1. Dr. Naglaa Youssef
Medical-Surgical Nursing Dep.
Faculty of Nursing
Cairo University

2. Content outlines
 Definition of pain
 Components of pain
 Types of pain
 Physiology of pain
 Management of pain
 Assessment of pain
 Nursing diagnosis of patient with pain
 Nursing care for patient with pain

3. Pain definition
 Pain has been defined as an „‟unpleasant sensation
usually associated with disease or injury‟‟ (Timby
2009).
 It causes physical discomfort that is a companied by
suffering, which is the emotional component of pain.
 the American Pain Society coined the phrase “Pain:
The 5th Vital Sign”

4.  Pain is „‟whatever the person says it is, and existing
whenever the person says it does‟‟ (Margo
McCaffery 1998).
 “It is not the responsibility of clients to prove that
they are in pain; it is the nurses‟ responsibility to
believe them.” (Crisp & Taylor, 2005).

5. Components of pain
Experience of pain includes:
Sensory
Affective
Cognitive
Behavioural
Physiological
Perception of pain characteristics: intensity, quality, location
Negative emotion: anxiety, fear, unpleasant sensation
Interpretation of pain
Coping strategy used to
express, avoid, or control pain
Nociceptive and stress
response

6. Types of pain
 Types of pain can be described/classified
according to:
Typesofpain
Source
Cutaneous
Somatic
Visceral
NeuropathicAetiology
Duration
Acute
Chronic
Nociceptive
pain

7. Cutaneous pain
 Discomfort feeling originates at the skin level,
e.g. trauma.

8. Nociceptive pain
Somatic
Involves superficial tissue: skin,
muscles, joints, bones
Location is well defined
Sensation is described as
Tender, Burning, Shooting,
Throbbing
e.g. cut skin, stretch a muscle too
far or exercise for a long period
of time.
Visceral
 Involves organs: heart,
stomach, liver..etc.
 Location: Diffuse
 Sensation is described as:
aching, cramping

9. Visceral pain
 Discomfort arising from internal organs.
 Is associated with injury or disease.
 It is sometimes referred (referred pain) or poorly
localized.
 Referred pain is a discomfort or pain perceived in a
general area of the body, usually away from the site
of stimulation. E.g., cardiac pain may be felt in the shoulder or left
arm, with or without chest pain.

10. Areas of referred pain

11.  Radiating pain
 Perceived in the source of pain and extended to
nearby tissue.

12. Neuropathic Pain
 Is pain that experienced days, weeks, or longer after the
cause of pain has been treated.
 Is called functional pain.
 Is due to dysfunction of the nervous system.
 E.g. phantom pain limb pain/sensation.
 a person with an amputated limb perceives that the limb still exists
and feels burning, itching, deep pain in tissues that have been
surgically removed.

13. Acute and chronic pain
Acute
• Recent/rapid onset
• Specific, localized
• Severity associated with the
acuity of disease
• Good response to medication
therapy
• Requires less drug therapy
• Suffering is decreased
• Associated with sympathetic
nervous system responses:
hypertension, tachycardia,
restlessness & anxiety.
Chronic
• Prolonged onset
• Nonspecific, generalized
• Severity out of promotion to the
disease
• Poor response to medication
therapy
• Requires more drug therapy
• Suffering is intensified
• Absence of autonomic nervous
system responses
• Psychological suffering:
depression & irritability.

14. Physiology of Pain
Specialized pain receptors or nociceptors can be excited by mechanical, thermal, or
chemical stimuli.
Nociceptors
Central Nervous System

15.  What is nociceptor?
 Is a type of sensory nerve (free nerve endings in
the skin) that sensitive to a noxious stimulus.
Nociceptors are also called pain receptors, but
the former term is preferred.
 Where does it locate?
 It locates in the:
 Skin, bones, joints, muscles & internal organs.

16. Physiology of pain
It is the process by which the person experiences pain occurs in
four phases:
Transduction Transmission Perception Modulation

17. First phase: Transduction
 Chemicals substances such as
 substance p, histamine & prostaglandins
Injured
cells
release
chemicals
excite
nociceptors
Pain medications can work during this phase by blocking the production of prostaglandin
(e.g., ibuprofen or aspirin) or by decreasing the movement of ions across the cell
membrane (e.g., local-anesthetic).

