1. Pain is a complex, subjective experience influenced by physiological, psychological, social, and cultural factors.
2. Accurate pain assessment is crucial for nurses and includes gathering subjective data from patients.
3. A nurse's key role is advocating for patients by assisting with pain management through both nonpharmacological and pharmacological interventions.
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Pain is defined as an “unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such”.
Free nerve endings – responsible for carrying noxious stimulus from both superficial as well as deep somatic and visceral pain sensations therefore reffered as nociceptors
According to type of impulses they carry second order neuron can be classified as –
LOW THRESHOLD MECHANOSENSORY( ligth touch, pressure and Proprioception)
NOCIOCEPTIVE SPECIFIC ( Noxious stimulation)
WIDE DYNAMIC RANGE ( wide range of stimulus intensities from nonnoxious to noxious.
SILENT NOCICEPTORS (It is an afferent neuron that appear to remain or silent to any mechanical stimulation .These neuron become active with tissue injury and add to the nociceptive input entering the CNS.
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Pain is defined as an “unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such”.
Free nerve endings – responsible for carrying noxious stimulus from both superficial as well as deep somatic and visceral pain sensations therefore reffered as nociceptors
According to type of impulses they carry second order neuron can be classified as –
LOW THRESHOLD MECHANOSENSORY( ligth touch, pressure and Proprioception)
NOCIOCEPTIVE SPECIFIC ( Noxious stimulation)
WIDE DYNAMIC RANGE ( wide range of stimulus intensities from nonnoxious to noxious.
SILENT NOCICEPTORS (It is an afferent neuron that appear to remain or silent to any mechanical stimulation .These neuron become active with tissue injury and add to the nociceptive input entering the CNS.
New product dedisions provide a dear path to the business. New product development
astep by step process. A Complete idea is required behind new product.
1 1deal Generation: The development of a product starts with the concept and idea.
The remaining process is depending on that idea.
2 Screening of Idea: This step is cruial to ensure that unsuitable ideas, for whatever
reason, are rejected as soon as possible. Ideas need to be considered objectively,
ideally by a group or committee.
3. Concept Development and Testing: After having an idea, next is the sreening
stage. The idea should now convert into concept. It has depth information which can
be visualizing by the consumer.
4. Anaysis of business: After finalization of concept, a business case needs to be kept
algTStogether to consider whether the new service /product will be gainful.
2665.Product Development If the nev product is approved, it will be approved to the
2marketing and technical development step.
6. Test Marketing: Market testing (test marketing or) is different to consumer testing.
in that it introduces the product that follows proposed plan of marketing.
od7. Commercialization: When the concept has been tested and developed, final
0decisions are required to move the product to its introduction into the market.
8. Launch: A detailed plan of launch is required for this step. This is the important
stage for success of a product
New Drug Development
So In present business atmosphere, it is more important to take smart decisions for
business. Innovative approaches and new products can put an organization on proper
pathway and to make a big success if appropriately analyzed and executed. Make it simpler
(Fig.2.1).0
Following parameters should keep in mind for a better decision:
Analyzing existing service and product portfolio frequently.
Knowing the position of functions of business, projects of departments and
initiatives.
Understanding the distribution of funds and assessing efficiency.
Having understanding of market for new opportunities and possible competition.
2.B PRODUCT BRANDING, PACKAGING AND LABELLING DECİSIONs
2.8.1 Branding
Branding has its existence from ancient era. According to Nilson (2000), the first example
of branding is found in the oil lamps' manufacture on the Greek islands thousands of years
back. Brand elements are name, sign, term, symbol, design or distinguishing characteristics.
Brand is not only a graphical design or a logo; it is the unique identity of the product.
