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INTRODUCTION Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is sometimes referred to as the FIFTH vital sign. In many aspects, pain is the most common reason for seeking health care. Because pain emanates from various modalities such as diagnostics tests, diseases and treatment procedures, nurses must be knowledgeable about the pathophysiology of pain and its management. Nurses encounter pain in a variety of setting, including acute are, outpatient, and long term care settings as well as in the home. The nurse has daily encounters with pain who anticipate pain or who are in pain. Understanding the phenomenon of pain and contemporary pain theories helps the nurse to intervene effectively. Pain Definition This is a subjective sensation to which people respond in different ways. It can directly impair health and prolong recovery from surgery, disease and trauma. Pain is a highly unpleasant and very personal sensation that cannot be shared with others. It can occupy all a person’s thinking, direct all activities, and change a person’s life. It is the noxious or unpleasant stimulation of threatened or actual tissue damage. This pain sensation is a different sensation because the purpose of pain is not to inform the CNS of the quality of the stimulus but rather to indicate that the stimulus is causing damage or injury to the tissues. It is the result of a complex pattern of stimuli generated at the pain site and transmitted to the brain for interpretation.
Common terminologies 1. Radiating pain—perceived at the source of the pain and extends to the nearby tissues 2. Referred pain— pain is felt in a part of the body that is considerably removed from the tissues causing the pain 3. Intractable pain—pain that is highly resistant to relief 4. Phantom pain—painful perception perceived in a missing body part or in a body part paralyzed from a spinal cord injury 5. Phantom sensation—feeling that the missing body part is still present 6. Hyperalgesia—excessive sensitivity to pain 7. Pain threshold—is the amount of pain stimulation a person requires in order to feel pain 8. Pain sensation—can be considered the same as pain threshold 9. Pain reaction—includes the autonomic nervous system and behavioral responses to pain 10.Pain tolerance—maximum amount and duration of pain that an individual is willing to endure 11.Nociceptors—pain receptors 12.Pain perception—the point which the person becomes aware of the pain • Pain threshold is similar in all people, but pain is tolerance and response vary considerably • Painful sensations are sensed by receptors. • We call the receptors NOCICEPTORS.
• Usually they are free nerve endings located widespread in the superficial layers of the skin, peritoneal surfaces, periosteum, arterial walls, pleural surfaces, joint surfaces and the falx and tentorium of the cranial vault. • These nociceptors are non-adapting to keep us constantly informed of the continuous presence of the painful stimulus that can damage the tissues. For pain to be perceived, nociceptors must be stimulated. These pain receptors can be stimulated by: (1)serotonin (2)histamine (3)potassium ions (4)acids (5)some enzymes Pain Categories Category of pain according to its origin A. Cutaneous pain—originates in the skin or subcutaneous tissue B. Deep somatic pain—arises from ligaments, tendons, bones, blood vessels, and nerves C. Visceral Pain—results from stimulation of pain receptors in the abdominal cavity, cranium and thorax. It tends to appear diffuse and often feels like deep somatic pain that is, burning aching, or feeling of a pressure. It is frequently caused by stretching of the tissues, ischemia or muscle spasm
Category of pain according to its cause
Acute pain/fast pain/sharp pain/initial pain following acute injury, disease or some type of surgery may have sudden or slow onset may last up to 6 months occurs within 0.1 second after application of stimulus
Easily localized Impulses travel through the type A delta fibers
Chronic malignant/ Cancer Related pain associated with cancer or other progressive disorder
C. Chronic nonmalignant/Dull/ Slow/ Delayed pain pain in the persons whose tissue injury is non progressive or healed last 6 months or longer and often limits normal functioning
Impulses travel through the type C fibers
not easily localized autonomic signs and symptoms like nausea, sweating and generalized hypotonia, usually accompany this pain Types of Pain Stimuli In general, there are 3 types of stimuli that can stimulate pain receptorsMechanical, Thermal and Chemical.
1. Mechanical stimulus- pressure, squeeze, pin prick 2. Thermal stimulus- heat and freezing temperature 3. Chemical stimulus
These are released when the tissue is injured or inflamed
b. Make the mechanoreceptors very sensitive to pain.
collectively called the “P” factors i. bradykinin ii. serotonin iii. histamine iv. prostaglandin v. substance P
Physiology of Pain
The Exact mechanism of pain transmission is still partially unknown. Stimulus Receptor
Type A Delta Nerve Fibers
Type C Nerve Fibers
Thalamus and/or Reticular system?
