Pain Management

By
Kalsoom Naz
Lecturer HIMS
 Objectives

At the end of this unit, learners will be able to:

 Define pain and the process of pain (physiological changes)
 Describe the different theories of pain theory.
 Differentiate between acute and chronic pain.
 Explain assessment of pain.
 Describe nursing diagnosis related to pain.
 Discuss the non-pharmacologic interventions pain management.
 Identify pharmacologic interventions for pain management
 Pain Definition
 An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.

 Pain is the fifth Vital sign and is regarded as

a symptom of an underlying condition

 It is a complex experience consisting of

physiological(redness, swelling, and warmth)
and a psychological response (pain full feeling) to a
noxious stimulus.
 Pain is a warning mechanism that
protects an organism by
influencing it to withdraw from
harmful stimuli; it is primarily
associated with injury or the threat
of injury.

 It is subjective and difficult to

quantify, because it has both an
affective and a sensory component
Nociceptors
 A nociceptor is a receptor of a sensory neuron (nerve cell) that responds
to potentially damaging stimuli by sending signals to the spinal cord
and brain. This process, called nociception, usually causes the
perception of pain

 Distributed throughout the body (skin, viscera, muscles, joints,

meninges) they can be stimulated by mechanical, thermal or chemical
stimuli.
Mechanism of pain
Mechanism of pain involve the following pathways
1. Ascending pathway
2. Descending pathway

Ascending pathway: the pathway that goes upward carrying sensory

information from the body via the spinal cord towards the brain is defined as
the ascending pathway

Descending pathway: the nerves that goes downward from the brain to the
reflex organs via the spinal cord is known as the descending pathway.
Process Of Pain
There are four major processes

 Transduction

 Transmission

 Modulation

 Perception
Transduction
 Transduction occurs when a stimulus, such as pressure, thermal energy, or
chemical irritation, is converted into a nerve signal or action potential. This
occurs at the ends of sensory nerve cells known as nociceptors whose
terminals are sensitive to this type of activation

Transmission
 Transmission is the process of transferring pain information from the
peripheral to the central nervous system. Signals are transmitted along the
axons of nociceptors. Primary nociceptive sensory nerve fibers, synapse with
second-order neurons in the dorsal horn of the spinal cord. From here, neurons
project to the brainstem, thalamus, and hypothalamus, as well as to reflex arcs
to mediate an avoidance response
Perception
 Perception of pain is the awareness typically an uncomfortable awareness
associated with a specific area of the body. It depends on the transmission of
pain signals through the thalamus to the cortex and limbic system . At this
point in pain processing, perception of the pain experience is influenced by
social and environmental cues, as well as by past personal experiences.
 Modulation
 The modulation of pain involves changing or inhibiting transmission of pain
impulses in the spinal cord. The multiple, complex pathways involved in the
modulation of pain are referred to as the descending modulatory pain
pathways (DMPP) and these can lead to either an increase in the transmission
of pain impulses (excitatory) or a decrease in transmission (inhibition).
Theories Of Pain
 Intensity theory
 Cartesian dualism theory
 Specificity theory
 Pattern theory
 Gate control theory
 Neuromatrix model
 Biopsychosocial
 Cartesian dualism theory (Renee Descartes 1596-1650)

 The dualism theory of pain hypothesized that pain was a mutually exclusive phenomenon.
 Pain could be a result of physical injury or psychological injury.
 However, the two types of injury did not influence each other, and at no point were they
combine and create a synergistic effect on pain, hence making pain a mutually exclusive
entity.
 In an attempt to explain furthermore, Descartes also included in his theory the idea that pain
has a connection to the soul
 He claimed that his research uncovered that the soul of pain was in the pineal gland,
consequentially designating the brain as the moderator of painful sensations
 The dualistic approach to pain theory fails to account for many factors that are known to
contribute to pain today.
 Furthermore, it lacks explanation as to why no two chronic pain patients have the same
experience with pain even if they had similar injuries.
 Intensity theory (ERB’s 1874)

