Pain Flashcards
what is pain?
*“Whatever the experiencing person says it is, existing whenever the
experiencing person says it does” (pg. 1233-1234).
*Human body’s defensive mechanism that indicates the person is
experiencing a problem.
*Physical suffering or discomfort, unpleasant sensory, emotional experience
*Chronic pain is the most common reason to seek healthcare
*Linked to restrictions in mobility and daily activities, dependence on opioids, anxiety and
depression, and poor perceived health or reduced quality of life
*Fifth vital sign
*According to the AMA, gives pain equal status with blood pressure, heart rate,
respiratory rate and temperature as vital signs. Consider assessing your patient’s pain
once V/S are taken and documented.
*Relief of pain is a client rightGreat resource:
https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm
peripheral nervous system
*Composed of sensory and motor neurons
*Pain perceived through sensory neurons
*Responded to through motor neurons
*Connections occur within spinal cord
*Nociceptors located at ends of small afferent neurons
*All tissues except brain
*Especially numerous in skin, muscles
the pain process
*Transduction: activation of pain
receptors
*Transmission: conduction along
pathways (A-delta and C-delta fibers)
*Perception of pain: awareness of the
characteristics of pain
*Modulation: inhibition or
modification of pain
bradykinin
powerful vasodilator that causes vasodilation and increases capillary permeability and constricts smooth muscles
prostaglandins
hormone like substance that send pain stimulation to the brain/CNS
substance P
sensitizes pain receptors on nerves to feel pain and also increases the rate f firing nerves.
origin of pain
Physical: cause of pain can be identified
Psychogenic: cause of pain cannot be identifiedHeadaches, back pain, stomach pain
Referred: pain is perceived in an area distant from its point
of originPain associated with a heart attack is often referred to the chest, arms, neck or
shoulders.
Pain from a gallbladder attack may be felt in the back of the shoulder.
signs of pain in infants/newborn
Challenging to distinguish
cause of discomfort and
to conduct an actual
assessment of pain, watch for the facial expression.
children/adolescents
Like infants, can be
difficult to assess and
determine.
Children’s capability to
describe pain increases
with age and experience.
Types of pain changes
throughout their
developmental stages
older adults
may have a higher pain tolerance, cognitive impairment is something we should watch for.
ethnicities
. Could be
considered a sign of
weakness or could be a
standard of accepting the
pain without complaint.
Cognitive level &
impairment
Some children may grow
up to “be brave” and
ignore the pain
acute pain
*Acute
*Sudden onset; varies in intensity from mild to severe
*Typically lasts less than 3-6 months. Could be as short as weeks
*Surgical pain
*“Protective in nature”-subjective.
*Warns an individual of tissue damage or disease.
chronic pain
*Persists greater than 6 months; lasts beyond the normal healing process
*Varying severity
*Periods of remission or exacerbation are common
*May or may not be localized
*May be limited, intermittent, or persistent
*Examples: frequent headaches, arthritis, back pain, fibromyalgia
1/3 of americans suffer from chronic pain
describe your pain? what does it feel like?
Described in terms of:*Location
*Site
*Radiation (spreads or extends to other areas)
*Referred- appears to arise in different areas of the body
*Phantom pain- can last for years & is normal. (BKA, AKA, etc)
*Intensity/Severity
*Mild, moderate, severe
*Standard 0-10 Scale
*1-4=mild pain
*5-6=moderate pain
*7-10=severe pain
*Visual Scale Faces
*Quality
*Stabbing, burning, itchy, aching, cold, dull, tender, shooting, numbness, throbbing, radiating, heavy, tender, cramping
*Duration/Onset
*When?
*How long has the pain been there?
*Timing
*Is it constant, intermittent? Both?
nociceptive pain
pain from a noxious stimuli being percieved as painful. sunburn, cuts, burns, bladder distention.
cutaneous pain
usually from cuts, the subcutaneous tissue is involved. and is superficial
somatic pain
*Is diffuse or scattered and originates in the tendons, ligaments, bones, blood vessels, and nerves. Common with everyday
injuries
visceral pain
*Poorly localized, and originates in the body organs in the thorax, cranium, and abdomen.
*Most common type of pain produced by disease (Examples:
constipation, menstrual cramps, gall stones, pain caused by cancer)
neuropathic pain
*Pain caused by a lesion or disease of the peripheral or central nerves
*Commonly described as burning, shooting or tingling (Examples: Phantom leg pain, spinal cord injury)
*Trigeminal neuralgia, diabetic neuropathy, phantom limb pain
gate control theory of pain
Proposed by Melzack and Wall, 1965Most widely accepted pain theory; most practical
*Describes the transmission of painful stimuli and recognizes a
relationship between pain and emotions.
