Pain management
Objectives:
Students will be able to understand:
What is pain
Types of pain
Physiology of pain
Types of Stimulus causing pain
Factors affecting pain
Difference b/w acute & chronic pain
Medical management of pain
Non-pharmacological pain management
Nursing intervention for pain management
What is pain?
“Pain is defined as a unpleasant sensory and emotional experience
associated with actual or potential tissue damage”.
Pain is also considered as one of the 5th vital signs, showing normal
physiological state of body.
Types of Pain
Pain can be classified into various types on the basis of location, duration, intensity and etiology.
1. Location:
Referred pain
Visceral pain
2. Duration:
Acute pain
Chronic pain
Types continued…
3. Intensity:
Mild
Moderate
Severe
4. Etiology
Nociceptive Pain (Muscle or bone injury etc.)
Somatic Pain (e.g. skin, connective tissue)
Neuropathic Pain (Peripheral nerve damage e.g. in diabetic patients)
Psychogenic Pain (Anxiety, depression-Coping style)
Idiopathic Pain (Pain without any known cause)
Acute Vs Chronic Pain
Acute pain Chronic Pain
Mild to severe Mild to severe
Sympathetic nervous system Parasympathetic nervous system
responses: responses:
• Increased pulse rate • Vital signs normal
• Increased respiratory rate • Dry, warm skin
• Elevated blood pressure • Pupils normal or dilated
• Diaphoresis
• Dilated pupils
Related to tissue injury; resolves Continues beyond healing
with healing
Client may be restless Client is usually depressed and
and anxious withdrawn
Client reports pain Client often does not mention
pain unless asked
Client may exhibit behavior Pain behavior often absent
indicative of pain: crying,
rubbing area, holding area
Physiology of Pain
“The physiological processes related to pain perception as described as
Nociception”.
Normal physiology of pain can be explained into four steps:
1. Transduction
2. Transmission
3. Perception
4. Modulation
1.Transduction:
Specialized pain receptors or nociceptors can be excited by mechanical, thermal, or
chemical stimuli.
During the transduction phase, harmful stimuli trigger the release of biochemical
mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P,
which sensitize nociceptors.
Pain medications block the production of chemical mediators.
2. Transmission:
This second process takes place into three steps or segments:
The first segment of transmission, the pain impulses travel from the peripheral
nerve fibers to the spinal cord.
The second segment is transmission of the pain signal through an ascending pathway
in the spinal cord to the brain.
The third segment involves transmission of information to the brain where pain
perception occur.
Pain control can take place during this second process of transmission. For example,
opioids (narcotic analgesics) block the release of neurotransmitters
3. Perception:
The third process, perception, is when the client becomes conscious of the
pain. Pain perception is the sum of complex activities in the CNS that may
shape the character and intensity of pain perceived and give meaning to the
pain.
Cognitive–behavioral therapy and approaches such as distraction and
imagery have been developed based on evidence that brain processes can
influence pain perception
4. Modulation
The “descending system,” this final process occurs when neurons in the brain send
signals back down to the dorsal horn of the spinal cord.
Pain can be controlled by tricyclic antidepressants (prevent reabsorption
of neurotransmitters) etc.
Gate-Control Theory
According to Melzack and Wall’s gate control theory (1965), this is based on two types
of nerve fibers named as:
Small diameter (A-delta or C) peripheral nerve fibers
Carry signals of noxious (painful) stimuli to the dorsal horn, where these signals are
modified when they are exposed to the substantia gelatinosa. Ion channels on the pre- and
postsynaptic membranes serve as gates that, when open, permit positively charged ions to
rush into the second-order neuron, sparking an electrical impulse and sending pain signals
to the thalamus.
Large diameter (A-beta) nerve fiber
Peripherally, large-diameter (A-beta) nerve fibers, which typically send messages of touch
or warm or cold temperatures, have an inhibitory effect on the substantia gelatinosa, and
may activate descending mechanisms that can lessen the intensity of pain perceived or
inhibit the transmission of those pain impulses—closing the (ion) gates.
