Pain Flashcards
Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a change in the nervous system, as well as being reflective of the patient’s past pain experiences and the meaning of pain.
What are the dimensions of pain?
cognitive, affective, physiologic, behavioral, sociocultural
Cognitive dimension of pain
Beliefs, attitudes, memories, and meaning attributed to pain that can influence the patient’s response to pain and should be incorporated into the comprehensive treatment plan
Affective dimension of pain
Emotional response to pain experience. Responses may include anger, fear, depression or anxiety. May be relieved by pain reflief and influenced by spirituality
Physiologic dimension of pain
Transmission of nociceptive stimuli that communicates tissue damage to the CNS
Behavioral dimension of pain
Observable actions used to express or control pain include facial expressions, social withdrawal, decrease in physical activity, use of relaxation and taking medications. Responses may also include fear, depression and anxiety
Sociocultural dimension of pain
Includes demographics, support systems, social roles, and culture. Age, gender, and education may influence beliefs and coping strategies. Sociocultural dimension of pain must be assessed without stereotyping
Narcotic Tolerance
This is the need for an increased dose to maintain the same degree of pain control. It is not as common as people think. If this develops the MD may choose to rotate drug instead of increasing the dose.
Physical Dependence
This is an expected response to ongoing exposure to pharmacologic agents manifested by withdrawal symptoms when blood levels drop abruptly. The drug should be tapered to avoid this barrier.
Addiction
This is a neurobiolgic condition where there is a drive to obtain and take substances for other than prescribed therapeutic value.
Endorphins
opiate-like peptides produced naturally by the body at neural synapses in the CNS which modulate the transmission of pain perception. They raise the pain threshold, produce sedation and euphoria.
Pain Threshold
The level that must be reached for an effect to be produced
Referred Pain
Pain that is perceived in an area distant from the site of the stimuli
Intractable Pain
Pain that continues to occur even with optimal medical management
Phantom Pain
A pain syndrome that occurs following surgical or traumatic amputation of a limb. The client experiences pain in the missing body part even though there is complete mental awareness that the limb is gone.
Somatic Pain
Pain arising from nerve receptors originating in the skin or close to the surface of the body
Visceral Pain
Pain arising from body organs, dull and poorly localized due to low number of nocipceptors
Neurogenic Pain
Also referred to as neuropathic pain. Arising from nerves
Gate Control Theory
Proposed by Ronald Melzack and Patrick Wall, gate control theory suggests that the spinal cord contains a neurological “gate” that either blocks pain signals or allows them to continue on to the brain. Unlike an actual gate, which opens and closes to allow things to pass through, the “gate” in the spinal cord operates by differentiating between the types of fibers carrying pain signals. Pain signals traveling via small nerve fibers are allowed to pass through, while signals sent by large nerve fibers are blocked. According to this theory synapses in the dorsal horns act as a gate that closes to keep impulses from reaching the brain or open to permit impulses to ascend to the brain. Gate control theory is often used to explain phantom or chronic pain.
Gate Control Theory & Nursing
The Gate Control Theory is one approach that helps to explain how thoughts and emotions of an individual modify the perception of pain. Clinically, RNs can use this model to treat the underlying causes of pain with nursing interventions such as massage, heat, cold, imagery, distraction, empathy and support
Factors that can affect an individual’s perception of and reaction to pain
- Ethnic and cultural values
- Developmental stage
- Environment and support individuals
- Past pain experiences
- Anxiety and stress
- Pain barriers
Infant (1 Month to 1 Year) Pain Perception, Behavioral responses and TNIs
- Give a glucose pacifier.
- Use tactile stimulation. Play music or tapes of a heartbeat
Toddler (1 to 2 Years) Pain Perception, Behavioral responses and TNIs
- No formal concept of pain related to immature thought process and poorly developed body image
- Reacts as intensely to painless procedures as to ones that hurt, especially when restrained
- Intrusive procedures, such as temperatures are very distressing
- Reacts to pain with physical resistance, aggression, negativism, and regression
Preschool (3 to 5 Years)Pain Perception, Behavioral responses and TNIs
- Pain perceived as punishment for bad thoughts or behavior
- Difficulty understanding that painful procedures help them get well
- Cannot differentiate between “good” pain (as a result of treatment) and “bad” pain (resulting from injury or illness)
- Reacts to painful procedures with aggression and verbal reprimands, e.g., “I hate you.” “You’re mean.”
- Distract the child with toys, books, pictures.
- Involve the child in blowing bubbles as a way of “blowing away the pain.”
- Hold the Child to provide comfort
School-Age Children (6 to 10 Years) Pain Perception, Behavioral responses and TNIs
- Reaction to pain affected by past experiences, parental response, and the meaning attached to it.
