n3180- ch. 10 pain ppt-student

8/13/2019 n3180- Ch. 10 Pain Ppt-student

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PainAssessment:

The Fifth Vital

Sign

Chapter

10


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Structure and Function

Neuroanatomic pathway Nociception Neuropathic pain Sources of pain Types of pain


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Neuroanatomic Pathway

Nociceptors nterneurons Anterolateral spinothalamic tract


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Nociception mportant to understand pain occurs on a

cellular le$el

%nly then can you appreciate patient&s report ofpainful sensations that de$elop after initial site of

in'ury heals Nociception is term used to descri(e how no)ious

stimuli are percei$ed as pain Nociception can (e di$ided into four phases

Transduction

Transmission

Perception

*odulation


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Nociceptors: speciali+ed ner$e endings

designed to detect painful sensations Transmit sensations to central ner$ous

system ,ocated within s-in. connecti$e tissue. muscle. and

thoracic/ a(dominal/ and pel$ic $iscera These nociceptors can (e stimulated directly (y

trauma or in'ury or secondarily (y chemicalmediators released from site of tissue damage

Nociceptors carry pain signal to central ner$ous

system (y two primary sensory !afferent# fi(ers: A

and C fi(ers


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Nociceptors: speciali+ed ner$e endings

designed to detect painful sensations !cont"# Afi(ers are myelinated and larger in diameter/ and they

transmit pain signal rapidly to CNS. locali+ed/ shortterm/ andsharp sensations result from A fi(er stimulation n contrast/ C fi(ers are unmyelinated and smaller/ and

transmit signal more slowly. sensations diffuse and aching/

and they persist after initial in'ury

Peripheral sensory Aand C fi(ers enter spinal cord (yposterior ner$e roots within dorsal horn (y tract of ,issauer

Fi(ers synapse with interneurons located within a specified

area of cord called su(stantia gelatinosa


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Nociception !cont"#


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Nociception !cont"# nitially/ first phase of transduction occurs when a

no)ious stimulus in form of traumatic or chemical in'ury/

(urn/ incision/ or tumor ta-es place in periphery

n'ured tissues then release a $ariety of chemicals/including su(stance P/ histamine/ prostaglandins/

serotonin/ and (rady-inin These are neurotransmitters that propagate pain

message/ or action potential/ along sensory afferent

ner$e fi(ers to spinal cord These fi(ers terminate in dorsal horn of spinal cord n second phase/ -nown as transmission/ pain impulse

mo$es from le$el of spinal cord to (rain


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Nociception !cont"# At synaptic cleft are opioid receptors that can (loc- this

pain signaling with endogenous or e)ogenous opioids owe$er/ if uninterrupted/ pain impulse mo$es to (rain

$ia $arious ascending fi(ers within spinothalamic tractto (rain stem and thalamus

%nce pain impulse mo$es through thalamus/ the

message is dispersed to higher cortical areas $ia

mechanisms that are not clearly understood at this time n third phase/ perception indicates conscious

awareness of painful sensation Cortical structures such as lim(ic system account for

emotional response to pain


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Nociception !cont"# %nly when no)ious stimuli are interpreted in these

higher cortical structures can this sensation (e

identified as pain

,astly/ pain message is inhi(ited through phase ofmodulation

2escending pathways from (rain stem to spinal cord

produce third set of neurotransmitters that slow down or

impede pain impulse/ producing an analgesic effect These neurotransmitters include serotonin.

norepinephrine. neurotensin. amino(utyric acid

!3A4A#. and our own endogenous opioids/

endorphins/ en-ephalins/ and dynorphins


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Neuropathic Pain

A(normal processing of pain message *ost difficult to asses (ecause its at

a neurochemical le$el

*ost difficult type of pain to assess andtreat

Neurochemical le$el


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Neuropathic pain ndicates type of pain that does not adhere to

typical phases inherent in nocicepti$e pain Neuropathic pain implies an a(normal processing

of pain message from an in'ury to the ner$e fi(ers %ften percei$ed long after site of in'ury heals Sustained on a neurochemical le$el that cannot (e

identified (y )ray/ computeri+ed a)ial tomography

!CAT# scan/ or magnetic resonance imaging !*5# 6lectromyography and ner$econduction studies

are needed


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Neuropathic pain !cont"# ndicates type of pain that does not adhere

to typical phases inherent in nocicepti$e

pain !cont"# 9ithin dorsal horn of spinal cord/ neurons are

thought to (e transformed into a

hypere)cita(le state and a minimal stimulus

can ultimately spiral into much larger painfuleffect


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Sources of pain

Pain sources (ased upon their origin Visceral pain originates from larger interior organs/ i"e"/

