CONCEPT OF PAIN“Whatever the person say it is, existing whenever theexperiencing person says it does”. :CONCEPT OF PAIN“Whatever the person say it is, existing whenever theexperiencing person says it does”. REY VINCENT H. LABADAN, RN FAMADOR O. GENALDO, RN MD


Slide 2:PAIN Pain is the most common reason for seeking health care Associated with actual or potential tissue damage American Pain Society: Pain, “The Fifth Vital Sign” Nurses, are primary advocate to pain relief Nurses have the capability to relieve pain merely by acknowledging the discomfort and confirming that measure will be taken.


Slide 3:DEFINITIONS OF PAIN It is a multidimensional phenomenon and is thus difficult to define It is a personal and subjective experience, and no two people experience pain in exactly the same manner It is best viewed as an experience, not merely as a manifestation of the disease condition IASP, offered the accepted medical definition as: an unpleasant sensory and emotional experience associated with actual or potential tissue damage.


Slide 4:DEFINITIONS OF PAIN According to Sternbach, pain is an abstract concept which refers to: A personal, private sensation of hurt A harmful stimuli that signals current or impending tissue damage A pattern of response to protect the organism from harm McCaffery: Pain is whatever the experiencing person says it is and existing whenever the person says it does. This makes the person the expert of his or her pain


Slide 5:DEFINITIONS OF PAIN Because clinical pain is subjective, the only people who can accurately define their own pain are those who are experiencing the pain Despite its subjective nature, the nurse is charged with accurate assessing and helping to relieve pain REMEMBER: all pain is real even if the cause can not be ascertained


Slide 6:PROBLEM OF PAIN (BARRIER OF PAIN RELIEF) Pain serves as a mechanism to warn us about the potential for physical harm in the natural environment It is the body’s protective mechanism to prevent tissue damage by providing the drive to withdraw from the pain-producing situation The discomfort and distress associated with pain often last far beyond the tissue-damaging experience Pain is the primary reason people seek health care and is associated with the length of hospital stay, longer recovery time, and poorer client outcomes Clients should be truthful in the onset and description of pain in order for the health care provider to give the proper medications


Slide 7:SPECIFIC BARRIER TO PAIN RELIEF Barriers Related to Healthcare Professionals: Inadequate or inaccurate information about pain management Inadequate or sub-optimal pain assessment techniques Concern about overuse of controlled substances and subsequent client addiction Concern about excessive adverse effects Concern about clients developing tolerance to analgesics


Slide 8:SPECIFIC BARRIER TO PAIN RELIEF Barriers Related to the Healthcare System: Low priority given to pain treatment in relation to other client needs Inadequate reimbursement for other or costly pain management therapies Restrictive regulation of controlled substances


Slide 9:SPECIFIC BARRIER TO PAIN RELIEF Less than optimal availability or access to treatment; Opioids are often unavailable in inner-city pharmacies as well as rural areas Nurses should work to ensure that necessary medications are available for clients, regardless of the environment


Slide 10:SPECIFIC BARRIER TO PAIN RELIEF Barriers Related to Clients: Reluctance to report pain or to take pain medications Fear that pain indicates the disease process is progressing Concern about being thought about as a complainer Reluctance to take medications for a variety of reasons Concern about adverse drug effects Concern about developing tolerance or addiction to pain medications


Slide 11:SPECIFIC BARRIER TO PAIN RELIEF Cost is a significant barrier to good analgesia; Health care providers should understand the causes of pain and the management in order to relieve the client from pain. Education is the primary action to begin to remedy the problems


Slide 12:Client Education Nurses can reassure clients that pain control is every client’s right Health professionals rely on the client to report pain, and that pain management will improve quality life Proactive education of clients and family / support persons is necessary, including information about addiction, drug tolerance, and physiological dependence Clients may use such terms as “hooked” when referring to addiction: Addiction: the compulsive use of a substance despite negative consequences, such as health threats or legal problems – 3 C’s SPECIFIC BARRIER TO PAIN RELIEF


