Pain Management

Basic things we need to know about pain

Presented by:
Benjamin B. Espada Jr.
Pain Definition
An unpleasant sensory and emotional experience,
associated with actual or potential tissue damage, or
described in terms of such damage.
Types of Pain
According to Source
1. Nociceptive Pain
 Is pain caused by damage to tissues. Tissue damage
activates the nociceptive nerve fibres and pain signals
are sent up through the spinal cord to the brain.
2. Neuropathic pain
 Is a special type of pain produced by damage to part of
the pain pathway. It is not associated with true tissue
damage; instead, the pain pathway is 'misfiring',
causing the experience of pain without actual injury.
Types of Pain
Acute or Chronic Pain
1. Acute Pain - is a short-term feeling of pain felt in response to an
easily identifiable cause. It might be caused by surgery, some kind
of trauma, or an acute illness. The feeling of pain is acting like a
sort of warning system to let you know that an injury has occurred.
Acute pain lasts for less than three months.
2. Chronic Pain - may begin as acute pain, but lasts longer than
would normally be expected for the sort of injury that has
occurred. Chronic pain may also occur when pain comes back for
an unknown reason. In chronic pain syndromes, the pain may feel
a lot worse than seems to fit with the injury or damage that can be
seen. The link between the tissue damage and the pain is lost.
Chronic pain may develop from acute pain for a number of reasons.
Other Classifications
1. Cutaneous Pain
 Pain that originates from the skin or subcutaneous tissue
2. Deep Somatic Pain
 Arises from ligament, tendons, bones, blood vessels and nerves
3. Visceral Pain
 Results from stimulation of pain receptors in the
abdominal cavity, cranium and thorax
4. Radiating Pain
 Pain perceived at the source but extends to nearby
tissues
Other Classifications
5. Referred Pain
 Pain felt in a part of the body that is considerably
removed from the tissue causing the pain
6. Intractable Pain
 Pain that is highly resistant to relief

7. Neuropathic Pain
 Long lasting, unpleasant with episodes of sharp pain
resulting from damage to peripheral CNS
8. Phantom Pain
 Pain perceived in a body part that is missing or paralyzed
Theories
Specific Theory
• This traditional approach (von Frey 1895) argues that there
is a special system of nerves which carries messages from
pain receptors in the skin to a pain centre in the brain. One
of the points in favour of this approach was the discovery
that there are specialised receptors in the skin for different
sensations like heat and touch. The problem with this
approach, as Melzack and Wall point out, is that it doesn’t
explain psychological pain, eg phantom limb pain. A further
problem has been revealed by recent technology which
allows us to record the activity of specific nerves but they do
not match pain specifically.
Theories
Pattern Theory
• Unlike specificity theory, pattern theory suggests that
there are no separate systems for receiving pain, but
instead the nerves are shared with other senses like
touch. The most important feature of pain is the pattern
of activity in the nervous system. So, too much
stimulation (eg too much touch) will cause pain.
Theories
Gate Control Theory

• Melzack and Wall (1965). This is the dominant theory today. It is

a biopsychosocial theory which combines the medical
approaches of previous theories with the psychological and
social factors that contribute to pain.
Theories
Gate Control Theory
• It contradicts pattern theory by stating that there are
separate nerves for pain and touch and that different
receptor fibres perform different functions
• Broadly it states that there is a gate mechanism in the spinal
cord which controls the passage of messages about pain. The
degree to which the gate is open or closed is affected by the
messages coming from pain fibres at the site of the damage
but also by messages coming from pain fibres and from the
brain. Hence rubbing a damaged area stimulates other
peripheral fibres and helps reduce the experience of pain.
Theories
Gate Control Theory
• Some factors are known to open the gate and some to
close it
Openers Closers

Physical conditions Physical conditions

- extent of injury - medication
- physical stimulation - counter stimulation
eg rubbing eg massage

Emotional conditions Emotional conditions

- anxiety - positive emotions
- depression - relaxation

Mental conditions Mental conditions

- focussing on pain - concentration
- boredom - distraction (hobby)
Factors Influencing Pain Response
1. Past Experiences
2. Anxiety and Depression
3. Culture
4. Age
5. Gender
Characteristics of Pain
1. Intensity
2. Timing
3. Location
4. Quality
5. Personal Meaning
6. Aggravating or Alleviating Factors
7. Pain Behaviors
PQRST in Pain Assessment
P – Precipitating or Predisposing Factors
Q – Quality
“Explain the feeling of pain? Crushing? Burning? Etc.”

