Pain Management Dr. Ali D. Abbas Instructor, Fundamentals of Nursing Department, College of Nursing, University of Baghdad ali_dukhan@yahoo.com LEARNING OBJECTIVES After mastering the contents of this lecture, the student should be able to: 1. Describe types of pain. 2. Assess the nature of pain as it relates to onset, intensity, and duration. 3. Discuss the physiology of pain. 4. Discuss the use of pharmacologic interventions in pain control. 5. Describe nonpharmacologic interventions in pain control. TERMINOLOGIES Acupuncture Biofeedback Electromyographic Electrostimulation Hydrotherapy Hypnosis Mindfulness Modulation Pain Perception Transduction Transmission Visualization ٠
CONTENTS 1. Introduction 2 2. The process of pain 2 3. Pain theories 4 4. Types of pain 6 5. Pain assessment 6 6. Pain management 10 7. References 13 ١
Introduction Pain is an unpleasant and personal sensation that cannot be shared with others. Pain as 'whatever the experiencing person says it is, existing whenever he (or she) says it does. Pain hints at the subjective nature of pain and the importance of believing the patient. People experience and react to pain differently and as nurses we cannot feel what the patient feels yet we have a duty to maintain the individual's dignity and where possible relieve their pain and promote comfort. Indeed pain management is an important aspect of nursing care. The process of pain There are four processes involved in nociception, a term used to describe the point at which an individual becomes conscious of pain: (1) transduction, (2) transmission, (3) perception and (4) modulation (see Fig. 1) 1. Transduction Transduction is the first process involved in nociception and begins with tissue injury. This injury is sensed by nociceptors (the nerve endings that sense pain). These trigger the release of chemical substances (e.g. prostagladins, bradykinin, serotonin, histamine, substance P) that help the pain impulse travel from the periphery to the spinal cord (see Fig. 1). ٢
2. Transmission The second process of nociception, transmission of pain, includes three segments. 1. The pain impulse travels from the peripheral nerve fibers to the spinal cord. 2. Transmission of the pain impulse by neurotransmitters from the spinal cord to the brain stem and thalamus (see Fig.1). 3. Transmission of pain impulse between the thalamus and cortex where pain perception occurs. 3. Perception The third process, perception, is when the patient becomes conscious of the pain. It is not known where the precise location for perception is in the brain. However it is believed & pain perception occurs in the cortical structures of the brain. 4. Modulation Modulation is the fourth process involved in nociception. During this process, nerves in the brain stem send signals back down to the spinal cord, releasing substances that act as natural painkillers such as endorphins and serotonin. These substances do not last long in the body and therefore their painkilling use is limited. ٣
(Fig.1) the process of pain perception Pain theories 1. Specificity theory: Von Frey (1895) argued that the body has a separate sensory system for perceiving pain just as it does for hearing and vision and this system contains its own special receptors for detecting pain stimuli, its own peripheral nerves and pathway to the brain, and its own area of the brain for processing pain signals. But this structure is not correct. ٤
2. Pattern theory: Goldschneider (1920) proposed that there is no separate system for perceiving pain, and the receptors for pain are shared with other senses, such as of touch. According to this view, people feel pain when certain patterns of neural activity occur, such as when appropriate types of activity reach excessively high levels in the brain. These patterns occur only with intense stimulation. 3. Gate Control Theory: Melzack and Wall (1965) proposed an alternative notion for the perception and treatment of pain. Their theory is based on the fact that pain impulses are normally carried to the spinal cord from the peripheries in small nerve fibres. Large nerve fibres, on the other hand, carry non-nociceptive stimuli such as touch, warmth, massage, vibration, etc. According to Melzack and Wall (1965) impulses travelling through the large fibres can block the impulses travelling through the small fibres at a gate which is situated at the spinal cord (see Fig.2). (Fig.2) a schematic illustration of the gate control theory ٥
Types of pain Pain assessment Assessment of pain includes collection of subjective and objective data through the use of various assessment tools and construction of a database to use in developing a pain management plan. ٦
Gathering subjective information regarding the client s pain is the first step in pain assessment. The client s perception of the pain should cover a description of several qualifiers, including: ý Intensity ý Location ý Quality (radiating, burning, diffuse) ý Associated manifestations (factors that often accompany the pain, such as nausea, constipation, or dizziness) ý Aggravating factors (variables that worsen the pain, such as exercise, certain foods, or stress) ý Alleviating factors (measures the client can take that lessen the effect of the pain, such as lying down, avoiding certain foods, or taking medication) Nurses must look for nonverbal signs of pain such as changes in motor activity or facial expression. It is also important to ask family members to share their observations the nurse should also determine a client s pain threshold and pain tolerance level. Tools used for assessing pain must be appropriate to the client s age and cultural context. 1. Initial Pain Assessment Tool This tool is particularly effective when clients have complex pain problems because it assesses location, intensity, quality, precipitating and alleviating factors, and how the pain affects function and quality of life ( see appendix A). ٧
2. Pain Intensity Scales Pain intensity scales are another quick, effective method for clients to rate the intensity of their pain. (Fig.3) pain intensity scales 3. Pain Diary Client input is essential if accurate assessment data are to be collected. Self-monitoring of symptoms can be promoted by having clients complete a pain diary; see the accompanying display. ٨
