Pain and Comfort

INTRODUCTION
 Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage.
 It is sometimes referred to as the FIFTH vital sign.
 In many aspects, pain is the most common reason for seeking health
care.
 Because pain emanates from various modalities such as diagnostics
tests, diseases and treatment procedures, nurses must be
knowledgeable about the pathophysiology of pain and its
management.
 Nurses encounter pain in a variety of setting, including acute are,
outpatient, and long term care settings as well as in the home.
 The nurse has daily encounters with pain who anticipate pain or who
are in pain.
 Understanding the phenomenon of pain and contemporary pain
theories helps the nurse to intervene effectively.

Pain Definition

 This is a subjective sensation to which people respond in different

ways.

 It can directly impair health and prolong recovery from surgery,

disease and trauma.
 Pain is a highly unpleasant and very personal sensation that cannot
be shared with others.
 It can occupy all a person’s thinking, direct all activities, and change a
person’s life.
 It is the noxious or unpleasant stimulation of threatened or actual
tissue damage.
 This pain sensation is a different sensation because the purpose of
pain is not to inform the CNS of the quality of the stimulus but rather
to indicate that the stimulus is causing damage or injury to the
tissues.
 It is the result of a complex pattern of stimuli generated at the pain
site and transmitted to the brain for interpretation.
Common terminologies

1. Radiating pain—perceived at the source of the pain and extends to the

nearby tissues

2. Referred pain— pain is felt in a part of the body that is considerably

removed from the tissues causing the pain

3. Intractable pain—pain that is highly resistant to relief

4. Phantom pain—painful perception perceived in a missing body part or in

a body part paralyzed from a spinal cord injury

5. Phantom sensation—feeling that the missing body part is still present

6. Hyperalgesia—excessive sensitivity to pain

7. Pain threshold—is the amount of pain stimulation a person requires in

order to feel pain

8. Pain sensation—can be considered the same as pain threshold

9. Pain reaction—includes the autonomic nervous system and behavioral

responses to pain

10.Pain tolerance—maximum amount and duration of pain that an

individual is willing to endure

11.Nociceptors—pain receptors

12.Pain perception—the point which the person becomes aware of the pain

• Pain threshold is similar in all people, but pain is tolerance and

response vary considerably

• Painful sensations are sensed by receptors.

• We call the receptors NOCICEPTORS.

 • Usually they are free nerve endings located widespread in the
superficial layers of the skin, peritoneal surfaces, periosteum, arterial
walls, pleural surfaces, joint surfaces and the falx and tentorium of
the cranial vault.

• These nociceptors are non-adapting to keep us constantly informed

of the continuous presence of the painful stimulus that can damage
the tissues.

For pain to be perceived, nociceptors must be stimulated. These pain

receptors can be stimulated by:

(1)serotonin

(2)histamine

(3)potassium ions

(4)acids

(5)some enzymes

Pain Categories

Category of pain according to its origin

A. Cutaneous pain—originates in the skin or subcutaneous tissue

B. Deep somatic pain—arises from ligaments, tendons, bones, blood

vessels, and nerves

C. Visceral Pain—results from stimulation of pain receptors in the

abdominal cavity, cranium and thorax. It tends to appear diffuse and
often feels like deep somatic pain that is, burning aching, or feeling of
a pressure. It is frequently caused by stretching of the tissues,
ischemia or muscle spasm
Category of pain according to its cause

A. Acute pain/fast pain/sharp pain/initial pain

 following acute injury, disease or some type of surgery

 may have sudden or slow onset

 may last up to 6 months

 occurs within 0.1 second after application of stimulus

 Easily localized

 Impulses travel through the type A delta fibers

B. Chronic malignant/ Cancer Related pain

 associated with cancer or other progressive disorder

C. Chronic nonmalignant/Dull/ Slow/ Delayed pain

 pain in the persons whose tissue injury is non progressive or

healed

 last 6 months or longer and often limits normal functioning

 Impulses travel through the type C fibers

 not easily localized

 autonomic signs and symptoms like nausea, sweating and

generalized hypotonia, usually accompany this pain

Types of Pain Stimuli

In general, there are 3 types of stimuli that can stimulate pain receptors-
Mechanical, Thermal and Chemical.
 1. Mechanical stimulus- pressure, squeeze, pin prick

2. Thermal stimulus- heat and freezing temperature

3. Chemical stimulus

a. These are released when the tissue is injured or inflamed

b. Make the mechanoreceptors very sensitive to pain.

c. collectively called the “P” factors

i. bradykinin iv. prostaglandin

ii. serotonin v. substance P

iii. histamine

Physiology of Pain

 The Exact mechanism of pain transmission is still partially unknown.

Stimulus

Receptor

Type A Delta Type C Nerve

Nerve Fibers Fibers

Neospinothalamic Paleospinothalamic
Tract Tract

Thalamus and/or
Reticular system?

