Terms in this set (49)
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described terms of such damage
psychological pain can present as physical pain
rule out physical pain first
The patient is the expert about the pain
Facts about pain
16 million people experience chronic arthritic pain
31 million report low back pain
50 million are fully or partially disabled from pain
10% of ED visits are related to chronic pain
75% of ED visits are related to acute pain
Sharp, stabbing, shooting
Generally, acute situations are sudden in onset and short in duration. Oddly enough, patients often say the pain has persisted for a long period of time in order to get the health care providers attention.
Then the question becomes, when did the pain get worse?
Physical responses to acute pain
Change in BP- most of the time increases but that can vary depending on hypovolemia or the source of the pain.
Focusing on pain
Defined in vague terms
Cause may be unknown
Chronic non-malignant pain. i.e. back pain
Chronic malignant pain. i.e. cancer pain
Not readily treatable
Associated with despair and withdrawal, poor sleep, decreased concentration
Location of pain
Superficial - cutaneous
Somatic- tissues of body wall, muscle, bone, cartilage, tendons, joints, nerves
Visceral - organs and their capsules
Referred pain: felt in an area distant from site of stimulus
Inflammatory pain is the most common pathologic condition causing pain.
Neuropathic pain causes numbness, burning, stabbing, needles.
Theory of referred pain
Nociceptors from several locations converge on a single ascending tract in the spinal cord. Pain signals from the skin are more common than pain from internal organs, and the brain associates activation of the pathway with pain in the skin (why pain from internal organs is sometimes felt on surface of the body)
Patterns of pain
extremely important in determining origin of pain.
Visceral pain is especially difficult to pin down. For example, we all think of RLQ pain for appendicitis. The truth is that many cases of appendicitis begin with peri-umilical pain.
Intra-abdominal injuries from blunt trauma may manifest as back pain or shoulder pain.
Cardiac pain is particularly problematic. Cardiac pain can manifest in a number of ways including back pain, jaw pain, abdominal pain, as well as shoulder and arm pain.
Women seem to have more difficulty localizing pain than men.
Relays information about four major modalities:
Organized into dermatomes
Transmits over three types of neurons
Neurons (sensory receptor to dorsal horn neurons)
Association neurons (transmit to thalmus)
Third order neurons (sensory cortex)
an area of skin that is mainly supplied by a single spinal nerve
an area of the skin supplied by nerve fibers originating from a single dorsal nerve root. The dermatomes are named according to the spinal nerve which supplies them. The dermatomes form into bands around the trunk but in the limbs their organization is more complex and tends to run vertically.
The amount of space on the somatosensory cortex devoted to each body part is proportional to the sensitivity of that part
Hand, finger, and face takes up big portion of the somatosensory cortex which is why those parts of the body are so sensitive
Blood, especially, is very irritating so it causes pain in the different parts of the abdomen as it moves. This reflects pressure in the peritoneal space:
for example, men will feel a kidney stone in the testicular area. A ruptured spleen is felt in the upper shoulder, due to blood from the rupture moving up your back.
refers to the normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful.
Simply stated, nociception means "normal" pain transmission.
Pain from surgery, trauma, burns, and tumor growth are examples of nociceptive pain
(somatic and visceral) described by pts as "aching", "cramping" or "throbbing"
results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply stated, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and poststroke pain syndrome.
(non-nociceptive) described by pts as "burning", "sharp" and "shooting"
combination of nociceptive and neuropathic pain
a patient may have nociceptive pain as a result of tumor growth and if the tumor is pressing against a nerve plexus the patient may also report radiating sharp and shooting neuropathic pain.
Sickle cell pain is usually a combination of both nociceptive pain from the clumping of sickled cells, and resulting perfusion deficits, and neuropathic pain from nerve ischemia.
Peripheral stimulus, such as chemical, electrical, mechanical or thermal, depolarizes nociceptors.
Chemical mediators include bradykinins, histamines, prostaglandins
Nociceptors = pain sense
Chemical initiation of pain
Chemical - chemicals released from injured and traumatized tissue make the nociceptor more permeable by damaging its membrane. This results in depolarization of the nociceptors membrane
Tissue Ischemia: decreased blood flow to tissues results in an accumulation of metabolic byproducts (lactic acid) which results in stimulation of nociceptors
Stimulation of mechanosensitive nociceptors
compression of blood vessels by the spastic muscle - this leads to decreased blood flow - increased concentration of lactic acid. The situation is compounded by an increase in tissue metabolism in the spastic muscle.
