NURS 171 Week 11: Pain Flashcards
Pain
- unpleasant sensory, emotional experience
- subjective experience
- can not be measured objectively
- can interfere with quality of life, interfere with activities of daily living
- destructive to both patient and family
- can be a warning sign
How can Pain be Classified?
- by region of the body involved
- cause
- duration
- pattern of occurrence/ quality
- intensity
- time since onset
Origin of Pain
site where pain is felt, not necessarily the source of pain
- cutaneous/superficial
- visceral
- deep somatic
- radiating
- referred
- phantom
- psychogenic
Origin of Pain: Cutaneous/ Superficial
arises in the skin or subcutaneous tissue
- ex: hot object/ paper cut
- significant short term pain
Origin of Pain: Visceral
(organs)
- stimulation of deep internal pain receptors
- most often in abdomen cavity, cranium, or thorax
- pain may vary from local, achy, discomfort to more widespread, intermittent and crampy pain
- ex: menstrual cramps, bowel disorders, and organ cancers
Origin of Pain: Deep Somatic
(deep tissue)
- ligaments, tendons, nerves, blood vessels, and bones
- more diffuse than cutaneous pain and lasts longer
- ex: fracture/ sprain, arthritis, bone cancer
Origin of Pain: Radiating
- starts at the origin
- extends to other locations
- ex: severe sore throat may extend to ears and head
- ex: GERD: chest pain
Origin of Pain: Referred
occurs in area distant from original site
-ex: MI–> down arm or across back
Origin of Pain: Phantom
perceived to originate from area that has been surgically removed
- after a limb has been removed, the nerve endings that remain, transmit to the brain that the body part still has pain, even though it has been removed
ex: amputated limbs: burning, itching, and deep pain
Origin of Pain: Psychogenic
believed to arise from the mind
- perceived pain though no physical cause can be identified
- when no medical reason can be found for the pain (is it real, or is it in the mind?)
Causes of Pain
- nociceptive
- neuropathic
Nociceptive
-pain receptors are stimulated
>visceral (organs)
>somatic (tissues + bones)
-most common type
-pain receptors (nociceptors are stimulated)
-noxious, thermal, chemical, or mechanical stimuli
-trauma, surgery, or inflammation
“aching”
-visceral (organs) and somatic (tissues and bones)
Neuropathic
nerves are injured
- complex and often chronic
- injury to one or more nerves
- repeated transmission of pain signals even in absence of painful stimuli
- nerve injury: poorly controlled diabetes, stroke, tumor, alcoholism, amputation, viral infection (shingles, HIV, AIDS)
- medications can trigger nerve injuries
- burning, numbness, itching and pins and needles or prickling pain
Duration of Pain
- acute
- chronic
- intractable
Duration of Pain: Acute
short duration/ rapid onset
- varies in intensity
- may last up to 6 months
- injury or surgery
- “protective” indicates potential or actual tissue damage
- usually disappears as tissue heals
Duration of Pain: Chronic
pain that has lasted 3 to 6 months or longer
- often interferes with activities of daily living
- related to a progressive disorder or with no current tissue injury such as neuropathic pain
- may experience periods of remission or exacerbation
- often viewed as insignificant by family + care providers
- patients may withdrawal, have depression, anger, frustration, and dependence
Duration of Pain: Intractable
chronic and highly resistant to relief
- frustrating
- multi-modal pain therapy
Quality of Pain: Described by Patients
- sharp
- dull
