1. Kate Black Kate Brazzale Lisa Molony
Pain
Kate Black
Kate Brazzale
Lisa Molony

2. Pain Aetiology Disorder/Disease Clinical Manifestations
Pathophysiology
Diagnosis
Pharmacological Management
Non-Pharmacological Management
Complications
Implications for Nursing Practice

3. What is pain?
According to the International Association for the Society of Pain,
Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

4. Aetiology: What causes pain?
“Pain can be due to a wide variety of diseases, disorders and conditions that range from a mild injury to a debilitating disease”.

5. Acute Pain
“The terms acute and chronic refer exclusively to the time course of the pain, irrespective of aetiology” (Craft, Gordon, and Tiziani, 2011, p.144).
Acute Pain:
Usually lasts less than 3 months
Sudden onset
Usually well defined
Predicable ending (healing)
Can lead to chronic pain if left untreated
Examples: cut to the finger, broken bone

6. Chronic Pain Chronic Pain: Persistent or recurring pain
Continues for more than 3 months
May last for months or even years
Can be difficult to diagnose and treat
Primary goal is not total pain relief but reducing pain relief
Examples include: arthritis and back pain

7. Categories of pain
Another way to categorise pain is on the basis of origin:
Nociceptive
Neuropathic
Psychogenic

8. Nociceptive Pain External / Somatic
Nociceptive pain is directly related to tissue damage and can be either external (somatic) or internal (visceral)
External / Somatic
Most common type of pain
Can be superficial -in the skin but may extend to the underlying tissues.
Usually described as: sharp, shooting, throbbing, burning, stinging
well defined area
Usually lasts from a few seconds to a few days
Examples include: paper cut, sprained ankle

9. Nociceptive Pain Internal / Visceral (Deep)
Less common and usually more severe
Originates in the walls of visceral organs
Poorly defined area
Described as: deep, aching, pressing or aching
Usually lasts a few days to weeks
Virtually a symptom of all diseases at some point during disease progression.
Often associated with feeling sick
Examples include: Major surgery, labour pain, irritable bowel.

10. Neuropathic Pain
Injury or disease of the central nervous system rather than the peripheral tissue.
May be due to nerve compression, inflammation or trauma
Usually lasts between a few months to many years.
Difficult to treat due to the lack of knowledge of the underlying cause.
Often associated with paraesthesia, hyperalgesia and allodynia
Burning, shooting or pins and needles (not sharp like nociceptive).

11. Psychogenic Pain
Psychological, psychiatric or psychosocial at the primary causes
Severe and persistent pain
Appears to have no underlying pathology.
Less common now due to medical technology
Pain experienced (Headaches, abdominal pain, back pain) is indistinguishable from that experienced by people with identifiable injuries or diseases.
This kind of pain can be very frustrating to sufferers and can interfere with their ability to function normally.

12. Clinical Manifestations
“No two people are likely to experience the same level of pain for a given painful stimulus” (Craft et al., 2011, p.150).
Pain Tolerance:
The maximum level of pain that a person is able to tolerate without seeking avoidance of the pain or relief
What affects Pain Tolerance?
Fatigue, anger, boredom, apprehension, sleep deprivation. Alcohol consumption, medication, hypnosis, warmth, distracting activities and strong beliefs or faiths.

13. Clinical Manifestations
Pain tolerance is influenced by a number of factors including;
Age
Cultural perceptions
Expectations
Gender
Physical and mental health

14. Clinical Manifestations
Age:
Different reaction to pain
Understanding of pain
Gender:
“Females display greater sensitivity to pain than males do. There are differences in the way women cope with pain, report pain and respond to pain” (Crisp & Taylor, 2009, p.1096).
Physical & Mental Health
Physical mobility
Depression, difficulty coping, fatigue.

15. Cultural Variations
Cultures vary in the meaning of pain, how if it expressed and how it is treated:
Meaning
Expression
Treatment

16. Pain Threshold
Pain Threshold is the lowest point at which pain can be felt
Entirely subjective
May vary from person to person but changes little in the same individual over time.

