arises in the skin or subcutaneous tissue

ex. burn

3rd degree burn - no pain

caused by stimulation of deep internal pain receptors

most often in abdominal cavity, cranium, or thorax

ex. menstrual cramps, labor pain, GI infections, bowel disorders, & organ cancers

originates in ligaments, tendons, nerves, blood vessels, & bones

ex. broken bone, nerve problems

starts at the source but extends to other locations

ex. heart burn - may radiate outward from the sternum to involve the entire upper thorax

occurs in an area that is distant from the original site

ex. MI, gallbladder pain felt in shoulder

perceived to originate from an area that has been surgically removed

ex. amputations

usually gets better with time

believed to arise from the mind

can be just as severe as pain from a physical cause

following acute injury, disease, or surgery

< 6 months

typically know the cause

potential or actual tissue damange

generally disappears as tissue heals

fast, sharp, or initial pain

associated with cancer or other progressive disorders (Rheumatoid Arthritis, Lupus)

> 6 months

no current tissue injury

periods of remission and exacerbation

don't usually know the cause

dull, slow, or delayed pain

When tissue injury is nonprogressive or healed

> 6 months

both chronic and highly resistant to relief

Highly resistant to medication

most common type of pain

pain receptors respond to stimuli that are potentially damaging

may occur as a result of trauma, surgery, or inflammation

may be described as:

sharp or dull, aching, throbbing, stabbing, burning, ripping, searing, or tingling

may describe its periodicity as:

episodic, intermittent, or contant

the recognition and definition of pain in the frontal cortex

the point at which the person becomes aware of the pain:

1) somatosensory cortex perceives & interprets physical sensations

2) limbic system - emotional reactions to stimuli

3) frontal cortex is involved in thought & reason

the point at which the brain recognizes & defines a stimulus as pain

repeated experience with pain can reduce a patient's threshold

duration or intensity of pain that a person is willing to endure

different for every person

includes the ANS and behavioral responses to pain

respirations may increase or decrease

increased HR

decreased O2sat

facial grimaces

pain signals can be either facilitated or inhibited

can change the perception of pain

2 mechanisms: endogenous analgesia system & gate-control mechanism

pain receptors - want us to know when we're in pain

nonadapting - to keep us constantly informed of the continuous presence of the painful stimulus that can damage tissues

somatic signals from nonpainful sources can inhibit signals of pain by closing the gate

stops impulses from getting to the brain to not feel pain

stimulation of touch fibers by:

rubbing, stroking, massage, vibration, application of ointments, heat, cold

kids cannot report exact locations of pain; commonly experience acute pain

elderly - high prevalence of pain

may falsely believe pain & suffering comes with old age - may not report pain

considered the 5th vital sign

if the patient is in pain, look at PRN meds

pain history from clients - OLDCARTS

behavioral & physiologic response

assess before and after administration of meds - evaluate effectiveness

used with kids and neuro patients/cognitive impairements

10 point pain intensity scale

rating of 3 - need to revise the pain treatment plan

rating of 6 or more - demands immediate attention; the meds aren't working

must always believe the client - pain is what the patient says it is

acute pain - elevated BP, appear ashen

chronic/unresolved pain - BP and P may be lower than normal, may report feeling faint

changes in v/s generally last only a short time - after more than an hour, the v/s typically return to what they were previously

normal v/s does not mean the patient is free of pain!

alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client

non-pharmacologic and pharmacologic

- use the most effective & least invasive method

patient can't have pain meds

relaxation exercises - teach patient slow, rhythmic breathing

distraction - watching TV, listening to music, family, reading, etc.

guided imagery - use of images (ex. beach)

biofeedback - using your mind to control the body (BP, HR, etc.)

interpersonal skills - humor, gentle words

physical care - bathing

method of pain relief based on the gate-control theory of pain

works best on pain that is localized and not diffuse

massage - effleurage (use of slow, long, guiding strokes) used for women in labor; always obtain verbal permission

transcutaneous electrical nerve stimulator (TENS) - pads directly applied to painful area; stimulates A-delta sensory fibers

percuatneous electrical stimulation (PENS) - stimulates peripheral sensory nerves; effective in short-term management of acute & chronic pain

acupuncture - application of extremely fine needles to stimulate the endogenous analgesia system; provides relief from dental pain & nausea from chemotherapy

acupressure - fingertips provide firm, gentle pressure over various pressure points; may release endorphins

application of cold - causes vasoconstriction, can help prevent swelling & bleeding; can reduce amount of pain that occurs during procedures; use immediately after injury or surgery

heat - promotes circulation, speeds healing; relieves joint stiffness, pain, and muscle spasms; use 72 hrs after acute injury

contralateral stimulation - stimulating the skin in an area opposite to the painful site

particularly helpful with arthritic joints

remove splints at regular intervals so that the patient can exercise the area to prevent further injury

relieve mild to moderate pain; many also reduce inflammation & fever

ex. acetaminophen, aspirin, ibuprofen

may be used for acute & chronic pain

many are compounded with opoids - allows for a lower dose of opoid to be administered

primarily act in the peripheral tissues by interfering with the production of prostaglandins

ex. aspirin, ibuprofen

common side effect of GI irritation - take with food, lower the dose, or use enteric-coated pills

