Pain management Flashcards
it is an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Pain
What are the Theories of Pain?
1) Pattern Theory
2) Specificity Theory
3) Gate Control Theory
4) Affect Theory
5) Parallel Processing Model
It states that there are
specific nerve receptors for
particular stimuli.
Specificity Theory
It states that pain is
perceived whenever the
stimulus is intense enough
Pattern Theory
It conceptualizes that there is a gate
in the spinal cord called substantia
gelatinosa cells in the dorsal horn
Gate Control Theory
In Gate Control Theory, what stimulate
impulses in large nerves which in
turn close the gate to back pain?
Back massage
It avers that the pain
is emotional
Affect Theory
it believes that the
physiologic or
neurologic deciphering
of the pain sensation
and the cognitive
emotional properties
occur along different
nerve fibers
Parallel Processing Model
What is the physiology of pain?
1) Transduction
2) Transmission
3) Perception
4) Modulation
What type of Nerve fiber that has the characteristics below:
- Conduct impulses rapidly
- Sharp, pricking pain
- Superficial, somatic pain
A-Delta Fibers
(Large, Myelinated)
What type of Nerve fiber that has the characteristics below:
- Conduct impulses slowly
- Dull, aching, burning sensation
- Deep somatic and visceral pain
C Fibers
(Small, Unmyelinated)
What is the gate in the spinal cord that is also in the dorsal horn?
substantia
gelatinosa cells
What are the Pain-producing stimuli?
Thermal,
Chemical or,
Mechanical stimuli
causes cellular damage
leading to a release of
neurotransmitters
Stimuli
determines the pain
intensity and location
Somatosensory cortex
determines how the person perceives pain
Association cortex (mainly the limbic system)
Are released the moment pain is perceived by the brain
Neuromodulators
deliver sensory impulses to the spinal cord, where they synapse with spinal
motor neurons
Delta A fibers
What are the types of Neurotransmitters (Excitatory)?
- PROSTAGLANDINS
- BRADYKININ
- SUBSTANCE P
- HISTAMINE
- SEROTONIN
- Released from plasma that escapes from neighboring blood vessels at the location of tissue
damage - Attaches to receptors on peripheral nerves, amplifying sensations of pain
- Attaches to cells that initiate the cascade leading to the production of prostaglandins
BRADYKININ
- Produced through the breakdown of phospholipids found in cellular membranes
- Increase pain sensitivity
PROSTAGLANDINS
- Discovered within the pain neurons of the dorsal horn (excitatory peptide)
- Required for the transmission of pain signals from the periphery to higher centers in the
brain - Induces vasodilation and edema
SUBSTANCE P
- Released from both the brainstem and dorsal horn to suppress pain transmission
SEROTONIN
- Generated by mast cells, leading to
capillary dilation and increase in capillary permeability
HISTAMINE
- Naturally occurring sources of
morphine-like substances within the
body - Triggered by stress and pain
- Found in the brain, spinal cord, and
gastrointestinal tract - Induce analgesia when they fasten to
opiate receptors in the brain - Found in increased levels in people
with less pain than others with the
same injury
NEUROMODULATORS (Inhibitory)
Low to moderate intensity pain or
superficial pain
- Trigger the fight or flight response
- Stimulate the sympathetic nervous
system
Severe , deep, or continuous pain
- Activate the parasympathetic
nervous system
What are the signs of pain?
- Teeth clenching
- Holding the affected area
- Adopting a hunched posture
- Grimace
What are the types of pain in terms of location?
- SUPERFICIAL OR CUTANEOUS
PAIN - DEEP OR VISCERAL
- REFERRED
- RADIATING
- Results from stimulation of the
skin - Short duration and localized
- Sharp sensation
- Examples: small cuts, insect bites
SUPERFICIAL OR CUTANEOUS
PAIN
- Perception of pain in non-affected
regions - Pain is experienced in a body part
that is separate from the actual
source of pain, and it can take on
various characteristics
REFERRED
- Results from stimulation of internal
organs - Spreads out and radiates in multiple
directions - Lasts longer than superficial pain
- Sharp, dull, or distinct to the organ
involved
DEEP or VISCERAL
crushing or
squeezing chest
pain
Myocardial
Infarction
severe and persistent
abdominal pain
Appendicitis
Intense pain
in the upper abdomen
Pancreatitis
chest pain or discomfort
that may radiate to
the left arm or jaw
Angina
pain radiating from the lower
back to the groin area
Kidney stones
originates in the
lower back or
buttock and
radiates down the
back of the leg,
often caused by
compression or
irritation of the
sciatic nerve
Sciatica
radiates from one side of the head and
may extend to the forehead, temples, or back of the head
Migraine Headache
- The feeling of pain spreading from
the original injury site to a different
area of the body - The sensation of pain moving or
coursing along a specific body part - Intermittent or constant
RADIATING
What are the types of pain in terms of duration?