17. Location
It is important record a patients pain location to be able to monitor any changes.
Pain can feel like it is coming from one part of the body but in fact it is another, this type of pain is called referred pain.

18. Signs and Symptoms: Signs: Symptoms: Change in temperature
Blood pressure
Respiratory rate
Heart rate
Short of breath
Sweating
Pallor
Dilated pupils
Swelling
Symptoms:
Fatigue
Feeling sick
Weakness
Numbness
Tenderness
Change in behaviour
Unable to sleep

19. PATHOPHYSIOLOGY
Pain Pathway
Classified as nociceptive

21. PATHOPHYSIOLOGY Transduction 1st Order Sensory Neurons
A Noxious Stimuli is converted (transduced) via specialized receptors on primary afferents into an electrical impulse (action potential).
noxious mechanical, chemical, or thermal stimulus
Occurs at nociceptors,
activated by intense stimuli
Strong physical stimuli and disease processes cause tissue damage and release chemicals (electrochemical reaction).
Chemicals bind and activate specific receptors on the nerve endings.
Increase the excitability of the neuronal cell membrane
Lead to generation of propagated action potentials.
Secondary messengers are released and activated
interact with the nucleus of the neuron to modulate response properties of affected neurons, leading to a state of peripheral sensitization in certain circumstances.
1st Order Sensory Neurons
Aδ and C Fibres to the posterior of the spinal cord

22. transduction

23. PATHOPHYSIOLOGY Transmission 2nd Order Sensory Neurons
action potentials (nerve impulses) are conducted to the central nervous system primarily via two types of primary afferent neurons:
thinly myelinated, faster conducting A delta fibers and
unmyelinated, slowly conducting C fibers, both termed primary afferents.
Action potentials result from activation of specific sodium channels
Peripheral transmission to the dorsal horn of the spinal cord
Synapse with the second order neurons (synaptic transmission).
Central transmission - Transmitted via neurons which cross the spinal cord and ascend to the thalamus and branches to the brainstem nuclei
SPINOTHALAMIC PATHWAY
Nociceptive impulses are relayed to multiple areas of the brain including the somatosensory cortex, the insula, frontal lobes and limbic system.
2nd Order Sensory Neurons
Cross the Spinal cord and ascend to the thalamus via the Spinothalamic Tract

24. Synaptic transmission
Once the action potential from the periphery reaches the first synapse at the dorsal horn of the spinal cord, a number of neuroactive substances are released.
These include several excitatory and inhibitory neurotransmitters and glial derived chemicals that participate in the immune responses.
Astrocytes and microglia in the dorsal horn are also involved and the sum of activity at the synapse results from release of excitatory and inhibitory neurotransmitters, which ultimately lead to generation of action potentials and central transmission of pain signals to higher centers.
Peripheral transmission
This electron micrograph depicts large myelinated, small lightly myelinated and unmyelinated fibers. Normally only the small diameter nerve fibers participate in transmitting pain sensations.

25. Synaptic transmission

26. Peripheral transmission

27. Peripheral transmission

28. PATHOPHYSIOLOGY Perception 3rd Order Sensory Neurons
The process by which a noxious event is recognized as pain by a conscious person.
Multiple areas of the brain are involved. There is no one location where perception occurs, although major defining components of pain are attributed to processes that take place in specific areas of the brain.
For example, the sensory-discriminative component is the result of activity in the somatosensory and the insular cortex, which allows the person to identify the type, intensity and bodily location of the noxious event.
The affective-emotional response to the noxious stimulus is mediated by the limbic system. Pain has an inseparable affective-emotional component that defines the response and associated behavior resulting from the initiating noxious event or stimulus.
3rd Order Sensory Neurons
To the higher brain centres of Limbic system
Frontal cortex, primary sensory cortex of the post central gyrus of parietal lobe

29. PATHOPHYSIOLOGY Modulation
Descending input from the brainstem influences central nociceptive transmission in the spinal cord.
Specific brainstem nuclei send projections to the dorsal horn of the spinal cord and when activated by ascending nociceptive impulses and other influences from the brain result in descending modulation.
Though not completely understood, modulation results in descending inhibition of nociception through the release of neurotransmitters such as serotonin, norepinephrine and endogenous opioids.
Modulatory processes can also increase descending facilitation of nociception and consequently pain. Psychological factors such as fear and anxiety exert facilitatory influences through these modulatory systems.