Brain ( Somesthetic
Areas)
 Factors affecting the Pain

A. Ethnic/Cultural values

B. Age/Developmental Stage

C. Environment and support persons

D. Past pain experiences

E. Meaning of pain

F. Anxiety and stress

Pain Assessment

2 mnemonics

OLDCART

 Onset

 Location

 Duration

 Characteristic

 Aggravating Factors

 Radiation

 Treatment (present and previous)

PQRST

 Provoked
  Quality

 Region/Radiation

 Severity

 Timing

Pain Scales

Premature Infant Pain Scale (PIPS)

 Use for premature infants (<36 weeks gestation)

In general:

 Scores<6 indicate minimal to no pain

 Scores of 6-12 indicate mild to moderate pain

 Scores >12 indicate moderate to severe pain

Neonatal Infant Pain Scale (NIPS)

 Use for infants, toddlers, or any child who is nonverbal

 For children with severe developmental delay or severe cognitive

delay, the NIPS

 may be modified in collaboration with the parent to better represent

that individual child’s pain behavior.

 The Advanced Practice Nurse (APN) from the Acute Pain Service
should be consulted in developing a plan for pain assessment and
management in this population.

In general:
  Scores of 0-2 indicate minimal pain to no pain

 Scores of 3-4 indicate moderate pain

 Scores of 5-7 indicate moderate to severe pain

Wong-Baker Faces Rating Scale (FACES)

 Use for children > 3 years old

 Self reports are valid and preferred for most children > 3 years old

 The FACES scale is available in multiple languages: English,

Spanish, Chinese, French, Italian, Japanese, Portuguese, Romanian,
and Vietnamese.

In general:

 Scores of 0-2 indicate minimal pain to no pain

 Scores of 3 indicate moderate pain

 Scores of 4-5 indicate moderate to severe pain

Verbal Analogue Scale (VAS)

 Use for children > 8 who understand the concept of order and
number

 Instructions for the VAS are available in multiple languages: English,

Spanish,

 Chinese, French, German, Greek, Hawaiian, Hebrew, Ilocano, Italian,

Japanese, Korean, Pakistan, Polish, Russian, Samoan, Tagalog,
Tongan, Vietnamese.

In general:
  Scores of 0-4 indicate minimal to no pain

 Scores 5-6 indicate moderate pain

 Scores of 7-10 indicate moderate to severe pain

Comfort Scale

 Use for intubated children

In general:

 Scores of 0-17 indicate mild to no pain

 Scores of 18-27 indicate moderate pain

 Scores of >27 indicate moderate to severe pain

Comfort

Definitions

Webster (1990) defined comfort in several ways:

 (a) to soothe in distress or sorrow;

 (b) relief from distress;

 (c) a person or thing that comforts;

 (d) a state of ease and quiet enjoyment, free from worry;

 (e) anything that makes life easy; and

 (f) the lessening of misery or grief by cheering, calming, or inspiring
with hope. In these definitions, comfort can be a verb, noun,
adjective, adverb, and it can be negative (absence of a recent
discomfort), neutral (ease), or positive (inspiring hope). The origin of
comfort is confortare, meaning to strengthen greatly

Kolcaba (1994, 2001, 2003) has defined comfort as "the immediate state
of being strengthened through having the human needs for relief, ease,
and transcendence addressed in four contexts of experience (physical,
psychospiritual, sociocultural, and environmental)"

Types of Comfort

1. Relief

 the state of having a discomfort mitigated or alleviated.

2. Ease

 the absence of specific discomforts.

 State of calm or contentment

 To experience ease a person does not have to have a previous

discomfort, although the nurse may be aware of predispositions
to specific discomforts (e.g., the tendency for shortness of
breath in an asthmatic child or acute anxiety in family members)

3. Transcendence

 the ability to "rise above" discomforts when they cannot be

eradicated or avoided (e.g., the child feels confident about
ambulation although (s)he knows it will exacerbate pain).

Three Types of Comfort Interventions

1. Standard comfort interventions

 to maintain homeostasis and control pain

2. Coaching
  to relieve anxiety,

o provide reassurance and information

o instill hope

o Listen

o help plan for recovery

3. Comfort food for the soul

 extra nice things that nurses do to make children/families feel

cared for and strengthened, such as massage or guided
imagery

Comfort Therapies

 Pleasure travels faster along nerve pathways than pain.

 Pleasure or comfort also causes our bodies to produce

elevated levels of our own endorphins or "feel-better"
hormones.

Basic Methods of Comfort Therapy

1. Patterned Breathing

 these breathing techniques provide comfort and focus

 Breathing enhances oxygen flow

2. Water

 Whether lying in the bubbling water of the Jacuzzi tub or sitting

on a shower stool using the hand-held shower massage, the
combination of warmth, water pressure and sound is very
comforting.
3. Heat and Cold

 Heat can be applied by a hot water bottle or warm washcloths;

cold can be applied by an ice bag, cold washcloth or bag of
frozen peas. Using heat and cold on separate parts of the body
at the same time can provide particularly effective pain relief; for
example, cool forehead with warmth on the lower back. For
maximum effect, change the heat and cold locations frequently,
about every 20 minutes.

