Pain is define as an unpleasant sensory and emotional experience associated with acute or potential tissue damage.

( Merskey and Bogduk)

Pain is what ever the experiencing person say it is, existing whenever he says it does.

pain is a complex mixture of physical, emotional and behavioral reactions. There are 3 physiology components

Reception

Perception

Reaction

 Any

cellular damage caused by thermal, mechanical, chemical or electrical stimuli results in the release of pain producing substances. Exposure to hot or cold, pressure, friction and chemical stimuli release substance such as histamine and potassium which combine with receptor sites on nociceptors to initiate the neural transmission associated with pain. When combination with pain receptors reaches threshold, activation of pain aneurons occurs.

2 types of peripheral nerve fibers conduct painful stimuli. (1) The fast , myelinated A-delta fibers Sharp, localized & distinct sensation (2) The small, slow unmyelinated Cfibers Relay impulses that are poorly localized, visceral, and persistent

Neuroregulators that affect the sending of nerve stimuli

Neurotransmitters

Substance P Serotoxin prostaglandins

Neuromodulators

endorphins bradykinin

(a) substance P Found in the dorsal horn Needed to transmit pain impulses from the periphery to higher brain centers Causes vasodilatations and edema (b) Serotoxin Released from the brain stem and dorsal horn

(c) prostaglandins
Generated

from the breakdown of phospholipids in cell membranes Believed to increase sensitivity to pain
NEUROMODULATORS
(a)

Endorphins Located within the brain, spinal cord and gastrointestinal Activated by stress and pain

(b)

bradykinin released from plasma that leaks from surrounding blood vessels at tissue injury site Binds to receptors on peripheral nerves, increasing pain stimuli Binds to cells that causes the chain reaction producing prostaglandins

 Its

gives the nurse a conceptual basis for pain- relief measures Melzack and Wall suggests that pain impulses can be regulated or even blocked by gating mechanisms along the central nervous system occurs within the spinal cord substantia gelatinosa [SG] cells, present in the dorsal horn. As well as sites within the thalamus, reticular formation and limbic system,

 The

theory suggests that pain impulses pass through when the gate is open and not while it is closed. Closing of gate is the basic for pain relief therapies. A balance of activity from sensory neurons and descending control fibers from the brain regulate the gating process. If dominant input is from A- delta and C fibers, the gates likely open and the client perceives pain.

It is the point at which a person is aware of pain. Meinhart and Mc Caffery describe three interactional systems of pain perception as
Sensory discriminative

Motivational affective

Cognitive evaluation

occurs between the thalamus and sensory cortex A person perceives the location, severity and character of pain. Factors that increase the awareness of stimuli increase pain perception

Interaction

between the reticular formation and limbic system results in pain perception The reticular formation creates a defensive response ,causing a person to interrupt or avoid the pain stimuli The limbic system controls emotional response and coping with pain.

Culture,

experience with pain and emotions influence a persons evaluation of the pain experience. Helps a person to interpret the intensity and quality of pain so that action can be taken. Higher cortical centers of the brain influence perception.

(a) Physiological Responses

When

acute pain impulses travel up the spinal cord toward the brain stem and thalamus, the autonomic nervous system is stimulates as part of stress response. If pain is unrelenting, severe or deep, typically involving visceral organs, the parasympathetic nervous system goes into action. Sustained physiological responses to pain could cause serious harm except in cases of severe traumatic pain, which may place a client into shock.

(b) Behavioural Response Responses integrate biological, social and psychological characteristics of the individual. Whether the pain is acute or chronic it influences the behavioural response. Clenching the teeth, facial grimacing, holding or guarding the painful part and bent posture are also indication of acute pain. Chronic pain affects the patients activity.

 Age Sex

Culture
Meaning Anxiety

of pain Attention

Previous

experience Coping style Gender Attention Depression Fatigue

Infants

demonstrate pain through crying, changes in vital signs, facial expression and extremity movement. Children without full vocabularies have difficulty verbally describing and expressing pain to parent or caregivers.

 Women

appear to be more sensitive to pain, requiring less stimulation to evoke a pain response than men.

Culture
Culture

influences how people perceive the causes and learn to react and express pain. Italian, Jewish, African- American and Spanish- speaking persons smile readily and use facial expressions and gestures to communicate pain.

 Increased

attention has been associated with increased pain.

Anxiety
High

anxiety level increased pain perception.

