This document discusses pain management. It defines pain and describes the types of pain, including referred pain, visceral pain, acute pain and chronic pain. It also discusses factors that affect the perception of pain, such as age, fatigue, genes, and psychological factors. The document outlines the pathophysiology of pain, including nociceptors, the four phases of nociceptor activation, and the pathway of pain transmission. It also discusses theories of pain modulation, like the gate control theory. The final sections cover pain assessment, pharmacological and non-pharmacological management of pain, and sample nursing care plans.

1. PAIN
MANAGEMENT
RAKCON
(BSc (H) Nursing 2nd year)

2. INTRODUCTION
Pain is a signal in your nervous system that something is wrong. It is
an unpleasant feeling, such as prick, tingle, sting, burn or ache.
Pain maybe sharp or dull. It may come & go or may be constant. It is
the most common reason for seeking medical consultation
worldwide.

3. DEFINITION
The International Association for the study of pain defines as "An
unpleasant sensory or emotional experience associated with actual
or potential tissue damage".

4. TYPES OF PAIN
ON THE BASIS OF LOCATION
• Referred Pain – Referred pain is when the pain you
feel in one part of your body is actually caused by
pain or injury in another part of your body.
• Visceral Pain - Visceral pain refers to pain
coming from body organs. Poorly localized, vague
dull pain.

5. TYPES OF PAIN
ON THE BASIS OF DURATION
• Acute Pain – Pain that is directly related to soft tissue damage such as a
sprained ankle or a papercut. Acute pain is of short duration but it gradually
resolves as the injured tissues heal (3 to 6 months).
• Chronic Pain – Persistent pain that lasts weeks to years. The pain maybe
caused by inflammation or dysfunctional nerves.

6. TYPES OF PAIN
ON THE BASIS OF INTENSITY
• Mild Pain – Pain scale reading from 1-3.
• Moderate Pain - Pain scale reading from 4-6.
• Severe Pain - Pain scale reading from 7-10.

7. TYPES OF PAIN
ON THE BASIS OF ETIOLOGY
• Physiological Pain – It is operative & useful response, enabling the individual rapidly &
accurately withdraw from the pain stimulus to avoid/reduce tissue damage.
• Deep Somatic Pain - It is poorly localized & may be associated with sweating & BP change.
It originates in tendons, ligaments, joints, bones & nerves.
• Neuropathic Pain - This pain is caused by damage or injury to the nerves that
transfer information b/w the brain & spinal cord from the skin, muscles & other parts of body.
The pain is usually described as a burning sensation.
• Psychogenic Pain - This pain is physical pain that is caused, increased or prolonged by mental,
emotional, or behavioral factors. Eg:- Headache, Back pain or Stomach pain.

8. FACTORS AFFECTING PERCEPTION OF PAIN
PHYSIOLOGICAL FACTORS
• Age – Children feel more pain because of low tolerance power.
• Fatigue - It heightens the perception of pain. The sense of exhaustion intensifies &
decreases coping abilities.
• Genes - Recent research on animal models may help to determine pain threshold.
• Neurological functions - A clients neurological functions can easily influence pain
experience.

9. SOCIAL FACTORS
• Attention – Focusing one's attention on pain can make the pain worse.
• Past Experience - Each person learn from painful experience. If a person has
repeated experience with some kind of pain, he/she become vigilant of the same pain.
FACTORS AFFECTING PERCEPTION OF PAIN

10. FACTORS AFFECTING PERCEPTION OF PAIN
SPIRITUAL FACTORS
• Spirituality/religiosity has a relevant meaning for patients who suffer from chronic pain & that
this variable influences the strategies to face & handle pain.
PSYCHOLOGICAL FACTORS
• Anxiety, Coping strategies.
CULTURAL FACTORS
• Meaning of pain.
• Ethnicity.

11. HARMFUL EFFECTS OF PAIN
• DEPRESSION – Chronic pain often results in depression.
• FATIGUE - Pain can raise BP, Breathing rate, Heart rate & cause Muscle tension. They can lead to
fatigue & changes in appetite.
• SLEEP ALTERATION – Sleep deprivation affects the pain experience. Eg:- Hyposomnia.
• DISABILITY – Inability to take care of physical activities or impaired ability.
• NEGATIVE EFFECTS ON ENDOCRINE SYSTEM - If pain persists unabated for too long, the hormonal
system is unable to tolerate the stress of pain & hormonal production is decreased.
• EFFECT OF IMMUNITY - Suppression of immune function associated with chronic pain may promote
tumor growth.

12. PATHOPHYSIOLOGY
The processing of noxious stimuli &
resulting perception of pain involve
the peripheral & central nervous
system.