- Better able to localize and describe pain accurately
- Pain can be exaggerated because of heightened fears of bodily injury, pain, and death
- Provide a behavioral rehearsal of what to expect and how it will look and feel.
Adolescent (11 to 18 Years) Pain Perception, Behavioral responses and TNIs
- Can locate and quantify pain accurately and thoroughly
- In general, highly controlled to responding to pain and painful procedures; brave in front of peers and not report pain
- Provide opportunities to discuss pain.
- Provide privacy.
- Present choices for dealing with pain. Encourage music or TV for distraction.
Adult Pain Perception, Behavioral responses and TNIs
- Behaviors exhibited when experiencing pain may be gender-based behaviors learned as a child.
- May ignore pain because to admit it is perceived as a sign of weakness of failure.
- May use pain for secondary gain, for example, to get attention.
- Deal with any misconceptions about pain.
- Focus on the patient’s control in dealing with the pain.
- Allay fears and anxiety when possible.
Elder Pain Perception, Behavioral responses and TNIs
- May perceive pain as part of the aging process.
- May have decreased sensations or perceptions of the pain.
- Lethargy, anorexia, and fatigue may be indicators of pain.
- May withhold complaints of pain because of fear of the treatment, of any lifestyle changes that may be involved, or of becoming dependent.
- May describe pain differently, that is, as “ache,” “hurt,” or “discomfort.”
- May have chronic pain which often results in depression, sleep disturbance, decreased motility, and social isolation
Pain Assessment
pattern, area, intensity, nature
Pain Pattern
How pain changes with time, its onset, and duration
Pain Area
Place on the body where pain is felt. helps provider to identify cause and treatment of pain. same as location of pain.
Pain Intensity
Amount of pain felt, rated using pain scales
Pain Nature
How the pain feels to the patient. The quality of pain, sharp, aching, burning, experiences such as anxiety, depression and fatigues can worsen nature of pain
Define Pain Pattern
Describes how the pain changes with time, activity or other factors. Refers to factors that increase or relieve pain
Examples of pain pattern desciptors
- Continuous, steady, constant
- Rhythmic, periodic, intermittent
- Brief, momentary, transient
Visual Analog Scale
Ask patient to place a mark on a line that best describes amount of pain. With a centimeter ruler, measure from “no pain” end of the scale to the patient’s mark and record centimeter number of the measurement of pain intensity. Example: “Patient has a 2.5 cm measurement of pain at 8 am.” At 10 am patient had a measurement of 3 cm pain. The pain would be worse at 10 am. Use with all patients age 5 or older.
Numeric Rating Scale
Explain to patient that at one end of the line is zero which means no pain. At the other end is ten which means worst possible pain. Ask patient to choose a number that best describes own pain. Use with all patients age 4 1/2 and older.
Wong FACES Pain Rating Scale
Can be used with children starting at age 3. Point to a face that best describes patient pain.
FLACC Scale
This scale is used to assess pain levels in cognitively impaired patients including patients recovering from anesthesia and children ages 2 months – 7years.
FLACC Score 0
No particular expression or smile, normal position or relaxed, lying quietly, normal position, moves easily, no cry awake or asleep, content, relaxed
FLACC Score 1
occasional grimace or frown, withdrawn, disinterested, uneasy, restless, tense, squirming, shifting back and forth, tense, moans or whimpers, occasional complaint, reassured by occasional touching, hugging or being talked to, distractible
FLACC Score 2
frequent to constant quivering chin, clenched jaw, kicking or legs drawn up, arched, rigid or jerking, crying steadily, screams or sobs frequently, frequent complaints, difficult to console or comfort
To use FLACC Scale
Assess each of the categories in the far left column to obtain a score of 0-2 then
Add the scores for all five categories to obtain a score of 0-10.
Behavioral Assessment
Behavioral assessments are important. Many individuals who are experiencing pain show it either by verbal complaints or nonverbal behaviors.
Nonverbal Facial Expressions Indicating Pain
Clenched teeth Wrinkles forehead Biting lips Scowling Closing eyes tightly Widely opened eyes or mouth
Nonverbal Vocalizations Indicating Pain
Crying Moaning Gasping Groaning Grunting
Nonverbal Body Movement Indicating Pain
Restlessness Protective body movement Muscle tension Immobility Pacing Rhythmic movement
Nonverbal Social Interaction Indicating Pain
Silence
Withdrawal
Reduced attention span
Focus on pain relief measures
Define Acute Pain
An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and DURATION OF LESS THAN 3 MONTHS OR TIME FOR NORMAL HEALING TO OCCUR.
