Pain Management Chapter 11 ATI chapter 4

Pain is a privately experienced, unpleasant sensation usually associated with
disease or injury
Emotional component of pain is
Types of pain
nocieptive or neuropathic
Onset intensity, and duration determine if pain is
acute or chronic
Nociceptive pain is
noxious stimuli that are transmitted form the pint of cellular injury over peripheral sensory nerves to pathways between the spinal cord and thalmaus and from the thalmus to the cerebral cortex of the brain
Somatic pain is caused by
mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin. or other structures composed of connective tissue
Superficial somatic pain?cutaneous pain is
such as from an insect bite or paper cut, perceived as sharp or burning discomfort
Mechanical pain would be
stubbing toe, chemical burn or thermal
skin deep
deeper somatic pain is caused by
deeper somatic pain produces sensations that are
sharp, throbbing and intense
Dull, aching, diffuse discomfort with long term disorders such as
Visceral pain arises from internal organs such as the heart, kidneys, and intestines that are
diseased or injured
Causes of visceral pain
ischemia (death of tissue due to blood loss), compression of an organ (tumor) intestinal distention (gas pain), contraction (spasm) of an organ (kidney stones, gallstones or uterine contractions)
visceral pain is usually accompanied by Autonomic Nervous System Symptoms such as
nausea, vomiting, pallor, hypotension and sweating
Referred pain is
discomfort in a general area of the body bu not in the exact site where an organ in located (like arm pain during a heart attack)
Neuropathic Pain is
pain processed abnormally by the nervous system
Neuropathic pain results from damage to either the
pain pathways in peripheral nerves or pain processing centers in the brain
Neuropathic pain is intense, shooting ,burning or described as
pins and needles or hot poker
Examples of neuropathic pain would be
phantom limb pain, spinal cord injuries, strokes, diabetes, and herpes zoster (shingles)
Cancer pain is
nociceptive and neuropathic
Radiation drugs can cause
nerve damage
adjuvant drugs are
made for one thing but used for something else (lyrica, neurotin)
Acute pain is
less than 6 months
Acute pain is protective and has a purpose T or F
Acute pain is associated with tissue trauma and eases with
healing (surgery, pain will lessen when healing begins)
Acute pain will manifest as SNS/F/F causing what symptoms
elevated blood pressure, elevated heart and respiratory rates, diaphoresis and dilated pupils, grimacing, moaning, flinching and guarding
Acute pain will lessen if you
treat the underlying problem
Chronic pain lasts
longer than 6 months, ongoing and reoccurs frequently
Chronic pain affects quality of life; others begin to show
negative reactions to the sufferer
Chronic Pain has no purpose and is not protective
T / F
Chronic pain may have periods of acute pain called
breakthrough pain
Manifestations of chronic pain are similar to
depression, including hopelessness, weight loss, fatigue, or physical immobility. Often the opposite of acute pain
Qualities of life activities affected by chronic pain
exercising, working around the house, sleeping, socializing, walking, sex
Four phases of pain transmission
Transduction, Transmission, Perception and Modulation
conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord. (like touching a hot iron)
Transduction is initiated by
cellular disruption
Nociceptors are
specialized pain receptors located in the free nerve endings of peripheral sensory nerves
A delta Fibers
can carry pain impulses rapidly;get sharp, acute initial pain
C Fibers are
throbbing, aching or burning after initial pain
Transmission is
peripheral never fibers form synapses with neurons in the spinal cord
Transmission impulses move
from the spinal cord to the brain
Transmission chemicals increase
pain transmission
4 chemicals that increase pain transmission
Substance P, Prostaglandins, Bradykinin, Histamine
Chemicals that decrease pain transmission
Seratonine and endorphines
brain experiences pain at a conscious level;locates pain, its intensity, and what it means
Perception gives pain an
emotional response
Pain threshold is
point at which the pain transmitting neurochemicals reach the brain, causing conscious awareness
decreased pain threshold
Pain tolerance is
the amount of pain a person endures once the threshold has been reached
Variables in pain tolerance
age, older adults may not complain, gender, men complain less, fatigue, tiredness decreases pain tolerance, culture, anticipatory fear
brain transmits a response down the spinal nerves to the point where the pain transmission originated to alter the pain experience. (pull hand back from hot stove)
Modulation causes
muscles to contract reflexively, moving the body away from painful stimuli
Endogenous opiods – neurochemicals like serotonin reduce
painful sensations
