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The Concept of

Asst. Prof. Chanell Jan C. Concepcion, RN, MHSS
Reviewer
Significance of Pain
A.Subjective response: only felt by the
person
B.Negative: discomfort
C.Protective role:
• warning of potential threat to health;
• prompt for person to seek medical
attention
D.Fifth vital sign
What is
Pain?
video
PAIN Defined
Pain:
• "an unpleasant
sensory and
emotional
experience
associated with
actual or potential
tissue damage, or
described in terms of
such damage"
(International Association on
the Study of Pain).
Pain:
• Pain has personal
meaning to individual
experiencing pain

• All pain is real
Pain:
• Response to and
warning of actual or
potential trauma

• Difficult to measure
Dimensions of Pain
Types of Pain
 Location
 Duration
 Intensity
 Etiology
Referred Pain

• pain perceived in area distant from
stimuli
• intense although there is little or no
pain at the point of noxious stimuli.
• eg. myocardial ischemia is not
felt as pain in the heart. Rather
it is felt as left arm, shoulder or
jaw pain.
• Visceral
– arises from body organs; dull and
poorly localized; with nausea and
vomiting; may radiate or is referred

• Superficial (Cutaneous)
– Arise from skin and subcutaneous
tissues
– tends to be easily localized

• Somatic (Deep Somatic Pain)
– Tissues of body wall, muscles, bone,
periosteum, cartilage, tendons, deep
facia, ligaments, joints, BV, nerves
Pain According to
Duration
• Acute Pain
• Chronic Pain
• Cancer Pain
Acute Pain
• sudden onset
• usually sharp and localized
• less than 6 months
• significant of actual or potential
injury to tissues
• initiates flight or fight stress
response
Chronic Pain
• prolonged pain
• more than 6 months
• often dull, aching, diffuse
• not always associated with specific
cause, often unresponsive to
conventional treatment
• most common is lower back pain
Characteristics of Acute and Chronic Pain

CHARACTERISTI ACUTE CHRONIC
CS
INTERMITTENT
• ONSET RECENT CONTINUOUS
LESS THAN MORE THEN
2. 6MONTHS 6MONTHS
DURATION
3. Sympathetic Absence of
AUTONOMIC Response Autonomic
Response
4. ASSOCIATED WITHDRAWAL
REPONSE
PSYCHOLOGIC ANXIETY DEPRESSION
5. OTHER
COMPONENT Libido
TYPES OF
RESPONSE
Appetite
The truth about Chronic Pain
(Today @ NBC)
CANCER –
RELATED PAIN

malignant pain is
considered to
have qualities of
both acute and
chronic pain.
Intensity
1-3 =Mild
4-6
=Moderate
7-10 =
Severe
(Kozier, 2008)
Etiology
• Physiologic Pain • Subcategories of
– Experienced when an Physiologic Pain
intact, properly – Somatic Pain
functioning nervous – Visceral
system send signals that
the tissues are
damaged, requiring
attention and proper
care.

Etiology
• Neuropathic Pain May be due to:
– Experienced by people • Illness (postherpetic
who have damaged or neuralgia, diabetic
malfunctioning nerves. peripheral
neuropathy)
• Injury (e.g. phantom
limb pain, spinal cord
injury pain
• Undetermined
reasons
Injury or Damage of the Nerve
• After damage of nerve  may cause
continuing pain
• Regeneration of nerves can lead to
changes in nociceptive pathways that
contribute to pathological pain.
• Healing process could be
accompanied by hyperalgesia (
sensitivity to pain) due to proliferation
of regenerating nerve fibers
• Neuroma formation – can be a
constant cause/source of pain
• (Show Nerve Injury Flash)
Concepts Associated with Pain

