INTRODUCTION

 Pain
o Unpleasant, highly personal experience
o Unpleasant sensory and emotional experience associated with actual or potential tissue damage
o May be imperceptible to others
o Not just a symptom
 It is a high-priority problem.
 Pain management
o Alleviation of pain or reduction of pain to a level of comfort that is acceptable to the client
 Persistent pain contributes to complications.

THE NATURE OF PAIN

 Universal experience but unique to each person
o Type of pain
o Psychosocial context or meaning
o Response
 Current categories of acute, chronic
 Underlying mechanisms
 Holistic view of care

TYPES OF PAIN
 Location
o Can be localized or radiating
o Can be referred or visceral
 Duration
o Acute pain
o Chronic pain
o Cancer pain
 Intensity
o Mild, moderate, or severe pain
 Etiology
o Nociceptive pain
 Experienced when an intact, properly functioning nervous system signals that tissues are
damaged, requiring attention and proper care
 Transient or persistent
 Subcategories
 Somatic
o Skin, muscles, bone, connective tissue
 Visceral
o Neuropathic pain
 Experienced by people who have damaged or malfunctioning nerves
 Subcategories
 Peripheral neuropathic pain
 Central neuropathic pain
 Sympathetically maintained pain
CONCEPTS ASSOCIATED WITH PAIN
 Pain threshold
o Least amount of stimuli needed for a person to label sensation as pain
 Pain tolerance
o Maximum amount of painful stimuli a person is willing to withstand without seeking avoidance, pain relief
 Hyperalgesia, hyperpathia
o Heightened responses to painful stimuli
 Allodynia
o Non-painful stimuli that produces pain, such as light touch
 Dysesthesia
o Unpleasant abnormal sensation

PHYSIOLOGY OF PAIN
 Central nervous system's structure constantly changes
o Constituency, function not well understood
 Perception of pain depends on:
o Body's analgesia system
o Nervous system's transmission
o Mind's interpretation of stimuli

NOCICEPTION
 Physiological processes related to pain perception
 Nociceptors (pain receptors)
 Transduction
o Nociceptors excited by stimuli
 Transmission
o First segment
 Pain impulse from peripheral nerve to spinal cord
o Second segment
 Transmission from spinal cord ascends via spinothalamic tracts to brain stem and
thalamus
o Third segment
 Transmission of signals between thalamus and the somatic sensory cortex (where
pain perception occurs)
 Perception
o Client conscious of pain
 Assesses intensity and character
 Assigns meaning
 Modulation
o Descending system
 Neurons sent back to dorsal horn of spinal cord
 Descending fibers release endogenous opioids; reabsorbed quickly

GATE CONTROL THEORY

  Small-diameter (A-delta or C) peripheral nerve fibers carry signals of noxious stimuli to the dorsal horn.
 Signals are modified when they are exposed to the substantia gelatinosa.
 Ion channels on the pre- and postsynaptic membranes serve as gates.
 When open, permit positively charged ions to rush into the second order neurons, sparking an electrical impulse and
sending signals of pain to the thalamus
 Large-diameter (A-beta) fibers have an inhibitor effect.
 May activate descending mechanism that can lessen intensity of perceived pain or inhibit transmission of pain
impulses
 Clinical application
o Stop nociceptor firing by treating the underlying cause
o Apply topical therapies
 Heat
 Cold
 TENS
 Massage
o Address client's mood
 Reduce fear, anxiety, anger
o Address client's goals
 Provide education and anticipatory guidance

RESPONSES TO PAIN
 Psychological and psychosocial effects
 Fight or flight triggered, may increase heart and respiratory rate, trigger reflexes, stop movement, lead to muscle
atrophy and dermal ulcers
 Unrelieved pain negatively impacts sleep, appetite, and quality of life and lowers immune system.
 "Windup phenomenon"
o 24hours of unrelieved severe pain alters structure and function of nervous system in a way that prolongs
and intensifies the pain experience.

FACTORS AFFECTING THE PAIN EXPERIENCE

 Ethnic and cultural values
o Can affect level of pain that an individual can tolerate
o Nurses must realize own attitudes, expectations about pain.
 Developmental stage
o Newborns experience pain
o Pain syndromes in pubertal women
o 57% of older adults live with pain.
 Environment and support people
o Noises, lights, and activity
o Some people withdraw, others prefer distraction of people and activity.
 Previous pain experiences
o Personally or exposure to suffering of someone close
o Influence of success or lack of success
 Meaning of pain
o If associated with positive outcome, better tolerated
 o Individuals with chronic pain
 Often become pessimistic, helpless, hopeless
 Anxiety, worry, and uncertainty

