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NURSING FOUNDATIONS II
~ PAIN PERCEPTION AND MANAGEMENT ~

PAIN
 Normal response to injury or disease
 Result of normal physiological processes
 Unpleasant emotional and sensory experience associated with actual or potential tissue damage
 Subjective sensation
o Symptom
 Protective
 Modified by developmental, behavioral, personality, and cultural factors
 Associated signs: crying, sweating, behavioral changes, increase in heart rate and BP

Mechanical +
Chemical +Thermal

Pain receptors
stimulate nociceptors

Spinal Cord

Brain

Pathway of nociception
Pain stimuli  dendrites  axon  peripheral nerves  spinal cord  thalamus  cerebral cortex

FOUR PHYSIOLOGIC PROCESSES INVOLVED IN NOCICEPTIVE PAIN

 Transduction – perception of stimuli, to travel along the peripheral nerves
 Conduction – travel along the peripheral nerves
 Transmission – from nerves to brain
 Modulation – transmission of message from nerves to brain and vice versa
o Perception – translation of message from stimuli

PAIN THEORIES
1. Intensity Theory – an emotion that occurs when a stimulus is stronger than usual
2. Specificity Theory (debugged 19th century theory) – a separate sensory system for perceiving pain
3. Pattern (Summation) Theory – people feel pain when certain patterns of neural activity occur characterized by intense stimulation
4. Endorphin/Enkephalin Theory – looks at the influence of hormones
5. Gate Control Theory – gating system along the CNS which regulate or block pain impulses

CLASSIFICATION OF PAIN BASED ON ETIOLOGY

1. Nociceptive Pain
a. Somatic Pain – musculoskeletal pain (fracture, joint pain)
i. Body surface or musculoskeletal system
b. Visceral Pain – internal organs
i. More generalized, not localized pain
 2. Neuropathic Pain – injury in the nerves, characterized as burning, shooting, pinning pain (stabbing or piercing), evident with cervical or
back injuries (Example: Funny Bone)
a. Peripheral neuropathic pain
b. Central neuropathic pain
CLASSICATION OF PAIN BASED ON DURATION
1. Acute Pain – usually continuous pain experience
a. Post-surgical, headache, trauma
2. Chronic Pain
a. Nociceptive – osteoarthritis or rheumatoid arthritis
b. Neuropathic
i. Central – post stroke, MS, spinal cord injury, phantom pain
ii. Peripheral – post-herpetic neuralgia, diabetes neuropathy, HIV related neuropathic pain
c. Mixed – lower back, cancer, fibromyalgia
d. Visceral – internal organs, pancreatitis, inflammatory bowel syndrome
e. Idiopathic – no known cause
f. Breakthrough Pain – common in cancer patients, sudden onset, pain from other sources

CHARACTERISTICS OF PAIN
1. Location
a. Localized
b. Referred
2. Intensity – refers to the magnitude or amount of pain
a. Mild, slight, moderate, severe, or excruciating
3. Duration/Pattern
a. Acute
b. Chronic – usually more than 6 months, not always associated with known causes
i. Recurrent acute
ii. Ongoing time-limited
iii. Chronic non-malignant – not life-threatening
iv. Chronic intractable non-malignant pain syndrome
4. Quality

ACUTE VS CHRONIC
Acute Chronic
Onset Abrupt Gradual
Duration 0 – 6 months More than 6 months
Intensity Mild, moderate, severe Mild, moderate, severe
Etiology Biologically identifiable May not be easily identified
Increase VS, dilated pupils, pallor, nausea and
Physical Response No ANS symptoms
vomiting, increased muscle tension, dry mouth

FACTORS INFLUENCING PAIN PERCEPTION/RESPONSE

 Physiologic
o Age
o Fatigue
o Genes
o Neural plasticity (adaptation)
o Peripheral sensitization
o Central sensitization
o Regenerative neuronal growth
 Ethnic and culture
 Environment, family, support people
 Past pain experiences
 Attention
 Spiritual factors
 Psychological factors
o Affective factors
 Suffering – emotional response to pain
 Unrelieved pain can cause emotional responses such as anger, fear, anxiety, sadness, or depression
 Behavioral factors
o Cognitive Factors
 Not knowing the outcome may increase pain
 Exhaustion and lack of sleep lead to difficult pan control
o Behavioral factors
 Anxiety
 Fear
 Fatigue
LIFESPAN CONSIDERATIONS
1. Newborns and infants
a. Usually respond with whole body movement
2. Toddler-Preschooler
a. Lethargy, fatigue, anorexia, regression
3. Older toddler
4. School-age adolescent
a. Try to be brave
b. More responsive to explanations
c. Learn about pain and perception from family member
d. Teenagers may be reluctant to complain due to peer pressure
5. Adults and older adults
a. Ability to interpret pain is complicated

MANIFESTATIONS OF PAIN
 Physiologic
o Neuroendocrine and metabolic
 Behavioral
o Verbal responses
o Non-verbal
o Impact on daily living