30. Diagnosis Diagnosis of Pain is complicated.
To diagnose pain, Nurses rely on
Objective Data.
Visual signs.
Subjective Data.
Patients descriptions.
Characteristics of Pain.

31. diagnosis Characteristics of Pain OPQRST Mnemonic Onset Provocation
Quality
Region/Radiation
Severity
Time

32. diagnosis Onset Provocation What was the patient doing at the time?
What precipitated the pain?
Is there any history of this pain in the patient?
Provocation
Aggravating Factors:
What causes the Pain to increase?
Alleviating Factors:
What makes it better or worse?

33. diagnosis 3. Quality 4. Region/Radiation
Get the patient to describe their pain to you in specific terms.
What does it feel like?
4. Region/Radiation
Where is the pain?
Where does the pain radiate?
Is it in one place?
Does it go anywhere else?
Did it start elsewhere and now localised to a different spot?

34. diagnosis 5. Severity Wong-Baker Faces Pain Rating Scale. Pain Rating
On a scale of 1 to 10, 10 being the worst pain you have experienced, what number would you assign to your discomfort?
Does their pain change with medication?
Wong-Baker Faces Pain Rating Scale.
Used for
Children
People whose first language is not English.

35. diagnosis

36. diagnosis 6. Time Are there any Associated Phenomena?
When did the pain start?
How long has the patient has this pain?
Are there any Associated Phenomena?
Factors consistent with pain e.g. Anxiety
Physiological responses
Sympathetic stimulation
Parasympathetic stimulation
Vital signs, skin colour, perspiration, pupil size, nausea, muscle tension, anxiety
Behavioural Responses
Posture, gross motor activities

37. Spinal nerves 3 Categories Dermatomes in relation to pain Dermatomes
Connective Tissue and Dermis
Myotome
Skeletal Muscle
Sclerotome
Vertebrae
Dermatomes in relation to pain
An area of skin in which sensory nerves derive from a single spinal nerve root.

38. Dermatomes Spinal Cord Dermatomatic Relationships Trigeminal Nerves
V1Ophthalmic Division – Eye
V2 Maxillary Division – Top of Jaw
V3 Mandibular Division – Bottom of Jaw
Cervical (C-2 - C-7)
fingers, neck, funny bone, and the scalp.
Thoracic (T-1 - T-12)
nipples, chest, belly button area, pubic bone, and lower sternum.
Lumbar (L-1 - L-5)
hips, the front of the legs, the shins, knee caps, and most of the feet.
Sacral (S-1 - S-5)
genitals, buttocks, back of the legs, and calves

39. Dermatomes

40. Diagnostic Tests Tests to verify pain. Ultrasound Imaging CT/CAT scan
High frequency sound waves to develop an image of the affected area.
CT/CAT scan
Computed Tomography or Computed Axial Tomography
X-rays to produce an image of a cross-section of the body.
MRI Scan
Large magnet, radio waves and a computer produces detailed images of the body.

41. Diagnostic - Tests Discography/Myelograms EMG (Electromyography)
A contrast dye is injected into the spinal disk to enhance the X-Ray.
EMG (Electromyography)
Evaluate the activity of the muscles.
Bone Scans
Diagnose and monitor infection and fracture of the bone

42. Diagnosis Psychological Assessment Pain Questionnaires
Determine Psychological Involvement.
Brain functions governing behaviour and decision making, including expectation, attention and learning.
Fear
Anxiety
Depression
Coping
Psychosocial involvement.
Plays a large role in pain perception.
Age, Sex, Culture, previous experiences.

