Complex mechanism and integrate with pyscho social context.
Part I Nursing 53AJudith Ontiveros, RN, MSN, CPAN
Objectives• Describe the physiological mechanism involved in the pain experience.• Compare and contrast the different types of pain and their significance.• Discuss some of the general assumptions about the pain experience.• List seven components of accurate pain assessment• Review the different types of pain management techniques.• Focus on nursing responsibilities associated with the pharmacological therapy of the pain experience.
Definitions of Pain “an unpleasant sensory andemotional experience associated with actual or potential tissuedamage, or described in terms of such damage.” American Pain Society (APS, 2003; Gordon, 2002.)
Definitions of Pain• Pain, classified as acute consists of a sudden feeling of discomfort that can develop from many sources, such as an acute illness, surgery, trauma, invasive equipment, nursing and medical interventions and immobility. If pain is inadequately treated it can lead to the development of chronic pain (Mc Caffrey, Frock, & Garguilo, 2003).
Definitions of Pain “Pain is an emergency!” •Melanie Simpson, RN, BA, BSN •OCN Cancer Institute of Kansas University “Pain is whatever the personexperiencing it says it is, existing whenever he says it does.” (Margo McCaffery, 1979)
Summarization• Pain: actual physical sensation of discomfort• Suffering: unpleasant emotional response to painPain is a very subjective and highly individualized experience
Implications for Nursing• Physical and emotional experience Not all body, not all soul!• In response to actual or potential tissue damage.• Pain is described in terms of such damage. Some won’t divulge painunless assessed or asked about. Assess in other ways… nonverbal, etc.
Implications for Nursing• Nearly 1/3 of Americans will experience chronic pain at some point in their lives. – Joint Commission (Accreditation of Healthcare Organizations)• Approximately 50 million with chronic pain• #1 cause of adult disability in the US• In younger people (18-34) – 82% experience grumpiness or irritable behavior as a result of their chronic pain
Implications for Nursing• Women affected more emotionally by their pain than men – 70 % suffer with stress – 55 % with loss of motivation • a study by the Cleveland Clinic• 3/10 men (28%) experience less desire for sex due to chronic pain• Costs are an estimated $100 billion in lost productivity every year – major cause of absenteeism
Implications for Nursing• Affects all body systems – Results in serious health issues – Increases risks of complications – Delays healing – Accelerates progression of fatal illnesses• Changes to nervous system can result in incurable chronic pain.• Question whether life is worth going on
Implications for Nursing• More than a symptom of a problem• Becomes a HIGH priority problem of its own entity. – Physiologic and psychologic dangersSevere Pain = Emergency SituationDeserves prompt, professional treatment
Components of the Pain Experience• Pain is a protective mechanism• Complex biopsychosocial phenomena• May or may not – have a cause – respond to interventions
Components of the Pain Experience• Reception: – sensation through pain receptors of the nervous system• Perception: – conscious mental recognition or registration of a sensory stimulus• Reaction: – the response a person takes after identifying the sensation
Nociception• Physiologic process related to pain perception – React to mechanical, thermal, or chemical stimuli – Potential or real tissue damage• Four physiologic processes – Transduction – Transmission – Perception – Modulation
Transduction• Nociceptors excited by stimuli• Noxious stimuli triggers release of biochemical mediators – Prostaglandins – Bradykinin – Serotonin – Histamine – Substance P• Movement across cell membrane• Pain Medications effective at this stage – Blocks Prostaglandins
Figure 46-2 Substance P assists the transmission of impulsesFigure 46-2 Substance P assists the transmission of impulsesacross the synapse from the primary afferent neuronacross the synapse from the primary afferent neuron second-order neuron in the spinothalamic tract second-order neuron in the spinothalamic tract
Transmission of Pain Impulses• 3 segments 1. Impulse travels from peripheral nerve to spinal cord • Substance P – neurotransmitter across synapse – Unmyelinated C fibers – dull aching pain – Thin A-delta fibers – sharp localized pain • Local medications work here to block impulses
Transmission of Pain2. Transmission from spinal cord and ascension – Spinothalamic tracts – To brain stem and thalamus • Opioids block release of neurotransmitters3. Signals to thalamus to somatic sensory cortex – Pain perception
Perception• Conscious of pain – Complex activity in CNS – Pyschosocial and meaning of pain to each individual shape the responses
Modulation• Descending System – Neurons in thalamus and brain stem send signals back to dorsal horn of spinal cord – Neurons in thalamus and brain stem send signals back down to dorsal horn • Descending fibers release endogenous opioid, serotonin, and norepinephrine • Inhibits noxious impulses (short-lived) • Amino Acids and excitatory glial cells facilitate pain signals – Tricyclic antidepressants help block uptake of NE and serotonin
Question• A nurse is evaluating a nursing student’s understanding of transcultural differences in responses to pain. Which of the following actions demonstrates a need for further teaching? – The African American culture believes pain and suffering is a part of life and is to be endured – The Mexican American culture believes that enduring pain is a sign of strength (but they still tend to be loud in expressing pain) – The Asian American culture tends to be loud and outspoken in expressions of pain - FALSE – Native Americans are quiet, less expressive verbally and nonverbally, and may tolerate a high level of pain
