Date post: | 16-Aug-2015 |
Category: |
Health & Medicine |
Upload: | youssef2000 |
View: | 34 times |
Download: | 0 times |
Dr. Naglaa Youssef
Medical-Surgical Nursing Dep.
Faculty of Nursing
Cairo University
Content outlines
Definition of pain
Components of pain
Types of pain
Physiology of pain
Management of pain
Assessment of pain
Nursing diagnosis of patient with pain
Nursing care for patient with pain
Pain definition
Pain has been defined as an „‟unpleasant sensation usually associated with disease or injury‟‟ (Timby
2009).
It causes physical discomfort that is a companied by suffering, which is the emotional component of pain.
the American Pain Society coined the phrase “Pain: The 5th Vital Sign”
Pain is „‟whatever the person says it is, and existing
whenever the person says it does‟‟ (Margo
McCaffery 1998).
“It is not the responsibility of clients to prove that
they are in pain; it is the nurses‟ responsibility to
believe them.” (Crisp & Taylor, 2005).
Components of pain
Experience of pain includes:
Sensory
Affective
Cognitive
Behavioural
Physiological
Perception of pain characteristics: intensity, quality, location
Negative emotion: anxiety, fear, unpleasant sensation
Interpretation of pain
Coping strategy used to
express, avoid, or control pain
Nociceptive and stress
response
Types of pain
Types of pain can be described/classified
according to:
Ty
pes
of
pai
n Source
Cutaneous
Somatic
Visceral
Neuropathic Aetiology
Duration
Acute
Chronic
Nociceptive
pain
Cutaneous pain
Discomfort feeling originates at the skin level,
e.g. trauma.
Nociceptive pain
Somatic
Involves superficial tissue: skin,
muscles, joints, bones
Location is well defined
Sensation is described as
Tender, Burning, Shooting,
Throbbing
e.g. cut skin, stretch a muscle too
far or exercise for a long period
of time.
Visceral
Involves organs: heart,
stomach, liver..etc.
Location: Diffuse
Sensation is described as:
aching, cramping
Visceral pain
Discomfort arising from internal organs.
Is associated with injury or disease.
It is sometimes referred (referred pain) or poorly
localized.
Referred pain is a discomfort or pain perceived in a
general area of the body, usually away from the site
of stimulation. E.g., cardiac pain may be felt in the shoulder or left
arm, with or without chest pain.
Areas of referred pain
Radiating pain
Perceived in the source of pain and extended to
nearby tissue.
Neuropathic Pain
Is pain that experienced days, weeks, or longer after the
cause of pain has been treated.
Is called functional pain.
Is due to dysfunction of the nervous system.
E.g. phantom pain limb pain/sensation.
a person with an amputated limb perceives that the limb still exists
and feels burning, itching, deep pain in tissues that have been
surgically removed.
Acute and chronic pain
Acute
• Recent/rapid onset
• Specific, localized
• Severity associated with the acuity of disease
• Good response to medication therapy
• Requires less drug therapy
• Suffering is decreased
• Associated with sympathetic nervous system responses: hypertension, tachycardia, restlessness & anxiety.
Chronic
• Prolonged onset
• Nonspecific, generalized
• Severity out of promotion to the disease
• Poor response to medication therapy
• Requires more drug therapy
• Suffering is intensified
• Absence of autonomic nervous system responses
• Psychological suffering: depression & irritability.
Physiology of Pain
Specialized pain receptors or nociceptors can be excited by mechanical, thermal, or
chemical stimuli.
Nociceptors
Central Nervous System
What is nociceptor?
Is a type of sensory nerve (free nerve endings in
the skin) that sensitive to a noxious stimulus.
Nociceptors are also called pain receptors, but
the former term is preferred.
Where does it locate?
It locates in the:
Skin, bones, joints, muscles & internal organs.
Physiology of pain
It is the process by which the person experiences pain occurs in
four phases:
Transduction Transmission Perception Modulation
First phase: Transduction
Chemicals substances such as
substance p, histamine & prostaglandins
Injured cells
release chemicals
excite nociceptors
Pain medications can work during this phase by blocking the production of prostaglandin
(e.g., ibuprofen or aspirin) or by decreasing the movement of ions across the cell
membrane (e.g., local-anesthetic).
