PAIN by serendipity

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									P A I N

 is a basic protective mechanism that alerts  A state of physical & mental disequilibrium

a person that something harmful is happening somewhere in the body

produced when there is real, threatened or fantasized physical & mental injury

 Merskey & Bogduk defined pain as an  Sternbach – an abstract concept which

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

refers to a personal, private sensation of hurt; a harmful stimulus that signals current or impending tissue damage

 Mc Caffery – whatever the experiencing persons

says it is and existing whenever the person say it does.  5th vital sign ( Brunners)  A personal and subjective experience that no 2 people experience pain in exactly the same manner.  Generally related to some type of tissue damage which serves as warning signal.

Trauma (Chemical, Mechanical & Thermal) ! ! ! Stimulation of Nociceptors (Nerve endings) ! ! ! Transmission of nociceptive fiber to the Spinal cord via the dorsal horn along with either A Delta fibers or C Delta Fibers

Ascend to the thalamus via the spinothalamic tract ! ! ! Project to the somatosensory cortex ! ! ! Pain perception (Feeling and reaction to pain) * A-delta fibers transmit painful impulses quickly, Pain is perceived as sharp and localized pain.Small myelinated fibers * C-delta fibers conduct impulses slowly, Pain is perceived as diffuse dull aching pain. Large unmyelinated. Pain last longer

Neurophysiological Transmission of Pain

Peripheral Transmission: Types of Receptors: a. Nociceptors(Noxious Stimuli)- found in skin, meninges, periosteum and some internal organs b. Thermoreceptors- heat & cold transmissions c. Mechanoreceptors- stretching, cutting, tearing

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Spinal Cord transmission Transmission in the cortex or thalamus

2 Types of Sensory Nerve Fibers for transmission of Pain Stimuli: 1. A Fibers- are small ,myelinated fibers that conducts stimuli rapidly, sharp well localized 2. C-Fibers- non-myelinated large fibers with slowest conduction time - believe to transmit the dull pain & last longer

 Gate Control Theory – This theory proposes that there is interaction between pain and other sensory modalities and that stimulation of fibers

that transmit non-painful sensations are able to block the transmission of pain impulses through an inhibitory gating circuit.  Specificity Theory/Sensory- there are separate and specific receptors for pain and these transmit information to pain centers in the brain.

 Pattern Theory/Intensity – pain

receptors share nerve endings and pathways with other sensory modalities but that different patterns of activity in the same neurons determine if sensations are perceived as painful or not painful. - Stimulation were intense enough to be interpreted as pain

Causes of Pain
 Physical Causes- include stimulation of nerve endings by injury, pressure, heat, cold, chemicals, mechanical trauma or oxygen

deprivation ex. Ischemia, muscle contraction, muscle spasm • Environmental causes- include extreme loud noises, drafts of hot or cold air, air pollution • Psychogenic Causes- tension/ stress - experience pain w/o any peripheral or organic cause

Components of Pain
 Painful Sensation- when one recognized that

there is pain
 Painful Reaction- set of events or responses

that originates from sensation - reaction act as a protective mechanism to protect the organism from impending harm

Attributes of Pain Experience
 Pain Threshold- refer to the intensity of the stimulation required to cause an individual to

experience pain. - essentially the same for individuals - application of stimuli to first sensation
Pain Tolerance- point at which the individual reacts to pain with verbal or non-verbal responses - level of sensory stimuli one is willing to tolerate

According to Duration:  ACUTE PAIN – usually of short duration -has an identifiable immediate onset -disappears along with healing -usually reversible or controllable with adequate treatment -often described as sharp, stabbing and shooting. - May be accompanied by observable physical responses including high or low b.p., tachycardia,diaphoresis, tachypnea, focusing on the pain and guarding the painful part.

