|
 




Jose Angelo S. Nate, RN



a state in which an individual
experiences and reports the presence of
severe discomfort or an uncomfortable
situation.

The American Pain Society (APS) defines

pain as an unpleasant subjective sensory
and emotional experience associated with
actual or potential tissue damage or
described in terms of such damage.

|
 


 Stimuli

Nerve Fibers (nociceptors)

A-delta fibers C-fibers

(large, myelinated) (small, unmyelinated)
- conducts impulses rapidly - conducts impulses slowly
- sharp, pricking pain - dull, aching burning sensation
- superficial somatic pain - deep somatic and visceral pain

Spinal cord (substantia gelatinosa)

Thalamus (center for awareness of pain)

Cerebral cortex (center for interpretation of pain)

Responses


  


K  




due to normal
processing of noxious stimuli; may damage
tissue if prolonged (e.g. somatic pain,
visceral pain)
K   

 




due to
abnormal processing of stimuli by peripheral
nervous system (PNS) or central nervous
system (CNS)
^|
 
 

- caused by damage in
the CNS (brain, brainstem, spinal cord) (e.g.
phantom limb)
^
 
 


caused by
damage to the nerves (e.g. trigeminal neuralgia)

   
 




 


 



the unconscious afferent
activity produced in the PNS or CNS by
stimuli that have the potential to damage
tissue
Œ °



the changing of noxious stimuli in
sensory nerve endings to energy impulses
Œ °




movement of impulses from site
of origin to the brain
Π


developing conscious awareness of
pain
Œ £  


the changing of pain impulses due to
the effects of V
V 
(e.g.
enkephalins, endorphins, dynorphins)
chemical
regulators that may modify pain
   
 




 


K 

  
 


  


sharp,
well-localized pain of short duration; caused by stimulation
of the cutaneous nerve-endings in the skin and results in a
well-localized ³burning´ or ³prickling´ sensation
e.g. minor wounds, minor (first degree) burns
K   
 


dull, aching, poorly-localized pain of
longer duration than cutaneous pain; originates in support
structures such as tendons, ligaments, and nerves or may
be deep pain
e.g. sprains, broken bones, myofascial pain
K -
  


pain that is usually more aching or
cramping and of a longer duration than somatic pain;
characterized as discomfort in the internal organs and is
less localized and more slowly transmitted than cutaneous
pain
K — 


pain originating from abdominal organs;
sensation is not felt in the organ itself but perceived at the spot
where the organs were located during fetal development

   
 




 


K  


sudden onset and relatively
short duration, mild to severe intensity, and a
steady increase in intensity over a period of
days to weeks
K —
  


repetitive, painful
episodes that may recur over a prolonged period or
throughout the client¶s lifetime
K |



 

- long-term
(lasting 6 months or longer), persistent,
nearly constant, or recurrent pain that
produces significant negative changes in the
client¶s life
K |

  


occurs almost daily over a
long period, has the potential of lasting months or
years, and has a high probability of ending

D|

 

 


 K |



 


 

|
occurs
almost daily and lasts for at least 6 months,
with intensity ranging from mild to severe;
may be caused by:
·Many forms of
 
(paroxysmal pain that
extends along the course of one or more nerves)
·Îow back pain
·Rheumatoid arthritis
·Ankylosing spondylitis
·
  
 

(a form of neuropathic pain that
occurs after amputation with pain sensations referred to
an area in the missing portion of the limb)
·£  
 


 (a group of muscle
disorders characterized by pain, muscle spasms,
tenderness, stiffness, and limited motion)

D|

 

 


å 
 


begins with the perception
of pain. The body assumes a fight-or-
flight reaction, initiated by the
sympathetic nervous system.
å — 

the pain experienced is
intense but brief. The parasympathetic
nervous system dominates.
å   


may be due to endorphins
counteracting the pain. This occurs when
the pain lasts for many hours or days.

   

— 


 
  — 

· Physiologic responses are mediated by the
autonomic nervous system. If the pain is
mild to moderate, it is manifested by
sympathetic response stimulation. If the
pain is severe, it is manifested by
parasympathetic response stimulation.
- 
  — 

· ehavioral responses (crying, grimacing)
· Emotional responses (depression,
withdrawal, social isolation)

°  — 

K 
·Infants exhibit discomfort through crying or
physical movement.
·Toddlers begin to develop skills needed to describe
pain or point to the area that is hurting.
·Children often revert to habits of their younger
years as a form of coping mechanism.
·Adolescents are reluctant to admit having pain for
fear of being called weak or sensitive.
·Adults may be reluctant to admit pain or seek
medical advice for fear of the unknown or fear of
the impact that treatment may have on their
lifestyle.
·Older adults may ignore pain, viewing it as an
unavoidable consequence of aging.
þ   







