Pain Assessment

Question 1

Pain is ……………

Answer 1

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage”

whatever the person says it is….. existing whenever the person says it does

Question 2

Should pain be addressed immediately?

Answer 2

Yes, All persons deserve prompt recognition and treatment of pain even when they cannot express their pain verbally

Question 3

Two classifications of pain ………….

Answer 3

Nociceptive and Neuropathic

Question 4

What are nociceptors?

Answer 4

Specialized pain receptors that detect painful sensations from the periphery and transmit them to the CNS

Question 5

What are the four phases of nociceptive pain?

Answer 5

Transduction
Transmission
Perception
Modulation

Question 6

Nociceptive Pain can be ………..

Answer 6

somatic or visceral

Somatic when it arises from the skin, connective tissue, muscle, bones, or joints

Visceral when it arises from internal organs

Question 7

Nociceptors are activated by

Answer 7

noxious stimuli that is either mechanical, thermal, or chemical in nature

Question 8

Nerve fibers that carry pain impulses ….

Answer 8

A delta fibers

C fibers

Question 9

A delta fibers

Answer 9

Large, myelinated fibers
Impulses travel quickly; “fast pain”
Release glutamate at the synapse with the spinal neurons

Question 10

C fibers

Answer 10

small and unmyelinated; impulses travel more slowly

Release glutamate and substance P

Question 11

What are endogenous opioids?

Answer 11

They are neurotransmitters produced by the body that block the transmission of the nerve pathway by binding with specific opioid receptors, reducing pain.

Question 12

What are the three types of opioid receptors ?

Answer 12

Mu, Kappa, Delta

Question 13

Examples of Endogenous Opioids

Answer 13

Enkephalins
Endorphins
Dynorphins
Endomorphins

Question 14

What do exogenous opioids do ?

Answer 14

These are opiate drugs - they relieve pain by attaching to opiate receptors, thus enhancing the natural endogenous opioid response

Question 15

Neuropathic pain is ………………….

Answer 15

an abnormal processing of the pain message from an injury to the nerve fibers.
Neuropathic pain does not follow the typical and rather predictable phases as in nociceptive pain.

Question 16

True or false. Nociceptive pain can evolve into neuropathic pain.

Answer 16

True… this can happen when pain is poorly controlled. The constant irritation and inflammation caused by a pain stimulus can lead to an altered form of the nerve cells, making them more sensitive to any stimulus. This also decreased the number of opioid receptors.

Question 17

How do First Order Neurons, Second Order Neurons and Third Order Neurons work together to transmit the pain signal to the brain?,

Answer 17

First order neurons are the nociceptors that are sensitive to certain substances and different types of noxious stimuli (mechanical, thermal, chemical) and generate the pain signal.
Second order neurons process the nociceptive information within the spinal cord and communicate with various pathways to transmit pain signal up spinal cord and to the thalamus
Third Order Neurons direct nociceptive pain signals to different areas of the brain such as the cerebral cortex where it is perceived

Question 18

What kind of substances do cells release when they are damaged ? Why does this matter ?

Answer 18

Prostaglandins
Histamine 
Bradykinin
Serotonin
Substance P

This matters because nociceptors are sensitive to these substances. When tissue is damaged and there is inflammation, these substances are released. Nociceptors detect this and generate a pain signal in the process of transduction.

Question 19

Characteristics of Acute pain

Answer 19

Goal is to treat cause to eliminate pain
Sudden, short term and self limiting - example - pulled a hamstring
follows predictable trajectory and dissipates when injury is healed

Question 20

What is incidence pain ?

Answer 20

Expected pain to result upon certain movements - such as shoulder pain when arms are raised

Question 21

Characteristics of Chronic Pain -

Answer 21

Insidious Onset, or follows acute
lasts beyond expected healing period
Goal is to manage pain and maintain function and quality of life

Question 22

Persistent/Chronic pain is diagnosed when the pain ……………..

Answer 22

continues for 6 months of longer

Question 23

Chronic pain outlasts its ________________

Answer 23

protective purpose

Question 24

Chronic pain originates from __________________ processing of pain fibers from ___________ or _____________ sites.

Answer 24

abnormal; peripheral; central

Question 25

Chronic Pain Cycle

Answer 25

Increased Pain ........ Increased Anxiety ................... Sleeping Problems ................ Not Coping Well ................... Increased Pain Chronic pain affects many aspects of a person's life

Question 26

Pain Tolerance

Answer 26

The intensity or duration of painful stimulation one endured before pain responses are initiated

Question 27

Pain Threshold

Answer 27

The point at which the stimulus is perceived as pain

Question 28

Different types of sources of pain

Answer 28

Deep Somatic Visceral Cutaneous Referred

Question 29

What is referred pain ? What is it the result of ?

