CONCEPT OF PAIN

Pain is whatever the

experiencing person says it is
and existing whenever the
person says it does.
 Learning Objectives:
• At the end of the lecture, students will be able
to:
1. define pain;
2. enumerate the different theories of pain;
3. describe and differentiate the different types
of pain;
4. discuss the different types of pain
management;
5. Assess clients experiencing pain.
• Pain is the most common reason
for seeking health care

• Associated with actual or

potential tissue damage

• American Pain Society: Pain, “The

Fifth Vital Sign”
• Nurses, are primary advocate to
pain relief
• Nurses have the capability to
relieve pain merely by
acknowledging the discomfort &
confirming that measures will be
taken.
 It is a personal & subjective experience, & no two
people experience pain in exactly the same manner
 According to Sternbach, pain is an abstract concept which
refers to:
 A personal, private sensation of hurt
 A harmful stimuli that signals current or impending
tissue damage
 A pattern of response to protect the organism from
harm
 DEFINITIONS OF PAIN
 Despite its subjective nature, the
nurse is charged with accurate
assessment with the objective to
relieve pain

 REMEMBER: all pain is real even

if the cause can not be
ascertained
 PROBLEM OF PAIN
 Pain is the primary reason people
seek health care & is associated
with the length of hospital stay,
longer recovery time, & poorer
client outcomes
 Clients should be truthful in the
onset & description of pain in
order for the health care provider
to give the proper medications
 SPECIFIC BARRIER TO PAIN RELIEF
Barriers Related to Healthcare Professionals:
 Inadequate or inaccurate
information about pain
management

 Inadequate or sub-optimal
pain assessment techniques

 Concern about overuse of

controlled substances &
subsequent client addiction

 Concern about excessive

adverse effects
 SPECIFIC BARRIER TO PAIN RELIEF
Barriers Related to the Healthcare System:
• Low priority given to pain
treatment in relation to other
client needs
• Inadequate reimbursement for
other or costly pain management
therapies
• Restrictive regulation of controlled
substances
• Less than optimal availability or
access to treatment;
- Opioids are often unavailable in inner-
city pharmacies as well as rural areas
- Nurses should work to ensure that
necessary medications are available for
clients, regardless of the environment
 SPECIFIC BARRIER TO PAIN RELIEF
Barriers Related to Clients:
• Reluctance to report pain or
take pain medications
• Fear that pain indicates the
disease process is progressing
• Concern about being thought
about as a complainer
• Reluctance to take medications
for a variety of reasons
• Concern about adverse drug
effects
• Concern about developing
tolerance or addiction to pain
medications
• Cost is a significant barrier to
good analgesia;
 SPECIFIC BARRIER TO PAIN RELIEF
Client Education
 Nurses can reassure clients that
pain control is every client’s right
 Health professionals
rely on the client to
report pain, & that pain
management will
improve quality life

 Proactive education of clients &

family / support persons is
necessary, including information
about addiction, drug tolerance,
& physiological dependence
 PERCEPTION OF PAIN
 It is likely determined by the
relative balance between
sensory peripheral input &
the mechanism of central
control in the brain

 Pain perception is influenced

by one’s tolerance for pain
 PERCEPTION OF PAIN
• Pain Threshold
 The lowest intensity of a
painful stimulus that is
perceived by the person as
pain

 May vary according to

physiologic factors such as
inflammation or injury near
pain receptors

 Essentially similar to all

people if the CNS and the
PNS are intact
 PERCEPTION OF PAIN
• Pain Tolerance
 The amount of pain the
person is willing to endure

 It is different for each person

who experience pain, based
on subjective factors such as
the meaning of the pain & the
setting

 Some people have a high

tolerance, e.g., they can
tolerate a lot of pain without
distress
PATHOPHYSIOLOGIC BASIS OF PAIN
• Theories of Pain
1. Specificity Theory
2. Pattern Theory
3. Gate Control Theory
 THEORIES OF PAIN
1. SPECIFICITY THEORY – most widely
accepted theory of pain transmission
through the end of 19th century.
♦ It advances the idea that the body’s
neurons & pathways for pain
transmission are specific & unique as
those for other body senses (such as taste
or touch)

