DeFiNiTiOnS oF pAiN

Pain is an unpleasant

sensory and emotional experience associated with actual or potential tissue damage.

 a personal private sensation of

hurt. a harmful stimulus that signal current or impending tissue damage. a pattern of responses to protect the organism from burn.

whatever the

experiencing person says it is existing whenever the person say it is

tErMiNoLoGiEs

 Radiating pain -perceived at the

source of the pain and extends to the nearby tissues Referred pain felt in a part of the body that is considerably removed or far from the tissues causing the pain

Excessive

sensitivity to pain

the amount of pain

stimulation a person requires before feeling pain least level of pain that the patient is able to detect

Includes the ANS and behavioural responses to pain Ex: ANS response- autonomic reaction of the body that often protect the individual from further harm. (automatic withdrawal of hand from hot object.) Behavioural response- is a learned response used as a method of coping with pain.

maximum amount and duration of pain that an individual is willing to endure greatest level of pain that the patient is able to tolerate

pain receptors Free nerve ending in the

skin that respond only to intense, potentially damaging stimuli.

the point which

the person becomes aware of the pain

tRiAd Of PaiN pErCePtiOn

1.Pain Receptor 2.Pain Stimuli 3.Pain Fibers

1. 2. 3.

Mechanical Thermal Chemical

Pain Fibers
There are two separate pathways that transmit pain impulses to the brain: (1) Type A-delta fibers are associated with fast, sharp, acute pain and (2) Type C fibers are associated with slow, chronic, aching pain

Pain Fibers

pAiN sYnDrOmEs

Referred pain is felt in

areas other than those stimulated. It may occur when stimulation is not perceived in the primary areas.

 The term psychogenic pain has

been used to describe pain for which no pathologic condition has been found or in which the pain appears to have a greater psychological basis than a physical one.

Pain in the neurologic system occurs in different forms. Neuralgia is sharp, spasmlike pain along the course of one or more nerves. Two common areas of neuralgia are the trigeminal nerve in the face and the sciatic nerve in the lower trunk. Causalgia, a form of neuralgia, is severe burning pain associated with injury to a peripheral nerve in the extremities.

Painful perception

perceived in a missing body part or in a body part paralyzed from a spinal cord injury

This type of pain is

a chronic pain that is resistant to cure or relief.

pAtHo PhYsiOLoGy oF pAiN

1.Transduction 2.Transmission 3.Perception 4.Modulation

cerebral cortex interprets quality pain stimulus Somato sensory cortex identifies location, intensity of pain association cortex determines how we feel pain limbic system (process emotional reaction to pain)

endogenous opioids (endorphins & enkephalins chemical substances of spinal and medullary dorsal horn, periaqueductal gray matter, hypothalamus and amygdala in the CNS) serotonin 5HT norepinephrine gamma amino butyric acid (GABA)

TyPeS oF pAiN

Categories of pain according to its 1. Origin 2. Onset 3. Severity 4. Cause or etiology

Category of pain according to its ONSET Acute pain following acute injury, disease or some type of surgery Chronic malignant pain associated with cancer or other progressive disorder Chronic nonmalignant pain in the persons whose tissue injury is non progressive or healed

According to cause/ physiologic basis of pain Mechanical - trauma - blockage of body duct - tumor - muscle spasm Thermal - extreme heat or cold

Chemical - Tissue ischemia

Blocked artery

Stimulation of pain receptors

Accumulation of Lactic acid

Theories of Pain
Gate control theory Sensory/specificity

theory Intensity theory

gAtE cOnTroL ThEoRy

Melzack and Watt

It states that there are no specific nerve receptors for particular stimuli a. This theory proposes that pain originates in specific pain receptors, not in free nerve endings b. It doesn t explain pain modulation by variables, such as social and cultural factors. It also doesn t account for pain syndromes, such as causalgia and phantom pain Nocireceptors noxious stimuli Thermoreceptors heat and cold Mechanoreceptors pressure, pulling or tearing sensation Chemoreceptors chemicals

It states that pain is perceived whenever the stimulus is intense enough. a. This theory relates pain intensity to the strength of the stimulus and the summation effect of continued stimulation b. This theory has been proposed because of the inadequacies of the specificity theory. However, it does not explain psychological factors related to pain

Factors influencing reaction to pain

Psychological Physiological Cultural

Infant: perceive pain and respond to its increasing sensitivity Toddler: respond by crying and anger because they perceive it as a threat to security or sense that pain is a punishment School age: try to be brave and not to cry or express much pain so parents and nurse will not be angry with them Adolescent: may not want to report pain in front of peers because they perceive complaints of pain as weakness Adult: may not report pain for fear that it indicates poor diagnosis. Nurse may mean weakness and failure

I LL EXEMPT IN THE PRELIM EXAM ANYONE WHO CAN PINPOINT FROM A CLASS PICTURE A STUDENT WHO IS HALFSLEEPY............READY?

