Kate Black Kate Brazzale Lisa Molony Pain Kate Black Kate Brazzale Lisa Molony

Pain Aetiology Disorder/Disease Clinical Manifestations Pathophysiology Diagnosis Pharmacological Management Non-Pharmacological Management Complications Implications for Nursing Practice

What is pain? According to the International Association for the Society of Pain, Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. http:/www.iasppain.orgContentNavigationMenuGeneralResourceLinks/PainDefinitions/default.htm

Aetiology: What causes pain? “Pain can be due to a wide variety of diseases, disorders and conditions that range from a mild injury to a debilitating disease”. http://www.localhealth.com/article/pain

Acute Pain “The terms acute and chronic refer exclusively to the time course of the pain, irrespective of aetiology” (Craft, Gordon, and Tiziani, 2011, p.144). Acute Pain: Usually lasts less than 3 months Sudden onset Usually well defined Predicable ending (healing) Can lead to chronic pain if left untreated Examples: cut to the finger, broken bone

Chronic Pain Chronic Pain: Persistent or recurring pain Continues for more than 3 months May last for months or even years Can be difficult to diagnose and treat Primary goal is not total pain relief but reducing pain relief Examples include: arthritis and back pain

Categories of pain Another way to categorise pain is on the basis of origin: Nociceptive Neuropathic Psychogenic

Nociceptive Pain External / Somatic Nociceptive pain is directly related to tissue damage and can be either external (somatic) or internal (visceral) External / Somatic Most common type of pain Can be superficial -in the skin but may extend to the underlying tissues. Usually described as: sharp, shooting, throbbing, burning, stinging well defined area Usually lasts from a few seconds to a few days Examples include: paper cut, sprained ankle

Nociceptive Pain Internal / Visceral (Deep) Less common and usually more severe Originates in the walls of visceral organs Poorly defined area Described as: deep, aching, pressing or aching Usually lasts a few days to weeks Virtually a symptom of all diseases at some point during disease progression. Often associated with feeling sick Examples include: Major surgery, labour pain, irritable bowel.

Neuropathic Pain Injury or disease of the central nervous system rather than the peripheral tissue. May be due to nerve compression, inflammation or trauma Usually lasts between a few months to many years. Difficult to treat due to the lack of knowledge of the underlying cause. Often associated with paraesthesia, hyperalgesia and allodynia Burning, shooting or pins and needles (not sharp like nociceptive).

Psychogenic Pain Psychological, psychiatric or psychosocial at the primary causes Severe and persistent pain Appears to have no underlying pathology. Less common now due to medical technology Pain experienced (Headaches, abdominal pain, back pain) is indistinguishable from that experienced by people with identifiable injuries or diseases. This kind of pain can be very frustrating to sufferers and can interfere with their ability to function normally.

Clinical Manifestations “No two people are likely to experience the same level of pain for a given painful stimulus” (Craft et al., 2011, p.150). Pain Tolerance: The maximum level of pain that a person is able to tolerate without seeking avoidance of the pain or relief What affects Pain Tolerance? Fatigue, anger, boredom, apprehension, sleep deprivation. Alcohol consumption, medication, hypnosis, warmth, distracting activities and strong beliefs or faiths.

Clinical Manifestations Pain tolerance is influenced by a number of factors including; Age Cultural perceptions Expectations Gender Physical and mental health

Clinical Manifestations Age: Different reaction to pain Understanding of pain Gender: “Females display greater sensitivity to pain than males do. There are differences in the way women cope with pain, report pain and respond to pain” (Crisp & Taylor, 2009, p.1096). Physical & Mental Health Physical mobility Depression, difficulty coping, fatigue.

Cultural Variations Cultures vary in the meaning of pain, how if it expressed and how it is treated: Meaning Expression Treatment

Pain Threshold Pain Threshold is the lowest point at which pain can be felt Entirely subjective May vary from person to person but changes little in the same individual over time.

