we're back it's time for chapter 10 in advanced Med search nursing nursing care patients in pain on page 120. the pain puzzle pain hurts and not just in a physical way it can make us feel emotionally sad or angry feel spiritually empty and lead to social isolation having pain is an experience that can affect every aspect of a person's being and how he or she functions in the environment pain management is the most common reason patients seek medical advice however despite the widespread nature of the problem and the millions of dollars spent on care pain often remains untreated or under treated nurses can make a difference in pain management nurses often worry about over-medicating patients and may think that they are doing good benefit beneficence or doing no harm non-malfeasance by withholding medication from a patient they do not believe is in pain see ethical considerations controlling pain in your in your online resources the questions then arise how can we know what pain is and how can we really tell when others are experiencing it definitions of pain according to McCaffrey 1968 a well-known pain management expert pain is whatever the experiencing person says it is existing whenever the experiencing person says it does this is a reminder to nurses to accept the patient's report of pain the International Association for the study of pain in 2017 describes pain in a bit more detail as an unpleasant sensory and emotional experience associated with actual or potential tissue damage and described in terms of such damage this definition indicates that pain is a complex problem that is not just physical in nature or always a result of tissue injury why does pain exist it is a protective mechanism or a warning in the presence of an injury pain may help to prevent further injury consider the patient who has a fracture and holds it still to prevent further damage or a child who touches a hot stove and pulls his or her hand away before a serious burn occurs the immediate pain that follows Burns surgery or other trauma to the body is referred to as acute pain acute pain prompts an inflammatory response in the body that subsides as healing takes place this type of pain is often associated with short-term objective physical signs such as increased heart rate and blood pressure as acute pain continues the physiological responses that accompany acute pain cannot be sustained without harm to the body as the body adapts Vital Signs return to normal when acute pain persists beyond the anticipated time of healing it is referred to as chronic pain chronic pain is typically diagnosed after a patient experiences three months or more of persistent pain examples include neck pain that continues years after an accident pain that accompanies diseases such as arthritis and Phantom limb pain because of the the body's ability to adapt patients with chronic pain may not appear to be in pain guard against labeling such a patient as a malingerer someone who pretends to be in pain or a drug seeker when pain is not treated effectively or lasts longer than expected suffering can occur suffering or feelings of continuous distress often accompanies pain in the study of suffering feral and Coyle concluded suffering is not synonymous with pain but it is closely associated with it physical pain is closely related to psychological social and spiritual distress pain that persists without meaning becomes suffering persistent pain can diminish patients quality of life it can make them feel as though their health is getting worse and take away their motivation for self-care suffering can often be relate relieved if patients believe they can achieve comfort a good assessment and individualized culturally responsive approaches to care increased the likelihood of comfort risks of uncontrolled pain why is untreated or under treated pain a bad thing complications can occur when pain is experienced the body produces a stress response to pain that causes harmful substances to be released from injured tissue reactions include breakdown of tissue increased metabolic rate impaired immune function and negative emotions in addition pain prevents the patient from participating in self-care activities such as walking deep breathing and coughing consider the patient who has had chest surgery and then has to cough and deep breathe it hurts pain may make the patient want to avoid coughing turning or even moving retained pulmonary secretions and pneumonia can develop if the patient is less active return of bowel function is delayed and an ileus which is a disruption of normal propulsive gastrointestinal activity can result when pain is well controlled complications can be avoided and patients can participate fully in recovery activities this will speed discharge as well as allow patients to do things that are meaningful and important to them when they get home pain and culture all individuals have learned patterns of behaviors beliefs and values that they share as members of a particular social group these cultural differences can affect responses to pain and expectations regarding treatment for example some patients may be dramatic and emotional when experiencing pain while others tend to be stoic and quiet be culturally responsive to the needs of patients by appropriately considering the unique attributes of the population you