- aching
- throbbing
- stabbing
- burning
- ripping
- searing
- tingling
Quality of Pain: Length
- Episodic
- Intermittent
- Constant
Quality of Pain: Intensity
- mild
- distracting
- moderate
- severe
- intolerable
What Happens When Someone Has Pain? Transduction
activation of nociceptors by stimuli
- activated by perception of mechanical, thermal, or chemical stimuli
- chemicals (bradykinin, histamine, prostaglandins) released: Bradykinins cause inflamed, red, swollen, tender
- Mechanical: trauma
- Thermal: extreme heat or cold
- Chemical: acid (like lemon juice) on open skin or tissue ischemia
Bradykinin
cause inflamed, red, swollen, tender
- inflammation is most frequent cause of pain
- released during transduction (when someone has pain)
What Happens When Someone Has Pain? Transmission
- conduction of pain message to spinal cord
- pain transmission involves chemicals called neurotransmitters
Transmission
peripheral nerves carry pain message to dorsal horn of spinal cord
-A Delta Fibers: myelinated fast pain impulses: acute, focused mechanical + thermal stimuli; bumped knee
-C Fibers: smaller unmyelinated fibers transmit slow pain impulses
>dull, diffuse pain impulses travel at a slow rate
>mechanical, thermal, and chemical stimuli
>lingering ache
Transmission: A Delta Fibers
myelinated fast pain impulses
- acute, focused mechanical and thermal stimuli
ex: bumped knee
Transmission: C Fibers
smaller, unmyelinated fibers transmit slow pain impulses
- dull, diffuse pain impulses travel at a slow rate
- mechanical, thermal, and chemical stimuli
- lingering ache
Pain Perception
recognizing and defining pain in frontal cortex
Pain Threshold
brain recognizes and defines stimulus as pain
Pain Tolerance
duration or intensity of pain a person can endure
Pain Modulation
changing pain perception by facilitating or inhibiting pain signals
- Endogenous Analgesia System
- Gate Control Theory
Pain Modulation: The Endogenous Analgesia System
neurons in the brain-stem activate descending nerve fibers that conduct impulses back to the spinal cord
- impulses trigger release of endogenous opioids and other substances to block pain impulse
- can be stimulated by various pain medications and non pharmacological measures
Endogenous Opioids
naturally occurring analgesic neurotransmitters
- inhibit the transmission of pain impulses
- bind to opiate receptor sites in the central and peripheral nervous system
- 4 receptor sites: Mu, Kappa, Delta, Sigma
- each site has a different affinity for various pain medications
4 Receptor Sites Endogenous Opioids Bind To
-Mu
-Kappa
-Delta
-Sigma
each site has a different affinity for various pain medications
The Gate Control Theory
pain impulses can be influenced/ controlled at the spinal level
- theory: block the “gate” with a non noxious stimulation and block the perception of pain
- asserts that non-painful input closes the “gates” to painful input which prevents pain sensation from traveling to the CNS
- stimulation by non noxious input is able to suppress pain
The Gate Control Theory: Two Types of Fibers
- those that produce pain
- those that inhibit pain
Examples for Gate-Control Theory
-TENS unit
-mediation
-exercise
-relation
-laughter
(compete with C fibers and block the gate)
What Factors Influence Pain?
- emotions
- developmental stage
- sociocultural factors
- communication skills
- cognitive impairments
Factors Influence Pain? Emotion: Fear
- is illness or injury life threatening?
- progressive pain intolerable?
- judged as weak if complain?
- addictive?
