Nature, Type, Physiology, Theories, Management, pain scale

1. Guide: Mrs. Shaila Mathew. M.Sc. (N)
Asst. Prof.
B.V.D.U C.O.N SANGLI
Presented by: Mr. Mahesh chand
F.Y.M.Sc.Nursing student.

2. “Nothing Begins And Nothing Ends,
That Is Not Paid With Moan,
For We Are Born In Others Pain,
And Perish In Our Own.”
(English Poet, Francis Thompson)

3. ALL ABOUT PAIN

4.  “An unpleasant, subjective, sensory
and unpleasant emotional experience
associated with potential or actual
damage or described in terms of such
damage”
According to McCaffery and Pasero
1990.

5. “ Whatever the person experiencing it says
it is, existing whenever he or she says it
does”
“Pain is the important aspect of self report,
pain is subjective, the clinician and the
nurse must accept the patient’s report of
pain.
American Pain Society

6.  Pain is much more phenomenon than a
physical sensation.
 Pain is a complex experience involving
physical ,emotional and cognitive
components.
 Pain is a highly subjective and much more
individualized sensation and emotion.
 Pain cannot be objectively measured ,only
the person experiencing it, can tell what and
how is he experiencing it.

7. Pain is classified on the basis of :
ORIGIN.
NATURE.

8. ON BASIS OF ORIGIN
 Cutaneous pain
 Somatic or deep pain.
 Visceral or splanchnic pain

9. Notice that the nociceptors labeled here are located in the EPIDERMIS
and that they are FREE NERVE ENDINGS, or afferent nerve dendrites
that are not encapsulated (as
touch, heat, and pressure
nerve endings are) e.g. tangled
hair pulled during combing
causes pain.
Cutaneous (“In the Skin”) Receptors

10.  Non localized.
 originates in supporting structures.
 Structures such as tendons, ligaments and nerves.
 Pain is in deep structures.(lumbar disc).
 Radiating in nature.
 For e.g. pain travels from lumbar region to the sciatic
nerve.

11.  Sensation of discomfort in the internal organs.
 Less localized.
 Rate of transmission slower than cutaneous pain.
 Transmitted through sympathetic and
parasympathetic fibers of autonomic nervous system.
 E.g. cramps in calf muscle, pain during diarrhea .

12. On basis of nature
 Pain is divided into :
 Acute pain.
 Recurrent acute pain
 Chronic pain
 Chronic acute pain
 Chronic non malignant pain

13.  Sudden onset.
 Short duration
 Associated with a specific condition , injury or tissue
damage.
 E.g. tooth ache, headache , needle stick injury.
 Patient exhibits following sign symptoms .
 Elevated heart rate.
 Increased respiratory rate.
 Dilated pupils
 Above signs resemble anxiety and fear.

14.  Repetitive painful episodes.
 Occurs over a prolong periods of time .
 Pain intervals alternate with painful episodes.
 E.g. arthritis pain.

15.  Definition
 “ A long term persistent ,nearly constant or recurrent
pain, producing significant changes in patients life.
 Chronic pain may last long after pathology is resolved .
 E.g. cervical and lumbar pain.

16.  Pain that lasts 6 months or longer
 Persists long after trauma has healed or in the absence
of trauma
 Common causes of chronic pain
 Physical problems stemming from chronic illness or
internal injuries
 Arthritis: inflammation of the joints
 Damage to peripheral or spinal nerves
 Neuropathic pain
 Can result from accidents, infections, surgery
 Unknown cause (possibly psychological?)
Chronic Pain

17.  It occurs almost daily.
 Continues over long periods , months, or
years.
 Pain may never stop
 E.g. cancer pain.

18.  Psychogenic pain
 Idiopathic pain
 Nociceptive pain
 Neuropathic pain
 Differentiation pain

19.  The specificity theory
 Pattern theory
 Gate control theory

20.  Based on assumption that pain was perceived
following injury.
 A single ,dedicated , hardwired system of afferent
nerves which carried messages from specific pain
receptors in the periphery to the pain center in
brain.

