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148 Cards in this Set

  • Front
  • Back
What is the definition of pain?
-unpleasant sensory and emotional experience with ACTUAL or POTENTIAL tissue damage
-pain is what the patient says it is and when the patient says it is occuring
Somatic pain can be broken down into what to subtypes?
Superficial and deep
Superficial pain is from the _____ and is well localized, sharp and (clearly/poorly) located
-skin
-clearly
Deep pain is from the _____ (many) and is dull, aching, throbbing, cramping and (clearly/poorly) localized?
-bone, ligaments, blood vessels and muscles
-poorly
Visceral pain is located where and results from what?
location: deep tissues or organs and surrounding structures
results from: stretching or ischemia
Visceral pain characteristics?
-deep, boring, diffuse, poorly defined, referred to a distant location
-associated with ANS
Neuropathic pain comes from?
peripheral receptors, afferent fibers in periphery or CNS
Neuropathic pain characteristics?
-shooting, burning, stabbing, cutting, tingling
-hard to treat, phantom pain

*unknown cause*
What is acute pain?
a biologically necessary physiologic response that provokes an escape/ protection reaction

*PROTECTIVE* --> Warning: tissue injury
usually temporary
Chronic pain has no useful ______ purpose and it lasts longer than ___ months
biological
6 (or longer than the expected time for the pain to disappear)
Cancer pain can be _____, ____ or a combo of both.
acute, chronic
Referred pain originates at a visceral site but is perceived as originating in a part of the body wall that is innervated by ____ entering the SAME segments of the nervous system.
neurons
Pain threshold is defined as?
the point at which a stimulus is perceived as painful
*almost EQUAL from person to person
What is pain tolerance defined as?
max intensity or duration of pain that a person is willing to endure before the person wants something done about the pain
-VARIES from person to person depending on genetic, cultural, psychological and familial factors
What are the 3 basic stimuli that activate specific pain receptors?
1) mechanical
2) thermal
3) chemical
some examples of mechanical stimuli are? (4)
1) pressure
2) brushing
3) pinch
4) prick
Examples of thermal stimuli are? (2)
-hot
-cold
examples of chemical stimuli are? (6)
-exogenous
-endogenous
-tissue damage
-inflammation
-vascular epithelial cells
-immune cells
Nociceptors are?
pain receptors

**stimuli activate nociceptors --> produce a certain pattern of APs --> travel through sensory afferent route --> production of chemicals into the tissues --> stimulate pain receptors --> produce APs
the two peripheral afferents are?
-A delta fibers
-c fibers
A delta fibers are _____ making them fast and responsible for ____ pain.
-myelinated
-acute
C fibers are _____ and responsible for _____ pain.
-unmyelinated
-chronic
3 Chemicals released in response to pain are?
-glutamate
-NE
-substance P
pain pathways to the cortex involve?
-second-order neurons
-third- order neurons
Second order neurons process _____ info and communicate with various reflex networks and sensory pathways in the spinal cord and travel to the ______.
-nociceptive
-thalamus
third order neurons ____ pain info to the cortex where is is perceived. both _____ and _____ areas.
-project
-primary and associative
The central processing of pain information includes the __________ cortex, the ________________ ____________, and the ____________ stem centers
The central processing of pain information includes the SOMATOSENSORY cortex, the LIMBIC SYSTEM, and the BRAIN stem centers
Pain information is perceived and interpreted in this part of the brain
-somatosensory cortex
Pain is transmitted to the ________________ cortex
-SOMATOSENSORY cortex
The ____________ ____________ experiences the components of pain
-limbic system
This part of the central processing of pain information in the brain recruits autonomic nervous system responses
-brain stem centers
The somatosensory cortex, the limbic system, and the brain stem centers are all part of the ____________ ____________ ___________.
-all part of the TOTAL PAIN EXPERIENCE
The endogenous analgesic center is located in the _____ __________
mid brain
__________________ __________________ _______________ in the medulla sends inhibitory signals to __________ horn neurons in the spinal cord
-Nucleus raphe Magnus

