CONCEPT OF

PAIN
(THE FIFTH VITAL SIGN)

Rowin Q. Montemar
PAIN
 Is a multidimensional phenomenon and thus difficult
to define

 Personal and subjective experience and no two

people have EXACTLY the same pain in a same
manner

 The International Association for the Study of Pain

(IASP) defines pain as unpleasant sensory and
emotional experience associated with actual or
potential tissue damage

 Sternbach defined pain as, an abstract concept, a

personal private sensation of hurt, harmful stimulus
that signals current or impending tissue damage
and pattern of response to protect the organism
from harm
PAIN

 Geach (1987) defined pain as the noxious stimulation of threatened or actual

tissue damage

 McCaffery (1979) defined pain as whatever the experiencing persons says it

is and existing whenever the person says it does

 It is an abstract concept that refers to a stimuli, physical or mental that signals

current impending tissue damage, a private, subjective bodily sensation of
hurt and a pattern of reaction or responses of the person experiencing pain
which is intended to protect the person from harm
COMPONENTS OF PAIN

1. Sensory-discriminative Component
- recognition of pain

2. Affective-motivational Component
- emotional and behavioral dimension

3. Cognitive-evaluative Component
- determined with past experience to pain
TYPES OF PAIN
ACUTE PAIN
- Short in duration (<6 months)
- Has identifiable and immediate onset
- Limited and predictable duration
- Described as: SHARP, STOBBING, SHOOTING
- Reversible and controllable with adequate
treatment
- Observable physical responses
Inc. Or dec. Blood pressure
Tachycardia
Diaphoresis
Focusing on pain
Guarding the painful part
TYPES OF PAIN
CHRONIC PAIN
- Develops more slowly and last longer than 6 months

Three types of Chronic Pain:

1. Chronic Non-malignant Pain
- Last more than 6 months
- Non-foreseeable end unless it is associated with very slow
healing as with burns
- Describe as HATEFUL or SICKENING and is typically much more difficult to
treat than acute pain

2. Chronic Intermittent Pain

- Exacerbation or recurrence of chronic condition
- Occurs only at specific periods
- Migraine, cluster headache, sickle cell crisis, intermittent abdominal pain
associated with GI disorders such as irritable bowel syndrome
TYPES OF PAIN
CHRONIC PAIN
Three types of Chronic Pain:

3. Chronic Malignant (Cancer related pain)

- Qualities both acute and chronic
- Category encompasses neuropathic,
deep visceral and bone pain
- Pain in the client suffering from cancer
- Direct result of tumor involvement
OTHER TYPES OF PAIN

1. Intractable Pain
- resistant to cure or relief
2. Phantom Pain
- actual pain felt in the body part that is no longer present
3. Radiating Pain
- perceived at the source and extend to surrounding or nearby
tissues
PHYSIOLOGIC CHANGES IN PAIN

Somatic Pain - arises from the skin, muscle or joints, maybe superficial
or deep
a. Superficial somatic pain > sharp, prickling type of pain. Usually
localized and brief.
b. Deep somatic pain > burning or aching pain. Stimulation of pain
receptor in deeper skin layer, muscle and joints.
PHYSIOLOGIC CHANGES IN PAIN

Visceral Pain - results of stimulation of pain receptors in the abdominal cavity

and thorax. Accompanied by an autonomic nervous system response.
Frequently caused by stretching of the tissues, ischemia or muscle spasm
TYPES OF PAIN STIMULUS

1. Mechanical
a.Trauma to tissues
b.Alteration in body tissue
c. Blockage of body duct
d. Tumor
e. Muscle spasm
2. Thermal
a. Extreme heat or cold
3. Chemical
a.Tissue ischemia
b. Muscle spasm
 NEUROLOGIC TRANSMISSION OF PAIN

Nociceptor is a pain reception

Damage to the receptor cells

The release of chemicals such as bradykinin (universal pain stimulus), an

amino acid chain that causes powerful vasodilatation and increase capillary
permeability, constricts smooth muscle and stimulate pain receptors