Slide 13:Clients may express anxiety about becoming “immune” to medication when discussing drug tolerance: Tolerance: The process by which the body requires a progressively greater amount of a drug to achieve the same result. Clients may worry about developing a physical drug dependence Dependence: A biologic need for a substance; if the substance is not supplied, physiological withdrawal symptoms occur Give clients permission to discuss concerns and fears SPECIFIC BARRIER TO PAIN RELIEF


Slide 14:Pain perception, or interpretation, is an important component of the pain experience Pain is perceived and interpreted based on the individual experience, thus pain is different for each person   Pain perception does not depend solely on the degree of physical damage Both the physical stimuli and psychosocial factors can influence the experience of pain PERCEPTION OF PAIN


Slide 15:It is likely determined by the relative balance between sensory peripheral input and the mechanism of central control in the brain Pain perception is influenced by one’s tolerance for pain PERCEPTION OF PAIN


Slide 16:Pain Threshold The lowest intensity of a painful stimulus that is perceived by the person as pain May vary according to physiologic factors such as inflammation or injury near pain receptors Essentially similar to all people if the CNS and the PNS are intact PERCEPTION OF PAIN


Slide 17:Pain Tolerance The amount of pain the person is willing to endure It is different for each person who experience pain, based on subjective factors such the meaning of the pain and the setting Some people have a high tolerance, e.g., they can tolerate a lot of pain without distress Only the person, not the health care team, can determine the person’s tolerance level PERCEPTION OF PAIN


Slide 18:TYPES OF PAIN Acute Pain Chronic Pain   Acute Pain Short duration (<6 months) Has an identifiable, immediate onset e.g. incisional pain after surgery Has limited and predictable duration e.g. postoperative pain disappears after wound healing


Slide 19:Described in sensory terms, such as “sharp”, “stabbing”, and “shooting” It is considered a useful and limiting pain : indicates injury and motivates the person to obtain relief by treatment of the cause. Acute pain is usually reversible or controllable with adequate treatment. Once the pain is relieved, the person returns to the pre-pain state. TYPES OF PAIN


Slide 20:Observable physiologic responses in acute pain: ↑ or ↓ BP Tachycardia Diaphoresis Tachypnea Focusing on pain Guarding the painful part The CVS and RS responses are due to the stimulation of the Sympathetic Nervous System as part of the fight or flight responses TYPES OF PAIN


Slide 21:Four Major Pain Management Goals: Reduce the incidence and severity of acute postoperative or post-traumatic pain Encourage clients to communicate unrelieved pain so that they can receive prompt evaluation and effective treatment Enhance comfort and satisfaction Contribute to fewer postoperative complications and shorter stays after surgical procedures TYPES OF PAIN


Slide 22:Chronic Pain A major health concern Defined in vague terms with some of unknown causes Lasts longer period of time and is not readily treatable Mental response of the person to pain depends on its duration and intensity The course of chronic pain usually takes months and years of pain Diverse treatment modalities have been used to treat the symptoms TYPES OF PAIN


Slide 23:Associated with withdrawal and despair, anxiety and depression Some clients learn to adapt and cope with pain, adjusting their lives Most people undergo major affective and behavioral changes when experiencing pain for prolonged periods : Chronic Pain Syndrome TYPES OF PAIN


Slide 24:Characteristics of Clients with CPS: Depressed mood ↑ or ↓ Appetite and weight Drastically restricted activity level leading to ↓ work capacity poor physical tone, ↑ depression Social withdrawal Preoccupations with the physical manifestations Poor sleep and chronic fatigue, resulting from inactivity, analgesics, depression and from pain TYPES OF PAIN


Slide 25:TYPES OF PAIN Types of Chronic Pain Chronic non-malignant pain e.g. Osteoarthritis Chronic, intermittent pain e.g. Migraine headache Chronic malignant pain e.g. Cancer pain


Slide 26:Chronic Non-Malignant Pain Usually considered in pain that lasts more than 6 months, or 1 month beyond the normal end of the condition causing the pain It is continuous or persistent and recurrent It is a frustrating condition, making it difficult for the person to live a normal life The pain is exhausting both physically and emotionally for themselves and their families Causes the person to be fearful, tense, fatigue, tending to become withdrawn and isolated Health care providers may feel frustrated and incompetent when their attempts to relieve chronic pain are ineffective TYPES OF PAIN


