NURS 342

UNIT I

Pain
Unpleasant sensory, emotional experience

with actual or potential tissue damage

Most common reason for seeking health
care
The fifth vital sign
Joint Commission (2005) standards: pain is
assessed in all patients, patients have
the right to appropriate assessment and
management of pain.
Pain is whatever a person says it is,
existing whenever the experiencing person
says it does (McCaffery & Pasero, 1999)
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Types of Pain
Acute pain
Chronic pain
Cancer-related pain
May be classified by location or

etiology

Pain Syndromes
Complex regional pain syndrome
Postmastectomy pain syndrome
Fibromyalgia
Hemiplegia associated shoulder pain
Pain associated with sickle cell disease
AIDS-related pain
Burn pain
Guillain-Barr syndrome, pain
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Harmful Effects of Pain

Sleep deprivation
Acute pain
Can affect respiratory, cardiovascular,

endocrine, immune systems

Stress response increases metabolic rate,
cardiac output, risk for physiologic disorders

Chronic pain
Depression
Increased disability
Suppression of immune function

Question
What is the time frame for pain that

can be classified as chronic?

A.1 month
B.2 to 3 months
C.4 to 5 months
D.Longer than 6 months

Answer
D. Longer than 6 months
Rationale: Chronic pain is constant or

intermittent pain that persists beyond

the expected healing time and that can
seldom be attributed to a specific
cause or injury. Chronic pain may be
defined as pain that lasts for 6 month
or longer, although 6 months is an
arbitrary period for differentiating
between acute and chronic pain.
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Pathophysiology of Pain
Nociceptors (pain receptors)
Transmission of pain (nocicetion)
Chemical substances
Prostaglandins (increase sensitivity of

pain receptors)
Endorphins, enkephalins (suppress pain
reception)

Nociception System Showing

Ascending and Descending Pathways
of the Dorsal Horn

Gate Control System

Theory

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Question
Tell whether the following statement is

true or false:
Endorphins represent the same
mechanism of pain relief as nonnarcotic
analgesics.

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Answer
False.
Rationale: Endorphins do not represent

the same mechanism of pain relief as

nonnarcotic analgesics. Endorphins
release inhibits the transmission of
painful impulses. They are endogenous
neurotransmitters structurally similar
to opioids. They are found in heavy
concentration in the central nervous
system.
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Factors that Influence Pain

Response
Past experience
Anxiety & depression
Culture
Gerontologic
Gender

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Nurses Role in Assessment

and Care of Patients in Pain
Assessment

Characteristics of pain
Intensity
Timing
Location
Quality
Personal meaning
Aggravating, alleviating factors
Pain behaviors

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Instruments for
Assessing the
Intensity
of pain: Visual
Analogue
Perception
of Pain

Scales and Other intensity scales

Faces Pain Scale-Revised
Using Pain Assessment Scales
Assessing Pain in Patients with
Disabilities

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Pain Intensity Scales

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Faces Pain Scale

Refer to fig. 13-4

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Question
The RN asks a patient to describe the

quality of pain. Which of the

following is a descriptive term for the
quality of pain?
A.Burning
B.Chronic
C.Intermittent
D.Severe
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Answer
A. Burning
Rationale: A descriptive term for the

quality of pain is burning. Chronic

and intermittent pain are examples
of types of pain. Severe is a
descriptive term for the intensity of
pain.

