1. objectives
    • 1. nerves involved in somatorsensory nervous sys. and how transmission/processing occurs
    • 2.  mechanisms/modulators of pain transmission
    • 3.  how/why pain is perceived diff in body
    • 4.  clin pan of pain across life
    • 5. funct. of eye/abn condi
    • 6. funct of eat/abn condi
    • 7. migraines, MD, Glaucome, OME, AOM, Emergency occular conditions!
  2. somatorsensory alterations
    1. pain

    • 2. hearing/balance
    •     a. vertigo/tinnitus
    •         I.  central processing disorder
    •     b.  conductive hearing loss
    •     c.  sensorineural hearing loss

    • 3. visions
    •     a. structural impairment (glaucoma, cataracts, macular degen)
    •     b.  eye mvmt impairment (CN 3, 4, 6) (strabismus, ambyopia, nystagmus, diplopia)
    •     c.  error in refraction (hyperopia, myopia, presbyopia, astygmatism)

    * in eye! emergency!
  3. pain
    - transmitted by somatosensory syst
  4. CNS composed of
    • sensory receptors
    • ascending pathoways
    • and
    • processing orders
  5. affecent pathways
    promote communication from structures in periphery to brain
  6. what does not go through spinal tract first
    ears, eyes, nose, mouth- head
  7. somatosensory neuronal organization
    • first order neuron
    • second order neuron
    • third order neuron
  8. first oder neuron
    communicates sensory info w. periphery to CNS
  9. second order neuron
    relays sensory input from reflex networds and sensory pathways to thalamus
  10. third order neuron
    communicates sensory info from thalamus to cerebral cortex (primary somatosensory cortex)
  11. sensory pathway to cerebral cortex
    • receptors (mediator release (seratonin, substance P) <incr inflammaton, tissue injury>) to
    • 1st order
    • spinal cord to
    • 2nd order
    • thalmus (primary processing- basal ganglia) to
    • 3rd order
    • cerebral cortex (refined interpretation, lots of neurons!!)
  12. basal ganglia
    • group of nuclei
    • connected to thalmus
    • voluntary motor control
    • "habits"
    • parkinsons, huntingtons disease related
  13. neuronal transmission
    • nerve fibers
    • dermatome innervation
    • pathways
  14. nerve fibers (3 types)
    • a fibers-  mylenated, Fast, large
    • b fibers- mylenated, Medium, small
    • c fibers- not mylenated, Slow
  15. dermatome innervation
    • body divides into different areas where nerve bundles go
    • ex. diabetic dermatime neuropathy, shingles
  16. stimulants along pathways, autonomic responses
    incr BP, HR, activation of seat glands, dilation of pupils, constr of blood vessels
  17. pain classification (3)
    • nociceptive
    • neurogenic
    • neuropathic
  18. nociceptive pain
    • nerve pathways- interpret pain
    • "inside pain", abd
    • stimulated by chem, mech, thermal

    • transduction (nerve impulses)
    • transmission (tissues to CNS), (A fibers- sharp tingling) (C- dull, ache, burning)
    • modulation (brain, thalamus)
    • perception (sensory, emotional, subjective reactions to stimuli)

    • can be acute or chronic- physical pain
    • "punch pain"
  19. neurogenic
    • acute primary injury pain
    • trauma, injury in nerve itself, numbness
    • does not follow a typical transmission pattern of impulse conduciton
    • ex. bike ride
  20. neuropathic
    • secondary damage from another disease to nerve
    • difficult to treat
    • - diabetes affects nerve cells- slow/tingling pain
    • - shingles- 72 hrs to treat- along dermatomes!!, herpeszoster
    • - chiken pox- varicella, hangs out in basal ganglia
  21. neuropathic 1.2
    • post herpetic neuralgia: complication of shingles
    • trigeminal neuralgia: facial pain
  22. 4th pan classification! is psychologic pain
    does not have physical component
  23. pain experience- 5th VS
    • subjective - 1-10 scale, variability, "chronic pt's"
    • 3 systems:
    • sensory/discriminitive
    • motivationa/affective
    • cognitive/evaluative
  24. sensory/discriminative- syst involved in pain experience
    • is nociceptive pain
    • senses comething has occurred
    • w/dray from stimulant
    • reflex
  25. motivational /affective- syst involved in pain experience
    • determines indiv conditions
    • initial interp. of pain by body
  26. congitive/evaluative- syst involved in pain expereince
    • higher level thought
    • manifest of pain/ how we think about pain/ express it
    • - socio cult issues, surrounding pain
  27. pain characterists- locaiton
    cutaneous, deep, visceral, referred
  28. pain characteristic- quality
    sharp, burning, diffuse, throbbing, stabbing
  29. pain characteristic- duration
    • acute- less than a mo.,
    • chronic-longer than a mo., continuous pain, no dissipation of pain, chronic pain from initial injury, (neuropathic can be chronic)

