CHAPTER 46 / Pain Management 1205
Pain is an unpleasant and highly personal experience that may
be imperceptible to others, while consuming all parts of the
person’s life. The best definition of pain comes from Margo
McCaffery, an internationally known nurse expert on pain. Her
often quoted definition of pain says “pain is whatever the person
says it is, and exists whenever he says it does” (McCaffery &
Pasero, 1999, p. 17). This definition certainly portrays how sub-
jective pain is. Another widely agreed-on definition of pain is
“an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of
such damage” (American Pain Society [APS], 2008). Three as-
pects of these definitions have important implications for
nurses. First, pain is a physical and emotional experience, not all
in the body or all in the mind. Second, it is in response to actual
or potential tissue damage, so there may not be abnormal lab or
radiographic reports despite real pain. Finally, pain is described
in terms of such damage. Given that some clients are reluctant
to disclose the presence of pain unless prompted, nurses will be
unaware of the client’s pain until they assess for it. Additionally,
it is clear that even nonverbal clients (e.g., preverbal children,
intubated clients, or clients with cognitive impairments) expe-
rience pain that demands nursing assessment and treatment
even if clients are unable to “describe in terms” the nature of
their discomfort.
A survey revealed that 26% of adults have experienced pain
lasting more than 24 hours in the last month (National Institutes
of Health, 2007). Between one third and one half of adults live
with some form of chronic pain with the prevalence being
higher among the older populations (Tabloski, 2010). Pain in-
terferes with functional abilities and quality of life. Severe or
persistent pain affects all body systems, causing potentially se-
rious health problems while increasing the risk of complica-
tions, delays in healing, and an accelerated progression of fatal
illnesses (Tabloski, 2010). Even if the original cause of the pain
heals, the changes in the nervous system resulting from subop-
timal pain management can result in the development of
chronic pain (D’Arcy, 2007). Persistent pain also contributes to
insomnia, weight gain or loss, constipation, hypertension, de-
conditioning, chronic stress, and depression. These effects can
interfere with work, recreation, domestic activities, and per-
sonal care activities to the point at which many sufferers ques-
tion whether life is worth living. Effective pain management is
an important aspect of nursing care to promote healing, prevent
complications, reduce suffering, and prevent the development
of incurable pain states. To be a true client advocate, nurses
must realize their role as advocates for pain relief.
Pain is more than a symptom of a problem; it is a high-
priority problem in itself. Pain presents both physiological and
psychological dangers to health and recovery. Severe pain is
viewed as an emergency situation deserving attention and
prompt professional treatment.
The Nature of Pain
Although pain is a universal experience, the nature of the expe-
rience is unique to the individual based, in part, on the type of
pain experienced, the psychosocial context or meaning, and the
response. Adding to the complexity, pain may be a physiologi-
cal warning system alerting the nurse to a problem or unmet
need demanding attention; or it may be a diseased, malfunc-
tioning segment of the nervous system. Advances in the under-
standing of physiological mechanisms may someday replace
the currently used categories of acute pain or chronic (persis-
tent) pain. In addition to the underlying mechanisms, nurses at-
tuned to a holistic view of care need to consider how these
physiological signals affect the mind, body, spirit, and social
interactions. In this section, a review is included of the scien-
tific, theoretical, and clinical concepts that form the foundation
of knowledge needed by nurses to assess and treat clients with
pain in a holistic, comprehensive fashion.
Types of Pain
Pain may be described in terms of location, duration, intensity,
and etiology.
Location
Classifications of pain based on location (e.g., head, back,
chest) may be problematic. The International Headache Soci-
ety (n.d.) recognizes approximately 80 different types of
headaches. Many have similar clinical presentations but differ-
ent clinical needs. Nevertheless, location of pain is an impor-
tant consideration. For example, if after knee surgery, a client
reports moderately severe chest pain, the nurse must act imme-
diately to further evaluate and treat this discomfort. The ability
to discriminate between cardiac and noncardiac chest pain
challenges even expert clinicians, but the fact that chest pain is
evaluated and treated differently than knee pain in this client is
understandable. Complicating the categorization of pain by lo-
cation is the fact that some pains radiate (spread or extend) to
other areas (e.g., low back to legs). Pain may also be referred
(appear to arise in different areas) to other parts of the body. For
example, cardiac pain may be felt in the shoulder or left arm,
with or without chest pain. Visceral pain (pain arising from or-
gans or hollow viscera) is often perceived in an area remote
from the organ causing the pain (Figure 46–1 ■).
Duration
When pain lasts only through the expected recovery period, it
is described as acute pain, whether it has a sudden or slow on-
set, regardless of its intensity. Chronic pain, also known as per-
sistent pain, is prolonged, usually recurring or lasting 3 months
or longer (APS, 2008), and interferes with functioning. Acute
and chronic pain elicit different physiological and behavioral
responses, as shown in Table 46–1. Although experts may dis-
agree on whether the cutoff point for chronic pain should be 3
or 6 months after onset, or expected healing time, NANDA In-
ternational (2009), specifies the accepted nursing diagnosis of
Chronic Pain to be mild to severe, constant or recurring, with-
out an anticipated or predictable end and a duration of greater
than 6 months (p. 355).
Cancer pain may result from the direct effects of the disease
and its treatment, or it may be unrelated. Over time, other diag-
noses have been included in the “malignant pain” category,
such as HIV/AIDS or burn pain, which tend to be treated more
aggressively than “noncancer pain.”
1206 UNIT 10 / Promoting Physiological Health

Heart
Lungs and
diaphragm
Liver
Gallbladder
Heart
Liver
Stomach
Liver
Kidneys
Ovaries

Appendix
Ureters

Bladder

Kidney

Anterior Posterior

Figure 46–1 ■ Common sites of referred pain from various body organs.

Intensity Etiology
Most practitioners classify intensity of pain by using a standard Designating types of pain by etiology can be done under the
scale: 0 (no pain) to 10 (worst possible pain) scale. Linking the broad categories of nociceptive pain and neuropathic pain.
rating to health and functioning scores, pain in the 1 to 3 range Nociceptive pain is experienced when an intact, properly func-
is deemed mild pain, a rating of 4 to 6 is moderate pain, and tioning nervous system sends signals that tissues are damaged,
pain reaching 7 to 10 is deemed severe pain and is associated requiring attention and proper care. For example, the pain expe-
with the worst outcomes. rienced following a cut or broken bone alerts the person to avoid
further damage until it is properly healed. Once stabilized or
healed, the pain goes away; thus this pain is transient. There
TABLE 46–1 Comparison of Acute and Chronic Pain may also be persistent forms of nociceptive pain. An example is
a person who has lost the protective cartilage in joints. Pain will
ACUTE PAIN CHRONIC PAIN
occur when the joints are stressed because the bone-to-bone
Mild to severe Mild to severe contact damages tissues. This common form of osteoarthritis
Sympathetic nervous system Parasympathetic nervous produces pain in millions of sufferers, some of whom have in-
responses: system responses: termittent pain whereas others have constant pain for years.
■ Increased pulse rate ■ Vital signs normal Subcategories of nociceptive pain include somatic and vis-
■ Increased respiratory rate ceral. Somatic pain originates in the skin, muscles, bone, or
■ Elevated blood pressure
connective tissue. The sharp sensation of a paper cut or aching
■ Diaphoresis ■ Dry, warm skin
of a sprained ankle are common examples of somatic pain. Vis-
■ Dilated pupils ■ Pupils normal or dilated
ceral pain results from activation of pain receptors in the organs
Related to tissue injury; Continues beyond healing
and/or hollow viscera. Visceral pain tends to be characterized
resolves with healing
by cramping, throbbing, pressing, or aching qualities. Often
Client may be restless and Client is usually depressed
anxious and withdrawn visceral pain is associated with feeling sick (e.g., sweating,
Client reports pain Client often does not mention nausea, or vomiting) as in the examples of labor pain, angina
pain unless asked pectoris, or irritable bowel.
Client may exhibit behavior Pain behavior often absent Neuropathic pain is associated with damaged or malfunction-
indicative of pain: crying, ing nerves due to illness (e.g., post-herpetic neuralgia, diabetic pe-
rubbing area, holding area ripheral neuropathy), injury (e.g., phantom limb pain, spinal cord
injury pain), or undetermined reasons. Neuropathic pain is typi-

cally chronic; it is described as burning, “electric-shock,” and/or
tingling, dull, and aching. Episodes of sharp, shooting pain can
also be experienced (Barker, 2009). Neuropathic pain tends to be
difficult to treat.
The two subtypes of neuropathic pain are based on the part
of the nervous system believed to be damaged (Barker, 2009).
Peripheral neuropathic pain (e.g., phantom limb pain, post-
herpetic neuralgia, carpal tunnel syndrome) follows damage or
sensitization of peripheral nerves. Central neuropathic pain
(e.g., spinal cord injury pain, poststroke pain, multiple sclerosis
pain) results from malfunctioning nerves in the central nervous
system (CNS). Sympathetically maintained pain occurs oc-
casionally when abnormal connections between pain fibers and
the sympathetic nervous system perpetuate problems with both
the pain and sympathetically controlled functions (e.g., edema,
temperature and blood flow regulation).
Common pain syndromes are briefly described in Clinical
Manifestations.
Concepts Associated with Pain
It is useful for nurses to differentiate pain threshold from pain
tolerance. Pain threshold is the least amount of stimuli that is
needed for a person to label a sensation as pain. Threshold stud-
ies are typically conducted in a laboratory with many controls
Common Chronic Pain Syndromes
■ Post-herpetic neuralgia, which currently affects 2 million
Americans, occurs when a case of herpes zoster (shingles)
typically erupts decades after a primary infection (chickenpox)
during a period of stress or compromised immune functioning.
After the painful unilateral vesicular rash fades, burning or
electric-shock pain in the area may persist for months or years.
Advancing age is a risk factor for persistent post-herpetic
neuralgia. Recently, a vaccine has been approved and is
recommended for all people over the age of 60 to prevent
shingles and the possibility of post-herpetic neuralgia.
■ Phantom pain. Phantom sensations, the feeling that a lost
body part is present, occur in most people after amputation.
For many, this sensation is painful and it may occur
spontaneously, or is evoked (e.g., by a poor-fitting prosthesis).
When the amputation involves a limb, it is termed phantom
limb pain, whereas following breast surgery, it is called
postmastectomy pain. If the limb was painful or mangled
before the amputation, that is commonly the sensation that is
experienced (unless the discomfort is completely relieved
prior to surgery). It is important for the nurse to remember to
explain the reasons for phantom limb pain, as clients may
have difficulty understanding why they have pain when the
limb is gone. They may start to question their sanity.
■ Trigeminal neuralgia. This is an intense stablike pain that is
distributed by one or more branches of the trigeminal nerve
(fifth cranial). The pain is usually experienced on parts of the
face and head. It is so severe that it produces facial muscle
spasms.
■ Headache. An estimated 40% of the worldwide population
suffers at least one severe, disabling headache per year. This
CHAPTER 46 / Pain Management 1207
and measured amounts of stimuli (typically electrically gener-
ated). Pain threshold may vary slightly from person to person,
and may be related to age, gender, or race, but it changes little in
the same individual over time. Pain tolerance is the maximum
amount of painful stimuli that a person is willing to withstand
without seeking avoidance of the pain or relief. Pain tolerance
varies considerably from person to person, even within the same
person at different times and in different circumstances. For ex-
ample, a woman may tolerate a considerable amount of labor
pain because she does not want to alter her level of alertness or
the vitality of her baby. She likely would not tolerate a fraction
of that pain during a routine dental procedure before requesting
appropriate pain relief medicine.
Hyperalgesia, allodynia, hyperpathia, and dysesthesia are
conditions of abnormal pain processing that may signal the de-
velopment of neuropathic processes. If recognized early these
may be reversed; if ignored, they may lead to the development
of incurable pain syndromes. The terms hyperalgesia and
hyperpathia may be used interchangeably to denote height-
ened responses to a painful stimuli (e.g., severe pain response
to a paper cut). Allodynia includes nonpainful stimuli (e.g.,
light touch, contact with linen, water, or wind) that produces
pain. Dysesthesia is an unpleasant abnormal sensation. Dyses-
thesia mimics or imitates the pathology of a central neuropathic
commonly occurring painful condition can be caused by
either intracranial or extracranial problems, serious or benign
conditions. To establish a plan to prevent or treat headache,
the nurse needs to assess the quality, location, onset,
duration, and frequency of the pain, as well as any signs and
symptoms that precede the headache. There are many
types of headaches, but the three most common include
migraine, tension type, and cluster. Migraine and tension-
type headaches are three times more common in women
than in men, while cluster headaches occur primarily in men.
■ Low back pain. Nearly everyone suffers from low back pain
at some time during their life. Americans spend at least $50
billion each year on low back pain. Most occurrences of low
back pain go away within a few days. Chronic back pain
persists for more than 3 months. It is often progressive and
the cause can be difficult to determine (National Institute of
Neurological Disorders and Stroke [NINDS], 2010).
■ Fibromyalgia. An estimated 5 million Americans suffer from
a condition known as fibromyalgia, a chronic disorder
characterized by widespread musculoskeletal pain, fatigue,
and multiple tender points. This disease is poorly understood
and primarily occurs in women. “Tender points” refers to
tenderness that occurs in precise, localized areas, particularly
in the neck, spine, shoulders, and hips. People with this
syndrome may also experience sleep disturbances, morning
stiffness, irritable bowel syndrome, anxiety, and other
symptoms. Although the symptoms present as muscle pain,
stiffness, and weakness, it is considered by many to be a
problem of abnormal CNS functioning, particularly as it
relates to the way nerves process pain.
1208 UNIT 10 / Promoting Physiological Health

BOX 46–1 Concepts Associated with Pain

Acute pain: Pain that is directly related to tissue injury and
resolves when tissue heals.
Cancer pain: Pain associated with the disease, treatment, or
some other factor in individuals with cancer.
Chronic or persistent pain: Pain that persists beyond 3 to 6
months secondary to chronic disorders or nerve malfunctions
that produce ongoing pain after healing is complete.
Intractable pain: A pain state (generally severe) for which there
is no cure possible even after accepted medical evaluation
and treatments have been implemented. The focus of
treatment turns from cure to pain reduction, functional
improvement, and the enhancement of quality of life.
Neuropathic pain: Pain that is related to damaged or
malfunctioning nervous tissue in the peripheral and/or CNS.
Nociceptive pain: Pain that is directly related to tissue damage.
May be somatic (e.g., damage to skin, muscle, bone) or
visceral (e.g., damage to organs).
Pain threshold: The least amount of stimuli necessary for a
person to label a sensation as pain.
Pain tolerance: The most pain an individual is willing or able to
tolerate before taking evasive actions.
The following states indicate abnormal nerve functioning, and
the associated cause needs to be identified/treated (as soon as
possible) before irreversible damage occurs:
Allodynia: Sensation of pain from a stimulus that normally does
not produce pain (e.g., light touch).
Dysesthesia: An unpleasant abnormal sensation that can be
either spontaneous or evoked.
Hyperalgesia: Increased sensation of pain in response to a
normally painful stimulus.
The following concepts are important reasons to prevent pain
or treat it as soon as possible to prevent the amplification,
spread, and persistence of pain:
Sensitization: An increased sensitivity of a receptor after
repeated activation by noxious stimuli.
Windup: Progressive increase in excitability and sensitivity of
spinal cord neurons, leading to persistent, increased pain.

pain disorder, such as the pain that follows a stroke or spinal
cord injury. See Box 46–1 for a review of concepts associated
with pain.
Physiology of Pain
The transmission and perception of pain are complex
processes. The central nervous system’s structure constantly
changes, and the constituency and function of its chemical me-
diators are not well understood. The extent to which pain is per-
ceived depends on the interaction between the body’s analgesia
system, the nervous system’s transmission, and the mind’s in-
terpretation of stimuli and its meaning.
Nociception
The peripheral nervous system includes specialized primary
sensory neurons that detect mechanical, thermal, or chemical
conditions associated with potential tissue damage. When these
nociceptors are activated, signals are transduced and transmit-
ted to the spine and brain where the signals are modified before
they are ultimately understood and then “felt.” The physiolog-
ical processes related to pain perception are described as
nociception. Four physiological processes are involved in no-
ciception: transduction, transmission, perception, and modula-
tion (D’Arcy, 2007; Paice, 2002).
Transduction
Specialized pain receptors or nociceptors can be excited by me-
chanical, thermal, or chemical stimuli (Table 46–2). During the
transduction phase, noxious stimuli trigger the release of biochem-
ical mediators, such as prostaglandins, bradykinin, serotonin, his-
tamine, and substance P, that sensitize nociceptors. Noxious or
painful stimulation also causes movement of ions across cell mem-
branes, which excites nociceptors. Pain medications can work dur-
ing this phase by blocking the production of prostaglandin (e.g.,
ibuprofen or aspirin) or by decreasing the movement of ions across

TABLE 46–2 Types of Pain Stimuli

STIMULUS TYPE PHYSIOLOGICAL BASIS OF PAIN
Mechanical
1. Trauma to body tissues (e.g., surgery) Tissue damage; direct irritation of the pain receptors; inflammation
2. Alterations in body tissues (e.g., edema) Pressure on pain receptors
3. Blockage of a body duct Distention of the lumen of the duct
4. Tumor Pressure on pain receptors; irritation of nerve endings
5. Muscle spasm Stimulation of pain receptors (also see chemical stimuli)
Thermal
Extreme heat or cold (e.g., burns) Tissue destruction; stimulation of thermosensitive pain receptors
Chemical
1. Tissue ischemia (e.g., blocked coronary artery) Stimulation of pain receptors because of accumulated lactic acid (and other
chemicals, such as bradykinin and enzymes) in tissues
2. Muscle spasm Tissue ischemia secondary to mechanical stimulation (see above)
 CHAPTER 46 / Pain Management 1209

Substance P
Second-order Primary afferent
Figure 46–2 ■ Substance P assists the transmission of impulses
across the synapse from the primary afferent neuron to a second-
order neuron in the spinothalamic tract.
the cell membrane (e.g., local anesthetic). Another example is the
topical analgesic capsaicin (Zostrix), which depletes the accumu-
lation of substance P and blocks transduction.
Transmission
The second process of nociception, transmission of pain, includes
three segments (McCaffery & Pasero, 1999). During the first seg-
ment of transmission, the pain impulses travel from the peripheral
nerve fibers to the spinal cord. Substance P serves as a neurotrans-
mitter, enhancing the movement of impulses across the nerve
synapse from the primary afferent neuron to the second-order
neuron in the dorsal horn of the spinal cord (Figure 46–2 ■). Two
types of nociceptor fibers cause this transmission to the dorsal
horn of the spinal cord: unmyelinated C fibers, which transmit
dull, aching pain, and thinA-delta fibers, which transmit sharp, lo-
calized pain. In the dorsal horn, the pain signal is modified by
modulating factors (e.g., excitatory amino acids or endorphins)
before the amplified or dampened signal travels via spinothalamic
tracts. The second segment is transmission from the spinal cord,
and ascension, via spinothalamic tracts, to the brainstem and thal-
amus (Figure 46–3 ■). The third segment involves transmission
of signals between the thalamus to the somatic sensory cortex
where pain perception occurs.
Pain control can take place during this second process of trans-
mission. For example, opioids (narcotic analgesics) block the re-
lease of neurotransmitters, particularly substance P, which stops
the pain at the spinal level. Capsaicin may also deplete substance
P, which could inhibit the transmission of pain signals.
Perception
The third process, perception, is when the client becomes con-
scious of the pain. Pain perception is the sum of complex activ-
ities in the CNS that may shape the character and intensity of
pain perceived and ascribe meaning to the pain. The psychoso-
cial context of the situation and the meaning of the pain based
on past experiences and future hopes and dreams help to shape
the behavioral response that follows.
Modulation
Often described as the “descending system,” this final process oc-
curs when neurons in the thalamus and brainstem send signals back
down to the dorsal horn of the spinal cord (Paice, 2002, p. 75).

