Concept of Pain

(Different Therapies)

Presenter: M. Salman Alam

(Nursing Instructor RCN)
9/7/2018 1
 Scenario

• 60 year old patient is having pain on the 5th day after the
abdominal surgery. She was shouting aloud as the pain
was intolerable. Upon assessment her pain scale was 8/10
and she was also nauseated. her vital signs were RR= 25,
P=110/min, BP = 155/90. her facial expression reveals too
much pain. After administration of pain medication the
nurse also provided the back massage and deep breathing
exercise to minimize the pain sensation.

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 Objectives
• At the end of the session learners will be able
to:
• Define Sensory perception and cognition .
• Describe the different theories of pain theory.
• Discuss classification of pain by location.
• Enumerate Physiological and
Psychosocial factors that affect pain
perception.
• Discuss the stages in which the bodies
respond to pain.
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 Objectives
• Identify guidelines to assess patient’s pain.
• Discuss non-invasive & non- pharmacological techniques to
relieve pain (Massage Therapy, Guided Imaginary).
• Plan and apply nursing process on a client experiencing pain.
• Discuss the implications of pain assessment for nursing
interventions.
• Explain the behavioral indicators of effects of pain.
• Discuss common Myths about pain.
• Explore advantages & disadvantages of selected pain
therapies.

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 Sensory perception and cognition
• Sensory perception is the process of receiving
stimuli or data.
• There are two types of Stimuli:
• External: visual, auditory,taste,smell,tactile
• Internal: feelings such as hungry, upset, good
etc

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 Sensation, Perception, and Cognition

• Sensation is the ability to receive and process

stimuli received through the sensory organs.
• Perception is the ability to experience,
recognize, organize, and interpret sensory
stimuli.
• Cognition is the intellectual ability to
understand the world and acts in it e.g. the
elements of memory, judgment, orientation
and thought process
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 Factors Affecting Sensation,
Perception, and Cognition
• Age
• Environment
• Lifestyle
• Stress
• Illness
• Medications

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 What is pain
• The International Association for the Study of
Pain (IASP) adopted the following definition
of pain. “Pain is an unpleasant sensory and
emotional experience associated with actual
or potential tissue damage, or described in
terms of such damage”
(APS, 1992; Mersky & Bogduk
1994).

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 TERM related to pain
Pain receptors:
Nerves endings in the tissues which receive pain stimuli. More in
skin and joints & less in organs and deeper tissues. Nociceptors
are the specialized pain receptors, can be excited by any stimulus.

Pain threshold:
Pain Threshold is the level at which a person first begins to
experience pain from a stimulus.

Pain Tolerance:
A person's Pain Tolerance level, is the overall level of pain a
person can tolerate before breaking down either physically or
mentally.

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 Pain stimulus

Mechanical Thermal Chemical

• Tissue trauma Extreme of heat Chemicl
(surgery, or cold released
accident) by injured cell or
• Inflammation microorganism
• Tumor Prostaglandin
• Muscle spasm Lactic Acid

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 Mechanism Of Pain
Pain receptors excited by stimulus

pain impulse travels from nerves fiber to spinal cord

To brain stem and thalamus

Transmit impulse to the somatic sensory cortex

Neuron in the thalamus & brain stem

send signal to stop pain impulses

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 Components of Pain

1. Location : where is the pain in the

body (head, legs, back etc).
2. Duration: acute or chronic
3. Intensity: pain scale
– 0: no pain
– 1-3: mild
– 4-6: moderate
– 7-10: severe

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 Acute and Chronic pain
Acute Pain Chronic Pain
Mild to severe Mild to severe
Sympathetic nervous system Parasympathetic nervous system
responses: responses:
Increased pulse rate, respiratory Vital signs
rate, blood pressure normal Dry,
Diaphoresis, Dilated pupils warm skin
Pupils normal or dilated
Related to tissue injury; resolve with Continues beyond healing
healing
Clients appears restless and anxious Clients appears depressed and
withdrawn
Clients report pain Client often does not mention pain
unless asked
Client exhibits behavior indicative of Pain behavior often
pain; crying, rubbing/holdingarea absent
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 Components of Pain
4. Etiology
Types ofpain
• Physiological Pain: when tissue are damage e.g. Skin
cut or broken bone.
• Somatic Pain: originates in skin, muscles or bones e.
g. sprained ankle.
• Visceral Pain: originates when pain receptors activates in
the organ e.g. Irritable bowel.
• Neuropathic pain: damage or malfunctioning nerves e.g.
nerve injury, Diabetic neuropathy.
• Peripheral Neuropathic Pain: damage to
peripheral nerves e.g. phantom limb pain.
• Central Neuropathic Pain: damage to the central nerves
e.g. spinal cord injury, stroke pain.
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 Coping

Age style Fatigue

Gender
Anxiety

Family and
social
support

Attention
Previous Meaning
Culture experience of pain

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 NURSING PROCESS
Scenario
• 60 year old patient is having pain on the 5th day after the
abdominal surgery. She was shouting aloud as the pain
was intolerable. Upon assessment her pain scale was 8/10
and she was also nauseated. her vital sign were RR= 25,
P=110/min, BP = 155/90. her facial expression reveals too
much pain. After administration of pain medication the
nurse also provided the back massage and deep breathing
exercise to minimize the pain sensation.

