Med Surg Test 1 Review (pain)

• }Whatever the person experiencing pain says it is
• }Unpleasant sensory and emotional experience associated with actual or potential tissue damage

• nociception
• }physiologic process that communicates tissue damage to CNS
• ◦Involves 4 processes
• - Transduction
• - Transmission
• - Perception
• - Modulation

• 1. Noxious stimuli causes cell damage with the release of sensitizing chemicals
• - prostaglandins
• - bradykinin
• - serotonin
• - substance P
• - histamine
• 2. These substances activate nociceptors and lead to generation of action potential

• Action potential continues from
• - site of injury to spinal cord
• - spinal cord to brainstem and thalamus
• - thalamus to cortex for processing

Concious experience of pain

Neurons originating in the brain stem descend to the spinal cord and release substances (e.g., endogenous opioids) that inhibit nociceptive impulses

• - increased cholesterol and fatty acids in blood for energy production systems
• - increased BP
• - localized inflammation (redness, swelling, heat and pain)
• - increased production of blood sugar for energy
• - decreased protein synthesis; intestinal movement (digestion); immune and allergic response systems
• - increased metabolism; e.g. faster heartbeat, faster respiration
• - faster blood clotting
• - increased stomach acids

• }Onset
• }Duration
• }Associated symptoms
• }Factors increasing or relieving pain
• }Pattern
• }LocationIntensity

• }Pain quality
• ◦Nature or characteristics
• –Sharp, aching, or burning

• }Associated symptoms
• ◦Can worsen pain
• –Anxiety
• –Fatigue
• Depression

• }Goals
• ◦Describe experience in order to treat
• ◦Identify goal for therapy and resources for self-management

• }Reduce dose of analgesic required and minimize side effects
• }Possibly alter ascending nociceptive input or stimulate descending pain modulation mechanisms

• } Massage
• }Exercise
• }Acupuncture
• }Heat or cold therapy
• }Cognitive therapies
• ◦Distraction
• ◦Hypnosis
• ◦Imagery
• ◦Relaxation
• }TENS or PENS

• Transcutaneous Electrical Nerve Stimulators (T.E.N.S)
• - generate electrical impulses sent through electrodes strategically placed over nerve centers.

• }Neuroaugmentation
• ◦Electrical stimulation of brain and spinal cord
• ◦Usually for intractable back pain
• ◦http://www.drkoop.com/video/93/13000.html

• }Nerve blocks
• ◦Interrupt all afferent and efferent transmission, not only nociceptive input ◦Used during and after surgery to manage pain

• }Neuroablative techniques
• ◦For severe pain unresponsive to other therapy
• ◦Destroy nerves to stop transmission

• ◦Nonopioid
• –Analgesic ceiling=Increasing dose above upper limit produces no greater analgesia
• –Do not produce tolerance or addiction
• –Many OTC

• ◦Opioid
• –Bind to receptors in CNS
• –Inhibition of transmission of nociceptive input
• –Common side effects
• –Constipation (most common)
• –Nausea/vomiting
• –Sedation
• –Respiratory depression
• –Pruritus

• ◦Co-analgesic or adjuvant
• –Used in conjunction with opioids & nonopioids
• –Generally developed for other purposes, but also effective for pain
• –Antidepressants
• –Antiseizure drugs
• –b2-Adrenergic agonists
• –Corticosteroids
• –Local anesthetics

• ◦Focus on prevention or control
• ◦Do not wait for severe pain
• ◦Constant pain requires around-the-clock administration (not PRN)
• ◦Fast-acting drugs for breakthrough pain

• ◦Dose adjustment based on assessment of analgesic effect versus side effects
• ◦Use the smallest dose to provide effective pain control with fewest side effects

• }Example:
• ◦1100- c/o severe pain in left foot-rated 8/10- describes as throbbing & constant-onset ½ hr ago- states “it started when I got out of bed this morning and put my foot down”- left foot pink & warm to touch- pedal pulses =88 & equal B-homan’s sign neg- DTRs 2+ B.
• ◦(goal and nursing diagnosis implied & doesn’t need to be charted)
• ◦1110- Repositioned foot without relief-massaged foot without relief obtained
• ◦1120- medicated with Tylenol #3 2 tabs PO
• ◦1145- stated “I’m comfortable. My pain is much better now”- rated 2/10

• –Need for increased dose to maintain same degree of pain control
• –Not as common as once thought
• –Rotate drug if tolerance develops, as increasing dose could contribute to hyperalgesia (extreme sensitivity to pain)

• –Expected response to ongoing exposure to pharmacologic agents manifested by withdrawal syndrome when blood levels drop abruptly
• –To avoid withdrawal, drug should be tapered

• –Neurobiologic condition with drive to obtain and take substances for other than prescribed therapeutic value
• –Tolerance and physical dependence not indicators of addiction