PaIN AND cOMFORT

STANLEY C. LUCES, M.D.

Definitions of PAIN
Pain

is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Pain

Is a subjective response to both physical and psychological stressors. All people experience pain at some point during their lives. Although it is experienced as uncomfortable and unwelcome, it is also serve as a protective role, warning of potentially health threatening conditions. The fifth vital signs, with recommendation to assess pain with each vital sign assessment.

Pain

Only the person affected can experienced pain, that is pain has personal meaning If the client says he has pain, the client is in pain. ALL pain is real. Pain has physical, emotional, cognitive, sociocultural and spiritual dimensions.

In many aspects, pain is the most common reason for seeking health care

Types of PAIN
Category of pain according to its 1. Origin 2. Onset 3. Severity 4. Cause or etiology

Types of PAIN
Category of pain according to its origin Cutaneous painoriginates in the skin or subcutaneous tissue Deep somatic painarises from ligaments, tendons, bones, blood vessels, and nerves Visceral Painresults from stimulation of pain receptors in the abdominal cavity, cranium and thorax.

Types of PAIN
Category of pain according to its ONSET Acute painfollowing acute injury, disease or some type of surgery Chronic malignant painassociated with cancer or other progressive disorder Chronic nonmalignant painin the persons whose tissue injury is non progressive or healed

Acute Pain

Have sudden or slow onset; it varies from mild to severe, some may last up to 6 months and subsides as healing takes place. It may be called fast pain, sharp pain, or initial pain. Impulses usually travel through the type A delta fibers and this pain is easily localized.

Chronic Pain

last 6 months or longer and often limits normal functioning. It is sometimes called dull pain, slow pain and delayed pain. Impulses travel in the type C fibers and are not easily localized.

TYPES AND CHARACTERISTICS OF PAIN

A. ACUTE PAIN - sudden onset, usually temporarily, localized. - Last for less than 6 months and has an identified cause. 3 major types: *1. Somatic pain- arises from nerve receptors originating in the skin or close to the surface of the body. ( sharp, diffuse, localized, dull) *2. Visceral pain- arises from body organs. (dull, poorly localized because of low number of nociceptors).Often associated with vomiting, nausea, hypotension, restlessness. *3. Referred pain- which is perceived in an area distant from the site of stimuli. It is commonly occurs with visceral pain

B. CHRONIC PAIN -Prolonged pain, usually lasting longer than 6 months. -It is not always associated with an identifiable cause, and often unresponsive to conventional medical treatment.

4 categories: *1. Recurrent acute pain- characterized by relatively well defined episodes of pain interspersed with pain free episodes. ex. Migraine. *2. Ongoing-time limited pain- with defined time period. Ex. Cancer pain which ends with control of the disease or death.

*3. Chronic nonmalignant pain- non life threatening pain that nevertheless persists beyond the expected time for healing. Ex. Chronic lower back pain *4. Chronic intractable nonmalignant pain syndrome-similar to chronic nonmalignant pain, but is characterized by the persons inability to cope well with the pain.

C. CENTRAL PAIN - Related to lesion in the brain that may spontaneously produce high frequency burst of impulses that are perceived as pain. Example: vascular lesion, tumor, trauma or inflammation.

D. PHANTOM PAIN - syndrome that occurs following amputation of the body part. E. PSYCHOGENIC PAIN - Is experienced in the absence of any diagnosed physiologic cause or event. The pain is real and may lead to physiologic changes such as muscle tension.

Pain related terms

Radiating painperceived at the source of the pain and extends to the nearby tissues Referred pain felt in a part of the body that is considerably removed from the tissues causing the pain

Pain related terms

Intractable

pain- highly resistant

to relief Phantom painpainful perception perceived in a missing body part or in a body part paralyzed from a spinal cord injury

Pain related terms

Hyperalgesiaexcessive

sensitivity to pain
Pain

Thresholdis the amount of pain stimulation a person requires in order to feel pain

Pain related terms

Pain Reactionincludes the autonomic nervous system and behavioral responses to pain

Pain related terms

Pain Tolerancemaximum amount and duration of pain that an individual is willing to endure Nociceptorspain receptors Pain Perceptionthe point which the person becomes aware of the pain

The pain receptor

NOCICEPTORS Usually they are free nerve endings located widespread in the superficial layers of the skin, peritoneal surfaces, periosteum, arterial walls, pleural surfaces, joint surfaces and the falx and tentorium of the cranial vault.

