Discussion Question

Darlene, age 32 years, has been having back pain for a number of years, ever since suffering a compressed L2 disc as the result of a motor vehicle accident that led to surgery and extensive physiotherapy. Now she is missing time from work as a secretary because of constant pain. Darlene has been referred to the chronic pain unit.

As the nurse working with Darlene, what aspects of disorders of pain are important to understand?
How would you effectively manage Darlene’s pain at this time?
APA STYLE

3 PARAGRAPHS 3 SENTENCES EACH

2 REFERENCES NOT OLDER THAN 2015

Chapter 14: Somatosensory Function, Pain, Headache, and Temperature Regulation

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

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1

The Somatosensory Component of the Nervous System

Function

Provides an awareness of body sensations such as touch, temperature, limb position, and pain

Composition

The sensory receptors consist of discrete nerve endings in the skin and other body tissues.

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2

Four Major Modalities of Sensory Experience

Discriminative touch

Temperature sensation

Body position

Nociperception (pain sensation)

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3

Types of Neurons Found in Sensory Systems

First-Order Neurons

Transmit sensory information from the periphery to the CNS

Second-Order Neurons

Communicate with various reflex networks and sensory pathways in the spinal cord and travel directly to the thalamus

Third-Order Neurons

Relay information from the thalamus to the cerebral cortex

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4

Sensory Neurons in the Spinal Track

Dorsal root ganglion

All somatosensory information from the limbs and trunk shares a common class of sensory neurons

The cell body of the dorsal root ganglion neuron, its peripheral branch, and its central axon form what is called a sensory unit

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5

Pathways from the Spinal Cord to the Thalamic Level of Sensation

The Discriminative Pathway

Crosses at the base of the medulla and the anterolateral pathway

Relays information to the brain for perception, arousal, and motor control

The Anterolateral Pathways

Consist of bilateral multisynaptic slow-conducting tracts

Provide for transmission of sensory information that does not require discrete localization of the signal source or fine discrimination of intensity

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6

Question #1

Which pathway is used for perception, arousal, and motor control?

The anterolateral pathways

The discriminative pathways

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7

Answer to Question #1

B. The discriminative pathways

Rationale: The discriminative pathways relay information to the brain for perception, arousal, and motor control.

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8

Processing Sensory Modalities

Receptors

Adequate stimuli

Ascending pathways

Central integrative mechanisms

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9

Central Processing of Pain Information

Transmission to the somatosensory cortex

Pain information is perceived and interpreted.

The limbic system

Emotional components of pain are experienced.

Brain stem centers

Autonomic nervous system responses are recruited.

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10

Clinical Assessment of Somatosensory Function

Diagnostic analysis of the level and extent of damage in spinal cord lesions involves

Testing of the ipsilateral dorsal column (discriminative touch) system.

Testing of the contralateral temperature projection systems.

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11

Pain Theories

Specificity Theory

Pattern Theory

Gate Control Theory

Pain modulation

Neuromatrix Theory—addresses further the brain’s role in pain

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Theories Explaining the Basis for Pain #1

Specificity Theory

Pain as a separate sensory modality evoked by the activity of specific receptors that transmit information to pain centers in the forebrain

Pattern Theory

Pain receptors share endings or pathways with other sensory modalities.

Different patterns of activity of the same neurons can be used to signal painful and nonpainful stimuli.

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13

Theories Explaining the Basis for Pain #2

Gate Control Theory

The presence of neural gating mechanisms at the segmental spinal cord level accounts for interactions between pain and other sensory modalities.

Neuromatrix

The brain contains a widely distributed neural network, called the body–self neuromatrix, that contains somatosensory, limbic, and thalamocortical components that work together to create the individual neural patterns.

