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NUR2229 > Week 1 - Pain concepts and assessment > Flashcards

Week 1 - Pain concepts and assessment Flashcards

1
Q

Definition of pain

A

Sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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2
Q

Types of pain

A
  • Acute
  • Persistent (previously chronic)
  • Nociceptive
  • Neuropathic
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3
Q

Types of pain mechanisms

A 
Nociceptive = tissue
- Somatic
- Visceral 
Neuropathic = nerve
NB: There is no pain without the brain
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4
Q

Nociceptive pain response (4)

A
  • Transduction
  • Transmission
  • Perception
  • Modulation
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5
Q

Afferent pathways related to sensation and perception of pain (3)

A
  • Nociceptors (pain receptors)
  • Afferent nerve fibres
  • Spinal cord network
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6
Q

Central nervous system related to sensation and perception of pain (5)

A
  • The limbic system
  • Reticular formation
  • Thalamus
  • Hypothalamus
  • Cortex
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7
Q

Efferent pathways related to sensation and perception of pain (3)

A
  • Reticular formation
  • Midbrain
  • Substantia gelatinosa in dorsal horn
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8
Q

Where are nociceptors distributed in?

A
  • Somatic structures (skin, muscles, connective tissue, bones, joints)
  • Visceral structures (visceral organs such as liver, gastrointestinal tract)
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9
Q

What are nociceptors?

A

Sensory receptors (nerve endings) activated by noxious stimuli, transmit impulses via C fibre and A-delta fibres.

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10
Q

What is transduction?

A
  • Response to tissue injury
  • Release of chemical mediators
  • Conversion of energy types
  • Generation of action potential
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11
Q

What are the chemical mediators of pain?

A
  • Prostaglandins
  • Substance P
  • Histamine (mast cells)
  • Bradykinins
  • Serotonin
  • Potassium
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12
Q

Three phases of transmission

A
  • Injury site to spinal cord (A-delta and C fibres)
  • Spinal cord to brain stem and thalamus
  • Thalamus to cortex
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13
Q

What are action potentials?

A

Action potentials are generated by voltage-gated ion channels embedded in a cell’s plasma membrane.

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14
Q

Pathways: ascending = sensory

From nociceptors to brain:

A
  • Complex transmission from periphery to dorsal root of spinal cord
  • Terminate in dorsal horn
  • Signals communicate with local interneurons
  • Neurons with long axons ascend to brain
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15
Q

Pathways: descending = motor

From brain to spinal dorsal horn:

A
  • Can be modulated (chemical substances, gate theory, actions)
  • Selective response to stimuli
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16
Q

Perception: conscious experience of pain

A
  • Reticular activating system (RAS)
  • Somatosensory system
  • Limbic system
  • Cortical structures
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17
Q

Modulation (afferent)

A
  • Signals from brain travelling downwards
  • Amplification of dampening of the pain system
  • Release of chemical substances
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18
Q

What chemical substances are released in modulation (afferent)?

A
  • Endogenous opioids
  • Encephalins
  • Endorphins
  • Serotonin
  • Noradrenaline (norepinephrine)
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19
Q

Modulation (efferent):

A
  • Occurs at all levels of the nervous system
  • Signals enhanced or inhibited
  • Influences pain perception
  • Helps explain variability in pain experience
  • The “gate theory”
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20
Q

Nerve fibres (A delta fibres):

A
  • Thinly myelinated
  • Large diameter
  • Fast-conducting fibres
  • Transmit well-localised, sharp pain
  • Sensitive to mechanical and thermal stimuli
  • Transmit signals rapidly: associated with acute pain
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21
Q

Nerve fibres (C delta fibres):

A
  • Unmyelinated, small diameter
  • Slow-conducting
  • Transmit poorly localised, dull and aching pain
  • Sensitive to mechanical, thermal, chemical stimuli
  • Activation associated with diffuse, dull, persistent pain
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22
Q

Nerve fibres (A beta fibres):

A
  • Highly myelinated
  • Large diameter
  • Rapid-conducting
  • Low activation threshold
  • Respond to light touch, transmit non-noxious stimuli
  • Gate theory: tactile non-noxious stimuli inhibits pain signal transmission
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23
Q

Deep somatic nociceptive pain

A
  • Muscles
  • Bones
  • Fascia
  • Tendons
  • Joints
  • Ligaments
  • Blood vessels
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24
Q

Superficial somatic nociceptive pain

A
  • Skin
  • Mucous membranes
  • Subcutaneous tissues
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25
Q

What is the gate theory?

