1. Stressors that Affect Perception & Cognition Pain NUR20 Fall 2009 Lecture # 14 K. Burger MSEd, MSN, RN, CNE PPP by Sharon Niggemeier RN, MSN Revised 11/06 K. Burger

2. Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage. Exists whenever the person says it does Referred to as 5 th VS Function of pain = Protective Mechanism A universal human experience

3. Pain Real experience treated with nursing and medical interventions Subjective-Tissue damage may not be proportional to extent of pain experienced Pain thresholds are similar for all people BUT pain tolerance & perception greatly differ Threshold = level of intensity that triggers neuropathways ( nocioceptors)

4. Types of Pain Acute Sudden onset Short duration < 3 months Cause …usually can ID Course…pain decreases over time Chronic Gradual or sudden Duration > 3 months Cause…may not know Course…doesn’t go away, periods of waxing/waning

5. Types of Pain Cutaneous- (superficial) caused by stimulation of nerve fibers in skin (burning/ sharp) Somatic – (deep) nonlocalized, originates in support structures strong pressure on tendons, bones ligaments (aching/throbbing)

6. Types of Pain Visceral - arises from internal organs, difficult to localize (Abdomen, Thorax, Cranium) Referred – pain felt in different area of body than actual tissue damage Psychogenic - pain from a mental event, no physical cause identified Neuropathic – damaged nervous system, long lasting

7. Types of Pain Phantom- sensation perceived when body limb or part is missing ( leg amputee has foot pain) Intractable- pain highly resistant to relief (bone Ca) Radiating- perceived at the source and extends to nearby tissue Idiopathic – chronic pain in the absence of any identifiable cause.

8. Pain Process Begins when there is enough tissue injury to reach a pain threshold Threshold = level of intensity needed to cause an action potential and neuron firing Neurotransmitters (excitatory) are released

9. Pain Process Four components: Transduction- tissue injury releases biochemical substances ( histamine, lactic acid, prostaglandins, bradykinin) that excite nocioceptors. Pain meds can work by blocking production of these biochemical substances EX: NSAIDS

10. Pain Process Transmission- impulses travel along primary afferent neurons to the dorsal horn of spinal column – substance P released – pain sensation transmitted to spinothalamic tract to brain Acute pain runs up large A fibers (myelinated) Fast Transmission – Sharp pain Diffuse pain runs up smaller C fibers (unmyelinated) Slower Transmission – Throbbing pain THINK ABOUT the last time you stubbed your toe. First felt sharp pain – followed by diffuse throbbing pain

11. Pain Process Perception- stimulus received by thalamus; transmitted to cortex where pain is consciously perceived Modulation- activation of endogenous opioids /neuromodulation system. Body releases pain blocking substances: endorphins, enkephalins, serotonin Also efferent message sent to muscles to withdraw from pain stimulus

12. Gate Control Theory - Melzack & Wall Theory that describes how external stimulation and cognitive techniques can affect pain transmission Impulses traveling on small diameter C fibers act to “open the gate” to pain. Impulses traveling on large diameter A fibers act to “close the gate” to pain. External stimulation such as massage/ heat/ cold/ TENS/ acupuncture on large A fibers “close the gate” to small C fibers and pain. Also, Cognitive techniques such as biofeedback, distraction, guided imagery can “close the gate”

13. Responses to Pain Physiologic Involuntary Sympathetic response (Fight or Flight): Increased BP, HR, R, Pallor, Diaphoresis If prolonged, deep, severe leads to Parasympathetic response: Decreased BP. HR, N&V, fainting

14. Responses to Pain Behavioral Voluntary Guarding, Rubbing, Grimacing, Moaning, Immobilization, restlessness Affective Psychological Anxiety, fear, fatigue, anger, depression, withdrawal-isolation, hopelessness

15. Factors Affecting Pain Previous experience with pain Developmental level & Age Culture/ethnic values Environment Gender Support systems Meaning of pain Anxiety/stress

16. Assessment: Pain Begins with acceptance of client report Includes: Subjective description – Client statement Use of a pain-rating scale Objective assessment – physical examination

17. Pain Assessment: The Fifth Vital Sign Pain Assessment Questions Questions to ask: –Where is your pain? –When did your pain start? –What does your pain feel like? –How much pain do you have now –What makes the pain better or worse? –How does pain limit your function/activities? –How do you behave when you are in pain? How would others know you are in pain? –What does pain mean to you? –Why do you think you are having pain?

