
• Chemicals that increases transmission of pain - Histamine,
bradykinin, acetylcholine, serotonin, and prostaglandin
Two main types of fibers involved in the transmission of
nociception:
• Smaller, myelinated Aδ (A delta) fibers - transmit
nociception rapidly, which produces the initial “fast pain.”
• Type C fibers - are larger, unmyelinated fibers that transmit
second pain; This type of pain has dull, aching, or burning
qualities that last longer than the initial fast pain.
Peripheral Nervous System
• Chemicals that reduce or inhibit the transmission or
perception of pain include endorphins and enkephalins.
• These morphinelike neurotransmitters are endogenous
Central Nervous System
• Nociception to the spinal cord via the Aδ and C fibers
continues.
• Nociception continues from the spinal cord to the reticular
formation, thalamus, limbic system, and cerebral cortex
• pain to be consciously perceived, neurons in the ascending
system must be activated
• Activation occurs as a result of input from the nociceptors
located in the skin and internal organs
Descending Control System
• The Descending Control System - system of fibers that
originate in the lower and midportion of the brain and
terminate on the inhibitory interneuronal fibers in the dorsal
horn of the spinal cord.
• prevents continuous transmissionof stimuli as painful
• As nociception occurs, the descending control system is
activated to inhibit pain.
• Inhibitory interneuronalfibers - interconnections between the
descending neuronal system and the ascending sensory tract
Descending Control System
• The enkephalins and endorphins are thought to inhibit pain
impulses by stimulating the inhibitory interneuronal fibers,
which in turn reduce the transmission of noxious impulses via
the ascending system (Puig & Montes, 1998).
Descending Control System
• The classic Gate Control Theory of pain, described by Melzack
and Wall in 1965, was the first to clearly articulate the existence
of a pain-modulating system (Melzack, 1996).
• non-painful input closes the nerve "gates" to painful input,
which prevents pain sensation from traveling to the central
nervous system.
Descending Control System
• The noxious impulses are influenced by a “gating
mechanism.”
• Melzack and Wall proposed that stimulation of the large-
diameter fibers inhibits the transmission of pain, thus
“closing the gate.”
• Conversely, when smaller fibers are stimulated, the gate is
opened
Descending Control System
• The gate control theory was important because it was the
first theory to suggest that psychological factors play a
role in the perception of pain
• explain how interventions such as distraction and music
therapy provide pain relief.
Placebo Effect
• occurs when a person responds to the medication or
other treatment because of an expectation that the
treatment will work rather than because it actually does
so.
• receiving a medication or treatment may produce
positive effects.
• The placebo effect results from the natural
(endogenous) production of endorphins in the descending
control system.
NURSING ASSESSMENT
OF PAIN
CHARACTERISTICS OF PAIN
• factors to consider in a complete pain assessment are
the intensity, timing, location, quality, personal meaning,
aggravating and alleviating factors, and pain behaviors
Intensity
• The intensity of pain ranges from none to mild
discomfort to excruciating
• The reported intensity is influenced by the person’s pain
threshold and pain tolerance
• Pain threshold is the smallest stimulus for which a
person reports pain, and the tolerance is the maximum
amount of pain a person can tolerate.
Timing
• nurse inquires about the onset, duration, relationship
between time and intensity
• asked if the pain began suddenly or increased gradually.
• Sudden pain that rapidly reaches maximum intensity is
indicative of tissue rupture, and immediate intervention
is necessary
Location
• best determined by having the patient point to the area
of the body involved
Quality
• The nurse asks the patient to describe the pain in his or
her own words without offering clues
• describe what the pain feels like
Aggravating and Alleviating Factors
• The nurse asks the patient what if anything makes the
pain worse and what makes it better
• helps detect factors associated with pain
• Knowledge of alleviating factors assists the nurse in
developing a treatment plan
Pain Behaviors
• nonverbal and behavioral expressions of pain are not
consistent or reliable indicators of the quality or
intensity of pain, and they should not be used to
determine the presence of or the degree of pain
experienced
• Physiologic responses to pain, such as tachycardia,
hypertension, tachypnea, pallor, diaphoresis, mydriasis,
hypervigilance, and increased muscle tone, are related to
stimulation of the autonomic nervous system
 INSTRUMENTS FOR
ASSESSING THE
PERCEPTION OF PAIN
Visual Analogue Scales
• useful in assessing the intensity of pain.
