Concept of Pain: Rey Vincent H. Labadan, RN

CONCEPT OF PAIN
“Whatever the person say it is, existing whenever the

experiencing person says it does”.
REY VINCENT H. LABADAN, RN

FAMADOR O. GENALDO, RN MD
PAIN
 Pain is the most common reason for seeking health care
 Associated with actual or potential tissue damage
 American Pain Society: Pain, “The Fifth Vital Sign”
 Nurses, are primary advocate to pain relief
 Nurses have the capability to relieve pain merely by

acknowledging the discomfort and confirming that measure will
be taken.
DEFINITIONS OF PAIN
 It is a multidimensional phenomenon and is thus difficult to

define
 It is a personal and subjective experience, and no two people

experience pain in exactly the same manner
 It is best viewed as an experience, not merely as a manifestation

of the disease condition
 IASP, offered the accepted medical definition as: an unpleasant

sensory and emotional experience associated with actual or
potential tissue damage.
DEFINITIONS OF PAIN
 According to Sternbach, pain is an abstract concept which refers

to:
 A personal, private sensation of hurt
 A harmful stimuli that signals current or impending tissue
damage
 A pattern of response to protect the organism from harm
 McCaffery: Pain is whatever the experiencing person says it is

and existing whenever the person says it does. This makes the
person the expert of his or her pain
DEFINITIONS OF PAIN
 Because clinical pain is subjective, the only people who can

accurately define their own pain are those who are experiencing
the pain
 Despite its subjective nature, the nurse is charged with accurate

assessing and helping to relieve pain
 REMEMBER: all pain is real even if the cause can not be

ascertained
PROBLEM OF PAIN (BARRIER OF PAIN RELIEF)
 Pain serves as a mechanism to warn us about the potential for
physical harm in the natural environment
 It is the body’s protective mechanism to prevent tissue damage by

providing the drive to withdraw from the pain-producing situation
 The discomfort and distress associated with pain often last far
beyond the tissue-damaging experience
 Pain is the primary reason people seek health care and is

associated with the length of hospital stay, longer recovery time,
and poorer client outcomes
 Clients should be truthful in the onset and description of pain in

order for the health care provider to give the proper medications
SPECIFIC BARRIER TO PAIN RELIEF
Barriers Related to Healthcare Professionals:
 Inadequate or inaccurate information about pain

management
 Inadequate or sub-optimal pain assessment techniques
 Concern about overuse of controlled substances and

subsequent client addiction
 Concern about excessive adverse effects
 Concern about clients developing tolerance to analgesics

Barriers Related to the Healthcare System:
 Low priority given to pain treatment in relation to other

client needs
 Inadequate reimbursement for other or costly pain

management therapies
 Restrictive regulation of controlled substances

 Less than optimal availability or access to treatment;
 Opioids are often unavailable in inner-city pharmacies

as well as rural areas
 Nurses should work to ensure that necessary

medications are available for clients, regardless of the
environment
Barriers Related to Clients:
 Reluctance to report pain or to take pain medications
 Fear that pain indicates the disease process is progressing
 Concern about being thought about as a complainer
 Reluctance to take medications for a variety of reasons
 Concern about adverse drug effects
 Concern about developing tolerance or addiction to pain

medications
 Cost is a significant barrier to good analgesia;
 Health care providers should understand the causes of pain

and the management in order to relieve the client from pain.
 Education is the primary action to begin to remedy the

problems
Client Education
 Nurses can reassure clients that pain control is every client’s
right
 Health professionals rely on the client to report pain,
and that pain management will improve quality life
 Proactive education of clients and family / support persons is

necessary, including information about addiction, drug
tolerance, and physiological dependence
 Clients may use such terms as “hooked” when referring to

addiction:
 Addiction: the compulsive use of a substance despite
negative consequences, such as health threats or
legal problems – 3 C’s
 Clients may express anxiety about becoming “immune” to
medication when discussing drug tolerance:
 Tolerance: The process by which the body requires a
progressively greater amount of a drug to achieve the
same result.
 Clients may worry about developing a physical drug

dependence
 Dependence: A biologic need for a substance; if the
substance is not supplied, physiological withdrawal
symptoms occur
 Give clients permission to discuss concerns and fears