18. Phase 2: Transmission (spread)
 Is the phase where stimuli moves from the peripheral
nervous system toward the brain.
 Types of nerve fibers
A-delta fibers
Smaller, myelinated fibers,
Carry impulses rapidly
Smaller, myelinated Aδ (A delta) fibers
transmit nociception rapidly, which produces
the initial “fast pain
Result in:
Sharp, localized pain, acute initial sensation.
e.g. touching a hot iron then withdraw from
pain provoking stimulus
C-fibers
Larger, unmyelinated fibers.
Carry impulses at a slow
rate. E.g. dull, aching,
burning sensation.

19.  Pain impulses move to higher level in the brain such
as: thalamus, cerebral cortex and limbic system by
assistance of substance P.
 Prostaglandin is a chemical that released from
injured cells speeds the pain transmission.
Opioids (narcotic analgesics) block the release of neurotransmitters,
particularly substance P, which stops the pain at the spinal level.

20. Phase 3: Perception
 What does perception mean?
 Is the person‟s „‟conscious experience of discomfort
„‟(Timby 2009).
 When does perception occur?
 It occurs when the pain threshold (‫األلم‬ ‫)عتبة‬ is
reached.

21. What is pain threshold?
 „‟Point at which sufficient pain-transmitting stimuli
reach the brain‟‟ (Timby 2009).
 The point at which a stimulus is perceived as
painful.
 What is pain tolerance?
 Is the maximum amount (intensity) or duration of
pain that person can endure or tolerate.

23. Phase 4: Modulation or descending ( ‫تعديل‬‫المسار‬ )
 Is the last phase of pain impulse transmission
where the brain interacts with the spinal nerves in a
downward way to alter the pain experience.
 Release of pain inhibiting neurochemicals that can
reduce the pain, such as:
 Endogenous opioids
 Gamma-aminobutyric acid

24. Gate control theory (Melzack and Wall, 1965)
Protective pain reflex.
Discomfort stimulus from skin
travel along sensory neuron to
dorsal horn of spinal cord,
synapses with motor neuron,
travels along spinal nerve to
skeletal muscle, causing
withdrawal from pain stimulus.

26. Physiological response to pain
 Pain produces a physiological stress response that includes
increased heart and breathing rates to facilitate the increasing
demands of oxygen and other nutrients to vital organs. Failure to
relieve pain produces a prolonged stress state, which can result in
harmful multisystem effects (Middleton, 2003).
 Incase of sever traumatic pain may place client into shock.

27. Vocalization
Moaning,
crying &
gasping
‫والبكاء‬ ‫الشكوى‬
‫ويلهث‬
Facial
expression
Grimace,
clenched
teeth, tightly
closed eye &
lip biting &
wrinkle
forehead
Body
movement
Immobilization
,restlessness
& muscle
tension
Social
interaction
Avoid the
conversation
or social
contacts
Behavioral response

28. Impact of pain on patient daily life
 Fatigue
 Sleeping disturbance
 Loss of appetite
 Social withdraw
 Disturb family life
 Tense muscles
 Impair immune system….poor healing, infection, ulcers.
 Stop activity…..complications of immobility such as
muscle atrophy, cardiovascular complications

29. Factors influencing pain perception
Factors
influence pain
Age
Gender
Culture
Environ
ment
Meaning
of pain
Anxiety
Fatigue
Previous
experience
Family
support
e.g. keep a
stiff upper lip
e.g. Money reward

30. • Assessment
• Nursing diagnosis
• Intervention
• Evaluation
Nursing
process
Caring for patient with pain

31.  Pain is the fifth vital signs that should be
assessed during assessment stage (the
American Pain Association).
Pain assessment

32. Method of assessing pain:
A. Taking history
B. Physical examination of pain

33. Pain Scales
 There are different pain intensity scales:
1. Word scales
2. Numeric scales
0
Mild
pain
Moderate
pain
Sever
pain
Very sever
pain
Worst
possible painNo pain
7 85 6 92 3 41
No pain
10
Worst
possible pain
Moderate
pain

34. 3. Linear (visual analogy) scale/VAS
4. Rating scale
No pain Pain as bad as it could
possible be

