Pain Management

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Pain Management

Dr. Ali D. AbbasInstructor, Fundamentals of Nursing Department, College of Nursing, University of Baghdad

ali_dukhan@yahoo.com

LEARNING OBJECTIVES

After mastering the contents of this lecture, the student should be able to:

1. Describe types of pain.

2. Assess the nature of pain as it relates to onset, intensity, and duration.

3. Discuss the physiology of pain.

4. Discuss the use of pharmacologic interventions in pain control.

5. Describe nonpharmacologic interventions in pain control.

TERMINOLOGIES

Acupuncture

Biofeedback

Electromyographic

Electrostimulation

Hydrotherapy

Hypnosis

Mindfulness

Modulation

Pain

Perception

Transduction

Transmission

Visualization

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7. References 13

CONTENTS

1. Introduction 2

2. The process of pain 2

3. Pain theories 4

4. Types of pain 6

5. Pain assessment 6

6. Pain management 10

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Introduction

Pain is an unpleasant and personal sensation that cannot be

shared with others.

Pain as 'whatever the experiencing person says it is, existing

whenever he (or she) says it does.

Pain hints at the subjective nature of pain and the

importance of believing the patient.

People experience and react to pain differently and as nurses

we cannot feel what the patient feels yet we have a duty to

maintain the individual's dignity and where possible relieve their

pain and promote comfort. Indeed pain management is an

important aspect of nursing care.

The process of pain

There are four processes involved in nociception, a term used

to describe the point at which an individual becomes conscious of

pain: (1) transduction, (2) transmission, (3) perception and (4)

modulation (see Fig. 1)

1. Transduction

Transduction is the first process involved in nociception and

begins with tissue injury. This injury is sensed by nociceptors (the

nerve endings that sense pain). These trigger the release of

chemical substances (e.g. prostagladins, bradykinin, serotonin,

histamine, substance P) that help the pain impulse travel from the

periphery to the spinal cord (see Fig. 1).

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2. Transmission

The second process of nociception, transmission of pain,

includes three segments.

1. The pain impulse travels from the peripheral nerve fibers to the

spinal cord.

2. Transmission of the pain impulse by neurotransmitters from the

spinal cord to the brain stem and thalamus (see Fig.1).

3. Transmission of pain impulse between the thalamus and cortex

where pain perception occurs.

3. Perception

The third process, perception, is when the patient becomes

conscious of the pain. It is not known where the precise location

for perception is in the brain. However it is believed & pain

perception occurs in the cortical structures of the brain.

4. Modulation

Modulation is the fourth process involved in nociception.

During this process, nerves in the brain stem send signals back

down to the spinal cord, releasing substances that act as natural

painkillers such as endorphins and serotonin. These substances do

not last long in the body and therefore their painkilling use is

limited.

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(Fig.1) the process of pain perception

Pain theories

1. Specificity theory:

Von Frey (1895) argued that the body has a separate sensory

system for perceiving pain—just as it does for hearing and vision—

and this system contains its own special receptors for detecting

pain stimuli, its own peripheral nerves and pathway to the brain,

and its own area of the brain for processing pain signals. But this

structure is not correct.

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2. Pattern theory:

Goldschneider (1920) proposed that there is no separate

system for perceiving pain, and the receptors for pain are shared

with other senses, such as of touch. According to this view, people

feel pain when certain patterns of neural activity occur, such as

when appropriate types of activity reach excessively high levels in

the brain. These patterns occur only with intense stimulation.

3. Gate Control Theory:

Melzack and Wall (1965) proposed an alternative notion for

the perception and treatment of pain. Their theory is based on the

fact that pain impulses are normally carried to the spinal cord from

the peripheries in small nerve fibres. Large nerve fibres, on the

other hand, carry non-nociceptive stimuli such as touch, warmth,

massage, vibration, etc. According to Melzack and Wall (1965)

impulses travelling through the large fibres can block the impulses

travelling through the small fibres at a gate which is situated at the

spinal cord (see Fig.2).

(Fig.2) a schematic

illustration

of the gate

control theory

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Types of pain

Pain assessment

Assessment of pain includes collection of subjective and

objective data through the use of various assessment tools and

construction of a database to use in developing a pain management

plan.

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Gathering subjective information regarding the client’s pain is

the first step in pain assessment. The client’s perception of the pain

should cover a description of several qualifiers, including:

ý Intensity

ý Location

ý Quality (radiating, burning, diffuse)

ý Associated manifestations (factors that often accompany the

pain, such as nausea, constipation, or dizziness)

ý Aggravating factors (variables that worsen the pain, such as

exercise, certain foods, or stress)

ý Alleviating factors (measures the client can take that lessen the

effect of the pain, such as lying down, avoiding certain foods, or

taking medication)

Nurses must look for nonverbal signs of pain such as changes

in motor activity or facial expression. It is also important to ask

family members to share their observations the nurse should also

determine a client’s pain threshold and pain tolerance level.

Tools used for assessing pain must be appropriate to the

client’s age and cultural context.

1. Initial Pain Assessment Tool

This tool is particularly effective when clients have complex

pain problems because it assesses location, intensity, quality,

precipitating and alleviating factors, and how the pain affects

function and quality of life ( see appendix A).

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2. Pain Intensity Scales

Pain intensity scales are another quick, effective method for

clients to rate the intensity of their pain.

(Fig.3) pain intensity scales

3. Pain Diary

Client input is essential if accurate assessment data are to be

collected. Self-monitoring of symptoms can be promoted by having

clients complete a pain diary; see the accompanying display.

