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PAIN Is a subjective response to both physical and psychologic stressors. All people experience pain at some point during their lives. Although pain usually is experienced as uncomfortable and unwelcome, it also serves a protective role, warning of potentially health-threatening conditions.

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2. Each individual pain event is a distinct and personal experience influenced by physiologic, psychologic, cognitive, socio-cultural, and spiritual factors. 1. For this reason pain is increasingly referred to as the fifth vital sign, with recommendations to assess pain with each vital sign assessment.

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3. Pain is the symptom most associated with describing oneself as ill, and it is the most common reason for seeking health care.

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Among the many definitions and descriptors of pain is the one most relevant: PAIN IS “WHATEVER THE PERSON EXPERIENCING IT SAYS IT IS, AND EXISTING WHENEVER THE PERSON SAYS IT DOES”.

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Only one person can experience pain; that is, pain has a personal meaning. If the client says he or she has pain, the client is in pain. All pain is real.

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Pain has physical, emotional, cognitive, socio-cultural, and spiritual dimensions. Pain affects the whole body, usually negatively. Pain may serve as both a response to and a warning of actual or potential trauma.


THEORIES AND NEUROPHYSIOLOGY OF PAIN One well known theory, gate control, suggests that the interaction of two systems determines pain and its perception.

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The substantia gelatinosa regulates impulses entering or leaving the spinal cord. The second system is an inhibitory system within the brainstem. In the substantia gelatinosa, these impulses encounter a “gate” that is thought to be opened and closed by the domination of either the large diameter touch fibers or the small-diameter pain fibers outnumber impulses along the large-diameter touch fibers then the gate is open and pain impulses travel unimpeded to the brain.

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The second system is described by the gate control theory, the inhibitory system, is thought to be located in the brainstem. It is believe that cells in the midbrain, activated by a variety of stimuli such as opiates, psychologic factors, or even simply the presence of pain itself, signal receptors in the medulla. These receptors in turn stimulate nerve fibers in the spinal cord to block the transmission of impulses from pain fibers. Tactile information is now known to be transmitted by both large-diameter and small diameter fibers, and interactions between sensory neurons is known to occur at multiple levels of the central nervous system.


STIMULI Nerve receptors for pain are called nociceptors. They are located at the ends of small afferent neurons and are woven throughout all the tissues of the body except the brain.

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Nociceptors are especially numerous in the skin and muscles. Pain occurs when biologic, mechanical, thermal, electrical, or chemical factors stimulate nociceptors. The intensity and duration of the stimuli determine the sensation. Long-lasting intense stimulation produces grater pain than brief, mild stimulation.

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Nociceptors are stimulated either by direct damage to the cell or by the local release of biochemicals secondary to cell injury. Bradykinin, an amino acid, appears to be the most potent pain producing chemical; other biochemical sources of pain include prostaglandins, histamine, hydrogen ions and potassium ions. These biochemicals are thought to bind nociceptors in response to noxious stimuli, causing the nociceptors to initiate pain impulses.


PAIN PATHWAY 1.Pain is perceived by the nociceptors in the periphery of the body(e.g. in thee skin or viscera). Cutaneous pain is transmitted through small afferen A-delta and even smaller C nerve fibers to the spinal cord. A-delta fibers are myelinated and transmit impulses rapidly. They produce sharp, well-defined pain sensations, such as those that result from cuts, electric shocks or the impact of a blow. A-delta fibers are associated with acute pain C. fibers are not myelinated and thus transmit pain impulses more slowly. The pain from deep body structures (such as muscles and viscera) is primarily transmitted by C fibers producing diffuse burning or aching sensation.

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2. Secondary neutrons transmit the impulses from the afferent neurons through the dorsal horn of the spinal cord, where they synapse in the subsstantia gelatinosa. The impulses then cross over to the anterior and lateral spinothalamic tracts. 3. The impulses ascend the anterior and lateral spinothalamic tracts and pass through the medulla and midbrain to the thalamus. 4. In the thalamus and cerebral cortex, the pain impulses are perceived, described, localized, and interpreted, and a response is formulated. A noxious impulse becomes pain when the sensation reaches conscious levels and is perceived and evaluated by the person experiencing the sensation.

