PAIN Jessica
MANAGEMEN Hernandez,
MSN, RN
T
Overview of pain
• Most common reason people seek
healthcare
• Under recognized
• Misunderstood
• Inadequately treated
• Purely subjective
• Misreported or under reported
• Review box 44.2: common biases
and misconceptions about pain
Effects of Pain
Decreased energy
Emotional and Cognitive components
Effects interpersonal relationships
Decreased quality of life
May lead to serious physical, psychological, social and
financial burdens.
Physiology of Pain
■ 3 minute Video link on physiology of pain
■ Nociception
– Transduction- Activation of pain receptors.
– Transmission- Conduction of pain sensations
from injury or inflammation site along nerve
pathways to spinal cord.
– Perception- Involves sensory process that
occurs when a stimulus for pain is present.
– Modulation- Process by which the sensation
of pain is inhibited or modified.
■ Tissue injury triggers neurotransmitters
– histamine and substance P produce
vasodilation and edema
– bradykinin and prostaglandins may increase
pain stimuli or sensitivity
Physiology of pain
■ Gate control theory of
pain
– Pain has emotional,
cognitive, and
physical components
– Non-noxious stimuli
have the ability to
‘close the gate’ to
perception of noxious
stimuli (pain)
Physiological Responses
Sympathetic (low/mod pain) Parasympathetic (severe/deep
pain)
Increased heart rate Decreased Heart Rate
Increased blood pressure Decreased Blood Pressure
Increased Blood Sugar Vomiting
Diaphoresis Pallor
Increased muscle tension Nausea
Dilation of pupils
Decreased gastric motility
Behavioral
Grimace, clenching of teeth,
guarding
Decrease activity, withdrawal
Agitation or restlessness
Classification of pain: by duration
■ Acute pain
– Short duration, transient
– Usually identifiable cause
– Predictable ending
– Can inhibit recovery
■ Chronic pain
– Prolonged, usually beyond 3-6 months
– Not always an identifiable cause (idiopathic)
– Often associated with significant psychological and cognitive
effects
■ Chronic, episodic pain
– Occurs sporadically over an extended period of time
Classification of pain: by
pathology
Nociceptive pain Neuropathic pain
“aching, “shooting, burning, Cancer pain
throbbing” pins and needles”
• Somatic: bone, • Diabetic • Often caused by
joint, muscle, neuropathy tumor
skin. • Phantom pain progression or as
• Visceral: organs • Spinal cord injury a result of
(can stimulate treatment
PNS) • More often
• Referred pain- nociceptive but
pain in separate can be either
part of body
from source
Factors influencing pain
PHYSIOLOGIC SOCIAL PSYCHOLOGIC CULTURAL
AL AL
Impacts of pain
■Quality of life
■Self care
■Work and school
■Social support
Assessment of Pain
Onset When did it start? How often? Acute or
O Chronic?
Location Where is your pain?
L
Duration How long does it last?
D
Characteristic Describe your pain (aching, shooting,
C burning, etc)
Alleviates What makes it better? Worse?
A Aggravates
Radiating Does it spread or radiate?
R
Timing When does the pain occur (ex. With certain
T activities?)
Severity 0-10 scale or alternative scale.
S
Assessment of Pain
P
Provocative What makes it better? Worse?
Palliative
Q
Quality Describe your pain (aching, shooting,
burning, etc)
R
Region Where is your pain? Does it spread or
Radiation radiate?
S
Severity How much pain do you have now? How
bad has it been in the past 24 hours?
T
Timing When did it start? How long does it last?
How often?
U
Understanding effect Describe what you cannot do as a result of
the pain. How does it impact your life?
Assessment of Pain: Tools
■ Numerical
■ FACES
■ Unable to self-
report
– FLACC
– PAINAD
– NVPS
– CPOT
Assessment of Pain: Tools
■ Tools for patients unable to self-report
– Infants and children: FLACC (face, legs, arm, cry, consolability)
– Dementia: PAINAD (breathing, negative vocalization, facial
expression, body language, consolability)
– General nonverbal pain scale: NVPS (face, activity, guarding,
vital signs)
– Critical Care patients: CPOT (face, muscle tension, body
movements, compliance with ventilator)
– See box 44.9 for an overview of nonverbal communicators of
pain
Diagnosis
Difficulty
Chronic Self care
Acute pain Coping
pain deficit
With Pain
Inadequat Impaired Impaired
Fatigue
e Pain Mobility Sleep
Control
Social
and others
Isolation
What is their acceptable level of
pain?
What are your patients' goals?