43. GENERAL PRINCIPLES of pain management
Treat the cause of pain where possible, not just the symptom
Make accurate diagnosis and assessment of pain extent and type to ensure appropriate analgesic prescription
Keep the patient pain free
Dose at regular specified intervals, particularly for chronic pain (rather than PRN)
Avoid the chronic pain stress cycle and 'sick role‘
Prevent adverse effects of opioids
Develop a patient management plan
Follow the WHO analgesia ladder

44. Pharmacological management
WHO has developed a three-step ladder for pain relief
If pain occurs, the use of oral of drugs should be administered in the following order:
non-opioids
mild opioids
strong opioids
Image: World Health Organization

45. Pharmacological management
Involves the management of pain through analgesics
Analgesic: a compound that relieves pain by altering perception of nociceptive stimuli without producing anaesthesia or loss of consciousness
Three types of analgesics:
Opioids (narcotic) analgesics
Non-opioid analgesics (NSAIDs)
Adjuvants (DISCUSS HERE WHAT ADJUVANTS ARE OR ADD IN A SLIDE LATER)

46. Pharmacological management
Routes of administration:
Oral
Intravenously
Continuous infusion (via SC or IV routes)
Rectally
Transdermal administration
Inhalation

47. Opioids Generally prescribed for moderate – severe pain
Act on CNS by binding with opiate receptors to modify perception and reaction to pain
The most commonly used opioid is morphine

48. opioids
Add table of commonly used opioids, advantages/disadvantages

49. Opioids Adverse drug reactions may include: respiratory depression
excessive sedation
constipation
nausea
vomiting
tolerance
dependence
dysphoria (a mood of general dissatisfaction, restlessness, anxiety)

50. nsaids Non-steroidal anti-inflammatory drugs
Used to treat mild – moderate pain
Work by acting on peripheral nerve receptors to reduce transmission and reception of pain stimuli
Common NSAIDs include:
Paracetamol
Aspirin
Ibuprofen
Naxopren (arthritis)

51. nsaids Adverse reactions may include:
gastrointestinal tract disorders (dyspepsia, nausea and vomiting, diarrhoea/constipation)
renal damage
asthma attacks
skin reactions
sodium retention and consequent heart failure and hypertension
Large overdoses of paracetamol can cause fatal acute liver damage if not promptly treated.

52. nsaids Aspirin vs Paracetamol
Aspirin is readily available OTC. It can be used in stroke prevention due to its anti-platelet qualities.
In normal doses, paracetamol is a safer OTC analgesic than aspirin for the following reasons:
adverse effects and allergic reactions are rare with therapeutic doses
there is low risk of gastic upset, renal impairment or peptic ulceration compared with aspirin
plasma protein binding is negligible (no risk of displacement causing drug interactions)
few serious adverse drug interactions
may be used by children
safe to use during pregnancy and lactation

53. Include slide on adjuvants?

54. Pharmacological management
Other drugs useful for analgesic effects
GABA analogues
Capsaicin
Local anasthetics
General anasthetics
Ethanol or phenol
Cannabinoids
Specific anti-migraine drugs
Herbal remedies (e.g. cloves, feverfew, kava kava, St John's wort, ginger, ginseng)

55. Non-Pharmacological management
Definition?
Useful for patients who:
find such interventions appealing
express anxiety and/or fear
may benefit from avoiding or reducing drug therapy
are likely to need to cope with a prolonged interval of post-operative pain
have incomplete pain relief after use of pharmacological interventions
are able to use the intervention without assistance (TENS, heat packs)

56. Non-Pharmacological management
RICE (rest, ice, compression, elevation)
Physiotherapy
Counter-irritants
TENS
Acupuncture
Psychotherapeutic methods
Surgery
Community support groups
Complementary and alternative medicine - aromatherapy, herbal medicines, spinal manipulation

57. Hot and cold therapy
From: Clinical Psychomotor Skills pg 153

58. psychotherapeutic
Psychotherapeutic methods - hypnosis, behaviour modification, biofeedback, techniques, assertiveness training, art and music therapy, the placebo effect
More info on this – find some journals
Heaps of info in Crisp & Taylor

59. Tens Machine

60. TENS MACHINE
Tens Machine

61. Complications Acute – Cardiovascular Respiratory?
Respiratory
Genitourinary/Gastrointestinal
Musculoskeletal
Pressure Ulcers whilst in Hospital if unable to move from the bed
Cognitive/Psychological
Possible Fear or Anxiety surrounding injury and healing process

