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PAIN

OBJECTIVE 1

DEFINITION

 An unpleasant, subjective sensory and emotional experience

associated with actual or potential tissue damage or described in
terms of such damage.(International Association for the Study of
Pain (IASP)
 Pain is whatever the experiencing person says it is, existing
whenever he says it does (Mc Caffery, 1979)

OBJECTIVE 2

Theories (1091 Kozier & Erb) Gate Control Theory (Melzack &
Wall 199….)

- Small diameter (A-delta or C) peripheral nerve fibers carry signals

of noxious (painful) stimuli to the dorsal horn, where these signals
are modified when they are exposed to the substantia gelatinosa
( the mileu in the nervous system), which may be imbalanced in an
excitatory or inhibitory direction, ion channels on the pre and post
synaptic membranes serve as gates that when open, permit
positively charged ions to rush into the second order neuron,
sparking an electrical impulse and sending pain signals to the
thalamus.
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Peripherally, large diameter (A-beta) nerve fibers which typically send

message of touch warm or cold temperature have an inhibitory effect on
the substantia gelatinosa and may activate descending mechanism that
can lessen the intensity of pain perceived or inhibiting the transmission
of those pain impulses closing the (ion gates.

Higher centers in the brain, especially those associated with affect and
motivation are capable of modifying the substantia gelatinosa which
influences the opening or closing of the gates example if a little girl is
playing with a ball that rolls under the couch and in the process of
relieving it her hand get stuck or pinched (the A-delta fibers are
activated), the anxiety of not knowing what to do, combined with the
negative impact on motivation (not being able to play with the ball),
excites the substantia gelatinosa and facilitates opening the gate
transmitting messages of pinching pain, when her mother comes and
frees her hand and kisses her “booboo” the A-delta fibers are activated
by the light touch, moisture and warmth of the kiss. The girl feels love
and is motivated to please her mother, all of which combine to calm the
substantia gelatinosa and close the gates, inhibiting the transmission of
further pain.

Clinically, nurses can use this model to stop nociceptor firing (treat the
underlying cause), apply topical therapies (e.g. heat, ice, electrical
stimulation or massage) and address the clients mood (e.g reduce fear,
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anxiety and anger) and goals (e.g. client education, anticipatory

guidance)

OBJECTIVE 3

COMPONENTS OF PAIN (GOOGLE)

1. Sensory discriminative: Analyzed in brain according to site,

intensity, duration and nature.
2. Emotional: Pain is associated to a greater or lesser degree with
emotions (e.g. anxiety, aversion or helplessness).
3. Autonomic: Pain leads to reactions of autonomic nervous system
(e.g. increase blood pressure and heart rate or nausea).
4. Motor: Protective reflexes, (e.g. withdrawing the hand) relieve
postures, muscle tension.
5. Cognitive: Pain is classified and evaluated on the basis of previous experience,
observation or information.

OBJECTIVE 4

TYPES OF PAIN

- Acute pain
- Chronic pain
- Cancer pain

Pain maybe described in terms of location, duration, intensity and etiology.

1. ACUTE PAIN: Follows acute injury, disease or surgical intervention, has a rapid onset,
varying in intensity (mild to severe) lasts for a brief time, usually less than 6 months.
National Institute of Health (NIH), 1986. It eventually resolves with or without treatment
after a damaged area heals. Acute pain seriously threatens a clients’ recovery and should
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be one of the priorities in the clients’ care. E.g acute post-operative pain hampers clients’
ability to become active and increase risk of complications from immobility.
Rehabilitation may be delayed, hospitalization may be prolonged if acute pain is not
controlled. All the client focuses on then is pain relief and teaching and motivating client
will be useless. After pain is relieved, the client and health care team can direct full
attention towards recovery.
2. CHRONIC PAIN (nonmalignant): Includes arthritis, low back pain, myofascial pain,
headaches and peripheral neuropathy (Mc Caffery & Pasero, 1999). These pains are due
to non-life threatening causes and frequently the cause is unknown. An injured area may
have healed long ago, yet the pain is ongoing and may not respond to treatment.
Healthcare workers are usually less willing to treat chronic pain as aggressively as acute
pain. The unpredictability of chronic pain frustrates the client frequently leading to
psychological depression. Is a major cause of psychological and physical disability
leading to problems e.g. loss of job, inability to perform simple daily activities, sexual
dysfunction and social isolation from family and friends. The client does not adapt to the
pain, but rather seem to suffer more with time because of physical and mental exhaustion.
Chronic pain creates the insecurity of never knowing how one will feel from day to day.
Symptoms of chronic pain include fatigue, insomnia, anorexia, weight loss, depression,
hopelessness and anger. The life of the person with chronic pain can be tragic, consults
many physicians, and accumulates various medications and interventions. Risk of taking
several medications may result in undesirable side effects. Doctors and other health care
providers can offer interventions in addition to pharmacological remedies, e.g. exercise,
biofeedback that can assist in chronic pain management.