*Small- and large-diameter nerve fibers conduct and inhibit pain
stimuli toward the brain.
*Gating mechanism determines the impulses that reach the brain.
*Other factors that have impact of this gate are past experiences,
the cultural and social environment, personal expectations,
beliefs about pain and etc.
*Factors that control gates: physical, emotional and behavioral
(responses to pain). See Box 35-1
patient self report of pain
*Identify pathologic conditions or procedures that may be
causing pain; consider physiologic measures (increased blood
pressure and pulse)
*Report of family member, other person close to the patient or
caregiver familiar with the person
nonverbal behaviors
*Nonverbal behaviors: restlessness, grimacing, crying, clenching
fists, protecting the painful area
*Physiologic measures: increased blood pressure and pulse
*Attempt an analgesic trial and monitor the results
A patient who has bone cancer is most likely
experiencing which of the following types of pain?
somatic Rationale: Deep somatic pain is diffuse or scattered and originates
in tendons, ligaments, bones, blood vessels, and nerves.
Cutaneous pain usually involves the skin or subcutaneous tissue.
Visceral pain is poorly localized and originates in body organs.
Referred pain is pain that originates in one part of the body and is
perceived in an area distant to that part.
perception of pain
Pain thresholdPain tolerance is the maximum level of pain that a person is able to
tolerate.
*Regular exposure to painful stimuli will increase pain tolerance
*Pain tolerance is distinct from pain threshold (the point at which
pain begins to be felt)
AdaptationLeads to protection of pain or injury
Modulation of painNeuromodulators
*Endorphins, dynorphins, enkephalins
https://i.pinimg.com/736x/2b/16/2a/2b162aafbda2866129f1abf41aa6c2a9–pharmacology-mnemonics-massage-therapy.jpg
Do not be judgmental…..
chronic pain
Greater
than 6
months
acute pain
sudden onset, less than 3-6 months, postsurgical pain.
breakthrough pain
moderate to severe pain due to temporary flare up. Transient
exacerbation of
pain that occurs spontaneously or
in relation to a specific predictable
or unpredictable
trigger*End-of-dose medication failure
central pain
Caused by damage to
nerves in CNS
due to stroke, MS, Parkinson
disease, or trauma.
May occur
immediately or
be delayed
May be less able to feel
normal touch
Described as burning, pins
and needles, aching, or
lacerating
phantom pain
Pain felt in amputated
limb or body
part even though it is
absent.
Usually recurring vs.
constantDescribed as
shooting, stabbing,
squeezing, throbbing, or burning
Associated with neurological
activity in
portions of brain once connected to amputated
body part
psychogenic pain
Pain associated with
psychological
factors vs. physiological
factors
Treatment should include
interventions for pain and
emotional
distress
general assessment of pain
*Patient’s verbalization and description of pain
*Duration of pain
*Location of pain
*Quantity and intensity of pain
*Quality of pain
*Chronology of pain
*Aggravating and alleviating factors
*Physiologic indicators of pain
*Behavioral responses
*Effect of pain on activities and lifestyle
*Visual assessment
*Especially important in newborns
nursing considerations with pain
Physical Assessment
-Vital Signs (b/p, pulse,
respiratory rate)
-Visual Exam: Inspection for injuries, etc
-Palpation of specific location
(is the patient guarded?)
-Testing motor functions
-Heart, lungs, breath sounds
factors affecting pain throughout the lifespan
Culture-Lifespan considerations*Age and developmental stage affect ability to describe pain
*Special considerations for assessing discomfort and promoting comfort for each stage
*Cultural differences in expressions of pain
*Ethnic variables
*Family, sex, gender, and age variables
*Religious beliefs
*Environment and support people
*Anxiety and other stressors
*Past pain experience
children and pain
*Infants, children less able to articulate pain, display
behavioral responses.
*Visual assessment important
Body movement, posture, crying
*Physiological considerations
*Untreated pain may result in:
Decreased growth and development
Decreased immune function
Lack of appetite
Hypertension
Increased sensitivity to future pain
children and pain
*Infants, children less able to articulate pain, display
behavioral responses.