are working with also take time to understand the ways in which culture can affect a patient's Health choices and Care expectations be mindful of your patients language family engagement spirituality and treatment preferences see cultural considerations it is important to evaluate a patient's Pain Care needs individually in addition pay careful attention to the ethical principles that influence patient care rather than making assumptions based on culture alone who's the boss in Risk in pain management the patient is at the center of the health care team the patient also knows best how pain feels and affects him or her providing accurate information and offering relevant choices in pain management helps patients to maintain autonomy just as risks benefits and alternatives to surgery and anesthesia are discussed with the patient so too should pain management options be discussed in the process of obtaining informed consent it is important to learn as much as you can about pain and Pain Management so you can effectively advocate for your patients and help with patient education the entire Health Care team is responsible for pain management all members must provide care in the most cost effective manner possible while continuing to provide the best quality effective pain management helps to improve patient function and reduces costs by minimizing the side effects of opioids preventing complications related to inadequate pain control and reducing the link of hospital or nursing home stay or a period of recovery various regulatory bodies recognize the importance of good pain management many have Incorporated a review of organizational pain management practices into accreditation and review processes these standards support the importance of appropriate and effective management of pain they address assessment and the safe pharmacological management of pain as well as patient and family teaching post-operative pain management of opioid induced side effects discharge planning and process Improvement examples of these guidelines are available through the joint commission website and the centers for Medicare and Medicaid services website for information on pain management visit the following websites for some sites you may need to type in pain into the search window there is the agency for Health Care research and quality the American Cancer Society the American chronic pain Association the American Society for pain management nursing Centers for Disease Control and prevention geriatricpain.org and the World Health Organization cultural considerations pain experiences May differ among cultures and individuals of various geographical regions family structures and ethnic racial or religious groups remember that people within groups vary see chapter four cultural expression language assessment listen for words or phrases the patient uses to describe discomfort such as achy sore fire burning shooting or having a knot observe use of non-verbal pain cues such as moaning or crying furrowed eyebrows a clenched jaw guarding or rubbing of body parts and Fetal positioning ask the patient about any nonverbal pain cues you see use standardized pain assessment scales allow adequate time for the patient to respond to questions about pain use words the patient uses to discuss pain needs offer pain medications and interventions family engagement observe how involved the family is in the patient's care teach the patient's family how to monitor the patient's discomfort Engage The Family to help with distraction and relaxation techniques spirituality look for evidence of the patient's religious beliefs such as clothing jewelry religious books or literature clergy at the bedside and patient engagement in prayer or meditation ask the patient whether he or she uses religion or faith as a part of healing incorporate traditional healing methods as much as possible encourage the use of prayer meditation and relaxation as the patient desires offer and encourage pain medicines to promote healing support the patient's spiritual practices treatment preferences ask the patient how he or she usually treats pain at home ask the patient what he or she feels is needed to be comfortable incorporate traditional home remedies such as hot or cold packs or other and other practices as permitted incorporate distraction and relaxation techniques administer medication promptly as requested the care of patients with pain is challenging however with a systematic and holistic approach to assessment and treatment good pain management can be achieved in this chapter the difficulties of pain assessment and treatment are discussed some of the tools needed to effectively deal with these challenges are presented common myths and barriers that continue to affect nursing practice are clarified first myths and barriers to effective pain management this is the bottom of page 122. many factors including a nurse's personal experiences with pain influence how patients with pain are treated why are some patients not believed when they report pain why do some nurses and other health care team members insist that patients behave a certain way before they are believed common myths about pain can impair a nurse's ability to be objective this may create barriers to effective treatment because there are few objective measures for pain many nurses