SEMINAR

ON
PAIN

SUBMITTED TO
PROF. Dr. JASMINE
Dept. of Medical-Surgical Nursing
MTPG & RIHS
SUBMITTED BY
ARYA.V
MSc Nursing 1st year

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 Serial CONTENT PAGE NUMBER
No
1 INTRODUCTION 4

2 HISTORY OF PAIN 4

3 DEFINITION 5

4 TERMINOLOGIES RELATED TO PAIN 5-6

5 PAIN PHYSIOLOGY 6-8

5.1 Pain in the Cortex 6
5.2 The Thalamus 6
5.3 Midbrain 7
5.4 The Pons 7
5.5 The Medulla 7-8
5.6 The Spinal Cord 8

6 TYPES OF PAIN 8-10

6.1 Nociceptive Pain 9
6.2 Neuropathic Pain 9
6.3 Location of Pain 9
6.4 Duration of Pain 10
6.5 Pain Intensity 10
6.6 Pain Etiology 10
6.7 Psychogenic Pain 10

7 FACTORS AFFECTING PAIN 11

8 PATHOPHYSIOLOGY OF PAIN 11-13

8.1 Transduction 11-12
8.2 Transmission 12
8.3 Modulation 12

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 8.4 Perception 13

9 SYMPTOMS OF PAIN 14
10 CHARACTERISTICS OF PAIN 14

11 PAIN THEORIES 14-16

11.1 Pattern Theory 14
11.2 Gate Control Theory 15
11.3 Neuromatrix Theory 16

12 ASSESSMENT OF PAIN 16-21

12.1 History 16
12.2 Pain Assessment Tools 17-20
12.3 Pain Diary 21
12.4 Physical Examination 21
12.5 Laboratory Tests 21

13 MANAGEMENT 22-30
13.1 Pharmacological Management 22-24
13.2 Non-pharmacological management 24-27
13.3 Psychological Approach 27-30
13.4 Surgical Management 30

14 NURSING MANAGEMENT 30-32

15 COMPLICATIONS 32
16 BIBILIOGRAPHY 33-35

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 1. INTRODUCTION :
PAIN: THE FIFTH VITAL SIGN is a complex, subjective experience. It is
the most common reason for a patient to seek medical care and the
number one reason for the patient to take medication. The nurse
primary role in pain management is to advocate for the patient by
believing reports of pain and acting promptly to relieve, while
respecting patient’s preference and values. Nurses are often
considered as “Cornerstone of Pain Management”.

2. HISTORY OF PAIN :

As long as humans have experienced pain, they have given

explanations for its existence and sought soothing agents to dull or cease
the painful sensation. Archaeologists have uncovered clay tablets dating
back as far as 5,000 BC which reference the cultivation and use of the
opium poppy to bring joy and cease pain. In 800 BC, the Greek writer
HOMER wrote in his epic, The Odyssey, of Telemachus, a man who used
opium to soothe his pain and forget his worries. While some cultures
researched analgesics and allowed or encouraged their use, others
perceived pain to be a necessary, integral sensation. Physicians of the 19th
century used pain as a diagnostic tool, theorizing that a greater amount of
personally perceived pain was correlated to a greater internal vitality, and
as a treatment in and of itself, inflicting pain on their patients to rid the
patient of evil and unbalanced humors. This article focuses both on the
history of how pain has been perceived across time and culture, but also
how malleable an individual's perception of pain can be due to factors like
situation, their visual perception of the pain, and previous history with
pain.

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 3. DEFINITION:
Pain is an unpleasant sensory and emotional experience arising from
actual or potential tissue damage or it may be described in terms related
to such damage.

“International Association for the Study of Pain”

4. TERMINOLOGIES RELATED TO PAIN :

Analgesia: Absence of pain in response to stimulation which would
normally painful.

Parasthesia: An abnormal sensation whether spontaneous or evoked.

Dysesthesia: An unpleasant abnormal sensation, whether spontaneous

or evoked.

