Understanding Pain and Nutrition in Healthcare

okay guys we are going to have our pain and nutrition lecture we just as a disclaimer before I get going I know that I would struggle with online modules I have a hard time enough paying attention in a real like live class And so if you're struggling to pay attention and struggling to learn from this, I get you. Do your best. As we're going through this lecture, please be sure to write down and bring to class any questions that you have, because I would love to sit down with you and review anything you need. So, yeah, make sure you're taking good notes. And if you have any questions, bring them to class. Let's talk about it. And that way we can still learn what we need to learn from these lectures. So. Let's get started. Pain and nutrition. I like giving this particular picture out of the get-go because it shows how you can have people in very similar circumstances expressing their feelings in very different ways, right? So here we are, my wife and I taking a family photo and we're smiling, pretending like we're having this joyous moment and our kid is very much more genuine at expressing how... all of us are feeling inside. So pain is very much this way. It has a lot of, you know, we might all be in the same circumstance or same similar conditions with pain, but we're each going to experience and express that in different ways. So yeah, let's, let's keep going. Pain is a difficult one as a nurse, because you're dealing with patients who can sometimes frustrate you with reporting high levels of pain with all these events. And there have been times where I've been frustrated and I'm like, okay, if I literally, I know that you sprained your wrist, but you're saying it's a 10 out of 10 pain, which means I can chop your leg off and set it on fire and let you watch it burn. And you wouldn't even feel it because your wrist is hurting you so much because you're maxed out. I don't know. It's frustrating. But just remember that we need to take... their description of pain seriously and don't let those frustrations get the better of you. Remember, nurses, we're all about advocating and serving these patients, advocating for and serving these patients. So what is pain? Pain is more or less whatever the patient says it is. It's an unpleasant sort of sensation. It may or may not be an association with tissue damage. But we consider it kind of this fifth vital sign, which is weird because all of the other vital signs are very objective. And yet we're sort of getting this pain report, which is coming from the patient's experience, which would suggest it's subjective. So how does it fit into that list of vital signs? How does that all work? Hopefully by the end of this lecture, it'll make a little more sense to you. We have a lot of variability with how people will present and describe their pain. Sometimes a lot of our frustration comes from patients like this gentleman here in the top left. They're a big man baby. They have a cold, and they're telling you that their headache from their cold is a 10 out of 10. And then you'll go to your other room where you have... patients like this lady here on the top right where it's like yeah i'm having this kidney stone but compared to giving birth naturally um i'd say this is about a seven you know it's just bizarre how different uh people's pain perspectives are um then you have patients like our middle guy here who are completely gone their highs could be and they're still telling you it's a 12 out of 10 even though they literally probably can't feel pain and What I see a lot of, probably more often than not, is a circumstance like this gentleman here to the right. I'm super anxious about what might be wrong with me, and I want you to take my problem seriously. It's a nine. So what they're thinking is not quoted, and what they say is it's a nine. And I just find this to be really, really relevant. I think people are often... hesitant to give a middle or lower number for their pain because in a sense that would be saying I don't want you to take this problem as seriously or I don't want this to be as much of a priority and of course they want it to be a priority for you. So sometimes I feel like they're giving this higher number out of a desire to get more attention to address the problem and when in doubt I feel like this disconnect. can usually be resolved with some really good patient education by putting their mind at ease and saying, look, I'm acknowledging what you're going through. I know for you, a six is probably a significant amount of pain. So, you know, so hopefully they're in a relationship with you that they feel comfortable giving you that number, knowing that you're going to respond with the same level of priority and take them seriously, regardless if they tell you an 11 versus a six, right? And then you have some patients that just aren't able to advocate and describe their own pain. And yet you can look at their face and you don't need a number to know that this little kiddo is miserable. Right. There's just a lot of discomfort in the facial expression, the posturing. Everything about this picture says, I don't feel good. So that's well, then you're like, well, is this observable? Am I observing this? Is this more? objective then? Where is this falling under the umbrella of things? And at the end of the day, really pain is subjective. Everything about pain ultimately is still arguably subjective because even in that kid's picture, the stimulus causing that response is still being perceived and expressed in that way. And so I would argue that everything about pain is going to be considered subjective. But I wanted to make it clear for test taking purposes to be consistent with other classes, I would consider a documented pain score as objective. So if there is a finding that says a patient's pain is seven is recorded as seven out of 10, then that recording of seven out of 10 would be objective. Sure, certainly there are some components that we can observe about pain. That could also be considered objective, but just know that for most all other intents and purposes, pain is going to be whatever the patient says it is. It's going to be subjective. There is a rabbit hole of anatomy that you can dive into with the process of pain and nerves and how they connect and communicate. For this particular lecture, I would not lose too much sleep over the anatomy portion. I'm going to be showing you a video that goes over a little bit of the anatomy, at least enough to kind of trigger some memory from some of your previous courses and get you back on cue with the anatomical functionality of pain. But feel free to brush up on this stuff. It's always helpful to know the... how the wheels are turning behind the scenes to make this happen. And it'll always make more sense when you're assessing if you know how the mechanics of it are working. But again, I wouldn't lose too much sleep in regards to test preparation over this particular area. I don't usually emphasize it much at all. Here's the video I was referring to. We're going to watch this video. I love the video. It's really entertaining. It also does a really good job of explaining how pain is different for different people. and why. And so here we go. Let's say that it would take you 10 minutes to solve this puzzle. How long would it take if you received constant electric shocks to your hands? Longer, right? Because the pain would distract you from the task. Well, maybe not. It depends on how you handle pain. Some people are distracted by pain. It takes them longer to complete a task and they do it less well. Other people use tasks to distract themselves from pain and those people actually do the task faster and better when they're in pain than when they're not. Some people can just send their mind to wandering to distract themselves from pain. How can different people be subjected to the exact same painful stimulus and yet experience the pain so differently? And why does this matter? First of all, what is pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is something we experience, so it's best measured by what you say it is. Pain has an intensity. You can describe it on a scale from 0, no pain, to 10, the most pain imaginable. But pain also has a character, like sharp, dull, burning, or aching. What exactly creates these perceptions of pain? Well, when you get hurt, special tissue damage-sensing nerve cells, called nociceptors, fire. and send signals to the spinal cord and then up to the brain. Processing work gets done by cells called neurons and glia. This is your gray matter and brain superhighways carry information as electrical impulses from one area to another. This is your white matter. The superhighway that carries pain information from the spinal cord to the brain is our sensing pathway that ends in the cortex, the part of the brain that decides what to do with the pain signal. Another system of interconnected brain cells called the salience network decides what to pay attention to. Since pain can have serious consequences, the pain signal immediately activates the salience network. Now you're paying attention. The brain also responds to the pain and has to cope with these pain signals. So motor pathways are activated to take your hand off a hot stove, for example. But modulation networks are also activated that deliver endorphins, and enkephalins, chemicals released when you're in pain or during extreme exercise, creating the runner's high. These chemical systems help regulate and reduce pain. All these networks and pathways work together to create more pain experience, to prevent further tissue damage, and help you to cope with pain. This system is similar for everyone, but the sensitivity and efficacy of these brain circuits determines how much you feel and cope with pain. This is why some people have greater pain than others, and why some develop chronic pain that does not respond to treatment, while others respond well. Variability in pain sensitivities is not so different than all kinds of variability in responses to other stimuli, like how some people love roller coasters, but other people suffer from terrible motion sickness. Why does it matter that there is variability in our pain brain circuits? Well, there are many treatments for pain, targeting different systems. For mild pain, non-prescription medications can act on cells where the pain signals start. Other stronger pain medicines and anesthetics work by reducing the activity in pain sensing circuits or boosting our coping system or endorphins. Some people can cope with pain using methods that involve distraction, relaxation, meditation, yoga, or strategies that can be taught like cognitive behavioral therapy. For some people who suffer from severe chronic pain, that is... pain that doesn't go away months after their injury should have healed. None of the regular treatments work. Traditionally, medical science has been about testing treatments on large groups to determine what would help a majority of patients, but this has usually left out some who didn't benefit from the treatment or experienced side effects. Now, new treatments that directly stimulate or block certain pain sensing, attention, or modulation networks are being developed. along with ways to tailor them to individual patients using tools like magnetic resonance imaging to map brain pathways. Figuring out how your brain responds to pain is the key to finding the best treatment for you. That's true personalized medicine. Really fun little video. I like that. Okay. So I liked how the video ended with kind of an explanation of how we're trying to do better at individualizing pain treatments. And I would just echo that. I think we are getting better with understanding different types of pain, how to treat them more appropriately. And a lot of that change and innovation was driven by the opioid pandemic. I mean, we were treating chronic pain incorrectly for a long time. I think that we're getting better at that. I think there's plenty of room for improvement. So hopefully it'll just get better and better. All right, we are going to move on to some terminology. All of these terminology questions, make sure you get those down. They should really be your easy free throw type questions on the exam. So first off, we have classifications of pain by cause. So no susceptive pain. This is pain that's caused by a new onset of injury or trauma or... tissue damage, something's being damaged and it wasn't damaged 10 minutes ago, but now it's damaged and now it's hurting. I would consider that a type of nociceptive pain. Neuropathic pain is very specific to nerve pain. It's like a nerve damage, nerve type of pain, phantom pain. It just has to do with nerves, very nerve focused type pain, neuropathic pain. And then inflammatory pain, as the name would suggest, is pain that is not necessarily due to injury or trauma, but more so to an inflammatory process. And the inflammatory process is specifically causing pain. So this could be like some autoimmune issues, maybe rheumatoid arthritis. This could be something like shingles. You know, shingles is kind of a nerve pain, but like The skin inflammation going on could be considered inflammatory. So anyways, if the description of the pain is leaning more towards inflammation, obviously that would be considered an inflammatory pain. These classifications are more on timing, duration, maybe a little bit of cause. Let's talk about them. Keep in mind, there are definitely areas of overlap between some of these. So yeah, for acute pain, acute pain would be something that is designed to be protective. I would see this very similar to nociceptive pain in that it's related to a specific injury or insult, damage, and really sudden onset. So again, very similar, but focusing more on the sudden onset and the fact that acute pain should have a start and a stop, right? It should go away. Versus chronic pain is going to have usually more of a progressive onset and then the pain is going to last months, three, six more months. A lot of things are considered chronic at three months. Definitely by the six month mark, you're looking at more of a chronic situation most of the time. Chronic pain is frustrating because it's not necessarily serving a protective purpose. With acute pain, it's like, yeah, I get it. I hurt my leg and the pain is reminding me to not use that leg for a little bit, right? It needs to rest. It needs to heal. It needs to be splinted. It needs to whatever. Whereas chronic pain, the pain's not going, the problem isn't going away. And so neither is the pain. And it's just more of a frustrating, like, well, then why? Why can't I just turn it off? I know the injury is there. It's never fully healing. Why can't I just turn the pain off and live without that? Unfortunately, that's usually not an option. When it comes to cancer pain, anything related to cancer, if there's any sign of cancer in the description, whether it's the cancer itself or its treatment, it would be considered a cancer type pain. And then intractable pain is any pain. that is just not responding to treatment. So again, this could overlap into any other category, but if the pain is not responding to treatment, whether it's acute or chronic, if it's just not feeling any better despite efforts, then we would consider it an intractable pain. We're going to get past the terminology for now. We're going to move to more of the mental type responses to pain. So when there is a lot of pain going on, especially like chronic type pains, then it tends to have a pretty strong psychological response. And that psychological response does have some similarities between different people. There's some patterns or some tendencies that we can identify. My thought here would be to not underestimate the impact of the mind on pain and how it affects our perception, how we are able to deal with it or not deal with it, even to the point where you might see somatization, where your mind is kind of creating a state of pain just because it's so focused on it and so good at imagining it. But in general, when