rely on assumptions rather than facts note the following myths myth a person who is laughing and talking is not in pain fact a person in pain is likely to use laughing and talking as a form of distraction this can be effective in managing pain especially when used with appropriate drug therapies patients may be more easily distracted when they have visitors and may ask for pain medication as soon as their family or significant other goes home myth respiratory depression is common in patients receiving opioid medications fact respiratory depression is uncommon in patients receiving opioid pain medications when medications are taken as prescribed if patients are monitored carefully when they are at risk such as with the first dose of an opioid or when a dose is increased respiratory depression is preventable a patient's respiratory status and level of sedation should be routinely monitored and recording you recorded using a level of sedation scale myth pain medication is more effective when given by injection fact oral Administration is the first choice if possible or whenever the intravenous IV route is not an option the IV route has the most rapid onset of action and is the preferred route for post-operative administration intramuscular injections are not recommended because they are painful have unreliable absorption from the muscle and have a lag time to Peak effect and Rapid fall off compared with oral Administration myth teenagers are more likely to become addicted to opioids than older patients fact addiction to opioids is uncommon in all age groups when taken for Pain by patients without a prior drug abuse history all patients using opioids should be monitored for medication effectiveness and taught how to appropriately discard unused medication myth pain is a normal part of aging fact although many older adults have medical conditions that cause pain pain is not a normal or anticipated part of aging and should be treated proactively effective pain treatment for older people helps them to maintain their Mobility longer and improve overall health critical thinking Mrs Smithers had an abdominal hysterectomy and is sitting up in bed in the morning after surgery putting on her makeup on morning rounds she's smiling but reports that her pain is at six on a scale of zero to ten Mr Brown has just been transferred from The Surgical Intensive Care Unit the day after surgery for multiple injuries he is moaning and reports his pain at a six on a scale of zero to ten number one which of these patients is really having as much pain as they say they are how can you make this judgment and I found the suggested answers at the end of the chapter on page 139 and I'm showing them on the left hand side of the screen it is important to accept both patients pain reports assessment should be based on what the patient says rather than what is observed each patient copes with his or her pain in a unique way and the nurse cannot judge whether one is in more pain than the other opioid addiction in 2015 alone more than 33 000 Americans died of opioid overdose according to the Centers for Disease Control and prevention a driving factor for the increasing numbers of opioid related deaths is misuse of prescription medications such as oxycodone hydrocodone and methadone understandably nurses often express concerns about patients who need large amounts of opioid pain medication or know exactly when their next dose of pain medication is due nurses May worry that such patients are addicted or that they are clock Watchers in truth if a patient is watching the clock or asking for more medicine the most likely reason is because he or she is in pain interestingly patients are commonly taught to know the name effects and dosage of other medications such as blood pressure medications and Insulin however when they ask for a specific analgesic by name concern that the patient is drug seeking is often raised addiction is something that many patients fear particularly today with increased media attention on opioid related deaths it is important to understand the difference between addiction tolerance and physical dependence when talking with patients and their families about opioid medications it is also important to verify that they understand these differences tolerance is a normal biological adaptation to long-term use of a drug the drug becomes less effective therefore a larger dose is required to provide the same level of pain relief physical dependence is a normal physiological response that most people experience after a week or more of continuous opioid use if an opioid is discontinued abruptly or if an opioid antagonist such as naloxone or Narcan is administered the patient can the patient experiences withdrawal syndrome withdrawal symptoms can include sweating tearing runny nose restlessness irritability Tremors dilated pupils sleeplessness nausea vomiting and diarrhea these symptoms can be prevented by decreasing the dose slowly over several days rather than stopping it suddenly according to the American Society of addiction medicine addiction also known as psychological dependence is a disease of the brain that causes the compulsive pursuit of a substance or behavior to obtain reward or relief from craving addiction is characterized by poor control over drug use craving reduced recognition of problem