R – Region or Radiation
Where is the origin and how far does it radiate
S – Severity
“In a range of 1-10, how painful is it?
T – Timing
Is it recurrent? Persistent? Intermittent?
Instrument for Assessing the Perception of
Pain
Visual Analogue Scales
Instrument for Assessing the Perception of
Pain
Faces Pain Scale
Instrument for Assessing the Perception of
Pain
Pain Assessment Algorithm
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Pathophysiology of Pain
Management
Pharmacologic Interventions
1. Analgesia
 Non Steroidal Anti Inflammatory Drugs
 Reduces swelling which causes pain and inhibits prostaglandin
 Narcotic Analgesic
 Modify central reception of pain, obliterating pain threshold
2. Anesthesia
 General Anesthesia
 Accompanied by loss of consciousness and amnesia
 Local Anesthesia
 No loss of consciousness but produces loss of sensation
Management
Nursing Responsibilities for Pharmacologic Interventions
(Opiod)
1. Analgesics are most effective when given before pain
becomes severe.
2. Do NOT under treat pain for fear of drug addiction.
3. Use appropriate pain assessment scale
4. May be life-threatening especially in persons with chronic
lung problems (COPD, Asthma), known/suspected head
injury.
5. Do NOT administer opioid analgesics to patients with
depressed respirations.
Management
Nursing Responsibilities for Pharmacologic
Interventions (Opiod)
6. Instruct to avoid activities requiring mental alertness.
7. Routinely evaluate effectiveness of opioid in relieving
pain and document the effectiveness
8. Enhance opioid effectiveness with non-
pharmacologic measures
9. Assess pain for type, location & intensity before & 10
– 45 minutes after administration (0 – 10 scale) –
document, document, document!
Management
Surgical
1. Neurectomy – Incision of cranial or peripheral nerve
2. Rhizotomy – Interruption of anterior or posterior
nerve root area closed to spinal cord
3. Chordotomy – Surgical Interruption of pain
conducting pathways in the cord
Management
Non Pharmacologic Interventions
1. Meditation – Focusing away from pain
2. Autogenic Training - Relaxation and self suggestion
away from pain
3. Progressive Relaxation Technique – Sytematic
relaxation
4. Acupressure – Pressure massage
5. Guided Imagery – Distraction away from pain
Management
Non Pharmacologic Interventions
6. Biofeedback – Providing information about bodily
information.
7. Transcutaneous Electrical Nerve Stimulation -
Transcutaneous electrical nerve stimulation (TENS)
uses a battery operated unit with electrodes applied
to the skin to produce a tingling, vibrating or
buzzing sensation in the area of pain. It is thought to
decrease pain by stimulating the non-pain receptors
in the same area as the fibers that transmit the pain.
Management
Non Pharmacologic Interventions
8. Hypnosis – Use of suggestion and focused attention
9. Distraction - Distraction, which involves focusing the patient’
attention on something other than pain. It is thought to reduce the
perception of pain by stimulating the descending control system ,
resulting in fewer painful stimuli being transmitted to the brain
10. Cutaneous Stimulation and Massage - The gate control theory of
pain proposes that the stimulation of fibers that transmit non-
painful sensations can block or decrease the transmission of pain
impulses. This includes rubbing the skin, massage and heat and
cold application. Massage also promotes comfort because it
produces muscle relaxation.
Management
Non Pharmacologic Interventions
11. Ice and Heat Therapy - Ice should be placed on the injury site
immediately after injury or surgery and should not be longer than
20 minutes. Ice therapy can significantly reduce the amount of
analgesic medication required.Heat increases blood flow to an
area and contributes pain reduction by speeding healing.Both dry
and moist heat may provide some analgesia, but their mechanism
of action are not well understood.
12. Acupuncture - This ancient Chinese practice uses very thin
needles at very specific points on the skin to treat disease and
pain. Practitioners of acupuncture undergo specialized training in
these techniques and may offer this treatment for certain painful
conditions.
Nurses Role in Pain Management
1. Administer pain-relieving interventions
2. Assess the effectiveness of those interventions
3. Monitor for adverse effects
4. Serve as an advocate for patients when the medications
don’t take effect.
5. Act as an educator to the patient and family
6. Assist in identifying goals for pain management
7. Establish a therapeutic nurse-patient relationship
8. Provide physical care
9. Manage anxiety related to pain