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Theory Test IV

Unit XII Pain

Margo McCaffery Internationally known nurse expert on pain
Margo McCaffery's definition of pain "Pain is whatever the person says it is, and exist whenever he says it does"
Widely agreed on definition of pain "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"
Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client.
How severe pain is viewed As an emergency situation deserving attention and prompt professional treatment.
Four terms in which pain may be described Location, duration, intensity, and etiology
Importance of pain location To be able to differentiate treatment for a particular area. (eg. knee pain is treated differently than chest pain)
Radiating pain (location) Pain spreads or extends to other area's (eg. lower pack pain extends to legs)
Referred pain (location) Pain that appears to arise in different parts of the body. (eg. cardiac pain may be felt in the shoulder or left arm, with or without chest pain)
Visceral pain (location) Pain arising from organs or hollow viscera. Often perceived in an area remote from the organ causing the pain. (eg. stomach ache)
Acute pain (duration) When pain lasts only through the expected recovery period, whether it has a sudden or slow onset, regardless of its intensity.
Chronic pain (duration) Persistent pain, is prolonged, usually recurring or lasting 3 months or longer, and interferes with functioning.
How to classify intensity Most practitioners use a standard scale: 0 (no pain) to 10 (worst possible pain) scale. Mild = 1-3, Moderate = 4-6, severe pain = 7-10
Broad categories of etiology of pain Nociceptive and Neuropathic
Nociceptive pain Experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care.
Subcategories of nociceptive pain Somatic and Visceral
Somatic pain Originates in the skin, muscle, bone, or connective tissue (Sharp sensation of a paper cut or aching of a sprained ankle)
Visceral pain Results from activation of pain receptors in the organs and/or hollow viscera. Cramping, throbbing, pressing, or aching. (Feeling sick)
Neuropathic pain Associated with damage or malfunctioning nerves due to illness, injury, or undetermined reasons. Typically chronic. Described as burning, "electric-shock", tingling, dull, and aching. Difficult to treat.
Subtypes of neuropathic pain Peripheral neuropathic pain and Central neuropathic pain
Peripheral neuropathic pain Follows damage or sensitization of these nerves. (eg. phantom limb pain, post-herpetic neuralgia, carpal tunnel syndrome)
Central neruopathic pain Results from malfunctioning nerves in the CNS. (eg. spinal cord injury pain, poststroke pain, multiple sclerosis pain)
Pain Threshold The least amount of stimuli needed for a person to label a sensation as pain. Varies slightly from person to person. Changes little in the same individual over time.
Pain Tolerance Maximum amount of pain a person is willing to tolerate before taking evasive measures. Varies considerable from person to person, even within the same person at different times/circumstances.
Hyperalgesia and hyperpathis May be used interchangeably. Heightened responses to painful stimuli. (severe response to a papercut)
Allodynia Includes non-painful stimuli that produces pain. (light touch)
Dysesthesia Unpleasant abnormal sensation that can be either spontaneous or evoked. (mimics pain that follows a stroke or spinal cord injury)
Four physiological processes involved with nociception Transduction, transmission, perception, modulation.
Nociception The physiological process related to pain perception.
Transduction During this stage harmful stimuli (knife, fire) trigger the release of biochemical mediators which sensitize nociceptors,
Nociceptors Specialized primary sensory neurons in the PNS that detect mechanical, thermal, or chemical conditions associated with potential tissue damage.
Transmission Second process of nociception. Includes three segments. Pain impulse travels from peripheral nerve to brain.
First segment of transmission Pain impulse travels from peripheral nerve fibers to spinal cord.
Second segment of transmission Transmission of signal though and ascending pathway in the spinal cord to the brain.
Third segment of transmission Transmission of information to the brain where pain perception occurs.
Substance P Neurotransmitter that enhances movement of impulses across the nerve synapse from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal cord.
How opioids affect the transmission process Block the release of neurotransmitters, particularly substance P, which stops pain at the spinal level.
Perception Third process of nociception. When the client becomes conscious of the pain. The CNS gives meaning to the pain (character and intensity)
Modulation The fourth and final process of nociception. Known as the "Descending system". Neurons in the brain send signal back down to the dorsal horn of the spinal cord.
What do the descending fibers release during the modulation process? Substances such as endogenous opioids, serotonin, and norepinepherine, which can inhibit or reduce the ascending painful impulses in the dorsal horn.
What do excitatory amino acids do? Name two. Glutamiate, N-methyl-d-aspartate (NMDA). They increase pain signals.