-idney/ stomach/ intestine/ gall(ladder/ pancreas Pain can stem from direct in'ury to organ or from

stretching of organ from tumor/ ischemia !lac- of (lood

supply eg" Acute appendecites#/ distention/ or se$erecontraction

6)amples of $isceral pain include ureteral colic/

acute appendicitis/ ulcer pain/ and cholecystitis

Visceral pain often presents with autonomic responsessuch as $omiting/ nausea/ pallor/ and diaphoresis


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Sources of pain

Pain sources (ased upon their origin !cont"# 2eep somatic pain comes from sources such as

(lood $essels/ 'oints/ tendons/ muscles/ and (one n'ury may result from pressure/ trauma/ or

ischemia Cutaneous pain deri$ed from s-in surface and

su(cutaneous tissues. in'ury is superficial/ with a

sharp/ (urning sensation !superficial pain#

,in-ing pain to a mental disorder !psychogenicpain# negates person&s pain report A clinician&s lac- of awareness and understanding

of neuropathic pain may contri(ute to this

misla(eling


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Sources of pain

Pain sources (ased upon their origin !cont"# Pain that is felt at a particular site (ut originates

from another location is termed referred pain 4oth sites are inner$ated (y same spinal ner$e/

and it is difficult for (rain to differentiate point oforigin

5eferred pain may originate from $isceral or

somatic structures eg: appendicites causes refered

pain


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Common Sites for 5eferred Pain

Pat Thomas/ ;00


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Types of Pain

Acute pain !from trauma/ surgeryetc""# Short term Selflimiting Follows a predicta(le tra'ectory 2issipates after in'ury heals

Chronic pain Continues for < months or longer

Types are malignant !cancer related# andnonmalignant 2oes not stop when in'ury heals


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Structure and Function:2e$elopmental CompetenceAging

adult

No e$idence e)ists to suggest that older

indi$iduals percei$e pain to a lesser degree or

that sensiti$ity is diminished

Although pain is common e)perience amongindi$iduals


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Structure and Function:

2e$elopmental Competence3ender2ifferences 3ender differences are influenced (y societale)pectations/ hormones/ and genetic ma-eup

Traditionally/ men ha$e (een raised to (e more

stoic a(out pain/ and more affecti$e or emotionaldisplays of pain are accepted for women

ormonal changes are found to ha$e strong

influences on pain sensiti$ity for women

9omen are two to three times more li-ely toe)perience migraines during child(earing years/

are more sensiti$e to pain during premenstrual

period/ and are si) times more li-ely to ha$e

fi(romyalgia


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Structure and Function:

Cultural Competence

Cultural differences in pain *ost research conducted on racial differences and

pain has focused on disparity in management of

pain for $arious races Comparing pain treatment for indi$iduals of color

!e"g"/ African Americans/ ispanics# with standard

treatment for indi$iduals with similar in'uries or

diseases Various studies descri(e how African American

and ispanic patients are often prescri(ed and

administered less analgesic therapy than white

patients/ although ma'ority of these differences is

small


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Su('ecti$e 2ata?ealth istory

Pain is always su('ecti$e Pain is whate$er the e)periencing person says

it is/ e)isting whene$er he or she says it does

Su('ecti$e report is most relia(le indicator of

pain

Pain assessment @uestions Pain assessment tools

P i A t ti


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Pain Assessment uestions

uestions to as-:

9here is yourpainB

9hen did your

pain startB

9hat does your

pain feel li-eB

ow much pain do

you ha$e nowB 9hat ma-es the

pain (etter or

worseB

ow does pain limit

yourfunctionacti$itiesB

ow do you (eha$e

when you are in

painB ow wouldothers -now you are

in painB

9hat does pain

mean

to youB

9hy do you thin-

you are ha$ing painB


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Pain Assessment Tools

nitial pain assessment 4rief pain in$entory ShortForm *c3ill Pain uestionnaire Pain rating scales

