Dr. Naglaa Youssef

Medical-Surgical Nursing Dep.

Faculty of Nursing

Cairo University

Content outlines

Definition of pain

Components of pain

Types of pain

Physiology of pain

Management of pain

Assessment of pain

Nursing diagnosis of patient with pain

Nursing care for patient with pain

Pain definition

Pain has been defined as an „‟unpleasant sensation usually associated with disease or injury‟‟ (Timby

2009).

It causes physical discomfort that is a companied by suffering, which is the emotional component of pain.

the American Pain Society coined the phrase “Pain: The 5th Vital Sign”

Pain is „‟whatever the person says it is, and existing

whenever the person says it does‟‟ (Margo

McCaffery 1998).

“It is not the responsibility of clients to prove that

they are in pain; it is the nurses‟ responsibility to

believe them.” (Crisp & Taylor, 2005).

Components of pain

Experience of pain includes:

Sensory

Affective

Cognitive

Behavioural

Physiological

Perception of pain characteristics: intensity, quality, location

Negative emotion: anxiety, fear, unpleasant sensation

Interpretation of pain

Coping strategy used to

express, avoid, or control pain

Nociceptive and stress

response

Types of pain

Types of pain can be described/classified

according to:

Ty

pes

of

pai

n Source

Cutaneous

Somatic

Visceral

Neuropathic Aetiology

Duration

Acute

Chronic

Nociceptive

pain

Cutaneous pain

Discomfort feeling originates at the skin level,

e.g. trauma.

Nociceptive pain

Somatic

Involves superficial tissue: skin,

muscles, joints, bones

Location is well defined

Sensation is described as

Tender, Burning, Shooting,

Throbbing

e.g. cut skin, stretch a muscle too

far or exercise for a long period

of time.

Visceral

Involves organs: heart,

stomach, liver..etc.

Location: Diffuse

Sensation is described as:

aching, cramping

Visceral pain

Discomfort arising from internal organs.

Is associated with injury or disease.

It is sometimes referred (referred pain) or poorly

localized.

Referred pain is a discomfort or pain perceived in a

general area of the body, usually away from the site

of stimulation. E.g., cardiac pain may be felt in the shoulder or left

arm, with or without chest pain.

Areas of referred pain

Radiating pain

Perceived in the source of pain and extended to

nearby tissue.

Neuropathic Pain

Is pain that experienced days, weeks, or longer after the

cause of pain has been treated.

Is called functional pain.

Is due to dysfunction of the nervous system.

E.g. phantom pain limb pain/sensation.

a person with an amputated limb perceives that the limb still exists

and feels burning, itching, deep pain in tissues that have been

surgically removed.

Acute and chronic pain

Acute

• Recent/rapid onset

• Specific, localized

• Severity associated with the acuity of disease

• Good response to medication therapy

• Requires less drug therapy

• Suffering is decreased

• Associated with sympathetic nervous system responses: hypertension, tachycardia, restlessness & anxiety.

Chronic

• Prolonged onset

• Nonspecific, generalized

• Severity out of promotion to the disease

• Poor response to medication therapy

• Requires more drug therapy

• Suffering is intensified

• Absence of autonomic nervous system responses

• Psychological suffering: depression & irritability.

Physiology of Pain

Specialized pain receptors or nociceptors can be excited by mechanical, thermal, or

chemical stimuli.

Nociceptors

Central Nervous System

What is nociceptor?

Is a type of sensory nerve (free nerve endings in

the skin) that sensitive to a noxious stimulus.

Nociceptors are also called pain receptors, but

the former term is preferred.

Where does it locate?

It locates in the:

Skin, bones, joints, muscles & internal organs.

Physiology of pain

It is the process by which the person experiences pain occurs in

four phases:

Transduction Transmission Perception Modulation

First phase: Transduction

Chemicals substances such as

substance p, histamine & prostaglandins

Injured cells

release chemicals

excite nociceptors

Pain medications can work during this phase by blocking the production of prostaglandin

(e.g., ibuprofen or aspirin) or by decreasing the movement of ions across the cell

membrane (e.g., local-anesthetic).