Slide 27:Chronic Intermittent Pain Refers to exacerbation or recurrence of the chronic condition The pain occurs only at specific periods, at other times the client is free from pain Pain management is directed toward the control of pain in such the same manner as that for individual with acute pain episodes e.g. migraine headache, abdominal pain of IBS TYPES OF PAIN


Slide 28:Chronic Malignant Pain Cancer–related pain Considered to have the qualities of both the acute and the chronic pain Encompasses neuropathic, deep visceral, and bone pain A diagnosis of cancer adds to the psychological component associated with potential physical deformity and the potential for impending death, preceded by agonizing suffering The mental anguish may intensify the perception of pain TYPES OF PAIN


Slide 29:Sources of Noxious Stimuli for Clients with Cancer Cell destruction: cell necrosis, ulceration, tumor invasion, tissue injury Inflammation: products of cell destruction Infection: bacterial invasion Ischemia/Hypoxia: edema, hematoma, occlusion of vessel by the tumor Noxious stretch/pressure: distention of thoracic and abdominal viscera, fascia, periosteum, occlusion of GIT and GUT structures, obstruction of ducts Nerve injury: direct injury through incising nerve structures, tumor invasion of peripheral nerves, spinal cord, and brain, chemotherapy and radiation injury TYPES OF PAIN


Slide 30:Comparison of Acute and Chronic Pain TYPES OF PAIN


Slide 31:Categories of Pain According to Origin Cutaneous Originates in the skin or subcutaneous tissue e.g. a paper cut causing a sharp pain with some burning Deep Somatic Arises from ligaments, tendons, bones, blood vessels, and nerves It is diffuse and tends to last longer than cutaneous pain e.g. ankle sprain TYPES OF PAIN


Slide 32:Visceral Results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax Tends to appear diffuse and feels like deep somatic pain e.g. burning, aching, or a feeling of pressure Frequently caused by stretching of the tissues, ischemia, or muscle spasm e.g. obstructed bowel TYPES OF PAIN


Slide 33:Description of Pain According to where it is experienced in the body:   Radiating Pain Perceived at the source of pain and extends to nearby tissues e.g. cardiac pain felt not only in the chest but also in the left shoulder and arm Referred Pain Felt in the part of the body that is considerably removed from the tissues causing the pain e.g. pain from one part of the viscera maybe perceived in an are of the skin remote from the organ causing the pain TYPES OF PAIN


Slide 34:Other Types of Pain   Intractable Pain Pain that is highly resistant to relief e.g. pain from advance malignancy   Neuropathic Pain The result of current or past damage to the peripheral or central nervous system and may not have a stimulus for pain Long lasting and unpleasant Described as burning, dull, and aching With episodes of sharp, shooting pain can be present TYPES OF PAIN


Slide 35:Phantom Pain A painful sensation perceived in the body part that is missing or paralyzed by spinal cord injury A neuropathic pain Episode of this pain type can be reduced if analgesia is given via the epidural catheter prior to amputation e.g. amputated leg   Phantom Sensation The feeling that the missing part is still present TYPES OF PAIN