Pain
perception point

Nociceptors
(receptors) Spinal Lateral spinothalamic tract
ganglia
A-delta fibers Dorsal horn
(fast transmission of (pain signal modified)
sharp, localized pain)

C fibers
(slow transmission of dull,
burning chronic pain)
Figure 46–3 ■ Physiology of pain perception.
1210 UNIT 10 / Promoting Physiological Health
These descending fibers release substances such as endogenous
opioids, serotonin, and norepinephrine, which can inhibit (dampen)
the ascending noxious (painful) impulses in the dorsal horn. In con-
trast, excitatory amino acids (e.g., glutamate, N-methyl-D-aspartate
[NMDA]), and the upregulation of excitatory glial cells can facili-
tate (amplify) these pain signals. The effects of excitatory amino
acids and glial cells tend to persist, while the effects of the inhibitory
neurotransmitters tend to be short lived because they are reabsorbed
into the nerves. Tricyclic antidepressants block the reuptake of nor-
epinephrine and serotonin; or NMDA antagonists (e.g., ketamine,
dextromethorphan) may be used to help diminish the pain signals.
Gate Control Theory
According to Melzack and Wall’s gate control theory (1965),
small-diameter (A-delta or C) peripheral nerve fibers carry sig-
nals of noxious stimuli to the dorsal horn, where these signals are
modified when they are exposed to the substantia gelatinosa (the
milieu in the CNS), which may be imbalanced in an excitatory
or inhibitory direction. Ion channels on the pre- and postsynap-
tic membranes serve as gates that, when open, permit positively
charged ions to rush into the second-order neuron, sparking an
electrical impulse and sending pain signals to the thalamus.
Peripherally, large-diameter (A-beta) nerve fibers, which
typically send messages of touch or warm or cold temperatures,
have an inhibitory effect on the substantia gelatinosa, and may ac-
tivate descending mechanisms that can lessen the intensity of pain
perceived or inhibit the transmission of those pain impulses—
closing the (ion) gates (Figure 46–4 ■).
Higher centers in the brain, especially those associated with af-
fect and motivation, are capable of modifying the substantia gelati-
nosa and influence the opening or closing of the gates. For
example, if a little girl is playing with a ball that rolls under the
couch, and in the process of retrieving it her hand gets stuck and
pinched (the A-delta fibers are activated), the anxiety of not know-
Theoretical gate
(open)
Dorsal horn
Large-diameter fiber
Small diameter fiber
carrying pain impulses
to brain
Spinal cord
Theoretical gate
(closed)
Large diameter fiber
carrying non-pain
impulses to brain
Small-diameter fiber
carrying pain impulses
Figure 46–4 ■ A schematic illustration of the gate control theory.
ing what to do, combined with the negative impact on motivation
(not being able to play with the ball), excites the substantia gelati-
nosa and facilitates opening the gates transmitting messages of
pinching pain. When her mother comes and frees her and “kisses
her boo-boo,” the A-delta fibers are activated by the light touch,
moisture, and warmth of the kiss. The girl feels love and is moti-
vated to please her mother, all of which combine to calm the sub-
stantia gelatinosa and close the gates, inhibiting the transmission
of further pain. Clinically, nurses can use this model to stop noci-
ceptor firing (treat the underlying cause), apply topical therapies
(e.g., heat, ice, electrical stimulation, or massage), and address the
client’s mood (e.g., reduce fear, anxiety, and anger) and goals (e.g.,
client education, anticipatory guidance).
Responses to Pain
The body’s response to pain is a complex process rather than a
specific action. It has both physiological and psychosocial as-
pects. Initially the sympathetic nervous system responds, result-
ing in the fight-or-flight response, with a noticeable increase in
pulse and blood pressure. The person may hold his or her breath,
or have short, shallow breathing. There may also be some reflex-
ive movements as the person withdraws from the painful stimuli
(Figure 46–5 ■). Over a matter of minutes, or hours, the pulse
and blood pressure return to baseline despite the persistence of
pain. Contrary to the adaptation noted in vital signs, the pain
fibers themselves adapt very little and become sensitized in a
way that intensifies, prolongs, and/or spreads the pain.
Unrelieved pain has been noted to have a potentially harm-
ful effect on a person’s well-being. Pain interferes with sleep,
Motor
impulse
Sensory impulse
(pain fibers)
Dorsal root
Figure 46–5 ■ Proprioceptive reflex to a pain stimulus.

affects appetite, and lowers the quality of life for clients and
their family members. A natural response to pain is to stop ac-
tivity, tense muscles, and withdraw from the pain-provoking
activities. This reduced mobility may produce muscle atrophy
and painful spasm, putting the client at risk of complications re-
lated to immobility or cardiopulmonary deconditioning. Un-
controlled pain impairs immune function, which slows healing
and increases susceptibility to infections and dermal ulcers.
The short, shallow breathing that accompanies pain produces
atelectasis, lowers circulating oxygen levels, and increases car-
diac workload. The physical stress and emotional distress of se-
vere or prolonged pain can contribute to the development of a
wide variety of physical and emotional disorders.
Persistent, severe pain changes the nervous system in a way
that intensifies, spreads, and prolongs the pain, risking the de-
velopment of incurable chronic pain syndromes. Beginning at
24 hours, persistent unrelieved severe pain changes the structure
and function of the nervous system in such a way that prolongs
and intensifies the pain experience. A windup phenomenon oc-
curs. This phenomenon is the result of repeated assault on affer-
ent nerves, creating a greatly enhanced response and activity
level in the CNS. The windup allows even normal tissue to be-
come extremely sensitive to pressure in areas that are not iden-
tified as painful. Examples of disease states where windup
becomes a problem are osteoarthritis and rheumatoid arthritis
(D’Arcy, 2007, p. 22). Thus to prevent the development of per-
sistent pain and promote overall health and well-being, the
nurse must act to promote optimal and expedient pain control.
Factors Affecting
the Pain Experience
Numerous factors can affect a person’s perception of and reac-
tion to pain. These include the person’s ethnic and cultural val-
CULTURALLY RESPONSIVE CARE Transcultural Differences in Responses to Pain
Expressions of pain vary from culture to culture and may vary
from person to person within a culture. Treat each client as an
individual and provide the type of pain relief that is the best fit
for the client.
AFRICAN AMERICANS
■ Some believe pain and suffering is a part of life and is to be
endured.
■ Some may deny or avoid dealing with pain until it becomes
unbearable.
■ Some believe that prayer and laying on of hands will free a
person from suffering and pain.
HISPANIC/LATINO
■ Mexican Americans may tend to view pain as a part of life
and as an indicator of the seriousness of an illness.
■ Some believe that enduring pain is a sign of strength.
■ Puerto Ricans may tend to be loud and outspoken in their
expressions of pain. This is a socially learned way to cope
and it is important for the nurse to not judge or disapprove.
ASIANS AMERICANS
■ Chinese culture values silence. As a result, some clients
may be quiet when in pain because they do not want to
cause dishonor to themselves and their family.
CHAPTER 46 / Pain Management 1211
ues, developmental stage, environment and support people,
previous pain experiences, and the meaning of the current pain.
Ethnic and Cultural Values
Ethnic background and cultural heritage have long been recog-
nized as factors that influence both a person’s reaction to pain and
the expression of that pain. Behavior related to pain is a part of
the socialization process. Individuals in one culture may learn to
be expressive about pain, whereas individuals from another cul-
ture may have learned to keep those feelings to themselves.
Although there appears to be little variation in pain threshold,
cultural background can affect the level of pain that an individual
is willing to tolerate. In some Middle Eastern and African cul-
tures, self-infliction of pain is a sign of mourning or grief. In other
groups, pain may be anticipated as part of the ritualistic practices,
and therefore tolerance of pain signifies strength and endurance.
Additionally, there are significant variations in the expression of
pain. Studies have shown that individuals of northern European
descent tend to be more stoic and less expressive of their pain than
individuals from southern European backgrounds.
Nurses must realize their own attitudes and expectations
about pain. Andrews and Boyle (2008) pointed out that nurses,
as part of a specific subculture, have been socialized to have
certain pain expectations. For example, nurses may place a
higher value on silent suffering or self-control in response to
pain. Nurses “expect” clients to be objective about pain and to
be able to provide a detailed description of it. Nurses who deny,
refute, or downplay the pain they observe in others may be cul-
turally incompetent (unaware and emotionally apathetic to-
ward others’ viewpoints). To become culturally competent,
nurses must become knowledgeable about differences in the
meaning of and appropriate responses to pain. They must be
sympathetic to concerns and develop the skills needed to ad-
dress pain in a culturally sensitive way.
■ Japanese may have a stoic (minimal verbal and nonverbal
expressions) response to pain. They may even refuse pain
medication. Bearing pain is considered a virtue and a
matter of family honor.
■ Filipino clients may believe that pain is “God’s will.” Some
elderly Filipino clients may refuse pain medication.
■ If the client is a Buddhist, remaining calm when in pain is
viewed as bringing oneself to a higher state of being.
NATIVE AMERICANS
■ In general, Native Americans are quiet, less expressive
verbally and nonverbally, and may tolerate a high level of
pain. They tend to not request pain medication and may
tolerate pain until they are physically disabled.
ARAB AMERICANS
■ Pain responses may be considered private and reserved for
immediate family, not for health professionals. As a result,
this may lead to conflicting perceptions among the family
members and the nurse regarding the effectiveness of the
client’s pain relief.
From Transcultural Health Care, 3rd ed. (pp. 71, 193, 274, 321), by L. D. Purnell and B. J. Paulanka,
2008, Philadelphia, PA: F. A. Davis; and “The Effect of Culture on Pain,” by Y. D’Arcy, 2009,
Nursing, 17(3), pp. 5–7.
1212 UNIT 10 / Promoting Physiological Health

Developmental Stage
The age and developmental stage of a client is an important
variable that will influence both the reaction to and the expres-
sion of pain. Age variations and related nursing interventions
are presented in Table 46–3.
The field of pain management for infants and children has
grown significantly. It is now accepted that anatomic, physiolog-
ical, and biochemical elements necessary for pain transmission
are present in newborns, regardless of their gestational age. For
many years, the myth of infants and children not “feeling” pain

TABLE 46–3 Age Variations in the Pain Experience

AGE GROUP PAIN PERCEPTION AND BEHAVIOR SELECTED NURSING INTERVENTIONS
Infant Perceives pain. Give a glucose pacifier.
Responds to pain with increased sensitivity. Use tactile stimulation. Play music or tapes of a
Older infant tries to avoid pain; for example, turns heartbeat.
away and physically resists.
Toddler and preschooler Develops the ability to describe pain and its Distract the child with toys, books, pictures. Involve
intensity and location. the child in blowing bubbles as a way of “blowing
away the pain.”
Often responds with crying and anger because Appeal to the child’s belief in magic by using a
child perceives pain as a threat to security. “magic” blanket or glove to take away pain.
Reasoning with child at this stage is not always Hold the child to provide comfort.
successful.
May consider pain a punishment. Explore misconceptions about pain.
Feels sad.
May learn there are gender differences in pain
expression.
Tends to hold someone accountable for the pain.
School-age child Tries to be brave when facing pain. Use imagery to turn off “pain switches.”
Rationalizes in an attempt to explain the pain. Provide a behavioral rehearsal of what to expect and
how it will look and feel.
Responsive to explanations. Provide support and nurturing.
Can usually identify the location and describe the
pain.
With persistent pain, may regress to an earlier
stage of development.
Adolescent May be slow to acknowledge pain. Provide opportunities to discuss pain.
Recognizing pain or “giving in” may be Provide privacy.
considered weakness.
Wants to appear brave in front of peers and not Present choices for dealing with pain. Encourage
report pain. music or TV for distraction.
Adult Behaviors exhibited when experiencing pain may Deal with any misconceptions about pain.
be gender-based behaviors learned as a child.
May ignore pain because to admit it is perceived Focus on the client’s control in dealing with the
as a sign of weakness or failure. pain.
Fear of what pain means may prevent some Allay fears and anxiety when possible.
adults from taking action.
Older Adult May have multiple conditions presenting with Thorough history and assessment is essential.
vague symptoms.
May perceive pain as part of the aging process. Spend time with the client and listen carefully.
May have decreased sensations or perceptions of
the pain.
Lethargy, anorexia, and fatigue may be indicators
of pain.
May withhold statements of pain because of fear Clarify misconceptions.
of the treatment, of any lifestyle changes that Encourage independence whenever possible.
may be involved, or of becoming dependent.
May describe pain differently, that is, as “ache,”
“hurt,” or “discomfort.”
May consider it unacceptable to admit or show pain.

has prevailed. Now, it is universally accepted that environmen-
tal, nonpharmacologic, and pharmacologic interventions are to
be used to prevent, reduce, or eliminate pain in neonates. Physi-
ological indicators may vary in infants, so behavioral observation
is recommended for pain assessment. Children may be less able
than an adult to articulate their experience or needs related to
pain, which may result in their pain being undertreated. How-
ever, children as young as 3 years can accurately report the loca-
tion and intensity of their pain if evaluated properly.
With puberty comes the emergence of some pain syndromes,
particularly in young women. Unfortunately, women are over-
represented in a large number of painful disorders, including
headaches, fibromyalgia, lupus, and menstrual-related disor-
ders. Men are more vulnerable to pain related to their occupa-
tional or risk-taking patterns, including burn pain, post-trauma
pain, and pain related to HIV/AIDS. A needless disparity con-
tinues that the very young, the very old, women, and ethnic mi-
norities are undertreated for their pain more frequently than
their adult male counterparts. Studies report that racial dispari-
ties in pain and health exist (Senior, 2008).
Studies have shown that chronic pain affects 25% to 50% of
older clients living in the community and 45% to 80% of those
in nursing homes (American Geriatrics Society, 2002; Tabloski,
2010). With the number of older persons in our society increas-
ing dramatically, by 2030, nurses will be caring for older adults
in all settings of care in greater numbers.
Older adults constitute the largest group of individuals seek-
ing health care services. The prevalence of pain in the older
Lifespan Considerations Pain
CHILDREN
Children continue to receive inadequate medication to treat
their pain. This may be due to nurses’ lack of knowledge about
how to evaluate pain in children. The pain of infants and young
children who cannot verbalize well is particularly difficult to
assess. Nurses will benefit from learning how to use pain
assessment tools and by being alert to the possibility that
children may be experiencing significant levels of pain, even if
they do not appear to be in pain.
OLDER ADULTS
The presentation of pain may vary in older adults for a variety of
reasons. Changes in nerve structure and functioning, or vascular
changes with aging may cause a variation in the pain sensation.
Sometimes the pain is heightened in those whose nervous
systems have been sensitized from previous unresolved pain,
whereas at other times significant tissue damage (e.g., silent
heart attack) may occur without pain being experienced. In
some situations, pain presents itself with atypical symptoms,
such as confusion, restlessness, or irritability. This is especially
true in clients with dementia who have a difficult time
understanding and verbalizing what they are feeling.
Maintaining optimal function is especially crucial for a high
quality of life in older clients. If pain is not effectively controlled,
the following areas are often affected in their daily lives:
■ Activity tolerance
■ Mobility
■ Ability to socialize
CHAPTER 46 / Pain Management 1213
population is generally higher due to both acute and chronic
disease conditions. Pain threshold does not appear to change
with aging, although the effect of analgesics may increase due
to physiological changes related to drug metabolism and excre-
tion (Crusse & Kent, 2009).
Environment and Support People
A strange environment such as a hospital, with its noises, lights,
and activity, can compound pain. In addition, the lonely person
who is without a support network may perceive pain as severe,
whereas the person who has supportive people around may per-
ceive less pain. Some people prefer to withdraw when they are in
pain, whereas others prefer the distraction of people and activity
around them. Family caregivers can be a significant support for a
person in pain. With the increase in outpatient and home care, fam-
ilies are assuming an increased responsibility for the management
of pain. Education related to the assessment and management of
pain can positively affect the perceived quality of life for both
clients and their caregivers (McCaffery & Pasero, 1999).
Expectations of significant others can affect a person’s per-
ceptions of and responses to pain. In some situations girls may
be permitted to express pain more openly than boys. Family
role can also affect how a person perceives or responds to pain.
For instance, a single mother supporting three children may ig-
nore pain because of her need to stay on the job. The presence
of support people often modifies a client’s reaction to pain. For
example, toddlers often tolerate pain more readily when sup-
portive parents or nurses are nearby.
■ Sleep disturbance
■ Ability to perform ADLs
■ Ability to remain as independent as possible.
All efforts, pharmacologic and nonpharmacologic, should be
used to help provide pain reduction, while maintaining or
enhancing functional ability. Involvement of the client and
family is important when working with the primary care
provider, pharmacist, and nurse to plan which treatment is
most appropriate and most acceptable to the client.
The principle “start low and go slow” is especially important
when ordering dosages and pain medications for older adults.
Typically, the starting dose of medicines for older adults is
reduced by 25% to 50%, and then titrated for effect.
Decreased renal and liver function may prolong the duration of
action, but it also increases the risk of toxicity from pain
medications in older clients. In particular, risk of silent
gastrointestinal bleeding and renal damage from nonsteroidal
anti-inflammatory drugs (NSAIDs) increases, so dosages and
lab work need to be carefully monitored related to hematocrit
and renal function (liver function is monitored with
acetaminophen). Comorbid conditions may also affect
medication selection in older adults, as clients with gastric
ulcers, hypertension, or the combination of asthma and nasal
polyps should not receive NSAIDs. Older adults with chronic
obstructive pulmonary disease (COPD) must have their
respiratory rate carefully monitored when placed on an opioid
pain reliever, especially at night when respirations slow and the
risk of oxygen desaturation is high.
 1214 UNIT 10 / Promoting Physiological Health
Previous Pain Experiences
Previous pain experiences alter a client’s sensitivity to pain. Peo-
ple who have personally experienced pain or who have been ex-
posed to the suffering of someone close to them are often more
threatened by anticipated pain than people without a pain expe-
rience. In addition, the success or lack of success of pain relief
measures influences a person’s expectations for relief and future
response to interventions. For example, a person who has tried
several nondrug pain relief measures without success may have
little hope about the helpfulness of nursing interventions and may
demand medication as the only thing that helps the pain.
Meaning of Pain
Some clients may accept pain more readily than others, de-
Recognizing Pain: Case Study
pending on the circumstances and the client’s interpretation of
its significance. A client who associates the pain with a positive
outcome may withstand the pain amazingly well. For example,
a woman giving birth to a child or an athlete undergoing knee
surgery to prolong his career may tolerate pain better because
of the benefit associated with it. These clients may view the
pain as a temporary inconvenience rather than a potential threat
or disruption to daily life.
By contrast, clients with unrelenting chronic, persistent pain
may suffer more intensely. Persistent pain affects the body,
mind, spirit, and social relationships in an undesirable way.
Physically, the pain limits functioning and contributes to the
disuse or deconditioning alluded to previously. For many, the
change in activities of daily living (ADLs), such as eating,
sleeping, toileting, also takes a toll. The side effects of the
many medications used to try to control the pain also place a
heavy burden on the body.
Mentally, individuals with chronic pain change their out-
look, becoming more pessimistic, often to the point of helpless-
ness and hopelessness. Mood often becomes impaired when
pain persists, because the sadness of being unable to do impor-
tant or enjoyable activities combines with self-doubts and
learned helplessness to produce depression. Anxiety, worry, and
uncertainty about coping with the pain may escalate emotion-
ally, to the point of panic. Spiritually, pain may be viewed in a
variety of ways. It may be perceived as a punishment for wrong-
doing, a betrayal by the higher power, a test of fortitude, or a
threat to the essence of who the person is. Pain may be a source
of spiritual distress, or it may be a source of strength and en-
lightenment. Socially, pain often strains valued relationships, in
part because of the impaired ability to fulfill role expectations.
Nursing Management
Assessing
Accurate pain assessment is essential for effective pain manage-
ment. Many health facilities make pain assessment the fifth vi-
tal sign. This strategy of linking pain assessment to routine vital
sign assessment and documentation represents a push to make
pain assessment a routine aspect of care for all clients. Given the
highly subjective and individually unique nature of pain, a com-
prehensive assessment of the pain experience (physiological,
psychological, behavioral, emotional, and sociocultural) pro-
vides the necessary foundation for optimal pain control.
The extent and frequency of the pain assessment varies accord-
ing to the situation and the organizational policy. For clients expe-
riencing acute, severe pain, the nurse may focus only on location,
quality, and severity, and provide interventions to control the pain
before conducting a more detailed evaluation. Clients with less se-
vere or chronic pain can usually provide a more detailed descrip-
tion of the experience. As the fifth vital sign, pain should be
screened for every time vital signs are evaluated. A simple screen-
ing question such as “Are you experiencing any discomfort right
now?” will usually suffice. For example, in the initial postopera-
tive period, vital signs are taken as frequently as every 15 minutes.
Screening for pain this frequently is justifiable because there is a
high incidence of pain in the perioperative period. Local, regional,
or general anesthesia may be wearing off, or if severe pain is re-
ported, the medication administered postoperatively is frequently
administered via the intravenous (IV) route and has a peak effect
noted within 15 minutes.
Major barriers to better pain control for both nurses and
clients relate to inadequate assessment of pain, believing the
client’s report of pain, and concerns about addiction (D’Arcy,
2008c). Given that many clients will not voice their pain unless
asked about it, pain assessments must be initiated by the nurse.
Some of the many reasons clients may be reluctant to report
pain are listed in Box 46–2. Because the words pain or complain
may have emotional or sociocultural meaning attached, it is bet-
ter to ask “Do you have any discomforts to report?” rather than
“Do you have any complaints of pain?” It is also essential that
nurses listen to and believe the client’s statements of pain. Be-
lieving the client’s statement is crucial in establishing the sense
of trust needed to develop a therapeutic relationship.
Pain assessments consist of two major components: (a) a pain
history to obtain facts from the client and (b) direct observation
of behaviors, physical signs of tissue damage, and secondary
BOX 46–2 Why Clients May Be Reluctant to Report Pain
■ Unwillingness to trouble staff who are perceived as busy
■ Don’t want to be labeled as a “complainer” or “bad”
■ Fear of the injectable route of analgesic administration—
especially children
■ Belief that unrelieved pain is an expected, normal part of
recovery or aging
■ Belief that others will think they are weak if they
express pain
■ Difficulty or inability to communicate their discomfort
■ Concern about risks associated with opioid drugs (e.g.,
addiction)
■ Concern about unwanted side effects, especially of
opioid drugs
■ Concern that use of drugs now will render the drug
inefficient later in life
■ Fear that reporting pain will lead to further tests and
expenses
■ Belief that nothing can be done to control pain
■ Belief that enduring pain and suffering may lead to
spiritual enlightenment

physiological responses of the client. The goal of assessment is
to gain an objective understanding of a subjective experience.
PAIN HISTORY
While taking a pain history, the nurse must provide an opportu-
nity for clients to express in their own words how they view the
pain and the situation. This will help the nurse understand what
the pain means to the client and how the client is coping with it.
Remember that each person’s pain experience is unique and that
the client is the best interpreter of the pain experience. This his-
tory should be geared to the specific client. For example, ques-
tions asked of a car crash victim would be different from those
asked of a postoperative client or someone suffering from
chronic pain. The initial pain assessment for someone in severe
acute pain may consist of only a few questions before interven-
tion occurs. In addition, the nurse should focus on the following:
䊏 Previous pain treatment and effectiveness
䊏 When and what analgesics were last taken
䊏 Other medications being taken
䊏 Allergies to medications.
For the person with chronic pain, the nurse may focus on the
client’s coping mechanisms, effectiveness of current pain man-
agement, and ways in which the pain has affected the client’s
body, thoughts and feelings, activities, and relationships.
Data that should be obtained in a comprehensive pain his-
tory include pain location, intensity, quality, patterns, precipi-
tating factors, alleviating factors, associated symptoms, effect
on ADLs, past pain experiences, meaning of the pain to the per-
son, coping resources, and affective responses. Questions to
elicit these data are shown in the Assessment Interview.
Location. To ascertain the specific location of the pain, ask
the client to point to the site of the discomfort. A chart
consisting of drawings of the body can assist in identifying pain
locations. The client marks the location of pain on the chart.
This tool can be especially effective with clients who have
more than one source of pain. A client who has multiple pain
sites of different character can use symbols to draw the
distribution of different pain types (e.g., circle aching areas,
mark areas where shock-like pain is felt with an X).
When assessing the location of a child’s pain, the nurse
needs to understand the child’s vocabulary. For example,
“tummy” might refer either to the abdomen or to part of the
chest. Asking the child to point to the pain helps clarify the
child’s word usage to identify location. The use of figure draw-
ings can assist in identifying pain locations. Parents can also be
helpful in interpreting the meaning of a child’s words.
When documenting pain location the nurse may use various
body landmarks. Further clarification is possible with the use
of terms such as proximal, distal, medial, lateral, and diffuse.
Pain Intensity or Rating Scales. The single most important
indicator of the existence and intensity of pain is the client’s report
of pain. In practice, nurses tend to use less reliable measures for
pain assessment such as changes in vital signs and observation of
client behaviors that they interpret as drug seeking (D’Arcy,
2008c). Pain assessment that is not done accurately or completely
CHAPTER 46 / Pain Management 1215
ASSESSMENT INTERVIEW Pain History
■ Location: Where is your discomfort?
■ Quality: Tell me what your discomfort feels like.
■ Intensity: On a scale of 0 to 10, with “0” representing
no pain (substitute the term client uses, e.g., “no
burning”) and “10” representing the worst possible
pain (e.g., “burning sensation”), how would you rate the
degree of discomfort you are having right now?
■ Pattern
a. Time of onset: When did or does the pain start?
b. Duration: How long have you had it, or how long
does it usually last?
c. Constancy: Do you have pain-free periods? When?
And for how long?
■ Precipitating factors: What triggers the pain or makes it
worse?
■ Alleviating factors: What measures or methods have
you found helpful in lessening or relieving the pain?
What pain medications do you use?
■ Associated symptoms: Do you have any other
symptoms (e.g., nausea, dizziness, blurred vision,
shortness of breath) before, during, or after your pain?
■ Effects on ADLs: How does the pain affect your daily
life (e.g., eating, working, sleeping, and social and
recreational activities)?
■ Past pain experiences: Tell me about past pain
experiences you have had and what was done to relieve
the pain.
■ Meaning of pain: What does having this pain mean to
you? Does it signal something about the future or past?
What worries or scares you the most about your pain?
■ Coping resources: What do you usually do to help you
deal with pain?
■ Affective response: How does the pain make you feel?
Anxious? Depressed? Frightened? Tired? Burdensome?
leads to undertreatment of pain. The use of pain intensity scales is
an easy and reliable method of determining the client’s pain
intensity. Such scales provide consistency for nurses to
communicate with the client (adults and children over the age
of 7) and other health care providers. To avoid confusion, scales
should use a 0 to 10 range with 0 indicating “no pain” and 10
indicating the “worst pain possible” for that individual. An
11-point (0–10) rating scale is shown in Figure 46–6 ■. The
inclusion of word modifiers on the scale can assist some clients
who find it difficult to apply a number level to their pain. For
example, after ruling out “0” and “10” (neither no pain nor the
worst possible pain), a nurse can ask the client if it is mild (2),
mild to moderate (4), moderate to severe (6), or severe (8).
0 1 2 3 4 5 6 7 8 9 10
No Mild Moderate Severe Very Worst
pain pain pain pain severe possible
pain pain
Figure 46–6 ■ An 11-point pain intensity scale with word modifiers.
1216 UNIT 10 / Promoting Physiological Health

