Unit 8 NRS 111A
Terms in this set (52)
The magnitude of the pain problem in the US is astounding. Annually in the US, _______ people experience acute pain as a result of injury or surgery.
25 million annually - chronic pain occurs at epidemic levels in the US.
What are the consequences of untreated pain?
* Unnecessary suffering
* Physical & psychosocial dysfunction
* Impaired recovery from acute illness and surgery
* Sleep disturbances
Why is pain under-treated?
* Inadequate skills to assess and treat pain
* Unwillingness to believe patient reports
* Lack of time, expertise, and perceived importance of pain assessments
* False concepts of addiction and tolerance
* Fear that we may hasten death
* Clinicians and researchers also cite legal and systems-level barriers including:
*** restrictions in the use of controlled substances, failure of health care organizations to provide clear standards of pain management practices, lack of standardized institutional pain management policies and procedures, and lack of accountability for pain management practices.
One definition of pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
A full assessment of pain should include asking about these 6 things - L,D,F,I,S,W
*Location - have patient point to area of pain
*Description - words used to describe pain
*Frequency - how often and what causes pain
*Intensity - rating scale(s)
*Side effect of pain - immobility, nausea/vomiting
*What eases pain - pharmacological or non-pharmacological actions
The financial impact of pain from unrelieved and inadequate management of pain costs an estimated ______ each year.
The assessment of pain -
is a subjective nature and a patients self-report is the most valid means of assessment.
Multiple dimensions of pain =
successful assessment and treatment of pain.
Dimensions of pain are _________
* Affective (negative emotions impair patient's quality of life)
* Behavioral (people unable to communicate may have behavioral changes like agitation, combativeness, etc.)
Harmful effects of unrelieved acute pain
(Table 10-1 pg. 128 Lewis)
affect all body systems - endocrine/metabolic, cardiovascular, respiratory, renal/urologic, gastrointestinal, musculoskeletal, neurologic and immunologic
occurs when there is release of chemical mediators(prostaglandins, bradykinin, serotonin, substance P, histamine) which activate nociceptors and lead to generate action potentials - process by which afferent nerve endings participate in translating noxious stimuli into nocioceptive impulses
physiologic process by which information about tissue damage is communicated to the CNS.
4 processes of nocioception
involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brain-stem, thalamus, and cerebral cortex (ascending pathway) - processes by which impulses are sent to the dorsal horn of the spinal cord and then along the sensory tracts to the brain.
conscious experience of pain - subjective experience of pain that results from the interaction of transduction, transmission and modulation as well as the psychologoical aspects of the individual
involves signals from the brain, going back down (descending pathways) the spinal cord (neurons that release substances like endogenous opioids that inhibit nociceptive to modify incoming impulses - process of dampening or amplifying these pain related neural signals - modulation takes place primarily in the dorsal horn of the spinal column but also elsewhere with input from ascending and descending pathways.
neurons that sense pain and send the sensation to the brain or spinal cord. There are a lot of different types of nociceptors including:
* thermal (sunburn)
* chemical (toxins)
* mechanical (surgery)
Pain can be catogorized in several ways. Most commonly, pain is classified as ___________ or _______________ based on underlying pathology.
normal response to noxious stimulus or injury of tissue, bones, skin, organs or joints - Somatic pain and Visceral pain (somatic pain usually well localized, may be cutaneous or musculoskeletal/visceral pain is from hollow organs or smooth muscles and is usually referred)
caused by a lesion or disease in the somatosensory nervous system (sensory - range from perceived numbness to paresthesias or hypersensitivites/examples are diabetic neuropathy, phantom limb pain, spinal cord pain, post stroke central pain)
tissue inflammation releases mediators which activate or sensitizes nociceptive pathways. (Ex. appendicitis, inflammatory bowel disease, rheumatoid arthritis)
Partial list of inflammatory mediators include:
cytokines IL-1-alpha, IL-1-beta, TNF-alpha, other factors released by infiltrating leukocytes or tissue mast cells
Gate control theory of pain
Pain has emotional & cognitive components in addition to a physical sensation. Gating mechanisms located along the central nervous system regulate or even block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed. Closing the gate is the basis for non-pharmacological pain-relief interventions. Factors such a stress and exercise increase the release of endorphins, often raising an individual's pain threshold. Because the amount of circulating substances varies with every individual, the response to pain varies.
Physiological responses of pain
Pain impulses ascend the spinal cord toward the brain stem and thalamus, stress response stimulates the ANS. Pain of low - moderate intensity and superficial pain elicit the fight or flight reaction of the general adaptation syndrome. Stimulation of the sympathetic branch of the autonomic nervous system results in physiological responses. Continuous, severe, or deep pain typically involving the visceral organs activates the parasympathetic nervous system. Sustained physiological responses to pain sometimes seriously harm individuals. Except in cases of severe traumatic pain which causes a person to go into shock, most people adapt to their pain and their physical signs return to normal. Thus patients in pain do not always have changes in their vital signs. Changes in VS more often indicate problems other than pain.
