McCaffrey (1979) “ Whatever the experiencing person says it is, existing whenever he says it does”

International Association for the Study of Pain (IASP) : Pain is an unpleasant sensory and emotional experience with actual or potential tissue damage, or described in terms of damage

Physiology of Pain1.Transduction

2.Transmission

3.Perception

4.Modulation

PHYSIOLOGY

1.Transduction – Noxious stimuli (Tse injury)

release of biochemical mediators (Prostaglandin, Bradykinin, Serotonin, Histamine, Substance P)

Sensitization nociceptors

Ion mov’t across cell membrane

excitement of nociceptors

Pain

2. Transmission – Peripheral nerve fibers Spinal Cord

(Pain impulses) Spinothalamic tract

Brainstem and Thalamus

Transmission

Somatic Sensory Cortex (Pain perception occurs)

PHYSIOLOGY

1. Transduction

2. Transmission

Substance P, assist transmission of impulses across the synapse in the Spinothalamic Tract

3. Perception – Client becomes conscious of the pain (Cortical structure)

4. Modulation – neurons from brainstem sends signals down to the dorsal horn to the spinal cord which releases biochemical mediators (opioids, serotonin and norepinephrine) eliciting reaction

Origins and Causes of Pain

1. Cutaneous Pain 2. Deep Somatic Pain 3. Visceral Pain

Ex. Paper cut

1st degree burn

Ex. Obstructed bowel

Myocardial Infarction

Types of Pain According to Duration and Intensity

Acute Chronic

TIME SPAN Less than 6 months 6 months or longer

LOCATION Localized, associated with specific injury, condition or disease-Resolved with healing

Difficult to pinpoint-Continues beyond healing

CHARACTERISTICS Often described as sharp-Diminishes as healing occurs

Often described as dull-Diffused and aching

PHYSIOLOGIC SIGNS Elevated HR, BP, RRMaybe DiaphoreticDilated Pupils

Normal VSNo diaphoresisNormal PupilsMay have weight loss

BEHAVIORAL SIGNS Crying and MoaningRubbing siteGuardingFrowningGrimacingRestlessness and AnxietyVerbalization of Pain

Physical ImmobilityHopelessnessListlessnessLoss of LibidoExhaustion and FatigueComplains of Pain only when askedDepressed and Withdrawn

INTENSITY Mild to Severe Mild to Severe

Types of pain according to where it is experienced:

1. Radiating pain 2. Referred pain-Percieved at the source of -Felt from the part that is remote from the tse causing the pain

pain and extends to nearby

tses

3. Intractable pain 4. Phantom pain

-highly resistant to relief -pain percieved in a part that is missing

5. Neuropathic pain-Damage to the NS & may not

have a stimuli (Current/Pass)

CONCEPTS ASSOCIATED WITH PAIN

1. Pain Threshold – A.K.A. Pain Sensation

-Hyperalgesia

2. Pain Tolerance

3. Pain reaction

TYPES OF PAIN STIMULI

A. Mechanical

1. trauma to body tissue- tissue damage, direct irritation of the pain receptors (Nociceptors); inflammation

2. alterations in body tissues- pressure on pain receptors

3. blockage of a duct – distention of the lumen of the duct

4. tumor – pressure on pain receptors, irritation of the nerve endings

5. muscle spasm – stimulation of the pain receptors; Chemical Stim.

B. Thermal1. Extreme temperature- tissue destruction, stimulation of the

thermosensitive pain receptors

C. Chemical

1. Tissue ischemia – stimulation of pain receptors because of accumulated lactic acid (Anaerobic Met.) in tissues and

chemical mediators like bradykinin and enzymes

2. Muscle spasm – tissue ischemia release enzymes which would irritate nociceptors

FACTORS INFLUENCING REACTION TO PAIN:

1. Causes, duration and intensity of pain and the amount of relief afforded by the individual by means of various medications

2. Cultural background or ethnic values

3. Philosophical beliefs and religious convictions

4. Degrees of anxiety and fear and the manner in which others respond to the afflicted individual

5. Age

6. Drug abuse

Theories of pain:1. Gate Control Theory- Peripheral nerve fibers carrying pain towards the spinal cord can have their inputs modified before transmission to the brain.

2. Sensory or Specificity theory – involvement of sensory receptors in specific body parts or organs

3. Intensity theory – intensity of pain is determined by the magnitude of the stimulus

Pain History:1. Location – “where is your pain?”

