Pain

Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding pain, and its management. Highly recommended for II B.Sc Nursing Students

1. PAIN
Mr. Aby Thankachan, M.Sc(N), PGDSH
Senior Tutor
Dept. of Medical Surgical Nursing
KMCH Con, Coimbatore

2. INTRODUCTION
Painiscomplexmulti-factorialphenomenon.Itis
anindividual,uniqueexperiencethattheymaybe
difficultyforclientstodescribeorexplainandisoften
difficultforotherstorecognize,understandsand
assess.
DEFINITION
"Anunpleasantsensoryandemotionalexperience
associatedwithactualorpotentialtissuedamageor
describedintermsofsuchdamage"
(Merskey and Bugdulk 1994)
Cont…

3. 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.

4. TYPES OF PAIN
Cutaneous Pain
Somatic Pain
Visceral pain
Referral Pain or neuropathic Pain.

5. oCutaneous pain
Cutaneouspainoriginatesattheskinlevelandthe
depthofthetraumadeterminesthistypeofsensation
thatisexperienced.
Somaticpain
Somaticpainisgeneratedfromdeeperconnective
tissuestructuressuchasmuscletendonsandjoints.
Visceralpain
Visceralpainarisesfrominternalorgansthatare
diseasedorinjuredandtendtobereferredorpoorly
localized.

6. Referralpainorneuropathicpain
Referredpaindescribesdiscomfortthatisperceivedin
ageneralareaofthebody,butnotintheexactsite
whereanorganisanatomicallylocated.

7. CATEGORIES OF PAIN
Acute pain
Chronic pain.
Acute pain
Acutepainisusuallyofshortduration(lasting
fromsecondsto6months)usuallyrecentonsetand
commonlyassociatedwithaspecificinjuryacutepain
indicatesthatdamagesorinjuryhasoccurred.
Ifnolastingdamageoccursandnosystematicexists
acutepainusuallydecreasesalongwithhealing.
Acutepainisreversibleforcontrollablewithadequate
treatment.
Unrelievedacutepainleadstochronicpainstates.

8. Chronic pain
Chronicpainmaybedefinedaspainthatlastfor6
monthsorlonger,neverthelessafter6monthsmost
painexperienceareaccompaniedbyproblemsrelated
tothepainitself.

11. THEORIES OF THE PAIN
Gate Control System

12. CHARACTERISTICS OF PAIN
Intensity
Theintensityofpainrangesfromnonetomild
discomforttoexcruciating.Thereisno
correlationbetweenreportedintensityandthe
stimulusthatproducedit.Thereportedintensity
isinfluencedbytheperson’spainthreshold
andpaintolerance.Painthresholdisthe
smalleststimulusforwhichapersonreports
pain,andthetoleranceisthemaximumamount
ofpainapersoncantolerate.

13. Timing
Sometimestheetiologyofpaincanbe
determinedwhentimeaspectsareknown.
Therefore,thenurseinquiresabouttheonset,
duration,relationshipbetweentimeand
intensity,andwhethertherearechangesin
rhythmicpatterns.Thepatientisaskedifthe
painbegansuddenlyorincreasedgradually.
Suddenpainthatrapidlyreachesmaximum
intensityisindicativeoftissuerupture,and
immediateinterventionisnecessary.

14. Location
Thelocationofpainisbestdeterminedby
havingthepatientpointtotheareaofthebody
involved.Somegeneralassessmentformshave
drawingsofhumanfigures,andthepatientis
askedtoshadeintheareainvolved.Thisis
especiallyhelpfulifthepainradiates(referred
pain).

15. Quality
Thenurseasksthepatienttodescribethepain
inhisorherownwordswithoutofferingclues.
Forexample,thepatientisaskedtodescribe
whatthepainfeelslike.Sufficienttimemustbe
allowedforthepatienttodescribethepainand
forthenursetocarefullyrecordallwordsthat
areused.Ifthepatientcannotdescribethe
qualityofthepain,wordssuchasburning,
aching,throbbing,orstabbingcanbeoffered.

16. PersonalMeaning
Patientsexperiencepaindifferently,andthepain
experiencecanmeanmanydifferentthings.Itis
importanttoaskhowthepainhasaffectedthe
person’sdailylife.Somepeoplecancontinueto
workorstudy,whileothersmaybedisabled.

