Unit 2

Pain
 Introduction

Pain is an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or
described in terms of such damage. It is the feeling common
to such experiences as stubbing a toe, burning a finger,
putting iodine on a cut, and bumping the "funny bone".
 Definition
According to Merskey and Bugdulk 1994
"An unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage" .

According to American Pain Society

American pain society cloned the phrase "pain the fifth
vital sign" to emphasize its significance of the importance
of effective management.

According to Mc Caughey and beeby 1989

“Whatever the person says it exists, whenever the
experiencing person says it does".
 Etiology and Precipitating factors
• Surgical or accidental trauma.
• Inflammation.
• Musculoskeletal disorders such as muscle spasm.
• Neuropathies secondary to such conditions as diabetes
mellitus acquired
• Immunodeficiency syndrome or multiple sclerosis.
• Visceral disorders such as myocardial infarction.
• Vascular disorders such as sickle cell anemia.
• Invasive diagnostic procedure.
• Excessive pressure, such as with immobility.
• Cancer.
 Types of Pain
•Cutaneous Pain
•Somatic Pain
•Visceral pain
•Referral Pain or Neuropathic Pain.
•Psychogenic pain.
•Phantom pain.
•Nociceptive
•Cutaneous pain
Cutaneous pain originates at the skin level and the depth of
the trauma determines this type of sensation that is
experienced. According to "Rosendhl and Buldock"
damage confirmed to the epidermis level pain is localized
and superficial subcutaneous tissue injury produces an
aching, throbbing pain.

•Somatic pain
Somatic pain is generated from deeper connective tissue
structures such as muscle tendons and joints.
•Visceral pain
Visceral pain arises from internal organs that are diseased or
injured and tend to be referred or poorly localized. Visceral
pain is usually accompanied by other autonomic nervous
system symptoms such as nausea, vomiting, Pallor,
hypotension and sweating.

•Referral pain/neuropathic pain.

Referred pain describes discomfort that is perceived in a
general area of the body, but not in the exact site where an
organ is anatomically located. Neuropathic pain also called,
functional or psychogenic pain, with typical characteristics.
It often experienced days, weeks or even months after the
source of the pain has treated and resolved. This leads to
speculate that there is dysfunctional chemical message that
is being transmitted to the brain.
•Psychogenic pain
Psychogenic pain, also called psychalgia or somatoform
pain is pain caused, increased, or prolonged by mental,
emotional, or behavioral factors. Headache, back pain, and
stomach pain are sometimes diagnosed as psychogenic.
Sufferers are often stigmatized, because both medical
professionals and the general public tend to think that pain
from a psychological source is not "real".

•Phantom pain
Phantom pain is pain from a part of the body that has been
lost or Phantom limb pain is a common experience of
amputees.
•Nociceptive pain
Nociceptive pain is initiated by stimulation of peripheral
nerve fibres that respond only to stimuli approaching or
exceeding harmful intensity (nociceptors), and may be
classified according to the mode of noxious stimulation;
the most common categories being "thermal" (heat or
cold), "mechanical" (crushing, tearing, etc.) and
"chemical" (iodine in a cut, chili powder in the eyes).
ACUTE PAIN
Acute pain is usually of short duration (in the surgery lasting
from 24 to 48 Hrs. and in the generally lasting from seconds
to 6 months) usually recent onset and commonly associated
with a specific injury acute pain indicates that damages or
injury has occurred .

CHRONIC PAIN
Chronic pain is of long duration, usually longer than a few
months and it last until the underlying cause is treated.
 Factors affecting pain
•Past experience – it is tempting to expect that a person
who has had multiple or prolonged experiences with pain
would be less anxious and more tolerant of pain than one
who has had little pain. However this is not true. Often the
more experience a person has had with pain, the more
frightened he/she is and wants relief from pain as soon as
possible. This person may be less able to tolerate pain, that
is, he/she wants quicker relief from pain before it gets more
severe. Though this person might have learned to fear the
pain and its treatment.

• Gender –Women reported higher pain intensity, pain

unpleasantness, frustration and fear, compared to men.
•Anxiety and depression – it is commonly believed that
depression and anxiety increases pain. Anxiety that is
unrelated to pain may actually decrease the pain. The
routine of anti-anxiety drugs may prevent the person from
reporting pain because of sedation and may impair the
patient’s ability to take deep breaths, get out of bed and
cooperate with the treatment plan.

• Culture – cultural factors also influence the response to

pain. These beliefs vary from one culture to another.
 Characteristics Of Pain
•Intensity – The intensity of pain ranges from none to mild
discomfort to excruciating.

