NRSG 126 - Week 4 Flashcards
comfort and mobility
Pain definition
- Pain is NOT normal and not normal with ageing!
- Most common reason individuals seek medical care.
- Pain is a general term describing uncomfortable sensations in the body.
o Activation of the nervous system.
Pain and subjective
o Subjective – but we must believe them and try to find a root cause. Check for signs of pain, swelling, grimacing, withdrawal, wounds, change in vitals in major events or shock. Acute vs chronic pain. Acute pain shows in vitals but chronic pain does not.
o 6th vital sign
Purpose of pain
- Purpose of pain: Defense mechanism. Good reminder for people to be careful to not injury themselves after surgery. Number on a scale can be different for everyone
Older Persons Experiencing Pain
- Experience of pain changes with age. Pathways might be slower, burns are a higher risk because detection is slowed. Reflexes slowed
- May have atypical presentation.
- Pain or pain treatments can have increased negative effects. Medications cannot dissolve right so they might be given less medication. NASAIDs increase the chance of GI bleeds, also steroids
- May have misconceptions re: pain management.
- 37% at home and 41% in institutions live with chronic pain
Transduction
- First phase: injury and response initiation
- Refers to how the pain nerve fiber recognizes the signal of tissue or cell damage.
- Nociceptors are sensory nerve cells that react to noxious stimuli by sending signals to the spinal cord and brain
o Damaged cells – burns, cut, etc.
o Chemical release – Pain-sensitizing & inflammatory substances
o Nociceptor activation – action potential
Transmission
- Second Phase: pain moves from PNS to CNS
- Pain-sensitizing & inflammatory substances spread the message
- via nerve fibers
- transmission of PAIN in dorsal horn
- spinothalamic tract (goes to the brain)
Peripheral Nerves: Types of Fibers
- A-delta fibers - myelinated, sharp, well localized, and short in duration
- C fibers- unmyelinated, dull, aching, diffuse nature, slow onset, and relatively long duration
Perception
- Third phase: conscious awareness of pain and interpretation
- Pain interpretation – somatosensory cortex – association cortex
- Intensity, quality, character, experience, location – location and intensity – how do we fell about the pain?; limbic system: emotion and memory (anxiety)
Mobility (what are you testing for in mobility)
- ROM- passive & active (passive is someone else moving for you)
- Gait - a person’s manner of walking
- Exercise
- Activity tolerance – how much activity can they tolerate. Pain can impact that, lung or heart conditions can affect it, also amenia.
- Proprioception- awareness of the body position and its parts. Proprioceptors are in muscles, bones and joints. The ability to walk without watching our feet. Controlled by our nervous system!
- Balance- Cerebellum and inner ear.
modulation
- Fourth phase: altered signals and response
- Pain increases or pain decreases
Mobility (what you check for)
- ROM- passive & active (passive is someone else moving for you)
- Gait – a person’s manner of walking
- Exercise
- Activity tolerance – how much activity can they tolerate. Pain can impact that, lung or heart conditions can affect it, also amenia.
- Proprioception- awareness of the body position and its parts. Proprioceptors are in muscles, bones and joints. The ability to walk without watching our feet. Controlled by our nervous system!
- Balance- Cerebellum and inner ear.
Skeletal System – 206 Bones!
- 5 functions:
o Support (e.g. all of our feet bones)
o Protection (e.g. our ribs & sternum)
o Movement (e.g. arms & legs)
o Mineral storage (e.g. femur)
o Hematopoiesis (e.g. hip bones) - Characterized by shape:
o Long (e.g. femur)
o Short (e.g. carpels)
o Flat (e.g. sternum)
o Irregular (e.g. vertebrae)
Support: Joints
- Connections between the bones
- Synarthrotic: bone on bone
- Cartilaginous: joints with little movement; cartilage found in between bones
- Fibrous: a joint where 2 bony surfaces meet with a ligament
- Synovial: freely moving joint covered by articular cartilage & connected by ligaments
Support: Ligaments, Tendons & Cartilage
- Ligament: flexible bands of fibrous tissue. They connect bones and cartilage; or bone to bone
- Tendons: fibrous bands of tissue that connect bone to muscle
- Cartilage: supporting connective tissue, used for shock absorption
Skeletal Muscles
- Muscles are made from fibers that contract when stimulated by impulses that travels from one nerve to the muscle across the neuromuscular junction.
