P A I N

Michael Emman D. Orbe, BSN, RNClinical Instructor

I. PAIN

Pain is a highly unpleasant and very personal sensation that cannot be shared with others.

One of the most complex human experiences; an individual phenomenon influenced by the interaction of affective, behavioral, cognitive and physiologic-sensory factors.

A. NOCICEPTORS

Sensory pain receptors are free nerve endings in the tissue that respond to tissue-injuring stimuli (noxious stimuli).

Receptors that respond to noxious temperature changes(thermoreceptors),chemicals(chemoreceptor), or pressure (mechanical receptors) transmit the pain if the noxious stimuli are sufficiently strong.

Found in the skin, blood vessels, subcutaneous tissue, muscle, fascia, periosteum, viscera, joints and other structures.

Cont… Nociceptors are located on two types of

peripheral nerve cells that are responsible for transmitting pain from the tissues to the central nervous system.

2 Types of peripheral nerve cells:1. A – delta fibers – give rise to the bright sharp

localized pain that is immediately associated with injury. (1st pain)

2. C – fibers – cause a second pain sensation that is dull, poorly localized, and persistent after injury.

B. ORIGINS & CAUSES of PAIN

Cutaneous pain – Originates in the skin or subcutaneous tissue.

e.g. paper cut causing a sharp pain Deep Somatic pain – arises from

ligaments , tendons, bones, blood vessels, and nerves. It is diffuse and tends to last longer than cutaneous pain

e.g. ankle sprain

Visceral pain – results form stimulation of pain receptors in the abdominal cavity, cranium, and thorax. Tends to appear diffuse and often feels like deep somatic pain, that is burning, aching or feeling of pressure.

e.g. ischemia, or muscle spasms.

C. TYPES of PAIN

Acute Pain – may have a sudden or slow onset; it varies from mild to severe, and may last up to 6 mos and subsides as healing takes place.

- it reflects potential and present tissue damage.

Cont. ….Types

Chronic Pain – 6 months or longer and often limits normal functioning.

- usually increases at night.

D. CONCEPTS ASSOCIATED WITH PAIN Pain Threshold – is the amount of pain

stimulation a person requires in order to feel pain.

Pain Reaction – ANS & behavioral response to pain; it protects the individual from further harm. (automatic withdrawal of hand from hot stove)

Pain tolerance – is the maximum amount & duration of pain that an individual is willing to endure; influenced by psychologic & socio cultural factor; appears to increase with age.

II. PAIN ASSESSMENT

An accurate assessment focusing on pain’s cause is essential for determining the proper therapy. The nurse must obtains a pain history, physical examination that focuses on the client’s physiologic & behavioral responses to pain.

A. Data that should be obtained on Pain Hx

1. Location – “Where is the pain located?” -This can be measured objectively by

using a drawing of a body outline. 2. Intensity - “What is the magnitude or

intensity (level) of the pain?” -Pain intensity is measured with the use

of scale

Cont….

3. Quality – Descriptive adjectives help people to communicate the quality of pain.

e.g. Hammer like, piercing like a knife

4. Pattern – it includes time of onset, duration, and persistence of or intervals without pain.

“ when the pain began (onset), how long the pain lasts, if recurrent-the length of interval without pain; when the pain last occurred.

Cont…..

5. Precipitating factors - activities that sometime precede pain.

6. Alleviating Factors – this will include the analgesics taken, rest, and application of heat or cold.

III. Physical Examination This will determine the client’s

physiologic and behavioral responses to pain.

The nurse needs to assess the client’s vital signs and observes the skin color, skin dryness, diaphoresis, facial expression, and body gestures.

Cont….

1. Physiologic Response - this may vary according to whether the

pain is acute or chronic.- Acute pain stimulates the sympathetic

nervous system, resulting in increased BP, PR, RR, pallor, diaphoresis, and pupil dilation.

Cont….. Chronic pain or visceral pain – parasympathetic

stimulation may be observed: lowered BP, decreased PR, pupil constriction & warm dry skin.

2. Affective Responses Vary according to the situation, degree & duration of

pain. The nurse needs to explore the clients

feeling( anxiety, fear, exhaustion, depression) People with chronic pain become depressed & tends

to be suicidal.

Cont…

3. Behavior Responses –The very young, aphasic and confused or disoriented persons often communicate their experience of pain only non-verbally.

- Facial expression is often the first indication of pain.

(clenched teeth, tightly shut eye, open somber eyes, lip biting & other facial grimaces)

Cont…

Immobilization of the body part, muscle guarding.

Rhythmic body movement – rubbing of affected body part.

Speech & vocal pitch –Rapid speech & elevated pitch often reflect anxiety;slow speech & monotonous tone can signal intense pain.

IV. Pain Management

It is the alleviation of pain or reduction in pain to a level of comfort that is acceptable to the client.

It includes two types of NURSING interventions: Pharmacologic & Non Pharmacologic.

1.Pharmacologic Pain Mgt. It involves the use of Opioids(narcotics), non-

opiods/NSAID, adjuvants, or co-analgesic drugs.

a. Opiods Analgesics – include opium derivatives, such as morphine and codeine.

b. Non-opoid – include NSAID such as aspirin , acetaminophen, and ibuprofen.

