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NUR2229 > Week 4 > Flashcards

Week 4 Flashcards

1
Q

Types of pain

A

Common terminology of overall types (time)
* Acute
* Persistent (previously chronic)
Related Pathways for different classifications
* Nociceptive
* Neuropathic

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2
Q

Nociceptive Pain

A

Nociceptive pain response
* Transduction
* Transmission
* Perception
* Modulation

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3
Q

Pathophysiology- pain

A

Nervous system has key three areas related to sensation and perception of pain:
1. Afferent pathways
2. Central nervous system
3. Efferent pathways

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4
Q

Afferent pathway

A

a) nociceptors (pain receptors)
b) afferent nerve fibres
c) spinal cord network

  • Afferent pathways terminate in the dorsal horn of the spinal cord
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5
Q

CNS pathway

A

The portions involved in the interpretation of the pain signals:
* the limbic system
* reticular formation
* thalamus
* hypothalamus
* cortex

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6
Q

Efferent pathways

A

Composed of the fibres connecting:
* reticular formation
* midbrain
* substantia gelatinosa in dorsal horn

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7
Q

Nociceptors

A
  • Sensory receptors (nerve endings) activated by noxious stimuli, transmit impulses via C fibre and A‐delta fibres
    Distributed in:
  • somatic structures (skin, muscles, connective tissue, bones, joints);
  • visceral structures (visceral organs such as liver, gastro‐ intestinal tract)
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8
Q

Transduction

A
  • Response to tissue injury
  • Release of chemical mediators
  • Conversion of energy types
  • Generation of action potential
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9
Q

Chemical mediators in pain

A
  • Prostaglandins
  • Substance P
  • Histamine (Mast cells)
  • Bradykinins
  • Serotonin
  • Potassium
  • Others
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10
Q

Transmission

A

Three phases:
* Injury site to spinal cord
- A‐delta and C fibres
* Spinal cord to brain stem and thalamus
* Thalamus to cortex

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11
Q

Action potential

A

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

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12
Q

Pathways: ascending = sensory

A
  • From nociceptors to brain
    • 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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13
Q

Pathways: descending = motor

A

From brain to spinal dorsal horn
* Can be modulated
- Chemical substances
- Gate theory
- Actions
* Selective response to stimuli

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14
Q

Perception

A

Conscious experience of pain
* Reticular activating system (RAS)
* Somatosensory system
* Limbic system
* Cortical structures

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15
Q

Modulation

A
  • Signals from brain travelling downwards
  • Release of chemical substances o Endogenous opioids
  • Encephalins
  • Endorphins
    • Serotonin
    • Noradrenaline (norepinephrine)
  • Amplification of dampening of the pain system
  • 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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16
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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17
Q

Nerve fibres- C 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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18
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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19
Q

Nociceptive pain- Superficial somatic

A

– Skin
– Mucous membranes
– Subcutaneous tissues

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20
Q

Nociceptive pain- Deep somatic

A

– Muscles
– Bones
– Fascia
– Tendons
– Joints
– Ligaments
– Blood vessels

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21
Q

Gate control theory

A
  • Melzack & Wall 1965
  • Theorised the existence of a “gate” that could facilitate/inhibit transmission of pain signals
  • Gate controlled by dynamic function of certain cells in dorsal horn
  • Substantia gelantinosa within dorsal horn is anatomical location of gate
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22
Q

Pain experience dependent on:

A
  • amount of information that gets “through” the gate to the brain
  • Competition between large and small fibres
  • Competition between pain fibres and non pain fibres
  • amount of downward signaling from brain
    • Endogenous chemical release
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23
Q

Gate control

A
  • Descending & ascending fibres meet at the gate
  • Gate open/closed depending on information received from various sources
  • T cells within dorsal horn facilitates the opening & closing
  • Activity such as touch can close the gate e.g. rubbing the injured site
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24
Q

Pain

A
  • Necessary, protective mechanism
  • Subjective experience, not necessarily consequential just from an external stimulus
  • Complex interplay of multiple factors
    – Biological
    – Psychological/affective
    – Sociological
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25
Q

Acute pain

A
  • Sudden onset
  • Mild to severe
  • Duration dependent on “normal healing”
  • Deep or superficial ‐ produce different pain
  • If pain continues ‘acute pain cycle’ may occur
  • e.g. migraine or angina may involve recurrent acute episodes
  • Person may be fully functional in between or life may be disrupted by constant threat/become persistent pain sufferer
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26
Q