-dorsal horn
Signals from the PAG area sends signals to the spinal cord which goes to the ___________ horn
posterior horn
Pain signals from the PAG area go to the spinal cord then to the posterior horn that increase or decrease the amount of ___________ __________ from nociceptors
***action potentials

--therefore OPENING or CLOSING the gate
If the "gate" is opened....
-more action potentials from nociceptors
-more pain
If the gate is closed...
-less action potentials
-feel less pain
PAG
periaqueductal gray

-serotonin tricyclics
Prostaglandins _______________ the pain signal
INCREASE
Opioids ____________ the pain signal
DECREASE
Opioids ________ the gate at the posterior horn
**close

ex: when we bang our elbow/hands, we massage
it --> closes gate --> less pain perceived --> less APs get through
Substances that will stimulate pain receptors mainly are these
Prostaglandins

*mainly stimulate the perception of pain*
Prostaglandins formed from this pathway
Arachidonic Acid
NSAIDs block _____ __ receptors
COX 1 (maintenance cells)
Vioxx (rarely used now due to s/e) and Celebrex block these receptors
COX II (inflammatory cells)
Morphine like drugs are derived from _______ and can be __________ or synthetic
-opium
-natural or synthetic
Morphine acts on receptors in spinal cord and causes
-epidural analgesia
Morphine acts on receptors in brain stem and causes
respiratory depression
Morphine acts on receptors in the GI tract and causes
constipation
Morphine acts on receptors in the brain directly and/or releasing ___________ which are ____________ ____________ like substances
-endorphins
-endogenous morphine like substances
Amitriptyline is in this drug class
tricyclic antidepressant
Tricyclic antidepressants increase the amount of ______________ in PAG
serotonin
TCAs are great for this type of pain
neuropathic pain
Neurontin is this type of medication
antiseizure medication
Neurontin suppresses the spontaneous ____________ of __________
-firing of neurons
Three dosing schedules for pain
1. PCA
2. fixed
3. PRN
Best way to treat pain
PCA

*gives a constant concentration of drug maintaining patient in the therapeutic range --> no pain*
2nd best way to treat pain
Fixed

*pain fluctuates within the therapeutic range --> not as well controlled*
Why is PRN a problem in treating pain?
-experience pain, need more drugs, more prone to side effects
Pain and Clinical Sequelae: Ventilation

Splinting >>> altered respiratory pattern and effort >> _________ lung capacity >> ________ airway clearance >> retention of secretions >> (develop this airway disease) >> DECREASE PaO2 (hypoxia)
-splinting >> altered resp pattern and effort >> DECREASED lung capacity >> INEFFECTIVE airway clearance >> retention of secretions >> DEVELOP PNA >> decrease PaO2
Splinting >> altered respiratory pattern and effort >> decreased lung capacity >> __/__ abnormalities >> shunt >> __/__ mismatch >> atelectasis >> decrease Pa O2 (hypoxia)
V/Q abnormalities
V/Q mismatch
Pain increases vasopressin, _______, aldosterone, and _________ which leads to fluid retention in the __________ and ___________ in preload, this eventually leads to tachycardia
renin, angiotensin

in the kidneys

increase in preload

*can precipitate MI, if concurrent cardiac problems are present*
Pain and Perfusion....

Pain activates the _______________ nervous system and causes increase afterload and tachycardia.....this increases ____________ demand leading to myocardial ischemia
SNS

myocardial demand
Pain and Perfusion...

Pain activates the SNS which vaso-_________ and ______________ regional blood flow and ____________ wound healing
vasoconstricts

decreases

decreases
Pain and Perfusion..