13. NOCICEPTORS
• Nociceptors are 'PAIN RECEPTORS' involved in the
transmission of pain perceptions that respond to
noxious stimuli.
• They are free nerve endings located all over the body,
including the skin, muscles, joints, bones, and
the internal organs.
3 TYPES :-
• MECHANICAL – detects sharp, prickling pain;
• THERMAL or MECHANO THERMAL – detects slow &
burning or cold & sharp pain;
• CHEMICAL – Chemicals released from tissue damage.
Eg:- prostaglandins & substances or from external
chemicals. Ex:- Topical Capsaicin.

14. 4 PHASES OF NOCICEPTORS
• TRANSDUCTION – Pain is caused by thermal, mechanical or chemical stimulation.
The energy of these stimuli gets converted into electrical energy. This energy
conversion is called transduction.
• TRANSMISSION - These electrical impulses are then sent to dorsal horn of spinal
cord & then along the sensory tract into the brain.
• PERCEPTION - It is the point at which the person is aware of pain.
• MODULATION – It is the process of damping or amplifying these pain related neural
signals.

15. PATHWAY OF PAIN
• Tissue injury.
• Release of Prostaglandins, Bradykinins, leukotrienes from the injured tissue.
• Activation of A & C delta fibres (1st order neurons).
• 2nd order neurons arising from the dorsal horn cells of spinal cord.
• Signal is transmitted via brain stem to 3rd order neurons in the thalamus.
• From the thalamus it is relayed in the somatosensory cortex where it
is perceived as pain.

17. GATE CONTROL
THEORY
• The theory that the spinal cord contains
a neurological 'gate' that blocks pain
signals or allow them to pass on the
brain.
• The 'gate' is opened by the activity of
pain signals travelling up
small nerve fibres & is closed by large
fibres or by information coming from
brain.
• The gate control theory of pain
asserts that non painful input closes
the nerve 'gates' to painful input,
which prevents pain
sensation from travelling to the brain.

18. ASSESSMENT OF PAIN
IT IS IMPORTANT FOR THE NURSE TO OBTAIN ACCURATE
INFORMATION FROM THE PATIENT CONCERNING THE PAIN, ITS
CHARACTERISTICS & DESCRIPTION OF PAIN.

19. CHARACTERISTICS OF PAIN
• INTENSITY OF PAIN – Ranges from none to mild discomfort to severe.
• TIMING - Sometimes etiology can be determined by knowing the time aspects.
• LOCATION – The location is best determined by having the patient point to the area of
body involved.
• QUALITY - The nurse asks the patient to describe the pain in his own words.
• PERSONAL MEETING - It is important to ask how the pain has affected the person's life.
• AGGRAVATING & ALLEVIATING BEHAVIORS – The nurse asks if anything making the pain more
worse & what it makes better & asks specially about the relation b/w activity & pain.
• PAIN BEHAVOIRS - Sometimes pain may be associated with verbal & non-verbal behaviors.

20. INTRUMENTS FOR ASSESSING PAIN
FACE PAIN SCALE
• This instrument has seven faces depicting expressions that range from contented to
obvious distress. The patient is asked to point to the dace that most closely resembles
the pain intensity felt.

21. INSTRUMENTS FOR ASSESSING PAIN
Numerical rating scales
The 0 to 10 apon scale is commonly and successfully used with
hospitalized and nursing home patient ,even those with mild to
moderate dementia . The scale is often displayed as a line numbered
from zero to ten.

22. Categorical scales :
Use words as the primary communication
tool and may also incorporate numbers ,
colors , or relative location to
communicate pain.

23. INSTRUMENTS FOR ASSESSING PAIN
VISUAL ANALOGUE SCALE (VAS)
• Visual analogue scales are useful in assessing the intensity of pain. One version of the
scale includes a horizontal 0-100 mm line, with ends indicating extreme of pain.

24. MANAGEMENT OF PAIN
PHARMALOGICAL MANAGEMENT OF PAIN
ANALGESICS :- Drugs which relief or reduce pain such as mild to moderate pain.
2 types :- Opioids & Non-opioids
(A) OPIOIDS – Also knowns as narcotic. Act centrally & cause addiction or compound that binds to
opioids receptors. Ex:- Morphine, tramadol.
Classified into 3 ->
(a) Opioids Agonist (b) Mixed Opioid Agonist (c) Opioid Antagonist.
(B) NON-OPIOIDS – Also known as Non-narcotic. Act peripherally & do not cause addiction. Ex:-
Paracetamol.

