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Pain
Pain is whatever the experiencing person says it is, existing whenever he or she says it is.
Duration of pain
  • Acute: rapid onset
  • Chronic: may be limited, intermittent, or persistent.
  • Chronic pain may go into periods of remission or exacerbation. It is often poorly localized
Sources of pain
  • Cutaneuous (superficial) pain: damage tissues
  • Somatic pain: damage to tendons, ligaments, bones
  • Visceral: pain associated with orgrans
Types of pain
  • Nociceptive pain: pain from tissue damage
  • Neuropathic pain: results from an injury to or abnormal functioning of peripheral nerves or the central nervous system
  • Intractable pain: resistant to therapy
  • Phantom pain: pain in a missing limb
  • Psychogenic pain: has a psychological source
  • Referred pain: pain that originates in one part of the body but is perceived in an area distant from its point of origin.
Allodynia
The condition in which an ordinarily painless stimulus, once perceived, is experienced as being painful.
Behavioral and psychological responses to pain
  • Behavioral (voluntary): guarding, moaning, restlessness
  • Psychological: depression, anger, frustration, hopelessness, withdrawal, anxiety.
Physiologic response to pain
  • involuntary
  • Moderate and superficial pain: sympathetic activiation ↑ BP, P, R, pupil dilation, muscle tension & rigidity, pallor, ↑ blood glucose, ↑ adrenalin
  • Severe and deep pain: parasympathetic activation, N/V, rapid irregular breathing, ↓ BP/P, prostration, fainting or unconciousness
Four stages of the pain process
  • Transduction
  • Transmission
  • Perception
  • Modulation
Transduction: activation of pain receptors
  • stimuli converted to electrical impulses that travel to the spinal cord
  • chemicals released: bradykinin (vasodilator, ↑ capillary permeability, constricts smooth muscle, triggers release of histamine and produces redness, swelling and pain associated with inflammation), histamine (works with bradykinin), substance p (sensitizes receptors on nerves to feel pain and increase firing rate), lactic acid, serotnin
Transduction: pain stimulators
  • mechanical
  • thermal
  • chemical
  • electrical
Transduction: organs and pain receptors
Some organs have pain receptors while others do not
Transmission of pain
Pain sensations move from the nerve endings, to the spinal cord, to the brain
Protective pain reflex
  • reflex arc
  • Happens before perception of pain
  • pain impulse comes into the dorsal root and synapses with motor neurons in the anterior root
  • results in immediate muscle contraction that removes the injured part from the source of pain
Gate control theory
  • smaller diameter nerves carry pain impulses
  • larger diameter nerves inhibit transmission of pain impulses
  • larger diameter nerves can overridr the impulses from the smaller ones
  • Large diameter nerves can be activiated with cold packs, heat, TENS, etc.
Perception of pain
  • pain threshold: the lowest intensity of stimulus that causes a person to recognize pain
  • Adaptaion: the pain threshold can be changed, slowly increasing a stimulus can increase the pain threshold
Modulation of pain
  • helps the body deal with pain
  • release of neuromodulators (endogenous opioid compunds)
  • endorphns, dynorphins, enkephalins
Factors that afect the pain experience
  • cultural norms
  • ethnic variables
  • family expectations
  • gender
  • age
  • religous beliefs
  • enviroment
  • anxiety
  • past pain experience
Pain is the 5th vital sign
  • Pain mst be assessed, treated, and reassessed.
  • comfort goals she be sought
General assessment of pain
  • Ptients verbalization and description of pain
  • duration
  • location
  • quantity and intensity
  • quality
  • chronology
  • aggravating and alleviating factors
  • physiologic indicators of pain
  • behavioral responses
  • effect of pain on activities and lifestyle
Gauging intensity of pain
  • 0-10 scale
  • wong-baker faces
  • visual analog scale
Assessing physiologic responses
  • V/S
  • skin color
  • persperation
  • pupil size
  • nausea
  • muscle tension
Assessing behavioral and affective responses
  • posture
  • gross motor activities
  • erbal expressions
  • anxiety, depression, withdrawal
Nursing diagnoses related to pain

  • pain

  • chronic pain

  • constipation r/t chronic use of narcotics

  • hopelessness



  • goals: pain will subside, pt engages in successful pain management program

Nonpharmacologic relief measures

  • caring relationships

  • ID cause and remove

  • provide rest

  • explain the use of pain meds

  • distraction, humor, imagery, music, relaxation, TENS/PENS

Pharmacologic relief measures
  • analgesics: reduce the persons pereption of pain and alter thr persons responses to discomfort
  • three classes: opioids, nonopioids, adjuvant drugs
Opioids
  • morphine, codeine, meperidine, methadone, hydromorphone
  • used for modereate to severe pain
  • side effects: sedation, nausea, constipation, respiratory depression
Sedation
Sedation occurs before respiratory depression
  • sedation scale:
  • 1. Awake and alert
  • 2. occasionally drowsy but easy to arouse
  • 3. frequently drowsy  and drifts off to sleep during conversation
  • 4. somnolent with minimal ot no response to stimuli
Respiratory depression
  • more common with acute pain rather than long term therapy
  • hold the opioid
  • physically stimulate thr pt (v/p)
  • remind the pt to deep breathe every few minutes
  • give narcan if needed
  • Give IVP slowly
  • RR should be >9 before resuming opioids
Addiction
  • fewer than 1% become addicted
  • physical dependece: the body is accustomed to the drug and suffers withdrawal symptoms
  • tolerance: the body becomes accustomed to the drug and needs a larger dose. can occur after 4 weeks of use
  • Addiction: compulsive opioid use for means other than pain control
Nonopioid drugs
  • used for mild to moderate pain
  • NSAIDS:
  • can cause GI side effects, take with food
  • dont take if pt has a bleeding disorder
  • can mask signs of an infection
  • somtimes combinded with opioids to provide more analgesia
Adjuvant drugs
  • Includes corticosteroids, anticonvulsants (neuontin), antidepressants (tricyclics)
  • used to enhance the effect of opioids and reduce the side effects
  • used to lessen anxiety
Evaluation of anagesics
  • evaluate the effectiveness of the analgesia (document reduction in pain)
  • evaluate any changes in patient condition that warrent a change in analgesia
  • watch for side effects and intervene
PCA
  • Patient controlled analgesia
  • lock-out interval to prevent overdose
  • Provides:
  • consistent analgesic blood levels
  • fast and predictable delivery
  • pt is in charge and doesnt have to wait
  • higher pt satisfaction with improved pain relief
Epidural Analgesia

  • used immediately postop and for chronic pain

  • inserted into the epidural space in the lumbar region

  • exits out the back for short term use

  • tunneled subcutaneously and exits on the side or abdomen for long term use

  • IV drip or pt controlled epidural analgesia (PCEA)

  • preservative free morphine or fentanyl

  • short term use not usually more than 24hrs

Local Analgesia

  • EMLA cream used topically (apply prior to painful procedure and cover with occlusive dressing 1hr prior)

Patient/Family teaching
Teach about:


  • the nature and causes of pain

  • the pain scale

  • goals for comfort

  • safety in the home when taking opioids (fall precautions, avoid CNS depressants, take with food, no driving, etc)

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