A
  • Theorised the existence of a “gate” that could facilitate/inhibit the transmission of pain signals
  • Gate controlled by dynamic function of certain cells in dorsal horn
  • Substantia gelatinosa within dorsal horn is anatomical location of gate
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26
Q

Gate control theory pain experience is dependant on:

A

Amount of downward signaling from brain
-Endogenous chemical release
Amount of information that gets “through” the gate to the brain
- Competition between large and small fibres
-Competition between pain fibres and non pain fibre

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27
Q

What is acute pain?

A
  • Sudden onset
  • Mild to severe
  • Duration dependent on “normal healing”
  • Deep or superficial - produce different pain
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28
Q

What is persistent pain? (chronic)

A
  • Extends beyond expected healing time
  • Gradual or sudden
  • Mild to severe
  • > 3-6 months (arbitrary)
  • Up to 30% population
  • Usually results from chronic pathological process
  • Gradual or ill defined onset
  • Continues unabated - progressively more severe
  • Usually no signs of sympathetic over activity (as seen with acute pain)
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29
Q

What is nociceptive somatic pain?

A
  • From mechanical, thermal or chemical excitation or trauma to peripheral nerve fibres
  • Mediated by widely distributed nociceptors
  • Pain described as dull or aching, throbbing and sometimes sharp
  • Opioid responsive
30
Q

What is nociceptive visceral pain?

A
  • Dull, poorly localised deep pain
  • Due to ischaemia, inflammation, obstruction
  • Vague associated symptoms, may be N & V
  • Referred pain
  • Reflex motor and sympathetic efferent activity
  • Cutaneous hyperalgesia
  • May be described as sickening, deep, squeezing, dull
31
Q

What is neuropathic pain?

A
  • Results from damage to, or pathologic changes of, the peripheral or central nervous system
  • May be mediated by NMDA receptor
  • Pain described as burning, tingling, shooting, electric-like, lightening-like
  • May exhibit opioid resistance or require higher doses for effect
32
Q

What is somatoform pain disorder?

A
  • Previously termed psychogenic pain
  • Pain caused, increased, or prolonged by mental, emotional, or behavioural factors
  • Diagnosis of exclusion
  • Label or diagnosis? Sufferers are often stigmatised
  • Headache, back pain and abdominal pain are sometimes diagnosed as SPD
33
Q

What is breakthrough pain?

A
  • Common in cancer patients
  • Sudden onset
  • Short duration
  • Unresponsive to normal pain management
34
Q

What is intractable pain?

A
  • Pain that is not relieved by ordinary medical, surgical or nursing measures
  • Pain usually persistent
35
Q

What is phantom pain?

A
  • Pain felt in a body part that is missing e.g. amputation
  • Sensation
  • Pain
36
Q

What is referred pain?

A

Felt at a site other than the injured/diseased organ/body part

37
Q

Variables that influence pain:

A
  • Genetic
  • Developmental
  • Familial
  • Psychological
  • Social
  • Cultural
38
Q

Psychological and physical aspects of pain:

A
  • Anxiety
  • Sense of helplessness
  • Poor insight
  • Lack of communication skills
  • Depressive mood
  • Cognitive deficits
  • Elderly
39
Q

Environmental aspects of pain:

A
  • Unhealthy environment
  • No community access
  • Poor finances
  • Limited education/ health literacy
  • Stressful living context
  • Lack of secure housing
40
Q

Social and interpersonal aspects of pain:

A
  • Lack of family support
  • Poor social networks
  • Unemployed
  • Avoidance of activities
  • Being single
  • Frequent hospitalisation
41
Q

What can pain be affected by?

A
  • Attention
  • Expectations: previous experience
  • Interpretation: attitudes and beliefs
  • Context: what is the meaning of pain
  • Emotions and mood: anxiety, depression, anger, sad
  • Coping strategies: perception of control
42
Q

What can cause persistent pain?

A
  • Loss of employment/income
  • Depression, fear, anxiety, grief, guilt, anger
  • Isolation
  • Sleep disorders
  • Marital and family dysfunction
  • Lowered self esteem and confidence
  • Catastrophising
43
Q

Pain assessment/plan:

A
  • Initial assessment
  • Assessment tools
  • Goals of pain management
  • Ongoing assessment
  • Documentation
44
Q

Factors relevant to effective treatment:

A
  • Ability to use appropriate pain measurement tools
  • Patients beliefs about pain, expectations and treatment preference
  • Coping mechanisms
  • Patients knowledge of pain management techniques and expectation of outcome
  • Family expectations and beliefs about pain and the patient’s illness
45
Q

Uni-dimensional pain assessment tools:

A
  • Measure only one dimension of the pain experience
  • Accurate, simple, quick, easy to use and understand
  • Scales have numeric/verbal rating/verbal descriptor e.g. to describe mild, moderate, severe pain
  • Commonly used for acute pain assessment and postoperative pain assessment
46
Q

Multi-dimensional pain assessment tools:

A
  • Provide information about the qualitative and quantitative aspects of pain
  • Tend to be used for persistent pain or if neuropathic pain is suspected
  • Require patients to have good verbal skills and sustained concentration: take longer to complete than uni-dimensional tools
47
Q

Assessment of acute pain:

A
  • Definable injury/illness
  • Definite onset
  • Duration limited and predictable - usually subsides as healing occurs
  • Associated with clinical signs of sympathetic overactivity
48
Q

Uni-dimensional pain scales:

A
  • Numerical
  • Visual analogue scale
  • Verbal rating scale
49
Q

Multi-dimensional pain scales:

A
  • PQRST
  • OPQRSTUV
  • Initial pain assessment tool
50
Q

What does the pain assessment PQRST stand for?

A 
P= Provocation/Palliation
Q= Quality/Quantity
R=Region/Radiation
S= Severity scale
T= Timing
51
Q

What does the pain assessment OPQRTSUV stand for?

A 
O= Onset
P= Provocation/Palliation
Q= Quality
R= Region/Radiation
S= Severity scale
T= Treatment
U= Understanding impact
V= Values
52
Q

What are the categories of a behavioural pain assessment scale?

A
  • Restlessness
  • Muscle tone
  • Vocalisation
  • Face
  • Consolability
53
Q

Functional activity score (A,B,C):

A

A- No limitation: the activity is unrestricted by pain
B - Mild limitation: the activity is mild to moderately restricted by pain
C ‐ Severe limitation: the ability to perform the activity is severely limited by pain

54
Q

Questions you can ask someone with persistent pain:

A
  • Is there a pattern of pain when you get up in the morning?
  • Does pain increase as day goes on/with activity?
  • What effect do analgesic medicines have on the pain?
  • Does pain wake you?
  • If you have severe pain, do you have any of the following effects: e.g. lethargy, nausea, changes in mood?
  • Is there any numbness or loss of muscle strength associated with the pain?
  • Do normal stimuli make pain worse, e.g. light touch, shower?
  • Is pain tolerable for most of the day?
  • What relieves pain?
  • Is there any weather that makes the pain worse?
55
Q

Multidimensional pain tools - persistent:

A
  • Brief pain inventory: long and short forms

- McGill Pain Questionnaire: long and short forms

56
Q

What is the brief pain inventory?

A
  • Assesses pain severity and the degree of interference with function, using 0‐10 NRS
  • Validated screening and monitoring tool
  • When to use (Initial assessment, patient reviews and monitoring, useful tool with children, elderly or CALD)
57
Q

What is the McGill Pain Questionnaire?

A
  • Evaluate sensory, affective‐emotional, evaluative, and temporal aspects of the patient’s pain condition
  • Three pain scores are calculated: the sensory, the affective, and the total pain index
58
Q

Paediatric pain assessment scales:

A
  • Routine questions
  • Verbal scales
  • Numeric scales
  • Pictorial scales
59
Q

Behavioural measures of pain include:

A
  • Age related behavioural
  • Motor responses
  • Facial expressions
  • Crying
  • Behavioural responses (e.g. sleep-wake patterns)
60
Q

Physiological changes due to pain include:

A
  • Altered observations (HR, RR, BP, etc)
  • Posture/tone
  • Sleep pattern
  • Skin colour/sweating
61
Q

Paediatric QUESTT:

A 
Q: Question the child 
U: Use a pain rating scale 
E: Evaluate behavior & physiological change 
S: Secure parents involvement 
T: Take cause of pain into account 
T: Take action and evaluate results
62
Q

Principles of pain:

A
  • Patients should be involved in their management plan
  • Pain management should be flexible and individualised
  • Pain should be managed early: established pain is more difficult to manage
  • Pain should be managed to a comfortable/tolerable level
63
Q

Management plan of pain - three phases:

A
  • Assessment: History and physical examination +/‐ further investigations
  • Management: discuss pain management options, providing information, assurance and advice encouraging return to normal activity
  • Review: reassess and revise
64
Q

What is allodynia?

A

Pain that occurs from a stimulus that does not normally provoke pain. For example, stroking the skin lightly with clothes or cotton wool will produce pain

65
Q

What is analgesia?

A

Absence of sensitivity to pain/no pain

66
Q

What is hyperanalgesia?

A

Excessive pain sensitivity, perception of a painful stimulus as more painful than normal

67
Q

What is paraesthesia?

A

Abnormal burning, tingling, or numbing sensation, typically associated with neuropathic pain

68
Q

Visceral pain origin:

A

Organs

69
Q

Nociceptive pain origin:

A

Connective tissue, eg skin, muscles, blood vessels

70
Q

Neuropathic pain origin:

A

Nerve damage

NUR2229 (6 decks)

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