pain 2

Answer 1

Physiological Reactions to Pain
Response Cause or Effect
Sympathetic Stimulation∗
Dilation of bronchial tubes and increased respiratory rate Provides increased oxygen intake
Increased heart rate Provides increased oxygen transport
Peripheral vasoconstriction (pallor, elevation in blood pressure) Elevates blood pressure with shift of blood supply from periphery and viscera to skeletal muscles and brain
Increased blood glucose level Provides additional energy
Diaphoresis Controls body temperature during stress
Increased muscle tension Prepares muscles for action
Dilation of pupils Affords better vision
Decreased gastrointestinal motility (nausea, vomiting) Frees energy for more immediate activity
Parasympathetic Stimulation †
Pallor Causes blood supply to shift away from periphery
Muscle tension Results from fatigue
Decreased heart rate and blood pressure Results from vagal stimulation
Rapid, irregular breathing Causes body defences to fail under prolonged stress of pain
Weakness or exhaustion Results from expenditure of physical energy

Answer 2

Superficial pain and pain of low to moderate intensity.

† Severe or deep pain.

Nonverbal or behavioural indicators of pain may include body movements, facial expressions, and vocalizations. Bracing, splinting, or protecting the painful part, rocking, body stiffening, jaw clenching, grimacing, frowning, crying, moaning, or screaming may indicate that pain is present. Affective responses can include social withdrawal, changes in eating or sleep patterns, stoicism, fear, anxiety, anger, or feelings of hopelessness. Valid and reliable tools exist to assist in the assessment of pain in people who are unable to self-report their pain. Lack of pain expression does not necessarily mean that a person has no pain. For example, premature and full-term infants sometimes do not cry in response to painful stimuli and they may exhibit few motor movements, especially after excessive and repeated exposure to pain. Similarly, opioids can blunt the behavioural expression of pain by sedating the patient. Yet, the patient who is sedated or sleeping can still be in pain.

Answer 3

Types of Pain
Pain may be categorized by its duration, such as acute and chronic pain; by its pathology, such as cancer pain and noncancer pain (e.g., pain associated with arthritis, diabetic neuropathy, low back pain, and headache); or by the process of action (nociceptive or neuropathic).

Answer 4

Acute pain usually has an identifiable cause—either somatic, visceral, or nociceptive—and is of short duration (usually less than 3 months). Acute pain has a predictable ending (healing) and an identifiable cause. Eventually it resolves with or without treatment after a damaged area heals. Evidence suggests, however, that unrelieved acute pain may have developmental and age-related consequences. For instance, significant and repeated exposure to acute pain during epochs of rapid early infant brain development may alter an infant’s pain response. Untreated or poorly treated intraoperative and postoperative pain and stress can also increase infant mortality and morbidity. Unrelieved moderate to severe postoperative pain can lead to the development of chronic pain.
No matter what the patient’s age, unrelieved acute pain can have a negative impact on recovery from illness or surgery, resulting in prolonged hospitalization, increased risk of complications from immobility (see Chapter 46), and delayed rehabilitation. When pain is not relieved, physical or psychological recovery can be delayed because the patient’s primary focus may be on achieving pain relief. Although it may not be possible to completely eliminate the pain, working with the patient and members of the interprofessional team to reduce pain to an acceptable level so that functional goals can be met is a realistic goal. The nurse’s primary goals should be to prevent pain whenever possible and to effectively manage pain so that patients can participate in their own recovery.

Answer 5

Persistent Postoperative Pain
Persistent postoperative pain (PPP) is defined as pain that persists beyond 2 to 3 months after a surgical procedure, with other pain causes excluded, which may include pre-existing pain or postoperative infection (Wang etal., 2018). PPP can be somatic, visceral, or neuropathic in origin. PPP occurs frequently, with incidences reported between 5 and 50%, and can be challenging to manage effectively, so prevention is paramount. PPP can be debilitating for the patient and can impact health care costs. Studies are underway to evaluate the efficacy of the role that regional anaesthesia plays in reducing the incidence of PPP (Weinstein etal., 2019).

