Nursing Assessment & Management of Pain

Comprehensive flashcards covering pain definitions, classifications, pathophysiology, assessment tools, and pharmacological management based on the nursing transcript.

Margo McCaffery's Landmark Definition (1968)

"Pain is whatever the experiencing person says it is, existing whenever he says it does."

IASP Definition of Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

The 5th Vital Sign, which is routinely assessed alongside blood pressure, heart rate, respiratory rate, and temperature.

Pain

Acute Pain

Pain lasting < 3 months

Acute Pain

typically caused by tissue injury or surgery, characterized by elevated vitals ($HR, BP, RR$) and behaviors like grimacing and guarding

Chronic Pain

Pain lasting $\geq 3-6$ months

Chronic (Non-Cancer) Pain

Often due to ongoing injury or nerve damage, characterized by normal vitals and effects such as withdrawal, depression, and fatigue.

Chronic (Cancer) Pain

Pain that is persistent or breakthrough due to tumor pressure, radiation or chemotherapy.

Nociceptive Pain

Normal processing of noxious stimuli, which can be further classified as somatic or visceral.

Somatic Pain

Nociceptive pain originating in bone, joint, muscle, skin, or connective tissue; described as aching, throbbing, and well-localized.

Visceral Pain

Nociceptive pain originating in internal organs; described as cramping, pressure, poorly localized, or referred.

Neuropathic Pain

Abnormal processing due to nervous system injury or dysfunction; described as burning, shooting, electric-shock-like, or "pins and needles."

Diabetic Neuropathy

Postherpetic Neuralgia

Phantom Limb

Examples of neuropathic pain

Allodynia

Pain caused by a normally non-painful stimulus, such as light touch.

Hyperalgesia

An exaggerated response to a normally painful stimulus.

Increase ACTH

Increase cortisol

Increase ADH

Increase epinephrine

Increase norepinephrine

Increase GH

Increase catecholamines

Increase renin

Increase angiotensin II

Increase aldosterone

Increase glucagon

Increase interleukin-1

decreased insulin

decrease testosterone

Endocrine Specific Responses to Pain (14)

Gluconeogenesis

Hepatic glycogenolysis

Hyperglycemia

Glucose intolerance

Insulin resistance

Muscle protein catabolism

Increase lipolysis

Metabolic Specific Responses to Pain (7)

Increase heart rate

Increase cardiac workload

Increase peripheral vascular resistance

Increase systemic vascular resistance

Increase myocardial oxygen consumption

Hypercoagulation

Deep vein thrombosis

Cardiovascular Specific Responses to Pain (7)

Decrease flows and volumes

Atelectasis

Shunting

Hypoxemia

Decrease cough, sputum retention

Infection

Respiratory Specific Responses to Pain (7)

Decrease urinary output

Urinary retention

Fluid overload

Hypokalemia

Genitourinary Specific Responses to Pain (4)

Decrease gastric and bowel motility

Gastrointestinal Specific Responses to Pain (1)

Muscle spasm

Impaired muscle function

Fatigue

Immobility

Musculoskeletal Specific Responses to Pain (4)

Reduction in cognitive function

Mental confusion

Cognitive Specific Responses to Pain (2)

Depression of immune response

Immune Specific Responses to Pain (1)

Increase behavioral and physiologic response to pain

Altered temperaments

Higher somatization

Possible altered development of the pain system

Increase vulnerability to stress disorders, addictive behavior and anxiety states

Developmental Specific Responses to Pain (5)

Debilitating chronic pain syndromes

postmastectomy pain

post thoracotomy pain

phantom pain

postherpetic neuralgia

Future Pain Specific Responses to Pain (5)

Sleeplessness

Anxiety

Fear

Hopelessness

Increase thoughts of suicide

Quality of Life Specific Responses to Pain (5)

Prostaglandins

Chemicals produced from arachidonic acid by the enzyme cyclo-oxygenase (COX) that contribute to pain and inflammation.