♦ free skin nerve endings act as pain

receptors, accept & transmit sensory
input in highly specific nerve fibers w/c
synapse in the dorsal horns of the
spinal cord, & cross-over to the
anterior & lateral spinothalamic tracts.
Pain impulses ascend to the thalamus
& cerebral cortex, where painful
sensations are perceived.
 THEORIES OF PAIN
2. PATTERN THEORY – proposed in the
early 1900s.
♦ It identifies 2 major types of pain
fibers:
a. rapidly conducting (A-delta) and
b. slowly conducting fibers (C-fibers)
The stimulation of these fibers forms
a pattern.
♦ Introduces the concept of central
summation. Peripheral impulses from
many fibers of both types are
combined at the level of the spinal
cord, & from there, a summation of
these impulses ascends to the brain
for interpretation.
 Theories of Pain
3. The Gate Control Theory of Pain
 explains why interventions such
as TENS (transcutaneous electrical
nerve stimulator), heat and cold, &
massage are effective

 Pain impulses are modulated by

a transmission blocking action
w/in the CNS

 Large-diameter cutaneous fibers

is stimulated (e.g. by rubbing) &
inhibit smaller diameter fibers to
prevent transmission of the
impulse (“close the gate”)
 Theories of PAIN
 Small-diameter nerve fibers
carry pain impulses through a
gate, but large diameter
sensory nerve fibers going
through the same gate can
close the gate & inhibit
transmission
- suggests that pain & its perception
are determined by interaction of 2
systems:
1. substantia gelatinosa (in the dorsal horns
of the spinal cord) regulates impulses
entering or leaving the spinal cord.
2. inhibitory system within the
brainstem.
 PATHOPHYSIOLOGIC BASIS OF PAIN
The Pain Pathway
 Pain is perceived by the
nociceptors in the
periphery of the body
(e.g. skin) transmitted
through small afferent A-
delta & C nerve fibers to
the spinal cord

 A-delta fibers are

myelinated & transmit
impulses rapidly
producing sharp, acute
pain sensations
 PATHOPHYSIOLOGIC BASIS OF PAIN…cont
 C fibers are not
myelinated & transmit
pain more slowly;
 Impulses are
generated from
deeper structures (such
as muscle & viscera)
producing more
aching, chronic pain
sensations
 Secondary neurons transmit
the impulses from the
afferent neurons through
the dorsal horn of the spinal
cord;
 PATHOPHYSIOLOGIC BASIS OF PAIN…cont

 A synapse in the
substantia gelatinosa
occurs;
 Impulses cross over &
ascend to anterior &
lateral spinothalamic
tracts & pass through
the medulla &
midbrain to the
thalamus
 PATHOPHYSIOLOGIC BASIS OF PAIN…cont

 Pain impulses are

perceived,
interpreted, & a
response is generated
in the thalamus &
cerebral cortex
PATHOPHYSIOLOGIC BASIS OF PAIN
PATHOPHYSIOLOGIC BASIS OF PAIN
• Painful Stimuli
– Causative Factors:
 Microorganisms:
Pneumonia
 Inflammation: Arthritis
 Impaired blood flow:
Angina
 Heat: Sunburn
 Electricity: Electrical
burn
 Obstruction: gallstone
 Spasm: Muscle cramp
 Swelling: Cellulitis
 PATHOPHYSIOLOGIC BASIS OF PAIN
Biochemical Sources
– Bradykinin : An amino acid, appears
to be the most potent pain-
producing chemical

– Prostaglandins: Chemical
substances that increase the
sensitivity of pain receptors by
enhancing the pain-provoking effect
of bradykinin
•  
– Histamines: released in response to
tissue injury/damage, & through the
sensitization of polymodal
nociceptors resulting in increased
firing rates, it contributes to the
generation of pain hypersensitivity.
 RESPONSE TO PAIN
Proprioceptive Reflex
 