Location It is important record a patients pain location to be able to monitor any changes. Pain can feel like it is coming from one part of the body but in fact it is another, this type of pain is called referred pain.

Signs and Symptoms: Signs: Symptoms: Change in temperature Blood pressure Respiratory rate Heart rate Short of breath Sweating Pallor Dilated pupils Swelling Symptoms: Fatigue Feeling sick Weakness Numbness Tenderness Change in behaviour Unable to sleep

PATHOPHYSIOLOGY Pain Pathway Classified as nociceptive

PATHOPHYSIOLOGY Transduction 1st Order Sensory Neurons A Noxious Stimuli is converted (transduced) via specialized receptors on primary afferents into an electrical impulse (action potential). noxious mechanical, chemical, or thermal stimulus Occurs at nociceptors, activated by intense stimuli Strong physical stimuli and disease processes cause tissue damage and release chemicals (electrochemical reaction). Chemicals bind and activate specific receptors on the nerve endings. Increase the excitability of the neuronal cell membrane Lead to generation of propagated action potentials. Secondary messengers are released and activated interact with the nucleus of the neuron to modulate response properties of affected neurons, leading to a state of peripheral sensitization in certain circumstances. 1st Order Sensory Neurons Aδ and C Fibres to the posterior of the spinal cord

transduction

PATHOPHYSIOLOGY Transmission 2nd Order Sensory Neurons action potentials (nerve impulses) are conducted to the central nervous system primarily via two types of primary afferent neurons: thinly myelinated, faster conducting A delta fibers and unmyelinated, slowly conducting C fibers, both termed primary afferents. Action potentials result from activation of specific sodium channels Peripheral transmission to the dorsal horn of the spinal cord Synapse with the second order neurons (synaptic transmission). Central transmission - Transmitted via neurons which cross the spinal cord and ascend to the thalamus and branches to the brainstem nuclei SPINOTHALAMIC PATHWAY Nociceptive impulses are relayed to multiple areas of the brain including the somatosensory cortex, the insula, frontal lobes and limbic system. 2nd Order Sensory Neurons Cross the Spinal cord and ascend to the thalamus via the Spinothalamic Tract

Synaptic transmission Once the action potential from the periphery reaches the first synapse at the dorsal horn of the spinal cord, a number of neuroactive substances are released. These include several excitatory and inhibitory neurotransmitters and glial derived chemicals that participate in the immune responses. Astrocytes and microglia in the dorsal horn are also involved and the sum of activity at the synapse results from release of excitatory and inhibitory neurotransmitters, which ultimately lead to generation of action potentials and central transmission of pain signals to higher centers. Peripheral transmission This electron micrograph depicts large myelinated, small lightly myelinated and unmyelinated fibers. Normally only the small diameter nerve fibers participate in transmitting pain sensations.

Synaptic transmission

Peripheral transmission

Peripheral transmission

PATHOPHYSIOLOGY Perception 3rd Order Sensory Neurons The process by which a noxious event is recognized as pain by a conscious person. Multiple areas of the brain are involved. There is no one location where perception occurs, although major defining components of pain are attributed to processes that take place in specific areas of the brain. For example, the sensory-discriminative component is the result of activity in the somatosensory and the insular cortex, which allows the person to identify the type, intensity and bodily location of the noxious event. The affective-emotional response to the noxious stimulus is mediated by the limbic system. Pain has an inseparable affective-emotional component that defines the response and associated behavior resulting from the initiating noxious event or stimulus. 3rd Order Sensory Neurons To the higher brain centres of Limbic system Frontal cortex, primary sensory cortex of the post central gyrus of parietal lobe

PATHOPHYSIOLOGY Modulation Descending input from the brainstem influences central nociceptive transmission in the spinal cord. Specific brainstem nuclei send projections to the dorsal horn of the spinal cord and when activated by ascending nociceptive impulses and other influences from the brain result in descending modulation. Though not completely understood, modulation results in descending inhibition of nociception through the release of neurotransmitters such as serotonin, norepinephrine and endogenous opioids. Modulatory processes can also increase descending facilitation of nociception and consequently pain. Psychological factors such as fear and anxiety exert facilitatory influences through these modulatory systems.