17. AggravatingandAlleviatingFactors
Thenurseasksthepatientwhatifanything
makesthepainworseandwhatmakesitbetter
andasksspecificallyabouttherelationship
betweenactivityandpain.Thishelpsdetect
factorsassociatedwithpain.Forexample,ina
patientwithadvancedmetastaticcancer,pain
withcoughingmaysignalspinalcord
compression

18. PainBehaviors
Whenexperiencingpain,peopleexpresspain
withmanydifferentbehaviors.Thesenonverbal
andbehavioralexpressionsofpainarenot
consistentorreliableindicatorsofthequalityor
intensityofpain,andtheyshouldnotbeusedto
determinethepresenceoforthedegreeofpain
experienced.Patientsmaygrimace,cry,rubthe
affectedarea,guardtheaffectedarea,or
immobilizeit.

19. PAIN ASSESSMENT
Assessmentisanessential,throughoften
overlookedstep,inpainmanagement.
Theseeffortsurgeclinicianstodesignatepainas
the“fifthvitalsigns”
Keytoaccurate
Toconducttheevaluationinaccordancewith
coreprinciples.

20. INSTRUMENT FOR ASSESSING THE
PERCEPTION OF PAIN
Visual analogue scales
Numeric pain intensity scales
Simple descriptive pain intensity scales

23. VISUAL ANALOGUE SCALES

24. PAIN MANAGEMENT
Pharmacologic interventions
Non-pharmacologic interventions

25. Premedication Assessment
Beforeadministeringanymedication,thenurse
asksthepatientaboutallergiestomedications
andthenatureofanypreviousallergic
responses.Trueallergicoranaphylactic
responsestoopioidsarerare,butitisnot
uncommonforapatienttoreportanallergyto
oneoftheopioids.Onfurtherexamination,the
nurseoftenlearnsthattheextentoftheallergy
was“itching”or“nauseaandvomiting.”

26. Thenurseobtainsthepatient’smedication
history(eg,current,usual,orrecentuseof
prescriptionorover-the-countermedicationsor
herbalagents),alongwithahistoryofhealth
problems.Certainmedicationsorconditions
mayaffecttheanalgesicmedication’s
effectivenessorthemetabolismandexcretionof
analgesicagents.

27. AGENTS USED THE PAIN
Thethreegeneralcategoriesofanalgesicsagents
areopioids,NSAID,andlocalanesthetics.
Otheradjunctiveagentssuchasantidepressant
andanticonvulsantmedicationmayalsobeused.

28. OpioidsAnalgesicAgents
Opioidscanbeadministeredbyvariousroutes,
includingoral,intravenous,subcutaneous,
intraspinal,intranasal,rectal,andtransdermal
routes.Thegoalofadministeringopioidsisto
relievepainandimprovequalityoflife;therefore,
therouteofadministration,dose,andfrequency
ofadministrationaredeterminedonanindividual
basis.
Opioidsanalgesic agents given orally may provide
a more consistent serum level than those given
intramuscularly.

29. DRUGS
Morphine 30-60mg(oral)or 10mg (parenteral)
Tramadol50-100mg (oral)
Codeine 15-30 mg oral
Adverse effects
Respiratory depression and sedation
Nausea and vomiting
Constipation
Pruritus

30. NON STEROIDAL ANTI
INFLAMMATORY DRUGS
NSAIDsarethoughttodecreasepainby
inhibitingcyclo-oxygenase(COX).
Theenzymeinvolvedintheproductionof
prostaglandinfromtraumatizedorinflamed
tissues.
TwotypesCOX,COX-1,andCOX-2

31. LocalAnestheticAgents
Localanestheticsworkbyblockingnerve
conductionwhenapplieddirectlytothenerve
fibers.Theycanbeapplieddirectlytothesiteof
injury(eg,atopicalanestheticsprayforsunburn)
ordirectlytonervefibersbyinjectionoratthe
timeofsurgery.

32. TOPICALAPPLICATION
Localanestheticagentshavebeensuccessfulin
reducingthepainassociatedwiththoracicor
upperabdominalsurgerywheninjectedbythe
surgeonintercostally.Localanestheticagentsare
rapidlyabsorbedintothebloodstream,resulting
indecreasedavailabilityatthesurgicalorinjury
siteandanincreasedanestheticlevelinthe
blood,increasingtheriskoftoxicity

33. Althoughpainmedicationisthemostpowerful
painrelieftoolavailabletonurses,itisnotthe
onlyone.Nonpharmacologicnursingactivities
canassistinrelievingpainwithusuallylowrisk
tothepatient.
NONPHARMACOLOGIC
INTERVENTIONS

34. CutaneousStimulationandMassage
Thegatecontroltheoryofpainproposesthat
thestimulationoffibersthattransmit
nonpainfulsensationscanblockordecreasethe
transmissionofpainimpulses.Several
nonpharmacologicpainreliefstrategies,
includingrubbingtheskinandusingheatand
cold,arebasedonthistheory.