K 
 


 


·Coping mechanisms that were used in the past may
affect clients¶ judgment as to how pain will affect
their lives and what measures they can use to
successfully manage the pain on their own.
K |    
·The level of intensity or duration of pain the client
is willing to endure is culturally determined.
·Expression of pain is also governed by cultural
values. In some cultures, tolerance to pain is
expected; in others, full expression of pain may
include animated physical and emotional responses.
þ   







· Pain management is most successful when the
underlying cause of pain is identified and treated
definitively.
· The client¶s self-report of the existence and
intensity of pain is the    


 

 of the nature of the pain.
· Assessment includes the collection of objective
and subjective data through the use of various
assessment tools and the construction of a
database to use in developing a pain
management plan.
· Pain assessment should be performed for every
client.
  

· 

  
the level of intensity at
which pain becomes appreciable or
perceptible; varies with each individual
and the type of pain.
· 

 

the level of intensity or
duration of pain the client is willing or is
able to endure.

  

  | 


Subjective data:
· Intensity
· Îocation
· Quality (radiating, burning, diffuse)
· Associated manifestations (e.g. nausea, constipation,
dizziness)
· Aggravating factors (e.g. exercise, certain foods, stress)
· Alleviating factors (e.g. lying down, avoiding certain foods,
taking medication)

Objective data:
· Client¶s facial expression and posture
· Presence (or absence) of restlessness
· Vital signs monitoring
· Ongoing use of assessment tools

  

· Indicators of pain:
^Reporting or complaining of pain
^Focusing on pain
^Crying or moaning
^Frowning or grimacing
^Rubbing or protecting painful areas
^Altering posture or movements to lessen pain
^Splinting painful areas by increasing muscle
tension
^Reporting insomnia, fatigue, or depression

  

K 




  
 
·6sed for initial pain assessment for clients who
have complex or persistent pain
·Assesses location, intensity, and quality, and
precipitating and alleviating factors, and how the
pain affects function and quality of life
K 





  
·Verbal rating scale (VRS)
uses adjectives ranging
from ³no pain´ to ³excruciating pain´ to describe
intensity
·Numeric rating scale (NRS)
clients are asked to
assign their pain a number, with zero meaning ³no
pain´ and 10 representing the worst possible pain

  
° 
Pain Intensity Scales
Verbal Rating Scale

No pain Mild Pain Moderate Severe Very Severe Worst

Pain Pain Pain Possible
Pain

Numeric Rating Scale

0 1 2 3 4 5 6 7 8 9 10

  
° 
K 



·ate and time
·Intensity
·Situation (what were you doing?)
·How did you feel?
·What were you thinking?
·What did you do to ease the pain?
·How effective was the pain control strategy?
K   


  

·Performed to identify the client¶s attitudes and beliefs
regarding pain and social support
·Initial assessment should include:
Œ Evaluation of the client¶s mood (depressed or anxious),
self-efficacy, coping skills, and concerns
ΠAssessment of social support, family or caregiver
relationship, work history, cultural environment,
spirituality, and accessibility to health care services

  
°
  
° 
 
 |

 


· Infants, children, and adolescents provide a special
challenge in pain assessment, because their pain
behaviors often differ from those considered normal
in the adult population.
· Two useful tools for assessing pain in children:
K w
! "þ  — 

 
can be used in children
as young as 3 years, as it helps them express their level of
pain by pointing to a cartoon face that most closely resembles
how they are feeling
K  "|
° 
consists of four red poker chips described
as ³pieces of hurt´ - ³a little bit of hurt´ ³a little more hurt´
³more hurt´ and "the most hurt you can have´

  
° 
þ  

— 

 

None Slight Tolerable Moderate Severe

K
Worst Pain
Imaginable
0 1-2 3-4 5-6 7-8 9-10

  
° 
K 


an unpleasant sensory and
emotional experience arising from actual
or potential tissue damage or described in
terms of such damage with sudden or
slow onset of any intensity from mild to
severe with an anticipated or predictable
end and a duration of less than 6 months
K |




defined as acute pain but
is constant and recurring without an
anticipated or predictable end and a
duration of greater than 6 months
| 




  
|

 



The Nursing Outcomes Classification (NOC)
system identifies four outcomes in the
domain of perceived health:
å Comfort level
V
V

VV V
 

VV
å Pain: Adverse psychological response

VV 
V V
  V
V

V V
 
V
V
  V V


å Pain: isruptive effects
VV 

V V
  V
V
VV
   
 
 
  
å Pain level
VV 
V V
  V
V








D 



    