Numeric rating scales

2escriptor scale


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nitial Pain Assessment

From *cCaffery */ Pasero C:

Pain: Clinical manual/ ed ;/ St"

,ouis/ 1DDD/ *os(y"


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4rief Pain n$entory

From *cCaffery */ Pasero C:

Pain: Clinical manual/ ed ;/ St"

,ouis/ 1DDD/ *os(y"


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Pain 5ating Scales


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>ni$ersal Pain Assessment Tool


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%('ecti$e 2ata

Preparation Physical e)amination process can help you

understand the nature of the pain Consider whether this is an acute or chronic

condition 5ecall that physical findings may not always

support patient&s pain complaints/ particularly for

chronic pain syndromes

Pain should not (e discounted when o('ecti$e/physical e$idence is not found 4ased on the patient&s pain report/ ma-e e$ery

effort to reduce or eliminate pain with appropriate

analgesic and nonpharmacologic inter$ention


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%('ecti$e 2ata

Preparation !cont"# According to American Pain Society

n cases in which cause of acute pain is uncertain/

esta(lishing a diagnosis is a priority/ (utsymptomatic treatment of pain should (e gi$en

while in$estigation is proceeding 9ith occasional e)ceptions/ !e"g"/ initial

e)amination of patient with an acute condition of

a(domen#/ it is rarely 'ustified to defer analgesia

until a diagnosis is made n fact/ a comforta(le patient is (etter a(le to

cooperate with diagnostic procedures


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%('ecti$e 2ata?Physical 6)am

Eoints?note Si+econtourcircumference

A5%*P5%*

*uscless-in?inspect Colorswelling

*assesdeformity

Sensation changes


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%('ecti$e 2ata?Physical 6)am

!cont"# A(domen?inspect and palpate

Contoursymmetry

3uardingorgan si+e

Pain (eha$ior?inspect Non$er(al cues

Acute pain (eha$ior

Chronic pain (eha$ior


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Acute Pain 4eha$iors

3uarding 3rimacing

Vocali+ations such as moaning

Agitation/ restlessness

Stillness

2iaphoresis Change in $ital signs


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%('ecti$e 2ata: Aging Adult

Although pain should not (e considered a7normal8 part of aging/ it is pre$alent

9hen older adult reports a history of conditions

such as osteoarthritis/ peripheral $ascular disease/

cancer/ osteoporosis/ angina/ or chronicconstipation/ (e alert and anticipate a pain pro(lem

%lder adults often deny ha$ing pain for fear of

dependency/ further testing or in$asi$e procedures/

cost/ and fear of ta-ing pain -illers or (ecoming adrug addict

2uring inter$iew you must esta(lish an empathic

and caring rapport to gain trust


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Sample Charting

Slide 10G


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A(normal Findings

5efle)i$e sympathetic dystrophy

Follows trauma to the ner$e

*ost commonly appears in H0 to


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9hich type of pain would cholecystitis

!gall(ladder disease# causeB

A" Somatic

4" Visceral

C" Cutaneous

2" Chronic

Slide 10H0


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9hat anticipated finding regarding patients withchronic pain should guide a nurse&s care

planningB

A" Patients with chronic pain ha$e trou(le

sleeping"4" Patients with chronic pain show ele$ated (lood

pressures"

C" Patients with chronic pain need less medication"

2" Patients with chronic pain may show few or nooutward signs of pain"

Slide 10H1

A ti t i i d 7Pl t


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A patient is crying and says/ 7Please get me

something to relie$e this pain"8 9hat should

the nurse do ne)tB

A"Verify that the patient has an order for pain

medications and administer order as directed"

4"Assess the le$el of pain and as- patient whatusually wor-s for his or her pain/ administer

pain medication as needed/ then reassess pain

le$el"

C"Assess the le$el of pain and gi$e medicationsaccording to pain le$el/ and then reassess pain"

2"5eposition the patient/ then reassess the pain


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The nurse is reassessing a patient&s pain le$el after

pain medication administration following a pain le$el

of D10" The patient states that his pain le$el is now a

10" 9hat should the nurse do ne)tB

A"Verify orders for medications and offer morepain medication/ if appropriate"

4"Continue to assess patient&s pain le$el"

C"2ocument the pain le$el in the chart"

2"There is no need for action/ (ecause the

patient&s pain is managea(le"

n3180- ch. 10 pain ppt-student

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