Pain and Comfort

Chapter 41
 Pain and Comfort

• Pain
– Is an elusive and complex phenomenon, and
despite its universality, its exact nature remains a
mystery. It is one of the body’s defense
mechanisms that indicates the person is
experiencing a problem. “Pain is whatever the
experiencing person says it is.”
• Comfort
– Through comfort and comfort measures . . .
Nurses provide strength, hope, solace, support,
encouragement, and assistance. A variety of
nursing theorists refer to comfort as a basic client
need for which nursing care is delivered
 Categories of Pain
• Duration
• Source
• Mode of Transmission
• Etiology
 Three Types of Pain
• There are three types of pain:
• acute pain
– Rapid in onset then disappears
• chronic pain
– Limited, intermittent, or persistent lasts
beyond the normal healing period.
• cancer pain or chronic malignant pain
 Source of Pain
• Cutaneous (superficial)
– Involves the skin or subcutaneous tissue
– Ex: a paper cut
• Somatic (deep)
– Is diffuse or scattered and originates in tendons,
ligaments, bones, blood vessels, and nerves
• Visceral
– Poorly localized and originates in body organs in the
thorax, cranium, and abdomen. Pain occurs as
organs stretch abnormally
 Mode of Transmission
• Referred Pain
– Pain can originate in one part of the body but
be perceived in an area distant from its point
of origin.

– Ex: Pain associated with Myocardial Infarction

(MI) or heart attack, pain may be referred to
neck, shoulder, or arms.
 Etiology of Pain
• Neuropathic pain
– Results from injury to or abnormal functioning of
Peripheral nerves or CNS. Described as burning or
stabbing
• Intractable pain
– Pain is persistent to therapy and persists despite a
variety of interventions
• Phantom pain
– Without demonstrated physiologic or pathologic
substance
– Ex: Amputated leg
 Physiology of Pain
• “Pain” – Physiological Mechanism of Pain
– It is helpful for the nurse to understand the
physiological effect of pain therapy on the
human body.
– The pain experience is a four stage process:
transduction, transmission, perception, and
modulation.
 The Pain Process
• Transduction—activation of pain receptors
• Transmission—conduction along
pathways (A-delta and C-delta fibers)
• Modulation—initiation of the protective
reflex response
• Perception of pain—awareness of the
characteristics of pain
 Transduction
• For pain to be perceived nociceptors must
be stimulated
• These pain receptors can be stimulated by
– Serotonin
– Histamine ( a damaged cell releases)
– Prostaglandins
– Substance P
 Transduction
• 3 types of stimuli can stimulate pain
receptors
– Mechanical
– Thermal
– Chemical
 Transduction (cont’d)
• Mechanical stimulus
– Friction from bed linens
– Pressure from a case
• Thermal stimulus
– Sunburn, cold water on a tooth with caries
• Chemical stimulus
– Acid burn
Pain Sensation and Relief
 Transmission of Pain Stimuli
• 2 separate pathways that transmit pain
impulses to the brain
– Type A – delta fibers (fast conducting)
• Fast, sharp, and acute pain
– Type C fibers
• Diffuse, visceral that burns or aches
 OBJECTIVE

Describe the gate control theory

of pain.
 Gate Control Theory of Pain
• Pain impulses can be regulated or even blocked
by gating mechanisms located along the central
nervous system. The theory suggests that pain
impulses pass through when a gate is open and
are blocked when the gate is closed.
• Large diameter cutaneous pain fibers can be
stimulated (rubbing like a massage) and may
inhibit smaller diameter fibers to prevent
transmission of the impulse (closing the gate)
• Using pain relief measures to close the gate like
massage, or warm compress
 Gate Control Theory of Pain
• Gate Control Theory
– Relationship between pain and emotion

– If cutaneous stimuli other than pain are

transmitted, the “gate” is temporarily blocked
by the stimuli.

– The brain cannot acknowledge the pain while

it is interpreting the other stimuli.
 Gate Control Theory of Pain
• Small-diameter nerve fibers
carry the pain stimuli through
the same gate

• Large diameter fibers that

carry the non-pain impulses go
through the same gate and
inhibit the transmission of
those pain impulses – close
the gate.

• Only a limited amount of

sensory info can be processed
by the nervous system at one
time centain cells interrupt the
signal and close the gate
Gate Control Theory of Pain
– A bombardment of sensory impulses will
close the gates to painful stimuli.
– Some patients can be distracted from pain
– Gating mechanisms can also be altered by
thoughts, feelings, and memories.
 Perception of Pain
• Pain threshold
– The perception of pain
– Lowest intensity of a stimulus that causes the
subject to recognize pain.
• Adaptation
– The pain threshold can be changed within a
certain range.
– Example: hand immersed in warm water then
water is gradually heated. Person will tolerate
longer than if had immersed in hot water.
 Modulation of Pain
• Modulation of pain
Sensation of pain is inhibited or modified
– Neuromodulators
• Release endogenous opioids include enkephalins,
endorphins and dynorphins which are morphine
like.
• Have analgesic activity and alter perception of
pain
• Bind to specific opioid receptors throughout CNS
clocking the release of pain-transmitting
substances
– Released when skin stimulation and
relaxation techniques along with certain
 OBJECTIVE

