Pain handouts

 An unpleasant sensory & emotional “suffering” experience usually associated with disease or
injury

 Universal, complex, subjective experience

 Most common reason why a person seek medical care

 Types of PAIN:

 Acute pain

 Results from acute injury, disease or surgery usually temporary, sudden onset and easily
localized (postoperative, trauma, burns, procedural, obstetric)

 Acts as a warning signal (activates “fight or flight” reaction)

  HR, BP, RR, mydriasis, sweating

 Chronic pain

 Chronic cancer pain

 Chronic noncancer pain

 ACUTE and CHRONIC PAIN:

Acute Chronic (CA & Non-CA pain)

- short duration - last for several months

(usually >3 or 6 mos.)

- associated w/ tissue - may or may not have well-

trauma/ identifiable cause defined cause

- diminishes w/ healing - begins gradually & persists

- mild to severe - ranges from mild to severe

intensity

- maybe accompanied by - may be accompanied by

anxiety & restlessness depression & fatigue, as

well as decreased functional

Nociceptive Pain

 Point of cellular injury

(noxious stimuli)

Peripheral

sensory nerves

SC Thalamus

Cerebral Cortex

Caused by:

Mechanical, Chemical, Thermal, Electrical injuries, D/O affecting bones, joints, muscle, skin, CT

 Superficial “Cutaneous” somatic pain

 Ex; Insect bite, paper cut

 “sharp” or “burning” discomfort

 Deep somatic pain

 Ex; trauma (fractures)

 Localized sharp, throbbing & intense sensations

 Arises from internal organs

 Caused by ischemia, compression of an organ (tumor), intestinal distention w/ gas, spasm

 Diffuse, poorly localized accompanied by autonomic NS symptoms (N&V, pallor, hypotension,

Referred pain – perceived in a general area of the body, but not in the exact site where an organ is
anatomically located

 Results from damage to the pain pathways or pain processing centers in the brain
Example:

 phantom limb pain

 Spinal cord injuries

 Strokes, diabetes, herpes zoster (shingles)

CANCER Pain

 May be either nociceptive or neuropathic pain

Tumor creating a pressure in the organ?

Effects of chemotherapy or radiation?

 Regardless of its nature, pattern, or cause, PAIN that is inadequately treated has harmful effects
beyond the suffering it causes…

 Impact of Unrelieved PAIN

 Physiologic impact:

 prolongs stress response,  HR, BP & oxygen demand,  GI motility, causes immobility,
 immune response, delays healing,  risk for chronic pain

 Quality of Life impact:

 interferes with ADL, causes anxiety, depression, fear, anger & sleeplessness, impairs
family, work & social relationships

 Financial impact:

 US - $100 billion/ year, increases hospital lengths of stay, leads to cost income &
productivity

 PAIN Transmission

4 phases:

 Transduction

 Transmission

 Perception

 Modulation

 Transduction
  Conversion of chemical information to electrical impulses

 Chem’l mediators (PG, bradykinin, S, histamine, subs P)  stimulate free nerve endings
“nociceptors”

 Impulses are carried by nerve fibers; A-delta fibers & C- fibers

A delta fibers C fibers

 myelinated fibers  unmyelinated/poorly

aka “mechanical myelinated fibers

nociceptors (respond conduct thermal, predominantly to mechanical

rather than chemical or mechanical impulses

thermal stimuli)

carries rapid (5-30m/sec), throbbing, aching or sharp, acute pain burning

ex: touching a hot (0.5-2m/sec)

iron

produces intermittent produces persistent pain pain

 Transmission phase

 Peripheral nerve fibers

form synapses with

neurons in the SC

 It will ascend to RAS,

limbic system, thalamus,

cerebral cortex

 Perception

 Brain experiences pain at the conscious level (conscious experience of discomfort)

 Modulation phase

 Last phase of pain impulse transmission, during which the brain interacts with the spinal nerves
  At this point, pain is reduced due to endogenous opioids release