Occurs with simulation of
pain receptors
Impulses → sensory pain
fibers → spinal cord →
synapse with → motor
neurons → travels back →
motor fibers → muscles
near the site of pain →
contracts in a protective
action
 RESPONSE TO PAIN….cont
The Reflex Arc
Stimulus - Sensory
receptor in the skin –
Sensory transmission –
Sensory nerve fibers –
Spinal nerve - Spinal cord
– Dorsal root (horn) –
Interneuron – Anterior
horn – Motor transmission
- Motor nerve fiber –
Effector muscles -
Response
RESPONSE TO PAIN
 TYPES OF PAIN
1. Acute Pain
2. Chronic Pain
 
• Acute Pain
 Short duration (<6 months)

 Has an identifiable,
immediate onset
 e.g. incisional pain after
surgery
 Has limited & predictable
duration
 e.g. postop pain
disappears after wound
healing
 TYPES OF PAIN
 Described in sensory terms,
such as “sharp”, “stabbing”,
& “shooting”

 It is considered a useful &

limiting pain : indicates
injury & motivates the
person to obtain relief by
treatment of the cause.

 Acute pain is usually

reversible/ controllable with
adequate treatment.
 TYPES OF PAIN

 Observable physiologic
responses in acute pain:
 ↑ or ↓ BP
 Tachycardia
 Diaphoresis
 Tachypnea
 Focusing on pain
 Guarding the
painful part
 TYPES OF PAIN
– Four Major Pain Management
Goals:

1. Reduce the incidence &

severity of acute
postoperative or post-
traumatic pain

2. Encourage clients to
communicate unrelieved
pain so that they can
receive prompt
evaluation & effective
treatment

3. Enhance comfort &

 TYPES OF PAIN

• Chronic Pain
 Defined in vague terms with
some of unknown causes
 Lasts longer period of time and
is not readily treatable
 Mental response of the person
to pain depends on its duration
& intensity
 The course of chronic pain
usually takes months & years of
pain
 Diverse treatment modalities
have been used to treat the
symptoms
 TYPES OF PAIN

 Associated with withdrawal

and despair, anxiety &
depression

 Some clients learn to adapt

& cope with pain, adjusting
their lives

 Most people undergo major

affective & behavioral
changes when experiencing
pain for prolonged periods :
Chronic Pain Syndrome
 TYPES OF PAIN
– Characteristics of Clients with
CPS:
 Depressed mood
 ↑ or ↓ Appetite and
weight

 Drastically restricted
activity level leading to
↓ work capacity poor
physical tone, ↑
depression

 Social withdrawal

 Preoccupations with the

physical manifestations
 TYPES OF PAIN

• Types of Chronic Pain

1. Chronic non-malignant pain
 e.g. Osteoarthritis

2. Chronic, intermittent pain

 e.g. Migraine headache

3. Chronic malignant pain

 e.g. Cancer pain
 TYPES OF PAIN
• Chronic Non-Malignant Pain
 pain that lasts more than 6
months & is continuous or
persistent & recurrent
 It is a frustrating condition,
making it difficult for the
person to live a normal life
 The pain is exhausting both
physically & emotionally for
themselves & their families
 Causes the person to be
fearful, tense, fatigue,
tending to become
withdrawn & isolated
 TYPES OF PAIN
• Chronic Intermittent Pain
 Refers to exacerbation or
recurrence of the chronic
condition

 The pain occurs only at

specific periods, at other
times the client is free from
pain

 Pain management is directed

toward the control of pain in
such the same manner as that
for individual with acute pain
episodes
 e.g. migraine headache
 TYPES OF PAIN
• Chronic Malignant Pain
 Cancer–related pain

