Pain Management

By; Nini A. (BSC, MSC)

 PAIN

“Pain is a more terrible lord of mankind

than death itself.” Albert Schweitzer
 "An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage“
 “whatever the person says it is, existing whenever the

experiencing person says it does” –

McCaffery & Pasero, 1999

 Emphasizes the highly subjective nature of pain

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 Pain is an almost universal experience, yet difficult to
define.

Pain is the most common reason people seek medical

treatment.

Pain occurs as the result of many disorders, diagnostic

tests, and treatments; it disables and distresses more
people than any single disease.

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 Types of Pain
Pain is categorized according to its duration, location, and
etiology.

1. Acute Pain

Usually of recent onset and commonly associated with

a specific injury, it indicates that damage or injury has
occurred. E.g. needle sticks, surgical incisions, burns,
and fractures.

Can last from seconds to 6 months.

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 2. Chronic Pain

Chronic pain is constant or intermittent pain that

persists beyond the expected healing time and that can
seldom be attributed to a specific cause or injury.

It may have a poorly defined onset, and it is often

difficult to treat because the cause or origin may be
unclear.

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 Pain Classified by Location
 Pain can also be categorized according to location (eg, pelvic

pain, headache, chest pain).

 This type of categorization aids in communication about and

treatment of the pain. For example, chest pain may suggest

acute coronary syndrome (ACS).

Pain Classified by Etiology

 Pain can also be categorized by etiology.

 E.g. Burn pain

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 Pain Transmission
Nociceptors also called as pain receptors are free
nerve endings in the skin that respond only to intense,
potentially damaging stimuli (mechanical, thermal, or
chemical)

The joints, skeletal muscle, fascia, tendons and cornea

also have nociceptors

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 Large internal organs do not contain nerve endings

Histamine, bradykinin, acetylcholine, serotonin, are

chemicals that increase transmission of pain.

Prostaglandins are chemical substances that are

believed to increase the sensitivity of pain receptors by
enhancing the pain provoking effect of bradykinin

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 Con…
Chemicals that reduce or inhibit the transmission

or perception of pain include endorphins and

enkephalins

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 The Pain Pathway
1. Transduction
2. Transmission
3. Modulation
4. Perception

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 Transduction
The process by which afferent nerve endings translate

noxious stimuli (e.g., a bee sting) into nociceptive

impulses.

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 Transmission
Is the process by which impulses are sent to the dorsal horn

of the spinal cord, and then along the sensory tracts to the
brain.
Pain impulses are transmitted by two fiber systems:

1. fast, sharp and well localized sensation (first pain) which is

conducted by A-delta fibers.

2. duller slower onset and often poorly localized sensation

(second pain) which is conducted by Cfibers.
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 Modulation
Ù It is the process of either dampening or amplifying the

pain-related neural signals.

Ù Periaqueductal gray (PAG) in the midbrain is

involved in modulating of pain.

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 Perception
 The conscious awareness of the experience of pain.

 Perception results from the interaction of transduction,

transmission, modulation, psychological aspects, and
other characteristics of the individual.

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 Factors influencing pain response

 Past experience

 Anxiety and Depression

 Gender

 Age

 Placebo effect

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 Past experience
prolonged experiences with pain will be less anxious and
more tolerant of pain than those who have had little
experience with pain
A person with repeated pain experiences may have learned
to fear the escalation of pain and its inadequate treatment.

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 Anxiety and depression
Anxiety that is relevant or related to the pain may
increase the patient’s perception of pain.
For example, the patient who was treated 2 years ago
for breast cancer and now has hip pain may fear that
the pain indicates metastasis.
Anxiety that is unrelated to the pain may distract the
patient and may actually decrease the perception of
pain.

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 Gender
The results of studies of gender in regard to pain levels
and response to pain have been inconsistent.
In some studies, women consistently reported higher
pain intensity, pain unpleasantness, frustration, and
fear, compared to men (Wise, Price, Myers, et al.,
2002).
Men and women are thought to be socialized to
respond differently and differ in their expectations
about pain

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 PAIN ASSESSMENT
Obtain a Pain History
 Allow the client to describe the pain to establish a

trust relationship between you and the client

 Discover the effects of pain on the client's quality of

life
 Assess for emotional and spiritual distress and coping

abilities

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 Con…
Ask about previous pain experience and what
measures have been effective as well as those who
have not

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 Visual Analogue Scales
Useful in assessing the intensity of pain

Includes a horizontal 10cm line, with anchors

indicating the extremes of pain

The client is asked to place a mark indicating where

the current pain lies on the line

Left: none or no pain

Right: severe or worst possible pain

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 Faces Pain Scale
 This instrument has six faces depicting expressions
that range from contented to obvious distress
 The client is asked to point to the face that most
closely resembles the intensity of his or her pain.