36. IceandHeatTherapies
Iceandheattherapiesmaybeeffectivepain
reliefstrategiesinsomecircumstances;however,
theireffectivenessandmechanismofaction
needfurtherstudy.Proponentsbelievethatice
andheatstimulatethenon-painreceptorsinthe
samereceptorfieldastheinjury.

38. Transcutaneous ElectricalNerve
Stimulation
Transcutaneouselectricalnervestimulation
(TENS)usesabatteryoperatedunitwith
electrodesappliedtotheskintoproducea
tingling,vibrating,orbuzzingsensationinthe
areaofpain.Ithasbeenusedinbothacuteand
chronicpainreliefandisthoughttodecrease
painbystimulatingthenon-painreceptorsinthe
sameareaasthefibersthattransmitthepain.

41. Distraction
Distractionhelpsrelievebothacuteandchronic
pain(Johnson&Petrie,1997).Distraction,which
involvesfocusingthepatient’sattentionon
somethingotherthanthepain,maybethe
mechanismresponsibleforothereffectivecognitive
techniques.Distractionisthoughttoreducethe
perceptionofpainbystimulatingthedescending
controlsystem,resultinginfewerpainfulstimuli
beingtransmittedtothebrain.

43. RelaxationTechniques
Skeletalmusclerelaxationisbelievedtoreduce
painbyrelaxingtensemusclesthatcontributeto
thepain.Considerableevidencesupports
relaxationaseffectiveinrelievingchroniclow
backpain(NIHTechnologyAssessmentPanel,
1995).

44. GuidedImagery
Guidedimageryisusingone’simaginationina
specialwaytoachieveaspecificpositiveeffect.
Guidedimageryforrelaxationandpainrelief
mayconsistofcombiningslow,rhythmic
breathingwithamentalimageofrelaxationand
comfort.

45. The nurse instructs the patient to close the eyes
and breathe slowly in and out. With each slowly
exhaled breath, the patient imagines muscle
tension and discomfort being breathed out,
carrying away pain and tension and leaving
behind a relaxed and comfortable body.

46. Hypnosis
Hypnosis, which has been effective in relieving
pain or decreasing the amount of analgesic
agents required in patients with acute and
chronic pain, may promote pain relief in
particularly difficult situations

47. Neurologicandneurosurgicalmethodsavailable
forpainreliefinclude
(1)stimulationprocedures(intermittentelectri-
calstimulationofatractorcentertoinhibitthe
transmissionofpainimpulses),
(2)administrationofintraspinalopioids,and
(3)interruptionofthetractsconductingthepain
impulsefromtheperipherytocerebral
integrationcenters.
Neurologic and Neurosurgical
Approaches to Pain Management

48. STIMULATION PROCEDURES
Electricalstimulation,orneuromodulation,isa
methodofsuppressingpainbyapplying
controlledlow-voltageelectricalpulsestothe
differentpartsofthenervoussystem.Electrical
stimulationisthoughttorelievepainby
blockingpainfulstimuli

49. InterruptionofPainPathways
Asdescribedabove,stimulationofaperipheral
nerve,thespinalcord,orthedeepbrainusing
minuteamountsofelectricityandastimulating
deviceisusedifallotherpharmacologicand
nonpharmacologictreatmentsfailtoprovide
adequaterelief

50. CORDOTOMY
Acordotomyisthedivisionofcertaintractsof
thespinalcord).Itmaybeperformed
percutaneously,bytheopenmethodafter
laminectomy,orbyothertechniques.
Cordotomyisperformedtointerruptthe
transmissionofpain(Hodge&Christensen,
2002).Caremustbetakentodestroyonlythe
sensationofpain,leavingmotorfunctions
intact.

51. RHIZOTOMY
Sensory nerve roots are destroyed where they
enter the spinal cord. A lesion is made in the
dorsal root to destroy neuronal dysfunction and
reduce nociceptiveinput. With the advent of
microsurgical techniques, the complications are
few, with mild sensory deficits and mild
weakness.