Topic- Pain, Wounds, Trauma and Management

By:

Mr. Barjinder Singh Mann

Introduction
Pain is a complex and multifactor phenomenon.
It is an individuals unique experience. It is difficult for others to recognize, understand &

assess. Unrelieved pain leads to debilitation, diminished quality of life & depression. In fact, unrelieved pain can also kill. It is the most common reason for seeking the health care.

Definition
Pain is an unpleasant sensory & emotional experience associated with actual or potential tissue damage.

Noxious stimuli, tissue damage, disease etc. Inflammatory response Converted into electrical signal (Transduction) Electrical signal carried by peripheral pain receptor called Nociceptor (conduction) A delta fibers (sharp, acute, well localized pain) C fibers (dull & achy pain)

Dorsal horn of spinal cord Nociceptor synapse with dorsal horn neurons (Transmission) Modulation of pain stimuli by inhibitory & facilitating control system in dorsal horn Ascending tract of neurons Higher centers of brain (cortex, frontal lobe, & limbic system)

Pain perception

A. According to duration:
1. Acute pain 2. Chronic pain

B.
1. 2. 3.

According to Location:
Superficial or Cutaneous Pain Deep Visceral Pain Deep Somatic Pain Referred Pain Radiating Pain Peripheral Pathological Pain

4.
5. 6.

1. Acute Pain
Generally caused by tissue damage.

Duration is short (less than 6 months).

Subsides with the appropriate interventions and as

resolution of tissue damage occur. Examples: Pain due to cut, injury etc.

2. Chronic Pain
It is of prolonged duration ( lasting at least 6

months) Based on certain distinguishing characteristics it is further divided in to following: a) Recurring Acute Pain b) Ongoing Time Limited Pain c) Chronic Benign Pain

a) Recurring Acute Pain

Characterized by recurring episodes of pain that may

continue over a lifetime. Example: Migraine headache

b) Ongoing Time Limited Pain

Characterized by a prolonged period of pain. It has high probability of ending with appropriate

interventions. Examples: Burn pain, Cancer pain etc.

c) Chronic Benign Pain

Generally due to non life threatening causes.

May not be responsive to many commonly used

interventions. May continue for the remainder of the persons life. Examples: Rheumatoid arthritis pain, etc.

According to Location: 1. Superficial or Cutaneous Pain

It is localized on the skin or the body surface.

The intensity of the pain usually correlates with the

intensity of stimulus. Examples: pain of sharp quality from pin stick, pain of stinging quality from an insect bite.

2. Deep visceral pain

Occurs in internal organs.

Tends to be diffused but may become localized if

continue. May be intermittent or constant. Quality is influenced by stimulus. Characterized as burning, dull, aching or sharp. May be accompanied by pain referred to superficial body locations, either adjacent or remote from affected area that are innervated by a particular spinal cord segment or nerve ending.

3. Deep Somatic Pain

Originates in muscles, nerves, bone, blood vessels &

other supporting tissues. These structures are poorly innervated, therefore the pain tends to be dull & poorly localized.

4. Referred Pain
It occurs in an area that is remote from the affected

area. It extend from the site of origin according to the Derm0atomes. Dermatomes are the body segments that are innervated by particular spinal cord nerves. Example: MI attack pain is experienced radiating in left axila to inner aspect of the left arm, liver and gall bladder pain experienced in right tip of scapula.

5. Peripheral Pathological Pain

It occurs in neural structures:

It is further of following types:

a) b)

c)
d) e) f) g)

Causalgia Trigeminal Neuralgia Postherpetic Neuralgia Phantom Pain Headache Cancer Pain Psychological Pain

a) Causalgia
Occurs in area of injured peripheral nerve.

Affect large diameter fibers.