there's a lot of pain going on, our attention tends to be on it. We tend to focus on it and it's hard. It gets harder and harder to distract yourself from that pain. So somebody who is focusing on their pain, they're going to have more. They're going to report it. They're going to cry. They're going to moan about it. And they're. facial features and their posturing is going to reflect their pain a lot more. Other emotional responses, people who have a lot of pain tend to deal with more anxiety, fear, depression. And then, you know, if the pain becomes chronic or if it's really, really severe, sometimes patients have a hard time seeing the light at the end of the tunnel. Maybe they just don't see a way out. and it becomes suicidal. They can have suicidal thoughts because of pain and just not seeing a solution or just not being able to bear the pain to the point where they'd rather just in their life to get past it. So as nurses, we need to be aware of these emotional responses, making sure that they're addressed, that we are educating and helping these patients physically and mentally and emotionally. It's a big deal. It's not to be underestimated. When it comes to cognitive responses, if you remember in that video, some people perform better cognitively. But I would say the majority of the time you're going to see, especially over time, chronically, you're going to see a decrease in cognitive performance. People with chronic pain a lot of times will refer to like fog brain or this difficulty with recall or with data analyzation. different things. They just sort of have a harder time performing cognitively. A lot of times they have a harder time managing their mood. They tend to be grumpy and shorter tempers, harder to cooperate and be patient with things. And then at the bottom there, it talks about somatization, where your mind is significantly exaggerating pain to the point where you're feeling it. in areas that don't have a reason to feel pain. I gave this chart here not to say that fibromyalgia is completely psychological, because it's not. We're learning more and more about the physiological aspect of fibromyalgia. We don't understand it super well, but I will say there is a large psychological... component to fibromyalgia. And a lot of times, if we do focus on the emotional aspect of pain, it tends to improve their symptoms more significantly than a lot of the medications or other measures we might try. So just things to keep in mind. When it comes to your physiologic responses to pain, please remember that these responses are heavily driven by the fight-or-flight type response and release of different hormones like your anti-diuretic hormone, your epinephrine, your norepinephrine, glucagon. Essentially, when your body is experiencing pain, the pain becomes the bear and we need to either fight the bear or run from the bear, right? So, you're getting this fight-or-flight response. And I think a lot of times that can help with acute pain, but it really presents a problem when we're talking about chronic pain. It puts people at risk for other chronic issues. So if we go through these real quick, people tend to have higher respiratory rates. They tend to have higher heart rates. And again, that fight or flight response is kicking in to facilitate for that. They tend to have decreased gastric. motility and more urinary retention. You don't want to stop and poo or pee before while you're running from the bear. You just got to get running. Right. So no time for that. Anybody got time for that. So you might see somebody with chronic pain dealing with constipation and other things like that. So just things to keep in mind. And then down here at the bottom, you can see they're going to deal with stiffer and more spasmodic muscles. They're going to have a harder time relaxing and having, you know, smooth muscle function without it being all irritated and tense. And then your glucose levels are going to be higher. It's a natural response of that glucagon and decrease in insulin production. So ultimately, you can, somebody who has chronic pain, their blood sugar levels are going to be higher over time. They might be looking at an increased risk for diabetes and other issues, other vascular type issues. So. It's really interesting how in an acute setting, these types of responses can be helpful, but in a chronic setting, they're usually... uh the opposite of helpful so we got a little bit more terminology for you so um if the pain is specific to skin it would be cutaneous pain if the pain is located in the thorax so basically shoulders to waist we would call that a visceral pain if uh the pain is more deep like deeper in a joint i can't really point at it because it's deep in there usually involving like bones, tendons, blood vessels. That would be considered more of a deep somatic pain. Radiating versus referred pain. This one's a big one. Students tend to struggle with these two terms and I like to test you on them. So make sure you're buckling up and paying attention here to get these two differentiated in your mind. If I'm talking about a radiating pain, what's happening is I am able to identify the source of the pain, and that's where the pain is starting, and the pain will then extend from the source. So let's say I injure my shoulder, and I now have shoulder pain, and that shoulder pain is radiating down my arm. I can connect the dots between the source and where that pain is going. That would be radiating pain. And we would compare that to referred pain. If I have referred pain, there is a source that's causing the pain, but there is not a clear line between where the pain is being caused and where the pain is being perceived. And a good example of this might be someone who is having a heart attack, not really having a lot of chest pain, but the pain is happening in their neck or maybe in their left arm. their neck and their left arm is fine. It's their heart, right? They don't, so sometimes our body has a hard time placing the pain because it's getting signals from areas it doesn't usually get signals from. And it's like, I don't know where to put this. I don't know where this signal exactly is. So let's say it's over there and it'll kind of throw it in a general area. even if it's not actually where the pain is happening. So again, if I can connect the dots between source and where the pain is perceived and it's extending out from that source, that would be radiating pain. If there is a disconnect between the source and where that pain is being perceived and it's away from that source, we would consider that referred pain. Phantom pain is specific to people who have had some sort of amputation of a limb or appendage. The nerves are still... saying, hey, there's some downstream nerves that aren't there anymore, but I can feel them, they're sending signals, and it kind of creates this symptom of pain in limbs or body parts that they don't have anymore. So kind of interesting. All right, our next couple of slides are going to be comparing, we have tolerance of pain or pain tolerance versus pain threshold. And so make sure those two are distinct in your mind. Tolerance, pain tolerance. I like to remember it by thinking how much, what is the maximum amount of pain that I can tolerate? And that tells you what pain tolerance is. It's the maximum amount of pain somebody can handle before it's just overwhelming and too much, before they're just gone, right? So our pain tolerance can have its moments where it's better or worse. And there are certain circumstances that we can identify that can either make pain better or worse. So in general, if I am bored, if I'm tired, if I'm anxious, if I'm not getting enough sleep, or if I'm having that pain happen over and over and over again, I tend to have a decrease in tolerance for that pain. That repeated exposure is kind of a sensitization and I'm more sensitive to it. And it bugs me more over time. And you'd think it'd be the opposite, but it's usually that way where you get repeated exposure to it and your brain tends to pick up on it more easily. It's more familiar with it and it almost anticipates it. So those are all reasons why your pain tolerance would go down. On the other hand, you can improve your pain tolerance by getting drunk, right? One of the few times in medical class where drinking alcohol is... on the positive list, right? So usually it's a risk factor. And it's like, yeah, don't do that. Well, in this case, so alcohol is a way to treat pain. It's not an effective. way, a treatment method long-term, right? You deal with some potential problems long-term treatment-wise, but drinking alcohol does increase your pain tolerance. It can make the pain easier to tolerate. We have pain medications that can help. And then as the video had mentioned, just as much as your mental status can exaggerate or focus on the pain, You can also train your mental status or your cognitive mindset about that pain to minimize or reduce or even eliminate the pain through things like distraction, meditation, cognitive behavioral type training, hypnosis. Being warm tends to help alleviate pain and distracting activities. And then interestingly enough, having a belief in something bigger than yourself also tends to help tolerate a little bit more pain, which I find encouraging. Let's see. When it comes to pain tolerance, you are going to see some influences by the people around you. So based on what the people around you are expecting you to express about your pain is going to affect your pain tolerance. Your own physical and mental health baseline is going to affect your pain tolerance. Your pain tolerance varies a lot, both between yourself and other people, and also between you and you in different periods of time. So when you're really young or really old, you tend to have a lower pain tolerance. And then when you're middle-aged adults, you tend to have a better pain tolerance. That's why you'll get the teenager in and you're like, you just can't handle pain. What's wrong with you? But in reality, it's like, yeah, that's what they're experiencing. They have a lower pain tolerance. So it's interesting. All right, let's compare that to pain threshold. Pain threshold, I try to think of like the threshold of a building, like you're carrying something or someone through that threshold. So pain threshold is essentially. When is the transition point between annoying or noxious and painful? So I can handle this much annoyingness and then it becomes painful. And some people, they can only handle this much annoying and then it becomes painful. So that's the pain threshold. Where's the starting point? Interestingly enough, the pain threshold that you have is going to stick with you for most of your life. That doesn't change a whole lot. And it also has a much... a better consistency among people. People tend to have pretty similar pain thresholds. All right, when it comes to pain, getting subjective data is absolutely essential. Pain is subjective. And so by getting the right subjective data, it's going to make or break it for you when it comes to assessing pain. So I wanted to give you guys some tips on getting that subjective data and doing it effectively. So tip number one, make sure that you're validating the patient's concerns and you're building a good trusting type relationship. This has been really impactful for me. My current second job is doing veteran evaluations if they have like a disability or injury claim that they think is related to their service. So my job is to assess these veterans, figure out how bad their issue is, and then report back to the military or VA and say, hey, this is where they're at, this is how bad it is, and this is or isn't really related to their service. And a big part of that is pain. So if they are claiming a knee injury as an injury related to their service, maybe their knee is technically functioning, but maybe the... The pain in their knee is keeping them from doing activities or hobbies or tasks that they would normally like to do. And these veterans are very much coming from a background of shut up and keep going. Right. You're in the battlefield. No one cares if your knee hurts. You keep running because you need to survive. Right. So definitely an interesting culture. that is fostered in the military in regards to health and pain reporting. So I can't tell you how many times I'm doing these assessments and I'm asking them all these different questions about their pain and when it hurts and why it hurts and how bad it hurts. And they're just, they're just super uncomfortable talking about it. They don't want to. bring it up and it's and they will often say things like yeah I just don't uh I don't like to be a complainer I don't like talking about it I um you know I don't want to sound like I'm a baby or whatever and I just have to remind them like this is literally my job I'm literally trying to get this information from you and I want it to be accurate so now's the time let it out talk about it you know And when they're talking about it, it really puts them in a vulnerable position. And so it is important that you validate it because when you are asking a lot of those questions, it can sometimes come across as distrustful or you don't really believe them or you're trying to be skeptical about what they're saying. And you have to make sure that's not the message you're sending. You have to make sure you're saying, yeah, I totally believe you. That would be that would be rough. That's that's a, you know. that's valid, right? So that's really going to help you when it comes to patient communication. And you might be thinking in your mind, what about those guys that are making it up and are just trying to manipulate me and say, yeah, I'm having all this pain because I want more pain medication or whatever. Just be aware that if you're not building that trust relationship, you're not going to get anywhere with them. You have to be able to build their trust. And once they trust you, they're much more likely to have a more open, transparent conversation about their pain. So either way, validation is important. Tip number two is a laundry list. So what I mean by laundry list, if you were to just say, hey, veteran guy, tell me about your knee pain. How does it feel? They're going to stare at you and they're going to say, it hurts right here. My knee hurts. What else do you want? pain and so it's really helpful to give them a list of options of how they might describe their pain different terms and a good example would be okay you're having knee pain tell me is that knee pain sharp dull aching throbbing burning tingling what kind of pain is it and then suddenly they have this nice list of oh i can connect the feeling with this term and it's easier for them to give a better description of their pain so We don't want to be leading with this list. We want the list to be nice and encompassing, but it's still a really good idea to give them some options to choose from so that they can have a better idea of what you're asking. Number three, it's always a good idea to reference previous pain experiences. A good example of this would be, oh, you're having chest pain. I see that you've had a heart attack about six years ago. Does your current pain feel similar to the pain you had back then? And if so, now I'm really nervous, right? So always kind of giving that previous experience is helpful. And then one and four are very similar, making sure that you're building that trustful relationship. A few other tips, make sure that you're in a calm, quiet, private environment. Again, talking about pain can be a vulnerable thing. And so making sure that they have a good environment to do that, where they can feel comfortable. This is a big one, asking open-ended questions. We like to give you quiz or exam questions that will say, hey, which one of these questions is best? And ultimately, it'll come down to the format of the question. So if I am trying to get a lot more volume from this person about their pain and just get like... More volume. I don't care what it is. Just give me volume. I want to know more about