ALTERED COMFORT
Donna Woshinsky, MSN RN CNE
“PAIN”
Class Objectives
physiology and classifications of
pain
 pain assessment
 nursing diagnoses
 interventions for pain
 evaluation

“Pain is whatever the experiencing person
says it is, existing whenever he says it
does”. McCaffery, 1979
“Pain is an unpleasant subjective
sensory and emotional experience
associated with actual or potential
tissue damage, or described in
terms of such damage.”
Merskey & Bogduk, 1994
PAIN
subjective experience
PAIN PHYSIOLOGY
nociception
neural mechanism by which pain is
recognized, transmitted and perceived
 nociceptors: sensory nerve fibers that
transmit pain signals
 nociceptors densely packed on outer layers
of body, more diffuse and unevenly
distributed in viscera
 nociceptors-afferent nerve fibers
Nociception: 4 steps

PAIN PHYSIOLOGY
nociception:
transduction
transduction
PAIN PHYSIOLOGY
nociception:
transduction
Neurotransmitters
(biological soup)
-bradykinin
-cytokines
-cox 1 & 2
-prostaglandins
-substance P
PAIN PHYSIOLOGY
nociception:
transduction
-Inhibit transduction:
inhibition of prostaglandin
synthesis by blocking action of
cyclooxygenase: example:
NSAIDs
PAIN PHYSIOLOGY
nociception:
transmission
neurotransmitters (prostaglandins,
substance P, etc.) cause pain fiber to be
depolarized
 sodium channel activated, generates the
action potential
A delta and C fibers

PAIN PHYSIOLOGY
nociception:
transmission
-Some Drugs inactivate the sodium
channel, inhibiting the action
potential:
Lidocaine, procaine (Novocain)
-Some drugs raise threshold for
activation (anti-seizure drugs):
Lamotrigine (Lamictal)
carbamazepine(Tegretol)
Gabapentin (Neurontin)
PAIN PHYSIOLOGY
nociception:
transmission
Dorsal Horn Synapse:
-excitatory neurotransmitters:
substance p
prostaglandins
PAIN PHYSIOLOGY
nociception:
Gate Theory
• another stimulus is able to “close the gate” on the
transmission of the pain impulse
• Theoretical rationale for acupressure, massage, TENS
(transcutaneous electrical nerve stimulation)
• Descending impulses from the brain can also open or
close the “gate”
PAIN PHYSIOLOGY
nociception:
PERCEPTION
-somatosensory
cortex: interpretation
of pain
-RAS: warning individual to attend to pain stimulus
-limbic system: emotional aspect to pain
-frontal cortex: pain recognition and definition
Pain Threshold vs. Pain
Tolerance

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Pain threshold: lowest intensity of a
stimulus that causes recognition of pain;
experience with pain can lower the
threshold.
Pain tolerance: Pain level a person can
endure; varies person to person, and even
in same person under different
circumstances.
PAIN PHYSIOLOGY
nociception:
PERCEPTION
Opioid analgesics alter the
perception and emotional response to
pain
PAIN PHYSIOLOGY
nociception:
MODULATION
Occurs at any level of pain neural pathway
 exogenous: medication
 endogenous: descending inhibitory neural
pathways
 neurotransmitters: serotonin, endorphins,
GABA, enkephalins, norepinephrine

PAIN PHYSIOLOGY
nociceptive process
Transduction: pain signal initiated
 Transmission: pain signal travels to spinal
cord, then to thalamus and beyond
 Perception: pain signal recognized and
interpreted by brain
 Modulation: pain signal inhibited

PAIN
“A self-limiting phenomenon”
Tissue healing and repair
 Inflammation decreases
 Breakdown of facilitators and
neurotransmitters
 Modulation via descending
inhibitory pathways
So why “Chronic Pain”?

TYPES OF PAIN
by origin
Cutaneous Pain
Somatic pain
Visceral pain
Neuropathic pain
Malignant pain
Cutaneous Pain
-Involves superficial structures such as
skin, and subcutaneous tissue
-sharp, stinging, burning
SOMATIC PAIN
-Structural pain: bones, muscles,
joints, tendons, ligaments
-well localized
-achy, dull, throbbing
-Massage, heat, cold all mechanisms
for relief
Radiating Pain


Starts at pain origin, extends to other
locations
Patient can locate origination and points of
extension
VISCERAL PAIN
-Originates from viscera
-not well localized
-result of stretching, distention,
ischemia or inflammation of internal
organs
-deep, cramping, pressure
-can be referred to distant sites
REFERRED PAIN
•Pain fibers from viscera and neural
touch fibers synapse onto wide
dynamic range neurons in dorsal horn
•when signal transmitted to brain,
brain presumes pain signal came from
area innervated by the neural touch
fibers
REFERRED PAIN
Radiating vs referred pain
NEUROPATHIC PAIN
-Source of pain is nerve
damage
-nerve fiber has reduced
firing threshold-hyperexcitable
-cross-over of touch fibers
possible
-example: phantom limb pain
-burning, searing, tingling,
numbness, “pins and
needles”
NEUROPATHIC PAIN
ALLODYNIA – normally non-painful
stimulus causes pain
HYPERALGESIA – increased pain
response to mildly noxious stimuli
MALIGNANT PAIN
(Intractable Pain)
-Often mix of visceral, somatic,
and neuropathic
-results from tumor, pressure,
inflammation, side effects of
treatment
-overwhelming, all-consuming
TYPES OF PAIN
by duration
Acute pain- Rapid onset, disappears when
underlying cause resolved
Chronic pain-persists beyond normal
healing period
ACUTE PAIN

