Beruflich Dokumente
Kultur Dokumente
NURS 6644
Disease Process
One definition of pain is the broadly accepted definition from the International
Association for the Study of Pain (IASP). The IASP defines pain as an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in terms of
such damage (Rodriguez, 2015, p. 339). Another definition is the definition that most learned
during nursing school. This description is whatever the experiencing person says it is, existing
whenever he says it does. This definition places the patient at the center of the experience
Pain can be classified by duration, such as acute or chronic; type such as nociceptive,
neuropathic, or psychogenic; site such as muscle, joint, or visceral; or etiology such as trauma or
disease (Rodriguez, 2015, p. 339). Patients may also experience more than one type of pain at a
time. Acute pain is a time-limited, unpleasant sensation that serves to warn a patient to limit a
movement. Acute pain has an emotional, cognitive and sensory feature that occurs from tissue
trauma or damage. This pain usually resolves with healing. Acute pain also produces protective
reflexes, such as those that cause us to draw away from fire. Acute pain is usually categorized as
is without biological value, lasting longer than the typical healing time, not responsive to
treatments based on specific remedies, and of a duration great than 6 months (Katz, Rosenbloom,
& Fashler, 2015, p. 160). Chronic pain persists beyond the expected recovery period after the
trauma or injury, usually lasting longer than six months. Chronic pain can be disruptive to sleep
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and activities of daily living. Chronic pain serves no protective or adaptive function (Rodriguez,
2015, p. 340). Chronic pain ranks among the most common, costly and incapacitating conditions
in later life. Painful conditions are one of the most common reasons that older people seek
health care in the ambulatory setting (Bicket & Mao, 2015, p. 577). Despite its high prevalence,
pain among older people is almost always the result of pathology, involving a physical or
psychological process. Combating this myth that pain is inevitable with aging represents one
of the educational challenges of being a healthcare provider (Bicket & Mao, 2015, p. 578).
Epidemiology
Pain. The word conjures different emotions in each individual. None of the emotions are
positive ones. This experience is most prevalent among the elderly population. The elderly are
the fastest growing population of people in todays society, and consequently, the pain that the
elderly commonly endure is become a more difficult and challenging problem for health care
providers to effectively manage. The U.S. Census Bureau in 2011 estimated that 20% of the
total population will be above the age of 65 in 2030. Approximately 66% of people over the age
of 65 report pain of some type, and the rate is higher for those individuals suffering from other
chronic illnesses and living in nursing homes (Jones et al., 2016, p. 1). Unfortunately, pain is
often underreported as some elderly patients, as well as healthcare providers, believe that pain is
Subjective
Chief Complaint. One of the types of pain is nociceptive. This pain occurs when
noxious stimuli active the afferent neurons. Some examples of nociceptive pain include a paper
cut on the skin, a femoral fracture, discomfort in the course of a cancerous tumor, or chest pain
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during a myocardial infarction. This process occurs during four phases: transduction,
modulating systems. There are many processes that are proficient at generating neural
modifications that produce neuropathic pain. One includes the reduced availability of m-opioid
peptide (MOP) receptors. The typical MOP agonist is morphine. The triggering of this receptor
by morphine causes analgesia, sedation and a minor drop in blood pressure, urticarial, euphoria,
decreased respirations, miosis, and reduced bowel motility (Rodriguez, 2015, p. 341).
reaction. Inflammatory cells surround the areas of tissue injury and generate cytokines and
chemokines that typically regulate the progression of recuperation and tissue restoration. These
chemicals can also inflame and alter the properties of the sensory neurons surrounding the area
of injury, creating a sense of pain in areas neighboring those of real injury (Rodriguez, 2015, p.
341).
History of Present Illness (HPI). Pain is the defining feature for many disease
diagnoses. It can serve as an index of the severity and activity of an underlying condition, a
prognostic indicator, and a determinant of health service use. Describing the epidemiology of
pain is challenging because of the subjective nature of the symptoms and a lack of consensus
regarding diagnoses and definitions. Identifying true first-ever episodes of pain, especially
musculoskeletal pain, is problematic because of recall over a lifetime. Many pain conditions are
episodic, with a large proportion of patients reporting symptoms that resolve and then recur with
varying time periods in between. The true incidence for most pain conditions may thus remain
Pain has survival value. Pain serves as a warning that all is not well, frequently signaling
injury or disease. It encourages us to seek medical help, contributes to the healing process by
promoting rest and recovery, and let us know, by its absence, when to resume activities. Pain
reminds us of past harmful events and situations, it teaches us what to avoid in the future, and
motivates us to act to terminate it. People born without the capacity to feel pain often do not live
beyond childhood because they fail to appreciate the implications of injury and disease. Acute
pain serves this survival function. However, chronic pain has no adaptive purpose. When
chronic pain is severe and intractable, it lodges itself in the core of the person and causes distress
and suffering. Chronic pain can ruin marriages and families. It can lead to job loss and other
financial problems, social isolation, worry, anxiety, depression, and even at times, suicide (Katz
most frequently used drugs. They are used extensively in the management of chronic pain and
inflammatory conditions, such as rheumatoid arthritis (RA) and osteoarthritis (OA), as well as
acute pain due to trauma, surgery, headache, musculoskeletal injuries, and cancer (Wehling,
2014). Management of pain and inflammation must consider those risks and find alternative
drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity such as
Past Medical History- The history is important to characterize a patients pain in order
to provide timely relief and treatment. The elderly can experience multiple pain syndromes from
different areas of the body and this should be considered while contemplating a differential
diagnosis.