(decrease or inhibit prostaglandin release)

Cont…..

c. Adjuvant analgesics –are medication that developed for uses other than analgesia but have found to reduce certain types of chronic pain.

e.g. mild sedatives or tranquilizers, diazepam; Antidepressant(Elavil), Anticonvulsant(tegretol) for neuropathies in Herpes zosters.

2. Nonpharmacologic pain Mgt.Goal of Physical intervention :- Provide comfort- Correct physical dysfunction- Alter physiologic responses- Reduce fears associated with pain-

related immobility or activity restrictions.

Cont…..a. Cutaneous stimulation – can provide effective

temporary pain relief. It distracts the client & focuses attention on the tactile stimuli, away from the painful sensations, thus, reducing pain perception.

- Create the release of endorphins that block the pain stimuli.

- Stimulate large diameter A-beta sensory nerve fibers thus decreasing the transmission of pain impulses through the smaller A-delta & C fibers

Cont….b. Immobilization – Immobilizing painful

body parts.

c. Tanscutaneous Electric Nerve Stimulation

(TENS) – same function as cutaneous stimulation.

Cont…. Goals of Cognitive-Behavioral Interventions:1. Alter pain perception2. Alter pain behavior3. Provide clients with greater sense of control

over pain.a. Distraction - it draws the client’s attention

away from the pain & lessen the perception of pain.

- e.g. slow rhythmic breathing, masssage & slow-rhythmic breathing, Active listening, Guided imagery.

Cont. …

Hypnosis – is an altered state of consciousness in which an individual’s concentration is focused and distraction is minimized.

Cont…. Example of Cutaneous stimulation:1. Massage

(Effleurage,Tapotement,Petrissage)2. Application of heat & colds3. Acupressure – based on the ancient

chinese healing of acupuncture. 4. Contralateral stimulation – stimulating

the skin in an area opposite to the painful area.

II. Rest & Sleep

A. Rest – implies calmness, relaxation without emotional stress, and freedom from anxiety.

- it restores a person’s energy, allowing the individual to resume optimal functioning.

- people deprived of rest are often irritable, depressed, tired and have a poor control of their emotion,

Cont….

B. Sleep – a state of consciousness which the individual’s perception and reaction to the environment are decreased.

- it is characterized by minimal physical activity , variable levels of consciousness, decreased responsiveness to stimuli.

C. Physiology of Sleep

1. Circadian rhythm – came from the latin, circa dies, “about a day”.

- biological clock, controlled from within the body and synchronized with environmental factors, such as light and darkness, gravity and electromagnetic stimuli.

D. Stages of sleep

a. NREM

- slow wave sleep- sleep during night, deep, restful sleep &

brings a decrease in physiologic functions.

E. REM Sleep Constitutes 25 % of the young adult Usually recurs about every 90 minutes &

lasts 5-30 min. It is not as restful as NREM sleep Most dreams takes place and retained in

the memory. During this stage the brain is more active

and brain metabolism increases.

F. Stages & Characteristics of NREMStage Characteristics

Stage 1 Relaxed & drowsy, Profound restfulness, usually lasts only a few minutes, floating sensation, eyes roll from side to side – lasts only a few minutes.

Stage 2 Stage of light sleep, body processes continue to slow down, eyes are generally still, heart & respiratory rates slightly decreases, and body temp falls easily aroused– 10 to 15 min

Stages & Characteristics of NREM

Stage Characteristics

Stage III HR & RR and other body processes slow further because of the denomination of PNS; Less easily aroused; not disturbed by sensory stimuli; skeletal muscles are very relaxed; reflexes are diminished & snoring may occur.

Stage IV Deep sleep; HR&RR drop 20% to 30% below as compared when awake; very relaxed, rarely moves & very difficult to arouse; eyes roll & some dreaming occurs; it restore the body physically.

Presleep

NREMStage1

NREMStage 2

NREMStage 3

NREMStage 4

NREMStage 3

NREMStage 2

REMSleep

NREMStage 2

G. Sleep Cycle

People pass through the 4 stages of NREM sleep, usually lasting about 1 hr.

Sleeper passes from stage I NREM through stages III to IV in about 20 to 30 min.

Stage IV last for 30 min. Followed by III & II; then 1st REM stage occurs

for 10 min. (1st sleep cycle) Usual sleeper exp 4-6 cycles in 7-8 hrs of

sleep.

H. Function of Sleep

It exerts physiologic effect on the nervous system & other body structures.

It increases muscle tone Necessary for protein synthesis, thus, allow

the muscles to repair.

I. Factors affecting sleep Quality of sleep- ability of an individual to

stay asleep & to get appropriate REM & NREM.

Quantity of sleep – total time the individuals sleeps.

Cont….. Age – sleep pattern variation occurs with

age. e.g. NB –14 to 18 h; Inf – 12to 14h; Tod –

10-12; PS –11h; Sch age – 10; Adol –8 Environment – can promote or hinder

sleep. Fatigue – it is thought that a person who

is moderately fatigued usually has a restful sleep.