Brain ( Somesthetic Areas)
Factors affecting the Pain A. Ethnic/Cultural values
C. Environment and support persons D. Past pain experiences E. Meaning of pain F. Anxiety and stress Pain Assessment 2 mnemonics OLDCART Onset Location Duration Characteristic Aggravating Factors Radiation Treatment (present and previous) PQRST Provoked
Quality Region/Radiation Severity Timing
Pain Scales Premature Infant Pain Scale (PIPS) Use for premature infants (<36 weeks gestation) In general: Scores<6 indicate minimal to no pain Scores of 6-12 indicate mild to moderate pain Scores >12 indicate moderate to severe pain Neonatal Infant Pain Scale (NIPS) Use for infants, toddlers, or any child who is nonverbal For children with severe developmental delay or severe cognitive delay, the NIPS
may be modified in collaboration with the parent to better represent that individual child’s pain behavior. The Advanced Practice Nurse (APN) from the Acute Pain Service should be consulted in developing a plan for pain assessment and management in this population.
Scores of 0-2 indicate minimal pain to no pain Scores of 3-4 indicate moderate pain Scores of 5-7 indicate moderate to severe pain Wong-Baker Faces Rating Scale (FACES) Use for children > 3 years old Self reports are valid and preferred for most children > 3 years old
The FACES scale is available in multiple languages: English, Spanish, Chinese, French, Italian, Japanese, Portuguese, Romanian, and Vietnamese.
In general: Scores of 0-2 indicate minimal pain to no pain Scores of 3 indicate moderate pain Scores of 4-5 indicate moderate to severe pain Verbal Analogue Scale (VAS) Use for children > 8 who understand the concept of order and number Instructions for the VAS are available in multiple languages: English, Spanish,
Chinese, French, German, Greek, Hawaiian, Hebrew, Ilocano, Italian, Japanese, Korean, Pakistan, Polish, Russian, Samoan, Tagalog, Tongan, Vietnamese.
Scores of 0-4 indicate minimal to no pain Scores 5-6 indicate moderate pain Scores of 7-10 indicate moderate to severe pain Comfort Scale Use for intubated children In general: Scores of 0-17 indicate mild to no pain Scores of 18-27 indicate moderate pain Scores of >27 indicate moderate to severe pain
Comfort Definitions Webster (1990) defined comfort in several ways: (a) to soothe in distress or sorrow; (b) relief from distress; (c) a person or thing that comforts; (d) a state of ease and quiet enjoyment, free from worry; (e) anything that makes life easy; and
(f) the lessening of misery or grief by cheering, calming, or inspiring with hope. In these definitions, comfort can be a verb, noun, adjective, adverb, and it can be negative (absence of a recent discomfort), neutral (ease), or positive (inspiring hope). The origin of comfort is confortare, meaning to strengthen greatly
Kolcaba (1994, 2001, 2003) has defined comfort as "the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental)" Types of Comfort
Relief the state of having a discomfort mitigated or alleviated.
2. Ease the absence of specific discomforts. State of calm or contentment
To experience ease a person does not have to have a previous discomfort, although the nurse may be aware of predispositions to specific discomforts (e.g., the tendency for shortness of breath in an asthmatic child or acute anxiety in family members)
3. Transcendence the ability to "rise above" discomforts when they cannot be eradicated or avoided (e.g., the child feels confident about ambulation although (s)he knows it will exacerbate pain). Three Types of Comfort Interventions
Standard comfort interventions to maintain homeostasis and control pain
to relieve anxiety,
provide reassurance and information
o instill hope o Listen o help plan for recovery
Comfort food for the soul extra nice things that nurses do to make children/families feel cared for and strengthened, such as massage or guided imagery
Comfort Therapies Pleasure travels faster along nerve pathways than pain. Pleasure or comfort also causes our bodies to produce elevated levels of our own endorphins or "feel-better" hormones. Basic Methods of Comfort Therapy
1. Patterned Breathing these breathing techniques provide comfort and focus
Breathing enhances oxygen flow
Whether lying in the bubbling water of the Jacuzzi tub or sitting on a shower stool using the hand-held shower massage, the combination of warmth, water pressure and sound is very comforting.
3. Heat and Cold
Heat can be applied by a hot water bottle or warm washcloths; cold can be applied by an ice bag, cold washcloth or bag of frozen peas. Using heat and cold on separate parts of the body at the same time can provide particularly effective pain relief; for example, cool forehead with warmth on the lower back. For maximum effect, change the heat and cold locations frequently, about every 20 minutes.
