Pain Flashcards
What are the 2 main pathways for pain ?
Can be either nociceptive and/ or neuropathic processing
why do we need to do a pain assessment ?
Better able to develop non-pharmacologic and/or pharmacologic strategies to obtain improved clinical results
where does pain originate ?
in the CNS PNS or both
pain signal will come from where
nociceptors which are specialized nerve endings needed to detect pain- can be found everywhere except in bone
nerves that transmit signals from the brain are called
efferent nerves or motor nerves - exiting the brain and message might require movement
nerves that transmit from the body to the CNS are called
afferent or sensory nerves in which will pick up that something has been impacted and will send message to brain
what is the substantia gelatinosa ?
Specific area of cord in which fibers synapse with interneurons , also considered to be lamina II in which sensor information is received from various parts of the body
- ** it is also the area where the nerves have to cross over to the other side of the spinal cord and go up to the brain via the anterolateral tract
what are the 4 phases of nociception ?
transmission, transduction, perception, modulation
nociceptive pain will develop when,
when functioning and intact nerve fibers in the periphery and CNS are stimulated
what happens in transduction ?
release of various chemical mediators ( histamine , prostoglandins, serotonin ) and the neurotransmitter will deliver pain message .
sensory afferent nerve fiber –> spinal cord—> dorsal horn
second set of neurotransmitters will carry signal across synaptic cleft( ATP, substance P, glutamate)
What happens in transmission ?
pain signal move from spinal cord to brain and impulse goes to thalamus ,where it will then start to be processed.
true or false ? there are opioid receptors in the synaptic cleft at the spinal cord that can block pain
True- if pain isnt blocked it will move to thalamus
what takes place during peception?
signal gets disperse to cortical areas ( limbic, and somatosensory areas ), pain dispersed to these areas allows for the sensation of pain to be identified
what happens in modulation ?
to dial down or turn off pain - descending pathways will release 3rd set of neurotransmitters( GABA, Serotonin,norepinephrine ) to induce analgesic effect
what is meant by the fact that nociceptive processing can be protective ?
can be a warning signal that injury is about to or has taken place.
when does neuropathic pain take place
when there is actual damage to the nerves that takes place and it implies that there is an abnormal processing of the pain message and will often turn into a chronic condition
True or false, nociceptive pain cannot turn into neuropathic pain?
False Nociceptive pain can change into a neuropathic pain overtime when pain has been poorly controlled
conditions that lead to neuropathic pain ?
Diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy
Example of neuropathic pain ?
Pain felt with phantom limb
why is diagnosis of neuropathic pain hard ?
cannot be recognized on MRI, CT or Xray scans
what tools can possibly be used to diagnose neuropathic pain ?
Electromyography and nerve-conduction studies are needed
propsoed mechanisms of neuropathic pain
Spontaneous and repetitive firing of nerve fibers, almost seizure like in activity
True or false ? In neuropathic pain, minor stimuli can lead to significant pain
true
What is visceral pain ?
originates from larger interior organs.
Stems from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction
visceral pain can be described as ?
dull, deep, squeezing or cramping
transmission of visceral pain ?
transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system
presentation of visceral pain
Presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis
what is deep somatic pain ?
comes from sources such as blood vessels, joints, tendons, muscles, and bone
presentation of deep somatic pain ?
nausea, sweating, tachycardia, and HTN due to ANS response.
deep somatic pain is often described as
as aching or throbbing
deep somatic pain can result from what kind of injuries ?
pressure, trauma, or ischemia.
Is deep somatic pain usually well localized and identifiable ?
Yes, most people can pinpoint directly which area is hurting with this kind of pain, Unlike Visceral pain
cutaneous pain
derived from skin surface and subcutaneous tissues, the injury is considered superficial. accompanied with a sharp burning sensation
Reffered pain is
felt at a particular site but originates from another location
- happens because both sites are innervated by the same spinal nerve - brain cant tell the difference
- can originate from either visceral or somatic structures
Gallbladder and shoulder is an example
acute pain :Short-term and self-limiting:
Often follows a predictable trajectory and dissipates after an injury heals. Eg. surgery, trauma and kidney stones
acute pain : Self-protective purpose
Acute pain warns individual of actual or potential tissue damage.
acute pain:Incident pain
Type of acute pain that occurs predictably with certain movements. Eg. pain in the lower back on standing
chronic pain is diagnosed when ?
The pain continues for more than 6 months
chronic pain : Malignant :
often parallels pathology created by tumor cells.
chronic Non Malignant pain :
Associated with musculoskeletal conditions, such as arthritis, low back pain, or fibromyalgia
what is breakthrough pain?
Transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome
when can breakthrough pain happen
End of dose medication failure: patient taking a long-acting opioid
treatment for breakthrough pain ?
Shorten interval dosing and/or increase medication
Preverbal infants are at high risk for ?
under treatment of pain
repetitive and poorly controlled pain in infants (daily heel sticks, venipunctures) can result in
in lifelong adverse consequences such as neurodevelopmental problems, poor weight gain, learning disabilities, psychiatric disorders, and alcoholism.
by 20 weeks of gestation ,
Ascending pathways are in place bu perception of pain may only be seen at 30 weeks because the cortex is immature
Inhibitory neurotransmitters are in insufficient supply until birth at full term( high sensitivity to painful stimuli
Does pain sensitvity get reduced as we age ?