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Family History- Having a family history of substance abuse, family members who have
had problems with alcohol, drugs or prescription medication that caused health, relationship, job
or legal issues, are at an increased risk for substance use disorders based on diagnostic criteria in
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Pestka, Nash, Evans,
Cronin, Bee, King, & ... Loukianova, 2015). Benefits of assessing family history include
heightened awareness of the genetic and environmental risks associated with a family history of
minimize consequences of substance use disorders, and likely substantial overall health-care cost
savings (Pestka, Nash, Evans, Cronin, Bee, King, & ... Loukianova, 2015).
Social History- Patients with chronic pain and major depressive disorder (MDD) need to
be asked about suicidal ideation and/or hurting others as well as a through social history. Other
questions to ask about include unemployment or disability, poor sleep quality, and self-perceived
mental health status, feeling of belongingness and perceived burdensomeness (Cheatle, 2014). It
leads to job loss and other financial problems, social isolation, worry, anxiety, depression, and, at
Constitutional- Patients with pain may feel at fault, disbelieved, and alone (Katz,
Rosenbloom, & Fashler, 2015). Untreated chronic pain in geriatric patients can result in
Pain- Geriatric pain assessment should be followed by a good history and physical exam.
It should be noted that meaningful pain scores can be more difficult to obtain in the elderly.
ruled out before ever deciding that someones symptoms are caused by mental disorder (Katz,
PAIN IN THE OLDER ADULT 7
Rosenbloom, & Fashler, 2015). Chronic pain may be localized (regional) or generalized and is
typically divided into five main possible categories, including myofascial, musculoskeletal
(mechanical), neuropathic pain, fibromyalgia and chronic headache (Pain Chronic Syndromes,
2016).
Medical dosage adjustments are frequently needed in elderly patients, due to variances in
drug metabolism, drug interactions due to polytherapy, and increased sensitivity to side effects
(Pain Chronic Syndromes, 2016). Suggested starting doses for common pain medications have
been distributed by the American Geriatric Society (Pain Chronic Syndromes, 2016). The tactic
to treat chronic pain syndromes includes treatments that are designed to alleviate or minimize
increases in the level of pain (Pain Chronic Syndromes, 2016). Most of these treatments will
require a multidisciplinary approach. The primary care physician should consider specialist
referral.
Diagnostic Tests
Plain x-rays of spine, bones and joints, identifies osteoporosis, fractures, osteoarthritis,
lytic bone lesions, arthritic changes. MRI of spine, identifies disc herniation with nerve root
impingement, lumbar stenosis and pathologic causes of pain. EMG and nerve conduction studies,
help identify and differentiate between peripheral causes of neuropathic pain, such as peripheral
minimizing patients functional limitations and relieving pain (Jones et al., 2016, p. 24). Opioids
can cause many of the elderly to fall and then further injure themselves. For this reason it is
PAIN IN THE OLDER ADULT 8
important to consider all of the treatment options, for mild to moderate pain, (McCartney &
Nelligan, 2014) recommend to first exclude treatable causes such as infection, loosening of
components or mal alignment. For this the initial treatment could include acetaminophen 1 g
severe pain, they recommend adding oral opioids such as oxycodone or hydromorphone to
Finally, for moderate to severe pain ( neuropathic component) it is suggested that Gabapentin
100300 mg every 8 hours titrated to effect up to 1,800 mg/day be used as well as Nortriptyline
25 mg at night. Also, topical capsaicin or lidocaine may be beneficial for selected patients. Non-
pharmacological and complementary treatments, we should first look at making sure their
depression is treated and then move on to cognitive behavioral therapy, acupuncture, TENS and
Chronic pain has not only an undeniable impact on a patients quality of life, but there are
also financial consequences. Caring for those with chronic pain can also lead to financial costs,
with the average costs being approximately $10,000 a year. Patients with pain also consume
close to twice as much health care resources as the general population. The total costs of the
cumulative burden of chronic pain, including the cost to patients, those who care for them, the
health care system, and the economy, is considerable. In the U.S., approximately 100 million
people were affected by chronic pain in 2010. The total costs ranged from $560-635 billion.
This annual cost is higher than for heart disease, cancer and diabetes (Henschke et al., 2015, p.
145).
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References
Bicket, M. C., & Mao, J. (2015). Chronic pain in older adults. Anesthesiology Clinic, 33, 577-
590. http://dx.doi.org/10.1016/j.anclin.2015.05.011
Cheatle, M. D. (2014). Assessing suicide risk in patients with chronic pain and depression.
Henschke, N., Kamper, S. J., & Maher, C. G. (2015, January). The epidemiology and economic
http://dx.doi.org/10.1016/j.mayocp.2014.09.010
Jones, M. R., Ehrhardt, K. P., Ripoll, J. G., Sharma, B., Padnos, I. W., Kaye, R. J., & Kaye, A.
D. (2016, February 20). Pain in the elderly. Current Pain Headache Report, 20(23).
http://dx.doi.org/10.1007/s11916-016-0551-2
Katz, J., Rosenbloom, B. N., & Fashler, S. (2015). Chronic Pain, Psychopathology, and DSM-5
McCartney, C., & Nelligan, K. (2014). Postoperative Pain Management After Total Knee
Arthroplasty in Elderly Patients: Treatment Options. Drugs & Aging, 31(2), 83-91 9p.
doi:10.1007/s40266-013-0148-y
Pain Chronic Syndromes. (2016). In Epocrates Essential for Apple iOS (Version 8.0) [Mobile
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Pestka, E., Nash, V., Evans, M., Cronin, J., Bee, S., King, S., & ... Loukianova, L. (2015).
Wehling, M. (2014). Non-steroidal anti-inflammatory drug use in chronic pain conditions with
special emphasis on the elderly and patients with relevant comorbidities: management
and mitigation of risks and adverse effects. European Journal Of Clinical Pharmacology,