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 Pain is a subjective experience for which people

Blue Print for Exams most often seek health care.
Chapter 44 - Pain Management  Pain is recognized and assessed as the fifth vital
1. Principles of pain management sign, and defined as whatever the patient states it
2. Assessing pain and using pain scales is.
3. Gate theory  Pain has both physical and emotional aspects,
4. Patient Controlled Analgesia (PCA) pumps which are influenced by cognitive, affective,
5. Implementation/pain management behavioral, and sensory perceptions.
6. Patient teaching  Pain serves several primary functions, three of
which are protection, proving warning/symptoms of
disease, and response to injury.
 Nociception is the process by which the sensation of
tissue injury is conducted from the peripheral to the
central nervous system.
 The highest concentration of nociceptors, the free
end of afferent sensory neurons, is in the skin; the
lowest concentration is in internal organs.
 There are four steps of nociception: transduction,
transmission, perception, and modulation.
 Each individual has a different pain threshold and
pain tolerance.
 The neurotransmitters involved in the inflammatory
response are bradykinin, substance P, histamine,
serotonin, cytokines, electrolytes (calcium ions,
sodium ions, potassium ions), and prostaglandins.
 Many theorists have attempted to explain the
human pain experience.
 The three key theories of pain perception are:
o Pattern theory
o Gate control theory
o Neuromatrix theory

Overview of Pain
Concept of Pain

Pain (importance of pain recognition >>  fifth vital sign)

 subjective experience for which people most often seek health care. 
 a complex perception, differs enormously among individuals even when they have the same injuries or illnesses
 cannot be objectively measured.

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The most widely used definitions of pain today are:

1. An “unpleasant sensory and emotional experience, associated with actual or potential tissue damage or
described in terms of such damage”
(International Association for the Study of Pain, 2014).

2. "Pain is whatever the person says it is, and that it exists whenever the person says it does
(Pasero and McCaffery, 2011)."

Perception of Pain

Pain has both physical and emotional aspects, which are influenced by the person’s cognitive, affective/behavioral and
sensory perceptions

Cognitive  An alert, oriented patient can:

- perceive pain, report pain
- perform behaviors to prevent or alleviate pain.
 Non-alert patients may have impaired ability to perceive, report, prevent or relieve pain.
 Patients with Alzheimer’s disease or other cognitive disorders:
- might not be able to express the location of pain, prevent pain, or relieve pain
- but they are capable of perceiving and experiencing pain.

Affective  Behavioral and psychological responses to pain include:

/ - grimaces - clenched teeth - agitation - restlessness
Behavioral
 Verbalization may include:
- crying - moaning - screaming

 Psychological responses to pain may include:

- anger - irritability - hopelessness - anxiety

 Patients who do not outwardly verbalize pain, or who have a stoic affect, are often assumed to be
pain-free, when, in fact, they are in pain.
 Studies indicate that expectations of certain behaviors indicate pain can influence the prescribing
and administration of pain medications
 Patients are more likely to receive pain medication when they demonstrate behaviors
expected of patients in pain.

Sensory  Any loss of sensory function directly influences the patient’s awareness of pain. When patients
cannot sense pain, they cannot communicate pain, prevent it or respond to it.

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Protective

 A warning signal about an unmet need, or malfunction of the nervous system secondary to a disease process
 A motor or sensory, or emotional response to a subjective feeling

Warning

 Warning about a disease or condition: symptom

 Disease entity that can be treated

Response

 Thermal injuries, e.g., sunburn

 Mechanical injury, e.g., fracture
 Chemical injury, e.g., inhalation of toxic fumes
 Ischemic injury, e.g., lack of oxygen to body tissues

Physiology of Pain

Nociceptors

The peripheral and central nervous systems process painful stimuli. Nociceptors are the free endings of afferent nerve
fibers. They are sensory neurons sensitive to thermal, mechanical, and chemical stimuli.
Nociceptors are distributed throughout the body but density differs:
 The highest density is found in the skin, making the skin extremely sensitive to pain.
 A lower density is found in joints and tissues; therefore, these areas are less sensitive than skin.
 The lowest density is in internal organs, which respond only to painful stimuli, e.g., on palpation or when

Pain Transmission

Nociception is the process by which pain, triggered by noxious stimuli, is conducted from the periphery to the central
nervous system. The event begins with the conversion of the noxious stimuli (injury) to an electrical impulse, which is
transmitted from one neuron (nerve) to the next with the help of neurotransmitters.

1. Frontal lobe (affective-motivational aspect)

conveys the degree of unpleasantness of the pain experience.
2. Parietal lobe (sensory-discriminative aspect)
helps the person localize where on the body injury occurred.
3. Temporal lobe (cognitive-evaluative aspect)
allows the person to plan ways of removing or getting away from the pain.
4. Cerebellum (thalamus is a relay station)
distributes sensory signals to several other regions of the brain.
5. Occipital lobe (cortical brain regions_
process the pain (cause of pain or reaction of pain) from the body and generate the actual experience of pain.
6. Brain stem
Pain signals travel from the spinal cord to the brain, including the brainstem, thalamus, and cerebral cortex.
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4 steps of Nociception
Transduction
 Injury occurs.
 Nociceptors identify pain stimuli and convert it into an electrical impulse.
 Injured tissues release neurotransmitters that are part of the inflammatory response.
 Neurotransmitters assist with transmission of pain signals across neurons.
 Inflammatory response is a significant cause of generalized pain.

Transmission
 Pain signal transmitted through afferent nerve to spinal cord and brain.
 Signals travel two pathways:
 A-delta fibers:
o Pain translated as sharp, acute pain. myelinated
 C fibers:
o Pain translated as diffuse, dull, and longer-lasting pain. unmyelinated
 Both A-delta and C fibers carry pain impulses from the spinal cord to the cerebral cortex of the brain.

