Pain Management

Pain Management Pain is a highly complex and subjective experience that originates from the CNS or peripheral nervous system or both. Nociceptors- specialized nerve endings that detect painful sensations from the periphery and transmit them to the CNS Nociceptors are located within the skin, connective tissue, muscle, and the thoracic, abdominal, and pelvic viscera

NOCICEPTION: Can be divided into four phases: Nociception is the term used to describe how noxious stimuli are typically perceived as pain. Can be divided into four phases: TRANSDUCTION TRANSMISSION PERCEPTION MODULATION

TRANSDUCTION Occurs when a noxious stimuli takes place in the periphery These injured tissues then release a variety of chemicals These chemicals are neurotransmitters that propagate a pain message along nerve fibers to the spinal cord TRANSMISSION Transmission-the pain impulse moves from the level of the spinal cord to the brain PERCEPTION Perception-indicates the conscious awareness of a painful sensation MODULATION The pain message is inhibited through the phase of MODULATION Descending pathways from the brain stem to the spinal cord produce a third set of neurotransmitters that slow down or impede the pain impulse, producing a analgesic effect

SOURCES OF PAIN: Pain sources are based upon their origin: VISCERAL DEEP SOMATIC PAIN CUTANEOUS PAIN REFERRED PAIN

VISCERAL Originates from the larger interior organs (kidney, stomach, intestine, gallbladder, pancreas) Can stem from direct injury to the organ or from stretching of the organ Ex: acute appendicitis, ulcer pain DEEP SOMATIC PAIN Comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Injury may result from pressure, trauma, or ischemia

CUTANEOUS PAIN Derived from skin surface and subcutaneous tissues. The injury is superficial, with a sharp, burning sensation REFERRED PAIN Pain that is felt at a particular site but originates from another location Both sites are innervated by the same spinal nerve May originate from visceral or somatic structures Ex: inflamed appendix RLQ of abdomen may have referred pain in the periumbilical area

TYPES OF PAIN: Pain can be classified by its duration ACUTE pain -short term and self-limiting, often follows a predictable track, and ends after an injury heals Ex: surgery, trauma, and kidney stones Acute pain warns the person of actual or potential tissue damage CHRONIC pain -diagnosed when the pain continues for 6 months or longer. It can last 5,15, or 20 years and beyond Chronic pain can be divided into malignant and nonmalignant Malignant-cancer related Nonmalignant- often associated with musculoskeletal conditions such as arthritis, low back pain, or fibromyalgia Chronic pain does not stop when the injury heals

Effects of pain Acute: It can affect pulmonary, cardiovascular, gastrointestinal, endocrine and immune systems. The stress response: is a neuroendocrine response to stress occurs with trauma also with other causes of severe pain. Pain effect is increased in cases of elderly, illness and injury. Stress response result in increased metabolic rate and cardiac output, impaired insulin response, increased cortisol production and increased fluid retention. Chronic: The same as acute pain in addition to that: it can result in depression and disability

Factors influencing pain response: -Past experience -Anxiety and depression -Culture -Age -Gender -Placebo effect: occurs when a person responds to a medication or other treatment because of an expectation that the treatment will work more than that actually do. It results from the natural production of endorphins in the descending control system.

Characteristics of Pain Intensity Timing Location Quality Personal meaning Aggravating and alleviating factors Pain behaviors

Characteristics of pain Intensity: It depends on the patient’s pain threshold (the smallest stimulus for which a person reports pain) and pain tolerance (the maximum amount of pain a person can tolerate). It ranges from none to mild, moderate,.. Timing: some times etiology of pain can be determined when time aspects are known. Location: Referral pain: pain that radiates. Quality: describe e.g. burning, stapping, squeezing, .. Personal meaning: how pain affect the person’s daily life. Aggravating and alleviating factors: Ascertain whether environmental factors influence pain Ascertain whether activity influence pain Pain behaviour: the way person expresses pain (nonverbal and behavioural expression) e.g. grimace, cry, rub the affected area, immobilize it, moan Physiologic response to pain such as: tachycardia, tachypnea, hypertension, pallor, diaphoresis, increased muscle tone, mydriasis, .

Nurses role in pain management - Help in relieving pain by administering relieving interventions. - Assess the effectiveness of these interventions. Monitoring for side effects. - Serving as advocate for patient when prescribed interventions are ineffective. - Serving as educator for patient and family to enable them to manage the prescribed interventions them selves.

General categories of analgesic agents 1- Local anaesthetic agents It works by blocking nerve conduction when applied directly to the nerve fibres e.g.Topical application,Intraspinal administration 2- Opioids analgesic agents: can be administered through different routes. side effects: - Respiratory depression and sedation - Nausea and vomiting - Constipation - Inadequate pain relief - Allergies - Tolerance and addiction Tolerance: the need for increasing doses of opioids to achieve the same therapeutic level Addiction: is a behavioural pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effect.

General categories of analgesic agents 3- Non Steroidal Anti Inflammatory Drugs (NSAID): They decrease pain by inhibiting cyclo-oxygenase. Side effects: stomach irritation, bleeding tendency, and renal impairment.

Second: Non pharmacological interventions 1- Cutaneous stimulation and message: include rubbing the skin 2- Ice and heat therapies 3- Transcutaneous Electrical Nerve Stimulation (TENS): producing tingling, vibrations, or buzzing sensation in the area of pain. 4- Distraction: involving focusing patient’s attention on some thing other than pain. 5- Relaxation techniques 6- Guided imaginary 7- Hypnosis