Slide 36:Nociception: The process of how pain is recognized consciously Four Steps of Nociception: Transduction Transmission Perception Modulation PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 37:Transduction Conversion of a stimulus to an action potential at the site of tissue injury Chemicals are released with cellular damage from such things as burns, radiation, pressure, tears, and cuts These chemicals sensitize the Primary Afferent Nociceptors (PANs) , fibers that carry the pain stimuli Aδ(delta) fibers: fast pain C fibers: slow pain Analgesics that work to block transduction, interferes the the production of chemicals that sensitize the PANs to begin the action potential NSAIDs: block the formation of prostaglandins PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 38:Transmission The neuronal action potential is transmitted to and through the CNS so it can be perceived The impulse is projected to the spinal cord It is processed in the dorsal horn - Referred Pain It is then transmitted to the brain   Analgesics that work at the level of transmission stabilize membranes by inactivating sodium channels, thus inhibiting action potential PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 39:Pain Perception The experience of pain occurs in the cortex May occur at a basic level in the thalamus   Modulation Efferent fibers descending from the brain stem modulate or alter pain PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 40:Theories of Pain Specify Theory Pattern Theory Gate Control Theory Specificity Theory Proposes that body’s neurons and pathways for pain transmission are specific, similar to other senses like taste Free nerve endings in the skin act as pain receptors, accept input, and transmit impulses along highly specific nerve fibers Does not account for differences in pain perception or psychologic variables among individuals PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 41:Pattern Theory Identifies two major types of pain fibers: rapidly and slowly conducting fibers Stimulation of these fibers forms a pattern; impulses ascend to the brain to be interpreted as painful Does not account for differences in pain perception or psychologic variables among individuals PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 42:The Gate Control Theory of Pain Offers an explanation for why such interventions as the TENS (trans-electrical nerve stimulator), heat and cold, and massage are effective These are theoretical gates in the dorsal horn Pain impulses can be modulated by a transmission blocking action within the CNS Large-diameter cutaneous fibers can be stimulated (e.g. by rubbing) and may inhibit smaller diameter fibers to prevent transmission of the impulse (“close the gate”) PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 43:Small-diameter nerve fibers carry pain impulses through a gate, but large diameter sensory nerve fibers going through the same gate can close the gate and inhibit transmission PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 44:PATHOPHYSIOLOGIC BASIS OF PAIN Schematic presentation of gate-control


Slide 45:The Pain Pathway Pain is perceived by the nociceptors in the periphery of the body (e.g., skin; transmitted through small afferent A-delta and C nerve fibers to the spinal cord A-delta fibers myelinated and transmit impulses rapidly producing sharp, acute pain sensations   C fibers are not myelinated and transmit pain more slowly; Impulses are generated from deeper structures such as muscle and viscera, producing more aching, chronic pain sensations Secondary neurons transmit the impulses from the afferent neurons through the dorsal horn of the spinal cord; PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 46:A synapse in the substantia gelatinosa occurs; Impulses cross over to anterior and lateral spinothalamic tracts Impulses ascend the anterior and lateral spinothalamic tracts and pass through the medulla and midbrain to the thalamus Pain impulses are perceived, interpreted, and a response is generated in the thalamus and cerebral cortex PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 47:PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 48:Stimuli For Pain The type of nerve receptors responsible for pain sensation is called nociceptor These receptors are located at the ends of small afferent neurons and are woven throughout all body tissues except the brain They are specially numerous in the skin and muscle A non-nociceptor is a nerve fiber that does not usually transmit pain Pain occurs when nociceptors are stimulated by a variety of factors PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 49:Painful Stimuli Causative Factors: Microorganisms: Pneumonia Inflammation: Arthritis Impaired blood flow: Angina Heat: Sunburn Electricity: Electrical burn Obstruction: gallstone Spasm: Muscle cramp Swelling: Cellulitis   The intensity and duration of stimuli determine the sensation Long-lasting, intense stimulation results in greater pain than brief, mild stimulation Nociceptors are stimulated either by direct damage to the cell or local release of biochemicals secondary to cell injury PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 50:Biochemical Sources:   Bradykinin : An amino acid, appears to be the most potent pain-producing chemical Prostaglandins: Chemical substances that increase the sensitivity of pain receptors by enhancing the pain-provoking effect of bradykinin   Histamines Hydrogen ions PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 51:Inhibitory Mechanisms of Pain Efferent fibers run from the reticular formation and mid-brain to the substantia gelatinosa in the dorsal horns of the spinal column Along these fibers, pain transmitted may be inhibited, although the exact process of the mechanism is not understood Endorphins (endogenous morphines) are natural occurring peptides present in neurons of the brain, spinal cord, and GIT PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 52:They work by binding with opiates receptors on the neurons to inhibit pain impulse transmission They are released in the brain in response to afferent noxious stimuli They are released in the spinal cord in response to efferent impulses PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 53:PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 54:Mechanisms of Altering Pain Endogenous Opioids Naturally occurring, morphine-like chemicals made in the CNS to inhibit transmission of pain by binding to opioid receptors in the CNS to block the transmission of nociceptive signals e.g. endorphin, norepinephrine, enkephalin   The endogenous analgesia center in the midbrain produces profound analgesia when stimulated Many analgesics modulate pain by mimicking endogenous neuromodulators The variability of individual endorphin levels may explain the fact that pain tolerance to the same stimulus are different from person to person PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 55:Surgical treatment of intractable pain (chronic progressive pain that is unrelenting and severely debilitating) interrupts the pain pathways PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 56:Types of Procedure: Nerve Block: destroys nerve roots chemically with phenol or alcohol Rhizotomy: destroy sensory nerve roots destroys sensory nerve roots at the level of entry into the spinal cord Cordotomy: transect the spinal pain pathway before the impulses ascend the spinothalamic tracts PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 57:PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 58:PATHOPHYSIOLOGIC BASIS OF PAIN


