ot pain 1

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PaIN AND cOMFORT

STANLEY C. LUCES, M.D.

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Definitions of PAIN

Pain is an unpleasant sensory and

emotional experience associated

with actual or potential tissuedamage.

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Pain

Is a subjective response to both physical andpsychological stressors.

All people experience pain at some point during

their lives. Although it is experienced as uncomfortable and

unwelcome, it is also serve as a protective role,warning of potentially health threatening conditions.

The fifth vital signs, with recommendation to assesspain with each vital sign assessment.

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Pain

Only the person affected can experiencedpain, that is pain has personal meaning

If the client says he has pain, the client is inpain. ALL pain is real.

Pain has physical, emotional, cognitive,sociocultural and spiritual dimensions.

In many aspects, pain is the most

common reason for seeking health care

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Types of PAIN

Category of pain according to its

1. Origin

2. Onset

3. Severity

4. Cause or etiology

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Types of PAIN

Category of pain according to its origin

Cutaneous pain—originates in the skinor subcutaneous tissue

Deep somatic pain—arises fromligaments, tendons, bones, bloodvessels, and nerves

Visceral Pain—results from stimulationof pain receptors in the abdominalcavity, cranium and thorax.

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Types of PAIN

Category of pain according to its ONSET

Acute pain—following acute injury,disease or some type of surgery

Chronic malignant pain—associatedwith cancer or other progressivedisorder

Chronic nonmalignant pain—in thepersons whose tissue injury is nonprogressive or healed

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Acute Pain Have sudden or slow onset; it varies

from mild to severe, some may last upto 6 months and subsides as healing

takes place. It may be called fast pain, sharp pain,

or initial pain.

Impulses usually travel through thetype A delta fibers and this pain iseasily localized.

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Chronic Pain

last 6 months or longer and oftenlimits normal functioning.

It is sometimes called dull pain,

slow pain and delayed pain.

Impulses travel in the type C fibersand are not easily localized.

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TYPES AND CHARACTERISTICSOF PAIN

A. ACUTE PAIN - sudden onset, usually temporarily, localized.- Last for less than 6 months and has an identifiedcause.

3 major types:*1. Somatic pain- arises from nerve receptorsoriginating in the skin or close to the surface of thebody. ( sharp, diffuse, localized, dull)*2. Visceral pain- arises from body organs. (dull,

poorly localized because of low number ofnociceptors).Often associated with vomiting,nausea, hypotension, restlessness.*3. Referred pain- which is perceived in an areadistant from the site of stimuli. It is commonly

occurs with visceral pain

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B. CHRONIC PAIN

-Prolonged pain, usually lasting longer than 6

months.-It is not always associated with an identifiablecause, and often unresponsive to conventionalmedical treatment.

4 categories:

*1. Recurrent acute pain- characterized byrelatively well defined episodes of pain

interspersed with pain free episodes. ex. Migraine.*2. Ongoing-time limited pain- with defined timeperiod. Ex. Cancer pain which ends with control ofthe disease or death.

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*3. Chronic nonmalignant pain- non lifethreatening pain that nevertheless persistsbeyond the expected time for healing. Ex.Chronic lower back pain

*4. Chronic intractable nonmalignant pain syndrome-similar to chronic nonmalignantpain, but is characterized by the person’s

inability to cope well with the pain.

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C. CENTRAL PAIN- Related to lesion in the brain that mayspontaneously produce high frequency burst of

impulses that are perceived as pain.Example: vascular lesion, tumor, trauma or

inflammation.

D. PHANTOM PAIN- syndrome that occurs following amputation of thebody part.

E. PSYCHOGENIC PAIN- Is experienced in the absence of any diagnosedphysiologic cause or event. The pain is real andmay lead to physiologic changes such as muscletension.

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Pain related terms

Radiating pain—perceived at thesource of the pain and extends to the

nearby tissues Referred pain— felt in a part of the

body that is considerably removed

from the tissues causing the pain

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Pain related terms

Intractable pain- highly resistantto relief

Phantom pain—painfulperception perceived in amissing body part or in a bodypart paralyzed from a spinal cordinjury

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Pain related terms

Hyperalgesia—excessivesensitivity to pain

Pain Threshold—is the amount of

pain stimulation a personrequires in order to feel pain

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Pain related terms

Pain Reaction—includes theautonomic nervous system and

behavioral responses to pain

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Pain related terms

Pain Tolerance—maximum amountand duration of pain that an

individual is willing to endure Nociceptors—pain receptors

Pain Perception—the point which the

person becomes aware of the pain

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The pain receptor

NOCICEPTORS Usually they are free nerve endings

located widespread in the superficial

layers of the skin, peritoneal surfaces,periosteum, arterial walls, pleuralsurfaces, joint surfaces and the falx andtentorium of the cranial vault.