• One version of the scale includes a horizontal 10-cm line,
with anchors (ends) indicating the extremes of pain.
• The person is asked to place a mark indicating where the
current pain lies on the line.
• The left anchor usually represents “none” or “no pain,”
whereas the right anchor usually represents “severe” or
“worst possible pain
Faces Pain Scale
• has seven faces depicting expressions that range from
contented to obvious distress.
• The patient is asked to point to the face that most
closely resembles the pain intensity felt.
NURSE’S ROLE IN PAIN
MANAGEMENT
NURSE’S ROLE IN PAIN
MANAGEMENT
• The nurse helps relieve pain by administering pain-
relieving interventions (including both pharmacologic
and nonpharmacologic approaches)
• assessing the effectiveness of those interventions,
monitoring for adverse effects, and
• serving as an advocate for the patient when the
prescribed intervention is ineffective in relieving pain
PAIN MANAGEMENT
STRATEGIES
PHARMACOLOGIC INTERVENTIONS
• Managing a patient’s pain pharmacologically is
accomplished in collaboration with the physician,
patient, and family
• The physician prescribes specific medications for pain or
may insert an intravenous line for administering
analgesic medications
• the nurse maintains the analgesia, assesses its
effectiveness, and reports if the intervention is
ineffective or produces side effects.
Premedication Assessment
• the nurse asks the patient about allergies to medications and the
nature of any previous allergic responses.
• The nurse obtains the patient’s medication history (e.g, current,
usual, or recent use of prescription or over-the-counter
medications
• Before administering analgesic agents, the nurse should
assess the patient’s pain status, including the intensity of current pain
changes in pain intensity after the previous dose of medication, and
side effects of the medication.
APPROACHES FOR
USING ANALGESIC
AGENTS
BALANCED ANESTHESIA
• Balanced analgesia refers to use of more than one form
of analgesia concurrently to obtain more pain relief with
fewer side effects
• Three general categories of analgesic agents are opioids,
NSAIDs, and local anesthetics.
• Using two or three types of agents simultaneously can
maximize pain relief while minimizing the potentially
toxic effects of any one agent
PRO RE NATA (PRN)
• the standard method used by most nurses and
physicians in administering analgesia was to administer
the analgesic pro re nata(PRN), or “as needed.”
• The standard practice was for the nurse to wait for the
patient to complain of pain and then administer
analgesia.
PREVENTIVE APPROACH
• considered the most effective strategy because a
therapeutic serum level of medication is maintained.
• analgesic agents are administered at set intervals so that
the medication acts before the pain becomes severe and
before the serum opioid level falls to a subtherapeutic level.
• Administering analgesic medication on a time basis, rather
than on the basis of the patient’s report of pain, prevents the
serum drug level from falling to subtherapeutic levels.
PREVENTIVE APPROACH
• Smaller doses of medication are needed with the
preventive approach because the pain does not escalate
to a level of severe intensity.
• In using the preventive approach, the nurse assesses the
patient for sedation before administering the next dose
INDIVIDUALIZED DOSAGE
• dosage and the interval between doses should be based
on the patient’s requirements rather than on an
inflexible standard or routine.
• one dose of an opioid medication given at specified
intervals may be effective for one patient but ineffective
for another.
• People metabolize and absorb medications at different
rates and experience different levels of pain
PATIENT-CONTROLLED ANALGESIA
• Used to manage postoperative pain as well as
chronic pain
• Patient-controlled analgesia (PCA) allows
patients to control the administration of their
own medication within predetermined safety
limits.