Caring for a client with chronic pain can be challenging, the nurse should not become
frustrated when relief measures fail. Likewise, nurse should not offer false hope for a cure.

3. CANCER PAIN: Is pain that may be due to tumor progression and its related pathology
invasive procedures, toxicities of reaction, infection and physical limitation (Foley,
1979). Not all clients with cancer will experience pain. But for those who do, the Agency
for Health Care Policy and Research (AHCPR) reports that up to 90% can have their pain
managed with relatively simple means. (Jacox et al 1994)
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Cancer pain can be chronic and or acute, nociceptive and neuropathic. It can be at the
actual site of the tumor or distant to the site, called referred pain. A new report by a client
with existing pain needs to be investigated.

OBJECTIVE 5
CAUSES OF PAIN (GOOGLE)
- Chronic pain can be caused by many different factors. Often, condition that accompany
normal aging may affect bones and joints in ways that cause chronic pain.
- Other common causes are nerve damage and injuries that fail to heal properly.

OBJECTIVE 6

NATURE OF PAIN (1282 POTTER & PERRY)

 Pain is much more than a single sensation caused by a specific stimulus. Pain is
subjective and highly individualized. The stimulus for pain can be physical and or mental
in nature, whereby damage may be to actual tissues or to a person’s ego (Mahon 1994).
Pain is tiring and demands a person’s energy. It can interfere with personal relationships
and influences the meaning of life. Pain cannot be objectively measured, such as with an
x-ray film or blood test. Although certain types of pain create predictable signs and
symptoms, often the nurse can only assess pain by relying on the client’s words and
behavior. Only the client knows whether pain is present and what the experience is like.
It is not the responsibility of clients to prove that they are in pain; it is the nurse’s
responsibility to believe them.
 Pain is a protective physiological mechanism. When felt, pain changes how a person
behaves. E.g a person with a sprained ankle avoids bearing full weight on the foot to
prevent further injury. A client with a history of chest pain learns to stop all activity when
pain develops.
Careful techniques must be used to assess for injury such as in the case of a burned hand,
a bruised chest wall. Clients who are unable to feel sensations such as after spinal cord
injury or stroke are unaware of pain in injuries. In these cases the nurse must anticipate
what sources of injuries might have and learn to monitor physiological changes such as
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vital signs. Pain is the leading cause of disability, as the average life span increases, more
people have chronic diseases in which pain is a common symptom.
Nurses care for clients’ with pain on a daily basis. Therefore, just as it is necessary to
monitor vital signs, so, too can pain be considered an important routine assessment along
with temperature, pulse, respiration and blood pressure. In some institutions pain is
treated as fifth vital sign.
OBJECTIVE 7
FACTORS INFLUENCING PERCEPTION OF PAIN (1092-1095 KOZIER & ERB)
 Ethnic and cultural values.
 Developmental stage
 Environment and support people
 Previous pain experience
 Meaning of pain
 Age
 Gender
 Attention
 Anxiety
 Fatigue
 Family and social support
 Coping style
 Religious beliefs

OBJECTIVE 8

PAIN MANAGEMENT (pp1303 – 1318 Potter & Perry)

- The nature of the pain and the extent to which it affects a person’s wellbeing determine
the choice of pain relief interventions.
- Pain therapy requires an individualized approach perhaps more so than any other client
problem. The nurse, client and often times the family must be partners in suing pain
control measures. Nurses administer and monitor interventions ordered by physicians for
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pain relief and independently pain relief measures that compliment those prescribed by a
physician.
- A client remedies are often successful, especially when the client has already had
experience with pain.

Generally, the least invasive or safest therapy should be tried first. If there is doubt about a
nursing therapy, the nurse should consult with a doctor.

HEALTH PROMOTION

Teaching clients about the pain experience reduces anxiety and helps clients achieve a sense of
control. Fears are enhanced if friends have had unpleasant experiences in similar circumstances.
Fear increases the perception of painful stimuli.

Explaining procedures in confident tones conveys a sense that the nurse will care for the client
correctly. The use of holistic health approach assumes a person’s own capacity for healing and
returns responsibility for health back to the individual. (Edelman & Mandle 1998)

Common holistic health approaches include wellness education, regular exercise, and rest,
attention to good hygiene practice and nutrition and management of IPR. When a person
develops pain or other discomforts there are tools the nurse can offer.

Failure of clinicians to assess a client’s pain, accept the findings and treat the report of pain is a
common cause unrelieved pain and suffering.

Through assessment and use of non pharmacological and or pharmacological interventions leads
to improved client outcomes.

