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Pain Management

INS,KMU
FON-2
Chap-4
 Pain
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.
Pain is a state in which an individual experiences and
reports the presence of severe discomfort or an
uncomfortable sensation.

Pain is a vital function of the nervous system in

providing the body with a warning of potential or actual
injury.
It is both a sensory and emotional experience, affected
by psychological factors such as past experiences ,beliefs
about pain, fear or anxiety

Pain is a Highly subjective experience

 Nature of Pain
 Can be a protective mechanism to prevent further
injury
 Warning of potential tissue damage

Common Myths About Pain

 The nurse is the best judge of a client’s pain.

 If pain is ignored, it will go away.
 Clients should not take any measures to relieve their
pain until the pain is unbearable.
 Most complaints of pain are purely psychological.
 Taking pain medication causes addiction
 Types of Pain
Pain can be described in two basic ways:
 Cause or origin
 Description or nature

Cutaneous pain: is caused by stimulation of the

cutaneous nerve endings in the skin.
Somatic pain: is non localized and originates in support structures. E.g
Bone & soft tissue, chest wall (Sharp/Dull)
Visceral pain: discomfort in the internal organs. Liver capsule
distension, Bowel obstruction
– Aching
– Constant or cramps
– Poorly localized
– Referred

Referred pain: pain originating from the abdominal organ.

 Types of Pain
Acute pain: is most frequently identified by sudden onset and
relative short duration. Examples are broken bones, strep throat,
and pain after surgery or injury
Recurrent acute pain: is identified by repetitive episodes that
may recur over a prolonged period of time or throughout the
client’s lifetime
Chronic Pain: Long-term, (lasting 6 months or longer),
persistent, nearly constant, or recurrent pain
Produces significant negative changes in client’s life
May last long after the pathology is resolved

Chronic malignant pain: occurs as a result of progressive tissue

injury.
Chronic nonmalignant pain: occurs in persons who do not have
progressive tissue injury
 Types of Pain
 Neuropathic Pain: Pain caused by a lesion or disease of the
somatosensory nervous system
example of neuropathic pain is called phantom limb
syndrome.
 This condition affects people who have had an arm or leg
amputated, causing pain or discomfort in the area of the
now- missing limb. The exact cause of phantom limb pain is
not known, but it is thought to be due to changes in both
the peripheral and central nervous systems following
amputation

 Hyperalgesia: Increased pain from a stimulus that normally

provokes pain
 Allodynia: Pain due to a stimulus that does not normally
provoke pain
 Physiology of Pain.

 Nociceptive painis the process by which an individual

becomes consciously aware of pain

 A nociceptor is a receptor of a sensory neuron (nerve cell)

that responds to potentially damaging stimuli by sending
signals to the spinal cord and brain. This process, called
nociception, usually causes the perception of pain

 They are the free nerve endings of primary afferent Aδ and C

fibers. Distributed throughout the body (skin, viscera,
muscles, joints, meninges) they can be stimulated by
mechanical, thermal or chemical stimuli.
 Physiology of Pain
 Aβ fibers are highly myelinated and of large diameter,
therefore allowing rapid signal conduction. They have a low
activation threshold and usually respond to light touch and
transmit non-noxious stimuli.

 Aδ fibers are lightly myelinated and smaller diameter, and

hence conduct more slowly than Aβ fibers. They respond to
mechanical and thermal stimuli. They carry rapid, sharp pain
and are responsible for the initial reflex response to acute
pain

 C fibers are unmyelinated and are also the smallest type of

primary afferent fiber. Hence they demonstrate the slowest
conduction. C fibers are polymodal, responding to chemical,
mechanical and thermal stimuli. C fiber activation leads to
slow, burning pain
Physiology of Pain.
Four principle processes are involved in nociception

 Transduction: Transduction of pain involves the changing of

noxious stimuli in sensory nerve endings to energy impulses
 Transmission: Transmission of pain involves the movement of
impulses from site of origin to the brain.
Reflex arc: A reflex arc is a neural pathway that controls an
action reflex
A reflex action, differently known as a reflex, is an
involuntary and nearly instantaneous movement in
response to a stimulus.
 Perception: Perception of pain occurs when the pain impulse
has been transmitted to the cortex and the person develops
conscious awareness of the intensity, location, and quality of
pain
Physiology of Pain

 Modulation: Modulation of pain refers to

activation of descending neural pathways that
inhibit transmission of pain

 The periaqueductal gray (PAG), dorsolateral

pontine tegmentum (DLPT), and rostroventral
medulla (RVM) are the key regions of the brain
involved in this descending pain modulation
Gate Control Theory of Pain
 Gate Control Theory
 Gate - located in the dorsal horn of the spinal
cord
 Smaller, slower nerve fibers carry pain impulses
 Larger, faster nerve fibers carry other sensations
 Impulses from faster fibers arriving @ gate 1st
inhibit pain impulses (acupuncture/pressure,
cold, heat, chem. skin irritation).
Brain

Pain
Gate
Heat, Cold,
Mechanical
 Gate control theory of pain
 Gate control theory of pain:
 The gate control theory of pain was proposed by Melzack
and Wall in 1965 to describe a process of inhibitory pain
modulation at the spinal cord level. It helps to explain
why when we bang our head, it feels better when we rub
it.
 By activating Aβ fibers with tactile, non-noxious stimuli
inhibitory inter neurons in the dorsal horn are activated
leading to inhibition of pain signals transmitted via C
fibers.