Hyperalgesia: An increased response to a stimulus which is normally

painful.

Hypoalgesia: Diminished pain in response to a normally painful stimulus.

Neuralgia: Pain in the distribution of nerve or nerves.

Neuropathic pain: Pain initiated or caused by a primary lesion or

dysfunction in the nervous system.

Nociceptor: A receptor that preferentially sensitive to noxious stimulus

or a stimulus which would be would become noxious if prolonged.

Noxious stimulus: A noxious stimulus is the one which is damaging to

normal tissue.

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 Pain threshold: The least experience or level of pain which a subject can
recognize.

Pain tolerance level: The greatest level of pain which a subject is

prepared to tolerate.

Peripheral neuropathic pain: Pain initiated or caused by a primary lesion

or dysfunction in a peripheral nervous system.

5. PAIN PHYSIOLOGY:
Major structures involved in pain physiology are:

5.1. Pain in the cortex

Major cortical players are

 The primary sensory cortex, S1

 The secondary sensory cortex , S2
 The anterior part of insula
 The cingulated gyrus.

5.2. THE THALAMUS
 The thalamus is the ‘central switching station’ of the brain.
Several of its multiple nuclei are concerned with pain. The
lateral nuclei deal with sensory/discriminative aspects, the
medial ones with ‘affective’ pain.

They include:

 Nucleus reuniens
 Rhomboidal nucleus
 Submedius nucleus

5.3. MIDBRAIN
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 There is a host of pain-related structures in the midbrain. Most of
this circuitry is involved in ‘affective’ pain, with extensive
connections to the reticular system of the brain system of the
brainstem. Important components are:

 The peri-aqueductal grey matter (PAG)

 The deep layers of superior colliculus
 The red nucleus
 The pre-tectal nuclei (anterior and posterior)
 The nucleus of Darkschewitsch
 The interstitial nucleus of Cajal
 The intercolliculus nucleus, nucleus cuneiformis nucleus.

5.4. THE PONS

The most important pain-related nucleus in the Pons is probably

the locus coeruleus. This is jam packed with noradrenaline-
containing neurons, and projects to a variety of brainstem
structures that modulate pain through pathways that descend to
spinal cord. Another notable group is the parabrachial nuclei.
Which receive a vast number of ascending spinoreticular fibers .

5.5 .THE MEDULLA

This is too involved in the affective aspects of pain. Important cell

groups are the nucleus gigantocellularis and related nuclei, the
lateral reticular nucleus, and a variety of other nuclei. It can be
divided in to several groups :

 ‘Discriminative’ fibers ascending from the spinal cord to the

lateral thalamus and hence to S1. These have been called
neospinothalamic fibers .
 ‘Affective’ fibers that follow a similar course from the spinal
cord , but end up in the reticular formation of the hindbrain.
These spinoreticulodiencephalic fibers have extensive

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 connections throughout the brainstem, and from there
project to the medial thalamus and cortex (S2)
 ‘DESCENDING FIBERS’ that pass down from the brain stem to
spinal cord, inhibiting incoming sensations of pain. A lot of
these descending fibers originate in the locus coeruleus,
others in the raphe nuclei.

5.6 THE SPINAL CORD

Traditionally, it was thought that most pain fibers entered the

dorsal root of spinal cord and then synapsed in the dorsal part of the
spinal grey matter, before passing the message up through the
spinothalamic tract. It is now known that this is gross oversimplification.

Histologically, the gray matter of the spinal cord is divided into ten
‘laminae’. The dorsal part divided in to five laminae, components of
which deal with most incoming pain fibers. Seventh is in between these
laminae and the more ventral laminae eight ninth and tenth refers to
the grey matter around the central control of the spinal cord.

6. TYPES OF PAIN:
Pain types are according to:

 Nociceptive pain
 Neuropathic pain
 Location of pain
 Duration of pain
 Pain intensity
 Pain etiology
 Psychogenic pain

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 6.1 NOCICEPTIVE PAIN:

 Somatic pain:- Well localized pain usually from bone or spinal

metastasis or injury to cutaneous or deep tissues.
 Visceral pain:- Poorly localized pain occurs as result of
nociceptor activation from stretching, distention, or contraction
of smooth muscles, ischemia of visceral wall, traction on
mesenteric attachment organs.