 The theory defines pain, not as a unique sensory experience but

rather, as an emotion that occurs when a stimulus is stronger than
usual
 This theory is based on Aristotle’s concept that pain resulted from
excessive stimulation of the sense of touch.
 Both stimulus intensity and central summation are critical
determinants of pain.
 It was implied that the summation occurred in the dorsal horn cells
 Specificity Theory (Von Frey, 1895)
 It holds that specific pain receptors transmit signals to a "pain center" in the brain
that produces the perception of pain
 Von Frey (1895) argued that the body has a separate sensory system for
perception just as it does for hearing and vision.
 This theory considers pain as an independent sensation with specialized
peripheral sensory receptors [nociceptors], which respond to damage and send
signals through pathways (along nerve fibers) in the nervous system to target
centers in the brain.
 These brain centers process the signals to produce the experience of pain.
 Thus, it is based on the assumption that the free nerve endings are pain receptors
and that the other three types of receptors are also specific to a sensory
experience.
 Pattern theory (John Paul Nafe 1929)
The pattern theory of pain suggests that the nerves involved in detecting pain also
detect other sensations.
 According to this theory, there are no specific nerve fibers or endings used just
for the sensation of pain. Instead, different sensations, such as cold, pain, heat,
and touch, are detected by the same nerves, which then send specific signal
patterns to the brain.
 The brain interprets the pattern, which includes both the sensation and its
intensity, and the specific sensation is felt.
 Scientists used this theory to help explain phantom limb pain, which is a
neuropathic pain experienced after a limb or part of a limb has been removed.
 However, the pattern theory of pain was disproved when scientists discovered
Gate Control Theory Ronald Melzack Patrick Wall 1965

 The gate control theory of pain asserts that non-painful input closes the
"gates" to painful input, which prevents pain sensation from traveling to
the central nervous system.
 Therefore, stimulation by non-noxious input is able to suppress pain.
 Neuromatrix Model
 Almost thirty years after introducing the gate control theory of pain, Ronald
Melzack introduced another model that contributed to the explanation of how
and why people feel pain.
 Until the mid-1900s, most theories of pain implied that this experience was
exclusively due to an injury that had occurred somewhere in the body.
 The thinking was that if an individual suffered an injury, whether it be
through trauma, infection or disease, a signal would transmit to the brain
which would, in turn, result in the sensation of pain.
 Although Melzack had contributed to these previous theories, it was his
exposure to amputees that were experiencing phantom limb pain in well-
healed areas that prompted his inquiry into this more accurate philosophy of
pain
 Continue…
 The theory he proposed is known as the neuromatrix model of pain. This
philosophy suggests that it is the central nervous system that is responsible for
eliciting painful sensations rather than the periphery.
 The neuromatrix model denotes that there are four components within the
central nervous system responsible for creating pain. The four components are
the
1. Body-self neuromatrix
2. The cyclic processing
3. Synthesis of signals
4. Sentinel neural hub
5. Activation of the neuromatrix.
 Continue..
 According to Melzack, the neuromatrix consists of multiple areas within the
central nervous system that contribute to the signal, which allows for the
feeling of pain.
 These areas include the spinal cord, brain stem and thalamus, limbic system,
insular cortex, somatosensory cortex, motor cortex, and prefrontal cortex.
 The signal that these areas of the central nervous system work together to
create is responsible for allowing an individual to feel pain, and he referred to
as the “neurosignature.”
 Furthermore, this theory states that input coming in from the periphery can
initiate or influence the neurosignature, but these peripheral signals cannot
create a neurosignature of their own.
 Biopsychosocial theory (George Engel
1977) model provides the most comprehensive explanation behind the etiology
The biopsychosocial
of pain.
 This specific theory of pain hypothesizes that pain is the result of complex interactions
between biological, psychological and sociological factors and any theory which fails to
include all of these three constructs of pain.
 They fails to provide an accurate explanation for why an individual is experiencing pain
 According to the biopsychosocial model of pain, the treatment of chronic pain must be
multifaceted.
 The primary treatment goal is to relieve physical pain, increase movement, and improve
overall functionality; however, this model also accounts for potential barriers in recovery.
 Interdisciplinary care may include primary care, psychiatric care, physical therapy,
occupational therapy, and case management.
 Treatment plans should be planned to the individual based on their physical, psychological,
and social needs.
Types of pain
 There are several ways to categorize pain. One is to separate it into
acute and chronic pain.
 Acute pain
typically comes on suddenly and has a limited duration. It's
frequently caused by damage to tissue such as bone, muscle, or
organs, and the onset is often accompanied by anxiety or emotional
distress.
 Chronic pain
lasts longer than acute pain and is generally somewhat resistant to
medical treatment. It's usually associated with a long-term illness,
such as osteoarthritis
Types of pain on the basis of body’s origin