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Nurses Role in Pain

Management
Identify Goals
Establish Trust
Teaching
Provide Physical Care
Manage Anxiety

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Physiologic Basis for Pain Relief

Pharmacologic Interventions
Opioid analgesics act on CNS to

inhibit activity of ascending

nocioceptive pathways
NSAIDS decrease pain by inhibiting
cyclo-oxygenase (enzyme involved in
production of prostaglandin)
Local anesthetics block nerve
conduction when applied to nerve
fibers
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Adverse Effects Opioid Agents

Respiratory depression
Sedation
Nausea, vomiting
Constipation
Pruritus
Overdose triad: coma, respiratory

depression, pinpoint pupils

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Opioid Tolerance and Addiction

Maximum safe opioid dosage must

be individually assessed
Tolerance develops in all patients
who take opioids for prolonged
periods
With tolerance, increased usage
needed to effect pain relief

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Opioid Tolerance and Addiction

(contd)
Dependence occurs with tolerance,

physical symptoms occur when

opioid is discontinued
Addiction: behavioral pattern
characterized by need to take drug
for psychic effects
Addiction from therapeutic use of
opioid is negligible

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Non-opioid Medications
Nonsteroidal Anti-inflammatory drugs

(NSAIDs)
Cox 1 & 2 Inhibitor: Ibuprofen (Advil, Motrin)
Cox 2 Inhibitor: Celecoxib (Celebrex)

Local Anesthetic Agents

Topical : Lidocaine 5% (Lidoderm)

Intraspinal

Tricyclic Antidepressant Agents and

Anti-seizure medications
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Pain Relief InterventionsPharmacologic

Balanced anesthesia
PRN medications
Routine administration: around the

clock (ATC) or preventive approach

PCA: patient-controlled analgesia

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Routes of Administration
Parenteral
Oral
Rectal
Transdermal
Transmucosal
Intraspinal and Epidural
Nursing Management

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Intrathecal and Epidural

Catheter Placement

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The Placebo Effect

A physiologic response that results

from an expectation that a treatment

will work.
American Society of Pain
Management Nurses (2005)
contends that placebos should not
be used to assess or manage pain.

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Gerontologic Considerations
More likely to have adverse drug

effects, drug interactions

Increased likelihood of chronic illness
May need to have more time
between doses of medication due to
decreased excretion, metabolism
related to aging changes
Avoid meperidine (Demerol) r/t CNS
excitation and seizures
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Nonpharmacologic
Interventions
Cutaneous stimulation, massage
Thermal therapies
Transcutaneous electrical nerve stimulation
Distraction
Relaxation techniques
Guided imagery
Hypnosis
Music therapy
Alternative therapies
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World Health Organization

(WHO) Guidelines for Treating
Level 1: Mild to moderate pain;
Pain
intensity of 1-3; nonopioids,
acetaminophen, NSAIDs, COX2
inhibitor (celecoxib, alone or with
adjuvant); adjuvants include tricyclic
antidepressants, SSRIs, antiseizure
medications e.g. gabapentin
(Neurontin) or pregabalin (Lyrica);
peripheral analgesics, e.g. lidocaine
patch
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WHO ladder (cont.)

Level 2: Moderate to severe pain;

intensity rating of 4-6; weak opioid or

nonopioid analgesic, alone or with
adjuvant; weak opioids include:
Tylenol with codeine No. 3);
hydrocodone products (Lortab and
Vicodin); oxycodone products
(Percocet, Oxycontin, and Combunox);
Ultram (a combination mu
agonist/SSRI)
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WHO ladder (cont.)

Level 3: Severe pain rated as 7-10;

strong opioid possibly with adjuvant.

Opioids: morphine (Roxanol elixir,
Kadian, Avinza); hydromorphone
(Dilaudid), methadone (Dolophine),
and fentanyl (Duragesic patch,
Fentanyl Oralets)
Source: Darcy, Y. (2006). Which
analgesic is right for my patient?.
Nursing 2006, 36 (7), 50-56.
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Neurologic and
Neurosurgical Methods for
Pain Control

Stimulation procedures
Interruption of pain pathways
Cordotomy
Rhizotomy

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Cordotomy

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Rhizotomy

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Evaluating Pain Management

Strategies
Relief of pain
Correct administration of prescribed

analgesic medications
Use of non-pharmacologic pain
strategies as recommended
Minimal effects of pain and minimal
side effects of interventions

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