By American Marketing Association, Brand can be defined as name, term, sign, symbol
or design, or a combination of them intended to identijy the goods and services of one seller or
group of sellers and to diferentiate them from those of other sellersa54
Branding is a process, where a company generates loyalty among consumers in the
market. Brands are designed with a motive to communicate customers the reason for the
existence of their product. Brand should have a strong connection with customers;
my presentation provide how can we approach patient with chronic pain, when we suspect psychiatric cause for chronic pain any how we explain chronic psychogenic pain and how we manage.
1. Part I
Nursing 53A
Judith Ontiveros, RN, MSN, CPAN
2. 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.
3. Definitions of Pain
“an unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.”
American Pain Society
(APS, 2003; Gordon, 2002.)
4. 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).
5. Definitions of Pain
“Pain is an emergency!”
•Melanie Simpson, RN, BA, BSN
•OCN Cancer Institute of Kansas University
“Pain is whatever the person
experiencing it says it is, existing
whenever he says it does.”
(Margo McCaffery, 1979)
6. Summarization
• Pain:
actual physical sensation of discomfort
• Suffering:
unpleasant emotional response to pain
Pain is a very subjective and
highly individualized
experience
7. 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 pain
unless assessed or asked
about. Assess in other
ways… nonverbal, etc.
8. 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
9. 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
10. 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
11. Implications for Nursing
• More than a symptom of a problem
• Becomes a HIGH priority problem of its
own entity.
– Physiologic and psychologic dangers
Severe Pain = Emergency Situation
Deserves prompt, professional treatment
12. Components of the Pain
Experience
• Pain is a protective mechanism
• Complex biopsychosocial phenomena
• May or may not
– have a cause
– respond to interventions
13. 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
15. 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
16. 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
17. Figure 46-2 Substance P assists the transmission of impulses
Figure 46-2 Substance P assists the transmission of impulses
across the synapse from the primary afferent neuron
across the synapse from the primary afferent neuron
second-order neuron in the spinothalamic tract
second-order neuron in the spinothalamic tract
18. 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
19. Transmission of Pain
2. Transmission from spinal cord and
ascension
– Spinothalamic tracts
– To brain stem and thalamus
• Opioids block release of neurotransmitters
3. Signals to thalamus to somatic sensory
cortex
– Pain perception
21. Perception
• Conscious of pain
– Complex activity in CNS
– Pyschosocial and meaning of pain to each
individual shape the responses
22. 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
23. 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
24. Gate Control Schematic
Small diameter (a-delta or C)
peripheral nerve fibers carry
signals of noxious stimuli to the
dorsal horn
Ion channels on the pre- and
postsynaptic membranes serve
as gates
When open, permit positively
charged ions to rush into the
second order neurons, sparking
an electrical impulse and
sending signals of pain to the
thalamus
25. Gate Theory
Large diameter (A-delta)
fibers have inhibitor
effect
May activate descending
mechanism that can
inhibit transmission of
pain
26.
27. Clinical Application of
Gate Control Theory
• Stop nociceptor firing
• Apply topical therapies
• Address client’s mood
• Address client’s goals
28. 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
29. 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
30. 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
31.
32. 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
33. 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
34. Types of Pain
• Neuralgia
– Paroxysmal pain along course of one or
more nerves
– Low back pain
– Rheumatoid arthritis
– Ankylosing spondylitis
• Flattening of vert…?
35. 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
36. Figure 46-1 Common sites of referred pain from
various body organs
37. 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
38. 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
39. 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
40. Concepts of Pain
• Pain Reaction
– Autonomic nervous system
• Withdrawal of hand from fire
– Behavioral responses to pain
• Method of coping with pain - learned
41. 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
43. 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
44. Total Pain Management
Four 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.
45.
46. Assessment
• Subjective Data
• Gathering subjective information
• Pain threshold
• Pain
• Examine pain qualifiers
• Subjective reports are considered primary
source of data collection
47. 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
48. 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.
49. 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
Editor's Notes
Local anesthetics – Zostrix or capsaicin
Complex mechanism and integrate with pyscho social context.