Pain may make a person immobile leading to venous ________ place the patient at and ___________ risk of DVT
stasis

increased
T/F Chronic pain requires it's own form of treatment
True
T/F does chronic pain has a significance
False-no significance
Phantom pain
"original tissue injury may resolve but the pain lingers"

ex: continuous pain is a result of rewiring pathways in the brain, even when after the gangrenous limb is removed
The ANS controls __________________ body functions
involuntary
What is the main center for the control of the ANS
hypothalamus
PNS
-conserve, restore energy, "feed and breed"
SNS
mobilizes when the organism is being threatened, "fight or flight"
Humans are Homeotherms what does this mean?
"maintain a certain temperature"
As part of homeostasis we keep a constant temp: 36.0°C - 37.5 °C (97 °F - 99.5 °F )
_________________in general is the purposeful maintenance of a stable INTERNAL environment by coordinated physiologic processes that oppose change
Homeostasis

*developed certain mechanisms to maintain a certain temperature, pH, osmotic pressure of blood, BP, amount of O2 in the blood, etc.*
The way by which the organism opposes the change is the ___________________________.
the feedback mechanism
Thermoregulatory Control Loop involves (3)
(Feedback Negative)
Receptors
Hypothalamus
Effector mechanisms
Thermoregulatory Control Loop Receptors
Temperature-sensitive ion channels thru-out body, receive/integrate thermal inputs from internal/external sensors

ex: receptors sense the temp in each area --> produce a certain patter of APs --> travel to the HYPOTHALAMUS --> compares these peripheral/core signals with the set point --> if temp is > than set point, puts into motion certain mechanisms to decrease heat
In relation to thermoregulation, where would deviations be detected around a set point?
Hypothalamus: The processing center; “thermostatic comparer”
Thermoregulatory Control Loop Effector Mechanisms
Initiate compensatory responses to correct deviation; also voluntary mechanisms
Core temps > 41° C (105.8° F) or < 34° C (93.2° F) -> impaired thermoregulation
Temperature is regulated by ____________ ____________mechanisms and is a balance between: (two things)
nervous feedback;

1. Increased heat production and heat conservation
2. Decreased heat production and increased elimination
Name 2 Mechanisms of Heat Production
Hypothalamic stimulation of shivering
SNS stimulation
Heat production and SNS stimulation
Epi, NE shift body metabolism to heat production from energy generation (brown fat) especially important in infants
________________stimulation of shivering: physiology and effectiveness
Hypothalamic stimulation of shivering
Gradual increase in muscle tone
Rapid muscle oscillations (shivering)
Increases heat production 4 to 5 times the norm
Three Mechanisms of Heat Conservation
1. SNS activation
2. Abolition of sweating
3. Behavioral control
Mechanisms of Heat Loss: (5) and explain each
1. Radiation
2. Conduction
3. Convection
4. Evaporation
5. Behavioral control
Fever is elevation in body temperature that is caused by ____________-induced (upward/downward) displacement of the _____ ______ of the ________________ thermoregulatory center
Elevation in body temperature that is caused by cytokine-induced upward displacement of the set point of the hypothalamic thermoregulatory center

*Prostaglandin E2 (PGE2) will displace set point*
Fever is Caused by a number of ____________and substances called, __________ _____________
Fever is Caused by a number of MICROORGANISMS and substances called, "EXOGENOUS PYROGENS"
Exogenous pyrogens induce ____cells to produce _____-producing mediators, called “endogenous pyrogens.” Interleukins (IL-1, IL-6), TNF-α (tumor necrosis factor) act on the ______________.
This causes: ______________.
Exogenous pyrogens induce HOST cells to produce FEVER-producing mediators, “endogenous pyrogens” - Interleukins (IL-1, IL-6), TNF-α act on the HYPOTHALAMUS.
This causes FEVER.
exogenous pyogens include:
bacteria, viruses, exotoxins etc.
Describe the fever mechanism in relation to set point:
We have a normal set point ie: 37 C. First, exogenous pyrogens inffect host cells... (at this point we are infected and experience prodromal symptoms, but do not have fever)... these infected host cells (macrophages, endotheilial cells) then produce endogenous pyrogens... these endogenous pyrogens then act on the hypothalamus and change the set point... This causes shivering because our current temp (37) is much lower than the new set point: 38+, so we shiver so we can get our core temp all the way up to our new set point of 38+. We take a tylenol and it changes our set point, we break the fever and sweat to get back down to our old/current set point of 37
3 Beneficial Effects of a Fever
1) "cook" the poisons
2) Enhance immune function
3) Inhibit microbial growth

