2. Introduction :-
• Pain is a subjective response to both
psychological and physical stressor. all
people usually experience pain at
some point during their lives.
Although pain is experienced as
uncomfortable and unwelcome.
3. Definition :-
• pain is an, unpleasant sensory and
emotional experience associated with
actual or potential tissue damage.
• pain is a personal and subjective
experience that can only be felt by the
sufferer.
4. Types of pain:-
• Acute pain:-Usually of recent onset and commonly
associated with a specific injury, acute pain
indicates that damage or injury has occurred. Pain
is significant in that it draws attention to its
existence and teaches people to avoid similar
potentially painful situations.
• Chronic pain:- chronic pain is constant or
intermittent pain that persists beyond the
expected healing time and that can seldom be
attributed to a specific cause or injury.
5.
6. Types of pain:-
• 1.Somatic pain:- caused by direct tumor
involvement of sensory receptors in cutaneous
and deep tissues.A. usually described as dull,
sharp, aching, and throbbing. Usually constant
and localized.
• 2.Neuropathic pain.A. Result from nerve injury or
compression.B. includes phantom pain and
postherpetic neuralgia.
• 3.Visceral pain.A. Usually described as deep, dull,
aching, squeezing, or pressure sensation. It can
be vague or ill-defined and can be referred to
cutaneous site,
7.
8. Other types of cancer related pain:-
• 1. NOCICEPTIVE PAIN:-This refers to pain resulting
from stimulation of peripheral nerves through
nociceptors. Pain impulses enter the spinal cord
through the dorsal horn, where they ascend to
higher centre’s in the brain. Inhibitory impulses
block transmission.
• 1. Peripheral neuropathic pain.
Peripheral neuropathic pain is caused by damage
within the peripheral nervous
9. Other types of pain conti..
• 2. Central neuropathic pain:-Central neuropathic
pain is neuropathic pain caused by damage within
the central nervous system. There is usually an
area of altered sensation incorporating the area of
pain. Cerebrovascular accident, or spinal cord
damage.
• 3. Sympathetically maintained
pain:Sympathetically maintained pain is due to
sympathetic nerve injury. Essential features are
pain (often burning) and sensory disorder related
to a vascular as opposed to neural distribution.
10. Principles of pain management:-
• 1.The goal of pain management is complete relief of
pain.
• 2.placebos are never indicated for the treatment of
pain.
• 3.physical dependence and tolerance commonly
occur, patient may require escalating doses of
medications to control pain.
• 4.it is essential that physicians and nurses and do
not confuse addiction with tolerance addiction is an
unrelated medical disorder with behavioral
components. These facts must also be stressed with
patients who are reluctant to take medications.
11.
12. Assessment of pain:-
• Assessment of a patient’s pain is a crucial skill,
which requires a structured approach, actively
listening ears and sharp eyes. Accurate assessment
is also helped by experience, and is not a “one off”
event, but constantly needs to be re-evaluated by
the health care team as they gather more
information and understanding.
Assessment questions:-
• There are many approaches to assessing pain, and
each professional will develop his / her own
approach to taking a pain history. Having a good
assessment technique is the basis for prompt and
appropriate management of a patient’s pain.
13. Pain History Principles:-
• 1. Seek to establish a relationship with the
patient.
• 2. Encourage the patient to do most of the
talking.
• 3. Begin with a wide-angle open question
before clarifying and focusing with more
specific ones.
• 4. Watch the patient for clues regarding pain.
14. Remember, as you are assessing the
patient, he/she is assessing you
1. Eye to eye level contact.
2. Clear introduction.
3. Avoid over-familiarity.
4. Explain what you plan to do.
5. Summaries back to the patient, “Have I heard
things correctly?“
6. Avoid patronizing.
7. Use language and terms appropriate to the
patient.
15.
16. Pain Assessment Scales:-
• Explain to the person that each face is for a person
who feels happy because he has no pain (hurt) or
sad because he has some or a lot of pain. Face 0 is
very happy because he doesn’t hurt at all. Face 1
hurts just a little bit. Face 2 hurts a little more. Face
3 hurts even more. Face 4 hurts a whole lot. Face 5
hurts as much as you can image, although you don’t
have to be crying to feel this bad.