Perception
 Brain translates afferent nerve signals as pain.
 Person perceives pain.
 Location, intensity, quality:
o Pain threshold: lowest intensity at which the brain recognizes pain.
o Pain tolerance: intensity or duration of pain that a person can, or is willing to, endure

Modulation
 Once pain is recognized, the brain can change the perception of pain by sending inhibitory signals via the spinal
cord.
 This signal results in the release of analgesic neurotransmitters called endogenous opioids.
o Enkephalins influence the emotional perception of pain.
o Beta-endorphins act on the central and peripheral nervous systems to reduce pain.
o Dynorphins modulate pain, stimulate pain or reduce it, depending on which receptors are activated.

Neurotransmitters
Now that you understand nociception, let's further explore neurotransmitters involved in the inflammatory response
and their functions.
Neurotransmitter Definition and Function
Bradykinin A peptide produced in the blood that mediates the inflammatory response and stimulates pain
receptors.
Substance P Neuropeptide that transports pain impulses from the periphery to the central nervous system.
Histamine An amine released by immune cells in response to inflammation.
Serotonin A neurotransmitter released from the brainstem and dorsal horn that inhibits pain transmission.
Cytokines Proteins secreted by immune system cells that control inflammation.
Electrolytes Molecules that activate nerve endings (synapses), which respond to painful stimuli by changing ionic
movement into and out of nerve cells.
Prostaglandins Hormone-like compounds derived from fatty acids that are thought to increase sensitivity to pain by
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Neurotransmitter Definition and Function

stimulating pain receptors on neurons (nerve cells).

Theory Theoretical Elements

Willem Noordenbos (1953): Pattern theory  When injury occurs, a signal is carried along large-diameter
This theory (1953) hinted at the physiological nerve fibers (touch fibers) that may inhibit pain signals.
basis of pain, is now accepted science, and  The difference between a large-diameter signal and a small-
provided the foundation for the gate control diameter signal determined whether a person felt pain.
theory.  Patterns of stimulation of nerve endings determined whether
the brain interprets stimuli as pain (Todd and Kucharski, 2004).
Melzack and Wall (1965) Gate control theory of  Tissue damage causes the release of neurotransmitters, ions,
pain prostaglandins, and serotonin.
Proposed the theory to explain why thoughts  Movement of these substances in and out of the cell creates
and emotions influence an individual’s an electrical impulse or action potential.
perception of pain.  The impulse can travel along sensory nerve A-delta fibers and
be translated as sharp pain by the brain, or it can travel along
sensory nerve C fibers and be recognized as persistent or
chronic pain.
 A gating mechanism exists in the dorsal horn of the spinal cord.
The interplay of signals at this gate determines whether painful
stimuli are stopped or go on to the brain.
 If the impulses are not transmitted to the brain, there is no
perception of pain.
 Endorphins and enkephalins fight pain. Receptor binding closes
the gate, inhibiting signal transmission to the brain, decreasing
or eliminating pain.
Melzack (2001)  The distinctive experience of pain is perceived and regulated
Contemporary pain theory proposing that pain by each person.
is a multidimensional experience controlled by a  Each person has a genetically-controlled network of neurons
body-self neuromatrix. that is unique and affected by that person’s physical,
psychological, cognitive, and life experiences.
 Additional factors affect the pain experience other than the
direct relationship between tissue injury and pain.

Chapter 41- Oxygenation

1. ALL-know everything!!!
2. Anatomy and physiology of heart and lungs
3. Pathophysiology of cardiac, vascular and respiratory systems
4. Electrical and blood conduction and circulation (heart and systemic)
5. Electrocardiogram, different arrhythmias and dysrhythmias
6. Heart failure (left vs right)
7. Cardiac Output
8. Pulse pressure
9. Pulse deficit
10. Orthostatic/postural hypotension
11. Principals of breathing –airway and oxygenation
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12. COPD, s/s of COPDs

13. Oxygenation needs and types of oxygen delivery-Nasal Cannula vs Masks, BiPap vs. CPAP
14. Oral and tracheal suctioning 
15. Patient teaching
16. Principals of delegation

Types of Pain

Key Points
 Pain is classified by cause, pathophysiology, and duration.
 Nociceptive pain can originate in visceral or somatic locations and can be referred or radiating.
 Acute pain lasts less than six months, while chronic pain lasts greater than six months.
 Neuropathic pain results from nerve injury.
 Psychogenic pain has no physical cause but is still felt as pain.
 Pain is treated differently, even though pain may occur from the same cause, because all patients are different.
 Differences in individual characteristics play a role in how patients react to pain and their perception of pain.
 Age, gender, culture, disability, religion, and morphology are factors that influence how patients respond to
pain.

Classifying Pain
There are different ways to classify pain, for example, by:
 Cause: Cancer, cardiac
 Pathophysiology: Nociceptive, physiologic, neuropathic
 Duration: Acute pain (lasting less than six months), chronic pain (lasting more than six months)
Treatment for each type of pain, regardless of how pain is classified, is different because each person’s response to pain
is different.

Nociceptive Pain
Nociceptive pain is the most common type of pain. This type of physiologic (physical) pain occurs when nociceptors are
stimulated in response to trauma, inflammation, tissue damage, or surgery. This pain is felt as sharp, burning, aching,
cramping, or stabbing.
Nociceptive pain originates in visceral and somatic locations, and may be referred or radiating.

Visceral Pain
 Originates from organs within the body.
 Gradual in onset and tends to last longer than other types of pain.
 Occurs from conditions such as chronic pancreatitis, inflammatory bowel disease, bladder distention, and
cancer.
 Generally described as dull, cramping, or aching and lasts for a long duration.

