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COMFORT AND PAIN

Disiapkan oleh:
Atlastieka P & Titis Kurniawan

Bagian Keperawatan Dasar


Fakultas Ilmu Keperawatan
Universitas Padjadjaran

OUTLINE
1.
2.
3.
4.
5.
6.

Overview
Definition
Types of Pain
Pain Experience
Pain Theory
Nursing Process:
- Pain Assessment
- Pain Management

Overview
Peone (Greece) = Hukuman
Warning suatu gejala penting
menunjukkan adanya masalah
Fungsi pertahanan (Survival function)
 menstimulasi reflek & mekanisme
pertahanan untuk melindungi tubuh dari
kerusakan lebih lanjut.
Bisa dianggap sebagai tanda-tanda vital
ke-5

.......Overview (Cont.)
Positive

Negative

- Peringatan adanya
kerusakan jaringan 
menstimulasi
perilaku/refleks untuk
mencegah kerusakan
lebih lanjut

Penderitaan  emosional, mood, &


fisik
Gangguan ADL & Tidur
Cardiovascular side effects
(hypertension & tachycardia)
Efek samping pengobatan (opioids
memicu konstipasi/nausea)
Delay mobilisasi  risiko
thromboembolism, atelectasis, retensi
secresi & pneumonia)

- Immobilisasi are luka utk


meningkatkan proses
penyembuhan

DEFINITION
 International Association for the Study of Pain (IASP): an
unpleasant sensory and emotional experience
associated with actual or potential tissue damage
(Merskey & Bogduk, 1994).
 Acute pain: pain of recent onset and probable limited
duration, usually has an identifiable temporal and causal
relationship to injury or disease (Ready & Edwards, 1992).
 Chronic pain: commonly persists beyond the time of
healing of an injury and frequently there may not be any
clearly identifiable cause (Ready & Edwards, 1992).

TIPE NYERI
Nyeri Akut & Kronik
Akut

Kronik

Terlokalisir
Tajam
Respon Sympathetic

Menyebar
Tumpul, aching
Respon Parasympathetic

Appears restless & anxious

Appears depressed & withdrawn

Pola onset jelas

Pola onset tidak jelas

< 3 bulan

> 6 bulan

.......TYPES OF PAIN (CONT.)


Intractable Pain: resistant terhadap pengobatan
Phantom Pain: nyeri yg terasa pada bagian tubuh yg sudah tdk ada
Radiating Pain: Nyeri yang menyebar ke jaringan sekitar sumber nyeri
Berdasar Sumber Fisiologis:
- Somatic Pain: muncul dari kulit, otot, sendi (superficial atau deep/dalam)
- Visceral Pain: dihasilkan oleh stimulasi nociceptors pada kavitas abdomen &
thorax

Berdasar Mekanisme Nyeri:


- Nocicepthic pain: dihasilkan dari rangsangan kimiawi, mekanik,maupun thermal
pada nociceptors
- Neuropathic Pain: disebabkan oleh kerusakan/disfungsi nervous system

Areas of Referred Pain


Ruptured ovary / fallopian tube (female)
Diaphragmatic irritation (swollen/ruptured spleen)

Diaphragmatic irritation (swollen/ruptured liver)


Pneumonia
Pleurisy
AMI
Appendicitis
Colon obstruction/diverticulitis
Kidney stone

Areas of Referred Pain


Ruptured ovary/fallopian tube (female)
Diaphragmatic irritation (swollen/ruptured liver)
Diaphragmatic irritation (swollen/ruptured spleen)

Cholecystitis
Pancreatitis
Leaking aortic aneurysm

Bladder
AMI

......Referred Pain (Cont.)


C2

T1
C5
C8
C7

C3
C4
C5
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10

C6
C5
C8
T1

T11

C8

T12
S2 L1
S
3 L2

C6
C8

C7

 Dermatomal rule  nyeri


adakalanya menyebar mengikuti
struktur organ yang berkembang dari
segmen yang sama saat
perkembangan embrio atau struktur
kulit dimana sumber nyeri berada

L3

 Contoh:
- Jantung dan lengan berasal dari
segmen embrio yg sama  nyeri
daerah jantung menyebar ke lengan

L4

CERVICAL (C)
THORACIC (T)
LUMBAR (L)
SACRAL (S)

L5

S1

The Dermatomes

THE PAIN EXPERIENCE


1. RECEPTION
2. TRANSMISSION/PERCEPTION
3. MODULATION

PAIN RECEPTION
Nociceptor  terstimulasi langsung oleh kerusakan
sel/jaringan, dan skunder oleh pelepasan zat kimia
(bradykinin)
Skin, internal tissues (periosteum, joint surface,
arterial walls)  mempunyai banyak reseptor nyeri
Alveoli & Brain  tidak mempunyai reseptor nyeri
Bradykinin  universal pain stimulus

.........PAIN RECEPTION (Cont.)