PERCEPTION OF PAIN
 Pain perception, or interpretation, is an important
component of the pain experience
 Pain is perceived and interpreted based on the individual

experience, thus pain is different for each person
 Pain perception does not depend solely on the degree of

physical damage
 Both the physical stimuli and psychosocial factors can

influence the experience of pain
PERCEPTION OF PAIN
 It is likely determined by the relative balance between
sensory peripheral input and the mechanism of central
control in the brain
 Pain perception is influenced by one’s tolerance for pain

PERCEPTION OF PAIN
Pain Threshold
 The lowest intensity of a painful stimulus that is perceived by
the person as pain
 May vary according to physiologic factors such as

inflammation or injury near pain receptors
 Essentially similar to all people if the CNS and the PNS are
intact
PERCEPTION OF PAIN
Pain Tolerance
 The amount of pain the person is willing to endure
 It is different for each person who experience pain, based on

subjective factors such the meaning of the pain and the
setting
 Some people have a high tolerance, e.g., they can tolerate a

lot of pain without distress
 Only the person, not the health care team, can determine
the person’s tolerance level
TYPES OF PAIN
1. Acute Pain
2. Chronic Pain
Acute Pain
 Short duration (<6 months)
 Has an identifiable, immediate onset

 e.g. incisional pain after surgery
 Has limited and predictable duration

 e.g. postoperative pain disappears after wound healing
TYPES OF PAIN
 Described in sensory terms, such as “sharp”, “stabbing”, and
“shooting”
 It is considered a useful and limiting pain : indicates injury

and motivates the person to obtain relief by treatment of the
cause.
 Acute pain is usually reversible or controllable with adequate

treatment.
 Once the pain is relieved, the person returns to the pre-pain

state.
TYPES OF PAIN
 Observable physiologic responses in acute pain:
 ↑ or ↓ BP
 Tachycardia
 Diaphoresis
 Tachypnea
 Focusing on pain
 Guarding the painful part
 The CVS and RS responses are due to the stimulation of the

Sympathetic Nervous System as part of the fight or flight
responses
TYPES OF PAIN
Four Major Pain Management Goals:
1. Reduce the incidence and severity of acute postoperative

or post-traumatic pain
2. Encourage clients to communicate unrelieved pain so

that they can receive prompt evaluation and effective
treatment
3. Enhance comfort and satisfaction
4. Contribute to fewer postoperative complications and

shorter stays after surgical procedures
TYPES OF PAIN
Chronic Pain
 A major health concern
 Defined in vague terms with some of unknown causes
 Lasts longer period of time and is not readily treatable
 Mental response of the person to pain depends on its

duration and intensity
 The course of chronic pain usually takes months and years of

pain
 Diverse treatment modalities have been used to treat the

symptoms
TYPES OF PAIN
 Associated with withdrawal and despair, anxiety and
depression
 Some clients learn to adapt and cope with pain, adjusting

their lives
 Most people undergo major affective and behavioral changes

when experiencing pain for prolonged periods : Chronic Pain
Syndrome
TYPES OF PAIN
Characteristics of Clients with CPS:
 Depressed mood
 ↑ or ↓ Appetite and weight
 Drastically restricted activity level leading to ↓ work

capacity poor physical tone, ↑ depression
 Social withdrawal
 Preoccupations with the physical manifestations
 Poor sleep and chronic fatigue, resulting from inactivity,

analgesics, depression and from pain
TYPES OF PAIN
Types of Chronic Pain
1. Chronic non-malignant pain
 e.g. Osteoarthritis
2. Chronic, intermittent pain

 e.g. Migraine headache
3. Chronic malignant pain

 e.g. Cancer pain
TYPES OF PAIN
Chronic Non-Malignant Pain
 Usually considered in pain that lasts more than 6 months, or
1 month beyond the normal end of the condition causing the
pain
 It is continuous or persistent and recurrent
 It is a frustrating condition, making it difficult for the person
to live a normal life
 The pain is exhausting both physically and emotionally for
themselves and their families
 Causes the person to be fearful, tense, fatigue, tending to
become withdrawn and isolated
 Health care providers may feel frustrated and incompetent
when their attempts to relieve chronic pain are ineffective
TYPES OF PAIN
Chronic Intermittent Pain
 Refers to exacerbation or recurrence of the chronic condition
 The pain occurs only at specific periods, at other times the