Somatic Pain

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 Pain emanating from the skin, muscles, joints, and bones.

 Occurs from conditions such as sunburn, lacerations, fractures, sprains, arthritis, and bone cancer.
 Generally sharp, burning, stabbing, localized, and lasts for a short duration.

Referred Pain
 Felt in a location of the body other than where it originated.
 Originates in internal organs, but is often felt in other locations.
 Example: pain from the pancreas is felt in the back, or pain from a heart attack is felt in the jaw or left arm.

Radiating Pain
 Extends from the source of pain (injury) to an adjacent area of the body.
 Example: gastroesophageal reflux. Pain originates in the stomach and radiates up the esophagus.

Types of Pain
Other types of pain include neuropathic, psychogenic, acute, and chronic pain.

Neuropathic Pain
 Originates from nerve injury.
 Pain continues even after the painful stimuli is gone.
 Sensations may include numbness, tingling, burning, aching, crushing, stabbing, or shooting.
 Other associated conditions include:
o Dysesthesia (unpleasant, abnormal sensation)
o Allodynia (pain from non-injury stimuli)
o Hyperalgesia (excessive sensitivity)
o Hyperpathia (greatly exaggerated pain reaction to stimuli)
 Associated with tumors, infection, chemotherapy, diabetes mellitus, cerebrovascular accident (such a stroke),
viral infections, carpal tunnel syndrome, and phantom limb pain (brain continues to receive messages following
amputation of a limb).

Psychogenic Pain
 Pain perceived by a person when there is no physical cause for pain.
 Caused, increased, or prolonged by mental, emotional, or behavioral factors.
 Sensations may include headache, back pain, stomach pain.

Acute Pain
 Rapid onset.
 Short duration (less than 6 months).
 Subsides with healing of injury.
 Associated with trauma, obstetrical labor, acute distress, or trauma.

Chronic Pain
 Persistent pain.
 Long duration (greater than 6 months).
 May be episodic or continuous.
 May lead to disability.
 Associated with arthritis, fibromyalgia, and neuropathy.
 Breakthrough pain is an increase in pain when chronic pain already exists.
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o Breakthrough pain is associated with surgery, injury, or a fluctuation in pain from an existing condition,
such as cancer.

Diversity Considerations
Differences in individual characteristics play a role in how patients react to pain and in their perception of pain. Studies
of pain and patient’s perception of pain provide insight into factors that influence a person’s pain experience. Some of
those considerations are:

Gender
Pain management can be influenced by gender. Studies indicate that:
 Women report being in more pain than men, which may be due to differences in estrogen and testosterone
levels (Mitchell, 2010).
 Women seek help for pain more often than men do, but women are less likely to receive treatment (Partners
Against Pain, 2014).
 Women are more likely to be given sedatives for pain, while men are more likely to be given analgesics for pain
(Partners Against Pain, 2014).

Culture, Ethnicity, Religion

Individuals of the same culture, ethnicity, or religion may express pain differently, and pain treatment may vary
depending on that person’s beliefs. Studies indicate that:
 Non-Hispanic white adults report more pain than other races (Mitchell, 2010).
 African Americans and Hispanics are undertreated and wait until pain is severe before taking pain medication
(Mitchell, 2010).
 Asian patients may try to hide cancer pain because it is believed by some to be a punishment for sins of the past
(IM, Lee, Lim, et al, 2009).

Disability
Some patients cannot respond to pain while others may require adjustments in pain dosages to meet their needs.
 Patients with impaired cognition may not be able to communicate pain. Facial expressions, vocalization of
noises, or changes in physical activity or routines may be signs of pain. Non-cognitive pain assessment tools
should be used for these patients. Patients who are intubated may be able to write or point to a pain
assessment tool to indicate their level of pain. If they cannot, blood pressure elevations, restlessness, or other
physical parameters can be used to assess for pain.

Morphology
Research indicates that obese people tend to experience more pain in more locations than individuals of average weight
(Janke, Collins, and Kozak, 2007). For these individuals, pain medication dosages may need to be adjusted on the basis of
height and weight, due to body surface area and metabolic differences.

Age

 Preterm infants may display behaviors different from those of term infants due to neurologic immaturity (Holsti
and Grunau, 2007).
 Young children generally display pain by crying. Distraction may be useful when treating their pain.
 Pain sensation is just as acute in older adults as in young-adult patients, but the transmission of pain impulses
may be altered by chronic diseases or conditions (D’Arcy, 2009).

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 Older adults who are depressed or cognitively impaired may be unable to accurately describe their pain.
Alternate pain assessment methods should be employed.

Assessment RT Pain

Physiologic Alterations from Pain

The body attempts to protect itself in response to acute injury or tissue damage. The sympathetic nervous system is
stimulated first, followed by the parasympathetic nervous system if pain is not relieved. Each body system has a specific
response to the stress caused by injury and pain. Sometimes these responses are not beneficial because of inflammation
(Pasero and McCaffery, 2011).

Endocrine
 Cortisol, catecholamines, glucagon, insulin, antidiuretic hormone (ADH), and other hormones are released.
 These hormones result in the breakdown of protein, fat, and carbohydrates.
 Hyperglycemia (high blood glucose) occurs from ineffective use of glucose due to pain and stress.

Cardiovascular
 Cardiac workload and oxygen demand increase.
 Oxygen delivery to cells decreases, increasing heart rate and force of contraction.
 Blood pressure increases.
 Increased workload may over time result in plaque formation, artery narrowing, blood clot formation, and heart
attack (myocardial infarction).
 Unrelieved pain leads to parasympathetic stimulation and decreased heart rate and blood pressure.