- ACUTE / TRANSIENT PAIN
- CHRONIC / PERSISTENT NON-
CANCER PAIN - CHRONIC EPISODIC PAIN
- Protective
- Has a known cause
- Short duration, less than 3 months
- Reduced damage to tissues
- Eventually resolves, whether or not
medical intervention is provided, once the affected area is healed
ACUTE / TRANSIENT PAIN
What is the Primary Nursing Goal in relieving Acute/Transient Pain?
Provide pain relief
- Not protective
- No purpose
- Lasts longer than 6 months
- Constant or recurring with mild to severe
intensity - No known cause
CHRONIC / PERSISTENT NON-
CANCER PAIN
- Occurs sporadically over extended periods of time
- May lasts for hours, days or weeks
- Example: migraine headaches, pain
associated with sickle cell disease
CHRONIC EPISODIC PAIN
How do you measure the intensity of pain?
By using pain assessment scales
What are the types of pain assessment scales?
- Numerical Rating Scale
- Verbal Rating Scale
- Visual Analog Scale
- Face Scale
What are the types of Pain in terms of Etiology/Pathology?
- CANCER PAIN
- PAIN BY INFERRED PATHOLOGICAL
PROCESSES
is experienced when an
intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care.
Nociceptive pain
pain arises from the bone, joint, muscle, skin or connective tissue; typically characterized by a dull or pulsating sensation and highly localized
Somatic (musculoskeletal)
pain that originates from internal organs like the gastrointestinal tract and pancreas.
Visceral (internal organ)
What are the types of Centrally Generated Pain?
- Differentiated pain
- Sympathetically Maintained Pain
damage to either the peripheral or central nervous system
Differentiated pain
injury to the central nervous system
Burning pain below the level of spinal cord
injury to the peripheral nervous system
Phantom pain
impaired regulation of the autonomic
nervous system (ANS)
Sympathetically Maintained Pain
Types of Peripherally Generated Pain
- Painful polyneuropathies
- Painful mononeuropathies
related with a known peripheral nerve injury
Painful mononeuropathies
pain experienced throughout the course of multiple peripheral
nerves
Painful polyneuropathies
A Type of Peripherally generated pain that has these examples:
- Diabetic neuropathy
- Alcohol-Nutritional neuropathy
- Guillain-Barre Syndrome
Painful polyneuropathies
What are the Factors Affecting the Pain Experience
- Ethnic and Cultural Values
- Developmental Stage
- Environment and Support People
- Previous Pain Experience
- Meaning of pain
- Emotional Responses to Pain
- Anxiety
- Attention
- Spiritual factors
- Neurological Function
- Coping style
A Type of Peripherally generated pain that has these examples:
- Nerve root compression
- Nerve entrapment
- Trigeminal neuralgia
Painful mononeuropathies
What are the concepts associated with pain?
- Pain Threshold
- Hyperalgesia
- Pain Tolerance
- Pain reaction
- Pain perception
- Bradykinin
- The amount of pain stimulation a person requires before
feeling pain (also pain sensation) - Generally fairly uniform among people
Pain Threshold
- Excessive sensitivity to pain
Hyperalgesia
The autonomic nervous system and
behavioral responses to pain
Pain reaction
The maximum amount and duration of pain that an individual is willing to endure. Varies greatly among people
Pain Tolerance
The actual feeling of pain
Pain perception
Universal stimulus for pain
Bradykinin
TYPES OF RESPONSES TO PAIN
1) Involuntary Response
2) Voluntary Response
are mediated by the autonomic
nervous system.
Physiologic responses
crying, moaning, grimacing, tossing
in bed, splinting the painful area, assuming fetal position
Behavioral responses
What are the three stages of Pain?
