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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

4:
Somatosensory

Function

, Pain, Headache, and Temperature Regulation

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.

Four Major Modalities of Sensory Experience
Discriminative touch
Temperature sensation
Body position
Nociperception (pain sensation)

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

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

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

Question #1
Which pathway is used for perception, arousal, and motor control?
The anterolateral pathways
The discriminative pathways

Answer to Question #1
B. The discriminative pathways
Rationale: The discriminative pathways relay information to the brain for perception, arousal, and motor control.

Processing Sensory Modalities
Receptors
Adequate stimuli
Ascending pathways
Central integrative mechanisms

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.

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.

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.

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.

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

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

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.

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

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

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

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

Types of Pain #2
Cutaneous
Sharp, burning pain
Origin in skin or subcutaneous tissues
Deep somatic
More diffuse and throbbing
Origin in body structures

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

Question #2
Which type of pain is perceived as sharp and intense?
Cutaneous
Visceral
Referred
Deep

Answer to Question #2
A. Cutaneous
Rationale: Cutaneous is a sharp, defined pain that originates in the skin or subcutaneous tissue.

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

Nonpharmacologic Interventions for Pain
Cognitive–behavioral
Relaxation
Distraction
Imagery
Biofeedback
Physical agents
Heat and cold
Stimulus-induced analgesia
Acupuncture and acupressure

Pharmacologic Treatment of Pain
Nonnarcotic analgesics
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Antiseizure medications
Antidepressants
Opioid analgesics
Morphine congeners

Painful Sensations
Allodynia
Hyperalgesia
Hyperesthesia
Paresthesias
Hyperpathia
Analgesia
Hypoalgesia
Hypoesthesia

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

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.

International Headache Society Classification of Headaches
Primary headaches
Headaches secondary to other medical conditions
Cranial neuralgias and facial pain

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

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

Copyright © 2019 Wolters Kluwer • All Rights Reserved
Categories of Migraine Headaches
Types of Migraines
Migraine without aura
Migraine with aura
Subtypes of Migraine
Ophthalmoplegic migraine
Hemiplegic migraine
Aphasic migraine
Retinal migraine

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.

Copyright © 2019 Wolters Kluwer • All Rights Reserved
Question #3
Which of the following is associated with grinding of teeth?
Tension-type headache
Cluster headache
Chronic daily headache
Temporomandibular joint syndrome

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.

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.

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.

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.

Copyright © 2019 Wolters Kluwer • All Rights Reserved
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.

Copyright © 2019 Wolters Kluwer • All Rights Reserved
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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