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The pain receptor- nociceptor

These nociceptors are non-adapting to keep us constantly informed of the

continuous presence of the painfulstimulus that can damage the tissues.

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The pain receptor

For pain to be perceived, nociceptors mustbe stimulated.

These pain receptors can be stimulated by:

serotonin

histamine

potassium ions acids

some enzymes, Substance P

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The pain stimuli

In general, there are 3 types of stimuli

that can stimulate pain receptors

Mechanical

Thermal

Chemical

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The pain stimulus

Mechanical stimulus- pressure, squeeze,pin prick

Thermal stimulus- heat and freezingtemperature

Chemical stimulus- collectively called the―P‖ factors- bradykinin, serotonin,

histamine, prostaglandin and substance P.

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Pain Syndromes

Referred Pain Referred pain is felt in areas other than

those stimulated. It may occur when

stimulation is not perceived in the primaryareas.

For example, the person having a heartattack.

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Pain Syndromes

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Pain Syndromes

Psychogenic Pain

The term psychogenic pain has been usedto describe pain for which no pathologiccondition has been found or in which thepain appears to have a greaterpsychologic basis than a physical one.

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Pain Syndromes

Neurologic Pain Pain in the neurologic system occurs in

different forms. Neuralgia is sharp,spasm-like pain along the course of one

or more nerves. Two common areas of neuralgia are the

―Trigeminal nerve‖ in the face and the―Sciatic nerve‖ in the lower trunk.

Causalgia, a form of neuralgia, is severeburning pain associated with injury to aperipheral nerve in the extremities.

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Pain Syndromes

Phantom limb pain

This is pain or discomfort perceivedby the person to be occurring in an

extremity that has been amputated. it is more likely to develop in those

who had pain before amputation and

may persist long after healing hasoccurred.

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Pain fibers

The precise mechanism of paintransmission and perception is unknown.

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Theory of pain

Gate Control Theory- This theory maintains that there is a

specialized system (gate control) thatmodulated sensory input before evokingperception and response to stimuli.

- Suggest the interaction of two systemsdetermines pain and its perception.

1st : The substantia gelatinosa regulatesimpulses entering or leaving the spinal cord.

2nd: the inhibitory system within the brain stem.

I t t

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A-delta fibers( small diameter)- carries

fast pain impulses C fibers in the spinal cord- carries slow pain impulses A- beta (large diameter)- carries impulses from tactile

stimulation. _________ In substantia gelatinosa, these implulses encounter a “gate”

that is thought to be opened and closed by the dominationof either large diameter touch fibers or small diameter painfibers.

If impulses from the touch fiber predominate, then they willclose the gate and the pain impulses will turned awaythere.

This explained why massaging a stubbed toe can reduceintensity and duration of the pain.

Ist system:

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Pain fibers

There are two separate pathways that transmitpain impulses to the brain:

(1) Type A-delta fibers are associated with fast,sharp, acute pain and

diameter – 2-5umconduction velocity – 12-30m/s

myelinated

(2) Type C fibers are associated with slow,

chronic, aching paindiameter – 0.4-1.2um

conduction velocity – 0.5-2m/s

unmyelinated

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Pain fibers

d

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2nd system:

- The inhibitory system, is thought to be

located in the brain stem.

- It is believed that cells in the midbrain ,activated by a variety of stimuli such as

opiates, psychologic factors, or even simplythe presence of pain itself, signal thereceptor in the medulla. This receptor inturns,stimulate nerve fibers in the spinalcord to block the transmission of impulsesfrom pain fibers.

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Inhibitory mechanisms The pain maybe modulated or inhibited. The analgesia system is a group of midbrain

neurons that transmits impulses to the pons andmedulla which in turn stimulate a pain inhibitory

center in the dorsal horns of the spinal cord. Endorphins- chemical inhibitory mechanisms is

fueled by endorphins, which are naturally occurringopioid peptides present in the neuron in the brain,

spinal cord and GIT.