Phase 2: Transmission (spread)
Is the phase where stimuli moves from the peripheral
nervous system toward the brain.
Types of nerve fibers
A-delta fibers
Smaller, myelinated fibers, Carry impulses rapidly
Smaller, myelinated Aδ (A delta) fibers transmit nociception rapidly, which produces
the initial “fast pain Result in:
Sharp, localized pain, acute initial sensation. e.g. touching a hot iron then withdraw from
pain provoking stimulus
C-fibers
Larger, unmyelinated fibers. Carry impulses at a slow
rate. E.g. dull, aching, burning sensation.
Pain impulses move to higher level in the brain such
as: thalamus, cerebral cortex and limbic system by
assistance of substance P.
Prostaglandin is a chemical that released from
injured cells speeds the pain transmission.
Opioids (narcotic analgesics) block the release of neurotransmitters,
particularly substance P, which stops the pain at the spinal level.
Phase 3: Perception
What does perception mean?
Is the person‟s „‟conscious experience of discomfort
„‟(Timby 2009).
When does perception occur?
It occurs when the pain threshold (عتبة األلم) is
reached.
What is pain threshold?
„‟Point at which sufficient pain-transmitting stimuli
reach the brain‟‟ (Timby 2009).
The point at which a stimulus is perceived as
painful.
What is pain tolerance?
Is the maximum amount (intensity) or duration of
pain that person can endure or tolerate.
Phase 4: Modulation or descending ( المسار تعديل )
Is the last phase of pain impulse transmission
where the brain interacts with the spinal nerves in a
downward way to alter the pain experience.
Release of pain inhibiting neurochemicals that can
reduce the pain, such as:
Endogenous opioids
Gamma-aminobutyric acid
Gate control theory (Melzack and Wall, 1965)
Protective pain reflex.
Discomfort stimulus from skin
travel along sensory neuron to
dorsal horn of spinal cord,
synapses with motor neuron,
travels along spinal nerve to
skeletal muscle, causing
withdrawal from pain stimulus.
Physiological response to pain
Pain produces a physiological stress response that includes
increased heart and breathing rates to facilitate the increasing
demands of oxygen and other nutrients to vital organs. Failure to
relieve pain produces a prolonged stress state, which can result in
harmful multisystem effects (Middleton, 2003).
Incase of sever traumatic pain may place client into shock.
Vocalization
Moaning, crying & gasping
الشكوى والبكاء ويلهث
Facial expression
Grimace, clenched
teeth, tightly closed eye & lip biting &
wrinkle forehead
Body movement
Immobilization ,restlessness
& muscle tension
Social interaction
Avoid the conversation
or social contacts
Behavioral response
Impact of pain on patient daily life
Fatigue
Sleeping disturbance
Loss of appetite
Social withdraw
Disturb family life
Tense muscles
Impair immune system….poor healing, infection, ulcers.
Stop activity…..complications of immobility such as
muscle atrophy, cardiovascular complications
Factors influencing pain perception
Factors influence pain
Age
Gender
Culture
Environment
Meaning of pain
Anxiety
Fatigue
Previous experience
Family support
e.g. keep a
stiff upper lip
e.g. Money reward
• Assessment
• Nursing diagnosis
• Intervention
• Evaluation
Nursing process
Caring for patient with pain
Pain is the fifth vital signs that should be
assessed during assessment stage (the
American Pain Association).
Pain assessment
Method of assessing pain:
A. Taking history
B. Physical examination of pain
Pain Scales
There are different pain intensity scales:
1. Word scales
2. Numeric scales
0
Mild
pain
Moderate
pain
Sever
pain
Very sever
pain
Worst
possible pain No pain
7 8 5 6 9 2 3 4 1
No pain
10 Worst
possible pain Moderate
pain
3. Linear (visual analogy) scale/VAS
4. Rating scale
No pain Pain as bad as it could
possible be
Components of pain assessment: COLDERR
Focus of assessment Components
Describe pain sensation (e.g. sharp, aching, burning) Character
When it started, sudden, gradually. Onset
Where it hurts, mark on a diagram Location
Constant versus intermittent in nature, how long Duration
Factors that make it worse Exacerbation
Factors that make it better Relief
Pattern of shooting/spreading/location of pain away
from its origin.