•Timing – sometimes the cause of pain can be determined by

the duration of pain. The patient is asked if the pain started
suddenly or increased gradually. Sudden pain that rapidly
reaches maximum intensity is indicative of tissue rupture,
and immediate intervention is necessary. Pain from ischemia
gradually increases and becomes intense over a period of
time.

•Location – the location of pain is best determined by having

the patient point to the area of the body involved. Some
general assessment forms have drawings of human figures,
and the patient is asked to shade the area involved.
•Quality – the nurse asks the patient to describe his/her pain
in his/her own words without offering clues. Sufficient time
must be allowed for the patient to describe his/her pain, and
the nurse must carefully record what the patient says. It is
important to document the exact words of the patient.

•Personal meaning – ask the patient how the pain has

affected the person’s daily life. Some people can continue to
work or study, while others may be disabled. Ask the patient
whether family members are affected by his/her illness.
•Aggravating and alleviating factors – the nurse asks
the patient whether there is anything that makes the pain
sharp or anything that relieves the pain. This helps to
assess the factors associated with pain.

•Pain behaviours – different people react to pain in

different manners these verbal and non verbal expressions
of pain are not consistent or reliable indicators of the
quality or intensity of pain. Patients may grimace, cry,
rub the affected area, guard the affected area, or
immobilize it. Others may moan, groan, grunt or sigh.
Assessment of Pain
 Management
 Pharmacological Management
S.No. DRUG DOSE AND ACTION SPECIAL
NAME ROUTE CONSIDERATION
S
1. Paracetamol 500 mg oral Analgesic and anti Fatal liver is possible
bid/tid. 60, 125, pyretic. when overdose
250 mg occurs.
suppositories,
500 and 1000
mg IV vials
2. NSAID’s 200-400 mg qid Inhibit the enzyme Can cause renal
(ibuprofen, oral cyclooxygenase, impairment, and
naproxen, which aids in the gastric ulceration,
indomethaci production of and increased wheeze
n, piroxicam, prostaglandins. in asthmatic patients.
diclofenac) Analgesic, antipyretic,
anti inflammatory,
anti platelet.
3. Strong Morphine - Strong analgesic Kidney and liver
opioid 10mg every 4 action for visceral failure. Habit
(morphine, hrs. pain, musculoskeletal forming.
diamorphine Diamorphine, pain, nerve pain, Withdrawal should
/heroin, oxycodone – sympathetic pain. not be sudden
hydromorph 5mg. otherwise it may
one, Hydromorpho produce withdrawal
oxycodone, ne – 1.3mg. symptoms like
fentanyl, Fentanyl – restlessness, muscle
pethidine) 1000mcg. spasm, back ache
Pethidine – and head ache.
100mg
4. Weak opioid Codeine – 30 Used for Slow withdrawal
(codeine, to 60 mg od, musculoskeletal and should be done.
tramadol, ) tramadol – 50 visceral pain. Inhibits Tramadol when used
to 100 mg dorsal horn of the with other drugs
every 4 hrs. spinal cord. such as anti
depressants can
cause reactions.
5. Muscle Diazepam- 2-5 Used to treat muscle Can cause sleep and
relaxants mg bid or tid. spasm by stimulating the patient will get
(diazepam, Baclofen – 30- GABA receptors in up feeling unfresh.
baclofen) 80 mg tid. the brain. Sleep disorder will
persist for up to 6
weeks after
withdrawal of the
drug.
 Non pharmacological management:

•Cutaneous stimulation and massage – massage which is

generalized cutaneous stimulation of the body specially
concentrates on the back and shoulders. Massage improves
blood circulation to the muscles and relaxes the muscle
spasms.
•Ice and heat therapies – for greatest effect ice should be
placed on the site of injury immediately after the injury. Ice
therapy after joint surgery can significantly reduce the amount
of analgesic medications required after surgery. Assess the
skin prior to application of ice. It should not be applied for
more than 20 minutes otherwise the rebound phenomena will
occur as the body will heat up. Long term application of heat
or cold therapy may result in nerve or skin injury.
•Relaxation techniques - Relaxation relieves pain or keeps
it from getting worse by reducing tension in the muscles.

•Foot reflexology - Reflexology is an alternative medicine

healing system in which specific points on the feet or hands,
known as reflex points, are manipulated to bring about
changes in other parts of the body.
NURSING MANAGEMENT

•Use pain assessment scale to identify intensity of pain.

•Assess and record pain and its characteristics: location, quality,

frequency and duration.

•Give comfortable position to the patient.

•Use comfortable devices.

•Provide analgesics as prescribed by physician.

•Instruct patient and family about potential side effects of

analgesics and their prevention and management.

•Teach patient additional strategies to relieve pain and

discomfort: distraction, relaxation etc.