62. Complications Chronic – Cardiovascular Respiratory?
Respiratory
Genitourinary/Gastrointestinal
Musculoskeletal
Pressure Ulcers whilst in Hospital if unable to move from the bed
Cognitive/Psychological
Possible Fear or Anxiety surrounding injury and healing process

63. Implications for Nursing Practice
Nurses role in pain management
Administer pain-relieving interventions
Assess the effectiveness of these interventions
Monitor for adverse effects
Be an advocate for the patient when the prescribed intervention is ineffective in relieving pain
Serve as an educator to the
patient and family

64. Implications for nursing practice
Establishing a nurse-patient relationship
Positive nurse-patient relationships and teaching are KEY
Communication and patient cooperation
Believe and acknowledge that the patient is in pain – reduces anxiety
‘I know you have pain' often eases the patients mind
Education is important
Provide information
‘I know you have pain' often eases the patients mind… ‘this type of procedure can be quite painful’…. Other phrases?
- Education is important because the patient or family may be responsible for managing pain at home and preventing or managing side effects
- The nurse should provide information by explaining how pain can be controlled
Speaking notes from Crisp and Taylor:
REGULAR ASSESSMENT OF PAIN STATUS (need more info on this)
It is the nurse’s role to administer and monitor interventions ordered by the doctor for pain relief, and also implement independent pain relief measures that compliment those prescribed by the doctor
Patient remedies are often most successful, particularly if the patient has experienced that sort of pain
Generally, the least invasive theory should be tried first
Also:
Education - clients are better prepared to handle any situation when they understand it.
Confidence and tone
Relevant play for children
Holistic health - ongoing state of wellness
Cultural implications

65. Implications for Nursing Practice
Identifying goals
May include decrease in the intensity, duration, frequency, or a reduction in the side effects of pain
Consider:
the severity of the pain
the anticipated harmful effects of pain
Anticipated duration of pain
‘No pain’ may be an unrealistic goal.
Will goal be achieved by pharmacological or non-pharmacological treatments or both?
(take speaking notes from Crisp and Taylor – Planning for nursing care. These notes are from medical-surgical nursing)

66. Implications for nursing practice
Providing physical care
Ensure the patient is as comfortable as possible
Ensure that physical and self-care needs have been met and that patient feels refreshed. This might include:
Fresh gown
Change of bed linen
Teeth are brushed
Hair is combed
Gives the nurse the opportunity to perform a complete assessment
Appropriate and gentle physical touch during care may also be reassuring and comforting
Assess skin integrity (patches, IV lines)
the patient in pain may not be able to participate in the usual activities of daily living or to perform usual self-care and may need assistance to carry out these activities - patients are more comfortable when physical and self-care needs have been met, such as a fresh gown, change of bed linen, along with efforts to make the person feel refreashed such as : brushing teeth, combing hair. - in some settings, providing physical care to the patient also gives the nurse the opportunity to perform a complete assessment, and to identify problems that may contribute to discomfort and pain - appropriate and gentle physical touch during care may also be reassuring and comforting - skin integrity should also be assessed during care, especially where patches or IV drips have been fitted

67. Implications for nursing practice
Managing anxiety related to pain
A patient who anticipates pain may become increasingly anxious.
Patients who are more anxious are likely to be less tolerant.
Educate the patient on pain and pain management
Gives a sense of control
Good nurse-patient relationship is crucial
Managing anxiety related to pain
Anxiety may affect a person's response to pain: the patient who anticipates pain may become increasingly anxious. - a patient who is more anxious about pain is likely to be less tolerant. - Teaching the patient about the nature of an impending potentially painful experience and ways to decrease pain may often decrease anxiety - learning baout measures to relieve pain may lessen the threat of pain, and give the patient a sense of control - anxiety related to the anticipation of pain or the pain experience itself may be managed effectively by establishing a relationship with the patient and through education

68. Implications for nursing practice
Interventions - Who else may be involved?
Oncology nurse
Physiotherapist
Occupational therapists
The family or caregiver
People in the community: visiting nurses, pharmacists, general practitioner, palliative care nurses

69. References

70. References