Cont…

Lifestyle- exercise, work shift Psychologic stress – Anxiety &

depression disturb sleep. Alcohol & stimulants – excessive alcohol

disrupts REM sleep. Often experience nightmares when effect of the alcohol has worn off.

Diet – dairy products (contains tryptophan)

Cont ….

Smoking – has a stimulating effect in the body.

Motivation – the desire of an individual to stay awake.

Illness – people who are more ill require more sleep.

Medications – affect the quality of sleep

J. Common Sleep Disorder

CATEGORY of Sleep disorder Primary Sleep disorders – sleep problem

is the main disorder Secondary – sleep disturbances cause

by another clinical disorder such as thyroid dysfunction, depression & alcoholism.

Cont….

1. Insomnia – the most common sleep disorder - inability to obtain an adequate amount or

quality of sleep.# 3 types of insomnia:a. Initial insomnia – difficulty of falling asleep.b. Intermittent or maintenance – difficulty of

staying sleep bec of frequent wakingc. Terminal insomnia –early morning or premature

waking.

Cont … Causes of insomniaa. Physical discomfortb. Mental over stimulation due to anxiety.c. Over consumption of drugs & alcohol

2. Hypersomnia – opposite of insomnia; excessive sleep, particularly in daytime.

Cont….

Causes of Hypersomnia

1. Nervous system damage

2. Kidney & liver disorder

3. Diabetic acidosis

4. Hypothyroidsm

5. Coping mechanism

Cont…3. Narcolepsy – “Narco”, numbness

Lepsis, seizure- sudden wave of sleepiness that occurs

during the day.- Also referred as sleep attack- Cause is unknown, but believed to be a

genetic defect of the CNS in w/c REM cant be controlled

Cont….4. Sleep apnea – it’s the periodic cessation

of breathing during sleep.- Often suspected when a the person has

a loud snoring, frequent nocturnal awakenings, excessive daytime sleepiness, insomnia.

- Last from 10 sec – 2 min; occur during REM or NREMs

Cont… 3 types of sleep apnea

a. Obstructive apnea – occurs when the structures of the pharynx or oral cavity block the air flow.

b. Central apnea – involves a defect in the respiratory center of the brain.

- all actions involve in breathing ceased (chest movement, airflow)

Cont…

c. Mixed apnea –combination of the the 2.

4. Parasomnias – refers to a cluster of waking behaviors that may interfere with sleep.

a. Somnabulism – sleep walking

- occurs during stages III&IV of NREM

- episodic & occurs 1-2 hafter falling asleep.

Cont…b. Sleeptalking – occurs during NREM sleep

before REM sleep.

- Rarely presents a problem to the person unless it is troublesome to others.

c. Nocturnal enuresis – Bedwetting

- occurs in children over 3 yrs

- often occurs 1 – 2 h after falling asleep,when rousing from NREM stage III - IV

Cont…

d. Nocturnal erection / emission – occur during REM sleep.

- begin during adolescence, does not present a problem.

e. Bruxism – clenching & grinding of teeth.

- occurs during stage II NREM

K. ASSESSMENTSleep assessment includes a sleep history, sleep diary & Physical examination.

1. Sleep history

a. Usual sleeping pattern, sleeping & waking hours; quality or satisfaction of sleep; time & duration of naps.

b. Bedtime ritualsc. Use of medicationsd. Sleep environment – dark room, temp.e. Recent changes in sleep patterns or

difficulty of sleeping.

2. Sleep diary

Clients with sleeping problem should keep & maintain a SD for at least 1 wk.

a. Total number of sleep hours/dayb. Activities performed by 2-3 hrs before

bedtime (type, duration and time)c. Bedtime rituals – food,fluid medicationd. Time of going to bed; trying to fall asleep,

instances of waking up, duration;waking up in the am.

e. Any worries that may affect sleep

3. Physical Examination

Observation of the client’s:a. Facial appearance – darkened areas around the

eyes, puffy eyelids, reddened conjunctiva, glazed or dull appearing eyes.

b. Behavior – irritability, restlessness, inattentiveness, slowed speech, slumped posture, hand tremor, yawning, rubbing the eyes, withdrawal, confusion, & incoordination.

c. Energy level – physically weak, lethargic, fatigued.s

L. Nursing care The major goal for the client with sleep

disturbance is to develop or maintain a sleeping pattern that provides sufficient energy for daily activities.

a. Reducing environmental distractions.

b. Promoting bedtime rituals

c. Teaching stress reduction

d. Relaxation techniques

L. Promoting Comfort & Relaxation

1. Provide loose fitting nightwear.2. Assists client’s with hygienic routines.3. Make sure that the bed linen is smooth,

clean & dry.4. Assist or encourage the client to void

before bedtime.5. Offer to provide a back massage before

sleep.

Cont…

6. Position dependent clients appropriately to aid muscle relaxation; provide supportive devices to protect pressure areas.

7. Schedule medications to prevent nocturnal awakenings.

8. Administer analgesic 30 min before sleep for patient suffering from pain.