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Some pain impulses ascend along the paleospinothalamic tract in the medial section of the spinal cord. These impulses enter the reticular formation and the limbic systems, which integrate emotional and cognitive responses to pain. Interconnections in the autonomic nervous system may also cause an autonomic response to the pain. In addition, deep nociceptors often converge on the same spinal neuron, resulting in pain that is experienced in a part of the body other than its origin.


INHIBITORY MECHANISMS Efferent nerve fibers run from the reticular formation and midbrain to the substantia gelatinosa in the dorsal horns of the spinal cord. Along these fibers, pain may be inhibited or modulated. The analgesia system is a group of midbrain neurons that transmits pain inhibitory center in the dorsal horns of the spinal cord The exact nature of this inhibitory mechanism is unknown.

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The most clearly defined chemical inhibitory mechanism is fueled by endorphins (endogenous morphins), which are naturally occurring opiod peptides present in neurons in the brain, spinal cord, and gastrointestinal tract. Endorphins in the brain are released in response to afferent noxious stimuli, whereas endorphins in the spinal cord are released in response to efferent impulses, Endorphins work by binding with opiate receptors on the neurons to inhibit pain impulse transmission.




ACUTE PAIN Acute pain has a sudden onset, is usually temporary, and is localized. Pain that lasts for less than 6 months and has an identified cause is classified as acute pain. The sudden onset usually results from tissue injury from trauma, surgery, or inflammation. The pain is usually sharp and localized, although it may radiate. The three major types of acute pain are:


SOMATIC PAIN Somatic pain, which arises from nerve receptors originating in the skin or close to the surface of the body. Somatic pain may be either sharp and well localized or dull and diffuse. It is often accompanied by nausea and vomiting .


VISCERAL PAIN Visceral Pain which arises from body organs. Visceral pain is dull and poorly localized because of the low number of nociceptors. The viscera are sensitive to stretching, inflammation, and ischemia but relatively insensitive to cutting and temperature extremes. Visceral pain is associated with nausea and vomiting hypotension, and restlessness. It often radiates or is referred.


REFERRED PAIN Referred Pain, which is perceived in an area distant from the site of the stimuli, It commonly occurs with visceral pain, as visceral fibers innervating other subcutaneous tissue areas of the body. Pain in a spinal nerve may be felt over the skin in any body area innervated by sensory neurons that share that same spinal nerve route. Body areas defined by spinal nerve routes are called dermatomes.

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Acute Pain warns of actual or potential injury to tissues. As a stressor, it initiates the fight-or-flight autonomic stress response. Characteristic physical responses include tachycardia, rapid and shallow respirations, increased blood pressure, dilated pupils, sweating and pallor. The person experiencing the pain responds to this threat with anxiety and fear. This psychologic response may further increase the physical responses to acute pain.


CHRONIC PAIN Chronic Pain is prolonged pain, usually lasting longer than 6 months. It is not always associated with an identifiable cause and is often unresponsive to conventional medical treatment. Chronic pain is often described as dull, aching, and diffuse. Unlike acute pain, chronic pain has a much more complex and poorly understood purpose.


FOUR CATEGORIES OF CHRONIC PAIN Recurrent Acute Pain is characterized by relatively well-defined episodes of pain interspersed with pain-free episodes. Examples of recurrent acute pain include migraine headaches and sickle cell crises. Ongoing time-limited pain is identified by a defined time period. Some examples are cancer pain, which ends with control of the disease or death, and burn pain, which ends with rehabilitation or death.

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Chronic nonmalignant pain is non-life-threatening pain that nevertheless persists beyond the expected time for healing. Chronic lower back pain falls into this category. Chronic intractable nonmalignant pain syndrome is similar to simple chronic nonmalignant pain, but is characterized by the person’s inability to cope well with the pain and sometimes by physical, social, and/or psychologic disability resulting from pain.

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The client with chronic pain often is depressed, withdrawn, immobile, irritable, and/or controlling. Although chronic pain may range from mild to sever and may be continuous or intermittent, the unrelenting presence of the pain often results in the pain itself becoming the pathologic process requiring intervention. The most common chronic pain condition is lower back pain.