The pain receptor- nociceptor

These nociceptors are non-adapting to keep us constantly informed of the continuous presence of the painful stimulus that can damage the tissues.

The pain receptor

For pain to be perceived, nociceptors must be stimulated. These pain receptors can be stimulated by: serotonin histamine potassium ions acids some enzymes, Substance P

The pain stimuli

In general, there are 3 types of stimuli that can stimulate pain receptors Mechanical Thermal Chemical

The pain stimulus

Mechanical stimulus- pressure, squeeze, pin prick Thermal stimulus- heat and freezing temperature Chemical stimulus- collectively called the P factors- bradykinin, serotonin, histamine, prostaglandin and substance P.

Pain Syndromes
Referred Pain Referred pain is felt in areas other than those stimulated. It may occur when stimulation is not perceived in the primary areas. For example, the person having a heart attack.

Pain Syndromes

Pain Syndromes
Psychogenic Pain The term psychogenic pain has been used to describe pain for which no pathologic condition has been found or in which the pain appears to have a greater psychologic basis than a physical one.

Pain Syndromes

Neurologic Pain Pain in the neurologic system occurs in different forms. Neuralgia is sharp, spasm-like pain along the course of one or more nerves. Two common areas of neuralgia are the Trigeminal nerve in the face and the Sciatic nerve in the lower trunk. Causalgia, a form of neuralgia, is severe burning pain associated with injury to a peripheral nerve in the extremities.

Pain Syndromes
Phantom limb pain This is pain or discomfort perceived by the person to be occurring in an extremity that has been amputated. it is more likely to develop in those who had pain before amputation and may persist long after healing has occurred.

Pain fibers

The precise mechanism of pain transmission and perception is unknown.

Theory of pain
Gate Control Theory This theory maintains that there is a specialized system (gate control) that modulated sensory input before evoking perception and response to stimuli. Suggest the interaction of two systems determines pain and its perception. 1st : The substantia gelatinosa regulates impulses entering or leaving the spinal cord. 2nd: the inhibitory system within the brain stem.

Ist system:
A-delta fibers( small diameter)- carries fast pain impulses C fibers in the spinal cord- carries slow pain impulses A- beta (large diameter)- carries impulses from tactile stimulation. _________ In substantia gelatinosa, these implulses encounter a gate that is thought to be opened and closed by the domination of either large diameter touch fibers or small diameter pain fibers. If impulses from the touch fiber predominate, then they will close the gate and the pain impulses will turned away there. This explained why massaging a stubbed toe can reduce intensity and duration of the pain.

Pain fibers
There are two separate pathways that transmit pain impulses to the brain: (1) Type A-delta fibers are associated with fast, sharp, acute pain and diameter 2-5um conduction velocity 12-30m/s myelinated (2) Type C fibers are associated with slow, chronic, aching pain diameter 0.4-1.2um conduction velocity 0.5-2m/s unmyelinated

Pain fibers

2nd system:
-

The inhibitory system, is thought to be located in the brain stem. It is believed that cells in the midbrain , activated by a variety of stimuli such as opiates, psychologic factors, or even simply the presence of pain itself, signal the receptor in the medulla. This receptor in turns,stimulate nerve fibers in the spinal cord to block the transmission of impulses from pain fibers.

Inhibitory mechanisms

The pain maybe modulated or inhibited. The analgesia system is a group of midbrain neurons that transmits impulses to the pons and medulla which in turn stimulate a pain inhibitory center in the dorsal horns of the spinal cord. Endorphins- chemical inhibitory mechanisms is fueled by endorphins, which are naturally occurring opioid peptides present in the neuron in the brain, spinal cord and GIT. - work by binding with opiate receptors on the neurons to inhibit pain impulse transmission.