behaviors and continued use despite harm patients with uncontrolled pain who desire treatment are not addicts sadly patients with a history of addiction are more likely to have poor pain control due to medication tolerance and health care provider bias careful assessment and monitoring of treatment are essential for all patients receiving treatment for pain particularly patients who are prescribed opioid analgesics pseudoaddiction has been described in patients who are receiving opioid doses that are too low or spaced too far apart to relieve their pain behavioral characteristics resembling psychological dependence such as drug-seeking behaviors develop in an attempt to get pain needs met in contrast to the addicted patient a patient with pseudo-addiction stops drug seeking behaviors when the pain is reduced to a tolerable level critical thinking Janet is hospitalized with pancreatitis and has severe abdominal pain she has a history of intravenous IV drug abuse she is receiving IV morphine every three hours two hours after her last dose she puts on her call light and says she is in severe pain which she rates as 15 on a scale of 0 to 10. you feel that you have given her enough morphine to kill a horse yet she keeps requesting more number one how is it possible for Janet to be in pain when she is receiving so much morphine and the answers are the back of the chapter and also on the left side of the screen remember pain is whatever the experiencing person says it is existing whenever the experiencing person says it does you must assume that Janet is in pain she has pancreatitis which is commonly very painful she has a history of IV drug abuse and is likely tolerant to the effects of the morphine she may be experiencing end of dose failure when pain medication does not last as long as expected if her vital signs are within normal limits it should be safe to treat her pain number two it's not time for medication what for more medication what should you do contact the registered nurse RN or health care provider to explain the problem making Janet wait another hour in pain is not appropriate number three you speak to the health care provider who prescribes acetaminophen Tylenol one thousand milligrams for breakthrough pain between morphine doses when you take it to Janet she rolls her eyes and says You must be kidding me how do you respond Tylenol Works differently from morphine and may offer minimal relief but is not an appropriate order for severe pain talk to the RN or supervisor and explain the situation number four what communication with Janet is important at this time listen to Janet and let her know that you understand she is in pain keep her updated at all times and assure her that you will continue to advocate for her until she receives adequate pain relief mechanisms of pain transmission pain is transmitted through four distinct processes one transduction represents the initiation of the stimulus and conversion of that stimulus into an electrical impulse at the time of the injury chemical neurotransmitters are released from damaged tissue these substances produced I mean include prostaglandins Brady Cannon serotonin and substance p number two transmission is the process of moving a painful message from the peripheral nerve endings through the dorsal root ganglion and the ascending tract of the spinal cord to the brain perception is actually feeling pain during perception the hypothalamus activates which controls emotional input and generates purposeful goal-directed Behavior meanwhile the cerebral cortex receives the pain message four modulation is the body's attempt to interrupt pain impulses by releasing endogenous or naturally occurring opioids endorphins are endogenous chemicals that act like opioids inhibiting pain impulses in the spinal cord and brain endorphins are the chemicals that stimulate the long distance Runners High Unfortunately they degrade too quickly to be considered effective analgesics and kefalins are one type of endorphin pain transmission nociceptive or neuropathic pain transmission can be nociceptive and neuropathic nociception refers to the body's normal reaction to noxious stimuli such as tissue damage with the release of pain producing substances no susceptive pain may be somatic or visceral somatic pain is localized in the muscles or bones patients can often point to the exact location of pain and will describe it as throbbing or aching cancer patients may experience somatic pain when the cancer has spread to the Bone or a tumor has invaded soft tissue visceral pain or organ pain is not well localized and is often described as cramping or pressure bowel obstructions and tumors in the lung can cause visceral pain symptoms pain may also be felt in parts of the body away from the pain Source such as low back or flank pain that often accompanies a bladder infection this is called referred pain figure 10.1 neuropathic pain is associated with injury to either the peripheral or central nervous system unlike no susceptive pain neuropathic pain is poorly localized and may involve other areas along the nerve pathway neuropathic pain is common in cancer patients following chemotherapy or radiation therapy it also occurs in patients who have fibromyalgia diabetic neuropathy and shingles the pain is often described as numbing tingling sharp shooting or