4. Psychosocial Pain Assessment Infants, children, and adolescents provide a special challenge in pain assessment because their pain behaviors often differ from those considered normal in the adult population. Certain myths hinder the accurate assessment and management of pain in children. Two useful tools for assessing pain in children are the Wong/Baker Faces Rating Scale and the Poker Chip Tool. The Wong/Baker Faces Rating Scale can be used with children as young as 3 years, and it helps children express their level of pain by pointing to a cartoon face that most closely resembles how they are feeling. (Fig.4) the Wong/Baker Faces Rating Scale The Poker Chip Tool consists of four red poker chips that can easily be carried in a pocket to be available when needed. The chips are aligned horizontally on hard surface in front of the child, and they are described as pieces of hurt. The chips are described from left to right as just a little bit of hurt, a little more hurt, more hurt, and the most hurt you could ever have. The child is then asked, How many pieces of hurt do you have right now? This tool can be used with children 4 to 13 years old. ٩
Pain management Establishment of a therapeutic relationship is the foundation for effective nursing care of the client experiencing pain. Clients, who trust their nurses to be there, to listen, and to act, are the clients who are most likely to be comfortable. 1. General overview of pain 1. Definition 2. Causes/contributing factors 3. Pain assessment, including use of assessment tools 4. Importance of preventive approach 5. Family involvement 2. Pharmacologic pain management Analgesics are substances that give temporary relief from pain without causing loss of consciousness. 1. Non-narcotic Analgesics the most commonly used of these analgesics are aspirin (and other salicylates), acetaminophen, NSAID (nonsteroidal anti-inflammatory drugs), such as ibuprofen. 2. Narcotic Analgesics these drugs include the opiates and opioids that are natural or artificial forms of opium, such as codeine or morphine. 3. Combination of Non-narcotics and Narcotic Analgesics many prescriptions are a combination of narcotics and non-narcotic and include acetaminophen and codeine, aspirin and codeine, propoxyphene and aspirin, caffeine and butalibital. 4. Corticosteroid these are made from synthetic hormones and used to treat bronchospasm (asthma). ١٠
5. Local Anesthetics these drugs are locally acting and can be injected to deaden the nerve so pain is not felt (as during a dental procedure). 6. Antidepressants these are helpful in the management of chronic pain. 7. Trigger Point Injections trigger point injection therapy is the injection of a painkilling substance deep into the muscle tissue that is located over a localized area of pain. 3. Nonpharmacologic pain management 1. Acupuncture a National Health Institute panel gave acupuncture the "thumbs-up" as a way to relieve nausea and pain. 2. Heat one of the most ancient ways to decrease pain is with the use of heat. 3. Cold is also an ancient treatment. Applying cold constricts local blood vessels and makes the area numb. 4. Electrostimulation transcutaneous electrical nerve stimulation (TENS) units (across the skin) are available by prescription. 5. Relaxation and Behavioral Techniques this type of treatment teaches a patient to use their mind to lessen or eliminate pain, especially chronic pain. 6. Biofeedback uses the mind to control the body when tension is the cause of pain, rather than arthritis, cancer, or nerve damage. 7. Electromyographic biofeedback this alerts patients to muscle strain and works especially well for jaw, neck, and shoulder pain, or tension headaches. 8. Visualization this is a mental technique similar to biofeedback. Athletes use visualization to enhance their performance. ١١
9. Relaxation is the release of stress, anxiety, and often pain. Relaxation techniques include deep breathing, muscle relaxation techniques, and meditation. 10. Hypnosis by using this form of relaxation, a patient can shut out distraction and focus on one subject, such as getting rid of pain. 4. Physical techniques and specialists 1. Anesthesiologists originated the idea for the modern pain clinic. 2. Exercise 3. Massage 4. Physical Therapy Physical therapists are trained professionals who treat the musculoskeletal system. 5. Physiatry Physiatrists are medical doctors who use physical methods and agents to treat patients suffering from pain. 5. Alternative health techniques 1. Acupuncture this is an ancient Chinese healing art. Acupuncture uses various techniques, including the insertion of various sized needles at specific points on the body (called meridians). 2. Acupressure very similar to acupuncture, acupressure is a method of using pressure to work on the meridians of the body for specific pain symptoms or disorders. 3. Hydrotherapy uses water to reduce pain by relieving the constant pressures on certain parts of the body. 4. Mindfulness meditation chronic pain sufferers often tell themselves, This will go on forever; I can't do anything anymore. Such thoughts can actually make their pain worse. ١٢
5. Life style changes good pain management programs teach people better ways to work and get a good night s sleep. Lifestyle changes (eg, lifting properly or supporting your lower back with a rolled towel while driving) can put a person back in control of their lives. 6. Surgery for pain Surgery to relieve pain is usually the last resort for treatment. It may seem as if cutting a nerve will cause the feeling of pain to disappear. 7. Psychological help Pain does not always follow the path of the body functions the patient s mental state also has a direct effect on a perception of pain. In many cases, an injured patient s pain is the emotional distress as well as the physical injury. REFERENCES Kozier, B., et al.: Fundamentals of nursing: Concepts process and practice, Pearson Prentric Hall, 2008, P.P.675-680. Kozier, B., et al.: Fundamentals of nursing, 7 th, New York Pearson Prentric Hall, 2004. Timby B., Fundamental nursing skill and concepts, Philadelphia, Lippincott Williams, Wilkins, 2005. ١٣
Appendix A ١٤