PAIN

INTRODUCTION
Pain is complex multi-factoried phenomenon. It is an individual, unique experience that they may be difficulty for clients to describe or explain and is often difficult for others to recognize, understands and assess.

DEFINITION
The international association for the study of pain (lASP) offers the accepted medical definition of pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" (Merskey and Bugdulk 1994) 'American pain society cloned the phrase "pain the fifth vital sign" to emphasize its significance of the importance of effective management. (American Pain Society) A broad definition of pain is 'Whatever the person says it is, existing whenever the experiencing person says it does". (Mc Caughey and beeby 1989 p.7) Pain is much more than a single sensation caused by a specific stimulus pain is
subjective and highly individualized.

The stimulus for pain can be physical and / or mental in nature whereby damage may be actual tissues or to a person's ego. (Machen 1994)

ETIOLOGY AND PRECIPITATING FACTORS

o Surgical or accidental trauma. o Inflammation. o Musculoskeletal disorders such as muscle spasm. o Neuropathies secondary to such conditions as diabetes mellitus acquired o immunodeficiency syndrome or multiple sclerosis. o Visceral disorders such as myocardial infarction. o Vascular disorders such as sickle cell anaemia. o Invasive diagnostic procedure. o Excessive pressure, such as with immobility. o Cancer.

Types of Stimulus Mechanical Biological Chemical

Source Alteration in body fluids Due to distention Space Occupying lesion (Tumor) Perforated Visceral Organ Bum (heat or extreme cold) Bum

Path physiological process Oedema distending body tissues. Over stretching of duct's narrow lueman (eg. passage of Kidney stone through ureter) Irritation of peripheral nerves by growth of lesion within confined space. Chemical irritation by secretions on sensitive nerve endings (eg. ruptured appendix, duodenal ulcer) Inflammation or loss of superficial layers of epidermis causing increased sensitivity of nerve endings Skin layers Burned with muscle and subcutaureous tissue injury causing injury to nerves endings

Thermal

Physical

TYPES OF PAIN
1. Cutanuous Pain 2. Somatic Pain 3. Visceral pain 4. Referral Pain or neuropathic Pain.

Cutaneous pain
Cutaneous pain originates at the skin level and the depth of the trauma determines this type of sensation that is experienced. According to "Rosendhl and Buldock" damage confirmed to the epidermis level pain is localized and superficial subcutaneous tissue injury produces an aching, throbbing pain.

Somatic pain
Somatic pain is generated from deeper connective tissue structures such as muscle tendons and joints. Visceral pain arises from internal organs that are diseased or injured and tend to be referred or poorly localized.

Visceral pain
Visceral pain is usually accompanied by other autonomic nervous system symptoms such as nausea, vomitting, Pallor, hypotension and sweating.

Referral pain or neuropathic pain.

Referred pain describes discomfort that is perceived in a general area of the body, but not in the exact site where an organ is anatomically located.

Neuropathic pain also called, functional or psychogenic pain, with typical characteristics. It often experienced days, weeks or even months after the source of the pain has treated and resolved (opstedd 1955). This leads to speculate that there is dysfunctional chemical message that is being transmitted to the brain. Pain is categorized into acute pain and chronic pain.

Acute pain
Acute pain is usually of short duration (lasting from seconds to 6 months) usually recent onset and commonly associated with a specific injury acute pain indicates that damages or injury has occurred. Pain is significant in that it draws attention to it's existence and teaches the person to avoid similar potentially painful situations. If no lasting damage occurs and no systematic exists acute pain usually decreases along with healing. Acute pain is reversible for controllable with adequate treatment. Unrelieved acute pain leads to chronic pain states. Adaptation to acute pain Response to Acute pain observable signs of discomfort Overtime Adaptation Decrease in observable signs although pain intensely unchanged
Normal blood pressure Normal rules rate Normal respiratory rate Normal pupils size Dry skin

Increases blood pressure Increases rules rate Increases respiratory rate Dilated pupils Perspiration

Acute pain

Focuses on pain Reports pain cries and moans

No report pain unless questioned quiet Turns attention to other than pain Physical inactivity or immobility sleeps or rests

Rubs painful part increases muscle tension

Frowns and Grimaces

Blank or normal facial expression

Characteristics of acute and chronic pain

Recent onset Remote onset

Symptomatic of primary injury of disease Uncharacteristic of primary injury or disease Specific and localized Nonspecific and generalized Severity associated with the acuity of the Severity out of proportion to the stage of injury or disease process the injury or disease Favourable response to drug therapy Requires less and less drug therapy Diminishes with pain Suffering decreases Associated with sympathetic nervous system responses such as hypertension, tachycardia restlessness anxiety Poor response to drug therapy Requires more and more drug therapy Persists beyond healing stage Suffering intensifies Absence of autonomic nervous system responses manifests depression and irritability.