Bradykinin to bind to the pain receptor endings 
pain impulses
Bradykinin  triggers pengeluaran inflammatory
chemicals substances (e.g. prostaglandin,
histamine, substan P)
Prostaglandin yg triger oleh adanya bradykinin 
menstimulasi reseptor nyeri & semakin
meningkatkan effects bradykinin & histamine

.......PAIN RECEPTION (Cont.)


All nociceptors are structurally similar, but they
respond differently to noxious stimuli according to
their body location
Pain occurs only when the pain message is
relayed via MS to the brain  interprets stimuli
Types of pain stimuli:
1. Mechanical; injury, tumor, blockage, tumor
2. Thermal; suhu ekstreme
3. Chemical; ischemik jaringan

....PAIN TRANSMISSION/PERCEPTION Cont.)


Pain Threshold (Ambang Nyeri):
Jumlah/intensitas stimulus nyeri yang dibuthkan
utk menimbulkan sensasi nyeri.
Pain Reaction:
1. Autonomic nervous system response
2. Behavioral response
Pain Tolerance: jumlah/intensitas & durasi
maximal yang memungkinkan individu
mentoleransinya

......PAIN TRANSMISSION/PERCEPTION (Cont.)


Tipe Serabut Saraf yg Mentransmisikan impuls nyeri :
1.

Myelinated type A fibers (, , ,and fibers). Type A


fibers conduct impulses quickly (12-80ms-1), transmit
sharp, prickling pain sensations associated with
superficial somatic pain.

2.

Unmyelinated type C fibers: transmit signals more


slowly (0.4-1 ms-1), transmit dull, aching, and burning
sensations of deep somatic & visceral pain. The pain
transmitted is less localized, more persistent

PAIN MODULATION
Regulator kimia alami dalam tubuh  endogenous
opioids
Endogenous opioids: berikatan dg reseptor opiat
diseluruh tubuh, terutama pada area dorsal medula
spinalis (MS) menghambat substan
neurotransmitter nyeri atau mengganggu proses
persepsi nyeri
Ada 3 golongan endogenous opioids: Enkephalins,
Endorphins, & Dynorphins.

PAIN MODULATION (Cont.)


Enkephalins  small polypeptides
 Menghambat release of substance P
 Ditemukan jg pada batang otak, limbic system, hypothalamus,
adrenal glands, & Gastro Intestinal Tract
 Paling terkenal: leu-enkephalin & met-enkephalin
Endorphins
larger polypeptides
 Kemungkinan distimulasi & disimpan oleh pituitary gland
 Juga ditemukan di hypothalamus, midbrain, & limbic system of CNS
 -endorphins > potent dari enkephalins
 Meningkat dengan exercise
Dynorphins
 Ditemukan di pituitary gland, hypothalamus, and MS
 Analgesic effect  50x lebih besar dari -endorphins

PAIN THEORIES
SPECIFICITY THEORY
PATTERN THEORY
GATE-CONTROL THEORY
PARALLEL PROCESSING MODEL

PAIN THEORIES (contd)

SPECIFICITY THEORY
 Originated about 200 years ago
Assumptions :
 pain travels from a specific nociceptor
to a pain center in the brain
 a direct relationship between pain
stimulus intensity & pain intensity
perceived
only one structure in the brain is
involved in a pain response

PAIN THEORIES (Cont.)


PATTERN THEORY
 Peripheral pattern theory
Peripheral nerve fibers are essentially the same & that a given pattern of
fiber stimulation is interpreted by the CNS as pain.
 Central summation theory
stimulation of the peripheral sensory nerves in turn stimulates specific
areas in the dorsal horn, then interpreted as pain
Input into the dorsal horn creates abnormal reverberatory activity in
closed self-exciting neuron loops.
 Sensory interaction theory
2 types of neurologic fibers involved in pain: small & large diameter
fibers
small fibers: carry nerve impulse pattern that produces pain
large fibers: inhibit the pain impulses
pain results when the number of small fibers outnumber the large fibers

.......PAIN THEORIES (Cont.)


