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INTRODUCTION
Pain is a universal human experience and the most common reason people seek medical
care. Pain tells us something is wrong in the structure or function of our body and that we
need to do something about it. Because pain is such a strong motivator for action, it is
considered one of the bodys most important protective mechanisms.
DEFINITIONS OF PAIN
The International Association for the Study of Pain defined pain as an
unpleasaGnt, subjective, sensory and emotional experience associated with actual
or potential tissue damage or described in terms of such damage (International
Association for the Study of Pain, 1979).
Pain, however, is much more than a physical sensation caused by a single entity. It is
subjective and highly individual, a complex mechanism with physical, emotional, and
cognitive components.
Pain cannot be objectively measured in the same way as, for example, the chemical
content of urine or the oxygen content level of blood. Only the person who is suffering
knows how the experience feels.
McCaffery defined pain as whatever the experiencing person says it is and
whenever he says it does (1979).
The American Pain Society goes further by stating that it is not the responsibility
of clients to prove they are in pain; it is the nurses responsibility to accept the
clients report of pain (2005).
PAIN-RELATED TERMINOLOGY
Algesia: Sensitivity to pain.
Breakthrough pain: Transitory increase in pain to a level greater than the clients wellcontrolled baseline level (McCaffery & Pasero, 2003).
contains primary sensory afferent neurons that have an important role in pain signaling. The
axons of these afferents diverge from the cell body in the dorsal root ganglion near the spinal
cord and send a short fiber centrally into the cord and a long fiber down the peripheral nerve into
the tissues. Their receptors detect mechanical, thermal, proprioceptive, and chemical stimuli.
Transmission is the process by which impulses are sent to the dorsal horn of the
spinal cord, and then along the sensory tracts to the brain.
The primary afferent neurons are active senders and receivers of chemical and electrical signals.
Their axons terminate in the dorsal horn of the spinal cord, where they have connections with
many spinal neurons. In turn, spinal neurons have input from many primary afferents. These
spinal neurons project axons to the contralateral thalamus, which in turn projects to the
somatosensory pathway, frontal cortex, and other areas. The somatosensory cortex is thought to
be involved in the sensory aspects of pain, such as the intensity and quality of pain, whereas the
frontal cortex and limbic system are thought to be involved with the emotional responses to it.
Modulation is the process of dampening or amplifying these pain-related neural
signals. Modulation takes place primarily in the dorsal horn of the spinal cord, but
also elsewhere, with input from ascending and descending pathways.
The gate control theory is a popular model of pain modulation proposed by Melzack and
Wall in 1965, later revised by Melzack and Casey in 1968. These investigators proposed
the existence of an endogenous ability to reduce or increase the degree of perceived pain
through modulation of incoming impulses at a gate located in the dorsal horn of the
spinal cord. The gate acts on signals from the ascending and descending systems and
weighs all of the inputs. The integration of these inputs from sensory neurons, the
segmental spinal cord level, and the brain, determines whether the gate will be opened or
closed, either increasing or decreasing the intensity of the ascending pain signal. The
role of psychological variables in the perception of pain, including motivation to escape
pain, and the role of thoughts, emotions, and stress reactions in increasing or decreasing
painful sensations, is evident in the gate control theory. An example is when patients
report more pain at night, when they are isolated and less distracted from their pain than
they might be during the day. The proposed gate can be opened or closed by
pharmacologic manipulation
GATE-CONTROL THEORY
Melzack and Wall proposed the gate-control theory to explain the relationship between
pain and the emotions (1982). According to the theory, a gating mechanism occurs when
a pain impulse travels to the substantia gelatinosa in the dorsal horn of the spinal cord.
There, trigger (T) cells influence the transmission of pain impulses. When their activity is
inhibited, the gate closes and impulses are less likely to be transmitted to the brain. This
mechanism is controlled by descending nerve fibers from the thalamus and cerebral
cortex, areas of the brain that regulate thought and emotions. The gate-control theory
helps explain how thoughts and emotions modify the perception of pain and why
interventions, such as imagery and distraction, help relieve it.
n, transduction, transmission and modulation, and psychological intervention.
