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Jarvis Chapter 10

we understand pain to develop by two main processes

nociceptive and neuropathic processing

a highly complex and subjective experience from the CNS, PNS, or both


specialized nerve endings designed to detect painful sensations from the periphery and transmit them to the CNS


nociceptor locations

within the skin, connective tissue, muscle, and thoracic, abdominal, and pelvic viscera

nociceptors can be stimulated

directly by trauma or injury, or secondarily by chemical mediators that are released from the site of tissue damage

nociceptors carry the pain signal to the CNS by two primary sensory (afferent) fibers

Aδ and C fibers

myelinated and larger in diameter, transmit the pain signal rapidly to the CNS. The sensation is very localized, short term, and sharp in nature

unmyelinated and smaller, transmit the signal more slowly. the seconday sensations are diffuse and aching and they last longer after the initial injury

C fibers

Aδ and C fibers fibers synapse with interneurons located within a special area of the spinal cord called the

substantia gelatinosa

pain signals cross over to the other side of the spinal cord after synapsing with the interneurons and ascend to the brain by the

anterolateral spinaothalamic tract

develops when nerve fibers in the periphery and in the CNS are functioning and intact

nociceptive pain

occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery. Chemicals such as substance P, histamine, prostaglandins, serotonin, and bradykinin are released


substance p, histamine, prostaglandins, serotonin, and bradykin

neurotransmitters that propagate a pain message, or action potential, along sensory afferent nerve fibers to the spinal cord

second set of neurotransmitters carry the pain impulse across the synaptic cleft to the dorsal horn neurons

substance p, glutamate, and ATP

the pain impulse moves form the level of the spinal cord to the brain. within the spinal cord, at the site of the synaptic cleft, are opioid receptors that can block this pain signaling with our own endogenous opioids or with exogenous opioids if they are administered. If not stopped, the pain impulse moves to the brain via various ascending fibers within the spinothalamic tract to the thalamus


indicates the conscious awareness of a painful sensation. Cortical structures such as the limbic system account for the emotional response to pain, and somatosensory areas can characterize the sensation. Only when the noxious stimuli are interpreted in these higher cortical structures can this sensation be identified as "pain"


the pain message is inhibited. fortunately our bodies have a built in system that will eventually slow down and stop the processing of painful stimulus. If not, we would continue to experience pain from childhood injuries and beyond. Descending pathways from the brain stem to the spinal cord produce a third set of neurotransmitters that slow down or impeded the pain impulse, producing an analgesic effect


neurotransmitters that slow down or impede the pain impulse producing a analgesic effect

serotonin, norepinephrine, neurotensin, GABA, and our own endogenous opioids, beta endorphins, enkephalins, and dynorphins

nociceptive processing is

protective. nociceptive pain is typically predictable and time limited based on the extent of the injury

examples of nociceptive pain

skinned knee, kidney stones, menstrual cramps, muscle strain, venipuncture, or arthritic joint pain

pain that does not adhere to the typical and rather predictable phases in nociceptive pain

neuropathic pain

neuropathic pain implies

an abnormal processing of the pain message from an injury to the nerve fibers. it is the most difficult pain to assess and treat

nociceptive pain can change into neuropathic pain

over time when pain has been poorly controlled

conditions that may cause neuropathy include

diabetes mellitus, herpes zoster, HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and chemo. further examples include CNS lesions such as stroke, MS, and tumors

visceral pain

originates in the larger interior organs: kidney, stomach, intestine, gallbladder, pancreas

the pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system in visceral pain

this is why it often presents along with vomiting, nausea, pallor, and diaphoresis

comes from sources such as blood vessels, joints, tendons, muscles, and bone

deep somatic pain

derived from the skin surface and subcutaneous tissues, the injury is superficial with a sharp, burning sensation

cutaneous pain

term attributed to pain with no known cause and assumed to have a psychiatric or emotional cause

psychogenic pain

pain that is felt at a particular site but originates from another location. may originate from visceral or somatic structures

referred pain

pain that is short term and self limiting, often follows a predictable trajectory, and dissipates after the injury heals

acute pain

an acute type of pain that happens predictably when certain movements take place

incident pain

persistant/chronic pain

diagnosed when the pain continues for 6 months or longer.

persistant pain can be further divided into

malignant and nonmalignant pain

malignant pain

often parallels the pathology caused by the tumor cells. Is induced by tissue necrosis or stretching of an organ by the growing tumor. Pain fluctuates within the course of the disease

chronic nonmalignant pain

often associated with musculoskeletal conditions such as arthritis, low back pain, and fibromyalgia

chronic pain originates

from abnormal processing of pain fibers from peripheral or central sites. because the pain is transmitted on a cellular level, our current technology cannot reliably detect this process

the most important and reliable indicator for pain

patient self-report

pain that starts again or escalates before the next scheduled analgesic dose

breakthrough pain

although pain is a common experience among individuals 65+

it is NOT a normal process of aging

the most common pain producing conditions for aging adults

arthritis, osteoarthritis, osteoporosis, PVD, cancer, peripheral neuropathies, angina, and chronic constipation

people with dementia

do feel pain, the somatosensory cortex is generally unaffected by dementia of the Alzheimer type