client is free from pain
 Pain management is directed toward the control of pain in

such the same manner as that for individual with acute pain
episodes
 e.g. migraine headache, abdominal pain of IBS
TYPES OF PAIN
Chronic Malignant Pain
 Cancer–related pain
 Considered to have the qualities of both the acute and the

chronic pain
 Encompasses neuropathic, deep visceral, and bone pain
 A diagnosis of cancer adds to the psychological component

associated with potential physical deformity and the
potential for impending death, preceded by agonizing
suffering
 The mental anguish may intensify the perception of pain

TYPES OF PAIN
Sources of Noxious Stimuli for Clients with Cancer
 Cell destruction: cell necrosis, ulceration, tumor invasion,
tissue injury
 Inflammation: products of cell destruction
 Infection: bacterial invasion
 Ischemia/Hypoxia: edema, hematoma, occlusion of
vessel by the tumor
 Noxious stretch/pressure: distention of thoracic and
abdominal viscera, fascia, periosteum, occlusion of GIT
and GUT structures, obstruction of ducts
 Nerve injury: direct injury through incising nerve
structures, tumor invasion of peripheral nerves, spinal
cord, and brain, chemotherapy and radiation injury
TYPES OF PAIN
Comparison of Acute and Chronic Pain
Acute pain Chronic pain
• Mild to severe • Mild to severe
• Sympathetic nervous system responses: • Parasympathetic nervous system

• ↑ HR, ↑ RR, ↑ BP, diaphoresis, dilated responses:
pupils • Vital signs normal, dry warm skin, pupils
normal or dilated
• Related to tissue injury: resolves with • Continuous beyond healing
healing
• Client appears restless and anxious • Client appears depressed or withdrawn
• Client reports pain • Client often does not mention pain unless
asked
• Client exhibits behavior indicative of pain: • Pain behavior often absent

crying, rubbing area, holding area
TYPES OF PAIN
Categories of Pain According to Origin
a. Cutaneous
 Originates in the skin or subcutaneous tissue
 e.g. a paper cut causing a sharp pain with some
burning
b. Deep Somatic
 Arises from ligaments, tendons, bones, blood vessels, and
nerves
 It is diffuse and tends to last longer than cutaneous pain

 e.g. ankle sprain
TYPES OF PAIN
c. Visceral
 Results from stimulation of pain receptors in the abdominal
cavity, cranium, and thorax
 Tends to appear diffuse and feels like deep somatic pain

 e.g. burning, aching, or a feeling of pressure
 Frequently caused by stretching of the tissues, ischemia, or

muscle spasm
 e.g. obstructed bowel
TYPES OF PAIN
Description of Pain According to where it is experienced in the
body:
a. Radiating Pain
 Perceived at the source of pain and extends to nearby
tissues
 e.g. cardiac pain felt not only in the chest but also in
the left shoulder and arm
b. Referred Pain
 Felt in the part of the body that is considerably removed
from the tissues causing the pain
 e.g. pain from one part of the viscera maybe
perceived in an are of the skin remote from the organ
causing the pain
TYPES OF PAIN
Other Types of Pain
a. Intractable Pain
 Pain that is highly resistant to relief
 e.g. pain from advance malignancy
b. Neuropathic Pain
 The result of current or past damage to the peripheral or
central nervous system and may not have a stimulus for pain
 Long lasting and unpleasant
 Described as burning, dull, and aching
 With episodes of sharp, shooting pain can be present
TYPES OF PAIN
c. Phantom Pain
 A painful sensation perceived in the body part that is missing
or paralyzed by spinal cord injury
 A neuropathic pain
 Episode of this pain type can be reduced if analgesia is given
via the epidural catheter prior to amputation
 e.g. amputated leg
d. Phantom Sensation
 The feeling that the missing part is still present
PATHOPHYSIOLOGIC BASIS OF PAIN
Nociception: The process of how pain is recognized consciously
Four Steps of Nociception:

1. Transduction
2. Transmission
3. Perception
4. Modulation
1. Transduction
 Conversion of a stimulus to an action potential at the site of
tissue injury
 Chemicals are released with cellular damage from such
things as burns, radiation, pressure, tears, and cuts
 These chemicals sensitize the Primary Afferent Nociceptors
(PANs) , fibers that carry the pain stimuli
 Aδ(delta) fibers: fast pain
 C fibers: slow pain
 Analgesics that work to block transduction, interferes the

the production of chemicals that sensitize the PANs to
begin the action potential
 NSAIDs: block the formation of prostaglandins
2. Transmission
 The neuronal action potential is transmitted to and through
the CNS so it can be perceived
 The impulse is projected to the spinal cord
 It is processed in the dorsal horn - Referred Pain
 It is then transmitted to the brain
 Analgesics that work at the level of transmission stabilize

membranes by inactivating sodium channels, thus inhibiting
action potential
3. Pain Perception
 The experience of pain occurs in the cortex
 May occur at a basic level in the thalamus
4. Modulation
 Efferent fibers descending from the brain stem modulate or
alter pain
Theories of Pain
1. Specify Theory
2. Pattern Theory
3. Gate Control Theory
1. Specificity Theory
 Proposes that body’s neurons and pathways for pain
transmission are specific, similar to other senses like taste
 Free nerve endings in the skin act as pain receptors, accept

input, and transmit impulses along highly specific nerve
fibers
 Does not account for differences in pain perception or

psychologic variables among individuals
2. Pattern Theory
 Identifies two major types of pain fibers: rapidly and slowly
conducting fibers
 Stimulation of these fibers forms a pattern; impulses ascend

to the brain to be interpreted as painful
 Does not account for differences in pain perception or

psychologic variables among individuals
3. The Gate Control Theory of Pain
 Offers an explanation for why such interventions as the TENS
(trans-electrical nerve stimulator), heat and cold, and
massage are effective
 These are theoretical gates in the dorsal horn
 Pain impulses can be modulated by a transmission blocking

action within the CNS
 Large-diameter cutaneous fibers can be stimulated (e.g. by

rubbing) and may inhibit smaller diameter fibers to prevent
transmission of the impulse (“close the gate”)
 Small-diameter nerve fibers carry pain impulses through a gate,
but large diameter sensory nerve fibers going through the same
gate can close the gate and inhibit transmission
Schematic
presentation
of gate-control
The Pain Pathway
 Pain is perceived by the nociceptors in the periphery of the
body (e.g., skin; transmitted through small afferent A-delta
and C nerve fibers to the spinal cord
 A-delta fibers myelinated and transmit impulses rapidly

producing sharp, acute pain sensations
 C fibers are not myelinated and transmit pain more slowly;

 Impulses are generated from deeper structures such as
muscle and viscera, producing more aching, chronic pain
sensations
 Secondary neurons transmit the impulses from the afferent

neurons through the dorsal horn of the spinal cord;
 A synapse in the substantia gelatinosa occurs;
 Impulses cross over to anterior and lateral spinothalamic

tracts
 Impulses ascend the anterior and lateral spinothalamic tracts

and pass through the medulla and midbrain to the thalamus
 Pain impulses are perceived, interpreted, and a response is

generated in the thalamus and cerebral cortex
Stimuli For Pain
 The type of nerve receptors responsible for pain sensation is
called nociceptor
 These receptors are located at the ends of small afferent

neurons and are woven throughout all body tissues except
the brain
 They are specially numerous in the skin and muscle
 A non-nociceptor is a nerve fiber that does not usually

transmit pain
 Pain occurs when nociceptors are stimulated by a variety of

factors
Painful Stimuli
Causative Factors:
 Microorganisms: Pneumonia
 Inflammation: Arthritis
 Impaired blood flow: Angina
 Heat: Sunburn
 Electricity: Electrical burn
 Obstruction: gallstone
 Spasm: Muscle cramp
 Swelling: Cellulitis
 The intensity and duration of stimuli determine the sensation

