Pain

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affecitve

Back 1

emotional response to pain

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physiologic

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genetic, anatomic, physical determinants of pain: the pain process, influences how painful stimuli are recognized and described

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behavioral

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observable actions used to express or control pain

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cognitive

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beliefs, attitudes, memories, and meaning given to painful experience

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sociocultural

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includes: age, gender, education, socioeconomic status, culture, support systems. influences pain perception, beliefs, and coping strategies

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acute pain

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less than 3 months
most common reason for health care visits
sudden onset
increase HR, RR, BP, also diaphorese, pallor, anxiety, agitation, confusion, and urinary retention

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chronic pain

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longer than 3 months
no adaptive role
decrease physical activity and movement, fatigue, withdrawal from others
onset gradual or sudden

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barriers to pain assessment

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failure to assess pain [patient may no want pain meds b/c of fear of addicition]
failure to accept patient's report of pain
faiure to act on patient's report of pain
concern that analgesics will mask diagnostic information
belief that non-cancer pain is not as painful as cancer pain
belief that anxiety is the cause of pain

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common misconceptions of pain

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a uniform pain threshold exists
increased experience with pain should teach a patient to be more tolerant and cope better with it
if a patient has pain, visible sign of discomfor will be present
with repeated and prolonged exposure, patine feels less pain
if patient can use non-pharmacological measures, pain is not present
i there is no physical evidence

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weak non-opioids

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NSAIDS- decrease inflammation, block protaglandin synthesis [acetaminaphen, naproxen]
ASA- one of the oldest apin relievers and most widely used

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Mu agonist opioids

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mechanisn of action: tramission of the impulse from the spinal cord to the brainstem and thalamus, depends upon release of substance P and other neurotransmitters

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morphine

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the gold standard of comparison for all other opioid analgesics

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Fentanyl

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durgesic patches
sublimaze
remifentani-- IV, rapid onset, brief duration; about 100X more potent than morphine and is used for analgesia during surgery of comparison for all other opioid analgesics

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Meperidine

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should not be ued on a prolonged basis, no more than a few days; it produces a toxic breakdown of product, noremeperidine, that leads to seizures. not a good choice for chronic pain

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hydromorphone

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dilaudid

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oxymorphone

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numorphan

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levorphanol

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levo-dromoran

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methadone

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effective orally and has a long duration of action [long plasma life]

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moderate-strong opioids

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oxycodone [oxycontin, percocet, percodan]; hydrocodone [lortab, vicodin]; codeine, propoxyphene [darvon, darvocet]

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adjunct drugs

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antidepressant, corticosteriods, alpha-2 adrenergic agonist, psychostimulnts, muscle relaxants, anticonvulsants, antipsycholtic/ antiemetics, anesthetic/ nerve block

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Nociceptive Pain

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normal processing of stimulus that damages normal tissue or had the potential to do so if prolonged

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Trandsuction

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the process of converting one energy form into another:
nociceptors are activate, causeing a mechanical, thermal, or chemical stimulus to be converted into an action potentional.
Damaged cells release chemical substances, which either increase pain input and help activate action potentional, or they sensitize nociceptors to activation

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trandsuction therapies

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NSAIDs block at the level of the chemical substances

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transmission

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3 steps projection to the CNS, dorsal horn processing, transmission to the brain

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projection to the CNS

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transmission of this action potential along the entire neuron is necessary for the cell to deliver the pain signal to the SC

can interupt transmission at this point by local anesthetics or antiseziure drugs

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Dorsal Horn processing

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if not blocked, signal arrives in teh CNS and is porcessed within the dorsal horn of the spinal cord

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Transmission to the brain

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fiber of dorsal horn neurons then enter the brain through several pathways:
1. spinothalamic tract
2. spinyhypothlamic tract
3. spinocervical tract
4. spinoreticular tract

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Perception

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stimulus recognized as pain, involves the reticular activating system [RAS], somatosensory systmem, and limbic system

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Reticular Activating System [RAS]

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warns the individual to attend to the pain stimulus

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Somatosensory System

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responsible for individual localizing pain and identifying pain characteristics

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Limbic system

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responsible for emotional and behavioral responses to pain

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Modulation

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descending pathways are activated and can inhibit or reduce transmission of pain

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pain chemicals

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prostaglandins, bradykinin, serotonin, substance P, histamine

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superficial somatic pain

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caused by injury to skin or superficial tissues
ex: minor burn

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deep somatic pain

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pain originates from ligaments, tendons, bone, connectivetissues, or muscle

slower onset, buring quality, dull and aching

ex. sprain, break

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visceral pain

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arises from internal organs

vague, poorly localized, pressure-like, dull

ex: appendix, stomach, bladder, kidney

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referred pain:

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wheen deep somatic or visceral pain is referred to a segment of skin b/c visceral fibers synapse @ the level of the SC where fibers innervate some subcut tissue

ex: MI often felt as left arm, shoulder, or jaw pain