Types Of Pain Stimuli
MECHANICAL
1. Trauma to body tissues (e.g., surgery)
2. Alterations in body tissues (e.g., edema)
3. Blockage of a body duct
4. Tumor
5. Muscle spasm
THERMAL
Extreme heat or cold (e.g., burns)
CHEMICAL
1. Tissue ischemia (e.g., blocked coronary artery)
2. Muscle spasm
Pain Assessment
Accurate pain assessment is essential for effective pain management. Many health facilities
make pain assessment the fifth vital sign. It is done by objective and subjective approach by
different means. For examples by using pain scales:
Numeric rating pain scale
Image-1
Image-2
Pain Assessment continue…
Baker Faces pain scale
Pain Assessment Pneumonic/Model/Method
Factors Affecting Pain Experience
Age or Developmental Stage
Gender
Ethnic and Cultural Values
Environment
Support Group
Coping Resources
Previous Pain Experiences
Meaning of Pain
Other medical comorbidities
Misconceptions About Pain (Table 46-5)
Pain Management
1. Pharmacological Pain Management
Pain management involves the use of opioids (narcotics), nonopioids such as
nonsteroidal anti-inflammatory drugs (NSAIDS) and Coanalgesic drugs.
Nonopioid analgesics/NSAIDS for mild pain e.g. (Acetaminophen, Ibuprofen,
Naproxen, Ketorolac)
Opioid analgesics e.g. (Codeine, Tramadol, Morphine, Methadone)
Co-analgesics e.g. (Tricyclic antidepressants, Anticonvulsants)
Continue…
2. Non-Pharmacological Pain Management
Nonpharmacologic pain management consists of a variety of physical main based on
targeting to Body, Mind, Spirit and Social Interaction:
Mind–body (cognitive–behavioral) intervention e.g. Meditation, Distracting Activities
(visual, auditory, tactile, intellectual)
Lifestyle pain management strategies that target the body, mind, spirit, and social interactions
Physical modalities include cutaneous stimulation, ice or heat application, immobilization,
massage etc.
Therapeutic exercises
Transcutaneous electrical nerve stimulation (tens)
Acupuncture or Acupressure
Nursing Interventions
Nursing interventions or nursing implementation for the patients having pain can be described as:
Monitor vital signs
Measures pain intensity and pain interference
Observe for the effects of pain on sleeping pattern or life style
Monitor the patient’s mood and response towards pain
Monitor for co-occurring risk for substance abuse
Monitor the complications of pain
Administer medications as prescribed by physician
Monitor and calculate the accurate dose, route, time of medicines advised by the physician
Educate the patient and family about the possible side effects of medicines especially of opioids drugs
Maintain proper diet and nutrition
Provide emotional support for patient and family
Provide Non-medical/Non-pharmacological management for pain (As mention above)
Medical Terminology related Pain
Acute pain: Directly related to tissue injury which resolves with healing
Chronic Pain: Pain that persists for 6 months or longer and remains even after healing of
cause
Pain threshold: The least amount of stimuli necessary for a person to label a sensation as pain.
Pain tolerance: The most pain an individual is willing or able to tolerate before taking evasive
actions.
Allodynia: Sensation of pain from a stimulus that normally does not produce pain (e.g., light
touch)
Dysesthesia: An unpleasant abnormal sensation that can be either spontaneous or evoked
Hyperalgesia: Increased sensation of pain in response to a normally painful stimulus
Fibromyalgia: Pain that is associated with muscles or bone (musculoskeletal)
Intractable pain: A pain state (generally severe) for which no cure is possible even after
accepted medical evaluation and treatments have been implemented.
Nerve block: is a chemical interruption of a nerve pathway, caused by injecting a local
anesthetic into the nerve.
Any Question…???
INSPIRATION
“If you are not willing to learn,
No one can help you
If you are determined to learn,
No one can stop you”