Other common chronic pain conditions include the following: : 

Other common chronic pain conditions include the following: Neuralgias are painful conditions that result from damage to a peripheral nerve caused by infection or disease. Postherpetic neuralgia(following shingles) is an example. Reflex sympathetic dystrophies are characterized by continuous sever, burning pain. These conditions follow peripheral nerve damage and present the symptoms of pain sospasm, muscle wasting and vasomotor changes(vosodilation followed by vasoconstriction)

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Hyperesthesias are conditions of oversensitivity to tactile and painful stimuli. Hyperesthesias result in diffuse pain that is usually increased by fatigue and emotional liability. Myofascial pain syndrome is a common condition mark by injury to or disease of muscle and facial tissue. Pain results from muscle spasm, stiffness, and collection of lactic acid in the muscle. Fibromyalgia isan example.

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Cancer often produces chronic pain, usually due to factors associated with the advancing disease. These factors include stretching of viscera, obstruction of ducts or metastasis bones. The malignant tumor also may mechanically stimulates pain or the production of biochemical's that cause pain. Pain also may be associated with chemotherapy and radiation therapy.

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Chronic Postoperative pain is rare but may occur following incisions in the chest wall, radical mastectomy, radical neck dissection and surgical amputation


CENTRAL PAIN Central pain is related to a lesion in the brain that may spontaneously produce high-frequency bursts of impulses that are perceived as pain. Thalamic pain, one of the most common types,is severe, spontaneous, and often continuous . Hyperesthesia (an abnormal sensitivity to touch, pain, or other sensory stimuli) may occur on the side of the body opposite to the lesion in the thalamus. The perception of body position and movement may also be lost.


PHANTOM PAIN Phantom Pain is a syndrome that occurs following amputation of a body part. The client experiences pain in the missing body part even though he or she is completely mentally aware that it is gone. This pain may include itching tingling, or pressure sensations. Or it may be more severe , including burning or stabbing sensations. In some cases, the client may describe a sensation that an amputated limb is twisted or cramped. It is thought that this type of pain may be due to stimulation of the severed nerves at the site of the amputation. Treatment is complex and unsuccessful.


PSYCHOGENIC PAIN Psychogenic pain is experienced in the absence of any diagnosed physiologic cause or event. Typically psychogenic pain involves a long history of severe pain. It is thought that the clients emotional needs prompt the pain sensations. Psychogenic pain is real, and may in turn lead to physiologic pain. This condition may result from interpersonal conflicts, a need for support from others, or a desire to avoid a stressful or traumatic situation. Depression is often present.


FACTORS AFFECTING RESPONSES TO PAIN Physical response to pain involves specific and often predictable neurologic changes. In fact, everyone has the same pain threshold and perceives pain stimuli at the same stimulus intensity. When describing a person as being highly sensitive to pain, one is referring to the persons pain tolerance, which is the amount of pain a person can endure before outwardly responding to it. The ability to tolerate pain may be decreased by repeated episodes of pain, fatigue, anger, anxiety, and sleep deprivation. Medications, alcohol, hypnosis, warmth, distraction, and spiritual practices may increase pain tolerance.

AGE : 

AGE Age influence a person’s perception and expression of pain. The older the adult with normal age-related changes in neurophysiology may have decreased perception of sensory stimuli and a higher pain tolerance. Chronic disease processes more common in the older adult. Such as peripheral vascular transmission. Individuals in this age group may have a typical responses to pain; decreased perception of acute pain, heightened perceptions of chronic pain and/or increased incidence of referred pain.


SOCIOCULTURAL INFLUENCES Each person’s response to pain is strongly influenced by the family, community, and culture. Socio-cultural influences affect the way in which a person tolerates pain, interprets the meaning of pain, and reacts verbally and nonverbally to the pain. Cultural standards also teach an individual how much pain to tolerate, what types of pain to report, to whom to report the pain and what kind of treatment to seek.


EMOTIONAL STATUS Emotional status influences the pain perception. The sensation of pain may be blocked by intense concentration (e.g. during sports activities) or may be increased by anxiety of fear. Pain often is increased when it occurs in conjunction with other illnesses or physical discomforts such as nausea or vomiting. The presence or absence of support people or caregivers that genuinely care about pain management also may alter emotional status and the perception of pain.

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Anxiety may increase the perception of pain, and pain in turn may cause anxiety. In addition, the muscle tension common with anxiety can create its own source of pain. Fatigue, lack of sleep, and depression also are related to pain experiences. Pain interferes with a person's ability to fall asleep and stay asleep and induces fatigue.