 Considered to have the

qualities of both the acute &
the chronic pain

 Encompasses neuropathic,
deep visceral, & bone pain

 A diagnosis of cancer adds to

the psychological component
associated with potential
physical deformity & the
potential for impending death,
preceded by agonizing
 OTHER TYPES OF CHRONIC PAIN
• The most common chronic pain
condition is lower back pain.
• Others include:
a. Neuralgias – painful conditions that
result from damage to a peripheral
nerve caused by infection or disease.
b. Reflex Sympathetic Dystrophies –
characterized by continuous severe burning
pain. These conditions follow peripheral
nerve damage & present the symptom of
pain, vasospasm, muscle wasting &
vasomotor changes.
c. Hyperesthesias – are conditions of
oversensitivity to tactile & painful stimuli.
Results in diffuse pain usually increased by
fatigue & emotional lability.
 OTHER TYPES OF CHRONIC PAIN…
cont
d. Myofascial Pain Syndrome – common
condition marked by injury to or disease of
muscle & fascial tissue. Pain results from
muscle spasm, stiffness & collection of lactic
acid in the muscle. Ex. fibromyalgia

e. CA – often produces chronic pain usually

due to factors associated with the advancing
disease. These factors include a growing tumor
pressing on nerves or other structures,
stretching of viscera, obstruction of ducts or
metastasis to bones.

f. Chronic Postoperative Pain – rare but may

occur following incision in the chest wall,
radical mastectomy, radical neck dissection &
surgical amputation
 TYPES OF PAIN
Sources of Noxious Stimuli for Clients with
Cancer
• Cell destruction: cell necrosis, ulceration,
tumor invasion, tissue injury
 Inflammation: products of cell
destruction
 Infection: bacterial invasion
 Ischemia/Hypoxia: edema, hematoma,
occlusion of vessel by the tumor
 Noxious stretch/pressure: distention of
thoracic & abdominal viscera, fascia,
periosteum, occlusion of GIT & GUT
structures, obstruction of ducts
 Nerve injury: direct injury through
incising nerve structures, tumor invasion
of peripheral nerves, spinal cord, &
brain, chemotherapy & radiation injury
TYPES OF PAIN
Comparison of Acute and Chronic Pain
Acute pain Chronic pain
• Mild to severe • Mild to severe

• Sympathetic nervous system responses: • Parasympathetic nervous system responses:

• ↑ HR, ↑ RR, ↑ BP, diaphoresis, dilated • Vital signs normal, dry warm skin, pupils
pupils normal or dilated

• Related to tissue injury: resolves with healing • Continuous beyond healing

• Client appears restless and anxious • Client appears depressed or withdrawn

• Client reports pain • Client often does not mention pain unless
asked

• Client exhibits behavior indicative of pain: • Pain behavior often absent

crying, rubbing area, holding area
 TYPES OF PAIN
Categories of Pain According to Origin
a. Cutaneous
 Originates in the skin or
subcutaneous tissue
 e.g. a paper cut
causing a sharp pain
with some burning

b. Deep Somatic
 Arises from ligaments,
tendons, bones, blood
vessels, & nerves

 It is diffuse & tends to last

longer than cutaneous pain
 e.g. ankle sprain
 TYPES OF PAIN
c. Visceral
 Results from stimulation of
pain receptors in the
abdominal cavity, cranium,
& thorax

