Ch. 8- Pain

Question 1

Pain

Answer 1

> Major reason people seek care when Pain

> Pain is a complex, multidimensional experience.

> For many, it is a major problem that causes suffering and reduces quality of life.

*Nurses have a central role in Assessment & Management
- Advocate for those in pain.

Question 2

Magnitude of Pain Problem

Answer 2

> 25 million people experience acute pain
116 million people have back pain, arthritis, and migraine headaches.
70% of cancer patients experience pain.
Consequences of untreated pain
Unnecessary suffering
Physical and psychosocial dysfunction
Immunosuppression
Sleep disturbances

• The financial impact of pain is staggering.
• In the United States, unrelieved and inadequately managed pain costs an estimated $560-635 billion yearly in direct medical treatment costs and lost work productivity.

Chronic are things that cannot resolve

Question 3

Pain Description

Answer 3

> Subjective: Patient’s experience and self-report are essential.

> It can be problematic when dealing with special populations (coma or dementia)

> Nonverbal information, such as behaviors, aids in assessing pain.

What are some examples of nonverbal pain behaviors?

> Patients who are comatose or suffer from dementia, patients who are mentally disabled, and patients with expressive aphasia possess varying abilities to report pain.

In these instances, you must incorporate nonverbal information, such as behaviors, into your pain assessment.

Question 4

Dimension of Pain

Answer 4

> Behavioral

• Observable actions used to express or control pain
  *Facial expressions
  *Socially withdrawn
  *Less physically active
  *Using relaxation
  *Taking medication

> Physiologic

• Genetic, anatomic, and physical determinants
  *Influence how stimuli are recognized and described.

Question 5

Affective

Answer 5

> Emotional response to pain experience
*Anger, Fear, Depression, Anxiety

> Suffering: severe distress associated with loss
*Eased by pain relief
*Influenced by spirituality

> Studies demonstrate a link between depression and pain.
*Treating one can relieve the symptoms of the other.

Question 6

Cognitive

Answer 6

> Beliefs, attitudes, memories, and meaning attributed to pain – Culturally driven

> Influence response to pain and must be incorporated into the comprehensive treatment plan

Question 7

Sociocultural

Answer 7

> Include demographics, support systems, social roles, and culture

> Age, gender, and education influence beliefs and coping strategies.

> Must be assessed without stereotyping

Question 8

Nociception

Answer 8

Physiologic process that communicates tissue damage to the CNS

Question 9

Transduction

Answer 9

Conversion of a noxious ( tissue damaging), mechanical (surgical incision), thermal (sunburn), or chemical (toxic substances) stimulus into a neuronal action potential

Question 10

Transmission

Answer 10

Three segments are involved:

> Transmission along the peripheral nerve fibers to the spinal cord

> Dorsal horn processing

> Transmission to the thalamus and the cerebral cortex

Question 11

Perception

Answer 11

> Occurs when pain is recognized, defined, and assigned meaning

> Nociceptive input is perceived as pain in the brain.

> There is no precise, known location where pain perception occurs.

Question 12

Modulation

Answer 12

> Activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain

> It can occur at the periphery, spinal cord, brainstem, and cerebral cortex

Question 13

Nociceptive Pain

Answer 13

> Damage to somatic or visceral tissue

> Surgical incision, broken bone, or arthritis
> Usually responsive to opioids and non-opioid medications

Question 14

Somatic Pain

Answer 14

> Superficial or deep
Localized
Arises from bone, joint, muscle, skin, or connective tissue

Question 15

Neuropathic Pain

Answer 15

> Damage to peripheral nerve or CNS

> Numbing, hot-burning, shooting, stabbing, or electrical in nature

> Sudden, intense, short-lived, or lingering
phantom limb pain, diabetic neuropathy,

Question 16

Visceral pain

Answer 16

> Tumor involvement or obstruction
Arises from internal organs such as the intestine and bladder

*Visceral pain comes from the activation of nociceptors in the internal organs and lining of the body cavities such as the thoracic and abdominal cavities.

Visceral nociceptors respond to inflammation, stretching, and ischemia.
Stretching of hollow viscera in the intestines and bladder that occurs from tumor involvement or obstruction can produce intense cramping pain.

