By: Mayla Lerias Saba, R.N., M.D.

A look at pain
Pain is a complex, subjective phenomenon that
involves biological, psychological, cultural,
and social factors to put it succinctly, pain is
whatever the patient says it is, and it occurs
whenever she says it does. The only true
authority on any given pain is the person
experiencing it.
Pain thresholds and tolerances vary. Pain
threshold is a physiologic attribute that
denotes the intensity of the stimulus needed
to sense pain. Pain tolerance is a
psychological attribute that describes the
amount of stimulus ( duration and intensity)
that the patient can endure before stating
that she’s in pain.

Theories about pain

Specificity
Pattern
Gate control
Let’s get specific
The specificity theory maintains that
individual specialized peripheral nerve fibers
are responsible for pain transmission. This
biologically oriented theory doesn’t explain
pain tolerance, nor does it allow for social,
cultural, or empirical factors that influence
pain.
Pain Pattern
The pattern theory suggest that
excessive stimulation of all nerve endings
produces a unique pattern interpreted by the
cerebral cortex as pain. Although this theory
addresses the brain’s ability to determine the
amount, intensity, and type of sensory input,
it doesn’t address no biological influences on
pain perception and transmission.
Opening the gate
The gate control theory asserts that
some sort of gate mechanism in the spinal
cord allows nerve fibers to receive pain
sensations. (See Understanding the gate
control theory.) This theory has encourage a
more holistic approach to pain management
and research by talking into account the no
biological components of pain. Pain
management techniques, such as cutaneous
stimulation, distraction, and acupuncture are,
in part, based on this theory.
Types of pain
There are two fundamental pain types acute and chronic.
Acute Pain
Acute pain commonly accompanies tissue damage
from injury or disease. It varies from mild to serve in intensity
and typically lasts for a brief period (less than 6 months). Acute
pain is considered a protective mechanism, alerting the
individual to tissue damage or organ disease as the underlying
disorder heals.

Relief and healing

Treatment goals for acute pain include relieving pain and
healing the underlying injury or disease responsible for the
pain. Palliative treatment may include surgery, drug therapy,
application of heat or cold, or psychological and behavioral
techniques to control pain.
Understanding the gate control
theory
Intensive research into the pathophysiology of
pain has yielded several theories about pain
perception, including the MelzackWall gate
control theory. According to this theory, pain
and thermal impulses travel along small-
diameter, slow-conducting afferent nerve
fibers to the spinal cord’s dorsal horns. There,
they terminate in an area of gray matter
called the substantia gelatinosa.
Open or close the gate
When sensory stimulation reaches a critical
level, a theoretical “gate” in the substantia
gelatinosa opens, allowing nearby
transmission cells to send the pain impulse to
the brain along the interspinal neurons to the
spinothalamic tract, and then to the thamalus
and cerebral cortex (see illustration below,
left). The small sizes of the fibers enhances
pain transmission. In contrast, large-diameter
fibers inhibit pain transmission Stimulation of
these large, fast-conducting afferent nerve
fibers counters the input of the smaller fibers,
thereby closing the theoretical gate in the
substantia gelatinosa and blocking the pain
transmission (see illustration below, rigth).
Keys to the gate

Descending (efferent) impulses along

various tracts from the brain and
brain stem can enhance or reduce
pain transmission at the gate. For
example, triggering specific brain
processes, such as attention,
emotions, and memory of pain, can
intensity pain by opening the gate.
 
Chronic pain
The cause or chronic pain isn’t always clear.
Chronic pain can stem from prolonged disease
or dysfunction, as in cancer and arthritis, or it
can be associated with a mental disorder such
as posttraumatic stress syndrome. It can be
intermittent, limited, or persistent and usually
6 months or longer. This type of pain is
strongly influenced by the patient emotions
and environment.
There are three categories of chronic pain:
1 chronic nonmalignant pain, such as the pain
associated with nonprogressive or healed
tissue injury
2 chronic malignant pain, such as the pain
associated with cancer or other progressive
disorder
3 chronic intractable pain, such as the pain that
increases as the patient ability to cope
deteriorates
Not the pain next door
Chronic pain isn’t always localized which
makes difficult at times for the patient
to clearly describe what he feeling.
Furthermore, a patient with chronic pain
reacts in different ways, making it
difficult for the health care professionals
to assess the pain. One patient may cry
out, one may groan and still another
may simply withdraw. Changes in
appetite, sleeping patty can be
important clues into the nature of the
Have a stable day