1. Pain threshold

2. Pain tolerance
Concepts Associated with Pain

1. Pain threshold
- The least amount of stimuli that is needed for
a person to label a sensation as pain.

2. Pain tolerance
- is the maximum amount of painful stimuli
that a person is willing to withstand without
seeking avoidance of the pain or relief.
Pain Threshold
• the point at which an individual
first acknowledge or interprets
a sensation as being painful
The least experience of pain
which a subject can recognize.
(IASP)
Pain Tolerance
–the individual’s ability to
endure the pain being
experienced
–The greatest level of
pain which a subject is
prepared to tolerate.
(IASP)
Nociceptive vs Neuropathic Pain
• Nociceptive Pain
pain in which normal nerves transmit
information to the CNS about trauma to
tissues
Pain in response to obvious stimuli
• Neuropathic Pain
Does not require the presence of an
identifiable noxious stimuli
pain in which there are structural and/or
functional nervous system
Ex. post herpetic (or post-shingles)
neuralgia
A. Nociception
B. Pain pathway
C. Chemical Mediators
D. Endorphins (endogenous
morphines/ opiates)
• nerve receptors for pain ends
• located in numerous skin and
muscles
• stimulated by direct cellular
damage or local release of
biochemicals from cellular
damage (e.g. bradykinin)
• the system
involved in
the
transmission
and
perception of
pain
nociceptors (nerve cell endings)
nociceptors
• mechanical-
instruments,
equipments
• thermal – flames, hot
liquids, steam
• chemical - noxious
substances
PROCESS OF PAIN
• threatened or actual tissue damage 
stimulates nociceptive neural
receptors
• Damage to the pain transmission
system itself
• Specific structures in the nervous
system are involved in transforming a
stimulus into a pain sensation
Neurons
Involved in
Pain
Perception:

• A-delta (αδ )

• C Fibers
A-delta (Aδ)
• Transmits signals more rapidly
• Delivers information on pain-
producing stimulus
• Determine the location, severity
and type of pain
• Perceived as sharp, cutting or
stabbing sensation
C Fibers
• Conducted more slowly
along pain pathway

• Characterized as dull,
burning sensations
associated with suffering
• Transduction
• Transmission
• Perception
• Modulation
Transduction
• Cell damage causes release of
sensitizing chemicals (prostaglandin,
bradykinin, serotonin, substance P, histamine)

• Stimulus is detected by nociceptive
receptors
• conversion of mechanical, chemical
and thermal information into electrical
activity in the nervous system.
Transduction
• Process of Depolarization
– Na enters; K exits

• Generates action potential

• Electrical energy  travel to
spinal cord
Transmission
• Movement of pain impulse from site
of transduction to the brain

• Message is relayed from receptors
to the CNS
Transmission
• 3 segments involved in
nociceptive signal transmission:
• Level of spinal cord
• Dorsal horn processing
• Transmission to thalamus &
cortex
Transmission of pain impulses
• Substance P and other neurotransmitters
transfer the impulse from the nociceptors to
the spinothalamic tract.
Perception
• Only when the impulses reach the
brain are they intellectually
recognized as pain.

• Brain perceives the sensation as
painful
Perception
• Dynamic and changing in response
to many factors

• May be brief (seconds or hours),
prolonged (hours or weeks) or even
permanent
Modulation
• Adjustment

• Refers to internal and
external ways of reducing
or increasing pain

– Where does modulation occur?
Modulation
• Pain modulation is determined by
activity in the endorphinergic system
and other pain modulating systems.

• In the endorphinergic system,
analgesia is mediated by
– the binding of endogenous opioid
compounds to special subsets of
receptors: mu, delta, and kappa.
Modulation
• Endorphins

• other neurotransmitters that
play a role in the endogenous
pain modulating system
include serotonin and
norepinephrine, GABA
Summary of Noceceptive
Processes
Drug Therapy
Interrupting the Pain Pathways
Pain Medication Mechanism of Action

Transduction –
NSAID -Blocks prostaglandin production
Local Anesthetics -Blocks action potential initiation
Antiseizure agents -Blocks action potential initiation
Corticosteroids -Blocks action potential initiation

