Acute and Chronic Pain

Client Interview of Pain

-Location: "Where does it hurt?" -Intensity: "On a scale of 0-10, with 0 representing no pain and 10 representing the worst possible pain, how would you rate your pain now?" -Duration: "How long have you had the pain, and how long does it usually last?" -Quality: " Tell me what your pain feels like. Is it burning throbbing, stabbing?"

Pain and Older Adults

80 percent of older adults have at least one chronic condition associated with pain and 20 percent have at least five coextisting chronic conditions. Physiological changes that affect how older adults perceive pain is decreased cerebral blood flow, neuronal loss, and a decreased synthesis of neurotransmitters and opioid receptors. A decrease in descending inhibitory signal from the brain produces increased pain sensations and decrease in excitatory neurotransmitters, receptors, and neurons produces more mild pain sensations.

Environmental and Social Support

A client's environment can influence the perceived intensity of pain. May perceive greater pain if in unfamiliar environment with many sources of disruption. Providing relaxed and welcoming environment helps decrease clients' perception of pain.

Location

A description of where the pain is located may give a primary indication of the client's underlying problem.

Narcotics

A term that means they are morphine like drugs that have potential for abuse. (controlled substances)

Types of Pain

Acute, chronic pain, breakthrough, central, phantom, and psychogenic.

Sensitization

An increased response to pain over time that causes a lower (pain tolerance)

Nerve block

An invasive therapy that is an injection of a local anesthetic around nerves to temporarily block nerve activity.

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Barriers to Pediatric Pain Management

Are related to inadequate pain assessment and a lack of knowledge about how to treat a child's pain safely.

The Meaning of Pain

Depending on the client's cultural beliefs, pain can take on many meanings. Clients who have strong spiritual beliefs often give a spiritual meaning to pain; punishment, test, gift from God.

Full Agonists

Bind with high affinity to mu opioid receptors in the peripheral and central nervous systems and produce a strong analgesic effect. EX. fentanyl, hydromorphone, methadone, morphine, and oxycodone. known to produce euphoria, respiratory depression, and tolerance.

Types of Pain Stimuli

Biological:Bacteria, Virus Mechanical: Shearing forces, Fractures Thermal: Extreme heat (burn), Extreme cold (frostbite) Electrical: Electrical burn, Electrical shock Chemical: Cleaning solutions, Tobacco smoke, Acids/bases, Radiation.

Children and Pain Memory

Children develop a pain memory that influences how they respond to pain in the future. A child's memory of a painful experience is a better predictor of future pain experiences than is the actual pain reported after a procedure, and children with pain-related anxiety are more likely to remember experiencing a greater intensity of pain than they initially reported.

Pain and Adults

Chronic pain is a widespread problem among adults, and conditions associated with chronic pain are more prevalent in women than in men. 80-90 percent of fibromyalgia cases are women. Women are more likely to develop diseases that cause pain. Women have lower pain threshold.

Cultural and Ethnic Influences on Pain

Clients from stoic cultures rarely vocalize pain. Individuals from expressive cultures routinely moan or scream when faced with pain, and they expect others to care for them to help relieve the pain. Culture affects how pain is described, the methods of treatment that a client is willing to undergo.

Previous Experience With Pain

Clients' previous experiences with pain play a major role in their perception of pain. Clients who have undergone a procedure without adequate pain management, seen a loved one suffer severe pain associated with a disease tend to experience more pain and anxiety then those who have not.

Physiological considerations for children in pain

Compared to adults, children normally have a higher pulse and respiratory rate and lower blood pressure. Children experience pain more intensely at the beginning of the painful episode, but the intensity decreases more rapidly than in an adult. Pain brings anxiety and stress to children to children who do not understand why they are in pain. If pain goes untreated in children , physiological consequences may include decreased growth and development, decreased immune function, lack of appetite, hypertension, and increased sensitivity to future pain.

Opioids

Drugs that act on one or more of three opioid receptors, mu, delta, and kappa. Most commonly referred to as narcotics.