Slide 59:The body’s response to pain is a complex process rather than a specific action It has both physiologic and psychosocial aspects Initially the Sympathetic Nervous System respond → fight-or-flight response As pain continues, the body adapts as the Parasympathetic Nervous System takes over → reversing many of the initial physiologic responses This adaptation to the pain occurs after several hours or days of pain The actual pain receptors adapt very little and continue to transmit pain message RESPONSE TO PAIN


Slide 60:The person may learn to cope with pain through cognitive and behavioral activities: diversions, imagery, excessive sleeping The individual may respond to pain by seeking out physical interventions to manage the pain: analgesics, massage, exercise Signs and Symptoms of pain: ↑ BP; ↑ HR;↑ RR Hypermotility Agitation Anxiety Grimacing Dilated pupils Crying and depression RESPONSE TO PAIN


Slide 61:Proprioceptive Reflex   Occurs with simulation of pain receptors Impulses → sensory pain fibers → spinal cord → synapse with → motor neurons → travels back → motor fibers → muscles near the site of pain → contracts in a protective action   The Reflex Arc Stimulus - Sensory receptor in the skin – Sensory transmission – Sensory nerve fibers – Spinal nerve - Spinal cord – Dorsal root (horn) – Interneuron – Anterior horn – Motor transmission - Motor nerve fiber – Effector muscles - Response RESPONSE TO PAIN


Slide 62:RESPONSE TO PAIN


Slide 63:Tools & Instruments Used These provide the client and nurse with an easy method to quantify pain A verbal report using intensity scale is a fast easy, and reliable method allowing the client to state pain intensity Thus, promoting consistent communication among the nurse, client, and other healthcare professionals about the client's pain status   Commonly used tools: “0-5” or “0-10” scale Visual analog scale: pain intensity scale FACES pain scale PAIN ASSESSMENT


Slide 64:Fig. 1 Numeric Pain Intensity Scale ↑ Fig. 2 Visual Analogue Scale ↑ Fig. 3 Face Pain Scale ↑


Slide 65:Physiologic Indicators of Pain Facial and vocal expression maybe the initial manifestations of pain Rapid eye blinking Biting the lip Moaning and crying, screaming Either closed or clenched eyes Stiff unmoving body position PAIN ASSESSMENT


Slide 66:ABCD Method of Pain Assessment The acronym was developed for CA pain; however, it is also appropriate for clients with any type of pain, regardless of the underlying disease   A – Ask about pain regularly; assess pain systematically B – Believe the client and family about the reports of pain and what relieves it C – Choose pain control options appropriate for the client, family, and setting D – Deliver the intervention in a timely, logical, and coordinated fashion E – Empower client and families, enable them to control their course to the greatest extent possible PAIN ASSESSMENT


Slide 67:PQRST Assessment for Pain Perception This method is especially helpful when approaching a new pain problem P – Pattern of pain; what precipitated the pain? Q – Quality and quantity of pain: sharp, stabbing, aching, burning, stinging, deep, crushing, viselike, or gnawing R – Radiation of pain to other areas of the body; the region of the pain S – Severity of the pain T – timing of the pain; when does it begin? How long does it last? How it is related to other events in the client’s life and activities? PAIN ASSESSMENT