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4. Psychosocial Pain Assessment

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. Certain myths

hinder the accurate assessment and management of pain in

children.

Two useful tools for assessing pain in children are the

Wong/Baker Faces Rating Scale and the Poker Chip Tool.

The Wong/Baker Faces Rating Scale can be used with children

as young as 3 years, and it helps children express their level of pain

by pointing to a cartoon face that most closely resembles how they

are feeling.

(Fig.4) the Wong/Baker Faces Rating Scale

The Poker Chip Tool consists of four red poker chips that can

easily be carried in a pocket to be available when needed. The chips

are aligned horizontally on hard surface in front of the child, and

they are described as “pieces of hurt.” The chips are described from

left to right as just a little bit of hurt, a little more hurt, more hurt,

and the most hurt you could ever have.

The child is then asked, “How many pieces of hurt do you have

right now?” This tool can be used with children 4 to 13 years old.

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Pain management

Establishment of a therapeutic relationship is the foundation

for effective nursing care of the client experiencing pain. Clients,

who trust their nurses to be there, to listen, and to act, are the

clients who are most likely to be comfortable.

1. General overview of pain

1. Definition

2. Causes/contributing factors

3. Pain assessment, including use of assessment tools

4. Importance of preventive approach

5. Family involvement

2. Pharmacologic pain management

Analgesics are substances that give temporary relief from pain

without causing loss of consciousness.

1. Non-narcotic Analgesics the most commonly used of these

analgesics are aspirin (and other salicylates), acetaminophen,

NSAID (nonsteroidal anti-inflammatory drugs), such as

ibuprofen.

2. Narcotic Analgesics these drugs include the opiates and opioids

that are natural or artificial forms of opium, such as codeine or

morphine.

3. Combination of Non-narcotics and Narcotic Analgesics many

prescriptions are a combination of narcotics and non-narcotic

and include acetaminophen and codeine, aspirin and codeine,

propoxyphene and aspirin, caffeine and butalibital.

4. Corticosteroid these are made from synthetic hormones and

used to treat bronchospasm (asthma).

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5. Local Anesthetics these drugs are locally acting and can be

injected to deaden the nerve so pain is not felt (as during a

dental procedure).

6. Antidepressants these are helpful in the management of chronic

pain.

7. Trigger Point Injections trigger point injection therapy is the

injection of a painkilling substance deep into the muscle tissue

that is located over a localized area of pain.

3. Nonpharmacologic pain management

1. Acupuncture a National Health Institute panel gave acupuncture

the "thumbs-up" as a way to relieve nausea and pain.

2. Heat one of the most ancient ways to decrease pain is with the

use of heat.

3. Cold is also an ancient treatment. Applying cold constricts local

blood vessels and makes the area numb.

4. Electrostimulation transcutaneous electrical nerve stimulation

(TENS) units (across the skin) are available by prescription.

5. Relaxation and Behavioral Techniques this type of treatment

teaches a patient to use their mind to lessen or eliminate pain,

especially chronic pain.

6. Biofeedback uses the mind to control the body when tension is

the cause of pain, rather than arthritis, cancer, or nerve

damage.

7. Electromyographic biofeedback this alerts patients to muscle

strain and works especially well for jaw, neck, and shoulder

pain, or tension headaches.

8. Visualization this is a mental technique similar to biofeedback.

Athletes use visualization to enhance their performance.

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9. Relaxation is the release of stress, anxiety, and often pain.

Relaxation techniques include deep breathing, muscle

relaxation techniques, and meditation.

10. Hypnosis by using this form of relaxation, a patient can shut

out distraction and focus on one subject, such as getting rid of

pain.

4. Physical techniques and specialists

1. Anesthesiologists originated the idea for the modern pain clinic.

2. Exercise

3. Massage

4. Physical Therapy Physical therapists are trained professionals

who treat the musculoskeletal system.

5. Physiatry Physiatrists are medical doctors who use physical

methods and agents to treat patients suffering from pain.

5. Alternative health techniques

1. Acupuncture this is an ancient Chinese healing art. Acupuncture

uses various techniques, including the insertion of various sized

needles at specific points on the body (called meridians).

2. Acupressure very similar to acupuncture, acupressure is a

method of using pressure to work on the meridians of the body

for specific pain symptoms or disorders.

3. Hydrotherapy uses water to reduce pain by relieving the

constant pressures on certain parts of the body.

4. Mindfulness meditation chronic pain sufferers often tell

themselves, “This will go on forever; I can't do anything

anymore.” Such thoughts can actually make their pain worse.

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5. Life style changes good pain management programs teach

people better ways to work and get a good night’s sleep.

Lifestyle changes (eg, lifting properly or supporting your lower

back with a rolled towel while driving) can put a person back in

control of their lives.

6. Surgery for pain

Surgery to relieve pain is usually the last resort for treatment.

It may seem as if cutting a nerve will cause the feeling of pain to

disappear.

7. Psychological help

Pain does not always follow the path of the body functions the

patient’s mental state also has a direct effect on a perception of

pain. In many cases, an injured patient’s pain is the emotional

distress as well as the physical injury.

REFERENCESKozier, B., et al.: Fundamentals of nursing: Concepts process and

practice, Pearson Prentric Hall, 2008, P.P.675-680.

Kozier, B., et al.: Fundamentals of nursing, 7th, New York Pearson

Prentric Hall, 2004.

Timby B., Fundamental nursing skill and concepts, Philadelphia,

Lippincott Williams, Wilkins, 2005.

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Appendix A