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Post-Operative Care of the Special Patient
Pain Management

1. Introduction
2. Physiology of pain
3. Causes of pain
4. Management of patient with pain and pain treatment
5. Management of pain with children and elderly people
6. Conclusion
7. Bibliography

Pain is a very complicated phenomenon that has been a mystery for many centuries. Even nowadays, it is hardly possible to estimate that the mystery of pain is fully revealed. Nonetheless, the modern science has achieved really great results and has basically managed to reveal the principle causes of pain, define its physiology. At the same time, the treatment of pain still remains a serious problem though mankind has a much larger experience in the problem of treatment of pain than in the understanding of its essence. It should be said that people have been attempting to treat pain since ancient epochs and in the course of time the ways of treatments were constantly improving. At the present moment, the modern science has a variety of tools to treat pain which are quite effective but often specialists face a problem that modern treatments, including pharmaceutical measures, being generally effective, sometimes can produce negative effects on human health that are mainly provoked by the side effect of some medicines. This is why in recent years, specialists have started to refer to alternative, non-pharmaceutical measures in the treatment of pain. In such a situation, it is extremely important to thoroughly analyze the modern ways of management of patients with pain and discuss most effective treatments of pain.
Physiology of pain
Before analyzing the management of patients with pain and effective ways of treatment, it is important to understand the essence of pain, its physiology in order to clearly realize what a treatment should actually target at and, what is more, it can help define what treatment is the most effective.
First of all, it should be said that there exist different views on pain and it is quite difficult to find a universal and absolutely unarguable definition of pain but briefly it can be defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Lilley et al 1999). At the same time, pain is not very precise notion and nowadays, specialists rather prefer use the term nociception instead of pain.
In this respect, it is necessary to precise that all nociceptors are free nerve endings that have their cell bodies outside the spinal column in the dorsal root ganglion. These sensory endings are responsible for the perception of pain and serves as vehicles of its transmission. Traditionally, specialists define three major kinds of pain: mechanical, thermal and chemical nociceptors. Basically nociceptors are displaced in skin but may be also found on internal surfaces of human organism such as periosteum and joint surfaces. In stark contrast deep internal surfaces are less exposed to nociceptors and, as a rule, pain in this surfaces can progress on the condition that the respective tissue is damaged.
Nowadays, specialists distinguish two types of nociceptors. On the one hand there are Ao fibers which are responsible for fast pain. These fibers are able to transmit signal from the source of pain at average rate between 6 to 30 meters. Basically, people can feel this kind of pain practically immediately, though, in actuality, the process of transmission may take about one tenth of a second. It can be described as sharp, acute, pricking pain. In general, these nociceptors are responsible for the transmission of either mechanical or thermal pain.
In contrast, slow pain is mediated by slower, unmyelinated or ‘bare’ type C pain fibers that send signals at rates between 0.5 to 2 meters per second. Traditionally, people perceive this pain as aching, burning, or throbbing. Often these nociceptors are responsible for the transmission of chemical pain. Nociceptors do not adapt to stimulus. Also it should be said that the long stimulation of pain receptors can led to the condition known as hyperalgesia.
As nociceptors perceive some kind of pain they transmit it at different rates to the central nervous system. Basically, the pain is transmitted either through the neospinothalamic tract, which is used as a transmitter for fast pain, or through the paleospinothalamic tract, which is used as a transmitter for slow pain.
It is also should be said that spinal cord d also plays an important role in the transmission of pain since due to its neurons the signals are sent to the brain stem and, in such a way, people perceive the pain. Remarkably that the time the signal may be transmitted from the source of pain to the brain stem is not long and on the sensual level the pain is often perceived as immediate. In such a way, the nervous system prevent the organism from the further possible damages if some trauma, for instance, occurs or can occur. Anyway, pain receptors warn the bran about the potential danger or malfunctioning of certain organs.
It is worthy of mention that Feinstein and his colleagues (1954) found that nociception could also “activate, generalized autonomic responses independently of the relay of pain to conscious level” causing “pallor, sweating, bradycardia, a drop in blood pressure, subjective faintness, nausea and syncope” (147).
Causes of pain
Basically, there may be different causes of pain which often related either to some trauma or disease of certain organs. It should be pointed out that visceral pain sensation is often referred by the central nervous system to a dermatome region which may be faraway from the originating organ. These correlate to the position of the organ in the embryo. For instance, the heart, which actually originates in the neck, can produce the classical pain and arm pain experienced during acute cardiac pain.