Perception refers to the subjective experience of pain that results from the
interaction of transduction, transmission, modulation, and the psychological aspects
of the individual.
As research continues furthering the understanding of this complex process, there is hope that
pain treatments can be developed to target specific parts of the physiologic pathway and become
more effective than current treatmen
Pain Perception
Pre-term infants
Newborn infants
Infants, 1 month
Toddlers/Preschoolers Can describe pain, its location and intensity; respond to pain by
crying, anger, sadness; may consider pain a punishment; may hold
someone accountable for pain and remember experiences in a
certain location, such as a clinic
School-age children
Adolescents
Adults
Fear of pain may prevent some 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
Older adults
Pain Perception
terms such as hurt or ache; may fear addiction to analgesics;
may not want to bother nurses or be a bad patient
Fatigue
Fatigue decreases coping abilities and heightens the perception of pain. When people are
exhausted from physical activity, stress, and lack of sleep, their perception of pain may be
heightened and their coping skills diminished. Thus, sleep and rest from physical,
emotional, and social demands are important measures to manage pain more effectively.
Genetic Makeup
Recent research suggests that sensitivity to and tolerance for pain may a genetically
linked trait (Ruda et al., 2000). This finding does not negate the need to manage pain
adequately, regardless of inherited traits.
Memory
Memory of painful experiences, especially experiences that occurred as a very young
child, may increase sensitivity and decrease tolerance to pain. For example, even young
children remember the pain of an immunization at the doctors office and henceforth may
be afraid to visit the doctor again.
Stress Response
Research has shown that severe, unrelieved pain can cause an overwhelming stress
response in both pre-term and full-term infants which can lead to serious complications
and even death (Pasero, 2004). In recent years, post-traumatic stress syndrome has been
the subject of extensive research, both as to its cause and its treatment (Hamilton, 2008).
Healing
Recent research suggests that unrelieved acute pain slows postoperative wound healing
(McGuire, 2006). This evidence is not surprising, given our increasing knowledge of the
effect of stress on the human body.
Neurologic Function
Any factor that interrupts or interferes with normal pain transmission affects the
awareness and response of clients to pain and places them at risk for injury. Analgesics,
sedatives, and alcohol depress the functioning of the central nervous system. Some
diseases, such as leprosy, damage peripheral nerves, decrease sensitivity to touch and
pain, and render sufferers more vulnerable to injury.
PSYCHOLOGICAL FACTORS
Fear and Anxiety
The relationship between pain and fear is convoluted and complex. Fear tends to increase
the perception of pain, and pain increases feelings of fear and anxiety. This connection
occurs in the brain because painful stimuli activate portions of the limbic system believed
to control emotional reactions.
Coping
People manage pain and other stressors of life in different ways. Some see themselves as
self-sufficient, internally controlled, and independent. As a result, they may deny pain or
be slow to admit they are suffering.
CULTURAL FACTORS
Cultural beliefs and values affect the way people respond to pain. As children they learn
what is and what is not acceptable behavior when experiencing pain. In some cultures, any
expression of pain is considered cowardly and shameful. In others, noisy demonstrations of
pain are expected and acceptable. The meaning of pain itself may be markedly different in
different cultures. Some ethnic groups see pain as a punishment for wrongdoing
PAIN CLASSIFICATION
There are two basic types of pain: acute and chronic.
Acute pain occurs for brief periods of time and is associated with temporary disorders. However,
it is always an alarm signal that something may be wrong.
Chronic pain is continuous and recurrent. It is associated with chronic diseases and is one of their
symptoms.
Pain intensity not only depends on the type of stimulus that caused it, but also on the subjective
perception of the pain. Despite a wide range of subjective perception, several types of pain have
been classified according to:
Gnawing pain. Continuous with constant intensity. It generally worsens with movement.
Throbbing pain. This is typical of migraine pain. It is caused by dilation and constriction
of the cerebral blood vessels.
Burning pain. A constant, burning feeling, like, for example, the type of pain caused by
heartburn.