6.2 NEUROPATHIC PAIN:

 Parasthesia
 Dysesthesia
 Allodynia
 Hypoalgesia
 Hyperalgesia

6.3 LOCATION OF PAIN:

 Referred pain:- Pain appear to arise in different areas. Occurs

when the painful sensation is felt in a site other than the one
where it is actually arising.
 Visceral pain:- Pain arising from organs or hollow viscera.
 Colicky pain:- Caused by muscle contractions of certain organs,
such as uterus during the menustrual period.

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 6.4 DURATION OF PAIN:

 Acute pain:- Pain that results from an acute injury , has a rapid
onset and short duration and subsides when injury is healed.
Sympathetic nervous system response.
 Chronic pain:- Persistent pain that lasts longer than 6 months
may be episodic or continues and may lead to disability.
Parasympathetic nervous system response.

6.5 PAIN INTENSITY:

 Mild pain:- Pain scale reading from 1-3.

 Moderate pain:- Pain scale reading from 4-7.
 Severe pain:- Pain scale reading from 8-10.

6.6 PAIN ETIOLOGY:

 Physiologic pain:- Nociceptive, as a symptom of a disease. Self-

limiting pain, proportionate to clinical finding.
 Pathologic pain:- Mostly neuropathic, a disease itself, difficult to
treat. Disproportionate to clinical finding.

6.7 PSYCHOGENIC PAIN:

Pain perceived by individual without physical cause. It may be

caused due to increased or prolonged mental or emotional factors.

Eg:-Headache, Backache.

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 7. FACTORS AFFECTING PAIN:
 Past experience
 Age
 Gender
 Fatigue
 Culture
 Anxiety
 Social and family support
 Attention
 Coping style

8. PATHOPHYSIOLOGY OF PAIN:
Pathophysiology consist of following mechanisms

TRANSDUCTION

TRANSMISSION

MODULATION

PERCEPTION

8.1 TRANSDUCTION:

Process of converting electrochemical response into electrical

signal/impulse. Neurotransmitters are produced as a part of
inflammatory response, release of bradykinin, substance p,
histamine, serotonin, cytokines, prostaglandin, sodium ions,

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 potassium ions and calcium ions activates pain receptors and
amplifies inflammatory response.

8.2 TRANSMISSION:

After transduction, the electric signal is transmitted through an

efferent nerve to the spinal cord and the brain. Substance p, which
transmits the pain impulse in nerve fibers, is one of the most
important neurotransmitter in the transmission process.

Signals from the nociceptors travel along two types of afferent

(sensory) fibers : A delta fiber, which are large diameter,
myelinated fibers with rapid conduction of signals that are
translated as sharp, acute pain. C fibers, which are smaller,
unmyelinated fibers with slow conduction of signals that are
translated as diffuse, dull and longer lasting pain. These signals are
transmitted by the spinothalamic lasting pain. A-delta and C fibers
in the peripheral tissues carry impulses to the dorsal root ganglia
and then on to the spinal dorsal horn, the spinothalamic tract, the
brainstem the thalamus, and the cerebral cortex.

8.3 MODULATION:

Modulation involves the activation of descending pathway that

exerts inhibitory or facilitatory effects on the transmission of pain.
Depending on the type and degree of modulation, nociceptive
stimuli may or may not be perceived pain. Modulation of pain
signals occurs at the level of periphery.

Descending modulator fibers release chemicals such as

serotonin, norepinephrine, GABA, and endogenous opioids that
can inhibit pain transmission. The high degree of processing of the
sensory impulses occurs at this level.

