jcmendiola_Achievers2013

GATE OPEN > PAIN

GATE CLOSED > NO PAIN
Care of Clients with Problems In Oxygenation,
Fluids and Electrolytes, Metabolism and Endocrine
(NCM103)
Pain

Pain
Words to Remember:
Nociceptors Is a free nerve ending that is a receptor for painful (noxious) stimuli
Nociception A system that carries information about inflammation and damage in tissue to the
spinal cord and brain
Pain Threshold Lowest intensity of a painful stimuli that is perceived by a person as pain
Pain Tolerance The duration and intensity of pain that the person is willing to endure

WHAT IS PAIN??
International Association for the Study of Pain (IASP)
o An unpleasant sensory and emotional experience associated with actual / potential
tissue damage
Whatever the patient says it is, existing whenever he says it does Margo McCaffery

Pathway for Pain Perception and Response


Gate Control Theory
Pain impulses can be blocked / regulated by a gating mechanism
o LARGE Fiber Stimuli = GATE IS CLOSED!
o SMALL Fiber Stimuli = GATE IS OPEN!
Suggests that psychological factors play a role in the perception of pain
Guided response in pain management

OPENING and CLOSEING The GATE














PATTERNS of PAIN
- Acute Pain
o Caused by activation of nociceptor
o Short duration (less than 6 months)
o Immediate onset
o Limited and often predictable duration
o Usually reversible / controllable with adequate treatment

FACTOR OPENS CLOSES
Physical Injury
Agitation
Medication
Emotional Anxiety
Stress
Frustration
Depression
Tension
Relaxation
Optimism
Happiness
Behavioral
(Cognitive)
Rumination
Boredom
Enjoyable activities
Complex Tasks
Distraction
Social Interaction

jcmendiola_Achievers2013
Allodynia Pain due to
a stimulus that does not
normally provoke pain
- Chronic Pain
o Usually lasts more than 6 months
o Has no foreseeable end unless it is associated with very slow healing process
o May have been obscure that the person does not know when it is first developed
o Course of chronic pain includes months to years
o Client complains of fatigue, sleep disturbance and limited function
o Evidence of depressive mood is present and exhibits behavior of chronically ill people

SOURCES of PAIN
Cutaneous (Superficial) Pain
Abrupt onset and a sharp / stinging quality
Slower onset and a burning quality
Well-defined localized pain of short duration
Somatic Pain
Originates from ligaments, tendons, bones, blood vessels and nerves
Somatic receptors are sparse; pain is dull and poorly localized
Poorly localized pain may produce nausea and can be associated with sweating and BP
changes
Pain from deep structure frequently radiates from the primary site
Inflammation is an important component of somatic pain
Inflammatory process produces vasodilation, redness, swelling and heat
The edematous tissue distends Stretching the sensitive tissue Further increasing
pain
Visceral Pain
Originates from the body organs
Pain is usually more aching and longer in duration
It is difficult to localize, several injuries to visceral tissues exhibit Referred Pain
Often manifested as sweating, restlessness, nausea, emesis, pallor and agitation
Abdominal pain will occur when body organs are perforated and their contents drain into
the peritoneal cavity
Referred Pain
Felt in an area distant from the site of the stimulus
Pain sensation may be intense and there may be little or no pain at the point of noxious
stimuli
Often baffling, warranting careful assessment
Neuropathic Pain
Caused by damage / injury to nerve fibers in the periphery or by damage to the CNS
Noxious *defined* impulses are generated at the site of the injury
Pain is felt as numbness, burning, stabbing needles and electric shock
Breakthrough Pain
A transient increase in pain of moderate to severe intensity that occurs against a
background of persistent pain of mild to moderate intensity that has been controlled
+ Kinds of Breakthrough Pain
Incident Pain
Predictable and occurs quickly within minutes
(Administer short acting medications may avoid flare ups and allow
clients to participate more fully in therapy)
It can occur with movement, coughing and increased activity
Idiopathic / Spontaneous Pain
It can occur randomly, and unpredictably; with little or no warning
It can be unrelated to activity level / adequacy of the persistent pain
function




jcmendiola_Achievers2013
O Phantom Limb Sensation
- A client may continue to experience sensations in the part amputated as if that part were
still present / attached
- Abnormal sensations perceived as presence of the limb paresthesia / pain (Nerve fibers
that served the past, continue to extend to the periphery ending at the incision site)
Psychogenic Pain
It is not caused by Nociception but by psychological factors
Some mental / emotional problems can cause increased prolonged pain
Usually the patient will report pain that does not exist
Common types of psychogenic pain are headache, muscle pain, back pain and stomach
pain
Usually diagnosed when other causes of pain are ruled out
It is treated with psychotherapy antidepressants and non-narcotic analgesics

