Pain .pptx

PAIN
MRS.P.HEPZIBAH ARULMANI.,B.Sc(N)
TUTOR,
SRM Trichy College of Nursing

PAIN
DEFINITION:
Pain is an unpleasant sensory and emotional.
Experience associated with actual or potential tissue
damage, or described in terms of such damage.

NATURE OF PAIN
• Pain is subjective and highly individualized.
• Its stimulus is physical and/or mental in nature.
• It interferes with personal relationships and
influences the meaning of life.
• Only the patient knows whether pain is present and
how the experience feels.
• May not be directly proportional to amount of tissue
injury.

SIGNS AND SYMPTOMS OF PAIN
• Increased respiratory rate
• Increased heart rate
• Peripheral vasoconstriction
• Pallor
• Elevated B.P.
• Increased Blood Glucose Levels

Cont;
• Diaphoresis
• Dilated pupils
• Moaning
• Guarding the area
• Restlessness
• Irritability

TYPES OF PAIN
PAIN
BASED ON
DURATION
BASED ON
LOCATION
BASED ON
INTENSITY
BASED ON
ETIOLOGY

pain
acute chronic
Chronic non
cancer
pain
Chronic cancer pain
Chronic episodic pain
Based on duration
TYPES OF PAIN

ACUTE PAIN
• When pain lasts only through the expected
recovery period, it is described as acute pain.
• Acute pain is protective, has an identifiable cause,
is of short duration, and has limited tissue damage
and emotional response.
• It eventually resolves, with or without treatment, after
an injured area heals.

Cont;
• Complete pain relief is not always achievable,
but reducing pain to a tolerable level is
realistic.
• Unrelieved acute pain can progress to chronic
pain.

CHRONIC PAIN
• Chronic pain is the pain that lasts longer than 6
months and is constant or recurring with a mild-to-
severe intensity.
• It does not always have an identifiable cause and
leads to great personal suffering.
• Examples: arthritic pain, head ache, peripheral
neuropathy.

Cont;
• The possible unknown cause of chronic pain,
combined with the unrelenting nature and uncertainty
of its duration, frustrates a patient, frequently leading
to psychological depression and even suicide.
• Associated symptoms of chronic pain include
fatigue, insomnia, anorexia, weight loss,
hopelessness, and anger.

Cont;
CHRONIC PAIN MAY BE :
 Chronic non cancer pain
 Chronic cancer pain
 Chronic episodic pain.

Chronic non cancer pain:
The chronic pain that resulted due to non cancer
disease conditions is termed as chronic non cancer pain.
Chronic cancer pain:
Cancer pain is the pain that is caused by tumor
progression and related pathological processes, invasive
procedures, toxicities of treatment, infection, and
physical limitations. Approximately 70% to 90% of
patients with advanced cancer experience pain.

Cont;
Chronic episodic pain:
• Pain that occurs sporadically over an extended
period of time is episodic pain.
• Pain episodes last for hours, days, or weeks.
Examples are migraine headaches.

CLASSIFICATION BASED ON LOCATION
This is based on the site at which the pain is
located. E.g.:
 Headache
 Back pain
 Joint pain
 Stomach pain - Cont;

Cont;
 Cardiac pain
• Referred pain: pain due to problems in other areas
manifest in different body part.
• For example, cardiac pain may be felt in the
shoulder or left arm, with or without chest pain.

Based on intensity:
Based on
Intensity
Mild pain Moderate pain Severe pain

BASED ON INTENSITY
Mild pain:
Pain scale reading from 1 to 3 is considered as
mild pain
Moderate pain:
moderate pain
Severe pain:
severe pain

CLASSIFICATION OF PAIN BASED ON ETIOLOGY
Nociceptive pain:
• Nociceptive pain is experienced when an intact,
properly functioning nervous system sends signals
that tissues are damaged, requiring attention and
proper care.
• For example, the pain experienced following a cut or
broken bone alerts the person to avoid further
damage until it is properly healed. - Cont;

Cont;
• Once stabilized or healed, the pain goes away
Somatic pain:
• This is the pain that is originating from the skin,
muscles, bone, or connective tissue.
• The sharp sensation of a paper cut or aching of a
sprained ankle are common examples of somatic
pain.

Visceral pain:
• Visceral pain is pain that results from the activation
of nociceptors of the thoracic, pelvic, or abdominal
viscera (organs).
• Characterized by cramping, throbbing, pressing, or
aching qualities.
• Examples: labor pain, angina pectoris, or irritable
bowel.

