Pain Patho



Pain Patho

Pain Defined

• Pain is a complex phenomenon composed of sensory experiences (time, space, intensity) & emotion, cognition & motivation

• Pain is what the patient states it is

• Most common reason people seek health care

• Disables people more than any disease

• Nurses assess pain better than a dr can sometimes

• Considered the 5th vital sign

• American pain society think we should assess pain on every pt

Pain Care Bill of Rights

As a person with pain, you have the right to:

• Have your report of pain taken seriously and be treated with dignity and respect by doctors, nurses, pharmacists, and other health care professionals.

• Have your pain thoroughly assessed and promptly treated.

• Be informed by your health care provider about what may be causing the pain, possible treatments, and the benefits, risks, and cost of each.

• Participate actively in decisions about how to manage your pain.

• Have your pain reassessed regularly and your treatment adjusted if your pain has not been eased.

• Be referred to a pain specialist if your pain persists.

• Get clear and prompt answers to your questions, take time to make decisions, and refuse a particular type of treatment if you choose.

Nursing responsibility & accountability

• What is our responsibility to our patients regarding pain control?

• We DO NOT judge!

• The prevalence of nurses & doctors getting sued over pain control is on the rise

• Remember we are patient advocates FIRST!

Types of Pain

• Acute Pain- recent onset w/in the last 6 months, with recent injury

• Chronic (persistent) pain- constant, persistent, goes beyond 6 months, seldom attributed to one specific injury, often difficult to treat, hard to treat

• Cancer-related pain- can be acute or chronic, usually involved with tumor placement

• Pain may also be classified by location or etiology

• Duration- how long

• Location- ex. If pt says they have a headache, then the pain is in their head

• Etiology – cause, deep burn, ex. Herpetic neuralgia- shingles from herpes

Effects of Pain

• Sleep deprivation

• Acute pain

– Can affect respiratory, cardiovascular, endocrine, and immune systems

– Stress response increases metabolic rate and cardiac output, and increases risk for physiologic disorders

• Chronic Pain

– Depression

– Increased disability

– Suppression of immune function

Neuroanatomy

• Portions of the nervous system responsible for the sensation & perception of pain

– Afferent pathways

• Composed of nociceptors (pain receptors)

• Travels to

– Efferent pathways

• Are responsible for modulating pain sensation

• Travels away

– CNS

• Interprets pain signals

• Helps in discrimination & localization of pain

• Activates coping responses such as:

• Fight or flight

• Release of corticosteroids

• Cardiovascular response

• Modulate spinal pain transmission

• Endorphins -

A delta fibers- very small, fast, mylinated – sharp, localized pain,

C fibers – unmylinated, slow, big fibers, if you twist your ankle takes longer for your brain to respond

Nociceptors- nerve endings that respond to severe pain – stimulate nerve fiber and send them to blood vessels, release histamine from the mast cells that cause vasodilation

• ACH, bradykinin, serotonin, substance P – all neurotransmitters that transmit pain

Nociception- transmission of pain

Prostaglandin- chemical substances that increase the sensitivity of pain receptors by enhancing the effect of bradykinin (pain provoking effect)

Chemical mediators- the ouch effect, cause vasodilation and increased vascular permeability (pain, swelling, redness)

Diaphoresis – sweating

Neurophysiology of Pain

• Gate control theory (Melzack & Wall, 1960’s)

– Pain impulses are transmitted from specialized skin receptors that act as a gate, opening & closing the afferent pathways to the transmission of painful stimuli

– Pain has emotional and cognitive functions

– Closing the gate is the basis for nonpharmalogical interventions – you can close the gate yourself

Perceptions of Pain

• Pain threshold

– The point at which pain is perceived

– Patient feels & reports pain

– Mainly biological but may be influenced by emotion & social factors

– Anxiety, age, gender, genetics, expectations – can increase or decrease pain perception

– Endorphines are the body’s morphine

– Threshold- point at which pt feels and reports pain

• Pain tolerance

– Ability to endure intensity of pain

– Expression or behavior

– More psychological & social

– Important to encourage people to take pain meds

– If pain is not relieved, it can alter the quality of life

Pain Perception Variables

• Age

– Cutaneous pain perception may decrease-WHY?

– Viseral pain perception may increase

– Elderly report pain less often (implications?)

• Slower metabolism, lower fat to lean muscle mass, have to be more careful with pain meds cause meds may stay in system longer, excretion and metabolism

• Gender

– Females more willing to verbalize than males

• Culture

– Some verbalize more than others

– Which?

