PAIN

By: REX KARL S. TEOXON, RN, MD

DR. REX KARL S. TEOXON

Definition of PAIN
It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is highly subjective and individual and it is the bodys defense mechanism indicating that there is a problem.

DR. REX KARL S. TEOXON

Types of Pain
Pain is described in terms of
Location Duration Origin Cause / physiologic basis

DR. REX KARL S. TEOXON

Types of Pain
1. Location in the body :

contd.

Radiating pain: it is perceived from the source of the pain and extends to near by tissues. Eg cardiac pain Referred pain: pain from one part of the abdominal viscera may be perceived in an area of the skin remote from the organ causing pain
DR. REX KARL S. TEOXON

Types of Pain

contd.

Intractable pain: which is highly resistant to relief eg: Pain in advanced malignancy Neuropathic pain: due to result of disturbance of the peripheral CNS, which is often severe (shooting or stabbing pain)

Phantom pain: painful sensation perceived in a part of the body that is missing
DR. REX KARL S. TEOXON

Types of Pain
2. According to Origin:

contd.

Cutaneous pain: sharp pain arising from skin and subcutaneous tissue Deep somatic pain: diffuse pain arising from ligaments,tendons,bones,blood vessels and nerves eg: sprain

Visceral pain: due to stimulation of pain receptors in the abdominal cavity, cranium and thorax eg: burning aching feeling of pressure caused by DR. REX KARL S. TEOXON muscle spasm in obstructed bowel

Types of Pain
3. According to Duration:
Acute pain

contd.

- lasts upto 6 months - sudden & slow onset - mild to severe pain

Chronic pain - lasts more than 6 months - difficult to relieve - eg. Chronic malignant pain
DR. REX KARL S. TEOXON

Comparison of acute & chronic pain

Acute pain
Warns of injury Recent onset Mild severe Lasts few seconds to 6 months Anxiety follows eg. Surgical interventions, trauma

Chronic pain
No purpose Continuous/ intermittent Mild severe Lasts long 6 months and more Depression follows eg. cancer, arthritis, trigeminal neuralgia

DR. REX KARL S. TEOXON

Responses to pain
Acute pain:
Increased Pulse rate Raised BP/ fall in BP & shock Increased respiration Dilated pupils Diaphoresis Muscle tension May rub, cry / hold area Reports pain Reduced GI motility

Chronic pain:
Vital signs usually normal Pupils normal or dilated Dry or warm skin Depression, irritability Withdrawal from interests & relationships Disturbed sleep Reduced libido Reduced appetite

DR. REX KARL S. TEOXON

Types of Pain

contd.

4. According to the physiologic basis of pain

Mechanical - trauma - blockage of body duct - tumor - muscle spasm Thermal - extreme heat or cold
DR. REX KARL S. TEOXON

Types of Pain
Chemical - Tissue ischemia

contd.
Blocked artery

stimulation of pain receptors

accumulation of lactic acid

DR. REX KARL S. TEOXON

Concepts associated with pain

Pain sensation / threshold
Pain reaction Pain tolerance

DR. REX KARL S. TEOXON

Physiology of pain
Pain perception & degree of perception depends on the interaction between 1. 2. Bodys analgesia system The nervous systems transmission & interpretation of stimuli.

DR. REX KARL S. TEOXON

Physiology of pain contd

Interaction of the following are important Peripheral pain sensors (nociceptors) Pain producing substances (algesic) Sensitization of nerve endings Sensory pathway Neurotransmitters
DR. REX KARL S. TEOXON

Physiology of pain contd

Peripheral pain sensors:
PNS consists of primary sensory neurons (touch, heat, cold, pain & pressure) Nociceptors receptors transmitting pain sensation

DR. REX KARL S. TEOXON

Physiology of pain contd

Nociceptors (Primary afferent ) sensory

Mechano receptors (A Delta)

Activated by threshold hormones
Mainly present in the skin Myelinated Usually small

Polymodal (C fibres)
Activated by high intensity, physical stimuli
Widely distributed Unmyelinated Large

Respond to strong pressure and stimuli

Impulses are rapid

Responds to tissue damage (mechanical, thermal, chemical)

Impulses are slow, prolonged

Pain usually sharp, localized, Dull, aching, poorly localized DR. REX KARL S. TEOXON pricking

Physiology of pain contd

Pain producing substances (algesic):

Excitatory neurotransmitters ( other name) Released by damaged tissues Thus directly or indirectly evoke pain
Eg: bradykinin, acetylcholine, potassium ions, prostaglandins & Substance P Substance P increases permeability of local blood vessels & produce local extravasations
DR. REX KARL S. TEOXON

