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 Pain
2. Transduction 3. Transmission 4. Perception 5. Modulation


• Transduction – Noxious stimuli (Tse injury)
release of biochemical mediators (Prostaglandin, Bradykinin, Serotonin, Histamine, Substance P) Ion mov’t across cell membrane

excitement of nociceptors Pain Spinal Cord

Sensitization nociceptors

2. Transmission – Peripheral nerve fibers
(Pain impulses)

Spinothalamic tract

Brainstem and Thalamus Transmission

Somatic Sensory Cortex (Pain perception occurs)


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 Ex. Paper cut 1st degree burn 2. Deep Somatic Pain 3. Visceral Pain Ex. Obstructed bowel Myocardial Infarction

Types of Pain According to Duration and Intensity
Acute TIME SPAN LOCATION Less than 6 months Localized, associated with specific injury, condition or disease -Resolved with healing Often described as sharp -Diminishes as healing occurs Elevated HR, BP, RR Maybe Diaphoretic Dilated Pupils Crying and Moaning Rubbing site Guarding Frowning Grimacing Restlessness and Anxiety Verbalization of Pain Mild to Severe Chronic 6 months or longer Difficult to pinpoint -Continues beyond healing


Often described as dull -Diffused and aching Normal VS No diaphoresis Normal Pupils May have weight loss Physical Immobility Hopelessness Listlessness Loss of Libido Exhaustion and Fatigue Complains of Pain only when asked Depressed and Withdrawn Mild to Severe




Types of pain according to where it is experienced:
1. Radiating pain
-Percieved at the source of pain and extends to nearby tses

2. Referred pain
-Felt from the part that is remote from the tse causing the pain

3. Intractable pain -highly resistant to relief

4. Phantom pain
-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. Thermal 1. 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

2. Causes, duration and intensity of pain and the amount of relief afforded by the individual by means of various medications 3. Cultural background or ethnic values 4. Philosophical beliefs and religious convictions 5. Degrees of anxiety and fear and the manner in which others respond to the afflicted individual 6. Age 7. 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:
• Location – “where is your pain?” • 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?

Mnemonics for Pain Assessment
OLDCART O – onset L – location D – duration C – characteristic A – aggravating factors R – radiation T - treatment
S – severity T - timing

P – provoked Q – quality R – region/radiation

COLDERRA C – Characteristics O – Onset L – Location D – Duration E – Exacerbation R – Radiation R – Relief A – Associated signs and symptoms

Assessing a child with pain

Age group Infant

Pain perception and Behavior

Selected Nsg. Intervention

pain Respond to pain w/ increased sensitivity Older infants tries to avoid pain Develops and physically resist Toddler (turns awaythe ability to describe pain and and its intensity and location prescho Often responds w/ crying and anger oler because child perceives pain as a threat to security Reasoning w/ child at this stage is not always successful May consider pain as punishment Feels sad May learn there are gender differences in pain expression Tends to hold someone accountable for the pain

pacifier Use tactile stimulation. Play music or tapes of a heartbeat Distract the child w/ toys, books, picture. Involve the child in blowing bubbles as a way of “blowing away the pain” Appeal to the child’s belief in magic by using a “magic” blanket or glove to take away pain Hold the child to provide comfort Explore misconceptions about pain

Age group Pain perception and Behavior Schoolaged

Selected Nsg. Intervention

to behave when facing pain Rationalizes in an attempt to explain the pain Responsive to explanations Can usually identify the location and describe the pain W/ persistent pain, may regress to an earlier stage of development

imagery to turn off “pain switches” Provide a behavioral rehearsal of what to expect and how it will look and feel Provide support and nurturing

Adolescen May be slow to acknowledge pain t Recognizing pain or “giving in” may be considered weakness Wants to appear brave in front of peers and not report pain

opportunities to discuss pain Provide privacy Present choices for dealing w/ pain. Encourage music or TV for distraction

Age Pain perception and Behavior grou p Adult Behaviors exhibited when experiencing pain may be gender-based behaviors learned as a child May ignore pain because to admit it is perceived as a sign of weakness or failure Fear of what pain means may prevent May have for taking action. Elder some adultsmultiple conditions

Selected Nsg. Intervention

w/ any misconception of pain Focus on the client’s control in dealing with the pain Allay fears and anxiety when possible

presenting w/ vague symptoms May perceive pain as part of the aging process May have decreased sensations or perceptions of the pain Lethargy, anorexia, and fatigue may be indicators of pain May withhold complaints of pain because of fear of the treatment, of any lifestyle changes that may be involved or becoming dependent



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


misconceptions Encourage independence whenever possible


2. Acknowledging the client’s pain a. Verbally acknowledge the presence of the pain b. Listen attentively to what the client says about the pain c. Convey that you are assessing the client’s pain to understand it better, not to determine whether the pain is real d. 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

2. 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

• 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

C. 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:
B. 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

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