Definition of Pain - NURSING LIJAN

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 14th ed. Chapter 12. (p 225)

Unpleasant sensory and emotional experience

resulting from actual or potential tissue damage.

This definition describes pain as a complex

phenomenon that can impact a person’s psychosocial,

emotional, and physical functioning.

Pain “whatever the experiencing person says it is,

existing whenever she/he says it does”. McCaffery, 1968

It is a subjective experience.

Definition of Pain

2 DR. AHMAD AQEL

Effects of Pain

• Affect every age, sex, race & socioeconomic class

• The primary reason people seek health care

• Unrelieved pain can affect every system in the body

– This is particularly harmful in patients whose health

is already compromised by age, illness, or injury.

3 DR. AHMAD AQEL

Effects of Pain

4 DR. AHMAD AQEL

Effects of Pain

5 DR. AHMAD AQEL

I. Acute pain

– Recent onset & associated with a specific injury

– have a relatively short duration, resolve with

normal healing.

– Decreases as healing occurs.

– example of acute pain: tissue damage as a result

of surgery, trauma, or burns produces

Types and categories of Pain

6 DR. AHMAD AQEL

II. Chronic pain

– either due to cancer or noncancer origin

– may resolve within months or persist throughout the

course of a person’s life.

– Constant or intermittent

– persists beyond the expected healing time & seldom be

attributed to a specific cause or injury.

– Poorly defined onset, Difficult to treat (unclear cause).

– examples: peripheral neuropathy from diabetes, back

or neck pain after injury, and osteoarthritis

Types and categories of Pain

7 DR. AHMAD AQEL

• Some conditions can produce both acute and chronic pain.

– For example, some patients with cancer have continuous chronic pain and also experience acute exacerbations of pain periodically—called breakthrough pain (BTP)—or

• Endure acute pain from repetitive painful procedures during cancer treatment.

Types and categories of Pain

8 DR. AHMAD AQEL

• According to inferred pathology I. Nociceptive (physiologic) pain refers to the normal

functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful “normal” pain transmission. a. Somatic pain

- Arises from bone, joint, muscle, skin - Described as aching or thrombing pain, Well localized

- E.g., surgical, trauma, wound and burn, labor pain, rheumatoid arthritis

b. Visceral pain: arises from visceral organ ( GIT, Panaceas); e.g., ulcerative colitis crohn’s disease, pancreatitis.

Types and categories of Pain

9 DR. AHMAD AQEL

II. Neuropathic (pathophysiologic) pain is pathologic and

results from abnormal processing of sensory input by the

nervous system as a result of damage to the peripheral or

CNS or both .

Neuropathic pain may be associated with abnormal

sensations called dysesthesia or pain from normally non-

painful stimuli (allodynia).

– Phantom pain: a result of peripheral nerve damage, post stroke

pain, pain following spinal cord injury

• pain that feels like it's coming from a body part that's no longer there

Types and categories of Pain

Endorphin is a hormone that your body produces to ease pain

and make you feel calm and happy."natural pain killers"

10 DR. AHMAD AQEL

Patients may have a combination of nociceptive & neuropathic

pain.

For example:

Pain from tumor growth>>> nociceptive pain & if pt

report radiating pain due to pressure against nerve plexus

>>> neuropathic pain

Sickle cell disease pain is usually a combination of nociceptive

pain from the clumping of sickled cells and resulting perfusion

deficits, and neuropathic pain from nerve ischemia.

Types and categories of Pain

11 DR. AHMAD AQEL

Nociception: the process by which information about tissue damage is conveyed to the CNS.

1) Transduction: the conversion of the energy from a noxious stimulus into electrical energy (nerve impulses) by sensory receptors called nociceptors

2) Transmission: the transmission of these neural signals from the site of transduction (periphery) to the spinal cord and brain

3) Perception: the appreciation of signals arriving in higher structures as pain

4) Modulation: descending inhibitory and facilitory input from the brain that influences (modulates) nociceptive transmission at the level of the spinal cord.