1) Activation
2) Rebound
3) Adaptation
where non-painful stimuli (contact with
linen, water or wind) produce pain
Allodynia
an unpleasant abnormal sensation,
mimics/imitates the pathology of a
central neuropathic pain disorder (ex.
Pain that follows a spinal cord injury)
Dysesthesia
- Is actual pain felt in a body part that is no longer present
- Painful sensation in a body part that is missing
Phantom pain
- The result of current or past damage to the peripheral or central nervous system and may not have a stimulus such as tissue or nerve damage
- Long lasting, unpleasant and can be described as burning, dull, aching, sharp, shooting pain
Neuropathic pain
It is primarily due to emotional factors with no physiologic basis
Psychogenic pain
Pain that stops and starts again
Intermittent pain
PQRST Mnemonic
Q – Quality / Quantity
R – Region / Radiation
S – Severity Scale
T – Timing
highly individualized and the most reliable indicator of the existence and intensity of pain
Self Report of pain
This pain assessment tool is intended to help patient care providers assess pain according to individual patient needs, explains and uses 0-10 Scale for patient self-assessment.
Universal Pain Assessment Tool
What are the different type of pain intensity scales?
1) Word scales
2) Numeric Scales
3) Linear (visual analog) scale/VAS
4) Rating scale
- Therapeutic touch. Energy is transmitted from one person to
another - Contralateral stimulation.
Stimulating the skin in an area
opposite to the painful area - Vibration
- Heat and cold application
enhance secretion of serotonin, a neurotransmitter that blocks transmission of pain impulses
Energy is transmitted from one person to another
Therapeutic touch
a method of treating chronic pain by applying electrodes to the skin and passing small electric currents through
sensory nerves and the spinal cord,
thus suppressing the transmission of
pain signals
TENS (Transcutaneous Electrical
Nerve Stimulation)
- Staring
- Slow, rhythmic breathing
- Recite, sing
- Describe something in detail
- Conversation
- Read, play games
- Busy oneself (chores, hobbies)
- Favorite toy
Techniques that Distract
Attention – to close the gate by
acting on the hypothalamus
- relax muscles
- Listen to music
- Guided imagery. Use of images or fantasy to achieve specific health-
related goals - Meditation, Yoga,
Conventional Methods
the use of monitoring devices that display information about the operation of a bodily function that is not normally consciously controlled, e.g. heart rate or blood pressure; conscious control of the physiologic response under the
control of ANS
physiological control technique
Non-Pharmacologic Pain Relief
Interventions
- Relaxation and Guided
Imagery - Distraction
- Cutaneous Stimulation
- Herbals
- Reducing Pain Perception
Involves stimulating the skin with the
use of mild electrical current that goes
through external electrodes
Transcutaneous Electrical
Nerve Stimulation (TENS)
Techniques that Promote Relaxation
- Conventional Methods
- Analgesic
- Placebo
A non-organic substance that satisfies the patient’s request for analgesic. It requires physician’s order
Placebo
Administer analgesic at the start of pain. It is no longer effective when pain reaches its peak
Analgesic
Factors in Pain Management
- Acknowledging & accepting client’s
pain - Assisting support persons – massaging
the clients back - Reducing misconceptions about pain
- Reducing fear and anxiety
- Preventing pain
Administration of analgesics prior
to an invasive or operative
procedure in order to treat pain
before it occurs
Preemptive analgesia
Types of Pharmacologic Pain Management
- Opioid Analgesics
- Nonopioids /NSAIDs
- Adjuvant analgesics
- Includes morphine and codeine
- Relieves pain and provides a sense of
euphoria
Opioid Analgesics
3 types of opioids:
- Full agonists
- Mixed agonists-antagonists
- Partial agonists
- Include acetaminophen and non-steroidal anti-inflammatory drugs such as ibuprofen
Nonopioids /NSAIDs
- Medications that was developed for a use other than analgesia but has been found to reduced chronic pain and sometimes acute pain in addition to its primary action
- Examples are mild sedatives or tranquilizers, antidepressants, anticonvulsants
Adjuvant analgesics
Any medication or procedure, including surgery that produces an effect in a client because of its implicit or explicit intent and not because of its specific physical or chemical properties
ADMINISTRATION OF PLACEBOS
