PAIN K A T E B L A C K K A T E B R A Z Z A L E L I S A M O L O N Y

PAIN

• • • • • • • • • • Aetiology Disorder/Disease Clinical Manifestations Pathophysiology Diagnosis Pharmacological Management Non-Pharmacological Management Complications Implications for Nursing Practice Pain Case Study

WHAT IS PAIN?

According to the International Association for the Society of Pain, Pain is “ an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ” .

(Loeser, 2011)

AETIOLOGY:

WHAT CAUSES PAIN?

• “Pain can be due to a wide variety of diseases, disorders and conditions that range from a mild injury to a debilitating disease” (Williams, 2011)

EXAMPLES OF PAIN

• • • • • Injury (Broken bone) Disease (Cancer) Condition (Arthritis) Illness (Influenza) Surgery (Caesarean Section)

ACUTE PAIN

“The terms acute and chronic refer exclusively to the time course of the pain, irrespective of aetiology ” (Craft, Gordon, and Tiziani, 2011, p.144).

Acute Pain:

• Usually lasts less than 3 months • Sudden onset • Usually know the cause of the pain • Usually well defined • Predicable ending (healing) • Can lead to chronic pain if left untreated • Examples: cut to the finger, broken bone

CHRONIC PAIN

Chronic Pain:

• • • • • Persistent or recurring pain Continues for more than 3 months May last for months or even years Can be difficult to diagnose and treat Primary goal is not total pain relief but reducing pain relief • Examples include: arthritis and back pain

CATEGORIES OF PAIN

Another way to categorise pain is on the basis of origin: • • • Nociceptive Neuropathic Psychogenic

NOCICEPTIVE PAIN

Nociceptive pain is directly related to tissue damage and can be either external (somatic) or internal (visceral)

External / Somatic

• • • • • • Most common type of pain Can be superficial -in the skin but may extend to the underlying tissues.

Usually described as: sharp, shooting, throbbing, burning, stinging well defined area Usually lasts from a few seconds to a few days Examples include: paper cut, sprained ankle

NOCICEPTIVE PAIN

Internal / Visceral (Deep)

• • • • • • • • Less common and usually more severe Originates in the walls of visceral organs Poorly defined area Described as: deep, aching, pressing or aching Usually lasts a few days to weeks Virtually a symptom of all diseases at some point during disease progression.

Often associated with feeling sick Examples include: Major surgery, labour pain, irritable bowel.

NEUROPATHIC PAIN

• • • • • • Injury or disease of the central nervous system rather than the peripheral tissue. May be due to nerve compression, inflammation or trauma Usually lasts between a few months to many years. Difficult to treat due to the lack of knowledge of the underlying cause.

Often associated with paraesthesia, hyperalgesia and allodynia Burning, shooting or pins and needles (not sharp like nociceptive).

PSYCHOGENIC PAIN

• • • • • Psychological, psychiatric or psychosocial are the primary causes Severe and persistent pain Appears to have no underlying pathology. Less common now due to medical technology Pain experienced (Headaches, abdominal pain, back pain) is indistinguishable from that experienced by people with identifiable injuries or diseases.

• This kind of pain can be very frustrating to sufferers and can interfere with their ability to function normally.

CLINICAL MANIFESTATIONS

“No two people are likely to experience the same level of pain for a given painful stimulus” (Craft et al., 2011, p.150).

Pain Tolerance:

The maximum level of pain that a person is able to tolerate without seeking avoidance of the pain or relief •

What affects Pain Tolerance?

Fatigue, anger, boredom, apprehension, sleep deprivation. Alcohol consumption, medication, hypnosis, warmth, distracting activities and strong beliefs or faiths.

CLINICAL MANIFESTATIONS

Pain tolerance is influenced by a number of factors including; • • • • • Age Cultural perceptions Expectations Gender Physical and mental health

CLINICAL MANIFESTATIONS

Age:

• Different reaction to pain • Understanding of pain

Gender:

• “Females display greater sensitivity to pain than males do. There are differences in the way women cope with pain, report pain and respond to pain” (Crisp & Taylor, 2009, p.1096).

Physical & Mental Health

• Physical mobility • Depression, difficulty coping, fatigue.

