LECTURE\POWERPOINT

MI [TRANS] LESSON 1: CARE AT RISK AND SICK CLIENTS WITH ALTERATION AND PROBLEMS

OUTLINE
I Pain
A Pain Threshold
B Pain Tolerance
C Pain Mechanism
i Cardinal Sign of Inflammation
ii Process
D Classification of Pain
i Nociceptive Pain • Stimulus up until the occurrence of pain complaint is called
ii Neuropathic Pain
Pain Tolerance.
iii Acute Pain
iv Chronic Pain
E Theories of Pain PAIN MECHANISM
i Nociceptive Pain • Nociception – process where tissue damage is
ii Neuropathic Pain communicated to the CNS.
iii Acute Pain • Nociceptors – receptors that (accept) perceived pain
F Pain Assessment stimulus.
II Nursing Implication
Stimulus
III Principles of Pain treatment
IV Pharmacologic Therapy
A Nonopioids
B Opioids Body
C Adjuvent Therapy
V Interventional therapy
A Therapeutic Nerve Blocks Damage injury
B Neuroaugmentation
VI Nondrug therapies
A Physical Pain Relief Strategies Nocicepteros
Inflamatory
Chemicals
B Cognitive Therapies

Action Potential Nerve Impulses

PAIN
• Pain – Unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or A & C Fibers
described in terms of such damage
o Cause: Physiologic alteration and Psychological
and emotional Dorsal horn
o (+) self-report

PAIN THRESHOLD thalamus

• Point/ amount (degree) at which stimulus needed to

perceived pain.
Cortex (lobe)
• Degree of pain may vary to one person or another.

interpretation

perception

Figure No.1
• Inflammatory chemicals
o Kinins (bradykinin)
o Prostaglandin
• Stimulus up until (the person feels pain) perception is called
o Histamine
Pain Threshold. • Two types of never impulses
• A fiber – myelinated sheet (fast transmission)
PAIN TOLERANCE o Acute Pain
• Time/ intensity of pain endured before initiation of over pain • C fibers – unmyelinated (slow transmission)
response & patient complain. o Chronic Pain
• Tolerance Increase  = alcohol consumption, medication,
hypnosis, warmth, distraction
CARDINAL SIGN OF INFLAMMATION
• Tolerance Decrease  = repeated exposure, fatigue, anger,
apprehension, sleep deprivation. • Calor (warmth)
• Rubin (redness)
• Tumor (swelling)
• Dolor (pain)
• Functio laesa (loss of function)

PROCESS

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• TRANSDUCTION – conversion of noxious stimuli (mechanical, • Specificity Theory (Sensory Theory)
thermal, chemical) into electrical signal (action potential). • Pattern Theory (Intensity Theory)
• Nociceptors • Gate Control Theory
o Histamine • Central Control Theory
o Bradykinin
o Prostaglandin SENSORY THEORY
o Substance P
• Specificity Theory
o Serotonin
• Pain is a sensory phenomenon (specific receptors, routes of
• TRANMISSION – signals relayed from periphery to spinal cord
transmission – CNS, center of registration, appreciation and
to the brain.
interpretation of the brain).
o A-delta Fiber – myelinated fibers (sharp pain)
o C Fibers – unmyelinated fibers (aching or throbbing)
o Transmission to Spinal Cord PATTERN THEORY
o Dorsal Horn Processing • Intensity Theory
o Transmission to Thalamus and Cortex • Pain is produces by intense stimulation of nonspecific fiber
• PERCEPTION – pain is recognized, defined and assigned receptor.
(conscious experience). • “any stimulus could be perceived as painful if the stimulation
• MODULATION – activation of descending pathway that exert were intense enough”.
effects on pain transmission.
o Areas: periphery, spinal cord, brainstem or cerebral GATE CONTROL THEORY
cortex • Substantia gelatinosa (dorsal horn) acts a a gate mechanism
o Chemical: (inhibitory neuro transmitters) serotonin, that can close and open to pain impulses
Norepinephrine, GABA, endogenous opiods, • (+) nerve message is pain = gate opens to the brain
endorphins.
• (+) conflicting impulses from on large diameter nerve fibers
from reticular formation/thalamus → gate closes.
CLASSIFICATION OF PAIN
• Nociceptive Pain CENTRAL CONTROL THEORY
• Neuropathic Pain
• Acute Pain • Brain opiates (analgesic properties) release are affected by
actions initiated by the care giver.
NOCICEPTIVE PAIN
PAIN ASSESSMENT
• Normal processing that damages normal tissue • Goal:
• Brought about cellular or tissue damage o Describe the pain experience
o SOMATIC – superficial and deep o Identify the goal for therapy and resources of self-
▪ Superficial: skin, mucous membranes & management
subcutaneous (sharp, burning or prickly) • Principles:
▪ Deep: bone, joint, muscle, skin & connective o Patient right to appropriate assessment and
tissues (deep, aching, throbbing) management.
o VISCERAL – internal organs and lining of body o Always subjective!
cavities d/t inflammation, stretching & ischemia. o Physiologic and behavioral signs of pain are not
reliable or specific
NEUROPATHIC PAIN o Unpleasant sensory and emotional experience
• Abnormal processing caused by damage to peripheral o Assessment approaches (tools) must be
nerve or structures of the CNS. appropriate
o CENTRAL: primary lesion or dysfunction in CNS o Exist even when no physical cause
▪ E.g., post-stroke, multiple sclerosis pain o Different experience and levels
o PERIPHERAL NEUROPATHIES: delt along the o (+) Chronic pain – may be more sensitive
distribution of one or many peripheral nerves d/t o Unrelieved pain has adverse consequences.
nerve damage
▪ E.g., DM neuropathy, trigeminal neuralgia, ELEMENETS OF ASSESSMENT
herpetic neuralgia. • PATTERN:
ACUTE PAIN o Pain onset
• Onset: Sudden o Duration
• Duration: <3mos, or until healing o Breakthrough Pain – transient pain even with RTC
• Cause: can identify a precipitating event medication
• Course:  overtime up to recovery o Incident Pain – transient pain cause by specific
• S/Sx: activity
o (1) SNS response • LOCATION:
o  HR, BP. RR o Origin and radiation
o Diaphoresis, pallor, anxiety, agitation, urine • INTENSITY
retention. o Numerical analogue scale
CHRONIC PAIN o Wrong-baker FACES Pain scale
• Onset: gradual or sudden
• Duration: >3mos (acute → past normal recovery)
• Cause: may not be known, differ from other mechanisms
• Course: does not go away → Intractable Pain
• S/Sx:
o Flat affect
o  physical activity fatigue, withdrawal from
interaction.