17. Theories of pain
1-The specificity theory.
This theory was based on the assumption that pain
was perceived following injury because there was a
single, dedicated, hard wired system of afferent
nerves which carried messages from specific pain
receptors in the periphery to a pain centre in the
brain. The simple idea proposed that specific nerve
endings in the skin and other tissues respond
exclusively to nociceptive stimuli .
18. Theories of pain
conti….
2- pattern theory.
This relate to the perception of pain to patterns of
impulses in the nervous system rather than to
impulses in dedicated pain pathways. The
patterns may be temporal(in time) or spatial(in
space). Pattern thepries may explain som chronic
or recurrent pains which occur when there are
nerve lesions.
19. Theories of pain
conti…...
3-The gait control theory.
In 1965, melzack and wall proposed the control
pain theory, which was the first one recognizing the
psychological aspects of pain are as important as
physiological aspects. The gate control theory
combined cognitive, sensory, and emotional
components in addition to the physilogical aspects
and proposed that they can act on a gate control
system to block the individual’s perception of pain.
The basic premise is that transmission of potentially
painful nerve impulses to the cortex is modulated
by spinal cord gating mechanism and by CNS
activity. As a result, the level of conscious
awareness of painful sensation is altered.
20. Theories of pain
conti…..
• Neuromatrix theory
• A newer theory of pain that answered some
of these questions. This new theory the
neuromatrix theory. Stipulates that every
human being has. An innate network of
neurons that they named the body self
neuromatrix, each persons matrix of neurons
in unique and is affected by all facets of the
persons physical, physiological and cognitive
traits and also by their experience.
21. Theories of pain
conti….
• Central baising theory.
This theory can explain the concept of learned
behaviour, this theory builds on the gate
theory(acting within the spinal cord) and addresses
brain influence on incoming and outgoing
messages. Cognitive effects can alter sensory
discrimination, the location of the pain source. The
pain (eg:referred pain)
22. Theories of pain
conti…….
• Endogenous opiates theory.
Least understood of all the theories simulation of
A-delta & C fibers causes release of B-endorphins
carried a ACTH/B- lipotropin is released from the
anterior pituatry in response to pain- broken
down into B- endorphins and corticosteroids
mechanism of action- similar to enkephalms to
block ascending nerve impulses transcutaneous
electrical nerve stimulation .(low frequency &
long pulse duration)
23. PAIN MANAGEMENT:-
• Pain is traditionally classified into different
modalities:- physical, psychosocial and spiritual.
Exploring a patient‘s anxieties and frequent
misconceptions related to these modalities can
be very beneficial. Pain will not be adequately
managed unless patients feel a degree of
participation/control over their situation. To
ignore such psychological aspects of care may
often be the reason for persisting pain.
24. MANAGEMENT OF NOCICEPTIVE
PAIN:-
• STEP 1 (Mild pain) Non-Opioid ± adjuvant.
Start treatment with paracetamol 500mg - 1g 6
hourly (q.d.s.) regularly. If step 1 medication are
not adequate in 24 hours, proceed to step 2.
STEP 2 (Mild to moderate pain) Weak Opioid ± step
one medication Start treatment with a combined
preparation of paracetamol with dextro
propoxyphene or codeine, or tramadol.
Dextropropoxyphene is available in combination
with paracetamol. total daily dose of 260mg .
25. Management of nonceptive pain
conti…
• STEP 3 (Moderate to severe pain) Strong Opioid ±
step onen medication If step two medication is
inadequate consider starting oral morphine. For
a patient taking 260mg dextropropoxyphene a
day, a minimum of morphine 5mg four hourly/
six times a day, i.e. a daily total of 30mg of
morphine is required.
26. ADJUVANTANALGESICS (CO-ANALGESICS)
noncept….type……..conti.
• An adjuvant analgesic drug is a drug which is not an
analgesic in its prime function but in combination
with an analgesic can enhance pain control.
• 1.Secondary analgesics:
Corticosteroids - pain caused by oedema
Antidepressants - neuropathic pain.
Anticonvulsants - neuropathic pain.
Muscle relaxants- muscle cramps.
Antispasmodics - bowel colic.
Antibiotics - infection pain.