Answer 29

Pain perceived at a different location other than the site of the painful stimulus/origin. It is the result of interconnecting sensory nerves

Question 30

Sympathetic response to low to moderate pain .............

Answer 30

``` Bronchial dilation Increased HR Peripheral vasoconstriction Hypertension Diaphoresis Increased muscle tension Dilated pupils Decreased GI motility ```

Question 31

Parasympathetic response to severe or deep nerve pain

Answer 31

``` Pallor Muscle Tension Decreased Heart Rate N/V Rapid, irregular breathing ```

Question 32

Pain Related Assessment Questions

Answer 32

``` Location Quality Chronology Setting Associated manifestation Alleviating factors Aggravating factors Meaning ```

Question 33

The major cause of chronic pain in the elderly has to do with .............

Answer 33

musculoskeletal problems - bones, joints, muscles

Question 34

When to assess and document pain ........

Answer 34

``` admission Regular intervals New pain Exacerbations Uncontrolled pain New therapy (new meds, increased doses) ``` Pain assessment needs to occur regularly and frequently – at admission to a facility or service; every month, week or shift, depending on the resident situation; whenever there is a new pain reported or observed; every time pain gets worse or is uncontrolled; and re-assess needs to happen with a new medication or other therapy is tried or when the dosage is increased.

Question 35

How to look for pain ?

Answer 35

Patient’s report of pain Body movements and facial expressions -including withdrawal, fatigue, grimaces, moans, and irritability, Sympathetic response Interest in usual events Ability to participate in usual activities Interference in life

Question 36

Pharmacologic Interventions for Pain

Answer 36

Non-opioid medications Opioid medications Adjuvant medications

Question 37

Nonpharmacologic interventions for pain

Answer 37

Cognitive Behavioral Therapies (CBT) Physical comfort measures Complementary/Alternative therapies

Question 38

Some people, especially older adults, may not use the word "pain." They may talk about how sore they are but not say they are in pain. For this reason it is important to .....................

Answer 38

be creative with the questions you ask to explore the presence of pain. ...... any discomfort, achiness, soreness, heaviness, burning sensations Once you know how a person refers to his pain, be sure to use that term consistently when assessing pain.

Question 39

Examples of Non physical pain .............

Answer 39

``` Existential distress Grief-anticipatory, complicated… Fear-uncertainty Dependency-helplessness Social Isolation-Loneliness Boredom ```

Question 40

Points to Remember about pain in nonverbal patients and those with dementia

Answer 40

Tolerance to acute pain possibly increases but pain threshold does not appear to change Dementia may blunt response to acute pain Cognitive impairment may decrease the perceived analgesic effectiveness Pain can negatively affect cognitive function

Question 41

Behaviors Related to Pain

Answer 41

``` More Obvious Grimacing or wincing Bracing Guarding Rubbing ``` ``` Less Obvious: Changes in activity level Sleeplessness, restlessness Resistance to movement Withdrawal/apathy Increased agitation, anger, etc. Decreased appetite Vocalizations ```

Question 42

Causes of Physical Pain in Patients with Dementia

Answer 42

``` Constipation or diarrhea Lodged food particles Contractures Ill fitting dentures Pressure ulcers UTI ```

Question 43

Things affecting perception of pain

Answer 43

``` Fatigue Anxiety Past experience Coping style Culture ```

Question 44

Different Perceptions of Pain

Answer 44

Punishment Threat loss Challenge

Question 45

Use of Pain Scales - what is important to assess?

Answer 45

Ask the patients individual "acceptable" pain score Using Faces rating scale, numeric scale, Oucher Scale

Question 46

Hierarchy of Data Sources

Answer 46

``` Patient’s report (if possible) Prior pain history Painful diagnoses Behavioral indicators Observer assessment Response to empirical therapy ```

Question 47

There is no pain __________________ when there is no pain _________________.

Answer 47

relief; assessment

Question 48

Why is it important to distinguish between nociceptive and neuropathic pain in the pain assessment?

Answer 48

Because neuropathic pain requires different types of pain medications than nociceptive pain

Question 49

characteristics of nociceptive pain

Answer 49

Dull, aching, pressure, tender

Question 50

characteristics of neuropathic pain

Answer 50

shooting, burning, electric shock, tingling

Question 51

Nociceptive pain responds to ..............

Answer 51

traditional pain medicines and therapies