Basic Human Needs Comfort and Pain Management

Pain
What is the real definition of pain? And what is pain management?? How can this information help me???

Pain

Unpleasant, subjective sensory and emotional experience associated with an actual or potential tissue damage Can be a factor inhibiting the ability and willingness to recover from illness Subjective experience

Comfort

Concept central to the art of nursing Through comfort measures nurses provide strength, hope, solace, support, encouragement, and assistance As subjective as pain

Pain
McCaffery on Pain-Pain is whatever the experiencing person says it is, existing whenever the person says it does. (Margo
McCaffery, 1979)

Pain relief is a basic legal right (American Bar

Association, 2000)

Nurses are ethically and legally responsible for managing pain and relieving suffering.

Pain Management
Effective pain management reduces physical discomfort Promotes earlier mobilization and return to work Shortens hospital stay and reduces health care costs

Pain Management

Nature of Pain
Subjective, highly individualized Stimulus can be physical and/or mental in nature Pain is tiring, places demands on persons energy Can interfere with relationships and influence the meaning of life

Nature of Pain
Cannot be objectively measured Certain types of pain produce predictable symptoms Pain Assessment-nurse relies on clients words and behaviors Protective physiologic mechanism, changes behavior

Pain Physiology
event stimulates pain receptors stimulus is transferred via specialized nerves to the spinal cord from there up to the brain- processed in the brain, Brain sends an impulse down the spinal cord, via descending nerves command the body to react eg withdraw the hand from a very hot object.

Thick, myelinated, fast conducting neurons Mediate the feeling of initial fast, sharp, highly localized pain.

Very thin, unmyelinated, slowconducting Mediate slow, dull, more diffuse, often burning pain.

Rabaan Tekanan

Class A- A- A- A- B C

Nerve Fibers Velocity Function

Fast Fast Intermediate Intermediate Small Small Motor
Touch, pressure Muscle tone Pain, temperature

Motor Pain

Describe the different types of pain sensation

bright, sharp, stabbing types of pain dull, throbbing, aching types.

Pain nerve fibers fast pain and slow pain

From the pain receptors, the pain stimulus is transmitted through peripheral nerves to the spinal cord and from there to the brain. This happens through two different types of nerves fibers: A-delta "fast pain and C-fibers slow pain nerve fibers.

What is fast pain and slow pain?

A pain stimulus, e.g. if you cut yourself, consists of two sensations. first fast pain sensation-is experienced as sharp. slow pain, more a dull and burning. Occurs after a short time lasts a few days or weeks, Chronic pain-if inappropriately processed by the body, it can last several months

Fast pain
nerves are called A-delta fibers. relatively thick size nerve fibers allow the pain stimulus to be transferred very fast (at a speed of five to 30 meter/second), hence the name This is all to make the body withdraw immediately from the painful and harmful stimulus, in order to avoid further damage.

Slow Pain
starts immediately after the fast pain is transmitted by very thin nerve fibers, called C-nerve fibers (their diameter is between 0.2 to 1 thousandth of a millimeter). pain impulse can only be transmitted slowly to the brain, at a speed of less than 2 meters per second. Body response -immobilization (guarding, spasm or rigidity), so that healing can take place.

Injury response

Chemical mediators are released from damaged tissue and inflammatory cells. Some inflammatory mediators directly activate nociceptors, while others act together to sensitize the pain pathway.

Natural Opioids-Endorphins
released from their storage areas in the brain when a pain impulse reaches the brain, bind to receptors in the pain pathway to block transmission and perception of pain.

Gate Control Theory

Melzack and Wall 1965.

