FAR EASTERN UNIVERSITY Institute of Nursing EVIDENCE-BASED NURSING

Submitted by:
ABANTAO, KIVEN LOYD C. ADALLA, MARIA RIZZA CARMELA R. ANDAYA, KRISTINE ALEXIS L. ANDRADE, MAUREEN B. ANGELES, NICHOLA JANE S.

BSN 218/GROUP 69-A

Submitted to: Dr.TED ALEJO (PROFESSOR-NC ! "E#E" $$$%

CLINICAL

UESTION!

&o o'()t me*odie+ e,-(,.e t-e e//e.t o/ (,(*0e+i.+ i, t-e m(,(0eme,t o/ (.ute 1(i, i, 1(tie,t+ 2-o -(3e u,de)0o,e .o)o,()y ()te)y by1(++ 0)(/t +u)0e)y4 I. CITATION!

u+i. $,te)3e,tio,+ (+ ( Com1*eme,t()y 5-e)(1y i, Po+t Co)o,()y A)te)y By1(++ G)(/t Su)0e)y to $m1)o3e P(i, Out.ome 2it- o'()t e*odie+6

II.

STUDY C"ARACTERISTICS! #. $ATIENT%S INCLUDED! P(tie,t+ i, t-e i,te,+i3e .()e u,it+ 2-o -(3e u,de)0o,e .o)o,()y ()te)y by1(++ 0)(/t +u)0e)y 2ou*d be +e*e.ted &. INTERVENTIONS CO'$ARED!

u+i. t-e)(1y i+ ( te.-,i7ue o/ .om1*eme,t()y medi.i,e t-(t u+e+ mu+i. 1)e+.)ibed i, ( +8i**ed m(,,e) by t)(i,ed t-e)(1i+t+6 P)o0)(m+ ()e de+i0,ed to -e*1 1(tie,t+ o3e).ome 1-y+i.(*! emotio,(*! i,te**e.tu(*! (,d +o.i(* .-(**e,0e+6 A11*i.(tio,+ )(,0e /)om im1)o3i,0 t-e 2e** bei,0 o/ 0e)i(t)i. 1(tie,t+ i, ,u)+i,0 -ome+ to *o2e)i,0 t-e +t)e++ *e3e* (,d 1(i, o/ 2ome, i, *(bo)6 u+i. t-e)(1y i+ u+ed i, m(,y +etti,0+! i,.*udi,0 +.-oo*+! )e-(bi*it(tio, .e,te)+! -o+1it(*+! -o+1i.e! ,u)+i,0 -ome+! .ommu,ity .e,te)+! (,d +ometime+ e3e, i, t-e -ome6 u+i. t-e)(1y -(+ bee, +-o2, to be (, e//i.(.iou+ (,d 3(*id t)e(tme,t o1tio, /o) 1(tie,t+ e91e)ie,.i,0 1(i, )e*(ted to ( 3()iety o/ di(0,o+e+6 u+i. t-e)(1y i,te)3e,tio,+ .(, /o.u+ o, 1(i, m(,(0eme,t /o) 1-y+i.(* )e-(bi*it(tio,! .()di(. .o,ditio,+! medi.(* (,d +u)0i.(* 1)o.edu)e+! ob+tet)i.+! o,.o*o0y t)e(tme,t! (,d bu), deb)ideme,t! (mo,0 ot-e)+6 u+i. i+ ( /o)m o/ +e,+o)y +timu*(tio,! 2-i.- 1)o3o8e+ )e+1o,+e+ due to t-e /(mi*i()ity! 1)edi.t(bi*ity! (,d /ee*i,0+ o/ +e.u)ity (++o.i(ted 2it- it6 Re+e().- )e+u*t+ (,d .*i,i.(* e91e)ie,.e+ (tte+t to

t-e 3i(bi*ity o/ mu+i. t-e)(1y e3e, i, t-o+e 1(tie,t+ )e+i+t(,t to ot-e) t)e(tme,t (11)o(.-e+6

(. OUTCO'ES 'ENTIONED!