- work by binding with opiate receptorson the neurons to inhibit pain impulsetransmission.

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Stimuli

Nociceptors - nerve receptors for pain. They arelocated at the ends of small afferent neurons andare woven throughout all the tissues of the body

except the brain. Numerous on skin and muscles. Nociceptors are stimulated either by direct damage

to the cell or by the local release of biochemicalssecondary to cell injury.

Bradykinin - an amino acid, appears to be themost abundant, and potent pain-producingchemical; others are prostaglandin, histamine,hydrogen ions and potassium ions.

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Pain Syndromes

Intractable pain

This type of pain is a chronic pain that isresistant to cure or relief.

- interfere with the quality of life.

E.g. arthritis and cancer.

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Gate Control theory

The gate control theory has led to therecognition that the pain can be reducedor modulated at four points:

The peripheral site of pain

The spinal cord

The brainstem

The cerebral cortex

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Gate Control theory

Small-diameter nerve fibers carry the painstimuli through the same gate

Large diameter fibers that carry the non-pain impulses go through the same gateand inhibit the transmission of those pain

impulses- that is close the gate.

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Gate Control Theory

The pain gate situated in the substantiagelatinosa cells in the dorsal horn of thespinal cord can be shut in several ways:

Stimulation of touch-fibers by rubbing,stroking, massage, vibration andapplication of liniments and other

ointments.

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Gate Control Theory

Endogenous opioids – (neuromodulators)release endogenous opioids: enkephalins,endorphins and dynorphins, which aremorphine-like in actions

Electrical stimulation of the skin’ssensory nerve fibers inhibits pain.

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Management of PAIN

NON-PHARMACOLOGIC

PHARMACOLOGIC

SURGICAL

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Management of PAIN

Altering Pain Transmission

Electrical stimulators

it modify the pain stimulus by blocking or

changing the painful stimulus withstimulation perceived as less painful.

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Pain management

Nerve block

A nerve block involves the injection ofsubstances such as local anesthetics orneurolytic agents (e.g., alcohol or phenol)close to nerves to block the conduction ofimpulses over the nerves.

Nerve blocks frequently are used for thesymptomatic relief of pain.

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Pain management

Acupuncture Small needles are skillfully inserted and

manipulated at specific body points,

depending on the type and location of pain. The gate control theory provides the best

explanation for the success of acupuncture.

The local stimulation of large-diameterfibers by the needles is thought to ―close

the gate‖ to pain.

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Pain management

Modifying the Pain StimulusCutaneous stimulation and massage

Cutaneous stimulation stimulates the

large A-beta fibers , closing the gateto impulses from the periphery.

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Pain management

Modifying the Pain StimulusCutaneous stimulation and massage

Methods of cutaneous stimulation includethe following

1. Lightly rubbing the affected area

2. Application of heat or cold to area

3. Whirlpool massage of area

4. Back rub or massage

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Pain management

Modifying the Pain Stimulus

Reducing additional physical stimuli

Interventions include the following measures:

Use a turning sheet for patients with severe neck,back, or general trunk pain.

Place a pillow under a painful joint when helping apatient change position.

Support limbs at the joints rather than the musclebellies when handling an extremity.

Avoid bumping the bed or moving it suddenly.

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Pain Management

Distraction

Distraction interferes with the pain stimulus,thereby modifying the awareness of the pain.

It relieves both acute and chronic pain bystimulating the descending pathway of pain.

E.g watching TV, listening to music, solving

puzzles, and reading comics, etcetera.

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Pain Management

Relaxation.

Full relaxation decreases muscle tensionand fatigue that usually accompanies pain.

It also helps to decrease anxiety, therebypreventing augmentation of the painstimulus

E.g. abdominal breathing at a slow,

rhythmic rate.

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Pain Management

Guided imagery

Guided imagery is the term used todescribe the use of images to improve

physiologic status, mental state, sell-image,or behavior.

Relaxation exercises before the use of this

approach facilitate the imaging process. Imagery techniques such as visualizing

oneself in a favorite setting-for example, aquiet beach-are more effective.

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Pain Management

Therapeutic touch

A less traditional therapy termed therapeutic touch,may be helpful to patients in pain

The therapist undergoes a brief period ofmeditation before coming in contact with thepatient.

During this period the therapist quiets his or her

internal energy levels and then touches the patientand transmits the healing energies.

