11. Pain Flashcards
What is pain?
- is the sensation of distress felt at physical, psychological and spiritual levels
- is a 5th vital sign
- is a personal and individual experience
- is a multidimensional phenomenon
Gateway theory
- nociceptors receive painful stimulus
- 3 nerves
- blocking the gate to manage pain
2 broad types of pain
- Nociceptive Pain
- caused by injury or inflammatory process
- involves 4 processes:
1) transduction
2) transmission
3) perception
4) modulation - reversible
- usually well localized, constant, with aching/throbbing quality
- responds well to opioids
- ex. fracture, burn, tumor, obstruction
2. Neuropathic Pain - caused by injury or malfunction within the CNS or PNS
- can occur without immediate tissue damage or inflammation process
-associated with:
-disease process sequela (diabetic neuropathy, inflammation around nerves (post-herpes neuralgia), viruses
burning, lancinating, or electric shock qualities
-does not respond well to opioids
complicated pain
caused by both physical and psychogenic stimuli
-ex. cancer pain can be caused by tumor pressure and inflammation on a nerve near/within an organ or bone
In addition, sorrow and suffering, anxiety and depression rt the diagnosis/outcomes/family pressures/loneliness/isolation… can contribute to complicated pain
Acute vs Chronic pain
ACUTE pain:
- sudden onset
- subsides after treatment
- affects BP, HR, RR
- behavioural changes often apparent, although culturally mediated
- if it becomes prolonged= chronic
- ex. appendicitis, kidney stones, surgical procedures, period pains
CHRONIC pain:
- ongoing or recurring (days-months-years)
- more difficult to treat
- dull, aching, always their quality
- often does not affect BP, HR, RR
- acute behaviour changes are less apparent
- ex. cancer, lower back, peripheral neuropathy
Classification of Pain by manifestation
Somatic: body aches
Visceral: organ
Referred: pain felt away from the source
Radiating: travelling along a nerve path
Neuropathic: nerve related, pins and needles, burning, numbing, freezing
Superficial: surface, skin deep
Vascular: pulsating, vessel
Chest: angina or potential myocardial infarction
Cramping: gastro-intestinal pain triggered by peristaltic waves
Cancer: severe, complex
Phantom: limb loss
Psychogenic: suffering caused by non-physical events
Negative Consequences
Physical:
- decreased functional ability
- decreased ADLs
- decreased immune response
- nausea
- insomnia
- anorexia
Psychosocial:
- isolation
- relationship stress
- inability to do work or normal activities
- loss of self esteem
- increased caregiver burden
Emotional:
- decreased leisure
- fear
- anxiety
- depression
- hopelessness
- loss of control
- possible risk of suicide
Spiritual:
- disconnected
- feeling unconnected with others, God, the Universe
- loss of meaning
Assessment
Pain scales:
(for rating pain)
- 0-10 scale
- verbal descriptor scale - ask about quality of pain
(comprehensive assessment tools) -body mapping of pain -pain diary -interview with pt and family (other indicators) -QOL indicators -ADL and activity level
LOTTAARRPP
Assessment for non-verbal or dementia pts
Basic Need Assessment:
-hunger, thirsty, need to void, cold, hot, position change, more light, need glasses, too noisy… (focus on removing stressors)
ADD protocol:
Step 1: look for physical signs of discomfort and treat (ex. infection, inflammation, moaning, crying, agitation, tense muscles, decreased appetite, rubbing a body part)
Step 2: Assess medical hx for potential sources of painful conditions (ex. hx of migraines, fractures)
Step 3: If no physical causes found, implement non-pharm comfort interventions
Step 4: If non-pharm interventions are ineffective, owkr with the prescribing physician to administer an analgesic trial
Faces scale
Pain assessment for advanced dementia (PAIN-AD)
- 4 categories
- breathing (laboured, hyperventilation..)
- negative vocalization (moan, cry…)
- facial expressions (grimace, confused…)
- body language (pulling away, tense…)
- consolability (can you console or not)
Barriers to Treatment
- health care provider’s bias
- pt’s misconception
- cultural beliefs
- cost of medication
- lack of knowledge
Pain defs
Pain threshold: the point when pain begins to be felt
Pain tolerance: the max level of pain someone can endure
Medication tolerance: the body is accustomed to the med so that adverse effects gradually diminish = good
Dependence: development of withdrawal symptoms when an opioid is suddenly discontinued
Addiction: craving, compulsive use, inability to control
Interventions for pain control
Non-pharmacological
Pain clinicals
-important for pts with complex pain
Religious leaders
-for when complicated pain (suffering) is causing physiological treatments to be ineffective
- music therapy
- pet therapy
- art therapy
- body movement therapy/stretches
- swimming or hydrotherapy
- biofeedback
- games, movies
- favourite foods
- gardening
- therapeutic touch
- counseling
- conversation
- heat/icing
- herbal formulations
- acupuncture
- prayer/meditation
- TENS (transcutaneous nerve stimulation)
Interventions for pain control
3 Pharmacological
- Non-Opioid Analgesics
- painkillers
- OTC for mild-mod pain
- better than opioids for bone and inflammation pain
- weigh risks vs benefits
- start with low dose, increase gradually
- may take weeks to begin to. worrk well
ex. Tylenol, ibuprofen, advil, aspirin, naproxen
- NOTE: Advil should not be used for chronic because it is a blood thinner and can cause gastrointestinal bleeding - Opioid Analgesics
-pain relievers that contain opium or synthetically made codeine sulfate
-NOTE: Meperidine HCL/ Demerol is NOT for older adults
-start LOW and GO SLOW for older adults
-ex. Methadone, Hydromorphone, morphine sulfate, Oxycodone, Fentanyl, Tramadol/Tramacet
Side Effects:
-constipation
-nausea, vomiting
-orthostatic hypotension
-dizziness
-confusion, drowsiness
*potential resp. depression
- Opiate antagonists:
- bind to opiate receptors and prevent a response
- used for reversal of opioid-induced resp. depression
e. Naloxone, Naltrexone
-physical tolerance requires increased doses over time, so ongoing assessment is critical to good pain management
- ALWAYS evaluate Sedation and VS after opioid admin
- use the POSS scale (pasero. opioid-induced sedation scale)
- Adjuvant Analgesics
-medications that can relieve pain in some conditions, but are not primarily meant for pain
-ex. antidepressants
anticonvulsants
corticosteroids
caffeine
-meds that can cause orthostatic hypo should be used cautiously with pts with CV conditions
-interactions with other meds must be monitored because older adults often have polypharmacy for other conditions
Evaluations
Therapeutic outcomes:
- decreased complaints of pain
- decreased severity of pain
- increased periods of comfort
- improved ADL, appetite, sense of well-being
- improved social
- improved QOL