Diagnosis Diagnosis of Pain is complicated. To diagnose pain, Nurses rely on Objective Data. Visual signs. Subjective Data. Patients descriptions. Characteristics of Pain.

diagnosis Characteristics of Pain OPQRST Mnemonic Onset Provocation Quality Region/Radiation Severity Time

diagnosis Onset Provocation What was the patient doing at the time? What precipitated the pain? Is there any history of this pain in the patient? Provocation Aggravating Factors: What causes the Pain to increase? Alleviating Factors: What makes it better or worse?

diagnosis 3. Quality 4. Region/Radiation Get the patient to describe their pain to you in specific terms. What does it feel like? 4. Region/Radiation Where is the pain? Where does the pain radiate? Is it in one place? Does it go anywhere else? Did it start elsewhere and now localised to a different spot?

diagnosis 5. Severity Wong-Baker Faces Pain Rating Scale. Pain Rating On a scale of 1 to 10, 10 being the worst pain you have experienced, what number would you assign to your discomfort? Does their pain change with medication? Wong-Baker Faces Pain Rating Scale. Used for Children People whose first language is not English.

diagnosis

diagnosis 6. Time Are there any Associated Phenomena? When did the pain start? How long has the patient has this pain? Are there any Associated Phenomena? Factors consistent with pain e.g. Anxiety Physiological responses Sympathetic stimulation Parasympathetic stimulation Vital signs, skin colour, perspiration, pupil size, nausea, muscle tension, anxiety Behavioural Responses Posture, gross motor activities

Spinal nerves 3 Categories Dermatomes in relation to pain Dermatomes Connective Tissue and Dermis Myotome Skeletal Muscle Sclerotome Vertebrae Dermatomes in relation to pain An area of skin in which sensory nerves derive from a single spinal nerve root.

Dermatomes Spinal Cord Dermatomatic Relationships Trigeminal Nerves V1Ophthalmic Division – Eye V2 Maxillary Division – Top of Jaw V3 Mandibular Division – Bottom of Jaw Cervical (C-2 - C-7) fingers, neck, funny bone, and the scalp. Thoracic (T-1 - T-12) nipples, chest, belly button area, pubic bone, and lower sternum. Lumbar (L-1 - L-5) hips, the front of the legs, the shins, knee caps, and most of the feet. Sacral (S-1 - S-5) genitals, buttocks, back of the legs, and calves

Dermatomes

Diagnostic Tests Tests to verify pain. Ultrasound Imaging CT/CAT scan High frequency sound waves to develop an image of the affected area. CT/CAT scan Computed Tomography or Computed Axial Tomography X-rays to produce an image of a cross-section of the body. MRI Scan Large magnet, radio waves and a computer produces detailed images of the body.

Diagnostic - Tests Discography/Myelograms EMG (Electromyography) A contrast dye is injected into the spinal disk to enhance the X-Ray. EMG (Electromyography) Evaluate the activity of the muscles. Bone Scans Diagnose and monitor infection and fracture of the bone

Diagnosis Psychological Assessment Pain Questionnaires Determine Psychological Involvement. Brain functions governing behaviour and decision making, including expectation, attention and learning. Fear Anxiety Depression Coping Psychosocial involvement. Plays a large role in pain perception. Age, Sex, Culture, previous experiences.