• A computerized pump controlled by patients by
giving small doses of pain medication via IV as
needed
 PATIENT-CONTROLLED ANALGESIA
• Typically an opioid medication is used in the pump
• One part of pain management after surgery
• A PCA pump is program to deliver a correct
amount of pain medication as prescribed by
anesthesiologist
• In pain, the patient may push the button in the
handset and small doses of medication is
delivered
 PATIENT-CONTROLLED ANALGESIA
• Patients who are controlling their own opioid
administration usually become sedated and stop
pushing the button before any significant
respiratory depression occurs.
• assessing respiratory status remains a major role
for the nurse.
Opioid Analgesic Agents
• Opioids can be administered by various routes, including oral,
intravenous, subcutaneous, intraspinal, intranasal, rectal, and
transdermal routes
• The goal of administering opioids is to relieve pain and improve
quality of life
• Factors that are considered in determining the route, dose, and
frequency of medication include
the characteristics of the pain (eg, its expected duration and severity),
the overall status of the patient,
the patient’s response to analgesic medications, and
the patient’s report of pain
Side Effects
• RESPIRATORY DEPRESSION AND SEDATION
• NAUSEA AND VOMITING
• CONSTIPATION
• INADEQUATE PAIN RELIEF
OTHER EFFECTS OF OPIOIDS
• Pruritus (itching) is a frequent problem associated with
opioids administered through any route, but it is not an
allergic reaction.
• Epidurally administered opioids may also cause urinary
retention or pruritus
• metabolism and excretion of analgesic medications will
be impaired in patients with liver or kidney disease,
increasing the risk of cumulative or toxic effects
OTHER EFFECTS OF OPIOIDS
• Patients with untreated hypothyroidism are more
susceptible to the analgesic effects and side effects of
opioids.
• hyperthyroidism may require larger doses for pain relief
• aging may be more susceptible to the depressant effects of
opioids and must be carefully monitored for respiratory
depression.
• Dehydrated patients are at increased risk for the
hypotensive effects of opioids
TOLERANCE AND ADDICTION
• Tolerance - the need for increasing doses of opioids to
achieve the same therapeutic effect, will develop in
almost all patients taking opioids over an extended
period
• Symptoms of physical dependence may occur when the
opioids are discontinued
• Addiction is a behavioral pattern of substance use
characterized by a compulsion to take the drug primarily
to experience its psychic effects
TOLERANCE AND ADDICTION
• Fear that patients will become addicted or dependent on
opioids has contributed to inadequate treatment of
pain.
• Addiction following therapeutic opioid administration is
so negligible that it should not be a consideration when
caring for the patient in pain
Nonsteroidal Anti-inflammatory Drugs
• NSAIDs are thought to decrease pain by inhibiting cyclo-
oxygenase (COX), the rate-limiting enzyme involved in
the production of prostaglandin from traumatized or
inflamed tissues
• There are two types of COX: COX-1 and COX-2.
• COX-1 is involved with mediating prostaglandin
formation; platelet aggregation and increased gastric
mucosal blood flow to promote mucosal integrity
Nonsteroidal Anti-inflammatory Drugs
• Inhibition of COX-1 will result in gastric ulceration,
bleeding, and renal damage.
• COX-2, mediates prostaglandin formation that results in
symptoms of pain, inflammation, and fever.
• inhibition of COX-2 is desirable
• Newer NSAIDs such as celecoxib (Celebrex), rofecoxib
(Vioxx), and valdecoxib (Bextra) are COX-2 inhibitors.
Nonsteroidal Anti-inflammatory Drugs
• Ibuprofen (Advil, Motrin), another NSAID, blocks both
COX-1 and COX-2 and is effective in relieving mild to
moderate pain and has a low incidence of adverse
effects.
• Aspirin, the oldest NSAID, also blocks COX-1 as well as
COX-2; however, because it causes frequent and severe
side effects, aspirin is infrequently used to treat
significant acute or chronic pain
Nonsteroidal Anti-inflammatory Drugs
• those with impaired kidney function may require a
smaller dose and must be monitored closely for side
effects
• . Patients taking NSAIDs bruise easily because NSAIDs
have some anticoagulant effect
• High doses or prolonged use can irritate the stomach
and in some cases result in gastrointestinal bleeding
Tricyclic Antidepressant Agents
and Anticonvulsant Medications
• Pain of neurologic origin (eg, causalgia) is difficult to treat
and in general is not responsive to opioid therapy
• pain syndromes are accompanied by dysesthesia (burning
or cutting pain), is more responsive to a tricyclic
antidepressant or an antiseizure agent.