 






#
å Assess the pain.
å Treat the contributing factor (pathology).
å Individualize the client¶s analgesic therapy.
å Choose the least invasive route of administration.
å Administer analgesics at regularly scheduled
intervals (RTC dosing) rather than on a PRN basis.
å Keep clients in control of their own analgesia as
much as possible.
å Titrate doses to provide maximum pain relief and
minimum side effects. Know that the right dose is
³whatever it takes to relieve the pain with the
fewest side effects.´

    
  
  



 
å | 




combining analgesics on
the basis of the World Health Organization¶s (WHO)
three-step analgesic ladder is imperative to provide
effective pharmacologic intervention for clients with
all types of pain. The use of adjuvant medication is
recommended.
$

 


are those drugs used to
enhance the analgesic efficacy of opioids, to treat
concurrent symptoms that exacerbate pain, and to
provide independent analgesia for specific types of pain.
- medications without intrinsic analgesic properties
- Adjuvant drugs include anticonvulsants,
antidepressants, and sedatives.
    
  
  



 
 £
 

° 



Tricyclic antidepressants Neuropathic pain frequently ŒMood elevation, enhancement of opioid

(amitryptiline, doxepin, described as dull, aching, or analgesia, direct analgesic effects
imipramine, trazodone) throbbing ŒAnticholinergic side effects: dry mouth,
constipation, urinary retention

Anticonvulsants (carbamazepine, Neuropathic pain frequently ŒSuppresses the spontaneous neuronal

clonazepam, phenytoin) described as sharp shooting, firing as sharp, that causes the type of pain
burning, or lacerating

Corticosteroids (dexamethasone, Pain due to cerebral or spinal ŒMood elevation, strong antiinflammatory
prednisone) cord edema or that in peripheral activity, appetite stimulation
nerves caused by perineural
edema

Antihistamine (hydroxyzine) Pain or nausea in the anxious ŒRelief of complicating symptoms, including
client anxiety, insomnia, nausea, and pruritus

Neuroleptic (methotrimeprazine) Alternative analgesic for clients ŒAntiemetic and anxiolytic

who are opioid-tolerant or have ŒThis is the one phenothiazine to date that
opioid-limiting side effects, has demonstrated analgesic properties:
especially constipation methotrimeprazine 15mg IM was found to
be equivalent to morphine 10mg IM

Psychostimulants Continued pain with opioid- ŒImproves opioid analgesia and decreases
(dextroampethamine, induced sedation sedation
methylphenidate)

$

 

 





å Maintain therapeutic serum levels

 V
V
V 
V 
V
 VV

   V
V 
 V
VV

 V
V

V V V


V
 V
VVV

 
 
 


VVV

å Choose appropriate route of
administration

    
  
  



 


  



     
Πnon-opioid class of pharmacologic agents
Πinhibits cyclooxygenase enzymes (COX-1 and COX-2)
and prevent the production of prostaglandin and
other substances providing analgesia, antipyresis,
and anti-inflammation
ΠCOX-1 is normally present in the GI tract, kidneys,
and platelets
catalyzes synthesis of prostaglandins
in the GI mucosa and platelets
ΠNSAIs produce GI side effects due to the disruption
of the protective effects of prostaglandins on the GI
mucosa
ΠCOX-2-selective NSAIs however have minimal effect
on COX-1 thus poses a lower risk of GI toxicity
    
  
  



 
Classes of NSAIs:
Y Propionic: Ibuprofen, naproxen,
ketoprofen
Y Acetic: Indomethacin, sulindac, tolmetin
Y Salicylic: Aspirin, sodium salicylate,
salicylamide
Y Anthranilic: Phenylbutazone, piroxicam
Y Pyrrolopyrroles: Ketorolac, etodolac
Y COX-2 inhibitors: Celecoxib, rofecoxib,
valdecoxib

    
  
  



 


  



     
Πstudies conducted on the prolonged use of COX-2-
selective NSAIs, specifically Rofecoxib (Vioxx)
however suggested an increased risk of CV events,
with double risk of MI (2004)
ΠNSAIs are useful in treating mild to moderate pain,
especially painful conditions involving inflammation
ΠNSAIs are also subject to the 


, that¶s
why it is imperative to educate the client and their
families to decrease the risk of significant side effects
and adverse reactions

    
  
  



 
D




Πopioids act on several sites in the central nervous
system (CNS) rather than on the peripheral nervous
system (PNS), as do the NSAIs
Πopioids alter the release of neurotransmitters,
interrupting pain transmission at several sites in the
CNS
Πopioid analgesics fall into 3 classes: pure opioid
agonists, partial agonists, and mixed agonist-
antagonists