- Functions of muscles:
o Moving, Stabilizing, Posture
o Heat, Circulation, Organ protection (muscles help move the venous blood to the heart, risks of blood clots) (compressions socks help)
Skeletal Muscles – 2 types of contractions
- Isotonic- muscles contraction and change in length
example- weight lifting - Isometric- muscles being tightened/ tense without moving body parts
example- yoga
Alignment, Postures and Balance
- Together these reduce risk of injury and facilitate proper function of other organs.
- Body alignment is relationship from one body part to another e.g. distal, mid, proximal.
- Body balance (equilibrium) happens when your center of gravity is balanced over a stable base.
Pain - Acute and Chronic
- Acute pain
o Sudden and typically resolves
o cause- illness or injury- trauma, surgery, infection, angina etc.
o vitals change, sympathetic nervous system activation (SNS)
o delirium, anxiety, agitation - Chronic pain
o Lasts over 3 months and often not resolved
o causes- illness or injury- cancer treatment, RA, OA, fibromyalgia etc.
o no vital change, body adaptation
o can cause anxiety, depression
Pain- Defined Levels
- mild
o not a problem, I can deal with is… ish - moderate
o Okay, starting to be an issue! - Serve
o OUCH! Medication STAT!!!
factors affecting pain
- Physiological
o Age
o Sleep
o Heredity
o Neurological Function - Psychological
o Anxiety
o Meaning of pain
o Spiritual
o Cultural - Social
o Attention
o Previous Experiences
o Family & Social Support
types of nociceptive pain
somatic pain - arises from bone, joint muscle, skin, or connective tissue, it is usually aching or throbbing in quality and is well localized
visceral pain - arises from visceral organs such as the gastrointestinal tract and pancreas
types of neuropathic pain
- deafferentation pain - injury to either the peripheral or central nervous system. Examples: Phantom pain may reflect injury to the peripheral nervous system; burning pain below the level of a spinal cord lesion reflects injury to the central nervous system
sympathetically maintained pain - - Sympathetically maintained pain. Associated with dysregulation of the autonomic nervous system. Examples: May include some of the pain associated with complex regional pain syndrome - Painful polyneuropathies. Pain is felt along the distribution of many peripheral nerves. Examples: Diabetic neuropathy, alcohol-nutritional neuropathy, and those associated with Guillain-Barré syndrome
2. peripheral - Painful mononeuropathies. Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: Nerve root compression, nerve entrapment, trigeminal neuralgia
Which of the following are examples of Somatic pain?
o Tibia Fracture
o Superficial Burn
o Arthritis
Which of the following are examples of Visceral pain?
o Menstrual Cramps
o Myocardial Infarction (MI) acute unless angina
o Appendicitis
Which of the following are examples of Deafferentation (acute)?
o Phantom Limb Pain, spinal cord injury, shingles, spinal tumor
Which of the following are examples of Sympathetic (fight of flight not working properly)?
o CRPS Complex Neuropathic Pain, Raynaud’s Disease
Which of the following are examples of Peripheral?