 Pain is often classified by the kind of damage that causes it.

 The two main categories are pain caused by tissue damage, also called nociceptive pain,
 Nociceptive pain arises from the stimulation of specific pain receptors. These receptors,
called nociceptors, can respond to heat, cold, vibration, stretching and chemical stimuli
released when tissues are irritated or injured. Some examples of Nociceptive pain include:
• Sprains
• Inflammation
• Obstructions
• Bone fractures
• Myo-facial pain
• Burns, bumps and bruises
 Neuropathic pain: Pain caused by nerve damage.

 Psychogenic pain, which is pain that is affected by psychological factors

 Somatic pain comes from the skin. muscles, and soft tissues

 visceral pain comes from the internal organs.

 Cutaneous pain is caused by stimulation of the cutaneous nerve endings in

the skin.
Nursing Diagnosis
 Acute pain related to inflammatory response of body cells to
disease conditions as evidence by tachycardia, pyrexia and
facial expressions and expressive behavior.

 Vomiting related to sever pain secondary to tissue damage.

 Increase level of discomfort related to pain secondary to bone

fracture.
Assessment of pain
 Pain assessment: is a multidimensional observational assessment of a
patients’ experience of pain
 It is a broad concept involving clinical judgment based on observation of
the type, significance and context of the individual’s pain experience.
 There are challenges in assessing pediatrics pain, none more so than in the
pre-verbal and developmentally disabled child. Therefore physiological
and behavioral tools are used in place of the self-report of pain. However
in children with developmental disabilities there can be incorrect
assumptions and there is a risk of under-treating pain. It is important to
take behavioral cues identified by parents and caregivers to improve pain
assessment in these children.
Pain assessment should be conducted during a patient’s admission
pain history
• location of pain
intensity of pain
Methods of assessing pain
1. COLDERRA
2. SOCRATES
3. PQRST

 Pain Assessment Tools

 There are three main tools used for the neonate, infant and child 3-18 years these tools reflect a
combination of self-report and behavioral assessment.
1. FLACC method
2. Wong-Baker faces pain scale 3-18 years
FLACC method
The acronym FLACC stands for Face, Legs, Activity, Cry and Consolability
• 2 months-8 years and also used up to 18 years for children with cognitive
impairment and/or developmental disability (always elicit support from parents or
careers to help with pain assessment)