Theoretical bases for PAIN

 Gate Control Theory:

 explains the relationship between pain & emotion

 results to a conclusion that pain is not just a physiologic response… that psychological
variables (behavior & emotion) also influence the perception of pain

 in this theory: a “gating mechanism” occurs in the SC

 Similar gating mechanisms exist in the nerve fibers descending from the thalamus and cerebral
cortex (areas that regulates thoughts & emotions, beliefs & values)

 When pain occurs, a person’s thoughts and emotions can modify perceptual phenomena as they
reach the level of conscious awareness

Significance of gate control theory:

 Recognition of holistic nature of pain

 Development of many cognitive-behavioral therapies (imagery & distraction) to relieve

Anatomic & physiologic bases for PAIN

Pain stimuli:

Sensory input

(thermal, mechanical, chemical stimuli)

“Nociceptors” “actual tissue damage”

(free nerve ending “intense stimulation”

receptors capable of

responding to painful chemical subs.

stimuli) (histamine, bradykinin

serotonin, NE, PG,

(+) pain receptors

1st order neurons:

 A delta fibers (skin, muscles)

 C fibers (muscles, periosteum, viscera)

2nd order neurons

Spinothalamic tract (found in dorsal horn of SC &

terminates at the thalamus)

Lateral spinal tract Paleospinothalamic tract

“ Neospinothalamic tract”  synapses with “emotion center”

 sensory pain discrimination LIMBIC system & “sleep-wake

 transmit pain more directly center” RETICULAR form’n

to the sensory cortex

Therefore, painful stimuli are

subjected to emotional &

behavioral influences

CNS Processing:

 Thalamus

- relay station for sensory

input from spinothalamic

tract of SC

 Midbrain

- signals the cortex to

increase awareness

of the stimuli

 Cortex
 - discrimination of

well-localized pain &

interpretation of pain

experience

Inhibitory & Facilitatory Mechanisms:

Neuroregulators – chem’l subs. that may influence the

sensory input to the SC

Neurotransmitters Neuromodulators/Endogenous

opiates

- chem’l that exert - natural opiate-like subs.

(-) or (+) activity found in the brain resp. for

@ the post synaptic pain relief

nerve cell membrane - composed of large a.a.

ex; AcH, NE, E, D, S peptides “alpha-endorphins”,

“beta-endorphins” &

“enkephalins”

 Opioid receptors

- “binding sites” for both endogenous opiates & opioid

analgesics

- drugs like morphine & morphine agonist binds to

these receptors

binds

- types: mu, kappa, delta, epsilon & sigma

- mu receptors are found throughout the CNS

horn of the SC

Terms used in the context of PAIN:

 Radiating pain—perceived at the source of the pain and extends to the nearby tissues

 Referred pain— pain is perceived in an area distant from the site of painful stimuli

 Intractable pain—pain that is highly resistant to relief

 Phantom pain—painful perception perceived in a missing body part or in a body part paralyzed
from a spinal cord injury

 Phantom sensation—feeling that the missing body part is still present

 Hyperalgesia—excessive sensitivity to pain

 Pain threshold “Pain Sensation” — the amount of pain stimulation a person requires in order to
feel pain

 Pain tolerance—maximum amount and duration of pain that an individual is willing to endure

 Nociceptors—pain receptors

 Pain perception—the point which the person becomes aware of the pain

Assessment:

 History

 Precipitating factors

 Does the client associate any activities, food, or other environmental factors
with the onset of pain?

 Aggravating factors

 What factors make the pain worse?

 Localization of pain

 Can the client localize the pain or describe where it travels or radiates?

 Character and quality of pain

 What words does the client use to describe the pain and its character, quality or
intensity?
  Duration of pain

“If the client is in pain when the nurse is obtaining the history, the session should be kept reasonably
short or continued at a later time”