8.4 PERCEPTION:

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 Perception of pain occurs when the brain translates the afferent
nerve signals as pain. The thalamus sends the impulses to the
somatosensory cortex, which perceives physical sensations about
the location, intensity, and quality of pain; to the limbic, which
controls emotional reactions to stimuli; and to the frontal cortex of
the brain, which is involved in thought and reason. The stimulation
of these areas allows a person to perceive pain.

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 9. SYMPTOMS OF PAIN:
 Restriction of movement
 Muscular weakness
 Delayed wound healing
 Increase blood pressure and heart rate
 Loss of appetite an sleep
 Renal and GI tract dysfunction
 Anxiety and depression
 Feeling of worthlessness

10. CHARACHTERISTICS OF PAIN:

 Somatic Nociceptic pain:- Aching, throbbing, stabbing.
 Visceral Nociceptic pain:- Cramping.
 Neuropathic pain:-Severe, sharp, burning pain, tingling,
numbness, and weakness.

11. PAIN THEORIES:

11.1 Pattern Theory:-

In 1953, William Noordenbos proposed that when an injury

occurs, a signal is carried along large diameter nerve fibers that may
inhibit a signal carried by thin fibers. He thought that a difference between
a large diameter signal and a small diameter signal determined whether a
person felt pain. Patterns of stimulation of the nerve endings determined
whether the brain interpreted the stimuli as pain. Noordenbos’s pattern
theory hinted at the physiology of pain that is now accepted science and
provided for the gate control theory.

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11.2 Gate Control Theory:-

Melzack and wall (1965) proposed the gate control theory of pain
to explain why thoughts and emotions influence pain perception. Tissue
injury causes the release of bradykinin, histamine, potassium ions, sodium
ions, calcium ions, and serotonin. Movement of these substances in and
out of the cell creates an action potential. The action potential can travel
along sensory nerve A-delta fibers and be translated by the brain as sharp
pain, or it can travel along sensory nerve C fibers and be interpreted as
chronic or persistent.

According to the theory, a gating mechanism exists in the dorsal

horn of the spinal cord. The interplay of signals from different nerve fibers
at this gate determines whether painful stimuli are stop or go on to brain.
Endorphins and enkephalins produced in the body fight pain by binding to
opioids receptors at synaptic nerve terminals. Receptor binding closes the
gate, inhibiting signal transmission to the brain and decreases or

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eliminating pain. Opioid medications, massage, non-painful stimuli, and
topical analgesics stimulate various nerve fibers, which close the gate,
inhibit impulse transmission to the brain, and reduce the recognition of C
fibers signals, resulting in analgesia.

11.3 Neuromatrix Theory:-

More recently, Melzack (2001) introduced pain theory suggesting

pain is a multidimensional experience controlled by a body self
Neuromatrix. The contemporary pain theory seeks to address the
distinctive experience of pain as it is perceived and regulated by each
person. The Neuromatrix theory proposes that each person has a
genetically controlled network of neurons that is unique and affected by
that person’s physical, psychological, cognitive and life experiences. This
theory seeks to take into consideration additional factors in the pain
experience other than the direct relationship between tissues and pain.

12. ASSESSMENT OF PAIN:-

 History
 Pain assessment tools
 Pain diary
 Pain scales
 Physical examination
 Tests and procedure to check for the underlying causes of pain

12.1 History:

 The onset of the pain

 The severity of the pain
 The quality of the pain
 The site of the pain
 Timing
 How the pain affecting functioning?

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12.2 Pain Assessment Tools:

Neonatal infant pain scale:-

Wong-Baker Faces Pain Rating Scale:-

This pain scale was originally developed for children as young as 3

year old.

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 FLACC SCALE:-

Numerical Rating Pain Scale:-

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Verbal Descriptor Scale (Pain Thermometer):-

Visual Analogue Scale:-

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MC Gill Pain Questionnaire:-

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It is a self report questionnaire that allows individuals to give their doctor
a good description of the quality and intensity of pain that they are
experiencing.