Transmission –
Opioids -Blocks release of substance P
Perception –
Opioids - conscious experience of pain
NSAIDs
Adjuvant (antidepressants)
Modulation –
Tricyclic antidepressants - Interferes with reuptake of
serotonin & norepinephrine
Pain
A
T
H
W
A
Y
• First, nerve endings in the finger sense
the injury to the finger (sensory
neurons)
• and they send impulses along axons
and enter the spinal cord in an area
called the dorsal horn (magenta
pathway).
• The incoming axons form a synapse
with neurons that project up to the
brain.
• The neurons that travel up the spinal
cord then form synapses with neurons
in the thalamus, which is a part of the
midbrain (magenta circle).
• The thalamus organizes this
information and sends it to the sensory
cortex (blue),
• Sensory cortex interprets the
information as pain and directs the
nearby motor cortex (orange) to send
information back to the thalamus
(green pathway).
• Again, the thalamus organizes this
incoming information and sends signals
Pain
Ascending
Pathway
Pain
Pathway
Other pain pathways:
• Descending pathway
– Pain modulation
• The spinothalamic pathway.
• The spinoreticular pathway
• The dorsal column pathway
• The spinomesencephalic tract.
• The spinohypothalamic pathway.
1. Bradykinin – a powerful vasodilator
that increases capillary permeability
and constricts smooth muscles.
2. Histamine – a compound found in all
cells. It is released in allergic
inflammatory reactions.

3. Acetylcholine – a neurotransmitter
substance widely distributed in body
tissues which functions as a vasodilator
and cardiac depressant
CHEMICAL MEDIATORS OF PAIN
4. Substance P –
•stimulant at pain receptor sites involved
in inflammatory response in local tissue
•Release of plasma by increasing
vascular permeability  availability of
bradykinin
•Contributes to prostaglandin release
CHEMICAL MEDIATORS OF PAIN

• 5. Prostaglandin – chemical substance
thought to increase the sensitivity of pain
receptors by enhancing the pain
provoking effect of bradykinin

• 6. Endorphin/Enkephalin – reduce or
inhibit the transmission of pain. Both are
found in heavy concentrations in the
CNS
INFLUENCE OF ENDOGENOUS OPIATES

• Endogenous – produced by the body
• Opiates – produce analgesia by
direct action on the CNS
• The endogenous opiates consists of
naturally occurring opioids and their
receptors
• Opioids – (e.g. endorphines,
enkephalins, dynorphin)
INFLUENCE OF ENDOGENOUS OPIATES

Opioids- are Endorphin- (endogenous
morphine- morphines) bind with opiate
like receptors on neuron to
substances inhibit pain impulse
synthesized transmission
in many
regions of
the CNS Enkephalins – (endogenous
(including opiates in the “kephalus”-
pituitary Greek for brain) a naturally
gland) occurring analgesic thought to
inhibit substance P release
Endorphins
• Levels vary among individuals
• People with:
 endorphin levels
 feel less pain
 endorphin levels
 feel more pain
Gate Control Theory
Melzack and Wall (1965)

•holistic nature of pain.
•many interventions
such as imagery and
distraction are used to
help relieve a client’s
pain.
•related to the
transmission of painful
stimuli
The theory states that:

• Small diameter nerve fibers -
conduct excitatory pain stimuli
toward the brain
• Large diameter nerve fibers -
appear to inhibit the transmission
of pain impulses from the spinal
cord to the brain
The theory states that:

3. gating mechanism that is believed by
some to be located in the substantia
gelatinosa cells in the dorsal horn of the
spinal cord

4. The excitatory/inhibitory signals at the
gate in the spinal cord determine the
impulses that eventually reach the brain
The theory states that:

5. Limited amount of sensory
information can be processed by the
nervous system at any given
moment.When too much information is
sent thru, certain cells in the spinal
column interrupt the signals as if
closing the gate.