o Diabetic Neuropathy
o Trigeminal Neuralgia
pain type
- Somatic
o Most common
o Skin, bone, joint, muscle & connective tissue
o Increases with movement
o Described well i.e. “throbbing”
o Localized
o Treatment: non opioids, opioids, heath/cold, topical - Visceral
o Internal organs
o Tends to be diffuse (not localized)
o Not as easy to describe- more vague
o Can also radiate (example: myocardial infarction aka heart attack)
o Treatment: Non opioids and opioids - Neuropathic
o Injury to the nerve or abnormal processing of stimuli by the peripheral or central nervous system
o Illness, injury may be undetermined
o May be described as burning, shooting, electrical, or prickling
o Not localized
o Chronic in nature
o Treatment: Adjuvants and opioids
Pain Treatment: Nonpharmacological Interventions
- Physical Modalities:
o Cold
o Heat
o Massage
o Positioning
o Bedding/Bed
o Acupressure
Pain Treatment: Pharmacological Interventions
- NSAIDS and non-opioids
- Opioids
- Co-analgesics
Non-opioids
o Mild to moderate pain
o Tylenol (risk of hepatoxicity)
o Max 4g a day
Topical
Topical- may benefit older adult, especially with slowed/decreased GI function
Opioid
o Moderate to severe pain
o respiratory depression (CNS is depressed, they will not know)
o Codeine, Morphine and Hydromorphone
o Risk of N/V (nasusa and vomiting), constipation, delirium, prurits
Co-analgesic (adjuvants)
o Not initially intended for pain
o Anticonvulsants, Corticosteroids, and Other (some antidepressants as well)
o Risk of decreased healing, osteoporosis
Effects of Pain and Pain Management
- Physiological- nausea (especially with liver), fatigue
- Psychological- depression, ineffective coping, anxiety, disturbed sleep, guilt, spiritual distress
- Psychosocial- impaired social interactions, sexual dysfunction
- Fear- addiction, impact of pain
- Increase hospital stay
- Delay healing
- Lead to chronic pain
addiction
- disease with genetic, psychological, and environmental factors
Tolerance
- exposure decreases effects
o opioid use then
o Simulation of opioid receptors in brain
o Upregulation (Upregulation= increased opioid receptors) of opioid receptors
o Receptors demand more opioids - New research says people with addicts need more pain meds
Dependence
- class-specific drug withdrawal syndrome
osteoporosis
o A chronic disease that is primarily age associated and can be exacerbated by gender (female), other health conditions and medications. Can have a major impact on mobility and safety and increases risks of fracture.
o “porous bones” = decreased bone mass- Chronic disease
o Primary: age-associated, post-menopausal
o Secondary: Hyperthyroidism (untreated), medications (steroids)
Pathological Fracture
o An injury that occurs from a chronic condition that weakens bones.
o Pathological= caused by disease
o Fracture (#)= break
o Causes: osteoporosis, cancer, osteomyelitis.
Osteoarthritis
o A chronic disease that commonly affects the knees and hips requiring surgery. Causes a lot of pain and affects mobility. Often referred to as “wear and tear” of the joint.
o Most common type of arthritis
o Progressive breakdown of joint cartilage & underlying bone
o Joints commonly affected: knees, hips, big toes, hands, spine
Rheumatoid Arthritis
o An autoimmune disorder that affects joints causing pain and deformity. Often occurs in the hands and can affects independence with ALDs.
o Autoimmune & inflammatory- painful swelling in multiple joints
o Injury to joint lining causes chronic pain, mobility issues & deformity.
o Joints commonly affected: hands, wrists and knees.
o Typically more than one joint
- Effects of lack of mobility: Deconditioning
o Immobility leads to decreased functional capacity affecting multiple systems: decline in physical; function. Wasting away, atrophy
Musculoskeletal Changes- Risk Factors
- Osteoporosis
o Gender
o Heavy caffeine use (Ca++)
o Ca &/or Vit D deficiency
o Low BMI
o Certain medications/diseases
o Too much/little exercise - OA
o Obesity (increased BMI)
o Trauma
o Genetics
o Overuse
o Gender (F>M) - Pathological Fracture
o Caused by disease that weakens the bone: Cancer, Osteoporosis. Osteomyelitis.
o 1 in 3 women and 1 in 5 men
Musculoskeletal Changes- Diagnosis
- Osteoporosis
o Assessment
o Dual-energy x-ray (bone density)
o Lab tests (Ca, CBC, Cr. Etc.)
o Shortened height, decreased weight, fractures. - OA
o Assessment
o X-ray* / MRI
o Rule out other causes: Blood tests, Fluid samples, arthroscopy
o Joint pain, aching, morning stiffness lasting <30 min, reduced ROM in affected joint(s) and possibly swelling. - Pathological Fracture
o Assessment
o X-ray
o Pain and a history increasing risk for pathological fracture. May/may not be from obvious injury.
