Stressors that Affect Perception

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Stressors that Affect Perception CognitionPain

• NUR20 Fall 2009Lecture 14K. Burger MSEd, MSN,
  RN, CNE
• PPP by Sharon Niggemeier RN, MSN
• Revised 11/06 K. Burger

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Pain

• Unpleasant sensory and emotional experience
  associated with actual or potential tissue
  damage.
• Exists whenever the person says it does
• Referred to as 5th VS
• Function of pain Protective Mechanism
• A universal human experience

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Pain

• Real experience treated with nursing and medical
  interventions
• Subjective-Tissue damage may not be proportional
  to extent of pain experienced
• Pain thresholds are similar for all people BUT
  pain tolerance perception greatly differ
• Threshold level of intensity that triggers
  neuropathways ( nocioceptors)

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Types of Pain

• Acute
• Sudden onset
• Short duration lt 3 months
• Cause usually can ID
• Coursepain decreases over time

• Chronic
• Gradual or sudden
• Duration gt 3 months
• Causemay not know
• Coursedoesnt go away, periods of waxing/waning

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Types of Pain

• Cutaneous- (superficial) caused by stimulation
  of nerve fibers in skin (burning/ sharp)
• Somatic (deep) nonlocalized, originates in
  support structures strong pressure on tendons,
  bones ligaments (aching/throbbing)

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Types of Pain

• Visceral - arises from internal organs, difficult
  to localize (Abdomen, Thorax, Cranium)
• Referred pain felt in different area of body
  than actual tissue damage
• Psychogenic- pain from a mental event , no
  physical cause identified
• Neuropathic damaged nervous system, long
  lasting

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Types of Pain

• Phantom- sensation perceived when body limb or
  part is missing ( leg amputee has foot pain)
• Intractable- pain highly resistant to relief
  (bone Ca)
• Radiating- perceived at the source and extends to
  nearby tissue
• Idiopathic chronic pain in the absence of any
  identifiable cause.

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Pain Process

• Begins when there is enough tissue injury to
  reach a pain threshold
• Threshold level of intensity needed to cause an
  action potential and neuron firing
• Neurotransmitters (excitatory) are released

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Pain Process

• Four components
• Transduction- tissue injury releases biochemical
  substances ( histamine, lactic acid,
  prostaglandins, bradykinin) that excite
  nocioceptors.
• Pain meds can work by blocking production of
  these biochemical substances EX NSAIDS

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Pain Process

• Transmission- impulses travel along primary
  afferent neurons to the dorsal horn of spinal
  column substance P released pain sensation
  transmitted to spinothalamic tract to brain
• Acute pain runs up large A fibers
  (myelinated)Fast Transmission Sharp pain
• Diffuse pain runs up smaller C fibers
  (unmyelinated)Slower Transmission Throbbing
  pain
• THINK ABOUT the last time you stubbed your toe.
• First felt sharp pain followed by diffuse
  throbbing pain

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Pain Process

• Perception- stimulus received by thalamus
  transmitted to cortex where pain is consciously
  perceived
• Modulation- activation of endogenous opioids
  /neuromodulation system. Body releases pain
  blocking substances endorphins, enkephalins,
  serotonin
• Also efferent message sent to muscles to
  withdraw from pain stimulus

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Gate Control Theory- Melzack Wall

• Theory that describes how external stimulation
  and cognitive techniques can affect pain
  transmission
• Impulses traveling on small diameter C fibers act
  to open the gate to pain.
• Impulses traveling on large diameter A fibers act
  to close the gate to pain.
• External stimulation such as massage/ heat/ cold/
  TENS/ acupuncture on large A fibers close the
  gate to small C fibers and pain.
• Also, Cognitive techniques such as biofeedback,
  distraction, guided imagery can close the gate

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Responses to Pain

• PhysiologicInvoluntary Sympathetic response
  (Fight or Flight)Increased BP, HR, R, Pallor,
  Diaphoresis
• If prolonged, deep, severe leads
  toParasympathetic responseDecreased BP. HR,
  NV, fainting

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Responses to Pain

• BehavioralVoluntaryGuarding, Rubbing,
  Grimacing, Moaning,Immobilization, restlessness
• AffectivePsychologicalAnxiety, fear, fatigue,
  anger, depression,withdrawal-isolation,
  hopelessness

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Factors Affecting Pain

• Previous experience with pain
• Developmental level Age
• Culture/ethnic values
• Environment
• Gender
• Support systems
• Meaning of pain
• Anxiety/stress

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Assessment Pain

• Begins with acceptance of client report Includes
• Subjective description Client statementUse of
  a pain-rating scale
• Objective assessment physical examination

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Pain Assessment Questions
Pain Assessment The Fifth Vital Sign

• Questions to ask
• Where is your pain?
• When did your pain start?
• What does your pain feel like?
• How much pain do you have now
• What makes the pain better or worse?