Respiratory
 Air exchange decreases.
 Respiratory rate increases in an attempt to circulate more oxygen to cells.
 Prolonged pain causes reluctance to breathe deeply, increasing the risk for atelectasis and pneumonia.

Muscular
 Muscle function and ability to perform activities of daily living (ADLs) become impaired.
 Muscle spasms, muscle tension, and fatigue develop.
 Prolonged pain initiates a withdrawal response.

Urinary
 Hormones such as ACTH, catecholamines, aldosterone, angiotensin II, prostaglandins, and others are released,
activating the renin-angiotensin system to increase blood pressure.
 Urine output decreases and urine retention increases, increasing blood pressure.
 Fluid overload and hypokalemia result.

Gastrointestinal

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 Gastric emptying and motility decrease.

 Indigestion occurs from slow food movement through the stomach.
 Metabolism decreases.
 Constipation develops from decreased intestinal motility.

Immune
 The inflammatory response is initiated secondary to pain and injury.
 Inflammatory mediators are released in an attempt to prevent further tissue injury, fight infection, and reduce
pain.
 This protective response contributes to persistent pain from the release of inflammatory mediators.

Pain: Clinical Manifestations

When pain is acute the sympathetic nervous system responds primarily with changes to the patient’s heart rate, blood
pressure and respiratory rate. But when pain is prolonged or chronic, the parasympathetic nervous system responds and
all body systems are eventually affected. In both cases, the changes can be observed and are objective signs of pain.

When assessing patients, the nurse observes for behaviors that exhibit pain and listens to patient verbalizations about
pain. The nurse also validates patient statements, which acknowledges the patient's pain experience and expresses
acceptance of the response to pain. In so doing, the nurse builds a trusting relationship with the patient. Pain is a very
subjective experience, but it can often be validated by observing the objective clinical signs of body system responses to
acute and chronic pain, especially when pain is severe or inadequately treated.

BODY SYSTEM CLINICAL SIGNS OF PAIN

Cardiovascular  Acute pain:
o Increased heart rate and force of contraction
o Increased systolic blood pressure
 Prolonged or chronic pain:
o Decreased systolic blood pressure
o Decreased heart rate
 Increased myocardial oxygen demand (indicated by chest discomfort or dyspnea)
 Increased vascular resistance (indicated by increased blood pressure)
 Hypercoagulation (indicated by blood clots)
 Chest pain
Respiratory  Increased respiratory rate
 Increased bronchospasms
 Pneumonia
 Atelectasis
Gastrointestinal  Delayed gastric emptying (indicated by indigestion)
 Decreased intestinal motility (indicated by decreased bowel sounds)
 Constipation
 Anorexia
 Weight loss
Musculoskeletal  Muscle spasms
 Increased muscle tension (indicated by inability to relax)
 Impaired mobility

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BODY SYSTEM CLINICAL SIGNS OF PAIN

 Weakness
 Fatigue
Endocrine  Fever
 Shock
Genitourinary  Decreased urine output
 Urinary retention (indicated by bladder fullness)
 Fluid overload (indicated by increased blood pressure or peripheral edema)
 Hypokalemia (indicated by low serum potassium levels)
Sensory  Pallor
 Diaphoresis
 Dilated pupils (acute pain)
 Constricted pupils (prolonged or chronic pain)
 Rapid speech (acute pain)
 Slow speech (deep or prolonged pain)
Immune  Impaired immune function (indicated by infection)
 Infection

Pain Assessment

The first step when assessing a patient’s pain is assessment of vital signs. Vital signs may vary from baseline, depending
on the severity and length of pain. Initially, the pulse and blood pressure may be elevated, which may indicate acute
pain and the need for pain medication or other comfort measures.

If pain is mild and vital signs are within normal limits for the patient, the nurse can perform comfort measures and
continue with the pain assessment. If pain is severe, a focused assessment of the patient’s pain is performed to ensure
the most appropriate pain relief measures are instituted. The thorough pain assessment is continued as soon as the
patient’s pain is relieved enough to continue with the pain assessment.

Pain is a very individual, subjective experience. A thorough pain assessment requires the nurse to ask specific questions
about pain.
Many health care professionals use the acronym SOCRATES as a tool to effectively assess patient pain. Let’s review the
meaning of each letter:
S: Site (Where is the pain located?)
O: Onset (When did the pain start? Was it gradual or sudden?)
C: Character (What is the quality of the pain? Is it stabbing, burning, or aching?)
R: Radiation (Does the pain radiate anywhere?)
A: Associations (What signs and symptoms are associated with the pain?)
T: Time course (Is there a pattern to when the pain occurs?)
E: Exacerbating or relieving factors (Does anything make the pain worse or lessen it?)
S: Severity (On a scale of 0 to 10, what is the intensity of the pain?)

Pain History
In addition to asking “SOCRATES” questions, nurses should ask patients about other pain factors:
 What are your past pain experiences?
 Are they similar to this pain experience?
 What effect is your pain having on ADLs?

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 What meaning do you associate with your pain?

 What coping strategies do you use to deal with the discomfort?
When patients are unable to communicate verbally, nurses must observe for signs or symptoms of pain and assess for
precipitating factors that could result in pain.

Pain Assessment Tools

Although there are no laboratory or diagnostic studies that assess for pain level, there are tools available to assist with
pain assessment for patients of all ages. Pain assessment tools are specifically designed to assess the intensity and
location of the pain and to help health care team members evaluate the effectiveness of pain management
interventions.
Pain assessment tools include cognitive and noncognitive scales.

0-10 Scale
This cognitive self-report scale allows patients to verbally rate and report their pain levels on a 0-10 numeric pain scale.
Self-report is the most reliable indicator of the existence and intensity of pain.
Reported pain level of 1 to 3 is considered mild pain. Reported pain in the range of 4 to 7 is moderate pain. Reported
pain in the range of 8 to 10 is considered severe (Glassford, 2008).
A numeric scale quantifies pain.