ASSESSING
 Fifth vital sign
 Extent, frequency varies according to situation and organizational policy.
 Two major components
o Pain history
 How client views pain and situation
 Nurse focus for acute pain
 Previous pain treatment and effectiveness
 Analgesics taken
 Other medications being taken
 Allergies to medications
 Nurse focus for chronic pain
 Coping mechanisms
 Effectiveness of current pain management
 Ways pain has affected client
 Location
 Ask patient to point to site
 Pain intensity or rating scales
 Single most important indicator
 11-point scale
 Wong-Baker FACES rating scale
 Specific scales for young children, older adults
 Pain quality
 Adjectives provide clues to cause
 Record description verbatim
 Pattern
 Onset, duration, intervals without pain
 Precipitating factors
 Such as physical activity, environment
 Alleviating factors
 Anything client has done to alleviate the pain and its effectiveness
 Associated symptoms
 Such as nausea, vomiting, dizziness, and diarrhea
 Effect on activities of daily living
 Helps nurse understand severity
 Coping resources
 May include seeking quiet, knowledge, distracting activities, or socializing
 Affective responses
 Need to explore client's feelings such as anxiety, exhaustion, depression, etc.
o Direct observation of behaviors, physical signs of tissue damage, secondary physiological responses
 Nonverbal responses to pain
  Facial expression
 Vocalizations like moaning and groaning or crying and screaming
 Immobilization of the body or body part
 Purposeless body movements
 Behavioral changes such as confusion and restlessness
 Rhythmic body movements or rubbing
 Early physiologic responses to acute pain
 Increased BP, HR, RR
 Pallor
 Diaphoresis
 Pupil dilation
 Signs may be absent in people with chronic pain.
 Daily pain diary
o Time of onset of pain
o Activity or situation
o Physical pain quality and intensity
o Emotions experienced and intensity
o Use of analgesics, relief measures
o Pain rating after intervention
o Comments

DIAGNOSING
 Specify the location
 Related factors, when known, can include physiologic and psychologic factors.
 Diagnostic labels
o Acute Pain
o Chronic Pain
 Pain as etiology of other nursing diagnoses
o Ineffective Airway Clearance
o Hopelessness
o Anxiety
o Ineffective Coping
o Ineffective Health Maintenance
o Self-Care Deficit (specify)
o Deficient Knowledge related to pain control measures
o Impaired Physical Mobility
o Insomnia