2. Intensity

3. Quality – “how does you pain feels like?”

4. Pattern – a) time of onset (“when did/does the pain start?); b) duration (“how long have you had it?, how long does it last?);

c) constancy (“do you have pain free periods? when? for how long?)

5. Precipitating factors – what triggers the pain or makes it worst?

6. Alleviating factors – what measures or methods have you found helpful in lessening or relieving the pain? What pain medication do you use?

7. Associated symptoms – do you have other symptoms before, during, after pain?

8. Effects on ADL – How does it affect your daily life?

9. Past pain experiences – Tell me about your past pain experiences that you have had and the effectiveness of pain relief measures.

10. Meaning of pain – how do you interpret your pain? What outcomes do you expect from this pain? What do you fear most about this pain?

11. Coping resources – what do you usually do to help cope with pain?

12. Affective response – How does the pain make you feel? Anxious? Depressed? Frightened? Tired? Burdensome?

OLDCART

O – onset

L – location

D – duration

C – characteristic

A – aggravating factors

R – radiation

T - treatment

PQRST

P – provoked

Q – quality

R – region/radiation

S – severity

T - timing

Mnemonics for Pain Assessment

COLDERRA

C – CharacteristicsO – OnsetL – LocationD – DurationE – ExacerbationR – RadiationR – ReliefA – Associated signs and symptoms

Assessing a child with pain

Age Age groupgroup

Pain perception and BehaviorPain perception and Behavior Selected Nsg. Selected Nsg. InterventionIntervention

InfantInfant Perceives painPerceives painRespond to pain w/ increased Respond to pain w/ increased sensitivitysensitivityOlder infants tries to avoid pain Older infants tries to avoid pain (turns away and physically resist(turns away and physically resist

Give pacifierGive pacifierUse tactile Use tactile stimulation. Play stimulation. Play music or tapes of a music or tapes of a heartbeatheartbeat

Toddler Toddler and and preschopreschooleroler

Develops the ability to describe pain Develops the ability to describe pain and its intensity and locationand its intensity and locationOften responds w/ crying and anger Often responds w/ crying and anger because child perceives pain as a because child perceives pain as a threat to securitythreat to securityReasoning w/ child at this stage is Reasoning w/ child at this stage is not always successfulnot always successfulMay consider pain as punishmentMay consider pain as punishmentFeels sadFeels sadMay learn there are gender May learn there are gender differences in pain expressiondifferences in pain expressionTends to hold someone accountable Tends to hold someone accountable for the painfor the pain

Distract the child w/ Distract the child w/ toys, books, picture. toys, books, picture. Involve the child in Involve the child in blowing bubbles as a blowing bubbles as a way of “blowing away way of “blowing away the pain”the pain”Appeal to the child’s Appeal to the child’s belief in magic by belief in magic by using a “magic” using a “magic” blanket or glove to blanket or glove to take away paintake away painHold the child to Hold the child to provide comfortprovide comfortExplore Explore misconceptions about misconceptions about painpain

Age groupAge group Pain perception and BehaviorPain perception and Behavior Selected Nsg. Selected Nsg. InterventionIntervention

School-School-agedaged

Tries to behave when facing painTries to behave when facing painRationalizes in an attempt to Rationalizes in an attempt to explain the painexplain the painResponsive to explanationsResponsive to explanationsCan usually identify the location Can usually identify the location and describe the painand describe the painW/ persistent pain, may regress W/ persistent pain, may regress to an earlier stage of developmentto an earlier stage of development

Use imagery to turn Use imagery to turn off “pain switches”off “pain switches”Provide a behavioral Provide a behavioral rehearsal of what to rehearsal of what to expect and how it will expect and how it will look and feellook and feelProvide support and Provide support and nurturingnurturing

AdolescenAdolescentt

May be slow to acknowledge painMay be slow to acknowledge painRecognizing pain or “giving in” Recognizing pain or “giving in” may be considered weaknessmay be considered weaknessWants to appear brave in front of Wants to appear brave in front of peers and not report painpeers and not report pain

Provide opportunities Provide opportunities to discuss painto discuss painProvide privacyProvide privacyPresent choices for Present choices for dealing w/ pain. dealing w/ pain. Encourage music or Encourage music or TV for distractionTV for distraction

Age Age grougroupp

Pain perception and BehaviorPain perception and Behavior Selected Nsg. Selected Nsg. InterventionIntervention

AdultAdult Behaviors exhibited when experiencing Behaviors exhibited when experiencing pain may be gender-based behaviors pain may be gender-based behaviors learned as a childlearned as a childMay ignore pain because to admit it is May ignore pain because to admit it is perceived as a sign of weakness or perceived as a sign of weakness or failurefailureFear of what pain means may prevent Fear of what pain means may prevent some adults for taking action.some adults for taking action.

