Pain and pain management

Definition

Pain can be defined as unpleasant sensory and emotional experience associated with actual or
potential tissue damage or described in terms of such damage. (International association for
study of pain (2007))

Pain is an unpleasant sensation signating that the body is damaged or threatened with an injury.

Pain is whatever the experiencing person say it is existing whenever he says it does pain is
what the patient says hurts.

Factors influencing pain

Pain is influenced by many different factors and therefore total pain encompasses four
dimensions:

Physical

Social

Psychological

Spiritual

Physical factors - related to mobility, sleeping patterns, feeding habits, dressing habits, limits
interaction with others, limits income, integrates with marital obligations. Psychological factors
related to irritability, anger, hopelessness, low self esteem, loss of confidence.

Spiritual aspect factors- detachment from original beliefs, anger, blames God and careers,
hopelessness and helplessness.

Pain behaviors

There are many questions related to nature of pain and how to stop it effectively. Initial thought
that pain was a direct function of tissue damage but was proved incorrect. It was found out that
major tissue damage could go with minor pain sensation. Melzack and wall explains the gate
theory for pain that messages pass through a gate in the spinal cord and route to the brain

In effect, pain messages may or may not be sent depending upon other sensory experience and
the moments attention and activity

Pain can be reduced by endorphins counteracting the pain messenger neurotransmitter

substance and attention distraction

There are receptors (proprioceptive receptors) that detect pain and pressure in the organs
Stimulation of pain receptors c ells releases a chemical called substance P which when released
to the spinal cord activates other neurons that send messages through spinal gates (opened by
pain signals) From the spinal cord, the message goes through to the brain activating cells in the
thalamus, somato sensory cortex, areas of frontal lobes and the limbic system. The brain then
interprets the pain information and sends signals that either open the spinal gates further causing
a greater experience of pain or close them dampening the pain. Such out come depends on the
psychological al aspects of the pain stimulus eg anxiety, fear, helplessness, intensify pain with
laughter, distraction and a sense of control can diminish it. A reason why one might bruise
himself and not know it if he was concentrating on some thing else. Psychological factors can
also influence the release of endorphin which can inhibit the transmission of pain signals in the
brain and in the spinal cord that inhibit release substance P

Research has shown that women apparently feel pain more intensively than men and they also
report pain more often than men. Men have been shown to cope better with many kinds of pain.

Pain felt in some areas of the body may not accurately represent where the trouble is, because
pain can be referred to another area. Referred pain happens because signals from several areas of
the body often lead into the same nerve pass ways going to the spinal cord and the brain eg pain
from a heart attack may be felt in the neck, jaw arms and abdomen pain from a gall bladder may
be felt in the shoulder.

People differ in their ability to tolerate pain; one may find a pain from a small cut intolerable
while another one can tolerate a major accident or knife wound with no complaint.

Ability to withstand pain depends on mood, personality and circumstances

Pain may even change with age, as people age they complain less of pain. Perhaps change in the
body decrease the sensation of pain. However, the elderly may simply be more stole than
younger people.

Classification of pain

The two major classifications of pain

Acute and chronic

Acute it is characterized by help- seeking behavior such as crying and moving about in a very
obvious behavior / manner. It is of sudden on set with limited duration and predictable

Clinical signs of sympathetic over activity, tachycardia, pallor, hypertension, sweating, anxiety
and grimacing crying

Caused by definite injury or illness

Chronic
It does not have some of the obvious physiological effects that characterize acute pain unless
chronic pain is over whelming patients rarely show the typical picture of distress associated with
acute pain

It is caused by a chronic pathologic process. It is of gradual on set or ill defined onset, may
become progressively more severe. Patients may appear depressed or withdrawn and there are
usually no signs of symphatic hyper- activity

The two classifications of pain can further be classified into:

Nociceptive and neuropathic pain

Nociceptive

This kind of pain indicates tat the nerve pathways are intact (the feeling of pain is a normal
response to a noxious stimulus) nociceptive pain can further be divided into two groups

Somatic

Visceral

Somatic pain

It is well defined as an aching, throbbing or gnawing sensations

It can be caused by bone or self tissue injury, ulceration/ injection

The pains can be controlled with common analgesics

Visceral

This king of pain is not well defined and is described as a feeling of pressure, cramping or
squeezing in nature

It cab be caused by tumors, obstruction of an outlet such as bovel, or strfetgching of the viscera
around an organ from tumor growth as in liver cancers .drugs like analgesics can be used to
reduce pain, steroids to reduce inflammation and antispasmedics help reduce spasms.