it. An open-ended question is going to be the way to go. If you're trying to really pinpoint a discrepancy between one or two items, you know, is the pain worse in the morning or the afternoon? They're going to say one or the other, and that's going to give you one data point. If you were to say, so when this pain is happening in the morning, what other symptoms come with it? Are you nauseous? Are you fatigued? Do you get headaches? What else is going on? Those types of open-ended questions are going to just open the door to way more information. So depending on what you're aiming at, those question formats can really help out. Make sure that you're listening carefully. Make sure that your posturing and your positioning is telling the patient that you're listening and showing them that you appreciate the information that they're giving you. And when in doubt, it's a great idea if you're not sure what they said or if you're not really sure what they're trying to communicate, it's a great idea to restate or quote what they're saying so that they can have a chance to clarify or edit their statement. And I find that pretty effective. And then to make sure we hit all the right points, there's a few mnemonics. Mnemonics? Mnemonics? Mnemonics. I think I said it right the first time. Several different memory tools that you can use to help you remember which questions to ask. You can find a bunch of them out there, old carts, whatever. But we like to stick with Cold Spa for consistency purposes. We talked about Cold Spa, I think, during the interview module. So we already talked about it a little bit, but we might give you a question on the exam that's like, okay, here's a description of this person's pain. What's missing? Maybe they told us the character of the pain and how bad it is, but the question never told us when it started or how long it's been going on. And so identifying those components and being able to find them is kind of what we're looking for there. All right, moving on. Pain scales. Pain scales are super important to know and utilize different pain scales for different patients in different circumstances. So when you're studying these pain scales, pain scales, be sure to know kind of when would be a good circumstance to use them, when not so much. The first two are pretty, the first one's very vague. So it could apply to almost anybody. You just sort of say, how bad is it? point to where you tend to land. We tend to see more of the numeric pain intensity scale used more often. So that one, most adults, we're going to start there. How bad is your pain? Zero to 10. Zero being no pain, 10 being worst possible pain. It's usually effective, but I also find that it has its problems, right? You'll get the people over saying, my pain is severe. It's a 10 out of 10, 10 out of 10, 10 out of 10. And it's like, okay, your ankle sprain should not be a 10 out of 10. Where's the disconnect, right? So sometimes I have found it helpful to switch to something like the simple descriptive pain intensity, and sometimes the patients feel a little more validated, right? So I know that you have really severe pain. So on this scale, would you say it's severe, very severe, or worst possible pain? And suddenly giving the pain score a six doesn't feel so discrediting, right? So. A really good option if you're having that disconnect to bring in this type of different scale to see if it helps you, you know, meet mutual grounds of understanding with what the patient's trying to communicate. These two scales are usually more specific for our younger pediatric population. With the Wong-Baker FACES scale, please understand that this is for toddlers and that the toddler is going to point to the face that matches their pain. And this is not something where you would be observing their face and picking the picture that matches their face. So yeah, the faces skill, again, you have a toddler, they're not great at talking about their pain or verbalizing it. They're not great at numbers and words. But they are able to understand the emotion behind these faces. And they can point to a face that that describes how they're feeling. So usually ages like three to six, you know, three to eight, somewhere around in there, just depending on the kid, right? So as much as this is anticipated for toddlers, I will say I've used it for adults, right? If I'm still not getting a disconnect, if I'm still getting a disconnect, and Mr. sprained ankle is still telling me 10 out of 10. Sometimes I'll break this bad boy out and be like, okay, you're sitting on your phone and your face looks like the yellow guy right over there. Hurts a little more, but you're telling me you're at a 10 out of 10, which is the red face that's crying and your face isn't red or crying. So where is this? Why is this disconnect happening? A lot of times that'll kind of help them. get a more reasonable number. Anyways, and then the FLAC pain scale. This one is specific for infants or kids or people that are just not able to advocate for themselves and not able to express their pain or verbalize their pain. Usually infants, neonates, that sort of circumstance. So what you're looking at is you're evaluating facial expressions, whether they're calm or grimacing, their legs, whether their legs are lying flat and calm versus thrashing about, their activity, are they involved in the environment around them? Or are they focused on their pain and rigid and jerking around? Are they crying? Are they sleeping? Are they able to be consoled? Are their parents around and are they able to calm them down? Or even the parents having a hard time and their kids just flipping out? You're going to go through each of these categories. You're going to score them down that box. You're going to add it up and that's going to be their pain scale. number. I like this. It's probably the most objective out of all the scales. So it certainly has its value. All right. There are some objective things that we can observe when people are in pain. And this, I find, comes into play when you have patients who are just, you know, there's still a disconnect between the number. they're giving you and what you're observing or what the injury would indicate for the pain level. And that can go both ways. Sometimes I see guys that are very stoic and they do not show their pain. They don't want to tell you it's hurting because they feel that is a sign of weakness and they've never been complainers. It's a three. I'm fine. And I just want it checked out. And then when they don't think you're looking or when they're standing up from sitting and you see this facial grimace in there. grabbing their back and that's something that you can still observe and document as an observation to kind of help paint the picture and create that consistency. But yeah, so you're looking at their posturing, their facial expressions, are they guarding, are they tense, all things to kind of keep in mind that we can observe when it comes to pain. A little bit more pain terminology coming at you. Um, so we have hypoalgesia. Hypo is usually slow or sluggish. In this case, we're talking about pain. And so if I have hypoalgesia, it means that my pain is less than it would be anticipated, less than anticipated for a certain type of injury. Somebody has a broken arm and they're like, yeah, it kind of hurts. You know, that would be That would be hypoalgesia. Analgesia is basically your normal pain response. Everything's appropriate. Hyperalgesia is the opposite of hypo. It's an exaggerated pain response. And that would be like the guy we were talking about before, sprained his ankle, giving you a 10 out of 10, an exaggerated pain response, hyperalgesia. Allodynia. Allodynia is referring to a stimulus or circumstance that should not cause pain, but for some reason is eliciting a fair amount of pain. Brushing hair is a pretty common example. It's not supposed to hurt to brush your hair. And if you're brushing their hair and they're like, oh my gosh, okay, that's allodynia. Another example I might give would be like if you're checking their knee reflexes, you got your reflex hammer and you're just tapping on the knee and below the kneecap. And for some reason, they're telling you that just hurts. Something like that. It's like, I'm not really hitting them hard. It really shouldn't be hurting them. And they're saying it is allodynia. Parasthesia is a really important term to know. Parasthesia is a classic nerve type pain. And it involves the burning, prickling, pins and needles type stuff that you'll see with nerve pain. And then sensitization is a process over time. It's built. by recurrent exposure to pain. Kind of touched on it already, but you just become hypersensitive to that stimulus, that pain stimulus. You're going to notice it more. You're going to almost be trained to anticipate it before it comes. And that's frustrating. All right, we are going to move into some of... some true or false questions to talk about maybe some myths. Make sure we're all on the same page. So question number one, infants cannot verbalize or understand pain. I would like to take out the understand part. I guess express, verbalize and express or localize their pain. Usually they aren't able to understand or I guess process their pain. to where they can localize it and that is true. I don't want you to think that infants don't have pain because they do. It's just a matter of processing and understanding it. Question number two, pain is not a normal process of aging. That is True. Don't let this one trip you up. Being old does not assume that you should be hurting everywhere. Things don't hurt unless there's usually a problem with aging. So it might be common to have a fair amount of aches and pains as you age, but it's not anticipated. Very young patients, neonates, and fetuses do not feel pain. That is false. And we need to do our due diligence to make sure we are addressing the pain, especially for those who are unable to verbalize or express if they are in pain. We usually kind of assume and just treat just to be on the safe side. I just gave it away. Pain is not always an indication of pathology or injury. That one is true. And there could be injury. There could not be. It just depends. Confused or demented patients do not feel pain. That's a very awful perspective. That is definitely false. So demented patients, Alzheimer's, sometimes they have a difficult time expressing their pain. And a lot of times it's noted in behavioral patterns. Maybe they're more agitated, they're more anxious, they're more upset. But, you know, even if they aren't processing it the same way and expressing it the same way, pain can still certainly be there. The next two are pretty similar. So societal expectations for gender are definitely there. Different societies will place different stereotype expectations on gender to influence that. And so just be aware of that and make sure that you're breaking down any barriers for communication on where their pain level is. In general, males are kind of anticipated to express less pain, females not the other way around. So yeah, genetics can impact and lead to an increase or decrease pain tolerance. That one is true. So really interesting. I'm not sure how that all connects, but there is some genetic predisposition to how we perceive our pain. And I keep clicking on it before I ask. That's okay. I think we all know this one. People who are saying they're in pain frequently are just addicts that want pain medication. That's definitely false. It may be true sometimes, but we can get into a lot of trouble by making that assumption. And I would prefer to treat my patients with trust and respect until they give me a reason to not. And yeah, patients who are sleeping do not have pain. False. definitely are going to sleep sometimes even if you're having pain you wake up the pain's still there usually your sleep is not quite as restful if you're in pain next slide trouble with opioids we can get preachy on this slide i don't want to go too crazy on it i think we all have a pretty decent understanding of the opioid pandemic and i would just say that i have seen people come to me and say look I'm addicted and it started because I broke my leg. I was given some opioids and I can't let them go. Please help me. I've seen people that have no idea that they're addicted and are completely addicted and dependent on opioids. I've seen opioids cause a lot of problems, both in patient health and in communication in the health setting, just all over the place, just problems. So. please be patient with these people. I think that how we've treated pain over the years has created a lot of problems. I think we're wading through those problems right now and we're getting better. I don't think opioids should ever have been used or should ever be used for chronic pain. It's just not appropriate. And I think we're figuring that out and we're getting better at avoiding opioid use for chronic situations. But when in doubt... Make sure that we are advocating for patients and not distrusting while still setting clear boundaries so that we're not manipulated. All right, we are leaving the pain conversation and we are moving on to nutritional assessment. If you're getting bored like I am, take a moment, pause, move around, get your blood pumping and jump back in. But Yeah, a little bit of a break here and then we're going to dive into nutritional assessment. Here we go. So we're going to talk about some different things about nutrition in regards to growing stages, diet. um risks for nutritional problems um and problems with nutrition and then we're going to switch into more of a hydration type status where we talk about um how to know if somebody is over or under hydrated but let's start here so nutritional stages to be aware of and when we are infants or kids We are growing like crazy. We have a lot of growing to do. And so we need nutrition. Breastfeeding is great. Breastfeeding. Breastfeeding is great if you're able. If not, it's okay. In general, though, I've seen nutrition where it's parents struggle with it with their kids. I've had kids come into my office and they are 13 years old and they already have type 2 diabetes because they are obese, like just morbidly obese. And even in those circumstances, my approach is never to say, hey, we need to do what we can to get your kid to lose weight. We need to just pull back on the calorie consumption, pull back on the nutrition. They need to lose weight. That is never appropriate for kids because they are still doing so much growing. What I do say is we need to try to just maintain the weight, right? Like maybe watch our portion sizes, but if they are not gaining weight as they grow, then it's a win, right? So keep them active, eat healthy foods, watch our portions. But kids aren't supposed to be losing weight. They're growing too much. Adolescents, we're still growing. We're maturing. If you're pregnant or breastfeeding, obviously you have a... much higher need for nutrients. So that's something important to keep in mind. And then unfortunately, when we get into our adulthood, our need for nutrients stabilizes. And that's when we tend to just put on the put on the weight, right? Like, I needed it 10 years ago, don't need it now. So we're just going to store that away for now. So you tend to see weight gain happen pretty often in adulthood. And then interestingly enough, when you get older, you tend to develop obstacles for nutrition that cause an increased need for nutrition, whether it's chronic disease, whether it's a difficulty with absorbing those nutrients. You typically have a harder time getting the nutrients you need as you're older. And so usually older adults, they need to be packing in more nutrition. It's really interesting. So how do we orient around with all these different diet recommendations? To be honest, nobody can agree with themselves. But the one that I think is the most modest and the most reasonable, I usually go with the Mediterranean diet approach. I think it has a good balance of exercise and it's not necessarily trying to eliminate anything, but it