6. The brain also appears to influence
the gating mechanism.
Gate Control Theory
Con’t…

• Works on the premise that the SG
(located in dorsal horn) modulates
afferent nerve impulses and influence
transmission of T cells. This activates
a central controlling mechanism
Gate Control Theory
Con’t…
• gate closes - impulses are less likely to be
transmitted to the brain.
Gate Control Theory
Melzack and Wall (1965)

• In Dorsal Horn of Spinal Cord

. A-Beta Brain
Sensory, Proprioception, Etc

T
SG

*Inhibitory Synapse
(Large Diameter NF)
A-Delta, C Fibers
Pain Transmission *Facilitator Synapse
(Small Diameter NF)
Gate Control Theory
Updates
(from Black, Hawks & Keene, 2002):
• Gate control theory is correct in predicting that
nociceptive information was modifiable in the dorsal
horn
• Researches have shown that the “Gate”
conceptualization is no longer tenable.
• Inhibition of pain is not limited to the SG
• “This theory is out of date”
• Many researches has more fully delineated the
physiologic mechanism underlying pain inhibition
• “Theory is incomplete and even incorrect in details”
(Fields, in Hawthorn, 1999)
Responses to Pain
Responses to Pain

• Physiologic
• Behavioral
• Other affective
response
PHYSIOLOGIC
REACTIONS TO PAIN
• involve the activation of the
sympathetic nervous system
• evokes the “fight or flight”
reaction
• with catecholamine release
from adrenal medulla.
Manifestations during the Fight-or Flight Response:

 Increased
mental
activity • Dilated pupil

• Bronchial
RR
 Dilation
HR
  Cardiac
Output  glucose

 arterial BP
 flow to
 fatty acids skeletal
muscles
Physical Response

• Moving Away
• Protecting painful area
• Restlessness
• Facial Expression – Grimacing, biting lips,
tensing of limb and body muscles
• Voluntary and involuntary protective body
movements (Guarding painful area)
Psychological or Behavioral RESPONSES:

• Refers to observable actions used to
express or control the pain
Verbal statements – praying,
swearing cursing, repeating non-
sensical phrases
Altered responses to environment
Vocal behaviors- moan, scream,
sighing, crying
Psychological or Behavioral RESPONSES:
• Body movements- rocking, rubbing,
stretching, shifting weight, pounding,
biting
• Physical contact with others
• Facial expression – grimace,
clenched teeth, tight shutting lips,
staring, wrinkling forehead, tearing
Other affective responses:
• Anger
• Fear
• Depression
• Anxiety
Ethic and Cultural Factors
Behavior related to pain is part of
the socialization process
Developmental Stage
Children are less able to articulate their
experience or needs related to pain
 puberty – emergence of pain syndrome
(esp. women)
* elderly – mostly
affected by chronic
pain
Environment & Support People
Strange environment can
compound pain
Support network affects
pain perception
Other factors that affect
pain perception & response:
Expectations
Family role
Past Experience with pain

 affects the way we perceive
our current pain
 Negative experience with
pain as children have
reported greater difficulties
managing pain
 Impact of past experience
may not be predictable
 Earlier pain experience allows
us to adopt coping
mechanisms
Meaning of Pain
Meaning of person’s pain
influences his or her response
to pain
e.g. pain in childbirth different
from pain in surgery
Known vs. unknown cause of
pain
Meaning or experience –
negative vs. positive
Expectation and the Placebo Effect

Client’s expectations play a
major role in a person’s pain
perception and effectiveness
of pain relief intervention
Placebo effect – may initiate
the body's endogenous
opiate system activated by
the expectation of relief
Nursing Process in the
Care of Clients in Pain
ASSESSMENT
• History and Physical
Examination

Intensity
Location
Quality
Duration
Pattern
COLDERR
• Character:
Character describe the sensation (e.g. sharp,
aching, burning)
• Onset:
Onset when it started, how it has changed
• Location:
Location where it hurts (all locations)
• Duration:
Duration constant vs. intermittent
• Exacerbation:
Exacerbation factors that make it worse
• Relief:
Relief factors that make it better
• Radiation:
Radiation pattern of
shooting/spreading/location of pain away from
its origin
The alphabet of PAIN
Protective or Palliative (Ask what provokes or
worsens pain; what relieves or causes pain to subside

Quality or Quantity (Ask for quality, associated
symptoms, pattern, interruption of ADL)

Region and Radiation (Location of pain and if it is
radiating)