COX-1

COX enzyme that is constitutive and always present

COX-2

COX enzyme that is induced, present with tissue injury

GI protection

Platelet function

Manifestation of Prostaglandins made by COX-1

Pain

Inflammation

Manifestation of Prostaglandins made by COX-2

Transduction

The first step in the pain process where noxious stimuli excite peripheral nociceptors and release biochemical mediators like Bradykinin and Histamine.

Transmission

The process where pain signals move from peripheral nerves (A-Delta and C fibers) to the spinal cord and then to the brain via the spinothalamic tract.

A-Delta Fibers

Large, myelinated fibers that transmit "first pain," which is fast, sharp, and localized.

A-Delta Fibers

Fibers that are sensitive to mechanical and thermal perception.

C Fibers

Small, unmyelinated fibers that transmit "second pain," which is slow, dull, aching, and burning.

C Fibers

Fibers that are sensitive to chemical stimulus

A-Beta fibers

Non-pain fibers that relay vibration, massage and tension

Perception

The point where the cerebral cortex identifies pain location/intensity and the limbic system processes the emotional response.

Modulation

The descending control process where the brainstem releases endogenous opioids like endorphins and enkephalins to inhibit pain transmission.

Gate Control Theory (Melzack & Wall)

The theory that small fibers open the gate in the substantia gelatinosa (dorsal horn) to allow pain signals to the brain, while large A-beta fibers can close the gate.

PQRST

A core assessment tool for Provoking/Palliative factors, Quality, Region/Radiation, Severity ($0-10$), and Timing.

Numeric Rating Scale (NRS)

A standardized $0$ to $10$ scale for alert adults where $0$ is no pain and $10$ is the worst possible pain.

Comfort measures

Non-Opioids

Interpretation for NRS score of 0

Wong-Baker FACES Scale

A scale using $6$ cartoon faces with scores ranging from $0$ to $10$ ($0, 2, 4, 6, 8, 10$) for pain assessment.

FLACC Scale

An assessment tool for infants or non-verbal patients scoring Face, Legs, Activity, Cry, and Consolability.

PAINAD Scale

Pain Assessment in Advanced Dementia; evaluates breathing, vocalization, facial expression, body language, and consolability.

WHO Analgesic Ladder

A four-step framework for pharmacologic management ranging from non-opioids (Step 1) to invasive procedures like nerve blocks (Step 4).

Acetaminophen (Tylenol)

A non-opioid primarily for analgesia and fever with a maximum daily dose of $4,000\,mg/24\,hr$ for standard adults.

N-acetylcysteine (Mucomyst)

The antidote for acetaminophen toxicity or liver injury.

NSAIDs

Nonsteroidal anti-inflammatory drugs (e.g., Ibuprofen, Naproxen) that inhibit COX-1 and COX-2 enzymes; risks include GI ulceration and renal impairment.

Ketorolac (Toradol)

An NSAID that must be limited to $\leq 5$ consecutive days due to severe renal and GI risk.

Meperidine (Demerol)

An opioid to avoid because its metabolite, normeperidine, causes CNS excitation, tremors, and seizures.

Pasero Opioid-Induced Sedation Scale (POSS)

A critical assessment scale where sedation level is monitored because it precedes respiratory depression in opioid use.

Naloxone (Narcan)

An opioid antagonist used for acute reversal; should be administered diluted and slowly unless in full arrest to prevent a withdrawal storm.

Adjuvant Analgesics (Co-analgesics)

Drugs like Gabapentin (anticonvulsant) or Amitriptyline (antidepressant) primarily indicated for other conditions but effective for neuropathic pain.

PCA by Proxy

A hazard where family members press the PCA button instead of the patient; nursing education must emphasize only the patient presses the button.

"Start Low and Go Slow"

A dosing strategy for gerontologic patients due to increased sensitivity to sedation and decreased renal/hepatic clearance.

Tolerance

A normal physiological response where an increased dose is needed over time to maintain the same analgesia.

Physical Dependence

A normal physiological response manifested by withdrawal symptoms if the drug is stopped abruptly.

Addiction (Substance Use Disorder)

A chronic, neurobiological disease characterized by impaired control, compulsive use, and continued use despite harm.

Central Sensitization

A "Wind-up" phenomenon involving NMDA receptor activation and increased neurotransmitter release, increasing chronic pain risk.