Universal Pain Tool

The Verbal Descriptor Scale and the Wong-Baker Facial Grimace Scale are cognitive tools in which patients describe their
pain verbally.
The Universal Pain Assessment Tool is a combination of the Verbal Descriptor Scale, the Wong-Baker Facial Grimace
Scale, and the Activity Tolerance Scale. It is available with foreign-language phrases explaining the pain levels.
This tool can be used worldwide for assessing pain (Mitchell, 2010).

Neonatal Infant Scale

The Neonatal Infant Pain Scale is recommended for use in children younger than 1 year of age.
A score higher than 3 indicates that the child is in pain. It is used as a noncognitive pain assessment scale in the neonatal
intensive care unit (NICU), newborn nursery, and pediatrics department to determine pain levels of newborns and
infants.
On the basis of the score, the nurse can determine the need for pain medication.

Key Points
 Acute injury or tissue damage triggers physiologic stress responses by the body to protect itself.
 The sympathetic nervous system is stimulated first by pain, followed by the parasympathetic nervous system
when pain is not relieved.
 Body systems have specific responses to unrelieved pain, some of which are not beneficial because of the
resulting inflammatory response.
 Multiple body systems are affected by pain, depending on its severity and duration.
 When pain is acute, the sympathetic nervous system responds.
 When pain is chronic or prolonged, the parasympathetic nervous system responds.
 Pain can be validated by observing the objective clinical signs of body system responses to acute and chronic
pain.
 The first step when assessing a patient’s pain is assessment of vital signs because vital signs are affected by pain.
Pain management may be needed before a thorough pain assessment can be completed.
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 Pain is a highly subjective patient experience, but severe or prolonged pain can be validated by observing
objective signs of pain such as changes in vital signs, cardiac function, or respiratory function.
 Nurses should assess pain by asking pertinent questions. The acronym SOCRATES can be used, along with other
questions, to thoroughly assess a patient’s pain history and current status.
 Cognitive and noncognitive pain assessment tools are available to help patients convey the intensity and
location of pain and to aid nurses in evaluating the effectiveness of pain management interventions.

NSG Dx & Planning RT Pain Mgt.

Because pain is highly subjective, it cannot always be objectively assessed. Nurses can validate severe or prolonged pain
by observing objective signs such as changes in heart rate or blood pressure, but when these are not present, subjective
pain reports form the basis for care planning.

Except in emergency situations, a thorough, focused assessment beginning with a health history facilitates the
identification of patient needs and problems related to pain. Following assessment, the type and meaning of the
patient’s pain are established, allowing the most appropriate nursing diagnoses to be selected, goals and outcomes to
be determined, and adequate pain management to begin.

Common nursing diagnoses directly associated with pain

North American Nursing Diagnosis Association International Classification for Nursing Practice (ICNP)
International (NANDA-I)
 Acute Pain
 Acute Pain
 Chronic Pain
 Chronic Pain
 Difficulty Coping
 Ineffective Coping
 Anxiety
 Disturbed Sleep Pattern
 Readiness for Enhanced Comfort

Pain Nursing Diagnoses

Insert nsg diagnosis format here

Acute Pain Related to long-bone fracture as evidenced by reported pain of 10 of 10, pain with movement,
and request for pain medication.
Chronic Pain Related to deformity of joints as evidenced by limited mobility, inability to manage activities of
daily living, and feelings of helplessness.
Ineffective Coping Related to severe pain as evidenced by inability to ask for help, lack of appetite, and poor
concentration.
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Pain Nursing Diagnoses

Anxiety Related to fear of increasing pain levels as evidenced by restlessness, quivering voice, and
increased blood pressure.
Disturbed sleep pattern Related to pain from chronic illness as evidenced by verbal complaints of inability to sleep, dark
circles under the eyes, and frequent yawning.
Readiness for Enhanced Evidenced by inquiry regarding use of decreasing dosage of pain medication for comfort and by
Comfort pain rating of 2 of 10.

PLANNING rt Pain Mgt.

When planning care, the nurse complies with ethical and legal aspects of pain management as stated in:
 The American Nurses Association (ANA) standards of practice
 The Code of Ethics for Nurses
 The Joint Commission regulatory standards
The most commonly encountered ethical dilemmas related to pain management are:
 Under treatment of pain, especially among elderly patients
 Thorough management of pain

Collaboration is an important aspect of pain management:

 The patient with pain requires collaboration among multidisciplinary health care team members, beginning with
the nurse.
 Other members may include providers, music therapists, massage therapists, physical therapists, pain
management specialists, muscle manipulation specialists, and other specialists who provide complementary
therapies to manage pain in addition to medication.
 The goal of collaboration is progression of the patient toward the desired outcome of pain relief.

Even though the nurse maintains ultimate responsibility for overseeing the implementation and proper completion of all
pain related care, some nonpharmacological pain management activities may be delegated to unlicensed assistive
personnel (UAP), including:
 Administering back rubs  Performing oral hygiene  Talking to the patient
 Repositioning the patient  Changing the linens  Darkening the room

Each delegated intervention can help to make the patient more comfortable and assist in decreasing pain.

Goal Statements

Goals and expected outcomes for the patient with pain are directed at alleviating the problem identified in the nursing
diagnosis, focus on pain relief, and take into consideration the patient’s economic status, psychosocial capabilities,
physical abilities, and available resources.