NO - No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished
Does Dementia has an impact on the ability to feel pain ?
Dementia does not impact ability to feel pain, but it does impact person’s ability to effectively use self-report tools.
- we look at body language instead of verbal communication
gender differences and pain are due to the ?
influenced by societal expectations, hormones, and genetic makeup
how are hormonal changes linked to pain ?
Women are two to three times more likely to experience migraines during childbearing years, are more sensitive to pain during premenstrual period, and are six times more likely to have fibromyalgia.
what is the problem with giving opioids?
-Effective against severe pain but can cause serious side effects
-Effects range from pain relief to euphoria.
Use can lead to physical dependence
side effects of opioids
Mu receptors in brainstem lead to possible respiratory depression , MU receptors in the small intestine can lead to constipation, MU receptors in dorsal horn and modulate perception of pain
Subjective pain report is considered ?
The gold standard of pan assessment
when performing the initial pain assessment,
Qualify all information in the patient’s own words
Questions to ask in pain assessment ?
Do you have pain, where is the pain, when did the pain start, what does the pain feel like ? how much pain do you have now , does the pain limit your functioning, how do you react usually when you are in pain, what makes the pain better or worse
pain is :
multidimensional in scope, encompassing physical, affective, and functional domains
Standardized overall pain assessment tools are more useful for what kind of pain ?
chronic pain conditions or particularly problematic acute pain problems.
How should you select the type of pain assessment ?
based on its purpose, time involved in administration, and patient’s ability to comprehend and complete tool.
what is an initial pain assessment ?
Clinician asks patients eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors.
Furthermore, clinician adds questions about manner of expressing pain and effects of pain that impairs one’s quality of life.
what is a brief pain inventory?
Clinician asks patient to rate pain within past 24 hours on graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep
what is the short form McGill pain questionaire?
Clinician asks patient to rank list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain
pain rating scales should be used to?
They can also do what ?
intended to reflect pain intensity.
- indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality
Numeric rating scales
patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain.
Verbal descriptor scales
have the patient use words to describe pain.
Visual analog scales
have the patient mark the intensity of the pain on a horizontal line from “no pain” to “worst pain.”
older adults respond better to using what kind of scale ?
when words are selected
PQRST Method of Pain Assessment
each initial stands for a series of questions to be asked to the patient regarding self report and symptoms
P=
= Provocation/palliation: What caused it? what makes better? What relieves it? What aggravates it?
Q=
Quality/quantity: sharp,dull, stabbing,burning,crushing,throbbing,etc
R=
Region/radiation: where is the pain located? Does it radiate?
S=
Severity scale : how severe is the pain on a scale of 0 to 10
T=
Timing: when did the pain start? How long did it last? How often does it occur? When do you usually experience (before meals,or after meals)
pain assessment with infants will be based on ?
on behavioral and physiologic cues.
Children 2 years of age can report pain and point to its location but cannot
rate pain intensity
when can rating scales be given to a child ?
at age 4-5 years
what rating scales can kids use?
Faces Pain Scale-Revised (FPS-R)
pain assessment with patients that cannot verbally communicate
identify pain using behavioral cues.
what are acute pain behaviors ?
Involve autonomic responses
Has a protective purpose
Individuals experiencing moderate to intense levels of pain may exhibit the following behaviors
Guarding, grimacing
Vocalizations such as moaning, agitation, restlessness, stillness
Diaphoresis,
Change in vital signs
Remember, the vital signs can also be altered by medications, fluid volume
Persistent (Chronic) pain behaviors
Often live with experience for months and years
Shows more variability than acute pain behaviors, adaption occurs over time
Higher risk for under detection
Bracing, rubbing
Diminished activity
Sighing
Change in appetite
assessing chronic pain in infants ?
There is no one assessment tool that adequately identifies pain in infants, clinicians should: Use a multidimensional approach
- Changes in facial activity and body movements may help assess pain.
tools used to assess pain in infants ?
CRIES
and FLACC
CRIES assessment ?
Measures postoperative pain in preterm and term neonates
Examines physiologic and behavioral indicators on 3 point scale, a
Flacc assessment ?
Nonverbal tool used for infants and young children up to age 3
Assesses 5 behaviors of pain (facial expression, leg movement, activity level, cry, and consolability)
older adults will often ??
Deny having any pain - for fear of dependency, further testing or invasive procedures, cost, and fear of taking painkillers or becoming a drug addict.
When do we use the PAINAD scale ?
pain assessment for advanced dementia patients , will evaluate Breathing, vocalization, facial expression, body language, and consolability
Quantified behaviors in category 0 to 2
Total score metric 0 to 10
Score of 4 or more requires treatment
Older adults with history of comorbidities
should anticipate pain
What should we observe in older adults in relation to pain
Observe for changes in functional behavior and/or behavioral cues
What is CRPS?
aka reflexive sympathetic dystrophy which is a chronic progressve nerve condition - caused from a short circuiting effect of the interaction between the sensory, motor, autonomic nervous system, and immune system
happens in men and women (40-60 yrs )
CRPS key feature ?
innocuous stimulus.
- light cotton brush causes severe pain
treatment of CRPS
High doses of medications (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms
physical therapy to regain limb function
