Pain Management
Kim L. Paxton MSN, ANP, APRN-BC
Bro. Jim O’Brien, OFM, Conv. R.N., M.S.N., O.C.N.
The International Association for the Study of
Pain defines Pain as:
“an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage or both.”
McCaffery, 1979
Regardless of the definition, most will agree that pain
has both Sensory & Behavioral components and is
strongly influenced by:
Physiologic
Psychologic
Sociologic factors.
Types of Pain
Acute Radiating
Chronic Referred
Cutaneous Intractable
Somatic Phantom
Visceral
Neuropathic
Characteristics of Acute Pain
Acute Pain serves a biologic purpose
It acts as a “warning signal” because it can
activate the sympathetic nervous system causing
various physiologic responses, similar to “fight or
flight”
Characteristics of Acute Pain
Has a short duration
Usually has a well-defined cause
Decreases with healing
Is reversible
Ranges for mild to severe
May be accompanied by anxiety and restlessness
Physiologic & Behavioral Responses to Acute Pain
Physiologic Response Behavioral Response
Acute Pain: Acute Pain:
Increased BP initially Restlessness
Increased pulse rate Inability to concentrate
Increased respirations Apprehension
Dilated pupils Distress
Perspiration
AcutePain:
Post-op pain is the most common example of Acute
Pain
The severity of postoperative pain may
be a predictor of long-term pain
Trauma
Burns
Procedural
Obstetric
PAIN’S VARIABLE FACE
Post-op pain management:
The use of “pre-emptive” analgesia is a “new”
technique
Pre-emptive analgesia includes administering
local anesthetics, opioids, & NSAIDs in pre-op,
intra-op, & post-op
Characteristics of Chronic Pain
Lasts more than 3 or > months
May or may not have well defined cause
Begins gradually and persists
Is exhausting and useless
Ranges from mild to severe
May be accompanied by depression, fatigue and
functional ability
Physiologic and Behavioral Responses to Chronic Pain
Physiologic Response Behavioral Response
Chronic Pain: Chronic Pain:
Normal BP Immobility or physical
Normal pulse rate inactivity
Normal respirations Withdrawal
Normal pupils Despair
Dry skin
Chronic Pain:
Often associated with non-cancer entities:
diabetic neuropathy
“phantom limb pain”
low back pain
no identifiable cause
Chronic Pain:
May have remissions and exacerbations
Oftentimes leads to depression & anger
Is not as readily treated as Acute Pain is by health care
workers
Chronic Pain Cancer
Cancer pains is caused by a the disease itself:
Nerve compression
Invasion of tissue
Bone metastasis
The cells of the substantia Gate Control Theory
gelatinosa
Can either inhibit or
facilitate the pain
impulses through the
trigger cells (T cells)
The T-cell acts as the
gate
If the gate is closed
there is less
probability of a
impulse being
transmitted to the
pain to illicit a pain
response
Sources of pain
Somatic pain
Cutaneous or superficial
Originates in skin or subcutaneous tissue
Has an abrupt onset, with a sharp, stinging
quality i.e., a paper cut
Deep, Somatic Pain:
Originates in the
bone, muscle, blood
vessels, connective
tissue
Has a slower onset, a
burning quality, &
lasts longer than
cutaneous pain i.e., a
sprained ankle
Somatic pain
Acute post-op Chronic
Incisional pain Bony mets
IV’s, catheters, drains Lumbar back pain
Skeletal muscle spasms PVD
Ortho procedures fibromyalgia
Arthritis
Osteo
Rhematoid
Visceral Pain:
Originates from the organs and linings of the body
cavity
Stimulation of pain receptors in the:
Abdominal cavity
Thorax
Characteristics of Visceral Pain:
Poor localization
Diffuse,
Deep cramping, aching, feeling of pressure
Examples include: chest tube, pancreatitis, bowel
obstruction
Visceral Pain
Post op acute Chronic
Chest tubes Pancraetitis
Drains Liver mets
Bladder distention Appendicitis
Bowel distention Cholecystitis
etc.
Neuropathic Pain:
Chronic
Diabetic neuropathies
Postherpetic neuralgia
Nerve compression: back injury
Neuropathic Pain:
Results from current or past damage to the nerve
fibers, spinal cord, central nervous system
Neuropathic Pain:
Characteristics include: long-lasting, poorly
localized, shooting, burning, sharp, numb, shock-
like
Examples: chemotherapy-induced neuropathies,
diabetic neuropathy
“Phantom Pain:”
Considered acute form
Usually pain that follows a limb amputation, although
the term can be applied to mastectomy & tooth
extractions
A type of neuropathic pain
Phantom Pain:”
Specific cause is unknown, but research suggests that is a
somatosensory “memory” that does not reside in a specific
region of the CNS, but may involve complex interactions
of neural networks in the brain
Asessment of Pain
Location
Character and quality – ask the patient to describe the
pain without suggesting words, unless he’s having
difficulty
Pattern – rarely the same at all times
Duration – how long does it last
Intensity – Use scale of “0 to “10”
Aggravating & alleviating factors
Types of pain
Localized pain:
Pain confined to the site of origin
Projected pain:
Pain along a specific nerve or nerve root
Types of pain
Radiating:
Perceived at the source of pain and extends into
nearby tissues
An example being: Cardiac pain that radiates down
the left shoulder and arm
Referred Pain:
Perceived in an area distant from the site of painful
stimuli
Ex. Right shoulder pain referred from gallbladder
Pain
Assessment
O - Onset
L - Location
D - Duration
C - Character
A - Associated/aggravating symptoms
R - Relieving factors / exacerbating
factors
T - Types of treatments patient has tried
Pain
Assessment
P – Provokes or Palliative
Q - Quality
R – Radiation
S – Severity
T – Time What were you doing when this started how
long have you had it.