Depression
Incidence

of depression is very high in patients with chronic pain. They experience many losses, such as their ability to enjoy life, to be in in control, to work, to socialize and to be independent.

o Fatigue

heightens pain perception. This intensifies pain and decrease coping abilities.

previous experience
Previous

experience of pain includes pain the patient has experienced personally and pain the patient has heard about from someone else.

Clients

perceive pain differently if it suggests a threat, loss, punishment or challenge. The meaning a client associated with pain affects the pain experience.
Family and social support Clients in pain often depend on family member for support, assistance or protection.

(1) Onset

and duration According to onset and duration pain can be classified into two
Onset & duration

Acute pain

Chronic pain

Non malignant origin

Malignant origin

DEFINITION SUPERFICIAL SKIN DEEP VISCERAL INTERNAL ORGAN REFERRED EXTRANCE OF SENSORY NEURONS FROM AFFECTS ORGANS INTO SPINAL CORD RADIATING EXTENDING SITE OF INJURY TO OTHER BODY PART

CHARACTERISTICS

EXAMPLES

SHORT DURATION, LOCALIZED SHARP SHARP,DULL

NIDDLE STICK, SMALL CUT

BURNING SENSATION

FELT IN PART OF THE BODY SEPARATE FROM PAIN

MYOCARDIAL INFRACTION

FEELS AS THROUGH IT TRAVEL DOWN

LOWBACK PAIN FROM RUPTURED INTERVERTEBRAL DISK

Description scales measure pain severity objectively. it consists of a line with 3 to 5 words descriptors equally spaced along the line. it ranked from No pain to unbearable pain. Numerical rating scales (NRS) used instead of word descriptions. In this case clients rate pain on a scale of 1 to 10. A visual analog scale (VAS) consists of a straight line without labelled subdivisions.

Wong and Baker (1988) developed a Faces scale to assess pain in children. This scale consists of 6 cartoon faces ranging from very happy, smiling face for no pain to increasingly less happy faces to a final sad, tearful face to worst pain. Children as young as 3 yrs of age can use the scale. advantage is that clients dont have to interpret the meaning of numbers or adjectives the face more clearly and quickly depict the concept of pain or discomfort.
o

 PHYSICAL

SIGNS AND SYMPTOMS: The heart rate, respiratory rate and blood pressure increases during the onset of pain. 1. Behavioural effects: Vocalizations Crying Screaming Gasping

Facial Expression Grimace Clenched teeth Wrinkled forehead Tightly closed or opened eyes or mouth Lip biting Body movement Restlessness Immobilization Muscle tension Increased hand and finger movements

Social interaction Avoidance of conversation or social contacts. Focus only on activities for pain relief. Reduced attention span.

PHARMACOLOGICAL PAIN THERAPY NON- NARCOTIC ANALGESICS Acetaminophen Acetylsalicylic acid Choline magnesium trisalicylate NSAID Ibuprofen Naproxen Naproxen sodium Indomethacin Tolmetin piroxican

 Post

operative pain Dysmenorrhea Fever Vascular headache Rheumatic & non rheumatic NARCOTIC ANALGESICS Meperidine Methylmorphine morphine

 Butorphanol Hydromorphone Fentanyl

ADJUVANTS Amitriptyline Hydroxyzine Caffeine Chlorpromazine diazepam

Reducing Pain Reception: Simple way to promote comfort is by removing or preventing painful stimuli. Pain can also be prevented by anticipating painful activities.

Cutaneous stimulation: It is the stimulation of the skin to relieve pain. A message, warm bath, ice bag and transcutaneous electrical nerve stimulation are simple ways to reduce pain perception. Advantage is that the measures can be used in the home, giving client and families some control over pain symptoms and treatments. It should not be used directly on sensitive skin areas.

Distraction : With meaningful sensory stimuli, a client can ignore pain. Distraction include singing, jokes, listening to music,playing games. Whipple found that soothing music and stimulating music can significally elevate pain thresholds. If pain becomes acute, it helps to increased the volume of the music, the client can concentrate better by rhythmically tapping fingers or patting the thigh to the beat.

Relaxation : It is mental and physical freedom from tension and stress. IT provide clients with self control when pain occurs, reversing the physical and emotional stress of pain. Clients who use relaxation techniques successfully go through physiological and behavioural change. include simple relaxation, imagery, hypnosis, biofeedback and music assisted relaxation.

 Use

different type of pain relief measures. Provide pain relief measures before pain become severe. Keep an open mind about ways to relieve pain. Keep trying. Protect the client. Educate the client about pain.