Another way to evaluate the intensity of pain for clients who
are unable to use the numeric rating scales is to determine the
extent of pain awareness and degree of interference with func-
tioning. For example, 0  no pain, 2  awareness of pain only
when paying attention to it, 4  can ignore pain and do things,
6  can’t ignore pain, interferes with functioning, 8  impairs
ability to function or concentrate, and 10  intense incapacitat-
ing pain. It is believed that the degree that pain interferes with
functioning is a good marker for the severity of pain, especially
for those with chronic pain.
CLINICAL ALERT
Perception is reality. The client’s self-report of pain is what
must be used to determine pain intensity. The nurse is
obligated to record the pain intensity as reported by the
client. By challenging the believability of the client’s report,
the nurse is undermining the therapeutic relationship and
preventing the fulfillment of advocacy and helping people
with pain, which is called for in the ANA’s Standards of
Professional Performance for Pain Management Nursing.
When noting pain intensity it is important to determine any
related factors that may be affecting the pain. When the inten-
sity changes, the nurse needs to consider the possible cause. For
example, the abrupt cessation of acute abdominal pain may in-
dicate a ruptured appendix. Several factors affect the perception
of intensity: (a) the amount of distraction, or the client’s concen-
tration on another event; (b) the client’s state of consciousness;
(c) the level of activity; and (d) the client’s expectations.
Not all clients understand or relate to numerical pain intensity
scales. These include preverbal children, older adults with im-
pairments in cognition or communication, and people who do
not speak English. For these clients the Wong-Baker FACES
Rating Scale (Figure 46–7 ■) may be easier to use. The FACES
scale includes a number scale in relation to each illustrated facial
expression so that the pain intensity can be documented. When
using the FACES rating scale, it is important to remember that
the client’s facial expression does not need to match the picture.
The pictures represent how much pain the client is experiencing.
Pain scales have been developed for use when assessing clients
with chronic pain. These scales include a numeric intensity rating
and other aspects of chronic pain, such as verbal descriptors, pic-
tures for the clients to draw the pain they are experiencing, and in-
dicators of mood (D’Arcy, 2007, p. 40). Two commonly used pain
scales are the Brief Pain Inventory (BPI) and the Short Form
McGill Pain Questionnaire (SF-MPQ).
When clients are unable to verbalize their pain for reasons of
age, mental capacity, medical interventions, or other reasons,
nurses need to accurately assess the intensity of each client’s
pain and the effectiveness of the pain management interven-
tions. For these clients, the nurse must rely on observation of
behavior.
Several validated behavioral pain rating scales are useful in
specific populations. The FLACC scale has been validated in
children 2 months to 7 years old and rates pain behaviors as man-
ifested by Facial expressions, Leg movement, Activity, Cry, and
Consolability measures that yield a 0 to 10 score (Herr et al.,
2006). Another scale specifically designed for neonates is
CRIES. This scale uses physiological indicators to assess behav-
iors that indicate pain. The key elements are Crying, Requires
oxygen, Increased vital signs, Expression, and Sleeplessness
(D’Arcy, 2007, pp. 45–46). A scale specifically designed for
older adults with advanced dementia is PAINAD. This scale
looks at five specific indicators: breathing, vocalization, facial
expression, body language, and consolability (Hargas & Miller,
2008). Given the diversity of pain and behaviors among clients
spanning a broad range of age and physical and mental capabil-
ities, it is unrealistic to believe a single pain assessment tool can

0 1 2 3 4 5
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST

Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a
lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even
more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the
person to choose the face that best describes how he is feeling.

Rating scale is recommended for persons age 3 years and older.

Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose the face
that best describes own pain and record the appropriate number.
Figure 46–7 ■ The Wong-Baker FACES Rating Scale.
From Hockenberry MJ, Wilson D. Winkelstein, ML: Wong’s Essentials of Pediatric Nursing, ed 7, St. Louis, 2005, p. 1259. Used with permission. Copyright, Mosby.
 CHAPTER 46 / Pain Management 1217

be applied across all populations. The pain scale needs to fit the Pain described as burning or shock-like tends to be neuropathic in
client being assessed. origin and may be responsive to anticonvulsants (e.g., gabapentin
For effective use of pain rating scales, clients need not only or pregabalin), with or without an opioid (e.g., morphine,
to understand the use of the scale but also to be educated about fentanyl, hydromorphone).
how the information will be used to determine changes in their
condition and the effectiveness of pain management interven- Pattern. The pattern of pain includes time of onset, duration,
tions. Clients should also be asked to indicate what level of and recurrence or intervals without pain. The nurse therefore
comfort is acceptable so that they can perform specific activi- determines when the pain began; how long the pain lasts;
ties. To align the client’s goals and expectations with reality, it whether it recurs and, if so, the length of the interval without
is important to note that acute pain can typically be decreased pain; and when the pain last occurred. Attention to the pattern
by 50% and chronic pain can be decreased by 25%. To ensure of pain helps the nurse anticipate and meet the needs of the
that optimal pain management is achieved, the client works to- client, as well as recognize patterns of grave concern (e.g.,
gether with professionals toward established goals of pain re- chest pain only on exertion).
duction and functional improvement. Precipitating Factors. Certain activities sometimes pre-
The use of a pain rating scale together with a pain flow sheet cede pain. For example, physical exertion may precede chest
(Figure 46–8 ■) has been shown to be effective in improving pain pain, or abdominal pain may occur after eating. These observa-
management (McCaffery & Pasero, 1999). Documentation can tions can help prevent pain and determine its cause. Environ-
be completed by the nurse, the client, or a caregiver. A rating scale mental factors such as extreme cold or heat and extremes of
can be used in acute, outpatient, and home care settings. humidity can affect some types of pain. For example, people
Pain Quality. Descriptive adjectives help people communicate with rheumatic conditions have worse pain on cold, damp
the quality of pain. A headache may be described as “unbearable” days or just before a large storm. Physical and emotional stres-
or an abdominal pain as “piercing like a knife.” The astute sors can also precipitate pain. Strong emotions can trigger a
clinician can glean subtle clinical clues from the quality of the migraine headache or an episode of chest pain. Extreme phys-
pain described; thus it is important to record the description ical exertion can trigger muscle spasms in the neck, shoulders,
verbatim. Some of the commonly used pain descriptors are listed or back.
in Table 46–4. Note that the term “unbearable” is listed as an Alleviating Factors. Nurses must ask clients to describe
affective term and “piercing” is a sensory term. Both pains are anything that they have done to alleviate the pain (e.g., home
real physical conditions signaling an underlying condition, but remedies such as herbal teas, medications, rest, applications of
the affective description “unbearable” suggests that there is a heat or cold, prayer, or distractions like TV). It is important to
coexisting emotional distress that needs to be addressed as well. explore the effect any of these measures had on the pain, whether
or not relief was obtained, or whether the pain became worse. It
is helpful to recommend a diary be kept to gather this information.
TABLE 46–4 Commonly Used Pain Descriptors
Associated Symptoms. Also included in the clinical
TERM SENSORY WORDS AFFECTIVE WORDS appraisal of pain are associated symptoms such as nausea,
Pain Searing Unbearable vomiting, dizziness, and diarrhea. These symptoms may relate
Scalding Killing to the onset of the pain or they may result from the presence of
Sharp Intense the pain.
Piercing Torturing
Drilling Agonizing Effect on Activities of Daily Living. Knowing how ADLs
Wrenching Terrifying are affected by pain helps the nurse understand the client’s
Shooting Exhausting perspective on the pain’s severity. The nurse should ask the
Burning Suffocating
client to describe how the pain has affected the following
Crushing Frightful
Penetrating Punishing aspects of life:
Miserable 䊏 Sleep
Hurt Hurting Heavy 䊏 Appetite
Pricking
䊏 Concentration
Pressing Throbbing
Tender
䊏 Work/school
Ache Numb Annoying
䊏 Interpersonal relationships
Cold Nagging 䊏 Marital relations/sex
Flickering Tiring 䊏 Home activities
Radiating Troublesome 䊏 Driving/walking
Dull Gnawing 䊏 Leisure activities
Sore Uncomfortable 䊏 Emotional status (mood, irritability, depression, anxiety).
Aching Sickening
Cramping Tender A rating scale of none, a little, or a great deal, or another range
can be used to determine the degree of alteration in ADLs.
 Sunrise Hospital and Medical Center & Sunrise Children's Hospital
1218

SR-1420 (6/00)
Pain Management Flow Sheet
*Monitoring Guidelines outlined on back of form Patient's stated pain level goal:
Mode of Administration Arousal Score:
Date
A-PO opioid and nonopioid medications 0 = Alert 1 = Medically sedated/ETT
B-PCA Infuser Basal with Patient Control Time 2 = Drowsy 3 = Somnolent
C-Continuous Infusion 4 = Asleep
D-Epidural Infuser Continuous Basal Only
Initials
E-Epidural Infuser Basal & Patient Control Non-Pharmacologic Interventions:
F-Intermittent IV/IM Injection
G-Transdermal opioids Mode of Admin C = Cold P = Pacifier
H-On-QPump D = Distraction PO = Positioning
I-Per Rectum Level of Pain H = Heat R = Relaxation
HO = Holding RO = Rocking
Level of Pain Assessment Scales I = Imagery S = SecurityObject
Location of Pain
Faces Pain Rating Scale M = Massage T = TensUnit
MU = Music O = Other
0 .............2...............4...............6..............8..............10 Frequency of Pain
Analgesia Order:
Type of Pain
1 = Increase in dosage/rate
2 = Decrease in doseage/rate
Arousal Score 3 = Extra bolus
1-10 Pain Scale
4 = PRN medication for break-through pain
0 - - - - - - - - - - - - - - - - 10 Non-Pharm. Intervent. 5 = Discontinue
No pain or pain relieved Worst pain imaginable Analgesia Order Reason for Analgesia Order:
0-10 Sum Scale
1 = Unrelieved pain
A. Vocal C. Facial
Reason for Order
2 = Decreased arousal/neuroscore
3 = Side effects (Seebelow)
0 = Positive/ETT 0 = Smiling Side Effects 4 = Discontinue therapy/change to oral route
1 = Whimpers 1 = Neutral
5 = Adverse drug reactions
2 = Crying 2 = Frown/grimace Adverse Effects (Y/N) (Document all adverse drug reactions in Nsg
3 = Screaming 3 = Clenched teeth
notes and complete an ADR report)
B. Body Movement D. Touching (localizing)
Sensory Function
Epidural Only Side Effects: O = None
0 = Moves easily 0 = Notouching Motor Function
1 = Neutral shifting 1 = Reaching/patting Epidural Only A = Anxiety N = Nausea
2 = Tense/flailing limbs 2 = Grabbing C = Confused R = Respiratory Depression
Neuro Score
Co = Constipation U = Urinary Rentention
Epidural Only
Location of Pain: I = Itching V = Vomiting
Catheter Site
Epidural Only Sensory Function Epidural Only
Cath Integrity
Epidural Only 0 = Moves all extremities well
Left Right
1 = Unable to move all extremities well
O2 Saturation Motor Function Epidural Only
Right Left
Respirations 0 = Able to feel tactile pressure
1 = Unable to feel tactile pressure
Pulse Neuro Score: Epidural Only

Blood Pressure 0 = No numbness, no weakness

1 = Medically sedated/ETT
See Nursing Notes 2 = Numbness without weakness
(Y/N) 3 = Numbness and weakness

Initials Signature Catheter Site: Epidural Only

1 = No redness, drainage, inflammation or swelling
2 = Red, inflamed
A = No pain 3 = Visable clear drainage
B-Z = Use letters to mark location of pain on graph 4 = Visable purulent drainage
5 = Visable serosanguinous/sanguinous drainage
Frequency of Pain:
6 = Swelling
O = Occasional F = Frequent C = Constant Patient Identification Label
Type of Pain Catheter Integrity Upon Removal: Epidural Only
A = Burning D = Sharp G = Isolated 1 = Catheter tip visually intact
B = Stabbing E = Shooting H = Other 2 = Catheter NOT visually intact-See Nsg Notes
C = Radiating F = Dull

Figure 46–8 ■ Pain management flow sheet.

Courtesy of Aprille Ciaverella, RN, and Lori Townsend, RN, at Sunrise Hospital and Medical Center and Sunrise Children’s Hospital, Las Vegas, Nevada.

Coping Resources. Each individual will exhibit personal
ways of coping with pain. Strategies may relate to earlier pain
experiences or the specific meaning of the pain; some may
reflect religious or cultural influences. Nurses can encourage
and support the client’s use of methods known to have helped
in modifying pain, unless they are specifically contraindicated.
Strategies may include seeking quiet and solitude, learning
about their condition, pursuing interesting or exciting activities
(for distraction), prayer (or other meaningful rituals), or social
(from family, friends, support groups, etc.).
Affective Responses. Affective responses vary according to
the situation, the degree and duration of pain, the interpretation of
it, and many other factors. The nurse needs to explore the client’s
feelings of anxiety, fear, exhaustion, level of function, depression,
or a sense of failure. Hollon (2009) states that the concurrent
prevalence of major depression with chronic noncancer pain is as
high as 85% (p. 77). Because many people with chronic pain
become depressed and potentially suicidal, it may also be
Can Client Lifestyle Influence the Nurse’s Management of Pain?
The aim of this study by Wilson (2008) was to explore whether
a client’s lifestyle influences nurses’ pain assessment and
management decisions. The researchers wanted to replicate a
study by McCaffery and Ferrell done in 1992 and also wanted
to compare the responses of two groups of expert nurses. The
nurses were defined as expert nurses because of their
postbasic education and clinical experience (minimum of 3
years or more). One group, the hospice/oncology nurse
experts, had additional education and clinical experience
concentrating on pain management. The other group, expert
generalists, had additional education and experience that
concentrated on a wide range of nursing skills and clinical
interventions. The researchers wanted to explore if additional
education and experience of pain and pain management in the
clinical setting influenced nurses’ attitudes in relation to pain.
Eighty-six nurses agreed to participate in the study. They
completed a self-administered questionnaire that addressed
pain knowledge, inferences of physical pain, and general
attitudes and beliefs about pain management. The variable of
lifestyle/socioeconomic status (SES) of the client was isolated
and manipulated; all of the other variables in the scenario
remained constant. Each nurse was given one scenario and
required to identify the client’s pain level and make pain
management decisions for given clinical situations. The two
scenarios differed in lifestyle factors. For example, one
scenario included Mike, a businessman who was in a car crash.
He is married with two children and his wife is sitting at his
bedside during visiting hours. The other scenario involved Ben
who is unemployed. Ben was in a motorcycle crash and
admitted consuming alcohol before the accident. (The alcohol
level was well below the legal limit.) His unemployed friends
are at his bedside, laughing and drinking alcohol. Both clients
are 32 years old, had sustained their injuries several days ago,
and were experiencing moderate to severe pain. They had not
received analgesia for 3 hours but their vital signs were normal.
Half of the hospice/oncology nurse experts and half of the
generalists received a questionnaire with the scenario involving
CHAPTER 46 / Pain Management 1219
necessary to assess the client’s suicide risk. In such situations, the
nurse needs to ask the client, “Do you ever feel so bad that you
want to die? Have you considered harming yourself or others
recently?” The vast majority of chronic pain sufferers, however,
are not actively suicidal and do not have a specific, lethal plan.
For those who express suicidal intent, nurses need to be familiar
with state regulations, organizational policies, and resources
available to guide practice in this area.
OBSERVATION OF BEHAVIORAL
AND PHYSIOLOGICAL RESPONSES
Aclient’s self-report is the gold standard for pain assessment. Not
all clients, however, are able to self-report. This group, referred
to as “nonverbal” clients, include the very young, individuals
who are cognitively impaired, critically ill, or comatose, and
some individuals at end of life. These clients are definitely a chal-
lenge as the nurse provides effective pain management.
There are wide variations in nonverbal responses to pain.
Facial expression is often the first indication of pain, and it may
Mike and the remainder of the nurses received a questionnaire
with the scenario involving Ben. This provided a mixed two-by-
two design. The dependent variables are the nurses’ responses
to three questions, two of which demanded a forced response
and one that allowed an open-ended response. The participants
were asked to respond as if they were the nurse in the
scenario.
The results showed that the lifestyle/SES of the client
influenced both the hospice/oncology nurse experts and the
generalist nurse experts’ decisions to acknowledge the client’s
self-report of pain. The generalist nurses were more likely to
agree with Mike’s report of pain than Ben’s and appeared to
allow lifestyle/SES to influence their pain management
decisions. The hospice/oncology nurse experts did not allow the
bias of lifestyle/SES to influence their pain management
decisions. However, both groups undermedicated both clients.
Both groups were asked to indicate any concerns that influenced
their decision to withhold medication. The generalist nurses
were concerned about respiratory depression and addiction for
both Mike and Ben but more so for Ben. This implies lack of
knowledge and that reliance on myths influenced their decisions.
The number of oncology/hospice nurses expressing concerns
about addiction and respiratory depression was less than half,
suggesting that they did not lack knowledge or agree to the
myths when undermedicating the clients.
IMPLICATIONS
Caution is needed in generalizing the findings of this study
because of the small number of participants. The results,
however, are consistent with other previous studies. The
findings do support the proposal that a client’s lifestyle/SES
can affect nurses’ pain management behaviors and this is
made worse by myths about addiction and respiratory
depression. Further research is needed to determine why
additional education and clinical experience about pain
management do not decrease the effects of lifestyle bias and
addiction myth.
 1220 UNIT 10 / Promoting Physiological Health
be the only one. Clenched teeth, tightly shut eyes, open somber
eyes, biting of the lower lip, and other facial grimaces may be
indicative of pain. Vocalizations such as moaning and groaning
or crying and screaming are sometimes associated with pain.
Immobilization of the body or a part of the body may also
indicate pain. The client with chest pain often holds the left arm
across the chest. A person with abdominal pain may assume the
position of greatest comfort, often with the knees and hips
flexed, and moves reluctantly.
Purposeless body movements can also indicate pain—for
example, tossing and turning in bed or flinging the arms about.
Involuntary movements such as a reflexive jerking away from
a needle inserted through the skin indicate pain. An adult may
be able to control this reflex; however, a child may be unable
or unwilling to do so.
Behavioral changes such as confusion and restlessness may
be indicators of pain in both cognitively intact and cognitively
impaired older clients (Bjoro & Herr, 2008). Older adults with
chronic pain may become agitated or aggressive.
Rhythmic body movements or rubbing may indicate pain. An
adult or child may assume a fetal position and rock back and
forth when experiencing abdominal pain. During labor a woman
may massage her abdomen rhythmically with her hands.
It is important to note that because behavioral responses are
controllable, they may not be very revealing. When pain is
chronic, behavioral responses are rarely overt because the indi-
vidual develops personal coping styles for dealing with pain,
discomfort, or suffering.
Physiological responses vary with the origin and duration of
the pain. Early in the onset of acute pain the sympathetic ner-
vous system is stimulated, resulting in increased blood pres-
sure, pulse rate, respiratory rate, pallor, diaphoresis, and pupil
dilation. The body does not sustain the increased sympathetic
function over a prolonged period and, therefore, the sympa-
thetic nervous system adapts, causing the responses to be less
evident or even absent. Physiological responses are most likely
Chronic Pain: Care Plan
to be absent in clients with chronic pain because of autonomic
nervous system adaptation. Thus, measures of physiological
responses (e.g., pulse, blood pressure) are poor indicators of
the presence, absence, or severity of pain.
When clients are unable to self-report pain, an alternative
approach based on the Hierarchy of Importance of Pain Mea-
sures, shown in Box 46–3, is recommended as a framework for
pain assessment (Pasero, 2009).
DAILY PAIN DIARY
For clients who experience chronic pain, a daily diary may help
the client and health care provider identify pain patterns in ad-
dition to factors that exacerbate or mediate the pain experience.
In home care, the family or other caregiver can be taught to
complete the diary with the family member who is unable to do
so alone. The record could include the following:
䊏 Time of onset of pain
䊏 Activity or situation
䊏 Physical pain character (quality) and intensity level (0–10)
䊏 Emotions experienced and intensity level (0–10)
䊏 Use of analgesics or other relief measures (intervention)
BOX 46–3 Hierarchy of Importance of Pain Measures
A FRAMEWORK FOR DETERMINING THE PRESENCE OF PAIN IN
“NONVERBAL” CLIENTS TO DEVELOP A TREATMENT PLAN
1. Attempt to obtain a self-report.
■ Do not assume a client is unable to self-report until
you have attempted to do so using a reliable and
valid self-report tool.
2. Consider underlying painful conditions and procedures.
■ When pain is assumed to be present, provide
appropriate treatment.
■ Some institutions use the abbreviation “APP”
(assume pain present).
3. Observe behavioral signs.
■ For example, facial expressions, restlessness, crying,
changes in activity.
■ Behavioral pain assessment tools may be helpful. It
is important to remember that a behavioral pain
score is not the same as a pain intensity rating.
4. Evaluate physiological indicators.
■ These are the least sensitive indicators of pain and
are given less importance in the hierarchy.
5. Conduct an analgesic trial to confirm the presence of
pain and develop a treatment plan, as appropriate.
■ Provide a low dose of an analgesic if pain is suspected.
■ Observe for behavioral changes.
■ A positive analgesic trial has occurred when
improvement in behaviors and pain is confirmed.
Note: A low dose of analgesic may not be high enough. If that dose was tolerated and if
there is no change in behavior, the dose should be increased or another analgesic added
and observe for change in behavior.
Reprinted from “Challenges in Pain Assessment,” 2009, by C. Pasero. Journal of
PeriAnesthesia Nursing, 24(1), pp. 50–54, with permission from Elsevier.
䊏 Pain rating after intervention taken
䊏 Comments.
Pain diaries have been shown to improve pain management
(Aguirre, Nevidjon, & Clemens, 2008). They avoid “recall
bias” and allow the client to understand and express their pain
experience and possibly determine patterns that can help
providers suggest better interventions. The diary may also in-
crease clients’ sense of control by helping them use medication
more effectively. For example, a pain diary may show the client
that waiting too long to take an analgesic means that it takes
longer to control the pain.
The recorded data in the diary provides the basis for devel-
oping or modifying the plan for care. For this tool to be effec-
tive, it is important for the nurse to educate the client and
family about the value and use of the diary in achieving effec-
tive pain control. Review the diary each visit, asking questions,
sharing observations, and providing hints. Determining the
client’s abilities to use the diary is essential.
Diagnosing
NANDA International (2009) includes the following diagnos-
tic labels for clients experiencing pain or discomfort:
䊏 Acute Pain
䊏 Chronic Pain.