PAIN THEORIES • QUALITY

IBARRA. MARIANO. ONG. PECUNDO. PERALTA. RICO 2

 [TRANS] LESSON 1:
o Nature and characteristics
▪ E.g. sharp, dull, throbbing, excruciating THERAPEUTIC NERVE BLOCKS
• PQRST OF PAIN • Infusion of local anesthetics to a particular area (regional
o P: Predisposing/ Provoking anesthesia)
o Q: Quality • Local infiltration of nerve injection
o R: Radiation
o S: Severity NEUROABLATIVE TECHNIQUE
o T: Time
• Severe pain unresponsive to other therapies
• DOCUMENTATION
• Destroy nerves by surgical resection, thermocoagulation or
• REASSESSMENT
radiofrequency.
o E.g. sensory nerve (rhizotomies), spinal cord
NURSING IMPLICATIONS (cardotomies), medulla (tractotomies).
• Assess pain in all patients
• Self-report is the single most indicator
NEUROAUGMENTATION
• Do not rely primarily on observations and objective signs
• Electrical stimulation of the brain/ spinal cord
• Address both physical & psychologic aspect
o E.g. chronic back pain
• Special considerations in communication problems
• Include family members (when appropriate)
NONDRUG THERAPIES
• No uniform pain threshold
• Physical Pain Relief Strategies
• Pain tolerance varies
• Cognitive Therapies
• Encourage patient to report pain.

PRINCIPLES OF PAIN TREATMENT PHYSICAL PAIN RELIEF STRATEGIES

• Massage
• Follow the principles in pain assessment
• Exercise
• Use a holistic approach
• Acupuncture
• Every patient deserves adequate management
• Heat & Cold Therapy
• Base treatment plan on patient’s goal
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Use both drug and nondrug therapies
• Use a multimodal approach to analgesic therapy (when
appropriate) COGNITIVE THERAPIES
• Use a multidisciplinary approach • Distraction
• Evaluate the effectiveness of all therapies • Hypnosis
• Prevent or manage medication side effects • Relaxation Strategies
• Patient and caregiver teaching o Relaxation breathing
o Imagery
o Meditation
PHARMACOLOGIC THERAPY
o Art & music therapy
• Nonopioids
• Opioids
• Adjuvent Therapy
REFERENCES
NONOPIOIDS Notes from the discussion by Prof. Jierico Paul C. Batario
• Mild to moderate pain
• Used in conjunction with opiods (opiod-sparing effect) Manila Doctors Colleges of Nursing PowerPoint Presentation:
(1) Analgesic ceiling
(2)  Tolerance/ dependence
(3) OTC
• ACETIMINOPHEN: Analgesic + antipyretic
o  Hepatotoxicity
o  Antiplatelet
• Anti-inflammatory
o SALICYLATES:  GI Bleeding
o NSAIDS: COX-1 → Protective functions
▪ COX-2 → Produced in site of injury

OPIOIDS
• Moderate to severe pain
• Binds to CNS receptors
(1)  nociceptive input from periphery to spinal cord
(2) After limbic system activity
(3) Activate descending inhibitory pathway

ADJUVENT THERAPY
• Corticosteroids
• Antidepressants
• Antiseizure Drugs
• GABA Receptor Agonist
• Alpaha-Adrenergic Agonist
• Local Anesthetics
• Cannabinoids

INTERVENTIONAL THERPAY
• Therapeutic Nerve Blocks
• Neuroaugmentation

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