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

Pain is whatever the person experiencing it says it is. » can be different to treat their pain

Physiology of Pain

• Experienced when an intact, properly functioning nervous system signals that tissues are damaged, requiring attention and proper care

• Transient (comes and goes) vs. Persistent (pain is continuous » prolonged)

• Subcategories

  • Somatic (system wide) » Skin, muscle, & bones

  • Visceral (organs) » Organs

    • Hard to describe » pain radiates to another body part

  • Neuropathic (nerve pain)

    • This is treated differently, to stop nerve transmission

    • Pain in lower extremities (Diabetes)

    • Hitting the sciatic nerve

    • Phantom pain (limb)

Nociception

• Transduction » Stimuli

• Transmission » Pain travels

• Perception » Conscious of pain

• Modulation » Natural mechanics within the body that modifies pain

Gate Control Theory » most common theory on how we interrupt pain

• Nerves must be functioning to feel pain

• A way to modulate the pain within the brain and its neurotransmitters

• Stimuli » along the nerve pathway » spinal cord » Brain

Contributing Factors

• Chemical

  • Ex) medication

    • Aspirin can cause irritation and bleeding in the stomach

  • Steroids, Iron supplements

• Developmental

  • Ex) Age

    • Their understanding of pain changes with age

    • Older adults » expect pain therefore don’t seek help

    • Preschool aged children may associate pain with punishment » may not understand if pain goes away

• Physical

  • Ex) radiation, pressure, trauma, heat/burns, temp, and surgeries

• Physiological

  • Ex) inflammation, Diabetes, renal calculi, arthritis

• Psychosociocultural

  • Your previous experiences with pain and how you handled it

  • How culture affects how you experience pain

  • Gender – woman can tolerate more pain because of menstrual cycle

    • Men aren’t as readily verbal about their pain – come off as non-masculine

• Iatrogenic

  • Physician induced » any procedure that causes pain

    • Ex) Foley catheter causing a painful UTI

    • Ex) IV’s, Drawing Blood, injections

Comparison of Acute and Chronic Pain

Acute

• Sympathetic nervous system

• Duration is less than 3 months

• Severity can range from slight to extreme

• Vitals usually increase – increase BP, RR, HR, temp (GAS)

• Skin may be flushed / red

• Pupils generally dilated

• Behavioral changes

  • Irritable

  • Guarding the area that is painful » “don’t touch me”

  • Crying

  • Wincing

  • Anxiety

  • Restlessness

  • Diaphoresis

Chronic » prolonged/ usually cyclical and irreversible

• parasympathetic nervous system

• duration persists more than 3 months

• severity can range

• vital signs are not always elevated – have become somewhat tolerable to the pain  adapts to pain

• Behavioral changes:

  • Depression

  • No Guarding

  • Some older adults don’t mention pain considering they are used to it

  • Dry/warm skin

  • Pupils constrict

Terminology

• Pain threshold

  • How much stimulus does it take for the person to feel pain » varies slightly but not to much

  • Entryway

• Pain tolerance

  • Maximum amount of pain that a person is willing to withstand before seeking relief

• How much pain an individual can handle » varies person to person

• Pattern

  • Onset, duration, consistency, reoccurrences, intervals of pain

• Precipitating factors

  • What aggravates the pain » Stressors that preceded or worsens pain

• Alleviating factors

  • What helps the pain? » interventions which decrease pain

• Intractable pain

  • Pain that doesn’t go away even with treatment

  • Cannot be managed even with treatment

    • Ex) Cancer

• Associated symptoms » Vomiting, nausea, headache, anorexia, and insomnia

• Location

  • Localized

  • Radiates – “travels” to surrounding body parts » happens with visceral pain

  • Referred – pain experienced in another area not close to the site of injury

    • Ex) heart attack felt in the jaw, or the shoulder

  • Diffuse- spreads to are all over » Kidney pain

• Quality or Character

  • Ex) describe your pain

    • Achy, dull, sharp, pins, throbbing, burning, stabbing

• Affective responses

  • Emotional responses

    • Does it give you suicidal thoughts?

    • Does it make you fearful

Pain Assessment Mneumonic (Subjective Data)

COLDERR

• Character/quality – stabbing, throbbing, burning

• Onset- when it starts

• Location- where it’s localized

• Duration- how long does it last

• Exacerbation- what makes it worse

• Relief

• Radiation- does it spread

PQRST

• Provoked (what brought the pain on)

• Quality – stabbing, throbbing, burning

• Region / Radiation- where it’s localized/ does it spread

• Severity – intensity

• Timing- when does it happen

OLDCARTS

• Onset- when it starts

• Location- where it’s localized

• Duration- how long does it last

• Characteristics- stabbing, throbbing, burning

• Aggravating Factors- stressors that precedes or worsens pain

• Radiating (referred, region, location)

• Treatment (has anything worked to alleviate the pain)

• Severity – intensity

Severity Pain Scale

• 0 (no pain)  1-3(mild pain) 4-5 (moderate pain) 5-7 (severe pain) 8-9 (severe pain  10 (worse pain possible)

Pediatric Pain scale:

• Wong Baker / Faces:

  • Comes in different languages for non-English patient’s

• Flacc scale:

  • Babies, non-verbal patient’s, and patient’s with dementia

Objective Data

• Behavioral responses to pain

  • Grimacing, sweating, moaning, guarding, restless, altered LOC, thrashing, obscene language

• Physiologic changes

  • Vital signs » unless it’s chronic pain  vital signs sometimes don’t change

    • Increased respiratory, heart rate , blood pressure

  • Skin changes

  • Pupillary changes

Additional Pain Data

• Associated symptoms

• Effects on ADLs

  • Are you still able to carry out daily tasks?

