Basic Human NeedsBasic Human Needs

Comfort and Pain ManagementComfort and Pain Management

Pain…

What is the real definition of pain?

And what is pain management??

How can this information help me???

PainPain

• 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

ComfortComfort

• Concept central to the art of nursing

• Through comfort measures nurses provide strength, hope, solace, support, encouragement, and assistance

• As subjective as pain

PainPain• 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 ManagementPain 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 PainNature of Pain• Subjective, highly individualized

• Stimulus can be physical and/or mental in nature

• Pain is tiring, places demands on person’s energy

• Can interfere with relationships and influence the meaning of life

Nature of PainNature 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, slow-conducting

Mediate slow, dull, more diffuse, often burning pain.

RabaanTekanan

Nerve FibersClass Velocity Function

A- Fast Motor

A- Fast Touch, pressure

A- Intermediate Muscle tone

A- Intermediate Pain, temperature

B Small Motor

C Small 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 TheoryMelzack 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 PainGate Control Theory of Pain

• Involves the addition of mechanoreceptors (A-beta 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

ExamplesPeripheral• Post herpetic neuralgia• Trigeminal neuralgia• Diabetic peripheral neuropathy• Postsurgical neuropathy• Posttraumatic neuropathyCentral• Posts troke painCommon descriptors2

• Burning• Tingling• Hypersensitivity to touch or cold

Examples • Pain due to inflammation• Limb pain after a fracture• Joint pain in osteoarthritis• Postoperative visceral pain Common descriptors2

• Aching• Sharp• Throbbing

Examples • Low back pain with

radiculopathy• Cervical

radiculopathy• Cancer pain• Carpal tunnel

syndrome

Mixed PainPain with

neuropathic and nociceptive components

Neuropathic PainPain initiated or caused by a

primary lesion or dysfunction in the nervous system (either peripheral or

central nervous system)1

Inflammatory PainInflammatory PainPain caused by injury to Pain caused by injury to

body tissues body tissues (musculoskeletal, (musculoskeletal,

cutaneous or visceral)cutaneous or visceral)22

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

Pain TypesPain Types

Physiology of PainPhysiology of PainCategoriesCategories

• Acute

• Chronic

• Idiopathic Pain

• Cancer pain

• Pain by Inferred Pathology/Nociceptive & Neuropathic

• Pain as a result of a Metabolic Need/Ischemic Pain

Nociceptive PainNociceptive 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 PainSomatic Pain

• Arises from bone, joint, muscle, skin or connective tissue

• Usually aching, throbbing, well-localized pain

• Responds to traditional analgesia

Visceral PainVisceral 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 PainNeuropathic Pain• Abnormal processing of sensory input by

the peripheral or CNS

• Treatment usually with tricyclic antidepressants, SSRI’s, 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 PainNociceptive Pain• Transduction

• Transmission

• Perception

• Modulation

Process #1—Transduction

• Transduction—nociceptors 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. Examples—local anesthetics, anticonvulsants used for neuropathic pain, migraines.

Process #2—Transmission

• 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 brain—opioids (narcotics) are effective analgesics because they block the release of neurotransmitters

Process #3—Perception of Pain

• The end result of the neural activity of pain transmission

• It is believed pain perception occurs in the cortical structures—behavioral 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 #4—Modulation 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 PainGate 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 PainPhysiological 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 PainPhysiological 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 PainBehavioral Responses to Pain

• Pain threatens physical & psychological well-being

• 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 body’s 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 stimuli’s 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 PainAcute 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 PainChronic 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 PainCancer 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 PainFactors Influencing Pain• Age• Gender• Culture• Meaning of pain• Attention• Anxiety• Fatigue• Previous Experience• Coping Style• Family & Social Support

Nursing ProcessNursing ProcessAssessmentAssessment

• 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 low-intensity 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.

AssessmentAssessment• Quality

• Pain pattern

• Concomitant Symptoms

• Effect of pain on client (physical, behavioral, effect on ADL)

• Cultural Considerations

Nursing ProcessNursing ProcessNursing DiagnosisNursing Diagnosis

• Anxiety

• Alteration in Comfort

• Self-care Deficit

• Sleep Pattern Dysfunction

• Sexual Dysfunction

Nursing ProcessNursing ProcessImplementationImplementation

• 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)

Pain Behaviors

Suffering

PainPerception

NociceptionLocal block

NSAIDs (Movicox ®)SurgeryPhysical modalities

Opioid

Adjuvants

NSAIDs?

Acetaminophene

Neural augmentation

Ablative surgery

Anti-depressants / psychotropics

Relaxation

Spiritual

Cognitive therapies

Functional restoration

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

Gottschalk et al., 2001

Alternative methodsAcupuncture

Physical Therapy

Chiropractics

Surgery

PharmacotherapyNon-opioid analgesics

Opioid analgesics

Nerve Blocks

Adjuvant analgesics (neuropathic, musculoskeletal)

Electrical StimulationTranscutaneous electrical nerve stimulation (TENS)

Percutaneous electrical nerve stimulation (PENS)

Acetaminofen

(NSAID)

Non-pharmacological MethodsNon-pharmacological Methods

Acupuncture• Relaxation• Guided Imagery• Distraction• Music• Biofeedback• Self-Hypnosis• Reducing Pain Perception• Cutaneous Stimulation (Heat or Cold

application, massage, TENS unit)

Pharmacologic MethodsPharmacologic Methods• Require a physicians order

• Guidelines set by regulatory agencies

• Analgesics most common method

• Tendency to under treat with pain meds

AnalgesicsAnalgesics• Non-opioid or non-narcotic agents & non-

steroidal anti-inflammatory agents (NSAIDS)

• Narcotics, Opioids

• Adjuvants, Co-analgesics

Diagnosis Drug Treatment

Acute and chronic pain NSAIDS (al Meloxicam/ Movi-cox), Opioids, Paracetamol

Myofascial pain dysfunction

Analgesics (Movi-cox), tricyclics, centrally-acting muscle relaxants, glucocorticoids

Neuropathic pain, neuralgias

Carbamazepine, phenytoin, baclofen, tricyclics, gabapentin, others?

 

NSAIDSNSAIDS• 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

NSAIDSNSAIDS• 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

OpioidsOpioids• 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

OpioidsOpioids• 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 TherapyAdjuvant Therapy• Sedatives, anti-anxiety, & muscle

relaxants

• Enhance pain control or relieve symptoms associated with pain

• Vistaril, Elavil, Thorazine, Valium, Ativan, Xanax

Patient-Controlled Analgesia Patient-Controlled Analgesia PCAPCA

• 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 PrescriptionPCA Prescription• Loading Dose

• Basal (Continuous rate)

• On demand dose

• Hourly maximum amounts can be prescribed

Local & Regional AnestheticsLocal & 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 ManagementEpidural 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 ManagementEpidural 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 ManagementCancer 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 client’s 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 client’s pain. The most appropriate action for the nurse to take when assessing the client’s 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 client’s

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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