Planning
and Set priorities
Expected
Outcomes Education
Teamwork and Collaboration
Implementation key concepts
■ Requires a holistic approach
■ Multimodal therapy may be needed
■ Refer to practice guidelines and stay current with evidence-based
practice
Implementation: pharmacological
therapy
■ Concepts
– Around the clock (ATC)
– PRN
– Breakthrough pain
■ Multimodal analgesia
Implementation:
pharmacological therapy
■ Analgesics
– Opioid (morphine, codeine, oxycodone,
hydromorphone)
– Non-opioid (acetaminophen, ibuprofen,
lidocaine)
– Adjuvant (antidepressants, anticonvulsants,
corticosteroids)
Implementation:
pharmacological therapy
■Opioids
– morphine, codeine, oxycodone,
hydromorphone
■ Side effects: nausea, constipation, confusion,
somnolence, respiratory depression
■ Start low, go slow
■ Monitor for drug tolerance if taken long term
■ Assess current or past substance
abuse/addiction
■ Reversal agent: Naloxone (Narcan)
Implementation:
pharmacological therapy, opioid
safety
Pasero Opioid Sedation Nursing interventions
Scale (POSS)
S-sleep, easy to arouse Acceptable; no action necessary. May
1 = awake and alert increase monitoring if needed
2 = slightly drowsy, easily
aroused
3 = frequently drowsy, drifts off to Unacceptable; increase monitoring,
sleep during conversation notify provider, decrease opioid dose
and consider alternative pain relief
4 = somnolent, minimal or no Unacceptable; stop opioid, consider
response to verbal or physical naloxone, increase monitoring, notify
stimulation provider
Implementation:
pharmacological therapy
■ Non-opioid
– Acetaminophen (Tylenol)
■ Max dose is 4000 mg in 24 hours
■ Cautious use with liver disease
– Ibuprofen (Advil)
■ Max dose is 3200 mg in 24 hours
■ May cause gastric upset, increase risk for bleeding,
kidney injury
– Lidocaine
■ Often used transdermal or via local anesthesia
Implementation:
pharmacological therapy, routes
■ PO, IM, IV, topical, etc.
■ Local anesthesia
– Peri-neural infusion
■ Regional anesthesia
– Epidural infusion
■ Patient controlled analgesia
(PCA)
Implementation:
pharmacological therapy,
patient-controlled analgesia
(PCA)
IV or Subcutaneous infusion
Locked system
Allows patients to self administer
opioids
Physically able to push button
Set dose with lockout for
time/frequency
Patient and family education
Verification by two nurses
Implementation: non-
pharmacological
therapies
Cognitive and behavioral approach
Relaxation and guided imagery
Distraction
Music
Cutaneous Stimulation
Cold and heat application
TENS (transcutaneous
electrical nerve stimulation)
Implementation:
non-pharmacological
therapies
■ Complementary and
integrative modalities
– Acupuncture
– Acupressure
– Chiropractic
– Massage
– Movement therapy (ex.
Yoga)
– Therapeutic touch
– Aromatherapy
– Herbals
Implementation:
Restorative and
Continuing Care
■ Pain clinics
■ Palliative care
■ Hospice
Pain management: barriers
Patient Healthcare providers
Fear of addiction Inadequate assessment
Don’t want to ‘be a bother’ Concern for addiction
Lack of knowledge Fear of legal repercussions
Cultural beliefs Don’t believe patient report
of pain
Language barrier Time constraint
Also read Box 44.19 Concern for side effects or
overdose
Developmental considerations
Pediatric Geriatric
Infants DO have the ability to feel pain Pain is NOT a normal change of
Infants and young children express pain aging
differently
Older adults may be less likely to
Infants and young children may require report pain
different pain assessments
Infants and children process medications
Older adults are at increased risk
differently (pharmacokinetics), so need to of side effects from medications
monitor more frequently
Adults with cognitive decline
may express pain differently
Evaluation
■ Nursing process is ongoing,
cyclical
■ Variations in expression of pain
■ Holistic evaluation
– What is effect of pain on
ADLs, sleep, appetite, work,
etc.
■ Fun video by nursing students th
at may help you remember conte
nt
References
■ Alila Medical Media. (February 28, 2022). Gate Control Theory of Pain,
Animation. https://youtu.be/M-rL8XdHo6Q?feature=shared
■ Herr, K., Coyne, P. J., Ely, E., Gélinas, C., & Manworren, R. C. (2019).
Pain Assessment in the Patient Unable to Self-Report: Clinical Practice
Recommendations in Support of the ASPMN 2019 Position Statement.
Pain Management Nursing 20(5), 404-417.
https://www.sciencedirect.com/science/article/pii/S152490421930162
6
■ Potter, P.A, Perry, A.G., Stockert, P.A., & Hall, A.M. (2022).
Fundamentals of nursing (11th ed.). Elsevier.
