PAIN

Ns. Lutfatul Latifah, M.Kep., Sp.Mat Click to edit Master subtitle style 4/15/12

*Pain is an unpleasant sensory or emotional experience

associated with actual or potential tissue damage, or described in terms of such damage (International Association for study of pain) *One of humans body defense mechanism that indicates the person is experiencing the problem *Subjective & individual *MsCaffery, 1979 :whatever the experiencing person says it is, existing whenever he/she says it does *A subjective symptom that only the patient can identify and describe

THE PAIN EXPERIENCE

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According to : *Duration of pain *Source of pain *Mode of transmission *Etiology

TYPES OF PAIN
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*Acute pain *Chronic malignant pain *Chronic non malignant pain

Duration of Pain
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*Rapid in onset, varies in

intensity from mild to severe *Warns the individual of tissue damage or organic disease *After its underlying cause is resolved, acute pain disappears *Pricked fingers, sore throat or surgery

*Acute pain
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*Pain that may be limited, intermittent or

persistent but that lasts beyond the normal healing period *Remission (the disease is present but the person does not experience the symptom *Exacerbation (the symptom reappear) *Chronic malignant pain (associated with cancer) *Non chronic malignant pain (tissue injury nonprogressive or healed)

*Chronic pain
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*Cutaneus pain (supervisial pain)

: involves skin or subcutaneous tissue) *Deep somatic pain : diffuse/scattered, originated in tendons, ligaments, bones, blood vessels, & nerves *Visceral pain : poorly localized & originates in body organs in the thorax, cranium, & abdomen
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*Source of Pain

*Referred pain

*Originates in one part of the

body but be perceived in an area distant from its poin of origin *Transmitted to a cutaneous site different from where pain originated *Ex: myocardial infarction/heart attack : pain reffered to neck, shoulder or arm (see fig 35-1)

*Mode of Transmission
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*Neuropathic pain *Intractable *Phantom pain *Psycogenic

*Etiology
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*Result from injury of peripheral nerves

or CNS *The exact cause is unknown *Can occur in many form *Short duration or lingering *Often described as burning or stabbing *Example: diabetic neurophaty (see table 35-1 pg 1114)

*Neurophatic pain
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*Intractable pain : pain is resistent to

therapy & persists despite a variety of intervention *Phantom pain : pain that is often referred to an amputated leg where reseptors & nerves are clearly absent is a real experience for the patient *Psychogenic pain : physical cause for the pain cannot be identified

* Intractable, Phantom &

Psychogenic pain 4/15/12

*Physiologic, Behavioral &

Affective (see Box 35-1 pg 1115) *The severity & duration affects responses to pain *(DArcy, 2008c) : increase in vital signs may occur briefly in acute pain & may absent in chronic pain

RESPONSES TO PAIN
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*Transduction *Transmission of pain stimuli *Perception of pain *Modulation of pain *The gate control theory of pain
THE PAIN PROCESS

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* This process occurs in the periphery when a

noxious stimulus causes tissue damage * Damage cells release substances that activate or sensitize nociceptors * This activation leads to the generation of an action potential * Sensitizing substances released by damage cell : prostaglandin, bradykinin, serotonin, substance p, histamin * Nociceptors are small nerve ending of A-delta & C fibers which do not adapt to repeated stimuli

*Transduction
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*The action potential continues from the site of damage to the

spinal cord & ascends to higher center *Transmission is said to occurs in 3 phases: 1. Injury site to spinal cord, impulses conducted to dorsal horn via A-delta fiber (large, fast, myelinated) & C-fibers (small, slow, unmyelinated) 2. Spinal cord to brain stem & thalamus

- Released of substance p & other neurotransmitter continues the

3.

impulse accross the synaptic cleft between nociceptor & the dorsal horn neurons - From the dorsal horn of the spinal cord, neuron such as the spinothalamic trac t ascend to the thalamus - Other tract carry the message to different center in the brain

Thalamus to cortex

*Transmission
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* The sensory process that occurs when stimulus

op pain is present * The persons interpretation of the pain * The threshold : the lowest intensity of a stimulus that causes the subject to recognize pain

*Perception
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*The process by which the sensation of pain

is inhibited or modified *Neurons originating in the brain stem descend to the spinal cord & release substances such as endogenous opioids, serotonin & norepinephrin that inhibit the transmission of nociceptive impulses *They appear to have analgesic activity & alter the perception of pain

*Modulation
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1. 2. 3. 4.

5.

Stimulation of nociceptors Impulses conducted to dorsal horn via A-delta fibers & C-fibers Dorsal horn : relay station & sensory processing area (substansia gelatinosa) Impilses conducted to brain via spinothalamic tracts : brainstem, thalamus, limbic system, cerebral cortex Pain perceived & response initiated
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* Pain pathway

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*The gate control theory

*Regulation of pain
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perception

* SUBSTANTIA GELATINOSA = gate control * Stimulation of large fibres * Release of endogenous opiates in SB * Block further impulses = close the gate * Stimulation of small fibres inhibit the SG & open
the gate

*The gate control theory

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FACTORS AFFECTING THE PAIN EXPERIENCE

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cultur e
& y et xi er r An h ot esso r st

c ni h Et
The pain experien ce

Environtm ent & support people

Re g s b igio eli u efs

Pas t pain exp erie ce n

mily, Fa , nder ge age

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NONPHARMACOLOGIC THERAPY OF PAIN

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*Using Distraction *Employing Humor *Listening to music *Using Imagery *Employing Relaxation *Using Cutaneous stimulation *Using Acupuncture *Using Hypnosis *Employing biofeedback *Providing therapeutic touch
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*Visual ;counting objects, reading, or

watching TV *Auditory : listening to music *Tactile kinesthetic : holding or strocking a loved person, pet or toy : rocking; slow rhytmic breathing *Project : playing achallenging game *Distraction alone relieved mild pain *Effective when used before pain or soon thereafter

*Using distraction
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*Help individual cope with pain and

may even have positive effect on the immune system *Humor only with patients who are responsives to its use and wish to use it

*Employing Humor
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*Can relax, soothe, decrease pain & provide

distraction *Decrease the need of pain medication *Before, during, after surgical experience ; help focus breathing technic during labor

*Listening to music
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*More effective for chronic pain than acute

pain

Using imagery
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*Reduce skeletal muscle tention and lessen

anxiety *Most effective when combined with slow, deep, easy breathing from the abdomen or diaphragm with the patients eyelids closed or with the individual focusing on a real or imagined fixed spot

*Using relaxation
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* The gate control theory * Massage * Application of heat/cold or both intermittenly * Acupressure * TENS

* Cutaneuos stimulation
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*Technique that uses needles of

various length inserted into spesific parts of body to produce insensitivity to pain

*Acupuncture
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*Technique that
produces a subconcious state accomplished by suggestion made by a hypnotist

*Hypnosis
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* Technique that uses a machine to monitor

physiologic responses through electrode sensors on the patients skin

* Employing biofeedback
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* Using ones hands to direct an anergy exchange

consciously from the practitioner to the patient

* Therapeutic touch 4/15/12

* Taylor, Lillis, LeMone & Lynn (2011)

Fundamentals of nursing the art and sciences of nursing care, 7th ed. Hongkong : Wolters Kluwer Health / Lippincott William & Wilkins * http://www.medscape.org/viewarticle/456762 * www.painbalance.org

*References
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