Pain

By Yohannes Ayalew (RN, BSc. N, MSc. N, PhD fellow)

Assistant professor of Nursing: AAU-2023
What is pain?
Scientists at the International Association for the
Study of Pain (IASP) have defined pain as:
➢ Pain is unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or it is described in terms of
such damage or
➢ Pain is defined as whatever the person
experiencing the pain says it is, existing
whenever the person says it does
✓It is important to note that both definitions
indicate that pain is a subjective experience
➢ In medical diagnosis, pain is regarded as
a symptom of an underlying condition. 2
Benefits of pain from those who
don’t experience pain
➢Pain motivates the individual to withdraw
from damaging situations

➢Forces the individual to seek medical help

➢Avoids similar experiences in the future

➢Protects the damaged body part while it

heals 3
Terms we need to know in relation to pain
1. Nociception- is the activation of the
primary afferent nerves with peripheral
terminals (free nerve endings) that
respond differently to noxious (tissue
damaging) stimuli

2. Nociceptors- function primarily to

sense and transmit pain signals

4
 Components/dimensions/ of pain
➢Pain results from complex interactions with
the dimensions, among these dimensions
pain can be understood by considering first
the physiologic and then the sensory,
affective, behavioral, and cognitive
dimensions

➢Each dimension is important in the

assessment and management of pain.

5
The five components/dimensions of pain

Physiologic
(Transmission of nociceptive stimuli)

Cognitive Sensory
(Beliefs, attitudes,
evaluations, goals) PAIN (Pain perception)

Behavioral Affective
(Behavioral responses) (Emotions, suffering)

6
Sensory, affective, behavioral, cognitive, and
socio-cultural dimensions of pain
➢ Sensory component of pain is the recognition of the
sensation as painful
➢ Affective component of pain refers to the emotional
responses to the pain experience
➢ Behavioral component of pain refers to the
observable actions used to express or control the
pain
➢ Cognitive component of pain refers to beliefs,
attitudes, memories, and meaning attributed to the
pain
➢ Socio-cultural dimension of pain encompasses
factors such as demographics (age, gender,
education, socio-economic status) 7
The physiologic dimension of pain
✓The pain process composed of 4
major steps
1. Transduction

2. Transmission

3. Perception

4. Modulation 8
1. Transduction
➢Is the first step of the pain process
➢It is conversion of a mechanical, thermal,
or chemical stimulus in to a neuronal
action potential
➢Peripheral nerve fibers are stimulated by
noxious pressure, heat, or chemical forces

9
2. Transmission
➢Once the PAN (Primary Afferent Nociceptors)
has been transduced, the neuronal action
potential must be transmitted to and through
the CNS before pain perceived

3. Perception
➢In the brain, nociceptive input is perceived as
pain

10
4. Modulation
➢Modulation involves the activation of
descending path ways that exert inhibitory or
facilitatory effects on the transmission of
pain

➢Depending on the type and degree of

modulation, the nociceptive stimuli may or
may not be perceived as pain

11
The pain process

12
 Referred pain
➢ Discovery that Wide Dynamic Range/WDR/ neurons
receive input from noxious stimuli from distant areas
provides a neural explanation for referred pain
➢ Input from nociceptive fibers and A-beta fibers
converge on the WDR neuron, and when the
message is transmitted to the brain, the originating
location is poorly localized
➢ Pain is there fore perceived in the body part
presumably innervated by the A-beta fiber rather
than from the viscera A-delta or C-fibers
➢ The concept of referred pain must be considered
when interpreting the location of pain deported by
the person with injury to or disease involving visceral
organs 13
Referred pain…cont.

14
Etiology and types of pain
➢ Pain is classified according to its underlying pathology
which results in the categories of nociceptive and
neuropathic pain
➢ Another useful scheme is to classify pain as acute or
chronic
Classification of pain as Nociceptive & Neuropathic
1. Nociceptive pain
➢ Is caused by damage to the somatic or visceral tissue
• Somatic pain is characterized by aching or throbbing pain
that is well localized, arises from bone, joint, muscle, skin,
or connective tissue
• Visceral pain which may result from stimuli such as tumor
involvement or obstruction, arises from internal organs such
as the intestine and bladder
➢ Nociceptive pain is usually responsive to non-opiods
as well as opioids 15
2. Neuropathic pain
➢Is caused by damage to nerve cells or
changes in spinal cord processing
➢Typically described as burning, shooting,
stabbing, or electrical in nature
➢Neuropathic pain can be sudden, intense,
short lived, or lingering
➢Neuropathic pain is not well controlled by
opioids analgesics alone, and treatment
often includes the use of adjuvant analgesics,
including tricyclic antidepressants
16
Classification of pain as Acute and Chronic
Acute pain Chronic pain
Onset Sudden Gradual or sudden

Duration < 3 months or as long > 3 months; may start as

as it takes for normal acute injury or event but
healing to occur continues past the normal
time for recovery