Common sites for peripheral nerve injuries are

extremities. Characterized by the persistent, intense and burning sensation. Sciatic nerve, radial & ulner nerves can be affected.

b) Trigeminal Neuralgia (Tic douloureux)

Occurs along one or more divisions of the trigeminal

nerves. It results from the neuritis caused by a pathological condition, such as degenerative lesions that cause damage to nerve root fibers. Characterized by episodes of severe pain that last for a short period or it may be ongoing. Sites affected are mouth, gums, lips, cheeks, nose & surface of head.

c) Postherpetic neuralgia
It occurs following infection of dorsal root ganglia.

Infection caused by Herpes Zoster virus.

Characterized by the burning, dull or sharp

sensation. Intensity varies from mild to severe. Sites affected are cervical, thoracic, lumbar & sacral. It may encircle whole body areas.

e) Headache
It occurs in pain sensitive structures in the head.

Blood vessels, the venous sinus, the cranial nerves,

the cranium periosteum and the skin and tissues covering the cranium, the first 3 cervical nerves, muscles and dura at the base of the base of brain. Types of headache are:
1. 2.

3.
4.

Muscle contraction/tension Migraine Cluster Headache secondary to disease

d) Phantom Pain
It is perceived as occurring in a non existent part,

such as an amputated limb or breast. Mechanism of pain is not clear.

f) Cancer Pain
It may be either acute or chronic in nature.

Acute pain may occur as an early symptom of

underlying pathological condition. It may be induced by diagnostic procedures, surgery or chemotherapy. It is usually time limited & often responds to a short course of analgesics. Chronic pain may occur as the cancer progress or metastasizes to soft tissues, bone. It also may be associated with ongoing cancer therapy.

g) Psychological Pain
Refers to pain for which there is no detectable

physiologic or organic origin. The pain is believed to arise from mental or emotional factors.

PAIN ASSESSMENT
Begins by careful patient observation, noting overall posture and presence or absence of overt pain behaviors. It is essential to ask the patient to describe in his/her own words. There are certain factors to consider in a complete pain assessment. These are as following:

Location Onset Duration Intensity Quality Aggravating & alleviating factors Associated factors

LOCATION
Ask patient to identify on the body line drawing the area or areas of pain or discomfort. Ask various questions about pain. Examples:

Is the pain is superficial or deep? Does it move?

ONSET
Ask specific questions to assess the onset of pain. Examples:

When did pain begins?

DURATION
It refers to the length of time the pain is felt. Ask questions from patient to assess the pain duration Examples:

How long does the pain last with each occurrence?

INTENSITY
It is the most subjective characteristic of pain. Assess the intensity of pain by following methods:

Simple descriptive pain intensity scale 0-10 numeric pain intensity scale Visual analogue scale (VAS) Faces pain scale ( Especially for children below 7 years of age)

QUALITY
To assess the quality of the pain ask various questions. Examples:

Describe what your pain feel like? Words such as dull, sharp, burning etc.

AGGRAVATING & ALLEVIATING FACTORS

Aggravating or Precipitating Factors:

Sudden movement Emotional stress Muscle tension Exercise Physical exertion Coughing Analgesics Position change Rest and sleep Heating or ice bags Music therapy Massage

Alleviating Factors:

ASSOCIATED FACTORS
It is important to assess the effects of pain on activities of daily living. Ask questions regarding the patients ability to participate in self care & daily activities. Examples:

Are you able to perform routine hygiene measures?

Pain Management
A. Medical management
a. Non-pharmacological management b. Pharmacological management

B. Neurological & neurosurgical Approaches C. Nursing Management

Non-Pharmacological Management
I.