Comfort Patient will report a pain level of less than 3 of 10 within 5 postoperative days.
Tolerance Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 week of starting
prescribed pain medication.
Cognition Patient will report increased ability to concentrate on routine activities within 2 hours of starting
prescribed dose of analgesia.
Anxiety Patient will report decreased anxiety, with no signs of restlessness, within 3 days of hospitalization.
Sleep Patient will state being able to sleep for 6 to 8 hours each night within 3 days of hospitalization.
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Readiness Patient will meet with a pain specialist to outline a plan for decreasing analgesia dosage within the
next 2 weeks.

Key Points
 Nursing diagnoses related to pain and discomfort are selected and individualized after assessing the patient’s
health history and analyzing objective and subjective patient data.
 Examples of common nursing diagnoses related to pain and discomfort include acute pain, chronic pain, and
ineffective coping.
 Comprehensive planning for the patient in pain requires collaboration among multidisciplinary team members,
including nurses, providers, music therapists, massage therapists, physical therapists, pain management
specialists, muscle manipulation specialists, and specialists who provide complementary therapies.
 Nurses maintain ultimate responsibility for all pain management care but can delegate nonpharmacological
tasks to UAPs. These tasks can facilitate patient comfort and relieve pain.
 Patient-centered goals must be directed at alleviating the specific problems identified for each nursing diagnosis
and must be appropriate for the patient experiencing pain, while also considering the patient’s economic status,
psychosocial capabilities, physical abilities, and resources.

Implemenation & Evaluation RT Pain

Nursing and Pain Management

Pain management is an essential element of nursing practice. Care is directed at reducing or eliminating the patient’s
pain. The Joint Commission (TJC) developed standards for pain management in an attempt to improve pain relief for
patients (Berry and Dahl, 2000).

The Fifth Vital Sign

Pain is known as the fifth vital sign because of its importance in the assessment process.
Assessing pain during routine vital sign assessment and documentation is routine standard of care for every patient.
The Joint Commission (TJC) requires every patient to be assessed regularly for pain and appropriate pain treatment to be
implemented.

The Nurse’s Role

The nurse’s role in pain management includes the use of the nursing process to:
 Assess the patient’s pain.
 Advocate for pain relief for the patient.
 Implement prescribed treatments for the patient’s pain.
 Educate the patient about pain treatment options.
 Evaluate patient responses to pain management interventions.
In most health care settings, only advanced practice nurses, clinical nurse specialists, physician assistants, and health
care providers can prescribe medications for pain relief.

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Assessment and the Plan of Care

Before the nurse can plan patient-centered care for a patient who is experiencing pain, a thorough assessment must be
conducted. Following analysis of assessment data, the nurse selects and individualizes nursing diagnoses that address
the patient’s pain. Joint Commission Pain Assessment Standards are used as guidelines during the planning process.

The goal of implementing pain management is to progress the patient toward the desired outcome of care, which is to
provide pain relief.

The Joint Commission's Pain Assessment Standards

The Joint Commission requires all organizations to meet certain pain assessment standards:
 Recognize the right of patients to have appropriate assessment and management of their pain.
 Identify patients with pain in an initial screening assessment.
 Perform a more comprehensive pain assessment when pain is identified.
 Record the results of the assessment in a way that facilitates regular reassessment and follow-up.
 Educate relevant providers in pain assessment and management.
 Determine and ensure staff competency in pain assessment and management.
 Address pain assessment and management in the orientation of all new staff.
 Establish policies and procedures that support appropriate prescribing and ordering of effective pain
medications.
 Ensure that pain does not interfere with participation in rehabilitation.
 Educate patients and their families about the importance of effective pain management.
 Address patient needs for symptom management in the discharge planning process.
 Collect data to monitor the appropriateness and effectiveness of pain management.
From Berry P, Dahl J: The new JCAHO pain standards: Implications for pain management nurses, Pain Manage Nurses
1(1): 3-12, 2000.

The Role of the Nurse in Pain Management

Patient Education

One of the most important nursing interventions for pain management is patient education. The nurse is responsible for
teaching the patient about prescribed pain management strategies included in the collaborative plan of care. When
teaching patients, the nurse must consider the patient’s ability to understand that teaching, otherwise teaching about
pain might not be effective.
Patient education regarding pain management should include:

Documentation
Teach patients:
 To keep a journal documenting the type of pain, activities related to the pain, intensity of the pain, and
measures used to relieve the pain. This information helps the nurse and/or provider establish trends and
determine if pain relief measures are effective.

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Treatments
Teach about:
 Non-pharmacologic treatment measures that can be used to relieve pain. These include massage, guided
imagery, muscle relaxation, and distraction.
 Self-administration of pain medication before pain becomes severe to maintain consistent blood levels of the
medication to produce sustained analgesia.

PCP Consult
Teach the:
 Importance of consulting with the primary care provider (PCP) before using herbal remedies to avoid
interactions with prescribed pharmacologic treatment.
 Importance of contacting the PCP or pain specialist if pain control measures are ineffective. This proactive
approach helps in managing the patient’s pain.

Resources/Support
Teach about:
 Community agencies, resources, and support groups that can provide additional information and educational
materials related to pain management.

NON-PHARMACOLOGIC PAIN MANAGEMENT

Independent Nursing Interventions

Non-pharmacologic pain interventions and alternative and complementary therapies are widely used interventions
today. These interventions target the mind, body, and spirit and promote a holistic approach to care.
It is important that nurses listen to and support patient requests for use of non-pharmacologic, alternative, or
complementary therapies. Increasing numbers of patients are embracing these interventions on the basis of their own
research and because they fear addiction or side effects from narcotic analgesics (Shumay, Maskarinec, Kakai, et al,
2001).
Non-pharmacologic interventions are those employed in conjunction with or in place of prescribed pharmacologic pain
management strategies. These are usually independent nursing interventions and do not require a provider’s order.

