Chapter 44 Pain Management - Overview of Pain

Skill assessment

'his process identifies the skill level of the manager before development. Beyond the mere determination of skill levels, this Step serves the further yet critical purpose of helping managers become self-aware of their own strengths and weaknesses relative to the skill in question.

Which body part is least sensitive to pain?

Internal organs The lowest density of nociceptors is found in internal organs, making them least responsive to painful stimuli.

Neurotransmitters

1. Bradykinin - A peptide produced in the blood that mediates the inflammatory response and stimulates pain receptors. 2. Substance P - Neuropeptide that transports pain impulses from the periphery to the central nervous system. 3. Histamine - An amine released by immune cells in response to inflammation. 4. Serotonin - A neurotransmitter released from the brainstem and dorsal horn that inhibits pain transmission. 5. Cytokines - Proteins secreted by immune system cells that control inflammation. 6. Electrolytes - Molecules that activate nerve endings (synapses), which respond to painful stimuli by changing ionic movement into and out of nerve cells. 7. Prostaglandins - Hormone-like compounds derived from fatty acids that are thought to increase sensitivity to pain by stimulating pain receptors on neurons (nerve cells).

perceptions of pain

1. Cognitive An alert, oriented patient can perceive pain, report pain, and perform behaviors to prevent or alleviate pain. Non-alert patients may have impaired ability to perceive, report, prevent or relieve pain. 2. Affective/Behavioral Behavioral and psychological responses to pain include grimaces, clenched teeth, agitation, and restlessness. Verbalization may include crying, moaning, or screaming. Psychological responses to pain may include anger, irritability, hopelessness, or anxiety. Patients who do not outwardly verbalize pain, or who have a stoic affect, are often assumed to be pain-free, when, in fact, they are in pain. 3. Sensory Any loss of sensory function directly influences the patient's awareness of pain. When patients cannot sense pain, they cannot communicate pain, prevent it or respond to it.

Nociception

1. Transduction > Injury occurs. > Nociceptors identify pain stimuli and convert it into an electrical impulse. > Injured tissues release neurotransmitters that are part of the inflammatory response. > Neurotransmitters assist with transmission of pain signals across neurons. > Inflammatory response is a significant cause of generalized pain. 2. Transmission Pain signal transmitted through afferent nerve to spinal cord and brain. Signals travel two pathways: > A-delta fibers:Pain translated as sharp, acute pain. > C fibers:Pain translated as diffuse, dull, and longer-lasting pain. > Both A-delta and C fibers carry pain impulses from the spinal cord to the cerebral cortex of the brain. 3. Perception > Brain translates afferent nerve signals as pain. > Person perceives pain. > Location, intensity, quality: Pain threshold: lowest intensity at which the brain recognizes pain. Pain tolerance: intensity or duration of pain that a person can, or is willing to, endure. 4. Modulation > Once pain is recognized, the brain can change the perception of pain by sending inhibitory signals via the spinal cord. > This signal results in the release of analgesic neurotransmitters called endogenous opioids. Enkephalins influence the emotional perception of pain. Beta-endorphins act on the central and peripheral nervous systems to reduce pain. Dynorphins modulate pain, stimulate pain or reduce it, depending on which receptors are activated.

Order the four steps in the nociception process.

2. Nociceptors identify painful stimuli and convert it into an electrical impulse. 1. Pain signals are transmitted through afferent nerve fibers to the spinal cord and brain. 4. The brain translates nerve signals as pain. 3. The brain changes the perception of pain by sending inhibitory signals via the spinal cord.

Pain Transmission

> Nociception is the process by which pain, triggered by noxious stimuli, is conducted from the periphery to the central nervous system. > The event begins with the conversion of the noxious stimuli (injury) to an electrical impulse, which is transmitted from one neuron (nerve) to the next with the help of neurotransmitters.

Protective

A warning signal about an unmet need, or malfunction of the nervous system secondary to a disease process A motor or sensory, or emotional response to a subjective feeling. Warning > Warning about a disease or condition: symptom Disease entity that can be treated Response > Thermal injuries, e.g., sunburn > Mechanical injury, e.g., fracture > Chemical injury, e.g., inhalation of toxic fumes > Ischemic injury, e.g., lack of oxygen to body tissues

Which nursing practice may be influenced by expectations of behaviors that indicate pain?

Administration of pain medication Expectations of certain behaviors can influence the administration of pain medications.

Which neurotransmitters are involved in controlling the inflammatory response?

Bradykinin Bradykinin mediates the inflammatory response. Histamine Histamine is released by immune cells in response to inflammation. Cytokines Cytokines are secreted by immune system cells to control inflammation.

Based on the density of nociceptors throughout the body, which condition would the nurse expect to require increased analgesia?

Burn The highest density of nociceptors is found in the skin, making it extremely sensitive to pain.

Which are verbal manifestations of the presence of pain?

Crying Crying is a verbal manifestation of pain. Moaning Moaning is a verbal manifestation of the presence of pain. Screaming Screaming is a verbal manifestation of the presence of pain

During the modulation process of nociception, which endogenous opioid has an influence on the emotional perception of pain?

Enkephalins Enkephalins influence the emotional perception of pain.

What term has been given to describe pain assessment in nursing?

Fifth vital sign The assessment of pain is known as the fifth vital sign

Which pain theory proposes that pain is caused by the movement of various substances in and out of the cell?