5-e)e ()e 3()iou+ 8i,d+ o/ mu+i.6 5-e mu+i. .*(++i/i.(tio,+ )(,0e /)om .*(++i.(* to +e3e)(* 8i,d+ o/ 1o1u*() mu+i. /o)m+6 &i//e)e,t 8i,d+ o/ mu+i. -(3e di//e)e,t 8i,d+ o/ e//e.t o, i,di3idu(*+6 5-e e//e.t m(y de1e,d u1o, (0e! 0e,de) (,d et-,i.ity6 ). DOES T"E STUDY FOCUS ON A SIGNIFICANT $ROBLE' OR CLINICAL $RACTICE* :e+! t-e +tudy doe+ /o.u+ o, ( +i0,i/i.(,t 1)ob*em o) .*i,i.(* 1)(.ti.e6 III. 'E"ODOLGY+ DESIGN! #. 'ET"ODOLGY USED!

S(m1*e +i'e i+ /i/ty 1o+t-o1e)(ti3e .o)o,()y ()te)y by1(++ 0)(/t +u)0e)y 1(tie,t+6 A** t-e )i0-t+ o/ t-e -um(, +ub;e.t+ 2ou*d be (d-e)ed to i, t-e +tudy6 Co*o) .oded o'()t mu+i. (,d b*(,8 C&+ 2i** be u+ed6 &(t( 2i** be .o**e.ted o, ( 7ue+tio,,(i)e (,d +t(ti+ti.(* me(,+ 2ou*d be em1*oyed to 1)o3ide t-e /i,di,0+ o/ t-e +tudy6 &. DESIGN!

A 7u(,tit(ti3e (,d 7u(*it(ti3e (++e++me,t 2i** be u+ed to +tudy t-e e//e.t o/ o'()t mu+i. i, )edu.tio, o/ 1(i, i, 1o+to1e)(ti3e .o)o,()y by1(++ 0)(/t +u)0e)y 1(tie,t+6 e(+u)eme,t o/ 1(i, 2i** be o, (,(*o0ou+ b(+i+ t(8i,0 i,to .o,+ide)(tio, t-e )edu.tio, i, 1(i, +e,+(tio, /e*t by t-e 1(tie,t6 (. DATA SOURCE!

5-e +ou).e+ o/ i,/o)m(tio, i, +tudy i,.*ude 1< ot-e) )e*(ted )e+e().-e+ mo+t o/ t-e )e+e().- /o.u+e+ o, (.ute 1(i, m(,(0eme,t out.ome+ i, +u)0i.(* 1(tie,t+! mu+i. )edu.e+ +e,+(tio, (,d di+t)e++ o/ 1(i, (,d e//e.t+ o/ )e*(9i,0 mu+i. o, +t)e++ )e+1o,+e o/ 1(tie,t+ i, 1(i,

). SUBJECT SELECTION! i. INCLUSION CRITERIA

P(tie,t+ 2-o -(3e ;u+t u,de)0o,e .o)o,()y ()te)y by1(++ 0)(/t +u)0e)y (,d ()e i, t-e i,te,+i3e .()e u,it6

ii.

E,CLUSION CRITERIA

A,y (,d (** 1(tie,t+ -(3i,0 tot(* *o++ o/ -e()i,0 o) +u//e)i,0 /)om im1(i)ed -e()i,06 -. "AS T"E ORIGINAL STUDY "AVE BEEN RE$LICATED* :e+! t-e o)i0i,(* +tudy -(+ bee, )e1*i.(ted6 .. /"AT /ERE T"E RIS0S AND BENEFITS OF T"E NURSING ACTION TESTED IN T"E STUDY* 5-e)e i+ u,8,o2, )i+8 o/ mu+i. t-e)(1y +1e.i/i.(**y i, o'()t t-e)(1y but t-e)e ()e m(,y 8,o2, be,e/it+ *i8e -e*1+ to )e*ie3e 1(i, (,d )edu.e +t)e++ (,d (,9iety /o) t-e 1(tie,t! )e+u*ti,0 i, 1-y+io*o0i.(* .-(,0e+! i,.*udi,0: = $m1)o3ed )e+1i)(tio, = "o2e) b*ood 1)e++u)e = $m1)o3ed .()di(. out1ut = Redu.ed -e()t )(te = Re*(9ed mu+.*e te,+io, u+i. t-e)(1y -(+ bee, +-o2, to -(3e ( +i0,i/i.(,t e//e.t o, ( 1(tie,t>+ 1e).ei3ed e//e.ti3e,e++ o/ t)e(tme,t! +e*/-)e1o)t+ o/ 1(i, )edu.tio,! )e*(9(tio,! )e+1i)(tio, )(te! be-(3io)(**y ob+e)3ed (,d +e*/-)e1o)ted (,9iety *e3e*+! (,d 1(tie,t .-oi.e o/ (,e+t-e+i( (,d (mou,t o/ (,(*0e+i. medi.(tio,6

IV.