Answer 5

Chronic Pain
Chronic pain is defined as pain that persists longer than 3 months and is associated with actual or potential tissue damage (IASP, 2017). It is estimated that one in four Canadians, or 25% of the population over 15 years of age, lives with chronic pain (Canadian Pain Task Force, 2021). It is distinctly different from acute pain. Chronic pain can be intermittent (occurs in a pattern) or persistent (lasting more than 12 hours daily), experienced at any point in life, including early childhood, and lead to great personal suffering. Chronic pain may be nonmalignant or related to cancer. Chronic noncancer pain is usually not life-threatening. However, patients with chronic noncancer pain are often frustrated because they cannot predict how they will feel from day to day, and the pain they experience may be unrelenting. The pain may result from an injured area that healed long ago but continues to be nonresponsive to treatment. Chronic noncancer pain may be experienced along with other symptoms such as sleep disturbances, depression, anxiety, and anger. This type of pain may be a major cause of psychological and physical disability, leading to issues such as job loss, school absenteeism, the inability to perform simple daily activities, sleep disturbances, sexual dysfunction, and social isolation.
Despite the fact that Canadians are among the largest opioid users per capita in the world, undertreated chronic noncancer pain is a challenge faced by patients and health care providers alike. Now, more than ever, health care providers may be reluctant to treat chronic noncancer pain with opioids. To help break the cycle of poor pain management, nurses should inform patients about concerns raised when they seek help from multiple health care providers and refer the patient to a pain team or chronic pain clinic, if available. The current Canadian guideline for chronic noncancer pain addresses the challenges with assessment and management of chronic noncancer pain and provides recommendations and tools for safe and responsible selection, prescription, titration, and monitoring of opioids.
For Canadian pain clinics, managing chronic pain during a pandemic has been increasingly challenging and approaches to care have pivoted. For pediatric patients with chronic pain (incidence 20%), access to interprofessional care was shifted from in-person appointments to virtual visits through a program provided by Hospital for Sick Children in Toronto during the COVID-19 pandemic. This program provided continued access to care while reducing risk of exposure and transmission (D’Alessandro etal., 2020).
The coping strategies used by individuals with chronic pain, as well as their personal beliefs, may determine how they will function with and adjust to pain. When managing pain, a comprehensive approach that includes both nonpharmacological and pharmacological strategies should be utilized. Furthermore, the treatment for chronic pain needs to be based on a triad of therapies using the following 3-P approach: physical, psychological, and pharmacological (Canadian Pain Task Force, 2021). Other methods, such as interventional pain management (IPM) strategies—which include peripheral nerve blocks, neuroaxial injections, and radiofrequency treatments that serve as target-specific interventions—can be used effectively to treat chronic pain. The IPM strategies further compliment the 3-P approach (Shanthanna etal., 2020). The use of evidence-informed adaptive coping strategies is encouraged, such as cognitive-behavioural therapy (CBT), relaxation techniques, positive thinking, visual imagery, and distraction.

Answer 6

Cancer Pain
Pain in a patient with cancer may be acute, chronic, or both. The pain may also be nociceptive, neuropathic, or both. Cancer pain may be caused by tumour progression and its related pathological process, invasive procedures, toxicities of treatment, infection, and physical limitations. It can be sensed at the actual site of the tumour or distant to the site. When pain is sensed at a site that is distant to the area of tissue damage it is called referred pain. For example, a patient who has pancreatic cancer may sense the pain from a pancreatic tumour in the lower back. Referred pain can occur in patients experiencing cancer pain or noncancer pain.
Any new report of pain by a patient with existing pain needs to be investigated. Although the need for treatment of cancer pain has become increasingly evident, the issue of undertreatment continues. Many individuals with cancer pain live at home in their community and pain is managed by themselves, by their families, or both. Research findings suggest that accessing community resources when pain is not well managed may be difficult for these families and that the stress of caring for a loved one with cancer pain can affect the health of family caregivers. The importance of establishing an organized, systematic, and comprehensive approach to pain assessment and treatment, as well as communicating with and supporting patients’ families, cannot be overemphasized; nurses have the potential to play pivotal roles in these endeavours.

Answer 7

Pain by Inferred Pathology Process
Identifying the cause of pain is one of the first steps in successfully managing pain. Nociceptive pain is pain caused by tissue damage and is subdivided into somatic (musculoskeletal) and visceral (internal organ) pain. Neuropathic pain arises from abnormal or impaired pain nerves (Table 32.2). Each of these pathological processes has distinct pain characteristics that are discussed later, under “Assessment” in the “Nursing Process and Pain” section.
Although nociceptive and neuropathic pain have historically been classified by nociceptor activation or lesions of the somatosensory system, the classification system has a gap in areas that do not specifically meet these criteria, namely complex regional pain syndrome (CRPS), fibromyalgia, and nonspecific low back pain. Subsequently, a new classification to capture these gaps is nociplastic pain (IASP, 2017). Nociplastic pain has been defined as “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain” (Trouvin & Perrot, 2019, p. 3).
Finally, the concept of mixed pain is emerging as well. Mixed pain can be a complex overlap of the nociceptive, neuropathic, or nociplastic pain types and can be acute or chronic in nature (Trouvin & Perrot, 2019).