When writing the diagnostic statement, the nurse should spec-
ify the location (e.g., right ankle pain, or left frontal headache). Re-
lated factors, when known, should also be part of the diagnostic
statement. These may include both physiological and psychologi-
cal factors. For example, in addition to the injurious agent, related
factors may include deficient knowledge of pain management
techniques or fear of drug tolerance or addiction.
Examples of clinical application of these diagnoses using
NANDA, NOC, and NIC designations are shown in Identify-
ing Nursing Diagnoses, Outcomes, and Interventions.
Because the presence of pain can affect so many facets of a
client’s functioning, pain may be the etiology of other nursing
diagnoses. Examples of such nursing diagnoses follow:
䊏 Ineffective Airway Clearance related to weak cough second-
ary to postoperative incisional abdominal pain
䊏 Hopelessness related to feelings of continual pain
䊏 Anxiety related to past experiences of poor control of pain
and anticipation of pain
䊏 Ineffective Coping related to prolonged continuous back
pain, ineffective pain management, and inadequate support
systems
䊏 Ineffective Health Maintenance related to chronic pain and
fatigue
䊏 Deficient Knowledge (Pain Control Measures) related to lack
of exposure to information resources
䊏 Impaired Physical Mobility related to pain and inflammation
secondary to arthritic pain in knee and ankle joints
䊏 Insomnia related to increased pain perception at night.
Planning
The established goals for the client will vary according to the di-
agnosis and its defining characteristics. Specific nursing inter-
ventions can be selected to meet the individual needs of the
client. Examples of clinical application of NOC outcomes and
NIC interventions are shown in Identifying Nursing Diagnoses,
Outcomes, and Interventions.
PLANNING INDEPENDENT OF SETTING
When planning, nurses need to choose pain relief measures ap-
propriate for the client, based on the assessment data and input
from the client or support persons. Nursing interventions may
include a variety of pharmacologic and nonpharmacologic
strategies. Developing a plan that incorporates a wide range of
approaches is usually most effective. Whether in acute care,
home care, or long-term care settings, it is important for every-
one involved in pain management to understand the plan of
care. The plan should be documented in the client’s record; in
home care, a copy needs to be made available to the client, sup-
port persons, and caregivers.
When the client’s pattern and level of pain can be antici-
pated or is already known, regular or scheduled administration
of analgesics can provide a steady serum level. With acute pain,
this may be possible in the first 24 to 48 hours following sur-
gery when the client is likely to have pain requiring opioid
analgesics. Frequency of administration can be adjusted to pre-
vent pain from recurring. When persistent, continuous pain ex-
ists, analgesics should be given around the clock (ATC), with
CHAPTER 46 / Pain Management 1221
additional as-needed (prn) doses available (APS, 2008). Non-
pharmacologic interventions should also be regularly sched-
uled. An additional advantage of scheduling is that the client
spends less time in pain and therefore does not experience as
much anxiety or fear of the recurrence of pain or the helpless-
ness of not knowing what to do when it flares.
PLANNING FOR HOME CARE
In preparation for discharge, the nurse should determine the
client’s and family’s needs, strengths, and resources. The ac-
companying Home Care Assessment describes the specific as-
sessment data required when establishing a discharge plan.
Using the assessment data, the nurse tailors a teaching plan for
the client and family.
Implementing
Pain management is the alleviation of pain or a reduction in
pain to a level of comfort that is acceptable to the client. Nurs-
ing management of pain consists of both independent and col-
laborative nursing actions. In general, noninvasive measures
may be performed as an independent nursing function, whereas
administration of analgesic medication generally requires a
medical order from a primary care provider. However, because
many analgesics are ordered to be administered on a prn basis,
the decision to administer the prescribed medication frequently
requires the nurse to make a judgment regarding the dose
amount and time of administration. Recent changes to the way
prn range orders are written provide more structure than in the
past. However, professional nursing judgment remains a key
Home Care Assessment
Pain
CLIENT
■ Level of knowledge: Pharmacologic and
nonpharmacologic pain relief measures selected; adverse
effects and measures to counteract these effects;
warning signs to report to primary care provider
■ Self-care abilities for analgesic administration: Ability to
use analgesics appropriately (e.g., to prepare correct
dosages of analgesics and adhere to scheduled
administration); physical dexterity to take pills or to
administer intravenous medications and to store
medications safely; and ability to obtain prescriptions or
over-the-counter medications at the pharmacy
FAMILY
■ Caregiver availability, skills, and willingness: Primary and
secondary persons able and willing to assist with pain
management; shopping if the client has restricted activity;
ability to comprehend selected therapies (e.g., infusion
pumps, imagery, massage, positioning, and relaxation
techniques) and perform them or assist the client with
them as needed
■ Family role changes and coping: Effect on financial status,
parenting and spousal roles, sexuality, social roles
COMMUNITY
■ Resources: Availability of and familiarity with resources
such as supplies, home health aid, or financial assistance
1222 UNIT 10 / Promoting Physiological Health

IDENTIFYING NURSING DIAGNOSES, OUTCOMES, AND INTERVENTIONS Clients Experiencing Pain

DATA CLUSTER Mary Anderson, 75, fell and broke her right hip while shopping. She had surgery yesterday to repair the fracture. She
rates her pain in the surgical site as 6 on a 0–10 scale and states the pain goes up to 9 when she is repositioned in bed. Vicodin 1–2
tablets q4h prn is ordered. She received a dose 5 hours ago. She states, “I try to hold out as long as I can before asking for a pain killer.”

NURSING SAMPLE DESIRED SELECTED

DIAGNOSIS/ OUTCOME*/ SAMPLE NOC INTERVENTION*/
DEFINITION DEFINITION INDICATORS DEFINITION SAMPLE NIC ACTIVITIES
Acute Pain/Unpleasant Pain Control [1605]/ Often demonstrated: Analgesic ■ Determine pain location,
sensory and emotional Personal actions to ■ Describes causal Administration characteristics, quality, and
experience arising from control pain factors [2210]/Use of severity before medicating client
actual or potential tissue ■ Uses analgesics pharmacologic ■ Instruct client to request prn pain
damage or described in appropriately agents to reduce or medication before the pain is
terms of such damage ■ Reports eliminate pain severe
(International Association uncontrolled ■ Provide comfort needs and other
for the Study of Pain); symptoms to activities that assist relaxation to
sudden or slow onset of health care facilitate response to analgesia
any intensity from mild professional ■ Correct misconceptions/
to severe with an ■ Reports pain myths client or family members
anticipated or predictable controlled may hold regarding analgesics,
end and a duration of particularly opioids (e.g., addiction
less than 6 months and risk of overdose)

DATA CLUSTER Lan Nguyen, 51, was diagnosed with breast cancer 3 years ago and had a metastatic lung tumor removed 6 months
ago. She describes prolonged post-thoracotomy pain as “hot, stabbing, and unbearable.” Lan states that although she loves sewing and
needlepoint she is unable to participate in these activities currently because of the pain.

Chronic Comfort Status Mildly compromised: Pain Management ■ Ensure client receives attentive
Pain/Unpleasant [2008]/Overall ■ Symptom control [1400]/Alleviation analgesic care
sensory and emotional physical, ■ Psychological of pain or a ■ Determine the impact of the pain
experience arising from psychospiritual, well-being reduction in pain experience on quality of life (e.g.,
actual or potential sociocultural, and to a level of sleep, appetite, activity, cognition,
tissue damage or environmental ease comfort that is mood, relationships, performance
described in terms of and safety of an acceptable to the of job, and role responsibilities)
such damage individual client ■ Select and implement a variety of
(International measures (e.g., pharmacologic,
Association for the nonpharmacologic, interpersonal) to
Study of Pain); sudden facilitate pain relief, as appropriate
or slow onset of any ■ Collaborate with the client,
intensity from mild to significant other, and other health
severe, constant or professionals to select and
recurring without an implement nonpharmacologic pain
anticipated or relief measures, as appropriate
predictable end and a ■ Monitor client satisfaction with
duration of greater than pain management at specified
6 months intervals
*

*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, interventions, and
activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

factor in relieving pain by determining which medication in BARRIERS TO PAIN MANAGEMENT

what dosage would best meet the client’s comfort needs.
Generally speaking, a combination of strategies works best for
the client in pain, especially chronic pain. Some strategies need to
be modified until the client obtains effective pain relief. See the
Practice Guidelines for individualizing care for clients with pain.
Misconceptions and biases about pain management involve at-
titudes of the nurse or the client as well as knowledge deficien-
cies. Clients respond to pain experiences based on their culture,
personal experiences, and the meaning the pain has for them.
For many people, pain is expected and accepted as a normal

CLIENT TEACHING Monitoring Pain in the Home Setting
■ Teach client to keep a pain diary to monitor pain onset,
activity before pain, pain intensity, use of analgesics or
other relief measures, and so on.
■ Instruct client to contact a health care professional if
planned control measures are ineffective.
PAIN CONTROL
■ Teach the use of preferred and selected nonpharmacologic
techniques such as relaxation, guided imagery, distraction,
music therapy, massage, and/or heat/cold.
■ Discuss the actions, side effects, dosages, and frequency
of administration of prescribed analgesics.
■ Suggest ways to handle side effects of medications.
■ Provide accurate information about tolerance, physical
dependence, and addiction if opioid analgesics are prescribed.
■ Instruct the client to use pain control measures before the
pain becomes severe.
■ Inform the client of the effects of untreated pain.
■ Demonstrate and have the client or caregiver return
demonstrate appropriate skills to administer analgesics
PRACTICE GUIDELINES Individualizing Care for Clients with Pain
■ Establish a trusting relationship. Convey your concern, and
acknowledge that you believe that the client is experiencing
pain. Saying “I believe you are in pain, and I am going to do
whatever I can to help you” will promote this trusting
relationship.
■ Consider the client’s ability and willingness to participate
actively in pain relief measures. Clients who are excessively
fatigued, sedated, or have altered levels of consciousness are
less able to participate actively. For example, a client with an
altered level of consciousness or altered thought processes
cannot safely or effectively use patient-controlled analgesia.
In contrast, a fatigued client may express a willingness to use
pain relief measures that require little effort, such as listening
to music or performing relaxation techniques.
■ Use a variety of pain relief measures. It is thought that using
more than one measure has an additive, if not synergistic,
effect in relieving pain. Two types of relief measures that
should be part of any pain treatment plan are active (relief
strategies that are self-initiated) and passive (relief strategies
that require the assistance of others). Establishing rapport
and client teaching are necessary components of all
therapeutic encounters. Because a client’s pain may vary
throughout a 24-hour period, different types of pain relief or
preemptive interventions may be scheduled (e.g.,
medication 1 hour before dressing change, relaxation
techniques with pleasant imagery after bedtime medication).
■ Provide measures to relieve pain before it becomes severe.
For example, providing an analgesic before the onset of pain
is preferable to waiting for the client to report pain, when a
larger dose may be required.
■ Use pain-relieving measures that the client believes are
effective. It has been recognized that clients are the
authorities about their own pain. Thus, incorporating the
CHAPTER 46 / Pain Management 1223
(e.g., skin patches, injections, infusion pumps, or patient-
controlled analgesia). If a home infusion pump is to be
used, caregivers need to be able to:
a. Demonstrate stopping and starting the pump.
b. Change the medication cartridge and tubing.
c. Adjust the delivery dose.
d. Demonstrate site care.
e. Identify signs indicating the need to change an
injection site.
f. Describe care of the pump and insertion site when the
client is ambulatory, bathing, sleeping, or traveling.
g. Perform problem solving for pumps when alarms are
activated.
h. Change the battery.
RESOURCES
■ Provide appropriate information about how to access
community resources, home care agencies, and
associations that offer self-help groups and educational
materials.
client’s preferred methods of relieving their pain into the
treatment plan should be seriously considered.
Former Football Player: Application Activity
■ The selection of pain relief measures should be aligned with
the client’s report of the severity of the pain. If a client
reports mild pain, an analgesic such as acetaminophen may
be indicated, whereas a client who reports severe pain
often requires a more potent relief measure. Telling a client
to ignore the pain (e.g., through distraction techniques)
when he or she is reporting severe pain is an example of a
misalignment of the pain severity and intervention selected.
■ If a pain relief measure is ineffective, encourage the client
to try it again before abandoning it. Medications may need
repeated doses to saturate plasma proteins before
sufficient “free drug” is available to work on the intended
target. Many nonpharmacologic measures require practice
before they are effective.
■ Maintain an unbiased attitude (open mind) about what may
relieve pain. New ways to relieve pain are continually being
developed. It is not always possible to explain the effectiveness
of particular pain relief measures; however, using approaches
the client believes will work should be considered.
■ Keep trying. Do not ignore a client because pain persists
despite failed attempts to alleviate the discomfort. In these
circumstances, reassess the pain and consider other relief
measures.
■ Prevent harm to the client. Pain therapy should not increase
discomfort or harm the client. Some pain relief measures
may have adverse effects, such as fatigue, but they should
not disable the client.
■ Educate the client and caregivers about pain. Clients and
support people need to be informed about possible causes
of pain, precipitating and alleviating factors, and alternatives
to drug therapy. Misconceptions also need to be corrected.
1224 UNIT 10 / Promoting Physiological Health
CULTURALLY RESPONSIVE CARE Clients in Pain
To be a true client advocate, the nurse must advocate for
proper pain management. This implies the nurse must
believe the client’s statement of pain. It is, therefore,
important to develop an effective, positive relationship with
the client, a relationship that incorporates caring behaviors.
■ Respect clients as individuals by:
• Recognizing that clients can hold different beliefs
about pain.
• Inquiring about the client’s beliefs and ways of
coping with pain.
■ Respect the client’s response to pain by:
• Recognizing that clients have the right to respond to
pain in the way they learned is appropriate.
• Recognizing that expressions of pain vary widely and
no expression is good or bad.
■ Recognize the variation within a culture by avoiding
stereotyping an individual. Expressions of pain vary
between cultures and within cultures.
From Transcultural Concepts in Nursing Care, 4th ed. (pp. 332–335), by M. M. Andrews and
J. S. Boyle, 2008, Philadelphia, PA: Lippincott Williams & Wilkins. Reprinted with permission.
part of illness. Clients and families may lack knowledge of the
adverse effects of pain and may have been provided incorrect
information regarding the use of analgesics. Clients may not re-
port pain because they suspect that nothing can be done, or they
think the pain is not severe enough or they feel it would distract
or prejudice the health care provider. Other common miscon-
ceptions are shown in Table 46–5.
Another barrier to effective pain management is the exag-
gerated fear of becoming addicted, especially when long-term
opioid use is prescribed. This fear is often held by both nurses
and clients. It is important that all individuals know the differ-
ence between addiction, physical dependence, and tolerance
(Box 46–4). Pseudoaddiction is a condition that results from
the undertreatment of pain where the client may become so fo-
cused on obtaining medications for pain relief that they become
angry and demanding, may “clock watch,” and may otherwise
seem inappropriately “drug seeking.” Nurses can differentiate
between pseudoaddiction and addiction if the client’s negative
behaviors resolve when the pain is treated effectively (Benedict,
2008; Hilton, 2007).
TABLE 46–5 Common Misconceptions About Pain
MISCONCEPTION
Clients experience severe pain only when they have had major
surgery.
The nurse or other health care professionals are the authorities
about a client’s pain.
Administering analgesics regularly for pain will lead to
addiction.
The amount of tissue damage is directly related to the amount
of pain.
Visible physiological or behavioral signs accompany pain and
can be used to verify its existence.
BOX 46–4 Definitions
The American Academy of Pain Medicine, the American Pain
Society, and the American Society of Addiction Medicine
recognize the following definitions and recommend their use.
ADDICTION
Addiction is a primary, chronic, neurobiologic disease, with
genetic, psychosocial, and environmental factors influencing
its development and manifestations. It is characterized by
behaviors that include one or more of the following: impaired
control over drug use, compulsive use, continued use
despite harm, and craving.
PHYSICAL DEPENDENCE
Physical dependence is a state of adaptation that is
manifested by a drug class specific withdrawal syndrome
that can be produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug, and/or
administration of an antagonist.
TOLERANCE
Tolerance is a state of adaptation in which exposure to a
drug induces changes that result in a diminution of one or
more of the drug’s effects over time.
From Definitions Related to the Use of Opioids for the Treatment of Pain, copyright 2010
American Pain Society, American Academy of Pain Medicine, American Society of
Addiction Medicine (http://www.ampainsoc.org/advocacy/opioids2.htm)
Nurses will provide care for clients who have substance
abuse problems or addictions. The occurrence of alcohol abuse
is 24% for men of all ages and 5% for women. Substance abuse
for illicit drugs is around 8% for men and 5% for women. Pre-
scription drug abuse has also grown (D’Arcy, 2007, pp.
121–122). Thus, a client could come to the acute care setting
for an elective surgery, through the ED, or have cancer and the
nurse will be caring for a client who has two separate problems:
pain and addiction. Unfortunately, clients with a present or past
history of substance abuse may suffer a great deal of pain need-
lessly. This is likely due to nurses’ fear of addiction when ad-
ministering opioid medications. Because addiction is a disease,
clients must be cared for appropriately. The American Society
for Pain Management Nursing (ASPMN) wrote a position
statement in 2002 that states: “Patients with addictive disease
CORRECTION
Even after minor surgery, clients can experience intense pain.
The person who experiences the pain is the only authority about
its existence and nature.
Clients are unlikely to become addicted to an analgesic provided
to treat pain.
Pain is a subjective experience, and the intensity and duration of
pain vary considerably among individuals.
Even with severe pain, periods of physiological and behavioral
adaptation can occur.

and pain have the right to be treated with dignity, respect, and
the same quality of pain assessment and management as all
other patients.”
It is important to first treat the pain. A myth held by nurses
is that if they treat the pain, they are contributing to the addic-
tion, but this is not true. In fact, undertreating the pain may
cause clients with an addictive disorder to increase their drug
use. Often, addicted clients require more pain medication than
usual, often more than the nurse is comfortable giving (Hilton,
2007). To best help the client, if possible, nurses should con-
sult with a pain management expert and an addiction specialist.
KEY STRATEGIES IN PAIN MANAGEMENT
Key strategies to reduce pain include acknowledging and accepting
the client’s pain, assisting support persons, reducing misconcep-
tions about pain, reducing fear and anxiety, and preventing pain.
Acknowledging and Accepting Clients’ Pain. According
to the professional standards of conduct, nurses have a duty to
ask clients about their pain and to believe their reports of discom-
fort. Challenging the client’s report of discomfort undermines
the environment of trust that is an essential component in the
therapeutic relationship. Consider these four ways of communi-
cating this belief:
1. Acknowledge the possibility of the pain. “Many people
with your condition are bothered by leg pain. Are you ex-
periencing any leg discomfort? What does it feel like?
How concerned/upset are you about it?”
2. Listen attentively to what the client says about the pain, re-
stating your understanding of the reported discomfort.
Adding an empathetic statement like “I’m sorry you are
hurting, it must be very upsetting. I want to help you feel
better” lets the client know you believe the pain is real and
intend to help.
3. Convey that you need to ask about the pain because, de-
spite some similarities, everybody’s experience is unique,
for example, “Many people with your condition report
having some discomforts. Do you have any pain or other
discomforts now?”
4. Attend to the client’s needs promptly. It is unconscionable
to believe the client’s report of pain and then do nothing.
PRACTICE GUIDELINES Strategies for Colleague Accountability in Pain Management
What do we do if the health care team does not respond
positively to the client’s report of pain?
■ Speak up! Inappropriate professional behavior will persist if not
challenged. If necessary, file an “incident” or “variance” report
for persistent patterns or egregious violations of standards of
care. These types of behaviors (ignoring reports of pain, failing
to treat or mistreating people with pain) are not only unethical,
but legally indefensible (D’Arcy, 2007).
■ Clarify that the sensation of pain is subjective and that
professionals have a duty to believe clients’ reports of their
symptoms.
CHAPTER 46 / Pain Management 1225
After determining the client has pain, discuss options and
plan actions for providing relief.
CLINICAL ALERT
So what if you are fooled by a client’s self-report of pain?
Evidence suggests 5% of people reporting pain are dishonest
and seeking some secondary gain. By believing everyone,
you will not shortchange the 95% of people who so
desperately need to have help controlling their pain, providing
them with competent, compassionate, and appropriate
nursing care based on the best available information.
Assisting Support Persons. Support persons often need
assistance to respond in a helpful manner to the person
Pain Management: Video
experiencing pain. Nurses can help by giving them accurate
information about the pain and providing opportunities for them
to discuss their emotional reactions, which may include anger,
fear, frustration, and feelings of inadequacy. Teaching the support
persons about the disease and medications (including warning
signs to report) and nondrug pain-relieving techniques they can
help with (e.g., massage, application of ice, coached relaxation
techniques) may diminish their feelings of helplessness and
strengthen their relationship. Support persons also may need the
nurse’s understanding and reassurance and perhaps access to
resources that will help them cope as they add the caregiver role
to an already stressful life circumstance.
Reducing Misconceptions About Pain. Reducing a client’s
misconceptions about the pain and its treatment will remove one
of the barriers to optimal pain relief. The nurse should explain to
the client that pain is a highly individual experience and that it is
only the client who really experiences the pain, although others
can understand and empathize. Misconceptions are also dealt with
when the nurse and client discuss the context of pain control as part
of the healing process. For example, a client may refuse pain
medicine out of concern for addiction, explaining that the pain is
more tolerable as long as he or she remains totally still. This
misconception overstates the risk of addiction (estimated at 5%
of clients without a history of substance abuse when treated for
acute pain) while underestimating the risks associated with
immobility (e.g., atelectasis, muscle atrophy, pressure ulcers,
infections).
■ Cite recommendations from evidence-based clinical practice
guidelines (e.g., American Pain Society, Agency for Health
Care Policy and Research), The Joint Commission standards,
organization-specific documents (e.g., mission statement,
patient bill of rights, practice standards), or relevant
research/quality reports. As necessary, distribute or post with
key passages highlighted.
■ Involve key committees, managers, and administrators in
studying and addressing the problem from a cost, quality,
competency, and credentialing perspective.
1226 UNIT 10 / Promoting Physiological Health

