Pain and Comfort INTRODUCTION Pain is an unpleasant sensory and emotional experience associated with actual or potential tissuedamage. It is sometimes referred to as the FIFTH vital sign. In many aspects, pain is the most common reason for seeking health care. Because pain emanates from various modalities such as diagnostics tests, diseases and treatment procedures, nurses must be knowledgeable about the pathophysiology of pain and its management. Nurses encounter pain in a variety of setting, including acute are, outpatient, and long term care settings as well as in the home. The nurse has daily encounters with pain who anticipate pain or who are in pain. Understanding the phenomenon of pain and contemporary pain theories helps the nurse to intervene effectively. Pain Definition This is a subjective sensation to which people respond in different ways. It can directly impair health and prolong recovery from surgery, disease and trauma. Pain is a highly unpleasant and very personal sensation that cannot be shared with others. It can occupy all a person’s thinking, direct all activities, and change a person’s life. It is the noxious or unpleasant stimulation of threatened or actual tissue damage. This pain sensation is a different sensation because the purpose of pain is not to inform the CNS of the quality of the stimulus but rather to indicate that the stimulus is causing damage or injury to the tissues. It is the result of a complex pattern of stimuli generated at the pain site and transmitted to the brain for interpretation. Common terminologies: 1. Radiating pain—perceived at the source of the pain and extends to the nearby tissues 2. Referred pain— pain is felt in a part of the body that is considerably removed from the tissues causing the pain 3. Intractable pain—pain that is highly resistant to relief 4. Phantom pain—painful perception perceived in a missing body part or in a body part paralyzed from a spinal cord injury 5. Phantom sensation—feeling that the missing body part is still present blood vessels. pleural surfaces. Acute pain/fast pain/sharp following acute injury. For pain to be perceived. Pain tolerance—maximum amount and duration of pain that an individual is willing to endure 11. Pain reaction—includes the autonomic nervous system and behavioral responses to pain 10. but pain is tolerance and response vary considerably • Painful sensations are sensed by receptors. burning aching. • We call the receptors NOCICEPTORS. and nerves C. peritoneal surfaces. disease or some type of pain/initial pain surgery may have sudden or slow onset may last up to 6 months occurs within 0. It is frequently caused by stretching of the tissues. Pain sensation—can be considered the same as pain threshold 9. bones. histamine. It tends to appear diffuse and often feels like deep somatic pain that is. These pain receptors can be stimulated by: serotonin. Hyperalgesia—excessive sensitivity to pain 7. Cutaneous pain—originates in the skin or subcutaneous tissue B.Pain perception—the point which the person becomes aware of the pain Pain threshold is similar in all people. or feeling of a pressure. tendons. Deep somatic pain—arises from ligaments.1 second after application of stimulus Easily localized • . nociceptors must be stimulated. • These nociceptors are non-adapting to keep us constantly informed of the continuous presence of the painful stimulus that can damage the tissues. • Usually they are free nerve endings located widespread in the superficial layers of the skin. acids and some enzymes Pain Categories Category of pain according to its origin A. Visceral Pain—results from stimulation of pain receptors in the abdominal cavity. joint surfaces and the falx and tentorium of the cranial vault. Pain threshold—is the amount of pain stimulation a person requires in order to feel pain 8.6. Nociceptors—pain receptors 12. periosteum. arterial walls. cranium and thorax. ischemia or muscle spasm Category of pain according to its cause. potassium ions. squeeze. Thermal stimulus . sweating and generalized hypotonia. Histamine.Mechanical. Chronic malignant/ Cancer Related pain Chronic nonmalignant/Dull/ Slow/ Delayed pain Impulses travel through the type A delta fibers associated disorder with cancer or other progressive pain in the persons whose tissue injury is non progressive or healed last 6 months or longer and often limits normal functioning Impulses travel through the type C fibers not easily localized autonomic signs and symptoms like nausea.pressure. usually accompany this pain Types of Pain Stimuli In general. pin prick 2. Mechanical stimulus .heat and freezing temperature 3. Collectively called “P” factors. prostaglandin. Chemical stimulus: These are released when the tissue is injured or inflamed making the mechanoreceptors sensitive to pain. substance P . 