Bradykinin triggers the production of inflammatory chemical such as histamine

This movement causes the area to become REDDENED, SWOLLEN, and

TENDER

Bradykinin also stimulates the release of prostaglandins. They sensitize the

pain receptors and enhance the effects of bradykinin and histamine

Pain occurs when the pain message is relayed via the spinal cord to the brain,
which then interprets the stimuli
STAGES OF PAIN

I. Transmission/ Perception Stage

Pain signals are transmitted along two types of nerve fibers:

a) Myelinated Type A Fibers - acute sharp pain signals
b) Unmyelinated Type C Fibers - transmit sensory input at a much slower rate and produce
slow, chronic pain

Pain stimuli:
a) Exogenous - acids, bases and caustic chemical agent
b) Endogenous - potassium, histamines, serotonin, plasma kinins, acetylcholine, acid pH,
substance P (somatostatin and other neuropeptides), and prostaglandin
STAGES OF PAIN

I. Transmission/ Perception Stage

Stimuli that activate Nociceptors:

Location of receptors: provoking stimuli
a) Skin: prickling, cutting, crushing, burning, freezing
b) GI: engorged or inflamed mucosa, distention or spasm or smooth muscle
c) Skeletal muscles: ischemia, injuries of connective tissue sheaths,
necrosis, hemorrhage, prolonged contraction and injection of irritating solution
d) Joints: synovial membrane inflammation
e) Arteries: piercing, inflamed
f) Headache: traction and displacement of arteries and meningeal structures, arterial
pulsation
STAGES OF PAIN

II. Transmission Stage

 Pain fibers enters the spinal cord through dorsal horn

 Release of Substance P
 Axon of 2nd order neuron cross spinal cord
 Enters lateral spinothalamic tract
 Ascend in the lateral area of spinal cord’s white matter to thalamus of the brain
 Pain impulses travel to the somatosensory area
 Cerebral cortex for interpretation
STAGES OF PAIN

III. Modulation Stage

Endogenous Opioids - chemical receptors that modify pain and are thought to bind
with opiate receptor sites throughout the body, thereby inhibiting the production of
substances that probably transmit pain impulses and may alter pain perception

Three Groups of Opioids:

1. Enkephalins - inhibit release of substance P
2. Endorphins - morphine within
3. Dynorphins - analgesic effect
 PAIN THEORIES
1. Specificity Theory
- Assumes that pain travels from a specific nociceptor to a pain center in
the brain
- It assumes a direct relationship between the intensity of the pain stimulus and
perceived intensity of pain
- It assumes that only one structure in the brain is involved in the pain response

2. Pattern Theory
Peripheral Pattern Theory - Peripheral nerve fibers are all essentially the same
and that a given pattern of fiber stimulation is interpreted by the CNS as pain
Central Summation Theory - Focuses on dorsal horn of the spinal cord
Sensory Interaction Theory - Proposes 2 types of neurologic fiber involved in
pain, the Small diameter fibers and Large diameter fibers
PAIN THEORIES

3. Gate Control Theory

- Peripheral never fibers carrying pain to the spinal cord can have their input
modified at the spinal cord level before transmission to the brain
- Synapses in the dorsal horn acts as gates that close to ascend to the brain
- Only when synaptic gates are open, as when impulses on the pain fibers
predominates, does the personal feel the pain

4. Parallel Processing Model

- Integrates both the physiologic and cognitive-emotional aspect of pain
ASSESSMENT OF PAIN

I. History
a. Pain location
b. Intensity
c. Quality
d. Pattern
e. Precipitating factors
f.Alleviating factors
g.Associated symptoms
h. Effects of ADL
i. Past pain experience
j. Meaning of pain
k. Coping resources
l.Affective response
ASSESSMENT OF PAIN