CLINICAL ALERT BOX 46–5 Categories and Examples of Analgesics

Emphasize to the client that at times, treatment may need to
NONOPIOID ANALGESICS/NSAIDS FOR MILD PAIN
balance the demands of providing pain reduction with
■ Acetaminophen (Tylenol, Datril)
functional improvement. Too much pain medicine might
■ Acetylsalicylic acid (aspirin)
impair alertness or gait; too much pain impairs alertness and
■ Choline magnesium trisalicylate (Trilisate)
ability to move. Thus a client may have to tolerate mild pain in
■ Ibuprofen (Motrin, Advil)
order to do what is necessary to maximize functioning and
■ Indomethacin sodium trihydrate (Indocin)
recovery (e.g., cough, deep breathe, and walk).
■ Naproxen (Naprosyn), naproxen sodium (Anaprox)
■ Ketorolac (Toradol)
■ Piroxicam (Feldene)
■ Meloxicam (Mobic)
■ Celecoxib (Celebrex) Cox II NSAID
Reducing Fear and Anxiety. It is important to help relieve
OPIOID ANALGESICS FOR MODERATE PAIN
strong emotions capable of amplifying pain (e.g., anxiety, anger, ■ Hydrocodone (Lortab, Vicodin)
and fear). When clients have no opportunity to talk about their ■ Codeine (Tylenol No. 3)
pain and associated fears, their perceptions and reactions to the ■ Tramadol (Ultram, Ultracet)
pain can be intensified. Often, these emotions are related to ■ Pentazocine (Talwin)
uncertainty about the future, feeling mistreated in the past, or OPIOID ANALGESICS FOR SEVERE PAIN
having unmet expectations. By providing accurate information, ■ Fentanyl citrate (Sublimaze, transdermal patches, Actiq
the nurse can also reduce many of the client’s fears or anxiety, lozenges)
while clarifying expectations can minimize frustration and ■ Hydromorphone hydrochloride (Dilaudid)
anger. Specifically, client education about the range of pain that ■ Oxycodone (OxyContin)
is considered normal for the condition as well as the types of ■ Morphine sulfate (morphine)
■ Oxymorphone (Opana)
discomforts that signal a potential for problems will help
■ Methadone (Dolophine)
alleviate this fear and uncertainty.
COANALGESICS
Preventing Pain. A preventive approach to pain management ■ Tricyclic antidepressants (nortriptyline, amitriptyline)
involves the provision of measures to treat the pain before it ■ Anticonvulsants (gabapentin, pregabalin)
occurs or before it becomes severe. Preemptive analgesia is the ■ Topical local anesthetic (Lidoderm)

administration of analgesics before surgery to decrease or relieve

pain after surgery. An example would be treating clients
World Health Organization Three-Step Approach. For
preoperatively with local infiltration of an anesthetic or an oral
clients with mild pain (1–3 on a 0–10 scale), step 1 of the analgesic
or parenteral administration of an opioid to reduce postoperative
ladder, nonopioid analgesics (with or without a coanalgesic) is the
pain. This concept is controversial with little evidence-based
research to support the practice (D’Arcy, 2008a, p. 53).
Nurses can use a preemptive approach by providing an anal-
gesic ATC, and supplementing with as-needed prn doses after sur-
F an
re c

gery or prior to painful procedures (e.g., dressing changes, physical

e e
c

d r
o p
m a

Opio
fr in
o

therapy). This strategy prevents the windup and sensitization de-

m
id f
to se or mod
scribed earlier that spreads, intensifies, and prolongs pain. v era
±No ere pain te
nop
± Ad ioid
PHARMACOLOGIC PAIN MANAGEMENT juva 3
nt
P ri
a nc
in r
o

Pharmacologic pain management involves the use of opioids

p ea
e s
rs in
is g

Opi
tin

(narcotics), nonopioids such as nonsteroidal anti-inflammatory oid

g

mod for m
drugs (NSAIDs), and coanalgesic drugs (Box 46–5). The e ild
±No rate pa to
World Health Organization (WHO) established the principles nop in
±A
djuvioid
of modern analgesic use with its three-step approach to treating ant 2
P ri
a nc
in r
o

cancer pain (Figure 46–9 ■). The three-step approach focuses

p ea
e s
rs in
is g
tin

on aligning the proper analgesic with the intensity of pain. This

g

No
n
has evolved into “rational polypharmacy,” which demands that ± A opioid
dju
health professionals be aware of all ingredients of medications van
t
that alleviate pain. Combinations reduce the need for high Pain
1
doses of any one medication, thus maximizing pain control
while minimizing side effects or toxicity. These multidrug
strategies, coupled with multimodal therapy (use of nondrug Figure 46–9 ■ The WHO three-step analgesic ladder.
approaches like heat, relaxation, TENS) may permit opioid From Cancer Pain Relief, 2nd ed., by World Health Organization, 1996, Geneva: Author. © Copyright
dose reduction and improve client outcomes. World Health Organization (WHO). All rights reserved.

appropriate starting point. If the client has mild pain that persists
or increases despite using full doses of step 1 medications, or if the
pain is moderate (4–6 on a 0–10 scale), then a step 2 regimen is
appropriate. At the second step, an opioid for moderate pain (e.g.,
codeine, tramadol) or a combination of opioid and nonopioid
medicine (e.g., oxycodone with acetaminophen, hydrocodone
with ibuprofen) is provided with or without coanalgesic
medications. If the client has moderate pain that persists or
increases despite using full doses of step 2 medications, or if the
pain is severe (7–10 on a 0–10 scale), then a step 3 regimen is
medically indicated. At the third step, an opioid for severe pain
(e.g., morphine, hydromorphone, fentanyl) is administered and
titrated in ATC scheduled doses until the pain is relieved.
CLINICAL ALERT
Combining opioid and nonopioid analgesics is a useful way to
manage pain, and is frequently overlooked. Each has different
mechanisms of action, side effects, and toxicity profiles.
Alternating the two or giving them at the same time creates
no danger and often produces a synergistic rather than
merely additive effect. By combining nonopioids and opioids,
pain management can be enhanced, reducing doses of
analgesics and decreasing the risks of side effects for both.
This practice is sometimes referred to as multimodal therapy.
Nonopioids/NSAIDs. Nonopioids include nonsteroidal
anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen.
All are useful for the management of acute and chronic pain.
Aspirin is the most common NSAID and is available over
the counter (OTC). Because it can prolong bleeding time,
clients should stop taking it 1 week prior to any surgical proce-
dure. Aspirin should never be given to children under 12 years
of age due to the possibility of Reye’s syndrome. The nurse
must also be aware that aspirin can cause excessive anticoagu-
lation if a client is taking the anticoagulant, warfarin.
Acetaminophen (Tylenol) does not affect platelet function
and rarely causes gastrointestinal (GI) distress. Aceta-
minophen, however, has serious side effects such as hepatotox-
icity and possible renal toxicity, especially with high doses or
with long-term use. Studies show that even with recommended
doses up to 4 grams per day, some clients may be at an in-
creased risk for liver toxicity (APS, 2008). The U.S. Food and
Drug Administration (FDA) currently requires warnings
against taking alcohol with acetaminophen. It is recommended
that otherwise young and healthy people limit their acetamino-
phen consumption to less than 3 grams per day, with suscepti-
ble individuals (e.g., older adults, those with a history of
alcoholism, dehydration, or liver disease) limiting their con-
sumption to 2.4 grams per day or less (American Liver Foun-
dation, 2007; Fosnocht, Taylor, & Caravati, 2008). Given that
acetaminophen is so well tolerated, it is often an ingredient in
OTC remedies (e.g., pain, fever, allergy, cough and cold prepa-
rations), so clients must be instructed to read the ingredient list
of all OTC medicines they take. Box 46–6 lists common med-
ications that contain acetaminophen.
CHAPTER 46 / Pain Management 1227
BOX 46–6 Common Pain Medications
Containing Acetaminophen
MEDICATION
■ Tylenol No. 3 (325 mg acetaminophen/30 mg codeine)
■ Percocet (325 mg acetaminophen/5 mg oxycodone)
■ Lortab (500 mg acetaminophen/5, 7.5, or 10 mg
hydrocodone)
■ Vicodin (500 mg acetaminophen/5 mg hydrocodone)
■ Tylox (500 mg acetaminophen/5 mg oxycodone)
■ Darvocet-N 100 (650 mg acetaminophen/100 mg
propoxyphene)
■ Vicodin ES (750 mg acetaminophen/7.5 mg hydrocodone)
NSAIDs have anti-inflammatory, analgesic, and antipyretic ef-
fects, whereas acetaminophen has only analgesic and antipyretic
Naproxen: Animation
effects. All NSAIDs relieve pain by inhibiting the enzyme cy-
clooxygenase (COX) chemical that is activated by damaged tis-
sue, resulting in decreased synthesis of prostaglandins. The
COX-1 specific isoforms (proteins) are found in platelets, the GI
tract, kidneys, and most other tissue, and are believed to be the
cause of the well-known side effects of NSAIDs (e.g., GI bleed,
diminished renal blood flow, and inhibited clotting).
In the 1990s a second isoform (COX-2) was found and be-
lieved to be specific only for pain and inflammation. The re-
sulting new “safer” (COX-2 selective) NSAIDs were tested,
approved, and widely used. These drugs demonstrated signifi-
cantly less GI bleeding, but uncommon cardiovascular events
and rare skin problems occurred in susceptible individuals. The
only COX-2 currently available in the United States is cele-
coxib (Celebrex). Although the COX-2 NSAIDs have fewer GI
side effects, they are no safer on renal function than the COX-
1 NSAIDs (APS, 2008). All prescription NSAIDs now must
carry the strong “black box” warning of the risks of using these
drugs. Even nonprescription NSAIDs (e.g., aspirin, ibuprofen,
naproxen) must be relabeled to warn consumers of the poten-
tial dangers of using those products.
Individual drugs in this category vary little in their analgesic
potency, but do vary in their anti-inflammatory properties, me-
tabolism, excretion, and side effects. These drugs have a ceil-
ing effect and a narrow therapeutic index. The ceiling effect
means that once the maximum analgesic benefit is achieved,
more drug will not produce more analgesia; however, more tox-
icity may occur. The narrow therapeutic index indicates that
there is not much margin for safety between the dose that pro-
duces a desired effect and the dose that may produce a toxic,
even lethal effect. The most common side effect of NSAIDs is
gastrointestinal, such as heartburn or indigestion. These effects
can become toxic or lethal if silent GI bleeding occurs. Given the
interference with platelet aggregation, a small stomach ulcer can
bleed a great deal, making it a potentially life-threatening con-
dition. Clients should be taught to take NSAIDs with food and
a full glass of water. Routine monitoring by a health profes-
sional is indicated if these preparations are taken daily for more
than a couple of weeks.
 1228 UNIT 10 / Promoting Physiological Health
TABLE 46–6 Misconceptions About Nonopioids
MISCONCEPTION
Regular daily use of NSAIDs is much safer than taking opioids.
A nonopioid should not be given at the same time as an opioid.
Administering antacids with NSAIDs is an effective method of
reducing gastric distress.
Nonopioids are not useful analgesics for severe pain.
Gastric distress (e.g., abdominal pain) is indicative of NSAID-
induced gastric ulceration.
From Pain: Clinical Manual, 2nd ed., by M. McCaffery and C. Pasero, 1999, St. Louis, MO: Mosby: Mosby, Inc. Reprinted with permission from Elsevier Science.
Table 46–6 lists common misconceptions about nonopioids.
Morphine: Animation
Opioids. There are three primary types of opioids:
1. Full agonists. These pure opioid drugs bind tightly to mu
receptor sites, producing maximum pain inhibition, an ag-
onist effect. A full agonist analgesic includes morphine,
the gold standard opioid. Other full agonists include oxy-
codone (e.g., Percocet, OxyContin), hydromorphone (e.g.,
Dilaudid), and fentanyl (Duragesic, Actiq). There is no
ceiling on the level of analgesia from these drugs; their
dose can be steadily increased to relieve pain. There is also
no maximum daily dose limit unless they are in compound
with a nonopioid analgesic drug.
2. Mixed agonists-antagonists. Agonist-antagonist analgesic
drugs can act like opioids and relieve pain (agonist effect)
when given to a client who has not taken any pure opioids.
However, they can block or inactivate other opioid analgesics
when given to a client who has been taking pure opioids (an-
tagonist effect). These drugs include dezocine (Dalgan),
pentazocine hydrochloride (Talwin), butorphanol tartrate
(Stadol), and nalbuphine hydrochloride (Nubain). They block
the mu receptor site and activate a kappa receptor site. If a
client has been receiving a mu agonist (e.g., morphine, Perco-
cet, or Vicodin for pain) daily for more than a couple of
weeks, the administration of a mixed agonist-antagonist may
result in an immediate and severe withdrawal reaction. These
drugs also have a ceiling effect that limits the dose. They are
not recommended for use with clients who are terminally ill.
In the opioid naïve client (individual who has not taken opi-
oids for a week or longer) with acute pain (e.g., migraine
headache), these agents have success and few side effects.
CORRECTION
Side effects from long-term use of NSAIDs are considerably more
severe and life threatening than the side effects from daily doses
of opioids. The most common side effect from long-term use of
opioids is constipation, whereas NSAIDs can cause gastric ulcers,
increased bleeding time, and renal insufficiency. Acetaminophen
can cause hepatotoxicity.
It is safe to administer a nonopioid and opioid at the same time.
Giving a dose of nonopioid at the same time as a dose of opioid
poses no more danger than giving the doses at different times. In
fact, many opioids are compounded with a nonopioid (e.g.,
Percocet [oxycodone and acetaminophen]).
Administering antacids with NSAIDs can lessen distress but may be
counterproductive. Antacids reduce the absorption and therefore
the effectiveness of the NSAID by releasing the drug in the
stomach rather than in the small intestine where absorption occurs.
Nonopioids alone are rarely sufficient to relieve severe pain, but they
are an important part in the total analgesic plan. One of the basic
principles of analgesic therapy is: Whenever pain is severe enough
to require an opioid, adding a nonopioid should be considered.
Most clients with gastric lesions have no symptoms until bleeding
or perforation occurs.
3. Partial agonists. Partial agonists have a ceiling effect in
contrast to a full agonist. These drugs such as buprenor-
phine (Buprenex) block the mu receptors or are neutral at
that receptor but bind at a kappa receptor site. Buprenor-
phine has good analgesic potency and is emerging as an al-
ternative to methadone for opioid maintenance and
narcotic treatment programs. The safety and favorable side
effect profile make it an increasingly popular choice.
Opioid Analgesics for Moderate Pain These include drugs
such as codeine or hydrocodone, or the nonspecific opioid, hy-
drocodone, and tramadol. These medicines are generally two to
four times more potent that nonopioids alone, and share some of
the risks of both drug classes. Most of these drugs are combina-
tions of a nonopioid with an opioid. With a rare exception, these
are controlled substances and must be ordered by a physician or
nurse practitioner, adhering to applicable federal and state laws.
These drugs also have a ceiling effect due to the nonopioid and a
maximum daily dose limit. There are advantages to giving com-
bination drugs, such as lowering the amount of any one medicine
needed in a 24-hour period, thus reducing the potential for side ef-
fects or toxicity; however, nurses need to be familiar with each
medication and be aware of daily dose limits of the ingredients as
well as the potential to receive duplicate medications for different
clinical indications (e.g., Tylenol in the mixed drug, Tylenol for
fever, and Tylenol in the headache preparation).
These opioids have a narrow therapeutic index. Codeine at
doses of 30 to 60 mg produces dose-limiting GI distress in
many people. A specific enzyme in the body (CYP450) is re-
quired to make codeine active in order for analgesia to be ef-
fected. About 10% of the population lack this enzyme and are

Narcotic Analgesic
CLIENT WITH PAIN
Opioids relieve moderate to severe pain by inhibiting the
release of substance P in both central and peripheral nerves,
reducing the perception of pain, producing sedation, and
decreasing the emotional stress of pain.
Oxycodone is a semisynthetic derivative of codeine. It is a
Schedule II controlled substance. It is often administered as a
combination drug with acetaminophen (Percocet, Tylox) or
aspirin (Percodan). It is also available as a single-agent
controlled-release medication (OxyContin).
NURSING RESPONSIBILITIES
■ Assess pain prior to and 60 minutes after administration.
■ Assess bowel function to prevent constipation.
■ Keep track of the total amount of acetaminophen or aspirin
the client is receiving when taking a combination drug. The
Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.
“poor metabolizers,” meaning they may not get any pain relief
at all from codeine (APS, 2008).
Tramadol (Ultram, Ultracet) is considered to be a nonspe-
cific opioid with a dual mechanism of action. It is a weak opi-
oid agonist and also inhibits the reuptake of norepinephrine and
epinephrine. The usual dose is 50 to 100 mg qid. Because tra-
madol lowers a person’s seizure threshold, no more than
400 mg per day should be given. Because of this dual mecha-
nism of action, caution is in order when taken with tricyclic an-
tidepressants or serotonin selective reuptake inhibitors due to
increased risk of seizures or serotonin syndrome (APS, 2008).
In the past, propoxyphene (Darvon) has been listed in this cat-
egory. Because of a reported 10,000 deaths associated with
Darvon products due to the accumulation of metabolites, the
FDA considered a Public Citizen petition to remove it from the
market. The FDA ultimately decided to keep pain medications
such as Darvon and Darvocet that contain propoxyphene on the
market with the requirement that propoxyphene manufacturers
increase the safety warning labels on the product (FDA, 2009).
Opioid Analgesics for Severe Pain Pure agonist opioid anal-
gesics include opium derivatives, such as morphine, hydromor-
phone, oxycodone, fentanyl, and methadone (APS, 2008). Opioid
is the pharmacologic class of pain relievers and is the correct
medical term. Many opioids are “scheduled” as a controlled sub-
stance (narcotic) due to the potential for misuse. Pure agonist opi-
oids relieve pain primarily by binding to mu receptors in the
peripheral and central nervous systems. In addition to pain reduc-
tion, changes in mood may make the person feel more comfort-
able even though the pain persists. As the most potent class of
pain relievers, these drugs are indicated for severe pain, or when
other medications have failed to control moderately severe or
worse pain. Among this class, meperidine (Demerol) has received
a lot of attention in recent years as a medication to avoid because
of its short half-life, toxic metabolite, and potential to induce
tremors and seizures with repeated doses. It should not be used
CHAPTER 46 / Pain Management 1229
oxycodone (OxyContin)
oxycodone/acetaminophen (Percocet)
oxycodone/aspirin (Percodan)
maximum daily dose of acetaminophen is 4,000 mg unless
the client is at risk for liver problems (e.g., older adult,
malnourished, or hepatic problems). For these clients, the
maximum amount is lower. The American Liver Foundation
(2007) now recommends no more than 3,000 mg daily for
any prolonged period of time.
CLIENT AND FAMILY TEACHING
■ Take with food to decrease GI upset.
■ Avoid crushing or chewing long-acting tablets (e.g., OxyContin).
■ Avoid alcohol or other CNS depressants.
■ Explain that the medication may cause dizziness, and
instruct to make position changes slowly.
■ Instruct that constipation is a common side effect. Discuss
preventive measures.
■ Take only as prescribed.
with infants and children, older adults, and clients with cancer
pain or sickle cell disease (APS, 2008). Most acute care settings
have taken it off their formularies for pain control.
Methadone is a synthetic opioid used for severe pain. The
nurse needs to be aware of the potential for serious problems
when a client is on methadone. Due to its long half-life (15 to
60 hours), there is an increased risk of sedation and respiratory
depression, especially in older adults. Studies also show that
methadone can prolong QT waves so a baseline cardiac (ECG)
follow-up is essential (APS, 2008).
Opioid Side Effects When administering any analgesic, the
nurse must review side effects. Side effects of the opioids typically
include respiratory depression, sedation, nausea/vomiting, urinary
retention, blurred vision, sexual dysfunction, and constipation.
The most concerning adverse effect of opioids is respiratory de-
pression (e.g., 8 per minute or less), which usually occurs early in
therapy among opioid-naïve clients, with dose escalation, or in
clients with drug–drug or drug–disease interactions. Clinically, the
client will appear overly sedated, and respirations will be slow and
deep with periods of apnea. The nurse should assess a client’s level
of alertness and respiratory rate for baseline data before adminis-
tering opioids. See the sedation rating scale in Box 46–7. Clients
will often manifest an increase in sedation before they manifest a
BOX 46–7 Sedation Scale
S  Sleep, easy to arouse
1  Awake and alert
2  Slightly drowsy, easily aroused
3  Frequently drowsy, arousable, drifts off to sleep during
conversation
4  Somnolent, minimal or no response to physical stimulation
Reprinted from Pain: Clinical Manual, by M. McCaffery and C. Pasero, page 267. Copyright
1999, Mosby, Inc., with permission from Elsevier.
1230 UNIT 10 / Promoting Physiological Health
BOX 46–8 Common Opioid Side Effects with Preventive and Treatment Measures
CONSTIPATION
■ Increase fluid intake (e.g., 6 to 8 glasses daily).
■ Increase fiber and bulk-forming agents to the diet (e.g.,
fresh fruits and vegetables). Increasing exercise is often
ineffective in controlling this type of constipation.
■ Administer daily stool softeners combined with a mild
laxative (e.g., Senokot-S) as a first line of prevention against
constipation for clients on opioid maintenance therapy.
■ Stimulants (bisacodyl), osmotic laxatives (lactulose, sorbitol,
and polyethylene glycol), enemas (tap water and sodium
phosphate), and even prokinetic agents (metoclopramide)
may be needed for refractory cases of constipation.
■ A new medication was recently approved for opioid-induced
constipation in end-of-life care, Relistor (methylnaltrexone
bromide). It is to be given subcutaneously, when other
methods prove ineffective (APS, 2008).
NAUSEA AND VOMITING
■ Inform client that tolerance to this emetic effect generally
develops after several days of opioid therapy.
■ Provide an antiemetic: the 5HT antagonist ondansetron
(Zofran), phenothiazines (Compazine, Phenergan), or the GI
stimulant metoclopramide (Reglan).
■ Change the dose or analgesic agent as indicated.
SEDATION
■ Inform client that tolerance usually develops over 3 to 5 days.
■ Consider the administration of a stimulant in the morning
(e.g., caffeine, Dexedrine, or Ritalin for adult clients) or an
alternative route of administration (e.g., epidural) to
counteract sedation.
decrease in respiratory rate and depth. Early recognition of an in-
creasing level of sedation or respiratory depression will enable the
nurse to implement prompt, appropriate measures promptly (e.g.,
pulse oximetry monitoring or obtaining an order to decrease the
opioid dosage). Box 46–8 provides suggested measures to prevent
and treat side effects of opioid analgesics. Tolerance to all opioid
side effects usually occurs within a few days, except for constipa-
tion. Because of this, the nurse must initiate and continue mea-
sures to prevent constipation during the entire time the client
receives opioids.
CLINICAL ALERT
Constipation is an almost universal adverse effect of opioid
use. All clients should receive prophylactic stimulant laxative
therapy, unless contraindicated. Stool softeners are not
useful alone, but are a good choice when combined with a
stimulant laxative (e.g., Senokot-S). If those products are
ineffective, a regimen of cathartic laxatives (e.g., bisacodyl),
followed by more aggressive forms of treatment (e.g.,
osmotic laxatives, enema, manual disimpaction) may be
necessary.
■ Observe client for evidence of respiratory depression that
may occur with sedation.
RESPIRATORY DEPRESSION
■ Administer an opioid antagonist, such as naloxone
hydrochloride (Narcan), cautiously by diluting 1 ampule in 10
mL of saline and then administering 1 mL per minute until the
respirations are  10/min. Make provisions for repeat
administration, continuous infusion, or a longer acting version
of a reversal agent because the half-life of naloxone is
considerably shorter than that of most opioids being reversed.
■ Be aware of the CNS depression risks of other medications
such as hypnotics, benzodiazepines, and sedatives,
especially in the opioid-naïve client.
■ Remember to titrate naloxone to prevent seizures,
arrhythmias, and returning pain.
■ Attempt to stimulate the client to breathe. Stop, change, or
slow the administration of opioids until respirations are
restored.
PRURITUS
■ Apply cool packs, lotion, and diversional activity.
■ Administer an antihistamine, for example,
diphenhydramine hydrochloride (Benadryl). Instruct client
about sedation effects.
■ Inform the client that tolerance also develops to pruritus
within a few days; otherwise, as with other unresolved side
effects, switching to another opioid may prove beneficial.
URINARY RETENTION
■ May need to catheterize client, or change or lower the
analgesic dose.
SAFETY ALERT
Assessing for sedation and respiratory status is critical
during the first 12 to 24 hours after starting opioid therapy.
The most critical period is during the peak effect of the first
dose (15 minutes if administered IV; first hour after IM, oral,
or rectal route). An exception is with opioids administered via
the spinal route. Respiratory depression may increase over
time with epidural infusions and with intrathecal analgesia;
respiratory depression may manifest 24 hours after the
spinal injection even after the analgesic effect has worn off.
In general, the longer the client receives opioids, the wider
the safety margin as the client develops a tolerance to the
sedative and respiratory depressive effects of the drug.
Equianalgesic Dosing. The term equianalgesia refers to
the relative potency of various opioid analgesics compared to a
standard dose of parenteral morphine (gold standard opioid).
This tool helps professionals individualize the analgesic
regimen by guiding the adjustment of medication, dose, time
interval, and route of administration. An equianalgesic chart can
be used to help provide doses of approximately equal ability to

