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Pain is:

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purely subjective and highly individualized

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Pain:

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CANNOT be measure objectively

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Pain is defined as:

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an unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

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Congress declared 2000 to 2010:

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The Decade of Pain Control and Research

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Pain continues to:

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be a leading public health problem in the US

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The pain experience is:

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complex, involving physical, emotional, and cognitive components

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The stimulus of pain is:

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physical and/or mental in nature

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What causes pain?

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Thermal, chemical or mechanical stimuli

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4 physiological processes of nociceptive (normal) pain:

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transduction, transmission, perception and modulation

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perception:

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the point at which a person is aware of pain

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modulation

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this inhibition of pain impulse is the fourth and last phase of the nocieptive process

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Acute/Transient Pain

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has an identifiable cause, short duration, limited tissue damage and emotional response

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Acute/Transient Pain eventually

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resolves, with or without treatment after an injured area has healed

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physical or psychological process is delayed

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as long as acute pain persists because the patient focuses all their energy on pain relief

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The primary nursing goal for the patient suffering from acute pain is:

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To provide pain relief that allows patients to participate in their recovery

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Chronic/Persistent Non Cancer Pain:

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is not protective and serves NO purpose

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Chronic/Persistent Non Cancer Pain:

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last longer than 6 months and is constant or recurring with mild to severe intensity

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Chronic/Persistent Non Cancer Pain:

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does not always have an identifiable cause

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Examples of: Chronic/Persistent Non Cancer Pain:

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arthritis, low back pain, headache, peripheral neuropathy

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Chronic/Persistent Non Cancer Pain:

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sometimes an injured area healed long ago, yet pain is ongoing and does not respond to treatment

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Chronic/Persistent Non Cancer Pain:

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DOES NOT adapt to pain

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Chronic/Persistent Non Cancer Pain:

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is a Major cause of psychological and physical disability

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Chronic/Persistent Non Cancer Pain has the follow associated symptoms:

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fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, and anger

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pseudoaddiction:

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often a person with chronic pain who consults with numerous health care providers is labeled a drug seeker, when he/she is actually seeking adquate pain relief

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Chronic Episodic Pain:

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pain that occurs sporadically over an extended period of time (hours, days or weeks)

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Examples of Chronic Episodic Pain:

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migraine headaches and pain related to sickle cell disease

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Cancer Pain:

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90% are able to have their pain managed with reatively simple means

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Cancer Pain:

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usually caused by tumor progression and related pathological processes, invasive procedures, toxicities of treatment, infection, and physical limitations

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In Cancer Pain the patient:

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senses pain at the actual site of the tumor or distant to the site-referred pain

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Pain by Inferred by Pathological Process: Identify cause of Pain:

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nocioceptive pain includes somatic (musculoskeletal) and visceral )internal organs) pain

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Pain by Inferred by Pathological Process: Identify cause of Pain:

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Neuropathic pain arises from abnormal to damaged pain nerves

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Nociceptive pain:

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Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids and/or opioids

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Somatic pain:

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a type of nociceptive pain that Comes from bone, joint, muscle, skin, or connective tissue; is usually aching or throbbing in quality and well localized

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visceral pain

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a type of nociceptive pain that Arises from visceral organs such as the gastrointestinal tract and pancreas; is sometimes subdivided:

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visceral pain

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1Tumor involvement of organ capsule that causes aching and fairly well-localized pain 2Obstruction of hollow viscus, which causes intermittent cramping and poorly localized pain

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Neuropathic pain:

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Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant analgesics

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Centrally generated pain 1 Deafferentation pain:

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Injury to either the peripheral or central nervous system Examples: Phantom pain indicates injury to the peripheral nervous system; burning pain below the level of a spinal cord lesion reflects injury to the central nervous system.

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Centrally generated pain: 2 ympathetically maintained pain

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Associated with impaired regulation of the autonomic nervous system

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Examples of centrally generated pain:

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Pain associated with complex regional pain syndrome, type I, type II

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Peripherally generated pain 1 painful polyneuropathies:

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Pain felt along the distribution of many peripheral nerves.