RESULT OF T"E STUDY

5-e)e -(+ bee, e3ide,.e /)om )e+e().- t-(t .e)t(i, ty1e+ o/ mu+i.! 2it1()ti.u*() em1-(+i+ o, o'()t mu+i.! .(, im1)o3e t-e .o,.e,t)(tio, *e3e*+! )e(+o,i,0! (,d e3e, (++i+ti,0 t-e -um(, body i, -e(*i,0 it+e*/6 5-i+ 1-e,ome,o, -(+ bee, .(**ed t-e o'()t E//e.t6 5-i+ +tudy +-o2+ t-(t o'()t E//e.t -(3e e9te,ded e//e.t to t-e /ie*d o/ 1(i, m(,(0eme,t6

V.

AUT"OR%S CONCLUSION AND RECO''ENDATIONS

I.

/"AT CONTRIBUTION TO CLIENT "EALT" STATUS DOES T"E NURSING ACTION 'A0E*

By u+i,0 o'()t E//e.t (+ ( ,o,-1-()m(.o*o0i.(* i,te)3e,tio, to t-e 1(tie,t e91e)ie,.i,0 1(i, 2i** -e*1 t-em (**e3i(te t-e 1(i, t-ey ()e /ee*i,06 A,d (*+o (d3e)+e e//e.t+ o/ d)u0+ .(, be )edu.ed6 U+i,0 o'()t E//e.t 2i** -e*1 i, im1)o3i,0 .*ie,t>+ -e(*t- +t(tu+ 2it-out t-e /e() o/ to9i.ity .(u+i,0 to t-e 1(tie,t6 But u+i,0 o'()t E//e.t i+ ,ot i,te,ded to +ub+titute 1-()m(.o*o0i.(* d)u0+ i, (**e3i(ti,0 1(i, it o,*y +e)3e+ (+ (, (*te),(ti3e i,te)3e,tio,6

II.

/"AT OVERALL CONTRIBUTION TO NURSING 0NO/LEDGE DOES T"E STUDY 'A0E*

5-e i++ue )e*(ted to (.ute 1(i, i, 1(tie,t+ t-(t -(3e bee, +ub;e.ted to di//e)e,t +u)0i.(* 1)o.edu)e+ -(+ /o) *o,0 bee, ( 1)ob*em6 $,(de7u(te 1(i, m(,(0eme,t )em(i,+ ( 1e)3(+i3e .*i,i.(* 1)ob*em i, t-e+e 1(tie,t+! *e(di,0 to 1-y+io*o0i.(*! 1+y.-o*o0i.(*! (,d /i,(,.i(* .o,+e7ue,.e+6 5-e u,)e*ie3ed (.ute 1(i, i, 1(tie,t+ i+ )e+1o,+ib*e /o) mo)bidity! (,d *o,0e) +t(y o/ t-e 1(tie,t+ i, t-e -o+1it(*+6 5-e +*o2e) -e(*i,0 )(te+! -i0-e) .om1*i.(tio, )(te+! (,9iety! +*ee1*e++,e++! i,.)e(+ed +u//e)i,0! (,d *o2e)ed 7u(*ity o/ *i/e +ee, i, t-e+e 1(tie,t+ i+ be*ie3ed to be ( )e+u*t i,

t-e de/i.ie,.y o/ (.ute 1(i, )e*ie/6 5-e)e ()e (*+o e.o,omi. .o,+e7ue,.e+! be.(u+e o/ t-e *o,0e) -o+1it(*i'(tio, )e7ui)ed t-(t ()e (++o.i(ted 2it- (.ute 1(i,6 VI. A$$LICABILITY

I.

DOES T"E STUDY $ROVIDE DIRECT ENOUG" ANS/ERS TO YOUR CLINICAL UESTION IN TER'S OF TY$E OF $ATIENT1 INTERVENTIONS AND OUTCO'ES* :e+! t-e +tudy 1)o3ide+ di)e.t e,ou0- (,+2e)+ to t-e .*i,i.(* 7ue+tio, i, te)m+ o/ ty1e o/ 1(tie,t! i,te)3e,tio,+ (,d out.ome+6

II.

IS IT FEASIBLE TO CARRY OUT NURSING ACTION IN T"E REAL /ORLD* :e+! it i+ /e(+ib*e to .())y out i, t-e )e(* 2o)*d6

VII.