Phase 2: Transmission (spread)

Is the phase where stimuli moves from the peripheral

nervous system toward the brain.

Types of nerve fibers

A-delta fibers

Smaller, myelinated fibers, Carry impulses rapidly

Smaller, myelinated Aδ (A delta) fibers transmit nociception rapidly, which produces

the initial “fast pain Result in:

Sharp, localized pain, acute initial sensation. e.g. touching a hot iron then withdraw from

pain provoking stimulus

C-fibers

Larger, unmyelinated fibers. Carry impulses at a slow

rate. E.g. dull, aching, burning sensation.

Pain impulses move to higher level in the brain such

as: thalamus, cerebral cortex and limbic system by

assistance of substance P.

Prostaglandin is a chemical that released from

injured cells speeds the pain transmission.

Opioids (narcotic analgesics) block the release of neurotransmitters,

particularly substance P, which stops the pain at the spinal level.

Phase 3: Perception

What does perception mean?

Is the person‟s „‟conscious experience of discomfort

„‟(Timby 2009).

When does perception occur?

It occurs when the pain threshold (عتبة األلم) is

reached.

What is pain threshold?

„‟Point at which sufficient pain-transmitting stimuli

reach the brain‟‟ (Timby 2009).

The point at which a stimulus is perceived as

painful.

What is pain tolerance?

Is the maximum amount (intensity) or duration of

pain that person can endure or tolerate.

Phase 4: Modulation or descending ( المسار تعديل )

Is the last phase of pain impulse transmission

where the brain interacts with the spinal nerves in a

downward way to alter the pain experience.

Release of pain inhibiting neurochemicals that can

reduce the pain, such as:

Endogenous opioids

Gamma-aminobutyric acid

Gate control theory (Melzack and Wall, 1965)

Protective pain reflex.

Discomfort stimulus from skin

travel along sensory neuron to

dorsal horn of spinal cord,

synapses with motor neuron,

travels along spinal nerve to

skeletal muscle, causing

withdrawal from pain stimulus.

Physiological response to pain

Pain produces a physiological stress response that includes

increased heart and breathing rates to facilitate the increasing

demands of oxygen and other nutrients to vital organs. Failure to

relieve pain produces a prolonged stress state, which can result in

harmful multisystem effects (Middleton, 2003).

Incase of sever traumatic pain may place client into shock.

Vocalization

Moaning, crying & gasping

الشكوى والبكاء ويلهث

Facial expression

Grimace, clenched

teeth, tightly closed eye & lip biting &

wrinkle forehead

Body movement

Immobilization ,restlessness

& muscle tension

Social interaction

Avoid the conversation

or social contacts

Behavioral response

Impact of pain on patient daily life

Fatigue

Sleeping disturbance

Loss of appetite

Social withdraw

Disturb family life

Tense muscles

Impair immune system….poor healing, infection, ulcers.

Stop activity…..complications of immobility such as

muscle atrophy, cardiovascular complications

Factors influencing pain perception

Factors influence pain

Age

Gender

Culture

Environment

Meaning of pain

Anxiety

Fatigue

Previous experience

Family support

e.g. keep a

stiff upper lip

e.g. Money reward

• Assessment

• Nursing diagnosis

• Intervention

• Evaluation

Nursing process

Caring for patient with pain

Pain is the fifth vital signs that should be

assessed during assessment stage (the

American Pain Association).

Pain assessment

Method of assessing pain:

A. Taking history

B. Physical examination of pain

Pain Scales

There are different pain intensity scales:

1. Word scales

2. Numeric scales

0

Mild

pain

Moderate

pain

Sever

pain

Very sever

pain

Worst

possible pain No pain

7 8 5 6 9 2 3 4 1

No pain

10 Worst

possible pain Moderate

pain

3. Linear (visual analogy) scale/VAS

4. Rating scale

No pain Pain as bad as it could

possible be

Components of pain assessment: COLDERR

Focus of assessment Components

Describe pain sensation (e.g. sharp, aching, burning) Character

When it started, sudden, gradually. Onset

Where it hurts, mark on a diagram Location

Constant versus intermittent in nature, how long Duration

Factors that make it worse Exacerbation

Factors that make it better Relief

Pattern of shooting/spreading/location of pain away

from its origin.