Stimuli

Nociceptors - nerve receptors for pain. They are located at the ends of small afferent neurons and are woven throughout all the tissues of the body except the brain. Numerous on skin and muscles. Nociceptors are stimulated either by direct damage to the cell or by the local release of biochemicals secondary to cell injury. Bradykinin - an amino acid, appears to be the most abundant, and potent pain-producing chemical; others are prostaglandin, histamine, hydrogen ions and potassium ions.

Pain Syndromes
Intractable pain This type of pain is a chronic pain that is resistant to cure or relief. - interfere with the quality of life. E.g. arthritis and cancer.

Gate Control theory

The gate control theory has led to the recognition that the pain can be reduced or modulated at four points: The peripheral site of pain The spinal cord The brainstem The cerebral cortex

Gate Control theory

Small-diameter nerve fibers carry the pain stimuli through the same gate Large diameter fibers that carry the nonpain impulses go through the same gate and inhibit the transmission of those pain impulses- that is close the gate.

Gate Control Theory

The pain gate situated in the substantia gelatinosa cells in the dorsal horn of the spinal cord can be shut in several ways: Stimulation of touch-fibers by rubbing, stroking, massage, vibration and application of liniments and other ointments.

Gate Control Theory

Endogenous opioids (neuromodulators) release endogenous opioids: enkephalins, endorphins and dynorphins, which are morphine-like in actions Electrical stimulation of the skins sensory nerve fibers inhibits pain.

Management of PAIN
NON-PHARMACOLOGIC

PHARMACOLOGIC

SURGICAL

Management of PAIN
Altering Pain Transmission Electrical stimulators it modify the pain stimulus by blocking or changing the painful stimulus with stimulation perceived as less painful.

Pain management
Nerve block A nerve block involves the injection of substances such as local anesthetics or neurolytic agents (e.g., alcohol or phenol) close to nerves to block the conduction of impulses over the nerves. Nerve blocks frequently are used for the symptomatic relief of pain.

Pain management
Acupuncture Small needles are skillfully inserted and manipulated at specific body points, depending on the type and location of pain. The gate control theory provides the best explanation for the success of acupuncture. The local stimulation of large-diameter fibers by the needles is thought to close the gate to pain.

Pain management
Modifying the Pain Stimulus Cutaneous stimulation and massage Cutaneous stimulation stimulates the large A-beta fibers, closing the gate to impulses from the periphery.

Pain management
Modifying the Pain Stimulus Cutaneous stimulation and massage Methods of cutaneous stimulation include the following 1. Lightly rubbing the affected area 2. Application of heat or cold to area 3. Whirlpool massage of area 4. Back rub or massage

Pain management
Modifying the Pain Stimulus Reducing additional physical stimuli Interventions include the following measures: Use a turning sheet for patients with severe neck, back, or general trunk pain. Place a pillow under a painful joint when helping a patient change position. Support limbs at the joints rather than the muscle bellies when handling an extremity. Avoid bumping the bed or moving it suddenly.

Pain Management
Distraction Distraction interferes with the pain stimulus, thereby modifying the awareness of the pain.

It relieves both acute and chronic pain by stimulating the descending pathway of pain. E.g watching TV, listening to music, solving puzzles, and reading comics, etcetera.

Pain Management
Relaxation. Full relaxation decreases muscle tension and fatigue that usually accompanies pain. It also helps to decrease anxiety, thereby preventing augmentation of the pain stimulus E.g. abdominal breathing at a slow, rhythmic rate.

Pain Management
Guided imagery Guided imagery is the term used to describe the use of images to improve physiologic status, mental state, sell-image, or behavior. Relaxation exercises before the use of this approach facilitate the imaging process. Imagery techniques such as visualizing oneself in a favorite setting-for example, a quiet beach-are more effective.

Pain Management
Therapeutic touch A less traditional therapy termed therapeutic touch, may be helpful to patients in pain The therapist undergoes a brief period of meditation before coming in contact with the patient. During this period the therapist quiets his or her internal energy levels and then touches the patient and transmits the healing energies.

