Pain Management Chapter 44

Subjective and Individualized

Patient Centered

Can be a warming sign of tissue damage

Four Physiological Processes
1) Transduction
2) Transmission
3) Modulation
4) Perception
Gate Control Theory
– stress response stimulates the ANS

– that non-painful input closes the “gates” to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.

– pain of low to moderate would elicit fight/flight response (sympathetic)
– normal isn’t the same for everyone
– continuous pain, severe or deep activates parasympathetic

Sympathetic Response (F/F)
Increase RR, HR, BP, blood glucose, cortisol level, diaphoresis, muscle tension, dilation of pupils

Decrease GI mobility


Parasympathetic Response
Decrease HR, BP

Irregular breathing

pallor (pale), nausea/vomiting

Behavioral Response
– pain can alter life quality and threaten well being
– tolerance varies
– verbal and nonverbal cues (clench teeth, grimace, guarding and holding painful part, bent posture (acute)
– chronic pain affects eating, sleeping, socialization, confusion (thinking)
– lack of expression doesn’t indicate no pain
– always make sure patient knows when to say they are in pain!!!
Types of Pain
Acute, Chronic Persistent, Chronic Episodic, Cancer Pain, and Idiopathic
Acute Pain
– persistent, normally identifiable cause, short duration, limited tissue damage, and emotional response
– threatens recovery by hampering ability to become active/involved in self care (exhaustion, immobility, sleep deprivation, and pulmonary complications)
*** provide pain relief (can progress to chronic pain)
Chronic Persistent Pain
– prolonged over 6 months, could be episodic
– no purpose but dramatic effect
– chronic non cancer is prolonged, variable of intensity and lasts longer than expected
– may not have identifiable cause (idiopathic)
** arthritis, low back pain, headache, fibromyalgia, peripheral neuropathy
– may cause fatigue, insomnia, anorexia, depression, weight loss, hopelessness, anger
Chronic Episodic Pain
– occurs sporadically over extended duration
Cancer Pain
(acute or chronic)
– normal (nociceptive = sharp, throbbing pain. Somatic = bone, joint, muscle, skin, CT or Visceral = visceral organs) from undamaged nerve or neuropathic (abnormal/damaged pain from nerves)
– pain at site or distant to referred pain
– caused by tumor, pathological process, invasive procedure, toxic chemotherapy, infection, or physical limitations
Idiopathic Pain
– chronic pain in absence of identifiable physical or physiological cause or pain perceived as excessive
Factors that Influence Pain
Age: young have poor understanding of pain and cant recall or associate it, older adults are not inevitable to pain but do have greater likelihood of pathological conditions to cause pain, age related changes, frailty, un-predicted reactions to meds, under report pain, increase in sensitivity, and high potential drug effects

Fatigue: heightens perception of pain and decreases coping abilities

Genes: play a role in sensitivity, perception or expression

Neurological Function: awareness and response to pain

Attention: attention increases with pain

Previous Experience: may know what to expect or cope better

Family/Social Support: make stressful experience less

Spiritual: active searching for meaning in situations

Anxiety: increase perception of pain

Coping Style


Ask about pain regularly
Believe patient and family
Choose pain control options
Deliver interventions promptly
Empower patient and family
Assessing for Pain
1) expression (non verbal = behavior, view conditions that would cause, assume they are in pain, and verbal)
2) classification
3) expectations
4) special attention to elderly and non verbal clients
5) self report!!! PQRST, meds, activity

-effect on client, influence on ADL’s

Characteristics of Pain
P = provoke
Q = quality
R = Relief
S = Severity
T = Timing
Scales for Pain
Wong Baker Scale (Faces 0-5)
FLACC = face, legs, activity, cry, consolability (0-2)
PAINAD = advanced dementia (breathing, neg voice, facial, body language, consolability)
Characteristics of Pain by Location
1) Superficial (like needlestick) = short duration, localized
2) Deep or Visceral (crushing or burning) = radiates, longer duration
3) Referred (like MI, pain is in jaw, left arm and shoulder) = pain goes to separate part of body
4) Radiating (radiates down body part) = intermittent or constant
Effects of Pain on Patient


Concomitant Symptoms (n/v, headache, depression, etc..)

