MEDICAL SURGICAL
1ST SEM LECTURE | PAIN
OUTLINE
1. PAIN
1.1. Pain Threshold
1.2. Pain Tolerance
1.3. Pain Mechanism
2. PATHOPHYSIOLOGY OF PAIN
3. CLASSIFICATION OF PAIN
4. THEORIES OF PAIN
5. NURSING CARE
5.1.Pain Assessment
5.2. Elements of Assessment
5.3. Nursing Implications
5.4. Principles of Treatment
5.5. Pain Treatment
5.6. Pharmacologic Therapy
5.7. Interventional Therapy
PAIN
• PAIN
o Unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or
described in terms of such damage.
• PAIN THRESHOLD
o Point/amount at which a stimulus
needed to perceived pain.
• PAIN TOLERANCE
o Time/intensity of pain endured
before initiation of over pain
response & patient complain
= alcohol consumption, medication,
hypnosis, warmth, distraction
= repeated exposure, fatigue, anger,
apprehension, sleep deprivation
BSN 301
• PAIN MECHANISM
§ Nociception- process where
tissue damage is
communicated to the CNS.
PROCESS:
1. TRANSDUCTION — conversion
of noxious stimuli (mechanical,
thermal, chemical) into electrical
signal (action potential)
-histamine
-bradykinin
-prostaglandin NOCICEPTORS
-substance
-serotonin
2. TRANSMISSION – signals relayed
from periphery to spinal cord to the
brain
§ A-delta Fibers: myelinated
fibers (sharp pain)
§ C Fibers: unmyelinated fibers
(aching or throbbing)
o Transmission to Spinal Cord
o Dorsal Horn Processing
o Transmission to Thalamus and
Cortex
3. PERCEPTION — pain is
recognized, defined and assigned
(conscious experience)
 MEDICAL SURGICAL
1ST SEM LECTURE | PAIN
4. MODULATION—activation of
descending pathway that exert
effects on pain transmission
§ Areas: periphery. spinal cord.
brainstem or cerebral cortex
§ Chemical: Serotonin
Norepinephrine, GABA,
Endogenous Opioids
• PATHOPHYSIOLOGY
OF PAIN
• CLASSIFICATION
OF PAIN
§ NOCICEPTIVE PAIN
o Normal processing that damages
normal tissue
¨ Somatic
Þ Superficial: skin, mucous
membranes &
subcutaneous (sharp,
burning or prickly)
Þ Deep: bone, joint. muscle,
skin & connective tissues
(deep, aching, throbbing)
BSN 301
¨ Visceral: internal organs and lining
of body cavities, inflammation,
stretching & ischemia.
§ NEUROPATHIC PAIN
o Abnormal processing caused by
damage to peripheral nerves or
structures of the CNS.
¨ Central: primary lesion or
dysfunction in CNS.
e.g. post-stroke. multiple sclerosis
pain.
¨ Peripheral Neuropathies: felt along
the distribution of one or many
peripheral nerves 61 nerve damage.
e.g. CM neuropathy, trigeminal,
neuralgia
¨ Deafferentation: loss of afferent
input e.g. phantom limb.
postmastectomy, SCl.
¨ Sympathetically Maintained:
persistent secondary to sympathetic
activity e.g. phantom limb. complex
regional pain syndrome.
-CRPS type I: tissue injury. surgery.
vascular
-CRPS type II: peripheral nerve
lesion
§ ACUTE PAIN
o Onset: sudden
o Duration: < 3mos. or until healing
o Cause: can identify a precipitating
event
o Course: overtime up to recovery
Þ S/Sx: (+) SNS response
Increase: HR, BP, RR
 MEDICAL SURGICAL
1ST SEM LECTURE | PAIN
diaphoresis. pallor, anxiety,
agitation. urine retention.
§ CHRONIC PAIN
o Onset. gradual or sudden
o Duration: > 3mos. (acute 4 past
normal recovery)
o Cause: may not be known, differ
from other mechanisms
o Course: does not go away
(Intractable Pain)
Þ S/Sx: Flat affect;
Decrease physical activity, fatigue,
withdrawal from interaction.
• THEORIES OF PAIN
§ SPECIFITY THEORY
o “Sensory Theory”
o Pain is a sensory phenomenon
(specific receptors, routes of
transmission - CNS, center of
registration, appreciation and
interpretation of the brain)
§ PATTERN THEORY
o “Intensity Theory”
o Pain is produced by intense
stimulation of non-specific fiber
receptors.
o “Any stimulus could be perceived as
painful if the stimulation were
intense enough”
§ GATE CONTROL THEORY
o Substantial gelatinosa (dorsal
horn) acts as a gate
mechanism that can dose and
open to pain impulses
Þ (+) nerve message is pain = gate
opens to the bran
BSN 301
Þ (+) conflicting impulses from on
large diameter nerve fibers from
reticular formation/ thalamus = gate
doses
§ CENTRAL THEORY
o Brain opiates (analgesic
properties) release are affected
by actions, initiated by the
care giver.
e.g. hypnosis
• NURSING CARE
• PAIN ASSESSMENT
o GOAL:
(1) Describe the pain
experience
(2) Identify the goal for therapy and
resources of self-management
o PRINCIPLES:
1. Patient right to appropriate
assessment and management
2. Always subjective!
3. Physiologic and behavioral signs
of pain are not reliable or specific
4. Unpleasant sensory and
emotional experience
 MEDICAL SURGICAL
1ST SEM LECTURE | PAIN
BSN 301

