53 a focus 6 pain part 1

Part I

Nursing 53AJudith Ontiveros, RN, MSN, CPAN

ObjectivesObjectives• Describe the physiological mechanism involved in the pain experience.

• Compare and contrast the different types of pain and their significance.

• Discuss some of the general assumptions about the pain experience.

• List seven components of accurate pain assessment

• Review the different types of pain management techniques.

• Focus on nursing responsibilities associated with the pharmacological therapy of the pain experience.

Definitions of PainDefinitions of Pain

“an unpleasant sensory and emotional experience associated

with actual or potential tissue damage, or described in terms of

such damage.”

American Pain Society (APS, 2003; Gordon, 2002.)


• Pain, classified as acute consists of a sudden feeling of discomfort that can develop from many sources, such as an acute illness, surgery, trauma, invasive equipment, nursing and medical interventions and immobility. If pain is inadequately treated it can lead to the development of chronic pain (Mc Caffrey, Frock, & Garguilo, 2003).


“Pain is an emergency!”•Melanie Simpson, RN, BA, BSN

•OCN Cancer Institute of Kansas University

“Pain is whatever the person experiencing it says it is, existing

whenever he says it does.” (Margo McCaffery, 1979)

SummarizationSummarization• Pain:

actual physical sensation of discomfort

• Suffering: unpleasant emotional response to pain

Pain is a very subjective and highly individualized

experience

Implications for NursingImplications for Nursing

• Physical and emotional experience

• In response to actual or potential tissue damage.

• Pain is described in terms of such damage.

Not all body, not all soul!

Some won’t divulge pain unless assessed or asked

about. Assess in other ways… nonverbal, etc.

• Nearly 1/3 of Americans will experience chronic pain at some point in their lives.

– Joint Commission (Accreditation of Healthcare Organizations)

• Approximately 50 million with chronic pain

• #1 cause of adult disability in the US

• In younger people (18-34)– 82% experience grumpiness or irritable behavior as a

result of their chronic pain



• Women affected more emotionally by their pain than men– 70 % suffer with stress – 55 % with loss of motivation

• a study by the Cleveland Clinic

• 3/10 men (28%) experience less desire for sex due to chronic pain

• Costs are an estimated $100 billion in lost productivity every year– major cause of absenteeism


• Affects all body systems– Results in serious health issues– Increases risks of complications– Delays healing– Accelerates progression of fatal illnesses

• Changes to nervous system can result in incurable chronic pain.

• Question whether life is worth going on


• More than a symptom of a problem

• Becomes a HIGH priority problem of its own entity. – Physiologic and psychologic dangers

Severe Pain = Emergency Situation

Deserves prompt, professional treatment

Components of the Pain Experience


• Pain is a protective mechanism

• Complex biopsychosocial phenomena

• May or may not– have a cause– respond to interventions



• Reception:– sensation through pain receptors of the nervous

system

• Perception: – conscious mental recognition or registration of a

sensory stimulus

• Reaction: – the response a person takes after identifying the

sensation

ReceptionReception

NociceptionNociception

• Physiologic process related to pain perception– React to mechanical, thermal, or chemical stimuli– Potential or real tissue damage

• Four physiologic processes– Transduction– Transmission– Perception– Modulation

TransductionTransduction• Nociceptors excited by stimuli

• Noxious stimuli triggers release of biochemical mediators– Prostaglandins– Bradykinin– Serotonin– Histamine– Substance P

• Movement across cell membrane

• Pain Medications effective at this stage– Blocks Prostaglandins

Figure 46-2 Substance P assists the transmission of impulses across the synapse from the primary afferent neuron second-order neuron in the spinothalamic tract

Figure 46-2 Substance P assists the transmission of impulses across the synapse from the primary afferent neuron second-order neuron in the spinothalamic tract

Transmission of Pain ImpulsesTransmission of Pain Impulses

• 3 segments

1. Impulse travels from peripheral nerve to spinal cord

• Substance P – neurotransmitter across synapse– Unmyelinated C fibers – dull aching pain– Thin A-delta fibers – sharp localized pain

• Local medications work here to block impulses

Transmission of PainTransmission of Pain

2. Transmission from spinal cord and

ascension– Spinothalamic tracts – To brain stem and thalamus

• Opioids block release of neurotransmitters

3. Signals to thalamus to somatic sensory

cortex–Pain perception

Figure 46-3

Physiology of

Pain Perception

Figure 46-3

Physiology of

Pain Perception

PerceptionPerception

• Conscious of pain– Complex activity in CNS– Pyschosocial and meaning of pain to each

individual shape the responses

ModulationModulation• Descending System

– Neurons in thalamus and brain stem send signals back to dorsal horn of spinal cord

– Neurons in thalamus and brain stem send signals back down to dorsal horn

• Descending fibers release endogenous opioid,

serotonin, and norepinephrine• Inhibits noxious impulses (short-lived)• Amino Acids and excitatory glial cells facilitate pain

signals

– Tricyclic antidepressants help block uptake of NE and serotonin

QuestionQuestion• A nurse is evaluating a nursing student’s

understanding of transcultural differences in responses to pain. Which of the following actions demonstrates a need for further teaching?