 Long-lasting, intense stimulation results in greater pain than brief,
mild stimulation
 Nociceptors are stimulated either by direct damage to the cell or
local release of biochemicals secondary to cell injury
Biochemical Sources:
Bradykinin : An amino acid, appears to be the most potent pain-

producing chemical
Prostaglandins: Chemical substances that increase the

sensitivity of pain receptors by enhancing the pain-provoking
effect of bradykinin
Histamines
Hydrogen ions
Inhibitory Mechanisms of Pain
 Efferent fibers run from the reticular formation and mid-

brain to the substantia gelatinosa in the dorsal horns of the
spinal column
 Along these fibers, pain transmitted may be inhibited,

although the exact process of the mechanism is not
understood
 Endorphins (endogenous morphines) are natural occurring

peptides present in neurons of the brain, spinal cord, and GIT
 They work by binding with opiates receptors on the neurons
to inhibit pain impulse transmission
 They are released in the brain in response to afferent

noxious stimuli
 They are released in the spinal cord in response to
efferent impulses
Mechanisms of Altering Pain
a. Endogenous Opioids
 Naturally occurring, morphine-like chemicals made in the
CNS to inhibit transmission of pain by binding to opioid
receptors in the CNS to block the transmission of nociceptive
signals
 e.g. endorphin, norepinephrine, enkephalin
b. The endogenous analgesia center in the midbrain produces

profound analgesia when stimulated
 Many analgesics modulate pain by mimicking endogenous
neuromodulators
 The variability of individual endorphin levels may explain the
fact that pain tolerance to the same stimulus are different
from person to person
 Surgical treatment of intractable pain (chronic progressive

pain that is unrelenting and severely debilitating) interrupts
the pain pathways
Types of Procedure:
 Nerve Block: destroys nerve roots chemically with phenol or
alcohol
 Rhizotomy: destroy sensory nerve roots destroys sensory

nerve roots at the level of entry into the spinal cord
 Cordotomy: transect the spinal pain pathway before the

impulses ascend the spinothalamic tracts
RESPONSE TO PAIN
 The body’s response to pain is a complex process rather than a
specific action
 It has both physiologic and psychosocial aspects
 Initially the Sympathetic Nervous System respond → fight-or-flight

response
 As pain continues, the body adapts as the Parasympathetic Nervous

System takes over → reversing many of the initial physiologic
responses
 This adaptation to the pain occurs after several hours or days of

pain
 The actual pain receptors adapt very little and continue to transmit
pain message
RESPONSE TO PAIN
 The person may learn to cope with pain through cognitive and
behavioral activities: diversions, imagery, excessive sleeping
 The individual may respond to pain by seeking out physical

interventions to manage the pain: analgesics, massage, exercise
Signs and Symptoms of pain:

 ↑ BP; ↑ HR;↑ RR
 Hypermotility
 Agitation
 Anxiety
 Grimacing
 Dilated pupils
 Crying and depression
RESPONSE TO PAIN
Proprioceptive Reflex
Occurs with simulation of pain receptors

Impulses → sensory pain fibers → spinal cord → synapse with →
motor neurons → travels back → motor fibers → muscles near the
site of pain → contracts in a protective action
The Reflex Arc

Stimulus - Sensory receptor in the skin – Sensory transmission –
Sensory nerve fibers – Spinal nerve - Spinal cord – Dorsal root (horn)
– Interneuron – Anterior horn – Motor transmission - Motor nerve
fiber – Effector muscles - Response
RESPONSE TO PAIN
PAIN ASSESSMENT
Tools & Instruments Used
 These provide the client and nurse with an easy method to
quantify pain
 A verbal report using intensity scale is a fast easy, and reliable

method allowing the client to state pain intensity
 Thus, promoting consistent communication among the nurse,

client, and other healthcare professionals about the client's pain
status
 Commonly used tools:

 “0-5” or “0-10” scale
 Visual analog scale: pain intensity scale
 FACES pain scale
0 1 2 3 4 5 6 7 8 9 10
No Pain Moderate Pain Unbearable Pain
Fig. 1 Numeric Pain Intensity Scale ↑
No Pain Pain as bad as could possibly be
Fig. 2 Visual Analogue Scale ↑
Fig. 3 Face Pain Scale ↑