Behavioral responses to pain
If left untreated or unrelieved, pain significantly alters QOL. Some choose not to report pain if they believe that it inconveniences others or if it signals loss of self-control, and some endure severe pain without assistance. Encourage patients to accept pain-relieving measures so they remain active and continue to maintain daily activities. In contrast, other patients seek relief before pain occurs, having learned that prevention is easier than treatment. Lack of pain expression does not indicate that the patient is not experiencing pain.
mild = <4/10
Moderate = 5/10 or 6/10
Severe = > 7/10
Duration of pain/acute
pain lasting less than 6 months
Duration of pain/chronic
pain lasting more than 6 months, lasting beyond tissue healing or lasting beyond the course of the acute disease
Duration of pain/acute-on-chronic
acute pain flare-up on top of chronic pain
Other pain constellations
complex cancer pain, migraines, fibromyalgia - well recognizable even though underlying causes may be poorly understood
Primary treatment for pain
*addressing the cause of the pain
*surgical correction or ongoing treatment of a chronic disease process
Eliminating pain becomes the goal once
cause is identified and a treatment is planned or initiated
Typical physical and behavioral manifestations/Acute pain
* Increased heart rate
*Increased respiratory rate
* Increased blood pressure
* anxiety, agitation, confusion
* Urine retention
Typical physical and behavioral manifestations/Chronic pain
* Predominantly behavioral manifestations
* flat affect
* decreased physical movement/activity
* withdrawal from others and social interaction
Usual goals of treatment for acute pain
pain control with eventual elimination
Usual goals of treatment for chronic pain
pain control to the extent possible
focus on enhancing function and quality of life
Core principles of pain assessment
1. Patients have the right to appropriate assessment and management of pain.
2. Pain is always subjective.
3. Physiologic and behavioral (objective) signs of pain (tachycardia, grimacing) are not sensitive or specific for pain.
4. Pain is an unpleasant sensory and emotional experience.
5. Assessment approaches, including tools, must be appropriate for the patient population.
6. Pain can exist even when no physical cause can be found.
7. Different patients experience different levels of pain in response to comparable stimuli.
8. Patients with chronic pain may be more sensitive to pain and other stimuli.
9. Unrelieved pain has adverse physical and psycho logic consequences. Acute pain that is not adequately controlled can result in physiologic changes that increase the likelihood of developing persistent pain.
Nursing implications of pain assessment
1. Assess pain in all patients.
2. The patient's self report of pain is the single most reliable indicator of pain.
3. Accept and respect this self report unless there are clear reasons for doubt.
4. Do not rely primarily on observations and objective signs of pain unless the patient is unable to self report pain.
5. Address physical and psychologic aspects of pain when assessing pain.
6. Special considerations are needed for obtaining assessment data for patients with difficulty communicating.
7. Include family members in the assessment process, when appropriate.
8. Do not attribute pain that does not have an identifiable cause to psychologic causes.
9. A uniform pain threshold does not exist.
10. Pain tolerance varies among and within individuals depending on various factors (heredity, energy level, coping skills, prior experience with pain).
11. Encourage patients to report pain especially those who are reluctant to discuss pain, deny pain when it is likely present, or fail to follow through on prescribed treatments.
Pain should be _____________ with any change in medical status.
Pain should be ________________ before, during and after any procedure.
Pain must be ______________ after pain medication and a _____________ score documented.
What is the time between initial medication and reassessment?
1-5 minutes for IV opioids; 30 minutes for PO anti-inflammatories
Pain is considered the 5th ______ _______.
vital sign - and should be assessed and documented with each set of vital signs. If a CNA takes and records VSs, the nurse MUST add the pain assessment score.
Methods of pain assessments
* choose the best tool for the patients age, ability and situation to get the most accurate assessment.
* instruct the patient that we need them to report possible side effect as soon as possible
* Verbal Pain Score (VPS) or Visual Analog Scale
* Non-verbal pain scale (NVPS)
* Numeric Rating Scale (NRS)
* Verbal Descriptor Scale (VDS)
* Faces Pain Scale (FPS)
*Comparative Pain Scale (words, descriptive, 3 categories)
* Behavioral Pain Scale for Patients Unable to Provide a Self Report of Pain
Education for RN's is mandated in the state of Oregon. How much time is required?
One time, 6 hours of pain education
Eleven tips for living with chronic pain
1. Learn deep breathing or meditation to help with chronic pain.
2. Reduce stress in your life. Stress intensifies chronic pain.
3. Boost chronic pain relief with the natural endorphins from exercise.
4. Cut back on alcohol, which can worsen sleep problems.
5. Join a support group. Meet others living with chronic pain.
6. Don't smoke. It can worsen chronic pain.
7. Track your pain level and activities every day.
8. Learn biofeedback to decrease pain severity.
9. Get a massage for chronic pain relief.
10. Eat a healthy diet if you're living with chronic pain.
11. Find ways to distract yourself from pain so you can enjoy life more.
Factors influencing pain
* Biological influences in the perception of pain
* Psychological influences
*Social & Cultural influences
Biological influences in the perception of pain are:
* Gender: differences in perception and reporting of pain
* Genetics: There are several genes which contribute to the expression or non-expression of pain. coMT gene is linked to higher predisposition to pain but is responsible for only 10% of pain perception.
* Number of nociceptors - nerves that send pain signals to the brain & spinal cord
Psychological influences in the perception of pain are:
* Fear of pain - which can lead to a patient not moving, especially if movement caused pain in the past
* Pain 'catastrophizing' - inability to stop thinking about one's pain, and to characterize pain as unbearable, which increases activity in areas of the brain which anticipate pain
* Negative affect (neuroticism) - a more irritable or anxious personality type - may be a precursor to pain-related fear or catastrophizing
* Emotional stress
Social & Cultural influences in the perception of pain are:
* Exprectation that "pain is just something you have tyo deal with" - less likely that pain will be communicated
* Overly solicitous family/caregiver - more likely to report pain
* Differences in reporting of pain among various cultural groups
Tools for assessing pediatric pain
* Wong - Baker Faces scale (however, don't make assumptions, check it out).
* FLACC Scale (ages 2 mos. - 7 yrs)
* CRIES scale (32 weeks - 1 year)
assesses face, legs, activity, cry and consolability to determine a pain score of 0-10. This is a useful tool with pre-verbal children and non-verbal adults.
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