Stroking or rubbing the neck, shoulders, back, thighs, feet or hands. No fancy techniques are required. Receptors in the skin pick up the signal of touch and elevate endorphins. Bare skin receives the signal best. Unscented powder or lotion are helpful for massage.
5. Attention Focusing and Meditation Fear and anxiety cause the release of stress hormones. You
can ease these feelings by envisioning a pleasant scene. 6. Progressive muscle relaxation 7. Biofeedback
This technique teaches the patient to relax the muscles in
the area of pain.
8. TENS is a counterstimulation technique with the goal of inhibiting
pain transmission. Results of its effectiveness are variable but some residents and some types of pain obtain relief from TENS. 9. Acupuncture—or acupressure to reduce pain sensation
Medical Interventions 1. Narcotic Analgesics Narcotic analgesics (pain medicine), such as Stadol and Demerol, are usually given directly into an IV already in place. Effects are felt within two to four minutes and are often described as "taking the edge off" of pain. Doses may be repeated every couple of hours and effects on the baby such as respiratory depression are minimal.
Continuous infusion of opioids is most effective in maintaining continuous pain relief with minimal risk of respiratory depression, especially in infants Intermittent Dosing is most effective when given in small, frequent doses. These scheduled doses should be given around the clock to avoid large peaks and valleys in pain control. Do not give the scheduled dose if a patient is experiencing increased sedation or respiratory depression Patient-controlled-analgesia (PCA) combines the benefits of continuous infusion and PRN dosing and has the added benefit of putting the patient/family in control of the child’s pain. i. PCA can be used in children who can understand the concept of cause and effect.
2. Non Narcotic Analgesics NSAIDS and acetaminophen are effective for acute or chronic painful conditions of mild to moderate intensity. NSAIDS work primarily on the peripheral nervous system to provide pain relief. It is safe to administer a non-opioid and an opioid at the same time.
Common side effects of NSAIDS include GI irritation/upset and antiplatelet effects contributing to some bleeding tendencies. NSAIDS have a ceiling effect, which means that increasing the dose above the recommended dose will not provide additional analgesia. Acetaminophen may be used for mild-moderate pain intensity or in conjunction with 3. Local Anesthesia
These numbing medications usually affect a small area. 4. Pudendal Block considered one of the safest forms of anesthesia and serious side effects are rare. 5. Epidural Anesthesia Epidural anesthesia involves the placement of a small catheter into the lower back by an anesthesiologist. A continuous infusion of medication is administered through the catheter to provide a constant level of anesthesia.
Epidural anesthesia provides excellent pain relief but has some side effects like:
Decrease in blood pressure
breathing problems severe headache, dizziness or, rarely, seizures. An epidural block, which is epidural anesthesia using a higher dosage of numbing medication, can be used for surgery. 6. Spinal Block
A spinal block is given as an injection into the lower block. A spinal block numbs the lower half of the body, provides
excellent relief from pain and starts working quickly. It has the same side effects as epidural anesthesia. 7. General Anesthesia General anesthetics are medications that cause a loss of consciousness. General anesthesia is given in one of two ways: o through a face mask o injected through an IV line. It works very quickly and results in almost immediate loss of consciousness After general anesthesia wears off, you will feel woozy and tired for several hours IN SUMMARY Pain is a subjective experience that is whatever the patient says it is and occurs whenever the patient says it occurs Although pain is a source of human misery, it minimizes injury and warns of disease Establishing rapport between the nurse and the patient enhances the effectiveness of pain relief measures Sedation does not always indicate pain relief Because patients may not always report pain, the nurse must assess them regularly Patients of all ages experience pain, but the way they express pain differs with age The nurse should be able to recognize physiologic, psychological and non-verbal ways of expressing pain
Lack of pain expressions does not always mean lack of pain Non-invasive pain relief measures can increase the effectiveness of pharmacological or invasive methods The nurse’s optimistic attitude about expected pain relief helps produce a positive result Educating the patient and family about pain reduces the anticipatory fear and anxiety, thereby increasing the patient’s tolerance Using a preventive approach for pain relief is more beneficial than waiting until pain becomes severe Intramuscular and intravenous routes are utilized for severe pain and the intramuscular for moderate pain and oral for mild pain The nurse must utilize the nursing process in relieving patient of “painful experiences”
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