Pain

Pain
 Unpleasant sensory/emotional
experience resulting from actual or
potential tissue damage
 Most common reason why people
seek health care
 is a defense mechanism when
the normal functioning of the
body is threatened by internal or
external sources
 5th vital sign
Goal of Pain Management

To provide pain relief & to carry

out ADL’s in as comfortable
manner as possible
 Nurses’ Role in Pain
Management
 Administer pain relief interventions
 Evaluates the effectiveness of
interventions given
 Patient advocate when interventions
are ineffective
 Serves as an educator to patient &
family regarding relief of pain
 All pain is real, even if it’s cause is
unknown
 The nurse must believe patients when
they report that they have pain
 Pain is not limited to verbal statements-
So the nurse is responsible for observing
nonverbal behaviors that may occur with
pain
 Pain theories:
 1. Specificity Theory – holds that
there are certain specific nerve
receptors that respond to noxious
stimuli and these are always
interpreted as pain

 2. Pattern Theory – any stimulus

could be perceived as painful if the
stimulation were intense enough.
 3. Gate control theory – there is
a specialized system (gate control)
that modulates sensory input before
evoking perception and response to
the stimuli.
 Pain threshold

 is the intensity of the stimulus

required to cause an individual to
experience pain.
 Pain tolerance
 the point at which the individual
reacts to pain with verbal or
other responses. Each individual
has different pain tolerance;
influenced by culture, age pain
experience and level of
consciousness
 Types of Pain:

 According to pattern:
 Constant pain – occurs continuously
 Intermittent pain – occurs
periodically
 Intractable Pain – not relieved by
ordinary measures
 According to location:
 Superficial or cutaneous pain-
near body surface
 Deep or Somatic – pain in
deeper tissues Involves
tendons, ligaments bones,
nerves and blood vessels.
 Visceral Pain – involves internal
organs
 Referred Pain – perceived in an
area distant from the site of stimuli.

 Ex. Kehr’s sign – in cholelithiasis

pain is felt in RUQ of abdomen and
pain radiates to epigastrium, back or
shoulder blades.
 According to duration:
 Acute pain
 Chronic pain
 Acute Pain
 Recent onset
 Lasts for a few seconds – 6
months
 Sharp, intense & easily localized
 indicates that damage or injury
has occurred
 Chronic Pain
 constant or intermittent that
persists over a period of time
 not attributed to a specific cause
or injury
 do not have a well defined onset
 pain that lasts for 6 months or
longer

The most common chronic pain

condition is lower back pain
 Other types of Pain:
 Cancer- Related Pain – may be
acute or chronic; due to tumor
 result of the cancer treatment or
maybe due to trauma.
 Pain maybe always present that
after fear of dying it is the 2nd
most common fear in cancer.
 Phantom Pain – is a syndrome
that occurs following amputation
of a body part; client experiences
pain in the body part even
though he/she is aware that it
was amputated
 Psychogenic pain - pain in the
absence of any diagnosed
physiologic cause or event; pain
is real, that may result from
interpersonal conflicts, a need for
support from others, or a
desire to avoid stressful or
traumatic situation.
Factors Affecting Perception &
Interpretation of Pain:
 Culture
 Gender
 Experience
 Age
 Time
 Level of consciousness
 Past experiences w/ pain
Behavioral Responses to Pain:

 Verbal – describing the pain (moaning or

crying)
 Non - Verbal – grimaced, tensed body
posture, labored speech
 Motor Response - withdrawing from
painful stimuli
Chemical Mediators of Pain
Chemicals that increase the transmission
or perception of pain:
 Histamine
 Bradykinin
 Acetylcholine
 Substance P. Prostaglandins
 Inhibitors of Pain
Transmission
 Endorphins – endogenous morphine –
inhibit the transmission of pain impulses
 Endorphins & Enkephalins are
endogenous chemicals that are similar to
opioids
 Inhibit pain impulses by blocking
impulses in the brain & spinal cord
 Gate Control Theory of
Pain
 Stimulation of fibers that transmit non
painful sensation blocks or decreases the
transmission of pain impulse through an
inhibitory gating circuit.
 'Pain gate' can be shut by stimulating
nerves responsible for carrying the touch
signal (mechaoreceptors) which
enables the relief of pain through
massage techniques, rubbing, and also
the application of heat bags and ice
packs.
 Pain Assessment
 The individual is the best judge of
personal pain
 Intensity – rate the pain on a verbal scale
0 to10 (0 = no pain; 10 = worst pain)
 Pain Rating Scale:
 Simple Descriptive Pain intensity scale
 0-10 Numeric Pain Intensity Scale
 Visual Analog Scale (VAS)
 Faces Pain Rating Scale (for 3yrs old &
above)
Ideally the nurse instructs the client with
the use of the pain rating scale before the
pain occurs i.e. before surgery
Characteristics of Pain:
 Duration (minutes, hours, days)
 Rhythm (continuous, intermittent)
 Quality (burning, pricking, vise-like,
aching)
 Factors that relieve pain (movement, rest,
cold, heat, over the counter meds)
 Effects of pain in ADL’s (sleep, appetite,
work)
 Person’s concern about pain, financial
burden, prognosis, interference with roles
Physiologic Indicators of
Pain
 Pulse – increased rate
 Respirations – increased depth &
frequency
 Blood pressure – increased systolic &
diastolic
 Diaphoresis, pallor, dilated pupils
 Nausea & vomiting (in severe cases)
 Behavioral Responses to
Pain
 Verbal statements
 Facial expressions
 Body movements (guarding)
 Altered responses to the environment
 Cry, moan, frown, immobilize a body
part, clench a fist & withdraw)
 Placebo Effect
 When a person responds to the
medication or other treatment because of
an expectation that it will work rather than
because it actually works.
 Results from natural production of
endorphins.
Pain Management Strategies

 Pharmacologic Interventions
 Safe & effective way to administer
analgesic is to ask the patient to rate the
pain & by observing responses to
medications
Preventive Approach
 Medication is given before the pain
becomes intensely severe
 Fear of promoting addiction or cause
respiratory depression health care
providers tend to administer inadequate
doses of opioid agents
 Patient Controlled
Analgesia
 Allows patients to control the
administration of their own medication
within predetermined safety limits
 Assessing respiratory status is a major
role for the nurse caring for the patient
receiving PCA.
Pharmacologic Management
 Anti-inflammatory drugs – ASA (Aspirin)
 Opioids – relieve patient’s pain &
improved the quality of patient’s life
(morphine SO4, codeine, meperidine,
demerol)
 NSAIDS – decrease pain by inhibiting the
release of prostaglandin
(Aspirin, COX 2 inhibitor)
 Psychotropic Drugs – Carbamazepine
Tegretol; given for patients with
trigeminal neuralgia
 Muscle relaxants- Dantrolene
 Vasodilators – Nitroglycerin; for Angina
Pectoris
 Local Anesthetics
 Local Anesthetics work by blocking
nerve conduction when applied
directly to the nerve fibers
I. Topical application – EMLA cream
(eutectic mixture of emulsion of local
anesthetics)
II. Nerve block – Injection of local
anesthetic (Lidocaine) w/ a mixture
of vasoconstrictive agent
(epinephrine )
III. Intraspinal administration
epidural anesthesia - an epidural
catheter is inserted, and anesthesia
may be continuous in low doses, or
intermittently.
Intraspinal & Epidural Routes
 Infusion of opioids or local
anesthetics into the subarachnoid
space, or epidural space to
effectively control pain in post
operative surgical clients, & for pain
that is unrelieved by other means.
 A catheter is inserted into the
subarachnoid at the thoracic or
lumbar level.
 Nonpharmacologic
Management
 Massage – makes patient comfortable
because it produces muscle relaxation
 Ice & heat therapies – ice therapy
decrease prostaglandins; must be placed
in the injury site immediately. Heat
application increase blood flow to the
area of injury; contribute to pain reduction
by promoting healing
 Transcutaneous Electrical Nerve
Stimulation (TENS) – stimulate non-pain
receptors in the same area as the fibers
that transmit the pain; placebo effect &
the production of endorphins that block
pain transmission
 Distraction – focusing patient’s attention
on something other than pain;
effectiveness depends on the patient’s
ability to receive & create sensory input
other than pain.
 Relaxation techniques – abdominal
breathing at a slow, rhythmic rate
 Guided Imagery – using one’s
imagination to achieve a positive effect;
combine slow rhythmic breathing with a
mental relaxation & comfort
- requires a considerable amount of time
& practice to be effective; 5 minutes 3x
/day
 Hypnosis – depends on the
hypnotic susceptibility of the
individual
 Management of Pain
 is a collaborative effort between the
Physician and the nurse. However, it is
the nurse who maintains analgesia,
assesses its effectiveness and reports if
the intervention is ineffective or produces
side effects.
 A preventive approach in nursing practice
is the administration of around the clock
pain medications.