Distraction Positioning Massage

Distraction lessens patient’s focus Positioning enhances comfort and Massage promotes relaxation, decreases
on and awareness of relaxation. Techniques include: muscle tension and pain
pain. Techniques include:  Patient positioning for rest and perception. Techniques include:
 Watching television proper body alignment  Progressive relaxation
 Listening to music  Postoperative splinting, such as techniques
 Engaging in conversation holding a pillow to abdomen for  Guided imagery
 Playing cards or games coughing and deep breathing  Meditation
 Reading exercises
 Engaging in crafts

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Alternative and Complementary Therapies

Alternative and complementary therapies are used by those patients who do not wish to use prescribed medications for
mild pain. Assessment for use of herbal remedies is essential because of risk for serious drug-to-drug interactions.
There are numerous examples of alternative and complementary therapies. A few are discussed here.

1. Herbs
Herbs with pain relieving properties:
 Ginger  Feverfew
 Rosehips  Black cohosh

2. Yoga
uses slow stretching and deep breathing to bring the body into balance and the mind into focus on something other
than pain. Yoga is used to:
 Build strength  Improve flexibility
 Release muscle tension

3. Biofeedback
a technique used to take control over body responses to pain through:
 Voluntary control over physiologic body activities, such as relieving muscle tension

4. Meditation
a technique that restores the body to a calm state to:
 Decrease pain and stress  Promote relaxation
 Control breathing

5. Hypnosis
a technique used to relieve pain by:
 Altering the state of consciousness to modify memory and perception of pain
 Reducing cortical activation associated with painful stimuli

6. Reiki
Techniques that diminish pain by:
 Using hand placement to correct or restore balance
 Restoring communication between cells

7. Chinese Medicine
Common interventions are:
 Acupuncture: The insertion of fine needles into the skin at various depths, causing secretion of endorphins and
interfering with transmission of pain impulses.
 Acupressure: The application of pressure at acupuncture sites, interfering with transmission of pain impulses.

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Neurologic and Neurosurgical Therapies

1. Spinal Cord Stimulation

 Electrical simulation device is implanted into the epidural space.
 Leads for the device are connected to a generator in the abdomen or buttocks.
 Used for treatment of chronic neurologic pain by producing a tingling sensation that alters pain perception.

2. Nerve Stimulation
 Low-intensity current is applied through electrodes attached to selective receptors on skin.
 Current interferes with transmission of pain impulses in nerve fibers, reducing pain and providing analgesia,
which improves mobility.
 A Transcutaneous Electrical Nerve Stimulation (TENS) unit is a portable, battery-operated stimulator with a lead
wire and electrode pads that are applied to the skin in the area of pain. TENS units are contraindicated for
patients with pacemakers or cardiac arrhythmias.

3. Cold and Heat

a. Cryotherapy
 Application of cold decreases swelling and pain, produces local analgesia, and slows nerve conduction,
which improves functioning.
 Ice bags and cold compresses are examples of cryotherapy.
b. Thermotherapy:
 Application of heat decreases pain by producing local analgesia, dilating blood vessels, and improving
functioning.
 Hot compresses, heating pads, and sitz baths are examples of thermotherapy.
 Apply heat or cold for only 15 minutes at a time to avoid tissue injury. It may be reapplied, alternating with 15 to
20 minute rest periods from heat or cold.

4. Surgery
a. Cordotomy
 Surgical procedure in which pain-conducting tracts in the spinal cord are disabled to diminish severe
pain or cancer pain.
b. Neurectomy
 Surgical removal of a nerve or a section of nerves to treat chronic pain when other treatments fail.
c. Rhizotomy
 Surgery to sever nerve roots in the spinal cord for neuromuscular conditions such as spastic cerebral
palsy and back pain.
d. Sympathectomy
 Surgical dissection of nerve tissue of the sympathetic nervous system in the cervical, thoracic, or lumbar
spine to disrupt signals to the brain.

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PHARMACOLOGIC PAIN MANAGEMENT

Overview

Pharmacological pain management is often essential for relief and control of pain.
Multimodal analgesia refers to the use of more than one intervention or means for controlling pain, such as two
medications (codeine combined with acetaminophen) or a medication combined with a complementary therapy (topical
ointment combined with massage).
Evidence suggests that when multimodal analgesia is used it:
 Is more effective
 Requires lower doses of each agent
 Produces fewer side effects
Preemptive analgesia is the administration of medications before the painful event to minimize pain. Examples include
administering medication before painful procedures, such as before wound care and prior to surgery.

Non-opioid Analgesics

are frequently prescribed because they are considered safer than opioid (narcotic) analgesics and are non-
addictive. Patients can, however, become dependent on non-opioid pain medications. These analgesics are used to treat
many types of mild to moderate pain.

Examples of non-opioid analgesics include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), such as

ibuprofen and aspirin.

Acetaminophen NSAIDS
 Analgesic and antipyretic capabilities  Analgesic and anti-platelet capabilities
 Safe for most patients  Useful for treating bone and inflammatory pain
 For patients with liver disease:  Significant side effects:
o Monitor closely o Gastrointestinal (GI) upset and bleeding
o Administer within safe dose range o Cardiac complications (myocardial
 Special caution used when given to infants, infarction)
children, and older adult patients o Renal complications (renal failure)
 Long-term use may result in:  To avoid GI complications:
o Hepatotoxicity o Administer with food
o Renal damage (renal failure) o Proton pump inhibitor or histamine 2-
o Leukopenia receptor blocker often prescribed for
 Daily dose should not exceed 3 to 4 grams patients on long-term NSAID therapy to
 Overdose may cause liver damage and can be reduce incidence of stomach ulcers
fatal

Opioid Analgesics
NARCOTICS, are the most effective agents for relief of moderate to severe pain. There are many types of opioid
analgesics, but the two most common are agonist and agonist-antagonist analgesics.