Gate Control Theory In the Gate Control Theory movement of neurotransmitters in and out of the cell creates an electrical impulse, which determines the perception of the individual's pain.

The nurse is caring for a patient with chronic back pain. The patient feels that he has an increase in back pain when he is experiencing stress. He wishes to practice relaxation techniques to decrease the perception of pain. Which pain theory is this practice associated with?

Gate Control Theory The Gate Control Theory proposes that thoughts and emotions influence an individual's perception of pain.

The nurse is caring for a postoperative patient. Which behavioral manifestations of pain are included in the pain assessment?

Grimace Behavioral manifestations of pain include grimaces, clenched teeth, agitation, and restlessness.

Which are psychological manifestations of the presence of pain?

Hopelessness Hopelessness is a psychological response to pain. Anger Anger is a psychological response to pain. Irritability Irritability is a psychological response to pain. Anxiety Anxiety is a psychological response to pain.

What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain?

Let me know at least 30 minutes before you transport her so I can administer her pain medication.

Which stimuli relates to a postoperative incision?

Mechanical Postoperative pain associated with an incision is related to mechanical stimuli.

Once pain is recognized, which process is responsible for the release of analgesic neurotransmitters?

Modulation Inhibitory signals are sent via the spinal cord and analgesic neurotransmitters are released during modulation.

Which statement provides an accurate description of pain?

Pain is subjective. Pain is a subjective experience; the patient describes the level of pain

The nurse is caring for a patient with chronic pain related to fibromyalgia. The patient is in the emergency department for pain control. The patient is complaining of generalized pain at a level of 7 on 1-10 scale. The nurse overhears a primary care provider complaining that this patient is drug-seeking. Which definitions of pain are important for the nurse to keep in mind?

Pain is what the patient says it is. The nurse should remember that the accepted definition of pain is that it is whatever the person says it is and it exists when the person says it does

Which definition accurately depicts pain?

Pain is whatever the individual says it is. Pain is relative to each person's thoughts, feelings and perceptions. There is no right or wrong answer when a patient is describing his or her pain

The nurse is conducting a pain assessment on a patient in the oncology unit. The patient is asked to describe the intensity of pain that she is willing to withstand. How is this documented?

Pain tolerance Pain tolerance is the intensity or duration of pain a person can endure.

A patient with Alzheimer's disease is being cared for in the medical-surgical unit. As pain assessments are conducted on a patient with a cognitive disorder, what is the nurse mindful of?

Patient may not be able to express the location of pain. Patients with Alzheimer's disease or other cognitive disorders may not be able to express the location of pain. Patient is able to experience pain. Patients with cognitive disorders are able to experience pain

Which theory proposes that pain signals determine if a person feels pain?

Pattern Theory Pattern Theory proposes that when injury occurs, a signal is carried along nerve fibers, which determine whether or not a person feels the pain

A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely

Performing neck, back, and shoulder exercises prescribed by a physical therapist

A patient has suffered burn injuries related to a house fire, and is in the burn center for pain control and dressing changes. What function does pain serve when it is associated with a thermal injury?

Response Pain occurs as a response to an injury

A patient with diabetes develops an infected wound on the plantar aspect of the foot. The patient reports that he never felt any pain or discomfort related to the wound. Which pain response is lacking in this type of injury?

Sensory This patient is lacking sensory input. Any loss of sensory function directly influences the patient's awareness of pain.

Which aspect of the brain helps a person localize where on the body the injury has occurred?

Sensory-discriminative aspect The sensory-discriminative aspect of the brain helps the person localize where on the body injury occurred.

Which body part is the most sensitive to pain?

Skin The density of nociceptors is highest in the skin, making it extremely sensitive to pain.

The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw?

The absence of physiological signs and symptoms is associated with chronic pain.

Which observation indicates that a patient's pain medication has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention?

The patient rates her current pain as 3 out of 10 on the pain rating scale.

A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain?

The patient rates his pain a 7 on a scale of 0 to 10

The Neuromatrix Theory proposes that pain is controlled by which factor?

The person In the Neuromatrix Theory, the experience of pain is perceived and regulated by each person.

Which physiologic process occurs when painful stimuli are first identified and converted into an electrical impulse?

Transduction Transduction occurs when nociceptors identify pain stimuli and convert it into an electrical impulse.

As the nurse conducts a comprehensive pain assessment, the patient is asked to describe the quality of the pain. The patient describes his pain as sharp and acute. Which phase of the nociception process is responsible for the type of pain impulse that is being detected by the patient?

Transmission During transmission, the pain signal is transmitted to the spinal cord and brain. Pain fibers carry impulses that are responsible for identifying pain as sharp or dull.

Which physiologic process occurs when pain signals travel through pathways to the brain and spinal cord?

Transmission Transmission is when the pain signal is transmitted through the afferent nerve to the spinal cord.

Pain defined

an unpleasant sensory and emotional experience associated with actual or potential tissue damage The importance of pain recognition has resulted in pain becoming known and assessed as the fifth vital sign.

Nociceptors

are the free endings of afferent nerve fibers. They are sensory neurons sensitive to thermal, mechanical, and chemical stimuli. Nociceptors are distributed throughout the body but density differs: > The highest density is found in the skin, making the skin extremely sensitive to pain. > A lower density is found in joints and tissues; therefore, these areas are less sensitive than skin. > The lowest density is in internal organs, which respond only to painful stimuli, e.g., on palpation or when infection is present.