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Examples of painful polyneuropathies

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Diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barré syndrome.

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Peripherally generated pain: 2 Painful mononeuropathies:

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Usually associated with a known peripheral nerve injury; pain felt at least partly along the distribution of the damaged nerve

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examples of painful mononeuropathies:

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Nerve root compression, nerve entrapment, trigeminal neuralgia

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Cancer Pain:

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90% are able to have their pain managed with relatively simple means

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Cancer Pain:

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Some patients with cancer experience acute and/or chronic pain. The pain is nociceptive and/or neuropathic

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Cancer Pain:

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is usually caused by tumor progression and related pathological processes, invasive procedures, toxicities of treatment, infection, and physical limitations.

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Cancer Pain:

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A patient senses pain at the actual site of the tumor or distant to the site, called referred pain.

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Cancer Pain:

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Although the treatment of cancer pain has improved, undertreatment of cancer pain continues.

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Pain by Inferred Pathological Process

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Identifying the cause of pain is the first step in successful treatment.

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Idiopathic Pain

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chronic pain in the absence of identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition

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Examples of Idiopathic Pain

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complex regional pain syndrome (CRPS)

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The following statements are false:

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Patients who abuse substances (e.g., use drugs or alcohol) overreact to discomforts.

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The following statements are false:

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Patients with minor illnesses have less pain than those with severe physical alteration.

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The following statement is false

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Administering analgesics regularly leads to drug addiction.

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The following statement is false

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The amount of tissue damage in an injury accurately indicates pain intensity.

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The following statement is false

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Health care personnel are the best authorities on the nature of a patient's pain.

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The following statement is false

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Psychogenic pain is not real.

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The following statement is false:

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Chronic pain is psychological.

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The following statement is false:

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Patients who are hospitalized will experience pain.

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The following statement is false:

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Patients who cannot speak do not feel pain.

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To help a patient gain pain relief

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view the experience through the patient's eyes

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Acknowledging personal prejudices or misconceptions

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helps you address patient problems more professionally

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When you become an active, knowledgeable observer of a patient in pain

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you more objectively analyze the pain experience.

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Factors influencing pain:

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Pain is a complex process, involving physiological, social, spiritual, psychological, and cultural influences.

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Factors influencing pain:

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Consider all factors that affect the patient in pain to ensure a holistic approach to the assessment and care of the patient.

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Factors Influencing Pain in Older Adults

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•With aging, muscle mass decreases, body fat increases, and percentage of body water decreases. This increases concentration of water-soluble drugs such as morphine, and the volume of distribution for fat-soluble drugs such as fentanyl increases

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Factors Influencing Pain in Older Adults

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•Older adults frequently eat poorly, resulting in low serum albumin levels. Many drugs are highly protein bound. In the presence of low serum albumin, more free drug (active form) is available, thus increasing the risk for side and/or toxic effects

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Factors Influencing Pain in Older Adults

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A decline of liver and renal function naturally occurs with aging. This results in reduced metabolism and excretion of drugs. Thus older adults often experience a greater peak effect and longer duration of analgesics

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Factors Influencing Pain in Older Adults

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Age-related changes in the skin such as thinning and loss of elasticity affect the absorption rate of topical analgesics.

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Physiological Factors and pain:

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Young children have trouble understanding pain and the procedures that cause it.

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Physiological Factors and pain:

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with developmental considerations in mind, you need to adapt approaches for assessing a child's pain, including what to ask and the behaviors to observe, and how to prepare a child for a painful medical procedure.

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Physiological Factors and pain:

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Pain is not an inevitable part of aging

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physiological factors and pain:

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Serious impairment of functional status often accompanies pain in older patients

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physiological factors and pain:

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Pain potentially reduces mobility, activities of daily living (ADLs), social activities, and activity tolerance. The presence of pain in an older adult requires aggressive assessment, diagnosis, and management

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The ability of older patients to interpret pain is complicated

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They often suffer from multiple diseases with vague symptoms that affect similar parts of the body.