Treat for chronic pain focuses on reducing or

eliminating the patient pain while
improving, or at least stabilizing, his ability
to conduct daily activities. It also attempts
to reduce the patient need for medication.
In mild chronic pain Treatment might
simply involve ice massage and exercise.
However, severe chronic pain typically
requires a multidisciplinary program to
address the physiological, psychological,
and social component of the patient’s
condition
Assessing pain

The only way to get an accurate understanding of

the patient’s pain is to ask him. Begin by asking
the patient’s to describe his pain Where does it
hurt? What exactly does it feel like? When does it
start, how long does it last, and how often does it
recur? What provokes it? What makes it feel
better? There are a variety of assessment tools
that can help. Encourage the patient to use one
to obtain a more accurate and consistent
description of pain intensity and relief two
important measurements.
Where does it hurt
Find out how the patient responds to pain. Does
his pain interfere with eating? Sleeping?
Working? His sex life? His relationship? Ask
the patient to point to the area where he feels
pain, keeping in mind That
Localized pain is felt only at its origin
Projected pain travel along the nerve pathways
Radiated pain extend in several direction from
the site of origin.
Referred pain occurs in places remote from the
site of origin.
Nature’s Source
Factors that influence the nature of patient’s pain
include duration, severity and source. The source
may be:
Cutaneous, originating in the skin or subcutaneous
tissue
Deep somatic, which include nerve, bone, muscle, and
supporting tissue
Visceral, which include the body organs. Watch for
physiological responses to pain (nausea, Vomiting
changes in vital signs) and behavioral responses to
pain (facial expression, movement and positioning,
what the patient say or doesn’t say). Also note
psychological responses, such as anger, depression,
and irritability.
About attitude

Assess the patient’s attitude about pain. Ask

him how he usually handles pain. Does he tell
other when he hurt, or does he try to hide it?
Does his family understand his pain and try to
help him deal with it? Does he accept their
help?
Pain Assessment tools
Several easy-to-use tools can help you better
understand the patient’s pain.
A rating scale is a quick method of determining
the patient’s perception of pain intensity. Ask
him to rate his pain on a scale from 1 to 10. With
1 representing pain-free and 10 representing the
most pain imaginable.
A face rating scale uses illustrations of five or
more faces with expressions that range from
happy to very unhappy. The patient chooses
the face that represents how he feels at the
moment. It's particularly useful with a young
child or a patient with language difficulty.
A body diagram allows the patient to draw the
location and radiation of pain on an illustration
of the body
A questionnaire provides the patient with key
question about the pain’s location, intensity,
quality, onset, and aggravate pain.
A questionnaire provides the patient with key
question about the pain’s location, intensity,
quality, onset, and aggravate pain.
Managing pain

Pain management can involve drug therapy

with opioid or nonopioid analgesic, including
patient controlled analgesic (PCA) and
adjuvant analgesic, neurosurgery;
transcutaneous electrical nerve stimulation
(TENS) and cognitive behavioral strategies
 Opioid analgesics

Opioid analgesics are prescribed to relieve

moderate to serve pain They include opiates
and opioid. Opiates are natural opium
alkaloids and their derivatives, opioid are
synthetic compound but can also include
opiates. Morphine is the prototype for both
types of opioid analgesic
The agony and the
ecstasy
Opioid analgesics are classified as agonists or
agonists-antagonists. Agonists are drugs that
produce analgesia by binding to central nervous
system (CNS) opiate receptors. These drugs are
the drugs of choice for severe chronic pain. They
include:
 Codeine
 Hydromorphone
 Levorphanol
 Meperidine
 Methadone
 Morphine
 Propoxyphene
Up the anti
Agonists-antagonists also produce analgesia by
binding to CNS receptors. However, they’re of
limited use for patients with chronic pain because
many have a ceiling effect or upper dosing limit.
As the dosage increases, they also can cause
hallucinations and other psychotomimetic effects
and, in opioid-dependent patients, can produce
withdrawal symptoms. This class of drugs
includes:
 Buprenorphine
 Butorphanol
 Nalbuphine
 Pentazocine
Caution is the key
Opioids can produce severe adverse effects;
therefore, caution is the key. They’re
contraindicated in patients with severe
respiratory depression and should be used
cautiously in patients with:
Chronic obstructive pulmonary disease
Hepatic or renal impairment, because they’re
metabolized by the liver and excreted by the
kidneys
Head injuries or any conditions that raises
intracranial pressure (ICP) because they
increase ICP and can induce miosis (which can
mask pupil dilation, an indicator of increased
 

