Module 2M: Concept of Pain

Anatomy and Physiology of the nervous system 2. Neuropathic Pain – pathologic, centrally
3 principal functions generated pain, peripherally generated pain
a.) Sensory input - results from abnormal processing of sensory
- Spider walking on your bare knee, sensory input input by the nervous system as a result of
detect that information damage to the PNS or CNS or both
b.) Integration
- Nervous system processes that input and decides 3. Mixed Pain – Components of both nociceptive
what should be done about it and neuropathic pain: poorly defined
c.) Motor input
- Response that occurs when your nervous system A-Beta Fibers
activates certain parts of your body - large diameter lightly myelinated
2 main parts in nervous system - conducts fast impulse
1. Central nervous system (CNS) - are the largest of the fibers and respond to
- Brain and spinal cord touch, movement and vibration but not normally
- Main control center transmit pain
2. Peripheral nervous system (ANS) - quick localization of pain
- All the nerves that branch out from your brain - responsible for rapid reflex withdrawal from the
and spine that allow your CNS to communicate painful stimulation
with the rest of the body
- Set up to work in both directions C Fibers
a. Sensory or afferent division: what picks up - small diameter unmyelinated
sensory stimuli and slings the information to the - conducts slow impulse
brain - produces poorly localized aching or burning pain
b. Motor or efferent division: the part that sends - responds to mechanical, thermal and chemical
directions from your brain to the muscles and stimuli
glands
▪ Somatic or voluntary nervous system: Somatic pain: cutaneous or superficial, deep somatic Visceral
rules the skeletal movement pain: tumor involvement, obstruction of hollow viscus
▪ Autonomic or involuntary system: keeps
your heart beating, lungs breathing and Categories of Neuropathic Pain
stomach churning 1. Centrally generated pain
✔ Sympathetic division: Mobilizes a. Deafferentation pain – injury to peripheral and
the body into action and gets all phantom pain
fired up b. Sympathetically maintained Pain – 2 complex
✔ Parasympathetic division: regional pain syndrome
relaxes the body and talks it
down
Peripherally generated pain
Pain c. painful polyneuropathies – diabetic neuropathy
- fifth vital sign (tingling, etc.)
- each pain is unique, personal experience d. painful mononeuropathies – trigeminal neuralgia
- subjective response to physical and psychological
stressors Seven Dimensions of Pain
- whatever the experiencing person says it is, existing 1. Physiological: body’s reaction, patient’s
whenever he says it does. perception
- unpleasant, subjective sensory and 2. Sensory: how severe the pain is, intensity, quality
emotional experience associated with actual or potential tissue 3. Affective: affects emotions, feelings. How does
damage, or described in terms of such damage (IASP, 2010) the pain affect your overall mood
4. Socio-cultural: special cultural practices
Types of pain 5. Behavioral: verbal/non verbal cues
a. Acute: short period doesn’t last more than 6 6. Cognitive: concerns beliefs, attitudes, intentions;
months how effective is the pain relief
b. Chronic: more than 6 months 7. Spiritual