 Tends to appear diffuse &

feels like deep somatic pain
 e.g. burning, aching, or
a feeling of pressure

 Frequently caused by
stretching of the tissues,
ischemia, or muscle spasm
 e.g. obstructed bowel
 TYPES OF PAIN
Description of Pain According to where it is
experienced in the body:
A. Radiating Pain
 Perceived at the source of pain
& extends to nearby tissues
 e.g. cardiac pain felt not
only in the chest but also in
the left shoulder & arm
B. Referred Pain
 Felt in the part of the body that
is considerably removed from
the tissues causing the pain
 e.g. pain from one part of
the viscera maybe perceived
in an area of the skin
remote from the organ
causing the pain
Referred Pain
 TYPES OF PAIN
Other Types of Pain
a. Intractable Pain
 Pain that is highly resistant to
relief
 e.g. pain from advance
malignancy 
b. Neuropathic Pain
 The result of current or past
damage to the peripheral or
central nervous system & may
not have a stimulus for pain
 Long lasting and unpleasant
 Described as burning, dull, &
aching
 With episodes of sharp,
shooting pain can be present
 TYPES OF PAIN
c. Phantom Pain
 A painful sensation perceived
in the body part that is
missing or paralyzed by spinal
cord injury
 Episode of this pain type can
be reduced if analgesia is
given via the epidural catheter
prior to amputation
 e.g. amputated leg
•  d. Phantom Sensation
 The feeling that the missing
part is still present
–e. Psychogenic – experienced in the
absence of any diagnosed physiologic
event or cause.
PATHOPHYSIOLOGIC BASIS OF PAIN

• Nociception: The process of how

pain is recognized consciously

• Four Steps of Nociception:

1. Transduction
2. Transmission
3. Perception
4. Modulation
1. Transduction
 Conversion of a stimulus to an action potential at the
site of tissue injury
 Chemicals are released with cellular damage from such
things as burns, radiation, pressure, tears, & cuts
 These chemicals sensitize the Primary Afferent
Nociceptors (PANs) , fibers that carry the pain stimuli
 Aδ(delta) fibers: fast pain
 C fibers: slow pain

 Analgesics that work to block transduction,

interferes the production of chemicals that sensitize
the PANs to begin the action potential
 NSAIDs: block the formation of prostaglandins
 PATHOPHYSIOLOGIC BASIS OF PAIN
1. Transduction
 Conversion of a stimulus to an action potential at the
site of tissue injury
 Chemicals are released with cellular damage from
such things as burns, radiation, pressure, tears, &
cuts
 These chemicals sensitize the Primary Afferent
Nociceptors (PANs) , fibers that carry the pain stimuli
 Aδ(delta) fibers: fast pain
 C fibers: slow pain

 Analgesics that work to block transduction,

interferes the production of chemicals that
sensitize the PANs to begin the action potential
 NSAIDs: block the formation of
prostaglandins
 PATHOPHYSIOLOGIC BASIS OF PAIN
2. Transmission
 The neuronal action potential
is transmitted to & through
the CNS so it can be perceived
 The impulse is projected to
the spinal cord
 It is processed in the
dorsal horn –
• Referred Pain
 It is then transmitted to
the brain
 
 Analgesics that work at the
level of transmission stabilize
membranes by inactivating
sodium channels, thus
inhibiting action potential
PATHOPHYSIOLOGIC BASIS OF PAIN

3. Pain Perception
 The experience of pain
occurs in the cortex
 May occur at a basic level
in the thalamus
•  
4. Modulation
 Efferent fibers descending
from the brain stem
modulate or alter pain
 FACTORS AFFECTING CLIENT’S
RESPONSE TO PAIN
1. Age – the older adult
with normal age-related
changes in
neurophysiology may have
decreased perception of
sensory stimuli & a higher
pain threshold.
 FACTORS AFFECTING CLIENT’S
RESPONSE
2. Sociocultural Influences – person’s
TO PAIN
response to pain is strongly influenced by
the family, community & culture. It
affects the way a client tolerates pain,
interprets the meaning of pain & reacts
verbally & nonverbally.
Ex. If the family of origin believes that
males should not cry & must tolerate
pain, he will appear withdrawn & will
refuse pain medications.
♦ Cultural standards teaches an individual
how much pain to tolerate, what types of
pain to report & to whom to report the
pain & what kind of treatment to seek
 FACTORS AFFECTING CLIENT’S
RESPONSE TO PAIN
3. Emotional status – pain sensation
may be blocked by intense
concentration (during sports act) or may be
increased by anxiety or fear. Pain often
is increased when it occurs in
conjunction with other illness or
physiological discomforts such as
nausea & vomiting.