relieve pain. The two basic techniques for calculating doses
based on equianalgesic equivalents are ratio and cross-
multiplication methods. For example, with the ratio technique,
it is known that the oral:IV morphine ratio is 3:1, meaning IV
morphine is three times more potent than oral morphine. Thus,
a client who has required 100 mg of IV morphine per day will
require 300 mg of oral morphine per day to control the same
level of pain. If a different client who had an opioid requirement
of 40 mg IV morphine per day were to be switched to oral
hydromorphone (Dilaudid), the equianalgesia chart shows that
10 mg IV morphine is equivalent to 7.5 mg hydromorphone
(Dilaudid). Using the cross-multiplication technique (where x
represents unknown dose), the following steps are calculated:
10 mg IV morphine  7.5 mg oral hydromorphone
40 mg IV morphine  x mg hydromorphone
Cross multiply:
10x  7.5  40
10x  300
x  30
Thus 30 mg oral hydromorphone per day would provide equiv-
alent analgesia to 40 mg of parenteral morphine per day. The
hydromorphone dose is then divided based on the duration of
action of the available preparations (Dilaudid every 4 hours).
CLINICAL ALERT
Many health care professionals underestimate the
effectiveness of ordinary aspirin and acetaminophen. The
ordinary dose of aspirin or acetaminophen relieves as much
pain as 1.5 mg of parenteral morphine, whereas standard
doses of mixed analgesics (e.g., Tylenol No. 3 or Percocet)
are approximately equivalent to 2.5 to 5 mg of morphine.
Coanalgesics. A coanalgesic (formerly known as an adjuvant)
is a medication that is not classified as a pain medication.
However, coanalgesics have properties that may reduce pain alone
or in combination with other analgesics, relieve other discomforts,
potentiate the effect of pain medications, or reduce the pain
medication’s side effects. Examples of coanalgesics that relieve
pain are antidepressants (increase pain relief, improve mood, and
improve sleep), anticonvulsants (stabilize nerve membranes,
reducing excitability and spontaneous firing), and local anesthetics
(block the transmission of pain signals). Anxiolytics, sedatives,
and antispasmodics are examples of medicines that relieve other
discomforts; however, they do not alleviate pain and thus should
be used in addition to rather than instead of analgesics. Examples
of medications used to reduce the side effects of analgesics include
stimulants, laxatives, and antiemetics.
Coanalgesics appear to be particularly beneficial for the man-
agement of neuropathic pain. Tricyclic antidepressant drugs are
prescribed for central neuropathic pain, which often manifests as
pain with a burning, unusual, or stinging quality. Anticonvulsant
drugs, such as gabapentin (Neurontin) or pregabalin (Lyrica) are
used for peripheral neuropathic conditions that often present
with a stabbing, shooting, or electrical-shock quality. Local anes-
CHAPTER 46 / Pain Management 1231
thetics such as the Lidoderm patch also alleviate neuropathic as
well as other types of pain, and are particularly useful for clients
with the skin sensitivity known as allodynia. There is a growing
scientific and clinical basis for the use of these medications in re-
lieving pain, especially for persistent pain that is not relieved by
the analgesic classes of medication alone.
ADMINISTRATION OF PLACEBOS
A placebo is “any medication or procedure that produces an effect
in clients resulting from its implicit or explicit intent and not from
its specific physical or chemical properties” (ASPMN, 2004, p. 1).
An example would be a sugar pill or an injection of saline. In con-
trast, the placebo effect is a perceptible, measurable consequence
of receiving a placebo that may have a healing or harmful effect
(ASPMN, 2004, p. 1). Some professionals try to justify the use of
placebos to elicit the desirable placebo effect or in a misguided at-
tempt to determine if the client’s pain is “real.” These reasons can-
not be justified on either a clinical or an ethical basis (APS, 2005).
The use of placebos, outside the context of an approved research
study, is deceptive and represents fraudulent and unethical treat-
ment. Many professional and pain management organizations
(e.g., ANA Code of Ethics for Nurses, American Society for Pain
Management Nursing, American Pain Society, Oncology Nursing
Society) have published position papers that adamantly oppose the
use of placebos without consent (Ashley, 2008).
ROUTES FOR OPIATE DELIVERY
Opioids can be given in the following routes: oral, transnasal,
transdermal, transmucosal, rectal, topical, subcutaneous, intra-
muscular, IV (bolus and continuous), and intraspinal (epidural
and intrathecal) and as continuous local anesthetics.
Oral. Oral administration of opioids remains the preferred route
of delivery because of ease of administration. Because the duration
of action of most opioids is approximately 4 hours, people with
chronic pain have had to awaken during the night to medicate
themselves for pain. To circumvent this problem, long-acting or
sustained-release formulations of morphine with a duration of 8 or
more hours have been developed. Examples of a long-acting
morphine are MS Contin, a controlled-release tablet, and Avinza,
a morphine sulfate extended-release capsule. Clients receiving
long-acting morphine may also need prn “rescue” doses of
immediate-release analgesics such as Actiq, the short-acting oral
transmucosal fentanyl citrate (OTFC) for acute breakthrough pain.
Another method of oral opiate delivery is high-concentration
liquid morphine. This formulation enables clients who can
swallow only small amounts to continue taking the drug orally.
Transnasal. Transnasal administration has the advantage of
rapid action of the medication because of direct absorption
through the vascular nasal mucosa. A commonly used agent is
the mixed agonist-antagonist butorphanol (Stadol) for acute
migraine headaches. Treating migraine headaches via the nasal
route of administration is particularly beneficial. Nausea,
vomiting, and gastroparesis often accompany migraines,
therefore oral medications are contraindicated.
Transdermal. Transdermal drug therapy is advantageous in
that it delivers a relatively stable plasma drug level and is
1232 UNIT 10 / Promoting Physiological Health
noninvasive. Fentanyl (Duragesic) is a lipophilic synthetic
opioid (i.e., binds to subcutaneous fat) and is currently
available as a skin patch with various dosages (12 to 100 mcg).
The nurse must remember that fentanyl is 100 times more
potent than morphine and is ordered in micrograms not
milligrams. It provides drug delivery for up to 72 hours. The
transdermal route is distinguished from the topical route in that
the effects of the medications are systemic after the medication
is absorbed. Nurses must teach clients not to use heat (e.g., hot
tubs, heating pads) with the fentanyl patch, because increased
absorption may result (Institute for Safe Medication Practices
[ISMP], 2007). A client with a fever may absorb the medication
faster because of the vasodilation from the increased skin
temperature. Used patches should be disposed of in a tamper-
proof container. This is especially true in the home setting
because a used patch can contain enough residual medication
to harm a small child or animal if ingested (APS, 2008).
Transmucosal. Many clients with cancer-related pain expe-
rience breakthrough pain even though they are on a fixed
schedule for pain control. The transmucosal route is helpful for
breakthrough pain because the oral mucosa is well vascular-
ized, which facilitates rapid absorption. Two forms of fentanyl
are available for transmucosal delivery: OTFC (Actiq) and fen-
tanyl buccal tablet (FBT; Fentora) (APS, 2008, p. 39).
Rectal. Several nonopiate and opiate medicines are now
available in suppository form. The rectal route is particularly
useful for clients who have dysphagia (difficulty swallowing)
or nausea and vomiting. It is best to use commercially available
rectal preparations, or have them compounded by a licensed
compound pharmacist.
Topical. Topical medications work directly at the point of ap-
plication on the body. They are useful for painful procedures
such as lumbar punctures or bone marrow biopsies or for injec-
tions. These products can also offer effective pain relief for
chronic pain syndromes such as peripheral neuropathy and/or
low back pain. OTC examples include Aspercreme and LMX4
(4% lidocaine).
Prescription topical medications include EMLA cream (lido-
caine and prilocaine), Synera (lidocaine and tetracaine), and Zingo
(lidocaine hydrochloride powder). Lidoderm is a topical patch ap-
proved for post-herpetic neuralgia. It has also been found to be
useful in other types of neuropathic pain. It must be applied on in-
tact skin and left in place for 12 hours and then off for 12 hours.
A new form of the NSAID diclofenac (Voltaren) is now
available, by prescription, for treatment of acute short-term
pain due to minor strains, sprains, and contusions (bruises). It
is called the Flector patch.
Subcutaneous. Although the subcutaneous route has been
used extensively to deliver opioids, another technique uses sub-
cutaneous catheters and infusion pumps to provide continuous
subcutaneous infusion (CSCI) of opioids. CSCI is particularly
helpful for clients (a) whose pain is poorly controlled by oral
medications, (b) who are experiencing dysphagia or GI obstruc-
tion, or (c) who have a need for prolonged use of parenteral opi-
oids. CSCI involves the use of a small, light, battery-operated
Supraclavicular
Abdomen
Figure 46–10 ■ Subcutaneous infusion needle placement. Sites for
subcutaneous infusion needle placement, which may be attached to
an ambulatory infusion pump. Other sites to consider include upper
arms and thighs. Sites should be rotated.
From Pain: Clinical Manual, 2nd ed. (p. 211), by M. McCaffery and C. Pasero, 1999, St. Louis, MO:
Mosby, Inc. Copyright Elsevier.
pump that administers the drug through a 23- or 25-gauge but-
terfly needle. The needle can be inserted into the anterior chest,
the subclavicular region, the abdominal wall, the outer aspects
of the upper arms, or the thighs. Client mobility is maintained
with the application of a shoulder bag or holster to hold the
pump (Figure 46–10 ■). The frequency of site change ranges
from 3 to 7 days. The maximum fluid volume should be less
than 3 mL/hr for continuous infusion (APS, 2008).
Because family caregivers must operate the pump as well as
change and care for the injection site, the nurse needs to pro-
vide appropriate instruction. Caregivers need to be able to:
䊏 Describe the basic parts and symbols of the system.
䊏 Identify ways to determine whether the pump is working.
䊏 Change the battery.
䊏 Change the medication.
䊏 Demonstrate stopping and starting the pump.
䊏 Demonstrate tubing care, site care, and changing of the injec-
tion site.
䊏 Identify signs indicating the need to change an injection site.
䊏 Describe general care of the pump when the client is ambu-
latory, bathing, sleeping, or traveling.
䊏 Identify actions to take to solve problems when the alarm
signals.
Intramuscular. The intramuscular (IM) route should be
abandoned for administration of analgesics (APS, 2008). Dis-
advantages include variable absorption, unpredictable onset of
action and peak effect, as well as the tissue damage that may re-
sult, even if properly administered. Regardless of precautions
taken, there is pain involved with administration. IM injection
may lead to nerve damage with persistent neuropathic pain
(APS, 2008, p. 47).
Intravenous. The IV route provides the most rapid onset for
pain relief with few side effects. However, just as the onset of
pain relief occurs in 5 to 10 minutes, so can adverse effects, such

as respiratory depression. The analgesic can be administered by
IV bolus or by continuous infusion. IV medications should be
given slowly to decrease adverse effects. Caution is needed to
prevent the introduction of air or bacteria into the tubing, and
to prevent the introduction of medications that are incompati-
ble with other medications dissolved in the IV solution.
Intraspinal. Another method of delivery is the infusion of
opioids into the epidural or intrathecal (subarachnoid) space
(Figure 46–11 ■). Analgesics administered via the intraspinal
route are delivered adjacent to the opiate receptors in the dorsal
horn of the spinal cord. Two commonly used medications are
morphine sulfate and fentanyl. All medicines administered via
the intraspinal route need to be sterile and preservative free
(preservatives are neurotoxic). The major benefit of intraspinal
drug therapy is superior analgesia with less medication used.
The epidural space is most commonly used because the dura
mater acts as a protective barrier against infection, including
meningitis, and there is less risk of developing a “spinal
headache.” Intraspinal catheters are not in constant contact
with blood, and thus an infusion can be stopped and restarted
later without concern that the catheter is no longer patent.
Intrathecal administration delivers medication directly into
the cerebrospinal fluid (CSF) that bathes and nourishes the
spinal cord. Medicines quickly and efficiently bind to the opi-
oid receptor sites in the dorsal horn when administered in this
fashion, speeding the onset and peak effect, while prolonging
the duration of action of the analgesic. An example of how the
route of administration affects the relative potency of opiates is
as follows: A client who requires 300 mg of oral morphine per
day to control pain will need 100 mg of parenteral morphine,
10 mg of epidural morphine, and only 1 mg of intrathecal mor-
phine in a 24-hour period. Very little drug is absorbed by blood
vessels into the systemic circulation. In fact, the drug must cir-
Figure 46–11 ■ Placement of intraspinal catheter in the epidural space.
CHAPTER 46 / Pain Management 1233
culate through the CSF to be excreted. As a result, there may be
a delayed onset (24 hours following the administration) of re-
spiratory depression, because medication that has left the
spinal opioid sites travels through the brain to be eliminated.
In contrast, the epidural space is separated from the spinal cord
by the dura mater, which acts as a barrier to drug diffusion. In ad-
dition, it is filled with fatty tissue and an extensive venous system.
With this diffusion delay, some medications (especially fat-soluble
medications like fentanyl) from the epidural space enter the sys-
temic circulation via the venous plexus. Thus a higher dose of
opiate is required to create the desired effect, which can produce
side effects of itching, urinary retention, and/or respiratory de-
pression. Often, an opioid (e.g., fentanyl) and a local anesthetic
(e.g., bupivacaine) are combined to lower the dose of opioid
needed. As a result, there may be an increase in fall risk for some
clients who develop muscular weakness in their legs or orthosta-
tic hypotension in response to the local anesthetic.
Intraspinal analgesia can be administered by three modes of
operation:
1. Bolus. A single or repeated bolus dose(s) may be provided.
When clients have spinal anesthesia (e.g., during a ce-
sarean section), a bolus of 1 mg intrathecal preservative-
free morphine can provide significant pain control for up
to 24 hours. For shorter acting medications, an epidural
catheter may be intact and accessed by a qualified health
professional (e.g., anesthesiologist or nurse anesthetist) to
administer bolus doses on an “as-needed” basis. Check
your state regulations and agency policy regarding who
can provide these bolus doses, how they are documented,
and the postbolus monitoring procedures.
2. Continuous infusion administered by pump. The pump
may be external (for acute or chronic pain) or surgically
Spinal cord
Pia mater
Subarachnoid space
Dura mater and
arachnoid mater
Epidural space
Catheter in
epidural space
Epidural
analgesia
Vertebra
Spinal cord
L2-L 3
intervertebral
space
1234 UNIT 10 / Promoting Physiological Health

implanted (for chronic pain) to provide a continuous infu-
sion of pain relievers into the epidural or intrathecal space.
3. Continuous plus intermittent bolus. With this mode of op-
eration, the client receives a continuous infusion with bo-
lus “rescue” doses administered for breakthrough pain.
Often a pump with patient-controlled epidural analgesia
(PCEA) capabilities is used for this mode of operation.
This is similar to patient-controlled analgesia (detailed
later) in which a basal rate may or may not be used to meet
the client’s anticipated analgesic need, with the client’s
ability to request an incremental dose at set intervals by
pressing a button. PCEA is often used to manage acute
postoperative pain, chronic pain, and intractable cancer
pain. The “walking epidurals” used for women in labor are
typically PCEA devices that are programmed in the bolus
mode without a continuous infusion (basal rate) set.
The anesthesiologist or nurse anesthetist inserts a needle
into the intrathecal or epidural space (typically in the lumbar
region) and threads a catheter through the needle to the desired
level. The catheter is connected to tubing that is then positioned
along the spine and over the client’s shoulder for the nurse to
access. The entire catheter and tubing are taped securely to pre-
vent dislodgment. Often an occlusive, transparent dressing is
placed over the insertion site for easy identification of catheter
displacement or local inflammation. Temporary catheters, used
for short-term acute pain management, are usually placed at the
lumbar or thoracic vertebral level and usually removed after 2
to 4 days. Permanent catheters, for clients with chronic pain,
may be tunneled subcutaneously through the skin and exit at
the client’s side or be connected to a pump implanted in the ab-
domen. Tunneling of the catheter reduces the risk of infection
and displacement of the catheter. After the catheter is inserted,
the nurse is responsible for monitoring the infusion and assess-
ing the client per institutional policy. Nursing care of clients
with intraspinal infusions is summarized in Table 46–7.
Misconceptions exist about the risks of spinal analgesia. This
is in part due to the importance of the technique of the profes-
sional while inserting the catheter. In general, clients receiving
epidural analgesia do not need to be monitored in an intensive
care setting, but they do need vigilant assessment of their pain,
neurologic and respiratory status, and the insertion site during
the course of therapy (Pasero, Manworren, & McCaffery, 2007).
SAFETY ALERT
As a precaution, have naloxone (Narcan), sodium chloride
0.9% diluent, and injection equipment on hand for each
client receiving an opioid-containing epidural infusion.
Continuous Local Anesthetics. Continuous subcutaneous
administration of long-acting local anesthetics into or near a surgi-
cal site is a technique being used to provide postoperative pain con-
trol. This technique has been used for a variety of surgical
procedures, including knee arthroplasty, abdominal hysterectomy,
hernia repair, and mastectomy. Nursing interventions for the client
with infusion of a continuous local anesthetic include the following:
䊏 Conduct pain assessment and documentation every 2 to 4
hours while the client is awake.
䊏 Check the dressing every shift to ensure it is intact. The
dressing is not usually changed in order to avoid dislodging
the catheter. Contact the primary care provider if the dress-
ing becomes loose.
䊏 Check the site of the catheter. It should be clean and dry.

TABLE 46–7 Nursing Interventions for Clients Receiving Analgesics Through an Epidural Catheter
NURSING GOALS INTERVENTIONS
Maintain client safety Label the tubing, the infusion bag, and the front of the pump with tape marked EPIDURAL to prevent
confusion with similar-looking IV lines. (Most epidural tubings are yellow for this reason.) Post sign above
client’s bed indicating epidural is in place. Secure all connections with tape. If there is no continuous
infusion, apply tape over all injection ports on the epidural line to avoid the injection of substances
intended for IV administration into the epidural catheter. Do not use alcohol in any care of catheter or
insertion site because it can be neurotoxic. Ensure that any solution injected or infused intraspinally is
sterile, preservative free, and safe for intraspinal administration.
Maintain catheter Secure temporary catheters with tape. When bolus doses are used, gently aspirate prior to medication
placement administration to determine catheter has not migrated into the subarachnoid space. (Expect 1 mL of
fluid return in syringe.) Assist client in repositioning or moving out of bed. Teach client to avoid tugging on
the catheter. Assess insertion site for leakage with each bolus dose or at least every 8–12 hours.
Prevent infection Use strict aseptic techniques with all epidural-related procedures. Maintain sterile occlusive dressing over
insertion site. Assess insertion site for signs of infection. Assess for increasing diffuse back pain or
tenderness and/or paresthesia on intraspinal injection because these are cardinal signs of intraspinal
infection (McCaffery & Pasero, 1999, p. 234).
Maintain urinary and Monitor intake and output. Assess for bowel and bladder distention.
bowel function
Prevent respiratory Assess sedation level and respiratory status q1h for the first 24 hours and q4h thereafter. Do not
depression administer other opioids or CNS depressants unless ordered. Keep an ampule of naloxone hydrochloride
(0.4 mg) available. Notify the clinician in charge if the respiratory rate falls below 8 per minute or if the
client is difficult to rouse.
 CHAPTER 46 / Pain Management 1235

䊏 Assess the client for signs of local anesthetic toxicity (e.g.,

cardiac arrhythmias, dizziness; ringing in the ears; a metallic
taste; tingling or numbness of the lips, gums, or tongue) or
neurologic deficit distal to the catheter insertion site. Primary (maintenance)
IV fluid
䊏 Notify the primary care provider of signs of local anesthetic tox-
icity or neurologic deficit. If detected early, prompt treatment
should be initiated in order to prevent serious complications.