Neuropathic pain:
• Neuropathic pain is associated with damaged or
malfunctioning nerves due to illness , injury, or
undetermined reasons.
Examples:
• Diabetic peripheral neuropathy
• Phantom limb pain
• Spinal cord injury pain - Cont;

• It is usually chronic.
• It is described as burning, “electric-shock,”
and/or tingling, dull, and aching.
• Neuropathic pain tends to be difficult to treat.
• Neuropathic pain is of two types based on which
parts of the nervous system is damaged.
• Peripheral Neuropathic Pain
• Central Neuropathic Pain.

Cont;
Peripheral neuropathic pain:
• Due to damage to peripheral nervous system
• E.g.: phantom limb pain
Central neuropathic pain:
• Results from malfunctioning nerves in the central
nervous system (CNS).
• E.g.: spinal cord injury pain,
• Post-stroke pain.

PHYSIOLOGY OF PAIN
The transmission and perception of pain are complex
processes. The central nervous system’s structure
constantly changes, and the constituency and function of
its chemical mediators are not well understood.
The extent to which pain is perceived depends on the
interaction between the body’s analgesia system, the
nervous system’s transmission, and the mind’s
interpretation of stimuli and its meaning.

Nociception:
• The peripheral nervous system includes primary
sensory neurons specialized to detect mechanical,
thermal or chemical conditions associated with potential
tissue damage.
• The signals, when these nociceptors are activated,
must be transduced and transmitted to the spine and
brain where signals are modified before they are
ultimately understood or“felt”. -Cont;

• 4 physiologic processed involved ( Transduction,
Transmission, Perception, and Modulation).
Transduction:
• During this stage, noxious stimuli ( with potential to
injure tissue) trigger the release of biochemical mediators
(prostaglandins, bradykinin, serotonin, histamine,
substance P which sensitize nociceptors. Noxious or
painful stimulation also causes movement of ions across
cell membranes, which excites nociceptors.

Cont;
• Pain medication can work during this phase by
blocking the production of prostaglandin(e.g.,
ibuprofen or aspirin) or by decreasing the movements
of ions across the cell membrane (e.g., local
anesthetic) . Topical analgesic capsaicin ( Zostrix)
depletes the accumulation of substance P and blocks
transduction.

Transmission:
• Includes 3 segments.
• First segment- Pain impulse travels from the peripheral
nerve fibers to the spinal cord.
• Second segment- Transmission from the spinal cord
and ascension via spinothalamic tracts, to the brain stem
and thalamus.
• Third segment- Involves transmission of signals
between thalamus to the somatic sensory cortex
where pain perception occurs.

Cont;
• Pain control can take place during this second
process. Opioids (narcotic analgesics) block the release
of neurotransmitters, particularly substance P, which
stops the pain at the spinal level.
• Capsaicin may also deplete substance P that could
inhibit the transmission of pain signals.

Cont;
Modulation:
Often described as “descending System” Occurs
when neurons in the thalamus and brain stem send
signals down to the dorsal horn of the spinal cord. These
descending fibers release substances such as endogenous
opioids, serotonin, and nor epinephrine which can
inhibit the ascending noxious(painful) impulses in the
dorsal horn.

Cont;
Perception:
Is when the client becomes conscious of the pain.
Pain perception is the sum of complex activities in
the Central Nervous System that may shape the
character and intensity of pain perceived and ascribe
meaning to the pain.

GATE CONTROL THEORY
• Gate control theory was described by Melzack and
Wall in 1965.
• This theory explains about a pain-modulating system in
which a neural gate present in the spinal cord can open
and close thereby modulating the perception of pain.
• The gate control theory suggests that psychological
factors play a role in the perception of pain. – Cont;

• It also suggests that physical pain is not a direct result
of activation of pain receptor neurons, but rather its
perception is modulated by interaction between
different neurons.
Centers in CNS:
The three systems located in the spinal cord act to
influence perception of pain
 The substantia gelatinosa in the dorsal horn.

Cont;
 The dorsal column fibers
 The central transmission cells.
• The dorsal horn is responsible for passing on
information which can be interpreted as pain. This
area is referred to as the 'gate' as it prevents the brain
from receiving too much information too quickly.
DORSAL HORN of spinal cord grey matter.

