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: serotonin, histamine, potassium ions, acids and 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;

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

Chronic malignant/ Cancer  associated with cancer or other progressive

Related pain disorder

Chronic  pain in the persons whose tissue injury is non

nonmalignant/Dull/ Slow/
Delayed pain
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:
These are released when the tissue is injured or inflamed making the
mechanoreceptors sensitive to pain. Collectively called “P” factors.

Bradykinin, serotonin. Histamine, prostaglandin, substance P

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/Gender
C. Environment and support persons
D. Past pain experiences
E. Meaning of pain
F. Anxiety and stress

Pain Assessment

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.

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

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,
 provide reassurance and information
 instill hope
 Listen
 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 (Guided Imagery) 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. Transcutaneous Electrical Nerve Stimulation (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, 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.

 Continuous infusion of opioids is most effective in maintaining continuous

pain relief with minimal risk of respiratory depression, especially in infants
 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
 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.

Side Effects of Opioid Therapy:

a. Respiratory Depression and Sedation
b. Nausea and Vomiting
c. Constipation
d. Inadequate Pain Relief
 e. Tolerance and Addiction

2. Non Narcotic Analgesics

 NSAIDS 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:
o Decrease in blood pressure
o Breathing problems
o Severe headache, dizziness
o Rarely seizures

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

Neurosurgical Approaches to Pain Management

 A. Cordotomy – division of certain spinal cord tracts
B. Rhizotomy – destruction of sensory nerve roots

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”