Classification of Pain by inferred pathology Characteristics of Pain

1. Nociceptive pain – physiologic, somatic pain, ● Timing – onset, duration, pattern; knowing the
visceral pain, normal pain transmission time cycle
- normal processing of stimuli that damages ● Location- describe/point the areas of
tissues or has the potential to do so if prolonged. discomfort/superficial/cutaneous
 ● Severity – characteristics of pain; how to use
pain scales
● Quality
● Aggravating & Precipitating factors – describe
activities
● Relief measures
Nociceptive Pain
a. transduction
b. transmission
c. perception
d. modulation
Cutaneous/superficial – skin, subcutaneous
Deep somatic – trauma, burn, osteoarthritis, cancer pain
Tumor involvement – cancer pain
Obstruction of Hollow viscus – obstruction of kidney stones
Factors influencing Pain response
1. psychological
2. cultural
3. social
4. Physiologic
Tools utilized for pain assessment
 Numeric rating scale (MRS)
 Wong baker Faces pain rating scale
 Faces pain scale-revised (FPS-R)
 Verbal descriptor scale (VDS)
 Visual analog scale (VAS)
 Pain assessment in advanced dementia (PAINAD)
– indicated for use in adults with dementia who are not able to
verbalize their needs
 Critical care pain observation tool (CPOT) – indicated
for use in critical care units who cannot self-report pain,
whether they may be intubated
Common Myths about Pain – And the Reality
1. THE MYTH: Pain is an unavoidable part of growing old. THE
REALITY: Chronic pain is common after age 65, and painful
conditions such as degenerative joint disease (also known as
osteoarthritis) increase with age. The prevalence of pain in
nursing home residents is estimated at 45–83%. Although pain
is common in older nursing home residents, it is not inevitable.
More important, it does not have to be tolerated—effective
treatments are available.
2. THE MYTH: Residents with dementia are unable to report
their pain
THE REALITY: Several studies have shown that many people
with dementia, even those with moderate to severe dementia,
can reliably report pain. Therefore, do not assume that
residents can’t report their pain based on a diagnosis or score
on a dementia rating scale. Evaluate first whether or not a
person can self-report before relying on caregiver report or
behavioral cues to determine pain.
3. THE MYTH: Pain is mostly an emotional or psychological
problem.
THE REALITY: Pain isn’t “in somebody’s head.” There are
physical reasons for pain. However, pain can cause negative
emotions that can worsen a person’s perception of pain.
Therefore, be sure to identify and address psychological issues
that affect an
older adult’s pain experience.
4. THE MYTH: Doctors and nurses are the experts about
pain.
THE REALITY: No, the older adult is the expert. Pain is a
complex, subjective experience that is best described by
the person who feels it. When the older adult cannot report
pain because of cognitive impairment or stroke, the people
who know the individual best should be consulted. These
people usually include family members and nursing assistants.
5. THE MYTH: It’s important to be stoic about pain.
THE REALITY: Being stoic about pain often is valued in our
society. This tendency may be more common among older
persons. Unfortunately, stoicism can prevent health care
providers from identifying and treating pain.
Teach older adults who “don’t want to
complain” that reporting pain is the only way to identify the
problem and treat it. They have a right to have their pain
treated and when they let their caregivers know they are
experiencing pain, they are not complaining.
6. THE MYTH: Any painful condition causes the same
amount and type of pain in all people.
THE REALITY: Pain perception is affected by many factors,
such as previous injury, stress, emotions, and fatigue. So,
depending on the person and the situation, two people can
respond very differently to the same painful stimulus.
7. THE MYTH: There’s not much that can be done to
relieve pain in nursing home Residents.
THE REALITY: There is much that can be done. Effective
chronic pain management often requires more than one
treatment approach. Therefore, a pain management plan
should include both medications and non-drug strategies.
Finding the best therapeutic regimen
for a particular individual may also involve several trials using
different strategies. Encourage older adults and families to be
hopeful and patient.
Strategies for using this information:
• Staff in-services: print each myth on a separate sheet of
paper. Divide the class into
small groups and give each group 1-2 of the sheets. Ask each
group to discuss and
write a response to the myth. Share responses and “The
Reality” with the entire class.
• Share the handout with family members and older adults at
resident council meetings or
family support group meetings. Discuss the handout.
• Include the handout with admission materials. Emphasize to
older adults and families that your facility is dedicated to
regular pain assessment and treatment. Older Adults
and families are part of the pain management team.
DEFINITION OF TERMS
• algogenic - a substance causing pain
• agonist - a substance that when combined with the
receptor produces the drug effect or desired effect.
• antagonist - a substance that blocks or reverses the
effects of the agonist by occupying the receptor site
without producing the drug effect
• addiction - a behavioral pattern of substance use
characterized by a compulsion to take the substance
(drug or alcohol) primarily to experience its psychic
effects
• balanced analgesia - using more than one form of
analgesia concurrently to obtain more pain relief with
fewer side effects.
• breakthrough pain (BTP) - a transitory increase in
pain that occurs on a background of otherwise
controlled persistent pain
• endorphins and enkephalins - chemicals that reduce
or inhibit the transmission or perceptions of pain
• dependence - occurs when a patient who has been
taking opioids experiences a withdrawal syndrome
when the opioids are discontinued
• narcotic - a drug that in moderate doses dulls the
senses, relieves pain, and induces profound sleep but
in excessive doses causes stupor, coma, or
convulsions.
• nociception - activation of sensory transduction in
nerves by thermal, mechanical, or chemical energy
impinging on specialized nerve endings; the nerves
involved convey information about tissue damage to
the central nervous system
• nociceptors - a receptor preferentially sensitive to a
noxious stimulus
• non-nociceptors - nerve fiber that usually does not
transmit pain
• opioid - a morphinelike compound that produces
bodily effects including pain relief, sedation,
constipation, and respiratory depression
• pain - an unpleasant sensory and emotional
experience resulting from actual or potential tissue
damage
• pain tolerance - the maximum intensity or duration of
pain that a person is able to endure
• pain threshold - the point at which a stimulus is
perceived as painful
• prostaglandins - chemical substances that increase
the sensitivity of pain receptors by enhancing the pain
provoking effect of bradykinin
• referred pain - pain perceived as coming from an area
different from that in which the pathology is occurring
• tolerance - a process characterized by decreasing
effects of a drug at its previous dose, or the need for
a higher dose of drug to maintain an effect
• patient-controlled analgesia - self-administration of
analgesic agents by a patient instructed about the
procedure
Possible Nursing Problems for PAIN: Acute Based from:
NANDA International, 14th Ed. o Activity intolerance
o Altered family processes
o Altered thought processes
o Anxiety
o Chronic pain
o Constipation
o Fear
o Hopelessness
o Ineffective individual coping
o Pain
o Powerlessness
o Risk for self-mutilation
o Sleep Pattern Disturbance
PAIN THEORIES
1. Specificity Theory
• proposed in the 17th century by Rene Descartes
• believed that the “thinking” mind was not
actively involved in the body’s response to pain
• merely a biological explanation and does not
address the multidimensional, complex, pain
process
• explained the activity of highly specific
peripheral nerve endings – receives sensory
information (environment) – transmits by nerve
fibers through the spinal cord to the pain center
or pineal body in the forebrain
2. Pattern Theory
• pain receptors share endings or pathways with
other sensory modalities
• but different patterns of activity in the same
neurons can be used to signal painful and non-
painful stimuli
• no longer considered a major theory
3. Gate Control Theory
• proposed by Ronald Melzack and Patrick Wall in
1965
• stimulation of the skin evokes nervous impulses
transmitted by three systems located in the
spinal cord
a. substantia gelatinosa in the dorsal horn
b. dorsal column fibers
c. central transmission cells that acts to
influence nociceptive impulses
✓ Large diameter A delta fibers inhibit the transmission of
pain thus, “closing the
gate” – pain sensation blocked
✓ Small diameter C fibers allows the passage of pain thus,
“opening the gate” –
pain sensation transmitted
✓ A beta or touch fibers – closes the gate and turns away pain
impulses