- fears can prolong or increase patients pain
Factors Influence Pain? Emotions: Confusion + Helplessness
- role guilt
- when alone may experience loneliness or even a sense of abandonment
Factors Influence Pain? Emotions: Anxiety + Depression
- anxiety + depression are common in people who are ill or hospitalized
- anxiety associated with acute pain
- anticipation of pain may trigger anxiety
- waiting for surgery or procedure
- depression most often linked with chronic pain, especially intractable pain
Factors Influence Pain? Emotions: Previous Pain Experience
- previous pain experience affect emotions
- previous numerous painful experiences can lead to more anxiety and more sensitivity to pain
- if previous pain was controlled are less anxious and trust in pain relief
Factors Influence Pain? Emotions
-fear
-confusion + helplessness
-anxiety + depression
-previous pain experience
-illness and pain trigger emotional reactions
-emotional reactions exacerbate pain
-pain is usually a combination of physical + emotions
Interventions: relieve feelings of fear + helplessness, reflective listening, gentle touch, pain medication
Factors Influence Pain? Emotions: Interventions
- relieve feelings of fear + helplessness
- reflective listening
- gentle touch
- pain medication
Older Adults Vs Pain Influence
- 50% or greater experience pain
- may be unable to report because of cognitive impairment
- nonverbal cues: grimacing, rapid blinking, withdrawal, labored breathing, altered gait or decreased activity
- some have mental confusion or collapse
- some lead to social isolation, depression, sleep disturbances, and mobility related problems
Nonverbal cues for Pain
- grimacing
- rapid blinking
- withdrawal
- labored breathing
- altered gait
- decreased activity
What Factors Influence Pain? Sociocultural Factors
we learn behaviors associated with pain through interactions with family and social support group
- ex: minimizing pain or expression pain often tied to culture
- crying, moaning, silence, brave, smiling at polite nurse
- do not assume
- culture sensitivity
Factors Influence Pain? Communication Skills
-challenges: stroke, dementia, intubation, or limited command of language
-watch for behavioral cues (nonverbal):
>decreased activity, grimacing, frowning, crying, moaning, irritability
Factors Influence Pain? Cognitive Impairments
Indicators:
- Facial expressions (sad, frightened, rapid blinking)
- Vocalizations (noisy breathing, profanity, verbally abusive)
- Changes in Physical Activity (fidgeting, pacing, rocking, disruptive behavior)
- Changes in Routine (refusing food, difficulty sleeping)
- Mental Status Changes (increased confusion)
- Physiological Cues (elevated vital signs)
Pain Responses
- Sympathetic Response
- Parasympathetic Response
- Behavioral Response
- Psychological Response
Pain Response: Sympathetic Response
(acute pain)
- increased alertness
- dilated pupils
- increased heart rate and force
- increased respiratory rate
- increased systolic blood pressure
- rapid speech
- pallor
Pain Response: Parasympathetic
(Deep or Prolonged Pain)
- changeable breathing pattern
- constricted pupils
- decreased pulse rate
- decreased systolic blood pressure with symptoms: feeling faint, possible syncope
- slow, monotonous speech
- withdrawal
Pain Response: Behavioral Responses
- agitation
- crying
- facial grimacing
- guarding of the painful area
- moaning
- withdrawing from painful stimuli
Pain Response: Psychological
- anger
- anxiety
- depression
- exhaustion
- fear
- hopelessness
- irritability
How Does the Body React to Unrelieved Pain? Endocrine
hormones released that affect carbohydrate, protein and fat metabolism, hyperglycemia and poor glucose use
How Does the Body React to Unrelieved Pain? Cardiovascular
- increased Heart Rate
- increased Blood Pressure
- Increased Cardiac Workload
- increased Oxygen Demand
- Hyper-coagulation (excessive blood clotting)
How Does the Body React to Unrelieved Pain? Musculoskeletal
- impaired muscle function
- fatigue
- impaired mobility (immobility)
How Does the Body React to Unrelieved Pain? Respiratory
-shallow breathing that can lead to pneumonia and atelectasis and under ventilation
How Does the Body React to Unrelieved Pain? Genitourinary
affects release of hormones that can lead to
- decreased urinary output
- fluid retention (fluid overload)
- urinary retention
- hypokalemia
- hypertension
- increased cardiac output
How Does the Body React to Unrelieved Pain? Gastrointestinal
intestinal secretions and smooth muscle tone increases and gastric emptying and motility decrease
-decreased gastric motility
Pain Assessment
- comprehensive pain history and assessment
- pain location and quality
- pain intensity
- aggravating and alleviating factors
- time and duration
- pain relief
- pain relief expectations
- ADLs affected?
- mobility
- depression? substance abuse?