GENERAL PRINCIPLES of pain management Treat the cause of pain where possible, not just the symptom Make accurate diagnosis and assessment of pain extent and type to ensure appropriate analgesic prescription Keep the patient pain free Dose at regular specified intervals, particularly for chronic pain (rather than PRN) Avoid the chronic pain stress cycle and 'sick role‘ Prevent adverse effects of opioids Develop a patient management plan Follow the WHO analgesia ladder

Pharmacological management WHO has developed a three-step ladder for pain relief If pain occurs, the use of oral of drugs should be administered in the following order: non-opioids mild opioids strong opioids Image: World Health Organization http://www.who.int/cancer/palliative/painladder/en/

Pharmacological management Involves the management of pain through analgesics Analgesic: a compound that relieves pain by altering perception of nociceptive stimuli without producing anaesthesia or loss of consciousness Three types of analgesics: Opioids (narcotic) analgesics Non-opioid analgesics (NSAIDs) Adjuvants (DISCUSS HERE WHAT ADJUVANTS ARE OR ADD IN A SLIDE LATER)

Pharmacological management Routes of administration: Oral Intravenously Continuous infusion (via SC or IV routes) Rectally Transdermal administration Inhalation

Opioids Generally prescribed for moderate – severe pain Act on CNS by binding with opiate receptors to modify perception and reaction to pain The most commonly used opioid is morphine

opioids Add table of commonly used opioids, advantages/disadvantages

Opioids Adverse drug reactions may include: respiratory depression excessive sedation constipation nausea vomiting tolerance dependence dysphoria (a mood of general dissatisfaction, restlessness, anxiety)

nsaids Non-steroidal anti-inflammatory drugs Used to treat mild – moderate pain Work by acting on peripheral nerve receptors to reduce transmission and reception of pain stimuli Common NSAIDs include: Paracetamol Aspirin Ibuprofen Naxopren (arthritis)

nsaids Adverse reactions may include: gastrointestinal tract disorders (dyspepsia, nausea and vomiting, diarrhoea/constipation) renal damage asthma attacks skin reactions sodium retention and consequent heart failure and hypertension Large overdoses of paracetamol can cause fatal acute liver damage if not promptly treated.

nsaids Aspirin vs Paracetamol Aspirin is readily available OTC. It can be used in stroke prevention due to its anti-platelet qualities. In normal doses, paracetamol is a safer OTC analgesic than aspirin for the following reasons: adverse effects and allergic reactions are rare with therapeutic doses there is low risk of gastic upset, renal impairment or peptic ulceration compared with aspirin plasma protein binding is negligible (no risk of displacement causing drug interactions) few serious adverse drug interactions may be used by children safe to use during pregnancy and lactation

Include slide on adjuvants?

Pharmacological management Other drugs useful for analgesic effects GABA analogues Capsaicin Local anasthetics General anasthetics Ethanol or phenol Cannabinoids Specific anti-migraine drugs Herbal remedies (e.g. cloves, feverfew, kava kava, St John's wort, ginger, ginseng)

Non-Pharmacological management Definition? Useful for patients who: find such interventions appealing express anxiety and/or fear may benefit from avoiding or reducing drug therapy are likely to need to cope with a prolonged interval of post-operative pain have incomplete pain relief after use of pharmacological interventions are able to use the intervention without assistance (TENS, heat packs)

Non-Pharmacological management RICE (rest, ice, compression, elevation) Physiotherapy Counter-irritants TENS Acupuncture Psychotherapeutic methods Surgery Community support groups Complementary and alternative medicine - aromatherapy, herbal medicines, spinal manipulation

Hot and cold therapy From: Clinical Psychomotor Skills pg 153

psychotherapeutic Psychotherapeutic methods - hypnosis, behaviour modification, biofeedback, techniques, assertiveness training, art and music therapy, the placebo effect More info on this – find some journals Heaps of info in Crisp & Taylor

Tens Machine

TENS MACHINE Tens Machine

Complications Acute – Cardiovascular Respiratory ? Respiratory Genitourinary/Gastrointestinal Musculoskeletal Pressure Ulcers whilst in Hospital if unable to move from the bed Cognitive/Psychological Possible Fear or Anxiety surrounding injury and healing process

