Unit XII Pain
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| Margo McCaffery | Internationally known nurse expert on pain
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| Margo McCaffery's definition of pain | "Pain is whatever the person says it is, and exist whenever he says it does"
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| 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"
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| Pain Management | Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client.
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| How severe pain is viewed | As an emergency situation deserving attention and prompt professional treatment.
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| Four terms in which pain may be described | Location, duration, intensity, and etiology
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| Importance of pain location | To be able to differentiate treatment for a particular area. (eg. knee pain is treated differently than chest pain)
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| Radiating pain (location) | Pain spreads or extends to other area's (eg. lower pack pain extends to legs)
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| 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)
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| 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)
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| Acute pain (duration) | When pain lasts only through the expected recovery period, whether it has a sudden or slow onset, regardless of its intensity.
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| Chronic pain (duration) | Persistent pain, is prolonged, usually recurring or lasting 3 months or longer, and interferes with functioning.
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| 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
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| Broad categories of etiology of pain | Nociceptive and Neuropathic
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| Nociceptive pain | Experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care.
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| Subcategories of nociceptive pain | Somatic and Visceral
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| Somatic pain | Originates in the skin, muscle, bone, or connective tissue (Sharp sensation of a paper cut or aching of a sprained ankle)
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| Visceral pain | Results from activation of pain receptors in the organs and/or hollow viscera. Cramping, throbbing, pressing, or aching. (Feeling sick)
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| 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.
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| Subtypes of neuropathic pain | Peripheral neuropathic pain and Central neuropathic pain
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| Peripheral neuropathic pain | Follows damage or sensitization of these nerves. (eg. phantom limb pain, post-herpetic neuralgia, carpal tunnel syndrome)
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| Central neruopathic pain | Results from malfunctioning nerves in the CNS. (eg. spinal cord injury pain, poststroke pain, multiple sclerosis pain)
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| 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.
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| 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.
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| Hyperalgesia and hyperpathis | May be used interchangeably. Heightened responses to painful stimuli. (severe response to a papercut)
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| Allodynia | Includes non-painful stimuli that produces pain. (light touch)
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| Dysesthesia | Unpleasant abnormal sensation that can be either spontaneous or evoked. (mimics pain that follows a stroke or spinal cord injury)
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| Four physiological processes involved with nociception | Transduction, transmission, perception, modulation.
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| Nociception | The physiological process related to pain perception.
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| Transduction | During this stage harmful stimuli (knife, fire) trigger the release of biochemical mediators which sensitize nociceptors,
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| Nociceptors | Specialized primary sensory neurons in the PNS that detect mechanical, thermal, or chemical conditions associated with potential tissue damage.
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| Transmission | Second process of nociception. Includes three segments. Pain impulse travels from peripheral nerve to brain.
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| First segment of transmission | Pain impulse travels from peripheral nerve fibers to spinal cord.
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| Second segment of transmission | Transmission of signal though and ascending pathway in the spinal cord to the brain.
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| Third segment of transmission | Transmission of information to the brain where pain perception occurs.
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| 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.
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| How opioids affect the transmission process | Block the release of neurotransmitters, particularly substance P, which stops pain at the spinal level.
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| Perception | Third process of nociception. When the client becomes conscious of the pain. The CNS gives meaning to the pain (character and intensity)
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| 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.
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| 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.
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| What do excitatory amino acids do? Name two. | Glutamiate, N-methyl-d-aspartate (NMDA). They increase pain signals.
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| What happens to the inhibitor neurotransmitters during the modulation process? | They are reabsorbed into the nerves. Effects are short lived.
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| How do Tricyclic antidepressants relieve pain? | By blocking the resorption of norepinephrine and serotonin and more available.
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| What are A-delta or C fibers? | Small-diameter peripheral nerve fibers that carry noxious (painful) stimuli to the dorsal horn.
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| When are noxious stimuli modified? | When they are exposed to the substantia gelatinosa.
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| Another name for the milieu in the CNS | Substantia gelatinosa
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| 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.
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| What are A-beta fibers? | Large diameter nerve fibers.
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| 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.
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| Natural responses to pain | Stop activity, tense muscles, and withdraw from pain-provoking activities.
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| How would persistent, severe pain change the nervous system? | Intensifies, spreads, and prolongs the pain, risking development of incurable chronic pain syndromes.
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| What is the fifth vital sign? | Pain assessment
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| FLACC | Used for clients that are unable to verbalize pain. Facial expression, Leg movement, Activity, Cry, Consolability.
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| 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.
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| Physical dependence | Dose significantly reduced or withdrawn. Withdraw symptoms experienced. Physiological dependence.
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| Addiction | Chronic, relapsing, treatable disease influenced by genetic, psychosocial, and environment factors. Phychological dependence.
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| 4 C's of addiction characterization | Craving for the substance. lace of Control over substance. Compulsive use. Continued use despite harm.
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| Pseudoaddiction | Condition that results from undertreatment of pain. Client becomes focused on obtaining medications. May "clock-watch" and seem to be "drug-seeking".
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| Preemptive analgesia | Administration of analgesics before surgery to decrease or relieve pain after surgery.
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| Pharmacologic pain management | Involves the use of opioids, nonopioids, and coanalgesics.
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| The most common NSAID | Nonsterioidal antiinflammatory drug - Aspirin
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| Three primary types of opioids | Full Antagonists, Mixed agonists-antagonists, Partial Agonists
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| Full antagonist | Pure opioid that has no ceiling on the level of analgesia from these drugs. (Morphine, oxycodone)
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| 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.
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| Partial agonist | Have a ceiling effect. Buprenorphine is emerging as a safer and more favorable alternative to methadone for opioid maintenance.
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| Opioid Side Effects. Which one is most concerning? | Sedation, respiratory depression, nausea/vomiting, urinary retention, blurred vision, sexual dysfunction, and constipation. RESPIRATORY DEPRESSION!
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| Coanalgesic | Medication not classified as a pain med. Has properties that may reduce pain. Antidepressants, anticonvulsants, and local anesthetics.
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| Preferred rout of opiate administration | Orally because of the ease of administration.
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| Advantage of transnasal administration of opiates | Rapid action because of direct absorption through the vascular nasal mucosa.
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| Advantage of transdermal drug therapy | Delivers a relatively stable plasma drug level and is noninvasive.
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| Advantage of transmucosal opiate administration | Good for "breakthrough pain" (cancer patients). Oral mucosa is well vascularized. Rapid absorption.
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| Advantage of rectal opiate administration | Particularly useful for clients with aphasia or nausea and vomiting.
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| Advantage of topical opiate administration | Work directly at the point of application on the body.
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| 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.
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| 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.
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| 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.
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| Advantage of intraspinal opiate administration | Superior analgesia with less medication used.
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| Patient Controlled Analgesia (PCA) | Interactive method of pain management that permits the client to treat their pain by self-administering doses.
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| Nerve block | Chemical interruption of a nerve pathway, caused by injecting local anesthetic into the nerve. Widely used during dental work.
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