Pain, the Fifth Vital Sign
Goal: to assess pain on a regular and ongoing bases
-accept clients pain assessment
Pain Treatment
- prescribed analgesic
- non pharmacological options
- consider risk of dependency, abuse + addiction
- assess pain before medication administration and after (relief?)
Assessing Pain: Focused Assessment
-obtaining a complete pain history: patient self report (onset, location, aggravating + alleviating factors)
-use pain scales
-change of condition
-need for more aggressive pain management
(increase in pain may indicate change in condition or a need for more aggressive pain management)
-Nonverbal signs of pain:
>physiological (vital signs)
>behavioral (withdrawal, guarding, moaning, agitation)
>psychological (fear, anxiety, irritability)
Pain Scales
- Visual Analogue Scale (VAS)
- Numeric Rating Scale (NRS)
- Simple Descriptor Scale
- Wong-Baker Faces Pain Rating Scale
Words Commonly Used to Describe Pain Across Cultures
- pain
- hurt
- ache
Non-verbal Signs of Pain
- facial expression
- posture
- body position
- changes in vital signs
- may not be acting like they are in pain
- use interpreter if different language is spoken
- treat underlying depression
Planning Outcomes
Goal: prevent, reduce, or eliminate pain
Planning Interventions
- control pain with least invasive/ most effective method
- include non-pharmacologic methods
- care depends on cause of pain (acute/chronic)
- actively listen to self report of pain
- provide analgesics promptly
- assess responses to analgesics + non-pharmacological measures including level of sedation (30 to 60 minutes after administration)
- manage side effects
- reduce anxiety and fear by including patient in pain management plan
- consult with healthcare provider for complex pain management issues
- alter treatment if not adequately relieved
- delegate appropriate strategies to nursing assistant personnel (NAP)
Pain Management Strategies
- reposition using pillows for support
- back rub or massage
- quiet/ dark room for sleep
- reduce clutter in patients room
- mouth care
- soft music
- using distraction
Non-pharmacological Measures Complimentary Therapy
-Based on "Gate Control Theory" >TENS unit >PENS unit >Spinal Cord Stimulator -acupuncture -acupressure -use of heat + cold -contralateral stimulation -immobilization -massage such as effleurage; slow guided strokes -myofasical release of overused or injured muscles + nerves
Non-pharmacological Measures Complimentary Theory Based on “Gate Control Theory”
- TENS
- PENS
- Spinal Cord Stimulator
TENS Unit
transcutaneous electrical nerve stimulator
- electrodes, connecting wire, and stimulator
- pads directly on painful area
- stimulates delta A fibers
- can be worn intermittently or longer periods of time
- complimentary therapy based on “gate control theory”
PENS Unit
Percutaneous electrical stimulation
- placed through the skin
- stimulates peripheral sensory nerves
- effective in short term/ acute and chronic pain management
- complimentary therapy based on “Gate Control Theory”
Non-pharmacological Measures Complimentary Therapy
- acupuncture
- acupressure
- use of heat + cold
- contralateral stimulation
- immobilization
- massage such as effleurage; slow, long guided strokes
- myofasical release of overused or injured muscles + nerves
Cognitive-Behavioral Interventions
- distraction
- relaxation techniques
- guided imagery
- diaphragmatic breathing
- hypnosis
- therapeutic touch
- humor
- expressive writing
- animal assisted therapy
Cognitive-Behavior Therapy: Distractions
- Visual: watch TV
- Tactile: massage, hugging favorite toy, holding loved one, stroking pet
- Intellectual: crossword puzzle, game
- Auditory: music therapy
- Olfactory: soothing smells with aromatherapy
Pharmacological Pain Relief Measures
- analgesics
- non-opioid analgesics
- opioid analgesics
Pharmacological Pain Relief Measures: Analgesics
- non-opioids
- adjuvants
- opioids
- analgesics work best if given before pain becomes too severe
- administer next dose before last dose wears off
- consider around the clock dosing