• Box 43-4 in Potter – Misconceptions

Pain & Personality

• Patients who may have or exhibit a decrease in pain tolerance & threshold:

– Anxiety & fear

– Fatigue

– Depression

– Negative past experiences

• Patients who may have or exhibit an increase pain threshold & tolerance:

– Rest & diversion

– Understanding & sympathy

– Elevation of mood

– Medication: analgesic, antiemetics, antidepressants

– WHY?

– Nursing implications?

Categories of Pain

• Somatic (superficial)

– Skin, bone & connective tissue

– Localized, constant ache, easy to describe, throbbing or aching

– Acute: incisions, muscle spasms, needle stick

– What chronic diseases would you associate with this type of pain?

• OA, RA, PVD, CA, Bone metastasis (mets)

• Visceral

– Organs & body cavity lining

– Diffuse, deep, cramp

– Pain resulting from stimulation of internal organs, any area on the inside of the body

– Pain can be sharp, dull, or unique to that particular organ

– Acute: intestine & chest

– What chronic diseases would you associate with this type of pain?

• Chronic: pancreatitis, liver mets & colitis

• Neuropathic

– Nerves, CNS

– Injury to CNS structure

– Poor localization, shocks, sharp, numb

– Acute: phantom pain, nerve compression

– Abnormal processing of sensory input by the peripheral or central system ???

– Electric like shocks

– Back pain often turns chronic if not relieved

– Diabetic neuropathy – injury to the peripheral nerves

– Polyneuropathy – often times are autoimmune disorders like MS, lupus (damages peripheral nerves)

Psychogenic pain:

o There is no known physical cause

• Is not imaginary & may be just as intense & distressing as somatogenic pain

• Complex regional pain syndrome**

• Thalamic pain syndrome- when thalamus and brain has been injured

Pain Management

• Assessment

– Health history

• Precipitating factors

• Aggravating factors

• Location & duration

• Character & quality

– 0-3 mild pain

– 4-6 moderate pain

– 7-10 severe pain

• Physical Assessment

– Body movement/posture

– Affect & behavior

– Vital signs

• How will they differ for chronic vs. acute pain?

– Chronic vs. acute pain

– Things to assess for:

• History of pain

• What happed that made you start having pain

• Meaning of pain

• Physical and emotional effects

• Objective- clients own words of pain

• Medical co morbidities – everything else the pt has wrong with them

• Chronic and consistent pain

• Focused physical and neurological assessment

• Guarding an area??

• See if manipulation or palpation is more responsive

• Acute often causes anxiety and restlessness that result in increased blood pressure, pulse and diaphoresis********

• Location of pain:

– Level

• Deep vs. superficial (somatic)

– Location

• Localized – confined to origin

• Projected – along nerve or fibers

• Radiating – diffuse around site

• Referred - perceived in area away from cause

Pain Assessment

• Character & quality

– Patient’s description

• Pattern

– Perception over time & with activity

• Intensity

– Pain Scales (verbal, non-verbal, coma)

– Measure pain & effectiveness, 0-10

• P – what provokes the pain (aggravating factors) & palliative measures (alleviating factors)

• Q – quality of pain

• R – region & radiation of pain

• S – severity (quantity) & setting

• T – timing

Pain Medication Comparison

• Consider route of administration

• Consider disease process (will drug be impeded during ADME)?

– Administration

– Distribution

– Metabolism

– Excretion

Goal: getting the pt back to their optimal functional- where they were before

Collaboration between the nurse, dr and pt

Monitor / evaluate - nurse

Dr orders meds\

1. Nurse asks pt about allergies

2. Always obtain med hx – on reconciliation form

3. Must report current meds and use of otc meds and herbals

4. Go back and ask pt how well med worked

5. Current treatments, diseases, organ function, kidney function, metabolism

• Analgesics

– ASA

– NSAID’s

• Cox-1 Inhibitors

• Cox-2 Inhibitors

– Vioxx, celebrex

• Opiates

– Prescribe for moderate to severe pain

– Bind to the receptors??

– Modify preception of pain

– SE: respiratory depression, sedation, ??