Severity (Use Pain scale; description of Intensity)

Timing (Ask when pain began, onset – sudden or gradual,
constant or intermittent?; time of day it occurs)
Assessment Scales
• For adults, adolescents, and older children (including those
with language barriers) who can say or point to a number, or who can point
to a face.
• a) Numerical Scale – 0 to 10 (11-point
intensity Scale)
• b) Wong-Baker Faces Scale
• For stoic or cognitively impaired adults, adolescents,
and children:
• FLACC Scale
• For Neonates/Infants
• a) N-PASS
• b) CRIES
• c) FLACC Scale
Intensity: Use PAIN SCALES
Location of Pain
Quality
•Sharp- pain that is sticking in nature &
intense
•Dull – pain that is not as intense or
acute as sharp pain but more
annoying than painful. More diffuse
than sharp pain
•Diffuse – pain that covers a wide area;
client cannot point to a specific area
without moving the hand over a large
surface, eg the entire abdomen
•Shifting – pain that moves from one area to
another such as from the lower abdomen to the
Periodicity

•Continuous – pain that
does not stop
•Intermittent – pain
that stops and starts
again
•Brief or transient –
pain that passes
quickly
Patterns
• Precipitating
• Alleviating
• Associated Symptoms
• Effect on ADL
• Coping Resources
Nursing Diagnosis

• Primary Nursing DX:
• Alteration in Comfort:
Pain related to tissue
injury from incision,
ischemia, tumor
encroachment in organs
Nursing Management of Pain
• Acknowledgement and Accepting
Client’s Pain
• Assisting Support Persons
• Reducing misconceptions about pain
• Reducing fear & anxiety
• Preventing pain
Pharmacologic Interventions for
Pain
• Medications: most common approach to
pain management
– Analgesics
• Non-narcotic (Acetaminophen)
• NSAIDS
• Narcotic analgesic
• Adjuvant analgesics
(antidepressants, anticonvulsants)
• Local anesthesia
WHO Analgesic Ladder
Non-narcotic or non-opioid
analgesics
• For nociceptive or neuropathic pain
• Effective in somatic components of
nociceptive pain such as joint and
muscle pain
• May also reduce fever and
inflammation
Non-narcotic
analgesics
• For mild to moderate pain
• Drug types:
• Acetaminiophen
• Salicylates
• NSAID
Non-Steroidal Anti
Inflammatory
(NSAIDs)
• Temporary relief from mild to
moderate pain
• Long-term treatment for osteoarthritis
and rheumatoid arthritis
• Acts mainly to interfere with
prostaglandin synthesis
Advantages of NSAIDs:
• Taken orally
• Don’t cause CNS or respiratory
depression when used in
therapeutic dose
• Generally available without
prescription
NSAIDs: Main teaching
points
• Act by inhibiting enzymes
(prostaglandin, cyclooxygenase, etc)
that normally enhance pain
• Peripherally acting painkiller
• Not addictive
• Some potential problems with gastric
side-effects
• Some central S/E
Example of NSAIDs:
• Ibuprofen
• Mefenamic acid
• Naproxen
• Piroxicam
• COX-2 Inhibitors (Vioxx, Celebrex)
Narcotic analgesics
• Natural or synthetic medications
with morphine-like actions
• Derived from opium
• (e.g. morphine) or Synthetic
narcotics (Oxycodone)
• act within and outside CNS
Opioids
• Related to morphine
• Works at morphine receptors
• Physical dependence
• Psychological dependence
• Development of tolerance
• Withdrawal effects
• Long term use effects (possibly
enhancing pain)
• Interaction with benzodiazepines
(central effect)
Examples of Opioids
• Mixed or Weak Opioid
– Butorphanol (Stadol)
– Hydrocodone (Vicodin)
– Codeine (Tylenol No. 3)
– Tramadol
Strong Opioid Analgesic
• Meperidine HCl (Demerol)
• Morphine Sulfate (Morphine)
• Methadone (Dolophine)
Common Opioids Side Effects
• Constipation
• N/V
• Sedation
– Tolerance – 3-5 days
– Consider stimulants (e.g. Ritalin)
– Alternative route (epidural)
Common Opioids Side Effects
• Respiratory Depression
– (first 12-24 hrs)
– Give opioid antagonist Naloxone
Hydrochloride (Narcan)
– Stop, Change, Slow