still puts things in perspective as far as how often we should be eating those desserts and carbs. um, versus whole grains and meats and that sort of thing. So I like it. I think it's pretty well balanced. I think it's sustainable. Um, I'm sure that, uh, will change over time. They'll call it something else. They'll adjust preferences. But at the end of the day, if you're just trying to eat healthy foods, um, focusing on your nutritional needs, getting your protein in, getting your, um, other nutrients in, um, everything in moderation, usually. things in moderation usually work out pretty good. I feel though that as time goes on, we tend to have more and more food that is dense in calories and less dense in nutrition. So something to keep in mind. Just because it fills you up doesn't mean it gives you the nutrients that your body's needing. And a lot of times that lack of nutrient availability perpetuates your appetite because you're still not getting what your body's asking for. And so it continues to ask for more. Your appetite still goes and goes and goes. And you just shove a bunch of carbs and calories down. And in reality, your body's like, hey, I was actually just wanting more of this nutrient. And it is nowhere to be found in the Burger King menu. So anyways, just food for thought. Get it? Food for thought. Pretty good one. All right. Let's see, risk factors for nutritional disorders or problems, obstacles in nutrition, having a lower socioeconomic status. I'm pretty sure everybody's feeling the burden of cost for healthy food these days. Um, working long hours and getting one or more meals from a fast food place or somewhere other than home. Guess who fits into that category? Nurses. It has been a challenge. I mean, we work 12 hour shifts most of the time. And I will say I've gotten to a 12 hour shift. I did all I could just to get there on time. And I hadn't had any food before I got there. And I'm like, all right, uh, when's this break time happening? I'm getting a little hungry. And they're like, well, you're going to get a 30 minute break around halfway through your shift. It's like, so I have 30 minutes to incorporate an entire day's worth of nutrition. That's a great setup. And you end up just snacking for breakfast. You end up binge eating for lunch. You're getting as much calories in as fast as you can. You're shoving it down. And then you're just coasting on fumes by the time you get off your shift. and you get home and you're starving. And again, you just eat way more than you should. And it's like 11 p.m. It's tough. It is a tough gig. So guys, make sure that you go in with a plan. When you start your 12 hour shifts, have a plan. Put in the effort to keep yourself healthy. You're going to thank yourself mentally, physically, emotionally. Everything's better when you're getting good nutrition. And it's not going to be found if we're eating out. Um, hopefully that'll shift with time and better food will become more available, but we'll see. Um, but yeah, the, the crappy food is more available and it's more convenient. So we're making a lot of bad decisions. Um, and we tend to go on a lot of crazy diets to lose weight fast because we want quick results. Um, other things to keep in mind, chronic diseases can get in the way of nutrition, especially those involving the gut. and absorption of nutrients. You can have issues with your mouth, like chewing, or loss of taste that can really become an obstacle with nutrition. And then again, limited access to food, whether it's because you live in a bad neighborhood, or maybe no one ever taught you how to cook healthy foods, or maybe lots of things that can be considered there. Be aware of food eating disorders. They can really mess you up. So be aware of them. Be aware that they are around you and they're very prevalent and they are often incorporated with mental health issues. And then also be aware that when your body is going through a repairing or a healing or reparative type process, your nutritional needs are going to increase, which is frustrating because we're in a hospital setting. We're trying to focus on healing with medications or IVs or whatever. And sometimes we overlook how important the nutrition is to really give the body, give that patient's body the tools it needs to heal. So we're getting better at acknowledging that as well, but we're, we still have some room for improvement there. making sure we're asking all the right questions about their eating habits. America has an obesity problem. That is an understatement. So I like this slide because it talks about how there certainly is accountability for the individual with their weight, but there are so many other factors that can go into it. And as nurses, sometimes we get a little bit biased towards people that struggle with obesity. We tend to sometimes find ourselves thinking, well, they ate their way into that problem. They caused that problem by themselves. So I'm not going to have the same patience or empathy for them because they caused it. Now they're dealing with the consequences. My argument to that is, number one, we are not there to judge. We're there to serve these patients. So if that's in your head, leave it at the door and give that patient everything you've got. I will say that it is easy to get frustrated with really obese patients because they are needy. They require more. There's more effort in every aspect of their health care, whether it's education, whether it's mobility, whether it's nutrition, pain control, it's all affected and it's all more difficult because of their weight. And as nurses, that's a struggle to not get a little frustrated or burned out towards that population. So make sure you're checking yourself. And when you're thinking about it, I hope that you realize that obesity is definitely becoming more and more of a system problem. I mean, you look at the statistics on this slide and the majority of Americans, the majority of American adults are obese. That's crazy. That statistic is just insane. And I don't think it's getting any better with time. So, you know, I hope that we understand that food availability and the culture and the expense and food costs, like it all plays into it. And we really have to step back and not place blame or guilt or shame on these patients. It's just not appropriate. And then I think my hope is, you know, is that the culture eventually changes. I think the food that is available to us will improve when there's a greater demand for it. The market always follows demand. And right now the demand is for the cheap, convenient, unhealthy food that tastes good. And until our culture changes and is not asking so much for that. then the market's not going to innovate and change in a way that allows for more availability and cost effectiveness for the healthy stuff. But when that change happens, and we are asking for the healthy options more than the unhealthy options, the market's going to move to that. So, you know, we really need to look at ourselves and our culture and figure out how we can change that. But that's enough of me getting preachy. Almost. I got one more preachy slide. This slide hits close to home. This was me in high school. I was a high school kid. That's me. I think you can see my mouse right over here, trying to look all cool looking into the distance. But these are my high school choir buddies. And then Brittany Keel, she's the girl right here photobombing. And then the one here in the bottom right, I wanted to bring this up. She died at age 16. She was basically not giving herself enough nutrients and exercising very strenuously. And that combination created a major electrolyte imbalance that caused her heart to stop while she was sleeping. And the morning came and they just found her gone in her bed. She died in her sleep. So the crazy thing there is she was beautiful, she was popular, she was socially inclined, easy for her to make friends. Everyone I'm sure would find themselves eager to be her in her shoes. And yet still underneath all of that was a terrible eating disorder. And so, you know, I don't want to be all doom and gloom here, but just be aware it's really, really common. It's very prevalent in Utah. And as nurses, I feel like we have a distinct position where we can potentially make a lot of impact by being aware and by offering resources, education, just bringing it to attention and support, like whatever we can do to help these people out. You never know when that small act of support could save a life, quite literally. So moving on. All right, we're moving more towards the assessment part of nutrition. Lots of different things to look at from overall appearance to body type to muscle tone, muscle distribution, fat distribution. All those are going to be taken into consideration when we're looking at a person's nutritional status. There are some tools that we can use. I would say the top two are the most relevant. BMI, you see that a ton. And we use it a lot, even though we all know it's not a particularly efficient tool. It overlooks a lot of circumstances and is not particularly accurate. But it's super easy to automatically calculate because we're already getting height and weight. And that's really all it asks for. And it'll calculate the BMI and pop that number out. You know, that number can be really frustrating for some people. I would just say, you know, give it the attention that it's due, acknowledge that relationship, and then try to understand it and move forward. But don't hang your hat on that. I think... I think there are better ways to measure health than such a superficial measurement. And studies show that waist circumference is actually a way better indicator of health. So the distribution of fat around the core, around the gut, abdomen area, tends to be the most problematic and is much more associated with chronic health risk. So I wish that we would have people stand on the scale. I wish we would measure their height, and then I wish we would get a little measuring tape and wrap it around their waist. And that was part of the normal routine. And who knows, maybe it will be in the coming years. BMI ranges, we talked about that in module 2. So go back, make sure you're familiar with those ranges as far as where. what BMI number obesity starts, where it transitions to morbid obesity, and that way you can use those numbers on a quiz or test question. All right, height and weight changes with aging. This is where we're bringing in a little bit of perspective for our geriatric population. Just know that as you age, you tend to have a very slow and some usually mild decline of height over time. And that's just the spacing in between your vertebrae, losing some of that spacing over time and you lose the height and consequence of that. And then as you get older, you tend to lose your muscle mass. You have a harder time hanging on to your muscle mass when you get in your 50s and 60s. And you tend to also lose your subcutaneous fat. But the rest, the other fats hang around. So, um... There are some older people that beat that statistic, and it's possible, but generally you tend to see a decrease in muscle mass as you age. All right, we are moving more of a focus towards hydration, which is fun. Hydration is focusing on how we measure the fluid status in a patient. And then what are some signs and symptoms of somebody having too much fluid versus too little fluid? Hopefully most of this is a review for you. But checking weight, input and output, that's where our kidneys get involved. Skin turgor, pitting edema, skin moisture, venous filling, jugular venous distension, all these are different tools that help us identify hydration status. We can also look at the tongue. We can look at the eyes if they're sunken in. I don't usually do a lot of eyeball poking or palpation, but you can always lower down the eyelid and see the conjunctiva and that can look dry or pink or pale. Lung sounds and blood pressure, all important tools to consider when we're looking at hydration status. Things that can change someone's hydration status. Living in Utah, right? We all tend to be a little dehydrated. just to overall higher temperatures. If we're not drinking enough water, if we're drinking alcohol or caffeine or other diuretic fluids, some medications change our fluid status. If our brain isn't telling us when we're thirsty or telling us we're thirsty all the time, I've seen both of those. And then just be aware anybody with a fever is also burning through naturally a lot of fluids. So you got to focus on hydration for those patients. All right, this is the fun part. What is associated with overhydration versus underhydration? Let's talk about the over part first. So in general, there are always going to be exceptions to everything. But in general, when we're talking about too much fluid, you're going to see weight gain, you're going to see edema, you're going to see veins that are popping out, because the fluid is getting backed up because there's too much fluid. So that would be an example of... that would be where the jvd or jugular venous dissension falls crackling lung sounds your lungs your chest cavity is this big open area and fluid just finds it quite convenient to slide right in there and you can get some crackly lung sounds and then in general if you have extra fluid your blood pressure tends to be higher because you have a higher volume in your vascular space so high blood pressure is most often associated with and i'm an overhydration fluid status. And if we compare that to dehydration, that tends to be associated with weight loss. um tenting tenting is where you pinch the skin and it should kind of tent while you pinch and then when you're done pinching boop it pops back to its normal flat shape and if somebody is really dehydrated especially if you do that on their chest and you'll see that you'll pinch the chest skin you'll let go and you'll see that skin it should it should bounce right back to being flat but if they're really dehydrated it'll stay in that tent shape and be a little more sluggish flattening back out. Your capillary refill is going to be a little sluggish. Your veins are going to be flat and hard to find. Your eyes are going to get sunken in. You're going to have dry mouth and dry tongue. Your blood pressure tends to be lower because you have less vascular volume, vascular space volume. And to compensate for that, you tend to have a higher heart rate. So as you're studying this, make sure you understand the pathology behind each of these findings, why one would be correlated with one and not the other. If you have questions about these, make sure you bring them to me because these are important to understand. A couple of questions to bring home a point, actually just one more question. True or false, dehydration in a healthy person is not usually a problem because the body is effective at maintaining a correct fluid balance. That is false. We are all at risk for being dehydrated. Any healthy person that doesn't take in enough fluids is going to be dehydrated. That's just the way it is. Our body can't create fluid. We have to take it in. We have to drink it in. So staying hydrated is a priority, especially when you're sick or if you have a fever or if you're exerting or whatever. Make sure you're staying hydrated. Healthy people are... really good at avoiding overhydration because your kidneys just pee it right on out, right? It's easier for us to get rid of fluid that's when we have too much than it is to try to create fluid when we don't have enough. And we can only do so much to hold on to fluid as opposed to letting it go. We're limited in that capacity. So anyways, normal healthy person at risk for dehydration. Not so much for overhydration if you're healthy. So, all right, you guys, we made it to the end. Again, please bring me any questions. I'd love to answer them during class if you weren't sure about something or you need a clarification on something. Otherwise, hope you enjoyed this online module. Good luck on your online quiz and good luck with your semester. I hope you're enjoying my class.