21.  Perception of pain to a pattern of impulses
in the nervous system, rather than to
impulses in dedicated pain pathways.
 The pattern may be temporal or spatial .
 E.g. nerve lesions.

22.  Proposed by Ronald Melzack and Patrick Wall in 1965
 Grew out of observations of WWII veterans and their
injuries
 Concept: pain messages are intercepted by specialized
nerve cells in the spinal cord before they reach brain
 For severe pain that could lead to damage
Nerve “gate” is wide open
 Message travels almost instantaneously
 For mild, weak pain
 Nerve gate sometimes closed
 Filter, block pain messages
Gate Control Theory

24. Nerve fibers that transmit touch
influences gatekeeper cells
Touch stimulate gatekeeper cells
to close “gate”
Decrease pain transmission
Rubbing sore area = relief
Gate Control Theory Cont’d

26.  Nociceptors
 Stimulus Transmission
 Termination
 Modulation

28.  Multiple
 Redundant
 Reciprocal
 Complex

30.  Physiologic dimension
 Behavioral dimension.
 Sensory dimension
 Cognitive dimension
 Affective dimension

31.  The four major steps by which pain is perceived in
neural mechanism.
 Transduction
 Transmission
 Perception
 Modulation

32.  Conversion of a mechanical, thermal or chemical
stimulus into a neuronal action potential.
 The nonious stimuli causes cell damage with the
release of sensitizing chemicals like prostaglandins,
bradykinin, serotonin. Histamines etc…
 These substances activate nociceptors and lead to
generation of action potential.

33.  It is the movement of pain impulses from the site of
transduction to the brain.
 Action potential continues from :
 - Site of injury to spinal cord.
 - spinal cord to brain stem & thalamus.
 -thalamus to cortex for processing.

34.  It occurs when pain is recognized, defined and
responded to by individual experiencing the pain.
 It is the conscious experience of the pain.


35.  It involves the activation of descending pathways, that
exert inhibitory or facilitatory effects on the transmission
of pain.
 The neurons originating in the brain stem descend to the
spinal cord and release substances that inhibit
nociceptive impulses.
 Modulations of pain signals can occur at the level of the
periphery, spinal cord, brain stem and cerebral cortex.
 Descending modulary fibers release chemicals such as
serotonin, norepinephrine, gamma- aminobutric acid
and endogeneous opoid that can inhibit pain
trasmission.

36.  This refers to observable actions used to express or
control pain
 For eg- facial expressions or grimmace may reflect pain
and discomfort.
 Posturing may be used to decrease pain associated
with specific movements

37.  Sensory component of pain is the recognition of
sensation as a painful stimuli.
 Sensory pain elements include
 - pattern
 - area
 - intensity
 - and nature of pain

38.  The various belief, attitudes, memories and meanings
attributed to pain forms the cognitive dimension.
 The meaning of pain according to patient is
particularly important

39.  The various emotional responses to pain experiences
are called as affect responses.
 Affect responses are :
 - anger
 - fear
 - anxiety
 - depression etc
 Negative emotions can impair the patient’s quality of
life

40.  Age.
 Gender
 Previous pain experience
 Drug abuse
 Cultural norms.
 Gerontology.

41.  History of pain.
 Location of pain.
 Intensity of pain.
 Precipitating factors
 Physical examination.

42.  Considered as the 5th vital sign.
 Assessed on pain scales.
 - Number scale
 - Faces scale
 -FLACC scale for neonates & infants.

43.  PAIN ASSESSMENT FOR GROUPS WITH SPECIFIC
NEEDS
AGE PAIN PERCEPTION
PRE TERM INFANTS Have anatomical and functional
ability to process pain by mid to
late gestation; seem to have greater
sensitivity to pain than term infants
or children

44. AGE PAIN PERCEPTION
NEW BORN INFANTS
Response to pain is inborn and
does not require prior learning;
respond to pain with behavioral
cues: facial, crying, body
movement
INFANTS
Infants can metabolize analgesics
and anesthesia effectively; can
increasingly recognize caregiver
as comforter
TODDLERS /
PRESCHOOLERS
Can describe pain, its location
and intensity; respond to pain by
crying, anger, and sadness; may
consider pain a punishment; may
hold someone accountable for
pain and remember experiences
in a certain location such as a