Radiation
Components of pain assessment
Focus of assessment Components
Rating for present pain severity using a pain
scale.
Intensity
Description own client‟s own words (like knife). Quality
prayer or other religious practices, withdrawal Coping resources
Pain characteristics that change. Variations
Repetitive or not. Patterns
Sleep, appetite, concentration, school, work,
driving, walking, slef-care.
Effects on ADL’S
N/V, dizziness, diarrhea Associated
Symptoms
Focus of assessment Components
Approaches used to control the pain and results
and effectiveness.
Current pain
treatment
Past medications or interventions and the
response, manner of expressing pain, personal
cultural, spiritual, or ethnic believes that can affect
pain management.
Pain treatment
history
Level of tolerance, expectation for level of pain
relief ability to restore function.
Person’s goal for
pain control
Nursing diagnoses
Ineffective airway clearance related to weak cough secondary to
incision abdominal pain
Activity intolerance related to pain (specify location as left ankle pain)
Immobilization related to pain (specify )
Sleep disturbance related to pain (specify)
Self care deficit (specify) related to poor pain control
Ineffective coping related to ineffective pain management (specify
location as left ankle pain)
Depression & anxiety related to pain (specify)
Deficient knowledge (specify pain medication) related to lack of
exposure to information resources
Planning (goals)
After 2 hours the patient:
Will report pain control or relief of pain
Will express satisfaction with pain control
Will states pain is 2/10
Will reported decrease in intensity of pain
Willing to try relaxation technique
Increases interactions with family and friends
Demonstrates use of new strategies to relieve pain
Interventions
1. Monitoring
2. Actions / interventions
3. Teaching
Monitoring
Use pain assessment scale to identify intensity of pain.
Assess and record pain and its characteristics:
location, quality, frequency, and duration.
Assess vital signs every 30 minutes
Actions / interventions
Aim of pain management to preventing, reducing,
relieving pain, such as:
Non-pharmacologic interventions
Pharmacologic management
Health teaching
Non-pharmacologic interventions
Relaxation techniques = releasing
tension
Education = support & coping
methods
Imagery = using mind to visualize
an experience=daydreaming
Distraction=switch from unpleasant
sensory experience to one more
pleasant
Acupuncture= thin needles
are inserted into the skin
Acupressure = tissue
compression
Meditation = concentrating
on a spiritual word or idea
Heat & cold = thermal
therapy = swelling &
vasodilatation
Types of distraction
Visual distraction
Tactile distraction
Auditory distraction
Talking Oder
Intellectual distraction
Reading, watching T.V Listen to music Message, deep breathing Hobbies, writing cross word puzzle
Pharmacologic
Analgesia = relief of pain. Gk
an- without + algesis-sense of pain.
Oral medications
Patient – Controlled
Analgesia (PCA)
Epidural analgesia
Injection in the lumber region
at the L2/3 or L3/4 space
Health teaching
Teach patient additional strategies to
relieve pain and discomfort: distraction,
relaxation, cutaneous stimulation, etc.
Instruct patient and family about potential
side effects of analgesics and their
prevention and management.
Approaches to pain management
Examples Intervention Approach
Aspirin, ibuprofen, Local anaesthetics, anti-
inflammatory medications
Interrupting pain
transmitting chemicals at
the site of injury
Epidural, rhizotomy,
sympathectomy
Intra spinal anaesthesia
and analgesia or
neurosurgery
Altering the transmission at
the spinal cord
Massage, acupuncture,
acupressure, heat, cold
electrical stimulation
Cutaneous stimuli Using gate closing
mechanism
Morphine, imagery,
distraction, hypnosis
Narcotics, non-
pharmacological
techniques
Blocking brain perception
Evaluation
Report pain level
Respiratory rate
Amount of medication, frequency use
Side effect of medication