35. Components of pain assessment: COLDERR
Focus of assessmentComponents
Describe pain sensation (e.g. sharp, aching, burning)Character
When it started, sudden, gradually.Onset
Where it hurts, mark on a diagramLocation
Constant versus intermittent in nature, how longDuration
Factors that make it worseExacerbation
Factors that make it betterRelief
Pattern of shooting/spreading/location of pain away
from its origin.
Radiation

36. Components of pain assessment
Focus of assessmentComponents
Rating for present pain severity using a pain
scale.
Intensity
Description own client‟s own words (like knife).Quality
prayer or other religious practices, withdrawalCoping resources
Pain characteristics that change.Variations
Repetitive or not.Patterns
Sleep, appetite, concentration, school, work,
driving, walking, slef-care.
Effects on ADL’S
N/V, dizziness, diarrheaAssociated
Symptoms

37. Focus of assessmentComponents
Approaches used to control the pain and results
and effectiveness.
Current pain
treatment
Past medications or interventions and the
response, manner of expressing pain, personal
cultural, spiritual, or ethnic believes that can affect
pain management.
Pain treatment
history
Level of tolerance, expectation for level of pain
relief ability to restore function.
Person’s goal for
pain control

38. Nursing diagnoses
 Ineffective airway clearance related to weak cough secondary to
incision abdominal pain
 Activity intolerance related to pain (specify location as left ankle pain)
 Immobilization related to pain (specify )
 Sleep disturbance related to pain (specify)
 Self care deficit (specify) related to poor pain control
 Ineffective coping related to ineffective pain management (specify
location as left ankle pain)
 Depression & anxiety related to pain (specify)
 Deficient knowledge (specify pain medication) related to lack of
exposure to information resources

39. Planning (goals)
 After 2 hours the patient:
 Will report pain control or relief of pain
 Will express satisfaction with pain control
 Will states pain is 2/10
 Will reported decrease in intensity of pain
 Willing to try relaxation technique
 Increases interactions with family and friends
 Demonstrates use of new strategies to relieve pain

40. Interventions
1. Monitoring
2. Actions / interventions
3. Teaching

41. Monitoring
 Use pain assessment scale to identify intensity of pain.
 Assess and record pain and its characteristics:
location, quality, frequency, and duration.
 Assess vital signs every 30 minutes

42. Actions / interventions
 Aim of pain management to preventing, reducing,
relieving pain, such as:
Non-pharmacologic interventions
Pharmacologic management
Health teaching

43. Non-pharmacologic interventions
 Relaxation techniques = releasing
tension
 Education = support & coping
methods
 Imagery = using mind to visualize
an experience=daydreaming
 Distraction=switch from unpleasant
sensory experience to one more
pleasant
 Acupuncture= thin needles
are inserted into the skin
 Acupressure = tissue
compression
 Meditation = concentrating
on a spiritual word or idea
 Heat & cold = thermal
therapy = swelling &
vasodilatation

44. Types of distraction
Visual
distraction
Tactile
distraction
Auditory
distraction
TalkingOder
Intellectual distraction
Reading, watching T.V
Listen to music
Message, deep breathing
Hobbies, writing cross word
puzzle

45. Pharmacologic
Analgesia = relief of pain. Gk
an- without + algesis-sense of
pain.
 Oral medications
 Patient – Controlled
Analgesia (PCA)
 Epidural analgesia
 Injection in the lumber region
at the L2/3 or L3/4 space

46. Health teaching
 Teach patient additional strategies to
relieve pain and discomfort: distraction,
relaxation, cutaneous stimulation, etc.
 Instruct patient and family about potential
side effects of analgesics and their
prevention and management.

47. Approaches to pain management
ExamplesInterventionApproach
Aspirin, ibuprofen,Local anaesthetics, anti-
inflammatory medications
Interrupting pain
transmitting chemicals at
the site of injury
Epidural, rhizotomy,
sympathectomy
Intra spinal anaesthesia
and analgesia or
neurosurgery
Altering the transmission at
the spinal cord
Massage, acupuncture,
acupressure, heat, cold
electrical stimulation
Cutaneous stimuliUsing gate closing
mechanism
Morphine, imagery,
distraction, hypnosis
Narcotics, non-
pharmacological
techniques
Blocking brain perception

48. Evaluation
 Report pain level
 Respiratory rate
 Amount of medication, frequency use
 Side effect of medication