45. AGE PAIN PERCEPTION
SCHOOL AGE CHILDREN
May try to be brave when facing a
painful procedure; may regress to
earlier stage of development;
seek to understand reasons for
pain
ADOLESCENTS
May be slow to acknowledge
pain; may consider showing signs
of pain a weakness; with
persistent pain may regress to
earlier stages of development
ADULTS
Fear of pain may prevent some
adults from seeking care; may
believe admission of pain is a
weakness and inappropriate for age
or sex; may consider pain a
punishment for moral failure

46. AGE PERCEPTION OF PAIN
May have decreased sensations or
perceptions of pain; may consider pain an
inevitable part of aging; chronic pain may
produce anorexia, lethargy, and
depression; may not report pain due to
fear of expense, possible treatment, and
dependency; often describe pain in
nonmedical terms such as "hurt" or
"ache"; may fear addiction to analgesics;
may not want to bother nurses or be a
"bad client"
OLDER
ADULTS

47.  Observational assessment of pain behaviour for people
with severe cognitive impairment, for example, the
Abbey pain scale.
 Pain Assessment Checklist for seniors with limited
ability to communicate.
 Visually impaired patient may benefit from using a
verbal rating scale

49.  A pain scale measures a patient's pain intensity or
other features. Pain scales are based on self-report,
observational (behavioral), or physiological data.
 Examples of pain scales
PAIN
SCALES
Self-report Observational Physiological
Infant —
Premature Infant
Pain Profile;
Neonatal/Infant Pain
Scale
—
Child
Faces Pain Scale -
Revised;Wong-Baker
FACES Pain Rating
Scale; Coloured
Analogue Scale
FLACC (Face Legs
Arms Cry
Consolability Scale);
CHEOPS (Children's
Hospital of Eastern
Ontario Pain Scale)
Comfort

51. Bieri-Modified: 6 cartoon faces
starting from a neutral state and
progressing to tears/crying. Scored
0-10 by the child. Used for children
>3 years.

52.  CRIES: Assesses Crying, Oxygen requirement, Increased
vital signs, facial Expression, Sleep. An observer provides
a score of 0-2 for each parameter based on changes from
baselineThe scale is useful for neonatal postoperative
pain.

53.  NIPS: Neonatal/Infants Pain Scale has been used mostly in
infants less than 1 yr of age. Facial expression, cry, breathing
pattern, arms, legs, and state of arousal are observed for 1
minute intervals before, during, and after a procedure and a
numeric score is assigned to each. A score >3 indicates pain
 CHEOPS: Children’s Hospital of Eastern Ontario Scale.
Intended for children 1-7 yrs old. Assesses cry, facial
expression, verbalization, torso movement, if child touches
affected site, and position of legs. A score >/= 4 signifies pain.

54. FLACC: Face, Legs, Activity, Crying, Consolability
scale has been validated from 2 mo to 7 years.
FLACC uses 0-10 scoring.

55. Numerical rating scale:
Used for adults and children 10 years old
or older
Rating Pain Level
0 No Pain
1 – 3
Mild Pain (nagging, annoying, interfering
little with ADLs)
4 – 6
Moderate Pain (interferes significantly with
ADLs)
7 – 10
Severe Pain (disabling; unable to perform
ADLs)

57. Dolorimeter
 instrument used to measure pain threshold and pain tolerance .
 "the measurement of pain sensitivity for pain intensity.".
 Dolorimeters apply steady pressure, heat, or electrical stimulation
to some area, or move a joint or other body part and determine
what level of heat or pressure or electric current or amount of
movement produces a sensation of pain.