Pain Management

Pharmacologic Treatment

Analgesics :
 Non opioids/ non- narcotic analgesics

 NSAIDs  Narcotic analgesics / opioids  Adjuvants / co- analgesics  Local anesthesia  Patient controlled analgesia  Epidural analgesia

  

Eg. Acetaminophen , acetyl salicylic acid Usually for Mild pain Mechanism of action:

- inhibiting synthesis of prostaglandins - inhibiting cellular responses during inflammation - act on peripheral nerve receptors to reduce transmission & reception of pain stimuli

Eg : Ibuprofen, Naproxen, Indomethacin, Piroxicam, Ketoralac Used for pain such as dysmenorrhea, headaches, rheumatoid arthritis, gout, soft tissue athletic injury Benefits: - No sedation - No interference with bowel or bladder function Nursing alert : Do not use in older clients Chronic use is not advised due to gastric irritation

 

    

Eg: meperidine, methylmorphine, morphine sulphate, fentanyl, hydromorphone Used in moderate to severe pain Acts in centers of brain & spinal cord to modify perception & reaction to pain Nausea, vomiting, constipation ,altered mental processes are common side effects Acts on CNS & cause depressing and stimulating effects. Opiates can cause respiratory depression

    

Sedatives, anti-anxiety agents, muscle relaxants Eg: amitriptyline, hydroxyzine, & diazepam Enhance pain control / relieve depression & nausea Can be given alone or with analgesics Indicated for chronic pain, pain associated with anxiety, depression, nausea & vomiting Adverse effects: Drowsiness, impaired coordination, judgement & mental alertness Misuse is a serious health problem

Temporary loss of pain conduction by inhibition of pain stimuli conduction in nerve endings Topical application on skin & mucous membrane or injected to anesthetize a body part Side effects - itching / burning of skin - localized rash - change in heart rate - increased risk of systemic side effects

A drug delivery system which is a safe method for post operative, traumatic & obstetrics, burns, terminal care pediatrics and cancer pain management Involves self IV drug administration Goal : to maintain a constant plasma level of analgesic so that the problems of client with needed dosing (PRN) are avoided Client preparation & teaching is important Check IV line & PCA device regularly

 

 

   

Easy access for clients for medication Allows self administration with no risks Pain relief without depending on nurses Small doses of medications at short intervals for sustained pain relief Stabilized serum drug levels Decreased anxiety

 

 

Patient becomes dependant on PCA If mobility is contraindicated, client may move due to decreased or no pain by PCA Respiratory depression Side effect may be constipation Mechanical failure of pump Relatives may press button for client Wrong programming parameters Incorrect placing of syringe can cause infusion of excessive drug doses Costly & if client may not understand the system

     

Permits control / reduction of severe pain without more serious sedative effects by blocking pain transmission at nerve root / spinal cord level Can be short / long term depending on the clients condition It involves placement of a catheter through a needle in the epidural space between L2 to L5 just after the epidural mater so continuous infusions of analgesic agents can be given

Advantages :
      

Excellent anesthesia Minimal sedation Long duration of action Early ambulation No repeated injections No significant effect on sensation Little effect on blood pressure / heart rate

Nursing alert:
    

Prevent catheter displacement Maintain catheter function Monitor for respiratory depression Prevent undesirable complications Maintain urinary & bowel functions

Contra indications for use:

       

If patient does not consent to the procedure Hemorrhagic disorders ( hematoma) Local sepsis ( meningitis / epidural abscess) Allergy to LA agents / opiates Abnormalities of spine Pre-existing hypotension Patients with neurological problems Inadequate / unavailable facilities to safely monitor and care for clients

A fine needle is inserted from the skin through the dura and arachnoid mater into the subarachnoid space between L2 to L3 Enables the injection of analgesic agents directly into the cerebrospinal fluid in one dose administration only Nursing Prioirity: Maintain flat on bed for 6 to 8 hours to prevent headache (prevents traction of brain and SC due to CSF leak)

MOMMY BAKIT PO ALAT CEREAL KO?!