Monitoring
Before giving an opioid analgesic, make sure the
patient isn’t already taking a CNS depressant such
as barbiturate. Concurrent use of another CNS
depressant enhances drowsiness, sedation, and
disorientation.
During administration, check the patient’s vital
signs and watch for respiratory depression. If his
respiratory rate declines to 10 breaths/minute or
less, call his name, touch him, and tell him to
breathe deeply. If he can’t be aroused of if he’s
confused or restless, notify the doctor and
prepare to administer oxygen. If ordered,
administer an opioid antagonist such as naloxone.
Understanding patient-controlled analgesia
A patient controlled analgesia (PCA) system
provides optimal opioid dosing while
maintaining a constant serum concentration
of the drug.
How it works?
A PCA system consists of a syringe injection
pump piggybacked into an I.V. or
subcutaneous infusion port. When the patient
presses a button, he receives a preset bolus
dose of medication. The doctor programs the
bolus dose and the “lock-out” time between
boluses, thus preventing overdose. The device
automatically records the number of times the
patient presses the button, helping the doctor
adjust the dosage.
In some cases, the PCA system allows a
reduction in drug dosage, possibly because
the patient feels more control over his pain
relief and knows that, if he’s in pain, analgesia
is quickly available. This tends to reduce the
patient’s level of stress and anxiety which can
exacerbate pain.
Patient teaching
Teach the patient About his drug therapy and ways to avoid or
resolve adverse effects. Tell him to:

 Take the prescribed drug before the pain becomes intense

to maximize its effectiveness and talk with the doctor if the
drug seems less effective over time.
 Not increase the dose or frequency of administration and
take a missed dose as soon as he remembers, while
maintaining the interval between doses.
 Skip the missed dose if it’s just about time for the next dose
to avoid serious complications of double dose.
 Refrain from drinking alcohol while taking the drug to avoid
pronounced CNS depression.
 Talk with his doctor if he decides to stop taking the drug
because the doctor can suggest an appropriate gradual
dosage reduction to avoid withdrawal symptoms.
 Avoid postural hypotension by getting up slowly when
getting out of bed or a chair.
 Eat a high-fiber diet, drink plenty of fluids, and takes a stool
softener, if prescribed.
Nonopioid analgesics
Nonopioid analgesics are prescribed to manage
mild to moderate pain. When used with an
opioid analgesic, they help relieve moderate
to severe pain and also allow lower dosing of
the opioid agent. These drugs include
acetaminophen and NSAIDs, such as aspirin,
ibuprofen, indomethacin, naproxen, naproxen
sodium, phenylbutazon, and sulindac.
 
Special effects NSAIDs and acetaminophen
produce antipyretic and analgesic effects. In
addition, as their name suggest, NSAIDs have
an anti inflammatory effect. Because these
drugs all differ in chemical structure, they
vary in their onset of action, duration or
effect, and method of metabolism and
excretion.

In most cases, the analgesic regimen includes

a nonopiod drug even if the patient’s pain is
severe enough to warrant treatment with an
opiod. They’re commonly used to treat
postoperative and postpartum pain,
headache, myalgia, arthralgia,
dysmenorrheal, and cancer pain.
Not so special effects
The chief adverse effects of NSAIDs include:
inhibited platelet aggregation (rebounds when
drug is stopped)
GI irritation
Hepatotoxicity
Nephrotoxicity
Headache
Liver damage (in long-term, high-dose use).
NSAIDs shouldn’t be used in patients with
aspirin sensitivity, especially those with
allergies, asthma, and aspirin-induced nasal
polyps, due to the increased risk of
bronchoconstriction or anaphylaxis. Also,
NSAIDs are contraindicated in patients with
thrombocytiopenia, and should be used
cautiously in neutropenic patients because
antipyretic activity may mask the only sign of
infection. Some NSAIDs are contraindicated in
patients with renal dysfunction, hypertension,
GI inflammation, or ulcers.
Before administering nonopioid analgesics, check
the patient’s history for a previous
hypersensitivity reaction, which may indicate
hypersensitivity to a related drug in this group. If
the patient is already talking an NSAID, ask him if
he has experienced GI irritation. If he has, the
doctor may choose to reduce the dosage or
discontinue the drug.
If the patient is undergoing long-term therapy,
report any abnormalities in renal and liver
function studies. Also, monitor hematologic
studies and evaluate complaints of nausea or
gastric burning. Watch for sign or iron deficiency
anemia, such as pallor unusual fatigue, and
 Patient teaching