Chronic pain
Chronic pain is a major health concern, the pain may have originally been acute in nature. Chronic pain may be defined as pain that lost for 6 months or longers, nevertheless rafter 6 months most pain experience are accompanied by problems related to the pain itself. Chronic pain may be divided in to three types. 1. Chronic non malignant pain such as from low back pain or rheumatoid arthritis 2. Chronic intermittent pain such as from migraines head ache 3. Chronic malignant pain, such as from cancer characteristics of clients experiencing chronic pain syndrome include the following: Depression Increased or decreased appetite and weight Drastically restricted activity level leading to reduced work capacity, poor physical tone, and increased depression. Social withdrawal and life role changes. Preoccupation with physical manifestations Poor sleep and chronic fatigue, which may result from inactivity, from, analgesics and depression as well as from pain. Decreased concentration.

1) CHRONIC NON-MALIGNANT PAIN Chronic pain mayor may not have an identicable cause, or the cause may be difficult to determine. It is continuous or persistent and recurrent eg: Rheumatoid arthritis. 2) CHRONIC INTERMITTANT PAIN Chronic intermittent pain refers to exacerbation or recurrence of the chronic condition. The pain occurs only as specific period of times the client is free from pain in other period. Ex., Migraine, Cluster headache, sickle cell and intermittent abdominal pain, gastro, intestinal disorders, chronic malignant pain. 3) MALIGNANT PAIN Malignant pain is considered to have qualities of both acute and chronic pain. The diagnosis of cancer adds mental anguish may intensify the perception of pain and an additional psychological component associated with potential deformity and the potential for impending death by agonizing suffering.

NEUROPHYSIOLOGY OF PAIN
NEUROREGULATORS NEUROTRANSMITTERS SUBSTANCE P.
Is found in the pain neurons of the dorsal horn (excitatory peptide) If needed to transmit pain impulses from the periphery to higher brain centers. Causes vasodilation and Oedema.

SEROTININ
Is released from the brain stern and dorsal horn to inhibit pain transmission.

PROSTAGLANDINS
Are generated from the breakown of phospholipids in cell membrances. Are believed to increase sensitivity to pain

NEURO MODULATORS
Endorphins and Dynorphins Are the body's natural supply of morphine -like substance Are activated by stress and pain Are located within the brain spinal cord and gastro intestinal tract

Cause analgesia when they attach to opiate receptors in the brain Are present in higher levels in people who have less pain than others with a similar injury.

BRADYKININ
Is released from plasma that leaks from surrounding blood vessels at the site of tissue injury. Binds to receptors on peripheral nerves, increasing pain stimuli. Binds to cells that cause the chain reaction producing prostaglandin's.

PATHOPHYSIOLOGY OF PAIN
The sensory experience of pain depends on the interactivity between the nervous systems and the environment. The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous system.

Pain transmission
Among the nerve mechanisms and structures involved in the transmission of pain perception to and from the area of the brain that interprets pain are nocieceptors or pain receptors, and chemical mediators. Nociceptors are receptor that preferentially sensitive to a noxious stimulus. Nociceptors are also called pain receptors, but the former term is preferred.