27. MANAGEMENT OF NEUROPATHIC
PAIN:-
• Up to 40% of cancer-related pain may have a
neuropathic mechanism involved. Neuropathic
pain may be difficult to control, so a wide variety
of treatments may be needed.
• 1st line 2nd line
• Opoids ketamine.
• Antidepressants ligocaine infusion.
• Anticonvulsant
• NSAIDs tens neurolytic Procedure.
• Corticosteroid capsaicin.
28. DRUGS USED IN NEUROPATHIC PAIN
OPIOIDS:-
• Opioids are usually partially effective in both
cancer-related and non-malignant neuropathic
pain. Opioids other than morphine have been
shown to be effective are tramadol and fentanyl.
• An alternative opioid analgesic may be tried
(tramadol, fentanyl) Management of side effects
can be tried (haloperidol to reduce
hallucinations).
29. Neuropathic pain opoids TRICYCLIC
ANTIDEPRESSANTS conti……
• The mechanism of analgesic action is principally
by facilitation of descending inhibitory pain
pathways. (They inhibit pre synaptic reuptake of
norepinephrine and serotonin. e.g:- amitriptyline
25-100mg imipramine 25 100mg
Many patients do not tolerate amitriptyline
especially in higher doses, therefore consider
changing to imipramine. Lower doses of tricyclic
antidepressants are found to produce pain relief
and faster response when compared with their
doses used in depressive.
30. ANTICONVULSANTS:-Neuropathic pain
conti…….opoids drug……………….
• These drugs work by dampening abnormal
electrical signals in the central nervous system e.g.
• valproate 100-600mg b.d.
• carbamazepine 100-400mg t.d.s.
• clonazepam 1-4mg o.d.
• gabapentin 100-600mg t.d.s.
• pregabalin 25-150mg b.d.
31. Neuropathic pain
conti…….opoids drug…………
• The benefits of a lower incidence of gastrointestinal
side effects from using COX-2 NSAIDs is reduced by
concurrent use of low dose aspirin. This makes the use
of COX-2 NSAIDs hard to justify when low dose aspirin
is being concurrently administered.
• Non-selective NSAIDs
• e.g.: ibuprofen 200-400mg t.d.s.( p.o.)
• diclofenac 50mg t.d.s. (i/m or suppository)
• naproxen 250-500mg b.d. (p.o. or suppository)
• ketorolac 10-30mg q.d.s (SC,p.o.)
33. MANAGEMENT OF POORLY
CONTROLLED PAIN:- conti…………….
• BREAKTHROUGH PAIN:-Breakthrough pain is a
flare in pain of rapid onset, moderate to severe
intensity and of short Duration. Incident pain,
when pain occurs in response to a specific
activity e.g. standing up, walking, changing
wound dressings, rectal examination, manual
evacuation. Spontaneous pain,
• HEADACHE:-Headache due to raised intracranial
pressure often responds well to the use of
steroids
34. MANAGEMENT OF POORLY
CONTROLLED PAIN:- conti…………….
• BONE PAIN:-A single fraction of radiotherapy
aimed at a localised area in the skeleton may
prove beneficial in the relief of bone pain,
whereas more widespread bone pain may be
improved by wider field radiotherapy or by
treatment with a bone seeking isotope e.g.
radioactive Sumarium NSAIDS.
• MUSCLE SPASM:-This can be hard to control, but
the use of skeletal muscle relaxants such as
diazepam 2mg t.d.s. or baclofen 5mg t.d.s.
35. MANAGEMENT OF POORLY
CONTROLLED PAIN:- conti…………….
• LIVER CAPSULE PAIN:-The pain is caused by
stretching of the peritoneum on the liver surface
and can often be eased by the use of steroids
(dexamethasone 4 -6 mg.
• INTESTINAL and URINARY TRACT COLIC:-Pain due
to bowel cramps is largely insensitive to morphine
but can be eased by smooth muscle relaxants such
as hyoscine butyl bromide.
36. ALTERNATIVE OPIOIDS TO MORPHINE
• 1st line morphine.
• 2nd line oxycodone, fentanyl, hydromorphone
• 3rd line methadone.