♦ Depression is clearly linked to pain:

serotonin, a neurotransmitter involved
in the modulation of pain in the CNS. In
clinically depressed clients, serotonin is
decreased leading to an increase pain
sensation.
 FACTORS AFFECTING CLIENT’S
RESPONSE TO PAIN
4. Past experiences with pain – if the
person’s childhood pain experiences were
responded appropriately by supportive
adults, he/she will have a healthy attitude.
5. Source & Meaning – if the client
perceives pain as deserved (ex. Just
punishments for sins), client may actually feel
relief that the punishment has
commenced.
6. Knowledge Deficit – if the client has a
clear & accurate perception of pain, it is
far easier for professionals to increase the
client’s knowledge of both the significance
of the pain & the strategies the client can
use to diminish discomfort in a timely
way.
 PATHOPHYSIOLOGIC BASIS OF PAIN
Mechanisms of Altering Pain
a. Endogenous Opioids
 Naturally occurring, morphine-like
chemicals made in the CNS to inhibit
transmission of pain by binding to opioid
receptors in the CNS to block the
transmission of nociceptive signals e.g.
endorphin, norepinephrine, enkephalin
•  b. The endogenous analgesia center in the
midbrain produces profound analgesia when
stimulated
 Many analgesics modulate pain by
mimicking endogenous
neuromodulators
 The variability of individual endorphin
levels may explain the fact that pain
tolerance to the same stimulus are
different from person to person
 PAIN ASSESSMENT
 The person may learn to cope with
pain through cognitive & behavioral
activities: diversions, imagery,
excessive sleeping
 The individual may respond to pain by
seeking out physical interventions to
manage the pain: analgesics, massage,
exercise
Signs and Symptoms of pain:
 ↑ BP; ↑ HR;↑ RR
 Hypermotility
 Agitation
 Anxiety
 Grimacing
 Dilated pupils
 Crying and depression
 PAIN ASSESSMENT
• Tools & Instruments Used
 These provide the client and
nurse with an easy method to
quantify pain

 A verbal report using intensity

scale is a fast easy, & reliable
method allowing the client to
state pain intensity

•  
 Commonly used tools:
 “0-5” or “0-10” scale
 Visual analog scale: pain
intensity scale
 FACES pain scale
 0 1 2 3 4 5 6 7 8 9 10