Non-opioid Analgesics
mild to moderate pain that is acute or chronic
- NSAIDs: Ibuprofen, naproxen, aspirin
- Acetaminophen (Tylenol)
- often compounded with opioids to allow for lower dose of opioid
Opioid Analgesics
- includes IV, IM, transdermal, and epidural forms
- client-controlled analgesia pump
- natural and synthetic compounds that relieve pain
- work by binding with pain receptor sites to block pain impulses (mu, delta, kappa, sigma)
- Mu most effective in relieving pain
- no maximum daily dose for Mu agonists
- Mu: codeine, morphine, hydrocodone, hydromorphone, fentanyl, methadone, oxycodone
Mu
pain receptor site
- most effective in relieving pain
- no maximum daily dose for Mu agonists
- Mu: codeine, morphine, hydrocodone, hydromorphone, fentanyl, methadone, oxycodone
NSAIDs
- largest group of non-opioid analgesics
- act primarily in peripheral tissues
- interfere with production of prostaglandins
Prostaglandins
- sensitize pain receptors
- involved with inflammation
NSAIDs Side Effects
- gastric irritation
- gastric bleeding
- kidney toxicity, hypertension, and heart failure in older adults with certain NSAIDs
NSAIDs Interventions
- administer low dose
- administer with food
- administer enteric coated pills
Acetaminophen
-non-opioid analgesic
-very little anti-inflammatory effect
-fewer side effects
-“safest”
-can cause liver toxicity
(recommended dose maximum is 4000 mg a day)
Adjuvant Analgesics
- may be used as a primary therapy for mild pain
- in conjunction with opioids for moderate to severe pain
- reduce the amount of opioids needed
- frequently used in managing neuropathic pain
Adjuvant Analgesics Medications
- anticonvulsants
- antidepressants
- local anesthetics
- topic agents (lidocaine)
- psycho-stimulants
- muscle relaxants
- neuroleptics
- corticosteroids
Adjuvant Analgesics Medications: Psycho-stimulants
produces a temporary increase in psycho-motor activity or temporary improvement in physical function or mental processes or both
-caffeine, nicotine, amphetamines, methamphetamine, ecstasy, cocaine, and methylphenidate
Opioid Analgesics: Agonist-Antagonist
- another group of opioids
- stimulate some opioid receptors but block others
- for moderate to sever acute pain
- should not be given to patients taking Mu agonist (morphine)
Opioid Analgesics Patient Misconceptions
- respiratory depression
- tolerance
- physical dependence
- psychological dependence
Opioid Misconception: Respiratory Depression
can be treated with naloxone, an opioid antagonist
Opioid Misconception: Tolerance
can occur but increasing the dose or changing the route of administration can correct the problem
-there is no ceiling on the analgesic affects of opioids
Opioid Misconception: Physical Dependence
leads to withdrawal symptoms when the drug is removed abruptly
Opioid Misconceptions: Psychological Dependence
commonly called addiction, occurs in less than 1% of patients even after long term prescribed use of opioids for pain
Opioid Analgesics: Screening for Abuse
- patients with tendency for abuse can become addicted
- healthcare professions needs to screen for drug, alcohol use and history
Opioid Side Effects
-drowsiness
-nausea, vomiting
-constipation
>Large Doses can lead to: respiratory depression, hypotension
>Assess before Administering: level of alertness, respiratory status
Opioid Analgesics: Large Doses Can Lead To
-respiratory depression
-hypotension
>assess before administering: level of alertness, respiratory status
Other Side Effects of Opioids
- difficulty with urination
- dry mouth
- sweating
- tachycardia
- palpitations
- bradycardia
- rashes
- urticaria (hives)
- Pruritis (itching)
Other Assessments for Opioids
- paradoxical reactions (increased pain)
- sedation (some sedation is to be expected)
Richmond Agitation- Sedation Scale
Sedation Rating Scale
- combative
- very agitated
- agitated
- restless
- alert and calm
- drowsy
- light sedation
- moderate sedation
- deep sedation
- unarousable
Routes of Administration for Opioids
- use safest and least invasive rout
- patient controlled analgesic (PCA) (allows patient to self administration for pain relief)