ex: if microbes grow best at 97 degrees, increasing the temp to 102 degrees will inhibit the microbes from growing as well
Below which temperature may a fever be beneficial?
40 degrees Celsius or 104 degrees Fahrenheit
A fever enhances immune function by....
increasing mobility & activity of WBCs
A fever can kill __________________ and has adverse effects on their ________________.
A fever can kill MICROORGANISMS and has adverse effects on their GROWTH.
High temperatures decrease the serum levels of which 3 elements?
What are these elements needed for?
1) zinc
2) iron
3) cooper

**these elements are needed for replication**
When someone has a fever, the body switches to which 2 forms of energy metabolism?
1) Lipolysis
2) Proteolysis

*body switches from glycolysis to lipolysis & proteolysis, depriving microbes from food sources*
Lysosomal breakdown prevents _____________ ___________ and enhances __________ and __________ function.
Lysosomal breakdown prevents VIRAL REPLICATION and enhances MACROPHAGE and NEUTROPHIL function.
5 Harmful Effects of a Fever
1) Increased basal metabolic rate
2) Rigors
3) Hypotension
4) Increase in cardiac output & heart rate
5) Temperatures over 40 degrees may not enhance immune function.
For every degree increase in body temperature, what percentage of the basal metabolic rate increases?
13%
Rigors increase the basal metabolic rate by what percentage?
400%
What are the 2 causes of hypotension associated with fever?
1) vasodilation
2) relative & absolute Hypovolemia
-sweating --> evaporate too much water
2 Situations when a Fever should be Treated
1) Fever is NOT the origin of an illness
2) Fever is the response to an illness.
Remember to treat the ________________________, not the ___________________.
Remember to treat the ILLNESS, not the FEVER.
________________ temperatures may be beneficial.
HIGHER temperatures may be beneficial.
2 Considerations when deciding whether to treat a fever or not
1) Individual patient's physiologic status
ex: older person --> increased HR from fever --> chest pain --> beneficial to give Tylenol/reduce fever
2) Evaluate benefits/risks for each patient

**make decision based on patient, NOT on temperature**
(True or False). Infants and young children have increased immune function.
FALSE

Infants and young children have DECREASED immune function.
What brain structure is not fully functional in children?
hypothalamus
Most frequent cause of fever in children is....
bacterial infections
___________ increases in temperature might indicate a ______________ infection in children.
SMALL (slight) increases in temperatures might indicate a SERIOUS infection in children.

*Treat early with antibiotics*
4 Signs of Toxicity in Children with a Fever
1) Lethargy
2) Cyanosis
3) Poor feeding
4) Labored breathing
(True or False) Baseline temperatures in the elderly tend to be lower.
True
How many degrees above baseline temperature would suggest a fever in an older adult?
2 degrees Fahrenheit

*Consider fever with increase of 2 degrees Fahrenheit above their baseline*
In 20% to 30% of the elderly, their infection will not produce a ....
fever
4 Signs & Symptoms of Infection in the Older Adult
1) Worsening mental status
2) Decreased function
3) Weakness
4) Fatigue
3 Abnormal Physiologic Process that Make it Difficult for Older Adults to Manifest with a Fever
1) Blunted response by the hypothalamus
2) Altered release of endogenous pyrogens
3) Failure of vasoconstriction & shiver
In the elderly with a fever and/or infection, _______________ therapy should be started promptly.
In the elderly with a fever and/or infection, ANTIBIOTIC therapy should be started promptly.
Hypothermia is defined as a core temperature less than .....
35 degrees Celsius or 95 degrees Fahrenheit
2 Causes of Hypothermia
1) Accidental
2) Controlled hypothermia
2 Examples of Accidental Hypothermia
1) Spontaneous decrease in core temp (ex: cold environment)
2) Submersion hypothermia
**children have better survival --> diving reflex
When is controlled hypothermia instituted ....
post cardiac arrest