Pain Management
Ice and Heat therapies ice should be placed on the injury site immediately after injury or surgery. Ice therapy can also relieve the pain if applied later after the injury. Remember to protect the skin from DIRECT application of ice and it should be applied NO longer than 20 minutes a time. Application of heat increases blood flow to an area and contributes to pain reduction by SPEEDING healing.

Hot versus Cold

HOT Use to RELIEVE joint stiffness, pain and muscle spasm Cold Use to control inflammation and pain

After acute attack After 72 hours (Udan)

ACUTE ATTACK

Myths and misconception about pain

1. Pain is a result not a cause. It is now recognized that unrelieved pain may sets up further responses such as anger, anxiety, immobility. Pain may delay healing and rehabilitation. 2. Chronic pain really a masked form of depression. Pain and depression are chemically related, not mutually exclusive. 3. Narcotic medication is too risky to be used in chronic pain. This common misconception often deprives clients of the most effective source of pain relief.

4. It is best to wait until a client has pain before giving medication.It is now widely accepted that anticipating pain has a noticeable effect on the amount of pain a client experiences. 5. Many clients lie about the existence or severity of their pain. Very few patient lie about their pain.

Medications
Nonnarcotic analgesics- use to treat mild to moderate pain. example: acetaminophen 2. NSAIDS- minimizing pain by interfering with prostaglandin synthesis. For mild to moderate pain and continue to be effective when combined with narcotics for moderate to severe pain. Ex. ASA, ibuprofen, celecoxib. 3. Narcotics opiods. For moderate to severe pain. Ex. Morphine, codeine, fentanyl
1.

4. Antidepressant -acts on the production and retention of serotonin in the CNS, thus inhibiting pain sensation. Promote normal sleeping pattern. 5. Local anesthetics - blocks the initiation and transmission of nerve impulses in a local area.

Responsibilities in Medication Administration of Narcotic Analgesics

Example: Demerol (Meperidine), Morphine (MS), Nubain, codeine Narcotics are regulated by federal law, must record the date, time, client name, type and amount of the drug used and sign the entry in the narcotic sheet. Keep narcotic antagonist, such as Naloxone, immediately available to treat respiratory depression.

Assess allergies or adverse effects previously experienced by the patient. Meperidine is associated with CNS toxicity and thus involves significant risk.For any client who is receiving more than one dose, monitor for nervousness, delirium, tremors, twitching, seizure. Assess for respiratory disease such as asthma, that might increase risk for respiratory depression

Assess the characteristics of pain and the effectiveness of drugs Take a baseline vital signs prior administration Client and Family teaching The use of narcotics to treat severe pain is unlikely to cause addiction Do not drink alcohol Increase intake of fiber and fluids to prevent constipation This drug causes dizziness, drowsiness and impaired thinking Report side effect to the physician

GUIDELINES FOR ASSESSMENT OF THE PATIENT WITH PAIN

1. Assess the characteristics of the patients pain P-Q-R-S-T

P- Provoking Factors what precipitated (triggered ) the pain? Has anything relieved the pain? what is the pattern of the pain?

Q - Quality of pain What is the quantity and quality of pain? Is the pain sharp, crushing, dull, burning, stinging? R - Region/ Radiation What is the region (location) of the pain? does it radiates? SSeverity of pain What is the severity of the pain? T - Timing What is the timing of the pain? When does it begin? How long does it last? T- Treatment Has the patient taken any medication to treat this? Time of last dose?

Pain Intensity Scales

GUIDELINES FOR ASSESSMENT OF THE PATIENT WITH PAIN

2. Assess the patients behavioral responses to the pain experience A. Determine if the pain is acute or chronic B. Observe for the following behavioral responses

GUIDELINES FOR ASSESSMENT OF THE PATIENT WITH PAIN

3. Assess factors that influence responses to pain A. Ethnic and cultural factors B. Previous pain experiences C. Meaning of the pain experience D. Patients responses to pain relief strategies