Classification of pain

A

Persistent pain (previously called chronic) Extends beyond expected healing time
* Gradual or sudden
* Mild to severe
* > 3 - 6 months (arbitrary)
* Up to 30% of population

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27
Q

Persistent (chronic) pain

A
  • 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)
    Issues
  • Not always associated with an identifiable cause
  • Often unresponsive to conventional medical treatment
  • Complex and pathophysiology is poorly understood
  • May limit normal functioning
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28
Q

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
    • sometimes sharp
  • Opioid responsive
    Physiologic structures:
  • Cutaneous: skin and sub‐cutaneous tissues
  • Deep somatic: blood, muscle, blood vessels, connective tissue
    Mechanism:
  • Activation of nociceptors
    Characteristics:
  • Well‐localised, constant, achy, may be initially acute
    Sources of acute pain:
    *Incisional pain, insertion sites of tubes and drains, wound complications, orthopaedic procedures, skeletal muscle spasms
    Sources of chronic pain syndromes:
  • Bony metastases, osteo/rheumatoid arthritis, low‐back pain, peripheral vascular disease
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29
Q

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 & sympathetic efferent activity
  • Cutaneous hyperalgesia
  • May be described as sickening, deep, squeezing, dull
30
Q

Nociceptor: visceral

A

Physiologic structures:
* Organs and linings of body cavities
Mechanism:
* Activation of nociceptors
Characteristics:
* Poorly localized, diffuse, deep, cramping or splitting
Sources of acute pain:
* Chest tubes, abdominal tube drains, bladder and intestinal distension
Sources of chronic pain syndromes:
* Pancreatitis, liver metastases, colitis

31
Q

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, lightning ‐like
  • May exhibit opioid resistance or require higher doses for effect
  • CNS
    – Stroke
    – MS
    – Spinal cord trauma
  • PNS alteration
    – Polyneuropathy
    – Entrapment neuropathy
    – Post herpetic (herpes/shingles) neuralgia
32
Q

Neuropathic: non‐nociceptor

A

Physiologic structures:
*Nerve fibres, spinal cord, and central nervous system
Mechanism:
* Sources of acute and chronic pain syndromes
Characteristics:
* Poorly localized: shooting, burning, fiery, shock‐like, sharp, painful numbness
Sources of acute and chronic pain syndromes:
*Nerve tissue injury due to diabetes, HIV, chemotherapy, neuropathies, post‐herpetic neuralgia

33
Q

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
34
Q

Cancer pain

A
  • Separate category
  • Usually persistent
  • Long‐term
  • Often treated as acute pain
  • Progressive nature
  • Those with cancer may experience both persistent and acute pain
35
Q

Breakthrough pain

A
  • Common in cancer patients
  • Sudden onset
  • Short duration
  • Unresponsive to normal pain management
36
Q

Intractable pain

A
  • Pain that is not relieved by ordinary medical, surgical or nursing measures.
  • Pain usually persistent
37
Q

Phantom pain

A
  • Pain felt in a body part that is missing
    – Sensation
    – Pain
38
Q

Referred pain

A

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

39
Q

Pain perception, expression and reaction

A

Influenced by variables:
* genetic
* developmental
* familial
* psychological
* social
* cultural

40
Q

Psychological and physical aspects of pain

A
  • Anxiety
  • Sense of helpless ness
  • Poor insight
  • Lack of communication skills
  • Depressive mood
  • Cognitive deficits
  • Elderly
41
Q

Environmental aspects of pain

A
  • Unhealthy environment
  • No community access
  • Poor finances
  • Limited education/health literacy
  • Stressful living context
  • Lack of secure housing
42
Q

Social and interpersonal aspects of pain

A
  • Lack of family support
  • Poor social networks
  • Unemployed
  • Avoidance of activities
  • Being single
  • Frequent hospitalisation
43
Q

Pain can be affected by:

A
  • Attention
  • Expectations: previous experience
  • Interpretation: attitudes and beliefs
  • Context: what is the meaning of the pain
  • Emotions and mood: anxiety, depression, anger, sad
  • Coping strategies: perception of control
44
Q

Psychosocial Aspects of 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
45
Q

Pain Assessment/Plan

A
  • Initial assessment
  • Assessment tools
  • Goals of pain management
  • Ongoing assessment
  • Documentation
46
Q