*Visual assessment important
Body movement, posture, crying
*Physiological considerations
*Untreated pain may result in:
Decreased growth and development
Decreased immune function
Lack of appetite
Hypertension
Increased sensitivity to future pain
developmental aspects of pain expression
*Infant: intense cry, unable to sleep or eat
*Toddler: verbal or physical aggression or withdrawal,
guarding the site or pain
*Preschooler: can verbalize but much “magical thinking”, see
pain as punishment
*School-age: can verbalize but very influenced by cultural
behaviors associated with pain
*Adolescent: can verbalize but may choose to be “tough” in
front of peers; regression
pain and adults
Pain and Adults
*Chronic pain widespread among adults
*In 2016, an estimated 20.4% of U.S. adults had
chronic pain and 8.0% of U.S. adults had high-
impact chronic pain. (CDC)
*Both were more prevalent among adults living in
poverty, adults with less than a high school education,
and adults with public health insurance (CDC)
*More prevalent among women than men
*Women more likely to develop pain-causing diseases
*Lower pain threshold and tolerance than men
*Men more susceptible to pain from:
- Headaches, coronary heart disease, gout,
duodenal ulcer, pancreatic disease
pain and older adults
*Most older adults have chronic pain
*Physiological changes of aging affect
perception of pain
*Drug interactions
*Barriers to pain management
*Inadequate knowledge of healthcare
providers
*Fear of pain medication dependence
*Noncompliance, financial barriers
cultural and ethnic influences
Cultural and ethnic influences:
*Variation in meaning of pain
*Variation in verbal and behavioral response to pain
*Culture plays critical role in pain expression and management
*Nurses have own attitudes, expectations but must provide
culturally competent care
the meaning of pain
*Positive view of pain may result in higher tolerance
*Decreases possible development of depression and anxiety about
pain
*Negative view of pain may bring feelings of hopelessness,
depression and anxiety
*Preventing enjoyment of life
*Lower quality of life physically, emotionally, socially
cultural
*Environmental and social support
*Strange environment can compound pain
*Lonely person without support network
*Perceives pain as severe
*Family education can positively affect perceived quality of life
*Caregiver, client
*Expectations of significant others
*Previous experience with pain
*Clients who have undergone procedure without adequate
pain management
*Clients who have seen a loved one suffer
*Influences how clients perceive efficacy of future treatments
pain assessment tools
*Numerical Scale- Most common
*Wong-Baker FACES
*Adults and children (>3 years old) in all patient
care settings)
*Beyer Oucher pain scale
*Used in young patients, combines a 0-100 scale with
6 photographs of children in pain
*CRIES pain scale
*Neonates & infants 0-6 months
*https://prc.coh.org/pdf/CRIES.pdf
*FLACC scale
*Infants and children (2 months–7 years) who are
unable to validate the presence of or quantify the
severity of pain
*COMFORT scale
*Infants, children and adults who are unable to use
the numeric rating
*Cognitive impairment or temporarily impaired due to
illness or medication
Which following pain assessment tool is recommended
for use with neonates ages 0 to 6 months?
Answer: D. CRIES pain scale
Rationale: The CRIES Pain Scale is a
tool intended for use with
neonates and infants from 0 to 6
months.
nursing interventions for pain
*Establishing trusting nurse–patient relationship
*Manipulating factors affecting pain experience
*Initiating nonpharmacologic pain relief measures
*Managing pharmacologic interventions
*Reviewing additional pain control measures, including
complementary and alternative relief measures
*Considering ethical and legal responsibility to relieve pain
*Teaching patient about pain
manipulating factors with pain
*Remove or alter cause of pain.
*Alter factors affecting pain tolerance.
Initiate nonpharmacologic relief measures.Distraction
*Humor
*Music
*Imagery
*Relaxation
*Cutaneous stimulation
*Acupuncture
*Hypnosis
*Biofeedback
*Therapeutic touch
*Animal-facilitated therapy
invasive therapy
*Nerve block (steroid injection)
*Chemical interruption of nerve pathway
*Injection of local anesthetic around nerves
complimentary/alternative pain control
*Independent nursing interventions- positioning
*Acupuncture
*Herbal supplements
*Guided imagery
*Support, laughter, focus on others
*TENS unit-
*uses electrical stimulation to inhibit transmission of painful impulses
relaxation therapy
*Reduce stress, induce sleep, reduce pain, calm emotions
*Four main categories (often combined)
*Breathing exercises
*Muscle relaxation
*Imagery
*Movement techniques
*Other forms: massage, acupuncture, meditation, biofeedback
*Allow for lower doses of medications for pain.