II. Physical Examination

a.Vital signs
b. Skin color
c. Skin dryness
d. Diaphoresis
e. Facial expression
f. Body gestures
g. Discomfort
h. Anxiety
ASSESSMENT OF PAIN

II. Physical Examination

i . Physiologic response
Acute pain which stimulate sympathetic nervous system
- Increased blood pressure
- Increased pulse rate
- Increased respiratory rate
- Pallor
- Diaphoresis
- Pupil dilation
Prolonged Severe Chronic or Visceral Pain which stimulate parasympathetic nervous system
- Lowered blood pressure
- Lowered pulse rate
- Lowered respiratory rate
- Warm, skin dry
- Pupil constriction
ASSESSMENT OF PAIN

II. Physical Examination

j. Behavioral response
- Facial expression is often the 1st indication of pain
- Immobilization of body parts
- Purposeless body movements
- Involuntary movements
- Rhythmic body movements
ASSESSMENT OF PAIN

III. Instruments for Assessing the Perception of Pain

a. Faces pain rating scale
b. Pain inventory
c. Visual analogue
d. Numerical rating
e. Verbal rating scales or verbal descriptors
f. Bourbonnais pain assessment tool
g. London pain chart

IV. Factors affecting Pain

a. Ethnic/ cultural values
b. Environment
c. Emotions
d. Expectations/ presence of others
e. Age
 PAIN MANAGEMENT
I. Non-Pharmacologic Interventions
Guided imagery
Hypnosis
Aromatherapy
Magnet therapy
Yoga and meditation
Acupuncture
Biofeedback
Therapeutic touch
Cutaneous stimulation and massage
Transcutaneous electrical nerve stimulation (TENS)
Heat and cold application
Deep breathing exercises
Distraction
Humor
PAIN MANAGEMENT

II. Pharmacologic Pain Relief/ Interventions

a. Oral Route
- Non-invasive, convenient and cost-effective
- Tablets, capsule, liquid, and sublingual form
- Peak effect: 1 ½ - hours
b. IM Route
- Common route but least desirable and should be
avoided (painful)
- Peak effect: within 30-60 minutes and accompanied
by rapid fall-off of effectiveness
- Side effects: trauma-induced fibrosis of muscle and
soft tissue, never damage and abscesses
PAIN MANAGEMENT

II. Pharmacologic Pain Relief/ Interventions

c. IV Route
- Most rapid pain relief
- Provided in absolute bolus (1 administration only) dose or by continuous infusion because
plasma levels of medications are maintained and occurrence of side effects is lessened
d. Rectal Route
- Alternative route parenteral administration for people unable to take oral medications
- Medications appropriate for rectal route include Morphine, Hydromorphone (Dilaudid),
Oxycodone (Percocet),
Methadone and Oxymorphone (Numorphan)
PAIN MANAGEMENT

II. Pharmacologic Pain Relief/ Interventions

e.Transdermal Route
- Provided in skin patch, most common opioid is Fentanyl
- Peak effect: 48 - 72 hours
- Easy way of maintaining independence and avoids the
inconvenience of frequent dosing
f.Transmucosal Route
- Sublingually (Methadone) and Lozenges (Oralet) or lollipop (Actiq)
- Effective breakthrough pain in clients with scheduled opioid medication around
the clock
PAIN MANAGEMENT

II. Pharmacologic Pain Relief/ Interventions

g. Intraspinal Route
- Injected intrathecally (inside the dura mater and
contains the spinal cord) or epidurally (outside the dura mater of spinal
cord and brain)
- Delivered the area with the intended receptor sites
h. Patient-controlled Analgesia
i. Nerve block or Analgesic block
- Inject local anesthesia to close the nerves, thereby blocking their
conductivity
FACTORS ABOUT ANALGESIC MEDICATIONS

