Comfort

Ch 41
Pain

• Considered the 5th Vital Sign

• Is what the patient says it is
Pain Basics

• Source
– Nociceptive – sensory
– Neuropathic – from nerves
– Psychogenic – mental
• Area to which it is referred
• Duration
– Acute
– Chronic
Sources of Pain

• Nociceptive
– Cutaneous
– Somatic
– Visceral
• Neuropathic
Types of Pain

• Physical cause — cause of pain can be

identified
• Psychogenic — cause of pain cannot be
identified
• Referred — pain is perceived in an area
distant from its point of origin
Duration of Pain

• Acute
– Rapid in onset, varies in intensity and duration
– Protective in nature
• Chronic
– May be limited, intermittent, or persistent
– Lasts for 6 months or longer
– Periods of remission or exacerbation are common
Pain Process

• Transduction — activation of pain

receptors
• Transmission — conduction along
pathways (A-delta and C-delta fibers)
• Modulation — initiation of the protective
reflex response
• Perception of pain — awareness of the
characteristics of pain
Chemicals of Pain

• Bradykinin
– Powerful vasodilator
– Constricts smooth muscle
– Involved in pain awareness
• Prostaglandins – send stimuli to CNS
• Substance P
– Sensitizes nerve receptors
– Increases rate of firing
Gate Control Theory

• Relationship between pain and emotions

• Small and large diameter nerve fibers
conduct and inhibit pain stimuli
• Gating mechanisms determine impulses
that reach the brain
Pain Perceptions

• Pain threshold – lowest intensity at which pain is

perceived
• Adaptation
• Modulation of pain – regulation or modified by:
– Neuromodulators- natural, resemble morphine
– Endorphins – pain blockers, prolonged effect
– Dynorphins – most potent
– Enkephalins – less potent, inhibit release of sub.P
Pain Responses

• Physiologic – automatic (involuntary)

responses
• Behavioral – change in behavior
• Affective – emotional response

• Box 41-1, p 1203

Factors in Pain

• Culture
• Ethnic variables
• Family, gender, and age variables
• Religious beliefs
• Environment and support people
• Anxiety and other stressors
• Past pain experience
Assessing Pain

• Psychological
• Emotional
• Sociologic
• Physiologic
Assessing Pain, cont’d

• Patient’s verbalization and description of

pain
• Duration of pain
• Location of pain
• Quantity and intensity of pain
• Quality of pain
• Chronology of pain
Assessing Pain, cont’d

• Patient’s verbalization and description of

pain
• Duration of pain
• Location of pain
• Quantity and intensity of pain
• Quality of pain
• Chronology of pain
More Assessing

• Aggravating and alleviating factors

• Physiologic indicators of pain
• Behavioral responses
• Effect of pain on activities and lifestyle
Assessment Tools

• McGill-Melzack pain questionnaire

• Pain scale
– 0 to 10
– Faces
• McCaggery method
• WILDA pain measurement scale
WILDA Scale

• Words that describe the pain

• Intensity of pain
• Location of pain
• Duration of pain
• Aggravating or alleviating factors
Diagnosing Pain

• Type of pain
• Etiologic factors
• Behavioral, physiological, affective
response
• Other factors affecting pain process
Nursing Interventions

• Establishing trusting nurse-patient

relationship
• Initiating non-pharmacologic pain relief
measures
• Considering ethical and legal responsibility
to relieve pain
• Teaching patient about pain
Nursing Plan

• Remove or alter cause of pain

• Alter factors affecting pain tolerance
• Initiate non-pharmacologic relief measures
Non-Drug Comfort Measures

• Distraction • Cutaneous stimulation

• Humor • Acupuncture
• Music • Hypnosis
• Imagery • Biofeedback
• Relaxation • Therapeutic touch
Drug-Related Treatments

• Analgesic administration
– Non-opioid analgesics
– Opioids or narcotic analgesics
• Adjuvant drugs
Administering Analgesics

• Patient controlled analgesia

• Epidural analgesia
• Local anesthesia
Sedation Scale

• 1 — awake and alert, no action necessary

• 2 — occasionally drowsy, but easy to
arouse, no action necessary
• 3 — frequently drowsy, drifts off to sleep
during conversation, reduce dosage
• 4 — somnolent with minimal or no
response to stimuli, discontinue opiod,
consider use of naloxone (Narcan)
Managing Chronic Pain

• Give medications orally if possible.

• Administer medications ATC (around-the-
clock) rather than prn.
• Adjust the dose to achieve maximum
benefit with minimum side effects.
• Allow patients as much control as possible
over the regimen.