So, yeah, make sure you're taking good notes. And if you have any questions, bring them to class. Let's talk about it. And that way we can still learn what we need to learn from these lectures. So.

Let's get started. Pain and nutrition. I like giving this particular picture out of the get-go because it shows how you can have people in very similar circumstances expressing their feelings in very different ways, right?

So here we are, my wife and I taking a family photo and we're smiling, pretending like we're having this joyous moment and our kid is very much more genuine at expressing how... all of us are feeling inside. So pain is very much this way.

It has a lot of, you know, we might all be in the same circumstance or same similar conditions with pain, but we're each going to experience and express that in different ways. So yeah, let's, let's keep going. Pain is a difficult one as a nurse, because you're dealing with patients who can sometimes frustrate you with reporting high levels of pain with all these events.

And there have been times where I've been frustrated and I'm like, okay, if I literally, I know that you sprained your wrist, but you're saying it's a 10 out of 10 pain, which means I can chop your leg off and set it on fire and let you watch it burn. And you wouldn't even feel it because your wrist is hurting you so much because you're maxed out. I don't know.

It's frustrating. But just remember that we need to take... their description of pain seriously and don't let those frustrations get the better of you.

Remember, nurses, we're all about advocating and serving these patients, advocating for and serving these patients. So what is pain? Pain is more or less whatever the patient says it is. It's an unpleasant sort of sensation. It may or may not be an association with tissue damage.

But we consider it kind of this fifth vital sign, which is weird because all of the other vital signs are very objective. And yet we're sort of getting this pain report, which is coming from the patient's experience, which would suggest it's subjective. So how does it fit into that list of vital signs?

How does that all work? Hopefully by the end of this lecture, it'll make a little more sense to you. We have a lot of variability with how people will present and describe their pain.

Sometimes a lot of our frustration comes from patients like this gentleman here in the top left. They're a big man baby. They have a cold, and they're telling you that their headache from their cold is a 10 out of 10. And then you'll go to your other room where you have...

patients like this lady here on the top right where it's like yeah i'm having this kidney stone but compared to giving birth naturally um i'd say this is about a seven you know it's just bizarre how different uh people's pain perspectives are um then you have patients like our middle guy here who are completely gone their highs could be and they're still telling you it's a 12 out of 10 even though they literally probably can't feel pain and What I see a lot of, probably more often than not, is a circumstance like this gentleman here to the right. I'm super anxious about what might be wrong with me, and I want you to take my problem seriously. It's a nine. So what they're thinking is not quoted, and what they say is it's a nine. And I just find this to be really, really relevant.

I think people are often... hesitant to give a middle or lower number for their pain because in a sense that would be saying I don't want you to take this problem as seriously or I don't want this to be as much of a priority and of course they want it to be a priority for you. So sometimes I feel like they're giving this higher number out of a desire to get more attention to address the problem and when in doubt I feel like this disconnect.

can usually be resolved with some really good patient education by putting their mind at ease and saying, look, I'm acknowledging what you're going through. I know for you, a six is probably a significant amount of pain. So, you know, so hopefully they're in a relationship with you that they feel comfortable giving you that number, knowing that you're going to respond with the same level of priority and take them seriously, regardless if they tell you an 11 versus a six, right? And then you have some patients that just aren't able to advocate and describe their own pain. And yet you can look at their face and you don't need a number to know that this little kiddo is miserable.

Right. There's just a lot of discomfort in the facial expression, the posturing. Everything about this picture says, I don't feel good. So that's well, then you're like, well, is this observable? Am I observing this?

Is this more? objective then? Where is this falling under the umbrella of things?

And at the end of the day, really pain is subjective. Everything about pain ultimately is still arguably subjective because even in that kid's picture, the stimulus causing that response is still being perceived and expressed in that way. And so I would argue that everything about pain is going to be considered subjective.

But I wanted to make it clear for test taking purposes to be consistent with other classes, I would consider a documented pain score as objective. So if there is a finding that says a patient's pain is seven is recorded as seven out of 10, then that recording of seven out of 10 would be objective. Sure, certainly there are some components that we can observe about pain. That could also be considered objective, but just know that for most all other intents and purposes, pain is going to be whatever the patient says it is. It's going to be subjective.

There is a rabbit hole of anatomy that you can dive into with the process of pain and nerves and how they connect and communicate. For this particular lecture, I would not lose too much sleep over the anatomy portion. I'm going to be showing you a video that goes over a little bit of the anatomy, at least enough to kind of trigger some memory from some of your previous courses and get you back on cue with the anatomical functionality of pain. But feel free to brush up on this stuff.

It's always helpful to know the... how the wheels are turning behind the scenes to make this happen. And it'll always make more sense when you're assessing if you know how the mechanics of it are working.

But again, I wouldn't lose too much sleep in regards to test preparation over this particular area. I don't usually emphasize it much at all. Here's the video I was referring to. We're going to watch this video.

I love the video. It's really entertaining. It also does a really good job of explaining how pain is different for different people.

and why. And so here we go. Let's say that it would take you 10 minutes to solve this puzzle.

How long would it take if you received constant electric shocks to your hands? Longer, right? Because the pain would distract you from the task.

Well, maybe not. It depends on how you handle pain. Some people are distracted by pain. It takes them longer to complete a task and they do it less well.

Other people use tasks to distract themselves from pain and those people actually do the task faster and better when they're in pain than when they're not. Some people can just send their mind to wandering to distract themselves from pain. How can different people be subjected to the exact same painful stimulus and yet experience the pain so differently? And why does this matter? First of all, what is pain?

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is something we experience, so it's best measured by what you say it is. Pain has an intensity.

You can describe it on a scale from 0, no pain, to 10, the most pain imaginable. But pain also has a character, like sharp, dull, burning, or aching. What exactly creates these perceptions of pain?

Well, when you get hurt, special tissue damage-sensing nerve cells, called nociceptors, fire. and send signals to the spinal cord and then up to the brain. Processing work gets done by cells called neurons and glia.

This is your gray matter and brain superhighways carry information as electrical impulses from one area to another. This is your white matter. The superhighway that carries pain information from the spinal cord to the brain is our sensing pathway that ends in the cortex, the part of the brain that decides what to do with the pain signal. Another system of interconnected brain cells called the salience network decides what to pay attention to. Since pain can have serious consequences, the pain signal immediately activates the salience network.

Now you're paying attention. The brain also responds to the pain and has to cope with these pain signals. So motor pathways are activated to take your hand off a hot stove, for example. But modulation networks are also activated that deliver endorphins, and enkephalins, chemicals released when you're in pain or during extreme exercise, creating the runner's high.

These chemical systems help regulate and reduce pain. All these networks and pathways work together to create more pain experience, to prevent further tissue damage, and help you to cope with pain. This system is similar for everyone, but the sensitivity and efficacy of these brain circuits determines how much you feel and cope with pain. This is why some people have greater pain than others, and why some develop chronic pain that does not respond to treatment, while others respond well. Variability in pain sensitivities is not so different than all kinds of variability in responses to other stimuli, like how some people love roller coasters, but other people suffer from terrible motion sickness.

Why does it matter that there is variability in our pain brain circuits? Well, there are many treatments for pain, targeting different systems. For mild pain, non-prescription medications can act on cells where the pain signals start. Other stronger pain medicines and anesthetics work by reducing the activity in pain sensing circuits or boosting our coping system or endorphins. Some people can cope with pain using methods that involve distraction, relaxation, meditation, yoga, or strategies that can be taught like cognitive behavioral therapy.

For some people who suffer from severe chronic pain, that is... pain that doesn't go away months after their injury should have healed. None of the regular treatments work. Traditionally, medical science has been about testing treatments on large groups to determine what would help a majority of patients, but this has usually left out some who didn't benefit from the treatment or experienced side effects.

Now, new treatments that directly stimulate or block certain pain sensing, attention, or modulation networks are being developed. along with ways to tailor them to individual patients using tools like magnetic resonance imaging to map brain pathways. Figuring out how your brain responds to pain is the key to finding the best treatment for you.

That's true personalized medicine. Really fun little video. I like that.

Okay. So I liked how the video ended with kind of an explanation of how we're trying to do better at individualizing pain treatments. And I would just echo that.

I think we are getting better with understanding different types of pain, how to treat them more appropriately. And a lot of that change and innovation was driven by the opioid pandemic. I mean, we were treating chronic pain incorrectly for a long time. I think that we're getting better at that. I think there's plenty of room for improvement.

So hopefully it'll just get better and better. All right, we are going to move on to some terminology. All of these terminology questions, make sure you get those down.

They should really be your easy free throw type questions on the exam. So first off, we have classifications of pain by cause. So no susceptive pain.

This is pain that's caused by a new onset of injury or trauma or... tissue damage, something's being damaged and it wasn't damaged 10 minutes ago, but now it's damaged and now it's hurting. I would consider that a type of nociceptive pain.

Neuropathic pain is very specific to nerve pain. It's like a nerve damage, nerve type of pain, phantom pain. It just has to do with nerves, very nerve focused type pain, neuropathic pain. And then inflammatory pain, as the name would suggest, is pain that is not necessarily due to injury or trauma, but more so to an inflammatory process. And the inflammatory process is specifically causing pain.

So this could be like some autoimmune issues, maybe rheumatoid arthritis. This could be something like shingles. You know, shingles is kind of a nerve pain, but like The skin inflammation going on could be considered inflammatory. So anyways, if the description of the pain is leaning more towards inflammation, obviously that would be considered an inflammatory pain.

These classifications are more on timing, duration, maybe a little bit of cause. Let's talk about them. Keep in mind, there are definitely areas of overlap between some of these. So yeah, for acute pain, acute pain would be something that is designed to be protective.

I would see this very similar to nociceptive pain in that it's related to a specific injury or insult, damage, and really sudden onset. So again, very similar, but focusing more on the sudden onset and the fact that acute pain should have a start and a stop, right? It should go away.

Versus chronic pain is going to have usually more of a progressive onset and then the pain is going to last months, three, six more months. A lot of things are considered chronic at three months. Definitely by the six month mark, you're looking at more of a chronic situation most of the time.

Chronic pain is frustrating because it's not necessarily serving a protective purpose. With acute pain, it's like, yeah, I get it. I hurt my leg and the pain is reminding me to not use that leg for a little bit, right? It needs to rest.

It needs to heal. It needs to be splinted. It needs to whatever.

Whereas chronic pain, the pain's not going, the problem isn't going away. And so neither is the pain. And it's just more of a frustrating, like, well, then why?

Why can't I just turn it off? I know the injury is there. It's never fully healing. Why can't I just turn the pain off and live without that? Unfortunately, that's usually not an option.

When it comes to cancer pain, anything related to cancer, if there's any sign of cancer in the description, whether it's the cancer itself or its treatment, it would be considered a cancer type pain. And then intractable pain is any pain. that is just not responding to treatment. So again, this could overlap into any other category, but if the pain is not responding to treatment, whether it's acute or chronic, if it's just not feeling any better despite efforts, then we would consider it an intractable pain. We're going to get past the terminology for now.

We're going to move to more of the mental type responses to pain. So when there is a lot of pain going on, especially like chronic type pains, then it tends to have a pretty strong psychological response. And that psychological response does have some similarities between different people. There's some patterns or some tendencies that we can identify. My thought here would be to not underestimate the impact of the mind on pain and how it affects our perception, how we are able to deal with it or not deal with it, even to the point where you might see somatization, where your mind is kind of creating a state of pain just because it's so focused on it and so good at imagining it.

But in general, when there's a lot of pain going on, our attention tends to be on it. We tend to focus on it and it's hard. It gets harder and harder to distract yourself from that pain.

So somebody who is focusing on their pain, they're going to have more. They're going to report it. They're going to cry. They're going to moan about it.

And they're. facial features and their posturing is going to reflect their pain a lot more. Other emotional responses, people who have a lot of pain tend to deal with more anxiety, fear, depression.

And then, you know, if the pain becomes chronic or if it's really, really severe, sometimes patients have a hard time seeing the light at the end of the tunnel. Maybe they just don't see a way out. and it becomes suicidal. They can have suicidal thoughts because of pain and just not seeing a solution or just not being able to bear the pain to the point where they'd rather just in their life to get past it.

