CONCEPT OF PAIN

PAIN Is a multidimensional phenomenon and thus difficult to define Personal and subjective experience and no two people have EXACTLY the same pain in a same manner The International Association for the Study of Pain (IASP) defines pain as unpleasant sensory and emotional experience associated with actual or potential tissue damage Sternbach defined pain as, an abstract concept, a personal private sensation of hurt, harmful stimulus that signals current or impending tissue damage and pattern of response to protect the organism from harm Geach (1987) defined pain as the noxious stimulation of threatened or actual tissue damage McCaffery (1979) defined pain as whatever the experiencing persons says it is and existing whenever the person says it does It is an abstract concept that refers to a stimuli, physical or mental that signals current impending tissue damage, a private, subjective bodily sensation of hurt and a pattern of reaction or responses of the person experiencing pain which is intended to protect the person from harm

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COMPONENTS OF PAIN 1. Sensory-discriminative Component - recognition of pain 2. Affective-motivational Component emotional and behavioural dimension 3. Cognitive-evaluative Component determined with past experience to pain TYPES OF PAIN 1. ACUTE PAIN - Short induration (<6 months) - Has identifiable and immediate onset - Limited and predictable duration - Described as: SHARP, STOBBING, SHOOTING - Reversible and controllable with adequate treatment - Observable physical responses  Inc. Or dec. Blood pressure  Tachycardia  Diaphoresis  Focusing on pain  Guarding the painful part 2. CHRONIC PAIN - Develops more slowly and last longer than 6 months Three types of Chronic Pain: i. Chronic Non-malignant Pain Last more than 6 months Non-foreseeable end unless it is associated with very slow healing as with burns Describe as HATEFUL or SICKENING and is typically much more difficult to treat than acute pain ii. Chronic Intermittent Pain Exacerbation or recurrence of chronic condition Occurs only at specific periods Migraine, cluster headache, sickle cell crisis, intermittent abdominal pain associated with GI disorders such as irritable bowel syndrome iii. Chronic Malignant (Cancer related pain) Qualities both acute and chronic Category encompasses neuropathic, deep visceral and bone pain Pain in the client suffering from cancer Direct result of tumor involvement OTHER TYPES OF PAIN

1. Intractable Pain resistant to cure of relief 2. Phantom Pain actual pain felt in the body part that is no longer present 3. Radiating Pain perceived at the source and extend to surrounding or nearby tissues PHYSIOLOGIC CHANGES IN PAIN 1. Somatic Pain arises from the skin, muscle or joints, maybe superficial or deep a. Superficial somatic pain > sharp, prickling type of pain. Usually localized and brief b. Deep somatic pain > burning or aching pain. Stimulation of pain receptor in deeper skin layer, muscle and joints 2. Visceral Pain results of stimulation of pain receptors in the abdominal cavity and thorax. Accompanied by an autonomic nervous system response. Frequently caused by stretching of the tissues, ischemia or muscle spasm TYPES OF PAIN STIMULUS 1. Mechanical a. Trauma to tissues b. Alteration in body tissue c. Blockage of body duct d. Tumor e. Muscle spasm 2. Thermal a. Extreme heat or cold 3. Chemical a. Tissue ischemia b. Muscle spasm NEUROLOGIC TRANSMISSION OF PAIN y Nociceptor is a pain reception y Damage to the receptor cells y The release of chemicals such as bradykinin (universal pain stimulus), an amino acid chain that causes powerful vasodilatation and increase capillary permeability, constricts smooth muscle and stimulate pain receptors y Bradykinin triggers the production of inflammatory chemical such as histamine y This movement causes the area to become REDDENED, SWOLLEN, and TENDER y Bradykinin also stimulates the release of prostaglandins. They sensitize the pain receptors and enhance the effects of bradykinin and histamine y Pain occurs when the pain message is relayed via the spinal cord to the brain, which then interprets the stimuli STAGES OF PAIN I. Transmission/ Perception Stage y Pain signals are transmitted along two types of nerve fibers: a) Myelinated Type A Fibers acute sharp pain signals b) Unmyelinated Type C Fibers transmit sensory input at a much slower rate and produce slow, chronic pain y Pain stimuli: a) Exogenous acids, bases and caustic chemical agent b) Endogenous potassium, histamines, serotonin, plasma kinins, acetylcholine, acid ph, substance P (somatostatin and other neuropeptides), and prostaglandin y Stimuli that activate Nociceptors: Location of receptors: provoking stimuli a) Skin: prickling, cutting, crushing, burning, freezing b) GI: engorged or inflamed mucosa, distention or spasm or smooth muscle c) Skeletal muscles: ischemia, injuries of connective tissue sheaths, necrosis, hemorrhage, prolonged contraction and injection of irritating solution d) Joints: synovial membrane inflammation