Slide 68:Ethnic and Cultural Values Behavior related to pain is a part of socializing process Individuals in one culture may have learned to be expressive about pain, whereas individuals from another culture may have learned to keep those feelings to themselves and not bother others Cultural background affect the level of pain that an individual is willing to tolerate Middle Eastern and Africans: self-inflection of pain is a sign of mourning or grief Other cultures: pain is anticipated as a ritualistic practices - tolerance of pain signifies strength and endurance Northern Europeans: more stoic and less expressive of their pain than from the Southern Europeans FACTORS AFFECTING PAIN EXPERIENCE


Slide 69:Developmental Stage Anatomic, physiologic, and biochemical elements necessary for pain transmission are present in newborns, regardless of their gestational age Children maybe less able to articulate their experience or needs related to pain resulting to under treatment Prevalence of pain in the older population is generally higher due to both acute and chronic disease conditions Pain threshold does not appear to change with aging, although the effect of analgesics may increase due to physiologic changes related to drug metabolism and excretion FACTORS AFFECTING PAIN EXPERIENCE


Slide 70:Environment and Support People Strange environment, like the hospital, can compound pain Person with no support network may perceive pain as severe compared to person with supportive people around   Past Pain Experience Previous pain experience alter a client’s sensitivity to pain People who personally experience pain or who have been exposed to the suffering of someone close are more threatened by anticipated pain than people with no experience FACTORS AFFECTING PAIN EXPERIENCE


Slide 71:Meaning of Pain Some clients may accept pain more readily than others, depending on circumstances and the client’s interpretation of its significance A client who associates the pain with a positive outcome may withstand the pain amazingly well e.g. a woman giving birth, An athlete undergoing knee surgery to prolong his career Clients with unrelenting chronic pain may suffer more intensely: respond with despair, anxiety, and depression and pain is looked on as a threat to body image or lifestyle and as a sign of impending death FACTORS AFFECTING PAIN EXPERIENCE


Slide 72:Anxiety and Stress Anxiety often accompanies pain The threat of the unknown and the inability to control the pain or the events surrounding it often augment the pain perception Fatigue reduces a person’s ability to cope, thereby increasing pain perception When pain interferes with sleep, fatigue and muscle tension often result and increase the pain: Cycle of Pain-Fatigue-Pain FACTORS AFFECTING PAIN EXPERIENCE


Slide 73:People in pain who believe that they can control their pain have decreased fear and anxiety, decreasing their pain perception A perception of lacking in control or a sense of helplessness tends to increase pain perception Clients who are able to express pain to an attentive listener and participate in pain management decisions can increase a sense of control and decrease pain perception FACTORS AFFECTING PAIN EXPERIENCE


Slide 74:Pharmacologic Pain Management   Opioids or Full Agonist Narcotic Analgesics Opioids are morphine-like compounds that produce systemic effects including pain and sedation   Relieve severe pain by binding to opioid (kappa, mu, and sigma) receptor sites in the CNS Agonists: substances that when combined with opioid receptor produces the drug effect or desired effect  e.g. Morphine sulfate, Meperidine (Demerol), Codeine, propoxyphene (Darvon) PAIN MANAGEMENT


Slide 75:Mechanism of action: Opioids block the release of neurotransmitters involved in the processing of pain Routes of delivery: oral, transdermal, continuous subcutaneous infusion (CSCI), IM, intravenous (PCA), and intraspinal PAIN MANAGEMENT


Slide 76:Side Effects of Opioids on diverse systems: CNS: analgesia, difficulty concentrating, drowsiness, euphoria, sedation, ↑ ICP, N/V, ↑ vagal stimulation of the bowel Immune system: increase release of histamine, vasodilatation of peripheral blood vessels, orthostatic hypotension GIT: sustained contraction of smooth muscles of the gut - constipation, increased biliary tone, biliary colic, Sensory system: miosis GUT: increase tone of the detrosur muscle and the bladder, increase tone of the vescical sphincter Respiratory system: decrease rate and depth of respiration, decrease cough reflex, bronchoconstriction PAIN MANAGEMENT