nonopiods anelgesics and NSAIDS
*Ibuprofen, acetaminophen, naproxen, celebrex
opiods and narcotic anelgesics
*Morphine, codeine, oxycodone, meperidine, hydromorphone,
methadone
*Typically in a double locked drawer and requires “a count”
*Witness required for any “waste” of a drug
adjuvant anelgesic drugs
*Anticonvulsants, antidepressants, multipurpose drugs
*Escitalopram (Lexapro), Prednisone (Steriods), Gabapentin
(Neurontin)
nonopiod anelgesics and NSAIDS
Analgesic and antipyretic
Acetaminophen and NSAIDs (ibuprofen, aspirin,
naproxen, celebrex)
Vary in anti-inflammatory properties
Have ceiling effect and narrow therapeutic index
Well tolerated take with food to avoid upset stomach
Comparable to morphine in providing pain relief
Fewer adverse events than with morphine
Liver and kidney toxicity with high dose, long-term
use
Combining medications may lead to inadvertent
overdose
Major side affect: GI UPSET and/or bleeding
(particularly with NSAIDS)
antiflammatory drugs
Anti inflammatory Drugs:
Advantages:
*Effective anti-inflammatory and treatment for bone pain
*Avoid side effects of opioids
Disadvantages:
*Inhibit platelet function
*Renal and gastrointestinal toxicity
acetaminophen
Advantages:
*Does not interfere with platelet function
*No gastrointestinal toxicity or renal toxicity
*Readily available and inexpensive
Disadvantages:
*Weak anti-inflammatory
*Liver toxicity
*Dose: 15 mg/kg PO q4h with max of 4000 mg/day
What is the max dose of acetaminophen that you can
give an adult patient in a 24 hour period?
4000mg
What is the max dose of ibuprofen that you can give an
adult patient in a 24 hour period?
3200mg
narcotics
*Potential for abuse; addictive
*Action = 4 hours; require frequent repeat dosing
*Most common: Morphine Sulfate (used PO, IV, or Epidural)
*Treats acute and chronic pain
*Constipation-common side effect
opiods with nonopiods
*Work better than either type alone
*Can take in lower doses
*Watch for Tylenol dosing- 4,000 mg in 24 hr
what to considor with opioids
*Physical dependence
*Body physiologically becomes accustomed
*Withdraw symptoms; sweats, shakes, tremors, pain, N/V and
GI upset
*Tolerance
*Body is accustomed and needs a larger dose (up to 10 times
the original dose)
full agonists
Full agonists (oxycodone, morphine, hydrocodone)
*High affinity to mu receptors in PNS and CNS
*Most potent pain relievers
*No ceiling effect (“top limit of pain management potential”)
*Euphoria, respiratory depression, tolerance
mixed agonist - antagonist
*Act as agonist at one opioid receptor, antagonist at a
different opioid receptor (less respiratory depression and
addiction potential)
*Give only as first opioid
*Not used for severe pain or if terminally ill
*Some examples of these drugs are pentazocine or Talwin,
nalbuphine or Nubain, and butorphanol or Stadol
side effects of opioids
*Respiratory depression (bradypnea) commonly feared
*Sedation
*Nausea/vomiting
*Constipation
*Urinary retention
*Pruritus
*Sexual dysfunction
*REVERSAL AGENT: naxolone HCL (Narcan) given IV or Intra-nasal
what caused 93,000 deaths in 2020
Lethal doses of
Fentanyl caused
93,000 deaths in
2020 and ~108,000
in 2021
methods of opioid administration
*Oral (PO): preferred
*Long-acting for continuous pain
*Short-acting/immediate release for intermittent pain or
breakthrough pain while on continuous
*Intramuscular (IM): not recommended
*Intravenous (IV):
*Intermittent scheduled or continuous infusion (basal) for
continuous pain
*PRN doses only for intermittent pain
*Patient controlled analgesia (PCA)
*Acute and chronic pain usage
IV vs IM vs Po
IV: Typically 5-10 minutes
IM: 15-30 minutes
PO: Typically 30-60 minutes
coanelgesics
*Have analgesic properties-typically used for other purposes
*Potentiate effects of pain medications
*Reduce pain medication side effects
*Effective at reducing neuropathic pain
*Fibromylagia, diabetic neuropathy
*Include antidepressants, anticonvulsants, antihypertensives,
antipruritics, corticosteroids, local anesthetics and
bisphosphonates.
