McCaffrey (1979) “ Whatever

the experiencing person says

it is, existing whenever he
says it does”

International Association for

the Study of Pain (IASP) :
Pain is an unpleasant
sensory and emotional
experience with actual or
potential tissue damage, or
described in terms of
damage
 Physiology of Pain
2. Transduction
3. Transmission
4. Perception
5. Modulation
PHYSIOLOGY
• Transduction – Noxious stimuli (Tse injury)
release of biochemical
Ion mov’t across cell membrane
mediators (Prostaglandin,
Bradykinin, Serotonin,
Histamine, Substance P)
excitement of nociceptors

Sensitization nociceptors Pain

2. Transmission – Peripheral nerve fibers Spinal Cord

(Pain impulses) Spinothalamic tract

Brainstem and Thalamus

Transmission

Somatic Sensory Cortex (Pain perception occurs)

PHYSIOLOGY

1. Transduction
2. Transmission
Substance P, assist transmission of impulses across
the synapse in the Spinothalamic Tract
3. Perception – Client becomes conscious of the pain
(Cortical structure)

4. Modulation – neurons from brainstem sends signals

down to the dorsal horn to the spinal cord which releases
biochemical mediators (opioids, serotonin and
norepinephrine) eliciting reaction
 Origins and Causes of Pain
1. Cutaneous Pain 2. Deep Somatic Pain 3. Visceral Pain

Ex. Paper cut Ex. Obstructed

bowel
1st degree burn
Myocardial
Infarction
Types of Pain According to Duration and Intensity
Acute Chronic
TIME SPAN Less than 6 months 6 months or longer
LOCATION Localized, associated with Difficult to pinpoint
specific injury, condition or -Continues beyond healing
disease
-Resolved with healing
CHARACTERISTICS Often described as sharp Often described as dull
-Diminishes as healing -Diffused and aching
occurs
PHYSIOLOGIC SIGNS Elevated HR, BP, RR Normal VS
Maybe Diaphoretic No diaphoresis
Dilated Pupils Normal Pupils
May have weight loss
BEHAVIORAL SIGNS Crying and Moaning Physical Immobility
Rubbing site Hopelessness
Guarding Listlessness
Frowning Loss of Libido
Grimacing Exhaustion and Fatigue
Restlessness and Anxiety Complains of Pain only
Verbalization of Pain when asked
Depressed and Withdrawn
INTENSITY Mild to Severe Mild to Severe
 Types of pain according to where it is experienced:
1. Radiating pain 2. Referred pain
-Percieved at the source of -Felt from the part that is remote from the tse causing the pain
pain and extends to nearby
tses
3. Intractable pain 4. Phantom pain
-highly resistant to relief -pain percieved in a part that is missing

5. Neuropathic pain
-Damage to the NS & may not
have a stimuli (Current/Pass)
CONCEPTS ASSOCIATED WITH PAIN

1. Pain Threshold – A.K.A. Pain Sensation

-Hyperalgesia

2. Pain Tolerance

3. Pain reaction
TYPES OF PAIN STIMULI

A. Mechanical
1. trauma to body tissue- tissue damage, direct irritation of the pain
receptors (Nociceptors); inflammation

2. alterations in body tissues- pressure on pain receptors

3. blockage of a duct – distention of the lumen of the duct

4. tumor – pressure on pain receptors, irritation of the nerve endings

5. muscle spasm – stimulation of the pain receptors; Chemical Stim.