Answer 17

> Sudden onset

• Less than 3 months time for normal healing
  A precipitating event or illness can be identified.
• Course of pain decreases over time and goes away as recovery occurs.
  Includes postoperative, labor, and trauma pain

> Treatment goal
Pain control with eventual elimination

> > Examples of acute pain include postoperative pain, labor pain, pain from trauma (e.g., lacerations, fractures, sprains), infection (e.g., dysuria from cystitis), and acute ischemia.

> > Treatment for acute pain includes analgesics for symptom control and treatment of the underlying cause (e.g., splinting for a fracture or antibiotic therapy for an infection). Normally, acute pain diminishes over time as healing occurs.
However, persistent acute pain can ultimately lead to disabling chronic pain states. For example, pain associated with herpes zoster (shingles) subsides as the acute infection resolves, usually within a month. However, sometimes, the pain persists and develops into a chronic pain state called postherpetic neuralgia.

Question 18

Acute pain can manifest reflect SNS activation

Answer 18

Increased heart rate
Increased respiratory rate
Increased blood pressure

Question 19

Chronic Pain

Answer 19

Persistent pain, Cause may be unknown
Gradual or sudden onset–may start acute
Characterized by periods of waxing and waning
Behavioral manifestations
Decreased physical movement/activity, fatigue
Withdrawal from others, anxiety, depression
Treatment goals
Control to the extent possible
Focus on enhancing function and quality of life

Question 20

Pain Assessment

Answer 20

> The nurse is often responsible to
> Gather and document data.
> Make collaborative decisions with patient and other healthcare providers.

> Regularly screen all patients for pain. One of the 5 P’s, also the 5th vital sign.

Identify goals for therapy and resources for self-management

Question 21

Pain Assessment (cont.)

Answer 21

Onset
Duration
Associated symptoms
Factors increasing or relieving pain
Elements (multidimensional)
Direct interview
Observation
Pattern
Location
Intensity
QualityDiagnostics
Physical examination

Question 22

Pain Characteristics

Answer 22

Breakthrough pain
Transient, moderate to severe
Occurs beyond treated pain
Usually rapid onset and brief duration with variable frequency and intensity
End-of-dose failure

*End-of-dose failure is breakthrough pain that occurs before the duration of pain relief that is expected with a specific analgesic.

For example, in a patient on transdermal fentanyl (Duragesic patches), the typical duration of action is 72 hours.

> Increased pain after 48 hours on the medicine would be characterized as end-of-dose failure.
End-of-dose failure signals the need for changes in the dose or schedule of the analgesic.

Question 23

Pain Treatment Principle

Answer 23

Every patient deserves adequate pain management—stated comfort goal.

Treatment based on the patient’s goals

Use drug and nondrug therapies

Multimodal and Interdisciplinary

Prevent and manage side effects.

Incorporate PATIENT TEACHING

Documentation is critical to ensure effective communication of pain assessment tools.

Question 24

Pain Reassessment

Answer 24

> It is critical to reassess at appropriate intervals, guided by
> Pain severity
> Physical and psychosocial condition
> Type of intervention
> Risks of adverse effects
>Institutional policy—must always reassess after an intervention

Question 25

Drug Therapy

Answer 25

Three categories of medications:

Nonopioid
Opioid
Adjuvant

Question 26

Nonopiods

Answer 26

> Analgesic ceiling
> Increasing the dose above the upper limit produces no greater analgesia.

> Do not produce tolerance or addiction

> Many are OTC—But are they safe?

• Aspirin and other salicylates
• Acetaminophen
  *NSAIDs — Side effects include GI problems, renal insufficiency, and hypertension.

Question 27

Opioids

Answer 27

> Bind to receptors in the CNS
> Inhibition of transmission of nociceptive input

> Pure agonists - Morphine, oxycodone, and codeine
> Potent, no analgesic ceiling, and have several routes for administration

> Combined with nonopioids for moderate pain
> codeine plus acetaminophen (Tylenol #3)
> hydrocodone plus acetaminophen (Vicodin) or ibuprofen (Vicoprofen)