Physiological and psychological interactions Suggested spinal gates in the dorsal horn at each segment of the spinal cord Competition at each gate for heat, touch or pain to be transmitted at each point

Gate Control Theory of Pain

Involves the addition of mechanoreceptors (Abeta neurons), which releases inhibiting neurotransmitter (Serotonin) If dominant input is from A-beta fibers, gating mechanism will close, pain reduced, due to release of Serotonin (Back rub) If dominant input from A-delta fiber, gate will be open and pain perceived Release of endorphins also close gate

Labour Pain
Variation in pain perception between individuals Why do these different perceptions of pain exist How do midwives respond to different expression of pain

Pain in Labour
C-fibres Uterine smooth muscle

A-delta traction and pressure on the peritoneum, uterine ligaments, urethra, bladder, rectum, lumbosacral plexus, fascia and muscles of the pelvic floor

Pain Types
Neuropathic Pain
Pain initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or central nervous system)1

Mixed Pain
Pain with neuropathic and nociceptive components

Inflammatory Pain
Pain caused by injury to body tissues (musculoskeletal, cutaneous or visceral)2

Examples Peripheral Post herpetic neuralgia Trigeminal neuralgia Diabetic peripheral neuropathy Postsurgical neuropathy Posttraumatic neuropathy Central Posts troke pain Common descriptors2 Burning Tingling Hypersensitivity to touch or cold

Examples

Examples

Low back pain with

radiculopathy Cervical radiculopathy Cancer pain Carpal tunnel syndrome

Pain due to inflammation Limb pain after a fracture Joint pain in osteoarthritis Postoperative visceral pain

Common descriptors2 Aching Sharp Throbbing

1. International Association for the Study of Pain. IASP Pain Terminology. 2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Physiology of Pain Categories

Acute Chronic Idiopathic Pain Cancer pain Pain by Inferred Pathology/Nociceptive & Neuropathic Pain as a result of a Metabolic Need/Ischemic Pain

Nociceptive Pain
Normal processing of stimuli that damages normal tissue or has the potential to do so if prolonged Usually responsive to nonopioids or opioids Somatic or visceral

Somatic Pain
Arises from bone, joint, muscle, skin or connective tissue Usually aching, throbbing, well-localized pain Responds to traditional analgesia

Visceral Pain
Arises from visceral organs such as the GI tract, heart, and pancreas. Can be subdivided further: 1. Tumor involvement of organ 2. Obstruction of hollow viscus

Neuropathic Pain
Abnormal processing of sensory input by the peripheral or CNS Treatment usually with tricyclic antidepressants, SSRIs, anticonvulsants Centrally generated pain Peripherally generated pain

Idiopathic Pain
Chronic pain in the absence of an identifiable cause Complex Regional Pain Syndrome

Ischemic Pain
Pain as a result of the metabolic need for oxygen Warning sign of tissue damage Cardiac pain (angina, MI) Vascular pain- Peripheral vascular disease, intermittent claudication

Nociceptive Pain
Transduction Transmission Perception Modulation

Process #1Transduction
Transductionnociceptors free nerve endings with the capacity to distinguish between noxious and innocuous stimuli. When exposed to mechanical (incision or tumor growth), thermal (burn), or chemical (toxic substance) stimuli, tissue damage occurs. Substances are released by the damaged tissue which facilitates the movement of pain impulse to the spinal cord. The substances released from the traumatized tissue are:
prostaglandins Bradykinin Serotonin substance P histamine

So, for instance

Non-steroidal anti-inflammatories, such as ibuprofen, are effective in minimizing pain because they minimize the effects of these substances released, especially prostaglandins. Corticosteroids, such as dexamethasone used for cancer pain, also interferes with the production of prostaglandins.

Transduction (cont.)
Sufficient amounts of noxious stimulation cause the cell membrane of the neuron (nervous system cell) to become permeable to sodium ions, allowing the ions to rush into the cell and creating a temporary positive charge. Then potassium transfers back into the cell, thus changing the charge back to a negative one. With this depolariztion and repolarization, the noxious stimuli is converted to an impulse. This impulse takes just milliseconds to occur.

 Some analgesics relieve pain primarily by decreasing the sodium and potassium transfers at the neuron level, thereby slowing or stopping pain transmission. Exampleslocal anesthetics, anticonvulsants used for neuropathic pain, migraines.