Muscle pain. Also known as myalgia, this pain involves the muscles and occurs after
excessive exertion or during inflammation.
Colicky pain. Caused by muscle contractions of certain organs, such as the uterus during
the menstrual period. Generally cyclic in nature.
Referred pain. Occurs when the painful sensation is felt in a site other than the one where
it is actually occurring, depending upon how the brain interprets information it receives
from the body.
Postoperative pain. Occurs after surgery and is due to lesions from surgical procedures.
Classification of Pain
Classification of pain: Classifying pain is helpful to guide assessment and treatment. There are
many ways to classify pain and classifications may overlap (Table 1). The common types of pain
include:
Nociceptive: represents the normal response to noxious insult or injury of tissues such as
skin, muscles, visceral organs, joints, tendons, or bones.
o
Examples include:
Examples include, but are not limited to, diabetic neuropathy, postherpetic
neuralgia, spinal cord injury pain, phantom limb (post-amputation) pain, and poststroke central pain.
The mediators that have been implicated as key players are proinflammatory
cytokines such IL-1-alpha, IL-1-beta, IL-6 and TNF-alpha, chemokines, reactive
oxygen species, vasoactive amines, lipids, ATP, acid, and other factors released by
infiltrating leukocytes, vascular endothelial cells, or tissue resident mast cells
There are well-recognized pain disorders that are not easily classifiable. Our understanding
of their underlying mechanisms is still rudimentary though specific therapies for those
disorders are well known; they include cancer pain, migraine and other primary
headaches and wide-spread pain of the fibromyalgia type.
Pain Intensity: Can be broadly categorized as: mild, moderate and severe. It is common to use a
numeric scale to rate pain intensity where 0 = no pain and 10 is the worst pain imaginable:
Mild: <4/10
Severe: >7/10
Chronic pain: pain lasting for more than 3-6 months, or persisting beyond the course of an
acute disease, or after tissue healing is complete.
Sources of Pain
The sources of pain are divided into three main categories: nociceptor, non-nociceptor,
and psychogenic.
Nociceptor pain results when tissue damage produces a pain-producing stimulus
Somatic pain is divided into deep somatic and cutaneous pain. Deep somatic
pain arises from bones, tendons, nerves, and blood vessels. Cutaneous pain
originates in the skin or subcutaneous tissue. Some body tissues, such as the
brain and lung, have no nociceptors, and some tissues have many.
nervous system.
Psychogenic pain is pain for which there is little or no physical evidence of
Nociceptor: Visceral
Physiologic structures
Mechanism
Activation of nociceptors
Characteristics
Mechanism
Activation of nociceptors
Characteristics
Mechanism
Characteristics
Sources of chronic pain Nervous tissue injury due to diabetes, HIV, chemotherapy,
syndromes
neuropathies, postherpetic neuralgia, trauma, surgery
Psychogenic
Physiologic structures
No organic structures
Mechanism
Emotional
Characteristics
Nonorganic
.
PAIN AND THE NURSING PROCESS
The nursing process includes assessment, diagnosis, planning, intervention, and
evaluation. To manage pain responsibly, nurses use each step of the nursing process.
Basic to every strategy for managing pain is showing respect for the validity of a clients
experience of pain. To communicate respect, nurses:
Assessing Pain
Pain is a red flag. It tells us there is a problem somewhere in the body that is crying out
for attention. In fact, pain is such an important indicator of health, its assessment has been
called the fifth vital sign, joining temperature, pulse, respiration, and blood pressure.
Even so, until we know more about a specific pain, we cannot fix it. To do this, nurses
must gather information from as many sources as possible, especially the primary source,
the person in pain. This investigation includes obtaining a comprehensive pain history,
making observations of behaviors, performing an appropriate physical examination, and
consulting with other healthcare professionals.
PAIN HISTORY
A pain history is obtained from written documents and from interviews with the person in
pain, family members, and other caregivers. It asks specific questions about the location,
intensity, quality, and history of the pain, as shown in the following box. In some
facilities these questions are printed on an assessment form, with space for answers to be
recorded beside each question.