PATIENT-CONTROLLED ANALGESIA
Patient-controlled analgesia (PCA) is an interactive method of
pain management that permits clients to treat their pain by self- PCA pump
administering doses of analgesics. The IV route is the most com-
mon in an acute care setting. Its use for postoperative pain has
been well documented. It is also helpful when oral pain manage-
ment is not possible (APS, 2008). The PCA mode of therapy
minimizes the roller-coaster effect of peaks of sedation and val- Y-connector site
leys of pain that occur with the traditional method of prn dosing. for PCA tubing and
primary line
With the parenteral routes, the client administers a predeter-
mined dose of an opioid by an electronic infusion pump. This al-
lows the client to maintain a more constant level of relief yet
need less medication for pain relief. PCA can be effectively used Figure 46–12 ■ PCA line introduced into the injection port of a pri-
for clients with acute pain related to a surgical incision, traumatic mary line.
injury, or labor and delivery, and for chronic pain as with cancer.
The prescriber orders the analgesic, dose, demand (bolus) or without additional PCA doses administered by the client. This
dose interval, and lockout interval. Standardized medications practice, however, is no longer recommended for opioid-naïve
and order sets are recommended. The most commonly used clients due to the risk of oversedation.
opioids for PCA are morphine, hydromorphone (Dilaudid), and As PCA has increased in use, so have errors and other prob-
fentanyl. Meperidine (Demerol) is no longer recommended for lems, such as adverse (untoward, undesirable, and usually
PCA (APS, 2008). Whether in an acute hospital setting, an am- unanticipated) events. Problems that reduce PCA safety in-
bulatory clinic, or with home care, the nurse is responsible for clude improper client selection, pump problems, programming
the initial instruction regarding use of the PCA. Two registered errors, and PCA by proxy.
nurses should double-check the initial settings and for any Clients who use PCA must be able to understand how to use
changes in dose or medication and both should document this PCA and be able to physically push the button independently.
on the medical record (ISMP, 2007). The nurse also is respon- Clients who are not good candidates for PCA include infants
sible for ongoing monitoring of the therapy (i.e., checking at and young children who do not understand how to safely use
least once every 4 hours) (D’Arcy, 2008c). The client’s pain,
ability to understand, and use of the device must be assessed at
regular intervals. Analgesic use is documented in the client’s
record. The most significant adverse effects are respiratory de-
pression and hypotension; however, they occur rarely.
Although PCA pumps vary in design, they all have similar
protective features. The line of the PCA pump, a syringe-type
pump, is usually introduced into the injection port of a primary
IV fluid line (Figure 46–12 ■). When clients need a dose of
analgesic, they can push a button attached to the infusion pump
and a preset dose is delivered (Figure 46–13 ■). The dose inter-
val is usually set at 6 or 8 minutes for postoperative clients. This
means that the client can give himself a dose of medication every
6 or 8 minutes. Even if the client pushes the button more fre-
quently, the client will receive only one dose during the set dose
interval. The lockout interval is set at either 1 or 4 hours (de-
pending on agency policy). The lockout interval controls how
much medication a client receives in a 1- or 4-hour period. Cur-
rent APS guidelines recommend a 6- or 8-minute dose interval
with a 1-hour lockout (D’Arcy, 2008b, p. 52). The 1-hour lock-
out allows for closer PCA monitoring by the nurse. Many pumps
are capable of delivering a basal rate (continuous infusion), with Figure 46–13 ■ The older child is able to regulate a PCA pump.
1236 UNIT 10 / Promoting Physiological Health
PCA, confused older clients, individuals who are obese or have
asthma or sleep apnea, and clients taking other drugs that po-
tentiate opioids, such as muscle relaxants (D’Arcy, 2008b).
The design of the PCA pump can be problematic. For exam-
ple, the activation button may look like a call light button. As a
result, the client can give himself a dose by mistake when he
thought he was calling for a nurse. The nurse needs to be famil-
iar with all the features of the pump and teach the client appro-
priate use. It is recommended that the same PCA pump model
be used throughout the facility.
Improperly programming the PCA pump is the most com-
mon human error. Examples of errors include confusing milli-
liters and milligrams, decimal point errors (i.e., order is for
0.5 mg and the pump is programmed for 5 mg), using the load-
ing dose for the bolus dose, and wrong lockout settings. To in-
crease safety upon PCA initiation, many institutions now
require that two nurses independently check client ID, drug and
concentration, and PCA pump settings.
PCA by proxy is a term that describes activation of the PCA
pump by anyone other than the client (Wuhrman et al., 2007, p. 6).
For example, a well-intentioned family member may push the but-
ton when the client is sleeping or already sedated, leading to
oversedation. A natural safety feature of PCA is that a client who is
sleeping or sedated will not push the button and overmedicate him-
self. That is why it is important that the client is the only person to
push the button. To counteract this, some institutions put signs on
the PCA pump stating “only the client to push PCA button.”
The ASPMN differentiates between PCA by proxy (unautho-
rized activation of the pump) and authorized agent–controlled
analgesia (AACA). AACA is a method of pain control in which
a consistently available and competent individual is authorized
by a prescriber and properly educated to push the PCA button
CLIENT TEACHING Client Self-Management of Pain
Choose a time to teach the client about pain management
when the pain is controlled so that the client is able to focus
on the teaching.
Teaching the client about self-management of pain may
include the following:
■ Demonstrate the operation of the PCA pump and
explain that the client can safely push the button
without fear of overmedicating. Sometimes it helps
clients who are reluctant to repeatedly push the button
to know that they must dose themselves (i.e., push the
button) 5 to 10 times to receive the same amount of
medication (10 mg morphine equivalent) they would
receive in a standard “shot.”
■ Describe the use of the pain scale and encourage the
client to respond in order to demonstrate understanding.
■ Explore a variety of nonpharmacologic pain relief
techniques that the client is willing to learn and use to
promote pain relief and optimize functioning.
■ Explain to the client the need to notify staff when
ambulation is desired (e.g., for bathroom use) if applicable.
Lifespan Considerations
PCA Pump
CHILDREN
■ Include the parents in teaching.
■ Assess the child’s ability to use the client control button.
OLDER ADULTS
■ Carefully monitor for drug side effects.
■ Use cautiously for individuals with impaired pulmonary or
renal function.
■ Assess the client’s cognitive and physical ability to use
the client control button.
when the client is unable and in response to the client’s pain
(Wuhrman et al., 2007, p. 6). Nurse-controlled analgesia is the
term used when the authorized person is the nurse responsible
for the client. The term is caregiver–controlled analgesia when
a nonprofessional individual (e.g., parent, significant other) is
the authorized person. AACA is not appropriate if the client is
determined to be able to use PCA.
NONPHARMACOLOGIC PAIN MANAGEMENT
Nonpharmacologic pain management consists of a variety of
physical, cognitive-behavioral, and lifestyle pain management
strategies that target the body, mind, spirit, and social interac-
tions (Table 46–8). Physical modalities include cutaneous stim-
ulation, ice or heat, immobilization or therapeutic exercises,
transcutaneous electrical nerve stimulation (TENS), and
acupuncture. Mind–body (cognitive-behavioral) interventions
include distracting activities, relaxation techniques, imagery,
meditation, biofeedback, hypnosis, cognitive reframing, emo-
tional counseling, and spiritually directed approaches such as
therapeutic touch or Reiki. Lifestyle management approaches in-
clude symptom monitoring, stress management, exercise, nutri-
tion, pacing activities, disability management, and other
approaches needed by many clients with persistent pain that has
drastically changed their life. For further information on selected
mind–body interventions and acupuncture, see Chapter 19.
This discussion is limited to selected physical and cognitive-
behavioral interventions.
Home Care Considerations
PCA Pump
■ Monitor for signs and symptoms of oversedation such as
excessive drowsiness, slowed respiratory rate, or change
in mental state.
■ Do not adjust settings without consulting with the
appropriate primary care provider.
■ Tape to the back of the pump the following emergency
contact numbers: emergency medical services, primary
care provider, home care agency, and pump manufacturer.
 CHAPTER 46 / Pain Management 1237

TABLE 46–8 Nonpharmacologic Physical Interventions: Cutaneous Stimulation. The

Interventions for Pain Control goals of physical intervention include providing comfort, alter-
ing physiological responses to reduce pain perception, and opti-
TARGET DOMAIN mizing functioning. Cutaneous stimulation can provide effective
OF PAIN CONTROL INTERVENTION temporary pain relief. It distracts the client and focuses attention
Body Reducing pain triggers, promoting comfort on the tactile stimuli, away from the painful sensations, thus re-
Massage ducing pain perception. Cutaneous stimulation is also believed
Applying heat or ice to interfere with the transmission and perception of pain by
Electric stimulation (TENS)
stimulating the large-diameter A-beta sensory nerve fibers that
Positioning, bracing (selective
immobilization) (close the gate) by activating the descending mechanisms that
Acupressure can reduce the intensity of pain, activate the endorphin system
Diet, nutritional supplements of pain control, and thus diminish conscious awareness of
Exercise, pacing activities pain. Selected cutaneous stimulation techniques include the
Invasive interventions (e.g., blocks) following:
Sleep hygiene
Mind Relaxation, imagery 䊏 Massage
Self-hypnosis 䊏 Application of heat or cold
Pain diary, journal writing 䊏 Acupressure
Distracting attention 䊏 Contralateral stimulation.
Repatterning thinking
Attitude adjustment
Cutaneous stimulation can be applied directly to the painful
Reducing fear, anxiety, stress
Reducing sadness, helplessness area, proximal to the pain or distal to the pain (along the nerve
Information about pain path or dermatome), and contralateral (exact location, opposite
Music therapy side of the body) to the pain. Cutaneous stimulation is con-
Spirit Prayer, meditation traindicated in areas of skin breakdown or impaired neurologic
Self-reflection regarding life and pain functioning.
Meaningful rituals
Energy work (e.g., therapeutic touch, Reiki) Massage Massage is a comfort measure that can aid relaxation,
Spiritual healing decrease muscle tension, and may ease anxiety because the phys-
Social interactions Functional restoration ical contact communicates caring. It can also decrease pain inten-
Improved communication sity by increasing superficial circulation to the area. Massage can
Pet therapy
involve the back and neck, hands and arms, or feet. The use of
Family therapy
Problem solving
ointments or liniments may provide localized pain relief with
Vocational training joint or muscle pain. Massage is contraindicated in areas of skin
Volunteering breakdown, suspected clots, or infections. See Skill 46–1.
Support groups

Providing a Back Massage

Effleurage is a type of massage consisting of long, slow,
gliding strokes. Research demonstrates that back massage
SKILL 46–1

can enhance client comfort, relaxation, and sleep.

Purposes
■ To relieve muscle tension
■ To decrease pain intensity
■ To promote physical and mental relaxation

ASSESSMENT
Assess:
■ Behaviors indicating potential need for a back massage,
such as a complaint of stiffness, muscle tension in the
back or shoulders, or difficulty sleeping related to
tenseness or anxiety
■ Whether the client is willing to have a massage, because
some individuals may not enjoy a massage
■ Contraindications for back massage (e.g., coagulation
issues, clots, impaired skin integrity, back surgery, vertebral
issues, or risk of fracture)

Continued on page 1238

 1238 UNIT 10 / Promoting Physiological Health

Providing a Back Massage—continued

PLANNING Equipment
Ensure that you have adequate time available for the massage. ■ Lotion
SKILL 46–1

Although the actual skill may require only about 5 minutes, the ■ Towel for excess lotion
entire process should be conducted in a calm and unhurried
manner.

Delegation
The nurse can delegate this skill to UAP; however, the
nurse should first assess for UAP’s comfort and ability, any
contraindications, and client willingness to participate.

IMPLEMENTATION
Providing a Back Massage: Skill Checklist

Preparation
Determine (a) previous assessments of the skin, (b) special
lotions to be used, and (c) positions contraindicated for the
client. Arrange for a quiet environment with no interruptions to
promote maximum effect of the back massage. 2 2
Performance
1. Prior to performing the procedure, introduce self and
verify the client’s identity using agency protocol. Explain
to the client what you are going to do, why it is
necessary, and how he or she can participate. Encourage
the client to give you feedback as to the amount of 1
pressure you are using during the back rub.
2. Perform hand hygiene and observe other appropriate 3 3
infection control procedures.
3. Provide for client privacy.
4. Prepare the client.
• Assist the client to move to the near side of the bed
within your reach and adjust the bed to a comfortable  One suggested pattern for a back massage.
working height. Rationale: This prevents back strain.
• Establish which position the client prefers. The prone
position is recommended for a back rub. The side-lying • Apply firm, continuous pressure without breaking
position can be used if a client cannot assume the contact with the client’s skin.
prone position. • Repeat above for 3 to 5 minutes, obtaining more lotion
• Expose the back from the shoulders to the inferior sacral as necessary.
area. Cover the remainder of the body. Rationale: This • While massaging the back, assess for skin redness
is to prevent chilling and minimize exposure. and areas of decreased circulation.
5. Massage the back. • Pat dry any excess lotion with a towel.
• Pour a small amount of lotion onto the palms of your 6. Document that a back massage was performed and the
hands and hold it for a minute. The lotion bottle can client’s response. Record any unusual findings.
also be placed in a bath basin filled with warm water.
Rationale: Back rub preparations tend to feel SAMPLE DOCUMENTATION
uncomfortably cold to people. Warming the solution 6/22/2011 1400 Reports aching, intermittent back pain.
facilitates client comfort.
• Using your palm, begin in the sacral area using
Wincing and grimacing when attempting to move in bed.
smooth, circular strokes. Rates pain at 4–5 on 0–10 scale. States uses massage to help
• Move your hands up the center of the back and then relieve pain when at home. Back massaged. Stated the
over both scapulae.
• Massage in a circular motion over the scapulae.
massage helped him “ to relax.” Lights dimmed and door to
• Move your hands down the sides of the back. room closed. _____________________ D. Aubrey, RN
• Massage the areas over the right and left iliac crests.
Massage the back in an orderly pattern using a variety 1430 Reports pain at 1–2/10. States feels “much more
of strokes and appropriate pressure.  comfortable.” Moving in bed with ease. _______ D. Aubrey, RN
EVALUATION
Compare the client’s current response to his or her previous response. Is there a positive client outcome such as increased
relaxation and decrease in pain and anxiety because of the back massage?

Heat and Cold Applications A warm bath, heating pads, ice
bags, ice massage, hot or cold compresses, and warm or cold sitz
baths in general relieve pain and promote healing of injured tis-
sues (see Chapter 36 ). Cold works best when applied within
the first 24 hours of injury or condition, while heat is primarily
used to treat the chronic phase of an injury or condition, usually
48 hours after an acute injury (Metules, 2007, p. 46.).
Acupressure Acupressure developed from the ancient Chinese
healing system of acupuncture. The therapist applies finger pres-
sure to points that correspond to many of the points used in
acupuncture (see Chapter 19 ).
Contralateral Stimulation Contralateral stimulation can be ac-
complished by stimulating the skin in an area opposite to the
painful area (e.g., stimulating the left knee if the pain is in the right
knee). The contralateral area may be scratched for itching, mas-
saged for cramps, or treated with cold packs, heat application, or
analgesic ointments. This method is particularly useful when the
painful area cannot be touched because it is hypersensitive, when
it is inaccessible by a cast or bandages, or when the pain is felt in
a missing part (phantom pain). The nurse should explain the ra-
tionale to the client in that nerves are crossed in the spinal cord,
and that is why these techniques may work contralaterally.
Immobilization/Bracing. Immobilizing or restricting the
movement of a painful body part (e.g., arthritic joint, traumatized
limb) may help to manage episodes of acute pain. Splints or
supportive devices should hold joints in the position of optimal
function and should be removed regularly in accordance with
agency protocol to provide range-of-motion (ROM) exercises.
Prolonged immobilization can result in joint contracture, muscle
atrophy, and cardiovascular problems. Therefore, clients should
be encouraged to participate in self-care activities and remain as
active as possible, with frequent ROM exercises.
Transcutaneous Electrical Nerve Stimulation. Trans-
cutaneous electrical nerve stimulation (TENS) is a method of
applying low-voltage electrical stimulation directly over
identified pain areas, at an acupressure point, along peripheral
nerve areas that innervate the pain area, or along the spinal
column. The TENS unit consists of a portable, battery-operated
device with lead wire and electrode pads that are applied to the
chosen area of skin (Figure 46–14 ■). Cutaneous stimulation
from the TENS unit is thought to activate large-diameter fibers
that modulate the transmission of the nociceptive impulse in the
peripheral and CNS (closing the pain “gate”), resulting in pain
relief. This stimulation may also cause a release of endorphins
from the CNS centers. The use of TENS is contraindicated for
clients with pacemakers or arrhythmias, or in areas of skin
breakdown. It is generally not used on the head or over the chest.
Cognitive-Behavioral Interventions. The goals of cognitive-
behavioral interventions include providing comfort, altering psy-
chological responses to reduce pain perception, and optimizing
functioning. Selected cognitive-behavioral interventions include
distraction, eliciting the relaxation response, repatterning think-
ing, and facilitating coping with emotions.
CHAPTER 46 / Pain Management 1239
Figure 46–14 ■ A transcutaneous electric nerve stimulator.
Distraction Distraction draws the person’s attention away from
the pain and lessens the perception of pain. In some instances, it
can make a client completely unaware of pain. Distraction makes
the person unaware of the pain only for the amount of time and to
the extent that the distracting activity holds his or her “undivided”
attention. For example, a client recovering from surgery may feel
no pain while watching a football game on television, yet feel
pain again during commercials or when the game is over. Differ-
ent types of distractions are shown in Box 46–9. Using multiple
forms of distraction simultaneously adds value to the activity. For
example, listening to music can be distracting; however, the value
can be added by tapping to the music, singing along, or playing
along on a musical instrument. Play therapy can be a distraction
for children.
Eliciting the Relaxation Response Stress increases pain, in
part by increasing muscle tension, activating the sympathetic ner-
vous system, and putting the client at risk for stress-related types
of pain (e.g., tension headaches). The relaxation response de-
creases and counteracts the harmful effects of stress, including the
BOX 46–9 Types of Distraction
VISUAL DISTRACTION
■ Reading or watching television
■ Watching a baseball game
■ Guided imagery
AUDITORY DISTRACTION
■ Humor
■ Music
TACTILE DISTRACTION
■ Slow, rhythmic breathing
■ Massage
■ Holding or stroking a pet or toy
INTELLECTUAL DISTRACTION
■ Crossword puzzles
■ Card games (e.g., bridge)
■ Hobbies (e.g., stamp collecting, writing a story)
1240 UNIT 10 / Promoting Physiological Health
Can a Child’s Postoperative Pain Be Reduced Using Guided Imagery?
Studies report that postoperative pediatric clients suffer moderate
to severe pain during hospitalization even after receiving
analgesics. The Agency for Health Care Policy and Research and
the American Society of Anesthesiologists have developed
guidelines that recommend using a combination of pharmacologic
and nonpharmacologic techniques to manage children’s pain.
Children use vivid imagination in their daily lives and the
researchers wondered if this skill could provide therapeutic
distraction for a child in pain. Researchers have examined imagery
interventions during procedures. However, few studies have
focused on guided imagery in the relief of postoperative pain in
children. The purpose of this study by Huth, Daraisch, Henson,
and McLeod (2009) was to establish content validity for the Magic
Island: Relaxation for Kids CD. The research questions asked if the
use of the audio CD would lead to decreased pain, increased
relaxation, and stimulate the imagination in school-age children
effect it has on physical, cognitive, and emotional functioning.
Eliciting this response requires more than simply helping a per-
son to relax; rather it involves a structured technique designed to
focus the mind and relax muscle groups. Basic techniques with
helpful scripts are available for common techniques including
progressive relaxation, breath-focus relaxation, and meditation.
The nurse can coach the client, urge self-directed meditation, or
provide an audiotaped guide to help elicit the relaxation response.
Many clients can achieve the desired state after a few attempts,
but mastery of this skill requires daily practice over a few weeks.
In general, relaxation techniques by themselves do not have re-
markable pain-relieving properties; however, they can reduce
pain that may have been exacerbated by stress. Some clients may
become more consciously aware of their pain while practicing re-
laxation techniques before they have learned mastery of control-
ling “mind chatter” and remaining mentally focused.
Once the client has mastered the basic skills for eliciting the
relaxation response, techniques of imagery or self-hypnosis
can be used. Both imagery and hypnosis begin with attaining a
deep state of relaxation and are capable of altering the experi-
ence of pain; for example, having the client replace the pain
with a feeling of pleasant numbness. Additional post-hypnotic
suggestions can then be made, linking these pleasant numb sen-
sations to coping efforts used during the day (e.g., “Every time
you stop to take a slow, deep, diaphragmatic breath, you will
feel this pleasant numbness instead of pain”).
Music therapy can also be useful for providing relaxation
and distraction from pain (Dunn, 2009). With iPods and
portable CD players, clients can listen to their favorite tunes as
a helpful distraction from pain.
Repatterning Unhelpful Thinking Some people harbor strong
self-doubts, unrealistic expectations (e.g., “I just want someone to
make the pain go away”), rumination (e.g., “I keep thinking about
my pain and the person who did this to me”), helplessness (e.g.,
“I can’t do anything”), and magnification (e.g., “My life is ruined,
I’ll never be a good parent because of my pain”). These cognitive
who have had surgery. A cross-sectional pre/post-test design was
used. A convenience sample of 17 children between 7 and 12
years of age who had recently undergone surgery was used in the
study. An eight-question tool was used to collect data regarding
relaxation and pain levels as well as details of what the child
imagined after listening to the CD. The results showed that the
imagery audio CD lowered self-reported pain from pre- to post-
intervention and stimulated their imagination; however, there was
no significant increased relaxation.
IMPLICATIONS
Despite the limitations of the study (e.g., small sample size),
the study provided evidence that children 7 to 12 years of age
were able to use guided imagery in the hospital setting.
Imagery can provide the child with another coping method to
address the stress of pain, illness, and hospitalization.
patterns have been identified as important contributors to treat-
ment failures and the intensification of pain, disability, and de-
pression. Nurses can help by challenging the truthfulness and
helpfulness of these thoughts, and replacing them with realistic
and confidence-building ones that are particularly powerful pre-
dictors of more effective coping, better clinical outcomes, and im-
proved quality of life.
Facilitating Coping Nurses can help by intervening with clients
who are anxious, are sad, or express overly pessimistic or help-
less points of view. Awareness of the client’s misperceptions or
unrealistic expectations also helps the professional avoid a com-
mon cause of therapeutic failure. Therapeutic communication
with an emphasis on listening, providing encouragement, teach-
ing self-management skills, sharing vicarious experiences, and
persuading them to act on their own behalf are strategies that en-
hance coping. Helping clients to better communicate with the
professional staff, family members, and friends can also promote
coping. Counseling from trained professionals may be indicated
for those clients with severe emotional distress, but must be of-
fered to them in a sensitive way that does not convey the notion
that pain is “in their head.” Chronic pain support groups have
been effective for many clients.
Selected Spiritual Interventions. The spiritual dimen-
sion encompasses a person’s innermost concerns and values,
including the ascribed purpose, meaning, and driving force in
his or her life. It may include rituals that help the individual
become part of a community or feel a bond with the universe
that is not necessarily religious in nature. For those who ex-
press their spirituality in a religious context, it is appropriate
to offer prayer, intercessory prayer (being prayed for by oth-
ers), or access to meaningful rituals. For some clients, a caring
presence, attentive listening, and facilitating the process of ac-
ceptance can help reduce spiritual distress, whereas other
clients benefit from manipulation of energy patterns (e.g., ther-
apeutic touch).