25. MANAGEMENT OF PAIN
NON-PHARMACOLOGICAL MANAGEMENT OF PAIN
1. Massage – It is a process of rubbing & kneading parts of the body, especially joints &
muscles with hands to relieve pain & decrease tension.
2. Positioning – It helps to prevent further complications reduces the risk for developing
injuries, prevents developing bed ulcers & most importantly reduce alleviate pain.
3. Hot & Cold therapy – H.C.T has been used for many decades and centuries to relieve
pain which includes muscle pain, joint pain, extremities pain, back pain & arthritis.

26. MANAGEMENT OF PAIN
• Acupuncture – It works by putting the needle in specific region of the body,
which stimulates the nerves. Each needle will cause no discomfort to little discomfort to
the patients, but it will produce a small injury at the insertion area which will stimulate
the body & the immune system to increase circulation, wound healing, pain modulation
& pain analgesia.

27. MANAGEMENT OF PAIN
• TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) - TENS is an electrical
device used to treat pain. It consists of battery-powered unit & has 2-4 leads
connected to sticky pads, which are positioned over the skin to cover or surround
the painful area.
• PROGRESSIVE MUSCLE RELAXATION – Progressive Muscle relaxation is a technique
where the participant involved tightens & relaxes different muscle groups
throughout the body in a progressive manner that would provoke a sense of
relaxation & comfort.

28. PSYCHOLOGICAL INTERVENTIONS
• COGNITIVE BEHAVIOR THERAPY (CBT) -> CBT for pain demonstrates small to
medium effects on pain & functioning compared to standard medical care for pain.
• MINDFULNESS-BASED STRESS REDUCTION -> This approach aims to disconnect the
link b/w sensory elements of pain from the emotional & evaluative elements and
enhances uncoupled awareness of both somatic & psychological sensations.

29. SURGICAL MANAGEMENT OF PAIN
1.NEUROSURGERY
2.NEUROCTOMY
3.CORDOTOMY
4.RHIZOTOMY

30. NURSING CARE PLAN
(1) NURSING DIAGNOSIS – Acute pain related to Inflammatory response of body cells to disease conditions as evidenced by
tachycardia, pyrexia & facial expressions.
GOAL – To prevent complications of pain or inflammation.
NURSING INTERVENTIONS :- Provide assessment to the patient & take vital signs & assess by pain scale.
- Provide comfortable position to the patient as semi fowler position and provide cool & calm environment to the patient.
- Windows & doors are open & air ventilation by fan are provided.
- If fever found consistent provide cold sponge to the patient.
- Provide analgesic medications as prescribed by physician to lower pain & inflammatory symptoms.
- Provide guided imagination therapy to the patient to lower pain level.
- Assess patient pain status, conditions of patient & give assurance to patient.

31. NURSING CARE PLAN
(2) NURSING DIAGNOSIS – Risk for volume deficient related to dehydration due to pain & hyperthermia as evidenced by
skin turgidity & dryness of oral mucosa.
GOAL – To minimize patient's pain & temperature & prevent from dehydration.
NURSING INTERVENTIONS -
- Monitor I/O chart of pt. & make pt. Comfortable by providing comfortable position & calm, ventilated environment to
pt.
- Provide IV fluid therapy, as prescribed.
- Assess for vital signs & pain; regularly.
- Provide plenty of oral intakes & plain liquid diet to pt.
- Provide soothing jelly to be applied over lips.

32. NURSING CARE PLAN
(3) NURSING DIAGNOSIS – Alternation of comfort related to uneasiness due to pain arising from medical problems or
superficial injury as evidenced by tissue swelling & inflammatory sign & pain scale score 8 out of 10.
GOAL – To lower pt.'s pain level from 8 to 4.
NURSING INTERVENTIONS -
- Assessment should be done to pt. for detection of reasons of uneasiness & assess pain scale every 2 hours.
- Provide air conditioning & cool, calm, noise free environment & atmosphere.
- Provide Anti-inflammatory & analgesics to pt., as prescribed by physician.
- Relaxation therapy should be given.
- Deep breathing exercises should be followed.
- Provide cold application to inflammatory area.

33. SUMMARY
• WE HAVE LAERNED WHAT IS PAIN, IT's TYPES, LOCATION,
PHYSIOLOGY, EFFECTS & VARIOUS NURSING MANAGEMENT TO
BE DONE IN DIFFERENT SITUATIONS.

34. CONCLUSION
• To conclude, I would like to say that pain relief should not be seen as
someone else's responsibility, nor just dismissed. Freedom from pain is
important to pts.
• Pain is most common reason for seeking medical care. It is also a common
reason why people turn to complementary health approaches.
• Nurses should have skills and knowledge not just in assessing the pain but
also in managing it as well.

35. BIBLIOGRAPHY
• BRUNNER & SUDDARTH's Textbook of Medical Surgical Nursing 13th edition.
• Wikipedia.
• Https/www.researchgate.net/pain