• Pruritus
• Urinary Retention
Adjuvant analgesics or
coanalgesic
• Drugs that have other primary indications but are
used as analgesics in some circumstances.
• Given in combination with opioids or used alone to
treat chronic pain.
• Examples of Adjuvant analgesics:
– Antidepressants: (such as tricyclic
antidepressants) promote serotonin and inhibit
pain, promotes sleep
– Anticonvulsants
– Local and topical anesthetics
Medications to Ease Pain
1. Oral
2. Sublingual
3. Buccal administration (Actiq – oral
transmucosal fentanyl citrate is a
flavored lozenges on a stick)
4. Intranasal
5. Rectal
6. Transdermal (e.g. Lidocaine patches,
EMLA)
7. Parenteral Route: IM, IV, SC - Patient
controlled analgesic (PCA)
8. Intrathecal, , Narcotic Infusion, epidural
Patient Controlled Analgesia
(PCA) Pumps
• Demand analgesia
• A specific type of SC, IV or intraspinal
delivery system
• A dose of opioid delivered when patient
decides the needed dose
• Infusion system
• Management of acute pain, post operative
pain and cancer pain.
PCA Advantages
• Less nurse time
• Patient reports
better pain relief
• Requires less total
analgesic meds
than patients on
PRN meds
• Have greater sense
of Control
• Physical Cutaneous Stimulation
• Transcutaneous Electrical Nerve
Stimulation (TENS)
• Cognitive-Behavioral Interventions
Transcutaneous Electrical
Nerve (TENS) Stimulation
• nerve conducts
electrical current and so
cannot conduct pain
Non-Pharmacologic
Interventions for Pain
a)Heat & Cold
Application
b)Guided Imagery
c)Hypnosis
d)Meditation
e)Biofeedback
f) Yoga
Non-Pharmacologic
Interventions for Pain
• Therapeutic touch
• Cutaneous Stimulation
(Massage)
• Distraction
• Deep Breathing and
Relaxation
• Music
• Progressive Relaxation
Training
Surgical Interventions to
Manage Pain
• Nerve blocks
– interrupts nociceptive transmission
– Chemical interruption of pain pathway
– Common in dental work
Surgical Interventions to
Manage Pain
• Neurosurgical interventions
– Implantation of drug-infusion system
– Neuroablation – destroys nerves
– Neuroaugmentation – electrical stimulation
Invasive Interventions to Manage Pain
Non-Pharmacologic/
Alternative Interventions for
Pain
Acupuncture
Alternative Therapies to Ease
Pain
Evaluation &
Documentation
• Evaluation: utilizes client
perception and pain rating scale to
document changes in pain
• Reassessment
• Important Considerations
• Documentations
• (show video)
The Ten Commandments of
Pain Management
• Thou shalt believe the patient’s report
of pain.
• Thou shalt assess and reassess the
patient’s response to pain
interventions.
• Thou shalt not be afraid of prescribing
or administering opioid analgesics.
• Thou shalt not prescribe inadequate
amounts of any analgesic.
Cont’d
The Ten Commandments of
Pain Management
• Thou shalt not use the abbreviation
PRN for continuous pain, but ATC.
• Thou shalt reassure the patient and
family that risk of opioid addiction is
rare.
• Thou shalt provide support for the
whole family.
• Thou shalt not limit thy approach
simply to the use of analgesics, but
also adjuvant drugs and “mind-body”
techniques.
The Ten Commandments of
Pain Management

• Thou shalt prevent or treat
side effects of opioids.
• Thou shalt not be afraid to
ask colleagues’ advice.

Modified from Twycross, R: Practical Palliative Care
Today. Spring 2000, Vol. 2. Center for Palliative
Studies at San Diego Hospice, San Diego.