REVIE/ER%S CONCLUSION AND CO''ENTARY

5-e +tudy -(d +-o2ed ( u,i7ue 2(y o/ )edu.i,0 o) (**e3i(ti,0 1(tie,t+> 1(i, 2-o u,de)0o,e Co)o,()y A)te)y By1(++ G)(/t Su)0e)y6 o+t*y! 1-()m(.o*o0i.(* i,te)3e,tio,+ ()e u+ed i, o)de) to )edu.e 1(i, but t-e +tudy 2(+ (b*e to +-o2 t-(t u+i,0 ,o,-1-()m(.o*o0i.(* i,te)3e,tio,+ i+ (*+o e//e.ti3e i, de.)e(+i,0 1(i,! but it doe+ ,ot +(y t-(t mu+i. t-e)(1y 2i** )e1*(.e t-e u+(0e o/ d)u06 5-e +tudy de1e,d+ o, m(,y *ite)(tu)e )e3ie2 )e*(ted to t-e to1i. i, o)de) to .ome out 2it- t-e out.ome! t-eo)ie+ ()e (*+o u+ed i, obt(i,i,0 t-e )e+u*t6

Wolfgang Amadeus Mozart was not only one of the greatest composers of the Classical period, but one of the greatest of all time. Surprisingly, he is not identified with radical formal or harmonic innovations, or with the profound kind of symbolism heard in some of ach!s works. Mozart!s best music has a natural flow and irresistible charm, and can e"press humor, #oy or sorrow with both conviction and mastery. $is operas, especially his later efforts, are brilliant e"amples of high art, as are many of his piano concertos and later symphonies. %ven his lesser compositions and #uvenile works feature much attractive and often masterful music. Mozart was the last of seven children, of whom five did not survive early childhood. y the age of three he was playing the clavichord, and at four he began writing short compositions. &oung Wolfgang gave his first public performance at the age of five at Salzburg 'niversity, and in (anuary, )*+,, he performed on harpsichord for the %lector of avaria. -here are many astonishing accounts of the young Mozart!s precocity and genius. At the age of seven, for instance, he picked up a violin at a musical gathering and sight.read the second part of a work with complete accuracy, despite his never having had a violin lesson. /n the years )*+0 . )*++, Mozart, along with his father 1eopold, a composer and musician, and sister 2annerl, also a musically talented child, toured 1ondon, 3aris, and other parts of %urope, giving many successful concerts and performing before royalty. -he Mozart family returned to Salzburg in 2ovember )*++. -he following year young Wolfgang composed his first opera, Apollo et $yacinthus. 4eyboard concertos and other ma#or works were also coming from his pen now. /n )*+5, Mozart was appointed Konzertmeister at the Salzburg Court by the Archbishop. eginning that same year, the Mozarts made three tours of /taly, where the young composer studied /talian opera and produced two successful efforts, Mitridate and 1ucio Silla. /n )**0, Mozart was back in Austria, where he spent most of the ne"t few years composing. $e wrote all his violin concertos between )**6 and )***, as well as Masses, symphonies, and chamber works. /n )*78, Mozart wrote his opera /domeneo, which became a sensation in Munich. After a

conflict with the Archbishop, Mozart left his Konzertmeister post and settled in 9ienna. $e received a number of commissions now and took on a well.paying but unimportant Court post. /n )*7, Mozart married Constanze Weber and took her to Salzburg the following year to introduce her to his family. )*7, was also the year that saw his opera :ie %ntf;hrung aus dem Serail staged with great success. /n )*76, Mozart #oined the <reemasons, apparently embracing the teachings of that group. $e would later write music for certain Masonic lodges. /n the early. and mid.)*78s, Mozart composed many sonatas and =uartets, and often appeared as soloist in the fifteen piano concertos he wrote during this period. Many of his commissions were for operas now, and Mozart met them with a string of masterpieces. 1e nozze di <igaro came )*7+, :on >iovanni in )*7*, Cos? fan tutte in )*58 and :ie @auberflAte in )*5). Mozart made a number of trips in his last years, and while his health had been fragile in previous times, he displayed no serious condition or illness until he developed a fever of unknown origin near the end of )*5). %ffects %"perimental sub#ects challenged by acute pain and patients in chronic pain e"perience impairments in attention control, working memory, mental fle"ibility, problem solving, and information processing speed.
B08C