59.  Numerical Pain scale

60.  Descriptive pain scale

61.  Facial expression scale

62.  Intensity
 Location
 Affective Response
 Composite Measures

63.  Impairment
 Functional limitation
 Disability

64.  Influence vs. causation
 Mediation
 Reinforcement
 Resonators
 Pain beliefs

65.  Observation Besides the subjective pain experience, patients can
exhibit predictable behaviors associated with their pain. These
behaviors have the advantage of being readily observable. They
are also reinforced over time--that is, they are learned behaviors.
Most important, they represent potential targets for behavioral
intervention
 Role of learning:One can observe for verbal and nonverbal
behavior associated with the pain experience. Examples of
verbal behavior include complaining of pain, or using other
vocalizations (e.g.., moaning). Nonverbal behavior can be
general, involving movement (e.g.., pacing), position, or more
specific (e.g.., guarding or rubbing a painful joint). Though
different researchers emphasize particular behaviors as "more
valid" indicators of pain, the behavioral expression of pain is
probably very personal.

66. The nervous system’s response to noxious (harmful) stimuli, also known
as “nociception”
 Examples of external stimuli: pricking, cutting, crushing, burning,
freezing
 Examples of internal stimuli: swelling, inflammation, distention
(Note: These are noxious stimuli, but other stimuli must cause these
stimuli—swelling, for instance, does not usually happen on its own)
Several factors contribute to reception of pain
Mechanical stimulation from sharp object
Potassium released from the insides of the damaged cells
Prostaglandins, histamines, and bradykinin from immune cells that
invade area of inflammation
Substance P from nearby nerve fibers
So, What is Pain, Anyway?

67. Attempt to measure one or
more dimensions of the
pain experience.

69. History
Intensity
Quality
Objective
Data
Comorb
id
Side
effects

70.  Ex. Electromyography
“Well, Phil, after years of vague
complaints and imaginary
ailments, we finally have
something to work with.”

71. The WHO 3-Step Ladder for
Pain Management

72. The advantages of the analgesic ladder include:
 Simplicity
 Flexibility
 Safety
 Multimodal analgesia.

73. Pain Tolerance
 Pain tolerance is generally higher in men
than in women, and decreases with age
 In men pain tolerance increases
significantly in repeat testing
 Researchers expect that gender role expectations effect how men
perform on the test
 A woman’s ability to handle pain may also relate to where she is in
her hormone cycles
 In animal studies it was found that females have fewer opioid
receptors than males, which may account for gender differences.

74. Types of analgesic
medications
 Analgesic drugs can be divided
into two groups:
 Non-opioid
- also referred to as non-
narcotic, peripheral, mild &
antipyretic agents
 Opioids
- also called narcotic, central or
strong agents

75. TYPE OF DRUG PHARMACOLOGIC
EFFECTS
ADVERSE EFFECTS
Salicylates:
 Aspirin
 Choline
salicylate
 Diflunisal
 Magnesium
salicylate
 Salsalate
 Sodium
salicylate
 Analgesia:
aspirin is used to reduce
mild to moderate pain
 Antipyretic:
aspirin is used to lower
body temperate & treat
a fever by causing
peripheral vasodilation
and sweating. Does not
reduce body
temperature below
normal (98.6°F)
 GI:
increased GI ulceration
& bleeding
 Bleeding:
prolonged bleeding time
due to aspirin binding to
platelets, reducing
platelet adhesiveness
 Allergy:
symptoms ranging from
mild rash to
anaphylactic shock

76. TYPE OF DRUG PHARMACOLOGICAL EFFECTS
SALICYCLATES
Aspirin
Choline salicylate
Diflunisal
Magnesium
salicylate
Salsalate
Sodium salicylate
Anti-inflammatory:
Reduces pain, redness & swelling of inflamed
areas by inhibition of prostaglandin synthesis,
vasodilation and increasing capillary permeability
Anticoagulation:
Reduces blood clotting by inhibition of
prostaglandin synthesis. Small doses are used to
prevent recurrence of strokes and myocardial
infarctions.
Pharmacokinetics:
Aspirin is rapidly absorbed from the stomach &
small intestine, then widely distributed to most
body tissues. Metabolized in the liver, then
excreted by the kidneys.
Mechanism:
Works by blocking prostaglandin synthesis in the
peripheral nerves & the hypothalamus portion of