So as nurses, we need to be aware of these emotional responses, making sure that they're addressed, that we are educating and helping these patients physically and mentally and emotionally. It's a big deal. It's not to be underestimated. When it comes to cognitive responses, if you remember in that video, some people perform better cognitively. But I would say the majority of the time you're going to see, especially over time, chronically, you're going to see a decrease in cognitive performance.

People with chronic pain a lot of times will refer to like fog brain or this difficulty with recall or with data analyzation. different things. They just sort of have a harder time performing cognitively. A lot of times they have a harder time managing their mood. They tend to be grumpy and shorter tempers, harder to cooperate and be patient with things.

And then at the bottom there, it talks about somatization, where your mind is significantly exaggerating pain to the point where you're feeling it. in areas that don't have a reason to feel pain. I gave this chart here not to say that fibromyalgia is completely psychological, because it's not. We're learning more and more about the physiological aspect of fibromyalgia. We don't understand it super well, but I will say there is a large psychological...

component to fibromyalgia. And a lot of times, if we do focus on the emotional aspect of pain, it tends to improve their symptoms more significantly than a lot of the medications or other measures we might try. So just things to keep in mind.

When it comes to your physiologic responses to pain, please remember that these responses are heavily driven by the fight-or-flight type response and release of different hormones like your anti-diuretic hormone, your epinephrine, your norepinephrine, glucagon. Essentially, when your body is experiencing pain, the pain becomes the bear and we need to either fight the bear or run from the bear, right? So, you're getting this fight-or-flight response. And I think a lot of times that can help with acute pain, but it really presents a problem when we're talking about chronic pain.

It puts people at risk for other chronic issues. So if we go through these real quick, people tend to have higher respiratory rates. They tend to have higher heart rates. And again, that fight or flight response is kicking in to facilitate for that. They tend to have decreased gastric.

motility and more urinary retention. You don't want to stop and poo or pee before while you're running from the bear. You just got to get running. Right. So no time for that.

Anybody got time for that. So you might see somebody with chronic pain dealing with constipation and other things like that. So just things to keep in mind. And then down here at the bottom, you can see they're going to deal with stiffer and more spasmodic muscles. They're going to have a harder time relaxing and having, you know, smooth muscle function without it being all irritated and tense.

And then your glucose levels are going to be higher. It's a natural response of that glucagon and decrease in insulin production. So ultimately, you can, somebody who has chronic pain, their blood sugar levels are going to be higher over time. They might be looking at an increased risk for diabetes and other issues, other vascular type issues. So.

It's really interesting how in an acute setting, these types of responses can be helpful, but in a chronic setting, they're usually... uh the opposite of helpful so we got a little bit more terminology for you so um if the pain is specific to skin it would be cutaneous pain if the pain is located in the thorax so basically shoulders to waist we would call that a visceral pain if uh the pain is more deep like deeper in a joint i can't really point at it because it's deep in there usually involving like bones, tendons, blood vessels. That would be considered more of a deep somatic pain.

Radiating versus referred pain. This one's a big one. Students tend to struggle with these two terms and I like to test you on them.

So make sure you're buckling up and paying attention here to get these two differentiated in your mind. If I'm talking about a radiating pain, what's happening is I am able to identify the source of the pain, and that's where the pain is starting, and the pain will then extend from the source. So let's say I injure my shoulder, and I now have shoulder pain, and that shoulder pain is radiating down my arm. I can connect the dots between the source and where that pain is going.

That would be radiating pain. And we would compare that to referred pain. If I have referred pain, there is a source that's causing the pain, but there is not a clear line between where the pain is being caused and where the pain is being perceived.

And a good example of this might be someone who is having a heart attack, not really having a lot of chest pain, but the pain is happening in their neck or maybe in their left arm. their neck and their left arm is fine. It's their heart, right?

They don't, so sometimes our body has a hard time placing the pain because it's getting signals from areas it doesn't usually get signals from. And it's like, I don't know where to put this. I don't know where this signal exactly is. So let's say it's over there and it'll kind of throw it in a general area. even if it's not actually where the pain is happening.

So again, if I can connect the dots between source and where the pain is perceived and it's extending out from that source, that would be radiating pain. If there is a disconnect between the source and where that pain is being perceived and it's away from that source, we would consider that referred pain. Phantom pain is specific to people who have had some sort of amputation of a limb or appendage.

The nerves are still... saying, hey, there's some downstream nerves that aren't there anymore, but I can feel them, they're sending signals, and it kind of creates this symptom of pain in limbs or body parts that they don't have anymore. So kind of interesting. All right, our next couple of slides are going to be comparing, we have tolerance of pain or pain tolerance versus pain threshold. And so make sure those two are distinct in your mind.

Tolerance, pain tolerance. I like to remember it by thinking how much, what is the maximum amount of pain that I can tolerate? And that tells you what pain tolerance is.

It's the maximum amount of pain somebody can handle before it's just overwhelming and too much, before they're just gone, right? So our pain tolerance can have its moments where it's better or worse. And there are certain circumstances that we can identify that can either make pain better or worse. So in general, if I am bored, if I'm tired, if I'm anxious, if I'm not getting enough sleep, or if I'm having that pain happen over and over and over again, I tend to have a decrease in tolerance for that pain.

That repeated exposure is kind of a sensitization and I'm more sensitive to it. And it bugs me more over time. And you'd think it'd be the opposite, but it's usually that way where you get repeated exposure to it and your brain tends to pick up on it more easily.

It's more familiar with it and it almost anticipates it. So those are all reasons why your pain tolerance would go down. On the other hand, you can improve your pain tolerance by getting drunk, right?

One of the few times in medical class where drinking alcohol is... on the positive list, right? So usually it's a risk factor.

And it's like, yeah, don't do that. Well, in this case, so alcohol is a way to treat pain. It's not an effective.

way, a treatment method long-term, right? You deal with some potential problems long-term treatment-wise, but drinking alcohol does increase your pain tolerance. It can make the pain easier to tolerate. We have pain medications that can help. And then as the video had mentioned, just as much as your mental status can exaggerate or focus on the pain, You can also train your mental status or your cognitive mindset about that pain to minimize or reduce or even eliminate the pain through things like distraction, meditation, cognitive behavioral type training, hypnosis.

Being warm tends to help alleviate pain and distracting activities. And then interestingly enough, having a belief in something bigger than yourself also tends to help tolerate a little bit more pain, which I find encouraging. Let's see.

When it comes to pain tolerance, you are going to see some influences by the people around you. So based on what the people around you are expecting you to express about your pain is going to affect your pain tolerance. Your own physical and mental health baseline is going to affect your pain tolerance.

Your pain tolerance varies a lot, both between yourself and other people, and also between you and you in different periods of time. So when you're really young or really old, you tend to have a lower pain tolerance. And then when you're middle-aged adults, you tend to have a better pain tolerance. That's why you'll get the teenager in and you're like, you just can't handle pain. What's wrong with you?

But in reality, it's like, yeah, that's what they're experiencing. They have a lower pain tolerance. So it's interesting. All right, let's compare that to pain threshold. Pain threshold, I try to think of like the threshold of a building, like you're carrying something or someone through that threshold.

So pain threshold is essentially. When is the transition point between annoying or noxious and painful? So I can handle this much annoyingness and then it becomes painful.

And some people, they can only handle this much annoying and then it becomes painful. So that's the pain threshold. Where's the starting point? Interestingly enough, the pain threshold that you have is going to stick with you for most of your life.

That doesn't change a whole lot. And it also has a much... a better consistency among people.

People tend to have pretty similar pain thresholds. All right, when it comes to pain, getting subjective data is absolutely essential. Pain is subjective. And so by getting the right subjective data, it's going to make or break it for you when it comes to assessing pain.

So I wanted to give you guys some tips on getting that subjective data and doing it effectively. So tip number one, make sure that you're validating the patient's concerns and you're building a good trusting type relationship. This has been really impactful for me. My current second job is doing veteran evaluations if they have like a disability or injury claim that they think is related to their service. So my job is to assess these veterans, figure out how bad their issue is, and then report back to the military or VA and say, hey, this is where they're at, this is how bad it is, and this is or isn't really related to their service.

And a big part of that is pain. So if they are claiming a knee injury as an injury related to their service, maybe their knee is technically functioning, but maybe the... The pain in their knee is keeping them from doing activities or hobbies or tasks that they would normally like to do. And these veterans are very much coming from a background of shut up and keep going.

Right. You're in the battlefield. No one cares if your knee hurts.

You keep running because you need to survive. Right. So definitely an interesting culture. that is fostered in the military in regards to health and pain reporting.

So I can't tell you how many times I'm doing these assessments and I'm asking them all these different questions about their pain and when it hurts and why it hurts and how bad it hurts. And they're just, they're just super uncomfortable talking about it. They don't want to.

bring it up and it's and they will often say things like yeah I just don't uh I don't like to be a complainer I don't like talking about it I um you know I don't want to sound like I'm a baby or whatever and I just have to remind them like this is literally my job I'm literally trying to get this information from you and I want it to be accurate so now's the time let it out talk about it you know And when they're talking about it, it really puts them in a vulnerable position. And so it is important that you validate it because when you are asking a lot of those questions, it can sometimes come across as distrustful or you don't really believe them or you're trying to be skeptical about what they're saying. And you have to make sure that's not the message you're sending.

You have to make sure you're saying, yeah, I totally believe you. That would be that would be rough. That's that's a, you know.

that's valid, right? So that's really going to help you when it comes to patient communication. And you might be thinking in your mind, what about those guys that are making it up and are just trying to manipulate me and say, yeah, I'm having all this pain because I want more pain medication or whatever.

Just be aware that if you're not building that trust relationship, you're not going to get anywhere with them. You have to be able to build their trust. And once they trust you, they're much more likely to have a more open, transparent conversation about their pain. So either way, validation is important. Tip number two is a laundry list.

So what I mean by laundry list, if you were to just say, hey, veteran guy, tell me about your knee pain. How does it feel? They're going to stare at you and they're going to say, it hurts right here. My knee hurts.

What else do you want? pain and so it's really helpful to give them a list of options of how they might describe their pain different terms and a good example would be okay you're having knee pain tell me is that knee pain sharp dull aching throbbing burning tingling what kind of pain is it and then suddenly they have this nice list of oh i can connect the feeling with this term and it's easier for them to give a better description of their pain so We don't want to be leading with this list. We want the list to be nice and encompassing, but it's still a really good idea to give them some options to choose from so that they can have a better idea of what you're asking. Number three, it's always a good idea to reference previous pain experiences. A good example of this would be, oh, you're having chest pain.

I see that you've had a heart attack about six years ago. Does your current pain feel similar to the pain you had back then? And if so, now I'm really nervous, right?

So always kind of giving that previous experience is helpful. And then one and four are very similar, making sure that you're building that trustful relationship. A few other tips, make sure that you're in a calm, quiet, private environment. Again, talking about pain can be a vulnerable thing. And so making sure that they have a good environment to do that, where they can feel comfortable.

This is a big one, asking open-ended questions. We like to give you quiz or exam questions that will say, hey, which one of these questions is best? And ultimately, it'll come down to the format of the question. So if I am trying to get a lot more volume from this person about their pain and just get like...

More volume. I don't care what it is. Just give me volume. I want to know more about it. An open-ended question is going to be the way to go.

If you're trying to really pinpoint a discrepancy between one or two items, you know, is the pain worse in the morning or the afternoon? They're going to say one or the other, and that's going to give you one data point. If you were to say, so when this pain is happening in the morning, what other symptoms come with it?

Are you nauseous? Are you fatigued? Do you get headaches?

What else is going on? Those types of open-ended questions are going to just open the door to way more information. So depending on what you're aiming at, those question formats can really help out.