CULTURAL VARIATIONS

Cultures vary in the meaning of pain, how if it expressed and how it is treated: • • • Meaning Expression Treatment

PAIN THRESHOLD

• Pain Threshold is the lowest point at which pain can be felt • Entirely subjective • May vary from person to person but changes little in the same individual over time.

LOCATION

It is important record a patients pain location to be able to monitor any changes.

Pain can feel like it is coming from one part of the body but in fact it is another, this type of pain is called referred pain.

SIGNS AND SYMPTOMS:

Signs:

• • • • • • • • • Change in temperature Blood pressure Respiratory rate Heart rate Short of breath Sweating Pallor Dilated pupils Swelling • • • • • • •

Symptoms:

Fatigue Feeling sick Weakness Numbness Tenderness Change in behaviour Unable to sleep

PATHOPHYSIOLOGY

• Pain is not a disorder or disease.

• A consequential reaction by the body to noxious stimuli.

• • Injury Disease • Pain incorporates • • • Cognition Emotion Behaviour • Simple pathway to the brain; • • • • Transduction Transmission Perception Modulation

PATHOPHYSIOLOGY

• Transduction • Process by which afferent nerve endings participate in translating noxious mechanical, chemical or thermal impulses into nociceptive impulses.

• • Strong physical stimuli and disease processes cause chemical release.

Once activated the chemicals bind to specific receptors.

• • chemicals such as bradykinin, cholecystokinin and prostaglandins, activate or sensitize nearby nociceptors Lead to the generation of Action Potentials (AP)

TRANSDUCTION

PATHOPHYSIOLOGY

• Transmission • 1 st Order Sensory Neurons • • • Located in the dorsal root ganglia in the posterior of the spinal cord.

AP’s are conducted to the CNS primarily via two types of primary afferent neurons • • A delta Fibres "Epricritic Pain" C Fibres "Protopathic Pain" 2 nd • • Order Sensory Neurons The impulse crosses the spinal cord and ascends to the thalamus and branches to the brainstem nuclei via central transmission.

Messages cross the cord and ascend to the thalamus via the Spinothalamic pathway, heading to the somatosensory cortex, the insula, frontal lobes and limbic system.

A-DELTA AND C FIBRES

Nerve fibre

Appearance Type of Pain

Aδ Epicritic C Protopathic A delta Fibres • "Epricritic Pain" • Mechanical message • Sharp, Fast pain • Thin Myelinated fibres increase speed of processing

Information carried

•

Sharp pain

(‘fast pain’) • Temperature •

Dull pain

(‘slow pain’) • Temperature • Itch

Diameter (micrometres)

1-5 0.2-1.5

Speed of signal conduction

5-35 m/sec 0.5-2.0 m/sec C Fibres • "Protopathic Pain" • Mechanical and Thermal Stimuli • Slow, dull, long lasting pain • Unmyelinated fibres, slower response

PERIPHERAL TRANSMISSION

• • Peripheral transmission An electron micrograph showing • • • large myelinated Aβ small lightly myelinated Aδ fibres unmyelinated fibers C Fibres.

SYNAPTIC TRANSMISSION

• • • • Synaptic transmission Action potential synapse at the dorsal horn of the spinal cord Neuroactive excitatory and inhibitory neurotransmitters are released Lead to generation of action potentials and central transmission of pain signals to higher centres.

PATHOPHYSIOLOGY

• Perception • When noxious stimuli is recognised.

• • • Multiple areas of the brain 3 rd Order Sensory Neurons • To the higher brain centres of Limbic system • m Frontal cortex, primary sensory cortex of the post central gyrus of parietal lobe Sensory-Discriminative Response • result of activity in the somatosensory and the insular cortex • allows the person to identify the type, intensity and bodily location of the noxious event. • Affective-Emotional Response • • Mediated by the limbic system. Defines the response and associated behaviour.

PATHOPHYSIOLOGY

• Modulation • Dampening or amplifying pain-related neural signals.

• Descending input from the brainstem influences central nociceptive transmission in the spinal cord. • • Descending inhibition of nociception through the release of neurotransmitters such as serotonin, norepinephrine and endogenous opioids. Gate Control Theory ( Melzack and Wall, 1965) • • • The body can reduce or increase the degree of perceived pain through modulation of incoming impulses at a gate located in the dorsal horn of the spinal cord. The integration determines whether the gate will be opened or closed, either increasing or decreasing the intensity of the ascending pain signal. Psychological variables in the perception of pain, including motivation to escape pain, and the role of thoughts, emotions, and stress reactions in increasing or decreasing painful sensations.