– Requires careful assessment

– Know which are less potent to high potent

– Know how much to give, what the effects are going to be and …

– Agonists (synergistic affects)

– Antagonists

• Enhance the effects of analgesics – tylenol3 (Tylenol + codeine)

• Acetaminophen- reduces the amount of opiate (ASA – aspirin)

Medication Considerations

• Potency

– Mg vs. Mcg

• Receptor binding

– Availability

• Toxicity

– Blood levels

• Overdose

– Assessment, planning, intervention, evaluation

– Assessment

– What’s the problem?

– What are we going to do about it?

– Remember your ABC’s

– Antagonist & their roles (compete with receptor sites) Ramazicon or Narcan (naloxon)- give for respiratory depression replaces opioid receptor ….???

• Idea is to keep the pain down by keeping a constant blood level

• Brunner chart 13-6****** tell you the ranges for opioids

• PCA- safe method for pain management – drug deliver system that allows the client to deliver pain meds to them self, does not let them OD because they can push the button all they want but there is only a certain amount of meds, when the light shines bright green the pt can get meds again

– good: machine records every time the pt hits the button and when the pt was successful, client gains control over their pain but teaching is critical, pt is the only one is supposed to push the button

• Chart 13-8 brunner – test question over this

• Table 43-6 PP, epidurals – 2 questions on test

• Physical dependence – withdraw symptoms with opiates , when the drug is stopped, decreased, or you admin an antagonist

• Drug tolerance – exposure to a drug produces changes , decrease in effectiveness of the drug over time

• Addiction – addictive behaviors include impaired control over drug use, compulsive use, continued use despite harm, craving

• (look up definitions**)

Non-Pharmacologic Interventions

• Considerations:

– What works for them

• Music

• Culture

• Prayer

• Guided imagery (find a happy place)

• Meditation

• Distraction

• Other?

Pain Management

Nature of Pain

• Involves physical, emotional, and cognitive components

• Physical and/or mental stimulus

• Is exhausting and demands energy

• Interferes with relationships

Physiology of Pain

|Transduction |Transmission |

|Perception |Modulation |

Types of Pain

|Acute/transient pain |Chronic/persistent |

|Protective, identifiable, short duration |Is not productive and has no purpose or may not have|

| |identifiable cause |

|Chronic episodic |Cancer |

|Occurs sporadically over an extended duration |Can be acute or chronic |

|Inferred physiological |Idiopathic |

|Musculoskeletal, visceral, or neuropathic |Chronic pain without an identifiable physical or |

| |psychological cause |

Nursing Knowledge Base

• Attitude of health care providers

– Malingerer or complainer

• Assumptions about clients in pain

– Biases based on culture, education, experiences

Factors Influencing Pain

• Physiological

– Age, fatigue, genes, neurological function

• Social

– Attention, previous experiences, family and support groups

• Spiritual

• Psychological

– Anxiety, coping style

• Cultural

– Meaning of pain, ethnicity

Nursing Process and Pain

• Pain management needs to be systematic.

• Pain management needs to include the client’s quality of life.

• Clinical guidelines are available to manage pain.

– American Pain Society

– National Guideline Clearing House

Assessment

• Client’s expression of pain

• Characteristics of pain

– Onset and duration

– Intensity

– Pattern

– Contributing symptoms

– Behavioral effect

– Location

– Quality

– Relief measures

– Effect of pain

– Influence on ADLs

Diagnosis and Planning

• Focuses on the specific nature of pain

• Mandates a thorough assessment

• Selected from NANDA-I–approved list

• Interventions selected after client goals and outcomes are identified

Implementation

• Nonpharmacological interventions

– Relaxation and guided imagery

– Distraction

– Music

– Cutaneous stimulation

• Massage, TENS, heat, cold, acupressure

– Herbals

Pharmacological Pain Relief

• Analgesics

– Nonopioids

– Opioids

– Adjuvants/coanalgesics

– PCA

– Local/regional anesthesia

– Topical agents

Chronic Noncancer and Cancer Pain Management

• Cancer pain either chronic or acute

• Breakthrough pain

• Transdermal and transmucosal fentanyl

Barriers to Effective Pain Management

• The client, health care provider, and health care system

• Physical dependence, addiction, and drug tolerance

• Placebos

Pain Clinics, Palliative Care, and Hospice

• Pain centers treat clients on an inpatient or outpatient basis.

• The goal of palliative care is to learn how to live life fully .

• Hospices are programs for end-of-life care.

Evaluation

• Evaluation of pain is considered a major responsibility of nurses.

• The client’s response to pain may not be obvious.

• Evaluating the appropriateness of pain medication will require nurses to evaluate clients 15 to 30 minutes after administration.

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