• Past pain experiences

• Meaning of pain to the person

• Coping resources

  • Meditation, relaxation, guided imagery, distraction

  • Educate the patient about pain

• Affective responses

Nursing Interventions

• Establish a trusting relationship – take their word for it

• Consider patient’s ability and willingness to participate – motivation, have to believe it’s going to work

• Use a variety of pain relief measures: pharmacologic and non-pharmacologic (do first before administrating medication)

• Provide pain relief before pain is severe

• Use pain relief measures the patient believe are effective

• Align pain relief measures with report of pain severity

• Encourage patient to try ineffective measures again before abandoning

• Maintain unbiased attitude about what may relieve pain

• Keep trying

• Prevent harm

• Educate patient, family and caregivers about pain

Opioids

• Examples – morphine, dilaudid

• No ceiling on analgesia » taking more has an affect and can even kill you

  • Depends on a person’s tolerance and patient’s history and situation

  • There is no max of dose

• Side effects

  • Depresses respiratory rate

  • Urinary retention, constipation, and nausea

• Routes – all routes » can be given through any site/route

  • Make sure it’s not leaking

• Antidote – Narcan

• Concerns

  • Addiction » keep taking medication when not needed

  • Dependence

    • Decrease blood levels of the drug » manifested by withdrawal syndrome

  • Tolerance

    • Adaptation to a drug » varies greatly » Build’s a tolerance overtime

    • Increased tolerance

    • The effectiveness of a drug decreases if you’re on it for prolonged periods of time

Nonopioids/NSAIDS – Intake through GI tract (given with food considering it’s irritating in the GI tract)

• Vary little in analgesic potency but do vary in anti-inflammatory effects, metabolism, excretions, and side effects

• Have a ceiling effect » you can only go so high » very short ½ life, taking more does not help

• Narrow therapeutic index

  • Ex) Acetaminophen, ibuprofen, aspirin (ASA)

Co-Analgesics / Adjuvant Medications – Medications which are not specifically designed to relieve pain, but which can help improve pain either alone or in combination w/medications

• Antidepressants

• Anticonvulsants

  • For neuropathic pain

• Local anesthetics

  • Nerve blocking

  • Regional anesthesia

• Placebos

• Use Nonopioids/NSAIDS with co-analgesics

Routes

Oral

• Preferred because of ease of administration

• Duration of action is often only 4 to 8 hours

• Must awaken during the night for medication

• Long-acting preparations developed

• May need rescue dose of immediate-release medication

PCA (Patient Controlled Analgesic

• Gives patient control of pain medications – IV pump machine

• Must be A&Ox4, always need a witness

• Not used frequently due to the opioid crisis

Other

• Transmucosa and transnasal

• Transdermal (lidocaine patch)

• Rectal

• Continuous subcutaneous infusion

• Intramuscular

• intravenous

Intraspinal

• Epidermal for pain management

Other ways to treat pain

Physical Modalities » Transmission of energy to or through the patient

• Cutaneous stimulation » massage, heat, cold, and therapeutic touch

• Immobilization or therapeutic exercises » repositioning

• Transcutaneous electrical nerve stimulation (TENS) » alters perception of patient’s pain » mild electric current to relieve pain » sending non-painful stimuli through injured tissues and into the nervous system

Cognitive Behavior (Mind/Body)

• Providing comfort

• Distraction

• Eliciting relaxation response

• Re-pattern thinking

  • Change how you perceive pain (anticipatory pain)

• Facilitating coping with emotions

• Interventions

  • Reducing pain triggers

  • Massage

  • Applying heat (dilates) or ice (constricts) » Icepack needs to be left 15-20 minutes » rebound phenomenon

  • Electric stimulation (TENS)

  • Positioning and bracing (selective immobilization)

  • Acupressure

  • Diet and nutritional supplements

  • Exercise and pacing activities

  • Invasive interventions

    • Surgical disruption of pain conduction

    • Sympathectomy

    • Spinal cord stimulation

Lifestyle Management

• Stress management

  • Deep breathing

• Exercise, nutrition

  • Release of endorphins

• Pacing activities

• Disability management

• Interventions

  • Relaxation and imagery

  • Self-hypnosis

  • Pain diary and journal writing

  • Distracting attention

  • Re-pattern thinking

  • Attitude adjustment

  • Reducing fear, anxiety, stress, sadness and helplessness

  • Providing information about pain » Educate

Spiritual

• Feel part of the community

• Bond with universe

• Religious activities

• Interventions

  • Prayer

  • Meditation

  • Self-reflection

  • Meaningful rituals

  • Energy work (therapeutic touch, Reiki)

  • Spiritual healing