shock-like options for treatment of pain medications that relieve pain are called analgesics analgesics make up the largest piece of the pain management puzzle they Encompass three main classes of medication opioids non-opioids and adjuvants opioids bind to opioid receptors in the brain spinal cord and other areas of the body inhibiting the perception of pain non-opioids include non-steroidal anti-inflammatory drugs NSAIDs and acetaminophen Tylenol adjuvants are different from opioid and non-opioids in that they include categories of medications that were originally approved by the Food Drug Administration for purposes other than pain relief for example depression some patients may require a combination of opioids adjuvants and NSAIDs to effectively manage their pain nurses should have a good understanding of these pharmacological treatment options non-opioid analgesics non-opioids are typically the first class of drugs used to treat mild pain they can be useful for acute and chronic pain from a variety of causes such as surgery trauma arthritis and cancer these drugs are limited in their use because they have a ceiling effect to analgesia a ceiling effect means that there is a dose Beyond which there is no improvement in the analgesic effect but there may be an increase in adverse effects when used with opioids the non-opioid dose must not exceed the maximum safe dose for a period a 24-hour period for example if a patient is receiving two acetaminophen hydrocodone Norco tablets every four hours continues to experience pain the dose cannot be increased because of the potentially toxic effects of acetaminophen at that dosage see table 10.1 for side effects and nursing implications non-opioids do not produce tolerance or physical dependence non-opioids work mainly peripherally at the site of injury rather than in the central nervous system as opioids do the exception in this class is acetaminophen which is believed to act on the central nervous system NSAIDs block the synthesis of prostaglandins one of many chemicals needed for pain Transmission in general it is helpful to include a non-opioid agent in any analgesic regimen even if the pain is severe enough to require the addition of an opioid table 10.1 analgesic and adjuvant agents medication class slash action non-opioids salicylates are peripherally acting analgesics they reduce pain fever and inflammation examples include aspirin nursing implications give with food in decrease platelet aggregation watch for bruising or bleeding with the salicylates non-steroidal anti-inflammatory drugs or NSAIDs are peripherally acting analgesics to reduce pain fever and inflammation examples are ibuprofen or Motrin ketorolac or Toradol naproxen or not no naprosen or Aleve nursing implications also give with food and watch for bleeding because they this decreases the platelet aggregation do not give keto relax for longer than five days Cox II Inhibitors reduce pain and inflammation with no effect on platelet aggregation examples are celecoxib or Celebrex nursing implications give with food acetaminophen relieves pain and fever no anti-inflammatory or anti-platelet effect examples acetaminophen or Tylenol also called affirmative nursing implications maximize safe dose maximum safe dose is 4 grams per day less for those who use alcohol be aware that other drugs contain acetaminophen such as cold remedies to prevent accidental overdose opioid and opioid combination agents bind opioid receptors in the central nervous system to alter perceptions of pain examples are codeine which is in Tylenol number one two three and four fentanyl also called sublimase and duragesic hydromorphone also called Dilaudid and exilego methadone also called dolophene morphine also called Ms ir and MS Contin there's oxycodone that goes by the name Oxy IR and oxycontin cotton hydrocodone or slash acetaminophen is called Norco also Lortab to pentadol is also called Nucynta and nucin to ER nursing implications may be combined with non-opioid for example acetaminophen monitor Vital Signs level of sedation and respiratory status avoid fentanyl patch in patient with fever heat increases absorption encourage fluids and fiber to prevent constipation codeine is contraindicated in pediatric patients never Crush extended release tablets adjuvant agents corticosteroids toxic to some cancer cells reduce pain by decreasing inflammation examples are prednisone prednisolone methylprednisolone and dexamethasone nursing implications for the corticosteroids are to administer with food benzodiazepines treat anxiety or muscle spasms associated with pain examples my my midazolam or versed diazepam or Valium nursing implications these can cause sedation which limits the amount of opioid that can safely be given at the same time as the benzodiazepine tricyclic antidepressants help relieve neuropathic pain examples include amitriptyline emipramine desipramine and Doxepin nursing implications often cause anticholinergic side effects for example sedation constipation blurred vision dry eyes and urinary retention serotonin norepinephrine reuptake inhibitor effective for nerve pain and depression examples are Duloxetine or Cymbalta nursing implications may take weeks before effect seen teach patient to continue the medication even if it seems ineffective at first anti-convulsants treat