Pain Management and Tolerance

Pain and Surgery

• Experiences of pain are unique to each individual
• Pain necessitates management through pharmacological, non-pharmacological, or surgical interventions

Defining Pain

• Pain is an "unpleasant sensory and emotional experience" linked to possible or actual tissue damage as defined by the American Pain Society

Pediatric Pain Sensitivity

• Infants aged 1-2 days exhibit less sensitivity to pain
• A fully developed behavioral response to pain typically emerges between 3-12 months

Pain Thresholds

• Pain thresholds indicate the point at which a person begins to experience pain

Pain Tolerance Parameters

• Pain tolerance refers to the maximum intensity or length of pain a person can withstand after surpassing their threshold
• Tolerance varies among individuals
• Tolerance in elderly patients is reduces
• Women generally appear to be more tolerant to pain than men

Decreasing and Increasing Tolerance

• Tolerance decreases with repeated exposure, fatigue, anger, boredom, apprehension, anxiety, fear, and sleep deprivation
• Tolerance increases with alcohol consumption, medication, hypnosis, warmth, and distracting activities
• Strong beliefs or faith can increase tolerance

Misconceptions About Pain

• The patients are best in judge of their own pain
• Pain management needs to be a team effort
• Pain is not a normal part of aging
• People in pain can be asleep
• Sleep is used as a coping mechansim
• Pain is a result rather than a cause
• Pain can lead to other problems
• There is always a cause to pain, but can be carefully assessed
• Age is not a determinant of pain
• One should let the patient lead on their own pain

Characteristics of Pain

• Pain is a subjective experience
• It may encompass emotional distress
• It is a symptom and not a disease
• Pain experience is different for everybody
• A diagnostic indicator
• Usually reported as discomfort

Components of Pain

• Components of pain include stimuli, perception, response, intensity and threshold

Tolerance and Barriers to Pain

• Lower expectation of pain relief, insufficient insurance, high medication expenses, or viewing pain as weakness are barriers to reporting pain
• Reluctance to report pain stems from expectations of low obtaining relief

Types of Pain by location

• Types of pain based on source: nociceptive, somatic (superficial and deep), visceral, neuropathic, and psychogenic

Types of Pain by characteristics

• Source includes Somatic pain, which is superficial and cutaneous

Acute Pain

• It lasts less than 6 months described as sharp, stabbing, and shooting and is accompanied by observable physical responses

Chronic Pain

• Chronic nonmalignant pain includes low back pain to rheumatoid arthritis
• Chronic intermittent pain includes migraine and headache
• Chronic malignant pain includes cancer

Chronic Pain Descriptions

• Could have remote onset, and uncharacteristic injury, non-specific, and generalized with suffering intensifies
• Severity may be out of sync with the stage of the injury or disease

How Chronic Pain Responds

• It can respond poorly to drug therapt and requires increase with beyond healing stage

Characteristics of Patients

• Experiencing chronic pain, can have depression, reduced appetite, lower physical tone, withdraw from social connections, reduced concentration, and poor sleep

Types of pain and stimulus

• Intermittent pain produces a physiological response, that is similar to acute
• Persistent pain enables adaptation, but the body functions are normal but the pain is still not relieved
• Referred pain describes a pain from organs that is perceived in a general area away from the body but not at the exact site

Pain Descriptions

• Myofascial pain is pain in trigger points, and impulses bombard the CNS, expressed at referred pain
• Sclerotomic & dermatomic pain is deep pain that results from nerve irritation/injury

Describing Pain Pathways

• Transmission of Pain uses Transduction, Transmission, Perception, and Modulation

Pain Signal System

• The Peripheral Nervous System carries pain impulses to and from the CNS
• The Spinal Cord transmits impulses to the brain
• The processes of pain are interpreted by the brain

Nerve Fibers

• Nociceptors recognize thermal, chemical, and mechanical stimuli
• A‐delta fibers transmit acute sharp pain
• C‐fibers produce Chronic-type pain

Autonomic Nervous System

• The Autonomic Nervous System controls involuntary functions
• This includes the sympathetic and parasympathetic
• This includes using neurotransmitters

Factors Affecting Pain

• Influencing factors include physiologic, affective, psychosocial, and cognitive aspects

Intensity Theory

• Pain is said to be the result of excessive sensory stimulation

Pattern Theory

• Painful and non-painful sensations are transmitted
• Utilizes nonspecific receptors via common pathways

Specificity Theory

• Describes 4 types of cutaneous sensation - touch, warmth, cold and pain
• Relates with a direct relationship between a stimulus and perception
• Does not address psychological factors that can affect it

Gate Control Theory

• Nerve fibers carry touch and pain
• Impulses transmitted to spinal cord
• Nerve cells in spinal cord receive pain/touch impulses
• Fibers from brain send inhibiting information toward spinal cord

Three Factors - Opening and Closing the Gate

• The amount of activity in afferent fibers
• The amount of activity in other peripheral fibers
• Messages that descend from the brain

Physical and Emotional Conditions that Open the Gate

• Physical issues - extent of injury and inappropriate activity level
• Emotional issues - anxiety or worry; tension and depression

Physical and Emotional Conditions that Close the Gate

• Physical issues - medications and counter stimulation, massage, and hot or cold
• Emotional issues - positive emotions and relaxation with rest

Mental Conditions that Open and Close the Gate

• Mental issues that open - Focusing on pain and boredom
• Mental issues that close - Intense concentration, and involvement with life