Cell damage

(mechanical, thermal, chemical)

Release of neurotransmitters ( algesics)

Activation of C & A delta fibers

Transmission of pain impulses 1. Along nociceptor fibers to spinal cord where synapsis takes place in the dorsal horn 2. From the spinal cord to the brain stem 3. Through connections between thalamus & cortex (spino thalamic tract)
DR. REX KARL S. TEOXON

Pain Perception & Modulation

Nociception: continues through reticular formation, thalamus, limbic system and cortex Conscious pain perception occurs at brain stem & thalamic level

Interpretation, localization & monitoring cortex

Midbrain gets stimulated & descending nerve fibers conduct impulses from brain to spinal cord Endorphins are released which decreases/block pain
DR. REX KARL S. TEOXON

Gate Control Theory

Concepts : modulation of inputs in the spinal dorsal horn by the substantia gelatinosa cells Brain is the active system that filters, selects and modulates inputs Dorsal horns are the sites at which dynamic activities like inhibition, excitation and modulation

occurred
DR. REX KARL S. TEOXON

Gate control theory contd

Peripheral nerve fibers carrying pain to the spinal cord can have their input modified at spinal cord level before transmission to brain Synapses in the dorsal horn acts as gates that close or open for the pain impulses Pain can be reduced at 4 points - peripheral site of pain - brain stem - spinal cord - cerebral cortex
DR. REX KARL S. TEOXON

Pharmacologic pain relief interventions

Analgesics :
- Non opioids/ non- narcotic analgesics - NSAIDs - Narcotic analgesics / opioids - Adjuvants / co- analgesics

Local anesthesia Patient controlled analgesia Epidural analgesia

DR. REX KARL S. TEOXON

Patient Controlled Analgesia (PCA)

A drug delivery system which is a safe method for post operative, traumatic & obstetrics, burns, terminal care pediatrics and cancer pain management Involves IV drug administration

Goal : to maintain a constant plasma level of analgesic so that the problems of as needed dosing (PRN) are avoided
Client preparation & teaching is important Check IV line & PCA device regularly DR. REX KARL S. TEOXON

Advantages of PCA
Easy access for clients for medication

Allows self administration with no risks

Pain relief without depending on nurses

Small doses of medications at short intervals for sustained pain relief Stabilized serum drug levels
Decreased anxiety
DR. REX KARL S. TEOXON

Advantages of PCA
Increased mobility for clients

Decreased risk of DVT

Patient has more control on pain management

Enhances patient participation in treatment

Less sedatory effects &nausea experienced due to small doses received Shorter hospital stay
DR. REX KARL S. TEOXON

Disadvantages of PCA
Patient becomes dependant on PCA If mobility is contra indicated, client may move due to decreased or no pain by PCA Respiratory depression Side effect may be constipation Mechanical failure of pump Relatives may press button for client

Wrong programming parameters

Incorrect placing of syringe can cause infusion of excessive drug doses

Costly & if client cant understand the system

DR. REX KARL S. TEOXON

Non pharmacologic interventions

Cognitive behavioral approaches:

1. Distraction
Diverting attention Reducing awareness of pain Increase pain tolerance

eg : music, TV, radio, playing game, reading, conversing, using computer etc
DR. REX KARL S. TEOXON

Cognitive behavioral approaches contd

2. Reducing pain perception
Removing / preventing painful stimuli especially for clients who are immobilized Consider aspects that can cause discomfort & pain and avoid them Control painful stimuli in your clients environment, eg: change wet dressings, positioning the client, preventing urinary retention, avoid exposing skin to irritants
DR. REX KARL S. TEOXON

Cognitive behavioral approaches contd

3. Bio-feed back
Using a machine that measures the degree of muscular tension with skin electrodes in microvolts A poly graph machine records the tensional level for the client to see Client learns to use relaxation technique / imagery to reduce tension Produce deep relaxation Effective for muscle tension & migraine headaches
DR. REX KARL S. TEOXON

4. Hypnosis

Cognitive behavioral approaches contd

Called as therapeutic suggestion Induces trance like state using focusing & relaxation techniques, giving the patient suggestions that may be helpful after the return of an alert state of consciousness Intense concentration reduces apprehension or stress

Should be done by trained person

Only effective when the individual cooperates
DR. REX KARL S. TEOXON

5. Physical approaches to pain management

Goals:

to provide comfort to correct physical dysfunctions to alter physiological responses to reduce fears associated with pain related immobility