DIAGNOSIS

• Diagnosis of Pain is complicated.

• To diagnose pain, Nurses rely on • • • Objective Data.

• Visual signs.

Subjective Data.

• Patients descriptions.

Characteristics of Pain.

DIAGNOSIS

•

Characteristics of Pain

• OPQRST Mnemonic • Onset • • • • • Provocation Quality Region/Radiation Severity Time

DIAGNOSIS

1.

• • • Onset What was the patient doing at the time?

What precipitated the pain?

Is there any history of this pain in the patient?

2.

• • Provocation Aggravating Factors: • What causes the Pain to increase?

Alleviating Factors: • What makes it better or worse?

DIAGNOSIS

3.

• Quality Get the patient to describe their pain to you in specific terms.

• What does it feel like?

4. Region/Radiation • • • • • Where is the pain?

Where does the pain radiate? Is it in one place? Does it go anywhere else? Did it start elsewhere and now localised to a different spot?

DIAGNOSIS

5. Severity • • Pain Rating • On a scale of 1 to 10, 10 being the worst pain you have experienced, what number would you assign to your discomfort? Does their pain change with medication?

• Wong-Baker Faces Pain Rating Scale.

• Used for • • Children People whose first language is not English.

DIAGNOSIS

DIAGNOSIS

6. Time • • When did the pain start?

How long has the patient has this pain?

• Are there any Associated Phenomena?

• • • Factors consistent with pain e.g. Anxiety • • • Physiological responses Sympathetic stimulation Parasympathetic stimulation Vital signs, skin colour, perspiration, pupil size, nausea, muscle tension, anxiety Behavioural Responses • Posture, gross motor activities

DERMATOMES

• 3 Categories • Dermatomes • • • Connective Tissue and Dermis Myotome • Skeletal Muscle Sclerotome • Vertebrae • Dermatomes in relation to pain • An area of skin in which sensory nerves derive from a single spinal nerve root.

DERMATOMES

• Spinal Cord Dermatomatic Relationships • • • • • Trigeminal Nerves • • • V1Ophthalmic Division – Eye V2 Maxillary Division – Top of Jaw V3 Mandibular Division – Bottom of Jaw Cervical (C-2 - C-7) • fingers, neck, funny bone, and the scalp.

Thoracic (T-1 - T-12) • nipples, chest, belly button area, pubic bone, and lower sternum.

Lumbar (L-1 - L-5) • hips, the front of the legs, the shins, knee caps, and most of the feet.

Sacral (S-1 - S-5) • genitals, buttocks, back of the legs, and calves

DERMATOMES

DIAGNOSTIC TESTS

Tests to verify pain.

• Ultrasound Imaging • High frequency sound waves to develop an image of the affected area.

• CT/CAT scan • • Computed Tomography or Computed Axial Tomography X-rays to produce an image of a cross section of the body. • MRI Scan • Large magnet, radio waves and a computer produces detailed images of the body.

DIAGNOSTIC - TESTS

• Discography/Myelograms • A contrast dye is injected into the spinal disk to enhance the X-Ray.

• EMG (Electromyography) • Evaluate the activity of the muscles.

• Bone Scans • Diagnose and monitor infection and fracture of the bone

DIAGNOSIS

• Psychological Assessment • Pain Questionnaires • Determine Psychological Involvement.

• Brain functions governing behaviour and decision making, including expectation, attention and learning.

• • • • Fear Anxiety Depression Coping • Psychosocial involvement.

• Plays a large role in pain perception.

• Age, Sex, Culture, previous experiences.

PHARMACOLOGICAL MANAGEMENT

• The management of pain through analgesics • Analgesic: a compound that relieves pain by altering perception of nociceptive stimuli without producing anaesthesia or loss of consciousness • 1.

Three types of analgesics: Opioids (narcotic) analgesics 2.

3.