Process #2Transmission
Impulse spinal cord brain stem thalamus central structures of brain pain is processed. Neurotransmitters are needed to continue the pain impulse from the spinal cord to the brainopioids (narcotics) are effective analgesics because they block the release of neurotransmitters

Process #3Perception of Pain

The end result of the neural activity of pain transmission It is believed pain perception occurs in the cortical structuresbehavioral strategies and therapy can be applied to reduce pain. Brain can accommodate a limited number of signals distraction, imagery, relaxation signals may get through the gate, leaving limited signals (such as pain) to be transmitted to the higher structures.

Process #4Modulation of Pain

Changing or inhibiting pain impulses in the descending tract (brain spinal cord) Descending fibers also release substances such as norepinephrine and serotonin (referred to as endogenous opioids or endorphins) which have the capability of inhibiting the transmission of noxious stimuli. Helps explain wide variations of pain among people. Cancer pain responds to antidepressants which interfere with the reuptake of serotonin and norepinephrine which increases their availability to inhibit noxious stimuli.

Gate Control Theory of Pain

Pain impulses can be regulated or even blocked by gating mechanism along CNS Theory suggests that pain impulses pass when gate is open and blocked when gate is closed Closing the gate is basis for pain relief interventions

Physiological Response to Pain

ANS stimulated as pain impulses ascend the spinal cord Pain of low to moderate intensity and superficial pain elicit the fight or flight reaction Sympathetic stimulation results in physiologic responses (Increased heart rate, peripheral vasoconstriction, dilatation of bronchial tubes, increased blood sugar)

Physiological Response to Pain

Continuous pain or severe, deep pain (visceral) involving organs puts the parasympathetic system into effect Parasympathetic stimulation results in pallor, muscle tension, decreased heart rate and BP, N/V, weakness, exhaustion

Behavioral Responses to Pain

Pain threatens physical & psychological wellbeing Some people choose not to express pain (belief, value, cultural influences) Typical body movements that indicate pain: clenching teeth, grimace, holding area, bent posture

 The pain response itself is a complex phenomenon involving sensory, behavioral (motor), emotional, and cultural components Once the painful impulse has been initiated and received by the brain, the interpretation of pain itself is based on interrelated biological, psychological, and social factors. Once these are stimulated, pain impulses are sent to the brain as a warning that the bodys integrity is at risk. The emotional response may be expressed by screaming, crying, fainting, or just thinking #@%&, that hurts!

 When the pain is intense or unexpected, an immediate reflex loop activates the behavioral response by sending instructions to motor nerves to remove the body part from the stimulus.
Sticking your finger with a needle Placing your hand on a hot stove

These stimulis activate specialized nerve fibers to send signals through a peripheral nerve network
Routing the impulses up the spinal cord to the brain

 When the afferent impulse reach the spinal cord, a reflex loop is formed within the tract to activate the muscles necessary to remove your hand or finger from the stimulus. The remaining impulses of the reflex continue on to the brain, where they are translated as pain, and you respond by saying ouch! or other choice words. If an individual has knowledge about a potentially painful stimulus, such as receiving an injection, cognitive mechanisms can inhibit the reflex loop and block portions of the behavioral response. As a the painful stimulus increases, so does the conscious effort required to keep from trying to escape from the stimulus.

 The emotional component may still be in place as you grimace, make a fist, or think what the @%^$ is this jerk doing to me. The cultural components of pain are almost too complex to define.
However, pain perception has been linked to ethnicity and socioeconomic status.

Example
Italian patents are less inhibited in the expression of pain than are the Irish or Anglo-Saxon patients

Ultimately, cultural components can be viewed as any variable that relates to the environment in which a person was raised and how that environment deals with pain and responses to pain.