PAIN ASSESSMENT
Physiologic Indicators of Pain
 Facial and vocal expression maybe the initial manifestations
of pain
 Rapid eye blinking
 Biting the lip
 Moaning and crying, screaming
 Either closed or clenched eyes
 Stiff unmoving body position
PAIN ASSESSMENT
ABCD Method of Pain Assessment
 The acronym was developed for CA pain; however, it is also
appropriate for clients with any type of pain, regardless of
the underlying disease
A – Ask about pain regularly; assess pain systematically

B – Believe the client and family about the reports of pain and
what relieves it
C – Choose pain control options appropriate for the client,
family, and setting
D – Deliver the intervention in a timely, logical, and coordinated
fashion
E – Empower client and families, enable them to control their
course to the greatest extent possible
PAIN ASSESSMENT
PQRST Assessment for Pain Perception
 This method is especially helpful when approaching a new
pain problem
P – Pattern of pain; what precipitated the pain?

Q – Quality and quantity of pain: sharp, stabbing, aching,
burning, stinging, deep, crushing, viselike, or gnawing
R – Radiation of pain to other areas of the body; the region
of the pain
S – Severity of the pain
T – timing of the pain; when does it begin? How long does it
last? How it is related to other events in the client’s
life and activities?
FACTORS AFFECTING PAIN EXPERIENCE
1. Ethnic and Cultural Values
 Behavior related to pain is a part of socializing process
 Individuals in one culture may have learned to be expressive
about pain, whereas individuals from another culture may
have learned to keep those feelings to themselves and not
bother others
 Cultural background affect the level of pain that an individual
is willing to tolerate
 Middle Eastern and Africans: self-inflection of pain is a sign
of mourning or grief
 Other cultures: pain is anticipated as a ritualistic practices -
tolerance of pain signifies strength and endurance
 Northern Europeans: more stoic and less expressive of their
pain than from the Southern Europeans
2. Developmental Stage
 Anatomic, physiologic, and biochemical elements necessary
for pain transmission are present in newborns, regardless of
their gestational age
 Children maybe less able to articulate their experience or

needs related to pain resulting to under treatment
 Prevalence of pain in the older population is generally higher

due to both acute and chronic disease conditions
 Pain threshold does not appear to change with aging,

although the effect of analgesics may increase due to
physiologic changes related to drug metabolism and
excretion
3. Environment and Support People
 Strange environment, like the hospital, can compound pain
 Person with no support network may perceive pain as severe

compared to person with supportive people around
4. Past Pain Experience

 Previous pain experience alter a client’s sensitivity to pain
 People who personally experience pain or who have been

exposed to the suffering of someone close are more
threatened by anticipated pain than people with no
experience
5. Meaning of Pain
 Some clients may accept pain more readily than others,
depending on circumstances and the client’s interpretation
of its significance
 A client who associates the pain with a positive outcome may

withstand the pain amazingly well
 e.g. a woman giving birth,
 An athlete undergoing knee surgery to prolong his career
 Clients with unrelenting chronic pain may suffer more

intensely: respond with despair, anxiety, and depression and
pain is looked on as a threat to body image or lifestyle and as
a sign of impending death
6. Anxiety and Stress
 Anxiety often accompanies pain
 The threat of the unknown and the inability to control the

pain or the events surrounding it often augment the pain
perception
 Fatigue reduces a person’s ability to cope, thereby increasing

pain perception
 When pain interferes with sleep, fatigue and muscle tension

often result and increase the pain: Cycle of Pain-Fatigue-Pain
 People in pain who believe that they can control their pain
have decreased fear and anxiety, decreasing their pain
perception
 A perception of lacking in control or a sense of helplessness

tends to increase pain perception
 Clients who are able to express pain to an attentive listener

and participate in pain management decisions can increase a
sense of control and decrease pain perception
PAIN MANAGEMENT
Pharmacologic Pain Management
1. Opioids or Full Agonist Narcotic Analgesics