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Different diseases sometimes cause similar symptoms

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For example, chest pain does not always indicate a heart attack; it also is a symptom of arthritis of the spine or an abdominal disorder

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Fatigue and Pain

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Fatigue heightens the perception of pain and decreases coping abilities

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Fatigue and Pain

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the perception of pain is even greater

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Fatigue and Pain

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Pain is often experienced less after a restful sleep than at the end of a long day.

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Genes influence on pain

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genetic information passed on by parents possibly increases or decreases the person's sensitivity to pain and determines pain threshold or pain tolerance

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Genes influence on pain

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modest genetic influence in the development of chronic widespread pain without significant differences experienced between men and women.

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neurological function influence on pain

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Any factor that interrupts or influences normal pain reception or perception (e.g., spinal cord injury, peripheral neuropathy, or neurological disease) affects the patient's awareness of and response to pain. Some pharmacological agents (analgesics, sedatives, and anesthetics) influence pain perception and response and thus require close monitoring.

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Social factors influece on pain: Attention::

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Increased attention is associated with increased pain, whereas distraction is associated with a diminished pain response

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Social factors influece on pain: Attention::

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pain-relief interventions such as relaxation, guided imagery, and massage. By focusing patients' attention and concentration on other stimuli, their perception of pain declines

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Previous experiences affect on pain:

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Prior experience does not mean that a person accepts pain more easily in the future

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Previous experiences affect on pain:

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Previous frequent episodes of pain without relief or bouts of severe pain cause anxiety or fear

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Previous experiences affect on pain:

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if a person repeatedly experiences the same type of pain that was relieved successfully in the past, the patient finds it easier to interpret the pain sensation

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Previous experiences affect on pain:

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When a patient has no experience with a painful condition, the first perception of it often impairs the ability to cope. For example, after abdominal surgery it is common for patients to experience severe incisional pain for several days

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Previous experiences affect on pain:

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you need to prepare a patient with a clear explanation of the type of pain to expect and methods to reduce it

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Family and social support affect on pain:

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the presence of family or friends can often make the pain experience less stressful

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Spirtual Factors:

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Spirituality stretches beyond religion and includes an active searching for meaning to situations in which one finds oneself.

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Spiritual factors and pain:

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Spiritual pain goes beyond what we can see. "Why has God done this to me?" "Is this suffering teaching me something?"

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Spiritual factors and pain:

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Other spiritual concerns include loss of independence and becoming a burden to family

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Spirtual pain goes way beyond:

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what we can see!

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Anxiety ....A person perceives pain differently if it

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suggests a threat, loss, punishment, or challenge

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the degree and quality of pain perceived by a patient

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influences the meaning of pain.

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Anxiety and pain:

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The relationship between pain and anxiety is complex

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Anxiety often increases the perception of pain,

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and pain causes feelings of anxiety. It is difficult to separate the two sensations.

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Anxiety and the critically ill:

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Critically ill or injured patients who perceive a lack of control over their environment and care have high anxiety levels.

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Coping style

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influences the ability to deal with pain

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Persons with internal loci of control perceive themselves

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as having control over events in their life and the outcomes such as pain.

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persons with external loci of control perceive

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that other factors in their life such as nurses are responsible for the outcome of events.

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Patients who self-administer small doses of intravenous (IV) pain medication using PCA during an acute episode

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successfully achieve pain control more quickly than those who rely on nurses to administer intermittent doses of pain medications.

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The meaning that a person associates with pain:

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affects the experience of pain and how one adapts to it

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Cultural beliefs and values affect

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how individuals cope with pain

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Some cultures believe that it is natural to be demonstrative about pain

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Others tend to be more introverted

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Asking patients about their tolerable pain level

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is the first step in helping them regain control.

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Assessing previous pain experiences and effective home interventions

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provides a foundation on which you can build

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Nursing Assessment Questions (on current pain)

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•Palliative or Provocative factors: What makes your pain worse? What makes it better?