4. Massage

 Stroking or rubbing the neck, shoulders, back, thighs, feet or

hands. No fancy techniques are required. Receptors in the
skin pick up the signal of touch and elevate endorphins. Bare
skin receives the signal best. Unscented powder or lotion are
helpful for massage.

5. Attention Focusing and Meditation

 Fear and anxiety cause the release of stress hormones. You

can ease these feelings by envisioning a pleasant scene.

6. Progressive muscle relaxation

7. Biofeedback

 This technique teaches the patient to relax the muscles in

the area of pain.

8. TENS is a counterstimulation technique with the goal of inhibiting

pain transmission. Results of its effectiveness are variable but some
residents and some types of pain obtain relief from TENS.
9. Acupuncture—or acupressure to reduce pain sensation
 Medical Interventions

1. Narcotic Analgesics

 Narcotic analgesics (pain medicine), such as Stadol and

Demerol, are usually given directly into an IV already in place.
Effects are felt within two to four minutes and are often
described as "taking the edge off" of pain. Doses may be
repeated every couple of hours and effects on the baby such as
respiratory depression are minimal.

a. Continuous infusion of opioids is most effective in

maintaining continuous pain relief with minimal risk of
respiratory depression, especially in infants

b. Intermittent Dosing is most effective when given in

small, frequent doses. These scheduled doses should
be given around the clock to avoid large peaks and
valleys in pain control. Do not give the scheduled dose
if a patient is experiencing increased sedation or
respiratory depression

c. Patient-controlled-analgesia (PCA) combines the

benefits of continuous infusion and PRN dosing and
has the added benefit of putting the patient/family in
control of the child’s pain.

i. PCA can be used in children who can understand

the concept of cause and effect.

2. Non Narcotic Analgesics

 NSAIDS and acetaminophen are effective for acute or chronic

painful conditions of mild to moderate intensity.
 NSAIDS work primarily on the peripheral nervous system to
provide pain relief.
 It is safe to administer a non-opioid and an opioid at the same
time.
  Common side effects of NSAIDS include GI irritation/upset and
antiplatelet effects contributing to some bleeding tendencies.
 NSAIDS have a ceiling effect, which means that increasing the
dose above the recommended dose will not provide additional
analgesia.
 Acetaminophen may be used for mild-moderate pain intensity
or in conjunction with
3. Local Anesthesia

 These numbing medications usually affect a small area.

4. Pudendal Block

 considered one of the safest forms of anesthesia and serious

side effects are rare.

5. Epidural Anesthesia

 Epidural anesthesia involves the placement of a small catheter

into the lower back by an anesthesiologist.

 A continuous infusion of medication is administered through the

catheter to provide a constant level of anesthesia.

 Epidural anesthesia provides excellent pain relief but has some

side effects like:

 Decrease in blood pressure

 breathing problems

 severe headache, dizziness or, rarely, seizures.

An epidural block, which is epidural anesthesia using a higher

dosage of numbing medication, can be used for surgery.

6. Spinal Block

 A spinal block is given as an injection into the lower block. A

spinal block numbs the lower half of the body, provides
 excellent relief from pain and starts working quickly. It has the
same side effects as epidural anesthesia.

7. General Anesthesia

 General anesthetics are medications that cause a loss of

consciousness.

 General anesthesia is given in one of two ways:

o through a face mask

o injected through an IV line.

 It works very quickly and results in almost immediate loss of

consciousness

 After general anesthesia wears off, you will feel woozy and tired
for several hours

IN SUMMARY

 Pain is a subjective experience that is whatever the patient says it is

and occurs whenever the patient says it occurs

 Although pain is a source of human misery, it minimizes injury and

warns of disease

 Establishing rapport between the nurse and the patient enhances the
effectiveness of pain relief measures

 Sedation does not always indicate pain relief

 Because patients may not always report pain, the nurse must assess
them regularly

 Patients of all ages experience pain, but the way they express pain
differs with age

 The nurse should be able to recognize physiologic, psychological and

non-verbal ways of expressing pain
 Lack of pain expressions does not always mean lack of pain

 Non-invasive pain relief measures can increase the effectiveness of

pharmacological or invasive methods

 The nurse’s optimistic attitude about expected pain relief helps

produce a positive result

 Educating the patient and family about pain reduces the anticipatory
fear and anxiety, thereby increasing the patient’s tolerance

 Using a preventive approach for pain relief is more beneficial than

waiting until pain becomes severe

 Intramuscular and intravenous routes are utilized for severe pain and
the intramuscular for moderate pain and oral for mild pain

 The nurse must utilize the nursing process in relieving patient of

“painful experiences”