Pain/Comfort Ch 41

Events that occur when the threshold of pain has been reaced and there is injured tissue

Injured tissue releases chemicals that excite nerve endings. A damaged cell releases HISTAMINE, which excites nerve endings. LACTIC ACID accumulates in tissues injured by lack of bloos supply and is believed to excite nerve endings and cause pain or lower

Acute pain

is generally rapid in onset, varies in intensity from mild to severe. It is protective in nature; that is, it warns the individual of tissue damage or organic disease. After its underlying cause is resolved, acute pain disappears. It should end once heali

Chronic Pain

pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. This newer definition of chronic pain no longer mentions the previous guideline of 3 to 6 months duration for pain to be considered chronic.

Chronic Malignant Pain

Pain associated with cancer or other progressive disorders

Chronic Non-malignant Pain

Pain in people whose tissue injury is nonprogressive or healed

Chronic Pain implications

Patients have difficulty describing chronic pain because it may be poorly localized. Moreover, healthcare personnel have difficulty assessing it accurately because of the unique responses of individual patients to persistent pain. Unlike acute pain, chron

Cutaneous or Superficial Pain

usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example Ex: Pain r/t surgical incision

Deep Somatic Pain

diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes

Visceral Pain

poorly localized and originates in body organs in the thorax, cranium, and abdomen. This pain occurs as organs stretch abnormally and become distended, ischemic, or inflamed.

Guarding

reflex contraction or spasm of the abdominal wall, may occur as a protective mechanism to prevent additional trauma to underlying structures

Referred Pain

Pain can originate in one part of the body but be perceived in an area distant from its point of origin. Ex: MI

How is pain referred

Referred pain is transmitted to a cutaneous (skin) site different from where it originated. This is possible because the pain can travel to other areas of the body innervated by the affected nerve root.

Neuropathic Pain

results from an injury to or abnormal functioning of peripheral nerves or the central nervous system
Complex regional pain, can be of short duration or lingering and is often described as burning or stabbing.

Allodynia

characteristic feature of neuropathic pain, is pain that occurs after a normally weak or nonpainful stimuli, such as a light touch or a cold drink.

Intractable

When pain is resistant to therapy and persists despite a variety of interventions,

Phantom Pain

The pain that is often referred to an amputated leg where receptors and nerves are clearly absent is a real experience for the patient, without demonstrated physiologic or pathologic substance

Psyhogenic pain

physical cause for the pain cannot be identified. Can be just as intense as physical pain

Behavioral (Voluntary) Responses

Moving away from painful stimuli
Grimacing, moaning, and crying
Restlessness
Protecting the painful area and refusing to move

Physiologic (Involuntary) Responses
Typical Sympathetic Responses When Pain Is Moderate and Superficial

Increased blood pressure
Increased pulse and respiratory rates
Pupil dilation
Muscle tension and rigidity
Pallor (peripheral vasoconstriction)
Increased adrenalin output
Increased blood glucose

Physiologic (Involuntary) Responses
Typical Parasympathetic Responses When Pain Is Severe and Deep

Nausea and vomiting
Fainting or unconsciousness
Decreased blood pressure
Decreased pulse rate
Prostration
Rapid and irregular breathing

Affective (Psychological) Responses

Exaggerated weeping and restlessness
Withdrawal
Stoicism
Anxiety
Depression
Fear
Anger
Anorexia
Fatigue
Hopelessness
Powerlessness

Transduction (1)

The activation of pain receptors . It involves conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn.

Nociceptors

The peripheral nerve fibers that transmit pain

When the threshold of perception for pain has been reached and when there is injured tissue

it is believed that the injured tissue releases chemicals that excite or activate nerve endings. For example, a damaged cell releases histamine, which excites nerve endings. Lactic acid accumulates in tissues injured by lack of blood supply and is believe

Sensitization

The prolonged effect of pain stimuli acting on the central nervous system can lead to ________, meaning that the threshold for activation of pain is lowered. At that point, even harmless stimuli can trigger pain

Bradykinin, Prostaglandins, Substance P

Other substances are also released that stimulate nociceptors or pain receptors

Bradykinin

a powerful vasodilator that increases capillary permeability and constricts smooth muscle, plays an important role in the chemistry of pain at the site of an injury even before the pain message gets to the brain. It also triggers the release of histamine

Prostaglandins

are hormone-like substances that send additional pain stimuli to the CNS

Substance P

sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves

neurotransmitters

Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are ________ or substances that either excite or inhibit target nerve cells.

Transmission (2)

Pain sensations from the site of an injury or inflammation are conducted along pathways to the spinal cord and then on to higher centers.