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14

Mechanisms of Pain

First-Order Neurons

Detect stimuli that threaten the integrity of innervated tissues

Second-Order Neurons

Process nociceptive information

Third-Order Neurons

Project pain information to the brain

Nociceptors

Aδ Fibers

Fast pain

C Fibers

Slow wave pain

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15

Transmission of Pain #1

Neospinothalamic tract

Provides for rapid transmission of sensory information to the thalamus

Transmission of sharp–fast pain information to the thalamus

Pain is experienced as bright, sharp, or stabbing in nature.

Synapses are made; the pathways continue to the contralateral parietal somatosensory area to provide the precise location of the pain.

Paleospinothalamic tract

Slow-conducting tracts that transmit sensory signals that do not require discrete localization or discrimination of fine gradations in intensity

Projects into the intralaminar nuclei of the thalamus

Diffuse, dull, aching, and unpleasant sensations that commonly are associated with chronic and visceral pain

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16

Transmission of Pain #2

Opioid peptides

Enkephalins

Endorphins

Dynorphins

Endogenous analgesic center in the midbrain.

Pontine noradrenergic neurons.

The nucleus raphe magnus in the medulla send inhibitory signals to dorsal horn neurons in the spinal cord.

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17

Pain Threshold and Tolerance

Pain Threshold

The point at which a stimulus is perceived as painful

Pain Tolerance

The maximum intensity or duration of pain that a person is willing to endure before the person wants something done about the pain

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18

Symptoms of Tissue and Nerve Injury

Allodynia

Pain from noninjurious stimuli to the skin

Hyperalgesia

Extreme sensitivity to pain

Analgesia

The absence of pain from stimuli that normally would be painful

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19

Types of Pain #1

Nociceptive Pain

Nociceptors (pain receptors) are activated in response to actual or impending tissue injury.

Neuropathic Pain

Arises from direct injury to nerves

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20

Acute Versus Chronic Pain

Acute Pain

Self-limiting pain that lasts less than 6 months

Chronic Pain

Persistent pain that lasts longer than 6 months

Lacks the autonomic and somatic responses associated with acute pain

Is accompanied by debilitating responses

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21

Types of Pain #2

Cutaneous

Sharp, burning pain

Origin in skin or subcutaneous tissues

Deep somatic

More diffuse and throbbing

Origin in body structures

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22

Types of Pain #3

Visceral

Diffuse and poorly defined

Results from stretching, distention, or ischemia of tissues

Referred

Originates at a visceral site but perceived as originating in part of the body wall that is innervated by neurons entering the same segment of the nervous system

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23

Question #2

Which type of pain is perceived as sharp and intense?

Cutaneous

Visceral

Referred

Deep

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24

Answer to Question #2

A. Cutaneous

Rationale: Cutaneous is a sharp, defined pain that originates in the skin or subcutaneous tissue.

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25

Assessments of Pain

Nature

Severity

Location

Radiation

Methods have been developed for quantifying a person’s pain based on the patient’s report.

Verbal descriptor

Numeric pain intensity

Visual analog

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26

Nonpharmacologic Interventions for Pain

Cognitive–behavioral

Relaxation

Distraction

Imagery

Biofeedback

Physical agents

Heat and cold

Stimulus-induced analgesia

Acupuncture and acupressure

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27

Pharmacologic Treatment of Pain

Nonnarcotic analgesics

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Antiseizure medications

Antidepressants

Opioid analgesics

Morphine congeners

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28

Painful Sensations

Allodynia

Hyperalgesia

Hyperesthesia

Paresthesias

Hyperpathia

Analgesia

Hypoalgesia

Hypoesthesia

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29

Pain and Pain Syndromes

Neuropathic pain

Originates from pathology

Trigeminal neuralgia

Facial tics or spasms and characterized by paroxysmal attacks of stabbing pain

Postherpetic neuralgia

Pain of shingles/herpes infection

Complex regional pain syndrome

Autonomic and vasomotor instability

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30

Phantom Limb Pain

Type of neurologic pain

Follows amputation of a limb or part of a limb

As many as 70% of amputees experience phantom pain.

