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ObjectivesUpon completion of this tutorial the learner
will:
Know the definition of pain
Have an increased understanding of the pathophsyiology of pain
Have a better understanding of why pain is masked due to hemodynamics
Understand the implications of undertreated pain and utilize appropriate interventions to improve patient outcomes
Tutorial Guide
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Definitions
Pain Myths
Pathophysiology
Pharmacology
Genetics
Fifth Vital Sign
Nursing Considerations
References
Pain DefinedMargo McCaffery is a registered nurse and
pioneer of the field of pain management nursing.
She defines pain as “whatever the experiencing person says it is, existing whenever and wherever the person say it does” (McCaffery, 1968, p. 95). This has become the prevailing conceptualization of pain for clinicians over the past few decades.
What are some pain myths?1. Addiction is common in patients taking pain
medication
2. All people in pain look uncomfortable or sick
3. If a person can sleep, they are not in pain
4. It is just anxiety, their pain is not that bad
5. People who take narcotics will become so sedated that they cannot function.
Myths Debunked1. Addiction to narcotics is rare and usually occurs in patients who have a prior history of drug abuse. When narcotics are properly prescribed and monitored for pain relief, there should be little concern about addiction.
Weiner, Peterson, and Keefe (1999)
Myths Debunked
2. Pain is invisible. You will come across many, many people in your life who are in pain and look fine. Each person is different in the way he or she feels and exhibits pain. A person’s pain is what they perceive it to be and cannot be judged by anyone else.
McCaffery and Pasero (1999)
Myths Debunked
3. Prolonged pain can exhaust the body to the point where sleep occurs, even though the pain continues.
McCaffery and Pasero (1999)
Myths Debunked
4. Excess anxiety and tension can cause the experience of heightened anxiety, increased pain and slower healing times. Anxiety, which is a stress response can cause numerous negative problems.
McCaffery and Pasero (1999)
Myths Debunked
5. When patients start to take a narcotic, they often feel drowsy. But their bodies usually will very quickly build up a resistance to the sedating effects. Some people, however, become more alert as they finally achieve pain relief.
McCaffery and Pasero (1999)
What is not a pain myth?
A. All people in pain look uncomfortable or sick
B. If a person can sleep, they are not in pain
C. Pain is whatever the patient says it is
D. It is just anxiety, their pain is not that bad
Pathophsyiology of PainComplex process that is
mediated by multiple pathways in the spine and brain
It is a sensory experience
Forms of Pain
1. Nociceptive/Inflammatory-Normal processing of stimuli
that damages normal tissue or has the potential to damage tissue if prolonged.
2. Neuropathic-Stimuli “abnormally”
processed by the central nervous system
McCaffery and Pasero (1999)
Pain Mechanism
1. Transduction: Noxious stimuli causes tissue damage and initiates the pain mechanism
2. Transmission: Action potential continues from site of damage and ascends to brain
3. Perception of pain: Conscious experience
4. Modulation: Attempt to inhibit pain experience
Transduction
Cell damage releases sensitizing substances
-prostaglandin
-bradykinin
-serotinin
-histamine
McCaffery and Pasero (1999)
Transmission
This phase of transmission occurs in the dorsal horn of the spinal cord
-The signal moves up from the site of injury or damage to the brain
McCaffery and Pasero (1999)
Perception of pain
The pain experience happens in this phase
-An individual will be aware of pain at this point
McCaffery and Pasero (1999)
Modulation
Neurons from the brain stem release serotinin, norepiphrine and endogenous opioids
-These are substances our body releases to fight pain
-An example might be if you burn your hand, your brain will tell you move it away from the heat
McCaffery and Pasero (1999)
Pain sensation
Mediators, as previously listed, heighten nociception and facilitate the communication of painful sensations to the spinal cord and the brain.