1. Evaluation of effectiveness of these drugs is completed by clinical assessment for changes

a. CNS: relief or decrease pain
b. LOC: excitement or dullness
c. Rate, depth, and pattern of respiration
d. Increase, decrease or irregular, regular HR and BP
e. GI: increase or decrease in bowel sounds, constipation
f. Laboratory test results: Serum creatinine level, CBC
count, electrolyte level, titers and uric acid level
2. Clients with pinpoint pupils means NARCOTIC TOXICITY
3.Withdrawal from dependence on narcotics includes nausea, vomiting, intestinal cramps, fever,
faintness and anorexia
FACTORS ABOUT ANALGESIC MEDICATIONS

4. If narcotics antagonists are given for respiration depression resulting from narcotic drugs, relapse of respiratory
depression occurs 15-20 minutes after administration of the antagonist, since the antagonist is short-acting than the
narcotic agent

A. Narcotics
Action: Combine with opiate receptors to produce an analgesic effect by altering perception of
pain
Uses: Severe or chronic pain, suppression of GI motility, dyspnea and antitussive effect
Major side effects:
- Toxicity: pinpoint pupils, coma
- CNS: sedation, confusion, drowsiness, euphoria
- Respiratory depression, hypotension
- GI: nausea, vomiting, constipation after multiple doses
- Tolerance and dependency
 FACTORS ABOUT ANALGESIC MEDICATIONS

A. Narcotics
WARNING: Interaction with alcohol and smoking decreases the effect. Do not administer to clients with
head injuries or increase ICP since this agent may mask any deterioration. Caution with chronic airway
limitation (CAL) and asthma to prevent respiratory depression

Nursing Implication:
1.Assess respiratory status: depth, rate, and rhythm. Hold
medication if RR is below 10 cycles/min. With shallow depth or
labored effort
2.Assess for hypotension and hold medication if systolic BP is less
than90mmHg
3. Monitor bowel elimination for constipation. Offer stool softeners
if prescribed, offer fluids, increase dietary fibers or increase assisted
ambulation
4. Instruct clients to ask for analgesics before the pain is too severe
5. Evaluate pain response to analgesic with the use of pain scale
FACTORS ABOUT ANALGESIC MEDICATIONS

6. Implement and teach patient about safety: Place

bed in low position and then side rails, get assistance
in ambulation, refrain from operation of machinery
or driving within 3-5 hours of taking the dose of medicines
7. Encourage non-pharmacological interventions

Common drugs:
Morphine Sulfate, Meperidin
Hydrochloride (Demerol)
Codeine Sulfate
Methadone Hydrochloride (Dolophine)
Hydromorphone Hydrochloride (Dilaudid)
 FACTORS ABOUT ANALGESIC MEDICATIONS
B. Mixed narcotic Agonist-antagonist Agent
Action: Bind with specific receptors to prevent the opioid from reaching an
opioid receptor site. These agents have no antitussive effects and
has fewer GI effects
Uses: Mild to moderate pain, respiratory depression, reduction in potential
for narcotic abuse and obstetric analgesia
Major side effects: Same with narcotics and withdrawal symptoms with
clients who are dependents: Nausea, vomiting, cramps, fever,
faintness, anorexia

WARNING: Abrupt withdrawal is contraindicated

Nursing implication:
1. Same with narcotics and avoid administration to clients dependent on
narcotics

Common drugs:
Butorphamol tartate (Stadol)
Nalbuphine Hydrochloride (Nubain)
 FACTORS ABOUT ANALGESIC MEDICATIONS

C. Narcotic Antagonists
Action: Compete with narcotics for receptor sites, thereby hindering the narcotic
effect. These agents work only on opioid
narcotic agonists
Uses: respiratory depression (particularly drug-induced), opioid
toxicity, diagnosis of opioid overdose, treatment of newborns
with addicted mothers
Major side effects:
Withdrawal symptoms in clients dependent on opiates or on
infants on mothers addicted to opiates: nervousness,
hypertension, palpitations, headache, and shortness of breath
GI: nausea and vomiting
CV: tachycardia and hypertension
Return of pain or discomfort for which narcotic agonist was
given
FACTORS ABOUT ANALGESIC MEDICATIONS