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e) Arteries: piercing, inflamed f) Headache: traction and displacement of arteries and meningeal structures, arterial pulsation Transmission Stage y Pain fibers enters the spinal cord through dorsal horn y Release of Substance P y Axon of 2nd order neuron cross spinal cord y Enters lateral spinothamic tract y Ascend in the lateral area of spinal cords white matter to thalamus of the brain y Pain impulses travel to the somatosensory area y Cerebral cortex for interpretation Modulation Stage y Endogenous Opioids chemical receptors that modify pain and are thought to bind with opiate receptor sites throughout the body, thereby inhibiting the production of substances that probably transmit pain impulses and may alter pain perception Three Groups of Opioids: 1. Enkephalins inhibit release of substance P 2. Endorphins morphine within 3. Dynorphins analgesic effect

PAIN THEORIES 1. Specificity Theory  Assumes that pain travels from a specific nociceptor to a pain center in the brain  It assumes a direct relationship between the intensity of the pain stimulus and perceived intensity of pain  It assumes that only one structure in the brain is involved in the pain response 2. Pattern Theory  Peripheral Pattern Theory Peripheral nerve fibers are all essentially the same and that a given pattern of fiber stimulation is interpreted by the CNS as pain  Central Summation Theory Focuses on dorsal horn of the spinal cord  Sensory Interaction Theory Proposes 2 types of neurologic fiber involved in pain, the Small diameter fibers and Large diameter fibers 3. Gate Control Theory  Peripheral never fibers carrying pain to the spinal cord can have their input modified at the spinal cord level before transmission to the brain  Synapses in the dorsal horn acts as gates that close to ascend to the brain  Only when synaptic gates are open, as when impulses on the pain fibers predominates, does the personal feel the pain 4. Parallel Processing Model  Integrates both the physiologic and cognitive-emotional aspect of pain ASSESSMENT OF PAIN I. History a. Pain location b. Intensity c. Quality d. Pattern e. Precipitating factors f. Alleviating factors g. Associated symptoms h. Effects of ADL i. Past pain experience j. Meaning of pain k. Coping resources l. Affective response II. Physical Examination

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Vital signs Skin color Skin dryness Diaphoresis Facial expression Body gestures Discomfort Anxiety Physiologic response y Acute pain which stimulate sympathetic nervous system  Increased blood pressure  Increased pulse rate  Increased respiratory rate  Pallor  Diaphoresis  Pupil dilation y Prolonged Severe Chronic or Visceral Pain which stimulate parasympathetic nervous system  Lowered blood pressure  Lowered pulse rate  Lowered respiratory rate  Warm, skin dry  Pupil constriction j. Behavioural response y Facial expression is often the 1st indication of pain y Immobilization of body parts y Purposeless body movements y Involuntary movements y Rhythmic body movements Instruments for Assessing the Perception of Pain a. Faces pain rating scale b. Pain inventory c. Visual analogue d. Numerical rating e. Verbal rating scales or verbal descriptors f. Bourbonnais pain assessment tool g. London pain chart Factors affecting Pain a. Ethnic/ cultural values b. Environment c. Emotions d. Expectations/ presence of others e. Age

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PAIN MANAGEMENT I. Non-Pharmacologic Interventions i. Guided imagery ii. Hypnosis iii. Aromatherapy iv. Magnet therapy v. Yoga and meditation vi. Acupuncture vii. Biofeedback viii. Therapeutic touch ix. Cutaneous stimulation and massage x. Transcutaneous electrical nerve stimulation (TENS)