12.3 Pain Diary:-

Patient may be asked to complete a pain diary. This involves recording,

usually for one week, level of pain several times a day, and making notes
on activities or other things that seem to worsen the pain, as well as of any
medication you take and the effect it has. This can be very helpful in
establishing whether there is any particular pattern to the pain, or any
triggers that could be avoided.

12.4 Physical Examination:-

Some form of physical examination is likely to be required in the

assessment of pain. Precisely what form this takes will obviously vary
according to the type and site of pain. Physical examination may be done
either to look for a possible cause for the pain, or to rule out possible
serious disease. Sometimes areas other than the painful area will be need
to be examined.

12.5 Laboratory Tests:-

 Blood tests
 Computerized tomography (CT)
 Electromyography
 Magnetic resonance imaging
 Nerve conduction study
 Radiography(X-ray)

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13. MANAGEMENT:-
 Pharmacological Management
 Non-pharmacological Management
 Psychological Approach
 Surgical Management

13.1 PHARMACOLOGICAL MANAGEMENT:

WHO 3 STEP LADDER FOR PAIN MANAGEMENT

Pain ladder or analgesic ladder was created by WHO as a guideline for the
use of drugs in the management of pain. Originally published in 1986 for
the management of cancer pain, it is now widely used for the
management of all types of pain.

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NON-OPIOID ANALGESIC

Non-Opioid oral analgesics medications include aspirin, other NSAIDS

and acetaminophen. Aspirin or acetylsalicylic acid, acts peripherally and
centrally to block the transmission of pain impulses. The NSAIDS are non-
specific analgesics and can be potentially be used for any type of acute and
chronic pain. The action of aspirin and other NSAIDS is through the
inhibition of cyclooxygenase (COX) enzymes, which mediate the
biosynthesis of prostaglandins. Prostaglandins exerts their effect through
peripheral sensitization of nociceptors to chemical mediators such as
bradykinin and histamine. The NSAIDS also decrease the sensitivity of
blood vessels to bradykinin and histamine, affect cytokine production by T-
lymphocyte, inhibit vasodilation and decrease the release of inflammatory
mediators from granulocytes and mast cells.

OPIOD ANALGESIC

Opioid refers to a group of medications, natural or synthetic with

morphine like actions. Opioid consist of several classes.

Antagonist-Naloxone

Agonist-antagonist-Buprenorphine

Agonist-Oxycodone

Opioids are used in the management of acute and chronic pain, such as
cancer. Morphine remains the most useful strong opioid, and the WHO
has recommended that oral morphine be part of the essential medication
list and be made available throughout the world as the medication of
choice for cancer pain.

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ADJUVANT ANALGESICS

Adjuvant analgesics include medications such as tricyclic

antidepressants, antiseizure medications, and neuroleptic anxiolytic
agents. The fact that pain suppression system has nonendorphin synapses
raises the possibility that potent, centrally acting, nonopiate medications
may be useful in relieving pain, serotonin has been shown to play an
important role in producing analgesia. The tricyclic antidepressants
medication that block the removal of serotonin from the synaptic cleft
have been shown to produce pain relief in some persons. Antiseizure
medications suppress spontaneous neuronal firing. Other agents such as
corticosteroids may be used to decrease inflammation and the nociceptive
stimuli responsible for pain.

PATIENT CONTROLLED ANALGESIA

PCA is defined by NIC system as “facilitating patient control of

analgesic administration and regulation”. PCA is a method to relieve pain
through self administration of analgesics (usually opioids like morphine) by
a client using a programmable pump connected to subcutaneous,
intravenous, epidural catheter. PCA is used in health care facilities and in
the home to mange post operative or cancer pain. The client is taught how
to manage or operate the PCA, to press the button of PCA pump to
administer the proper bolus dose of the prescribed analgesic as
demanded. PCA is contraindicated in confused and sedated clients.

13.2 NON-PHARMACOLOGICAL MANAGEMENT:

BED REST

Bed rest supports immobilization with its deleterious affects on bone,

connective tissue, muscles, and psychological wellbeing.