Discuss techniques and rationales

that assist clients with pain.
 Factors affecting the Pain
Experience
• Culture • Religious Beliefs
– Attitudes, values – Illness or pain viewed as
• Family punishment by God.
– Response or expression • Environment and Support
influenced by
people
• Gender – Presence or absence of
– Female more vocal others caring, sense of
– Men don’t cry powerlessness
• Age • Anxiety/Stressors
– Pain is not part of normal – Threat of the unknown
aging process
– Is disease related • Past Pain Experience
Clients at risk when assessing and
treating pain
• A client’s self-report is the single most reliable
indicator of the intensity of pain and the
evaluation of treatment. Many client’s fail to
report or discuss pain/discomfort due to
ineffective communication. Those at risk include:
– Children
– Elderly
– Cognitively impaired/unconscious
– Non-English speaking
– Different cultures
– History of substance use
 OBJECTIVE

Discuss common misconceptions

about pain.
 Common Biases and
Misconceptions of Pain
• Pain is a subjective, highly individualized
experience.
• Pain is the leading cause of disability and
source of frustration.
• Myths that should be irradicated include:
– The doctor has ordered pain-relieving
medication for me, which I will be given
routinely.
– If I ask for something for my pain, I may
become addicted to the medication.
 Common Biases and
Misconceptions of Pain
• cont’dare false:
The following statements
– Sometimes it’s better to put up with the pain than
to deal with the side effects of the pain medication.
– I should somehow be able to control my pain. It is
immature to talk about pain.
– It is better to wait until the pain gets really bad
before asking for help. If I take the medication now
for moderate pain, it won’t relieve severe pain later
on.
– I don’t want to bother anyone – I know how busy
they are.
– It’s natural for me to have pain after surgery. After
a few days, I should notice it lessening.
 Pain scales
• Pain is the “5th Vital
Sign”
The Nursing Process and “Pain”
Assessment
• Nurse works closely with client explore signs
and symptoms of pain with each client (cannot
allow personal biases to prejudice their
assessment of pain
• Physical signs and symptoms
– Interpret cues – facial expressions; look for verbal and
nonverbal expressions, changing vital signs,BP, pulse
and resp rate.
– Young children may be asked to point to the area that
hurts.
– May have to ask specific questions if there is a
problem with developmental or psychotic problems.
 The Nursing Process and
“Pain” Assessment (cont’d)
• Explore client’s subjective report
– Is the single most reliable indicator of pain
– Ask questions regarding the severity, onset,
durations, time most often happens
– There are several instruments to assist
– The nurse with assessing pain. For location the
nurse may use a body diagram to have client draw
the site of the pain; or a pain scale, maybe
numbered 0-10 (no pain – severe) or descriptive
from no pain, mild, mod, severe to unbearable.
For children, there is the “Oucher” scale – which
has faces of children from comfort to severe
discomfort.
– Quality of pain is described as throbbing, sharp,
The Nursing Process and “Pain”
Assessment cont’d
• Pain history – time/duration; precipitating events,
aggravating factors; relieving factors;
concomitant symptoms; past experiences with
pain
• Alterations in lifestyle
– Pain may interfere with activities of daily living
– Cause sleep disturbances
– May restrict mobility
– Ability to work
 Nursing Diagnoses
• Anxiety
• Hopelessness
• Mobility, impaired physical
• Pain
• Pain, chronic
• Self-care deficit
• Sexual dysfunction
• Sleep pattern disturbance
 Outcome Identification and
Planning
• The client will:
– Describe a gradual reduction of pain, using a
scale ranging from 0 (no pain) to 10 (pain as
bad as it can be).
– Demonstrate competent execution of
successful pain management program
(specify).
 Nonpharmacologic Pain Relief

• Distraction • Cutaneous
• Humor stimulation
• Music • Acupuncture
• Imagery • Hypnosis
• Relaxation • Biofeedback
• Therapeutic touch
 Pharmacologic Pain Relief
Measures
• Analgesic administration
• Nonopiod analgesics
• Opioids or narcotic analgesics
• Adjuvant drugs
 Analgesic Administration
• Analgesic
– Pharmaceutical agent that
relieves pain
• Nonopiod analgesics
– Acetaminophen & NSAID’s
• Opioid analgesics
– Controlled substances
– Morphine, codeine,
meperidine,
hydromorphone,
methadone
• Opioid (con’t)
– Produce analgesiz by
attaching to opioid
receptors in the brain
– s/e, respiratory depression,
nausea, constipation
• Adjuvant drugs
– Anticonvulsants,
antidepressants, and
multipurpose drugs
 Additional Methods for
Administering Analgesics
• Patient-Controlled Analgesia
– Provides effective individualized analgesia
and comfort
– Portable infusion pump that is prefilled most
frequently with morphine, fentanyl, or
hydromorphone
• Epidural Analgesia
– Provides pain relief during the immediate
postoperative phase
– Catheter is inserted into epidural space
The WHO 3-Step Analgesic Ladder
 Evaluation
• Client is main resource
• The family is another valuable resource
• Evaluate the client’s perceptions of
treatment effectiveness
• Re-evaluate