No Pain Moderate Pain Unbearable Pain

Fig. 1 Numeric Pain Intensity Scale ↑

No Pain Pain as bad as could possibly be

Fig. 2 Visual Analogue Scale ↑

Fig. 3 Face Pain Scale ↑

 0 1 2 3 4 5 6 7 8 9 10

No Pain Moderate Pain Unbearable Pain

Fig. 1 Numeric Pain Intensity Scale ↑

No Pain Pain as bad as could possibly be

Fig. 2 Visual Analogue Scale ↑

Fig. 3 Face Pain Scale ↑

 PAIN ASSESSMENT
• Physiologic Indicators of Pain

 Facial & vocal expression

maybe the initial
manifestations of pain
 Rapid eye blinking
 Biting the lip
 Moaning & crying,
screaming
 Either closed or clenched
eyes
 Stiff unmoving body
position
 PAIN ASSESSMENT
ABCD Method of Pain Assessment
 The acronym was developed for CA
pain; however, it is also appropriate for
clients with any type of pain, regardless
of the underlying disease
•  - A – Ask about pain regularly; assess pain
systematically
– B – Believe the client & family about the
reports of pain & what relieves it
– C – Choose pain control options
appropriate for the client, family, &
setting
– D – Deliver the intervention in a timely,
logical, & coordinated fashion
– E – Empower client & families, enable
them to control their course to the
greatest extent possible
 PAIN ASSESSMENT
• PQRST Assessment for Pain Perception
 This method is especially helpful
when approaching a new pain
problem
• P – Pattern of pain; what
precipitated the pain?
• Q – Quality & quantity of pain:
sharp, stabbing, aching, burning,
stinging, deep, crushing, viselike,
or gnawing
• R – Radiation of pain to other
areas of the body; the region of
the pain
• S – Severity of the pain
• T – timing of the pain; when does
it begin? How long does it last?
How it is related to other events
in the client’s life and activities?
 FACTORS AFFECTING PAIN
1.
EXPERIENCE
Ethnic & Cultural Values
 Behavior related to pain is a part of
socializing process
 Individuals in one culture may have
learned to be expressive about pain,
whereas individuals from another culture
may have learned to keep those feelings
to themselves & not bother others
 Cultural background affect the level of
pain that an individual is willing to
tolerate
 Middle Eastern & Africans: self-infliction
of pain is a sign of mourning or grief
 Other cultures: pain is anticipated as a
ritualistic practices - tolerance of pain
signifies strength & endurance
 FACTORS AFFECTING PAIN
2. Developmental Stage
EXPERIENCE
 Anatomic, physiologic, &
biochemical elements necessary
for pain transmission are present
in newborns, regardless of their
gestational age

 Children maybe less able to

articulate their experience or
needs related to pain resulting to
under treatment

 Prevalence of pain in the older

population is generally higher due
to both acute & chronic disease
conditions
 FACTORS AFFECTING PAIN
EXPERIENCE
3. Environment & Support People
 Strange environment, like the
hospital, can compound pain
 Person with no support network
may perceive pain as severe
compared to person with
supportive people around
4. Past Pain Experience
 Previous pain experience alter
a client’s sensitivity to pain
 People who personally
experience pain or who have
been exposed to the suffering of
someone close are more
threatened by anticipated pain
than people with no experience
 FACTORS AFFECTING PAIN
5. Meaning of Pain
EXPERIENCE
 Some clients may accept pain
more readily than others,
depending on circumstances &
the client’s interpretation of its
significance

 A client who associates the

pain with a positive outcome
may withstand the pain
amazingly well
 e.g. a woman giving
birth,

 An athlete undergoing knee

surgery to prolong his career
 FACTORS AFFECTING PAIN
EXPERIENCE
6. Anxiety & Stress
 Anxiety often accompanies
pain
 The threat of the unknown and
the inability to control the pain
or the events surrounding it
often augment the pain
perception
 Fatigue reduces a person’s
ability to cope, thereby
increasing pain perception
 When pain interferes with
sleep, fatigue and muscle
tension often result and
increase the pain
 PAIN MANAGEMENT
• Pharmacologic Pain Management 
1. Opioids or Full Agonist Narcotic
Analgesics
 Opioids are morphine-like
compounds that produce
systemic effects including pain
and sedation

 Agonists: substances that

when combined with opioid
receptor produces the drug
effect or desired effect
  e.g. Morphine
sulfate, Meperidine
(Demerol), Codeine,
propoxyphene
(Darvon)
 PAIN MANAGEMENT

 Mechanism of action:
Opioids block the release of
neurotransmitters involved
in the processing of pain

 Routes of delivery: oral,

transdermal, continuous
subcutaneous infusion
(CSCI), IM, intravenous
(PCA), and intraspinal
 PAIN MANAGEMENT
Side Effects of Opioids on diverse systems:
1. CNS: analgesia, difficulty concentrating,
drowsiness, euphoria, sedation, ↑ ICP, N/V,
↑ vagal stimulation of the bowel
2. Immune system: increase release of
histamine, vasodilatation of peripheral
blood vessels, orthostatic hypotension
3. GIT: sustained contraction of smooth
muscles of the gut - constipation, increased
biliary tone, biliary colic,
4. Sensory system: miosis (excessive pupil
constriction)
5. GUT: increase tone of the detrusor muscle
and the bladder, increase tone of the vesical
sphincter
6. Respiratory system: decrease rate and
depth of respiration, decrease cough reflex,
bronchoconstriction
 PAIN MANAGEMENT