Patients have the right to adequate assessment and management of pain. T /F
Nurses are accountable for the assessment of pain T/F
The nurse’s role is that of an
advocate and educator for effective pain management
What is pain:
Whatever the patient tells you it is
Pain is private and the patient is the only reliable source of quantifying pain T/F
Clients description of subjective pain
onset, quality, intensity, location and duration
What makes the pain better or worse
ask the client
Clients objective nonverbal behaviors for pain
clenched jaw, frowning, crying, rocking or fidgeting
exaggerated pain response
Acute pain will temporarily increase BP, Pulse, respiration will eventually levelize so they are not an accurate indicator of pain
Assessments biases with pain
client’s pain is misunderstood
Pain assessment tools that are objective
numeric scale, word scale, linear scale, faces scale (Wong Baker)
Assessment Standards of the Joint Commission for Accredited healthcare facilities
Right to assessment and pain management, Assessment for appropriate age, developmental level, condition and culture, Pain is reassessed regularly, client’s choices of pain management are respected and healthcare workers are educated
Joint Commission components of pain assessment
intensity, location, quality, onset, duration, variations, patterns,alleviating factors, aggravating factors, present pain management regimen, pain management history, effects of pain, person’s goal for pain control, physical examination of pain
Pain management techniques
blocking brain perception, interrupting pain transmitting chemicals with NSAIDS, combining analgesics(opioids and nonopioids), substituting sensory stimuli, altering pain transmission
WHO recommends the 3 tier approach for pain management
1. non-opiod +/- adjuvant
2. Opiod for mild/moderate pain +/- non opiod +/- adjuvant
3. Opiod for moderate/severe pain +/- non-opiod +/- adjuvant
Pain management Opioids -Narcotics
interfere with pain perceptions centrally at the brain
Use narcotics for
moderate to severe pain (post op, mi, cancer)
Narcotic drugs
oxycodone, norphine sulfate, fentanyl and codeine
Narcotic side effects
sedation, n/v, constipation, paralytic ileus, respiratory depression, urinary rentention, hypotension, and physical dependancy
pregnancy/lacatation/head injury/cns depression, copd, liver/kidney disease, caution with the elderly/ children/ suicidal patients and those with addiction issues
atelectasis is
lung collapse
reversal agent for narcotics
When patients are taking narcotics, encourage them to
t, c, db to prevent atelectasis (turn, cough and deep breathe)
Maintain safety
bed in low position, call light in preach, instruct the patient to call for assistance ambulating
duragesic patches need to be changed every
72 hours
meperidine (demerol)
restrict to 48 hours and not recomended in older adults
non opiod algesics -not narcotics alter
neurotransmission at the peripheral level or site of injury
Administer NSAIDS with
food to prevent GI upset
N-acetyleysteine (Mucomyst) is
reversal agent for acetaminophen overdose
acetaminophen should not be given more than
4g/per day
Adjuvant analgesics enhance the effects of nonopiods, help alleviate other symptoms that aggreavate pain such as
depression, seizures, inflammation and are useful in neuropathic pain
carbamazepine (Tegretol)
diazepam (Valium)
Tricyclic antidepressants
amitriptyline (Elavil)
hyroxyzine (Vistaril)
desamethasone (Decadron)
Nutritional supplemnts
glinko biloba (anti inflammatory) glucosamine
Equinalagesic dose
oral dosage that provides the same level of relief as a parenteral dose
Palliative sedation
relieving intractable pain experienced by a dying patient
Transcutaneous Electrical Stimulation
TENS delivers bursts of electricity to the skin and underlying nerves
Percutaneous Electrical Nerve Stimulation
PENS TENS plus acupuncture
other non pharmaceutical approaches to pain
imagery, hypnosis, physical/occupation therapy and counseling
Administration of analgesics every
3 hours rather than PRN often provides uniform relief of pain
Acknowledge a pts pain and respond
When caring for a client with pain, which of the following is an essential action by the nurse
giving assurance that pain management is a nursing and agency priority
Oral dose will be higher than the parenteral dose
take nsaid with food
perform pain assessment when vital signs are taken
The nurse is correct in identifying that the client is at greater risk for an adverse effect of opiate analgesic if they are treating for
non verbal behaviors for pain
eating poorly, moans frequently, client is emotionally irritable, client resists repositioning
It is speculated that some nondrug methods relieve pain by releasing
endogenous opiates
Conscious experience of discomfort is
Point at which pain trasmitting neurochemicals reach the brain causing awareness
pain threshold
the amount of pain a person endures after the threshold has been met
pain tolerance