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EXERCISE

Correction of posture may be simplest technique to relieve symptoms

in patients with non- specific neck or lower back pain.

MASSAGE

Massage can be help to relieve pain directly, by gently stimulating

nerves in the skin, which can be send signals into the spinal cord. These
throw out signals from pain fibers that are sending a pain message into the
spinal cord. Massage may also help by reducing symptoms such as the
build- up of fluid in the tissues and by relaxing, which can raise pain
threshold.

ACUPUNCTURE

Acupuncture is a principle modality of medicine which focuses on

healing within a unified system of body, mind, and spirit. As a result it is
generally uses in conjunction with herbal, massage, diet, and exercise
therapies.

Acupuncture decrease pain by increasing the release of chemicals

that block pain called endomorphins. Many acu- point are near nerves.
When stimulates these nerves cause a dull ache or feeling of fullness in the
muscle. The stimulated muscles send a message to the central nervous
system causing the release of endorphins. Endorphins along with
neurotransmitters block the message of pain from being delivered up in to
the brain.

YOGA THERAPY

Yoga is an ancient Indian practice combining stretching, breathing

exercise, maintaining certain postures and meditations; it is a holistic
treatment for various physical and psychological ailments such as back
pain, and emotional stress.

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MAGNETO THERAPY

The magnet are applied to the skin in an attempt to decrease

fibromyalgia headaches, back pain, neck and shoulder pain, knee arthritis
and foot pain.

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

TENS has been used to treat patients with various pain conditions,
including neck and low back pain. Uses a battery operated unit with
electrodes applied to the skin to produce a tingling, vibrating, or buzzing
sensation in the area of pain.

TRACTION

Cervical traction is a therapeutic modality that can be administered

with the patient in the supine or sedated position. Traction can reduce
neck pain, and works though a number of mechanisms including passive
stretching of myofascial elements, gapping of facet joints, improving
neural foraminal opening and reducing cervical disc herniation. It should
be done in combine with ROM exercise, appropriate strengthening and
correction of postural issues.

MANIPULATION & MOBILIZATION

Manipulative treatment is commonly used in treatment of patients

with neck pain and associated disorders. It include soft tissue myofascial
release, muscle energy / contract relax and high velocity low amplitude
manipulation. Soft tissue myofascial release includes effleurage,
petrissage, friction, tapotement. Improves flexibility, decrease the
perception of pain, and decrease level of stress hormone.

DISTRACTION

Involves focusing the client’s attention on something other than pain.

Reduce pain by stimulating the descending control system.

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 Effectiveness depends on client’s ability to relieve and create sensory
input other than pain such as watching TV, listening music.

SUPERFICIAL HEAT

Superficial heat can produce heating effects at depth limited to

between 1cm to 2cm. Helpful in diminishing pain and decreasing local
muscle spasm.

CRYOTHERAPY

Cryotherapy can be achieved through the use of ice, ice packs, or

continuously via adjustable cuffs attached to cold water dispensers.
Usually most effective in the acute phase of treatment, used in patients
after physical therapy sessions or their homes to reduce pain and
inflammatory response.

13.3 PSYCHOLOGICAL APPROACH:

COGNITIVE & BEHAVIOUR THERAPY

Mindfulness-based cognitive therapy, the use of stress reduction and

relaxation, has been found to reduce chronic pain in some patients.
Applied behavior analysis views chronic pain as a consequence of both
respondent and operant conditioning, where a patient learns to display
pain behavior in the presence of specific environmental antecedents and
consequence. The model was first proposed by Fordyce in 1976. Though
cognitive-behavioral intervention can be an effective and economical
means of treating chronic pain, the effects are rather modest and a
substantial portion of patients gain no benefit.

BIOFEEDBACK

Biofeedback based on behavioral principles has shown some success

for chronic pain, demonstrating greater improvement in one study than
peers undergoing cognitive-behavioral therapy and conservative medical

27
treatment, though a different study showed improvements over waitlist
controls but no difference between biofeedback and cognitive-behavioral
therapy.