Severity Mild to severe Mild to severe

Cause of Generally can identify a May not be known;

precipitating event or original cause of pain may
pain illness differ from mechanisms
that maintain the pain
17
 Acute pain Chronic pain
Course of Decreases over time and
goes away as recovery
Typically pain does not go
away; characterized by periods
pain occurs of waxing and waning

Typical Manifestations reflect Predominantly behavioral

sympathetic nervous manifestations like:
physical system activations, • Flat affect
and like: • Decreased physical
• Increased heart rate
behavioral • Increased respiratory
movement/activity/
• Fatigue
manifestati rate • Withdrawal from others and
ons • Increased blood pressure social interactions
• Diaphoresis/pallor
• Anxiety, agitation,
confusion
• Urine retention

Usual goals Pain control with eventual

elimination
Pain control to the extent
possible; focuses on enhancing
of function and quality of life
18
treatment
Pain management
➢ Always the patient must be believed, because this
principle reflects the basic definition of pain as a
subjective experience
✓ The patient is not only the best judge of his or her own
pain, but also is the expert on the effectiveness of each
pain treatment
➢ Treatment plans should use a combination of drug
and non drug therapies
➢ All therapies must be evaluated to ensure that they
are meeting the patients goal
➢ A multidisciplinary approach is necessary to address
all dimensions of pain
➢ Drug side effects must be prevented and/or
managed
➢ Patient and family teaching should be 19 the
cornerstone to the treatment plan
 Simple descriptive pain intensity scale

No Mild Moderate Severe Very severe Worst

pain pain pain pain pain possible
pain

O - 10 numeric pain intensity scale

0 1 2 3 4 5 6 7 8 9 10

Visual analog scale/VAS/

No Worst
pain possible
pain

Figure:- Pain measurement scales 20

Figure:- Pain measurement scale…cont.
21
 A. Pharmacologic therapy
1. Scheduling analgesics
➢ Appropriate analgesics scheduling should focus on
preventive or ongoing control of pain rather than
providing analgesics only after the patient’s pain has
become severe
➢ Titration- analgesic titration is dose adjustment
based on assessment of the adequacy of analgesic
effects versus the side effects produced
➢ Analgesic can be titrated upward or downward,
depending on the situation
➢ The goal of titration is to use the smallest dose of
analgesic that provides effective pain control
22
with the fewest side effects
2. Analgesic ladder
➢Proposed by WHO (World Health Organization)
➢The WHO treatment plan calls for concurrent
treatment of the cause of the pain when
possible and use of a three step ladder
approach

23
 Step 3
Opioids for moderate or severe pain
E.g.: Morphine, Hydromorphone,
Methadone, etc

Step 2
Opioids for mild to moderate pain
E.g.: Codien, Oxycodien, etc

Step 1
Figure: The analgesic
Non-opioids for mild pain ladder proposed by the
E.g.: Aspirin, Acetaminophen, World Health Organization
24
NSAIDs and + Adjuvants /WHO/
Note that:
➢If pain persists or increases, drugs from
the next higher step are used to control
the pain
➢For chronic non malignant pain and
cancer pain, drug use is recommended
from the bottom of the ladder to the top (i.e,
up the ladder from step 1 to step 2 to step
3)
➢For acute pain, the steps can be reversed
in order from the top ladder to the bottom
ladder (i.e, down the ladder from step 3 to
step 2 to step 1) as recovery occurs and 25
pain decreases
How analgesics work

26
 B. Surgical therapy
1. Nerve block
➢Are used to reduce pain by temporarily or
permanently interrupting the transmission of
nociceptive input by application of local
anesthetics or neurolytic agents
➢For intractable chronic pain, nerve blocks are
used when more conservative therapies fail
➢Nerve blocks have been a successful pain
management technique for more localized
chronic pain states 27
2. Surgical intervention
➢Neurosurgical interventions are
performed for severe pain that is
unresponsive to all other therapies
✓Neuroablative techniques destroy nerves,
thereby interrupting pain transmission
✓Neuroablative interventions that destroy the
sensory division of a peripheral or spinal
nerve are classified as neurectomies

28
 C. Non-pharmacologic therapy
➢The strategies are believed to alter ascending
nociceptive input or stimulate descending pain
modulation mechanisms
➢Non pharmacologic pain relief methods can
be categorized as physical or cognitive
strategies
I. Physical
1. Massage
➢Common method
➢Massage techniques can be
✓Acupressure
29
✓Trigger point massage
2. Vibration
➢Is thought to provide pain relief by activating
mechanoreceptors in the muscle
3. Acupuncture
➢Is a technique of traditional Chinese medicine
in which very thin needles are inserted in to
the body at a designated points
4. Heat therapy
➢Is the application of moist or dry heat to the
skin
➢For exposure to large areas of the body,
patients can immerse themselves in a hot
30
bath, shower, or whirlpool
5. Cold therapy
➢ Involves the application of either moist or dry cold to
the skin
➢ It is believed to be the most effective than heat
therapy
✓ Relieves more pain than heat therapy
✓ Works faster than heat
✓ Provides longer lasting pain relief than heat