BeditC-heory BeditCSpecificity

:escartes! pain pathway. /n his )++6 Treatise of Man, DenE :escartes traced a pain pathway. F3articles of heatF GAH activate a spot of skin G H attached by a fine thread GccH to a valve in the brain GdeH where this activity opens the valve, allowing the animal spirits to flow from a cavity G<H into the muscles that then flinch from the stimulus, turn the head and eyes toward the affected body part, and move the hand and turn the body protectively. -he underlying premise of this model . that pain is the direct product of a no"ious stimulus activating a dedicated pain pathway, from a receptor in the skin, along a thread or chain of nerve fibers to the pain

center in the brain, to a mechanical behavioral response . remained the dominant perspective on pain until the mid.nineteen si"ties.B0)C BeditC3attern Specificity theory Gdedicated pain receptor and pathwayH has been challenged by the theory, proposed initially in )7*6 by Wilhelm %rb, that a pain signal can be generated by stimulation of any sensory receptor, provided the stimulation is intense enoughI the pattern of stimulation Gintensity over time and areaH, not the receptor type, determines whether nociception occurs. Alfred >oldscheider G)756H proposed that over time, activity from many sensory fibers might accumulate in the dorsal horns of the spinal cord and begin to signal pain once a certain threshold of accumulated stimulation has been crossed. /n )5J0, Willem 2oordenbos observed that a signal carried from the area of in#ury along large diameter Ftouch, pressure or vibrationF fibers may inhibit the signal carried by the thinner FpainF fibers . the ratio of large fiber signal to thin fiber signal determining pain intensityK hence, we rub a smack. -his was taken as a demonstration that pattern of stimulation Gof large versus thin fibers in this instanceH modulates pain intensity.B0,C BeditC>ate Control -his all set the scene for Melzack and Wall!s classic )5+J Science article F3ain MechanismsI A 2ew -heoryF.B00C $ere the authors proposed that the large diameter GFtouch, pressure, vibrationFH and thin GFpainFH fibers meet at two places in the dorsal horn of the spinal cordI the FtransmissionF G-H cells, and the FinhibitoryF cells. oth large fiber signals and thin fiber signals e"cite the - cells, and when the output of the - cells e"ceeds a critical level, pain begins. -he #ob of the inhibitory cells is to inhibit activation of the - cells. -he - cells are the gate on pain, and inhibitory cells can shut the gate. /f your large diameter and thin fibers have been activated by a no"ious event, they will be e"citing - cells Gopening the pain gateH. At the same time, the large diameter fibers will be exciting the inhibitory cells Gtending to close the gateH, while the thin fibers will be impeding the inhibitory cells Gtending to leave the gate openH. So, the more large fiber activity relative to thin fiber activity, the less pain you will feel. -hey had conceived a neural Fcircuit diagramF to e"plain why we rub a smack.B0)C -he authors then added the most enduring and influential element of their theoryI a pain modulating signal coming down from the brain to the dorsal horn. -hey pictured the large fiber signals traveling, not only from the site of in#ury to the inhibitory and - cells in the dorsal horn, but also up to the brain where, depending on the state of the brain, they may trigger a signal back down to the dorsal horn to further modulate inhibitory cell activity and so pain intensity. -his model provided a neuroscientific rationale for taking seriously the effect of motivation and cognition on pain intensity. B0)C BeditC:imensions

/n )5+7 Melzack and Casey described pain in terms of its three dimensionsI FSensory.discriminativeF Gsense of the intensity, location, =uality and duration of the painH, FAffective.motivationalF Gunpleasantness and urge to escape the unpleasantnessH, and FCognitive.evaluativeF Gcognitions such as appraisal, cultural values, distraction and hypnotic suggestionH. B5C-hey theorized that pain intensity Gthe sensory discriminative dimensionH and unpleasantness Gthe affective.motivational dimensionH are not simply determined by the magnitude of the painful stimulus, but LhigherM cognitive activities Gthe cognitive. evaluative dimensionH can influence perceived intensity and unpleasantness. Cognitive activities Fmay affect both sensory and affective e"perience or they may modify primarily the affective.motivational dimension. -hus, e"citement in games or war appears to block both dimensions of pain, while suggestion and placebos may modulate the affective.motivational dimension and leave the sensory.discriminative dimension relatively undisturbed.F Gp. 60,H -he paper ended with a call to actionI F3ain can be treated not only by trying to cut down the sensory input by anesthetic block, surgical intervention and the like, but also by influencing the motivational.affective and cognitive factors as well.F Gp. 60JH BeditC-heory today