HYPNOSIS

A 2007 review of 13 studies found evidence for the efficacy of

hypnosis in the reduction of pain in some conditions, though the number
of patients enrolled in the studies was small, bringing up issues of power
to detect group difference, and most lacked credible controls for placebo
and/ or expectation. The authors concluded that ‘although the findings
provide support for the general applicability of hypnosis in the treatment
of chronic pain, considerably more research will be needed to fully
determine the effects of hypnosis for different chronic pain conditions’.

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OSTEOPATHY & CHIROPRACTIC

Patient with backache are particularly likely to seek help from an

osteopath or chiropractor at some point, but these specialists will treat
other parts of the body too.

Chiropractors treat bone, joint, and muscle problems and the effects
that they have on the nervous system. Chiropractors believe that
interferences with the muscle, skeletal and nervous systems impair the
body’s normal functions and lower its resistance to disease. They work on
all the joints of the body, focusing on the spine, and use their hands to
make specific adjustments that they claim improve the efficiency of the
nervous system and release the body’s natural healing ability. Some
chiropractors use water, light, massage, ultrasound, electric or heat
therapy. They may also give you supports such as straps, tapes and braces.
The chiropractic approach to healthcare is holistic, stressing the patients
overall health and wellness. Chiropractors counsel patients about
nutrition, exercise, changes in lifestyle and stress management, but do not
prescribe drugs or perform surgery.

Osteopaths primarily work on joints and muscles with their hands.

Treatment methods range from massage of muscles and connective
tissues to manipulation and stretching of joints. The aim is to alleviate
pain, restore freedom of motion and enhance the body’s own healing
power. Just like chiropractors, osteopaths also look at relevant
psychological and social factors holistic approach. Osteopathy can be used
to relieve chronic and acute problems including joint oain, upper and
lower back pain, sciatica and arthritis.

PAIN CLINIC

The pain clinic uses services of specialists such as neurology,

psychology, physical therapy, orthopedics, anesthesiology and
neurosurgery. Bedsides clinic, the pain clinician also treats emotional,
behavioral and social aspects of the suffering. Management of pain due to
terminal cancer is also an important function at any pain clinic. Specialized
cancer clinics, have been established at few centers in India. Drugs such as
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oral morphine and other invasive methods are available in apin clinics for
relieving cancer pain.

13.4 SURGICAL MANAGMENT

 Neurectomy: It interrupts cranial or peripheral nerves by an incision.

The procedure is used when pain is localized to a small part of the
body.
 Rhizotomy: Interruption of anterior and posterior nerve root area
close to the spinal cord.
 Chordotomy: It is the most extensive and involves resection of the
spinothalamic tract. An incision a few mm in length made in the
anterolateral pathway opposite side on which pain located.
 Tractotomy: It is the surgical division of the antero-lateral pathway in
the brain stem.
 Intracranial Stimulation: This therapy is a destructive intracranial
procedure. Under local anesthesia a stimulating electrode is inserted
in to the posterior end of third ventricle. The proximal end of
connected to a battery driven stimulator which is operated by client.
 Radiation Therapy: Is used in treating pain caused by malignant
conditions such as bone pain. It is also very useful in reducing the
size of tumors pressing on nerves and other organs.

14. NURSING MANAGEMENT:-

ONGOING ASSESSMENT

 ASSESS PAIN CHARACTERISTICS:

 Quality
 Severity
 Anatomical location
 Onset
 Duration
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  Aggravating factors
 Relieving factors
 Assess for signs and symptoms associated with Pain
 Assess the patient’s perception of the effectiveness of methods used
for pain relief in the past
 Evaluate gender, cultural, societal, and religious factors that may
influence the patient’s pain experience and response to pain relief
 Assess the patients expectations about pain relief
 Assess the patient’s attitude towards pharmacological and non
pharmacological method in pain management
 Assess the patient ability to perform activities of daily living
 Assess for cause of pain
 Assess appropriateness of patient as a patient controlled analgesia
(PCA).