Examples: 1. Acupressure / acupuncture 2. Cutaneous stimulation (massage, heat application, TENS,) 3. Binders, Chiropractice
DR. REX KARL S. TEOXON

6. Acupressure / Acupuncture
Chinese technique Various points in the body stimulate the flow of Qi (chee) or natural meridians ( lines/passage ways) of energy that pass through the body Used for backache, migraines Post operative pain Acupressure - application of pressure to various points of body Acupuncture insertion of extremely fine needles into various points of the body. The needles unblock the meridians allowing free flow of energy and relief DR. REX KARL S. TEOXON of symptoms

Acupuncture Acupuncture is a traditional Chinese medicine that stimulates specific points in the body in order to restore a proper balance of various chemicals. This practice is used to treat a range of conditions, including chronic pain, drug addiction, arthritis, and mental illness.
DR. REX KARL S. TEOXON

DR. REX KARL S. TEOXON

7. Cutaneous stimulation
Massage stimulates circulation, relaxes muscles, increases patients sense of well being Application of heat used to soothe / relieve pain from muscular strain / overwork eg: for healing tissues Application of cold reduces swelling, calming muscle spasms, reducing pain in joints & muscles
DR. REX KARL S. TEOXON

Cutaneous stimulation contd

TENS (Transcutaneous Electric Nerve Stimulation)

Placing electrodes on the painful area of patients skin Low current running through the electrodes acts to block the pain sensation. Must have a doctors order Should be done by a trained person Used for post operative pain and post traumatic patients DR. REX KARL S. TEOXON

Cutaneous stimulation contd

Percutaneous Electrical Stimulation (PENS) For relief of back pain, headaches Electric current sent through thin needle probes positioned in soft tissues & muscles of the back

DR. REX KARL S. TEOXON

8. Binders
Clothes wrapped around a limb / body part
Used for strains, sprains & surgical incisions Supports the surface & internal tissues during movement, coughing and other activities

DR. REX KARL S. TEOXON

9. Chiro-practice
Involves manipulation or adjustment of the joints and adjacent tissues of the body, particularly spinal column

Non-invasive
Drug free treatment Should be done a doctor chiro-practitioner.
DR. REX KARL S. TEOXON

10. Rest and sleep

May be interrupted due to pain, fear or side effects of medication Assist patient in obtaining enough sleep and rest so as to promote healing & maintain health

DR. REX KARL S. TEOXON

11. Use of Placebos

Any medication / procedure that produces an effect resulting from its implicit / explicit intent from its specific physical / chemical properties
eg : normal saline, empty capsules,or same procedure like electrodes with no therapeutic value
DR. REX KARL S. TEOXON

Biofeedback in Progress A patient at a biofeedback clinic sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions, and may help some paralyzed patients regain the use of their limbs.
DR. REX KARL S. TEOXON

Barriers to pain management

Patient factors:

Fear of discussing pain Fear of being labelled a complainer Fear that treatment will be discontinued Fear that pain discussion will divert the physicians attention from the underlying disease Fear of taking pain medications ( opioids)
DR. REX KARL S. TEOXON

Barriers to pain management (cont)

Professional factors: Poor pain assessment skills Concern about drug side effects Exaggerated fear of addiction Lack of knowledge and skills in pain management

DR. REX KARL S. TEOXON

Barriers to pain management (cont)

Health system factors: Unavailability of some drugs Cost of care Unavailability of doctors, nurses, and other healthcare professionals Inadequate physician reimbursement for pain management and palliative care
DR. REX KARL S. TEOXON

Barriers to pain management (cont)

Other factors: Ethnic and cultural values Individual management strategies Environmental support Support of other people Previous experience The meaning of current pain Anxiety and stress levels
DR. REX KARL S. TEOXON

Overcoming barriers to pain management

Principles: Respect patients autonomy - treat patients as individuals - no two patient experience same pain The willingness to do good for patients Commitment to avoid harm to patients - untreated patients suffer physically, psychologically and emotionally Justice equal treatment for all patients DR. REX KARL S. TEOXON

Overcoming barriers to pain management contd..