Coanalgesic

Drugs that are primarily for another purpose but also have some analgesic properties, can also be used to treat pain alone or in combination with other analgesic drugs. Examples are antidepressants, anticonvulsants, antihypertensives, antipruritics, corticosteroids, and local anesthetics.

Verbal Descriptor Scales

Include words to help describe the pain intensity, such as mild, moderate, or severe. It help with client who have trouble rating their pain numerically. Mild Pain- is pain only when paying attention to it. Severe Pain- Impairs ability to function.

Central Pain

Is caused by damage to nerves in the central nervous system due to stroke, multiple sclerosis, Parkinson disease, or trauma. Central pain may occur shortly after the causative injury, or it may be delayed for weeks or years.

Neuropathic Pain

Is caused by nerve malfunction or injuries resulting from trauma, disease, chemicals, infection, and tumors. The consequent spontaneous pan may be due to damage of either peripheral nerves or central nerves.

Chronic recurrent pain

Is characterized by intense episodes of pain interspersed with periods of no pain. A common example of chronic recurrent pain is migraine headaches

Chronic intractable benign pain

Is chronic pain that is always present, although the intensity varies. The most common type of chronic intractable benign pain is lower back pain.

Breakthrough Pain

Is defined as "a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain." There are three main types of this kind of pain: Incident pain, Idiopathic pain, End-of-dose medication failure.

Face Pain Scale

Is most commonly used for children starting at age 3. Also can be used for client who don't speak English. Most common are the Wong-Baker FACES Rating Scale and the Faces Pain Scale-Revised.

Idiopathic Pain

Is not associated with any known cause. It occurs unpredictable and is therefore harder to treat. Idiopathic pain usually last longer than incident pain.

Psychogenic Pain

Is pain associated with psychological factors, including mental or emotional problems, rather than physiological factors, such as injury or disease. Often stigmatized as hypochondriacs, but pain is real and should be treated with interventions from both pain and emotional distress.

End-of-dose Medication Failure

Is pain experienced at the end of one dose of medication before the next dose is scheduled. Although end-of-dose medication failure has traditionally been considered breakthrough pain, some experts now believe that it is not breakthrough pain because it indicates that the background pain is not adequately controlled. It can be prevented by shortening the time between doses or increasing the medication dose.

Phantom Pain

Is pain felt in an amputated limb or body part. It is usually recurring rather than constant, and clients often describe their pain sensations as shooting, stabbing, squeezing, throbbing, or burning.

Chronic pain

Is pain that lasts beyond the expected time of healing, usually for at least 6 months; it does not always have a known cause. It can range from mild to severe. It has three main categories: Chronic recurrent pain, chronic intractable benign pain, and chronic progressive pain.

Chronic progressive pain

Is pain, associated with a chronic condition that worsens over time, such as cancer or rheumatoid arthritis.

Referred Pain

Is sensed in a region other than the site of origin. It occurs when nerve fibers that innervate the injured region and nerve fibers from other regions of the body converge at the same level in the spinal cord. Ex. referred pain from pancreatitis and shoulder pain from myocardial ischemia.

Incident Pain

Is short-term, predictable pain that accompanies a movement or activity. It can be caused by voluntary act such as movement, involuntary act such as coughing, or procedural events such as changing a wound dressing.

Opioid Side Effects

Most severe is respiratory depression. Constipation, nausea and vomiting, sedation, pruritus, sexual dysfunction.

Ceiling effect

Nonopioid drugs have this, It is where once the client consumes a specific dosage level, consuming more of the drug will not produce a greater analgesic effect but may increase toxic effects.

Diagnostic Test to determine cause of pain

Pain scales, change in vital signs, the prevalence of cortisol and catecholamines in blood tests.

Nociceptors

Or sensory receptors that respond to pain, send a signal along the sensory neurons to the spinal cord, where the signal is transmitted to the brain for interpretation. The brain then sends a signal back to the site of pain via motor neurons, causing the body to respond to the painful stimuli. They are specialized pain receptors that are present on all body tissues, with the exception of the brain. Skin and muscles contain many nociceptors.