• How does pain limit your function/activities?
• How do you behave when you are in pain? How would
  others know you are in pain?
• What does pain mean to you?
• Why do you think you are having pain?

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Pain Assessment Tools
Pain Assessment The Fifth Vital Sign

• Pain rating scales
• Descriptive No pain mild- severe
• - Numerical 0-10
• Visual analog Wong Baker

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Objective Data - Physical Exam
Pain Assessment The Fifth Vital Sign

• Inspect the site of pain
• Take vital signs
• Perform physical exam
• Note pain behaviors

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Nsg Dx Pain

• Acute pain R/T decreased blood supply to
  myocardium AEB pt. Clutching chest and stating
  my chest pains are here again, I need my nitro ,
  BP 160/90, HR 94, and pallor.
• Acute pain R/T tissue damage( mechanical,
  thermal, chemical) AEB
• Chronic pain R/T tumor progression AEB

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Nsg Dx - Pain

• Pain may be PART of a nursing diagnosis
• Ineffective airway clearance r/t weak cough and
  post-op incisional pain AEB
• Self care deficit r/t chronic pain

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Planning Pain

• Outcome criteria Client will
• Utilize a pain rating scale to identify pain and
  determine comfort level.
• Report that pain management regimen relieves pain
  to satisfactory level.
• Describe how unrelieved pain will be managed.

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Interventions Pain

• Establish trusting nurse-client relationship
• Comfort measures-administering analgesics
  -modifying environment-nonpharmacologic relief
  measures
• Client teaching is an important part of a pain
  mgt plan
• Explore strategies that have been effective for
  the client in the past

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Analgesics

• Analgesics relieve pain3 general classes
• Nonopioid -acetaminophen, ASA nonsteroidal
  antinflammatory drugs (NSAIDs) ibuprofen, Advil
• Opioids (narcotics)- morphine, codeine
• Adjuvant drug developed for use other than
  analgesic but enhances effect of opioids by
  providing added relief (diazepam, Elavil)

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Non-Opioids

• Decrease inflammatory response
• Work on peripheral nervous system
• Block release of excitatory neurotransmitters (
  ie histamine)
• Slower onset Longer peak action
• Side effects stomach irritation, liver and
  renal damage, bleeding

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Opioids

• Decrease cognitive perception of pain
• Work on Central Nervous System
• Block (lock into) pain receptors
• Faster onset Shorter duration
• Side effects respiratory depression, dizziness,
  sedation, nausea, constipation
• Emergency Rx for overdose Narcan

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Adjuvants

• Not classified as analgesics
• Provide synergistic additive effect
• Antidepressants
• Muscle Relaxants
• Corticosteroids

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Principles of analgesic administration

• Individualize the dose
• Give regularly instead of prn ATC or PCA
• Recognize side effects and treat appropriately
• Use combinations that enhance analgesics
• Monitor for tolerance and treat appropriately

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Principles of analgesic administration

• Monitor for physical dependence- body physically
  adapts to opioids and withdrawal symptoms can
  occur upon sudden stoppage THIS IS NOT
  ADDICTION
• Addiction (psychological dependence)- compulsive
  drug use craving for opioid for effects other
  than pain relief

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Interventions PainModifying the Environment

• Removing or altering the cause of painLoosening
  a tight binderEmptying a distended bladder
• Altering factors affecting pain
  toleranceEnvironmental control Quiet, dim
  lightingAllow client to restPosition for comfort

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Interventions PainNon-pharmacologic Measures

• Distraction
• Guided Imagery
• Relaxation
• Music
• Biofeedback
• Cutaneous stimulationTENS, massage, heat, cold,
  acupressure

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Interventions PainClient Teaching

• Function / cause of pain
• When pain can be anticipated
• Assurance that it is acceptable to express
• Assurance that it will be believed
• Assurance that measures will be taken to relieve
  it promptly
• How to use pain scale
• What pain control measures can be used

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Remember to tell clients that PAIN is easier to
treat before it gets too severe !
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Evaluation Pain

• Goals met ?
• Pain controlled ?
• Comfort level acceptable to pt ?
• Modify plan- change meds, incorporate new
  interventions including alternative therapies