Acute Pain
Follows acute injury, disease, surgical intervention Rapid onset Varies in intensity (mild-severe) Lasts a brief period of time (less than 6 months)

Chronic Pain
Prolonged Varies in intensity Lasts longer than 6 months Also known as chronic non-malignant pain Arthritis, headache, myofascial pain, low back pain

Cancer Pain
Pain that is due to tumor progression Related to pathology, invasive procedures, infection, toxicities of Rx Can be acute or chronic, nociceptive or neuropathic At the actual site or distant to the site (Referred pain)

Factors Influencing Pain

Age Gender Culture Meaning of pain Attention Anxiety Fatigue Previous Experience Coping Style Family & Social Support

Nursing Process Assessment

AHCPR guidelines for assessing pain Clients expression of pain Characteristics of pain Onset & duration Location Intensity (Pain scales-numerical, FACES)

Assessment of pain
Visual analogue scale
Picture

McGill pain questionnaire

Part I: is used to localize the pain and identify whether the perceived source of the pain is superficial (external), internal, or both. Part II: incorporates the VAS that was described in the visual analogue scale. Part III: is the pain rating index, a collection of 76 words grouped into 20 categories. Patients are to underline or circle the words in each group that describes the sensation of pain being experienced.
Groups 1-10= somatic in nature Groups 11-15= affective Group 16= evaluative Group 17-20= miscellaneous words that are used on in the scoring process.

Scoring
Add up the total number of words chosen, up to the maximum of 20 words (one for each category)
The level of intensity of pain is determined by the value assigned to each word.
1st word = 1 point 2nd word = 2 point And so on

Pt could have a high score of 20, but have a lowintensity score by selecting the 1st word in each category.

Submaximal Effort Tourniquet Test

In 1966, Smith et al described a method of matching a patients pain using a SETT. The SETT is performed by inflating a BP cuff to above systolic pressure on the pt elevated arm. Once the cuff is inflated, the pt is instructed to open and close the hand or fist rhythmically.
A handgrip dynamometer and a metronome can be used for standardization.

The pt should continue opening and closing the hand or fist until the cramping sensation that he or she feels matches the pain from the original pathology. The amount of time that elapses form onset to fruition of matched pain is the recorded objective measure. The SETT can be repeated at every tx session to gauge tx progress and is effective in matching all types of pain

Placebo Effect
Placebo stems from the Latin word for I shall please
Used to describe pain reduction obtained from a mechanism other than those related to the physiological effects of the tx. Linked to psychological mechanisms

All TM have some degree of placebo effect

Most studies involving TM involving the use of a sham TM (ultrasound set at the intensity of 0) and an actual treatment have shown levels of pain in each group.

Assessment
Quality Pain pattern Concomitant Symptoms Effect of pain on client (physical, behavioral, effect on ADL) Cultural Considerations

Nursing Process Nursing Diagnosis

Anxiety Alteration in Comfort Self-care Deficit Sleep Pattern Dysfunction Sexual Dysfunction

Nursing Process Implementation

Non-Pharmacological and pharmacological Methods Non-pharmacologic methods-lessen pain, can be used at home or in hospital Utilize cognitive-behavioral & physical approaches Allow patients some control

Pain: A conceptual approach to treatment

(Biopsycosocial approach)
Cognitive therapies Functional restoration
Pain Behaviors Suffering

Anti-depressants / psychotropics
Relaxation Spiritual

Opioid

Pain Perception

Adjuvants
NSAIDs? Acetaminophene Neural augmentation
Nociception

Local block

NSAIDs (Movicox )
Surgery Physical modalities

Ablative surgery

1. Looser JD, Cousins MJ. Med J aust 1990;216: 153-208; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3. Mynors-Wallis L, et al. Br J Psychiatry. 1997;170:113-119.; 4. Morley S, et al. Pain. 1999;80:1-13.

Targets of Pain Therapies

Pharmacotherapy
Non-opioid analgesics Opioid analgesics Nerve Blocks Adjuvant analgesics (neuropathic, musculoskeletal)

Acetaminofen

Electrical Stimulation
Transcutaneous electrical nerve stimulation (TENS) Percutaneous electrical nerve stimulation (PENS)

Alternative methods
(NSAID)
Gottschalk et al., 2001

Acupuncture Physical Therapy Chiropractics Surgery

Non-pharmacological Methods

Acupuncture Relaxation Guided Imagery Distraction Music Biofeedback Self-Hypnosis Reducing Pain Perception Cutaneous Stimulation (Heat or Cold application, massage, TENS unit)

Pharmacologic Methods
Require a physicians order Guidelines set by regulatory agencies Analgesics most common method Tendency to under treat with pain meds