• tricyclic antidepressant agents, such as amitriptyline (Elavil)
or imipramine (Tofranil), are prescribed
• The patient needs to know that a therapeutic effect may not
occur before 3 weeks
Tricyclic Antidepressant Agents
and Anticonvulsant Medications
• Antiseizure medications such as phenytoin (Dilantin) or
carbamazepine (Tegretol) also are used in doses lower
than those prescribed for seizure disorders
NONPHARMACOLOGIC
INTERVENTIONS
Cutaneous Stimulation and Massage
• The gate control theory of pain proposes that the
stimulation of fibers that transmit nonpainful sensations
can block or decrease the transmission of pain impulses
• Several nonpharmacologic pain relief strategies,
including rubbing the skin and using heat and cold, are
based on this theory.
• Massage, which is generalized cutaneous stimulation of
the body, often concentrates on the back and shoulders
Ice and Heat Therapies
• Proponents believe that ice and heat stimulate the non-pain
receptors in the same receptor field as the injury.
• assess the skin prior to treatment and to protect the skin from
direct application of the ice.
• Ice should be applied to an area for no longer than 20 minutes
at a time
• Long applications of ice may result in frostbite or nerve injury
• Application of heat increases blood flow to an area and
contributes to pain reduction by speeding healing
Transcutaneous Electrical Nerve
Stimulation (TENS)
• Transcutaneous electrical nerve
stimulation (TENS) uses a battery
operated unit with electrodes applied to
the skin to produce a tingling, vibrating, or
buzzing sensation in the area of pain
• used in both acute and chronic pain relief
and is thought to decrease pain by
stimulating the non-pain receptors in the
same area as the fibers that transmit the
pain
Distraction
• Distraction helps relieve both acute and chronic pain
(Johnson & Petrie, 1997).
• involves focusing the patient’s attention on something
other than the pain, may be the mechanism responsible
for other effective cognitive techniques
• Distraction is thought to reduce the perception of pain
by stimulating the descending control system, resulting
in fewer painful stimuli being transmitted to the brain.
Distraction
• Distraction techniques may range from simple
activities, such as watching TV or listening to music, to
highly complex physical and mental exercises.
• Visits from family and friends are effective in relieving
pain
Relaxation Techniques
• Skeletal muscle relaxation is believed to reduce pain by
relaxing tense muscles that contribute to the pain
• A simple relaxation technique consists of abdominal
breathing at a slow, rhythmic rate; patient may close
both eyes and breathe slowly and comfortably.
Guided Imagery
• Guided imagery is using one’s imagination in a special way to
achieve a specific positive effect.
• Guided imagery for relaxation and pain relief may consist of
combining slow, rhythmic breathing with a mental image of
relaxation and comfort
• The nurse instructs the patient to close the eyes and breathe
slowly in and out.
• With each slowly exhaled breath, the patient imagines muscle
tension and discomfort being breathed out, carrying away pain and
tension and leaving behind a relaxed and comfortable body
Hypnosis
• Hypnosis, which has been effective in relieving
pain or decreasing the amount of analgesic
agents required in patients with acute and
chronic pain
• Its effectiveness depends on the hypnotic
susceptibility of the individual
CRITICAL THINKING
SKILLS
SITUATION: A 45-year-old patient has just returned from the
postanesthesia care unit (PACU) after a laparoscopic
cholecystectomy. She has a history of rheumatoid arthritis for
which she takes celecoxib (Celebrex) 200 mg bid. She rates her
pain intensity from the recent surgery as a 6 (on a 0 to 10 scale)
and is complaining of severe pain in multiple joints.
1. Discuss the factors contributing to the pain that this patient is
experiencing.
2. What would be the best approach to manage her pain?
3. Analyze the effect of her rheumatoid arthritis and joint pain on
her postoperative pain and its management