OBTAINING A PAIN HISTORY
Location: Where is your pain? Ask client to point to the area of pain.
Intensity: On a scale of 0 to 10, with 0 representing no pain, how much pain would you say
you are experiencing? If your pain were a temperature, how cold or hot would it be (warm,
hot, blistering)? If your pain were a sound, how loud would it be (silent, quiet, strident,
booming)?
Quality: In your own words, tell me what your pain feels like (worms under the skin,
shooting, needle pricking, tingling, etc.).
Chronology/pattern: When did the pain start? Does your pain come and go? How often?
How long does it last?
Precipitating factors: What triggers the pain, or what makes it worse?
Alleviating factors: What measures have you found that lessen or relieve the pain? What
pain medications do you use? How much and how often?
Associated symptoms: Do you have other symptoms before, during, or after your pain
begins (dizziness, blurred vision, nausea, and shortness of breath)?
BEHAVIORAL OBSERVATIONS
Most people who suffer pain usually show it either by verbal complaint or nonverbal
behaviors. The following table lists some typical behaviors nurses may observe when
they assess people in pain.
teeth
Wrinkled
forehead
Biting lips
Scowling
Vocalizations
Body Movement
Social Interaction
Crying
Restlessness
Moaning
Protective body
Gasping
Groaning
Grunting
movement
Muscle tension
Immobility
Silence
Withdrawal
Reduced attention
span
Focus on pain
relief measures
Vocalizations
Closing eyes
Body Movement
Pacing
Rhythmic
Social Interaction
tightly
Widely
movement
opened eyes or
mouth
PHYSICAL EXAMINATION
When clients complain of pain or show it by their behavior, nurses need to take action to
find the cause. Assessment is most effective if the pain history interview and behavioral
observations are conducted at the same time as the physical examination. For example, if
a client complains of acute pain on the sole of a foot, the nurse visually examines the foot
for unusual signs, observes the person for behavioral cues of pain, and asks about the
onset, intensity, quality, and pattern of the pain and what makes it worse or better. If the
cause is not identified immediately, the nurse refers the client for further assessment.
Diagnosing Pain
person with osteoarthritis may decide to delay hip replacement surgery and maintain
mobility as long as possible with the aid of a cane and analgesics for pain.
Interventions
PAIN MANAGEMENT
PHARMACOLOGIC INTERVENTIONS
There are two primary groups of pain medications: nonopioids and opioids. A third group
of drugs called adjuvants or co-analgesics address symptoms that often accompany pain,
such as insomnia, anxiety, muscle spasm, anorexia, and depression.
Nonopioid Analgesics
Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site
to decrease the level of inflammatory mediators. This group of analgesics includes drugs
such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs)
such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin). The specific actions and
dosages of these analgesics vary. Generally speaking, however, they have analgesic,
antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain.
With the exception of acetaminophen, most nonopioids are potent anti-inflammatory
agents. These drugs are especially effective when the primary cause of pain is
inflammation, as occurs in rheumatoid arthritis and bone cancer. When tissue is damaged,
a series of biochemical events leads to the release of prostaglandin, which causes edema,
inflammation, and pain.
Two isoenzymescyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2)play
an important part in this biochemical process. Drugs that inhibit their action, especially
that of COX-2, reduce prostaglandin production and the inflammation it creates.
However, these drugs must be used with caution because the safety of long-term use has
not been verified. The following table lists some common nonopioid analgesics.
Adult Dose
Considerations
Acetaminophen
(Tylenol)
650975 mg q 4 hr
Aspirin
650975 mg q 4 hr
Indomethacin
(Indocin)
150200 mg/day
Naproxen
(Naprosyn)
Opioid Analgesics
Opioid analgesics are classified as full agonists, partial agonists, and mixed agonistantagonists.
o Full agonists bind to receptor sites, block pain impulses, and produce maximum
pain controlan agonist effect. Full agonists include such drugs as morphine
(Kadian, Avinza, Rylomine intranasal), meperidine (Demerol), fentanyl
(Duragesic patch, Fentanyl oralets), oxycodone hydrochloride (OxyContin), and
hydromorphine (Dilaudid).
