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  1. 1. Pain<br />Mary Corcoran RN,BSN, MICN<br />
  2. 2. Pain In ER<br />Most frequent Complaint<br />Traditionally inadequately treated for many patients<br />ED Nurses are the patients primary advocate for control of pain<br />
  3. 3. Types of pain<br />Acute<br />Sudden onset<br />Chronic<br />Prolonged- Months to years<br />Cancer<br />May increase with treatment, or changes in the disease process<br />Neuropathic<br />Burning, numbness sensation- usually peripheral<br />Visceral<br />Cramping, bloating, stretching sensation- usually abdominal<br />Somatic<br />Aching, or throbbing- joint type pain<br />
  4. 4. Definitions of Pain Terminology<br />Allodynia- Pain due to stimulus that does not normally provoke pain<br />Analgesia- Absence of pain in response to a stimulus that should be painful<br />Hyperalgesia- An increased response to a stimulus that is normally painful<br />Hypersthesia- Increased sensitivity to stimulation, excluding special senses<br />Neuralgia- Pain in the distribution of a nerve or verves <br />
  5. 5. Definitions cont<br />Neuritis- Inflammation of a nerve or nerves<br />Neuropathy- A disturbance of function or pathologic change in a nerve<br />Noxious Stimulus- a stimulus damaging to normal tissue<br />Pain Threshold- The least experience of pain that a patient can recognize<br />Pain Tolerance Level- The greatest level of pain that a patient can tolerate<br />Parasthesia- An abnormal sensation whether spontaneous or evoked<br />
  6. 6. Definitions of Addiction<br />Tolerance- A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drugs effects over time<br />Physical Dependence- A state of adaptation that includes tolerance and a withdrawal syndrome with dosage decrease or agonist administration<br />Addiction- is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestation<br />Pseudoaddiction- patients exhibit behaviors of addiction, which resolve when the pain is treated<br />
  7. 7. Pathophysiology<br />Nociceptors<br />Pain receptors located in the skin, muscle, joints, arteries and viscera<br />Stimulated by chemical, thermal or mechanical stimuli<br />Examples of stimuli<br />Laceration, Burns, or strain to a muscle (inflammation)<br />
  8. 8. PathophysiologyPain Fibers-transmit action potentials of nociceptors<br />Myelinated A-Delta Fibers<br />Unmyelinated C Fibers<br />Rapidly Transmit the pain impulse (Fast Pain)<br />Produces a Sharp Pain Sensation<br />Are slower (slow pain) <br />Produce diffuse burning or aching sensation of pain<br />Also produce deep throbbing pain, visceral, pain, and chronic pain<br /><ul><li>Both eventually terminate in the subsantiagelatinosa (say that 10 times fast) in the dorsal horn of the spinal cord</li></li></ul><li>Pathophysiology<br />Spinal Cord<br />The “Pain Gate”- The connection between primary and secondary order neurons, and regulates the conduction of pain impulses to the brain<br />Thalamus- functions as a relay station for pain impulses<br />Neospinothalmicpathway- conducts “fast” pain fibers, letting the brain know intensity, location, and duration of pain<br />Paleospinothalamic pathway- Transmits “slow” pain fibers, makes it difficult to specifically localize pain sensation<br />
  9. 9. Pathophysiology<br />The Brain<br />The third order neurons, located in the Thalamus, Brain stem, and midbrain, communicate with the CNS, and triggers communication between all areas of the brain<br />The limbic and reticular tracts respond to pain signals- resulting in the person arousing to danger, release of stress hormones, and emotional response to pain<br />
  10. 10. Pathophsiology<br />Pain Modulation and Endogenous Opioids<br />These work together to decrease the sensation of pain, allowing the body to suffer debilitating pain, and still survive (ie endorphins)<br />
  11. 11. Barriers to pain management<br />The perception of “Drug Seeking”<br />Disparities in treatment of minorities and women<br />Fear of negative physiologic effects of opioid administration<br />Physician and RN lack of education regarding pain management<br />Inadequate treatment of high-risk patients <br />Older adults, Developmentally delayed, non-English, and children<br />The belief that physiologic signs are more reliable than patient self report<br />
  12. 12. How do we assess pain?<br />Most adults will be able to use a simple 0-10 scale to describe the severity of their pain<br />
  13. 13. What about kids?<br />Most school age children (5+) will be able to use the Wong- Baker FACES Scale<br />
  14. 14. What about babies?<br />Children age 3mo-7yrs can be scored using the FLACC scale<br />
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  17. 17. How do we Treat Pain?<br />Pharmacologic<br />Non-Pharmacologic<br />Opioids<br />Morphine, Dilaudid, Fentanyl<br />NSAIDS<br />Motrin, Toadol<br />PCA<br />Opioids administered by patient<br />Topical Lidocaine<br />LET/TAC solution, EMLA cream<br />Positioning/Elevation<br />Heat/Cold therapy<br />Heat for chronic<br />Cold for acute<br />Distraction technique<br />Reading, movies, talk etc<br />Works well for children<br />
  18. 18. Procedural Sedation<br />MINIMAL- pt responds normally<br />MODERATE (“Conscious”)- airway and CV function maintained<br />DEEP- pt not easily aroused<br />ANESTHESIA- required assisted ventilation<br />Sedation- minimizes <br />movement, pain, <br />and anxiety during procedure<br />