Analgesics
Non-opioid or non-narcotic agents & nonsteroidal anti-inflammatory agents (NSAIDS) Narcotics, Opioids Adjuvants, Co-analgesics

Diagnosis
Acute and chronic pain

Drug Treatment
NSAIDS (al Meloxicam/ Movi-cox), Opioids, Paracetamol

Myofascial pain dysfunction

Neuropathic pain, neuralgias

Analgesics (Movi-cox), tricyclics, centrally-acting muscle relaxants, glucocorticoids Carbamazepine, phenytoin, baclofen, tricyclics, gabapentin, others?

NSAIDS
Relief of mild to moderate pain Believed to inhibit prostaglandins & inhibits cellular response during inflammation Acts on peripheral nerve receptors to reduce the transmission & reception of pain Does not cause sedation or respiratory depression or interfere with bowel/bladder function Avoid prolonged or overuse in elderly

NSAIDS
Used in arthritic pain, minor surgical, dental procedures, low back pain, should be initially used in mild-moderate post-op pain Motrin, Naprosyn, Indocin, Toradol

Opioids
Moderate to severe pain Act on CNS, act on higher brain centers & spinal cord binding with opiate receptors to modify perception of or reaction to pain Risk for depression of vital nervous system functions

Opioids
If pain is anticipated for longer than 12-24 hours, ATC timing should be used instead of PRN timing Opioids can be used effectively with elderly, START LOW & GO SLOW Morphine, Demerol, Codeine, Percocet, Fentanyl, Hydromorphone Opioid antagonist- NARCAN-reverses effect

Adjuvant Therapy
Sedatives, anti-anxiety, & muscle relaxants Enhance pain control or relieve symptoms associated with pain Vistaril, Elavil, Thorazine, Valium, Ativan, Xanax

Patient-Controlled Analgesia PCA

Drug delivery system Patients have control over pain therapy Safe method for post-op, traumatic, or cancer pain Self-administration without risk of overdose IV administration

PCA Prescription
Loading Dose Basal (Continuous rate) On demand dose Hourly maximum amounts can be prescribed

Local & Regional Anesthetics

Wound suturing Delivery of baby Performing simple surgery Epidural Analgesia for post-op pain management, L&D pain, chronic cancer pain On-Q Pain Pump

Epidural Pain Management

Short or long term Administered into spinal epidural space Catheter is left in place, secured with tape and dressing Can be continuous infusion or daily injection

Epidural Pain Management

Monitor hourly for: 1. Catheter Displacement 2. Catheter Function 3. Respiratory Depression 4. Side effects: N/V, itching, urinary retention, constipation 5. Pain effect

Cancer Pain Management

Long acting preparations, sustained release Drug dependence low in cancer related pain Can develop tolerance, requiring higher doses Goal is to minimize pain, rather than cure it

Anamnesa nyeri secara sistematik dan

teratur Berprasangka baik (percaya) terhadap keluhan pasien atau keluarga Carilah metode kontrol nyeri yang nyaman untuk pasien dan keluarga Dilakukan intervensi yang tepat waktunya, logis dan terkoordinasi Edukasi pasien dan keluarga untuk mengatasi nyeri sekuat mungkin

Clicker Question
1. When a smiling and cooperative client complains of discomfort, nurses caring for this client often harbor misconceptions about the clients pain. To properly care for clients in pain, nurses need to remember that: A. Chronic pain is psychological in nature. B. Clients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. The amount of pain is reflective of actual tissue damage.

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Clicker Question
2. Established pain management guidelines direct nurses to frequently assess the clients pain. The most appropriate action for the nurse to take when assessing the clients reaction to pain is to: A. Ask what precipitates pain. B. Question the client about the location of pain. C. Offer the client a pain scale to objectively identify the pain. D. Use open-ended questions to find out about the clients pain.

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Clicker Question
3. A client has just undergone abdominal surgery. When discussing with the client several pain relief interventions, the most appropriate recommendation would be: A. Adjunctive therapy B. Nonopioids C. NSAIDs D. PCA pain management

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