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 Assessment data
• PHYSIOLOGICAL RESPONSES /
OBJECTIVE DATA
➢ Increase in BP
➢ Increase heart rate
➢ Increase respiratory rate
➢ Associated characteristics
➢Nausea , vomiting ,fatigue,
anorexia

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CONT…
Verbal response
➢ moaning, groaning/ crying , sighing, screaming
➢praying , swearing or cursing, repeating nonsensical
phrases.

Non Verbal response

➢ Facial expression
➢ Body action
➢ Behaviors

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 CONT…
Subjective Data
Normal pattern identification
1. Where is the pain located?
2. What is the magnitude or intensity (level) of the pain?
3. What level of pain would be tolerable by patient?
4. How does the pain feel to the client; how is it describe ?
5. How does the pain changes with rest activity or time?

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Cognitive Perceptual Pattern
This pattern includes:
• Pain: Acute /Chronic
• Sensory/ perceptual alteration (specify)
(visual, auditory, gustatory, tactic, olfactory)
• Peripheral neurovascular alteration
• Knowledge deficit
• Thought process altered
• Decisional conflict (specify)

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 COLDERRA
• Character: Throbbing(hurting), sharp,
dull, crushing/hammering
• Onset: When it starts
• Location: Epi-gastric, Rt Hypochondria
• Duration: for 5 min, continuous, intermittent
• Exacerbation (pain increase): with positioning,
on sitting, on breathing (what increases pain)
• Relieving: with pain killers, by pressing on the site
• Radiate: moves to right side from the left
• Associate: with vomiting, dizziness
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 Assessment tool FHP

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 Pain assessment

• P= Provocative or Palliative: What makes the pain better or

worse?
• Q= Quality: Describe the pain. Is it burning,
shooting, aching, stabbing, crushing, etc?
• R= Radiation: Does the pain radiate to another body part?
• S= Severity: On a scale of 0-10, (10 being the worst)
how bad is your pain? (may use other scales also)
• T= Timing: Does it occur in association with something
else? (i.e. eating, exertion, movement)

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9/7/2018 Cognitive and perception pateern 24
 Nursing diagnosis

• Alteration in comfort i-e acute / chronic pain

related to tissue trauma secondary to surgical
procedure as evidences by patients pain score
of 8 (0-10)

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 Planning
By the end of my shift
• Patient pain will be reduce by 2 degree.
• Patient vital sign will be in normal range
after receiving the back massage.

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 Nursing Interventions
Pain Relive Techniques
• Physical pain relief techniques
– Positioning and hygiene
– Cutaneous Stimulation
• Massage therapy (pressure)
• Heat & Cold fomentation

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CONT…
• Cognitive Pain relief techniques
1. Anticipatory Guidance
2. Distraction
3. Guided imagery
4. Hypnosis

• Behavioral pain relief techniques

1. Relaxation (deep breathing exercise)
2. Meditation

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 CONT…
• Pharmacological management
1. Non opioid/ Non-narcotic analgesics
Aspirin , Non steroidal Anti inflammatory
Drugs (ANSIDs) & Acetaminophen

2. Opioid/ Narcotic analgesics

Morphine , pethidine

3. Epidural and Intrathecal analgesia

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Routine Clinical approach to pain Assessment & Management
“ABCD”

A- Ask about pain regularly and Assess pain systematically

B -Believes the client and family in their report of pain & what
reliefs it
C-Choose pain control options appropriate for the client family
& Setting.
D-Deliver interventions in a timely , logical and coordinated
function
E-Empower clients & their families. Enable them to control
their cause to the grater extent possible.
(From Jacox A & others: Management of cancer pain, clinical practices
guideline NO.9,AHCPR Pub. No.90-0592,March 1994)

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 Some barriers
• May interfere while caring client:
• Health care provider
– Lack of knowledge about the pharmacology of
opioids
– Regulation of control substances
• Patient
– Patient fear of addiction, tolerance,
dependence
– Unwanted side effects

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 EVALUATION
By the end of my shift patients
• Pain was reduced by two degree
• vital signs were the within normal range (Write it
down) after back massage.

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 scenario
• A 65 yrs old man admitted with complain of
loss of sensation on right side of the body.
According to family member, he was
disoriented, fainted and had difficulty in
swallowing since two days. He has history of
hypertension since 15 years. He has no control
on urine and stool. On physical examination, it
was found he has no reflexes on right side,

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 CONT:
• Gag reflex is absent. His vital signs are
T 37C,P100/m,R24/m and BP 170/110.
• Write down the problem list: actual, risk and
possible
• Take one problem and make NCP

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 Reference

• Erb, G., & Kozier, B. (2008).

Fundamentals of nursing: Concepts,
process and practice. (8th ed.). Addison –
Wesley.

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