Degions of the cerebral corte" associated with pain. Specificity, the theory that pain is transmitted from specific pain receptors along dedicated pain fibers to a pain center in the brain, has withstood the challenge from pattern theory, though the Fpain centerF in the brain has become an elaborate neural network. Wilhelm %rb!s G)7*6H early pattern theory hypothesis, that a pain signal can be generated by intense enough stimulation of any sensory receptor, has been soundly disproved.B06C A.delta and C peripheral nerve fibers carry information regarding the state of the body to the dorsal horn of the spinal cord.B0JC Some of these A.delta and C fibers GnociceptorsH respond only to painfully intense stimuli, while others do not differentiate no"ious from non.no"ious stimuli. B06C A.:.Craig and colleagues have identified fibers dedicated to carrying A.delta fiber pain signals, and others

dedicated to carrying C fiber pain signals up the spinal cord to the thalamus in the brain.B0+C -here is a specific pain pathway from nociceptor to brain. 3ain.related activity in the thalamus spreads to the insular corte" Gthought to embody, among other things, the feeling that distinguishes pain from other homeostatic emotions such as itch and nauseaH and anterior cingulate corte" Gthought to embody, among other things, the motivational element of painHKB0JC and pain that is distinctly located also activates the primary and secondary somatosensory cortices.B0*CB07C -he gate control theory has not fared well. Most of the dorsal horn interneurons identified by Melzack and Wall as inhibitory are in fact e"citatory, B06C and 4o#i /nui and colleagues have recently shown that pain reduction due to non.no"ious touch or vibration can result from activity within the cerebral corte", with minimal contribution at the spinal level.B05C Melzack and Casey!s )5+7 picture of the dimensions of pain is as influential today as ever, firmly framing theory and guiding research in the functional neuroanatomy and psychology of pain. BeditC%volutionary and behavioral role 3ain is part of the body!s defense system, producing a refle"ive retraction from the painful stimulus, and tendencies to protect the affected body part while it heals, and avoid that harmful situation in the future. B0C
B68C

/t is an important part of animal life, vital to healthy survival. 3eople with congenital insensitivity to

pain have reduced life e"pectancy.B6)C /diopathic pain Gpain that persists after the trauma or pathology has healed, or that arises without any apparent causeH, may be an e"ception to the idea that pain is helpful to survival, although (ohn Sarno argues that such pain is psychogenic, enlisted as a protective distraction to keep dangerous emotions unconscious.B6,C /t is not clear what the survival benefit of some e"treme forms of pain Ge.g. toothacheH might be, and the intensity of some forms of pain Gfor e"ample as a result of in#ury to fingernails or toenailsH seems to be out of all proportion to any survival benefits. BeditC-hresholds 9ariations in pain threshold or in pain tolerance occur between individuals for various reasons including cultural background, ethnicity, genetics, and gender. /n pain science, thresholds are measured by gradually increasing the intensity of a stimulus such as electric current or heat applied to the body. -he Fpain perception thresholdF is the point at which the stimulus begins to hurt, and the Ftolerance thresholdF is reached when the sub#ect acts to stop the pain. -here is significant variation in pain perception and tolerance thresholds between cultural groups. <or e"ample, people of Mediterranean origin report as painful certain radiant heat intensities that northern %uropeans describe as warmth, and /talian women tolerate less electric shock than (ewish or 2ative American women. Some individuals in all cultures have considerably higher than normal pain perception and tolerance thresholds. <or instance, patients who e"perience painless heart attacks have significantly higher pain thresholds for electric shock, heat and arm.muscle cramp than those who e"perience painful heart attacks. B60C

