PAIN

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PAIN

• Deborah Cary, MSN
• Professor Nursing
• Broward Community College

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General Study Habits

• Review vocabulary words listed at the
  beginning of the chapter
• Answer the critical thinking questions/review
  questions at the end of the chapter
• Pay attention to tables/illustrations
• Highlight and take additional notes

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Statistics

• Pain is the 5th vital sign
• The most common sx prompting office visits
• Second leading cause of work related
• absenteeism 50 million lost
  workdays annually
• Leading cause disability in working-age
  population
• Significant concerns among elderly and expected
  to increase with aging of the population

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Definition
Pain is whatever the person experiencing
pain says it is, existing whenever the
person says it does.Margo McCafferty
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Basic Principle

• ALWAYS BELIEVE PATIENT

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Causes of Pain

• ACUTE
• SURGERY
• INJURY
• CHRONIC
• HEADACHES
• BACK PAIN
• CANCER

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Consequences of Pain

• IMPAIRED RECOVERY
• SUPPRESSED IMMUNE SYSTEM
• SLEEPLESSNESS

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S/S Unrelieved Pain

• Resp/cardiac dysfunction
• Decreased gastric motility
• Increased muscle contraction
• Increased catabolism

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Nonreporting

• Fear of addiction
• Side Effects
• Pain is inevitable
• Fatalism

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International Association for the Study of Pain
definition

• Pain is an unpleasant sensory and emotional
  experience associated with actual or potential
  tissue damage

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Nociception

• Activation of primary afferent nerves with
  peripheral terminals that respond
  differently to noxious stimuli

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• Suffering state of severe distress associated
  with events that threaten the intactness of the
  person can occur in or out of pain presence and
  pain can occur with or without suffering
• From Lewis, 6th edition

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Dimensions of Pain

• Physiologic
• Sensory
• Affective
• Behavioral
• Cognitive

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Pathway of Nociceptive Pain

• Transduction
• Transmission
• Perception
• Modulation

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Drug Therapies

• NSAIDS Advil, Motrin, Aleeve (Naprosyn)
• Corticosteroids Decadron,
  methylprednisolone, Cortisone
• Neurontin, MS Contin, Opiods, Time-released
  patches (Lidocaine, Fentanyl)
• Pumps epidural, intrathecal
• Epidural Injections
• Local analgesics

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Sensation of Pain

• Dermatomes
• Referred Pain
• Sensitization

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Perception

• Perception is the pain that is responded to by an
  individual
• RAS responsible for ANS response
• Strategies directed toward behavior are
  distraction, relaxation and imagery

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Modulation

• Evaluation of descending pathways that either
  facilitate or inhibit the effects of transmission
• Norepinephrine and serotonin
• GABA-endogenous opioids can inhibit pain
  transmission

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Responses to Pain

• Affective anger, fear, depression and
• anxiety
• Behavioral observable actions
• facial expression, posturing
• chronic pain affects function

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• Beliefs, attitudes, memories, meaning
• attributed to pain
• Coping distraction, negative thoughts
• Sociocultural demographics
• Age, Gender, Education, Socioeconomic
  status, support systems, social roles/cultures

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Types Pain

• Neuropathic Pain
• Nociceptive Pain
• Somatic Pain
• Visceral Pain

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Types Acute Pain

• Cutaneous superficial
• Somatic Pain - originates SC tissue, joints,
  tendons, muscles and fascia
• Visceral Pain from compression, distention or
  stretching of viscera

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Assessment

• History
• Description
• Aching and soreness
• Burning, stabbing, dull,
  throbbing

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Sensory

• P Pattern
• A Area
• I Intensity
• N Nature

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Area of Pain

• Helps in determining possible cause and
  treatment
• Referred from origin to another site
• Radiates ex sciatica
• Ask pt to point to the site and describe exact
  area of pain on a map

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Intensity of Pain

• Assesses the severity
• Use numerical scale of 0-10 with communicative
  patients
• Children - use the faces chart (Wong) Visual
  Analog
• Comatose or Unresponsive - FLACC

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Nature of Pain

• Quality or characteristics of pain
• McGill Pain Questionnaire
• Neuropathic pain (pain over damaged nerves)
  burning, cold, shooting, stabbing or itchy
• Nociceptive (pain over intact nerves) sharp,
  aching, throbbing, cramping

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Breakthrough Pain

• Transient, moderate to severe pain
• Occurs above the pain treatment by analgesics
• Common with Ca patients
• Rapid in onset, brief in duration with variable
  intensity and freq. of occurence

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Risks for Inadequate Control

• Racial minorities
• Elderly
• Past or current substance abusers

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Procedural Pain

• Episodic
• Procedural or incident
• Occurs during painful procedures

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Scheduling

• Prevent or control pain
• Premedication
• Around-the-clock

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WHO Guidelines

• ANALGESIC LADDER
• Step I mild pain
• Step II moderate pain
• Step III Mod to severe pain

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Mild Pain

• 1-3 on scale
• Nonopioids
• Ceiling effect
• Use of adjuvant drugs

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Moderate Pain

• 4-6 on 0-10 scale
• Step II drugs - Opoids
• Mu Agonists
• Mixed Agonists-Antagonists

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Moderate to Severe Pain

• 7-10 LEVEL
• STEP III POTENT DRUGS
• NO ANALGESIC CEILING
• MANY DELIVERY ROUTES
• M/S STANDARD FOR COMPARISON
• CHECK RESPIRATORY RATE!!!

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Adjuvant Therapy

• Tricyclic antidepressants
• Antiseizure
• Useful neuropathic pain
• A2-adrenergic agonists
• Corticosteroids

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Methods of Delivery

• Intravenous most common
• Continuous, bolus, PCA
• PCA uses infusion pump
• Altered LOC precludes use
• Monitor carefully with
  alterations
• in clearance drug from system

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Epidural Pain Control

• Post major abdominal, thoracic, orthopedic
  surgery
• Common side effects
• Complications
• Nerve Blocks local anesthetics or neurolytic
  agents

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Nonpharmacologic

• MASSAGE
• VIBRATION
• TENS UNITS
• ACUPUNCTURE
• HEAT AND COLD
• ULTRASOUND
• RELAXATION MUSIC
• GUIDED IMAGERY

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Barriers

• Tolerance chronic exposure
• Treatment increase dose, substitute drug,
• augment
• NO CEILING effect with agonist drugs
• Communication

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Barriers to Assessment in Geriatrics

• Belief that pain is a normal part of aging
• Nothing can be done to relieve the pain
• Fears re reporting pain label them as a burden
  or a bad patient
• Greater fear of opiods

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Barriers

• Physical Dependence
• Withdrawal
• Addiction
• Concerns re side effects
• Forgetting to take medication
• Biases of nursing