Pain and its management

Yuni Permatasari istanti

What is Pain??

Introductory Ideas
Sensation of the affected level of unpleasantness
Perception of actual or threatened damage
Perception based on expectations, past
experience, anxiety, suggestions, cognitive
factors
Acute
Chronic

Pain is Subjective
Simple Spinal Reflex Arc

Significance of Pain
Pain
A clear example of the mindbody
(BPS) model (and most common problem
associated with going to HCP)

Adaptive as a biological warning signal

(e.g., congenital insensitivity to pain)

The Physiology of Pain

How you know that you stubbed your
toe handout Receptor
1. Nociceptor a specialized neuron that
perceives and responds to painful stimuli
2. Special pain nerve fibers
A-Delta Fibers -- Large, myelinated (fast)
nerve fibers that transmit sharp, stinging pain
C-Fibers -- Small, unmyelinated nerve fibers
that carry dull, aching pain

The Physiology of Pain

How you know that you stubbed
your toe handout
3. Dorsal Horn pains arrival to the
CNS
4. Brain perception of pain. Heavily
influenced by emotion, context,
expectations, etc. (illustration next
slide)

Pain Pathways

PAG area of midbrain (next slide)

Pain Pathways
Periaqueductal
Gray (PAG)
midbrain
region-activates a
descending
neural pathway
that uses
serotonin to

Gate Control Theory

Proposed by Melzack & Wall (1965)
A neural gate in the spinal cord
regulates the experience of pain
Pain is not the result of a straightthrough sensory channel

The Gate Control Theory

of Pain

The Biochemistry of Pain

Substance P

(pain NT)

NTs (e.g., serotonin) that alter gate

Enkephalins, endorphins, dynorphins
(endogenous opioids)

Psychosocial Factors in the

Experience of Pain
Stress
pain perception is influenced by stress
(emotionality and pain experience)
stress leads people to engage in behaviors
(i.e., grinding teeth, tensing muscles), which in
turn lead to pain
Good news: Stress-Induced Analgesia (SIA)
a stress-related increase in tolerance to
pain, mediated by the bodys endogenous
opioids

Psychosocial Factors in the

Experience of Pain
Learning
modeling
secondary gain / reinforcement
culturally learned -- groups establish
norms for the degree to which suffering
should be openly expressed and the
form that pain behaviors should take

Psychosocial Factors in the

Experience of Pain
Cognition
anticipation of pain is often worse than
pain itself
placebo and pain (e.g., child who gets ear
examined feels better)

expectations of ability to cope (e.g.,

control and pain PCA morphine)

Pain Management
Overview:
The Fifth Vital sign
Body Temp, Pulse, BP, Resp Rate, Pain

Measuring pain
Chronic pain issues
Treatment

PAIN ASSESSMENT

Chronic Pain Management

Acute vs. Chronic pain
Who becomes a chronic pain patient?
Not necessarily related to pain intensity
More important are reactions:
Physical (postural changes)
Functional disability (pain interferes with life activities)
Reactions to pain episodes and to stress

The toll of chronic pain

Pain)

(video clips from Psychology of

The toll of chronic pain

Dysfunction
report high levels of pain, feel they have little
control over their lives, and are extremely inactive

Interpersonal distress
perceive little social support and feel other people
in their lives dont take their pain seriously
often poor communication
sexual relationships deteriorate

Cost
Huge medical bills
Undergone many treatments (e.g., multiple
surgeries) and rely on painkillers
Job loss/disability

Treating Pain
Pharmacological Treatments
Analgesic (pain-relieving) drugs are the
mainstay of pain control
Include central acting opioid drugs
and peripherally acting nonopioid
drugs

Opioid Analgesics
Formerly called narcotics
Agonists (excitatory chemicals e.g.,
morphine) act on receptors in the
brain and spinal cord
Patient controlled analgesia
addresses control and
undermedication

Nonopioid Analgesics
Nonsteroidal Anti-Inflammatory
Drugs (NSAIDs)
Aspirin, ibuprofen -- relieve pain and
reduce inflammation at the site of
injured tissue

Other Medical Interventions

Counterirritation
Analgesia in which one pain is relieved by
creating another, counteracting stimulus

Transcutaneous Electrical Nerve

Stimulation (TENS)
A counterirritation form of analgesia
involving electrically stimulating spinal
nerves near a painful area

Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapy (CBT)
A multidisciplinary pain-management
program that combines cognitive,
physical, and emotional interventions
used by 73% of clinicians who treat chronic
pain

Cognitive-Behavioral Therapy
Components
Education and goal-setting component is
used to clarify clients expectations
Cognitive interventions to enhance
patients self-efficacy and sense of control
over pain
Teaching new skills for responding to pain
triggers
Promote increased exercise and activity
levels

Cognitive-Behavioral
Interventions
Biofeedback / muscle relaxation
Cognitive distraction
Imagery / virtual reality therapy

(see Sci

American Aug 2004)

Hypnosis

Cognitive restructuring to
challenge illogical beliefs and
maladaptive thoughts (next slide)

Reshaping Pain Behavior

Identify the events (stimuli) that
precede pain behaviors (responses)
as well as the consequences that
follow (reinforcers)

Which Approach to Pain

Control Works Best?
It depends on which type and aspect of pain
Overall, the most effective programs are
multidisciplinary in nature, combining the
cognitive, physical, and emotional
interventions of CBT with the judicious use
of analgesic drugs
Effective programs also encourage patients
to develop (and rehearse) a specific painmanagement program
Group settings are probably most effective

NURSING CARE PLAN

Assessment
Nursing Diagnosis
NOC dan NIC

CONTOH KASUS
Seorang laki-laki 45th dibawa ke RS
dengan keluhan nyeri pinggang sejak
2 bulan yang lalu. Nyeri hilang
timbul, apabila nyeri datang pasien
tidak bisa beraktivitas sama sekali.
Riwayat pekerjaan pasien sebagai
kuli bangunan sejak 25 tahun yang
lalu.

TUGAS
Buat kelompok dengan anggota
maksimal 5 orang
Buat rencana asuhan keperawatan
pada pasien tersebut
Tugas dikumpulkan pada tanggal 20
Mei 2011