women are two to three times more likely to experience

migraines during childbearing years, are more sensitive to pain during the premenstrual period, and are six times more likely to have fibromyalgia

various studies describe how black and hispanic patients are often

prescribed and administered less analgesic therapy than whites

pain is defined as an

unpleasant sensory and emotional experience associated with actual or potential tissue damage

pain is always


pain is multidemensional in scope

encompassing physical, affective, and functional domains

select the pain assessment tool based on

its purpose, time involved in administration, and the patient's ability to comprehend and complete the tool

use the pain tool consistently before and after treatment

to see if the treatment has been effective

standardized overall pain assessment tools

are more useful for chronic pain conditions or particularly problematic acute pain problems. examples are the initial pain assessment, the brief pain inventory, and the mcgill pain questionnaire

the clinician asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. further, the clinician adds questions about the manner or expressing pain and the effects of pain that impair one's quaility of life

initial pain assessment

asks the patient to rat the pain within the last 24 hours using graduated scales with respect to its impact on areas such as mood, walking, and sleep

the brief pain inventory

asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain

the short form mcgill pain questionnaire

unidimensional and are intended to reflect pain intensity. They can indicate baseline intensity, track changes, and give some degree of evaluation to a treatment modality

pain rating scales

asks the patient to choose a number that rates the level of pain for each painful site. 0 being no pain and 10 indicating worst pain ever

numeric rating scales

lists words that describe different levels of pain intensity, such as no pain, mild pain, moderate pain, and severe pain

descriptor scales

in cases in which the cause of acute pain is uncertain

establishing a diagnosis is the priority but symptomatic treatment of pain should be given while the investigation is proceeding

with occasional exceptions (the initial exam of the patient with acute abdominal pain)

it is rarely justified to defer analgesia until a diagnosis is made


an audible and palpable crunching that accompanies movement

note the size and contour, measure the circumference for comparison with baseline, check passive and active ROM

the joints

inspect color, swelling, and any masses or deformities

the muscles and skin

absent pain sensation


increased pain sensation


severe pain sensation is evoked with a stimulus that does not normally induce pain


observe contour and symmetry, palpate for muscle guarding and organ size


behaviors are influenced by a wide variety of factors with pain

including the nature of the pain (acute v. chronic), age, and cultural or gender expectations

acute pain behaviors

guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vitals

cardiac acute pain responses

tachycardia, elevated BP, increased myocardial o2 demand, increased CO

pulmonary acute pain responses

hyperventilation, hypoxia, decreased cough, atelectasis

GI acute pain responses

nausea, vomiting, ileus

renal acute pain responses

oliguria, urinary retention

Musculoskeletal acute pain responses

spasms, joint stiffness

endocrine acute pain responses

increased adrenergic activity

CNS acute pain responses

fear, anxiety, fatigue,

immune acute pain responses

impaired cellular immunity, impaired wound healing

poorly controlled chronic pain responses

depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life

chronic pain behaviors

persons try to give little indication that they are in pain and therefore are at higher risk for underdetection. behaviors include bracing, rubbing, diminished activity, sighing, and change in appetite

older adults will often deny pain for fear of

dependency, further testing or invasive procedures, cost, and fear of taking pain killers/becoming a drug addict

when you look for behavioral cues look at changes in functional status in aging adults

observe for changes in dressing, walking, tolieting, or involvement in activities

look for a sudden onset of acute confusion in aging adults

may indicate poorly controlled pain

people with dementia communicate pain through their behavior

agitation, pacing, and repetitive yelling

when asked if they are having pain, people with dementia may say no

words have lost their meaning

evaluates five common behaviors of breathing, vocalization, facial expression, body language, and consolability

the PAINAD scale, used on people with dementia

a score of 4 or more on the PAINAD scale

indicates a need for pain management

treat underlying cause, NSAIDS, opioid, muscle relaxant, corticosteriod, biphosphonate

treatments for somatic or visceral pain

primary lesion in neuropathic pain


somatic pain descriptors

dull,aching, well localized, nocturnal

somatic pain associated disorders

postop pain, bone metastases, arthritis, sports injury, mechanical back pain

visceral pain descriptors

deep squeezing pressure, local tenderness and referred, poorly localized

visceral pain associated factors

liver metastases, pancreatic cancer

neuropathic pain descriptors

constant dull ache, burning, stabbing, vice like, electric shock like, numbness, tingling, allydynia, hyperalgesia, hyperpathia

neuropathic pain treatment options

tricyclic antidepressants (TCA), anticonvulsant, antidepressant, antineuroleptic, local anesthetic, biphosphonate, corticosteroid, opioid, interventional techniques

a chronic progressive nerve condition, characterized by burning pain, swelling, stiffness, and discoloration of the affected extremity. If affects both men and women, usually around 40-60 and occurs weeks to months after a nerve inury. involves a complex interaction of sensory, motor, and autonomic nerves, as well as the immune system. Nerve injury may modify the usual pain pathway causing a neuropathic windup or short circuit mechanism. KEY FEATURE: typically innocuous stimulus can create a sever, intense painful response.

Reflexive sympathetic dystrophy or complex regional pain syndrome

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