POST EXPERIENCES WITH PAIN Previous experiences with pain are likely to influence the person’s response to a current pain episode. If supportive adults responded to childhood experiences with pain appropriately, the adult usually will have a healthy attitude to pain. The responses of health care providers to the person in pain can influence the person’s response during the next episode . If providers respond to pain with effective strategies and caring attitude, the client will remain more comfortable during any subsequent pain episode and anxiety will be avoided.

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If however , the pain is not adequately relieved, or if the client feels that empathetic care was not given, anxiety about the next pain episode sets up the client for a more complex and therefore more painful event


SOURCE AND MEANING The meaning associated with the pain influences the experience of pain. If the client perceives the pain as deserved (e.g. “just punishment for sins”)’ then the client may actually feel relief that the punishment has commenced. If the client believes that the pain will relieve him or her from an unrewarding job, dangerous military service, or even stressful social obligations there may similarly feeling relief.


KNOWLEDGE A lack of understanding of the source outcome and meaning of the pain can contribute negatively to the pain experience. It is important to assess the client’s readiness to learn, use methods of teaching that are effective for the client and family and evaluate learning carefully. Teaching must include the process of the pain, its predictable course (if possible) and the proposed plan of care.


MYTHS AND MISCONCEPTIONS ABOUT PAIN MYTH 1 Pain is a result not a cause. According to the traditional view, pain is only a symptom of a condition. However, it is now recognized that unrelieved or poorly relieved pain itself sets up further responses, such as immobility, anger, and anxiety; pain may also delay healing the rehabilitation. MYTH 2 Chronic pain is really a masked form of depression. Serotonin plays a chemical role in pain transmission and is also the major modulator of depression. Pain and depression are chemically related, not mutually exclusive.

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MYTH 3 Narcotic medication is too risky to be used in chronic pain. This common misconception often deprives clients of the most effective source of pain relief. It is true that other methods should be tried first; If they prove ineffective narcotics should be consider as an alternative. MYTH 4 It is best to wait until a client has pain before giving medication. It is now widely accepted that anticipating pain has a noticeable effect on the amount of pain a client experiences. MYTH 5 Many clients lie about the existence or severity of their pain. Very few clients lie about their pain. MYTH 6 Postoperative pain is best treated with intramuscular injections. The most commonly used postoperative pain relief for many years was meperidine given intramuscularly.


MEDICATIONS Medication is the most common approach to pain management. Various drugs with many kings of delivery systems are available These drugs include non narcotic analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) narcotics,s synthetic narcotics antidepressants and local anesthetic agents.


NONNARCOTIC ANALGESICS Non narcotic analgesics such as acetaminophen(Tylenol) produce analgesia and reduce fever. The exact mechanism of action is unknown. They are used to treat mild to moderate pain


NSAIDs NSAIDs act on peripheral nerve endings and minimize pain by interfering with prostaglandin synthesis. Examples are aspirin, ibuprofen and celecoxib (Celebrex). NSAIDs have I=anti-inflammatory , analgesic and antipyretic actions. These are the treatment of choice for mild to moderate pain and continue to be effective when combined with narcotics for moderate severe pain.


NARCOTICS(OPIODS) Narcotics or opiods are derivatives of the opium plant . These drugs are the pharmacologic treatment of choice for moderate to severe pain.


ANTIDEPRESSANTS Antidepressants within the tricyclic and related chemical groups act on the production and retention of serotonin in the CNS thus inhibiting pain sensation. They also promote normal sleeping patterns, further alleviating the suffering of the client in pain


LOCAL ANESTHETICS Drugs such as benzocaine and zylocaine are part of a large group of substances that block the initiation and transmission of nerve impulses in a local area, thus blocking pain as well . Local anesthetics can be delivered by a variety of methods .


DURATION OF ACTION Each of the pharmacologic agents has a unique absorption and duration of action. The nurse caring for client in pain must understand that no drug will have a totally predictable course of action, because each person absorbs, metabolizes, and excretes medications at different dosage levels.


ROUTES OF ADMINISTRATION ORAL- The simplest route for both client and nurse is the oral (PO) route. Special nursing care is still required, because some medications must be given with food, some are irritating to the gastrointestinal system and some clients have trouble swallowing pills.