PLANNING
 Goals vary according to the diagnosis and its defining characteristics.
 Planning independent of setting
o Select pain relief measures appropriate for client
o Base pain relief measures on assessment data and input from client or support persons
 Planning independent of setting
 o Include variety of pharmacologic and nonpharmacologic interventions
o Plan with wide range of strategies
o Document plan in client record and for home care
o Involve client and support persons
 Planning for home care
o Adapt to level of knowledge and ability of client and support people and community
resources
 Pain management
 Alleviation of pain
 Reduction in pain to level acceptable to client
 Independent nursing actions
 Collaborative nursing actions
 Noninvasive measures are independent functions.
 Administration of analgesics requires a medical order.
 Establish a trusting relationship
 Consider client's ability and willingness to participate
 Use a variety of pain relief measures
 Provide pain relief before pain is severe
 Use pain relief measures client believes are effective
 Align pain relief measures with report of pain severity
 Encourage client to try ineffective measures again before abandoning them
 Maintain unbiased attitude about what may relieve pain
 Keep trying
 Prevent harm; therapy should not disable.
 Educate client and caregiver about pain
 Barriers to pain management
o Lack of knowledge of adverse effects of pain
o Misinformation about use of analgesics
o Misconceptions about pain
o Client not reporting pain
o Fear of becoming addicted
o Tolerance
 State of adaptation to medication
 Exposure to a drug induces changes
 The result is diminution of one or more of drug's effects over time.
o Physical dependence
 State of adaptation to medication
 Manifested by withdrawal syndrome
 Produced by abrupt cessation, rapid dose reduction, decreasing blood level of
the drug, and/or administration of antagonist
o Addiction
 Primary, chronic, neurobiologic disease
 Genetics, psychosocial factors, and environment are influential
  Behaviors can include:
 Impaired control over drug use
 Compulsive use
 Craving
 Continued use despite harm
o Pseudoaddiction
 Undertreatment of pain
 Focus on obtaining medications to the point of becoming demanding, angry
 Key strategies in pain management
o Acknowledging and accepting clients' pain
 Acknowledge possibility of pain
 Listen attentively to client's description
 Convey that you believe client and are asking questions because everyone's
pain is unique
 Attend to client's needs promptly
o Assisting support people
o Reducing misconceptions about pain
o Reducing fear and anxiety
o Preventing pain
 Preemptive analgesia
 Pharmalogic pain management
o Opioids (narcotics)
o Nonopioids/nonsteroidal anti- inflammatory drugs (NSAIDs)
o Co-analgesic drugs
o World health organization three-step analgesic ladder
 Step 1
 For clients with mild pain (1–3 on a 0–10 scale)
 Use nonopioid analgesics (with or without a coanalgesic)
 Step 2
 For client with mild pain that persists or increases
 Pain is moderate (4–6 on a 0–10 scale).
 Use of a weak opioid ( e.g., codeine, tramadol, pentazocine) or a
combination of opioid and nonopioid medicine (oxycodone with
acetaminophen, hydrocodone with ibuprofen)
 Step 3
 Client with moderate pain that persists or increases or with severe pain
 Pain is severe (7–10 on a 0–10 scale).
 Strong opioids (e.g., morphine, hydromorphone, fentanyl)
o Nonopioids/NSAIDs
 Vary little in analgesic potency but do vary in anti-inflammatory effects,
metabolism, excretion, and side effects
 Have a ceiling effect
 Narrow therapeutic index
 Examples are acetaminophen, ibuprofen, aspirin, and naproxen.
 o Opioids
 Full agonists
 No ceiling on analgesia
 Dosage can be steadily increased to relieve pain.
 E.g., morphine, oxycodone, hydromorphone
 Mixed agonist–antagonists
 Act like opioids and relieve pain
 Can block or inactivate other opioid analgesics
 E.g., dezocine, petazocine hydrochloride, butorphanol tartrate,
nalbuphine hydrochloride
 Partial agonists
 Have a ceiling effect
 E.g., buprenorphine
 Opioid analgesics for moderate pain
 Most are controlled substances and must be ordered by primary care
provider or nurse practitioner.
 Often narrow therapeutic index
 Opioid analgesics for severe pain
 Meperidine
 Methadone
 Opioid side effects
 Include sedation, nausea/vomiting, urinary retention, blurred vision,
sexual dysfunction, and constipation.
 Respiratory depression
o Most concerning
o 8 breaths per minute or less
o Increase in sedation before
 Equianalgesic dosing
o Relative potency of drug compared to standard dose of
parenteral morphine
o Guides adjustment of medications, dose, time, interval, and
route of administration
 Coanalgesics
 Not classified as pain medications but have properties that increase
pain relief
o Antidepressants
o Anticonvulsants
o Local anesthetics
o Others
 Administration of placebos
o Medications or procedures that produce an effect from intent, not from physical or
chemical properties
o Ethically used only in context of approved research study
 Routes for opiate delivery
o Oral
  Preferred because of ease of administration
 Duration of action is often only 4–8 hours.
 Requires awakening during night for medication
 Long-acting or sustained-action preparations developed
 May need rescue dose of immediate- release medication
o Transnasal
 Enters blood immediately
o Transdermal
 Delivers relatively stable plasma drug level
 Noninvasive
o Transmucosal
 Onset of action rapid
o Rectal
 Useful for clients with dysphagia or nausea/vomiting
o Topical
 Directed at the point of application
o Subcutaneous
 Continuous infusion
 Used for pain poorly controlled by oral medications, clients with
dysphagia or GI obstruction, or clients with need for prolonged use
 Requires client or caregiver teaching about how to operate pump and
care for injection site
 Intramuscular
 Should be avoided
 Variable absorption
 Unpredictable onset of action and peak effect
 Tissue damage
 Intravenous
 Provides rapid and effective relief with few side effects
 Respiratory depression can occur rapidly.
 Intraspinal
 Needs to be sterile
 Must be preservative-free medication
 Provides superior analgesia with less medication used
 Can be administered by bolus, continuous pump infusion, or continuous
pump infusion plus intermittent bolus
 Continuous local anesthetics
 For administration into or near surgical site
o Conduct pain assessment and document q 2–4 hours while
client is awake
o Check dressing every shift
o Check the site of the catheter
o Assess client for signs of local anesthetic toxicity
o Notify primary care provider of signs of local anesthetic toxicity
or neurologic defect
  Patient-controlled analgesia
o Interactive method
 Allows clients to administer own doses of analgesics
o Minimizes peaks of sedation and valleys of pain that occur with prn dosing
o Electronic infusion pump Patient-controlled analgesia
o Safety mechanisms are crucial.
 Dose interval and lockout are established to prevent fatal overdosing.
 Nonpharmacologic pain management
o Consists of variety of pain management strategies
 Physical
 Cognitive–behavioral
 Lifestyle pain management
o Targets body, mind, spirit, and social interactions
o Provide comfort
o Alter physiologic responses to reduce pain perception
 Distract client from painful sensations
 Stimulate A-beta nerve fibers, activate mechanisms that reduce pain intensity,
activate endorphins, diminish conscious awareness of pain
o Optimize functioning
o Reducing pain triggers
o Promoting comfort
o Physical interventions: cutaneous stimulation
 Massage
 Heat or cold applications
 Acupressure
 Contralateral stimulation
o Immobilization/bracing
o Transcutaneous electric nerve stimulation
o Cognitive–behavioral interventions
 Distraction
 Eliciting the relaxation response
 Repatterning unhelpful thinking
 Facilitating coping
o Selected spiritual interventions
 Imagery techniques related to religious experience
 Inspiration
 Nonpharmacologic invasive therapies
o Nerve block
 Chemical interruption of nerve path
 Injected anesthetic (e.g., novocaine)

EVALUATING
 Goals established in the planning phase are evaluated according to specific desired outcomes.
 If not met, seek further information
o Adequate analgesics (change time, dose, interval?)
o Client's beliefs considered? Appropriate teaching provided? Clear instructions?
o Client receiving adequate support?
o Client's physical condition changed?