Dr. Mahmoud Maharmeh

1. Dr. Mahmoud Maharmeh

2. What is pain means to you

3. Pain • Pain is the primary reason people seek health care and one of the most common conditions that nurses treat. • pain continue to be undertreated. Improved understanding of pain mechanisms has advanced treatment for pain. • Unrelieved pain has the potential to affect every system in the body and cause numerous harmful effects. `(Table 12-1)

4. Undertreated chronic pain can impair an individual’s ability to carry out daily activities and diminish quality of life. • In addition to disability, undertreated pain causes significant suffering. • Individuals with poorly controlled pain may experience anxiety, fear, anger, or depression. • Pain is also a major cause of work absenteeism, underemployment, and unemployment.

5. Pain • Joint Commission (2005) standards: “patients have the right to appropriate assessment and management of pain.” • Unpleasant sensory, emotional experience with actual or potential tissue damage (APS; 2008). This definition emphasizes that pain is a complex experience that includes multiple dimensions.

6. “Pain is whatever a person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968). Pain is subjective. • This definition emphasizes that pain is a subjective experience with no objective measures. • It also stresses that the patient, not clinician, is the authority on the pain and that his or her self-report is the most reliable indicator of pain.

9. Pain is better classified by its inferred pathology • Nociceptive pain (physiologic, normal): results from tissue injury. • Nociception refers to the process by which information about tissue damage is conveyed to the central nervous system (CNS).

10. Nociceptors are sensory receptors that are preferentially sensitive to tissue trauma or a stimulus that would damage tissue if prolonged. • These receptors are the free endings of (primary afferent) nerve fibers distributed throughout the periphery • Signals from these nociceptors travel primarily along two fiber types: slowly conducting unmyelinated C-fibers and small, myelinated, and more rapidly conducting A-delta fibers • Injury to tissue causes cells to break down and release various tissue byproducts and mediators of inflammation (e.g., prostaglandins, substance P, bradykinin, histamine, serotonin, cytokines)

11. Nociceptive Pain Nociception includes four specific processes (transduction, transmission, perception, and modulation): • Transduction (أصل الكلمة بمعنى محوّل للطاقة): the conversion of the energy from a noxious thermal, mechanical, or chemical stimulus into electrical energy (nerve impulses) by sensory receptors called nociceptors

12. Figure 12-1, A-transduction

13. Nociceptive Pain • Transmission • The transmission of these neural signals from the site of transduction (periphery) to the spinal cord and brain

14. Nociceptive Pain • Perception • The perception of pain is an uncomfortable awareness of some part of the body, characterized by a distinctly unpleasant sensation and negative emotion best described as threat. • It requires activation of higher brain structures for the occurrence of awareness, emotions, and drives associated with pain • The focus on reducing pain here is on mind–body therapies, such as distraction and imagery

15. Figure 12-1, C- Perception

16. Nociceptive Pain • Modulation. (تعديل, تغيير مسار الأحداث) • Descending inhibitory and facilitory input from the brain that influences (modulates) nociceptive transmission at the level of the spinal cord. • Serotonin and norepinephrine are inhibitory neurotransmitters that are released in the spinal cord and brain stem by the descending (efferent) fibers of the modulatory system (to ↓ pain). • Some antidepressants provide pain relief by blocking the body’s reuptake (resorption) of serotonin and norepinephrine, extending their availability to fight pain. • Endogenous opioids are located throughout the peripheral and central nervous systems, and like exogenous opioids, they bind to opioid receptors in the descending system and inhibit pain transmission.