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RECTAL-The rectal route is helpful for client who are unable to swallow. Several of the opiod narcotics are available in this form. To be effective, any rectal medication must be placed above the rectal sphincter. TRANSDERMAL- The transdermal, or patch form of medication is increasingly being used because it is simple, painless and delivers continuous level of medication. To apply a medication transdermally, the nurse or client must clip any hair from the area, clean the site with clear water, dry the cleansed area, apply to patch immediately upon opening the package and ensure that the contact is complete, especially around the edges.

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INTRAMUSCULAR- Once the most popular route for pain medication administration, the IM route is being reconsidered. Its disadvantages include uneven absorption from the muscle, discomfort on administration and time consumed to prepare and administer the medication. INTRAVENOUS- The IV route provides the most rapid onset, usually ranging from 1-15 minutes. Medication can be given by drip, bolus, or patient-controlled analgesia (PCA) a pump with a control mechanism that affords the client self management of pain.

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SUBCUTANEOUS- the SC route is accepted, but It is less commonly used than other methods. Its disadvantages and advantages is similar to IV route. NERVE BLOCKS- Anesthetics sometimes in combination with steroidal anti-inflammatory drugs are injected by a physician or nurse anesthesist or near a nerve usually in an area bet. The nociceptor and the dorsal route.


SURGERY CORDOTOMY-Is an incision into the anterolateral tracts of the spinal cord to interrupt the transmission of pain. Because it is difficult to isolate the nerves responsible for upper body pain, this surgery is most often performed for pain in the abdominal region and legs, including severe pain from terminal cancer. NEURECTOMY- Is the removal of a nerve It is sometimes used for pain relief. A peripheral neurectomy is the severing o f a nerve at any point distal to to the spinal cord.

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SYMPATHECTOMY-The nerves play an important role in producing and transmitting the sensation of pain. It involves destruction by injection or incision of the ganglia of sympathetic nerves, usually in the lumbar region or the cervicodorsal region at the base of the neck RHIZOTOMY-Is the surgical severing of the dorsal spinal routes. It is most often performed to relieve the pain of cancer of the head, neck or lungs.


TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION TENS unit consist of a low voltage transmitter connected by wires to electrodes placed by the client as directed by the physical therapist. The client experiences a gentle tapping or vibrating sensation over the electrodes. The control theory clarifies how TENS works.

Advantages of TENS : 

Advantages of TENS Avoidance of drug side effects. Good interaction with other therapies. DISADVANTAGE(S) Costly The need for expert training for initiation


COMPLEMENTARY THERAPIES ACUPUNCTURE- It is an ancient Chinese system involving the stimulation of certain specific points on the body to enhance the flow of vital energy(chi) along pathways called meridians. Points can be stimulated by the insertion and withdrawing of needles, The application of heat, massage, laser or electrical stimulation; or a combination.


BIOFEEDBACK Is an electronic method of measuring physiologic responses such as brain waves, muscle contraction, and skin temperature, and then “ feeding” this information back to the client.


HYPNOTISM Hypnosis is a trance state in which the mind becomes extremely suggestible. To achieve, the client sits or lies down in a dimly lighted, quiet room. The client relax and fix attention on object. The therapist repeats a calm and soothing voice simple phrases “ simply means relaxation instruction”


RELAXATION Relaxation involves learning activities that deep in the body and mind. Relaxation distracts the client, lessens the effects of stress from pain relief measures, and increases perception of pain control.

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It involves redirection of the clients attention away from the pain and onto something that the client finds more pleasant. DISTRACTION


CUTANEOUS STIMULATION It is believed that skin stimulation is effective in relieving pain because it prompts closure of the gate in the substantian gelatinosa. It may be accomplished by massage, vibration, application of heat and cold, and therapeutic touch.


ASSESSEMENT CLIENT PERCEPTIONS – the most reliable indicator of the presence of degree of pain is the client’s own statement about the pain. The MCGill Pain Questionnaire is a useful tool in assessing the clients subjective experience of the pain. PSYCHOLOGIC RESPONSES- This may include muscle tension; tachycardia; rapid shallow respirations; increased blood pressure; dilated pupils; sweating; and pallor. BEHAVIOARL RESPONSES-Pain behaviors of people to pain SELF MANAGEMENT OF PAIN- Personal attempts of client to manage of pain


NURSING DIAGNOSIS AND INTERVENTIONS The primary nursing diagnosis for clients in pain are acute pain and chronic pain.

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