    • *chronic pancreatitis- remove alch, less acute pain but still have chronic pain!!
    • sub chronic- if long pain is getting better, dissipating
  30. efferent pathway
    descends back to dorsal horn of spinal cord providing feedback to initial locaiton
  31. pain transmission
    • signal modulation
    • signal perception
  32. pain transmission- signal modulation
    • substance released during impulse- transmission
    • modulate how pain is felt

    acute pain will lesson: bc of signal modulation
  33. pain transmission- signal perception
    sensory- somatosensory cortex- and amotional- limbic syst involvement
  34. other modulators of pain- opiate receptors- cause constipation- gut stops working
    • - endorphins (powerful surpressor or pain, raise pain threshold), released by stress, exercise, sex
    • ex. accupunture, mu receptor (in brain and gut), runners higs

    - enkephalin- strong or weak analgesic?, inhibit and insite pain

    - dynorphin- 5-50x's more powerful than endorphins, impedes, incites pain signals

    - endomorphins

    - inhibitory neuromodulators- can precent pain signaling in brain (GABA, glycine, serotnonine, norepinephrine)

    - also insite pain: kinins, prosetglandins
  35. pain management
    • non pharm- mediate behavior, therpy
    •     cognitive-behavioral- meditation guided imagery, accupuncture
    •     physical agents- ice

    pharm- analgesics
  36. pain threshold
    lowest intensity at which a stimulus is perceived as painful
  37. pain tolerance
    • amt of time or intensity of pain
    • chronic- tolerence tends to rise
  38. assesspain
    • - subjective expereince
    • - older adults  won't complain use worse "achy, sore, etc"
    •       check ADL's, affect, mood, phys funct
    • - children 3-4yo use wong-baker faces pain scale
  39. pain in adv dementia (PAIN AD)
    •                              1                                    2
    • breathering-  short, hyper vent        noisy, cheyne-strokes
    • neuro-   moan groan                      crying, calling out
    • facial exp-   sad                             grimacing
    • body lang-  tense                          rigid, striking out
    • consolability- distracted             unconsolable
  40. alterations in vision- refraction
    accomodation- lens will bend to accomodate the distance the obj is, not bend enoug- errors, older- lens become tougher

    • hyperopia- does not meet at the back of eye, correction- meet in the back of the eye
    •        can see far and not near- older adults (reading), alt transmision of light

    • myopia- meets before the back of eye and crosses, correction- meet in the back of the eye
    •        can see near but not far, lens thickness

    astigmatism- irregular curvature of cornea/lens, blurring vission

    presbyopia- far sighted-ness, age-related
  41. alterations in vision- eye mvmt
    strabismus- stoke, muscle wkness, patch, cross eye, muscles not working

    amblyopia- lazy eye, results from strabismus, loss of visual detail, from uncoordinated eye mvmt and focus

    diplopia- lack of coordination, double vision, eyes in 2 different direction

    • nystagmus- involv oscil of eyes, ping pong
    • issue in vestibular region of brain
  42. alteration in vision- protective structures
    • conjunctivitis- pink eye
    •        viral- 1 eye, not too much discharge, no meds given
    •        bacterial- 2eyes, itching, tearing/discharge, redness, meds given

    cataract- clouded, cornea, eye may be aquared bc part of pupil can be cut out
  43. Macular degeneration- patho
    * one see's with retina
    degeneration of fovea- central portion of retinal macula, hardening and obstruciton of retinal arteries