Non-opioid analgesics (NSAIDs) Adjuvants

PHARMACOLOGICAL MANAGEMENT

• Routes of administration: • Oral • Continuous infusion (via SC or IV routes) • PCA (patient controlled analgesia) • • • • Epidural Rectally Transdermal administration Inhalation

GENERAL PRINCIPLES OF PAIN MANAGEMENT

• • • • • • • • Treat the cause of pain where possible, not just the symptom Make accurate diagnosis and assessment of pain extent and type Keep the patient pain free Dose at regular specified intervals Avoid the chronic pain stress cycle Prevent adverse effects of opioids Develop a patient management plan Follow the WHO analgesia ladder

PHARMACOLOGICAL MANAGEMENT

• • WHO has developed a three-step ladder for pain relief If pain occurs, the use of oral of drugs should be administered in the following order: 1.

2.

3.

non-opioids mild opioids strong opioids Image: World Health Organization http://www.who.int/cancer/palliative/painladder/en/

OPIOIDS

• Generally prescribed for moderate – severe pain • Act on CNS by binding with opiate receptors to modify perception and reaction to pain • The most commonly used opioid is morphine

COMMON OPIOIDS

Drug Morphine Codeine Fentanyl Methadone Pholcodine Tramadol Pethidine Hydromorphone Oxycodone Dextropropoxyphene Heroin

 

Description

 The ‘gold standard’ analgesic, used for severe acute and chronic pain         Absorbed well orally or parentally Very potent with a short duration of action which can be taken via IM, slow IV, lozenge (lollipop) or patch dosage Analgesic properties similar to morphine, but has extended half life and better oral bioavailability Virtually no analgesic effects, but good for treatment of nausea, cough suppression Synthetic analgesic used in the treatment of moderate - severe pain, but is less effective and more expensive than morphine. Effective for short term use but is not suitable orally due to low bioavailibility Semi-synthetic opioid with a faster onset but a shorter duration of action than morphine Potent synthetic opioid up to 10 times more potent than codeine. It is effective as a night time suppository dosage in patients unable to swallow.

Synthetic analgesic suitable for treatment of mild to moderate pain with significant side effects including accumulation and cardiotoxicity.

Classified as a schedule 9 drug, and is a popular drug of abuse

OPIOIDS

• Adverse drug reactions may include: • respiratory depression • excessive sedation • constipation • • • • • nausea vomiting tolerance dependence dysphoria (a mood of general dissatisfaction, restlessness, anxiety)

NSAID

S • • • • Non-steroidal anti-inflammatory drugs Used to treat mild – moderate pain Work by acting on peripheral nerve receptors to reduce transmission and reception of pain stimuli Common NSAIDs include: • • • • Paracetamol Aspirin Ibuprofen Naxopren (arthritis)

NSAID

S • • Adverse reactions may include: • gastrointestinal tract disorders • renal damage • asthma attacks • • skin reactions sodium retention and consequent heart failure and hypertension Large overdoses of paracetamol can cause fatal acute liver damage if not promptly treated.

NSAID

S

Aspirin vs Paracetamol

• Aspirin is readily available OTC. It can be used in stroke prevention due to its anti-platelet qualities.

• In normal doses, paracetamol is a safer OTC analgesic than aspirin for the following reasons: • adverse effects and allergic reactions are rare • there is low risk of gastric upset, renal impairment or peptic ulceration compared with aspirin • • • few serious adverse drug interactions may be used by children safe to use during pregnancy and lactation

PHARMACOLOGICAL MANAGEMENT

• • • • • • • •

Other drugs useful for analgesic effects

GABA analogues Capsaicin Local anaesthetics General anaesthetics Ethanol or phenol Cannabinoids Specific anti-migraine drugs Herbal remedies

NON-PHARMACOLOGICAL MANAGEMENT

• • Management of pain without the use of analgesia Useful for patients who: • • • • find such interventions appealing express anxiety and/or fear may benefit from avoiding or reducing drug therapy need to cope with a prolonged interval of post-operative pain • • have incomplete pain relief after use of pharmacological interventions are able to use the intervention without assistance (TENS, heat packs)

NON-PHARMACOLOGICAL MANAGEMENT

• • • • • • • • RICE (rest, ice, compression, elevation) Physiotherapy TENS Acupuncture Psychotherapeutic methods Surgery Community support groups Complementary and alternative medicine aromatherapy, herbal medicines, spinal manipulation

HOT AND COLD THERAPY

• • Heat • • • increase circulation and oxygen and nutrient flow to an area by vasodilation of the arterioles, reduced blood viscosity and increased capillary permeability. Reduces swelling, inflammation and ischaemia. reduces muscle spasm and induces muscle relaxation.