INTERVENTIONS

 Anticipate need for pain relief

 Response immediately to complaint of pain
 Eliminate additional stressors or sources of discomfort
 Provide rest to facilitate comfort, sleep, and relaxation
 Ensure the proper pain relief method
 Provide analgesic as prescribed
 Evaluate effectiveness and observe side effects

FUNCTIONS OF NURSE IN PAIN MANGEMENT

 Ensuring informed consent for pain management

 Assess pain using standard pain management scale
 Educate staff, patient, and relatives about pain and its
management
 Ensure that pain medication is given round the clock
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  Intervening to treat pain before the pain become worse
 Try to use non pharmacological techniques to alleviate pain
 Documentation of pain assessment, intervention, and evaluation
activities
 Intervene to minimize drug side effects
 Regular monitoring of patient to avoid over medication.

15. COMPLICATIONS OF PAIN:-

Deconditioning

a. “Overuse” of ancillary musculoskeletal tissue with degeneration

b. Decreased mobility
c. Obesity
d. Muscle atrophy
e. Contractures
f. Neuropathies

Hormonal

a. Excess catecholamine production with hypertension and tachycardia

b. Glucocorticoid excess or deficiency
c. Hypotestosteronemia
d. Insulin - Lipid abnormalities
e. Immune suppression

Neuropsychiatric

a. Nerve - Spinal cord degeneration

b. Cerebral atrophy
c. Depression/suicide
d. Insomnia
e. Attention deficit
f. Memory loss
g. Cognitive decline

16. BIBILIOGRAPHY:
32
 BOOKS

[1] B T Basavanthappa. Fundamentals of Nursing. 2 ndedition. Bangalore:

Jaypee Publications; Page no.935-958

[2] Helen Hark Reader, Marry Annhogen. Fundamentals of Nursing and

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[3] B. Kozier. Fundamentals of Nursing. 3 rdedition. US: Elsevier

Publications; Page no.1177-1200

[4] M. Wilkson, Vanledven. Fundamentals of Nursing- Theory, Concepts &

Application. 1stedition. US: Elsevier Publications; Page no.699-721

[5] Samtasoni. Textbook of Advanced Nursing Practice. 1 stedition.

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[7] Huether, M. C Cane, Brashers, Rote. Understanding Pathophysiology.

4thedition. Missouri: Mosby Elsevier Publications; Page no.305-310

[8] Carol Mattson Porth. Essentials of Pathophysiology. 3 rdedition.

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[9] Ignatavicius, Workman. Medical Surgical Nursing Patient Centered

Collaborative Care. 7thedition. US: Elsevier Publications; Page no.39-63

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[11] M. Black, Jane Hokinson Hawks. Medical Surgical Nursing Clinical

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[12] M. Black, Esther Matasserin, Jacobs. Lukmann and Sorensen’s Medical

Surgical Nursing. 4thedition. US: Saunders Publication; Page no.311-359

33
[13] Lewis, Derkson et al. Medical Surgical Nursing Assessment,
Management of Clinical Problems. 8thedition. US: Elsevier Publications;
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[14] Dewit, Stromberg, Dallred. Medical Surgical Nursing Concepts &

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[15] F. Craven, Constance, J. Hirnle. Fundamentals of Nursing. 5 thedition.

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[16] Linton. Introduction to Medical Surgical Nursing. 4 thedition. US:

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JOURNALS

34
[1] Mark P. Jensen. The Official Journal of Pain. 2018; Volume19 (no.9)

[2] Taylor & Francis Group. Canadian Journal of Pain. 2017; Volume1 (no.1)

[3] Wolter Kluwer. Pain Reports. 2014; Volume155 (no.5)

WEBSITES

[1] https://en.m.wikipedia.org>wiki>pain

[2] https://en.m.wikipedia.org>wiki>Mcgill

[3] https://www.slideshare.net>mobile>ppt

[4] https://www.journals.elesevier.com

[5] https://www.macmillan.org.uk.pain

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