K A T E B L A C KK A T E B R A Z Z A L E

L I S A M O L O N Y

PAIN

PAIN

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

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”.

http:/www.iasppain.orgContentNavigationMenuGeneralResourceLinks/PainDefinitions/default.htm

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”.

http://www.localhealth.com/article/pain

AETIOLOGY: WHAT CAUSES PAIN?

Kate, if you want this picure it’s not problem, just delete this slide,

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

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

CATEGORIES OF PAIN

Another way to categorise pain is on the basis of origin:

• Nociceptive• Neuropathic• Psychogenic

NOCICEPTIVE PAINNociceptive 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

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.

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).

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.

CLINICAL MANIFESTATIONS

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.

“No two people are likely to experience the same level of pain for a given painful stimulus” (Craft et al., 2011, p.150).

CLINICAL MANIFESTATIONS

Pain tolerance is influenced by a number of factors including;

• Age• Cultural perceptions • Expectations• Gender• Physical and mental health

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.

CULTURAL VARIATIONS

Cultures vary in the meaning of pain, how if it expressed and how it is treated:• Meaning • Expression • Treatment

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.

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.

SIGNS AND SYMPTOMS:

Signs:• 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

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

DIAGNOSIS• Diagnosis of Pain

is complicated.

• To diagnose pain, Nurses rely on• Objective Data.• Visual signs.

• Subjective Data.• Patients

descriptions.• Characteristics of

Pain.

DIAGNOSIS

• Characteristics of Pain• OPQRST Mnemonic• Onset• Provocation • Quality• Region/Radiation• Severity• Time

DIAGNOSIS

1. Onset• What was the patient doing at the time?• What precipitated the pain?

2. Provocation • Aggravating Factors:• What causes the Pain to increase?

• Alleviating Factors:• What makes it better or worse?

DIAGNOSIS

3. Quality • 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?

DIAGNOSIS

5. Severity • 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.

DIAGNOSIS

DIAGNOSIS

6. Time• 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

DIAGNOSTIC TESTS

Tests to verify pain.• 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.

• Discography/Myelograms• A contrast dye is injected into the spinal disk to

enhance the X-Ray.

DIAGNOSTIC - TESTS

• EMG (Electromyography)• Evaluate the activity of the muscles.

• Bone Scans• Diagnose and monitor infection and

fracture of the bone

• Ultrasound Imaging• High frequency sound waves to develop an

image of the affected area.

DIAGNOSTIC TESTS

• Psychological Assessment• Psychosocial involvement.• Questionnaires.

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‘• Follow the WHO analgesia ladder• Prevent adverse effects of opioids• Develop a patient management plan

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: 1. non-opioids 2. mild opioids 3. strong opioids

Image: World Health Organizationhttp://www.who.int/cancer/palliative/painladder/en/

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:1. Opioids (narcotic) analgesics2. Non-opioid analgesics (NSAIDs)3. Adjuvants (DISCUSS HERE WHAT ADJUVANTS ARE

OR ADD IN A SLIDE LATER)

PHARMACOLOGICAL MANAGEMENT

• Routes of administration:• Oral• Intravenously• Continuous infusion (via SC or IV routes)• Rectally• Transdermal administration• Inhalation

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

OPIOIDS

• Add table of commonly used opioids, advantages/disadvantages

OPIOIDS

• Adverse drug reactions may include: • respiratory depression• excessive sedation• constipation• nausea• vomiting• tolerance • dependence• dysphoria (a mood of general dissatisfaction,

restlessness, anxiety)

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)

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.

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

INCLUDE SLIDE ON ADJUVANTS?

PHARMACOLOGICAL MANAGEMENT

Other drugs useful for analgesic effects• GABA analogues • Capsaicin• Local anasthetics (e.g. lignocaine)• General anasthetics (e.g. halothane, nitrous oxide)• Ethanol or phenol • Cannabinoids • Specific anti-migraine drugs• Herbal remedies (e.g. cloves, feverfew, kava kava, St

John's wort, ginger, ginseng)

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)

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

HOT AND COLD THERAPY

• From: Clinical Psychomotor Skills pg 153

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

TENS MACHINE

TENS MACHINE

TENS MACHINE

COMPLICATIONS

COMPLICATIONS

IMPLICATIONS FOR NURSING PRACTICE

DELETE THIS SLIDE LATER!• Instruction/education on how to use pain score• Cultural implications:• Non-English speaking patients• Stoicism• Cultural healing methods• Stereotyping gender/age

• How is this pain likely to impact on the patients lifestyle, other people,

IMPLICATIONS FOR NURSING PRACTICE

Planning for nursing care (from Crisp & Taylor)• Synthesise information• Use critical thinking to ensure client's care plan

integrates key points• Establish a therapeutic relationship with the patient,

and discuss realistic expectations for an individualised care plan

• Planned interventions must be appropriate for the nature and type of pain

• Goals should be specific and have measurable outcomes

• Set priorities for treatment

IMPLICATIONS FOR NURSING PRACTICE

Interventions Who will be involved?• Oncology nurse • Physiotherapist• Occupational therapists• The family or caregiver• People in the community: visiting nurses,

pharmacists, general practitioner, palliative care nurses

IMPLICATIONS FOR NURSING PRACTICE

Implementation • The patient and the nurse must work in partnership when it

comes to pain management (incl: Explanation of analgesia and use of PCA)

• 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

IMPLICATIONS FORNURSING PRACTICE

Other considerations• 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

REFERENCES

REFERENCES