Define Chronic Pain
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a DURATION OF GREATER THAN 3 MONTHS. (PER MCC GUIDELINES)
State in which the individual experiences pain that persists for a period of time beyond the usual course of acute illness or a reasonable duration for the injury to heal, is associated with a chronic pathological process or recurs at intervals for months or years
Defining Characteristics Acute Pain
Expressions of pain are extremely variable and cannot be used in lieu of self report
- Loss of appetite
- Inability to deep breathe, ambulate, work, sleep, perform ADLs
- Guarding
- Self-protective behavior
- Self focus
- Narrowed focus
- Distraction behavior ranging from crying to laughing
- Muscle tension or rigidity
Onset Acute Pain
Sudden
Severity Acute Pain
Mild to severe
Onset Chronic Pain
Gradual or Sudden
Severity Chronic Pain
Mild to severe
Defining Characteristics Chronic Pain
Expressions of pain are extremely variable and cannot be used in lieu of self report
- Loss of appetite
- Inability to deep breathe, ambulate, work, sleep, perform ADLs
- Guarding
- Fatigue
- Withdrawal from others and social isolation
- Self-protective behavior
- Self focus
- Narrowed focus
- Distraction behavior ranging from crying to laughing
- Muscle tension or rigidity
Course of pain Acute Pain
Over time and goes away as recovery occurs related to tissue injury; resolves with healing
Course of Pain Chronic Pain
typically pain does not go away, periods of waxing and waning, continues after healing and withdrawn
Physical and Behavioral Manifestations Acute Pain
SYMPATHETIC PHYSIOLOGIC RESPONSE “Flight or fight” response increase blood pressure increase heart rate increase respiratory rate Diaphoresis Dilated pupils
BEHAVIORAL RESPONSE
- i ncrease anxiety and restlessness
- Crying, rubbing area, holding area
- Patient reports pain
Physical and Behavioral Manifestations Chronic Pain
PARASYMPTHETIC PHYSIOLOGIC RESPONSE normal vital signs
Dry, warm skin
Normal or dilated pupils
BEHAVIORAL RESPONSE
- Depression and withdrawn
- Pain behavior often absent
- Patient often does not report pain unless asked
TNI Acute Pain
- Uses pain rating scale to identify current level of pain and determine a comfort/function level
- Reports that the pain management regimen relieves pain to a (specify level) with acceptable or manageable side effects.
- States an ability to obtain sufficient amounts of rest and sleep.
TNI Chronic Pain
- Uses pain rating scale to identify current level of pain and determine a comfort/function level
- States a specific plan for pharmacological and non-pharmacological pain relief
- Demonstrates ability to pace self, taking rest breaks before they are needed.
- Performs ADLs with minimal interference from pain and medication side effects.
Examples of Acute Pain
- Somatic
- Visceral
- Referred pain
Examples of Chronic Pain
- Phantom
- Psychogenic
- Intractable
Treatment goals Acute Pain
pain control with eventual elimination
Treatment goals Chronic Pain
Enhance function and quality of life
World Health Organization Three Step Analgesic Ladder
The World Health Organization Three Step Analgesic Ladder is a guide to selecting the initial analgesic level and dosing. The ladder presents a treatment model for pain where treatment gets more aggressive the further up the ladder you go. Continued reassessment is needed to modify the treatment plan based on the patient’s response.
World Health Organization Mild Pain
1-3 on scale. Nonopiod medication with an adjuvant medication if the patient has neuropathic pain
World Health Organization Moderate Pain
4-6 on scale. Opioid medication in low dose is added with the nonopioid and adjuvant medication continued
World Health Organization Severe Pain
7-10 on the scale. Higher doses of the opioid, nonopiod and adjuvant medications are continued. When a patient presents with severe pain ordered medications are prescribed at the appropriate level for that patient’s pain
What is the limitation of the World Health Organization’s three step analgesic ladder?
The misconception that mild to moderate pain opioids, such as codeine, must be used in step three. It is recommended that smaller doeses of strong opioids, such as morphine, are just as effective and preclude having to switch medications at a later time
TNIs for Acute and Chronic Pain
- Assess whether patient is experiencing pain at the time of the interview. If so, provide appropriate interventions to provide pain reflief. Assess patient’s pas experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects, typical coping responses, and how they express pain on initial interview
- Teach patient to report pain location, intensity, using a pain rating scale and quality when experiencing pain. Find out about patient’s pain reaction, pain threshold, and pain tolerance
- Determine patient’s current medication use
- Administer ordered pain medications. It is important to use the least invasive route of administration capable of providing adequate pain control. Oral is the route of choice with a functioning GI tract
Pain Reaction
the autonomic nerous system and behavioral responses to pain
Pain Threshold
Intensity of the noxious stimuli necessary for the individual to perceive pain
Pain Tolerance
Duration of time of the intensity of which an individual accepts a stimulus above the pain theshold becaore making a verbal or overt pain response
When is around the clock pain medication especially helpful?
24-48 hours after surgery