B. Thermal
1. Extreme temperature- tissue destruction, stimulation of the
thermosensitive pain receptors

C. Chemical
1. Tissue ischemia – stimulation of pain receptors because of
accumulated lactic acid (Anaerobic Met.) in tissues and
chemical mediators like bradykinin and enzymes
2. Muscle spasm – tissue ischemia release enzymes which
would irritate nociceptors
FACTORS INFLUENCING REACTION TO PAIN:
2. Causes, duration and intensity of pain and the amount of
relief afforded by the individual by means of various
medications
3. Cultural background or ethnic values
4. Philosophical beliefs and religious convictions
5. Degrees of anxiety and fear and the manner in which
others respond to the afflicted individual
6. Age
7. Drug abuse
 Theories of pain:
1. Gate Control Theory- Peripheral nerve fibers carrying pain towards
the spinal cord can have their inputs modified before transmission to
the brain.
2. Sensory or Specificity theory – involvement of
sensory receptors in specific body parts or organs

3. Intensity theory – intensity of pain is determined by

the magnitude of the stimulus
 Pain History:
• Location – “where is your pain?”
• Intensity
3. Quality – “how does you pain feels like?”

4. Pattern – a) time of onset (“when did/does the pain start?);

b) duration (“how long have you had it?, how
long does it last?);
c) constancy (“do you have pain free periods?
when? for how long?)

5. Precipitating factors – what triggers the pain or makes it

worst?

6. Alleviating factors – what measures or methods have you

found helpful in lessening or relieving the pain? What pain
medication do you use?

7. Associated symptoms – do you have other symptoms before,

during, after pain?
8. Effects on ADL – How does it affect your daily life?

9. Past pain experiences – Tell me about your past pain

experiences that you have had and the effectiveness of
pain relief measures.

10. Meaning of pain – how do you interpret your pain?

What outcomes do you expect from this pain? What do
you fear most about this pain?

11. Coping resources – what do you usually do to help

cope with pain?

12. Affective response – How does the pain make you feel?
Anxious? Depressed? Frightened? Tired? Burdensome?
 Mnemonics for Pain Assessment
OLDCART
PQRST
O – onset

L – location P – provoked

D – duration Q – quality

C – characteristic
R – region/radiation
A – aggravating factors
S – severity
R – radiation
T - timing
T - treatment
 COLDERRA

C – Characteristics
O – Onset
L – Location
D – Duration
E – Exacerbation
R – Radiation
R – Relief
A – Associated signs and symptoms
Assessing a child with pain
Age Pain perception and Behavior Selected Nsg.
group Intervention
Infant Perceives pain Give pacifier
Respond to pain w/ increased Use tactile
sensitivity stimulation. Play
Older infants tries to avoid pain music or tapes of a
heartbeat
Toddler (turns awaythe
Develops andability
physically resist pain
to describe Distract the child w/
and and its intensity and location toys, books, picture.
prescho Often responds w/ crying and anger Involve the child in
oler because child perceives pain as a blowing bubbles as a
threat to security way of “blowing away
Reasoning w/ child at this stage is the pain”
Appeal to the child’s
not always successful
May consider pain as punishment belief in magic by
using a “magic”
Feels sad
blanket or glove to
May learn there are gender take away pain
differences in pain expression Hold the child to
Tends to hold someone accountable provide comfort
for the pain Explore
misconceptions about
pain
Age group Pain perception and Behavior Selected Nsg.
Intervention
School- Tries to behave when facing pain Use imagery to turn
aged Rationalizes in an attempt to off “pain switches”
explain the pain Provide a behavioral
Responsive to explanations rehearsal of what to
Can usually identify the location expect and how it will
and describe the pain look and feel
Provide support and
W/ persistent pain, may regress
to an earlier stage of development nurturing