For patient talking and NSAID, teach him the

signs and symptoms of overdose,
hypersensitivity, and GI bleeding, such as
rash, dyspnea, confusion, blurred vision,
nausea, bloody vomitus, and black, tarry
stools. Tell him to report any of these signs to
his doctor immediately.
If the patient is talking acetaminophen, teach
him that nausea, vomiting, abdominal cramps,
or diarrhea may indicate an overdose and that
he should notify his doctor immediately.
 Neurosurgery
Neurosurgery is an extreme form of pain
management and is rarely needed. However ,
there are a number of procedures, such as
rhizotomy and cordotomy, that can control
pain by surgically modifying critical points in
the nervous system. (see surgical intervention
for pain,)

 
Surgical intervention for pain
Surgery is typically considered to manage pain
only when pharmacologic therapies fail. More
and more however, these techniques are
being used earlier with excellent effect.
Surgical procedures used to treat pain include
neurectomy, rhizotomy, cordotomy,
cryoanalgesia, and radio frequency lesioning.
Neurectomy involves resection or partial or
total excision of a spinal or cranial nerve. This
procedure is relatively quick and only requires
local or regional anesthesia. Unfortunately.
Loss of motor sensation is a possible adverse
effect, and pain relief may only be temporary,
peripheral neurectomy is consider when all
standard pain management therapies have
failed.
Rhizotomy involves cutting a nerve to relief
pain. Rhizotomy of the dorsal nerve root may
produced analgesia for localized severe pain,
such as on the trunk, abdomen, or limb. Motor
function is usually unaffected if one dorsal
nerve root for the area is left intact.
 
Cordotomy can be performed as an open
surgery or percutaneously. A unilateral
cordotomy is performed to relieve somatic
pain on one side of the body. A bilateral
cordotomy is performed to relieve visceral
pain on both sides of the body.
Cryoanalgesia deactivates a nerve using a
cooled probe that cause temporary nerve
injury. Nerve function returns over time and
the procedure can be repeated. Cryoanalgesia
can provide pain relief for the patient with
pain from a surgical scar, a neuroma trapped
in scar tissue, and occipital neuralgia.
Radio-frequency lesioning

Radio-frequency lesioning may affect the nerve

from heat generated, the magnetic field
created by the radio waves, or both nerve
function is stopped for a prolonged period. If it
does return, the procedure can be repeated.
The most frequent use of this technology is to
retreat pain related to the facet joint and
lumbar sympathetic and peripheral nerves.
Because it’s a focused therapy. It’s used when
specific nerves can be targeted.
 Tens

Tens relieves acute and chronic pain

by using a mild electrical current
that stimulates nerve fibers to block
the transmission of pain impulses to
the brain. The current is delivered
through electrodes placed on the
skin at points determined to be
related to the pain. TENS is used to
treat:
 Chronic back pain
 Postoperative pain
 Dental pain
 Labor pain
 Pain from peripheral neuropathy or nerve injury
 Postherpetic neuralgia
 Reflex sympathetic dystrophy
 Musculoskeletal trauma
 Arthritis
 Phantom limb pain.
 
TENS is contraindicated if the patient has a
pacemaker. The current may also interfere
with electrocardiography or cardiac
monitoring. Furthermore, TENS shouldn’t be
used when the etiology of the pain is unknown
because it might mask a new pathology.
Asses the patient for signs of excessive or
inadequate stimulation. Muscle twitching may
indicate overstimulation, whereas an inability
to feel any tingling sensation may mean that
the current is too low. If the patient complaints
of pain or intolerable paresthesia, check the
settings, connections, and electrode
placements. Adjust the settings if necessesary.
If you must relocate the electrodes during
treatment, first turn off the TENS unit. Evaluate
the patient’s response to each TENS treatment
and compare the results. Also, use your
baseline assessment evaluate the
effectiveness of the procedure.
If the patient will use the TENS unit at home,
have him demonstrate the procedure,
including electrode placement, the settings of
the unit’s control, electrode removal, and
proper care of the equipment. Explain that he
should strictly follow the prescribed settings
and electrode placement.
Warm against using high voltage, which can
increase pain, or using the unit to treat pain
for which he doesn’t know the cause. Also tell
the patient to notify the doctor if pain worsens
or develops at another site.
Behavior modification and relaxation
techniques may be used to help the patient
reduce the suffering associated with pain.
These techniques included biofeedback,
distraction. Guided imagery, hypnosis, and
meditation. These “mind-over-pain”
techniques allow the patient to exercise a
degree of control over his pain. In addition,
they have the added benefit of being virtually
risk-free with few contraindications. Even so, if
the patient has a significant psychiatric
problem, a psychotherapist should teach him
the relaxation techniques