FACTORS AFFECTING PAIN
~ Perception of Pain
o Perception and interpretation is an important component of pain experience
o Both physical stimuli and psychosocial factors can influence our experience of pain
o Anxiety, experience, attention, expectation and the meaning of the situation in which
injury occurs affect pain perception
o Pain perception does not depend solely on the degree of physical damage, it is also
influenced by ones tolerance of pain
~ Tolerance
~
~ Sociocultural Function
o Race, culture, and ethnicity are factors that can influence all sensory response to pain
o People from different cultures may handle pain in various ways
o The nurse should recognize the patients way of dealing with pain and must accept it
o Health care providers must be sensitive to the contribution of cultural factors and
language barriers in order to facilitate adequate pain management
~ Age
o Age may change a perception and expression of pain
o Adults may not report pain for it may mean weakness, failure / loss of control
o Older people may think pain is simply something to be endured as a normal part of aging
process
o Pain would also be seen as a sign..
~ Gender
o Men report less pain than women regardless of ethnicity
o Health care providers who value bearing pain without complement may say women as
complainers and may ignore / ** their pain experience
~ Meaning of Pain
o If the cause of pain is known, the person may be better able to interpret the meaning and
to deal with the experience
o If the meaning of pain is negative, then the pain may be perceived more intensely
~ Anxiety
o The degree of anxiety experienced by the client may also influence the response to pain
o Anxiety intensifies pain perception
o If the cause is unknown, anxiety is likely to be higher and the pain worsens
~ Past Experiences with the Pain
o Past experiences with pain affects the way that the current pain is perceived
o Negative experiences with pain as children can have difficulty managing pain
o Patients with miserable experiences in the past may perceive the next episode intensely
even though the medical conditions may be similar



jcmendiola_Achievers2013
ASSESSMENT OF PAIN
Intensity = Patient self Report of pain rating
Location = Ascertained by verbal description / by pointing the location
Quality = Descriptive adjective like Stabbing like a knife! or Throbbing
Duration = Time of onset, interval and duration of pain
Aggravating / Alleviating Factor = What makes it worse / better?
Distress = Emotional component may intensify pain

Tools for Assessing PAIN
Visual Analogue Scale (VAS)
o A horizontal 10-cm line with anchors (ends) indicating the extremes of pain
o The person is asked to place a mark indicating where the current pain is
Faces Pain Scale
o This instrument has SEVEN faces depicting the range from contented to obvious distress
o The patient is asked to point to the face that most closely resembles the pain intensity felt

Physical Intervention
a. Comfort Measures Clean, smooth sheets, soft support pillows, warm blankets and soothing
environment
b. Position Changes Movements are pain relieving interventions (Moving the body relieves
muscle spasms and provide a degree of pain relief)
c. Massage Back rub is particularly relaxing at bedtime and may block pain so as to promote
comfort sleep (Foot massage is particularly helpful and cost effective)
d. Heat and Cold Application
Heat is an excellent means of pain reduction of relief that is amenable to nursing
autonomy
Cold Application also brings pain reduction or relief
(Ice may also be used to prevent / reduce edema and inflammation)
e. Transcuteneous Electrical Nerve Stimulations (TENS)
- Delivers electrical bursts through the skin to superficial and deep nerves
- Used with clients with chronic pain such as muscle pain from arthritis
f. Acupressure A non-invasive method of pain reduction or relief based on principles of
acupuncture (Pressure, massage, or other Cutaneous stimulation such as heat / cold application is
applied over acupuncture sites)

Cognitive/Behavioral Interventions
a. Deep Breathing It is for relaxation and is easy to learn; it also contributes to pain relief
by reducing muscle tension and anxiety
b. Progressive Relaxation Gradually tightens and deeply relaxes various muscle groups
proceeding systematically from one area of the body to the next (It also decreases anxiety
and excessive muscle contraction)
c. Rhythmic Breathing It is both relaxation and distraction. It can be combined with
rhythm such as music / ticktocking clock. Concentration is necessary in this type of
intervention (It focuses attention away from pain but focuses on the breathing and the
rhythm)
d. Music It can be relaxing distraction, releases endogenous opioids or dissociation
- Physiologic response to relaxation
e. Guided Imagery
Helps patients visualize a pleasant experience this kind of intervention
This kind of intervention uses distraction which increases pain tolerance
f. Distraction Attention is directed away from the painful sensations or the negative
emotional arousal associated with the pain episode (Interventions include watching
movies, doing crafts, interacting with others and reading books / magazines)


jcmendiola_Achievers2013
> These groups do not cause
physical dependence or tolerance
> The site of action is at the
periphery at the receptor site where
they serve as an anti-inflammatory
function and prevent the production
of prostaglandin
g. Meditation
Focuses ones attention away from pain
Provides energy and peace to the person who is meditating
Communicates with spiritual being
h. Hypnosis
Based on suggestive dissociation and the process of focusing ones attention
The Hypnotherapist must be skilled and informed and must avoid negative
effects
i. Humor
It has been postulated that humor elevates endogenous opioids or endorphins
It increases the number of natural killer cells of the immune system
It makes people feel better relaxed, and in less pain

MEDICAL MANAGEMENT OF PAIN
+ GOAL:
a. Diagnosis of painful condition
b. Reduction of the severity and intensity of pain to tolerable levels
c. Observation of the psychological consequences of pain

ANESTHESIA
- Pharmacologic substances that abolishes pain generally causes loss of
feeling and sensation
- TYPES:
1. General
2. Local
3. Regional (Nerve Block)
ANALGESICS
- Medications developed to provide pain relief
- Two Types
1. Non Opioid Analgesic
a. Aspirin
b. Salicylate Salts
c. Acetaminophen
d. NSAIDS
2. Opioid Analgesia
- Derived from natural opium alkaloids and their synthetic
derivations
- Added to medication regimen when pain is moderate to
severe