Radiation

Components of pain assessment

Focus of assessment Components

Rating for present pain severity using a pain

scale.

Intensity

Description own client‟s own words (like knife). Quality

prayer or other religious practices, withdrawal Coping resources

Pain characteristics that change. Variations

Repetitive or not. Patterns

Sleep, appetite, concentration, school, work,

driving, walking, slef-care.

Effects on ADL’S

N/V, dizziness, diarrhea Associated

Symptoms

Focus of assessment Components

Approaches used to control the pain and results

and effectiveness.

Current pain

treatment

Past medications or interventions and the

response, manner of expressing pain, personal

cultural, spiritual, or ethnic believes that can affect

pain management.

Pain treatment

history

Level of tolerance, expectation for level of pain

relief ability to restore function.

Person’s goal for

pain control

Nursing diagnoses

Ineffective airway clearance related to weak cough secondary to

incision abdominal pain

Activity intolerance related to pain (specify location as left ankle pain)

Immobilization related to pain (specify )

Sleep disturbance related to pain (specify)

Self care deficit (specify) related to poor pain control

Ineffective coping related to ineffective pain management (specify

location as left ankle pain)

Depression & anxiety related to pain (specify)

Deficient knowledge (specify pain medication) related to lack of

exposure to information resources

Planning (goals)

After 2 hours the patient:

Will report pain control or relief of pain

Will express satisfaction with pain control

Will states pain is 2/10

Will reported decrease in intensity of pain

Willing to try relaxation technique

Increases interactions with family and friends

Demonstrates use of new strategies to relieve pain

Interventions

1. Monitoring

2. Actions / interventions

3. Teaching

Monitoring

Use pain assessment scale to identify intensity of pain.

Assess and record pain and its characteristics:

location, quality, frequency, and duration.

Assess vital signs every 30 minutes

Actions / interventions

Aim of pain management to preventing, reducing,

relieving pain, such as:

Non-pharmacologic interventions

Pharmacologic management

Health teaching

Non-pharmacologic interventions

Relaxation techniques = releasing

tension

Education = support & coping

methods

Imagery = using mind to visualize

an experience=daydreaming

Distraction=switch from unpleasant

sensory experience to one more

pleasant

Acupuncture= thin needles

are inserted into the skin

Acupressure = tissue

compression

Meditation = concentrating

on a spiritual word or idea

Heat & cold = thermal

therapy = swelling &

vasodilatation

Types of distraction

Visual distraction

Tactile distraction

Auditory distraction

Talking Oder

Intellectual distraction

Reading, watching T.V Listen to music Message, deep breathing Hobbies, writing cross word puzzle

Pharmacologic

Analgesia = relief of pain. Gk

an- without + algesis-sense of pain.

Oral medications

Patient – Controlled

Analgesia (PCA)

Epidural analgesia

Injection in the lumber region

at the L2/3 or L3/4 space

Health teaching

Teach patient additional strategies to

relieve pain and discomfort: distraction,

relaxation, cutaneous stimulation, etc.

Instruct patient and family about potential

side effects of analgesics and their

prevention and management.

Approaches to pain management

Examples Intervention Approach

Aspirin, ibuprofen, Local anaesthetics, anti-

inflammatory medications

Interrupting pain

transmitting chemicals at

the site of injury

Epidural, rhizotomy,

sympathectomy

Intra spinal anaesthesia

and analgesia or

neurosurgery

Altering the transmission at

the spinal cord

Massage, acupuncture,

acupressure, heat, cold

electrical stimulation

Cutaneous stimuli Using gate closing

mechanism

Morphine, imagery,

distraction, hypnosis

Narcotics, non-

pharmacological

techniques

Blocking brain perception

Evaluation

Report pain level

Respiratory rate

Amount of medication, frequency use

Side effect of medication