Aspirin - can also inhibit platelet aggregation (clumping)

very little anti-inflammatory effect; has a analgesic & fever-reducing properties

fewer side effects - probably safest nonopiod

can cause severe hepatotoxicity in patients who consume alcohol & in patients with liver disease

relieve intense pain by binding to opiate receptors & activating endogenous pain suppression in the CNS

most common side effects - nausea, vomiting, constipation, & drowsiness

opiod antagonist - naloxone (Narcan)

trasmit slow pain impulses, that is, dull, diffuse pain impulses that travel at a slow rate

conduct pain from mechanical, thermal, & chemical stimuli

onset of acute pain - reacts automatically by activating sympathetic nervous system; fight-or-flight response - minimizes blood loss, maintains perfusion to vital organs, prevents & fights infections, promotes healing

pain continues - body adapts, parasympathetic nervous system takes over; actual pain receptors continue to transmit pain message so that the person remains aware of the tissue damage - largely protective

ongoing pain triggers release of excessive amounts of ACTH, ADH, GH, catecholamines, & glucagon

insulin & testosterone levels decrease

results in weight loss, tachycardia, fever, increased RR, & death

unrelieved pain leads to hypercoagulation and an increase in HR, BP, cardiac workload, & O2 demand

may lead to unstable angina, intracoronary thrombosis, & myocardial ischemia & infarction

unrelieved pain causes impaired muscle function, fatigue, & immobility

can affect ADL's & engaging in physical therapy

pain causes splinting (voluntary limiting of thoracic & abdominal movement in an effort to reduce pain), splinting reduces tidal volume & increases inspiratory & expiratory pressures

can result in pneumonia & atelectasis

can occur with opoids

increasing the dose or changing the route of administration can correct the problem

leads to withdrawal symptoms when the drug is removed abruptly

can be prevented by decreasing the dose slowly over time

addiction

occurs in less than 1% of patients even after long-term prescribed use of opioids for pain

stimulate Mu receptors and are used for acute, chronic, & cancer pain

ex. codeine, morphine, Dilaudid, fentanyl, methadone, & oxycodone

excellent meds for breakthrough pain

pain that "breaks through" relief provided by analgesics

breakthrough analgesia - a rescue or extra dose

drugs used - should have a rapid onset & short duration

when possible - give the same drug as that given for ongoing pain relief

no maximum daily dose limit & no "ceiling" to the level of analgesia from these drugs

stimulate some opioid receptors but block others

ex. Talwin & Nubain (mixed), Buprenex (partial agonists)

appropriate for acute moderate to severe pain

inappropriate for severe escalating pain

not recommended as first-line drugs in any kind of pain - there is a limit to the analgesia they can provide & must be administered parenterally

should not be given with mu agonists

use the safest & least invasive route

Oral - preferred route unless rapid onset of analgesia is desired; relief for mild to severe pain

Transdermal - effective for ongoing pain relief but does not provide immediate relief; fever will increase absorption

Rectal - when patient is vomiting, has a GI obstruction, or is at risk for aspiration

Subcutaneous - intermittent injections or continuous administration of opioids (patients who cannot tolerate oral opioids or who have dose-limiting side effects from oral administration & have limited venous access); used for chronic cancer pain

Intramuscular - painful, slow onset of action, & absorption is unreliabe; not preferred route; often used for short-term pain postoperatively

Intravenous - produces immediate pain relief, desirable for acute or escalating pain; most commonly used for short-term therapy

Patient-controlled analgesia (PCA) - gives the patient a sense of control over the pain; if the patient reaches the limit set, the pump will automatically trigger a "lock out"; patient teaching

Intraspinal analgesics - placement of a catheter in the subarachnoid space or the epidural space

approximately equal analgesia that a variety of opioids will prodide

dose calculations provide a starting point when changing from one opioid to another

may be used as primary therapy for mild pain or in conjunction with opioids for moderate to severe pain

reduce the amount of opioid the patient requires

useful if the patient experiences significant side effects from escalating doses of opiods

type of regional anesthesia

anesthetic agent injected into or around the nerve that supplies sensation to a specific part of the body

most affect a plexus (network of nerves)

may be used for short-term pain (surgical procedures) or long-term pain management of chronic pain

injection of local anesthetics into body tissues

short-acting - lidocaine

long-acting - marcaine

applying an agent that contains cocaine, lidocaine, or benzocaine directly to the skin, mucous membranes, wounds, or burns

quickly absorbed & provides pain relief for mild to moderate pain

permanent destruction of nerve pathways

used as a last resort for intractable pain

interrupts pain & temperature sensation below the tract that is severed

most frequently done for leg & trunk pain

interrupts the anterior or posterior nerve route that is located between the ganglion and the cord

anterior - generally used to stop spastic movements

most often used for head and neck pain produced by cancer

used to eliminate intractable localized pain

pathways of peripheral or cranial nerves are interrupted to block pain transmission

severs the paths to the sympathetic division of the ANS

outcomes - improvement in vascular blood supply & elimination of vasospasm

used to treat pain from vascular disorders

take a substance abuse history for all patients- should include information on alcohol intake

Symptoms:

-repeated requests for opioid injections even though surgery was several days ago

- refusal to try oral medication

- continued high opioid dose, even though surgery or acute illness has passed

observe patient carefully - S/Sx my also indicate untreated withdrawal or increased pain due to complications

be careful not to undertrea pain with patients whom you know to abuse substances

placebo - any medication or procedure, including surgery, that produces an effect in a patient because of its implicit or explicit intent, not because of its specific physical or chemical properties

usually tablets containing sugar, saline, or water

placebos do not have a useful place in pain management:

- if the patient responds to placebo, it does not mean that the patient did not have pain

- placebos may be effective at one time and not at another

- their use involves deceit

thoroughly document the pain management plan and the patient's response:

- expected outcome

- patient's pain level at the present time

- patient's response to any intervention

- any adverse reactions

- planned interventions to improve the pain relief