Factors relevant to effective treatment

A
  • Ability to use appropriate pain measurement tools.
  • Patient’s beliefs about pain, expectations and treatment preference
  • Coping mechanisms
  • Patient’s knowledge of pain management techniques and expectation of outcome
  • Family expectations and beliefs about pain and the patient’s illness
47
Q

Pain assessment tools

A

*Uni‐dimensional tools
* 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

48
Q

Multi‐dimensional 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.
49
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
50
Q

Pain Scales: uni‐dimensional

A
  • Numerical
  • Visual analogue scale
  • Verbal rating scale
51
Q

Numeric Pain Rating Scale

A
  • Most commonly used
  • Line with 0 (no pain) at one end and 10 (worst pain possible) at the other
  • The patient is asked to rate pain intensity by picking the number that most closely represents the level of pain that the patient is experiencing
52
Q

Visual analogue scale

A

Instruct the patient to point to the position on the line between the faces to indicate how much pain they are currently feeling.

53
Q

Verbal Rating Scale

A

Uses
* verbal descriptors, e.g. mild, moderate, severe
or
* quality descriptors, e.g. ache, agonizing, or discomfort

54
Q

Multidimensional Pain Tools

A

Acute
– PQRST
–OPQRTSUV
– Initial pain assessment tool

55
Q

PQRST

A

P = Provocation/Palliation
Q = Quality/Quantity
R = Region/Radiation
S = Severity Scale
T = Timing

56
Q

OPQRSTUV

A

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

57
Q

Functional activity score

A
  • Ask the patient to perform an activity related to their painful area, e.g.
    – deep breathe and cough for thoracic injury
    – move affected leg for lower limb pain
  • Observe during the chosen activity and score: A, B or C.
    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
  • NB Relative to baseline: refers to any restriction above any pre‐existing condition the patient may already have.
58
Q

Asst. functional and medical problems

A
  • Associated symptoms
  • Effect of pain on activities
  • Family history / Medical and drug history
  • Medications/treatments and their effect on pain
  • Physical examination
  • Evaluation of disability associated with the pain
  • Psychosocial
59
Q

Location and description of pain

A
  • Identify factors that exacerbate or relieve pain.
  • Describe the character of pain using quality/sensory descriptors, e.g. sharp, throbbing, burning.
  • Observe for signs of neuropathic pain including descriptions: e.g. shooting, burning, stabbing, allodynia
  • How long does the pain last, e.g. continuous, intermittent
60
Q

Assessment of persistent Pain

A
  • May not have
    – definable injury / illness
    – definite onset
  • Duration
    – not limited: persistent beyond normal healing time
    – unpredictable
  • No clinical signs of sympathetic overactivity
61
Q

Additional questions: persistent pain

A
  • Is there a pattern to 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 day?
  • What relieves pain?
  • Is there any weather that makes the pain worse?
62
Q

Multidimensional Pain Tools

A

Persistent
* Brief pain Inventory: long and short forms
* McGill Pain Questionnaire: long and short forms

63
Q

Brief Pain Inventory (BPI)

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
64
Q

McGill Pain questionnaire

A
  • McGill Pain Questionnaire (MPQ)
  • Short‐form MPQ (SF‐MPQ)
  • 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.
65
Q

Paediatric Assessment

A

Self‐reported measures of pain include :
* routine questions
* verbal scales
* numeric scales
* pictorial scales

Behavioural measures of pain include:
* age related behavioural changes
* motor responses
* facial expressions
* crying
* behavioural responses (e.g. sleep‐wake patterns)

66
Q

Physiological: RCH

A

Physiological changes include:
* altered observations (HR, RR, BP, etc.)
* posture/tone
* sleep pattern
* skin colour/sweating
These are not good indicators to use in isolation

67
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

68
Q

Pain rating scales for children

A
  • Faces
  • Numeric
  • Behavioural
  • Behavioural/physiological
69
Q

FACES pain rating scale: RCH

A

The patient is asked to pick the face that best represents the pain that he or she is experiencing
* These faces show how much something can hurt.
* “Point to the face that shows how much you hurt [right now]”.
* Do not use words like ‘happy’ and ‘sad’.
* This scale is intended to measure how children feel inside, not how their face looks.

70
Q

Acute pain effects: Developmental

A
  • ↑behavioural/physiologic responses to pain
  • Altered temperament
  • ↑vulnerability to stress disorders
  • Addictive behaviours
  • Anxiety states
  • Infant distress behaviour
  • Future pain: persistent pain syndromes

NUR2229 (6 decks)

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