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NUR2229 > Wk 5: Pain concepts and assessment > Flashcards

Wk 5: Pain concepts and assessment Flashcards

1
Q

Define 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

Key points of pain

A
  • a different pheromone for each person
  • pt is the authority of their own pain
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3
Q

What are some types of pain?

A

Times
- Acute (at time of healing)
- chronic/persistent (3-6 months)

Pathways of pain
- Nociceptic (common pain, something wrong with specific tissue)
* Somatic (tissues)
* Vicera (organ tissue)
* chances with movement
e.g. bee stings, muscle injury
- Neuropathic (damaging to the nervous system)
* nerve
* something wrong with NS.
e.g. nerves, pinching, disease
*more likely to be chronic

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4
Q

What are the elements of the nociceptive pain response?

A
  • Transduction
  • Transmission
  • Perception
  • Modulation
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5
Q

What are the three pathways of the NS?

A
  1. afferent pathway (asending to the brain)
  2. Central nervous system (where pain is percieved)
  3. efferent pathway (motor pathways that come down from CNS)
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6
Q

What are key features of the afferent pathway?

A
  • hold nociceptors (pain receptors)
  • afferent nerve fibres
  • spinal cord network
  • terminated in the dorsal horn of the spinal cord
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7
Q

What are key features of the 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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8
Q

What are key features of the efferent pathway?

A

Composed of the fibres connecting:
* reticular formation (projections into that thalamus)
* midbrain (cantain nerves and nucli)
* substantia gelatinosa in dorsal horn (recieves different types of sensory information)

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9
Q

What are nociceptors? and what are the two types?

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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10
Q

What is the speed of C and A-delta fibres?

A

C fibres: slow
A-delta: fast

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11
Q

Describe transduction

A

= initial response to injury
- release of chemical mediators
- conversion of energy types
- generation of action potential

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12
Q

Describe chemical mediators of pain

A
  • Prostaglandins (lipid compunds, mediators of alleri/inflamatory reaction so pain and swelling)
  • Substance P (vaso dilator, NT, regulates excitability of dorsal horn)
  • Histamine (Mast cells) (increase blood flwo, fluid and protien rush to the tissue space= red and swelling)
  • Bradykinins (vasodilators and tissue swellers)
  • Serotonin (NT released by platlets)
  • Potassium (important for opening and closing of potasium channels and creation of action patential)
  • Others
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13
Q

Describe the three phases of transmission

A

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

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14
Q

Describe the asending pathway

A

ascending = sensory
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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15
Q

Describe the desending pathway

A

descending= motor
From brain to spinal dorsal horn
Can be modulated
- release of chemical substances
- Gate theory
- Actions

Selective response to stimuli

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16
Q

Describe perception

A

Conscious experience of pain (ouch!) (comes through afferent pathway)
* Reticular activating system (RAS)
* Somatosensory system
* Limbic system
* Cortical structures

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17
Q

Describe modulation and its part of the pathway

A

Signals from brain travelling downwards

Release of chemical substances
- Endogenous opioids
* Encephalins
* Endorphins
- Serotonin
- Noradrenaline (norepinephrine)

= Amplification of dampening/modulation of the pain system

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18
Q

What are some impacts on modulation?

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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19
Q

Describe 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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20
Q

Describe 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
  • more relted to persistant pain but can be both
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21
Q

Describe delta A 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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22
Q

What are the types of somatic pain? and what body parts do they impact?

A

Superficial somatic
– Skin
– Mucous membranes
– Subcutaneous tissues

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

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23
Q

What impacts pain perception?

A
  • previous experince
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24
Q

What is modulation?

A
  • the inhibition or enchantment of signals
  • Occurs at all levels of the nervous system
  • Influences pain perception
  • Helps explain variability in pain experience
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25
Q

Explain the gate control theory?

A
  • Gate controlled by dynamic function of certain
    cells in dorsal horn that stops some impulse getting to the brain.
  • Substantia gelantinosa within dorsal horn is
    anatomical location of gate

Pain experience dependent on:
- 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

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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26
Q

What are some examples of things that help close the pain ‘gate’

A
  • rubbing
  • heat
  • tens machine in labour
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27
Q

What is the purpose of pain? and what impacts it?

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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28
Q

Explain how pain can be contextual?

A

You may not feel pain at the time as your focous is else where. e.g. soldiger in battle
different to a women in labour expecting a baby

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29
Q

What are the classifications of pain?