Cont;
Neurons involved in pain conduction
 Primary:
( From the ‘nociceptors’) to the dorsal horn of the
spinal cord.
 Secondary:
From the dorsal horn to the thalamus.
 Tertiary:
From thalamus to cortex and awareness.

RESPONSES TO PAIN
• The body’s response to pain has both physiologic
and psychological aspects. The sympathetic
Nervous System responds, resulting in fight-or-
flight response, with noticeable increase in pulse
and blood pressure. The person may hold his breath
or have short, shallow breathing.
- Cont;

Cont;
• Pain interferes with sleep, affects appetite and
lowers quality of life for clients and their family
members.
• Natural response is to stop activity, tense muscles,
and withdraw from the pain-provoking activities
which reduced mobility that may produce muscle
atrophy and painful spasm.

Cont;
• Uncontrolled pain impairs immune function, which
slows healing and increase susceptibility to infections
and dermal ulcers.
• This short, shallow breathing that accompanies pain
produces atelectasis , lowers circulating oxygen and
increase cardiac load.

FACTORS INFLUENCING PAIN
 Developmental factors
 Physiological factors
Fatigue, genes, neurological functioning
 Social factors
Attention, previous experience, family and
social support, spiritual factors.

Cont;
 Psychological factors
Anxiety, coping style.
 Cultural factors

Developmental factors :
Age:
• Age influences pain, particularly in infants and older
adults.
• Young children have trouble understanding pain
and the procedures that cause it.
• If they have not developed full vocabularies, they
have difficulty verbally describing and expressing
pain to parents or caregivers.

Cont;
• With the developmental factors in mind
assessment should be done for pain in
children.
• Older adults have a greater likelihood of developing
pathological conditions, which are accompanied by
pain.

Physiological Factors:
Fatigue.
• Fatigue heightens the perception of pain and
decreases coping abilities.
• If it occurs along with sleeplessness, the
perception of pain is even greater.
• Pain is often experienced less after a restful sleep
than at the end of a long day.

Genes.
• Research on healthy human subjects suggests that
genetic information passed on by parents possibly
increases or decreases the person’s sensitivity to pain
and determines pain threshold or pain tolerance.
Neurological Function.
• Any factor that interrupts or influences normal pain
reception or perception (e.g., spinal cord injury) affects
the patient’s awareness of and response to pain.

Cont;
Social Factors:
Attention.
The degree to which a patient focuses attention on
pain influences pain perception. Increased attention is
associated with increased pain, whereas distraction is
associated with a diminished pain response

Cont;
Previous Experience.
• If a person repeatedly experiences the same type of
pain that was relieved successfully in the past, the
patient finds it easier to interpret the pain sensation.
• If a person is having worst previous experience he
may experience much pain.

Cont;
Family and Social Support:
• The presence of family or friends can often make the
pain experience less stressful.
• The presence of parents is especially important for
children experiencing pain.

Cont;
Spiritual Factors:
• Spiritual questions include “Why has this
happened to me?” “Why am I suffering?” Spiritual
pain goes beyond what we can see. “Why has God
done this to me?” “Is this suffering teaching me
something?”
• If the person is experiencing like this feelings it
makes much painful

Cont;
Psychological Factors:
Anxiety:
• Anxiety often increases the perception of pain,
and pain causes feelings of anxiety.
• Critically ill or injured patients who perceive a lack
of control over their environment and care have high
anxiety levels. This anxiety leads to severe pain.

Cont;
Coping Style.
• Persons with better coping levels perceives less
pain than the person with lower coping levels.

Cont;
Cultural Factors:
• Cultural beliefs and values affect how
individuals cope with pain.
• Individuals learn what is expected and accepted
by their culture, including how to react to pain.
• Culture affects pain expression. Some cultures believe
that it is natural to be demonstrative about pain.
Others tend to be more introverted.

PAIN ASSESSMENT AND MANAGEMENT
• P Precipitating/Alleviating Factors:
– What causes the pain?What aggravates it?
Has medication or treatment worked in the
past?
• Q Quality of Pain:
– Ask the patient to describe the pain using
words like “sharp”, dull, stabbing, burning”

Cont;
• R Radiation
– Does pain exist in one location or radiate to other
areas?
• S Severity
– Have patient use a descriptive, numeric or visual
scale to rate the severity of pain.
• T Timing
– Is the pain constant or intermittent, when did it
begin.