1. there are 3 types of stimuli that can stimulate pain receptors. Bradykinin. serotonin. Thermal and Chemical. Physiology of Pain The Exact mechanism of pain transmission is still partially unknown. Stimulus Receptor Type A Delta Nerve Fibers Type C Nerve Fibers Neospinothalamic Tract Paleospinothalamic Tract Thalamus and/or Reticular system Brain ( Somesthetic Areas) . the NIPS may be modified in collaboration with the parent to better represent that individual child’s pain behavior. C. In general: Scores of 0-2 indicate minimal pain to no pain Scores of 3-4 indicate moderate pain . E. toddlers. F. D. Ethnic/Cultural values Age/Developmental Stage/Gender Environment and support persons Past pain experiences Meaning of pain Anxiety and stress Pain Assessment OLDCART Onset Location Duration Characteristic Aggravating Factors Radiation Treatment (present and previous) PQRST Provoked Quality Region/Radiation Severity Timing Pain Scales Premature Infant Pain Scale (PIPS) Use for premature infants (<36 weeks gestation) In general: Scores<6 indicate minimal to no pain Scores of 6-12 indicate mild to moderate pain Scores >12 indicate moderate to severe pain Neonatal Infant Pain Scale (NIPS) Use for infants. or any child who is nonverbal For children with severe developmental delay or severe cognitive delay.Factors affecting the Pain A. B. French. Korean. Chinese. Russian. Chinese. Japanese. German. Pakistan. French. Vietnamese. Japanese. although the nurse may be aware of predispositions to specific discomforts (e. the tendency for shortness of breath in an asthmatic child or acute anxiety in family members) 3. Hebrew. Transcendence . Tagalog. Italian. Romanian. Tongan. Relief the state of having a discomfort mitigated or alleviated. Greek. Italian. Spanish. Spanish. Hawaiian.. Ilocano. 2. Samoan.g. State of calm or contentment To experience ease a person does not have to have a previous discomfort. Polish. and Vietnamese. Ease the absence of specific discomforts. Portuguese. In general: Scores of 0-4 indicate minimal to no pain Scores 5-6 indicate moderate pain Scores of 7-10 indicate moderate to severe pain Comfort Scale Use for intubated children In general: Scores of 0-17 indicate mild to no pain Scores of 18-27 indicate moderate pain Scores of >27 indicate moderate to severe pain Comfort Types of Comfort 1. Scores of 5-7 indicate moderate to severe pain Wong-Baker Faces Rating Scale (FACES) Use for children > 3 years old Self reports are valid and preferred for most children > 3 years old The FACES scale is available in multiple languages: English. In general: Scores of 0-2 indicate minimal pain to no pain Scores of 3 indicate moderate pain Scores of 4-5 indicate moderate to severe pain Verbal Analogue Scale (VAS) Use for children > 8 who understand the concept of order and number Instructions for the VAS are available in multiple languages: English. Patterned Breathing These breathing techniques provide comfort and focus Breathing enhances oxygen flow 2.g. provide reassurance and information instill hope Listen help plan for recovery Comfort food for the soul extra nice things that nurses do to make children/families feel cared for and strengthened. Massage . such as massage or guided imagery Comfort Therapies Pleasure travels faster along nerve pathways than pain. For maximum effect. about every 20 minutes. 2. Heat and Cold Heat can be applied by a hot water bottle or warm washcloths. the combination of warmth. Using heat and cold on separate parts of the body at the same time can provide particularly effective pain relief. for example.. change the heat and cold locations frequently. cold washcloth or bag of frozen peas. Pleasure or comfort also causes our bodies to produce elevated levels of our own endorphins or "feel-better" hormones. 3. 3. the child feels confident about ambulation although (s)he knows it will exacerbate pain). cool forehead with warmth on the lower back. water pressure and sound is very comforting. Three Types of Comfort Interventions 1. Basic Methods of Comfort Therapy 1. Water Whether lying in the bubbling water of the Jacuzzi tub or sitting on a shower stool using the hand-held shower massage. Standard comfort interventions to maintain homeostasis and control pain Coaching to relieve anxiety. cold can be applied by an ice bag. 4. the ability to "rise above" discomforts when they cannot be eradicated or avoided (e. These scheduled doses should be given around the clock to avoid large peaks and valleys in pain control. Receptors in the skin pick up the signal of touch and elevate endorphins. Effects are felt within two to four minutes and are often described as "taking the edge off" of pain. Nausea and Vomiting c. Acupuncture—or acupressure to reduce pain sensation Medical Interventions 1. No fancy techniques are required. Results of its effectiveness are variable but some residents and some types of pain obtain relief from TENS. 9. frequent doses. Respiratory Depression and Sedation b. Constipation d. 8. Unscented powder or lotion are helpful for massage. Progressive muscle relaxation 7. especially in infants Intermittent Dosing is most effective when given in small. Side Effects of Opioid Therapy: a. 5. back. are usually given directly into an IV already in place. shoulders. thighs. Bare skin receives the signal best. Continuous infusion of opioids is most effective in maintaining continuous pain relief with minimal risk of respiratory depression. 