17. Nociception System Showing Ascending and Descending Pathways of the Dorsal Horn

18. Neuropathic pain: results from abnormal processing of sensory input by the nervous system as a result of damage to the peripheral or central nervous system or both. • Mixed: tissue injury + damage (or pressure) to nerves (e.g., cancer and sickle cell pain)

19. Neuropathic Pain • Caused by damage to, or dysfunction of, the peripheral or central nervous system. • Neuropathic pain may occur in the absence of tissue damage and inflammation. • Peripheral sensitization: hypersensitivity to any stimuli. Central sensitization: abnormal hyperexcitability of central neurons in the spinal cord. Allodynia: pain from a normally nonnoxious stimulus (clothes, bed sheets, touch)

20. From skin, connective tissue, bone, joint, muscle • Describe as aching, throbbing • Well localize • Example: surgical wound, burn • From visceral organs (GI track, liver) • May be localize such as tumor in organ capsule (aching) • Poorly localize such as obstruction of hollow viscus (cramping) • Described as stabbings, electric shocks, burning, coldness, "pins and needles" sensations, numbness and itching • Treatment: antidepressant, anticonvulsants, local anesthetics Responsive to nonopioids, opioids, and local anesthetics

21. Phantom Pain: Painful sensations that seem to be coming from the part of the limb that is no longer there. The limb is gone, but the pain is real. The onset of this pain most often occurs soon after surgery It is neuropathic pain

22. Types and Categories of Pain 1. Acute Pain • Acute pain was once defined simply in terms of duration. • It is now viewed as a “complex, unpleasant experience with emotional and cognitive, as well as sensory, features that occur in response to tissue trauma.”

23. Acute pain serves an important biological function, as it warns of the potential for or extent of injury. • Therefore, increasing attention is being focused on the aggressive prevention and treatment of acute pain to reduce complications, including progression to chronic pain states.

24. 2. Chronic Pain • Chronic pain was once defined as pain that extends 3 or 6 months beyond onset or beyond the expected period of healing. • Chronic pain is now recognized as pain that extends beyond the period of healing, with levels of identified pathology that often are low and insufficient to explain the presence and/or extent of the pain.

25. Chronic pain is also defined as a persistent pain that “disrupts sleep and normal living, ceases to serve a protective function, and instead degrades health and functional capability.”

26. 3. Cancer Pain • Pain associated with potentially life-threatening conditions such as cancer is often called “malignant pain” or “cancer pain.”

27. 4. Chronic NoncancerPain • A subtype of chronic pain is CNCP, which refers to persistent pain not associated with cancer. In contrast to patients with chronic cancer pain, patients with CNCP often report pain levelsthat only weakly correspond to identifiable levels of tissue pathology and/or respond poorly to standard treatments.

28. Consequences Undertreatment of Pain? • Physiological consequences • Quality of life c. Financial consequences

29. Barriers to the appropriate assessment &management of pain 1. Barriers Within the HealthCare System • Systems barriers to pain assessment and management include an absence of clearly articulated practice standards and failure of the system to make pain relief a priority. • For example, some health care organizations fail to adopt a standard pain assessment tool or to provide staff with sufficient time and/or chart space for documenting pain-related information.

30. 2. Health Care Professional Barriers • Clinicians’ attitudes, beliefs, and behaviors contribute to the undertreatment of pain. • Forexample, some clinicians do not view pain relief as important and/or do not want to “waste time” assessing pain.

31. 3. Patient and Family Barriers • Patient characteristics (e.g., age, language, cognitive abilities, coexisting physical or psychological illness, cultural traditions) may impair a patient’s ability to communicate. • Patients may be reluctant to report pain to clinicians due to low expectations of obtaining relief, fears, or concerns about what the pain means (e.g., worsening disease, death), analgesic side effects, or addiction.

32. 4. Legal and Societal Barriers • Legal and societal issues also contribute to the undertreatment of pain. The former include restrictive laws or regulations about the prescribing of controlled substances as well as confusion about the appropriate role of opioids in pain treatment.

33. 5. Addiction • Many medications, including opioids, play important roles in pain management. However, concerns about their potential misuse and misunderstanding of the nature and risk of addiction limit their appropriate use.

34. Assessment Pain • Assessment is an essential, but challenging, component of any pain management plan. • Pain is subjective, so no satisfactory objective measures of pain exist. • Pain is also multidimensional, so the clinician must consider multiple aspects (sensory, affective, cognitive) of the pain experience. • Finally, the nature of the assessment varies with multiple factors (e.g., purpose of the assessment, the setting, patient population, clinician), so no single approach is appropriate for all patients or settings.