    1.  dry (atrophic)- no treatment, loss of sight, Drusen deposition- yellow deposits, under macula- CHRONIC

    2. wet (exudative)- choroidal neovascularization, stoppable
  44. MD- clinical manifestations
    • distortion of central vision
    • decr ability to read, recognize faces, colors
    • blindness

    for dry/atrophic: slow progressive symptoms

    for wet/exudative: rapid and severe vission loss, dark central spot
  45. Glaucoma- pahto
    vision loss due to optic nerve damage- incr intra occular pressure- HTN in eye-in aqueous humor

    optic nerve killed bc of aqueous humor
  46. Glaucoma- primary open angle
    • patho:
    • (chronic)
    • clogged, trabecular network at the point where the iris and cornea meetimpaired aqueous humor drainage leading to  incr intraocular pressure (IOP)

    • clinical manifestations:
    • gradual, irreversible, blind spots in field of vision, initially limited to periphery, progresses centrally,
    • needs to be treated early!
  47. Glaucoma- angle closure
    • patho:
    • acute, EMERGENCY, occurrs quickly
    • rapid IOP from blocked aqueous humor drainage

    • clinical manifestations:
    • induced by incr pupil dilation
    • eye pain (EMERGENCY), headaches, nausea, blurred vision, rainbows around lights at night, damage to optic nerve leads to vision loss
  48. Glaucoma- normal tension
    poor blood flow to optic nerve
  49. Glaucoma- treatment
    give anti-hypertensive drugs
  50. Eye emergencies
    retinal detachment, loss of vision, no pain

    acute close angle glaucoma- pain, pressure, loss of vision

    herpes zoster keritis- red eye, vesicles around eyelid

    central retinal arteroccuson
  51. alterations in hearing and balance: external canal
      obsturction: cerumen, mass

      inflammation: otitis externa
  52. alterations in hearing and balance: middle ear
    • barotrauma: diving, plane, tymp membr, perforation: a hole that will heal
    • inflammation:
    •      otitis media (OME- effusion) generally blocked Eustachian tube, acute infection
    •      mastoiditis- in mostoid bone/skull by outer ear, drainage from ear, ear pain, swelling behind ear, can cause problems w/ hearing/balance

          otosclerosis- abnormal sponge like bone in middle ear

    Conductive hearing loss
  53. alterations in hearing and balance: inner ear
    • neural dysfunction
    •       sensorineural hearing loss
    •      equilibrium disruption-
    •           Meniere disease-  vertigo, when part of canal  becomes swollen

    • inflammation
    •    labyrinthitis- inner ear inflamm
  54. hearing measured in decibels and can be

    sensorineural (loud noise, makes hairs die, presbycusis),


    processing disorder (someting wrong in somator sensory)
  55. Acute Otitis Media- patho

    infection in middle ear- generally bacterial

    effusion(fluid) in middle ear creats an optimal envir. for pathogen growth

    associated w/ URI

    - first will see if it can fix on its own

    tympanic membrance: red and pushed out
  56. Otitus Media with Effusion

    effusion (fluid) in the middle ear

    trapping of fluid by obstruction in the eustachian tube

    not associated with inflammation

    tymp membr pushed out, NOT red
  57. Otitus Media clinical manifestation- general
    • acute pain
    • fever
    • impaired hearing
    • perforated tympanic membr
    • enlarged periauricular lymph nodes- mostly AOM
    • runny nose- rhinorrhea- mostly AOM
  58. Acute Otitus Media clinical manif
    • acute onset
    • middle ear effusion
    • inflammation
    • recurrent
    • greater than 3 episodes in 6 mo's or 4 over one year
  59. Otitus Media with Effusion
    middle ear effusion
  60. you are taking care of a 72 yr old M, pt develops rash, burning pain
    concerned for
    shingles herpes zosterleads to post herpatic neuralgianeuropathic pain
  61. pt: sudden loss of vision in left eye
    first send pt to ER
  62. 82 yr old pt with dementia recovering from broken hip
    more combative than usual
    caused by
    acute pain- pain is untreated or undertreated
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