GATE-CONTROL THEORY (Melzack & Wall, 1982)
 Synapses in the dorsal horns act as GATES that close to
keep impulses from reaching the brain or open to permit
impulses to ascend
 A person feels pain when the synaptic gates are open, as
when impulses on the pain fibers predominate
 Higher CNS activities, such as anxiety, past experience,
attention, and the meaning of the situation  can
influence the opening or closing of the gates

.........PAIN THEORIES (Cont.)


PARALLEL PROCESSING MODEL (Leventhal & Everhart, 1979)
 Integrates both the physiologic and cognitive-emotional
aspects of pain
 3 levels of pain process :
1. Involves autonomic neural coding of the pain stimulus
along specific neural fibers
2. Involves combining the neural encoding with past pain
experience (adaptation)
3. Involves utilizing the individuals beliefs about pain that
affect the persons needs and activities relative to the
pain

PAIN RESPONSES
3 STAGES OF PAIN RESPONSES :
1. ACTIVATION
 Perception of pain, fight-or-flight reaction, initiated by
sympathetic nervous system
2. REBOUND
 Pain experienced is intense but brief
 Parasympathetic nervous system takes over
3. ADAPTATION
 Pain is long-lasting
 Sympathetic response decreased
 General adaptive reaction, hours  days (give up or fight
back)

........PAIN RESPONSES (contd)

Sympathoadrenal
Responses

Parasympathetic
Responses

Behavioral
Responses

Affective
Response

Pulse Rate

Pulse Rate

Immobility

Fear/Fright

Systolic BP

Systolic BP, syncope

Withdrawal

Anxiety

Rubbing body part

Depression

Nausea/Vomiting

Grimacing

Anger

Warm, dry skin

Restlessness

Hopelessness

Pallor

Prostration

Writhing

Powerlessness

Pupil dilation

Pupil constriction

Unusual postures

Fatigue/exhaustion

Rapid speech/elevated
pitch

Slow, monotonous
speech

Extreme quietness
(stoicism)

Feeling of being
punished

Withdrawal

Groaning

RR
Diaphoresis
Muscle tension

Alertness

Crying

FACTORS AFFECTING PAIN EXPERIENCE

Environment

Emotions

PAIN EXPERIENCE
Ethnic/Cultural Values
Age & Development

Expectations/Presence of Others

ASSESSING PAIN
PAIN HISTORY
P : Provoke (Precipitating Factors), Palliative(Alleviating Factors,
Coping Resources), Past pain experiences
Q : Quantity (Intensity/Scale), Quality
R : Region (Location)
S : Severity (Meaning, Affective Response, Associated symptoms,
Effects on ADLs)
T : Time (Pattern  Onset, Duration, Constancy)

PHYSICAL EXAMINATION
 Physical & Behavioral Responses

PAIN ASSESSMENT TOOLS


 Measuring pain-intensity
 Descriptions: slight, mild, medium, severe, or excruciating
1. Numeric Rating Scale
2. Wong-Baker Faces
3. Cries Pain Scale
4. FLACC Scale
Lihat
artikel
5. Comfort Scale
6. CNVI (Checklist of Nonverbal Indicators)
7. Schmidt Sting Scale

NURSING PROBLEMS

Pain
Chronic Pain
Ineffective airway clearance
Anxiety
Ineffective breathing pattern
Ineffective individual coping
Fear

Altered health maintenance


Hopelessness
Knowledge deficit about pain
Impaired physical mobility
Self-care deficit
Sleep pattern disturbances

PAIN MANAGEMENT
Non-pharmacological Management
Acupuncture
Aromatherapy
Biofeedback /relaxation
Breathing exercises
Distraction techniques
Environment Modification
Guided imagery (visual, auditory,
olfactory, gustatory,
tactile-proprioceptive)
Heat and cold pack
Laughter
Massage

Music
Physical therapy
Radiation
Self-hypnosis
Spinal cord stimulation (SCS)
TENS (Transcutaneous Electrical Nerve
Stimulation)
Touch energy therapies

PHARMACOLOGICAL PAIN MANAGEMENT


NSAIDs (Nonsteroidal Anti Inflammatory Drugs)
ibuprofen, naproxen, etc
COX2 Inhibitors  acetaminophen
Opioids (morphine, hydromorphone, oxycodone,
hydrocodone, codein methadone, fentanyl,
tramadol, meperidine, etc)
Anti-convulsants/Sedative agents
Anti-depressants

THE END

THANK YOU