1/2/25, 10:53 AM Ch 36 Yoost fundamental of the nursing 2nd edition.

Ch 36 Pain Management

● The Concept of Pain

○ Pain has physical and emotional aspects.

○ Pain is whatever the person with the pain says it is and that it exists
whenever the person says it does.

○ Pain may prevent injury or results from injury.

○ Pain is the most subjective of all symptoms that patients experience.

○ Cognitive, affective, behavioral, and sensory factors can influence

pain.

● Nursing and Pain Management

○ Pain should be assessed and documented to provide comfort.

○ In addition to assessing for pain, the nurse:

■ Diagnoses pain.
■ Monitors for pain management.
■ Evaluates the level of pain relief.
■ Advocates for the patient.
■ Educates the patient about treatment options for pain management.

○ Nociception
■ Transduction
● At the site of tissue injury, nociceptors detect pain stimuli and
convert (transduce) this electrochemical response into an
electrical impulse (signal).
■ Transmission
● The action potential, or electrical signal, is transmitted
through an afferent nerve to the spinal cord and brain.
■ Perception
● Perception (recognition) of pain occurs when the brain
translates the afferent nerve signals as pain.

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● Pain threshold is the lowest intensity at which the brain

recognizes the stimulus as pain.
● Pain tolerance is the intensity or duration of pain that a
patient is able or willing to endure.
■ Modulation
● Once pain is recognized, the brain can change the
perception of it by sending inhibitory input to the spinal cord
to impede the transmission.

○ Pain Theories
■ Specificity Theory
● Provided a foundation for later research that identified the
existence of pain receptors and peripheral pathways
■ Sensory Interaction Theory
● Provided a foundation for the gate control theory
■ Gate Control Theory
● According to the theory, the interplay of signals from different
nerve fibers at a gating mechanism in the dorsal horn of the
spinal cord determines whether painful stimuli are stopped or
go on to the brain.
● This theory is the basis for most of our interventions.
● Most of our interventions are to keep that gate closed.
■ Neuromatrix Theory
● Suggests that pain is a multidimensional experience
controlled by a body-self neuromatrix.
● Proposes that each person has a unique genetically
controlled network of neurons.
● Everyone experiences pain differently, responds differently,
and responds to treatment differently.

○ Types of pain
■ Acute pain
● <3 to 6 months
■ Chronic pain
● >3 to 6 months
■ Nociceptive pain (physical)
● Visceral (inside)
● Somatic (outside)
● Referred (when the pain you feel in one part of your body is
actually caused by pain or injury in another part of your

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body) (e.g., For example, an injured pancreas could be

causing pain in your back, or a heart attack could be
triggering pain in your jaw.)
● Radiating (the pain starts at one location and radiates
around to other locations. )
■ Neuropathic pain (nerve injury)
● Dysesthesia
● Allodynia
● Hyperalgesia
● Hyperpathia
● Phantom pain→ The brain continues to receive
messages from the area of an amputation
○ Plasticity
■ Psychogenic pain
● The pain is brought on by chronic stress, chronic worry, or
chronic fatigue.

● Altered Structure and Function

○ Alterations in pain pathways
■ Damage and hypersensitivity anywhere along the pain pathway can
alter a patient’s perception of pain

○ Physiologic alterations caused by pain

■ Acute injury triggers physiologic stress responses; these responses
may have adverse effects for the patient if pain is left untreated.

○ Factors influencing pain

■ Age, gender, morphology, disabilities, culture, ethnicity, and religion
play a role in the behavioral reaction to pain and in the perception
of pain.

● Assessment
○ Pain history and assessment
■ SOCRATES
● S = site
● O = onset
● C = character
● R = radiation

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● A = associations
● T = time course
● E = exacerbating/relieving factors
● S = severity

○ Pain assessment tools

○ Vital signs

○ Physiologic responses to pain

■ Chronic or prolonged pain
● Decrease in the systolic blood pressure and a decrease in
the pulse rate below the patient’s normal baseline.

○ Behavioral and psychological responses to pain

■ Behavioral responses
● Facial grimaces, clenched teeth, rubbing or guarding of the
painful area, agitation, restlessness, and withdrawal from
painful stimuli
■ Psychological responses
● Anxiety, fear, depression, anger, irritability, helplessness, and
hopelessness

● Nursing Diagnosis
○ Common ICNP® nursing diagnoses directly associated with pain
include:
■ Acute Pain: Supporting Data: long-bone fracture, reported pain of
10 of 10, pain with movement, request for pain medication
■ Chronic Pain: Supporting Data: deformity of joints,, limited mobility,
inability to manage activities of daily living, and feelings of
helplessness
■ Difficulty Coping: Supporting Data: severe pain, inability to ask for
help, lack of appetite, and poor concentration

● Planning
○ Goals and outcome statements

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■ The following are examples of goals or outcome statements:

● Patient will report a steady decrease in pain level to 4-5/10
within 5 postoperative days.
● Patient will perform activities of daily living each day,
reporting chronic pain at a level of 3 or less within 1 week of
starting on newly prescribed pain medication.
● Patient will report increased ability to concentrate on routine
activities within 2 hours of receiving the prescribed dose of
analgesia.
● Patient will state being able to sleep for 6 to 8 hours each
night within 3 days of hospitalization.
● Implementation and Evaluation
○ Multimodal pain management combines a variety of treatments

○ Nonpharmacologic pain management and complementary and

alternative therapies
■ Positioning, splinting, massage, progressive relaxation techniques,
guided imagery, and meditation
■ Distraction (television, music, and conversation)
■ Spiritual support (prayer and meditation)
■ Neurologic and neurosurgical pain therapies

○ Pharmacologic pain management

■ Multimodal analgesia
● Trying to attack the pain from different areas.
■ Pre-emptive analgesia
● Administration of medication before a painful event minimize
pain
■ Non-opioid analgesics
● Acetaminophen (Tylenol)
○ 3-4 g is max
○ Overdose cause liver pain
● Nonsteroidal anti-inflammatory drugs (NSAIDs)
○ Good for inflammation and swelling

○ Pharmacologic pain management

■ Opioid analgesics
● Agonist analgesics → Morphine
● Agonist-antagonist analgesic → Nubian
● Antagonist analgesics → Narcan

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○ Pharmacologic pain management

■ Opioid analgesics
● Patient-controlled analgesia (PCA)
○ Safety concerns
○ Please see box 36.11
● On-Q infusion pump
● Transdermal administration
○ A medicated adhesive patch that placed on skin
● Intrathecal injection
○ Used as spinal anesthesia for surgery or canser pain
● Epidural analgesia
○ Used for labor pain and surgery
● Nerve block
○ The injection of a local anesthetic into or near spinal
nerves for temporary pain control.
○ Used for dental works

○ Addiction
■ Substance use disorder in patients
■ Substance use disorder in nurses

○ Accidental ingestion
■ Patient education
■ 60,000 ER visits a year among children

○ Medical marijuana
■ Used to treat neuropathic pain and spasms of multiple sclerosis,
pain and/or nausea from cancer and its treatment, and pain from
HIV and AIDS

● Nursing Care Guideline: Patient-Controlled Analgesia

○ Background
■ Patient-controlled analgesia involves the intravenous administration
of a controlled substance as a pain medication.
■ Patient control of the infusion pump is restricted to certain
parameters, as prescribed by the primary care provider (PCP)
■ Patient controlled, not family controlled

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■ Nurses should follow facility policies for frequency of assessment

and documentation of PCA use.

○ Documentation Concerns
■ Note the patient and family education that was provided.
■ Education may initially occur preoperatively.
■ Education must be reinforced postoperatively.
■ Record assessment and monitoring results.
■ Document the medications administered, medications remaining,
and pump settings on each shift.

○ Evidence-Based Practice
■ Research indicates that PCA provides more effective analgesia and
fewer episodes of breakthrough pain.
■ Some studies indicate that PCA reduces patient length of
hospitalization, and increases patient satisfaction and feelings of
control in their treatment (Katz, Takyar, et al, 2016)

● Implementation and Evaluation

○ Pharmacologic pain management
■ Adjuvant or coanalgesic medications
● Works synergisticy with standard pain medications to
enhance pain relief and to treat side effects of the medication
■ Antiemetics → anti-nausea
■ Laxatives → for opioid
■ Ketorolac → after surgery, the pain meds that the nurse give
afterwards works better.
■ Caffeine → for headache

○ Palliative care
■ For patients of any age/any stage of serious illness
■ Improves quality of life

○ Therapeutic decision making

■ Titrating doses → Start with lower doses
■ Around-the-clock (ATC) dosing (e.g., administer every 6 hrs)
■ World Health Organization’s (2017) pain relief ladder

○ Barriers to adequate management

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■ Patient barriers: fear of addiction, cost of medication, and no

access to health care
■ Health care provider barriers: poor pain assessment skills,
inaccurate beliefs, prejudicial attitudes, delayed diagnosis

○ Pain management for addicted patients

■ American Society for Pain Management Nursing (ASPMN) and the
American Society of Addiction Medicine (ASAM) guidelines for pain
management

○ Barriers within the health care system

■ Pain not a priority, systematic pain management approaches and
pain management teams not in place, inadequate reimbursement
for pain medications, regulations may restrict access to medications
■ Patients have a right to pain relief.
■ Inadequate pain management may lead to detrimental outcomes.

○ Evaluation
■ Medication intervention
● Documents the time the medication was given, the time of
postintervention reassessment, and the duration of
acceptable pain relief post intervention
● Document the pain scale on every shift
● Provide patient education about medications at discharge
● Document teaching
● If pain relief goals are unmet, collaborate with other health
care team members and the patient to determine other
options for treatment

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