Neuropathic pain

Such kind of pain indicates that there is damage to the nerve pathways, abnormal response to a
normal or noxious stimulus

It is caused by infiltration by cancer, infection from HIV or herpes zoster, peripheral neuropathy
from drugs, crus injury or surgery
It is described as burning, pricking, stinging pains and needles, insects crawling under the skin,
numbness, hypersensitivity, shooting and electric shocks

The drugs of choice are adjuvants, they tend to work better than analgesics. anti depressentants
are most commonly used, anti convulsants for shooting pain. pain may be partly or totally
resistant to opiates.

A good example of neuropathic pain is phantom pain

PAIN RELATED TO PSYCHOLOGICAL DISORDERS

Pain is usually caused by disease, so health workers search first for a treatable cause. Some
people have persistent pain with out evidence of disease that would cause the pain. Others have a
degree of pain and disability out of proportion to what most people with a similar injury or
disease experience

Psychological processes often account for at least part of these complaints. The perceived pain
may be predominantly psychogenic in nature /origin or it may be caused by a physical disorder
but exaggerated in degree or duration because of psychological stresses.

Most often psychologically produced pain present as headache, low back pain, facial pain,
abdominal pain or pelvic pain. The fact that such pain originates from psychological cause does
not mean it is not real, it requires treatment sometimes by psychologists.

Treatment varies from person to person and health workers will try to match the treatment with
the persons needs

Measuring pain

Pain may be sharp or dull, intermittent or constant, throbbing or consistent, at a single site or all
over. The intensity can vary from minor to intolerable. No laboratory test can prove the presence
or severity of pain

Therefore the effective pain management is through measuring pain ie holistic assessment of the
patient following key points

Physical assessment- history of pain

Ask the following questions

The onset of pain

The exact nature of the pain

The site and ractiation of the pain

The type of pain

The duration of pain and change

Precipitating / aggravating factors

The impact of functional ability mood or sleep

The effect of previous treatment

What the pain mean to patient (deteriorating /dying)

Physical examination

Examine the patient from head to toe and pay special attention to reported areas of pain, inspect,
palpate, percuss and ausvitate when possible

Note level of tenderness during palpation

Psychological assessment

Take history of the understanding of the patients, the emotional and psychological response

How the pain is interfering with individuals ability to carry our his role

Hopes and fears

Plans for the future

Losses and disappointments that have already been faced by the individual

Any unfinished business

Thins that an individual wants to accomplish

Social assessment

How the illness has interfered with ones roles

Family history- who is around, where are they , how supportive

Life stress- what is happening with regard to ones, jobs, housing, children sources of support etc

The use of a family tree (gonogram) encourage people to open up areas of concern

Identify patterns and perceive family conflicts

It acts as therapeutic tool to help people talk about their present and previous experiences, death
and their vulnerabilities
Spiritual assessment

Assess in terms of;

How symptoms are described

Language

The role of family, individual family member and the family

Issues of autonomy and confidentiality

Attitudes towards ill health

Attitudes towards food and diet

Medical medicine and other therapies

Attitudes towards death

Ritual surrounding deaths

Pain assessment tools

Different settings use different assessment tools which help to quantify and qualify the patients
pain

A baseline is established on the initial consultation and from which progress is plotted usually on
a graph.

Pain rating scales are useful in

Establishing the severity of pain the patient is experiencing

Following the course of the patients pain

Assessing the effects of treatment interventions

Pain measurement must be done at regular intervals .in severe cases remember that most
measurement instruments do not acknowledge presence of anxiety and can therefore produce
false high or false low sores.

There are a number of tools available both for children and adults

1. The numerical rating scale

The health worker asks the patient to rate their pain intensity on a numerical scale that usually
ranges from 0-10. 0 indicates no pain, 10 indicates worst pain. imaginable (some times 0-5 scale
is used)

A variation of the scale is a verbal description scale, which use words such as mild pain, milt- to-
moderate pain, moderate pain or severe pain.

2. The hand scale

This ranges from a clenched hand (fist) representing no hurt/pain to five extended fingers
(represents hurt most) with each extended finger indicating increasing levels of pain.

The faces scale

This scale comprises six cartoon faces with expression ranging from a broad smile representing
no hurt to a very sad face representing hurts worst.

Ensure that the patients are adequately trained to use the selected tool, ensuring that they are
rating their pain and not their emotions

After instigating appropriate analgesia, the pain scare should be reassessed and the Rx modified
accordingly it should be done with in 2-3 days of initiating Rx and is an essential component of a
good care .

Assignment

Read on pain management including the WHO analgesic ladder.