The pain often begins as sensations of tingling, heat and cold, or heaviness, followed by burning, cramping, or shooting pain.

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31

International Headache Society Classification of Headaches

Primary headaches

Headaches secondary to other medical conditions

Cranial neuralgias and facial pain

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32

Types of Headaches

Migraine headache

Etiology and pathophysiology, clinical manifestations, and treatment

Tension-type headache

Etiology and pathophysiology, clinical manifestations, and treatment

Cluster headache

Etiology and pathophysiology, clinical manifestations, and treatment

Chronic daily headache

Etiology and pathophysiology, clinical manifestations, and treatment

Temporomandibular joint syndrome

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33

Temporomandibular Joint Pain

Common cause of head pain

Imbalance in joint movement because of poor bite, bruxism, or joint problems

Referred pain

Commonly presents as facial muscle pain, headache, neck pain, or earache

Tx: NSAIDs

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Categories of Migraine Headaches

Types of Migraines

Migraine without aura

Migraine with aura

Subtypes of Migraine

Ophthalmoplegic migraine

Hemiplegic migraine

Aphasic migraine

Retinal migraine

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35

Treatment of Headaches

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in controlling pain because they block the enzyme needed for prostaglandin synthesis.

Nonpharmacologic treatment of migraines includes the avoidance of migraine triggers, such as foods or smells that precipitate an attack.

Pharmacologic treatment of migraines involves both abortive therapy for acute attacks and preventive therapy.

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Question #3

Which of the following is associated with grinding of teeth?

Tension-type headache

Cluster headache

Chronic daily headache

Temporomandibular joint syndrome

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37

Answer to Question #3

D. Temporomandibular joint syndrome

Rationale: Temporomandibular joint syndrome is brought about by clenching and grinding of the teeth, usually while sleeping.

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38

Pain in Children and Older Adults #1

Misperceptions of pain in children and adults by caregivers

Infants

Pain pathways, cortical and subcortical centers, and neurochemical responses associated with pain transmission are developed and functional by the last trimester of pregnancy.

May be attenuated due to underdeveloped pathways

For infants and noncommunicating children, physiological symptoms must be used for assessment.

Children can self-report pain.

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39

Pain in Children and Older Adults #2

Research is inconsistent about whether there are age-related changes in pain perception.

Some apparent age-related differences in pain may be due to differences in willingness to report the pain rather than actual differences in pain.

Assessment ability varies greatly with the mental state of patient.

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40

Pain Treatment in Children

Children experience and remember pain, and even fairly young children are able to accurately and reliably report their pain. Recognition of this has changed the clinical practice of health professionals involved in the assessment of children’s pain.

Pharmacologic (including opioids) and nonpharmacologic pain management interventions have been shown to be effective in children. Nonpharmacologic techniques must be based on the developmental level of the child and should be taught to both children and parents.

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Pain Treatment for the Elderly

When prescribing pharmacologic and nonpharmacologic methods of pain management for the older population, care must be taken to consider the cause of the pain, the person’s health status, the concurrent therapies, and the person’s mental status.

In the older population, where the risk of adverse events is higher, the nonpharmacologic options are usually less costly and cause fewer side effects.

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Body Temperature and Regulation

Mechanisms of Heat Production

Mechanisms of Heat Loss

Radiation

Conduction

Convection

Evaporation

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Increased Body Temperature-Fever

Mechanisms

Purpose

Patterns

Clinical Manifestations

Diagnosis

Treatment

Fever in Children

Fever in Older Adults

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Increased Body Temperature- Hyperthermia

Heat cramps

Heat exhaustion

Heatstroke

Drug fever

Malignant hyperthermia

Neuroleptic malignant syndrome

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Decreased Body Temperature- Hypothermia

Accidental hypothermia

Systemic hypothermia

Neonatal hypothermia

Perioperative hypothermia

Diagnosis and treatment

Therapeutic hypothermia

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Gastrointestinal Discussion APN Week 3

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