UNIT 9

PAIN MANAGEMENT
27.06.2022

• Presented by: Ms. Haimene

Definition of concepts
Pain is:
- what the patient says HURTS
- an unpleasant and highly personal experience
that may be imperceptible to others.
Arthur Rosenfeld once said “Feeling pain is
unhealthy and to endure pain is unnecessary”
Concepts associated with pain:
1.Pain threshold refers to the lowest intensity at which a given stimulus is
perceived as painful. The intensity at which a stimulus e.g. heat, pressure begins to
evoke pain. This is a minimum point at which something such as heat or pressure
causes you to feel pain.
It is a point beyond which a stimulus causes pain, or the upper limit of
tolerance to pain Or can be defined as the point at which a stimulus such as
pressure, temperature activates pain receptors to produce a sensation of pain
(the point at which pain begins to be felt.
2.Pain tolerance is influenced by people’s emotions, bodies and lifestyle. Referred
to how much pain a person can reasonable handle or the maximum amount of pain
you can handle.
The highest intensity of pain stimuli that a person can tolerate voluntarily
without seeking medical or other interventions
Concepts associated with pain….

Hyperalgesia severe pain, used interchangeably

to denote heightened responses to pain stimuli
Hyperpathia: Also severe pain
Allodynia: Non-painful stimuli e.g light touch
Dysesthesia: unpleasant abnormal sensation
Physiology of pain
Transduction-
Transmission
Perception
Modulation
Pls read fundamentals of nursing concepts, process
and practice by kozier and Erb’s 9th edition. Pg 1227
Describe the four processes that are involved in pain transmission
 Transduction- noxious or unpleasant stimuli trigger the release of chemical mediators such as
prostaglandins, bradykinin, serotonin and histamine. Nociceptors are stimulated by the
movement of ions across cell membranes.
 Transmission- pain impulses are transmitted from the peripheral receptors to the dorsal horn
of the spinal cord. Substance P (a neurotransmitter) enhances the movement of these impulses
from the site of transduction to the spinal cord.
 Perception- Is when the person becomes aware of the pain that is, the character, intensity
Several factors affect pain perception e.g past experiences, age, culture etc
 Modulation- Occurs when motor neurons in the thalamus and brain stem sends signals back to
the spinal cord which stimulates production of endogenous opioids serotonin and
norepinephrine endorphins and encephalins which inhibit nociception
This helps to diminish pain signals
Pain threshold
Factors that raise the pain threshold:
- Insomnia and Fatigue
- Fear of dying and Fear of pain
- Anger and Boredom
- Abandonment, especially pt’s with HIV and AIDS
- Stigma associated with the disease
- Loss of self esteem
Pain threshold cont…
Factors that reduce pain threshold
- Relief of symptoms
- Relief of existing pain
- Sleep and adequate rest
- Sympathy and Companionship
- Reduction of anxiety
- Diversion-switching ur focus onto something else
Types of pain
Pain may be described in terms of location, duration, intensity and
etiology. 1.Location: Pain based on location e.g head, back and chest.
Pain may also be referred to other part of the body. E.g cardiac pain may
also be felt in the shoulder. Visceral pain; pain arising from organs or
hollow viscera, remote from the organ causing the pain.
2.Duration; Pain can be acute (sudden)or chronic (persistent).
3.Intensity; using a standard scale : 0 (no pain) to 10 (worse possible
pain). Pain in the 1 to 3 range is deemed mild pain and a rate of 4 to 6 is
moderate pain and pain reaching 7 to 10 is deemed severe pain.
Types of pain…..
4. Etiology; Designating types of pain by etiology can be
done under the broad categories of nociceptive pain and
neuropathic pain.
1. Nociceptive pain; is experienced when an intact
properly functioning nervous system sends signals that
tissues are damaged , requiring attention and proper care.
E.g a pain experienced following a broken bone alerting
the person to avoid further damage until it further healed.
Types of pain…..
These include (a)somatic pain ( originate in the skin, muscles,
bones or connective tissues) and neuropathic pain (associated
with damaged or malfunctioning nerves due to illness e.g post
herpetic neuralgia).
(b)Visceral pain- It is felt in the internal organs and main body
cavities. The cavities are divided into the thorax (lungs and
heart), abdomen (bowels, spleen, liver and kidneys), and the
pelvis (ovaries, bladder, and the uterus). The pain receptors -
nociceptors - sense inflammation, stretch and ischemia (oxygen
starvation).
2. Neuropathic pain
It is associated with damaged or malfunctioning nerves due to
illness e.g post herpetic neuralgia, spinal cord injury pain. Pain
that comes from the nervous system is called non-nociceptive
because there are no specific pain receptors. It is mostly chronic.
The types are:
a)Peripheral neuropathic pain- Follows damage of peripheral
nervous system nerves e.g a damaged limb where there if
phantom pain
b)Central neuropathic pain- Results from malfunctioning
nerves in the central nervous system e.g multiple sclerosis
Subjective data the nurse would collect during pain assessment
 Onset of pain in order to determine if it is acute or chronic pain
 Location of pain or region
 Characteristics e.g., pricking dull throbbing, aching
 Aggravating and reliving factors e.g., movement, position, food intake etc
 Radiation to other regions or organs of the body
 Timing of the pain whether its continuous, intermittent
 Severity of the pain (mid moderate or severe
 Associated symptoms e.g., nausea, vomiting, sweating, blurred vision etc
 Any treatment previously used for the pain
 Perception of what caused the pain
The different between acute pain and chronic pain
Acute Pain Chronic pain
Mild to severe Mild to severe
Sympathetic nervous system response: Parasympathetic nervous system
responses
Increased PR Normal vital signs
Increased RR
Elevated BP
Diaphoresis Dry warm skin
Dilated Pupils Normal or dilated pupils