35. Principles of Pain Assessment and Management • Patients have the right to appropriate assessment and management of pain • Pain is always subjective • Physiological and behavioral (objective) signs of pain (e.g., tachycardia, grimacing) • Assessment approaches, including tools, must be appropriate for the patient population. • Pain can exist even when no physical cause can be found.

36. Different patients experience different levels of pain • Pain tolerance varies among and within individuals • Patients with chronic pain may be more sensitive to pain and other stimuli. • Unrelieved pain has adverse physical and psychological consequences. • Assessment should address physical and psychological aspects of pain.

37. Assessment Pain • Patient’s self report is the standard for assessing the existence and intensity of pain. • Health care professionals do not have the right to deprive any patient of appropriate assessment and treatment simply because they believe a patient is not being truthful. • Pain is reassessed and documented on a regular basis to evaluate the effectiveness of treatment. • At a minimum, pain should be reassessed with each new report of pain and before and after the administration of analgesic agents

38. When did the pain begin? Where does it hurt? (Use diagram, when possible.) What does the pain feel like? How severe is the pain right now? (Use numeric rating scale to How severe is the pain right now? (Use numeric rating scale to • Onset and duration • Location(s) • Quality • Intensity (severity) Associated symptoms obtain score, when possible.) • Exacerbating or alleviating factors How severe is the pain right now? (Use numeric rating scale to

39. Intensity (severity)(using a reliable and valid pain assessment tool, e.g., numerical rating scale & FACES pain scale, visual analog scale).

40. Quality (e.g., “sharp,” “shooting,” or “burning”…to identify neuropathic pain) Amer A. Hasanien, RN, CNS, PhD

41. Management strategies • What methods have you used to manage the pain? • What methods have worked? Past and current: Medications ( “natural,” nonprescription, and prescription) Nonpharmacologic treatments Coping strategies (e.g., prayer, distraction)

42. Relevant medical history • How is your general health? • Have you had any problems with pain in the past? • If so, how did you manage the pain? Prior illnesses including Psychiatric illnesses and chemical dependence), surgeries, and accidents Acute or chronic illnesses Prior problems with pain and treatment outcomes

43. Relevant family history • How is the health of your family? • Do any family members have problems with pain? Health of family members Family history of chronic pain or illnesses

44. Psychosocial history • Are there any recent sources of increased stress? • How has the pain affected your mood? Past or current: Developmental, marital, or vocational problems Stressors or depressive symptoms

45. Impact of the pain on the patient’s daily life • How has the pain affected your work and relationships • How is your sleep? • How is your appetite? Impact of the pain on the patient’s: Work Other daily activities (e.g., chores, hobbies) Personal relationships Sleep, appetite, emotional state

46. Patient’s expectations and goals • What are your goals for treatment? Expectations and goals for pain management in regard to pain intensity, daily activities, and quality of life

47. How to assess pain in non-verbal patients? (e.g., cognitively impaired, critically ill (intubated, unresponsive), comatose, or dying, Patients who are receiving neuromuscular blocking agents or are sedated from anesthesia). Answer: Nurses usually use the “The Hierarchy of Pain Measures” p 220 Amer A. Hasanien, RN, CNS, PhD

48. Pain Assessment in non-verbal patients • Attempt to obtain self-report • Review pathology, condition, procedures • Observe behaviors • Evaluate physiologic indicators • Conduct an analgesic trial

49. Pain Management • Pharmacologic Management of Pain: Pain is a complex phenomenon requires more than one analgesic agent to manage it safely and effectively, this approach is called, multimodal analgesia • Combines drugs with different underlying mechanisms, • Allows lower doses of each of the drugs in the treatment plan, • Reduces the potential for each to produce adverse effects. • Multimodal analgesia can result in comparable or greater pain relief than can be achieved with any single analgesic agent

50. Pain Management • Routes of Administration • Oral route (the preferred, least expensive, best tolerated, and easiest to administer ) • For patients who cannot swallow or are NPO (nothing by mouth) or nauseated, other routes of administration are used. • Intravenous (IV) (ex. postoperative) • Rectal (can cause bleeding; diarrhea, perianal abscess or fistula)