Cutaneous Stimulation

II. Auditory Stimulation

III. Relaxation
Music Therapy Distraction

Transcutaneous Electrical Nerve Stimulation (TENS) Heat Therapy Cold Therapy Massage Vibration Therapy

IV. Rest And Sleep V. Hypnosis

Breathing Exercises Progressive Relaxation Training(PRT) Guided Imagery Biofeedback

Transcutaneous Electrical Nerve Stimulation (TENS)

Heat Therapy

Cold Therapy

Massage

Vibration Therapy

Music Therapy & Distraction

Breathing Exercises

Progressive Relaxation Training(PRT)

Guided Imagery

Biofeedback

Rest & Sleep

Hypnosis

Pharmacological Management
Pre-medication assessment
Before administrating drug the nurse should ask about allergies to the medications & nature of any previous allergic response. Obtain history of medication. (E.g. current, usual or recent use of prescription or OTC medications or herbal agents) History of health disorder. Assess patients racial background.

Agents Used To Treat Pain

A. Opioids Analgesic Agents B. Non-steroidal Anti-inflammatory Drugs (NSAIDs) C. Local Anesthetic Agents D. Tricyclic Antidepressant Agents & Antiseizures Medication

A. Opioid Analgesic Agents

Some of the Opioids used are:
Morphine 30-60mg (oral), 10mg (Parentral) Codeine 15-30mg, up to 60-360mg/24h (oral) Oxycodone 5-20mg (oral) Tramadol 50-100mg (oral) Respiratory depression & sedation Nausea & vomiting Constipation Pruritis Addiction

Adverse Effects

B. Non-steroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are thought to decrease pain by inhibiting Cyclooxygenase(COX), the enzyme involved in the production of prostaglandin from traumatized or influenced tissue. Some of the NSAIDs are:
Aspirin(Acetylsalicyclic Acid) Tylenol (Acetaminophen) Ibuprofen (Motrin, Advil, Nuprin)

C. Local Anesthetic Agents

These working by blocking nerve conduction when directly given to the nerve fibers. Topical Application:
5% Lidocaine (Lidoderm) patch. EMLA (Emulsion of Local anesthetics)

Intraspinal Administration:
Local anesthetic agents administration through an epidural catheter is applied directly to the nerve root.

D. Tricyclic Antidepressant Agents & Antiseizures medications

Pain of neurologic origin like Causalgia, Postherpetic neuralgia etc. are difficult to treat & in general is not responsive to opioid therapy. Some of the Antidepressant Agents & Antiseizures medications are:
Imipramine (Antidepressants) Carbamezepine (Antiseizure)

Approaches For Using Analgesic Agents

Balanced Analgesia: Pro-Re-Nata (As Needed): Preventive Approach:
Use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects. The standard practice was for the nurse to wait for the patient complaint & then administer analgesia. Medication is administered at set intervals so that the medication acts before the pain become severe. It is most effective because a therapeutic serum level of medication is maintained. PCA pumps permits the patient to self administer continuous infusions of medication safely & to administer extra medication with episodes of increased pain or painful activities.

Patient Controlled Analgesia (PCA):

PCA Pump

Routes Of Administration
Prenatal Route (IM, IV, Subcutaneous) Oral Route Rectal Route Transdermal Route Transmucosal (In case of Cancer) Intraspinal and Epidural Routes

B.Neurological & Neurosurgical Approaches

Implantable Electrical Stimulation Systems Neurosurgeries
Neurectomy Rhizotomy Sympathectomy Tractotomy Corodotomy Hypophysectomy

Acupuncture

Implantable Electrical Stimulation System

Neurectomy

Rhizotomy

Sympathectomy

Tractotomy

Corodotomy

Hypophysectomy

Acupuncture

Nursing Management
Nursing Diagnosis:
Pain related to superficial incision, tissue damage, injury, burn. Sleep pattern disturbances related to discomfort. Impaired physical mobility related to impaired body comfort. Knowledge deficit related to pain management, including alternative therapies to control pain. Anxiety related to pain experience and pain mangement.

Nursing Process
Identify goals for pain management Establish the nurse patient relationship & teaching. Providing physical care Manage the pain Managing the anxiety related to pain Evaluating pain management strategies.

Multidisciplinary Approach To Pain Control

Nurse Physical therapist Occupational therapist Clinical psychologist Social worker Spiritual or religious counselor Dietician

Wounds

Definition: Wounds are the injury to the soft tissues that can vary from minor tears to sever crush injuries.

