NOTES ON PAIN AND PAIN MANAGEMENT-MSN I
✔ Pain- an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage or described in terms of such damage,
sensation of physical or mental suffering.
-A sensation of physical or mental hurt or
suffering that causes distress or agony to the
one experiencing it.
-Is subjective in nature, only the person
experiencing it may describe it.
-Is protective in nature because it provides
warning signal for tissue injury. It helps
minimize injury and is often a protective injury-
protection mechanism.
✔ Pain- is whatever the experiencing person say it is,
existing whenever he say does-Mc-Caffery
✔ Persistent pain- a pain that contributes insomnia,
weight gain, constipation, etc.
✔ Severe pain- an emergency situation deserving
attention and professional treatment.
✔ Comfort- implies renewal amplification of power.
 Types of Comfort:
1. Relief- experience of having a specific need to
meet
2. Ease- state of calm
3. Transcendence-state in which client ease above.
 Theories of Pain:
1. Pattern Theory- states that pain is perceived
whenever stimulus is intense enough.
2. Specificity Theory- It states that there is a specific
nerve receptor for particular stimuli. E.g.
Nociceptor-noxious stimuli, Thermoreceptor-
heat/cold, Mechano receptor- pressure,
Chemoreceptor-Chemicals
3. Gate Control Theory- There is a gate in the spinal
cors called substantia gelatinosa. When the gate
is open, pains stimulus is transmitted, thus pain is
perceived. When the gate is closed, stimulus is
blocked thus, no pain is perceived. This is
introduced by Melzack and Wall
4. Affect Theory- It avers that pain is emotional. The
intensity of pain perceived depends on the value
of the organ affected to the individual.
5. Parallel Processing Model-Physiologic or
neurologic decipheringof pain sensation and
cognitive emotional properties occur along
different nerve fibers.
RAZEL G. CUSTODIO, BSNS III-3
 Types of Pain:
A. By Location
✔ Referred pain- appear to arise in different
areas.
✔ Visceral pain- pain arise from organ or hollow
viscera.
B. By Duration
✔ Acute pain-it has a sudden/slow onset and
regardless of its’ intensity.
✔ Chronic pain-is prolonged, usually
recurring/persisting over 6 months or longer. It is mild
to severe, constant or recurring w/o anticipated or
predictable end.
✔ Cancer pain- may result from direct effect of the
disease and its treatment may be unrelated to disease
and its treatment with cancer.
✔ HIV/AIDS pain- malignant pain which tend to be
treated more aggressively.
C. By Intensity
✔ Mild- pain ranging from1-3
✔ Moderate-pain ranging from 4-6
✔ Severe-pain ranging fro, 7-10 w/ worst outcome
D. By Etiology
✔ Physiological pain- pain when an intact,
properly functioning nervous system sends signals that
tissues are damaged.
✔ Somatic- originates in the skin, muscles, bones
and connective tissues.
✔ Cutaneous pain-occurs over body surface or
skin.
✔ Radiating pain-felt at a source and extends to
surrounding tissues.
✔ Visceral pain- results from activation of pain
receptor or hollow viscera; tends to be poorly located
and may have a cramping quality and feeling sick.
✔ Neuropathic pain-experienced by people who
have damaged/malfunctioning nerves, abnormal due
to illness and abnormal nerves in PNS or CNS. It is
typically chronic, burning, tingling and electric shock
like pain.
✔ Peripheral neuropathic pain- follows damage
and or sensitization of peripheral nerves.
✔ Central neuropathic pain- results from
malfunctioning nerves in the CNS.
✔ Sympathetically maintained pain-occurs
occasionally when abnormal connections between
pain fibers and SNS. Perpetuate problems with both
the pain and sympathetically controlled functions.
 NOTES ON PAIN AND PAIN MANAGEMENT-MSN I
 Pain Concepts:
✔ Pain threshold-least amount of stimuli needed for a
person to label a sensation as pain.
✔ Pain tolerance-maximum amount of pain stimuli
that a person is willing to withstand without seeking
avoidance of pain relief.
✔ Hyperalgesia/hyperpathia-a heightened response
to a painful stimuli or increased sensation of pain.
✔ Allodynia- sensation of pain from a stimuli normally
not producing pain. It is also skin sensitivity to pain.
✔ Dysesthesia- unpleasant abnormal sensation, ✔
imitates the pathology of central neuropathic pain
disorder.
✔ Nociceptive pain-pain directly related to tissue
damage and may be somatic.