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 Pain Management Strategies
Non pharmacologic interventions
+ Non-pharmacologic nursing activities can assist in
pain relief
+ Not a substitute for medication

+ Combining non pharmacologic interventions with

medications may be the most effective way to relieve
pain
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 Cutaneous stimulation and massage
Massage is a generalized cutaneous stimulation of the
body that often concentrates on the back and
shoulders

Massage have an impact in the descending control

system and does not merely stimulate non pain
receptors

Promotes comfort through muscle relaxation

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 Thermal therapies
Proponents believe that ice and heat stimulate the non
pain receptors in the same receptor field as the injury

Ice should be placed on the injury site immediately

after injury or surgery

Ice therapy after joint surgery can significantly reduce

the amount of analgesic medication required

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 Assess skin first before applying ice

Ice should be applied on an area for no longer than 15

to 20 minutes at a time and should be avoided in
clients with compromised circulation

Application of heat increases circulation to an area

and contributes to pain reduction by speeding healing

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

Thought to reduce the perception of pain

Effectiveness depends on the client’s ability to receive and

create sensory input other than pain

Examples are watching TV, listening to music, complex

physical and mental exercises

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 Pharmacologic interventions
Premedication assessment
The nurse should ask the client about allergies to

medications and the nature of any previous allergic

responses
The nurse obtains the client’s medication history,

along with a history of health disorders

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 Nonopioids
Generally the first class of drugs used for treatment of
pain

Useful for acute and chronic pain from a variety of

causes such as: surgery, trauma, arthritis, and cancer

Have a ceiling effect to analgesia

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 Examples are salicylates (aspirin); NSAIDS (ibuprofen,

ketorolac, naproxen); COX-2 inhibitors (celecoxib);

acetaminophen

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 Opioids
The goal of administering this medication is to
relieve pain and improve quality of life
Opioids are classified as full agonists, partial
agonists, or mixed agonists and antagonists
Full agonists have complete response at the opioid
receptor site.

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 æ Partial agonists has lesser response

æ The mixed agonists and antagonists activates one type

of opioids receptor while blocking another
æ Controlled-release opioids such as oxycodone and
morphine are effective for prolonged, continuous
pain.

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 Common adverse effects of opioids are: CRINCS!

C- constipation

R- respiratory depression

I- itching

N- nausea, vomiting

C- constricted pupils

S- sedation

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 Benzodiazipines
 Midazolam (Versed) or diazepam (Valium) are
effective for the treatment of anxiety or muscle
spasms associated with pain
 These drugs do not provide pain relief except in the
treatment of muscle spasms
 May cause sedation

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 Tricyclic antidepressants

Amitriptyline, imipramine, desipramine, and doxepin

have been shown to relieve pain related to neuropathy and
other painful nerve related conditions

Instruct clients to continue taking the medications even if

they seem ineffective at first.

Additional benefits of this class of medications may

include mood elevation and improved ability to sleep

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 Surgical interventions
Cordotomy
Is the division of certain tracts of the spinal cord

May be performed percutaneously, by the open method

after laminectomy, or by other techniques
Is performed to interrupt pain transmission

Care must be taken to destroy only the sensation of pain,

leaving motor functions intact

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 Pre and post operative care
Preoperative Nursing interventions
♣ Preoperative teaching
Deep-breathing, coughing, & incentive spirometers
Mobility & active body movement
Pain management
Cognitive coping strategies

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 ♣ Preoperative psychosocial interventions
Reducing Preoperative Anxiety
Decreasing fear
Respecting cultural, spiritual & religious beliefs
♣ General preoperative nursing interventions
Managing nutrition & fluids
Preparing the bowel for surgery
Preparing the skin

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 ♣ Immediate preoperative nursing interventions
Administering pre-anesthetic medications
Maintaining the preoperative record
Transporting the patient to the pre-surgical area
Attending to family needs

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 Post operative nursing management
♣ Admitting the patient to the post anesthesia care unit
The nurse who admits the patient to the PACU reviews the
following information with the anesthesiologist or
anesthetist:
Medical diagnosis & type of surgery performed
Pertinent past medical history & allergies
Patient’s age & general condition, airway patency, vital
signs
Anesthetics & other medications used during the procedure
Any problems that occurred in the operating room that
might influence post operative care

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 Pathology encountered
Fluid administered, estimated blood loss & replacement
fluids
Any tubing, drains, catheters, or other supportive aids
Specific information about which the surgeon,
anesthesiologist, or anesthetist wishes to be notifying

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 Nutritional care for surgical patients
Malnutrition increases postoperative morbidity and

mortality and early intervention reduces this risk.

Plasma protein concentrations and body weight are

unreliable because underlying disease frequently alters

them.
Most patients can safely resume an oral diet soon after

surgery and feeding proximal to a new small or large

bowel anastomosis is safe and advantageous.
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 Cont..
Contraindications include patients with a new anastomosis

in the upper gastrointestinal tract, postoperative small bowel

obstruction, and ileus.
In acute intestinal failure, artificial nutritional support

(enteral and/or parenteral) must be commenced at an

appropriate time.
Close collaboration with a nutrition support team is

essential.

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 Reading assignment??
Mechanism of acute pain

Mechanisms of chronic pain

Factors related associated with pain

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 End!!

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