Two types of nociceptors
A fibers and C fibers
fast fibers, myelinated, carry acute, sharp, sudden pain messages
Lightly myelinated fibers
Well localized, sharp pain
typically is elicited by mechanical or thermal stimuli.
slow fibers carry diffuse, throbbing pain
Small unmyelinated fibers
Diffuse burning, aching
slow wave pain or second pain because it is slower in onset and longer in duration. It typically is incited by chemical stimuli, or persistent mechanical or thermal stimuli. The slow post excitatory potentials generated in the C fibers are now believed to be responsible for chronic pain.
the amount of pain a person is willing to endure.
the lowest intensity of a painful stimulus that is perceived by a person as pain
Pain is multifaceted
Difficult for clients to describe
Leads to debilitation:
Diminished quality of life
No single universal treatment
Listening to concerns
Assessing pain intensity
Distress levels 0 - 10 pain scale
Planning for care
Educating client about pain
Promoting use of non-pharm techniques
Onset and duration
Associated features or secondary signs/symptoms
Associated factors: stress/fatigue/activities/nausea
Provocation- what makes pain worse/ better?
Quality- What does the pain feel like? sharp, dull?
Radiation- Is the pain in one place or does it move around?
Site- Where is your pain? How painful on scale of 0-10?
Timing- When did the pain start? How often?
Administration of pain relieving medication
Repositioning the client
Heat and/or cold
Facilitating the client's expression of feelings
Providing support and reassurance
Reducing external stimuli
Teaching the client self-management strategies
Providing diversion therapy
Chaplaincy Referral for spiritual support
Heat or cold packs
Art or music therapy
Transcutaneous Electrical Nerve Stimulation (TENS) -therapy that uses low-voltage electrical current for pain relief.
Medication that relieves pain
Aspirin (acetylsalicylic acid)
Medical Marijuana cream-cancer pts, terminal illnesses
Derived from natural opium alkaloids and their synthetic derivatives
Categorized from weak to strong
Used when the pain is moderate to severe
Tolerance and physical dependence is seen in long term administration
Tolerance: the state at which an organism no longer responds to a drug and a higher dose is required to achieve the same effects
Opioid narcotic analgesics
*naturally occuring opioids
Action of narcotics
Decreased GI motility (constipation)
Euphoria (addiction, physical dependence)
Miosis (pinpoint pupils)
EVERY PT GIVEN A NARCOTIC IS A FALL RISK
put rails up and advise pt to not get oob w/o assistance
Opioids and constipation
Constipation is the most common side effect seen with opioid use and results from the increased smooth muscle tone and decreased motility of the GI tract.
Opioids diminish the propulsive peristaltic contractions in the small and large intestine and delay the passage of gastric contents.
A diet high in fiber with plenty of fluids and stool softening medication, such as COLACE, is a common prophylactic treatment.
Opioids and nausea/vomiting
Opioids may precipitate nausea and vomiting because of their action on the brain stem centers. Morphine like agents may affect the vestibular system which can produce these manifestations. Anti-emetic agents may also be administered. Remember that certain anti-emetics (like phenergan) can actually potentiate the opiate. This side effect decreases with analgesic use.
Opioids and respiratory depression
caused by diminished sensitivity of the respiratory center to carbon dioxide.
All opioids have the potential to produce respiratory depression, which can be rapidly reversed with an opioid antagonist, typically Naloxone.
Carefully assess and reassess each client after giving the medication for the occurrence of respiratory depression.
Also remember that if you have to give Narcan, the respiratory depression of opioids will outlast the narcan, so you may have to repeat the dose.
Adverse effects of opioid analgesics
Nausea and Vomiting
Sedation / Respiratory depression**
Remember issues with opioid analgesics in the elderly population; confusion, agitation, fall risk
Reversal agent for narcotics (opioids): Morphine, Dilaudid, Fentanyl
NARCAN (naloxone) usual dose: 0.1-0.4mg IV; may repeat as needed; short half-life relapse of depressed RR can occur again in 1-2 hours, close monitoring required
Reversal agent for benzodiazapines (Versed, Ativan)
ROMAZICON(flumazenil) 0.2mg IV may repeat in 30 second increments; up to total dose of 3mg; may increase doses to 0.5mg after 3rd 0.2mg dose
Barriers to pain management (related to pt)
Reluctance to report pain
Concern about not being a "good" patient
Reluctance to take pain meds
Fear of addiction
Worries about unmanageable side effects
Concern about becoming tolerant to medications
Barriers to pain management (for healthcare professional)
Concern about use of controlled substances
Fear of client addiction
Concern regarding side effects of analgesics
Concern regarding tolerance of medications
Problems r/t health care system
Cancer pain - low priority for high doses often needed
Restrictions on use of controlled substances
Access/ availability of treatment.
Mistrust of alternative therapies
Evaluation of pain management
Decreasing the level of pain, as stated by the patient
Increasing patient's ability to participate in activities of daily living without pain
Allow the patient to sleep comfortably
Encourage the patient to participate in therapeutic exercises to speed healing
Tips for pain management
Pain is much easier to treat when it is mild
Drug addicts can have real pain...but it is not all physical
It is useful to know signs associated with pain in case you have communication problems
Drugs that paralyze people (as for surgery) are not effective for pain control
Know your drugs and the reversal agents
Think outside the box for alternative therapy
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