Related to tissue injury, resolves with healing Continues beyond healing

Client is restless & anxious Usually depressed & withdrawn
Reports pain Does not mention pain unless asked
Exhibit behavior indicative of pain: crying, rubbing the area,
holding area Pain behavior often absent
Types of pain….
Physical pain
- Soft tissue
- The viscera-internal organs
- Bone and joint pain
- Nerve compression and damage pain
- Raised intracranial pressure
- Pain related to treatment e.g. cancer treatment
Mental pain
- Fear of pain and suffering
- Fear for death and dying
Types of pain cont…
Social pain:
- Loss of a job and income
- Loss of effectiveness in the community
- Loss of body image
Spiritual pain:
- Weigh up the significance of life
- Question the meaning of life
Clinical signs/symptoms of pain
A pain history needs to be taken. (Subjective)
Observing the behavioral responses by the patient
(Objective) e.g
Facial expression (e.g teeth grinding, biting the lips etc
Purposeful body movements (e.g immobilizing the
painful body part, etc
Purposeless body movements (e.g flinging arms about, tossing
(moving from side to side) and turning).
Rhythmic body movements (e.g rubbing, tapping, massaging).
Changes in speech (e.g rapid speech and elevated pitch may indicate
anxiety; slow speech and monotonous tone can be a signal of intense
pain
Associated symptoms, (e.g nausea and vomiting, dizziness,
constipation).
Faces scale
A full history and assessment of a patient is necessary for
successful pain management.
Body weight and other physical factors may influence
treatment of pain.
The presence of other diseases such as kidney or liver disease
will influence the type and dosage of any drugs to be
administered.
Patients with debilitating diseases, whether old or young, have
a heightened sensitivity to the effects of narcotics.
Pain assessment
PQRST tool for questions to assess pain:
Precipitating and relieving factors:
What makes your pain better / worse?
Quality of pain:
How will you describe your pain
Radiation of the pain
Is the pain in one place or does it move?
Site and severity of pain:
Where is your pain? How bad is it?
Timing and previous treatment:
- How often do you get the pain? When? Are you on pain
treatment? Does it help? NB: Read more on nursing assessment on p.g 1238
Identify the subjective data the nurse would collect during pain assessment
 Ask about-Onset of pain in order to determine if it is acute or chronic pain
 Location of pain or region
 Characteristics e.g., pricking dull throbbing, aching
 Aggravating and reliving factors e.g., movement, position, food intake etc
 Radiation to other regions or organs of the body
 Timing of the pain whether its continuous, intermittent
 Severity of the pain (mid moderate or severe
 Associated symptoms e.g., nausea, vomiting, sweating, blurred vision etc
 Any treatment previously used for the pain
 Perception of what caused the pain
factors that affect pain perception
 Culture
 Developmental factors-Age and Gender
 Meaning of pain
 Psychological factors –Anxiety and depresion
 Pain control strategies
 Past experience of pain
 Attention seeking / received
Possible nursing diagnosis and interventions
 Acknowledge reports of pain immediately so as to decrease anxiety in the patient
and it fosters development of trusting relationships.
 Assessment of pain characteristics such as quality, severity, location, onset,
duration and precipitating factors to be done to so as to effectively plan for pain
management strategies.
 Assess for signs and symptoms relating to pain as some patients may deny
presence of pain
 Monitor vital signs to confirm presence of pain such as temperature, pulse and
blood pressure which are high in patients with acute pain
 Assess skin which may be pale and cool to touch in the presence of acute pain.
 Assess to what degree cultural, environmental, intrapersonal and intrapsychic
factors may contribute to pain or pain relief.
 Rule out presence of a distended bladder which may be indicative of pain.
 Rule out anxiety and fear related to effect of hospitalization and outcome of the
surgical procedure done which may be exacerbating the pain.