CHRONIC PAIN – Lasts for a long periods of time and is not readily treatable. a.Chronic Non-Malignant Pain – pain that lasts for more than 6 months constant or intermittent that persists beyond the expected healing time. -cause of origin is unclear -the person experiencing continuous or continually recurring pain tend to become increasingly engrossed in their illness b. Chronic Intermittent Pain – refers to exacerbation or recurrence of the chronic condition. -Pain occurs only at specific periods of time, at other times the client is free from pain.

c.Chronic Malignant Pain (Cancer-related) – Malignant pain is considered to have qualities of both acute and chronic pain. Pain may be a result of cancer treatment or the direct result of tumor involvement.
 Progressive Pain- gradual increase in severity of pain

According to Location:
 Cutaneous/superficial- originates in the dermal segment & usually produce sharp pain  Deep/somatic- originates in the deep tissues like

muscles, nerves, tendons, ligaments & blood vessels  Visceral- involve4s the internal organs  Central- originates in the CNS received in the mind for which there is no apparent peripheral cause  Phantom limb- pain originates in area that was already absent

According to Pattern:
 Constant pain- occurs continously

 Intermittent Pain- occurs periodically
 Intractable Pain- not relievedby ordinary


 Past Experience- some people who had a multiple or


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prolonged pain experiences would be less anxious and more tolerant of pain than the one who has had little pain. Anxiety and Depression – anxiety is associated with pain because of concerns and fears about the underlying disease, and depression on the other hand is associated with major life changes due to the limiting effects of pain. Culture/Beliefs Age – Pain perception is diminished in the elderly person. Elderly people perceived pain as a part of normal aging. Gender Placebo Effect –

Characteristics of Pain:
 Localized Pain- conformed to the site of origin

 ProjectedPain - occurs along the distribution of nerves  RadiatedPain - extends to other site
 ReferedPain - occurs to other site other than the

source of pain

Nursing Assessment of Pain
 Intensity – Ask patient about the present pain intensity   

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using the assessment tool Timing – Ask if pain began suddenly or increase gradually. Location – Ask patient to point the area of the body with pain. Quality – Ask patient to describe pain in his own words without giving a clue. Personal Meaning – How pain affected patients life. Pain Behaviors – Non-verbal and behavioral expressions of pain. Aggravating and Alleviating Factors – what makes the pain worse and what makes it better.

Nursing Care of a Client with Pain
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b.   a. b.

Identifying Goals for Pain Management Establishing The Nurse-Patient Relationship and Teaching Positive nurse-patient relationship characterized by trust Health Teaching Providing Physical Care Managing Anxiety Related to Pain Sensitization Measures to relieve pain (Pharmacologic and NonPharmacologic

Pain Management Strategies
Non-Pharmacologic  Cutaneous Stimulation and Massage  Ice and Heat Therapies  Transcutaneous Electrical Nerve Stimulation (TENS)  Distraction  Relaxation Techniques  Guided Imagery – combining slow rhythmic breathing with mental mage of relaxation and comfort.  Hypnosis

 Anesthetic Agents – can cause loss of feeling and sensation a. General anesthesia – usually accompanied by loss of

consciousness and reflexes along with amnesia regarding the experience. b. Local Anesthetics – Produce anesthesia in a restricted area of the body without loss of consciousness c. Regional anesthesia- injected near a sensory nerve causing anesthesia in the distribution of the nerve d. Neurolytic Agents – Produce prolonged nerve blocks which destroy the nerves

 Analgesics a. Non-opioid – does not cause physical

dependence and tolerance, e.g. Aspirin, Salicylate Salts, Acetaminophen,NSAIDS b. Opioids – used for moderate to severe pain.can cause physical dependence and tolerance if taken for a long time.

Route of administration for moderate to severe pain
 Parenteral – produces effect more rapidly than oral 


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administration, but of shorter duration. Oral Route – severe pain can be relieved with oral opioids if doses are high enough. In terminally ill patients, doses may be increased gradually as the disease progresses and causes more pain or as the person builds up a tolerance to the medication. Rectal – for patients who cannot take medications with any other route Transdermal – Transmucosal – Intraspinal and Epidural – used to control pain in postoperative patients and those with severe pain secondary to a terminal disease.

Neurosurgical Treatment
 Cordotomy – a division of certain tracts of the spinal cord. This procedure interrupts or destroys conduction of pain while touch and position sense are preserved. Used most frequently in controlling severe pain of terminal cancer  Rhizotomy – A surgical division of the spinal

roots and is used in controlling severe chest pain of lung cancer and for pain relief in head and neck malignancies. Accomplished with laminectomy

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