Assessment Overview

• Effective treatment starts with analysis by a healthcare provider using patient descriptions of their assessment
• Considers their impact, problems medically/psychosocially, evaluation, evaluation is needed to understand

Determining Goals

• Determine if treatment fits any common pain syndromes and identify structural problems
• Try to understand the mechanisms behind the issues in order to describe the negative physical and psychosocial impacts

Pain Assessment

• Includes assessment of Pattern onset & duration, location, level, description in a PQRST format
• P = Provocation or what activities
• Q = Quality or pain
• R = Referral/Radiation
• S = Severity, pain scale used
• T = Timing
• Medical history helps to understand unique experience and provide a plan

Tools for Assessment

• There are baselines created with a patient's progression
• Tools include McGill Melzack Pain Questionnaire to better multidimensional assessment using 20 word descriptions

5 methods of managing acute or chronic pain

• These are blocking brain, interrupting chemicals, combining analgesics with adjuvant drugs, gate-closing mechanisms, and changing the cord

Goal in pain Management

• Prevent or relieve acute or chronic pain
• 1. Reduce pain 2. Control acute pain 3. Protect the patient w/ progressive exercises

Pain Relief Medications

• Adjuvant Drug Therapy uses drugs that are otherwise indicated for other conditions than to be used as analgesics in the case of pain

• Examples are Antidepressants, or Anticonvulsants like Carbamazepine for localized anesthesia like Mexiletine, or to reduce joint/musculoskeletal joint pain with NSAIDs like Diflunisal with salsalate

• Acetic or Proprionic acids for headaches

• Opioid Analgesics is the most effective and interacts with neurological receptors within the nervous system which activates action for endorphins

Opioid Medications

• Opiod Agonist-antagonist has analgesic effect
• Opiod antagonists have no effect
• Opiod medications can cause side effects, like constipation, nausea, itch, urinary retention, dry mouth, sexual dysfunction, and fatigue

Non-Drug Interventions

• Applying RICE to the area with acute injuries or along with swelling
• Applying heat works by improving the blood flow to the area due to high temperature causing inflammation, but it should not be used for too long
• Applying heat is very effective for treating arthritis or muscle pain

Applying Heat

• Warm the water used and make sure it is warm and NOT HOT
• It Should be applied to the area for less than or equal to 20 mins
• Stop immediately if swelling occurs

When not to use Heat

• If you are bruised, swollen, have open wound, diabetes, thrombosis, or MS, do not use heat

What can Cold do?

• Cryotherapy known to reduce blood glow to the injured location reducing inflammation which will cause less pain around that location
• It can temporarily reduce the nerve signals

Methods for applying cold

• Ice packs, coolant sprays, massage, or ice baths

What Can You combine with Cold?

• Combine Cryokinetics is used
• You can also use whole body cold therapy chambers

When Not to use Cold

• Do not have lack of sensations, have nerve damage, or poor circulation

Precautions With Cold

• If applied for too long can damage skin or nerve damage
• Consult a doctor regarding cardiovascular or heat and do not use if swelling is not reduced in 48 hours
• Notify your doctor also

TENS Units and Methods

• Use Transcutaneous Electrical Stimulation is an electrical unit that delivers different frequencies and skin stimulation
• Increasing chance that it helps by trying it on a TENS device
• Method: Acupunture, acupressure, percutaneous(PENS)

Noninvasive Methods

• Mind/Body address these aspects helps reduced and improve control
• Reduces stress and provides well-being
• Cognitive aims to address the attitudes for a particular

Cognitive behavior

• Is known to reduce the feelings of helplessness that leads to stress on the patient
• Imagery can help the patient be more realistic and balanced through productive life

Physical Therapy

• Useful in teaching patients regarding how to move safely
• Includes both passive and active exercise

Concept of Surgery

• Surgery as a branch is concerned with conditions and diseases associated with operative methods

Total process of surgery

• A total care for surgical needs that follows preoperative, intra operative & management, and postoperative needs

Six objectives of surgery

• Includes to correct deformities/defects; fix injuries; alter the structure;
• Provide curing the disease, provide suffering and improve live

Surgical Process

• Incision, excision, diagnostics, repair
• Includes reconstruction, termination, palliation, aesthetics, and harvest

Types of Surgery

• Surgeries known as bypass/shunt are vascular and drainage, while surgical are stabalization, staging, extraction, and diversion

Pathologies Needing Surgery

• Obstruction, perforation, abrasion, or a tumor

Surgical terms

• OR, theater - Facility where the operative parts are treated
• Peri operative term to determine the range during surgical procedures
• OR nurse legally responsible nurses to protect QOL of patient

Surgeries that must happen

• Awareness based on infection, removing the technique is to reduce risk, destroy/treat
• Also must implement the surgical procedure, surgical intervention

Categories of Surgical Procedure

• Incision, surgical,
• Invasive substance combat sepsis

Types of medical terminologies

• Anesthesia, inability with or without knowing
• Known as valid, you can only know

List of Medical Terminologies

• Includes Abdomin (o) – abdomen , Aden (o) ​– gland, Angi (0) ​– vessel, Arthr (0) ​ – joint, Broncho – bronchus, Card, Cephal (o) ​ - head, and everything related to medical anatomy

Goals of Surgery

• To preserve dynamic balance through diagnostic and to help

Conditions that help maintain surgery

• Condition help restore or reconstruct from trauma or injury and genetic defaults

Three Categories

• Known Invasive surgeries

Minimally Methods

• Are known for not damaging

Procedure types of Surgeries

• It needs to be based on what the surgery will provide, whether diagnostics, exploratative,reconstructive, or planned