o Partial agonists produce a lesser response than full agonists and include such
drugs as buprenorphine (Buprenex) and nalbuphine (Nubain
Preventative Measures
Cardiovascular Hypotension, palpitations, flushing Monitor blood pressure and heart rate
CNS
Genitourinary
Urinary retention
Integumentary
Respiratory
Some medications combine nonopioid with opioid analgesics in one tablet to offer two
different levels of pain reliefacting both on peripheral nerve endings at the injury site
and at the level of the central nervous system. Acetaminophen with codeine is such a
medication.
Adjuvant Analgesics
Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than
pain but have been found to enhance the effects of analgesics. Caregivers need to
remember that these are helper drugs, not substitutes for analgesics. Clients in pain still
need analgesics. The following table describes some common adjuvant analgesics.
Anti-epileptic drugs
Antispasmodic
Botulinum toxin
Migraine headache
Lidocaine
Psychostimulants
Steroids
Cannabis (Marijuana)
Cannabis is a psychoactive herb derived from the flowers of hemp plants. Although many
people associate it with the treatment of pain, it is not currently accepted for any use by
the U.S. Drug Enforcement Administration, which lists it as a Schedule 1 drug of the
Controlled Substance Act of 1970. Even so, it is marketed as dronabinol (Marinol) and
used in the treatment of glaucoma and intractable nausea. All parts of the plant contain
various psychoactive substances, including tetrahydrocannabinol (THC), the chemical
believed to cause typical psychic effects such as alterations of mood, memory, motor
coordination, cognitive ability, and self-perception. Many states have established medical
marijuana programs to regulate the growth, sale, and use of cannabis.
Placebos
A placebo is a sugar pill, an inactive substance prescribed as if it were an effective dose
of a medication. Research has found that placebos produce hoped-for results in 30% to
50% of the people who take them (Thompson, 2000). This so-called placebo effect has
been exploited for centuries by hucksters and charlatans who sell tonics, treatments, and
gadgets to people in pain. Because their purpose is to deceive and strip clients of the right
to make informed decisions, legitimate medical practice does not use placebos. Such
acts violate the ethical principles of honesty and autonomy. The only exception to this
prohibition is when subjects give prior consent for the possible use of placebos in
research studies.
World Health Organization Pain Management Ladder
Because of widespread misconceptions about treatment of chronic pain and addiction, in
1990 the World Health Organization (WHO) recommended a three-step pain management
ladder based on the intensity of pain.
1. Mild pain (intensity 13 on the 010 standard): Use nonsteroidal antiinflammatory drugs and adjuvants. If pain persists, then
2. Mild to moderate pain (intensity 46): Use combination medications such as
oxycodone and acetaminophen and adjuvants. If pain persists, then
3. Moderate to severe pain (intensity 710): Use potent opioids such as morphine,
fentanylm methadone, and adjuvants.
To prevent under-treatment of malignant cancer pain, some authorities recommend a
different approach. They begin the treatment of malignant cancer pain with strong
opioids, providing immediate relief, then slowly reduce the type and dosage until pain
relief is achieved at the lower level (Jackson & Stanford, 2003).
Routes of Administration
Analgesics can be administered by many routes. Each has advantages and disadvantages
as well as indications and contraindications. The overriding considerations are
effectiveness and safety. The table below lists some of the most common routes for the
administration of analgesic drugs.