What happens to the inhibitor neurotransmitters during the modulation process? They are reabsorbed into the nerves. Effects are short lived.
How do Tricyclic antidepressants relieve pain? By blocking the resorption of norepinephrine and serotonin and more available.
What are A-delta or C fibers? Small-diameter peripheral nerve fibers that carry noxious (painful) stimuli to the dorsal horn.
When are noxious stimuli modified? When they are exposed to the substantia gelatinosa.
Another name for the milieu in the CNS Substantia gelatinosa
What happens when the ion channels (gates) in the pre- and postsynaptic membranes are open? Permit positively charged ions to rush into the second-order neuron, sparking an electrical impulse and sending pain signals to the thalamus.
What are A-beta fibers? Large diameter nerve fibers.
Actions of A-beta fibers Send messages of touch or warm or cold temperatures, and may activate descending mechanism that can inhibit the transmission of pain - closing the ion gates.
Natural responses to pain Stop activity, tense muscles, and withdraw from pain-provoking activities.
How would persistent, severe pain change the nervous system? Intensifies, spreads, and prolongs the pain, risking development of incurable chronic pain syndromes.
What is the fifth vital sign? Pain assessment
FLACC Used for clients that are unable to verbalize pain. Facial expression, Leg movement, Activity, Cry, Consolability.
Opioid Tolerance Dose, over time, leads to a decreased sensitivity of the drug's analgesic effect. Increasing doses are needed to provide the same level of pain relief.
Physical dependence Dose significantly reduced or withdrawn. Withdraw symptoms experienced. Physiological dependence.
Addiction Chronic, relapsing, treatable disease influenced by genetic, psychosocial, and environment factors. Phychological dependence.
4 C's of addiction characterization Craving for the substance. lace of Control over substance. Compulsive use. Continued use despite harm.
Pseudoaddiction Condition that results from undertreatment of pain. Client becomes focused on obtaining medications. May "clock-watch" and seem to be "drug-seeking".
Preemptive analgesia Administration of analgesics before surgery to decrease or relieve pain after surgery.
Pharmacologic pain management Involves the use of opioids, nonopioids, and coanalgesics.
The most common NSAID Nonsterioidal antiinflammatory drug - Aspirin
Three primary types of opioids Full Antagonists, Mixed agonists-antagonists, Partial Agonists
Full antagonist Pure opioid that has no ceiling on the level of analgesia from these drugs. (Morphine, oxycodone)
Mixed agonists-antagonist Can act like opioid and relieve pain (agonist effect) or can block or inactivate other opioid analgesics when taken with pure opioids (antagonist effect). Does have a ceiling that limits dose.
Partial agonist Have a ceiling effect. Buprenorphine is emerging as a safer and more favorable alternative to methadone for opioid maintenance.
Opioid Side Effects. Which one is most concerning? Sedation, respiratory depression, nausea/vomiting, urinary retention, blurred vision, sexual dysfunction, and constipation. RESPIRATORY DEPRESSION!
Coanalgesic Medication not classified as a pain med. Has properties that may reduce pain. Antidepressants, anticonvulsants, and local anesthetics.
Preferred rout of opiate administration Orally because of the ease of administration.
Advantage of transnasal administration of opiates Rapid action because of direct absorption through the vascular nasal mucosa.
Advantage of transdermal drug therapy Delivers a relatively stable plasma drug level and is noninvasive.
Advantage of transmucosal opiate administration Good for "breakthrough pain" (cancer patients). Oral mucosa is well vascularized. Rapid absorption.
Advantage of rectal opiate administration Particularly useful for clients with aphasia or nausea and vomiting.
Advantage of topical opiate administration Work directly at the point of application on the body.
Advantage of subcutaneous catheters opiate administration Provides continuous subcutaneous infusion (CSCI). Small, battery operated pump with a butterfly needle in the anterior chest, subclavicular region, abdominal wall, outer upper arms, or thighs.
Advantage of intramuscular opiate administration No advantages. Opiates should not be administered through this route. Variable absorption, unpredictable onset of action and peak, tissue damage may result.
Advantage of intravenous opiate administration Provides the most rapid onset for pain with few side effects. Onset as well as adverse effects can occur within 5-10 minutes.
Advantage of intraspinal opiate administration Superior analgesia with less medication used.
Patient Controlled Analgesia (PCA) Interactive method of pain management that permits the client to treat their pain by self-administering doses.
Nerve block Chemical interruption of a nerve pathway, caused by injecting local anesthetic into the nerve. Widely used during dental work.
Created by: Jnford15