 Assess patient’s willingness for pain relief as some patients may be satisfied if pain is
no longer massive and others demand complete elimination of pain which then
influences perceptions of effectiveness of treatment modalities and their participation.
 Initiate non pharmacological strategies to eliminate pain.
 Encourage patient to implement cognitive-behavioral strategies such as imagery,
distraction and deep breathing exercises as taught during the pre-operative period to
lessen stress, tension, and subsequently relieve pain.
 Implement cutaneous stimulation in the patient by performing massage so as to trap
the pain transmission and increase endorphin levels and to minimize tissue edema.
 Heat compresses are to be implemented so as to decrease pain by improving blood
flow to the area and to reduce pain reflex; cold compress will lessen pain,
inflammation and
General measures to relieve pain and promote
comfort
Correct alignment and positioning in bed e.g by
correctly positioning the patient’s leg in a cast, pain may
be relieved to such an extent that no analgesic is required.
The muscles surrounding painful inflamed or injured
tissues should be supported in such a way that ensures the
complete relaxation of these muscles
Massage is most useful in the early stage of
inflammatory swellings and in treating the pain of
various forms of myalgia, fibrositis or labour. Effective
massage however can be a useful way as to other pain
relief measures and may lessen the need for drugs.
The nurse must protect the patient from pain-producing
stimuli such as distension of hollow visceral organs (full
bowel/bladder) or further damage to traumatized tissue.
Injured tissue should be handled carefully
Painful procedures should be done at a time when pain-
relieving medications are having their maximum effect.
Analgesic doses should be planned so that the dose can
be given prior to a painful procedure or dressing.
Drainage tubes should be checked frequently to ensure
that they are not caught, stretched, pulled, kinked or
looped and that they are positioned correctly to enhance
drainage and reduce distension and pressure.
Care must be taken to prevent fatigue. Over-tiredness
decreases pain tolerance.
Immobilization may reduce pain caused by
inflammation or the interruption of blood supply.
Elevation may relieve pain in swollen body parts
A position of semi-flexion may reduce the pain of joint
disorders.
The pain of muscle spasm may be relieved by a change
in position.
Frequent position changes along with a good body
alignment may prevent painful muscle contractures.
Any unmet needs that may be contributing to a patient’s
pain should be identified.
If a patient’s basic needs are met, pain or discomfort
may be reduced or even eliminated.
Non-pharmaceutical methods of pain management
Physical:
- Massage, exercise, physiotherapy, surgery
Psychological:
- Strengthening coping mechanisms through
counselling, relaxation therapies
Social:
- Help patient to resolve social or cultural problems
through community resources , financial and legal
support
Spiritual:
- Religious counselling and prayers.
(African Palliative Care Association (APCA) p 43)
WHO three step ladder approach to analgesic
pain management
Step 1:
Non-opioid (Paracetamol, Aspirin) + adjuvant (antidepressant). If pain is not
controlled by step 1 move to step 2 by adding a week opioid.
Step 2:
Opioid for mild to moderate pain (codeine) + non-opioid(paracetamol) +
adjuvant (antidepressant). If an opioid for mild to moderate pain has been used to
maximum dose and the patient still has pain, move to step 3 by changing to a
strong opioid.
Step 3:
Strong opioid (morphine) + non-opioid + adjuvant
(African Palliative Care Association (APCA) p 43-44).
NB: Home work: Define and explain the following pain
related terms:
• Imagery
• Distraction
• Massage
• Acupuncture
• Therapeutic touch
• Immobilisation
References
Berman, A & Snyder, S., (2014). Kozier & Erb’s
1.

Fundamental of Nursing, Concept, Process, and Practice.

9th edition. United State of America: Pearson
2. Nettina, S.M. (2010) lippincott. Manual of Nursing
practice. Tokyo: Wolter