77. NSAIDs
Etodolac, Ibuprofen, Ketoprofen, Naprosyn
PHARMACOLOGICAL EFFECTS
 Analgesia:
used to reduce mild to moderate pain.
 Antipyretic:
used to lower body temperate & treat fever by causing
peripheral vasodilation and sweating.
 Anti-inflammatory:
Reduces pain, redness & swelling of inflamed areas by
inhibition of prostaglandin synthesis, vasodilation and
increasing capillary permeability.
 Anticoagulation:
Reduces blood clotting by inhibition of prostaglandin
synthesis. Small doses are used to prevent recurrence of strokes
and myocardial infarctions

78.  Pharmacokinetics:
NSAIDs absorbed from the stomach & small intestine,
then widely distributed to most body tissues.
Metabolized in the liver, then excreted by the kidneys.
 Mechanism:
Works by blocking prostaglandin synthesis in the
peripheral nerves & the hypothalamus portion of the
brain.

79. ADVERSE EFFECTS
 GI:
increased GI ulceration & bleeding
 CNS:
increased drowsiness, sedation, confusion, headache,
vertigo, strange dreams
 Bleeding:
prolonged bleeding time due to NSAIDs binding to
platelets, reducing platelet adhesiveness
 Allergy:
symptoms ranging from mild rash to anaphylactic
shock

80. PHARMACOLOGIC EFFECTS
 Analgesia:
used to reduce mild to moderate pain.
 Antipyretic:
used to lower body temperate & treat a fever by causing
peripheral vasodilation and sweating.
 Pharmacokinetics:
absorbed from the stomach & small intestine, then
distributed to body tissues. Metabolized in the liver, then
excreted by the kidneys.
 Mechanism:
Exact mechanism not known, but believed to work in the
CNS, not the peripheral nervous system.

81.  compound that affects the opioid receptors, thereby
reducing pain sensation.
 preoperatively, to...
 reduce anxiety
 reduce the amount of general anesthesia used
 produce analgesia
 in some cough preparations
 in some strong antidiarrheal treatments

82.  Opioid Agonist
Used to treat moderate to severe pain. Morphine is
considered the prototype.
 Mixed Opioid Agonist
Used to treat moderate to severe pain. Not commonly
used in dentistry. Physical dependence to
Buprenorphine is low and withdrawal is mild.
 Opioid Antagonist
Used to counteract the pharmacologic and reverse
reactions of opioid agonists and mixed agonists and in
the management of overdoses.

83. OPIOID
CLASS
PHARMACOLOGIC EFFECTS
Agonist:
 Codeine
 Hydrocodone
 Hydromorphone
 Meperidine
 Morphine
 Oxycodone
Mixed agonist:
 Buprenorphine
Antagonist:
 Nalbuphine
 Nalorphine
 Naloxone
 Pentazocine
 Sedation:
produces sedation at therapeutic doses
 Euphoria:
may decrease anxiety, increase relaxation and a feeling of
well being
 Dysphoria:
some patients experience feelings of irritability &/or anxiety
 Cough Suppression:
can decrease coughing. Used in some cough medications
 GI Effect:
causes decrease in propulsive contractions & motility, may
lead to constipation
 Respiration:
reduces the rate & depth of respiration, this effect is dose
dependent.

84. Agonist:
 Codeine
 Hydrocodone
 Hydromorphone
 Meperidine
 Morphine
 Oxycodone
Mixed agonist:
 Buprenorphine
Antagonist:
 Nalbuphine
 Nalorphine
 Naloxone
 Pentazocine

85.  Sedation:
produces sedation at therapeutic doses
 Euphoria:
may decrease anxiety, increase relaxation and a
feeling of well being
 Dysphoria:
some patients experience feelings of irritability &/or
anxiety
 Cough Suppression:
can decrease coughing.
 GI Effect:
causes decrease in propulsive contractions & motility,
may lead to constipation
 Respiration:
reduces the rate & depth of respiration, this effect is
dose dependent.