 NON PHARMACOLOGICAL PAIN RELIEF INTERVENTION

- Include cognitive behavioral and physical approaches.
- The goals of cognitive behavioral interventions are to change the client’s perception of
pain (ii) to alter pain behavior (iii) to provide clients with a greater sense of control. E.g.
relaxation and guided imagery.
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- Physical agents have the goal of providing comfort, correcting physical dysfunction,
altering, physiological responses and reducing fears associated with pain related
immobility.

GUIDELINES FOR ACUTE PAIN MANAGEMENT (AHEPR, 1992)

Non pharmacological interventions to be appropriate for clients who meet the following criteria

 Find such intervention appealing

 Express anxiety or fear
 May benefit from avoiding or reducing drug therapy
 Are likely to experience and need to cope with a prolonged interval of post-operative
pain.
 Have incomplete pain relief after use of pharmacological interventions.
a. ACUPRESSURE: Application of pressure over a particular points in the body to relieve
discomfort.
- Relaxation and guided imagery. Relaxation measures or techniques include mediation,
yoga, zen, guided imagery and progressive relaxation exercises.
- Guided imagery: client creates an image in the mind and gradually becomes less aware of
pain.
P1307 – example of how a nurse coaches a client into relaxation.
- Distraction: example of activities enjoyed by client that may act as distractions, singing,
praying, describing photos or pictures aloud, listen to music, watching tv and playing
games.
- Music (p1307 Potter & Perry): play an instrument, sing a song, classic music.
- Biofeedback: for muscle tension, migraine headaches.
- Self-hypnosis: is like day dreaming, reduces apprehension and stress, person concentrates
on only one thought.
- Reducing pain perception: one simple way to promote comfort is by removing or
preventing painful stimuli.
- Cutaneous stimulation: (stimulation of skin to relieve pain).Massage, warm bath, ice bag
transcutaneous electrical nerve stimulation (TENS)
 PHARMACOLOGICAL PAIN RELIEF INTERVENTION (P1309 Potter & Perry)
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ACUTE PAIN MANAGEMENT (ACUTE CARE)

- Analgesics
i. Non opioid/non-narcotic and non-steroidal anti-inflammatory drugs (NSAIDS)
ii. Narcotic analgesics or opioids
iii. Adjuvants or coanalgesics
- Patient controlled analgesia
- Local and regional anesthetics
- Epidural analgesia
 Surgical intervention for pain relief. E.g dorsal rhizotomy, chordotomy
 Cancer pain management. Non pharmacological and pharmacological interventions can
be used together.
 Pain clinics and hospices

EVALUATION

The evaluation of pain is one of many nursing responsibilities that require effective critical
thinking. The client’s behavioral responses to pain relief interventions are not always obvious.

- The nurse must be an intense observer and know what responses to anticipate on the basis
of the type of pain, the intervention, the timing of the interventions, the physiological
nature of the injury or disease and the client’s previous responses.
- If the nurse assess that a client continues to have discomfort after an intervention, it may
be necessary to try a different approach. E.g if an analgesic provides only partial relief,
the nurse may add relaxation exercises or guided imagery exercises.
- The nurse may also consult with the doctor about increasing doses or decreasing the
interval between the doses or trying different analgesics.
- The nurse also evaluates the clients’ perception of the effectiveness of the interventions.
The client may help decide the best times to attempt a treatment. In essence, the client is
the best judge of whether an intervention works.
- The nurse also assesses tolerance to therapy and the overall relief obtained. E.g if a nurse
administers an analgesic, side effects from the medication and the client reported pain
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relief must be assessed. Similarly, after timing a client, the nurse should return to
determine whether the client is tolerating the new position and whether pain has subsided.
If an intervention aggravates discomfort, the nurse stops it immediately and seeks an
alternative.
- Time and patience are necessary to maximize the effectiveness of pain management.
- The nurse evaluates the entire pain experienced to determine interventions that are most
effective and times that they should be administered.

 CLIENT EXPECTATIONS
The client, if able is the best resource for evaluating the effectiveness of pain relief
measures. The nurse must continually assess whether the character of the patient’s pain
changes and whether individual interventions are effective.
The family often is another valuable resource, particularly in the case of the client with
cancer who may not be able to express discomfort during the latter stage of terminal
illness.
- The nurse is successful in treating the pain when the client’s expectation of pain relief are
met.
- The nurse uses evaluative criteria in determining the outcome of pain relief interventions,

Effective communication of a clients’ assessment of pain and his or her response to

intervention is facilitated by accurate and thorough documentation. This communication
needs to transpire from nurse to nurse, shift to shift and nurse to other health care providers.

- This is the professional responsibility of the nurse caring for the client to report what has
been effective for managing the client’s pain.
- The client is not responsible for ensuring that this information is accurately transmitted.
- A variety of tools e.g. a pain flow sheet, a diary will help centralize information about
pain management.
- The client expects the nurse to be sensitive to his/her pain and to be diligent in attempts
to manage that pain.
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