Pain
The Assessment
A. - Mental status
- Pain scale
- VS
- Any other symptoms present
- Check your site prior to administration
B. - Follow the 6 rights
C. - Reassess in a timely manner
Intractable Pain:
Moderate to severe pain that cannot be relieved by
any known treatment, or pain that is highly resistant to
relief methods
Nurses are challenged to use a variety of
pharmacologic & non-pharmacologic methods of
relief
Example: Advanced Bone Cancer Pain
Pain and children
Pain Rating Scales for Children:
FACES Pain Rating Scale – shows a series of happy to
really hurting faces, and the child simply points
Oucher Scale
Poker Chip Scale – children under five use poker chips
that represent 1-4 pieces of “hurt” to show how much
they’re hurting
The “Pain Scale”
Assessing Pain in Children:
With Infants, observe for:
Tears
High-pitched sharp cry,
Stiff posture
Clenched fists
Inconsolable
FLACC Behavioral Pain Assessment Scale
Assessing Pain in Children:
With Toddlers, there’s a limited vocabulary, and difficulty
making comparisons. Observe for:
Crying
Rocking
Not wanting to be touched
Behavior changes
Assessing Pain in Children:
Preschoolers can describe pain, but have trouble
with intensity. Observe for:
Gritting teeth
Covering painful areas with
their hands
Unusual behavior
School-Age & Adolescent Children:
May continue having difficulty describing pain
Younger children may still struggle with their
understanding of increments of pain
Older children may fear looking like a “baby” if
they report pain
ShotBlocker
• The device is positioned
over the injection site
• The blunt contact points are
pressed firmly against the
skin.
• The shot is immediately
administered through the
opening.
• After the injection
the ShotBlocker is lifted
from the skin and discarded.
Non-Pharmacologic Pain Management
Ice Biofeedback requires the
Heat use of a special machine
Elevation that allows the patient to
Distraction see how his body reacts
to his efforts. When the
Imagery
patient is connected to
Relaxation the machine, he performs
Biofeedback a relaxation technique.
Music The machine responds
with tones, lights, or a
digital readout.
Pharmacologic Pain Management:
Non-Opioid Analgesics
NSAID’s
Opioid Analgesics
PCA’s
Epidurals
Adjuvant Drugs – enhance effects of opioids & lessen
anxiety i.e., antidepressants
PCA pump and
Patient
activation cord
PCA pump
Analgesics & Adjuvant* Therapy
Non-Opioids: ASA, Tylenol
NSAID’s: Ibuprofen, Celebrex, Toradol
Opioids: Morphine, MS-Contin, Dilaudid, Demerol, Fentanyl
Patch
Combination Opioid/NSAID’s: Tylenol #3, Lortab, Vicodin,
Percocet, Percodan
* Adjuvant Therapy: Tegretol, Dilantin, Neurontin, Elavil,
Zoloft, & Paxil
For a Narcotic OVERDOSE, we give:
NARCAN
An Opioid (Narcotic) antagonist
0.4mg – 2mg IVP
AKA: Naloxone Hydrochloride
Usually given IV SLOWLY! Too rapid administration
results in nausea, vomiting, tremors, sweating, increased
BP, & tachycardia.
Setting A Pain Goal
This is mutually agreed upon between the patient
and the Health Care Team!
Questions to consider:
What is realistic?
What is tolerable?
What are the patient’s life goals? i.e., would the
patient rather have more pain, but be more alert?
Addiction, Physical Dependence, and Tolerance:
Addiction: persistent craving for and abuse of a drug for
recreational reasons; it is a psychological phenomenon, not a
physical one.
Physical Dependence: a physiological adaptation of the body
tissues so that continued administration of the drug is required
for normal tissue function. Withdrawal is suffered if drug is
discontinued!
Tolerance: a common physiologic result of chronic opioid use;
larger doses of opioid are required to achieve the same level of
analgesia.
Surgical Interventions for Pain:
Neurectomy – resection or partial or total
excision of a spinal or cranial nerve.
Rhizotomy – cutting a nerve to relieve pain;
sensory nerve roots are destroyed where they
enter the spinal cord.
Surgical Interventions for Pain:
Cordotomy – the surgeon cuts the pain pathways at
the midline portion of the spinal cord – before
impulses ascend.
Nerve Blocks – localizing a nerve root and injecting
it with a local anesthetic or with a chemical agent to
achieve permanent neurolysis
What is a TENS Unit?
TENS stands for “transcutaneous electrical
nerve stimulation”
It relieves acute and chronic pain by using a
mild electrical current that stimulates nerve
fibers to block transmission of pain impulses to
the brain. It is delivered through the application
of electrodes placed on the skin at points related
to pain
The TENS Unit
Nursing Diagnoses related to Pain:
Fear related to pain
Powerlessness related to pain
Altered sexuality related to illness & pain
Activity intolerance related to pain
Sleep pattern disturbance related to pain
Self-Care deficit related to pain
A feeling of hopelessness related to pain
Evaluation: Outcomes for the Client with Pain:
Report that acute pain is relieved or reduced
Report that chronic pain is relieved, reduced, or NOT
worsened
Establish realistic goals given limitations imposed by
chronic pain
Perform activities of daily living
Patient and Family Education:
Teach the names of the medications
Promote adherence to the pain regime – medication on a
scheduled basis vs. prn
Don’t wait until the pain is unbearable
Keeping a “pain diary”
Mechanisms of action of the medications(s): long-acting
vs. short-acting
Review adjuvant therapy – i.e., anti-anxiety
Goal of Pain Management:
A HAPPY,
Comfortable Patient!