5. Assessment approaches (tools)

must be appropriate.
6. Exist even when no physical
cause.
7. Different experience and levels
8. (+) Chronic pain — may be more
sensitive
9. Unrelieved pain has adverse
consequences.
§ MANAGEMENT STRATEGIES
✓ coping differences (non-
pharmacologic)
§ IMPACT OF PAIN
✓ quality of life (sleep. enjoy life.
social)

• ELEMENTS OF § BELIEF, EXPECTATIONS &

ASSESSMENT GOAL
✓ promote or hinder management
§ PATTERN
✓ Pain onset § PQRST OF PAIN
✓ Duration P: Predisposing/ Provoking
Q: Quality
✓ Breakthrough Pain — transient pain
R: Radiation
even with RTC medication.
S: Severity
✓ Incident Pain — transient pain caused T: Timing
by specific activity.
§ DOCUMENTATION
§ LOCATION
✓ Origin and radiation § REASSESSMENT

§ INTENSITY
• NURSING IMPLICATIONS
✓ Numerical analogue scale
✓ Wong-Baker FACES Pain Scale
§ QUALITY
✓ Nature and characteristic
e.g. sharp, dull, throbbing, excruciating.
§ ASSOCIATED
✓ anxiety. fatigue. depression
✓ Assess pain in all patients
✓ Self-report is the single most
indicator
✓ Do not rely mainly on observations
and objective signs
✓ Address both physical &
psychologic aspect
✓ Special considerations in
communication problems
✓ Include family members (when
appropriate!)
✓ No uniform pain threshold
✓ Pain tolerance vanes
✓ Encourage patient to report pain
 MEDICAL SURGICAL
1ST SEM LECTURE | PAIN
• PRINCIPLES OF PAIN
TREATMENT
1. Follow the principles in pain
assessment.
2. Use a holistic approach.
3. Every patient deserves adequate
management.
4. Base treatment plan on patient's
goal.
5. Use both drug and nondrug
therapies.
6. Use a multimodal approach to
analgesic therapy (when
appropriate).
7. Use a multidisciplinary approach.
8. Evaluate the effectiveness of all
therapies.
9. Prevent or manage medication side
effects.
10. Patient and caregiver teaching.
• PHARMACOLOGIC
THERAPHY
§ NONOPIOIDS
o Mild to moderate pain
o Used in conjunction with
opioids (opioid-sparring
effect)
(1) analgesic ceiling
(2) tolerance/ dependence
(3) OTC
Þ Acetaminophen: analgesic +
antipyretic
✓ Hepatotoxicity antiplatelet,
anti-inflammatory
Þ Salicylates: Inc. GI bleeding
NSAIDS:
BSN 301
COX-1- protective functions
COX-2 - produced in site of
injury
§ OPIOIDS
o Moderate to severe pain -
Binds to CNS receptors
(1) nociceptive input from periphery
to spinal cord
(2) alter limbic system activity
(3) activate descending inhibitory
pathway
Þ Opiod Agonists: bind to mu
receptors acute & chronic pain 8
analgesic ceiling
e.g. morphine. oxycodone.
codeine. methadone.
oxymorphone. levorphanol,
tramadol.
Þ Mixed Agonist-Antagonist:
agonists on kappa receptors weak
antagonists on mu receptors.
✓ Decrease respiratory
depression
✓ (+) analgesic ceiling
e.g. nalbuphine pentazocine.
Butorphanol.
 MEDICAL SURGICAL
1ST SEM LECTURE | PAIN
BSN 301

§ ADJUVANT THERAPY
Þ Corticosteroids § PHYSICAL PAIN RELIEF
Þ Antidepressants STRATEGIES
Þ Antiseizure Drugs Þ Massage
Þ GABA Receptor Agonist Þ Exercise
Þ Alpha-Adrenergic Agonist Þ Acupuncture
Þ Local Anesthetics Þ Heat & Cold Therapy
Þ Cannabinoids Þ Transcutaneous Electrical
Nerve Stimulation (TENS)
• INTERVENTIONAL
THERAPY

§ THERAPEUTIC NERVE
BLOCKS
o Infusion of local anesthetics to
a particular area (regional
anesthesia)
o local infiltration or nerve
injection

Þ Neuroablative Technique
o severe pain unresponsive
to other therapies
o destroy nerves by surgical
resection.
thermocoagulation or
radiofrequency
o e.g. sensory nerve
(rhizotomies), spinal cord
(cardotomies). medulla
(tractotomies)

§ NEUROAUGMENTATION
o Electrical stimulation of the
bran spinal cord.
o e.g. chronic back pain