BeditC:iagnosis See also: Pain scales A person!s self report is the most reliable measure of pain, with health care professionals tending to underestimate severity.B66C A definition of pain widely employed in nursing, emphasizing its sub#ective nature and the importance of believing patient reports, was introduced by Margo McCaffery in )5+7I F3ain is whatever the e"periencing person says it is, e"isting whenever he says it doesF. B6JCB6+C -o assess intensity, the patient may be asked to locate their pain on a scale of 8 to )8, with 8 being no pain at all, and )8 the worst pain they have ever felt. Nuality can be established by having the patient complete the Mc>ill 3ain Nuestionnaire indicating which words best describe their pain.B*C BeditCMultidimensional pain inventory -he Multidimensional 3ain /nventory GM3/H is a =uestionnaire designed to assess the psychosocial state of a person with chronic pain. Analysis of M3/ results by -urk and Dudy G)577H found three classes of chronic pain patientI FGaH dysfunctional, people who perceived the severity of their pain to be high, reported that pain interfered with much of their lives, reported a higher degree of psychological distress caused by pain, and reported low levels of activityK GbH interpersonally distressed, people with a common perception that significant others were not very supportive of their pain problemsK and GcH adaptive copers, patients who reported high levels of social support, relatively low levels of pain and perceived interference, and relatively high levels of activity.F B6*C Combining the M3/ characterization of the person with their /AS3 multia"ial pain profile is recommended for deriving the most useful case description. B)6C

Classification -he /nternational Association for the Study of 3ain G/AS3H classification system recommends describing pain according to five categoriesI duration and severity, anatomical location, body system involved, cause, and temporal characteristics Gintermittent, constant, etc.H. B),C -his system has been criticized by Woolf and others as inade=uate for guiding research and treatment, B)0C and an additional category based on neurochemical mechanism has been proposed.B)6C BeditC:uration 3ain is usually transitory, lasting only until the no"ious stimulus is removed or the underlying damage or pathology has healed, but some painful conditions, such as rheumatoid arthritis,peripheral neuropathy, cancer and idiopathic pain, may persist for years. 3ain that lasts a long time is called chronic, and pain that resolves =uickly is called acute. -raditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onsetK the two most commonly used markers being 0 months

and + months since the onset of pain,B)6C though some theorists and researchers have placed the transition from acute to chronic pain at ), months. B)JC Others apply acute to pain that lasts less than 08 days, chronicto pain of more than si" months duration, and subacute to pain that lasts from one to si" months.B)+C A popular alternative definition of chronic pain, involving no arbitrarily fi"ed durations is Fpain that e"tends beyond the e"pected period of healing.F B)6C Chronic pain may be divided into FcancerF and FbenignF.B)+C BeditCDegion and system 3ain can be classed according to its location in the body, as in headache, low back pain and pelvic painK or according to the body system involved, i.e., myofascial pain Gemanating from skeletal muscles or the fibrous sheath surrounding themH, rheumatic Gemanating from the #oints and surrounding tissueH, causalgia GFburningF pain in the skin of the arms or, sometimes, legsK thought to be the product of peripheral nerve damageH, neuropathic pain Gcaused by damage to or malfunction of any part of the nervous systemH, or vascular Gpain from blood vesselsH. B)6C BeditCCause -he crudest e"ample of classification by cause simply distinguishes FsomatogenicF pain Garising from a perturbation of the bodyH from FpsychogenicF pain Garising from a perturbation of the mindI when a thorough physical e"am, imaging, and laboratory tests fail to detect the cause of pain, it is assumed to be the product of psychic conflict or psychopathologyH. B)6CSomatogenic pain is divided into FnociceptiveF Gcaused by activation of nociceptorsH and FneuropathicF Gcaused by damage to or malfunction of the nervous systemH.B)*C BeditC2ociceptive 2ociceptive pain is initiated by stimulation of nociceptors, and may be classified according to the mode of no"ious stimulationK the most common categories being FthermalF Gheat or coldH, FmechanicalF Gcrushing, tearing, etc.H and FchemicalF Giodine in a cut, chili powder in the eyesH. 2ociceptive pain may also be divided into Fsuperficial somaticF and FdeepF, and deep pain into Fdeep somaticF and FvisceralF. Superficial somatic pain is initiated by activation of nociceptors in the skin or superficial tissues, and is sharp, well.defined and clearly located. %"amples of in#uries that produce superficial somatic pain include minor wounds and minor Gfirst degreeH burns. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly.localized painK e"amples include sprains and broken bones. Visceral pain originates in the viscera GorgansH and often is e"tremely difficult to locate, and several visceral regions produce FreferredF pain when in#ured, where the sensation is located in an area distant from the site of in#ury or pathology.B)7C BeditC2europathic