Respect other culture Educate the patient with pain management options Create conducive environment Utilize all available resources Involve family members or care givers Assess all factors affecting pain experience and deal with them appropriately Obtain knowledge &skill in pain management Improve communication between staff &patients Trust and believe patients, families and caregivers on the information provided onS.pain experience DR. REX KARL TEOXON

PROFESSIONALS MISCONCEPTIONS ABOUT PAIN IN CHILDREN

Fallacies & facts

Fear of Addiction
Fear of Respiratory Depression

DR. REX KARL S. TEOXON

Pain Management in Children

Fallacies about children & pain:
Infants do not feel pain Children tolerate pain better than adults Children cannot tell you where they hurt Children always tell the truth about pain Children become accustomed to pain or painful procedures Behavioral manifestations reflect pain intensity Narcotics are more dangerous for children than they are for adults
DR. REX KARL S. TEOXON

Why is treating pain important?

Pain can affect the childs ability to breathe easily, perform physical, and eat normally Pain can affect his / her activity level Pain interferes with sleep and energy level Pain alters moods and interferes with relationships Pain relief prevents or relieves suffering Pain relief may help speed up healing and allow clients to leave the hospital sooner
DR. REX KARL S. TEOXON

How is pain treated in children?

1. NIPS - (Neonatal Infant Pain Scale) For babies 2. CHEOPS - (Childrens Hospital of Eastern Ontario Pain Scale) 3. OUCHER - For older children 4. Comfort Scale - For unconscious children
DR. REX KARL S. TEOXON

How is Pain Treated in Children?

Reducing pain depends on:
1.Cause of the pain 2.Situation of the child is in 3.Childs medical and psychological condition

Important thing about pain treatment is that it is an ongoing process and to make sure that pain is being relieved as best possible, with minimum side effects
DR. REX KARL S. TEOXON

How can I help the child be comfortable?

1. Be yourself 2. Speak up for the child
Know what to expect, i.e. side effects Preventive action- planning ahead helps Reduce stress and help child be relaxed and distracted Staying ahead of pain After care, (i.e.) withdraw gradually
DR. REX KARL S. TEOXON

When to call the childs doctor

If pain is not being relieved by the treatments prescribed If you think the child is having side effect from the treatment, i.e. vomiting, itching, or urination problem If child is too sleepy If child is not making sense when he/she talks
DR. REX KARL S. TEOXON

Types of Pain in Children

Illnesses e.g., cancer pain, flu, ear infection
Surgical Pain inpatient or outpatient Tests & Investigations Injuries/Trauma e.g., spraining an ankle, fracture
DR. REX KARL S. TEOXON

Surgical Pain
Causes:
Incision or cut Muscle spasms or cramps (ortho surgery) Bladder cramps Tubes left in place post surgery Air or blood inside the belly or chest (referred pain) Backaches, muscular aches or other discomforts Gas pain
DR. REX KARL S. TEOXON

Surgical Pain (cont)

Treatment: 1ST-2ND DAY post op are usually the worst Strong pain medication (IV), then to oral when allowed PO. eg. Morphine which is safe for babies

DOSING is done by weight

Staying Ahead of pain, then to catch up

+ non-prescription meds & anti-inflammatory drugs

DR. REX KARL S. TEOXON

Pain control
Epidurals Nerve Blocks Caudal Analgesia PCA

Massages & Healing touch

PT TENS Biofeedback, Acupuncture
DR. REX KARL S. TEOXON

Pain Control (cont)

Special Instructions emphasize that the child does not have to be brave or put up with the pain

After Care dont give more than instructed; if pain medication is not working, call the doctor Activity getting out of bed & moving around helps the body recover post surgery, WHEN APPROPRIATE
DR. REX KARL S. TEOXON

Sedation
Type of Sedation Chosen is Based on: 1. Childs Age 2. Childs Weight 3. Exam to be performed *Can either be oral or IV
DR. REX KARL S. TEOXON

Nursing care
1. MONITORING
2. TOTAL CARE (HOLISTIC) Airway, Positioning, Comfort Level, I&O 3. SAFETY MEASURES Risk of fall, injuries

DR. REX KARL S. TEOXON

Aids to the Assessment of Pain in Children

Direct communication Indirect behavioral methods Physiological status

DR. REX KARL S. TEOXON

Suggestions for Improvements in Pediatric Pain Control

Greater use of local anesthetic techniques
Patient controlled analgesia Psychological techniques Biofeedback and relaxation techniques

DR. REX KARL S. TEOXON

DR. REX KARL S. TEOXON

Visual analogue scale

Visual Score

0 Verbal Score No pain

1-2-3 Hurts little

4-5-6 Hurts a lot

7-8 Really hurts a lot

9-10 Extremely hurts

Observer scoring

Appears pain free

Comfortable except on movement

Uncomfortable

Distressed can be comforted

Distressed

DR. REX KARL S. TEOXON

DR. REX KARL S. TEOXON