Stressors that Affect Perception &

CognitionPain

NUR20 Fall 2009Lecture # 14K. Burger MSEd, MSN, RN, CNE

PPP by Sharon Niggemeier RN, MSNRevised 11/06 K. Burger

Pain• Unpleasant sensory and emotional

experience associated with actual or potential tissue damage.

• Exists whenever the person says it does

• Referred to as 5th VS

• Function of pain = Protective Mechanism

• A universal human experience

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)

Types of PainAcute

• 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

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)

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

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.

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

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

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

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

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”

Responses to Pain

• PhysiologicInvoluntary Sympathetic response (Fight or Flight):Increased BP, HR, R, Pallor, Diaphoresis

• If prolonged, deep, severe leads toParasympathetic response:Decreased BP. HR, N&V, fainting

Responses to Pain

• BehavioralVoluntaryGuarding, Rubbing, Grimacing, Moaning,Immobilization, restlessness

• AffectivePsychologicalAnxiety, fear, fatigue, anger, depression,withdrawal-isolation, hopelessness

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

Assessment: Pain

Begins with acceptance of client report Includes:

• Subjective description –Client statementUse of a pain-rating scale

• Objective assessment – physical examination

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?

Pain Assessment: The Fifth Vital SignPain Assessment Tools

• Pain rating scales

– Descriptive No pain – mild- severe

- Numerical 0-10

- Visual analog Wong Baker

Pain Assessment: The Fifth Vital Sign

Objective Data - Physical Exam

• Inspect the site of pain

• Take vital signs

• Perform physical exam

• Note pain behaviors:

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 ……

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

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.

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

Analgesics

• Analgesics –relieve pain3 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)

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

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

Adjuvants

• Not classified as analgesics

• Provide synergistic additive effect

• Antidepressants

• Muscle Relaxants

• Corticosteroids

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

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

Interventions: PainModifying the Environment

• Removing or altering the cause of painLoosening a tight binderEmptying a distended bladder

• Altering factors affecting pain toleranceEnvironmental control Quiet, dim lightingAllow client to restPosition for comfort

Interventions: PainNon-pharmacologic Measures

• Distraction

• Guided Imagery

• Relaxation

• Music

• Biofeedback

• Cutaneous stimulation:TENS, massage, heat, cold, acupressure

Interventions: PainClient 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

Remember to tell clients that PAIN is easier to treat before it

gets too severe !

Evaluation: Pain

• Goals met ?

• Pain controlled ?

• Comfort level acceptable to pt ?

• Modify plan- change meds, incorporate new interventions including alternative therapies