A-delta-fibers

fast-conducting
larger
transmit acute, well-localized pain

C-fibers

slow-conducting
convey diffuse, visceral pain that is often described as burning and aching.

A protective pain reflex, Reflex Arc

is responsible for withdrawal of an endangered tissue from a damaging stimulus. Sensory impulses travel over A-fibers through the dorsal root ganglion to the dorsal horn of the spinal cord. At this point, the sensory nerve impulse synapses with a motor ne

cortex

Highest level of integration of sensory impulses of pain

Gate Control Theory

describes the transmission of painful stimuli and recognizes a relation between pain and emotions.

Mechanisms of Gate Control Theory

certain nerve fibers, those of small diameter, conduct excitatory pain stimuli toward the brain, but nerve fibers of a large diameter appear to inhibit the transmission of pain impulses from the spinal cord to the brain.

Gating mechanism

that is believed by some to be located in substantia gelatinosa cells in the dorsal
horn of the spinal cord. The exciting and inhibiting signals at the gate in the spinal cord determine the impulses that eventually reach the brain. Thus, only a limited am

Influences on gating mechanism

The brain can also influence the gating mechanism. Past experiences and learned behaviors, which are interpreted by the brain, regulate or adjust the eventual behavioral responses to pain. Thus, the gating mechanism appears to be influenced by the amount

Interventions a/c to gate control theory

mechanical and electrical interventions or heat and pressure may provide effective pain relief. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses

Perception (3)

sensory process that occurs when a stimulus for pain is present. It includes the person's interpretation of the pain.

pain threshold

The threshold of perception,is the lowest intensity of a stimulus that causes the subject to recognize pain.

Adaptation

the pain threshold can be changed within a certain range. Ex: Person can tolerate ^ temp h20 as it is gradually heated more than if the hand was plunged into hot h20 w/out prep

Modulation (4)

The process where the sensation of pain is inhibited or modified

Neuromodulators

regulate or modify the sensation of pain
endogenous opioid compounds,( naturally present, morphine-like chemical regulators) in the spinal cord and brain.
Have analgesic activity and alter the perception of pain.
Produce their analgesic effects by binding

Endorphines

Opioid neuromodulator
Produced at neural synapses at various points in the CNS pathway.
Powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria.
May be released when certain measures are used to relieve pain, such as sk

Dynorphin

An endorphin that has the most potent analgesic effect

Enkaphalins

widespread throughout the brain and dorsal horn of the spinal cord
Considered less potent than endorphins.
Reduce pain sensation by inhibiting the release of substance P from the terminals of afferent neurons.

Sharp (Quality)

Pain that is sticking in nature and that is intense

Dull (Quality)

Pain that is not as intense or acute as sharp pain, possibly more annoying than painful. It is usually more diffuse than sharp pain.

Diffuse (Quality)

Pain that covers a large area. Usually, the patient is unable to point to a specific area without moving the hand over a large surface, such as the entire abdomen

Shifting (Quality)

Pain that moves from one area to another, such as from the lower abdomen to the area over the stomach.

Quality

sore, stinging, pinching, cramping, gnawing, cutting, throbbing, shooting, viselike pressure.

Severe or excruciating
Moderate
Slight or mild

These terms depend on the patient's interpretation of pain. Behavioral and physiologic signs help assess the severity of pain. On a scale of 1 to 10, slight pain could be described as being between about 1 and 3; moderate pain, between about 4 and 7; and

Continuous (Perodicity)

Pain that does not stop

Intermittent (Periodicity)

Pain that stops and starts again

Brief or Transient

Pain that passes quickly

Anxiety

almost always present when pain is anticipated or being experienced, tends to increase the perceived intensity of pain. The threat of the unknown is ordinarily more devastating and anxiety producing than a threat for which one has been prepared.

Characteristics of Pain assessed

Patient's verbalization and description of the pain
Duration of the pain
Location of the pain
Quantity and intensity of the pain
Quality of the pain
Chronology of the pain
Aggravating factors
Alleviating factors
Physiologic indicators of pain
Behavioral r

Basic methods to assess individual pain

Patient's self-report
Report of family member, other person close to the patient, or caregiver who is familiar with the patient
Nonverbal behaviors (restlessness, grimacing, crying, clenching fists, protecting the painful area)
Physiologic measures (incre

Indications of pain in a child

Irritability and restlessness
Crying, screaming, or other verbal expression of pain
Grimacing, grinding of teeth, or clenching fists
Touching or grabbing of painful body part
Kicking, thrashing, or attempting to move away from a painful stimulus

Assessment BEFORE Intervention!