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Pain Management

Ice and Heat therapies ice should be placed on the injury site

immediately after injury or surgery.

Ice therapy can also relieve the pain ifapplied later after the injury.

Remember to protect the skin fromDIRECT application of ice and it should be

applied NO longer than 20 minutes a time. Application of heat increases blood flow

to an area and contributes to painreduction by SPEEDING healing.

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Hot versus Cold

HOT Cold

Use to RELIEVE

joint stiffness, painand muscle spasm

Use to control

inflammation andpain

After acute attackAfter 72 hours

(Udan)

ACUTE ATTACK

Myths and misconception

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Myths and misconceptionabout pain

1. ―Pain is a result not a cause .‖ It is now recognized

that unrelieved pain may sets up further responses suchas anger, anxiety, immobility. Pain may delay healing andrehabilitation.

2. ―Chronic pain really a masked form of depression .‖ Pain and depression are chemically related, not mutuallyexclusive.

3. ―Narcotic medication is too risky to be used in chronic pain.” This common misconception oftendeprives clients of the most effective source of pain relief.

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4. ―It is best to wait until a client has pain before giving medication .‖It is now widely accepted thatanticipating pain has a noticeable effect on theamount of pain a client experiences.

5. “Many clients lie about the existence or severity of their pain .” Very few patient lie about

their pain.

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Medications

1. Nonnarcotic analgesics- use to treat mildto moderate pain.

example: acetaminophen

2. NSAIDS- minimizing pain by interferingwith prostaglandin synthesis. For mild tomoderate pain and continue to be effectivewhen combined with narcotics formoderate to severe pain.

Ex. ASA, ibuprofen, celecoxib.

3. Narcotics – opiods. For moderate tosevere pain.

Ex. Morphine, codeine, fentanyl

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4. Antidepressant

-acts on the production and retention of serotoninin the CNS, thus inhibiting pain sensation. Promote

normal sleeping pattern.5. Local anesthetics

- blocks the initiation and transmission of nerve

impulses in a local area.

Responsibilities in Medication

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Responsibilities in MedicationAdministration of Narcotic

AnalgesicsExample: Demerol (Meperidine), Morphine

(MS), Nubain, codeine

Narcotics are regulated by federal law, mustrecord the date, time, client name, type andamount of the drug used and sign the entry inthe narcotic sheet.

Keep narcotic antagonist, such as Naloxone,immediately available to treat respiratorydepression.

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Assess allergies or adverse effects previouslyexperienced by the patient.

Meperidine is associated with CNS toxicityand thus involves significant risk.For anyclient who is receiving more than one dose,monitor for nervousness, delirium, tremors,twitching, seizure.

Assess for respiratory disease such asasthma, that might increase risk forrespiratory depression

Assess the characteristics of pain and theff i f d

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effectiveness of drugs

Take a baseline vital signs prior

administrationClient and Family teaching

The use of narcotics to treat severe pain isunlikely to cause addiction

Do not drink alcohol

Increase intake of fiber and fluids to preventconstipation

This drug causes dizziness, drowsiness andimpaired thinking

Report side effect to the physician

GUIDELINES FOR ASSESSMENT OF

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GUIDELINES FOR ASSESSMENT OFTHE PATIENT WITH PAIN

1. Assess the characteristics of the patient’spain

P-Q-R-S-T

P- Provoking Factors

what precipitated (triggered ) the pain?

Has anything relieved the pain?what is the pattern of the pain?

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Q - Quality of painWhat is the quantity and quality of

pain? Is the pain sharp, crushing, dull,burning, stinging?R - Region/ Radiation

What is the region (location) of the

pain? does it radiates?S - Severity of painWhat is the severity of the pain?

T - TimingWhat is the timing of the pain? Whendoes it begin? How long does it last?

T- TreatmentHas the patient taken any medication totreat this? Time of last dose?

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Pain Intensity Scales

GUIDELINES FOR ASSESSMENT OF THE

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GUIDELINES FOR ASSESSMENT OF THEPATIENT WITH PAIN

2. Assess the patient’s behavioral responses to

the pain experience

A. Determine if the pain is acute or chronic

B. Observe for the following behavioral

responses


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PATIENT WITH PAIN

3. Assess factors that influence responses topain

A. Ethnic and cultural factors

B. Previous pain experiences

C. Meaning of the pain experience

D. Patient’s responses to pain relief strategies

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ot pain 1

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