PainMary Corcoran RN,BSN, MICN

Pain In ER• Most frequent Complaint• Traditionally inadequately treated

for many patients• ED Nurses are the patients primary

advocate for control of pain

Types of pain• Acute

o Sudden onset

• Chronico Prolonged- Months to years

• Cancero May increase with treatment, or changes in the disease process

• Neuropathico Burning, numbness sensation- usually peripheral

• Visceralo Cramping, bloating, stretching sensation- usually abdominal

• Somatico Aching, or throbbing- joint type pain

Definitions of Pain Terminology

• Allodynia- Pain due to stimulus that does not normally provoke pain

• Analgesia- Absence of pain in response to a stimulus that should be painful

• Hyperalgesia- An increased response to a stimulus that is normally painful

• Hypersthesia- Increased sensitivity to stimulation, excluding special senses

• Neuralgia- Pain in the distribution of a nerve or verves

Definitions cont• Neuritis- Inflammation of a nerve or nerves• Neuropathy- A disturbance of function or

pathologic change in a nerve• Noxious Stimulus- a stimulus damaging to normal

tissue• Pain Threshold- The least experience of pain that

a patient can recognize• Pain Tolerance Level- The greatest level of pain

that a patient can tolerate• Parasthesia- An abnormal sensation whether

spontaneous or evoked

Definitions of Addiction

• Tolerance- A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drugs effects over time

• Physical Dependence- A state of adaptation that includes tolerance and a withdrawal syndrome with dosage decrease or agonist administration

• Addiction- is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestation

• Pseudoaddiction- patients exhibit behaviors of addiction, which resolve when the pain is treated

Pathophysiology• Nociceptors

o Pain receptors located in the skin, muscle, joints, arteries and viscera

o Stimulated by chemical, thermal or mechanical stimuli

Examples of stimuli• Laceration, Burns, or strain to

a muscle (inflammation)

PathophysiologyPain Fibers-transmit action potentials of nociceptorsMyelinated A-Delta

Fibers Unmyelinated C Fibers

• Rapidly Transmit the pain impulse (Fast Pain)

• Produces a Sharp Pain Sensation

• Are slower (slow pain) • Produce diffuse

burning or aching sensation of pain

• Also produce deep throbbing pain, visceral, pain, and chronic pain

• Both eventually terminate in the subsantia gelatinosa (say that 10 times fast) in the dorsal horn of the spinal cord

Pathophysiology• Spinal Cord

o The “Pain Gate”- The connection between primary and secondary order neurons, and regulates the conduction of pain impulses to the brain

o Thalamus- functions as a relay station for pain impulses• Neospinothalmic pathway- conducts “fast”

pain fibers, letting the brain know intensity, location, and duration of pain• Paleospinothalamic pathway- Transmits

“slow” pain fibers, makes it difficult to specifically localize pain sensation

Pathophysiology• The Brain

o The third order neurons, located in the Thalamus, Brain stem, and midbrain, communicate with the CNS, and triggers communication between all areas of the brain• The limbic and reticular

tracts respond to pain signals- resulting in the person arousing to danger, release of stress hormones, and emotional response to pain

Pathophsiology• Pain Modulation and Endogenous

Opioidso These work together to decrease the sensation

of pain, allowing the body to suffer debilitating pain, and still survive (ie endorphins)

Barriers to pain management• The perception of “Drug Seeking”• Disparities in treatment of minorities

and women• Fear of negative physiologic effects

of opioid administration• Physician and RN lack of education

regarding pain management• Inadequate treatment of high-risk

patients o Older adults, Developmentally delayed, non-

English, and children

• The belief that physiologic signs are more reliable than patient self report

How do we assess pain?

•Most adults will be able to use a simple 0-10 scale to describe the severity of their pain

What about kids?• Most school age children (5+) will be able

to use the Wong- Baker FACES Scale

What about babies?• Children age 3mo-7yrs can be scored using the

FLACC scale

How do we Treat Pain?

Pharmacologic Non-Pharmacologic

• Opioidso Morphine, Dilaudid, Fentanyl

• NSAIDSo Motrin, Toadol

• PCAo Opioids administered by

patient

• Topical Lidocaineo LET/TAC solution, EMLA cream

• Positioning/Elevation• Heat/Cold therapy

o Heat for chronico Cold for acute

• Distraction techniqueo Reading, movies, talk etco Works well for children

Procedural Sedation• MINIMAL- pt responds normally• MODERATE (“Conscious”)- airway and CV

function maintained• DEEP- pt not easily aroused• ANESTHESIA- required assisted ventilation

Sedation- minimizes movement, pain, and anxiety during procedure