A

Actue or persistant

Neuropathic
Somatoform (psychogenic)
- no identifiable casue but person feels pain e.g psychogenic
Nociceptive
- viceral
- somatic

Others inlcude
- referred pain
- phantom pain
- cancer pain
- intractable pain
- Breakthrough pain

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30
Q

Describe acute pain

A
  • sudden onset
  • mild or significant
  • duration is dependant on the healing
  • sympathetic signs e.g. hypertension, tachy
  • is protective pain that indicates something
  • can be deep or supericial
  • can be apart of a /acute pain cycle’ that recurrent acute episodes e.g. migrane or angina

*life may be distrupted with the pain and then anticipation of pain

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31
Q

Describe persistant pain

A

aka chronic
- extends beyond normal healing time
- >3-6 months
- gradual or sudden
- mild or sever
- up to 30% of population have this
- usually results in chronic or pathological process
- gradual or ill defines onset
- progressives in severity
- no sympathatic response
- often unresponsive to medical treatment
- no protective pain= doent sever a purpose
- this along with not knowing when it will stop can lead to negative psychological symptoms e.g. depression

32
Q

Describe nociceptove pain

A
  • Response to nociceptors/nerve pathway
  • Normal processing
33
Q

Describe neurogenic/neuropathic pain

A
  • Nerve damage (peripheral or central)
  • Abnormal processing along nerve pathway
34
Q

Describe somatopain disorder

A
  • no physical cause found to casue pain
  • no evidence or organic disease
  • moved away from psychogenic disease
  • associated with mental health conditions of anxiety or despession
  • real and distressing
35
Q

Name the following of somatic pain

A

Psychological structures;
Cutaneous: skin and sub‐cutaneous tissues
Deep somatic: blood, muscle, blood vessels,
connective tissue

Mechanism:
- Activation of nociceptors

Sources of 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

36
Q

Describe nociceptive viceral 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= increase in sensitivity to pain in the tissue surrounding organ
  • May be described as sickening, deep, squeezing, dull
37
Q

Name the following of somatic pain

A

Psychological structures;
Organs and linings of body cavities

Mechanism:
- Activation of nociceptors

Characteristics
- Poorly localized, diffuse, deep, cramping or splitting

Sources of pain
- Chest tubes, abdominal tube drains,
bladder and intestinal distension

Sources of chronic pain syndromes:
- Pancreatitis
- liver metastases
- colitis

38
Q

Describe neuropathic pain

A

Results from damage to: pathologic changes of, the
peripheral or central nervous system

  • May be mediated by NMDA receptor (excitatory NT that is release with noxious peripheral stimuli)
  • Pain described as burning, tingling, shooting, electric-like, lightning‐like
  • May exhibit opioid resistance or require higher doses for effect
  • contract to nociceptic pain
39
Q

What are some causes of neuropathic pain?

A

CNS
- Stroke
- MS
- Spinal cord trauma

PNS alteration
- Polyneuropathy e.g. from diabetes
- Entrapment neuropathy (nerve is traped)
- Post herpetic (herpes/shingles) neuralgia

40
Q

Name the following of somatic pain

A

Physiologic structures
- Nerve fibres, spinal cord, and central
nervous system

Mechanism
- Non‐nociceptive injury to nervous system
structures

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

41
Q

Describe somatoform pain and what are some symtpoms?

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
42
Q

Describe cancer pain?

A

Due to
- cancer progression
- treatment related e.g. incision
- toxicities or treatments
- physical limitations

  • Usually persistent
  • Long‐term
  • Often treated as acute pain
  • Progressive nature
  • Those with cancer may experience both persistent and acute pain
  • common to come as break though pain
43
Q

Define breakthrough pain

A
  • Common in cancer patients
  • Sudden onset
  • Short duration
  • Unresponsive to normal pain management
44
Q

Define intractable pain

A

= Pain that is excruating and contacnt
- not relieved by ordinary
medical, surgical or nursing measures.
- Pain usually persistent
- causes negative mental health
- can prevent sleep
- can cause over-excitation of CVD so can be seen sometimes on medical tests

Causes
- poly mialgia
- spinal disease post surgery
- migranes

45
Q

Describe phantom pain

A
  • pain the is felt in a body part that is missing.
  • feels as though pain is in part that is is missing
    = neuropathic pain
46
Q

Describe referred pain

A

Felt at a site other than
the injured/ diseased
organ/body part
- e.g. angina paint hat may be felt in shoulder or jaw

47
Q

What are some factors that influence pain perception, expression and reaction?

A
  • genetic
  • developmental
  • familial
  • psychological
  • social
  • cultural
  • not related to the extent of tissue damage necessarily as these come into play
48
Q

What are some psychological and phsyical aspect of pain?

A
  • Anxiety
  • Sense of helpless ness
  • Poor insight
  • Lack of communication skills
  • Depressive mood
  • Cognitive deficits
    • dementia cant explain pain
  • Elderly
49
Q

What are some environmental impacts of pain?

A
  • Unhealthy environment
  • No community access
  • Poor finances
  • Limited education/health literacy
  • Stressful living context
  • Lack of secure housing
50
Q

What are some social and interpersonal impacts of pain?