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


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-guarding, wincing,
moaning, crying
-elevated BP, pulse,
respiratory rate
-pallor, diaphoresis
-anxiety
-mask of pain
Anxiety and worry
-usually aggressively
managed
-ex. post-surgical pain
CHRONIC PAIN



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-may have no outward
manifestations
-normal vital signs
-slackened facial features,
flattened affect
-social isolation,
decreased engagement
with usual activities of
daily living, fatigue,
depression, hopelessness
possible
-sometimes unknown
source
-unpredictable course
ASPECTS OF THE PAIN
EXPERIENCE
physiological
emotional
behavioral
cognitive
FACTORS AFFECTING THE
PAIN EXPERIENCE
AGE (developmental level)
Misconception: infants do not feel
pain, or, do not feel as intense pain as
older children and adults
 Fetus: neural mechanism for
processing pain stimuli fully developed
by mid to late gestation

Inadequately controlled pain in
infancy/childhood may lead to
decreased pain tolerance in adulthood.
FACTORS AFFECTING THE
PAIN EXPERIENCE
Elderly
 no scientific evidence pain
sensitivity decreases with age
 elderly tend to underreport
pain
 elderly have learned coping
mechanisms for pain
FACTORS AFFECTING THE
PAIN EXPERIENCE
opioid use in elderly
 elderly as group fear addiction
 healthcare workers fear side
effects
 ”start low, go slow”
 long acting opioid preparations,
patches or pills, used with
adjuvants, can be very successful
FACTORS AFFECTING THE
PAIN EXPERIENCE
CULTURE
 Acceptable means of expressing
pain are learned
FACTORS AFFECTING THE
PAIN EXPERIENCE
ANXIETY
pain can cause anxiety
 anxiety may activate
physiological mechanisms that
facilitate pain signal transmission
 anxiety decreases pain tolerance

NURSING PROCESS RELATED
TO PAIN:
ASSESSMENT
-assess when behavioral manifestations
of pain
-assess when pain is suspected and
patient cannot or will not express pain
-do not make assumptions
-caution: patients may use alternative
terminology
NURSING PROCESS RELATED
TO PAIN:
ASSESSMENT
Onset and duration
location
intensity
quality
Pattern (chronology)
Aggravating/alleviating factors
associated symptoms
PAIN INTENSITY
PAIN INTENSITY
NURSING PROCESS RELATED
TO PAIN:
ASSESSMENT
Onset and duration
location
intensity
quality
Pattern (chronology)
Aggravating/alleviating factors
associated symptoms
NURSING PROCESS RELATED TO
PAIN:
ASSESSMENT
Assess the effect of the pain on the patient
physiologically, emotionally, behaviorally
 physiological signs of pain
 anxiety
 depression
 coping ability
 ability to manage ADL
 behaviors, and ability to socialize

SPECIAL ASSESSMENT

INFANTS
 CRIES assessment
tool
crying
 requires oxygen
 increased vital signs
 expressions
 sleeplessness

SPECIAL ASSESSMENT
IMPAIRED ELDERLY
 APP, utilize input of
family
 observe and score behaviors

change in behavior,
particularly restlessness,
withdrawal, or decreased
mobility
 change appearance



change in vocalizations
Agitation, aggression
SPECIAL ASSESSMENT: FLACC
-
NURSING DIAGNOSIS
Acute Pain (incisional) r/t tissue trauma
secondary to surgery AEB client states
incision pain is “8”
 Chronic Pain (joint) r/t inflammation of
joints secondary to rheumatoid arthritis AEB
client states “I’ve had this pain for years.”
 Anxiety r/t perceived threat to biological
integrity AEB client stating “it hurts so much
to move, something must be wrong!”

NURSING DIAGNOSIS
Insomnia r/t difficulty assuming usual sleep
position secondary to pain AEB client states
“I always sleep on my side, but it hurts too
much to turn that way”.
 Self care deficit bathing r/t post-op pain
AEB client stating “I am in too much pain to
wash up. I’ll do it tomorrow.”
 Impaired Mobility r/t pain AEB client stating
“I don’t want to walk, my leg hurts too
much.”

PLANNING
Overall goal in pain management:
Patient will have maximal pain
relief and quality of life.
PLANNING
GOALS
-Patient will report reduced pain
intensity and quality within 2 hours.
-Patient will demonstrate use of
behavioral techniques to reduce
pain by (date).
-Patient will recognize causal
factors for pain and use measures
to modify these by (date)
INTERVENTIONS
Non-pharmacological
(complementary)
-comfort measures
-distraction: music, Lamaze
-guided imagery
-relaxation/meditation
-mindfulness-based stress reduction
-cutaneous stimulation
INTERVENTIONS
heat and cold
TENS- transcutaneous electrical
nerve stimulation
Disturbed Energy Field

Therapeutic Touch, Reiki

techniques to rebalance, or unblock the flow
of Chi
W.H.O. ANALGESIC LADDER
FREEDOM FROM
PAIN
STRONG OPIOID + NONOPIOID + ADJUVANT
PAIN PERSISTING
OR INCREASING
WEAK OPIOID+
NON-OPIOD+
ADJUVANT
PAIN PERSISTING
OR INCREASING
NON-OPIOID+
ADJUVANT
PAIN
WHO ANALGESIC
LADDER
EVALUATION
Does the patient have maximal
pain relief?
Revisit assessment: assess
intensity, quality, associated
symptoms, level of activity
If necessary, revise plan, try other
interventions, report to MD