Main article:

europathic pain

2europathic pain is caused by damage to or malfunction of the nervous system, and is divided into FperipheralF Goriginating in the peripheral nervous systemH and FcentralF Goriginating in the brain or spinal cordH.B)5C 3eripheral neuropathic pain is often described as Lburning,M Ltingling,M Lelectrical,M Lstabbing,M or Lpins and needles.M B,8C umping the Ffunny boneF elicits peripheral neuropathic pain. BeditC3sychogenic Main article: Psychogenic pain 3sychogenic pain, also called psychalgia or somatoform pain, is a sensation of pain caused, increased, or prolonged by mental, emotional, or behavioral factors. B,)CB,,C $eadache, back pain, and stomach pain are sometimes diagnosed as psychogenic.B,)C Sufferers are often stigmatized, because both medical professionals and the general public tend to think that pain from a psychological source is not FrealF. $owever, specialists consider that it is no less actual or hurtful than pain from any other source. B,0C 3eople with long term pain fre=uently display psychological disturbance, with elevated scores on the Minnesota Multiphasic 3ersonality /nventory scales of hysteria, depression andhypochondriasis Gthe Fneurotic triadFH. Some investigators have argued that it is this neuroticism that causes acute in#uries to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and an"iety fall, often to normal levels. Self.esteem, often low in chronic pain patients, also shows striking improvement once pain has resolved.B,6C L-he term !psychogenic! assumes that medical diagnosis is so perfect that all organic causes of pain can be detectedK regrettably, we are far from such infallability... All too often, the diagnosis of neurosis as the cause of pain hides our ignorance of many aspects of pain medicine.M Donald Melzack, )55+. B,6C BeditC3hantom pain Main article: Phantom pain 3hantom pain is the sensation of pain from a part of the body that has been lost or from which the brain no longer receives physical signals. /t is a type of neuropathic pain. 3hantom limb pain is a common e"perience of amputees. One study found that eight days after amputation, *, per cent of patients had phantom limb pain, and si" months later, +J percent reported it. B,JC Some e"perience continuous pain that varies in intensity or =ualityK others e"perience several bouts a day, or it may occur only once every week or two. /t is described as shooting, crushing, burning or cramping. /f the pain is continuous for a long period, parts of the intact body may become sensitized, so that touching them evokes pain in the phantom limb, or phantom limb pain may accompany urination or defecation. B,+C

1ocal anesthetic in#ections into the nerves or sensitive areas of the stump may relieve pain for days, weeks or, sometimes permanently, despite the drug wearing off in a matter of hoursK and small in#ections of hypertonic saline into the soft tissue between vertebrae produces local pain that radiates into the phantom limb for ten minutes or so and may be followed by hours, weeks or even longer of partial or total relief from phantom pain. 9igorous vibration or electrical stimulation of the stump, or current from electrodes surgically implanted onto the spinal cord all produce relief in some patients. B,+C 3araplegia, the loss of sensation and voluntary motor control after serious spinal cord damage, may be accompanied by root GFgirdleFH pain at the level of the spinal cord damage, visceral pain evoked by a filling bladder or bowel, or, in five to ten per cent of paraplegics, phantom body pain in areas of complete sensory loss. 3hantom body pain is initially described as burning or tingling but may evolve into severe crushing or pinching pain, fire running down the legs, or a knife twisting in the flesh. Onset may be immediate or may not occur until years after the disabling in#ury. Surgical treatment rarely provides lasting relief.B,+C BeditC3ain asymbolia Main article: Pain asymbolia 3ain science acknowledges, in a puzzling challenge to /AS3 definition, B)C that pain may be e"perienced as a sensation devoid of any unpleasantnessI this happens in a syndrome calledpain asymbolia or pain dissociation, caused by conditions like lobotomy, cingulotomy or morphine analgesia. -ypically, such patients report that they have pain but are not bothered by it, they recognize the sensation of pain but are mostly or completely immune to suffering from it.B,*C BeditC/nsensitivity to pain -he ability to e"perience pain is essential for protection from in#ury, and recognition of the presence of in#ury. %pisodic analgesia may occur under special circumstances, such as in the e"citement of sport or warI a soldier on the battlefield may feel no pain for many hours from a traumatic amputation or other severe in#ury.B,7C $owever, insensitivity to pain may also be ac=uired following conditions such as spinal cord in#ury, diabetes mellitus, or more rarely leprosy.B,5C A small number of people suffer from congenital analgesia GFcongenital insensitivity to painFH, a genetic defect that puts these individuals at constant risk from the conse=uences of unrecognized in#ury or illness. Children with this condition suffer carelessly repeated damage to their tongue, eyes, #oints, skin, and muscles. -hey may attain adulthood, but have a shortened life e"pectancy.