6. Exercise
➢ Is a critical part of the treatment plan for a patient
with chronic non-malignant pain
➢ Exercise acts via many mechanism to relieve pain
✓ It enhances circulation and cardiovascular fitness
✓ Reduces edema
✓ Increases muscle strength and flexibility
✓ Enhance physical and psychosocial functioning 31
II. Cognitive
➢ Is a techniques used to alter the affective, cognitive,
and behavioral components of pain that includes a
variety of cognitive strategies and behavioral
approaches
1. Distraction
➢ It involves redirection of attention on something
and away from the pain
➢ It is simple but it is powerful strategy to relieve pain
➢ Can be achieved by engaging the patient in any
activity that can hold his or her attention
✓ Imagery- is a structured distraction techniques that uses
the patient’s own imagination to develop sensory images
that divert focus away from the pain sensation and
emphasize other sensory experiences and pleasant
memories 32
2. Hypnosis
➢ Is a structured technique that enables a patient to achieve a
state of heightened awareness and focused concentration
that can be used to alter the patent’s pain perception

3. Relaxation
➢ The goal of relaxation is to reach a state that is free from
anxiety and muscle tension
➢ Relaxation reduces:
✓ Stress
✓ Decreases acute anxiety
✓ Distracts from the pain
✓ Alleviates skeletal muscle tension
✓ Combats fatigue
✓ Facilitates sleep
✓ Enhances the effectiveness of other pain relief measures
➢ Elicitation of the relaxation response requires a:
✓ Quiet environment
✓ Comfortable position 33
✓ Mental device as a focus of concentration
Myths and barriers to effective pain
management
➢Treatment of patients in pain is influenced by
a number of factors, including the way the
Nurse was treated when in pain as a child

➢Common myths about pain may impair the

Nurse’s ability to be objective about pain and
create barriers to effective treatment

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 Myth Fact
A person who is A person in pain is likely to use laughing
laughing and and talking as a form of distraction. This
talking is not in can be very effective in the management
pain of pain especially when used in
conjunction with appropriate drug
therapies
If morphine is Morphine is an opioid agonist. Opioid
given too early to doses can be escalated (titrated upward)
the patient with in definitely as needed as the patient’s pain
cancer pain, it will increases. There is no ceiling effect, or
not work when maximum effective dose. Side effects such
the patient really as sedation or clinically significant
needs it, toward respiratory depression may temporarily
the end, when the limit the dose or the rate at which the dose
pain is worse can be increased 35
 Myth Fact
Respiratory Respiratory depression is
depression is uncommon in patients receiving
common in opioid pain medications. If patients
patients are monitored carefully when they
receiving are at risk, such as with the first
opioid pain dose of an opioid or when a dose is
medications increased, respiratory depression is
preventable. A patient’s respiratory
status and Level Of Sedation should
be routinely monitored using an LOS
scale

36
 Myth Fact
Pain Intramuscular /IM/ injection are not
medication is recommended because they are painful,
have unreliable absorption from the muscle
more effective and have a lag time to peak effect and rapid
when given by falloff compared with oral administration.
injection Oral administration is the first choice if
possible; the Intravenous /IV/ route has the
most rapid onset of action and is the
preferred route for postoperative
administration
Teenagers are Addiction to opioids is very uncommon in all
more likely to age groups when taken for pain by patients
without a prior drug abuse history
become
addicted than
older patients 37
Harmful effects of unrelieved pain
System Response
Endocrine ➢ Increased adrenocorticotropic
hormone (ACTH)
✓ Increased cortisol
✓ Increased anti-diuretic hormone(ACTH)
✓ Increased epinephrine
✓ Increased nor-epinephrine
✓ Increased growth hormone
✓ Increased rennin
✓ Increased aldosterone
✓ Decreased insulin
✓ Decreased testestrone
38
Harmful effects of unrelieved pain…cont.
System Response
Metabolic ✓ Gluconeogenesis
✓ Glycogenolysis
✓ Hyperglycemia
✓ Glucose intolerance
✓ Insulin resistance
✓ Muscle protein catabolism
✓ Increased lipolysis
Immunologic ✓ Decreased immune response

39
Harmful effects of unrelieved pain…cont.
System Response
Cardiovascular ✓ Increased heart rate
✓ Increased cardiac out put
✓ Increased peripheral vascular
resistance
✓ Hypertension
✓ Increased myocardial oxygen
consumption
✓ Increased coagulation

40
Harmful effects of unrelieved pain…cont.
System Response
Respiratory ✓ Decreased tidal volume
✓ Atelectasis
✓ Hypoxemia
✓ Decreased cough
✓ Sputum retention
✓ Infection

Neurologic ✓ Reduction in cognitive functions

✓ Mental confusion
41
Harmful effects of unrelieved pain…cont.
System Response
Genitourinary ✓ Decreased urinary out put
✓ Urinary retention

Gastrointestinal ✓ Decreased gastric and bowel

mobility

Musculoskeletal ✓ Muscle spasm

✓ Impaired muscle function
✓ Fatigue
✓ Immobility 42