SURGICAL

TREATMENT

Dorsal Rhizotomy: Rhizotomy:



Dorsal nerve roots ( posterior) are resected as they enter spinal cord Effective for local pain relief Loss of pain sensation but has full motor function and thermal sensation

 

Cardotomy or spinothalamic tractotomy



Extensive & involves resection of the spinothalamic tract ( unrelieved pain) Risk of permanent paralysis is more due to edema / accidental resection of motor nerves Permanent loss of pain & temporary sensation in the affected areas

NONPHARMACOLOGIC

A.Cognitive Behavioral Approaches:

1. Distraction
  

Diverting attention Reducing awareness of pain Increase pain tolerance eg : music, TV, radio, playing game, reading, conversing, using computer etc

2. Reducing Pain Perception

  

Removing / preventing painful stimuli especially for clients who are immobilized Consider aspects that can cause discomfort & pain and avoid them Control painful stimuli in your clients environment, eg: change wet dressings, positioning the client, preventing urinary retention, avoid exposing skin to irritants

3. Bio-feed back
    

Using a machine that measures the degree of muscular tension with skin electrodes in microvolts A polygraph machine records the tensional level for the client to see Client subsequently will try to learn to use relaxation techniques / imagery to reduce tension May produce deep relaxation if effective Effective for muscle tension & migraine headache

Biofeedback in Progress A patient at a biofeedback clinic sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions, and may help some paralyzed patients regain the use of their limbs.

4. Hypnosis
 

Called as therapeutic suggestion Induces trance like state using focusing & relaxation techniques, giving the patient suggestions that may be helpful after the return of an alert state of consciousness Intense concentration reduces apprehension or stress Should be done by trained person Only effective when the individual cooperates

  

Goals:
   

to provide comfort to correct physical dysfunctions to alter physiological responses to reduce fears associated with pain related immobility

Examples: 1. Acupressure / acupuncture 2. Cutaneous stimulation (massage, heat application, TENS) 3. Binders, Chiropractice

 

Chinese technique Various points in the body stimulate the flow of Qi (chee) or natural meridians ( lines/passage ways) of energy that pass through the body Used for backache, migraines and post operative pain Acupressure - application of pressure to various points of body Acupuncture insertion of extremely fine needles into various points of the body. The needles unblock the meridians allowing free flow of energy and relief of symptoms

 

A. Massage stimulates circulation, relaxes muscles, increases patients sense of well being B. Application of heat used to soothe / relieve pain from muscular strain / overwork eg: for healing tissues C. Application of cold reduces swelling, calming muscle spasms, reducing pain in joints & muscles

D. TENS (Transcutaneous Electric Nerve Stimulation)  Placing electrodes on the painful area of patient s skin  Low current running through the electrodes acts to block the pain sensation.  Must have a doctor s order  Should be done by a trained person  Used for post operative pain and post traumatic patients

E. Percutaneous Electrical Stimulation (PENS)

 

For relief of back pain, headaches Electric current sent through thin needle probes positioned in soft tissues & muscles of the back

  

Clothes wrapped around a limb / body part Used for strains, sprains & surgical incisions Supports the surface & internal tissues during movement, coughing and other activities

May be interrupted due to pain, fear or side effects of medication Assist patient in obtaining enough sleep and rest so as to promote healing & maintain health

Involves manipulation or adjustment of the joints and adjacent tissues of the body, particularly spinal column Non-invasive Drug free treatment Should be done by a doctor chiro-practitioner.

  

Any medication / procedure that produces an effect resulting from its implicit / explicit intent even with or without its specific physical / chemical properties eg : normal saline, empty capsules,or same procedure like electrodes with no therapeutic value

Nursing Process for Pain Management

1. Assessment:
    

Goal is to gain an objective understanding of a subjective experience Accurate pain assessment Physiologic, psychologic, behavioral, emotional, & socio cultural Listen to your patient Establish trust

 

Coping responses : prayer, distraction Daily pain diary

Objective Assessment  Behavioral responses  Physiological responses  Associated symptoms : nausea, vomiting  Effect on ADL

2. Nursing Diagnosis:


Acute pain, chronic pain, altered discomfort - specify the location of pain - etiologic / precipitating factors - other diagnoses related to pain eg: sleep pattern disturbance alteration in nutrition ineffective individual coping self care deficit

3. Planning expected outcomes * Choose the pain relief measures appropriate the client based on assessment data 4. Implementation 5. Evaluation of the plan 6. Documentation

for