2. Mixed Agonist-Antagonist
narcotic analgesics

 Routes and side effects

same as full agonists
 e.g. Nalbuphine
(Nubain), Butorphanol
(Stadol)
 PAIN MANAGEMENT
3. Non-Opioid Analgesics
 Main effect: analgesia

 Pain relief is by inhibiting the

synthesis and release of
prostaglandins at the peripheral
nerve endings at the site of injury

 Antipyretic effect: decrease core

temperature by reducing
sympathetic outflow from the
hypothalamic temperature-
regulating center, promoting
peripheral vasodilatation,
sweating, and heat loss
 e.g. aspirin,
acetaminophen, NSAIDs
 PAIN MANAGEMENT
 Non-opioid analgesics with anti-
inflammatory actions:
 Act by stabilizing lysosomal
membranes and preventing the
release of proteolytic enzymes into
surrounding tissue during
inflammation
 e.g. corticosteroids (hydrocortisone,
prednisone, dexamethasone), NSAIDs
 Non-opioid analgesics with anti-platelet
aggregation:
 Decrease platelet aggregation by
inhibiting the enzyme cyclooxygenase
in platelets thus preventing the
formation of the aggregating
substance thromboxane
 e.g. aspirin, clopidogrel
 PAIN MANAGEMENT
– Side Effects of NSAIDs
 CNS: mental confusion,
drowsiness, dizziness,
headache
 GIT: dyspepsia, N/V, diarrhea,
GI bleeding, GI ulceration,
abdominal pain
 GUT: sodium retention, water
retention, hyperkalemia,
nephrosis
 Integumentary system:
urticaria, skin eruptions
 Hematologic: prolonged
bleeding time,
thrombocytopenia, bleeding
gums
 Sensory: tinnitus, vertigo, visual
changes, reversible hearing loss
 PAIN MANAGEMENT
• Analgesic Adjuvants:
 Enhance the sedation effects
of Opioids & reduce painful
muscle spasm, anxiety, stress,
tension, & depression that
accompany pain

 These drugs add to the action

or effectiveness of
opioid/non-opioid analgesic
 e.g. Amitryptyline
(Elavil), Chlorpromazine
(Thorazine), Diazepam
(Valium), Hydroxine
(Vistaril)
 PAIN MANAGEMENT
WHO analgesic ladder for the
treatment of cancer pain:

– Step 1: non-opioid, (+/-)

adjuvant

– Step 2: opioid for mild to

moderate pain , (+) non-
opioid, (+/-)
adjuvant

– Step 3: opioid for moderate

to severe pain , (+/- ) non-
opioid, (+/-) adjuvant
PAIN MANAGEMENT
 PAIN MANAGEMENT
• Non-pharmacologic Pain
Management
 
1. Cutaneous stimulation:
massage, application of
heat or cold, acupressure,
contra-lateral stimulation
and immobilization

2. TENS, acupuncture,
placebos, cognitive-
behavioral: distraction,
guided imagery, meditation,
biofeedback, hypnosis
PAIN MANAGEMENT
Surgical Management of Pain
 
 Nerve block: destruction of a nerve roots by a
chemical agent
 e.g. phenol, alcohol

 Rhizotomy: surgical destruction of a dorsal nerve

root as they enter the spinal cord

 Neurectomy: surgical excision of a peripheral nerve

 Cordotomy: surgical resection of pain pathways in

the spinal cord
PAIN MANAGEMENT
PAIN MANAGEMENT
Cordotomy
PAIN MANAGEMENT
Rhizotomy
REFERENCES

 Medical – Surgical Nursing 7th edition by Joyce Black

 Brunner & Suddarth’s Medical – Surgical Nursing 14th edition by

Hinkle and Cheever

 Fundamentals of Nursing, 7th edition by Barbara Kozier

 Prentice Hall Reviews and Rationales Series for NCLEX-RN

D’ end,
Tnk u!