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Nursing Assessment Questions (on current pain)

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Quality: How do you describe your pain?

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Nursing Assessment Questions (on current pain)

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Region or Radiation: Show me where you hurt. Does it stay there or does it spread somewhere else?

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Nursing Assessment Questions (on current pain)

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Severity: On a scale of 0 to 10, how bad is your pain now?

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Nursing Assessment Questions (on current pain)

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What is the worst pain you have had in the past 24 hours?

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Nursing Assessment Questions (on current pain)

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What is the average pain you have had in the past 24 hours?

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Nursing Assessment Questions (on current pain)

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Timing: Is your pain constant, intermittent, or both?

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Nursing Assessment Questions (on current pain)

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U: Effect of pain: What does your pain prevent you from doing that you would like to do?

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Nursing Assessment Questions (about Allergies)

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Do you have any allergies to medications?

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Nursing Assessment Questions (about Allergies)

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What type of problems have these allergies caused/

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Nursing Assessment Questions (about Allergies)

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How are these allergies treated?

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Nursing Assessment Questions (About Current Medications)

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What medications are you taking now?

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Nursing Assessment Questions (About Current Medications)

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Are you taking any herbs?

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Nursing Assessment Questions (About Current Medications)

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Are these medications and herbs effective in relieving the pain?

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Nursing Assessment Questions (About Current Medications)

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Which nonpharmacological treatments have you tried to relieve the pain?

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Nursing Assessment Questions (About Current Medications)

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Which medications have you tried in the past that worked to stop your pain?

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Nursing Assessment Questions (About Current Medications)

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Have you ever used recreational drugs or alcohol to alleviate pain?

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Nursing Assessment Questions (About Current Medications)

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Have you ever been diagnosed with a gastrointestinal bleed or a kidney or liver disorder?

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Nursing Assessment Questions (About Current Medications)

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Are you being treated for any other medical conditions?

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Nursing Assessment Questions (About Current Medications)

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With whom do you live, and how do they help you when you have pain?

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If the pain is acute or severe, it is unlikely that:

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the patient will be able to provide a detailed description of the entire experience

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During an episode of acute pain you:

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primarly assess its location, severety and quality

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For patients in chronic pain, a thorough assessment includes:

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affective, cognitive, behavioral, spiritual and social dimensions

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using the ABC's of pain management

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is an effective way to manage pain

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Routine Clinical Approach to Pain Assessment and Management (ABCDE)

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A: Ask about pain regularly. Assess pain systematically.

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Routine Clinical Approach to Pain Assessment and Management (ABCDE)

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B: Believe the patient and family in their report of pain and what relieves it.

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Routine Clinical Approach to Pain Assessment and Management (ABCDE)

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C: Choose pain control options appropriate for the patient, family, and setting.

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Routine Clinical Approach to Pain Assessment and Management (ABCDE)

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D: Deliver interventions in a timely, logical, and coordinated fashion.

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Routine Clinical Approach to Pain Assessment and Management (ABCDE)

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E: Empower patients and their families. Enable them to control their course to the greatest extent possible.

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Possible Sources for Error in Pain Assessment

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•Bias, which causes nurses to consistently overestimate or underestimate the pain that patients experience

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Possible Sources for Error in Pain Assessment

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•Vague or unclear assessment questions, which lead to unreliable assessment data

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Possible Sources for Error in Pain Assessment

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•Use of pain assessment tools that are not evidence based

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Possible Sources for Error in Pain Assessment

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•Patients who do not always provide complete, relevant, and accurate pain information

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Possible Sources for Error in Pain Assessment

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•Patients who are cognitively impaired and unable to use pain scales

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Pain is the:

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5th Vital Sign

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a patient's self report of pain is the:

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most reliable indicator of its exsistence and intensity

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A common misconception is that

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individuals who are nonverbal as a result of dementia or cognitive impairments do not experience pain

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Patients who are nonverbal often present with atypical manifestations of pain caused by

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pathophysiological changes in the brain

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