• It may be difficult to assess children with cognitive impairment and/or are non-
verbal. Ask the parent or career to help you explain their child’s pain behavior.
 How to use FLACC Method
Each category (Face, Legs etc.) is scored on a 0-2 scale, which results in a total pain
score between 0 and 10. The person assessing the child should observe them briefly
and then score each category according to the description supplied.
FLACC has a high degree of usefulness for cognitively impaired and many critically
ill children
Wong-Baker faces pain scale 3-18 years
 Self report
How to use?
Explain to the person that each face is for a person who feels happy because
he has no pain (hurt) or sad because he has some or a lot of pain.
 Face 0 is very happy because he doesn't hurt at all.
 Face 2 hurts just a little bit.
 Face 4 hurts a little more.
 Face 6 hurts even more.
 Face 8 hurts a whole lot.
 Face 10 hurts as much as you can imagine, although you don't have to be
crying to feel this bad. Ask the person to choose the face that best describes
how he is feeling.
 Visual Analogue scale
 8-years and older
 Self report
 How to use?
 Ask the child using numbers from 0 = no pain through to 10 being the worst
pain
Physiological indicators
• Heart rate may increase
• Respiratory rate and pattern may shift from normal i.e.: increase, decrease or
change pattern
• Blood pressure may increase
• Oxygen saturation may decrease
 Physiological indicators in isolation cannot be used as a measurement for
pain. A tool that incorporates physical, behavioral and self report is
preferred when possible. However, in certain circumstance (for example, the
ventilated and sedated child) physiological indicators of pain can be helpful
to determine a patient’s experience of pain
Non-pharmacological intervention

 Non-pharmacological pain therapy refers to interventions that do not involve the use
of medications to treat pain.

 The goals of non-pharmacological interventions are to decrease fear, distress and

anxiety, and to reduce pain and provide patients with a sense of control.
 \
 The advantage of non-pharmacological treatments is that they are relatively
inexpensive and safe
Non-pharmacological therapies are typically categorized into:
 Physical (sensory) interventions
 Psychological interventions
Sensory intervention
 Physical (sensory) interventions typically are patient-specific and inhibit
nociceptive input and pain perception. Some measures that can reduce
pain intensity and improve the patient quality of life such as
 Massage
 Positioning
 Hot and cold treatment
 Transcutaneous electrical nerve stimulation (TENS)
 Acupuncture
 Progressive muscle relaxation
Psychological intervention
 Continuous pain may lead to development of maladaptive status and
behavior that worsen day to day function, increase distress, or enhancing the
experience of pain
Most commonly used psychological interventions are
 Cognitive behavioral therapy
 Yoga
 Meditation (relaxation)
 Guided imagery
 Spirituality and religion in pain management
 Music therapy.
Pharmacological intervention
 Pharmacological pain therapy refers to interventions that involve the use of
medications to treat pain.
 A wide range of drugs are used to manage pain resulting from
inflammation in response to tissue damage, chemical agents/pathogens
(nociceptive pain) or nerve damage (neuropathic pain).

WHO Analgesic Ladder Step 1-3

 Originally developed by the World Health Organization (WHO) to improve
management of pain
 The 3 step WHO analgesic ladder is also used for providing stepwise pain
relief for pain due to other causes.
 Non-opioid medications
Step 1 - WHO Analgesic ladder Mild to Moderate pain:
 Non-steroidal anti-inflammatory drugs (NSAIDs)
 Paracetamol also known as acetaminophen
 Aspirin also known as acetylsalicylic acid (ASA)

Compound analgesics
Step 2 on the WHO analgesic ladder – mild to moderate pain
 Compound analgesics are a combination of drugs in a single tablet usually
including codeine (a weak opiate) and aspirin or paracetamol.
 Examples include co-codamol and co-dydramol which contain codeine
and paracetamol in various formulas (8/500, 10/500, 15/500, 30/500)
where the first number refers to the amount of codeine and the second to
paracetamol
Opioid medications
Step 3 on the WHO analgesic ladder – severe pain
 Medications derived from morphine (or synthetic analogs) mimic the
body’s own analgesic system and are strongest and most effective
painkillers currently available.
 Opioid medications include morphine, oxycodone, codeine, tramadol,
buprenorphine, fentanyl and diamorphine (heroin)
Topical analgesics: Topical analgesics can provide localized pain relief and
are used to treat acute and chronic pain, such as musculoskeletal and
neuropathic pain, as well as muscle pain related to trauma.
 Topical analgesics include rubefacients, topical NSAIDs and local
anesthetics.