Make sure that you're listening carefully. Make sure that your posturing and your positioning is telling the patient that you're listening and showing them that you appreciate the information that they're giving you. And when in doubt, it's a great idea if you're not sure what they said or if you're not really sure what they're trying to communicate, it's a great idea to restate or quote what they're saying so that they can have a chance to clarify or edit their statement.

And I find that pretty effective. And then to make sure we hit all the right points, there's a few mnemonics. Mnemonics?

Mnemonics? Mnemonics. I think I said it right the first time.

Several different memory tools that you can use to help you remember which questions to ask. You can find a bunch of them out there, old carts, whatever. But we like to stick with Cold Spa for consistency purposes. We talked about Cold Spa, I think, during the interview module.

So we already talked about it a little bit, but we might give you a question on the exam that's like, okay, here's a description of this person's pain. What's missing? Maybe they told us the character of the pain and how bad it is, but the question never told us when it started or how long it's been going on.

And so identifying those components and being able to find them is kind of what we're looking for there. All right, moving on. Pain scales. Pain scales are super important to know and utilize different pain scales for different patients in different circumstances. So when you're studying these pain scales, pain scales, be sure to know kind of when would be a good circumstance to use them, when not so much.

The first two are pretty, the first one's very vague. So it could apply to almost anybody. You just sort of say, how bad is it?

point to where you tend to land. We tend to see more of the numeric pain intensity scale used more often. So that one, most adults, we're going to start there. How bad is your pain? Zero to 10. Zero being no pain, 10 being worst possible pain.

It's usually effective, but I also find that it has its problems, right? You'll get the people over saying, my pain is severe. It's a 10 out of 10, 10 out of 10, 10 out of 10. And it's like, okay, your ankle sprain should not be a 10 out of 10. Where's the disconnect, right?

So sometimes I have found it helpful to switch to something like the simple descriptive pain intensity, and sometimes the patients feel a little more validated, right? So I know that you have really severe pain. So on this scale, would you say it's severe, very severe, or worst possible pain?

And suddenly giving the pain score a six doesn't feel so discrediting, right? So. A really good option if you're having that disconnect to bring in this type of different scale to see if it helps you, you know, meet mutual grounds of understanding with what the patient's trying to communicate. These two scales are usually more specific for our younger pediatric population.

With the Wong-Baker FACES scale, please understand that this is for toddlers and that the toddler is going to point to the face that matches their pain. And this is not something where you would be observing their face and picking the picture that matches their face. So yeah, the faces skill, again, you have a toddler, they're not great at talking about their pain or verbalizing it.

They're not great at numbers and words. But they are able to understand the emotion behind these faces. And they can point to a face that that describes how they're feeling. So usually ages like three to six, you know, three to eight, somewhere around in there, just depending on the kid, right? So as much as this is anticipated for toddlers, I will say I've used it for adults, right?

If I'm still not getting a disconnect, if I'm still getting a disconnect, and Mr. sprained ankle is still telling me 10 out of 10. Sometimes I'll break this bad boy out and be like, okay, you're sitting on your phone and your face looks like the yellow guy right over there. Hurts a little more, but you're telling me you're at a 10 out of 10, which is the red face that's crying and your face isn't red or crying. So where is this? Why is this disconnect happening? A lot of times that'll kind of help them.

get a more reasonable number. Anyways, and then the FLAC pain scale. This one is specific for infants or kids or people that are just not able to advocate for themselves and not able to express their pain or verbalize their pain.

Usually infants, neonates, that sort of circumstance. So what you're looking at is you're evaluating facial expressions, whether they're calm or grimacing, their legs, whether their legs are lying flat and calm versus thrashing about, their activity, are they involved in the environment around them? Or are they focused on their pain and rigid and jerking around?

Are they crying? Are they sleeping? Are they able to be consoled? Are their parents around and are they able to calm them down?

Or even the parents having a hard time and their kids just flipping out? You're going to go through each of these categories. You're going to score them down that box.

You're going to add it up and that's going to be their pain scale. number. I like this.

It's probably the most objective out of all the scales. So it certainly has its value. All right. There are some objective things that we can observe when people are in pain. And this, I find, comes into play when you have patients who are just, you know, there's still a disconnect between the number.

they're giving you and what you're observing or what the injury would indicate for the pain level. And that can go both ways. Sometimes I see guys that are very stoic and they do not show their pain. They don't want to tell you it's hurting because they feel that is a sign of weakness and they've never been complainers.

It's a three. I'm fine. And I just want it checked out.

And then when they don't think you're looking or when they're standing up from sitting and you see this facial grimace in there. grabbing their back and that's something that you can still observe and document as an observation to kind of help paint the picture and create that consistency. But yeah, so you're looking at their posturing, their facial expressions, are they guarding, are they tense, all things to kind of keep in mind that we can observe when it comes to pain.

A little bit more pain terminology coming at you. Um, so we have hypoalgesia. Hypo is usually slow or sluggish. In this case, we're talking about pain.

And so if I have hypoalgesia, it means that my pain is less than it would be anticipated, less than anticipated for a certain type of injury. Somebody has a broken arm and they're like, yeah, it kind of hurts. You know, that would be That would be hypoalgesia. Analgesia is basically your normal pain response. Everything's appropriate.

Hyperalgesia is the opposite of hypo. It's an exaggerated pain response. And that would be like the guy we were talking about before, sprained his ankle, giving you a 10 out of 10, an exaggerated pain response, hyperalgesia.

Allodynia. Allodynia is referring to a stimulus or circumstance that should not cause pain, but for some reason is eliciting a fair amount of pain. Brushing hair is a pretty common example.

It's not supposed to hurt to brush your hair. And if you're brushing their hair and they're like, oh my gosh, okay, that's allodynia. Another example I might give would be like if you're checking their knee reflexes, you got your reflex hammer and you're just tapping on the knee and below the kneecap.

And for some reason, they're telling you that just hurts. Something like that. It's like, I'm not really hitting them hard. It really shouldn't be hurting them.

And they're saying it is allodynia. Parasthesia is a really important term to know. Parasthesia is a classic nerve type pain.

And it involves the burning, prickling, pins and needles type stuff that you'll see with nerve pain. And then sensitization is a process over time. It's built. by recurrent exposure to pain. Kind of touched on it already, but you just become hypersensitive to that stimulus, that pain stimulus.

You're going to notice it more. You're going to almost be trained to anticipate it before it comes. And that's frustrating.

All right, we are going to move into some of... some true or false questions to talk about maybe some myths. Make sure we're all on the same page.

So question number one, infants cannot verbalize or understand pain. I would like to take out the understand part. I guess express, verbalize and express or localize their pain.

Usually they aren't able to understand or I guess process their pain. to where they can localize it and that is true. I don't want you to think that infants don't have pain because they do.

It's just a matter of processing and understanding it. Question number two, pain is not a normal process of aging. That is True.

Don't let this one trip you up. Being old does not assume that you should be hurting everywhere. Things don't hurt unless there's usually a problem with aging. So it might be common to have a fair amount of aches and pains as you age, but it's not anticipated.

Very young patients, neonates, and fetuses do not feel pain. That is false. And we need to do our due diligence to make sure we are addressing the pain, especially for those who are unable to verbalize or express if they are in pain. We usually kind of assume and just treat just to be on the safe side. I just gave it away.

Pain is not always an indication of pathology or injury. That one is true. And there could be injury.

There could not be. It just depends. Confused or demented patients do not feel pain. That's a very awful perspective.

That is definitely false. So demented patients, Alzheimer's, sometimes they have a difficult time expressing their pain. And a lot of times it's noted in behavioral patterns.

Maybe they're more agitated, they're more anxious, they're more upset. But, you know, even if they aren't processing it the same way and expressing it the same way, pain can still certainly be there. The next two are pretty similar.

So societal expectations for gender are definitely there. Different societies will place different stereotype expectations on gender to influence that. And so just be aware of that and make sure that you're breaking down any barriers for communication on where their pain level is. In general, males are kind of anticipated to express less pain, females not the other way around.

So yeah, genetics can impact and lead to an increase or decrease pain tolerance. That one is true. So really interesting. I'm not sure how that all connects, but there is some genetic predisposition to how we perceive our pain.

And I keep clicking on it before I ask. That's okay. I think we all know this one. People who are saying they're in pain frequently are just addicts that want pain medication. That's definitely false.

It may be true sometimes, but we can get into a lot of trouble by making that assumption. And I would prefer to treat my patients with trust and respect until they give me a reason to not. And yeah, patients who are sleeping do not have pain. False.

definitely are going to sleep sometimes even if you're having pain you wake up the pain's still there usually your sleep is not quite as restful if you're in pain next slide trouble with opioids we can get preachy on this slide i don't want to go too crazy on it i think we all have a pretty decent understanding of the opioid pandemic and i would just say that i have seen people come to me and say look I'm addicted and it started because I broke my leg. I was given some opioids and I can't let them go. Please help me.

I've seen people that have no idea that they're addicted and are completely addicted and dependent on opioids. I've seen opioids cause a lot of problems, both in patient health and in communication in the health setting, just all over the place, just problems. So. please be patient with these people. I think that how we've treated pain over the years has created a lot of problems.

I think we're wading through those problems right now and we're getting better. I don't think opioids should ever have been used or should ever be used for chronic pain. It's just not appropriate.

And I think we're figuring that out and we're getting better at avoiding opioid use for chronic situations. But when in doubt... Make sure that we are advocating for patients and not distrusting while still setting clear boundaries so that we're not manipulated.

All right, we are leaving the pain conversation and we are moving on to nutritional assessment. If you're getting bored like I am, take a moment, pause, move around, get your blood pumping and jump back in. But Yeah, a little bit of a break here and then we're going to dive into nutritional assessment.

Here we go. So we're going to talk about some different things about nutrition in regards to growing stages, diet. um risks for nutritional problems um and problems with nutrition and then we're going to switch into more of a hydration type status where we talk about um how to know if somebody is over or under hydrated but let's start here so nutritional stages to be aware of and when we are infants or kids We are growing like crazy. We have a lot of growing to do.

And so we need nutrition. Breastfeeding is great. Breastfeeding. Breastfeeding is great if you're able.

If not, it's okay. In general, though, I've seen nutrition where it's parents struggle with it with their kids. I've had kids come into my office and they are 13 years old and they already have type 2 diabetes because they are obese, like just morbidly obese.

And even in those circumstances, my approach is never to say, hey, we need to do what we can to get your kid to lose weight. We need to just pull back on the calorie consumption, pull back on the nutrition. They need to lose weight.

That is never appropriate for kids because they are still doing so much growing. What I do say is we need to try to just maintain the weight, right? Like maybe watch our portion sizes, but if they are not gaining weight as they grow, then it's a win, right?

So keep them active, eat healthy foods, watch our portions. But kids aren't supposed to be losing weight. They're growing too much.

Adolescents, we're still growing. We're maturing. If you're pregnant or breastfeeding, obviously you have a... much higher need for nutrients. So that's something important to keep in mind.

And then unfortunately, when we get into our adulthood, our need for nutrients stabilizes. And that's when we tend to just put on the put on the weight, right? Like, I needed it 10 years ago, don't need it now. So we're just going to store that away for now.

So you tend to see weight gain happen pretty often in adulthood. And then interestingly enough, when you get older, you tend to develop obstacles for nutrition that cause an increased need for nutrition, whether it's chronic disease, whether it's a difficulty with absorbing those nutrients. You typically have a harder time getting the nutrients you need as you're older. And so usually older adults, they need to be packing in more nutrition. It's really interesting.

So how do we orient around with all these different diet recommendations? To be honest, nobody can agree with themselves. But the one that I think is the most modest and the most reasonable, I usually go with the Mediterranean diet approach.

I think it has a good balance of exercise and it's not necessarily trying to eliminate anything, but it still puts things in perspective as far as how often we should be eating those desserts and carbs. um, versus whole grains and meats and that sort of thing. So I like it.

I think it's pretty well balanced. I think it's sustainable. Um, I'm sure that, uh, will change over time.