 The concept of the gate control theory is that non-painful

input closes the gates to painful input, which results in
prevention of the pain sensation from traveling to the
CNS
 Gate Control Theory
Blocking Transmission of Pain
 Pain Assessment Infants
(FLACC)
0 1 2
FACE No particular Occasional grimace Frequent to constant
expression or smile or frown, quivering chin,
withdrawn, clenched jaw
disinterested

LEGS Normal position or Uneasy, restless, Kicking or legs drawn

relaxed tense up
ACTIVITY Lying quietly, normal Squirming, shifting Arched, rigid, or
position, moves back and forth, jerking
easily tense

CRY No cry Moans or whimpers, Crying steadily,

occasional screams or sobs
complaints

CONSOLABILITY Content, relaxed Reassured by Difficult to console or

touching, hugging, comfort
voice, distraction

Behavioral pain assessment scale total (0–

10)
(Numerical rating scale
(NRS) Pain Assessment
Adult
 Faces rating scale (FRS)
Pain Assessment
Children
 Other Pain Theories

 Central Biasing Theory

 Specificity Theory (Von Frey, 1895)
 Strong's Theory (Strong, 1895)
 Pattern Theory Central Summation Theory
(Livingstone, 1943)
 The Fourth Theory of Pain (Hardy, Wolff, and
Goodell, 1940s)
 Sensory Interaction Theory
 Specificity
Theory
Von Frey (1895) argued that the body has a separate
sensory system for perceiving pain just it hearing and
vision. , which respond to damage and send signals
through pathways in the nervous system to in the
brain.
The free nerve endings are pain receptors and that
the specific to a sensory experience.
 Pattern Theory

Gelds(1920) proposed that there is no separate

system for perceiving pain.
The receptors for pain are shared with other senses,
such as of touch. , warmth and other non-damaging
damaging stimuli, give rise to non-painful or painful
experiences as a result of differences in the patterns
of the signals sent through the nervous system
Strong's Theory (Strong, 1895)

This theory states that pain was an experience

based on both the noxious stimulus and the
psychic reaction or displeasure provoked by the
sensation.
The Fourth Theory of Pain
(Hardy, Wolff & Goodell)
 It stated that pain was composed of two
components: the perception of pain and the
reaction one has towards it.

 The reaction was described as a complex

psychological process

 Involving cognition, past experience, culture and

various psychological factors which influence pain
perception
 Central Biasing Theory
 Descending neurons are activated by: stimulation of A-
delta & C neurons

 Cause release of enkephalins (PAG=Periaqueductal gray)

and
serotonin (NRM=Nucleus raphe Magnus)

 Endorphin and enkephalin are the body's natural

painkillers. When a person is injured, pain impulses travel
up the spinal cord to the brain. The brain then releases
endorphins and enkephalins. Enkephalins block pain
signals in the spinal cord. Endorphins are thought to
block pain principally at the brain stem.
 Harmful Effects

Cardiovascular and respiratory systems are

significantly affected by the pathophysiology of
pain
 adrenergic stimulation
 hyper coagulation, leading to DIC
  heart rate
  cardiac output
  myocardial oxygen consumption
 Non-pharmacologic Pain
Management
 Physical
 Massage
 Heat and cold
 Acupuncture
 Behavioral
 Relaxation
 Art and
play
therapy
 Cognitive
 Distractio
n
 Imagery
and
Hypnosis
 Pain Medications
Acetaminophen every 4-6 hours
 Ibuprofen ; 6-8 hours
 Opiate ;according to dose minimum
24hours Oxycodone 4-5 hour duration
Codeine
Ketorolac ; No more than 24-72 hours in children less than
2 years Fentanyl ; Potent (100x morphine), short duration
Hydromorphone ; 5x more potent
Morphine; Weak opiate
Providing timely and effective pain management to the
injured patient can help strengthen the
patient’s lines of resistance
 Avoid humanity to pain

“Pain is a more terrible lord of mankind than death

itself.”
Albert Schweitzer
 Key points
 The pain experienced by patients is a result of the
interaction between sensory and emotional
experiences
 Aδ fibers transmit rapid, sharp, localized pain
 C fibers transmit slow, diffuse, dull pain
 Pain transmission can be modulated at a number of
levels, including the dorsal horn of the spinal cord
and via descending inhibitory pathways
 The spinothalamic and spinoreticular tracts are
important ascending pain pathways
 Neuropathic pain can be spontaneous and is often
described as burning, shooting, or stabbing
 Key Points

Endorphin and enkephalin are the body's natural

painkillers. When a person is injured, pain impulses
travel up the spinal cord to the brain. The brain then
releases endorphins and enkephalins. Enkephalins
block pain signals in the spinal cord. Endorphins are
thought to block pain principally at the brain stem.
Both are morphine-like substances whose functions
are similar to those of opium- based drugs
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