✔ Sensitization-an increased sensitivity of a receptor
after repeated activation by noxious stimuli or
nociceptor.
✔ Wind-up-progressive increase in excitability and
sensitivity of spinal cord neurons leading to
persistent increased pain.
✔ Pain perception- actual feeling of pain.
✔ Bradykinin-universal stimulus for pain.
 Clinical Manifestations of Pain:
✔ Postherpetic neuralgia- a case of herpes zoster
typically erupts decades after a primary infection.
Has vesicular rash with burning and electric shock
pain.
✔ Phantom pain –feeling that a lost body part is
present.
✔ Phantom limb pain-feeling that a lost body part is
present after limb amputation.
✔ Postmastectomy pain-feeling that a lost breast is
present.
✔ Trigeminal neuralgia-intense stab like pain that is
distributed by 1 or more branches of trigeminal
nerve.
✔ Headache- caused by intracranial or extracranial
problem.
✔ Fibromyalgia-a chronic disorder characterized by
widespread musculoskeletal pain, fatigue and multi-
tender points.
✔ Psychogenic pain-due to emotional factors
✔ Intermittent-pain stops and starts again.
 Pain Pathway:
RAZEL G. CUSTODIO, BSNS III-3
Stimuli→ Nociceptor→ A Delta Fiber or C
Fiber→Ganglion→Dorsal horn→Spinothalamaic
tract→Thalamus (center of awareness of
pain)→Cerebral cortex (center for interpretation of
pain)→Responses
 Pain Physiology:
✔ Primary sensory neurons- specialized to detect
mechanical, thermal and chemical condition
associated with potential tissue damage.
Nociception-physiologic processes related to pain
perception.
✔ Nociceptors-specialized pain receptor that can be
excited by mechanical, thermal, and chemical stimuli.
1. Transduction phase- noxious stimuli trigger to
release of biochemical mediators and cause
movement of ions across cell membrane exciting
nociceptors.
2. Transmission phase-includes 3 segments:
1st segment-pain impulsivetravels from the PN
fibers to spinal cord.
✔ Substance P-serves as a
neurotransmitter, enhancing the
movement of impulses across nerve
synapse.
✔ Dorsal horn- pain signal is mediated and
modified by modulating factors before
amplified or damped signal via
spinothalamic tract
2nd segment-transmission from spinal via
spinothalamic tract to brainstem and thalamus.
3rd segment-transmission of signals between
thalamus to somatic sensory cortex.
3. Modulation phase-descending system, occurs
when neurons in the thalamus and brainstem
send signals back down to dorsal horn of spinal
cord.
✔ Excitatory glial cell amino acids- tends
to persist or amplify pain.
4. Perception phase-final phase. It is when client
becomes conscious to pain
✔ Pain perception- sum of complex
activities in CNS that may character pain
and its intensity.
 NOTES ON PAIN AND PAIN MANAGEMENT-MSN I
 GATE CONTROL Theory Concepts
✔ Substantia gelatinosa- milieu of CNS. May
imbalanced in an excitatory or inhibitory direction-
opens/closes the gate.
✔ Ion channels-located on the pre or post synaptic
gate and also serve as a gate.
✔ A delta nerve fibers-typically send messages of
touch/warm or cold temperature. It has inhibitory
effect to sustantia gelatinosa.
 Factors Affecting pain: Ethnic/Cultural
Norms, Sex, Developmental stage, age
Environment or support people, Past pain ✔
experience, Meaning of pain, etc.
 Responses to Pain:
✔ Involuntary- Physiologic mediated by ANS or SNS.
In SNS-mild while in PNS-severe
✔ Voluntary-Behavioral or emotional response.
 3 Stages of Pain Response: ✔ Full agonist- bind tightly to Mu receptor sites
✔ Activations-Begins with perception of pain. A
fight/flight response initiated by SNS.
✔ Rebound-Intense but brief initiated by PNS. ✔ Mixed
✔ Adaptation-it is due to endorphins counteracting
pain when pain last for many hours /days.
 Pain Assessment and tools:
CHARACTER-sensation
ONSET-when the pain started
LOCATION-where
DURATION-constant vs intermittent
EXACERBATION-factors making it worst
RELIEF-factors making it better
RADIATION-pattern of shooting
✔ Wong-Baker Faces Rating Scale-for preverbal
children.
✔ FLACC Scale-has been validated in children from2
mos-7yrs.