*Can be used to treat pain after surgery (post-op), burns, or
trauma
*Be cognizant of max Tylenol dose and Ibuprofen dose in a 24 hr
period
examples with drugs
Antianxiety Lorazepam
Antiemetic Ondansetron
Steroids Prednisone
Insomnia Ambien
Anti-gas Simethicone
Examples:
Neuropathic pain Neurontin
Antianxiety Lorazepam
Antiemetic Ondansetron
Steroids Prednisone
Insomnia Ambien
Anti-gas Simethicone
the anelgesic ladder
Step 1 mild pain
Nonopioid analgesic
(with/without coanalgesic)
Step 2 mild - moderate pain
Weak opioid, combination of opioid and nonopioid
(with/without coanalgesic)
Step 3 moderate - severe pain
Strong opioid administered around the clock
Titrated until pain relieved
numeric sedation scale
*S: sleep, easy to arouse: no action necessary
*1: awake and alert; no action necessary
*2: occasionally drowsy, but easy to arouse; no action necessary
*3: frequently drowsy, drifts off to sleep during conversation;
reduce dosage
*4: somnolent with minimal or no response to stimuli;
discontinue opioid, consider use of naloxone
normal respiration rates
Normal respiration rate:
Adults is 12-18 breaths per minute
School aged is 18-30
examples of long acting opioids
A. Fentanyl patch
B. OxyContin
C. Methadone
PCA pump
VPatient-controlled analgesia (PCA)*Can be used for post-surgical pain or chronic pain syndromes
*Patient pushes the button and gets the medication as ordered
epidural anelgesia
*Used for pain relief during postoperative phase
*Used for children with terminal cancer or children or
adults under going surgery.
*Preparing for delivery
local anesthesia
*Anesthetic agents may be applied
topically to the skin, mucous membranes or injected
*Nerve blocks common in dental work,
surgery, wound closure and minor procedures
osteoarthritis
Osteoarthritis (OA)
A degenerative joint disease that is the most common chronic condition of the joints
Effects about 31 million Americans
50,000 children in the United States have OA: Juvenile rheumatoid arthritis most common
Often referred to as “wear and tear”
Occurs when the cartilage or cushion between joints breaks down leading to pain,
stiffness and swelling.
Most effected parts of the body:
Hips
Knees
Fingers
Feet
OA symptoms
Symptoms:Pain and stiffness (most common)
*Affected joints may get swollen; particularly after lots of activity
*Limited range of motion depending on where its located
*Clicking or cracking sound
*Fatigue
*Tenderness
*Bone spurs on imaging
OA risk factors
*Risk Factors:
No specific cause
Women; although not clear why
>45 years of age
Rare in children
Factors that lead to OA:
*Obesity (BMI)
*Injury (fractures, ligament tears)
*Overuse (athletes)
*Family history
*Diabetes
OA examination and diagnosis
OA Examination & Diagnostics
Diagnosis after healthcare examination
*Assessing for range of motion, tenderness, signs and symptoms of joint damage
*PMH and risk factors
Diagnostic tests
*Joint aspiration-insertion of needle into joint for fluid to assess for crystals or joint
deterioration
*X-ray-can help show any damage to the joints or bone spurs
*MRI-obtains a better view of the cartilage and other joint structures
https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925
If the cartilage wears down completely, bone will rub on bone.
OA treatment
No cure
*Manage symptoms (pain)
*NSAIDS
*Analgesics
*Corticosteriods
*Hyaluronic acid. Occurs naturally in joint fluid, acting as a shock absorber and lubricant. However, the acid appears to
break down in people with osteoarthritis. The injections are done in a doctor’s office.
*Duloxetine (Cymbalta) Typically used as an antidepressant, but approved to help treat chronic pain, including
osteoarthritis pain.
*Nonpharmocological approach- massage, acupuncture, vitamins, relaxation techniques
*Improve joint mobility (physical activity)
*Weight management
*Stretching
*Surgery
*joint surgery can repair or replace severely damaged joints, especially hips or knees.
*PT/OT
*Tens Unit-provides some short term relief
postsurgical pain overview
*“Post-Op” pain: response to tissue trauma during surgery
*“Post Surgical” Refers to both inpatient and outpatient patients
*Post-op pain typically lasts 4-6 weeks. This can vary depending on the type of surgery
*Length of stay also varies (type of surgery, pain control, complications, etc)
*Post Anesthesia Care Unit (PACU)
*Holding area for patients after their procedure
*Important to monitor safety- Side rails need to be up and bed in low position. Bed alarm should also be
on. Help assist your patients with ambulation while on heavy narcotics and post-anesthesia.
*PRN pain medications- be timely! Often ordered every 2-4 hours
*Pain assessment is done prior to administering pain medications and 30 minutes after to assess
effectiveness
*Consider route of administration