Speaking about the pain in different organs and parts of the body, it should be said that the pain in head and neck may be provoked by trauma, temporal arteritis, otitis media or externa, glaucoma, migraine, tension headache, cluster headache, etc. The pain in thorax, may be provoked by trauma, cancer, pulmanory embolism, cholecystitis, perimenstrual, etc. The pain in the abdomen may be caused by cancer, peptic ulcer disease, gastroenteritis, abdominal aortic aneurism, appendicitis, ectopic pregnancy, pelvic inflammatory disease, etc. The pain in the back may result from muscle strain, cancer, spinal disc herniation, degenerative disc disease, coccyx. Furthermore, the pain in limbs may be caused by muscle strain, deep vein thrombosis, peripheral vascular disease, spinal disc herniation, sciatica. Finally, the pain in joints can be provoked by osteoarthritis, rheumanoid arthritis, gout pseudogout, osteonecrosis, trauma, hemarthrosis, inflammatory bowel disease, psoriatic arthritis, Reiter’s syndrome.
Management of patient with pain and treatment of pain
Unquestionably, patient with pain should receive a very serious and careful treatment. Primarily, it is necessary to underline that it is important to avoid the unnecessary disturbance of the patient and provide him/her with the sufficient amount of rest time so that he/she could repose and gradually recover from the disease or problem that have actually caused the pain.
However, before starting the treatment itself, it is necessary to properly assess the pain according to the pain scale that will provide an opportunity to select the most effective way of treatment of the patient. It should be said that there are different pain scales which are basically used as tools that can help health care providers not only measure but also diagnose a patient’s pain intensity.
Traditionally, among the most widely spread pain scales may be named three forms of scales such as visual, verbal, numerical. Other scales mainly represent the combinations of the three mentioned above. Nowadays, one of the most widely spread pain scales is the Wong-Baker Faces Pain Rating Scale which actually combines all three forms of scales since it uses five images of faces depicting different emotions from the normal state to acute or unbearable pain. Basically, the scale goes from 0 to 5 and each number is accompanied by the respective image of a face. At the same time, both numbers and faces are accompanied by verbal correspondences: 0 - no hurt, 1 – hurts a little bit, 2 – hurts a little more, 3 – hurts even more, 4 – hurts a whole lot, 5 – hurts worst.
As a rule, in order to ease pain, especially acute one, pharmacological measures are undertaken. Traditionally, analgesics such as narcotics or NSAIDs and pain modifiers such as tricyclic antidepressants or anticonvulsants are used. In this respect, it is worthy of mention that some analgesics can cause negative side effects that can be potentially quite dangerous for the patient’s health. This is why it is necessary to be very careful while using analgesics and before applying such a treatment it is necessary to find out whether it is safe for the patient. In the case, if the treatment has been already started and unexpectedly some side effects have been revealed, t is highly recommended to stop the use of the analgesics and substitute them using a different pharmacological substance or even use an alternative way of treatment.
In fact, in such a situation, non-pharmaceutical measures may be also undertaken. Among the most effective non-pharmaceutical measures may be named the following: interventional procedures, physical therapy and physical exercise, application of ice and/or heat. Also, many specialists underline that the use of psychological measures, such as biofeedback and cognitive therapy, may be often quite effective.
Management of pain with children and elderly patients
Analyzing the problem of pain, it is extremely important to pay a particular attention to children and elderly patients since these two categories of patients are particularly exposed to the higher risk of the treatment of pain.
First of all, it should be said that managing of pain with children the first problem a doctor can face is the localization of pain. In other words, it is quite difficult to clearly understand where the pain is actually localized and, what is more, often children, especially very young ones, cannot simply explain what kind of pain they have. In such a situation verbal description of the pain may be absolutely ineffective and this is where the Wong-Baker Faces Pain Rating Scale may be extremely helpful as it can visualize the rate of pain and such visualization may be more comprehensible to children.
It is worthy of mention, that some elderly people may have similar problems with identification of pain as their senses gets to be less sharp and neuron transmission is not so effective as younger people have. Moreover, elderly people also have a number of limitations concerning the use of pharmacological measures as well as children have. Practically, it means that it is necessary to be very careful while selecting pharmacological measures.
As for possible alternatives, such as non-pharmacological treatment it is also not always applicable to children and elderly people as sometimes they cannot physically afford such a treatment.
Furthermore, it is necessary to remember that a doctor should be particularly careful about the management of pain with children and elderly people as they are more vulnerable to negative effects of treatment as well as pain itself.
Thus, taking into account all above mentioned, it is possible to conclude that management of patient with pain is an extremely complicated process. To treat the pain effectively, it is necessary to have a profound knowledge of physiology of pain and be bale to clearly define what exactly have caused the pain in the particular case of management of a patient with pain. At the same time, it is equally important to know the effective ways of treatment of pain among different categories of patients, i.e. children, adults, elderly people and, what is more it is necessary to be able and modify measures undertaken in the process of treatment depending on the state of a patient. Nonetheless, in spite of recent scientific achievements in the field of management of patients with pain, it is still necessary to continue researches of pain and ways of its treatment in order to improve the quality of health care services and increase safety of treatment of pain.

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