– The African American culture believes pain and suffering is a part of life and is to be endured

– The Mexican American culture believes that enduring pain is a sign of strength (but they still tend to be loud in expressing pain)

– The Asian American culture tends to be loud and outspoken in expressions of pain - FALSE

– Native Americans are quiet, less expressive verbally and nonverbally, and may tolerate a high level of pain

Gate Control SchematicGate Control Schematic

Small diameter (a-delta or C) peripheral nerve fibers carry signals of noxious stimuli to the dorsal horn

Ion channels on the pre- and postsynaptic membranes serve as gates

When open, permit positively charged ions to rush into the second order neurons, sparking an electrical impulse and sending signals of pain to the thalamus

Gate TheoryGate Theory

Large diameter (A-delta) fibers have inhibitor effect

May activate descending mechanism that can inhibit transmission of pain

Clinical Application ofGate Control Theory Clinical Application ofGate Control Theory

• Stop nociceptor firing

• Apply topical therapies

• Address client’s mood

• Address client’s goals

Factors Affecting PainFactors Affecting Pain

• Ethnic and Cultural Values– Affects reaction and expression of pain– Behavior = socialization process

• Developmental Stage• Environment and Support People• Past Pain Experiences

Factors Affecting PainFactors Affecting Pain

• Meaning of Pain– Positive outcomes - temporary inconveniences– Chronic pain – suffer intensely– Despair, anxiety, depression– Threat to body image, lifestyle, impending

death

• Anxiety and Stress

• Social and Spiritual Influences

Types of Pain Types of Pain

• Acute Pain– Lasting only through recovery period– Can be sudden or slow onset

• Chronic Pain– Prolonged, recurring, persisting over six

months– Interferes with functioning– Chronic malignant pain

• Associated with life threatening illness

Types of PainTypes of Pain

• Chronic malignant pain – Associated with life threatening illness

• Chronic non-malignant Pain– Non-life-threatening– Not responsive to current therapies– May continue for patient’s life time

Chronic non-malignant PainChronic non-malignant Pain

• Phantom Limb Pain– Occurs after amputation– Pain sensations referred to missing area

• Myofascial pain syndromes– Group of muscles disorders– Pain, muscle spasm, tenderness, stiffness,

limited motion

• Pain severe enough to disable patient– Chronic intractable non-malignant pain

syndrome


• Neuralgia– Paroxysmal pain along course of one or

more nerves

– Low back pain

– Rheumatoid arthritis

– Ankylosing spondylitis• Flattening of vert…?


• Radiating Pain– Perceived at source of pain– Extends to nearby tissues– Example: Cardiac pain to left arm

• Referred Pain– Felt in part of body removed (separate) from

tissues causing pain (nerve piggy backs)

– Example: Gallbladder-upper back, chest

Figure 46-1 Common sites of referred pain from various body organs

Figure 46-1 Common sites of referred pain from various body organs

Categories of PainCategories of Pain

• Cutaneous– Originates in skin or subcutaneous tissue

• Paper cut• Sharp and burning

• Deep somatic– Ligaments, tendons, bones, blood vessels,

nerves– Diffuse– Last longer than cutaneous

• Sprain

• Visceral Pain– Stimulation of pain receptors in abdominal

cavity, cranium, thorax– Diffuse– Burning, aching, or feeling of pressure– Caused by stretching of tissues, ischemia,

muscle spasms– Bowel obstruction

Categories of PainCategories of Pain

Concepts of PainConcepts of Pain• Pain Threshold

– Least amount of pain stimulation a person requires in order to feel pain

– Generally uniform in one person– Pain Sensation

• used interchangeably with threshold

– Related to age, gender, or race

Concepts of PainConcepts of Pain

• Pain Reaction– Autonomic nervous system

• Withdrawal of hand from fire

– Behavioral responses to pain• Method of coping with pain - learned

Concepts of PainConcepts of Pain

• Pain Tolerance– Maximum amount and duration of pain an

individual is willing to endure– Varies greatly– Influenced by psychological and sociocultural

factors– Increases with age

Abnormal Pain ConditionsAbnormal Pain Conditions

• Hyperalgesia / Hyperpathia– Heightened response to painful stimuli

• Severe reaction to paper cut

• Allodynia– Nonpainful stimuli produces pain

• Sheets

• Dysesthesia– Unpleasant abnormal sensation– Mimics neuropathy (spinal cord injury)

Physiological Indications of Acute Pain

• Dilated pupils

• Increased perspiration

• Increased rate/ force of heart rate

• Increased rate/depth of respirations

• Increased blood pressure

• Increased basal metabolic rate

• Decreased urine output

• Decreased peristalsis of GI tract

Total Pain ManagementTotal Pain Management

Four aspects must be addressed:

1. Physical2. Psychological (help them calm down, allow meds to work)

3. Social

4. Spiritual

Last 3 can be met only after pain and related symptoms (e.g., N/V, anxiety) are controlled.

AssessmentAssessment

• Subjective Data

• Gathering subjective information

• Pain threshold

• Pain

• Examine pain qualifiers

• Subjective reports are considered primary source of data collection

Nurse’s RolePatient Advocate


• Pain Assessment– Crucial Nursing Function

• Conduct self-assessment about pain– Values and expectations about pain behaviors– Avoid biases when assessing

– JCAHO – Pain is 5th vital sign – 2000– Subjective Data

• Gathering subjective information– Pain threshold– Pain

• Examine pain qualifiers• Subjective reports are considered primary source of data

collection



• Planning– Mutual goal setting with patient– Nonpharmacologic and pharmacologic

interventions– Several approaches combined– Multidisciplinary approach

• Preventive Approach– Treatment in mild pain or if anticipated

*Addiction is of less concern with acute pain than with chronic pain.



• Implementation– Nonpharmacologic interventions for mild pain– Pharmacologic for moderate to severe

• Nonpharmacologic used as adjuncts• Mainstay for treatment of pain

• Responsibilities of administration– Determine to give, which one– Assess response to analgesia– Report when a change is needed– Teach regarding use of medications

53 a focus 6 pain part 1

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