**decrease oxygen requirements by brain cells**
3 Risk Factors for Hypothermia
1) Infants
2) Elderly
3) Predisposition
Why are infants at an increased risk for hypothermia?
*high ratio of surface area to body mass

-high surface area allows for more heat to escape, esp. from the head-
6 Factors that place the Elderly at an Increased Risk for Hypothermia
1) inadequate heating
2) malnutrition
3) decreased fuel for heat generation
4) loss of body fat
5) ETOH & sedatives might dull mental awareness
6) inhibit shivering
3 Conditions that Predispose people to Hypothermia
1) CV disease
2) Cerebral vascular disease
3) Hypothyroidism
8 Neurological Manifestations of Hypothermia
1) poor coordination
2) stumbling
3) slurred speech
4) irrationality
5) amnesia
6) hallucinations
7) pupil dilation
8) stupor --> death
2 Manifestations of the Skin with Hypothermia
1) blueness
2) puffiness
Hypothermia leads to a decrease in _________________ rate and _______________ and __________________ functions.
Hypothermia leads to a decrease in METABOLIC rate, and CARDIAC and RESPIRATORY functions.

**decreased respiratory rate**
With cold diuresis, fluid shifts _______________ the core and is interpreted by the brain as ________________________.

The body responds with ___________________ ___________________ that results in __________________.
With cold diuresis, fluid shifts TOWARDS the core and is interpreted by the brain as HYPERVOLEMIA.

The body responds with INCREASED DIURESIS that results in DEHYDRATION.
Major Cause of Death in Hypothermia
V-fib
3 Mechanisms for Re-Warming a Hypothermic Individual
1) Passive external
2) Active external
3) Active core
2 Examples of Passive External Mechanisms for Rewarming
1) blankets
2) warm fluids
2 Examples of Active External Mechanisms for Rewarming
1) heating pads
2) Bair-Hugger
3 Examples of Active Core Mechanisms for Rewarming
1) Warm IVFs
2) Warm oxygen
3) Extracorporeal Circulation
Rewarming collapse is a collapse of the __________ ___________ and ___________ __________ due to the rapid return of cold, acidic blood from the periphery to the center.
Rewarming collapse is a collapse of the BLOOD PRESSURE and CARDIAC OUTPUT due to the rapid return of cold, acidic blood from the periphery to the center.
Over how many hours should a person who underwent therapeutic hypothermia s/p cardiac arrest be rewarmed?
12-24 hours

**to prevent massive vasodilation**
Process of Pain Production
stimuli activate nociceptors --> produce a certain pattern of APs --> travel through sensory afferent route --> production of chemicals into the tissues --> stimulate pain receptors --> produce APs
Who manages pain in the U.S.?
*anesthesiologists --> no pain specialists in the U.S.*
An example of a feedback positive mechanism for maintain homeostasis?
*contractions with delivery/pregnancy --> maintained until baby is born
3 Ways an Organism Opposes Change via the Feedback Mechanism
1) Sensors --> detect a change & transfer the info to the center
2) Center --> compares the data to a SET point
3) Mechanisms --> return the parameter within the values of the set point
Rapid muscle oscillations
shivering
SNS Activation in Heat Conservation
increases skin vasoconstriction --> conserves the heat in the core
Abolition of Sweating in Heat Conservation
decreases evaporation at the skin level
Behavioral Control in Heat Conservation (3)
1) Physical Activity
2) Dressing
3) Moving close to a heat source
Describe Heat Loss via Radiation. Give an example.
loss through infrared rays to cooler surfaces

*60% of human heat is lost this way
*ex: decrease room temperature in a febrile patient
Describe Heat Loss via Conduction. Give an example.
loss through contact with cooler surfaces

*ex: ice packs & cooling blankets
Describe Heat Loss via Convection. Give an example.
loss through air movement around the body

ex: fans --> gets heat away from the body
Describe Heat Loss via Evaporation. Give an example.
0.5 calories is lost for each mL of water

*ex: sweating (important in hot temps)
**if it's humid, cannot evaporate heat as well