Musculoskeletal Changes- Treatment
- Osteoporosis
o Exercise/falls prevention
o Physiotherapy
o Dietician
o Vitamins & minerals
o Medications - OA
o NSAIDS, Non-opioid (Tylenol), adjuvant (Cymbalta)
o TENS
o Exercise +/- Wt. loss
o Mobility aids
o Surgery - Pathological fracture #
o Surgery
o Pain control
o Palliative care
Role of the nurse
- Knowledge of pain and mobility
- Knowledge of exemplars discussed
- Knowledge of ADPIE
Nursing Process: Assessment
- Assessment: To be reviewed and practiced in lab: OPQRSTUV or LOTARP, MSKL assessment
o subjective and objective findings - Patient information: history, risk factors etc.
OPQRSTUV
- O: Onset
- P: Precipitating/Palliating (what makes it better or worse)
- Q: Quality/Quantity = type of pain and severity
- R: Region/Radiation= Location of pain?
- S: Severity (pain scale)
- T: Timing = constant or intermittent
- U: Understanding (pt’s) of the pain and its impact & impact on ADLs (what do you think is causing this pain)
- V: Values (pt’s) (what are your cultural and religous or other values about pain)
LOTARPS
- L: Location
- O: Onset
- T: Type/Timing
- A: Aggravating, alleviating & associated symptoms
- R: Radiation
- P: Precipitating event
- S: Severity
Nursing Process: Assessment - Possible reasons for not reporting pain?
- Fear
- Is it worth reporting?
- Normal part of ageing- misconception
- Fear of addiction
- Do not want to bother nurses
- Consider the impact of understanding/knowing the pathology of the pain.
- Idiopathic means unknown cause
Nursing Process: Assessment – Pain: Behavioural and nonverbal indicators:
o Facial expressions: Grimacing, furrowed brow, holding eyes tightly shut, pursed lips.
o Guarding, holding, rubbing
o Moaning, crying/ few sounds
o Restless, agitated, irritability, anger
o Altered sleep patterns
o Changes to appetite
o Vitals and diaphoresis (acute pain)
- Consider cultural differences and beliefs around pain, expression, meaning, goals, and pain treatment.
- Misconceptions associated with pain and ageing or gender.
Nursing Process: Assessment - Activity & Exercise
- Age: think back to the normal changes in older adults…what happens???
- Environmental issues: time, finances, physical barriers can help with the patients activity or exercise
- Disease process (ask how it affects mobility)
Nursing Process: Assessment – Mobility (consider the following…)
- Congenital abnormalities
- Bone, joint and muscle disorders
- CNS damage and disorders
- MSKL trauma
- Other chronic diseases
Nursing Process: Diagnosis
- Focuses on the specific nature of pain and mobility (or lack of)
- Examples:
- Anxiety
- Fatigue
- Acute pain
- Chronic pain
- Ineffective coping
- Ineffective role performance
- Disturbed sleep pattern
- Impaired physical mobility
- Impaired walking
- Impaired transfer ability
- Activity intolerance
- Risk for pressure ulcer
Nursing Process: Planning
- Support pain control and encourage mobility!
This leads to fewer complications & increased patient benefits! - SMART format.
- Consider setting.
- Prioritize interventions.
Client & family education. - Consult other HCPs P.R.N.
Nursing Process: - Implementation & Evaluation
- Pain
o Administer/support pain treatment
o The client has no pain or manageable pain - Mobility
o Consult PT and OT, supply with appropriate devices
o The client can safely mobilize independently - When there is an alteration in mobility, each body system is at risk for impairment.