Patient will receive a satisfactory level of pain relief within 24 hours
– reports a 3/10 or less in scale
– uses pain relief measures safely
– level of discomfort doesn’t interfere with dressing
– avoids factors that intensify pain
Interventions for Pain Management
1) Massage (don’t massage legs)
2) Guided Imagery (thinking of a better place)
3) Music
4) Distraction
5) Cutaneous Stimulation = Tens unit, massage, bath, cold application, acupressure
6) Herbals = echinacea, ginseng, gingko, biloba, garlic
7) remove or prevent painful stimuli
8) Hypnosis, exercise, prayer, journaling, therapeutic touch, aromatherapy
9) Pharmacological
Pharmalogical Pain Relief
1) Analgesic
-non opiod
– acetaminophen (not anti-inflammatory, for muskuloskeletal pain)
– NSAIDS (anti-inflammatory, for acute intermittent pain like headaches and muscle strain, could cause GI bleed or renal insufficiency): toradol/Ketolorac, ibuprofen, naproxen
– opiod (narcotic): for moderate to severe pain
– morphine (narcan, nalaxone for overdose), hydromorphone (dilaudid), fentanyl, oxycodone, propoxyphene, meperidine (demerol), hydrocodone (vicodin)
– cause constipation, CNS changes (could cause respiratory distress, depression, impaired sleep, decreased libido
– adjuvants or co-analgesics (alone or w/analgesic): sedatives, anticonvulsants, steriods, anti depressants, anti anxiety, muscle relax

ATC = around the clock
PRN = when needed
Multimodal analgesia = two separate pain meds for different things

Principles When Administering Analgesics
1) know patients previous response if any
2) select proper medications when more than one is ordered
3) know accurate dosage
4) assess right time and interval for administration
PCA (patient controlled analgesia)
– self administer opiods with minimal risk or overdose
– deliver a specific does at specific time intervals (usually every 8-15 minutes)
– family/friends should not push
– good for post op
Topical Anesthetic
– prescription and OTC creams, ointments, patches that are applied to painful area
– common = NSAID, capsaicin (peppers)
– applied on skin
Local Anesthesia (CAINS)
– local infiltration of an anesthetic med to induce loss of sensation to body part
– for brief surgical procedures
– regional anesthesia (injection of infusion of local anesthetic to block group of sensory nerve fibers)
Perineural Local Anesthetic Infusion
– unsutured catheter near nerve and exits from surgical wound
– cain meds might run through pump or disposable pump (ON-Q) to reduce pain
– blocks motor and sensory nerve
Epidural Analgesia (regional anesthetic)
– preservative free opiods infused, may include local anesthetic as well (label line)
– treat acute post op pain, rib fracture pain, labor/delivery pain, chronic cancer pain
– controls/reduces severe pain and reduces opiod oral or IV requirement
– short or long term
– into spinal epidural space

**nursing interventions: prevent catheter displacement/infection, maintain bowel/urinary function, prevent undesirables, monitor for respiratory depression

Transdermal Analgesic
– patches are worm 48-72 hours
– find patch at least every 8 hours
– fentanyl, lidocaine into sharps container
Supporting Patient
– provide emotional support, protect from injury, patient education
– invasive interventions for pain relief are available (intrathecal pumps/injections, spinal cord/brain stimulation, neuroblative procedures, trigger point injections, cryoablation, intraspinal medications
-procedure pain management: premedicating, non pharmalogical therapies
– cancer pain and chronic non cancer pain management: non pharm + phar interventions together, provide emotional support and educate, non cancer pain should use opiods to improve level of function
Where patient has severe pain from chronic illness but medications don’t relieve it all the way and signs/symptoms are misunderstood. They may become addicted to the medications.
Barriers to Effective Pain Management
– Client, Provider, or HC system
– physical dependence (a state of adaptation that is manifested by a drug class – specific, withdrawwal, syndrome produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and or administration of an antagonist. Common symptoms of opiod withdrawal include shaking, chills, abdominal cramps, excessive yawning, and joint pain)
– addiction (a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. Addictive behavior include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving)
– drug tolerance (a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time.)
– placebo: pharmalogically inactive preparations or procedures that produce no beneficial or therapeutic effect (RESEARCH ONLY BC UNETHICAL)
Restorative Care
ANA supports aggressive treatment of pain/suffering even if it hastens a patient’s death
– pain clinics, palliative care (successfully manage life limiting conditions), and hospices (care for patient at end of life, strong opiods because the disease not the opiods are killing the patient
Major responsibility of the nurse
– client response may not be obvious
– evaluate for change in severity and quality of pain
– appropriateness of pain medications will require nurses to evaluate client 1 hour after IV and 2 hours after oral meds (15-30 min after administration)
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