Nociceptors
Nociceptors are free nerve endings in the skin that responds only to intense, potentially damaging stimuli. Such stimuli may be mechanical thermal or chemical in nature. The joint, skeletal muscle, fascia, tendons, and cornee also has nocicreptors that have the potential to transmit stimuli that produce pain. However the large internal organs (viscera) do not contain nerve endings that respond only to painful stimuli. Pain originating in these organs results from intense stimulation of receptors that have other purposes. For example:- Inflammation stretching, ischeamia relation to intensive response in these multipurpose fibers and can cause sever pain. Nociceptors are part of complex multidirectional path ways. There nerve fibers branch very near their origin in the skin and send fibers to local blood vessel, mast cells, hair follicles and sweat glands. When these fibers are stimulated, histamine is released from the mast cells causing vasodilatations. Nocieceptors respond to highintensity mechanical thermal and chemical stimuli, some receptors responds to only one type of stimuli others, called poly modal nociceptors, responds to all these types

of stimuli. These highly specialized neurons transfer the mechanical, thermal or chemical stimuli into electrical activity or action potentials. The coetaneous fibers located more centrally further branch and communicate with the Para vertebral sympathetic chain of the nervous system and with large internal organs. As a result of the connections between these nerve fibers, pain is after accompanied by vasomotor autonomic, and visceral effects. In a patient with sever acute pain ex.: gastro intestinal peristalysis may decrease or stop.

PERIPHERAL NERVOUS SYSTEM

A number of algogenic (pain-causing) substances that affect the sensitivity of nociceptors are released in to the extra cellular tissue as a result of tissue damage. Histamine, bradykinin, acetylcholine, serotonin, and substance are chemical that increase the transmission of pain. The transmission of pain also referred to as 'nociception'. 'Prostaglandins are chemical substances thought to increase the sensitivity of pain receptors be enhancing the pain provoking effect of bradykinin. These chemical medial mediations also cause vasodilatation and increased vascular perability, resulting in redness, warmth and swelling of the injured area. Once nociception is initiated the nociceptive action potentials are transmitted by the peripheral nervous systems (porth 2002). The first order travel from the periphery to spinal card via the dorsal horn. There are two main types of fibers involved in the transmission of nociception A((A delta) fibers transmit nociceptors rapidly, which produces the initial 'fast pain'. Type c fibers are larger, unmyelinated fibers that transmit what is called second pain. This type of pain dull, aching or burning qualities that last longer than the initial fast pain. The type and concentration of nerve fibers to transmit pain vary by tissue type. If there is repeated C fiber, input a greater response is noted in dorsal horn neurons, causing the person to perceive more pain. In other words the same noxious stimulus produces hyperalgesia and the person reports greater pain them was felt at the first stimulus. Chemical that reduce or inhibit transmission or perception of pain include endorphins and enkephclins. These morphine like neuro transmitters are endogenous. (produced by the body) Endorphins and enkephalins are found in heavy concentrations in the central nervous systems, particularly the spinal and medullary dorsal horn, the periaqueductal Gray matter, hypothalamus and amygdala. Morphine and other opoid medications act at receptor sites to suppress the excitation initiated by noxious stimulus.

CENTRAL NERVOUS SYSTEMS

After tissue injury occurs nociception to the spinal cord via the A and C fibers continues. The fibers enter the dorsal horn, which is divided into laminae based on cell type. The laminae II cell type is commonly refers to as the substantia gelantosa. In the substantia gelantosa are projections that relay nocieception to other parts of the spinal card. Nociceptions continues from the spinal card to the reticular formation, thalamus, limbic system and cerebral cortex. Here nociception is localized and its characteristics become apparent to the person including the intensity. The involvement of the reticular formation limbic and reticular activating systems is responsible for the individual's variations in the perception of noxious stimuli. Individuals may report the same stimulus the differently based on their anxiety past experiences and expectations. This is result of the conscious perception of pain. For pain to be consciously perceived, neurons in the ascending systems must be activated. Activation occurs as result of input from the nociceptors located in the skin and internal organs. Once activated, the inhibitory inter neuronal fibers in the dorsal horn inhibit or turn off the transmission of noxious stimulating information in the ascending pathway.

