BSN Notes: Common Signs And Symptoms: Pain

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PAIN
Meaning
            An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Pain Mechanism
Nociception is the physiological process by which information about tissue damage is communicated to the CNS
Pain perception consists of four processes:
1.       Transduction
2.       Transmission
3.       Perception
4.       Modulation
Transduction
·         Is the conversion of a mechanical, thermal or chemical stimulus into a neuronal action potential.
·         It occurs at the level of peripheral nerves, in particular the free nerve endings or nociceptor.
·         Noxious stimulus causes cell damage with the release of numerous chemicals into the area surrounding these nociceptors.
Transduction Substances includes:
·         Prostaglandins
·         Bradykinin
·         Serotonin   
·         Substance P 
·         Histamine 
·         Hydrogen ions
·         ATP
These substances activate nociceptors and lead to generation of action potential.
Activation results in an action potential, which is carried from the nociceptors to the spinal cord via myelinated A-delta fibers  and unmyelinated, slowly conducting C fibers.

Transmission
Transmission is the movement of pain impulses from the site of transduction to the brain
Action potential continues from-
Site of injury to spinal cord
Dorsal Horn processing
Spinal cord to brain stem to thalamus
Thalamus to cerebral cortex for processing

Perception
·         Conscious experience of pain
·         Perception occurs when pain is recognized, defined and responded to by the individual experiencing pain.
·         Pain perception involves several brain structures.
Modulation
·         Modulation involves the activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain.
·         Depending on the type and degree of modulation, pain is perceived.
·         Modulation of pain signals can occur at the level of periphery, spinal cord, brainstem and cerebral cortex.
·         Descending modulatory fibers release chemicals - serotonin, norepinephrine, GABA, endogenous opioids that inhibit pain transmission.
 Types of pain
·         Nociceptive
·         Neuropathic pain
·         Acute & chronic pain

Nociceptive pain
·         Nociceptive pain is caused by damage to somatic or visceral tissue.
·         Somatic pain: It is characterized as deep, aching or throbbing that is well localized, arises from bone, joint, muscle, skin or connective tissue.
·         Visceral pain: which may result from stimuli such as tumor involvement or obstruction, arises from internal organs such as the intestine & bladder.
Neuropathic pain
·         Neuropathic pain is caused by damage to peripheral nerves or CNS
·         Common causes are trauma, inflammation, DM, tumors, toxins and neurological disorders
·         Pain is typically described as numbing, burning, shooting, stabbing or electrical in nature. 
·         Neuropathic pain can be sudden, intense, short lived or lingering
 Difference between acute & chronic pain
Characterstics
Acute pain
Chronic pain
Onset

Sudden
Gradual or sudden 
Duration

<  3 months

>  3 months
Severity

Mild to severe

Mild to severe

Cause of pain

Surgery
May not be known

Course of pain
Goes away as recovery occurs
Typically pain does not go away

Goals of treatment
Pain control
Pain control to the extent possible

Pain Assessment
Pain characteristics:
·         Pattern of pain: onset and Duration
·         Area of pain: Precise location, Radiating
·         'Intensity of pain; use pain scale -  no pain to worse pain.
·         Nature of pain: burning, shooting, stabbing, sharp, aching, throbbing and cramping.
Management
Drug therapy
Non-opioid Analgesics
·         Acetaminophen
·         Salicylates: E.g.- Aspirin
·         NSAIDS: Ibuprofen, Diclofenac, COX-2 inhibitors (cyclooxygenase).
Opioid analgesics 
·         Morphine
·         Fentanyl

Adjuvent drugs for pain
·         Corticosteroids - for inflammation
·         Antidepressants (Imipramine) - Neuropathic pain
·         Antiepileptic drugs (Tegretol) - Neuropathic pain
·         Muscle relaxant (Baclofen) - Neuropathic pain and muscle spasm.
·         Alpha 2 Adrenergic agonist (Clonidin) - Neuropathic pain, given intrathecally.  
·         Anesthetics (Lidocaine 2.5%)
Administration Routes
·         Oral
·         Sublingual
·         Rectal - Suppository
·         Transdermal -  Applied on non- hairy skin.
·         Parenteral - IV, 1M
·         Intra spinal - Involves insertion of a catheter into the subarachnoid space (Intra thecal) or epidural space (epidural).
·         Patient controlled analgesia
·         Intervention therapy: Therapeutic nerve block - local anesthetics administered to reduce pain.
Non-pharmacologic therapy
·         Massage
·         Vibration
·         Transcutaneous electrical nerve stimulation (TENS)
·         Percutaneous electrical nerve stimulation (PENS)
·         Acupuncture, exercise
·         Heat therapy  
·         Cold therapy
Cognitive therapies
·         Distraction
·         Hypnosis

·         Relaxation

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