6. You can ease these feelings by envisioning a pleasant scene. Transcutaneous Electrical Nerve Stimulation (TENS) is a counterstimulation technique with the goal of inhibiting pain transmission. Biofeedback This technique teaches the patient to relax the muscles in the area of pain. Do not give the scheduled dose if a patient is experiencing increased sedation or respiratory depression Patient-controlled-analgesia (PCA) combines the benefits of continuous infusion and PRN dosing and has the added benefit of putting the patient/family in control of the child’s pain. feet or hands. Inadequate Pain Relief . Stroking or rubbing the neck. Narcotic Analgesics Narcotic analgesics. Attention Focusing (Guided Imagery) and Meditation Fear and anxiety cause the release of stress hormones. 4. It works very quickly and results in almost immediate loss of consciousness After general anesthesia wears off. Epidural anesthesia provides excellent pain relief but has some side effects like: o Decrease in blood pressure o Breathing problems o Severe headache. A spinal block numbs the lower half of the body. Epidural Anesthesia Epidural anesthesia involves the placement of a small catheter into the lower back by an anesthesiologist. NSAIDS work primarily on the peripheral nervous system to provide pain relief. Acetaminophen may be used for mild-moderate pain intensity or in conjunction with 3. Tolerance and Addiction 2. A continuous infusion of medication is administered through the catheter to provide a constant level of anesthesia. provides excellent relief from pain and starts working quickly. which means that increasing the dose above the recommended dose will not provide additional analgesia. It has the same side effects as epidural anesthesia. General anesthesia is given in one of two ways: o through a face mask o injected through an IV line. you will feel woozy and tired for several hours Neurosurgical Approaches to Pain Management . Non Narcotic Analgesics NSAIDS are effective for acute or chronic painful conditions of mild to moderate intensity. 7. Local Anesthesia These numbing medications usually affect a small area. It is safe to administer a non-opioid and an opioid at the same time.e. Pudendal Block considered one of the safest forms of anesthesia and serious side effects are rare. General Anesthesia General anesthetics are medications that cause a loss of consciousness. Spinal Block A spinal block is given as an injection into the lower block. 5. NSAIDS have a ceiling effect. Common side effects of NSAIDS include GI irritation/upset and antiplatelet effects contributing to some bleeding tendencies. dizziness o Rarely seizures 6. but the way they express pain differs with age The nurse should be able to recognize physiologic. psychological and non-verbal ways of expressing pain Lack of pain expressions does not always mean lack of pain Non-invasive pain relief measures can increase the effectiveness of pharmacological or invasive methods The nurse’s optimistic attitude about expected pain relief helps produce a positive result Educating the patient and family about pain reduces the anticipatory fear and anxiety. it minimizes injury and warns of disease Establishing rapport between the nurse and the patient enhances the effectiveness of pain relief measures Sedation does not always indicate pain relief Because patients may not always report pain.A. the nurse must assess them regularly Patients of all ages experience pain. thereby increasing the patient’s tolerance Using a preventive approach for pain relief is more beneficial than waiting until pain becomes severe Intramuscular and intravenous routes are utilized for severe pain and the intramuscular for moderate pain and oral for mild pain The nurse must utilize the nursing process in relieving patient of “painful experiences” . Rhizotomy – destruction of sensory nerve roots IN SUMMARY Pain is a subjective experience that is whatever the patient says it is and occurs whenever the patient says it occurs Although pain is a source of human misery. Cordotomy – division of certain spinal cord tracts B.