Complications Chronic – Cardiovascular Respiratory ? Respiratory Genitourinary/Gastrointestinal Musculoskeletal Pressure Ulcers whilst in Hospital if unable to move from the bed Cognitive/Psychological Possible Fear or Anxiety surrounding injury and healing process

Implications for Nursing Practice Nurses role in pain management Administer pain-relieving interventions Assess the effectiveness of these interventions Monitor for adverse effects Be an advocate for the patient when the prescribed intervention is ineffective in relieving pain Serve as an educator to the patient and family

Implications for nursing practice Establishing a nurse-patient relationship Positive nurse-patient relationships and teaching are KEY Communication and patient cooperation Believe and acknowledge that the patient is in pain – reduces anxiety ‘I know you have pain' often eases the patients mind Education is important Provide information ‘I know you have pain' often eases the patients mind… ‘this type of procedure can be quite painful’…. Other phrases? - Education is important because the patient or family may be responsible for managing pain at home and preventing or managing side effects - The nurse should provide information by explaining how pain can be controlled Speaking notes from Crisp and Taylor: REGULAR ASSESSMENT OF PAIN STATUS (need more info on this) It is the nurse’s role to administer and monitor interventions ordered by the doctor for pain relief, and also implement independent pain relief measures that compliment those prescribed by the doctor Patient remedies are often most successful, particularly if the patient has experienced that sort of pain Generally, the least invasive theory should be tried first Also: Education - clients are better prepared to handle any situation when they understand it. Confidence and tone Relevant play for children Holistic health - ongoing state of wellness Cultural implications

Implications for Nursing Practice Identifying goals May include decrease in the intensity, duration, frequency, or a reduction in the side effects of pain Consider: the severity of the pain the anticipated harmful effects of pain Anticipated duration of pain ‘No pain’ may be an unrealistic goal. Will goal be achieved by pharmacological or non-pharmacological treatments or both? (take speaking notes from Crisp and Taylor – Planning for nursing care. These notes are from medical-surgical nursing)

Implications for nursing practice Providing physical care Ensure the patient is as comfortable as possible Ensure that physical and self-care needs have been met and that patient feels refreshed. This might include: Fresh gown Change of bed linen Teeth are brushed Hair is combed Gives the nurse the opportunity to perform a complete assessment Appropriate and gentle physical touch during care may also be reassuring and comforting Assess skin integrity (patches, IV lines) the patient in pain may not be able to participate in the usual activities of daily living or to perform usual self-care and may need assistance to carry out these activities - patients are more comfortable when physical and self-care needs have been met, such as a fresh gown, change of bed linen, along with efforts to make the person feel refreashed such as : brushing teeth, combing hair. - in some settings, providing physical care to the patient also gives the nurse the opportunity to perform a complete assessment, and to identify problems that may contribute to discomfort and pain - appropriate and gentle physical touch during care may also be reassuring and comforting - skin integrity should also be assessed during care, especially where patches or IV drips have been fitted

Implications for nursing practice Managing anxiety related to pain A patient who anticipates pain may become increasingly anxious. Patients who are more anxious are likely to be less tolerant. Educate the patient on pain and pain management Gives a sense of control Good nurse-patient relationship is crucial Managing anxiety related to pain Anxiety may affect a person's response to pain: the patient who anticipates pain may become increasingly anxious. - a patient who is more anxious about pain is likely to be less tolerant. - Teaching the patient about the nature of an impending potentially painful experience and ways to decrease pain may often decrease anxiety - learning baout measures to relieve pain may lessen the threat of pain, and give the patient a sense of control - anxiety related to the anticipation of pain or the pain experience itself may be managed effectively by establishing a relationship with the patient and through education

Implications for nursing practice Interventions - Who else may be involved? Oncology nurse Physiotherapist Occupational therapists The family or caregiver People in the community: visiting nurses, pharmacists, general practitioner, palliative care nurses

References

References