Porth and Matfin (2009)
What is nociceptive pain?A. Stimuli abnormally processed by the ce
ntral nervous system
B. Normal processing of stimuli that damages normal tissue or has the potential if prolonged
C. Processing of pain through the liver
Pain Mediators
Some of the pain mediators: adrenocorticotropic hormone (ACTH), glucocorticoids, catecholamines, substance P, prostaglandins, leukotrienes, bradykinin, histamine, and serotonin
Bradykinin
Bradykinin is a molecule produced by enzymes at the site of an injury and then binds to receptors to cause pain.
McCaffery and Pasero (1999)
Serotinin
Serotonin also is an important regulator for pain sensation, and abnormal levels of serotonin can contribute to painful events such as migraine headaches.
McCaffery and Pasero (1999)
Substance P
Substance P is a protein found in the brain and spinal cord, and is associated with some inflammatory processes.
Its function is to cause pain.
McCaffery and Pasero (1999)
Prostaglandins
Prostaglandin is produced during inflammatory responses, and it helps to mediate some of the cardinal features of inflammation, including pain, edema, and fever
Stock, Shinjo, Burkhardt, Roach, Taniguchi, Ishikawa, Kim, Flannery, Coffman, McNeish, and Audoly, (2001).
Histamine
Histamine is released by mast cells.
Substance P is released which causes mast cells to release histamine, which in turn stimulates the nociceptors
Overproduction of histamine promotes inflammation by causing vasodilatation and increased capillary permeability.
Effects of Mediators
Each of these has one or more effects on the body. And many of these bio-chemicals are inflammatory -- that is, they cause the injury site to swell up.
Inflammation and Pain
Nociceptive stimulation perpetuates the inflammatory response.
Inflammation of peripheral tissues can cause the vicious cycle of pain
Porth and Matfin (2009)
InflammationSome of the chemical mediators that are
released during injury and inflammation:
-Prostaglandins
-Leukotrienes
-Histamine
Inflammation causes pain
However, if the inflammation is prolonged or out of control, it can cause destruction.
This is what occurs in arthritis, where the inflammation actually destroys the joints.
Destruction causes pain
Stress Response to Pain
Stress causes the Endocrine System to release excessive amounts of:
-Adrenocorticotrophic Hormone (ACTH)
-Cortisol
-Growth Hormone
-Catecholamines
-Glucagon
Porth and Matfin (2009)
Function of Catecholamines
Click to learn more
Decrease in insulin-which allow more serum glucose in the blood stream
Increase in glucagon-which increases serum glucose
Increase in heart rate
Increase in cardiac contractility
Function of ACTH
Click to learn more
Stimulates release of cortisol
Adds to the effect of catecholamines
Adds to the effect of glucagon-increase in blood sugar
ACTH
Cortisol
Stress
Catecholamines and cortisol are released during the stress response to alert the individual to a threat or challenge.
What are Catecholamines NOT responsible for:a. Decrease in insulin
b. Increase in glucagon
c. Increase in heart rate
d. Increase in cardiac contractility
e. Decrease in heart rate
Pattern developing?
Stress and pain mediators overlap
Inflammation and pain mediators overlap
Inflammation and Stress can increase pain
Pain as the fifth vital
The importance of the adequate assessment and optimal management of pain has received a great deal of attention
Green, Wheeler, and LaPorte (2003)
Pain, “the fifth vital sign” as defined by Ruth Massaro, an executive vice president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Hemodynamics and Pain
As nurses we have been educated to look for hypertension and tachycardia as a symptom of pain but we now know that this is not an accurate to way evaluate pain.
Why…….
Rationale for vitals
Healthy individuals will seek an equilibrium to return to the stable vital signs despite severe pain
Some individuals will have medical conditions that cause bradycardia and hypotension and severe pain will not change the vital signs
McCaffery and Pasero (1999)
The Fifth Vital
Using the pain rating as the fifth vital sign will remind all staff to assess pain regularly.
This makes pain visible and raises awareness of the importance of pain management.
McCaffery and Pasero (1999)
How can I tell if my patient has pain?a. Ask them
b. Check their vitals
a. Look for grimacing or other outward signs
Genetics and pain
Genetics can influence effective pain management
We all have polymorphisms that can affect the effectiveness of pain medication
CYP2D6 Polymorphism
The CYP2D6 enzyme is involved in metabolism of up to 25% of drugs.