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Agonist Analgesics Agonist-antagonist Analgesics

Actions/Uses  Change the patient’s perception of pain while  Depress pain impulse transmission at the
also relieving pain. spinal cord by interacting with opioid
 Most effective for severe pain rated between receptors.
7 and 10.  Most effective for moderate to severe
pain.
Examples  Morphine, hydromorphone, oxycodone,  Pentazocine, burophanol, dezocine, and
fentanyl, and meperidine. nalbuphine.
Administration  Administered orally, intramuscularly,  Administered intramuscularly or
intravenously. intravenously.
 May be administered every 1-3 hours IM or IV  May be administered every 1-4 hours
depending on dose. depending on drug.
Precautions  Assess level of pain relief following  Assess level of pain relief following
administration. administration.
 Assess for respiratory depression, seizures,  Assess for drowsiness, dizziness, nausea,
nausea, vomiting, constipation, itching, urinary vomiting, itching, respiratory depression.
retention.  Narcan is prescribed for respiratory
 Antihistamine may be prescribed for itching. depression.
 Document results in the patient’s medical  Monitor for opioid withdrawal.
record. Symptoms include vomiting, hypertension,
 Narcan is prescribed for agonist analgesic and anxiety.
overdose.

Safe Practice Alert

Check vital signs before administering opioid analgesics. Overdose of opioids may cause respiratory depression.
Respiratory depression is defined as fewer than 10 respirations per minute. Administer 0.4 to 2 mg of naloxone every 2
to 3 minutes to a maximum dose of 10 mg to increase the respiratory rate to more than 10 respirations per minute.
Administering opioids when a patient is hypotensive (systolic blood pressure of 90 or less) also may cause hypo
perfusion.

Patient-Controlled Analgesia (PCA)

a system in which an electronically controlled infusion pump immediately delivers a prescribed amount of analgesic to
patients when they activate a button, alleviating the need to wait for the nurse to administer pain medication. PCA
administers more frequent, but smaller doses of medication, which improves pain control. Medications are usually
opioids, such as morphine sulfate, fentanyl, or hydromorphone.

Safe use of PCA is explored here in more detail:

Delivery
PCA prescribed medications may be delivered:
 Intravenously (into a vein), which is the most common method
 Subcutaneously, under the skin
 Epidurally, between the dura mater and the spinal cord

Prescriptions

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The provider prescribes PCA medications and dosages for all patients and PCA by proxy orders.
Patient control of the infusion pump is restricted to:
 Continuous doses of pain medication with additional boluses administered by the patient as needed.
 Specific lockout times between patient doses to avoid overdosing.
PCA by proxy is authorized activation of the PCA pump by someone other than the patient:
 Authorized nurse-controlled or caregiver-controlled anesthesia by PCA when a patient is unable to activate the
dosing button.
 Indicated for young children and unconscious or incompetent adults.

Nursing Actions
PCA pump:
 Two nurses verifying or witnessing medication changes
 Checking orders against pump settings at the change of shift and when changes are made to pump settings
 Monitoring:
o PCA pump function
o Fluid levels
o IV line patency
 Assessing:
o Patient respiratory rate, level of consciousness, blood pressure
o Access site for infiltration or phlebitis, when administered intravenously
o Patient pain level, for itching, nausea, and vomiting (common side effects of opiates)
 Evaluating:
o Effectiveness of pain relief by assessing patient’s level of pain relief
 Documenting:
o Pain interventions (PCA use) and evaluations in the patient’s medical record

Evidence-Based Practice
Evidence supports:
Benefits of patient PCA pump use include:
 Satisfaction related to control of pain
 Self-management rather than having to ask for or wait for the nurse to administer medication
Benefits for nurse when patients self-administer pain medication by PCA include:
 Increased time available for patient care due to decreased requests for what could be hourly pain medication
administration
PCA use can be a safe method for pain management when adequate education, policies, and procedures are in place
(Taylor, 2010).

Safe Practice Alert

Administer the prescribed medication dose that best manages pain and has the fewest side effects.

Key Points
 Pain management is an essential intervention in the plan of care for patients with pain.
 Planning for patients with pain is based on The Joint Commission (TJC) standards for pain management, with the
goal of achieving pain relief for patients.
 Integral parts of meeting pain management standards and ensuring ethical, legal, and professional pain practice
standards include, but are not limited to, strategies such as assessing, evaluating, communicating, and
documenting.
 Patient education is a primary pain management intervention.
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 Non-pharmacological pain management interventions such as distraction, positioning, and massage are
independent nursing actions that can be implemented without a provider’s order. They can be used as adjuncts
to pain medications.
 Alternative and complementary therapies are widely used by patients with mild pain who do not wish to use
prescribed medications to treat their pain. These therapies are used in addition to, or as replacements for,
pharmacological pain interventions.
 Brain stimulation or neurologic and neurosurgical electrical stimulation pain therapies may be of benefit to
patients with chronic pain.
 Multimodal analgesia and preemptive analgesia are commonly used pharmacological interventions employed to
manage pain.
 Non-opioid analgesics are over-the-counter pharmacological medications, such as acetaminophen and NSAIDS,
used to treat mild to moderate pain. Opioid analgesics, including agonist and agonist-antagonist analgesics, are
frequently prescribed to treat severe pain.
 Patient-controlled analgesia (PCA) is an electronically-controlled infusion pump that immediately delivers a
prescribed amount of analgesic to patients when they activate a button, eliminating the need to wait for the
nurse to administer pain medication.
 Delivery parameters, pain medication prescriptions, and nursing actions are considerations when patients
receive pain medications by PCA pumps.

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