Pain: The Fifth Vital Sign

1. GENERAL PRINCIPLES OF
PAIN
Scope of the Problem

Pain is also a major economic problem and a leading cause of

disability that hampers the lives of many people, especially
older adults.

Chronic pain is the most common cause of longterm

disability, affecting millions of Americans and others
throughout the world.
Inadequate pain management can lead to many consequences affecting the
patient and family members.

IMPACT OF UNRELIEVED PAIN

 Physiologic Impact
 Quality-of-Life Impact
 Financial Impact
Prolongs stress response

Increases heart rate, blood pressure, and oxygen demand

Decreases GI motility Causes immobility

Decreases immune response

Delays healing

Increases risk for chronic pain

 Quality-of-Life Impact

Causes anxiety, depression, hopelessness, fear, anger, and

sleeplessness
Impairs family, work, and social relationships
 Financial Impact
Costs Americans billions of dollars per year
Increases hospital lengths of stay
 Leads to lost income and productivity
 Categorizing Pain
Pain can be categorized in two ways:
by type related to the characteristics of the pain or by the
physiologic source of the pain.
The two major types of pain are:
Acute and chronic.
 Acute pain often results from sudden, accidental trauma (e.g., fractures, burns, lacerations) or
from surgery, ischemia, or acute inflammation.
 Chronic pain or persistent pain is further divided into two subtypes.

Chronic cancer pain

is pain associated with cancer or another progressive

disease such as acquired immune deficiency syndrome (AIDS).

The cause of pain is usually life threatening.

Chronic non-cancer pain

 Chronic non-cancer pain is associated with tissue injury that has healed or is not associated
with cancer, such as arthritis or chronic back pain. This type of pain is the most common
ACUTE

 Has short duration

 Usually has a well-defined cause

 Decreases with healing

 Is reversibl
 Serves a biologic purpose (warning sign)

 Ranges from mild to severe intensity

 May be accompanied by anxiety and restlessness

CHRONIC (OR PERSISTENT)

 Lasts longer than 3 months

 May or may not have welldefined cause
 Begins gradually and persists
 Is exhausting and serves no biologic purpose
 Ranges from mild to severe intensity
 May be accompanied by depression and fatigue, as well as
decreased functional ability
 ACUTE PAIN
 Almost everyone experiences acute pain at some time. The

major distinction between acute pain and chronic pain is the

effect on biologic responses.

 Acute pain serves a biologic purpose. It acts as a warning
signal by activating the sympathetic nervous system and
causing various physiologic responses.
These responses are similar to those found in “fight-or-flight”
reactions and include:
 Increased heart rate

 Increased blood pressure

 Increased respiratory rate
 Dilated pupils
 Sweating
activation of sympathatic NS

↑ cardiac contractility → ↑ HR → ↑ cardiac output

 The severity of postoperative pain may be a predictor of

long-term pain.
 The use of preemptive analgesia is a technique designed to
decrease pain in the postoperative period, decrease the
requirements for a postoperative analgesic, prevent
morbidity, and decrease hospital stay.
In general, intrathoracic and upper intra-abdominal surgical
approaches are associated with more severe, steady wound
pain and with pain on movement after surgery.
Many patients who undergo superficial surgery of the head and
neck, chest wall, or limbs report minimal postoperative pain.
Muscle-splitting procedures, like thoracotomy, are generally
far more painful than muscle-stretching procedures, such as
open hysterectomy.
Patients who have joint replacements for severe arthritic pain
often report less pain after surgery than before surgery because
the damaged joint cartilage has been removed.
 Chronic Pain

Chronic pain or persistent pain is often defined as pain that lasts

or recurs for indefinite periods, usually for more than 3 months.

The onset is gradual, and the character and quality of the pain
change over time.
Because chronic pain often involves deep body structures,
 Chronic Cancer Pain.

I. Most patients with advanced cancer have moderate to

severe pain

II. The sources of pain include nerve compression, invasion of

tissue, and/or bone metastasis, an extremely painful
condition.

III. Cancer treatments also can cause pain (e.g., from surgery
and toxicities from chemotherapy and radiation therapy).
 Chronic Non-Cancer Pain.
Chronic non-cancer pain was formerly called chronic nonmalignant pain.
However, most pain experts, and certainly patients who suffer with daily pain, believe that all
pain is malignant—thus the newer term.
Chronic non-cancer pain may be caused by chronic diseases such as rheumatoid arthritis,
back injuries, and fibromyalgia.
 PHYSIOLOGIC SOURCES OF PAIN

 Nociceptive Pain: Somatic Pain and Visceral Pain

Somatic Pain
Cutaneous or superficial: eng ; skin and subcutaneous tissues
Visceral Pain
Organs and the linings of the body cavities

 Neuropathic Pain : Nerve fibers, spinal cord, and central nervous system