neuropathic pain examples are carbamazepine or tagritol and Gabapentin also called Neurontin nursing implications must be taken regularly to get the full benefit opioid analgesics opioids are drugs that have actions similar to those of morphine opioids are classified by how they affect receptors in the nervous system they may be full agonists or stimulators partial agonists mixed agonists or antagonists or blockers full agonists have a complete response at the opioid receptor site a partial Agonist has a lesser response a mixed Agonist or an antagonist activates one type of opioid receptor while blocking another morphine a full Agonist is often the drug of choice for treating severe pain it is the standard against which all other analgesics are compared sea table 10.4 for equiano's G6 doses of medications morphine is long-acting four to five hours and available in many forms making it convenient and affordable for patients it also has a slower onset than many other opioids other examples of opioids include controlled release drugs such as oxycodone or Oxycontin hydrolorphone or Dilaudid or exalgo and to pentadol also called Nucynta ER which are effective for prolonged continuous pain be safe never crush a controlled or time release tablet because the tablet is designed to deliver a dose of medication over time crushing it could deliver the entire dose at once resulting in an overdose opioids alone have no ceiling effect to analgesia this means that doses can be can safely be increased to treat worsening pain if the patient's respiratory status and level of sedation are stable however inappropriate prescribing can lead to hyperalgesia or increased sensitivity to pain patients with hyperalgesia have pain at the slightest touch such as the moving of sheets and require further medical intervention institutions must have policies and procedures in place related to opioids to prevent medication errors and reduce the risk of serious side effects other common side effects include confusion and fatigue which can increase a patient's risk for Falls sea table 10.1 for additional information and adverse effects of opioids although opioids are important in pain management they are also on a short list of high alert drugs that can harm or even kill patients if they are not administered carefully institutions must have policies and procedures in place related to opioids to prevent medication errors and reduce the risk of serious side effects it is especially important to be vigilant for side effects in patients unaccustomed to opioids such patients are sometimes called opioid naive nursing care tip be vigilant for side effects in patients unaccustomed to opioids particularly constipation patients taking opioids for three days or more should be on bowel management programs that include a stimulant laxative such as Senna also called Ex-Lax or Senokot in cases of severe constipation the health care provider May prescribe a laxative specifically for opioid-induced constipation such as naloxygel also called movantic or methylnotrexone also called realistor opioids are added to non-opioids for pain that cannot be managed effectively by non-opioids alone the use of a centrally acting opioid with a peripherally acting non-opioid can increase pain relief and reduce the amount of opioid needed control release opioids such as oxycodone or Oxycontin and Morphine also called MS Contin are effective for prolonged continuous pain whenever a control release form of medication is used it is important to have an immediate release medication available for breakthrough pain for example transient pain that arises during generally effective pain control such as oral morphine solution oxycodone immediate release which is Oxy IR or Hydro more phone immediate release Dilaudid table 10.2 equino analgesic chart morphine 5 milligrams is the parenteral dose and the oral dose is 15 milligrams for codeine the parenteral dose is only 60 milligrams while the oral dose is 100 milligrams for hydromorphone the parental dose is 1.5 while the oral dose is 4 milligrams for Methadone the parental dose is five milligrams and the oral dose is 10 milligrams for myperidine The Perennial dose is 50 milligrams and the oral dose is 150 milligrams for Oxycodone there is no parenteral dose but the oral dose is 10 milligrams note approximate doses of medications and milligrams to equal the same amount of pain relief between drugs or the same drug different route so these are all have the equivalent amount of pain relief relatively speaking consult pharmacist and health care provider before changing drugs or routes critical thinking Mrs Zales a 32 year old woman is admitted for a hysterectomy after being treated for painful endometriosis for 12 months after her surgery she has a patient controlled analgesia PCA pump with Hydromorphone which is effective in relieving her pain 48 hours after surgery the surgeon discontinues the PCA pump and orders oral hydrocodone with acetaminophen it is ineffective so an order is added for hydromorphone 2 milligrams orally every three to four hours as needed the nurse gives only one dose of the Hydromorphone and then thinking that her pain should be lessening switches Mrs Zales back to the hydrocodone with acetaminophen by the next morning Mrs Zales is in severe pain the on-call health care provider orders