Continuous subcutaneous administration of long-acting
local anesthetics into or near the surgical site in cases like mastectomy, hernia repair, abdominal hysterectomy
CONTINUOUS LOCAL ANESTHESIA
- An interactive pain management that permits clients to treat their pain by self-administering doses of analgesics
- Oral route: most common
- Other methods: subcutaneous, IV, epidural
PATIENT-CONTROLLED ANALGESIA
- The most prevalent
and efficient approach to alleviate
pain - Reduce or block the
perception of pain
signals in the body
ANALGESICS
- A drug delivery system that
enables patients to self-
administer opioids while
significantly reducing the
chances of an overdose
occurring
PATIENT-CONTROLLED
ANALGESIA (PCA)
- Pain-relieving drugs that are
applied externally to the skin
rather than being ingested
or injected
TOPICAL ANALGESICS
- Locally injecting an
anesthetic medication to
numb a specific area of the
body and induce a loss of
sensation in that particular
region - Induce a transient absence
of sensation by impending
nerve conduction
Local Anesthesia
- The local anesthetic is used
to obstruct a cluster of
sensory nerve fibers
Regional Anesthesia
- Used for the treatment of
acute post-operative pain,
labor and delivery pain, and
chronic cancer pain
Epidural Analgesia
Acetaminophen and Non-
steroidal Anti-inflammatory
Drugs
NON-OPIOIDS
- Most tolerated and safest
pain-reliever - Hepatotoxicity – major
adverse effect - no anti-inflammatory effects
and its action is unknown
Acetaminophen
- Aspirin, Ibuprofen, and COX-
2 Inhibitors - Provide mild to moderate
pain relief - Highly likely to inhibit
prostaglandins - Safe for short-term pain
relief
Non-steroidal Anti-
inflammatory Drugs (NSAIDs)
Prescribed for moderate to
severe pain
OPIOIDS
commonly prescribed for cancer pain
and other forms of severe
pain
Morphine
medication prescribed for
palliative care or opioid-
tolerant patients
Hydromorphone
used for its analgesic action for a short
duration during anesthesia or immediate postoperative period; pain-relieving adjunct for either general or regional anesthesia
Fentanyl
Not categorized as pain
relievers but has qualities
that may reduce pain alone
or combined with other
analgesics
ADJUVANTS
enhance pain relief, improve mood,
and decrease agitation
Anti-depressants
interrupt the transmission of pain
signals and are employed for
pain localized in specific
regions of nerve distribution
Local anesthetics
reduces anxiety and improves sleep
Anxiolytics
improves sleep
for patients with chronic
pain
Sedatives
interrupts cranial or peripheral nerves by an incision such as pain in the lower leg or foot arising from vascular occlusion
Neurectomy
- interruption of the anterior or posterior nerve root area close to the spinal cord, between the ganglion & cord.
- Performed on cervical nerve roots to alleviate pain of the head and neck from cancer or neuralgia
Rhizotomy
- The surgical interruption of pain-conducting pathways within the spinal cord.
- The incision is made in the anterolateral pathway opposite to the side on which
the pain is located - Usually done for pain in the legs and trunk to obliterate pain and temperature
sensation
Cordotomy or Spinothalamic Tractotomy
Surgical resection of the anterolateral pathway in the brainstem
Tractomy
Removal of the postcentral gyrus (part of the sensory cortex of the
brain)
Gyrectomy
Destroying the pituitary gland by injection with absolute alcohol
Hypophysectomy
Chemical interruption of a nerve pathway by injecting a local
anesthesia into the nerve
Nerve block
- Pathways of the sympathetic division of the autonomic nervous system are
severed - This process eliminates vasospasm, improves peripheral blood supply thus
effective in treating painful vascular disorders like angina and Raynaud’s
disease
Sympathectomy
- Used in nonmalignant pain that has not been controlled with less invasive
therapies - Involves insertion of a cable that allows the placement of an electrode directly
into the spinal cord - The cord is attached to a device that sends electrical impulses to the spinal cord
to control pain.
Spinal Cord Stimulation
chemical regulators that may modify
pain
Endogenous Opioids
Types of Endogenous Opioids used in Pain modulation
- Enkephalins
- Endorphins
- Dynorphins
They inhibit the release of substance P, a neurotransmitter which enhances transmission of pain impulses
Enkephalins
More potent that enkephalins
Endorphins
They have an analgesic effect which is 50 times more potent than endorphins