✔ Legmut Facial Expression-cry, activity and
consolability.
 Pharmacologic Pain Management:
✔ Rational Polypharmacy-demands that H ✔
professionals should be aware of all ingredients of
medications that alleviate pain and use combinations
to reduce the need for high doses.
✔ Multimodal therapy-uses nondrug approaches like
heat relaxation.
RAZEL G. CUSTODIO, BSNS III-3
 WHO 3 STEPS APPOACH FOR OPIODS
1. STEP 1-Non-opiod analgesics is the
appropriate starting pt.
2. STEP 2- A weak opioid or combination
of opioid or combination of
opioid/nonopioid with or w/o analgesic
meds
3. STEP 3-strong opiates are administered
and titrated.
✔ Ceiling effect- Once the maximum analgesics
benefit is achieved more drug will not produce more
analgesia.
Equianalgesia-refers to the relative potency of
various opioid analgesics compared to a standard
dose of parenteral morphine
✔ Placebo- any medication including surgery that
produces an effect in the client because of its
implicit/ explicit effect and not because of its specific
physical or chemical property.
 TYPES OF OPIOIDS
producing maximum pain inhibition, an agonist
effect, has no ceiling effect
Agonist-Are antagonists-agonists-
antagonists analgesics-act like opioids and relieve
pain, block and inactivate other opioid analgesics,
block Mu receptor but activates Kappa receptor site.
✔ Partial agonist- have ceiling effect in contrast to full
agonist; block Mu receptor or are neutral receptor
but bind with kappa receptor site, good analgesic
potency, most popular
 TYPES OF COANALGESICS
✔ Coanalgesic/adjuvant- a medication that is not
classified as a pain medication but may reduce pain
specifically Neuropathic pain.
✔ Tricyclic antidepressant- useful for central
neuropathic pain, burning, stinging quality.
✔ Anticonvulsant-particularly useful into peripheral
neuropathic conditions that often present w/
stabbing, shooting and electric shock pain.
✔ Lidoderm-alleviate neuropathic as well as other
types of pain particularly allodynia.
 OTHER PHARMACOLOGIC MGT.
Epidural Space- most commonly use in Intraspinal
route of administration of pain med. It is because it
has the durameter that acts as protective carrier.
✔ Continuous Local Anesthetics- continuous
subcutaneous administration of long acting local
 NOTES ON PAIN AND PAIN MANAGEMENT-MSN I

anesthetics into a near surgical site. Useful for

post.op px.
✔ Patient-controlled analgesia-interactive method of
pain management that permits clients to treat their
pain by self administration of analgesia.
 SURGICAL MGT.
✔ Neurectomy-Interrupts cranial or peripheral nerves
by an incision.
✔ Rhizotomy- Interruption of the anterior or posterior
nerve root area close to the spinal cord.
✔ Cordotomy or Spinothalamic Tractotomy-The
surgical interruption of pain-conducting pathways
within the spinal cord. The incision is made in the
anterolateral pathway opposite the side on which the
pain is located.
✔ Tractotomy-Surgical resection of the anterolateral
pathway in the brainstem.
✔ Gyrectomy-removal of the postcentral gyrus (part of
the sensory cortex of brain)
✔ Hypophysectomy-Destroying of the pituitary gland
by injection with absolute alcohol.
✔ Nerve block- chemical interruption of a nerve
pathway effecting by injecting a local anesthethic
into a nerve.
✔ Sympathectomy-pathways of the sympathetic
division of ANS are severed.
✔ Spinal cord stimulation- used with persistent pain
that has not been controlled with less invasive
therapies, insertion of electrodes
 NON-PHARMACOLOGIC MGT.
✔ Cutaneous Stimulation-provide effective temporary
pain relief. It distracts client focus.
✔ Massage-comfort measure that can aid relaxation,
decrease muscle tension, anxiety, etc.
✔ Heath and Cold Application-heals injury
✔ Acupressure-from ancient Chinese healing system
of acupuncture where finger pressure is applied to
many points of the body.
✔ Contralateral stimulation-can be accomplished by
stimulating the skin in an area opposite to painful
area.
✔ Bracing-restriction of mvt.
✔ Transcutaneous Electrical Nerve Stimultaion
(TENS)- is a method of applying low voltage
electrical stimulation directly over pain.
✔ Distraction- draws the person’s attention away from
pain and perception of pain.
✔ Hypnosis-deep state relaxation.

RAZEL G. CUSTODIO, BSNS III-3