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xi. Heat and cold application xii. Deep breathing exercises xiii. Distraction xiv. Humor Pharmacologic Pain Relief/ Interventions a. Oral Route  Non-invasive, convenient and cost-effective  Tablets, capsule, liquid, and sublingual form  Peak effect: 1 - hours b. IM Route  Common route but least desirable and should be avoided (painful)  Peak effect: within 30-60 minutes and accompanied by rapid fall-off of effectiveness  Side effects: trauma-induced fibrosis of muscle and soft tissue, never damage and abscesses c. IV Route  Most rapid pain relief  Provided in absolute bolus (1 administration only) dose or by continuous infusion because plasma levels of medications are maintained and occurrence of side effects is lessened d. Rectal Route  Alternative route parenteral administration for people unable to take oral medications  Medications appropriate for rectal route include Morphine, Hydromorphone (Dilaudid), Oxycodome (Percocet), Methadone and Oxymorphone (Numorphan) e. Transdermal Route  Provided in skin patch, most common opioid is Fentanyl  Peak effect: 48 72 hours  Easy way of maintaining independence and avoids the inconvenience of frequent dosing f. Transmucosal Route  Sublingually (Methadone) and Lozenges (Oralet) or lollipop (Actiq)  Effective breakthrough pain in clients with scheduled opioid medication around the clock g. Intraspinal Route  Injected intrathecally (inside the dura mater and contains the spinal cord) or epidurally (outside the dura mater of spinal cord and brain)  Delivered the area with the intended receptor sites h. Patient-controlled Analgesia i. Nerve block or Analgesic block  Inject local anesthesia to close the nerves, thereby blocking their conductivity

FACTORS ABOUT ANALGESIC MEDICATIONS 1. Evaluation of effectiveness of these drugs is completed by clinical assessment for changes a. CNS: relief or decrease pain b. LOC: excitement or dullness c. Rate, depth, and pattern of respiration d. Increase, decrease or irregular, regular HR and BP e. GI: increase or decrease in bowel sounds, constipation f. Laboratory test results: Serum creatinine level, CBC count, electrolyte level, titers and uric acid level 2. Clients with pinpoint pupils means NARCOTIC TOXICITY 3. Withdrawal from dependence on narcotics includes nausea, vomiting, intestinal cramps, fever, faintness and anorexia 4. If narcotics antagonists are given for respiration depression resulting from narcotic drugs, relapse of respiratory depression occurs 15-20 minutes after administration of the antagonist, since the antagonist is short-acting than the narcotic agent A. Narcotics

Action: Combine with opiate receptors to produce an analgesic effect by altering perception of pain  Uses: Severe or chronic pain, suppression of GI motility, dyspnea and antitussive effect  Major side effects:  Toxicity: pinpoint pupils, coma  CNS: sedation, confusion, drowsiness, euphoria  Respiratory depression, hypotension  GI: nausea, vomiting, constipation after multiple doses  Tolerance and dependency  WARNING: Interaction with alcohol and smoking decreases the effect. Do not administer to clients with head injuries or increase ICP since this agent may mask any deterioration. Caution with chronic airway limitation (CAL) and asthma to prevent respiratory depression  Nursing Implication: 1. Assess respiratory status: depth, rate, and rhythm. Hold medication if RR is below 10 cycles/min. With shallow depth or labored effort 2. Assess for hypotension and hold medication if systolic BP is less than 90mmHg 3. Monitor bowel elimination for constipation. Offer stool softeners if prescribed, offer fluids, increase dietary fibers or increase assisted ambulation 4. Instruct clients to ask for analgesics before the pain is too severe 5. Evaluate pain response to analgesic with the use of pain scale 6. Implement and teach patient about safety: Place bed in low position and then side rails, get assistance in ambulation, refrain from operation of machinery or driving within 3-5 hours of taking the dose of medicines 7. Encourage non-pharmacological interventions  Common drugs:  Morphine Sulfate, Meperidin  Hydrochloride (Demerol)  Codeine Sulfate  Methadone Hydrochloride (Dolophine)  Hydromorphone Hydrochloride (Dilaudid) B. Mixed narcotic Agonist-antagonist Agent  Action: Bind with specific receptors to prevent the opioid from reaching an opioid receptor site. These agents have no antitussive effects and has fewer GI effects  Uses: Mild to moderate pain, respiratory depression, reduction in potential for narcotic abuse and obstetric analgesia  Major side effects: Same with narcotics and withdrawal symptoms with clients who are dependents: Nausea, vomiting, cramps, fever, faintness, anorexia  WARNING: Abrupt withdrawal is contraindicated  Nursing implication: 1. Same with narcotics and avoid administration to clients dependent on narcotics  Common drugs:  Butorphamol tartate (Stadol)  Nalbuphine Hydrochloride (Nubain) C. Narcotic Antagonists  Action: Compete with narcotics for receptor sites, thereby hindering the narcotic effect. These agents work only on ipioid narcotic agonists  Uses: respiratory depression (particularly drug-induced), opioid toxicity, diagnosis of opioid overdose, treatment of newborns with addicted mothers  Major side effects:

 Withdrawal symptoms in clients dependent on opiates or on infants on mothers addicted to ipiates: nervousness, hypertension, palpitations, headache, and shortness of breath  GI: nausea and vomiting  CV: tachycardia and hypertension  Return of pain or discomfort for which narcotic agonist was given  Nursing implications: 1. Monitor client closely for return of respiratory depression 2. Assess and implement interventions to relieve pain and nausea 3. Assess vital signs every 5 minutes: RR and BP. Report is HR is more than 120 beats/min. And BP over 140/90mmHh 4. Assess for withdrawal findings and treat accordingly 5. Know that physicians could order repeated dose, which varies between drugs, within 30 minutes to 1 hour for acute respiratory depression usually IV push  Common drugs and dose  Naloxone Hydrochloride (Narcan): IM, SC  Naltrexone (Revia), PO  Nalmefene (Revex), IM, IV, SC D. Non-narcotic Analgesic  Actions: Inhibits the enzymes necessary for the synthesis of prostaglandin, treat pain, and act on the hypothalamus to regulate body temperature  Uses: Mild to moderate pain, fever reduction, inflammation and inflammatory disorders, transient ischemic attacks (TIA), MI, an additive effects with antiplatelet or anticoagulant  Major side effects:  Toxicity: liver, kidney damage, tinnitus, hearing loss, confusion, lethargy, hyperventilation  Hypersensitivity  GI distress: heartburn, dyspepsia  GI bleeding  Aspirin products given during or after viral infection can produce Reyes syndrome in children age 18 or under  WARNING: Children can develop acetaminophen toxicity. All aspirin products should be avoided in children below 18 years old esp. With those chicken pox or during or after viral illness since Reyes syndrome may occur. Contraindicated with use of anticoagulant drugs, patients with ulcers or those consume alcohol and competition with highly protein bound agents (Warfarin, Digoxin, SSRIs)  Nursing implications: 1. Assess temperature every 4 hours 2. Administer Acetylcysteine (Mucomyst), PO as antidote for acetaminophen toxicity which should be treated immediately usually given 3-4 days 3. Evaluate degree of pain relief (pain scale 4. Teach parents that more is not better with these agents esp. Acetaminophen, avoid alcohol ingestion with these agents, to eat when taking the medication to relieve GI symptoms 5. Assess signs of bleeding: nasal,. Oral, with brushing teeth, pink-tinge urine, melena or dark tarry stool, excessive or easy brusing, oozing from minor wounds or venipuncture sites 6. Assess for allergies before administration  Common drugs:  Acetaminophen  Acetylsalicylic acid or Aspirin, Alka-Seltzer SURGICAL DESTRUCTION OF PAIN STIMULI 1. Rhizotomy sensory nerve roots are destroyed where they can enter the spinal cord

2. Cordotomy is the division of certain tracts of the spinal cord. Performed by open method after laminectomy 3. Neurectomy peripheral of cranial nerves interrupt the transmission of pain 4. Symphatectomy pathways of sympathetic division of the autonomic nervous system are severed PAIN-RELATED NURSING DIAGNOSIS y Acute Pain related to injury y Chronic pain related to chronic physical/ psychosocial disability y Impaired physical mobility related to pain y Activity intolerance related to unrelieved pain y Ineffective coping related to severe pain, lack of knowledge of possible coping methods y Anxiety related to past experience of poor pain control y Sleep pattern disturbance related to unrelieved pain at night y Fear related to anticipation of pain experience PLAN/ IMPLEMENTATION y Establish therapeutic relationship y Teach patient about pain relief y Reduce anxiety and fear y Provide comfort measures EVALUATION y Achieves pain relief y Patient or family administers prescribed analgesics correctly y Uses non-pharmacologic pain strategies as recommended y Reports minimal effects of pain and minimal side effects of interventions *