Pain assessment:
Assess for objective signs of pain:
 Facial expressions:
Facial grimacing (a facial expression that usually
suggests disgust or pain), frowning (facial
expression in which the eyebrows are brought together,
and the forehead is wrinkled), sad face.
 Vocalizations : Crying, moaning
 Body movements : Guarding , resistance to moving

Pain Assessment Tools:
These are various tools that are designed to
assess the level of pain. The most commonly used
tools are:
 Verbal Rating Scale
 Numeric Rating Scale
 Wong Baker’s Faces Pain Scale

WONG BAKER’S FACES PAIN SCALE

Cont;
Management Of Pain:
Pain can be managed through:
 Pharmacological interventions
 Non pharmacological interventions

Pharmacological Therapy:
• Pharmacological therapy is given by using
analgesics.
• The analgesics may be non opioids (NSAIDS) or
opioids or adjuvant
• NSAIDS: Non steroidal anti inflammatory
drugs
• Opioids: Opioids are medications that relieve pain.
Derived from opium.

Cont;
Pharmacological interventions:
Adjuvants :
Adjuvants are drugs originally developed to treat
conditions other than pain but also have analgesic
properties.

PHARMACOLOGICAL INTERVENTIONS
WHO Pain Management Ladder
Step1:
NSAIDS+
Adjuvants
Step2:
NSAIDS + Mild
Opioids +
Adjuvants
Step 3:
Strong opioids +
NSAIDS +
adjuvants

WHO Pain Management Ladder
WHO steps
STEP2
STEP3
STEP1
Pain scale reading
1-3
4-6
7-10

Pharmacological Interventions:
• Nonopioids:
– Used alone or in conjunction with opioids for mild
to moderate pain
– E.g. NSAIDS- Paracetamol, aspirin.
• Opioids:
– For moderate or severe pain
– E.g. morphine, codeine

Cont;
• Adjuvants:
– Used for analgesic reasons and for sedation and
reducing anxiety.
– E.g.
• Tri-cyclic antidepressants
• Anti epileptics
• Cortico steroids

Cont;
Patient-Controlled Analgesia:
• A drug delivery system called patient- controlled
analgesia (PCA) is a safe method for pain
management that many patients prefer.
• It is a drug delivery system that allows patients to
self-administer opioids (morphine and fentanyl)
with minimal risk of overdose.

Cont;
• PCA infusion pumps are portable and
computerized and contain a chamber for a
syringe or bag that delivers a small, preset dose
of opioid.
• To receive a demand dose, the patient pushes a
button attached to the PCA device.

TopicalAnalgesics:
• Topical analgesics are applied over the patients
skin either in the form of topical ointments or
transdermal patches.
• The patches will be sticking to the skin and delivers a
small amount of dosage continuously.

LocalAnesthesia:
• Local anesthesia is the local infiltration of an anesthetic
medication to induce loss of sensation to a body part.
• Health care providers often use local anesthesia during
brief surgical procedures such as removal of a skin lesion
or suturing a wound by applying local anesthetics
topically on skin to anesthetize a body part.
• The drugs produce temporary loss of sensation by
inhibiting nerve conduction.

Cont;
Regional Anesthesia:
• Regional anesthesia is the injection of a local
anesthetic to block a group of sensory nerve fibers.
• Examples of regional anesthesia include
epidural anesthesia and spinal anesthesia.

Cont;
Non-Pharmacological Pain Management:
• For many individuals, the use of non-
pharmacologic methods enhances pain relief.
• These nonpharmacological strategies are often used
in combination with medication.
Non-Pharmacological therapies:

Cont;
The methods are:
 Heat & Cold applications
 Meditation
 Distraction
 Imagery
 TENS application
 Music therapy

Cont;
 Massage
 Yoga
 Acupuncture
 Herbal therapy- Garlic, Echinacea, Ginseng.

Cont;
Superficial Heat:
Superficial heat can produce heating effects at a
depth limited to between 1 cm and 2 cm. Deeper
tissues are generally not heated owing to the thermal
insulation of subcutaneous fat and the increased
cutaneous blood flow that dissipates heat. It has been
found to be helpful in diminishing pain and
decreasing local muscle spasm. - Cont;

Superficial heat, such as the hydrocollator pack, should
be used as an adjunct to facilitate an active exercise
program. It is most often used during the acute phases of
treatment when the reduction of pain and inflammation
are the primary goals.
Cryotherapy:
Cryotherapy can be achieved through the use of ice,
ice packs, or continuously via adjustable cuffs attached to
cold water dispensers. -Cont;