Adolescen May be slow to acknowledge pain Provide opportunities

t Recognizing pain or “giving in” to discuss pain
may be considered weakness Provide privacy
Wants to appear brave in front of Present choices for
peers and not report pain dealing w/ pain.
Encourage music or
TV for distraction
Age Pain perception and Behavior Selected Nsg.
grou Intervention
p
Adult Behaviors exhibited when experiencing Deal w/ any
pain may be gender-based behaviors misconception of pain
learned as a child Focus on the client’s
May ignore pain because to admit it is control in dealing with
perceived as a sign of weakness or the pain
failure Allay fears and
Fear of what pain means may prevent anxiety when possible
Elder some
May adults for taking
have multiple action.
conditions
presenting w/ vague symptoms
May perceive pain as part of the aging
process
May have decreased sensations or
perceptions of the pain
Lethargy, anorexia, and fatigue may be
indicators of pain
May withhold complaints of pain
because of fear of the treatment, of any
lifestyle changes that may be involved or
becoming dependent
Cont. May describe pain differently, that is, Clarify
as “ache’, “hurt”, or “discomfort” misconceptions
May consider it unacceptable to Encourage
admit or show pain independence
whenever possible
PAIN MANAGEMENT
 GENERAL STRATEGIES FOR PAIN:
2. Acknowledging the client’s pain

a. Verbally acknowledge the presence of the pain

b. Listen attentively to what the client says about
the pain
c. Convey that you are assessing the client’s pain to
understand it better, not to determine whether the
pain is real
d. Attend to the client’s needs promptly

2. Assisting support persons – give info; discuss their

emotional reaction
3. Reducing misconceptions about pain

4. Reducing fear and anxiety – encouraging verbalization, being

honest and sincere, promptly attending to their needs and
giving accurate information
 PHARMACOLOGICAL PAIN MANAGEMENT:
2. Opioid/Narcotic analgesics
- Binds to Opiate receptors and
activate endogenous pain
suppression in the CNS

2. Non-narcotic analgesics
/NSAID – Acts on peripheral
nerve endings at the injury site
& decrease inflammatory
mediators

3. Adjuvant analgesic
- Developed other than for
analgesia but found to decrease
certain types of chronic pain
Alternative Delivery Systems for Opioids:

1. PCA pump
2. Epidural/ Intrathecal (Subarachnoid)
Anesthesia
 Advantages
• Good pain control
• Relieves anxiety of patient when waiting for nurse
to give the pain meds
• Promotes clients independence and control over
the situation
• Lower doses of opioids are given compared to
PRN
• Report more analgesia with fewer S/E
• As pain lessens, client adjust to doses eventually
stop taking the analgesic
3. Transdermal analgesia

4. Local Anesthesia
B. Non-pharmocological pain management

I. Cutaneous stimulation

a. Massage

b. Heat and cold application

c. Accupressure

d. Contralateral stimulation
II. Immobilization
III. Transcutaneous Electrical Nerve Stimulation

IV. Placebo – any medication or procedure that produces an effect

because of its implicit or explicit intent and not because of its specific
physical or chemical properties. A.K.A. Water Pill
2. Cognitive Behavioral interventions

C. Distraction
1. Slow rhythmic breathing

2. Massage

3. Rhythmic singing and tapping

4. Active listening

5. Guided imagery

B. Hypnosis - based on suggestion, dissociation and focusing attention

Types of Distraction:
B. Visual Distraction

- reading or watching T.V

- watching a ball game

- guided imagery

B. Auditory distraction

-humor/joke

- listening to music
C. Tactile distraction

- slow, rhythmic breathing

- massage

- holding or stroking a pet or toy

D. Intellectual distraction

- puzzles

- card games

- engaging in hobbies
Example of NURSING DIAGNOSIS FOR PAIN:
• Acute Pain
• Chronic Pain
• Ineffective airway clearance r/t weak cough secondary to
postoperative incisional abdominal pain
• Hopelessness r/t continual pain
• Anxiety r/t past experiences of poor control of pain and to anticipation
of pain
• Ineffective coping r/t prolonged continuous back pain, ineffective
management and inadequate support system
• Ineffective health maintenance r/t chronic pain and fatigue
• Self care deficit (specify) r/t poor control to pain
• Deficient knowledge (pain control measures) r/t lack of exposure to
information resources
• Impaired physical mobility r/t arthritic pain in knee and ankle joints
• Disturbed sleep pattern r/t increased pain perception at night
 End of
Presentation!

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