Cold • promotes vasoconstriction • • reduces oedema and bleeding in an area reduces the inflammatory process and decreases contractility of muscles and cellular metabolism.

PSYCHOTHERAPEUTIC

•

Psychotherapeutic methods include

• • • • • • Hypnosis behaviour modification biofeedback techniques assertiveness training art and music therapy the placebo effect

TENS MACHINE

• • • • • Transcutaneous Electronic Nerve Stimulation Form of electroanalgesia Works in three ways to relieve pain: 1.

2.

3.

Hormone release Gating effect Broken brain pathways Commonly used during labour, post-ceasarean, and for back pain and sciatica Can also be used to treat post-natal depression

TENS MACHINE TENS MACHINE

COMPLICATIONS

• Many people believe pain is something “…you have to live with” • Research has indicated that women have a higher prevalence of chronic pain syndromes and diseases associated with chronic pain than men.

• Untreated pain is a serious ailment • Total pain relief is desirable, but sometimes reducing pain to a tolerable level is more realistic.

UNTREATED ACUTE PAIN

“symptom of injury or disease at the tissue level, tends to resolve as the injury or disease does ” These symptoms are dependant on the area affected.

• Cardiovascular • Increased blood pressure and heart rate as a result of Injury or Infection.

• Immune • Increased Immune response • Respiratory • Increased respirations as a result of fear or pain.

• Musculoskeletal • Tensing of muscles to counteract pain.

• Risk of pressure ulcers whilst in hospital if unable to move from the bed.

• Cognitive/Psychological • Possible Fear or Anxiety surrounding injury and healing process.

• • Short term implications for work and social life.

Anger, Irritability.

UNTREATED CHRONIC PAIN

“no physical cause for the pain can be found or pain persists long after the injury has healed” • • • • Cardiovascular • Increase in Heart Rate and Blood pressure • Lead to an increased risk of Heart Disease Immune • • Impaired immune responses Delayed healing Respiratory • Risk of Respiratory Depression due to some medications Genitourinary/Gastrointestinal • Impaired functioning • • Constipation or abdominal pains due to ongoing medication Changes in appetite • Incontinence • • Musculoskeletal • Tense muscles • • Limited mobility A lack of energy Cognitive/Psychological • • Depression, Anger and Anxiety Affected emotional responses due to depression.

• • • • • • • Fear of re-injury.

Long term implications for work and social life.

Sleeping Disorders Hormonal Imbalances Sexual Dysfunction Lack of concentration and mental clarity Dependence on medication

IMPLICATIONS FOR NURSING PRACTICE

• • • • •

Nurses role in pain management

Administer pain-relieving interventions Assess the effectiveness of these interventions Monitor for adverse effects Be an advocate for the patient when the prescribed intervention is ineffective in relieving pain Serve as an educator to the patient and family

IMPLICATIONS FOR NURSING PRACTICE

Establishing a nurse-patient relationship

• Positive nurse-patient relationships and teaching are KEY • Communication and patient cooperation • Believe and acknowledge that the patient is in pain – reduces anxiety • ‘I know you have pain' often eases the patients mind • Education is important • Provide information • Establish goals for the patient

IMPLICATIONS FOR NURSING PRACTICE

•

Providing physical care

Ensure the patient is as comfortable as possible and that physical and self-care needs have been met • Opportunity to reassess and comfort the patient • Assess skin integrity (patches, IV lines)

IMPLICATIONS FOR NURSING PRACTICE

• • • • •

Managing anxiety related to pain

A patient who anticipates pain may become increasingly anxious.

Patients who are more anxious are likely to be less tolerant.

Educate the patient on pain and pain management Gives a sense of control Good nurse-patient relationship is crucial

IMPLICATIONS FOR NURSING PRACTICE

• • • • • •

Interventions - Who else may be involved?

Oncology nurse Physiotherapist Occupational therapists Doctor or pharmacist The family or caregiver People in the community: visiting nurses, pharmacists, general practitioner, palliative care nurses

CASE STUDY

• • • Name: David Age: 30 Admitted to hospital due to injured Calcanium caused by injury at work where he fell 3 metres.