C. Narcotic Antagonists
Nursing implications:
1. Monitor client closely for return of respiratory depression
2.Assess and implement interventions to relieve pain and nausea
3.Assess vital signs every 5 minutes: RR and BP. Report is HR is more
than 120 beats/min. And BP over 140/90mmHh
4.Assess for withdrawal findings and treat accordingly
5. Know that physicians could order repeated dose, which varies
between drugs, within 30 minutes to 1 hour for acute respiratory
depression usually IV push

Common drugs and dose

Naloxone Hydrochloride (Narcan): IM, SC
Naltrexone (Revia), PO
Nalmefene (Revex), IM, IV, SC
 FACTORS ABOUT ANALGESIC MEDICATIONS
D. Non-narcotic Analgesic
Actions: Inhibits the enzymes necessary for the synthesis of
prostaglandin, treat pain, and act on the hypothalamus to
regulate body temperature
Uses: Mild to moderate pain, fever reduction, inflammation and
inflammatory disorders, transient ischemic attacks (TIA), MI,
an additive effects with antiplatelet or anticoagulant
Major side effects:
Toxicity: liver, kidney damage, tinnitus, hearing loss, confusion,
lethargy, hyperventilation
Hypersensitivity
GI distress: heartburn, dyspepsia
GI bleeding
Aspirin products given during or after viral infection can produce
Reye’s syndrome in children age 18 or under
 FACTORS ABOUT ANALGESIC MEDICATIONS
WARNING : Children can develop acetaminophen toxicity. All aspirin products should be avoided in children below 18 years old esp.
With those chicken pox or during or after viral illness since Reye’s syndrome may occur. Contraindicated with use of anticoagulant drugs, patients with
ulcers or those consume alcohol and competition with highly protein bound agents (Warfarin, Digoxin, SSRI¶s)

Nursing implications:
1. Assess temperature every 4 hours
2. Administer Acetylcysteine (Mucomyst), PO as antidote for acetaminophen
toxicity which should be treated immediately usually given 3-4 days
3. Evaluate degree of pain relief (pain scale)
4. Teach parents that more is not better with these agents
esp. Acetaminophen, avoid alcohol ingestion with these agents, to eat when taking the
medication to relieve GI symptoms
5. Assess signs of bleeding: nasal,. Oral, with brushing teeth, pink-tinge urine, melena or
dark tarry stool, excessive or easy bruising, oozing from minor wounds or venipuncture
sites
6. Assess for allergies before administration

Common drugs:
Acetaminophen
Acetylsalicylic acid or Aspirin, Alka-Seltzer
SURGICAL DESTRUCTION OF PAIN STIMULI

1. Rhizotomy - sensory nerve roots are destroyed where they can enter the
spinal cord
2. Cordotomy - is the division of certain tracts of the spinal cord. Performed by
open method after laminectomy
3. Neurectomy - peripheral of cranial nerves interrupt the transmission of pain
4. Symphatectomy - pathways of sympathetic division of the autonomic nervous
system are severed
PAIN-RELATED NURSING DIAGNOSIS

 Acute Pain related to injury

 Chronic pain related to chronic physical/ psychosocial disability
 Impaired physical mobility related to pain
 Activity intolerance related to unrelieved pain
 Ineffective coping related to severe pain, lack of knowledge of possible coping
methods
 Anxiety related to past experience of poor pain control
 Sleep pattern disturbance related to unrelieved pain at night
 Fear related to anticipation of pain experience
PLAN/ IMPLEMENTATION

 Establish therapeutic relationship

 Teach patient about pain relief
 Reduce anxiety and fear
 Provide comfort measures
EVALUATION

 Achieves pain relief

 Patient or family administers prescribed analgesics correctly
 Uses non-pharmacologic pain strategies as recommended
 Reports minimal effects of pain and minimal side effects of interventions
END 