Attempting to intervene before an accurate assessment has been completed may mask the real cause of the patient's pain and lead to false assumptions and even further progression of symptoms and the disease process.

Pain Tolerance

point beyond which a person is no longer willing to endure pain

Distraction

Conscious attention often appears to be necessary to experience pain, whereas preoccupation with other things has been observed to distract the patient from pain. Requires the patient to focus attention on something other than the pain.
Compatible with th

Therapeutic Effects of Laughter

Causes the following physiological and psychological effects:
Decreases levels of epinephrine (the stress hormone)
Activates the immune system
Elevates the threshold for pain and can minimize the pain sensation
Promotes spiritual and psychological coping

Imagery

Used to decrease pain sensation-> imagine something that involves one or all of the senses, concentrate on that image, and gradually become less aware of the pain.
More effective for patients with chronic pain than for patients with acute, severe pain.

Techniques for Guided Imagery

Help the patient to identify the problem or goal.
Suggest that the patient begin the imagery with several minutes of focused breathing, relaxation, or meditation.
Help the patient to develop images of the problem, as well as personal internal resources (e

Relaxation

techniques reduce skeletal muscle tension and lessen anxiety.
Most effective as a pain alleviator when combined with slow, deep, easy breathing from the abdomen or diaphragm, with the patient's eyelids closed or with the individual focusing on a real or i

Positive effects of relaxation

Improved quality of sleep
Distraction from the pain
Decreased fatigue
Increased confidence and sense of self-control in coping with pain
Lessening of the detrimental physiologic effects of continued or repeated stress from pain
Increased effectiveness of

Cutaneous Stimulation

techniques that stimulate the skin's surface

Why Cutaneous Stimulation alleviates pain

The gate control theory of pain postulates that cutaneous nerve fibers are large-diameter fibers carrying impulses to the CNS. When the skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decrease

Examples of Cutaneous Stimulation

Massage (with or without analgesic ointments or liniments containing menthol)
Application of heat or cold, or both intermittently Acupressure
Transcutaneous electrical nerve stimulation (TENS)

Acupressure

involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins

TENS

noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful impulses carried over small-diameter fibers.
Effective in reducing postoperative pain and improving mobility after surgery.

Acupuncture

technique that uses needles of various lengths inserted into specific parts of the body to produce insensitivity to pain.

PENS

Complementary therapy used particularly for the management of acute and chronic pain syndromes.
This form of acupuncture combines the advantages of both electroacupuncture and TENS and consists of needle probes being placed into soft tissue to stimulate p

Hypnosis

technique that produces a subconscious state accomplished by suggestions made by a hypnotist, has been used successfully in many instances to control pain. The person's state of consciousness is altered by suggestions so that pain is not perceived as it n

Biofeedback

technique that uses a machine to monitor physiologic responses through electrode sensors on the patient's skin. The feedback signal or unit transforms the physiologic data into a visual display. Upon seeing pain-related responses, such as increased muscle

Biofeedback decreases the individual's pain by

reducing the anxiety associated with lack of control over bodily functions, distracts the person's attention from the pain to concentration on the person's inner state and the feedback signal, and reduces the cause of the pain.

Therapeutic Touch

an alternative therapy that involves using one's hands to direct an energy exchange consciously from the practitioner to the patient to facilitate healing or pain relief

analgesic

is a pharmaceutical agent that relieves pain

Analgesics Fx to

reduce the person's perception of pain and to alter the person's responses to discomfort.

3 general classes of drugs used for pain relief

1. Nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDs])
2. Opioid analgesics (all controlled substances; eg, morphine, codeine, meperidine, hydromorphone, methadone)
3. Adjuvant drugs (anticonvulsants, antidepressants, an

Opoid Analgesic

the major class of analgesics used in the management of moderate to severe pain because of their effectiveness. In sufficient dosage, they are considered capable of relieving pain of virtually every nature.
Produce analgesia by attaching to opioid recepto

Physical Dependence

the body physiologically becomes accustomed to the opioid and suffers withdrawal symptoms if the opioid is suddenly removed or the dose is rapidly decreased.

Addiction

a pattern of compulsive opioid use for means other than pain control

Tolerance

occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief.

Expected responses of opioid use

physical dependence and tolerance are expected responses; patients treated with opioids for pain rarely develop addiction.
The tolerance and physical dependence that can occur after 4 weeks of regular opioid use and result in a decrease in analgesic effec

opioid doses that are safe but ineffective

can be increased by 25% for unrelieved mild pain, 25% to 50% if a patient rates his pain as moderate, and 50% to 100% to control severe pain that is unrelieved by the current dose.