A
  • Lack of family support
  • Poor social networks
  • Unemployed
  • Avoidance of activities
  • Being single
  • Frequent hospitalisation
51
Q

What psychological aspects can be affected by pain?

A

Attention: person pays to it

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

52
Q

What are some psychological aspected 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
53
Q

Define transduction and explain how it occurs

A

the conversion of mechanical, thermal or chemical stiumli to neuronal action potential.

= cell damage releases sentising cibstances such as prostaglandins bradyinins, subsance P, histamine, leukotrines, serotonin and ATP which results in;
1: the generation of an action potenital along the neuronal membrane
2: the abnormal processing of stimuli by the nervous system (neural pain) plus chnage along the neuronal membrane.

54
Q

Define transition and explain how it occurs

A

= where stimulated nocioceptors transmit impulses to the CNS by means of specalised sensory fibres. Nocioceptors terminate at the CNS so substance P is realised and picked up by opoid receptors on the other side of the synaptic clef at the dorsal horn neurons.
- from dorsal horn though spinal cord on asending tracts to the brain.
- the spinothalamic tract neurons carry implusles to the thalamus.
- Thalamus acts as a relay station sending the impulses to cnteral structures in the brain processing.

54
Q

Define and describe perception

A

= the brain nociceptors input is perceived as pain.
This process involves may brain structures and there is no single precise ;ocation where it occurs.

55
Q

Define and describe modulation

A

= neurons that chnage or inhibit nociceptive impulses such as endogenous opoids, serotonin and norepinerphrine (noradrenalise) resulting in modulation of pain signals.
The modulation occurs in the area of the dorsal horn. Previous experiences are one example of ways that can affect how pain is revoeced.

56
Q

Outline a pain assessment/plan for acute pain

A

Initial assessment
Assessment tools
Goals of pain management
Ongoing assessment
Documentation

57
Q

name one benefit and limitation of a pain assessment tool

A

+ quick
+ easy
+ relatively accurate

  • one dimensional look at pain
  • room for error
58
Q

What are some key points of assessment for any pain?

A
  • Definable injury / illness
  • Definite onset
  • Duration limited and predictable – usually subsides as healing occurs
  • Associated with clinical signs of sympathetic
    overactivity
59
Q

What are 3 pain scores?

A
  • numerical
  • visual analogue
    • instructs patient to point of a scale
  • verbal rating
    • descriptive
60
Q

What is an example of a pain assessment tool for acute pain?

A

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

61
Q

What may be considered in a behaviours pain assessment tool?

A
  • face
  • restlessness
  • muscle tone
  • vocalisation
  • consolability

Scored a 0-2 and equates to out of 10

62
Q

What is a FAS score?

A

Description of limitation created by the pain.
e.g. move affected leg or take a deep breath and cough for thoracic injury
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

63
Q

What are two points that may help differ acute to chronic pain?

A
  • acute is shorter in nature and subsdes after healing
  • acute has sympathetic symptoms e.g. increased HR and BP where as chronic will not
64
Q

What are some key points of assessment of persistant pain that you may not assess for chronic?

A
  • the labile nature it coming and going
  • does it increase with activity for example?
  • does pain wake them from sleep?
    does it cause symptoms such as mood changes, lethargy, nausea
65
Q

Explain BPI

A

Assesses pain severity and the degree of interference with function, using 0‐10 NRS
Assesses things like
- mood
- walking ability
Sleep
- relationship with others
enjoyment for life
- rating of pain severity out of 10

66
Q

What are some good pain assessment tool for children?

A
  • routine questions
  • verbal scales
  • numeric scales
  • pictorial scales
67
Q

What are some behavioural measures of pain?

A
  • age related behavioural changes
  • motor responses
  • facial expressions
  • crying
  • behavioural responses (e.g. sleep‐wake patterns)
68
Q

What are some physiological signs of pain?

A
  • altered observations (HR, RR, BP, etc.)
  • posture/tone
  • sleep pattern
  • skin colour/sweating

**not good indicators if in isolation

69
Q

What is the QUESTT peads assessment tool?

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

70
Q

What is the FLACC peads assessment tool?

A

Faces
Legs
Activity
Cry
Consolability

71
Q

What is McGills pain assessment? and what does it assess?

A

Persistent pain questionnaire
- sensory
- affecting
- total pain

72
Q

What is brief assessment pain assessment? and what does it assess?

A

for persistent pain
- pain severity and effects of function
- 1-10

73
Q

What is the behaviour pain assessment?

A
  • for acute and persistent
  • used when someone is in so much pain that they can communicate

Faces
Wrestlessness
muscle tone
vocalisation
confusability

74
Q

What is the FLACC pead pain assessment

A

Face
Legs
Cry
Consulability

75
Q
A

NUR2229 (6 decks)

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