DESCENDING CONTROL SYSTEM

The descending control system is system of fibers that originate in the lower and mid position of the brain and terminate in the inhibitory inter neuronal fibers in the dorsal horn of the spinal cord. This system is probably always somewhat active it prevents continuous transmission of stimuli as painful, partly through action of the endorphins. As nociception occurs the descending control system is activated to inhibit pain. Cognitive process may stimulate endorphin production in the descending control system. The effectiveness of this system is illustrated by the effects of distraction. The person who has visitors may not report pain because activation of the descending control result in less noxious or painful information is being transmitted to consciousness. The interconnections between the descending neural system and the ascending sensory tract are called inhibitory inter neuronal fibers. These fibers contain encephalin and are primarily activated through the activity of non nociceptor

peripheral fibers in the same receptor filed as the pain receptor, and descending fibers, grouped in a system called descending control. The enkephalin and endorphins are thought to inhibit pain impulses by stimulating the inhibitory inter neuronal fibers, which in turn reduce the transmission of noxious impulses via the ascending system. Another way to categorize pain is to speak to the pathophysiology of the pain, nociceptive pain (either somatic or visceral) or neuropathic pain. There are four processes of nociceptive pain transduction. Tansmission perception and modulation A client in pain cannot discriminate among the processes. However understanding each process helps the nurse recognize factors that can cause pain symptoms and accompany pain and the rationale and actions of select therapies. (MC Caffery and Pasero 1999)

Brain
Central control Action control

Large fibers

Stimulation from receptors

+ I + +

+
Transmissio n cells

Substantia gelatinosa

E
Small fibers

Gate Control System

GATE CONTROL THEORY

The Classic Gate Control thorny of pain described by Melzack and Wall in 1965 was the first to clearly articulate the existence of a pain-modulating system (Melzeck 1996) this theory purposes that stimulation of the skin evokes nervous impulses that are then transmitted by the three systems located in the spinal card. The substantia gelatinosa in dorsal horn. The dorsal column fibers and the central transmission cells

to influence nociceptive impulses. The noxious impulses are influenced by a "gating mechanism". Melzek and Wall proposed that stimulation of the large-diameters inhibit the transmission of pain thus "closing gate" conversely when small fiber are stimulated, the gate is opened. The gating mechanism is influenced by nerve impulses that descend from the brain. This theory proposes a specialized system of large diameters fibers that activate selective cognitive process of the modulating properties of the spinal gate. The gate control theory was important because it was the first theory to suggest that psychological factors playa role in the perception of pain. This theory helps to explain how interventions such as distraction and music therapy provided pain relief. Melzack (1996) extended the gate control theory after carefully analyzing phantom limb pain. He proposed that large widespread network of neurons exists that consists of loops between the thalamus and cortex and between the cortex and the limbic system and he named this network the neuromatrix. The neuromatrix theory might explain pain phenomena its contribution to understanding pain management remains to be seen. Regards of patient's culture, nurses need to learn about that particular and be aware of power and communication issue that will affect care outcomes.

FACTORS INFLUENCE THE PAIN RESPONSE

A person pain experience is influenced by a number of factors including past experience with pain, anxiety, culture, age, gender and expectations about pain relief. These factors may increase or decrease the perceptions of pain increase or decrease tolerance for pain and affect the responses to pain.

Coping style

Family and social support

Age

Previous experience

Sex Pain experience Culture

Anxiety

Attention

Meaning of pain

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Age
Although many older people seek health care because of pain the way a younger person responds to pain differ from the older person. Because elderly people have a slower metabolism and greater ratio of body fat to muscle mass than younger people small doses of analgesic agents may be sufficient to relieve pain.

Gender
Women had higher pain intensity, pain unpleasantness, frustration and fear compared to men.

Placebo Effect
A placebo effect occurs when a person responds to the medication or others treatments because of an expectation that the treatment will work rather than because it actually does so simply receiving a medication or treatment may produce positive effects. The placebo effect results from the natural (endogenous production of endorphins in the descending control system. A patients positive expectations about treatment may increase the effectiveness of medications or other intervention.

Past Experience
It is tempting to expect that a person who has had multiple or prolonged experience with pain would be less anxious and more tolerance of pain than one who has had little pain. For most people however, this is not true often the more experience a person has had pain, the more frightened he or she is about subsequent painful events. This person may be less able to tolerate pain that is, he or she wants relief from pain sooner and before it because sever. This reaction is more likely to occur of the person has received inadequate pain relief in the past. A person with repeated pain experiences may have learned to fear the escalation of pain its inadequate treatment. Once a person experience severs pain that person knows just how severe it can be conversely, someone who has never had severe pain may have no fear of such pain. The way a person responds to pain is a result of many separate painful events during a life time. For some past pain may have been constant and relenting as in prolonged or chronic and persistent pain. The individual who has pain for months or years may become irritable withdrawn and depressed.