Adjuvant Drugs

typically used for other purposes but are also used to enhance the effect of opioids by providing additional pain relief. They may also reduce side effects from prescribed opioids or lessen anxiety about the pain experience. Commonly used: corticosteroids

guidelines are recommended for effective, individualized pain management in any setting:

Review the pain scale of choice thoroughly.
Discuss the benefits of using a pain scale.
Try various pain control measures.
Use pain control measures before pain increases in severity.
Ask the patient what has proved effective for pain relief in the past.

Timing

is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense.

A p.r.n. drug regimen

not been proven effective for people experiencing acute pain.
In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient.
Later, however, in the postoperative course, a p.r.n. schedule

Continuous IV infusion of opioids

effective for the relief of acute postoperative pain

ATC or Regular administration of analesics

Superior pain management for chronic pain, or cancer related pain Long-acting controlled-release oral morphine or oxycodone or use of a fentanyl patch have been proven effective for this type of pain.
PRN prorocol totally inadequate

Breakthrough Pain

temporary flare-up of moderate to severe pain that occurs even when the patient is taking ATC medication for persistent pain.
can be classified as either incident pain (eg, pain caused by movement) or
end-of-dose pain, where the pain occurs before the nex

Treating breakthrough pain

treated more effectively with supplemental doses of an opioid taken on a p.r.n. basis, rather than with an increase in the dose of the ATC medication.

Breakthrough dose

dose of the breakthrough drug is usually calculated as 10% to 15% of the total daily ATC dose. If there is an increase in the ATC dose, it is important to recalculate the breakthrough dose to provide adequate pain control

Nursing interventions that can eliminate acute postoperative pain

maintaining a steady serum level of the analgesic (PCA or epidural analgesia can help here), treating side effects quickly and aggressively, encouraging use of nondrug complementary therapies as adjuncts to the medical regimen, and expecting incident pain

The major principles that guide treatment for chronic(or cancer) pain include:

Giving medications orally, if possible.
Administering medication ATC rather than on a p.r.n. basis.
Adjusting the dose to achieve maximum benefits with minimal side effects.
Allowing patients as much control as possible over their medication regimen.

Recommendations for analgesic administration for older adults

Avoid the use of meperidine (Demerol), propoxyphene (Darvon products), pentazocine (Talwin), and indomethacin (Indocin) because of risks of increased toxicity in older adults

Recommendations for analgesic administration for older adults

Avoid IM injections whenever possible because of diminished muscle, fat stores, and circulation, which can affect bioavailability of the drug.

Recommendations for analgesic administration for older adults

Administer analgesics on a scheduled, basis rather than p.r.n

The most frequently prescribed drugs for PCA administration are

morphine, fentanyl, and hydromorphone.

PCA advantages 1

Consistent analgesic blood level is maintained rather than the inconsistent analgesia obtained with periodic intramuscular injections, which results in sharp rises and falls of serum opioid levels.

PCA advantages 2

The analgesic is delivered intravenously so that absorption is faster and more predictable than with the intramuscular route.

PCA advantages 3

The patient is in charge of the pain management program

PCA advantages 4

The patient tends to use less medication because it is self-administered before the pain becomes too severe.

PCA advantages 5

The patient is more satisfied and has improved pain relief.

Epidural analgesia

can be used to provide pain relief during the immediate postoperative phase (particularly after thoracic, abdominal, orthopedic, and vascular surgery) and for chronic pain situations

Epidural placement (anesthesiologist)

inserts the catheter in the midlumbar region into the epidural space between the walls of the vertebral canal and the dura mater or outermost connective tissue membrane surrounding the spinal cord.

Epidural analgesic action

The narcotic or opioid acts directly on the opiate receptors in the spinal cord, and pain relief is achieved with smaller doses and less severe side effects.
drug of choice is usually preservative-free morphine or fentanyl.

Fentanyl

Because the epidural space contains blood vessels, nerves, and fat, lipid-soluble ______ is readily dissolved and has a rapid onset of action (5 minutes) but a short duration of action (approximately 2 hours).

Morphine

a hydrophilic opioid,(has a high affinity for water). It has a slower onset of action but may exert its analgesic effect for as long as 24 hours because it remains longer in the cerebrospinal fluid (CSF) and spinal tissue

Local Anesthetics

may be applied topically to the skin or mucous membranes or injected into the body to produce a temporary loss of sensation and motor and autonomic function in a localized area. The agents work by chemically blocking the nerve pathways involved in pain se