Lifespan Considerations Pain Management
INFANTS
■ Giving an infant, particularly a very-low-birth-weight infant, a
water and sucrose solution administered through a pacifier
provides some evidence of pain reduction during
procedures that may be painful, but should not be a
substitute for anesthetic or analgesic medications.
CHILDREN
■ Distract the child with toys, books, or pictures.
■ Hold the child (or ask the parent to hold) to console and
promote comfort.
■ Explore misconceptions about pain and correct in
understandable “concrete” terms. Be aware of how your
explanations may be misunderstood. For example, telling a
child they won’t hurt during surgery because they will be
“put to sleep” will be very upsetting to a child who knows
of an animal that was “put to sleep.”
Through improved spiritual insights, individuals with pain can
find meaning in what seems incomprehensible and learn to cope
with the intolerable. This process often begins by making peace
with their past, being spiritually aware in the present, and making
a commitment to go forward with life despite the pain (Carson &
Koenig, 2008). By shifting awareness from within to external
sources of power, pain sufferers can transcend the limits of their
pain to find new energy and a renewed sense of purpose.
NONPHARMACOLOGIC INVASIVE THERAPIES
A nerve block is a chemical interruption of a nerve pathway, ef-
fected by injecting a local anesthetic into the nerve. Nerve blocks
are widely used during dental work. The injected drug blocks
nerve pathways from the painful tooth, thus stopping the transmis-
sion of pain impulses to the brain. Nerve blocks are often used to
relieve the pain of whiplash injury, lower back disorders, bursitis,
and cancer. With the intention of quieting “pain generators” (irri-
table nerves that cause the pain), a combination of a long-acting
local anesthetic and a steroid is injected adjacent to the problem
nerve (e.g., lumbar epidural steroid injections, joint injections).
The local anesthetic should provide relief for several hours, before
the effect of the steroid begins a day or two later. Often a series of
three injections is scheduled weeks or months apart. Each subse-
quent injection should result in a longer duration of pain relief. No
Home Care Considerations
Pain Management
■ Teach the client to keep a pain diary to monitor pain onset,
activity before pain, pain intensity, use of analgesics, or
other relief measures and effectiveness of each measure.
■ Instruct the client to contact a health care professional if
planned pain control measures are ineffective.
■ Teach the use of preferred and selected nonpharmacologic
techniques such as relaxation, guided imagery, distraction,
music therapy, and massage.
CHAPTER 46 / Pain Management 1241
■ Children can use their imagination during guided imagery.
Ask the child to imagine a “pain switch” (even give it
a color) and to visualize turning the switch off in the
area where there is pain. A “magic glove” or “magic
blanket” is an imaginary object that the child applies on
areas of the body (e.g., hand, thigh, back, hip) to lessen
discomfort.
OLDER ADULTS
■ Promote clients’ use of pain control measures that have
worked in the past for them.
■ Spend time with clients and listen carefully.
■ Clarify misconceptions. Encourage independence whenever
possible.
■ Carefully review the treatment plan to avoid drug–drug,
food–drug, or disease–drug interactions.
more than three injections per year are recommended because of
the mineral-robbing effect steroids have on bones in the area.
Evaluating
The goals established in the planning phase are evaluated ac-
cording to specific desired outcomes, also established in that
phase (see Identifying Nursing Diagnoses, Outcomes, and In-
terventions earlier in this chapter). To assist in the evaluation
process, flow sheet records or a client diary may be helpful. A
weekly log or diary can be structured in a similar fashion for
the individual client. For example, columns including day,
time, onset of pain, activity before pain, pain relief measure,
and duration of pain can be devised to help the client and nurse
determine the effectiveness of pain relief strategies.
CLINICAL ALERT
The statement “Please tell me how I can best help you control
your pain” sends a couple of subtle messages that are an
important part of treatment planning and evaluation of care.
First, it places the ownership and responsibility for controlling
pain on the client. Second, it acknowledges that the client may
be the best judge of what is needed, respecting the cultural
meaning of pain and acceptable ways of expressing/controlling
pain. Third, it establishes the nurse’s role in helping the client
be more comfortable and in control of his or her condition.
■ Instruct the client to use pain control measures before the
pain becomes severe.
■ Inform the client of the effects of untreated pain.
■ Provide appropriate information about how to access
community resources, home care agencies, and
associations that offer self-help groups and educational
materials.
 1242 UNIT 10 / Promoting Physiological Health

If outcomes are not achieved, the nurse and client need to
explore the reasons before modifying the care plan. The nurse
might consider the following questions:
䊏 Is adequate analgesic being given? Would the client benefit
from a change in dose or in the time interval between doses
or in the type of analgesic?
䊏 Were the client’s beliefs, expectations, and values about pain
therapy considered?
䊏 Did the client understate the pain experience for some reason?
䊏 Were appropriate instructions provided to allay misconcep-
tions about pain management?
Critical Thinking Checkpoint: Answers
䊏 Did the client and support people understand the instructions
about pain management techniques?
䊏 Is the client receiving adequate support for both physical
pain and emotional distress?
䊏 Has the client’s physical condition changed, necessitating
modifications in interventions?
䊏 Should selected intervention strategies be reevaluated?
See the Nursing Care Plan and the Concept Map.

Critical Thinking Checkpoint

Mrs. Lundahl underwent abdominal surgery approximately 6
hours ago. She has a 15-cm midline incision that is covered
with a dry, intact surgical dressing. On assessment, you note
that Mrs. Lundahl is perspiring, lying in a rigid position, holding
her abdomen, and grimacing. Her blood pressure is 150/90,
heart rate 100, and respiratory rate 32. When asked to rate her
pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as
long as she remains perfectly still. There is a sharp area of pain
at her incision; however, the most bothersome pain is crampy
and dull, like she was “kicked in the stomach” with severe
exacerbations that come in unpredictable waves.
1. What conclusions, if any, can be drawn about Mrs.
Lundahl’s pain status?
2. Does Mrs. Lundahl’s rating her pain as 5 mean that she is
not experiencing pain severe enough to warrant
intervention?
3. What type of pain is Mrs. Lundahl experiencing?
4. What interventions, in addition to pain medication, may be
useful in reducing Mrs. Lundahl’s pain?
5. How will you know if your interventions have been
effective in reducing Mrs. Lundahl’s pain?
See Critical Thinking Possibilities answers on student resource website.

NURSING CARE PLAN Acute Pain

ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*

Nursing Assessment Acute Pain related to tissue Pain Control [1605] as evidenced by
Mr. C. is a 57-year-old businessman who was admitted to injury secondary to surgical often demonstrating ability to
the surgical unit for treatment of a possible strangulated intervention (as evidenced by ■ Use analgesics as recommended
inguinal hernia. Two days ago he had a partial bowel restlessness; pallor; elevated ■ Use nonanalgesic relief measures
resection. Postoperative orders include NPO, IV infusion pulse, respirations, and ■ Report uncontrolled symptoms to
of D5 1/2NS at 125 mL/hr left arm, nasogastric tube to systolic blood pressure; health care professional
low intermittent suction. Mr. C. is in a dorsal recumbent dilated pupils; and report of
Pain Level [2102] As evidenced by
(supine) position and is attempting to draw up his legs. 7/10 abdominal pain)
mild to no
He appears restless and is complaining of abdominal pain
■ Reported pain
(7 on a scale of 0–10).
■ Protective body positioning
■ Restlessness
Physical Examination Diagnostic Data
■ Pupil dilation
Height: 188 cm (6 3) Chest x-ray and urinalysis
■ Perspiration
Weight: 90.0 kg (200 lb) negative, WBC 12,000
■ Change in BP, HR, R from normal
Temperature: 37°C (98.6°F)
baseline data
Pulse: 90 beats/min
Respirations: 24/min
Blood pressure: 158/82 mmHg
Skin pale and moist, pupils
dilated. Midline abdominal
incision, sutures dry and intact.

NURSING CARE PLAN Acute Pain—continued
NURSING INTERVENTIONS*/SELECTED ACTIVITIES
Pain Management [1400]
Perform a comprehensive assessment of pain to include
location, characteristics, onset, duration, frequency, quality,
intensity or severity, and precipitating factors of pain.
Consider cultural influences on pain response (e.g., cultural
beliefs about pain may result in a stoic attitude).
Reduce or eliminate factors that precipitate or increase Mr. C.’s
pain experience (e.g., fear, fatigue, monotony, and lack of
knowledge).
Teach the use of nonpharmacologic techniques (e.g., relaxation,
guided imagery, music therapy, distraction, and massage) before,
after, and if possible during painful activities; before pain occurs
or increases; and in combination with other pain relief measures.
Provide Mr. C. optimal pain relief with prescribed analgesics.
Medicate before an activity to increase participation, but evaluate
the hazard of sedation.
Evaluate the effectiveness of the pain control measures used
through ongoing assessment of Mr. C.’s pain experience.
Analgesic Administration [2210]
Check the medical order for drug, dose, and frequency of
analgesic prescribed.
Determine analgesic selections (narcotic, nonnarcotic, or NSAID)
based on type and severity of pain.
Institute safety precautions as appropriate if Mr. C. receives
opioid analgesics.
Instruct Mr. C. to request prn pain medication before the pain is
severe.
Evaluate the effectiveness of analgesic at regular, frequent
intervals after each administration and especially after the initial
doses, also observing for any signs and symptoms of untoward
effects (e.g., constipation, nausea and vomiting, dry mouth, and
respiratory depression).
Document Mr. C.’s response to analgesics and any untoward
effects.
Implement actions to decrease untoward effects of analgesics
(e.g., constipation and gastric irritation).
CHAPTER 46 / Pain Management 1243
RATIONALE
Pain is a subjective experience and must be described by the
client in order to plan effective treatment.
Each person experiences and expresses pain in an individual
manner using a variety of sociocultural adaptation techniques.
Personal factors can influence pain and pain tolerance. Factors
that may be precipitating or augmenting pain should be
reduced or eliminated to enhance the overall pain
management program.
The use of noninvasive pain relief measures can increase the
release of endorphins and enhance the therapeutic effects of
pain relief medications.
Each client has a right to expect maximum pain relief. Optimal
pain relief using analgesics includes determining the preferred
route, drug, dosage, and frequency for each individual.
Medications ordered on a prn basis should be offered to the
client at the interval when the next dose is available.
Turning and ambulation activities will be enhanced if pain is
controlled or tolerable. Assessing level of sedation should
precede the activity to ensure necessary safety precautions
are put in place.
Research shows that the most common reason for unrelieved
pain is failure to routinely assess pain and pain relief. Many
clients silently tolerate pain if not specifically asked about it.
Ensures that the nurse has the right drug, right route, right
dosage, right client, right frequency.
Various types of pain (e.g., acute, chronic, nociceptive,
neuropathic) require different analgesic approaches. Some types
of pain respond to nonopioid drugs alone, while others can be
relieved by combining a low-dose opioid with a nonopioid.
Side effects of opioids include drowsiness and sedation.
Severe pain is more difficult to control and increases the
client’s anxiety and fatigue. The preventive approach to pain
management can reduce the total 24-hour analgesic dose.
The analgesic dose may not be adequate to raise the client’s
pain threshold or may be causing intolerable or dangerous side
effects or both. Ongoing evaluation will assist in making
necessary adjustments for effective pain management.
Documentation facilitates pain management by
communicating effective and noneffective pain management
strategies to the entire health care team.
Constipation is the most common side effect of opioids, and a
treatment plan to prevent occurrence should be instituted at
the beginning of analgesic therapy. For Mr. C., constipation
could result from his primary condition or his analgesia.
Assess for overall GI functioning, possible complications of
surgery (e.g., ileus), as well as opioid-induced constipation or
NSAID-induced gastritis.
Continued on page 1244
 1244 UNIT 10 / Promoting Physiological Health

NURSING CARE PLAN Acute Pain—continued

Simple Relaxation Therapy [6040]

Consider Mr. C.’s willingness and ability to participate,
preference, past experiences, and contraindications before
selecting a specific relaxation strategy.
Elicit behaviors that are conditioned to produce relaxation, such
as deep breathing, yawning, abdominal breathing, or peaceful
imaging.
Create a quiet, nondisruptive environment with dim lights and
comfortable temperature when possible.
Individualize the content of the relaxation intervention (e.g., by
asking for suggestions about what Mr. C. enjoys or finds
relaxing).
Demonstrate and practice the relaxation technique with Mr. C.
Evaluate and document his response to relaxation therapy.
The client must feel comfortable trying a different approach to
pain management. To avoid ineffective strategies, the client
should be involved in the planning process.
Relaxation techniques help reduce skeletal muscle tension,
which will reduce the intensity of the pain.
Comfort and a quiet atmosphere promote a relaxed feeling
and permit the client to focus on the relaxation technique
rather than external distraction.
Each person may find different images or approaches to
relaxation more helpful than others. The nurse should have a
variety of relaxation scripts or audiovisual aids to help clients
find the best one for them.
Return demonstrations by the participant provide an
opportunity for the nurse to evaluate the effectiveness of
teaching sessions.
Conveys to the health care team effective strategies in
reducing or eliminating pain.

EVALUATION
Applying Critical Thinking: Answers

Outcomes partially met. The client verbalizes pain and discomfort, requesting analgesics at onset of pain. States “the pain is a 2”
(on a scale of 0–10) 30 minutes after an IV analgesic administration. Requests analgesic 30 minutes before ambulation. States
willingness to try relaxation techniques; however, has not attempted to do so.
*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, interventions, and
activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

APPLYING CRITICAL THINKING

1. Is there any other assessment data you would want to 3. What kind of data would you gather prior to having a
gather to help plan Mr. C.’s pain management? discussion with the primary care provider about options
2. Mr. C. does not have a PCA. What nursing interventions for improving pain control in this client?
are important? See Critical Thinking Possibilities answers on student resource website.
 CHAPTER 46 / Pain Management 1245

CONCEPT MAP Acute Pain

LC • 6' 3", 200 lb • HR = 90

57 y.o. male • C/o abdominal pain (7/10) • BP = 158/82
Strangulated inguinal • Restless • Resp = 24
assess • Legs drawn up to chest • Skin pale, moist
hernia --> partial bowel
obstruction --> second • Pupils dilated • CXR and UA negative
day postop • Midline abd incision with • WBC 12,000
sutures dry and intact

generate nursing diagnosis

Acute Pain r/t tissue injury secondary to surgical intervention

outcome outcome

Outcomes partially Pain Control aeb often Pain Level aeb mild Outcomes partially
met: demonstrating ability to: to no: met:
• Requests • Use analgesics • Reported pain • Verbalizes pain
analgesic evaluation appropriately • Protective body evaluation and discomfort
30 minutes • Use nonanalgesic positioning • States pain is
before relief measures • Restlessness 2/10 30 minutes
ambulation • Report uncontrolled • Pupil dilation after analgesic
• Willing to try symptoms to health • Perspiration • No protective
relaxation care professional • Change in BP, HR, body positioning
techniques but R from normal • No pupil dilation
has not done so baseline data
to date

nursing intervention nursing intervention nursing intervention

Analgesic Administration Simple Relaxation Therapy Pain Management

activity activity activity activity activity

activity activity activity

Evaluate Demonstrate and Pain Consider

effectiveness practice relaxation Assessment cultural
of analgesic techniques influences

Determine type Instruct to Check willingness Reduce or

of analgesic request to use relaxation eliminate factors
based on pain analgesic at strategies that increase
assessment onset of pain the pain
1246 UNIT 10 / Promoting Physiological Health
Chapter 46 Review
CHAPTER HIGHLIGHTS
■ Pain is “whatever the person says it is, and exists whenever
he says it does.” It is a subjective sensation to which no two
people respond in the same way. It can directly impair health
and prolong recovery from surgery, disease, and trauma.
■ Types of pain may be described in terms of location, duration,
intensity, and etiology.
■ Pain threshold is generally similar in all people, but pain
tolerance and response vary considerably among individuals.
■ The physiological processes related to pain perception are
described as nociception. Four processes are involved in
nociception: transduction, transmission, perception, and
modulation.
■ For nociceptive pain to be perceived, nociceptors must be
stimulated. Three types of pain stimuli are mechanical, thermal,
and chemical.
■ According to the gate control theory, peripheral nerve fibers
carrying pain to the spinal cord can have their input modified at
the spinal cord level before transmission to the brain. This
theory is the basis of many pain intervention strategies,
especially nonpharmacologic interventions.
■ Numerous factors influence a person’s perception and reaction
to pain: ethnic and cultural values, developmental stage,
environment and support people, previous pain experiences,
and meaning of pain.
■ Pain is subjective, and the most reliable indicator of the
presence or intensity of pain is the client’s self-report. Pain
assessment is the fifth vital sign. Assessment of a client who
is experiencing pain should include a comprehensive pain
history.
■ Although the nursing diagnosis given to clients experiencing
pain is Acute Pain or Chronic Pain, the pain itself may be the
etiology of many other nursing diagnoses.
■ Overall client goals include preventing, modifying, or
eliminating pain so that the client is able to partly or completely
resume usual daily activities and to cope more effectively with
the pain experience.
TEST YOUR KNOWLEDGE
1. During the transduction phase of nociception, which method
of pain control is most effective?
1. Tricyclic antidepressants
2. Opioids
3. Ibuprofen
4. Distraction
■ When planning, nurses need to choose pain relief measures
appropriate for the client, based on assessment data.
■ Pain management includes two basic types of nursing
interventions: pharmacologic and nonpharmacologic.
■ Key strategies to reduce pain include acknowledging and
accepting the client’s pain, assisting support persons, reducing
misconceptions about pain, reducing fear and anxiety, and
preventing pain.
■ Pharmacologic interventions, ordered by the physician (or
nurse practitioner), include the use of opioids, nonopioids such
as NSAIDs, and coanalgesic drugs.
■ The World Health Organization recommends a three-step
ladder approach to manage chronic cancer pain. This model
establishes the pharmacologic foundation on which other types
of pain are managed.
■ Placebos should never be used to determine whether or not
someone is in pain. Deceptive use of placebos is unethical.
■ Analgesic medication can be delivered through a variety of
routes and methods to meet the specific needs of the client.
These routes include oral, transnasal, transdermal,
transmucosal, rectal, topical, subcutaneous, intramuscular, IV,
and intraspinal and as continuous local anesthetics.
■ Patient-controlled analgesia enables the client to exercise
control and treat the pain by self-administering doses of
analgesics.
■ Physical modalities of nonpharmacologic pain interventions
include cutaneous stimulation such as massage, hot and cold
applications, acupressure, and contralateral stimulation;
immobilization/bracing; and transcutaneous electrical nerve
stimulation (TENS).
■ Cognitive-behavioral interventions include distraction
techniques, eliciting the relaxation response, repatterning
thinking, facilitating coping, and selected spiritual interventions.
■ Evaluation of the client’s pain therapy includes the response of
the client, the changes in the pain, and the client’s perceptions
of the effectiveness of the therapy. Ongoing verbal or written
feedback from the client and family is integral to this process.
2. When a client has arrived at the nursing unit from surgery,
the nurse is most likely to give priority to which of the
following assessments?
1. Pain tolerance
2. Pain intensity
3. Location of pain
4. Pain history

3. A client who describes his pain as 6 on a scale of 1 to 10 is
classified as having which of the following?
1. Mild pain
2. Mild to moderate pain
3. Moderate to severe pain
4. Very severe pain
4. A client who had abdominal surgery 4 hours ago is receiving
a continuous epidural infusion of an analgesic. Which of the
following observations indicates the nurse should monitor
the client closely?
1. Drowsy; drifts off to sleep before completing a sentence
2. Respirations  18/minute
3. Drowsy; easily aroused
4. Pain rating 1–2/10
5. The client has an order of morphine 2.5 to 5.0 mg
intravenous (IV) every 4 hours. He received 2.5 mg IV 4
hours ago for pain rated at 3 on a scale of 0 to 10. He is now
watching television and visiting with family members. When
asked about his pain, he rates it as a 5. His vital signs are
stable. What nursing intervention is the most appropriate?
1. Give morphine 3.5 mg IV and inform him to continue
watching TV because it is a distraction from the pain.
2. Give 2.5 mg of morphine IV to avoid the client becoming
addicted.
3. Give nothing at this time because he is not exhibiting any
signs of pain.
4. Give morphine 5.0 mg IV and reassess in 20 minutes.
6. During an admission nursing assessment, a client with
diabetes describes his leg pain as a “dull, burning
sensation.” The nurse recognizes this description to be
characteristic of which type of pain?
1. Physiological
2. Somatic
3. Visceral
4. Neuropathic
Pearson Nursing Student Resources
Find additional review materials at
nursing.pearsonhighered.com.
Prepare for success with additional NCLEX®-style practice
questions, interactive assignments and activities, web links,
animations, videos, and more!
READINGS AND REFERENCES
SUGGESTED READINGS
Burn, J., & Hastings, J. (2007). Addiction: A nurse’s story.
American Journal of Nursing, 107(8), 75–79.
The author tells the story of a nurse’s experience of becoming a
nurse, becoming an addict, being discovered as a drug user,
rehabilitation, and recovery. The story is well told and reflects how
vulnerable nurses are to addiction. The nurse who told the story
hopes that his story will help someone else see that he or she may
have a problem and take action to begin recovery.
D’Arcy, Y. (2009). Sticking to the safe side with fentanyl
patches. Nursing, 39(3), 62–63.
Millions of prescriptions for fentanyl patches are being written each
year. The author describes steps the nurse can take to improve client
safety when using them.
Narayan, M. C. (2010). Culture’s effects on pain
assessment and management. American Journal of
Nursing, 110(4), 38–47.
CHAPTER 46 / Pain Management 1247
7. Which interventions, when implemented by the nurse, would
apply the gate control theory of pain? Select all that apply.
1. Oral analgesics around the clock
2. Massage
3. Patient-controlled analgesia
4. Heat or cold application
5. Teaching
8. Which statement best reflects the nurse’s assessment of
the fifth vital sign?
1. “Do you have any complaints?”
2. “Are you experiencing any discomfort right now?”
3. “Is there anything I can do for you now?”
4. “Do you have any complaints of pain?”
9. When planning care for pain control of older clients, which
principles should the nurse apply? Select all that apply.
1. Pain is a natural outcome of the aging process.
2. Pain perception increases with age.
3. The client may deny pain.
4. The nurse should avoid use of opioids.
5. The client may describe pain as an “ache” or
“discomfort.”
10. A client recovering from abdominal surgery refuses
analgesia, saying that he is “fine, as long as he doesn’t
move.” Which nursing diagnosis should be a priority?
1. Deficient Knowledge (pain control measures)
2. Ineffective Health Maintenance
3. Risk for Ineffective Airway Clearance
4. Impaired Physical Mobility
See Answers to Test Your Knowledge in Appendix A.
The author describes how culture affects the pain experience, pain nurses. Pain Management Nursing, 10(4), 174–187.
assessment and management, problems complicating pain doi:10.1016/J.PMN.2008.07.001
management, providing “culturally comfortable” care, culturally sensitive Decker, S. A. (2009). Behavioral indictors of postoperative
pain assessment, and culturally comfortable pain management. pain in older adults with delirium. Clinical Nursing
Quinlan-Colwell, A. D. (2009). Understanding the paradox Research, 18, 336–347.
of patient pain and patient satisfaction. Journal of doi:10.1177/1054773809341734
Holistic Nursing, 27, 177–182. Harrison, D., Loughnan, P., Manias, E., & Johnston, L.
doi:10.1177/0898010109332758 (2009). Analgesics administered during minor painful
Using a holistic, caring approach, nurses can optimize the effect of procedures in a cohort of hospitalized infants: A
analgesia and facilitate comfort for the person living in pain. The prospective clinical audit. Journal of Pain, 10, 715–722.
author describes how nurses who care in a holistic manner can doi:10.1016/j.jpain.2008.12.011
promote high levels of client satisfaction even in the case of Im, E. O., Lee, S. H., Liu, Y., Lim, H. J., Guevara, E., &
significant pain. Chee, W. (2009). A national online forum on ethnic
differences in cancer pain experience. Nursing
RELATED RESEARCH Research, 58, 86–94.
Carlson, C. L. (2009). Use of three evidence-based doi:10.1097/NNR.0b013e31818fcea4
postoperative pain assessment practices by registered