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Anxiety and Depression

Post operative anxiety is most related to preoperative anxiety and post operative complications. However anxiety that relevant or related to pain may increase the patient's perceptions of pain. In chronic pain saturations depression is associated with major life changes due to the limitations effects of the pain, specific un employment, longer durations of pain are associated will an increased incidence of depression.

Culture
Belief about pain and how to respond to it differs from one culture to the next. Early in childhood, individual learn from those around them what responses to pain are acceptable or unacceptable. o o o o o o o o The main issue to consider who caring for patient of different culture are : What does not idleness to the patient? Are there culturally based stigmas related to this illness or pain? What is the role of the family is health care decisions? Are traditional pain relief remedies used? What is the role of stoicism in that culture? Are there culturally determined ways of expressing and communications pain? Does the patient have any fears about the pain? Has the patient seen or does the patient want to see a traditional healer?

MISCONCEPTIONS AND MYTHS

Many misunderstanding exist about pain. For Eg.: Many health care provides believe that it is possible to predict the amount of pain people should prove, based on their medical condition. However, the diagnosis or type of surgery is not effective fundamental basis for determining the amount of pain the person should be experiencing or the analgesic required to relieve that pain. Both children and older adults experience unrelieved pain because health professionals in correctly assume that age predicts pain. The clients do not visibly physiologic or behavioural signs of pain often leads to the belief by the health care provides that they do not have pain. A more likely explain is that the client has adapted to the pain. Real pain has an identifiable cause. Pain is part of aging. If the pain is relieved by non pharmaceutical pain relief technique, the pain was not real anyway.

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NEGATIVE EFFECT OF PAIN

A barrier to adequate pain management has been the belief that pain, while uncomfortable has few negative physiologic effects. Unrelieved pain can affect the major organ systems pulmonary, cardiovascular gastrointestinal, endocrine and immune systems. Unrelieved pain has resulted in untoward effects that have resulted in creased cost that effect all of society. Costs are increased because of longer hospital stays the need to treat the negative effect of pain and the clients loss of productivity. Pain prevents coughing, deep breathing and signing, leading to pulmonary with significant associated morbidity and mortality. Pain may also prevent ambulation, contributing to the development of deep vein thrombosis and potential life threatening pulmonary emboli. Pain of any type induces release of catecholamine and stress hormones. Cardio vascular complications and decreased immune activity may results. Reflex muscle contraction may be enhanced resulting in increased muscle tension and spasm. Abdominal wall muscle tension and spasm reduce the ability of the chest wall to expand. As a result clients take short shallow frequent breaths. Oxygen and carbon dioxide exchange is less effective with this breathing pattern vital capacity has been reported to decrees to 40 % of pre surgery capacity when pain was not relieved and to only 70 % of pre-surgery values when pain was totally relieved. Intestinal and bladder smooth muscle tone is affected such that peristalsis and bladder motility are decreased. Bowel and bladder distention may result. The decreased motility of the bowel contributes to constipation. If distension is severe enough the abdominal contents may interfere with the ability of the diaphragm to expand. It appears as through constipation may be complication of either opoid administration or unrelieved pain. Catecholamine secretion in response to pain leads to increased myocardial oxygen Demand and consumption. Clients with arteriosclerosis may be imperiled to the point myocardial ischemia, dysrhythemias, infraction cardiac failure and death. Older adults - at greatest risk for atherosclerotic vascular changes are greatest risk for receiving inadequate pain reduction and / or relied on the basis of the negative effects of pain relieving is priority.

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SOURCES OF PAIN
Pain can arise from different types of body structures cutanaeous (superficial) pain arises from them skin surface and is localized fairly easily because the pain is transmitted along defined neurological pathways called dermatone. A dermatone is the region of the skin served by one spinal nerve and dorsal root.