Types Of Wounds

Laceration Avulsion Abrasion Contusion/Ecchymosis/Bruising Hematoma Stab Cut Patterned

Laceration

Skin tears with irregular edges & vein bridging.

Avulsion

Tearing away of tissue from the supporting structures.

Abrasion

Wound caused by superficial damage to the skin. No deeper than the epidermis.

Contusion/Bruising/Ecchymosis

Blood trapped under the surface of skin due to capillaries burst.

Hematoma

Tumor like mass of blood trapped under the skin.

Stab

Incision of the skin with well defined edges, usually caused by the sharp instruments. A stab wound is typically deeper than longer.

Cut

Incision of skin with well defined edges. Usually longer than deeper.

Patterned

Wound representing the outlines of the object causing the wound. Example: wound caused by steering wheel.

Management Of Wounds

Wound Cleaning:
Hair

around the wound should be clipped or cut if interfere with wound closure. Clean with normal saline. Antibiotic agents (povidine iodine or hydrogen peroxide) should not be allowed to get deeper into the wound without thorough rinse. Dead tissues and foreign matter should be removed from wound. After cleaning a non adherent dressing should be applied.

Wound Management(contd..)

Primary Closure:

If indicated, the wound is sutured or stapled. Suturing is done under local anesthesia. Sterile stripes of reinforced microporous tape or a bonding agent(skin glue) may be used.
May be indicated if tissue has been lost or there is high risk for infection. A thin layer of gauze covered by an occlusive dressing may be used. Wound is splinted to prevent motion & decrease the possibility of contracture. Tetanus prophylaxis.

Delayed Primary Closure:

Definition: It is an unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body can not protect itself.

a)

Polytrauma or multiple trauma:

Caused by single catastrophic event that causes life threatening injuries to at least two distinct organs or organ systems. E.g. trauma form bomb explosion Injury occurred when the human body hits or hit by a large outside object. E.g. hit by a car. Injury occurred when an object pierces the skin & enters a tissue of body, creating an open wound. E.g. gunshot, stabbing etc.

b)

Blunt Trauma:

c)

Penetrating Trauma:

MRI CT Scan X- Rays

The goals are to determine the extent of injuries & to establish priorities of treatment. Essential life saving procedures performed simultaneously by emergency team. As soon as patient is resuscitated, clothes are removed or cut off & a rapid physical examination is performed. Transfer from field to emergency department. Treatment in a trauma center for patient experiencing major trauma.

i. ii. iii. iv. v.

vi. vii.

Establish airway & ventilation Control hemorrhage Prevent & treat hypovolemic shock Assess for head & neck injuries. Evaluate for other injuries (reassess head & neck, chest. Assess abdomen, back & extremities) Splint fractures Perform a more thorough & ongoing examination & assessment

Summarization

Introduction of pain Definition of pain Pathophysiology of pain Types of pain Factors affecting pain perception Pain assessment Pain management Definition of wound Types of wounds Management of wounds Definition of trauma Types of trauma Assessment & diagnostic finding for trauma Management of trauma

Bibliography
Saunders, Manual of Nursing Care, W.B. Saunders

Company, Philadelphia. Page no. 338-362 Black & Hawk, Medical Surgical Nursing Vol. I, 7th Edition, Saunders, St. Louis, Missouri. Page No.440483 Brunner & Suddarth, Textbook of Medical Surgical Nursing Vol. I & II, 12th Edition, Wolter Kluwer, India Pvt. Ltd. New Delhi. Page No. 231-260, 2163-2166 Health Action, Feb 2012, Printed and Published By Dr. Placida, India. Page No. 8-12 ANS (Advance in Nursing Sciences), Vol. 34, JulySep 2011, Wolter Kluwer, Lippincott. Page No. 215228 www.google.com www.wikipedia.com

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