intramuscular liparidine Mrs Zales discharge is delayed until her pain can be controlled what do you think happened number one Mrs Zales may have been tolerant to opioids because of her need for medication for chronic pain during the past year for this reason she needed more medication than a non-tolerant patient who does not usually use opioids intramuscular injections are not recommended because they are painful absorption is not predictable and there is a delay between injection and relief a more rational approach to Mrs Zale's pain management would have been regular pain assessment with around-the-clock treatment until the pain began to subside and a recommendation to the hcp to switch meperidine to IV hydromorphone number two how could the delayed discharge have been avoided if her pain level had been better controlled she might have been discharged on oral analgesics without the delay number three who were the important team members in this scenario the most important team member here was Mrs Zales the patient should be at the center of the team if she had listened to more if she had been listened to more carefully and her history considered she might have been kept more comfortable reperidine or Demerol was at one time a commonly used synthetic opioid but it is no longer recommended in most cases meperidine is an opioid Agonist when broken down in the body it produces a toxic metabolite called normoperidine normaperidine is a cerebral irritant that can cause adverse effects ranging from dysphoria and irritable mood to seizures more uh Norma paradine has a long Half-Life even in healthy patients so those with impaired kidney function are at increased risk the paradine use should be avoided in patients over age 65. patients within impaired kidney function and patients taking a monoamine oxidase inhibitor m-a-o-i antidepressants in general the use of meperidine should be limited to young healthy patients who need an opioid for a short period and to those who have unusual reactions or allergic responses to other opioids the effective dose of oral Metro maperidine is three to four times the peril uh parental dose and is never recommended fentanyl can be given parental relief or intraspinally called sublimase or by transdermal patch called duragesic fentanyl is commonly used with IV with anesthesia for surgery it also is used to relieve post-operative pain via IV patient-controlled analgesia pump or epidural discussed later in this chapter IV fentanyl has a short duration of action and must be given more often than other opioids to maintain an effective level of analgesia the transdermal fentanyl patch is useful for a patient with stable chronic pain the patch lasts 48 to 72 hours after application critical thinking Mrs Shepherd is 92 years old and has undergone an open cholecy suspectomy her continuous epidural infusion of analgesic is discontinued at 1400 or 2 in the afternoon on the second day the second post-operative day the health care provider orders oral acetaminophen with hydrocodone every three to four hours as needed for pain at 1700 Mrs Shepard refuses to get out of bed because her pain is seven on a scale of zero to ten the nurse checks the medication administration record and notes that she has not yet received a dose of acetaminophen and hydrocodone number one why is Mrs Shepherd in so much pain and the answers are found at the end of the chapter and on the left side of the screen pain medication is most effective when given on a routine schedule around the clock to avoid breakthrough pain this is Shepherd's epidural infusion should continue to relieve her pain for a time up to several hours after it is discontinued depending on the medication used the oral medication is most effective when given at the time the epidural is stopped so that it is taking effect as the epidural effects wear off see gerontological issues for special considerations for the older patients number two What complications can occur as a result of her pain prevents patients from moving freely post-operative complications such as retained pulmonary secretions and ileus can occur when patients are immobile effective pain management can help prevent these complications number three which each analgesic tablet contains 325 milligrams of acetaminophen and five milligrams of hydrocodone the maximum daily dose of acetaminophen is 4 grams if she takes one tablet every three hours is her dose safe if she takes a dose every three hours then she will receive eight doses in 24 hours and 325 milligrams times 8 is 20 600 milligrams or 4 grams which is below the maximum safe dose of 4 000 milligrams recall that older patients metabolize and excrete medications more slowly than younger patients always be mindful of the total acetaminophen dosages consumed number four what can be done to relieve her pain and prevent it in the better prevent it in the future Mrs Shepherd should be instructed about what her role will be when her pain management regimen is altered does she have to ask for the pain medication or will it just be brought to her patient and family education are vital to success in management of a patient's pain opioid antagonists and this is the bottom of page 128 so we will end part one here and you can stay tuned for part two which will start with with opioid antagonists on page 128 thank you