Deep Somatic Pain

It arises from a variety of body connective tissue blood vessels, and the periosteum of bone excessive pressure and chemical stimulations are others causes somatic pain, such as Rheumatic arthritis. Visceral pain arises from body organs and their capsules. This type is more likely to be diffuse or poorly localized and to be described as a dull or vague pain. Because the nerves that transmit viscera1 pain impulses follow the pathway of the sympathetic nerves to the spinal cord, visceral pain is often accompanied by autonomic symptoms such as sweating, diarrhea, cramps or high blood pressure. Visceral pain may also be sensed as referred pail which is pain that is felt is an area of the body that is distant from the actual sources of pain.

THE PAIN EXPERINCE

In 1968 Mi1zack and Casey proposed three major dimensions of the pain experience. o Sensory - Discriminatative o Cognitive - Evaluate o Motivational - Affective. Somatosenstory projections, the limbic system, brain centers that mediated visual and vestibular mechanism and cognitive process were intended and contributors to the over all pain experience.

Sensory Dimensions
The Physical sensations of pain can alert a person that tissue injury occurred. It can serve a useful, diagnostic purpose and triggers a medical plan of care can use the client's description of pain and its location to help diagnose the medical problem.

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Cognitive Dimensions
It is impossible to separative the physical sensation of pain from co-existing intellectual and emotional process. When a client's attention is focused on pain, the pain is usually perceived to be more intense is nature. A pain behaviour is anything a person says or does that infers the presence of pain. Behavioral expression of pain are learned from others and may be culturally influenced. The pain of meaning also effects its intensity, its emotional impact on the client and sometimes the clients the response to medical and nursing interventions. Pain can threaten beliefs about control and self image, largely because most people fear a loss of independence. The feeling that pain cannot be controlled can produce extreme anxiety and sense of helplessness. Which chronic, malignant pain, pain may server as a valuable reminders that they are still alive.

Affective Dimensions
Affective or emotional factors can aggravate and be aggravated by the pain experience. Anxiety, apprehension and depression are affected by the perception of pain. The dimensions of the human personality such as predisposition to respond in certain ways to specific circumstances can influence how a client adapts to or deals with painful process. Pain can also deplete a persons energy. When a clients emotional recourses are very low the response to pain is more intense. The most in consequential stressors can triggers pain disproportionate to the circumstances. Wherever actual pain is there physical sensation of discomfort, suffering is the unpleasant emotional response to pain.

CONCLUSION
The Pain is unpleasant unique emotional sensory experience for each individual. Pain is protective primarily as a mechanism but it is also complex biopsychosocial phenomenon. The incorporations of client self- report into working definition of pain acknowledge the highly subjective of nature. The client evaluation of path is most our important indicator of its nature and intensity.

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SUMMARY
As we learnt about pain is 'Whatever the experiencing person says it is and existing whenever he says it does' The IASP says definition and the person experience of pain is acute and chronic stage of illness. Cause of pain and factors influencing pain are age, culture social factors, in coping with pain. Pain management is one of the functions of the nurse that's why she has to asses diagnosed and implementing the plans to relieve the pain of client for early recovery.

BIBLIOGRAPHY
1. Suzanne C. Smeltzer, Brenda G. Bare and Suddarths, Text Book of Medical Surgical Nursing, Lippincott Publications, 2001, Page No. 173-185. 2. Joyce M. Black, Janc Hokanson Hawks, Medical Surgical Nursing Clinical Management for Positive Outcomes , 7th edition, Saunders Publications, 2005, Volume No. 1, Page No. 446-453. 3. Partrica Potter, Anne Griffin Perry, Basic Nursing Essential for Practice , 5th edition, Mosby Publications, 1999, Page No. 708-733. 4. B.T. Basavanthappa, Fundamentals of Nursing, Jaypee Brothers Publications, New Delhi, 2004, Page No. 404-427. 5. Poening Mekenzie, Pharmacologys and Drug Management for Nurses, Churchill Living Store Publications, 1995, Page No. 330-335. 6. Barbara C-Bullock, Pathophysiology Adaption and Alteration in Function , Lippincott Publications, Page No. 1007-1019. 7. Nancy Hollyway RN MSN, Medical Surgical Care Planning, Spring House Corporation, Pennysylvania, 3rd edition, 1999, Page No. 88.

Journal Reference
8. The Nursing Journal of India, August 1998, XXXIX, No.8, Page No. 170 - 172. 9. The Nursing Journal of India, June 2006, Vol XCVII, Page No. 6.

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