Gate Control SchematicSmall diameter (a-delta or C)peripheral nerve fibers carrysignals of noxious stimuli to thedorsal hornIon channels on the pre- andpostsynaptic membranes serveas gatesWhen open, permit positivelycharged ions to rush into thesecond order neurons, sparkingan electrical impulse andsending signals of pain to thethalamus
Gate TheoryLarge diameter (A-delta)fibers have inhibitoreffectMay activate descendingmechanism that caninhibit transmission ofpain
Clinical Application of Gate Control Theory• Stop nociceptor firing• Apply topical therapies• Address client’s mood• Address client’s goals
Factors Affecting Pain• Ethnic and Cultural Values – Affects reaction and expression of pain – Behavior = socialization process• Developmental Stage• Environment and Support People• Past Pain Experiences
Factors Affecting Pain• Meaning of Pain – Positive outcomes - temporary inconveniences – Chronic pain – suffer intensely – Despair, anxiety, depression – Threat to body image, lifestyle, impending death• Anxiety and Stress• Social and Spiritual Influences
Types of Pain• Acute Pain – Lasting only through recovery period – Can be sudden or slow onset• Chronic Pain – Prolonged, recurring, persisting over six months – Interferes with functioning – Chronic malignant pain • Associated with life threatening illness
Types of Pain• Chronic malignant pain – Associated with life threatening illness• Chronic non-malignant Pain – Non-life-threatening – Not responsive to current therapies – May continue for patient’s life time
Chronic non-malignant Pain• Phantom Limb Pain – Occurs after amputation – Pain sensations referred to missing area• Myofascial pain syndromes – Group of muscles disorders – Pain, muscle spasm, tenderness, stiffness, limited motion• Pain severe enough to disable patient – Chronic intractable non-malignant pain syndrome
Types of Pain• Neuralgia – Paroxysmal pain along course of one or more nerves – Low back pain – Rheumatoid arthritis – Ankylosing spondylitis • Flattening of vert…?
Types of Pain• Radiating Pain – Perceived at source of pain – Extends to nearby tissues – Example: Cardiac pain to left arm• Referred Pain – Felt in part of body removed (separate) from tissues causing pain (nerve piggy backs) – Example: Gallbladder-upper back, chest
Figure 46-1 Common sites of referred pain from various body organs
Categories of Pain• Cutaneous – Originates in skin or subcutaneous tissue • Paper cut • Sharp and burning• Deep somatic – Ligaments, tendons, bones, blood vessels, nerves – Diffuse – Last longer than cutaneous • Sprain
Categories of Pain• Visceral Pain – Stimulation of pain receptors in abdominal cavity, cranium, thorax – Diffuse – Burning, aching, or feeling of pressure – Caused by stretching of tissues, ischemia, muscle spasms – Bowel obstruction
Concepts of Pain• Pain Threshold – Least amount of pain stimulation a person requires in order to feel pain – Generally uniform in one person – Pain Sensation • used interchangeably with threshold – Related to age, gender, or race
Concepts of Pain• Pain Reaction – Autonomic nervous system • Withdrawal of hand from fire – Behavioral responses to pain • Method of coping with pain - learned
Concepts of Pain• Pain Tolerance – Maximum amount and duration of pain an individual is willing to endure – Varies greatly – Influenced by psychological and sociocultural factors – Increases with age
Abnormal Pain Conditions• Hyperalgesia / Hyperpathia – Heightened response to painful stimuli • Severe reaction to paper cut• Allodynia – Nonpainful stimuli produces pain • Sheets• Dysesthesia – Unpleasant abnormal sensation – Mimics neuropathy (spinal cord injury)
Physiological Indications of Acute Pain• Dilated pupils• Increased perspiration• Increased rate/ force of heart rate• Increased rate/depth of respirations• Increased blood pressure• Increased basal metabolic rate• Decreased urine output• Decreased peristalsis of GI tract
Total Pain ManagementFour aspects must be addressed: 1. Physical 2. Psychological (help them calm down, allow meds to work) 3. Social 4. Spiritual Last 3 can be met only after pain and related symptoms (e.g., N/V, anxiety) are controlled.
Assessment• Subjective Data• Gathering subjective information• Pain threshold• Pain• Examine pain qualifiers• Subjective reports are considered primary source of data collection
Nurse’s Role Patient Advocate• Pain Assessment – Crucial Nursing Function • Conduct self-assessment about pain – Values and expectations about pain behaviors – Avoid biases when assessing – JCAHO – Pain is 5th vital sign – 2000 – Subjective Data • Gathering subjective information – Pain threshold – Pain • Examine pain qualifiers • Subjective reports are considered primary source of data collection
Nurse’s Role Patient Advocate• Planning – Mutual goal setting with patient – Nonpharmacologic and pharmacologic interventions – Several approaches combined – Multidisciplinary approach• Preventive Approach – Treatment in mild pain or if anticipated*Addiction is of less concern with acute pain than with chronic pain.
Nurse’s Role Patient Advocate• Implementation – Nonpharmacologic interventions for mild pain – Pharmacologic for moderate to severe • Nonpharmacologic used as adjuncts • Mainstay for treatment of pain• Responsibilities of administration – Determine to give, which one – Assess response to analgesia – Report when a change is needed – Teach regarding use of medications