Visceral Pain

Originates from internal body organs and the linings of body cavities in the chest, abdomen, and pelvic areas. Because internal organs have few nociceptors, visceral pain is usually described as dull,deep, or aching. They respond to inflammation, stretching, and ischemic changes rather than lacerations.

Somatic Pain

Originates from nociceptors located in the skin and musculoskeletal tissues. It is typically localized and described as being sharp. It may be accompanied by swelling, cramping, or bleeding, and it usually responds well to mild analgesics.

Describing Pain

Pain can be described in terms of location, intensity, quality, and duration.

Intensity

Pain intensity is often described as mild, moderate or sever. It can also be rated on visual analog scales such as the faces pain rating scale (which is useful in illiterate or younger clients) or the numerical scale from 0-10 pain scale with 0 being no pain and 10 indicating the worse pain possible.

Nociceptive Pain

Pain resulting from external stimuli on an uninjured, fully functional nervous system.

Gate Control Theory

Proposed by Melzack and Wallin 1965, is the most widely accepted pain theory to date, although it still does not completely encompass all aspects of pain. The gate theory states that stimulation of small-diameter (pain) fibers causes gates to open, whereas stimulation of large-diameter (heat,cold, mechanical) fibers causes gates to close.

Pain Quality Assessment Scale

Rates several quality descriptors of pain on a scale of 0-10: intense, sharp/dull, het/cold, sensitive, tender, etc..

Three theories about pain

Specificity theory, peripheral pattern theory, gate control theory.

Peripheral Pattern Theory

States that all sensory nerve fiber endings are the same, and pain is felt only when the fibers are intensely stimulated.

Specificity Theory

States that pain is a specific sensation that uses sensory neurons separate from other sensations such as heat and touch.

Pain Tolerance

The maximum amount of pain a client will tolerate. Higher levels of stress associated with pain, and an inability to cope with painful experiences.

Children and behavioral response to pain

The most common behavioral responses to pain are crying and grimacing. Any behavior that is out of the ordinary may e an indicator of pain or discomfort, both physical and emotional pain.

Pain Threshold

The point at which pain is initially felt.

Quality

The quality of pain can be expressed with common description. A client with sharp pain may say it feels like being stabbed, and a client with burning pain may say it feels like being on fire.

Mixed Opioids Agonisits

Two types: mixed agonist-antagonist opioids (nubain) and opioids mixed with nonopioids (opioid with acetaminophen, aspirin, ibuprofen.)

Numerical pain scales

Use an 11 point rating scale (0-10). The are usually presented horizontally with 0 on the left and 10 on the right. Can be combined with other scales.

Observational or Behavioral Pain Scale

Used to determine pain intensity for clients who are unable to provide a verbal report. Include FLACC scale, CHEOPS, and BOPS. These pain scales us a numerical scale (0-2 or 0-3) to rate the clients for various behaviors.

Pain flow sheet

Used to document the clients' pain over time based on the location, intensity, and type of pain as well as pharmacologic interventions, side effects, and sedation level.

Edmonton Symptom Assessment System

Uses a 0-10 scale to assess pain, fatigue, drowsiness, nausea, depression, anxiety, feelings of well-being, shortness of breath, and appetite.

Acute Pain

Usually has a sudden onset as a result of an identifiable tissue injury, such as surgery, inflammation, or traumatic injury. Acute pain initiates the autonomic fight-or-flight response. Three primary categories of acute pain are somatic pain, visceral pain, and referred pain.

Rational Polypharmacy

WHO's three-stop approach allows the healthcare provider to give increasingly potent combinations of analgesic drugs until the client's pain is managed effectively by this practice. It is an opioid-sparing approach that combines multiple medications with different mechanisms of actions.

Weak and Partial Agonist

Weak opioid agonists, such as, codeine and hydrocodone, have a low affinity for the opioid receptors. Partial agonist have high affinity for the opioid receptors but produce only a partial effect.