• •

Previous Medical History:

Already had previous soft tissue injury in his ankle from playing football a year ago.

Suffered from migraines for past 15 years.

Upon Admission Doctor prescribes:

Entenox gas (initially to examine David's foot) Ibuprofen Pethidine Tramadol Maxalon Intravenous normal saline

CASE STUDY

• • David’s new foot injury is acute, nociceptive internal (visceral) pain Migraine is chronic, psychogenic pain • • • • • • • •

Signs:

B/P: 120/70 Temperature: 36.6

Pulse: 120 Respirations: 22 Sao2: 100% Pain 9/10 Sweating Pallor • • • • • • •

Symptoms:

Slight agitation Moaning Scored pain 9/10 1 hour of “throbbing’ sensation pain in left foot Tingling sensation in his metatarsal and tarsals Swelling and bruising over calcanium Unable to bare weight

PATHOPHYSIOLOGY

• • • • Acute trauma to the Calcinium.

Pain is Transduced by the Spinal Nerves located near the L5 Dermatome.

The messaged is first Transmitted via the Adelta fibres then the C fibres.

• A delta Fibres "Epricritic Pain" • Mechanical message • • Sharp, Fast pain Myelinated fibres increase speed of processing • Impulses conducted at around 20m/sec C Fibres "Protopathic Pain" • • Mechanical and Thermal Stimuli Slow, dull, long lasting pain • unmyelinated fibres, slower response • Impulses conducted at around 2m/sec

PATHOPHYSIOLOGY

• • The message is Perceived in the Frontal cortex and the primary sensory cortex of the post central gyrus of parietal lobe. The message is interpreted and an appropriate response is formulated - in Davids case, to release neurotransmitters Modulation.

• release of neurotransmitters such as serotonin, norepinephrine and endogenous opioids to counter the pain

DIAGNOSIS

• • • •

Onset

• Fell on Right Calcanium falling from a 3m height at work.

• Previous Soft Tissue Injury from football on the same calcanium one year ago.

Provocation

• Unable to bear weight on his foot

Quality

• 1 hour of Throbbing pain in right foot • • Tingling sensation in Metatarsals and Tarsals Odema and Contusions over Calcanium

Region/Radiation

• Right Calcanium • Not noted as radiating.

DIAGNOSIS

• • •

Severity

• Patient Pain Score - 9/10

Time

• This injury - Short amount of time • But precipitated by a previous injury on the same location

Associated Phenomena

• Physiological Manifestations • • • Pallor Sweating Behavioural Manifestations • Agitated • Moaning • Nauseous

TREATMENT

• • • •

Non Pharmacological

The doctor has prescribed the R.I.C.E. treatment to help with David's pain.

Hot and/or cold therapy Relaxation and distraction techniques • • • • •

Pharmacological:

Ibuprofen Pethidine Tramadol Maxolon

COMPLICATIONS

• • • • • •

Acute

Cardiovascular • Increased Blood Pressure and heart rate as a result of Injury Immune • Increased immune response Respiratory • Increased respirations as a result of pain.

Musculoskeletal • Tensing of muscles to counteract pain • Pressure Ulcers whilst in Hospital if unable to move from the bed Cognitive/Psychological • Possible Fear or Anxiety surrounding injury and healing process • Short term implications for work and social life Anger, Irritability

COMPLICATIONS

• • • • •

Chronic

Cardiovascular • Chronic Stress reaction can lead to an increase in Heart Rate and Blood pressure Respiratory • Risk of Respiratory Depression due to Tramadol Use Genitourinary/Gastrointestinal • • Constipation or abdominal pains due to ongoing medication Changes in appetite Musculoskeletal • • • Tense muscles Limited mobility A lack of energy Cognitive/Psychological • • • • • Depression, Anger and Anxiety Affected emotional responses due to depression.

Fear of re-injury.

Long term implications for work and social life Dependence on medication (Pethidine)

IMPLICATIONS FOR NURSING PRACTICE

• • • • For David, being a 30 year old male who is coherent, we would most likely use the numerical scale. Pain should be assessed throughout David's treatment.

By using the pain scale with David, we should be able to gauge quantifiable changes in his pain over time, rather than by simply asking him 'how are you feeling' once in a while. Include his family in the education process, as they may need to assist in managing David's pain once he is discharged.

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