Deal w/ any Deal w/ any misconception of painmisconception of painFocus on the client’s Focus on the client’s control in dealing with control in dealing with the painthe painAllay fears and Allay fears and anxiety when possibleanxiety when possible

ElderElder May have multiple conditions May have multiple conditions presenting w/ vague symptomspresenting w/ vague symptomsMay perceive pain as part of the aging May perceive pain as part of the aging processprocessMay have decreased sensations or May have decreased sensations or perceptions of the painperceptions of the painLethargy, anorexia, and fatigue may be Lethargy, anorexia, and fatigue may be indicators of painindicators of painMay withhold complaints of pain May withhold complaints of pain because of fear of the treatment, of any because of fear of the treatment, of any lifestyle changes that may be involved or lifestyle changes that may be involved or becoming dependent becoming dependent

Cont.Cont. May describe pain differently, that is, May describe pain differently, that is, as “ache’, “hurt”, or “discomfort”as “ache’, “hurt”, or “discomfort”May consider it unacceptable to May consider it unacceptable to admit or show painadmit or show pain

Clarify Clarify misconceptionsmisconceptionsEncourage Encourage independence independence whenever possiblewhenever possible

PAIN MANAGEMENT

GENERAL STRATEGIES FOR PAIN:

1. Acknowledging the client’s pain

a. Verbally acknowledge the presence of the painb. Listen attentively to what the client says about the painc. Convey that you are assessing the client’s pain to understand it better, not to determine whether the pain is reald. Attend to the client’s needs promptly

2. Assisting support persons – give info; discuss their emotional reaction

3. Reducing misconceptions about pain

4. Reducing fear and anxiety – encouraging verbalization, being honest and sincere, promptly attending to their needs and giving accurate information

PHARMACOLOGICAL PAIN MANAGEMENT:1. Opioid/Narcotic analgesics

- Binds to Opiate receptors and

activate endogenous pain

suppression in the CNS

2. Non-narcotic analgesics

/NSAID – Acts on peripheral

nerve endings at the injury site

& decrease inflammatory

mediators

3. Adjuvant analgesic

- Developed other than for

analgesia but found to decrease

certain types of chronic pain

Alternative Delivery Systems for Opioids:

1. PCA pump

2. Epidural/ Intrathecal (Subarachnoid) Anesthesia

Advantages• Good pain control• Relieves anxiety of patient when waiting for nurse

to give the pain meds• Promotes clients independence and control over

the situation• Lower doses of opioids are given compared to

PRN• Report more analgesia with fewer S/E• As pain lessens, client adjust to doses eventually

stop taking the analgesic

3. Transdermal analgesia

4. Local Anesthesia

B. Non-pharmocological pain management

I. Cutaneous stimulation

a. Massage

b. Heat and cold application

c. Accupressure

d. Contralateral stimulation

II. Immobilization

III. Transcutaneous Electrical Nerve Stimulation

IV. Placebo – any medication or procedure that produces an effect because of its implicit or explicit intent and not because of its specific physical or chemical properties. A.K.A. Water Pill

2. Cognitive Behavioral interventions

A. Distraction

1. Slow rhythmic breathing

2. Massage

3. Rhythmic singing and tapping

4. Active listening

5. Guided imagery

B. Hypnosis - based on suggestion, dissociation and focusing attention

Types of Distraction:

A. Visual Distraction

- reading or watching T.V

- watching a ball game

- guided imagery

B. Auditory distraction

-humor/joke

- listening to music

C. Tactile distraction

- slow, rhythmic breathing

- massage

- holding or stroking a pet or toy

D. Intellectual distraction

- puzzles

- card games

- engaging in hobbies

Example of NURSING DIAGNOSIS FOR PAIN:

• Acute Pain

• Chronic Pain

• Ineffective airway clearance r/t weak cough secondary to postoperative incisional abdominal pain

• Hopelessness r/t continual pain

• Anxiety r/t past experiences of poor control of pain and to anticipation of pain

• Ineffective coping r/t prolonged continuous back pain, ineffective management and inadequate support system

• Ineffective health maintenance r/t chronic pain and fatigue

• Self care deficit (specify) r/t poor control to pain

• Deficient knowledge (pain control measures) r/t lack of exposure to information resources

• Impaired physical mobility r/t arthritic pain in knee and ankle joints

• Disturbed sleep pattern r/t increased pain perception at night

End of Presentation!

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