They'll call it something else. They'll adjust preferences. But at the end of the day, if you're just trying to eat healthy foods, um, focusing on your nutritional needs, getting your protein in, getting your, um, other nutrients in, um, everything in moderation, usually. things in moderation usually work out pretty good.

I feel though that as time goes on, we tend to have more and more food that is dense in calories and less dense in nutrition. So something to keep in mind. Just because it fills you up doesn't mean it gives you the nutrients that your body's needing. And a lot of times that lack of nutrient availability perpetuates your appetite because you're still not getting what your body's asking for. And so it continues to ask for more.

Your appetite still goes and goes and goes. And you just shove a bunch of carbs and calories down. And in reality, your body's like, hey, I was actually just wanting more of this nutrient.

And it is nowhere to be found in the Burger King menu. So anyways, just food for thought. Get it?

Food for thought. Pretty good one. All right. Let's see, risk factors for nutritional disorders or problems, obstacles in nutrition, having a lower socioeconomic status.

I'm pretty sure everybody's feeling the burden of cost for healthy food these days. Um, working long hours and getting one or more meals from a fast food place or somewhere other than home. Guess who fits into that category? Nurses.

It has been a challenge. I mean, we work 12 hour shifts most of the time. And I will say I've gotten to a 12 hour shift.

I did all I could just to get there on time. And I hadn't had any food before I got there. And I'm like, all right, uh, when's this break time happening? I'm getting a little hungry. And they're like, well, you're going to get a 30 minute break around halfway through your shift.

It's like, so I have 30 minutes to incorporate an entire day's worth of nutrition. That's a great setup. And you end up just snacking for breakfast. You end up binge eating for lunch.

You're getting as much calories in as fast as you can. You're shoving it down. And then you're just coasting on fumes by the time you get off your shift.

and you get home and you're starving. And again, you just eat way more than you should. And it's like 11 p.m.

It's tough. It is a tough gig. So guys, make sure that you go in with a plan.

When you start your 12 hour shifts, have a plan. Put in the effort to keep yourself healthy. You're going to thank yourself mentally, physically, emotionally. Everything's better when you're getting good nutrition.

And it's not going to be found if we're eating out. Um, hopefully that'll shift with time and better food will become more available, but we'll see. Um, but yeah, the, the crappy food is more available and it's more convenient. So we're making a lot of bad decisions. Um, and we tend to go on a lot of crazy diets to lose weight fast because we want quick results.

Um, other things to keep in mind, chronic diseases can get in the way of nutrition, especially those involving the gut. and absorption of nutrients. You can have issues with your mouth, like chewing, or loss of taste that can really become an obstacle with nutrition. And then again, limited access to food, whether it's because you live in a bad neighborhood, or maybe no one ever taught you how to cook healthy foods, or maybe lots of things that can be considered there.

Be aware of food eating disorders. They can really mess you up. So be aware of them. Be aware that they are around you and they're very prevalent and they are often incorporated with mental health issues. And then also be aware that when your body is going through a repairing or a healing or reparative type process, your nutritional needs are going to increase, which is frustrating because we're in a hospital setting.

We're trying to focus on healing with medications or IVs or whatever. And sometimes we overlook how important the nutrition is to really give the body, give that patient's body the tools it needs to heal. So we're getting better at acknowledging that as well, but we're, we still have some room for improvement there.

making sure we're asking all the right questions about their eating habits. America has an obesity problem. That is an understatement.

So I like this slide because it talks about how there certainly is accountability for the individual with their weight, but there are so many other factors that can go into it. And as nurses, sometimes we get a little bit biased towards people that struggle with obesity. We tend to sometimes find ourselves thinking, well, they ate their way into that problem. They caused that problem by themselves. So I'm not going to have the same patience or empathy for them because they caused it.

Now they're dealing with the consequences. My argument to that is, number one, we are not there to judge. We're there to serve these patients.

So if that's in your head, leave it at the door and give that patient everything you've got. I will say that it is easy to get frustrated with really obese patients because they are needy. They require more.

There's more effort in every aspect of their health care, whether it's education, whether it's mobility, whether it's nutrition, pain control, it's all affected and it's all more difficult because of their weight. And as nurses, that's a struggle to not get a little frustrated or burned out towards that population. So make sure you're checking yourself. And when you're thinking about it, I hope that you realize that obesity is definitely becoming more and more of a system problem. I mean, you look at the statistics on this slide and the majority of Americans, the majority of American adults are obese.

That's crazy. That statistic is just insane. And I don't think it's getting any better with time.

So, you know, I hope that we understand that food availability and the culture and the expense and food costs, like it all plays into it. And we really have to step back and not place blame or guilt or shame on these patients. It's just not appropriate. And then I think my hope is, you know, is that the culture eventually changes.

I think the food that is available to us will improve when there's a greater demand for it. The market always follows demand. And right now the demand is for the cheap, convenient, unhealthy food that tastes good. And until our culture changes and is not asking so much for that.

then the market's not going to innovate and change in a way that allows for more availability and cost effectiveness for the healthy stuff. But when that change happens, and we are asking for the healthy options more than the unhealthy options, the market's going to move to that. So, you know, we really need to look at ourselves and our culture and figure out how we can change that. But that's enough of me getting preachy.

Almost. I got one more preachy slide. This slide hits close to home.

This was me in high school. I was a high school kid. That's me. I think you can see my mouse right over here, trying to look all cool looking into the distance.

But these are my high school choir buddies. And then Brittany Keel, she's the girl right here photobombing. And then the one here in the bottom right, I wanted to bring this up.

She died at age 16. She was basically not giving herself enough nutrients and exercising very strenuously. And that combination created a major electrolyte imbalance that caused her heart to stop while she was sleeping. And the morning came and they just found her gone in her bed.

She died in her sleep. So the crazy thing there is she was beautiful, she was popular, she was socially inclined, easy for her to make friends. Everyone I'm sure would find themselves eager to be her in her shoes. And yet still underneath all of that was a terrible eating disorder.

And so, you know, I don't want to be all doom and gloom here, but just be aware it's really, really common. It's very prevalent in Utah. And as nurses, I feel like we have a distinct position where we can potentially make a lot of impact by being aware and by offering resources, education, just bringing it to attention and support, like whatever we can do to help these people out.

You never know when that small act of support could save a life, quite literally. So moving on. All right, we're moving more towards the assessment part of nutrition.

Lots of different things to look at from overall appearance to body type to muscle tone, muscle distribution, fat distribution. All those are going to be taken into consideration when we're looking at a person's nutritional status. There are some tools that we can use.

I would say the top two are the most relevant. BMI, you see that a ton. And we use it a lot, even though we all know it's not a particularly efficient tool.

It overlooks a lot of circumstances and is not particularly accurate. But it's super easy to automatically calculate because we're already getting height and weight. And that's really all it asks for.

And it'll calculate the BMI and pop that number out. You know, that number can be really frustrating for some people. I would just say, you know, give it the attention that it's due, acknowledge that relationship, and then try to understand it and move forward.

But don't hang your hat on that. I think... I think there are better ways to measure health than such a superficial measurement. And studies show that waist circumference is actually a way better indicator of health. So the distribution of fat around the core, around the gut, abdomen area, tends to be the most problematic and is much more associated with chronic health risk.

So I wish that we would have people stand on the scale. I wish we would measure their height, and then I wish we would get a little measuring tape and wrap it around their waist. And that was part of the normal routine. And who knows, maybe it will be in the coming years.

BMI ranges, we talked about that in module 2. So go back, make sure you're familiar with those ranges as far as where. what BMI number obesity starts, where it transitions to morbid obesity, and that way you can use those numbers on a quiz or test question. All right, height and weight changes with aging. This is where we're bringing in a little bit of perspective for our geriatric population.

Just know that as you age, you tend to have a very slow and some usually mild decline of height over time. And that's just the spacing in between your vertebrae, losing some of that spacing over time and you lose the height and consequence of that. And then as you get older, you tend to lose your muscle mass. You have a harder time hanging on to your muscle mass when you get in your 50s and 60s.

And you tend to also lose your subcutaneous fat. But the rest, the other fats hang around. So, um...

There are some older people that beat that statistic, and it's possible, but generally you tend to see a decrease in muscle mass as you age. All right, we are moving more of a focus towards hydration, which is fun. Hydration is focusing on how we measure the fluid status in a patient.

And then what are some signs and symptoms of somebody having too much fluid versus too little fluid? Hopefully most of this is a review for you. But checking weight, input and output, that's where our kidneys get involved.

Skin turgor, pitting edema, skin moisture, venous filling, jugular venous distension, all these are different tools that help us identify hydration status. We can also look at the tongue. We can look at the eyes if they're sunken in.

I don't usually do a lot of eyeball poking or palpation, but you can always lower down the eyelid and see the conjunctiva and that can look dry or pink or pale. Lung sounds and blood pressure, all important tools to consider when we're looking at hydration status. Things that can change someone's hydration status.

Living in Utah, right? We all tend to be a little dehydrated. just to overall higher temperatures. If we're not drinking enough water, if we're drinking alcohol or caffeine or other diuretic fluids, some medications change our fluid status. If our brain isn't telling us when we're thirsty or telling us we're thirsty all the time, I've seen both of those.

And then just be aware anybody with a fever is also burning through naturally a lot of fluids. So you got to focus on hydration for those patients. All right, this is the fun part.

What is associated with overhydration versus underhydration? Let's talk about the over part first. So in general, there are always going to be exceptions to everything.

But in general, when we're talking about too much fluid, you're going to see weight gain, you're going to see edema, you're going to see veins that are popping out, because the fluid is getting backed up because there's too much fluid. So that would be an example of... that would be where the jvd or jugular venous dissension falls crackling lung sounds your lungs your chest cavity is this big open area and fluid just finds it quite convenient to slide right in there and you can get some crackly lung sounds and then in general if you have extra fluid your blood pressure tends to be higher because you have a higher volume in your vascular space so high blood pressure is most often associated with and i'm an overhydration fluid status. And if we compare that to dehydration, that tends to be associated with weight loss.

um tenting tenting is where you pinch the skin and it should kind of tent while you pinch and then when you're done pinching boop it pops back to its normal flat shape and if somebody is really dehydrated especially if you do that on their chest and you'll see that you'll pinch the chest skin you'll let go and you'll see that skin it should it should bounce right back to being flat but if they're really dehydrated it'll stay in that tent shape and be a little more sluggish flattening back out. Your capillary refill is going to be a little sluggish. Your veins are going to be flat and hard to find. Your eyes are going to get sunken in.

You're going to have dry mouth and dry tongue. Your blood pressure tends to be lower because you have less vascular volume, vascular space volume. And to compensate for that, you tend to have a higher heart rate.

So as you're studying this, make sure you understand the pathology behind each of these findings, why one would be correlated with one and not the other. If you have questions about these, make sure you bring them to me because these are important to understand. A couple of questions to bring home a point, actually just one more question. True or false, dehydration in a healthy person is not usually a problem because the body is effective at maintaining a correct fluid balance. That is false.

We are all at risk for being dehydrated. Any healthy person that doesn't take in enough fluids is going to be dehydrated. That's just the way it is.

Our body can't create fluid. We have to take it in. We have to drink it in. So staying hydrated is a priority, especially when you're sick or if you have a fever or if you're exerting or whatever.

Make sure you're staying hydrated. Healthy people are... really good at avoiding overhydration because your kidneys just pee it right on out, right?

It's easier for us to get rid of fluid that's when we have too much than it is to try to create fluid when we don't have enough. And we can only do so much to hold on to fluid as opposed to letting it go. We're limited in that capacity. So anyways, normal healthy person at risk for dehydration.

Not so much for overhydration if you're healthy. So, all right, you guys, we made it to the end. Again, please bring me any questions. I'd love to answer them during class if you weren't sure about something or you need a clarification on something.

Otherwise, hope you enjoyed this online module. Good luck on your online quiz and good luck with your semester. I hope you're enjoying my class.

Transcript for:Understanding Pain and Nutrition in Healthcare

Transcript for:
Understanding Pain and Nutrition in Healthcare