• Opioids control pain by blocking receptors (mainly
mu and kappa), which are present predominantly
in the dorsal horn of the spinal cord but also in the
brain stem and in the peripheral nerves.
37. SPECIFIC MANAGEMENT OF OPIOID
SIDE EFFECTS:-
Opioid induced Drowsiness & Cognitive impairment
Hallucinations or Delirium. . Renal failure alone can
cause myoclonus, but also causes opioid
metabolites to accumulate which increase the risk
of opioid toxicity. Constipation. Nausea & Vomiting
Pruritus. Generalized Pain (Rare). an increase in the
opioid dose may lead to worsening of the pain and
opioid toxicity.
38. NON-PHARMACOLOGICAL
INTERVENTIONS:-
• Complementary Therapies.
• Acupuncture:it is stimulate of specific acupoint
along the skin of body involving various method
like heat. Pressure. Or laser or penetration of thin
needles{chines medication.
• Reflexology:-it is zone therapy is an alternative
medicine or pseudo science involving the physical
act of applying pressure to the feet to improve
natural function.
• Art therapy:-it is very due to its origins in two fields
art and psychotherapy it can focus on the making
process therapeutic.
39. NON-PHARMACOLOGICAL
INTERVENTIONS:-
• Touch therapy:-it is therapeutic touch know as
some as non contact therapeutic touch is an energy
therapy which practitioness claim promotes healing
and reduce pain and anxiety.
• Aromatherapy:-it is a form of alternative medicine
that uses volantile plant materials know as essential
oils. Other aromatic compounds for the purpose of
altering a persons mind, mood, cognitive function.
40. NON-PHARMACOLOGICAL
INTERVENTIONS:-
• Music therapy:-it is use of interventions to
accomplish individual goal within therapeutic
relationship by a professional it is improve a
cognitive functioning or motor or skills.
• Hypnotherapy:-it is a form of psychotherapy
used to create unconscious change in the
patient in the form of new respone thoughts,
attitudes behavior feelings it called
hypnotherapy.
41. NON-PHARMACOLOGICAL
INTERVENTIONS:-
• Other Non-Pharmacological Intervention.
• Positioning:-it is activity and process of identifying a
problem or approtunity and developing a solution
based on research.
• Reassurance:-to restore the confidence to assure
again. They are very worried and need someone to
help them. Stop worrying by saying kind or helpful
things.
• Good communication:-the ability to communicate
effectively is important in relationship education
and work .
42. NON-PHARMACOLOGICAL
INTERVENTIONS:-
• Diversional therapy:the diversional therapists
promote the involvement in leisure, recreation and
play by reducing barrier of clients providing
apportunity.
• Splinting of a fractured limb:-it used a cast will
cause pressure sore you can choose wheter or not
you will put a layer of cotton wool or orthopaedic.
• Psychological support. it help individuals and
communities to heal the psychological wound and
rebuild social structure after emergency critical
event.
43. NON-PHARMACOLOGICAL
INTERVENTIONS:-
• Relaxation:-this therapy is use any method,
process, procedures or activity that help a
person to relax stat of increased calmness.
• Joint mobility - passive & active:-the hands on
therapy where the patients must physical move
their joints and muscles as part of the treatment
process.
• Spiritual counseling:-psycho-spiritual counseling
take the soul. Rather than the mind as its
starting point of balance it has an expanded
view of life.
44. Nursing intervention in pain :-
• 1.Screen for pain at each visit, evaluate objectively
the nature of the patients pain, including location,
duration, quality, and impact on daily activities.
• 2.Assess patient history and physical examination
findings and laboratory values to differentiate
expected pain.
• 3.Use a pain intensity scale of 0 {no pain} to 10
{worst possible pain} or other pain scale as
appropriate. on the possible,
• 4.Assess relief from medications and duration of
relief.
• 5.Base the initial analgesic choice on the patients
report of pain.
45. Nursing intervention in pain :-
• 6.Administer drugs orally whenever possible,
avoid I.M. injection.
• 7.Administer analgesia, around the clock, rather
than as needed.
• 8.convey the impression that the patients pain is
understood and that the pain can be controlled.
• 9.provide ongoing support and open
communication.
• 10.Use alternative measures to relieve pain such
as guided, imagery, relaxation, and biofeedback