- oral
- parenteral
- epidural
- subcutaneous
- intravenous
PCA (patient controlled analgesic)
- includes infusion pump, syringe, IV tubing, and a hand held trigger
- programmed by nurse
- dosing to manage patients pain effectively
- most have a maximum dose allowed for given period of time
Opioid Analgesic Routes: Oral
- convenient and safe
- produces steady and analgesic levels
- mild to severe pain
Opioid Analgesic Route: Transdermal
- applied to skin
- delivers continuous release of drug for up to 72 hours
- febrile patients will have increased absorption
- does not provide immediate relief
- proper disposal
Opioid Analgesic Route: Subcutaneous
- used for intermittent injections and continuous administration of opioids
- absorption and distribution vary according to site
Opioid Analgesic Route: IM
- not preferred route
- sterile abscesses and fibrotic tissue can result
Opioid Route: IV
- produces immediate pain relief
- desirable for acute and escalating pain
- short term therapy in hospital setting
- in home setting for patients with cancer and other pain situations where oral intake is not tolerable
- requires venous access
Opioid Routes: Epidural (or intraspinal)
- delivery of analgesia
- requires placement of a catheter in the subarachnoid, epidural or intrathecal space
- risk of infection, hematoma, and nerve damage as well as dural puncture
Chemical Pain Relief Measures
- regional anesthesia
- local anesthesia
- topical anesthesia
Chemical Pain Relief Measures: Regional Anesthesia
anesthetic agent injected into or around the nerve that supplies sensation to a specific part of the body used in surgery, childbirth, and long-term pain management
- nerve blocks
- epidural injection
Chemical Pain Relief Measures: Local Anesthesia
short or long acting
-injection of local anesthetics into body tissue
Chemical Pain Relief Measures: Topical Anesthesia
applying an agent directly to the skin, mucous membranes, wounds, or burns
-absorbed quickly and provides relief for mild to moderate pain
Surgical Interruption of Pain Conduction Pathways
- Cordotomy
- Rhizotomy
- Neurectomy
- Sympathectomy
Cordotomy
interrupts pain and temperature sensation
Rhizotomy
interrupts anterior or posterior nerve route that is located between the ganglion and the cord
Neurectomy
used to eliminate intractable localized pain
Sympathectomy
severs the paths to the sympathetic division of the autonomic nervous system
Misconceptions that interfere with pain management: perceptions of the patients
- pain is a sign of weakness
- part of aging
- no pain, no gain
- fears of addiction
Misconceptions that interfere with pain management: perceptions of caregivers
- others in the same situation do not have pain
- no obvious physical cause
- concerns for drug seeking behavior and addiction
Managing Pain In Older Adults
- many take multiple medications–> drug interactions
- drug distribution is altered due to changes in blood flow to organs, protein binding, and difference in body composition
- at risk for under-treatment of pain due to concern about confusion + sedation by caregivers
- may not communicate about pain effectively
- both unmanaged pain + pain medication can increase risk of falling
Managing Post-Operative Pain
- use pain assessment tool
- individualize plan
- use a variety of analgesic and non-pharmacological techniques
- administer around the clock dosing
- monitor for side effects of analgesics
Managing Pain in Patients with Substance Abuse or Active Addiction
-physical dependence + addiction not the same
>addiction is psychological dependence (compulsive use with self destructive behaviors o obtain drug)
-nurse should remain non judgmental
Be Aware of the Following Behaviors and Consult Pain Management Specialist With Patients with Substance Abuse
- repeated requests for injections
- refusal to try oral medications
- doctor shopping
- pharmacy shopping
Evaluation
- compare finding with expected outcome
- determine whether pain management strategy is effective
- reassess patients pain regularly