18. Pain Assessment: The Fifth Vital Sign Pain Assessment Tools Pain rating scales –Descriptive No pain – mild- severe - Numerical 0-10 -Visual analog Wong Baker

19. Pain Assessment: The Fifth Vital Sign Objective Data - Physical Exam Inspect the site of pain Take vital signs Perform physical exam Note pain behaviors:

20. Nsg Dx: Pain Acute pain R/T decreased blood supply to myocardium AEB pt. Clutching chest and stating “ my chest pains are here again, I need my nitro”, BP 160/90, HR 94, and pallor. Acute pain R/T tissue damage ( mechanical, thermal, chemical) AEB …… Chronic pain R/T tumor progression AEB ……

21. Nsg Dx - Pain Pain may be PART of a nursing diagnosis Ineffective airway clearance r/t weak cough and post-op incisional pain AEB… Self care deficit r/t chronic pain

22. Planning: Pain Outcome criteria: Client will… Utilize a pain rating scale to identify pain and determine comfort level. Report that pain management regimen relieves pain to satisfactory level. Describe how unrelieved pain will be managed.

23. Interventions: Pain Establish trusting nurse-client relationship Comfort measures: -administering analgesics -modifying environment -nonpharmacologic relief measures Client teaching is an important part of a pain mgt plan Explore strategies that have been effective for the client in the past

24. Analgesics Analgesics –relieve pain 3 general classes Nonopioid -acetaminophen, ASA & nonsteroidal antinflammatory drugs (NSAIDs) ibuprofen, Advil Opioids (narcotics)- morphine, codeine Adjuvant –drug developed for use other than analgesic but enhances effect of opioids by providing added relief (diazepam, Elavil)

25. Non-Opioids Decrease inflammatory response Work on peripheral nervous system Block release of excitatory neurotransmitters ( ie histamine) Slower onset – Longer peak action Side effects: stomach irritation, liver and renal damage, bleeding

26. Opioids Decrease cognitive perception of pain Work on Central Nervous System Block (lock into) pain receptors Faster onset – Shorter duration Side effects – respiratory depression, dizziness, sedation, nausea, constipation Emergency Rx for overdose = Narcan

27. Adjuvants Not classified as analgesics Provide synergistic additive effect Antidepressants Muscle Relaxants Corticosteroids

28. Principles of analgesic administration Individualize the dose Give regularly instead of prn ATC or PCA Recognize side effects and treat appropriately Use combinations that enhance analgesics Monitor for tolerance and treat appropriately

29. Principles of analgesic administration Monitor for physical dependence- body physically adapts to opioids and withdrawal symptoms can occur upon sudden stoppage THIS IS NOT ADDICTION Addiction (psychological dependence)- compulsive drug use craving for opioid for effects other than pain relief

30. Interventions: Pain Modifying the Environment Removing or altering the cause of pain Loosening a tight binder Emptying a distended bladder Altering factors affecting pain tolerance Environmental control Quiet, dim lighting Allow client to rest Position for comfort

31. Interventions: Pain Non-pharmacologic Measures Distraction Guided Imagery Relaxation Music Biofeedback Cutaneous stimulation: TENS, massage, heat, cold, acupressure

32. Interventions: Pain Client Teaching Function / cause of pain When pain can be anticipated Assurance that it is acceptable to express Assurance that it will be believed Assurance that measures will be taken to relieve it promptly How to use pain scale What pain control measures can be used

33. Remember to tell clients that PAIN is easier to treat before it gets too severe !

34. Evaluation: Pain Goals met ? Pain controlled ? Comfort level acceptable to pt ? Modify plan- change meds, incorporate new interventions including alternative therapies