 Opioids are morphine-like compounds that produce systemic
effects including pain and sedation
 Relieve severe pain by binding to opioid (kappa, mu, and

sigma) receptor sites in the CNS
 Agonists: substances that when combined with opioid

receptor produces the drug effect or desired effect
 e.g. Morphine sulfate, Meperidine (Demerol),
Codeine, propoxyphene (Darvon)
PAIN MANAGEMENT
 Mechanism of action: Opioids block the release of
neurotransmitters involved in the processing of pain
 Routes of delivery: oral, transdermal, continuous

subcutaneous infusion (CSCI), IM, intravenous (PCA), and
intraspinal
PAIN MANAGEMENT
Side Effects of Opioids on diverse systems:
1. CNS: analgesia, difficulty concentrating, drowsiness,
euphoria, sedation, ↑ ICP, N/V, ↑ vagal stimulation of
the bowel
2. Immune system: increase release of histamine,
vasodilatation of peripheral blood vessels, orthostatic
hypotension
3. GIT: sustained contraction of smooth muscles of the gut -
constipation, increased biliary tone, biliary colic,
4. Sensory system: miosis
5. GUT: increase tone of the detrosur muscle and the
bladder, increase tone of the vescical sphincter
6. Respiratory system: decrease rate and depth of
respiration, decrease cough reflex, bronchoconstriction
PAIN MANAGEMENT
2. Mixed Agonist-Antagonist narcotic analgesics (opioid)
 Relieves severe pain by binding with kappa receptors while
simultaneously blocking the mu receptors
 Routes and side effects same as full agonists

 e.g. Nalbuphine (Nubain), Butorphanol (Stadol)
PAIN MANAGEMENT
3. Non-Opioid Analgesics
 Main effect: analgesia
 Pain relief is by inhibiting the synthesis and release of

prostaglandins at the peripheral nerve endings at the site of
injury
 Antipyretic effect: decrease core temperature by reducing

sympathetic outflow from the hypothalamic temperature-
regulating center, promoting peripheral vasodilatation,
sweating, and heat loss
 e.g. aspirin, acetaminophen, NSAIDs
PAIN MANAGEMENT
 Non-opioid analgesics with anti-inflammatory actions:
 Act by stabilizing lysosomal membranes and preventing
the release of proteolytic enzymes into surrounding
tissue during inflammation
 e.g. corticosteroids (hydrocortisone, prednisone,
dexamethasone), NSAIDs
 Non-opioid analgesics with anti-platelet aggregation:

 Decrease platelet aggregation by inhibiting the enzyme
cyclooxygenase in platelets thus preventing the
formation of the aggregating substance thromboxane
 e.g. aspirin, clopidogrel
PAIN MANAGEMENT
Side Effects of NSAIDs
 CNS: mental confusion, drowsiness, dizziness, headache
 GIT: dyspepsia, N/V, diarrhea, GI bleeding, GI ulceration,
abdominal pain
 GUT: sodium retention, water retention, hyperkalemia,
nephrosis
 Integumentary system: urticaria, skin eruptions
 Hematologic: prolonged bleeding time,
thrombocytopenia, bleeding gums
 Sensory: tinnitus, vertigo, visual changes, reversible
hearing loss
PAIN MANAGEMENT
Analgesic Adjuvants:
 Enhance the sedation effects of Opioids and reduce painful
muscle spasm, anxiety, stress, tension, and depression that
accompany pain
 These drugs add to the action or effectiveness of opioid/non-

opioid analgesic
 e.g. Amitryptyline (Elavil), Chlorpromazine (Thorazine),
Diazepam (Valium), Hydroxine (Vistaril)
PAIN MANAGEMENT
WHO analgesic ladder for the treatment of cancer pain:
Step 1: non-opioid, (+/-) adjuvant
Step 2: opioid for mild to moderate pain , (+) non-opioid, (+/-)

adjuvant
Step 3: opioid for moderate to severe pain , (+/- ) non-opioid,

(+/-) adjuvant
PAIN MANAGEMENT
PAIN MANAGEMENT
Non-pharmacologic Pain Management
1. Cutaneous stimulation: massage, application of heat or cold,

acupressure, contra-lateral stimulation and immobilization
2. TENS, acupuncture, placebos, cognitive-behavioral:

distraction, guided imagery, meditation, biofeedback,
hypnosis
PAIN MANAGEMENT
Acupuncture
PAIN MANAGEMENT
Surgical Management of Pain
 Nerve block: destruction of a nerve roots by a chemical agent

 e.g. phenol, alcohol
 Rhizotomy: surgical destruction of a dorsal nerve root as they

enter the spinal cord
 Neurectomy: surgical excision of a peripheral nerve
 Cordotomy: surgical resection of pain pathways in the spinal

cord
PAIN MANAGEMENT
PAIN MANAGEMENT
Cordotomy
PAIN MANAGEMENT
Rhizotomy
REFERENCES
 Medical – Surgical Nursing 7th edition by Joyce Black
 Brunner & Suddarth’s Medical – Surgical Nursing 11th edition by

Suzzane Smeltzer
 Fundamentals of Nursing, 7th edition by Barbara Kozier
 Prentice Hall Reviews and Rationales Series for NCLEX-RN

D’ end,
Tnk u!

Concept of Pain: Rey Vincent H. Labadan, RN

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Concept of Pain: Rey Vincent H. Labadan, RN

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CONCEPT OF PAIN

“Whatever the person say it is, existing whenever the

REY VINCENT H. LABADAN, RN

 Pain is the most common reason for seeking health care

 Associated with actual or potential tissue damage

 American Pain Society: Pain, “The Fifth Vital Sign”

 Nurses, are primary advocate to pain relief

 Nurses have the capability to relieve pain merely by

 It is a multidimensional phenomenon and is thus difficult to

 It is a personal and subjective experience, and no two people

 It is best viewed as an experience, not merely as a manifestation

 IASP, offered the accepted medical definition as: an unpleasant

 According to Sternbach, pain is an abstract concept which refers

 McCaffery: Pain is whatever the experiencing person says it is

 Because clinical pain is subjective, the only people who can

 Despite its subjective nature, the nurse is charged with accurate

 REMEMBER: all pain is real even if the cause can not be

 It is the body’s protective mechanism to prevent tissue damage by

 Pain is the primary reason people seek health care and is

 Clients should be truthful in the onset and description of pain in

 Inadequate or inaccurate information about pain

 Inadequate or sub-optimal pain assessment techniques

 Concern about overuse of controlled substances and

 Concern about excessive adverse effects

 Concern about clients developing tolerance to analgesics

 Low priority given to pain treatment in relation to other

 Inadequate reimbursement for other or costly pain

 Restrictive regulation of controlled substances

 Less than optimal availability or access to treatment;

 Opioids are often unavailable in inner-city pharmacies

 Nurses should work to ensure that necessary

 Reluctance to report pain or to take pain medications

 Fear that pain indicates the disease process is progressing

 Concern about being thought about as a complainer

 Reluctance to take medications for a variety of reasons

 Concern about adverse drug effects

 Concern about developing tolerance or addiction to pain

 Health care providers should understand the causes of pain

 Education is the primary action to begin to remedy the

 Proactive education of clients and family / support persons is

 Clients may use such terms as “hooked” when referring to

 Clients may worry about developing a physical drug

 Give clients permission to discuss concerns and fears

 Pain is perceived and interpreted based on the individual

 Pain perception does not depend solely on the degree of

 Both the physical stimuli and psychosocial factors can

 Pain perception is influenced by one’s tolerance for pain

 May vary according to physiologic factors such as

 It is different for each person who experience pain, based on

 Some people have a high tolerance, e.g., they can tolerate a

 Has an identifiable, immediate onset

 Has limited and predictable duration

 It is considered a useful and limiting pain : indicates injury

 Acute pain is usually reversible or controllable with adequate

 Once the pain is relieved, the person returns to the pre-pain

 The CVS and RS responses are due to the stimulation of the

1. Reduce the incidence and severity of acute postoperative

2. Encourage clients to communicate unrelieved pain so

3. Enhance comfort and satisfaction

4. Contribute to fewer postoperative complications and

 Defined in vague terms with some of unknown causes

 Lasts longer period of time and is not readily treatable

 Mental response of the person to pain depends on its