Slide 77:Mixed Agonist-Antagonist narcotic analgesics (opioid) Relieves severe pain by binding with kappa receptors while simultaneously blocking the mu receptors Routes and side effects same as full agonists e.g. Nalbuphine (Nubain), Butorphanol (Stadol) PAIN MANAGEMENT


Slide 78:Non-Opioid Analgesics Main effect: analgesia Pain relief is by inhibiting the synthesis and release of prostaglandins at the peripheral nerve endings at the site of injury Antipyretic effect: decrease core temperature by reducing sympathetic outflow from the hypothalamic temperature-regulating center, promoting peripheral vasodilatation, sweating, and heat loss e.g. aspirin, acetaminophen, NSAIDs PAIN MANAGEMENT


Slide 79:Non-opioid analgesics with anti-inflammatory actions: Act by stabilizing lysosomal membranes and preventing the release of proteolytic enzymes into surrounding tissue during inflammation e.g. corticosteroids (hydrocortisone, prednisone, dexamethasone), NSAIDs Non-opioid analgesics with anti-platelet aggregation: Decrease platelet aggregation by inhibiting the enzyme cyclooxygenase in platelets thus preventing the formation of the aggregating substance thromboxane e.g. aspirin, clopidogrel PAIN MANAGEMENT


Slide 80:Side Effects of NSAIDs CNS: mental confusion, drowsiness, dizziness, headache GIT: dyspepsia, N/V, diarrhea, GI bleeding, GI ulceration, abdominal pain GUT: sodium retention, water retention, hyperkalemia, nephrosis Integumentary system: urticaria, skin eruptions Hematologic: prolonged bleeding time, thrombocytopenia, bleeding gums Sensory: tinnitus, vertigo, visual changes, reversible hearing loss PAIN MANAGEMENT


Slide 81:Analgesic Adjuvants: Enhance the sedation effects of Opioids and reduce painful muscle spasm, anxiety, stress, tension, and depression that accompany pain These drugs add to the action or effectiveness of opioid/non-opioid analgesic e.g. Amitryptyline (Elavil), Chlorpromazine (Thorazine), Diazepam (Valium), Hydroxine (Vistaril) PAIN MANAGEMENT


Slide 82:WHO analgesic ladder for the treatment of cancer pain: Step 1: non-opioid, (+/-) adjuvant Step 2: opioid for mild to moderate pain , (+) non-opioid, (+/-) adjuvant Step 3: opioid for moderate to severe pain , (+/- ) non-opioid, (+/-) adjuvant PAIN MANAGEMENT


Slide 83:PAIN MANAGEMENT


Slide 84:Non-pharmacologic Pain Management   Cutaneous stimulation: massage, application of heat or cold, acupressure, contra-lateral stimulation and immobilization TENS, acupuncture, placebos, cognitive-behavioral: distraction, guided imagery, meditation, biofeedback, hypnosis PAIN MANAGEMENT


Slide 85:Acupuncture PAIN MANAGEMENT


Slide 86:Surgical Management of Pain   Nerve block: destruction of a nerve roots by a chemical agent e.g. phenol, alcohol Rhizotomy: surgical destruction of a dorsal nerve root as they enter the spinal cord Neurectomy: surgical excision of a peripheral nerve Cordotomy: surgical resection of pain pathways in the spinal cord PAIN MANAGEMENT


Slide 87:PAIN MANAGEMENT


Slide 88:PAIN MANAGEMENT Cordotomy


Slide 89:PAIN MANAGEMENT Rhizotomy


Slide 90:REFERENCES Medical – Surgical Nursing 7th edition by Joyce Black Brunner & Suddarth’s Medical – Surgical Nursing 11th edition by Suzzane Smeltzer Fundamentals of Nursing, 7th edition by Barbara Kozier Prentice Hall Reviews and Rationales Series for NCLEX-RN


Slide 91:D’ end, Tnk u!