• Intramuscular temperatures can be reduced by
between 3 °C and 7 °C, which functions to reduce
local metabolism, inflammation, and pain.
• Cryotherapy works by decreasing nerve conduction
velocity, termed cold-induced neuropraxia, along pain
fibers with a reduction of the muscle spindle activity
responsible for mediating local muscle tone.
- Cont;

• It is usually most effective in the acute phase of
treatment, though it can be used by patients after their
physical therapy sessions or their home exercise
program to reduce pain and the inflammatory response.
Exercise:
Correction of posture may be the simplest technique to
relieve symptoms in patients with nonspecific neck or low
back pain, though it is extremely difficult to change
habits. - Cont;

• The physician should instruct patients to assume their
worst postural “slump position” with forward protrusion
of the head, flexion of the neck, rounding of the
shoulders, and increased thoracic kyphosis and reversed
lumbar lordosis while sitting.
• Next, the physician should instruct patients to correct
these postural abnormalities through retraction and
extension of the head, retraction of the shoulders,
extension of the thoracic spine, and return of the lumbar
lordosis.

Bed Rest:
The use of prolonged bed rest in the treatment of patients
with neck and low back pain and associated disorders is
without any significant scientific merit.
Bed rest supports immobilization with its deleterious
effects on bone, connective tissue, muscle, and
psychosocial well-being.
For severe radicular symptoms, limited bed rest of less
than 48 hours may be beneficial to allow for reduction of
significant muscle spasm brought on with upright activity.

Cont;
Patients should be instructed to avoid resting with the
head in a hyper flexed or extended position. The proactive
approach emphasizes activity modification as opposed to
bed rest and immobilization.
Transcutaneous Electrical Nerve Stimulation:
Transcutaneous electrical nerve stimulation (TENS)
has been used to treat patients with various pain
conditions, including neck and low back pain.

Success may be dictated by many factors, including electrode
placement, chronicity of the problem, and previous modes of
treatment.
TENS is generally used in chronic pain conditions and not
indicated in the initial management of acute cervical or lumbar
spine pain.
Overall, research is limited in regard to the isolated use of
TENS in the treatment of patients with acute cervical and
lumbar spine disorders, though it has been used in combination
with ROM exercises, spray and stretch, and myofascial release.

Acupuncture:
Traditional Chinese acupuncture involves the insertion of
extremely fine needles into the skin at specific
“acupoints”.
This may relive pain by releasing endrophins,the body’s
natural pain killing chemicals, and by affecting the part of
the brain that governs serotonin, a brain chemical involved
with mood.
Acupuncture is generally quite safe, and the complication
rate appears to be quite low.

Massage :
Massage, which is cutaneous stimulation of the body
promotes comfort through muscle relaxation.
Distraction:
It helps to relive both acute & chronic pain.
Distraction techniques may be watching TV or listening
to music.

Cont;
Manipulation and Mobilization:
 Manipulative treatment is commonly used in the
treatment of patients with neck pain and associated
disorders.
 Many different types of manual treatment exist,
including soft tissue myofascial release, muscle
energy/contract-relax, and high-velocity low-
amplitude manipulation.

 Soft tissue myofascial release may include various
techniques, including effleurage, petrissage, friction,
and tapotement. It has been shown to improve
flexibility, decrease the perception of pain, and
decrease the levels of stress hormones.
Traction:
 Cervical traction is a therapeutic modality that can be
administered with the patient in the supine or seated
position. - Cont;

 Traction may reduce neck pain and works through a
number of mechanisms including passive stretching of
myofascial elements, gapping of facet joints, improving
neural foraminal opening, and reducing cervical disc
herniation.
 It has been found to reduce radicular symptoms in
individuals with confirmed radiculopathy and localized
neck pain in individuals with cervicogenic pain and
spondylosis.

Cont;
 Cervical traction may be initiated during physical
therapy with the patient properly instructed in home
use.
 It is not a stand-alone treatment modality and should
be done in conjunction with range-of- motion (ROM)
exercises, appropriate strengthening, and correction of
postural issues.

Cont;
Therapeutic modalities:
 Should be considered an adjunct to an active treatment
program in the management of acute low back pain.
They should never be used as the sole method of
treatment.
 The prescribing physician should first be aware of all
indications and contraindications for a prescribed
modality and have a clear understanding of each
modality and its level of tissue penetration.

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