86.  Pharmacokinetics:
Opiods are absorbed when administered
intramuscularly, orally, subcutaneously, intravenously,
nasally, & trans dermally. The onset of action is quick,
with analgesic response occurring 30 to 40 minutes.
Opiods are metabolized in the liver and excreted
through the kidneys. They do cross the placental
barrier.
 Mechanism:
Bind to receptors along the pain-analgesia pathway of
the central nervous system, inhibiting pain sensations

87.  Respiratory Depression And Sedation
 Nausea And Vomiting
 Constipation
 Inadequate Pain Relief
 Other Effects Of Opioids
 allergies
 pruritus
 urinary retention
 tolerance and addiction

88.  Corticosteroids
 Anticonvulsants (carbamazepine, valproate,
clonazepam, phenytoin, and gabapentin)
 Tricyclic antidepressants (amitriptyline, desipramine,
imipramine, nortriptyline)
 Bisphosphonates (pamidronate) and calcitonin
 Neuroleptic medications ( haloperidol, chlorpromazine
or risperidone)
 Anxiolytics ( lorazepam)

89.  Heat
 Cold application
 Massage therapy
 Physical therapy
 Transcutaneous electrical nerve stimulation
(TENS)
 Spinal cord stimulation (SCS)
 Aromatherapy
 Laughter
 Music
 Biofeedback
 Self-hypnosis
 Acupuncture

90. Music and Pain
An hour a day keeps the
doctor away

91. SURGICAL INTERVENTIONS OF PAIN
 CORDOTOMY
A division of certain tracts of the spinal cord .
Cordotomy is performed to interrupt the transmission
of pain.
 RHIZOTOMY
Sensory nerve roots are destroyed where they
enter the spinal cord.

93. ASSESSMENT

95. NURSING DIAGNOSIS
Pain acute
 Self-care deficit
 Anxiety
 Ineffective coping
 Fatigue
 Impaired physical mobility
 Imbalanced nutrition less than body requirements
 Ineffective role performance
 Disturbed sleep pattern
 Sexual dysfunction
 Impaired social interaction

96. PLANNING
 Goals and outcomes
Ex: goal- “the client will achieve a satisfactory level of pain relief
within 24 hours”; possible outcomes-“ reporting that the pain is a 3 or
less on scale, using pain relief measures safely”
 Setting priorities:
Ex: pain related to incisional pain can be reduced by analgesics
but pain related to early labor contractions will only reduced by
relaxation excercises.
 Continuity of care:
A comprehensive plan includes a variety of resources for pain
control which include nurse specialists, doctors of pharmacolology,
physical therapist, occupational therapist.

97.  IMPLEMENTATION
 EVALUATION

98.  1.Cutaneous stimulation.
 2.Acupunture
 3.Acupressure
 4.Massage or rub
 5.Magnets
 6.Biofeedback
 7.Humor

101. Recently published articles available on
Science Direct.
1)Implementation of Health Information
Technology in Routine Care for Fibromyalgia:
Pilot Study
Available online 20 November 2015
Toni Sparks | Jennifer Kawi | Nancy Nivison
Menzel | Kendall Hartley
...

102. 2)Ability of the Pain Recognition and
Treatment (PRT) Protocol to Reduce
Expressions of Pain among
Institutionalized Residents with
Dementia: A Cluster Randomized
Controlled Trial
Available online 12 November 2015
Yi-Heng Chen | Li-Chan Lin

103. 3)Characteristics of Patients with Lower
Extremity Trauma with Improved and
Not Improved Pain During
Hospitalization: A Pilot Study
Available online 3 November 2015
Mari A. Griffioen | Meg Johantgen |
Kathryn Von Rueden | Joel D.
Greenspan | Susan G. Dorsey | Cynthia
L. Renn

104. References
1.Luckmans Core Principles and Practice of Medical
Surgical Nursing by Arlene L, Polashi & Suzanne.1st
Edition page no 262-263,270,1555-1556.
2.Textbook of Medical Surgical Nursing, Joyce N Black,
8TH Edition page no 351-374.
3.Introduction to Medical Surgical Nursing Linton, 4TH
Edition page no 202-223.
4. Medical Surgical Nursing B.T. Basavanthappa, 2nd
Edition page no 76-82
5. Medical Surgical Nursing Phipps 8TH Edition page no
333-358

105. 105