About 10% of Caucasians and 3% of Asian people have this genetic polymorphism.
Used with permission from P. Jannetto
What does CYP2D6 polymorphism really meanPolymorphism is a genetic mutation that
changes the rate of the conversion codeine to morphine.
Of note, Morphine is a metabolite of codeine that relieves pain
Consequently, some individuals do not achieve analgesia from codeine
Categories of CYP2D6 Polymorphisms
Super Metabolizers: Clear the drug rapidly and need higher dose
Intermediate Metabolizers: Slow to obtain relief and build up effect
Poor Metabolizers: Have no ability to clear the drug and become toxic easier
Used with permission from P. Jannetto
What is CYP2D6 polymorphism?
a. A genetic mutation affecting pain medication effectiveness
b. About 10% of Caucasians and 3% of Asian people have this genetic polymorphism.
c. Polymorphism is a genetic mutation that makes it impossible for the conversion codeine to morphine.
d. All of the above
Pharmacology
Analgesics reduce nociception by one of three mechanisms
1. Inhibition of local pain mediators i.e. blocking prostaglandins with anti-inflammatory drugs
2. Interruption of neural impulse i.e. a peripheral nerve block
3. Altering the perception of pain in the central nervous system i.e. opiates
Fentanyl
Has minimal hemodynamic effects
Virtually devoid of histamine-releasing properties and may therefore be preferred in presence of hemodynamic instability or bronchospasm.
Key points of Fentanyl
Bolus Fentanyl prior to initiation of drip to prevent pain and help reach the “steady state”
Bolus Fentanyl prior to drip rate increase to achieve better pain control
Why give Fentanyl with hemodynamic
instability?a.
Most rapid onset and shortest duration of action
b. Easy to titrate
c. Has minimal hemodynamic effects
d. A, B, and C are correct
e. None of the above
Nursing considerations
If we treat pain only when patients act like they are in pain, then our patients will be forced to learn how to act and convince us that they have pain.
This creates manipulative patients
Seisser and Ward (2002)
Nursing considerations
Accepting and responding to the report of pain may result in giving analgesics to patients who may not have pain, it ensures that everyone who does have pain receives an attentive pain plan.
McCaffery and Pasero, (1999)
Nursing considerations
Harmful and expensive consequences of unrelieved pain:
-More likely to have atelectasis
-Longer hospital stay
-Triggers the stress response and release catecholamines, etc.
-Increased stress may delay healing
ReferencesGreen, C., Wheeler, J., and LaPorte, F. (2003). Clinical decision making in pain
management: Contributions of physician and patient characteristics to variations in
practice. The Journal of Pain, (4)1, 29-39.
http://office.microsoft.com/en-us/tou.aspx
McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-
environment interactions. Course syllabus, University of California at Los Angeles
Students’ Store.
McCaffery, M. and Pasero, C. (1999). Pain: Clinical Manual (2nd ed.) St. Louis: Mosby.
Porth, C.M., and Matfin, G. (2009). Pathophysiology: Concepts of Altered Health States.
(8th ed.) Lippincott.
References
Seisser, M. and Ward, S. (2002). Margo McCaffery on quality in pain management. Journal
for Healthcare Quality, (24)6, 19-22.
Stock, J., Shinjo, K., Burkhardt, J., Roach, M., Taniguchi, K., Ishikawa, T., Kim, H.S.,
Flannery, P.J., Coffman, T.M., McNeish, J.D., and Audoly, L.P. (2001). The
prostaglandin E2 EP1 receptor mediates pain perception and regulates blood pressure.
The Journal of Clinical Investigation, 107(3): 325–331.
Weiner, D., Peterson, B., and Keefe, F. (1999). Chronic pain-associated behaviors in the
nursing home: resident versus caregiver perceptions. International association for the
study of pain, 80, 577-588.
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