Indications
Contraindications
Indications
Contraindications
lozenges
Rectal (R)
Intramuscular (IM)
Intravenous (IV) bolus Offers most rapid pain relief Requires IV access; gives only brief
(515 min) but lasts less than pain relief when prolonged relief is
60 min
needed
Continuous
intravenous (IV)
infusion
Patient-controlled
analgesia (PCA)
Allows predetermined IV
Requires IV access, client
bolus of analgesic when client cooperation, close supervision; does
desires pain relief
not give continuous pain relief
Subcutaneous (SC)
opioid infusion
Continuous, prolonged
Requires site change every 7 days of
parenteral opioids when IV 27-gauge butterfly needle; potential
not possible; allows home use site irritation
Intraspinal (neuraxial),
intrathecal, epidural,
subarachnoid,
intraventricular
Transdermal skin
patch
Nasal sprays
Indications
Contraindications
onset of action
Principles for the Use of Analgesics
To guide caregivers, the American Pain Society (2005) identifies thirteen principles
regarding the use of analgesics to control pain:
1. Individualize the route, dosage, and schedule of analgesics medications.
2. Administer analgesics on a regular basis if pain is present most of the day.
3. Know the dose and time course of several opioid analgesic preparations:
Change the dose or route of the same drug to maintain constant blood
levels.
Add another drug that counteracts the adverse effects, such as a stimulant
for sedation.
8. Do not use meperidine (Demerol) because of neurotoxicity risk or mixed agonistantagonists (Talwin) because of psychotomimetic effects.
9. Do not use placebos to assess the nature of pain..
NONPHARMACOLOGIC INTERVENTIONS
Although there are myriad drugs to relieve pain, all have some risk and cost. Fortunately,
there are many nonpharmacologic interventions to reduce pain, especially when used in
conjunction with pharmacologic measures. Described as physical and cognitivebehavioral interventions, many of these approaches are noninvasive, low-risk,
inexpensive, easily performed and taught, and within the scope of nursing practice.
Physical interventions give comfort, increase mobility, and alter physiologic responses.
Cognitive-behavioral interventions alter the perception of pain, reduce fear, give a greater
sense of control, and are considered holistic nursing practice.
Physical Interventions
Comfort measures such as clean and smooth sheets, soft and supportive pillows,
warm blankets, and a soothing environment have been used by nurses throughout
history to relieve pain and suffering. These measures may be difficult to provide
in the noisy, mechanized healthcare facilities of today. Nonetheless, they are
important to the mental and physical well-being of patients.
from plants are: digitaloid found in the foxglove plant (digitalis), saponins found in
sarsaparilla (irritant laxatives), alkaloids found in nightshades (atropine), and alkaloids
found in the opium poppy (morphine) (McGuigan & Krug, 1942).
Energy fields. Such healing measures are based on theories about unseen forces in the
human body. Acupuncture, for instance, is based on an ancient Chinese theory that two
opposing forces, yin and yang, move along meridians in the body. When these forces
are out of balance, pain and illness result. There are at least 350 acupuncture points by
which energy flows are accessible. The theory posits that by stimulating these points
with very fine needles, the energy flow can be rebalanced and pain relieved (Mayo
Clinic, 2009; NCCAM, 2009b).
o
Touch energy therapies come from very old beliefs that life forces or energy
move through the body in specific paths. Touch therapies believe disease may
cause these paths to become blocked. The therapies use touch to help unblock
these paths, and allow the energy to flow normally. Unblocking the paths may
help you relax and decrease pain.
SUMMARY
Pain, however, is much more than a physical sensation caused by a single entity. It is
subjective and highly individual, a complex mechanism with physical, emotional, and
cognitive components. Although there are myriad drugs to relieve pain, all have some
risk and cost. Fortunately, there are many nonpharmacologic interventions to reduce pain,
especially when used in conjunction with pharmacologic measures. Described as physical
and cognitive-behavioral interventions, many of these approaches are noninvasive, lowrisk, inexpensive, easily performed and taught, and within the scope of nursing practice.
Physical interventions give comfort, increase mobility, and alter physiologic responses.
Cognitive-behavioral interventions alter the perception of pain, reduce fear, give a greater
sense of control, and are considered holistic nursing practice.
BIBLIOGRAPHY
Brunner and suddarths medical surgical nursing(2000); usa.
Lippincott raven, 9th ed.
372-378.
Joyce M.Black. medical surgical nursingnew delhi, (2005);
Elservier , 7th ed
1706-1724.
http://www.thenewstoday.info/2006/12/10/pain management . htm
http://www.nlm.nih.gov/medlinepluslency article/000077.htm.