    
  
  



 
Classes of Opioid Analgesics:
Y  

 


are those that produce a maximal
response from cells when they bind to the cells¶ opioid
receptor sites
e.g. Morphine, fentanyl, methadone, hydromorphone, codeine,
meperidine
- not subject to the ceiling effect
as the dosage is
increased, there is increasing pain relief, with the only
limiting factor being the degree of side effects, particularly
respiratory depression and constipation
Y £
 


 


a compound that blocks
opioids effects on one receptor type while producing opioid
effects on a second receptor site
e.g. utorphanol, pentazocine, nalbuphine
- believed to be subject to the ceiling effect for pain relief, as
well as the ceiling effect for respiratory depression

    
  
  



 
 


 

|
Πa method to relieve pain through self-administration
of analgesics (usually opioids, e.g. Morphine) by a
client using a programmable pump connected to a
subcutaneous, intravenous, or epidural catheter
Πused in health care facilities and in the home to
manage postoperative or cancer pain
Πthe client is taught how to operate the PCA, to press
the button of the PCA pump to administer the proper
bolus dose of the prescribed analgesic as demanded
ΠPCA is contraindicated in sedated and confused
clients

    
  
  



 




a gradual process that occurs when a
person has developed both a biological and a
psychosocial dependence on the substance of use
° 

occurs after repeated administration of an
opioid analgesic, when a specific dose loses its
effectiveness and the client requires larger and larger
doses to produce the level of analgesia

 


reaction of the body to abrupt
discontinuation of an opioid after repeated use;
withdrawal syndrome

    
  
  



 
| 


 
 





Πesigned to educate clients and to modify
client¶s attitudes and behaviors
ΠAn important part of the multimodal
approach to pain management and can be
used in conjunction with appropriate
analgesics
ΠA major goal of these interventions is to
help the client gain a sense of control over
the pain



    
  
  



 
The  
   

, put forward
by Ronald Melzack (a Canadian psychologist)
and Patrick avid Wall (a ritish physician) in
1962, and again in 1965, is the idea that the
perception of physical pain is not a direct
result of activation of nociceptors, but instead
is modulated by interaction between different
neurons, both pain-transmitting and non-
pain-transmitting. The theory asserts that
activation of nerves that do not transmit pain
signals can interfere with signals from pain
fibers and inhibit an individual's perception of
pain.

Ë 
  

K 
 


a pain management strategy that
focuses the client¶s attention on something other than
the pain and associated negative emotions
e.g. watching TV, listening to music, interactive games
K — 


a technique that teaches clients to
monitor their negative thoughts and replace them
with ones that are more positive
K —  



%
a variety of methods used
to decrease anxiety and muscle tension
å  
a strategy that uses mental images to assist with
relaxation (e.g. to alleviate anxiety)
å  
   


a strategy in which
muscles are alternately tensed and relaxed (e.g. reduction of
skeletal muscle tension)




    
  
  



 
K !
 "
a process through which individuals
learn to influence their physiological responses
K |
   
 

#
å | 
 
 


the term used to identify techniques
believed to activate the endogenous opioid and monoamine
analgesia systems
e.g. cold applications/cryotherapy, heat applications, massage
K °

  
 

#
å °

  
 
 
 

°
a
method of applying minute amounts of electrical stimulation to
large-diameter nerve fibers via electrodes placed on the skin
å 

insertion of small solid needles into the skin
and musculature at specific sites and at various depths
å  
firm pressure is applied by the fingers to
specific acupuncture points on the body to unblock the 
(energy)



    
  
  



 
K Other non-pharmacological therapies:
å 
  

- important in treatment of chronic pain
- PROM should not be used if it increases pain or discomfort
å 



- dietary practices affect pain
- some foods trigger pain episodes (e.g. red wine, cheese, citrus
fruits, cured meats)
- some foods help alleviate pain associated with chronic diseases
(e.g. cherries and berries with red, blue, or black skin)
å º  
- instruct clients to consult with health care provider before using
any herbal remedies because of possible drug interactions
å 




- changes in one¶s environment may reduce pain levels (e.g. pet
therapy, horticultural therapy, music therapy)




    
  
  



 
K —
&  
interruption of the anterior or posterior
nerve root area close to the spinal cord
K  
interrupts cranial or peripheral nerves
by an incision
K |    

  
 °   
the
surgical interruption of pain-conducting pathways
within the spinal cord. The incision is made in the in
the anterolateral pathway opposite the side on which
the pain is located
K Ë 
removal of the postcentral gyrus (part
of the sensory cortex of the brain)
K º   
destroying of the pituitary gland
by injection with absolute alcohol


  

 





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'K