Pain pathway

13 DR. AHMAD AQEL

What happens during transduction?

• Damaged cells release mediators of inflammation (prostaglandins, substance P, bradykinin, histamine, serotonin, cytokines).

• Nociceptor activation:

• Nociceptors are sensory receptors that are sensitive to tissue trauma or a stimulus .

• Signals from these nociceptors travel along two fiber types:

unmyelinated C-fibers, slowly conducting

myelinated A-delta fibers, rapidly conducting

Pain pathway

14 DR. AHMAD AQEL

• Clinical implications

– Some analgesics target the inflammatory process

such as NSAIDs inhibit cyclooxygenase (COX), thus

decreasing the synthesis of prostaglandins.

– Other analgesics (antiepileptic drugs, local

anesthetics) block channels, thus inhibiting the

generation of nerve impulses.

What happens during transduction?

Pain pathway

15 DR. AHMAD AQEL

• Nerve impulses are transmitted to the spinal cord and brain in several phases:

• Periphery to the spinal cord:

• Spinal cord to the brain

– Clinical implications Some analgesics inhibit signals in the dorsal horn (DH).

• For example, opioid analgesics bind to opioid receptors on primary afferent and DH neurons.

What happens during transmission?

Pain pathway

16 DR. AHMAD AQEL

• Information from some dorsal horn (DH) projection

neurons travels via the thalamus to the

somatosensory cortex, where information about

the location, intensity, and quality of the pain is

identified.

What happens during perception?

Pain pathway

17 DR. AHMAD AQEL

• Descending pathways

- The reduction of DH transmission by descending inhibitory input from the brain.

• Nerve fibers release inhibitory substances (endogenous opioids, norepinephrine) that bind to receptors inhibit transmission.

• Clinical implications Some analgesics enhance the effects of descending inhibitory input. For example, some antidepressants are used to treat some types of chronic pain.

What happens during modulation?

Pain pathway

18 DR. AHMAD AQEL

• Assess posture and pain behaviors.

• Ask the patient to describe pain in own words

Factors to consider in pain assessment

– intensity, timing, location ,quality, personal

meaning of pain; aggravating and alleviating

factors; and pain behaviors.

Pain assessment

19 DR. AHMAD AQEL

Questions to assess pain • Where is the pain located? How long does it last? How

often does it occur? • How would you describe the pain? • What brings the pain on? • What relieves the pain or makes it worse? • What do you think is causing your pain? • What do you fear most about the pain? • What problems does the pain cause you? • Who else have you consulted about the pain? Family

members? • What treatments do you think might help you with

the pain?

20 DR. AHMAD AQEL

Patient’s self report is the standard for assessing the

existence and intensity of pain.

HCPs do not have the right to deprive any patient of

appropriate assessment and treatment because they

believe a patient is not being truthful.

Pain is reassessed and documented on a regular basis to

evaluate the effectiveness of treatment.

At a minimum, pain should be reassessed with each new

report of pain and before and after the administration of

analgesic agents

Pain assessment

21 DR. AHMAD AQEL

Pain Assessment

22 DR. AHMAD AQEL

o Location of pain, radiation of pain. o Intensity (severity): using a reliable and valid pain assessment tool, e.g., numerical rating scale & FACES pain scale, visual analog scale).

o Quality (e.g., “sharp,” “shooting,” or “burning”…to

identify neuropathic pain)

23 DR. AHMAD AQEL

Pain Assessment

when started? constant or intermitted?

Onset and duration

what make it worse or better?

Aggravating and relieving factors

Effect of pain on function and quality of life

(e.g., being able to sleep)

Comfort-function (pain intensity) goal

The patient’s culture, past pain experiences, perception and meaning of pain, distress that it cause, and medical history such as comorbidities, laboratory tests, and diagnostic studies

Other information

24 DR. AHMAD AQEL

Pain Assessment