Pain Management
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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International Association for the Study of
Pain defines it as “an unpleasant sensory
and emotional experience associated with
actual or potential tissue damage”
McCaffery, a nurse and leader in the pain
management field, has a more useful
definition for nurses: “Pain is whatever the
person experiencing it says it is and exists
whenever he says it does”
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Sensory experiences: time/space, emotions,
cognition
Afferent pathways
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Efferent (or descending) pathways
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Nociceptors
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◦ Nerves that carry messages to the brain for
interpretation
◦ Carry messages away from the brain via spinal
cord
◦ Receptors that activate the afferent pathways
◦ Unevenly distributed in muscles, tendons,
subcutaneous tissue, and the skin
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Pain receptors are sensitive to chemical
changes, temperature, mechanical stimuli,
and tissue damage
Pain receptors are unable to adapt to
repeated stimuli and thus continue to react
until stimuli are removed
When pain receptors are stimulated,
impulses are transmitted to the spinal cord
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Impulses then travel up the spinal cord to
the brain
In the brain, the cortex interprets the
impulses as pain and identifies the location
and qualities of the pain
Endorphins and enkephalins, natural
opioid-like substances: block transmission
of painful impulses to the brain
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Pain reflects physical and psychosocial
factors
Painful impulses are transmitted to the
spinal cord through small-diameter nerve
fibers in the afferent pathway
When these fibers are stimulated, the gating
mechanism opens in the spinal cord, which
permits the transmission of impulses from
the spinal cord to the brain
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Factors that cause the gate to open include
tissue damage, a monotonous environment,
and fear of pain
Stimulation of large-diameter fibers can
close the gate and interfere with impulse
transmission between spinal cord and the
brain, causing diminished pain perception
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Figure 15-1
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Although people may have the same injury
or insult, they may respond differently
because many physical and psychosocial
factors affect the response to pain
Important for health professionals to be
nonjudgmental and to avoid comparing one
individual in pain with another
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Pain threshold
◦ Point at which stimulus causes sensation of pain
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Pain tolerance
◦ Intensity of pain that a person will endure
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Age
Physical activity and nervous system
integrity
Surgery and anesthesia
◦ Type of surgery performed and the type of
anesthesia used can influence the response to
pain
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Culture and ethnicity
◦ Different ways of expressing/responding to pain
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Religious beliefs
◦ Some patients may pray and believe that divine
intervention will help them to endure the pain
◦ Others may view pain as a punishment for sins
◦ Some believe that suffering is required before
pain relief
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Past experiences and anxiety
◦ May have developed positive coping strategies to
deal with previous painful experiences
◦ If strategies were unsuccessful, may be very
anxious and overwhelmed by another painful
experience
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Situational factors
◦ If pain associated with a serious illness, it may
have a greater effect on mood and activity than if
the pain were associated with a less serious
condition
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Activates the fight-or-flight response;
certain physiologic responses initiated
The nervous system responses measured by
increased heart rate, respiratory rate, and
blood pressure
Acute and chronic pain elicit different kinds
of responses
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Follows the normal pathway for pain from
nociceptor activation to the brain and may
be called nociceptive pain
Cause is known and treatable
It serves as a warning of tissue damage and
subsides when healing takes place
Behavioral and physiologic signs: when
patient guards or rubs a body part, wrinkles
the brow, bites the lip, and has changes in
the heart rate, blood pressure, and
respiratory rate
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Persists/recurs for >6 months; may last a
lifetime
Most chronic pain is neuropathic pain because
it follows an abnormal pathway for pain
Results from nerve damage from anatomic and
physiologic conditions and underlying diseases
Includes unusual sensations such as burning,
shooting pain, and abnormal sensations that
occur when there is no painful stimulus present
See Table 15-2, p. 206
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Chronic pain serves no useful purpose;
acute warns of tissue damage and trauma
Nursing assessment to identify
◦ Type and amount of pain
◦ Chronic or acute
◦ If acute and chronic pain at the same time
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Figure 15-2
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Should be done on admission and on a
regular basis
Assessment of vital signs is called the fifth
vital sign
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Six steps
◦ Accept the patient’s report
◦ Determine the status of the pain
◦ Describe the pain
 Location, quality, intensity, aggravating and
alleviating factors
◦ Examine the site of the pain
◦ Identify coping methods
◦ Document assessment findings and evaluate
interventions
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Figure 15-5
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Those that do not employ drugs
Physical interventions
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Physical comfort measures
Environmental control
Stimulation techniques
Anxiety reduction
Distraction
Psychological interventions
◦ Relaxation
◦ Imagery
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Nonopioid analgesics
◦ Aspirin, acetaminophen, and
nonsteroidal anti-inflammmatory drugs
(NSAIDs) such as ibuprofen
◦ Generally initial treatment choice for
mild pain
◦ Act mostly on the peripheral nervous
system
◦ Antipyretic (fever-reducing), analgesic
(pain-reducing), and/or antiinflammatory (inflammation-reducing)
properties
◦ See Table 15-4, p. 216
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For moderate to severe acute pain, chronic
cancer pain, and some other types of pain
Opioids: potency/duration of action vary
Opioid agonists
◦ Examples: codeine, methadone (Dolophine),
hydromorphone (Dilaudid), meperidine (Demerol),
morphine, and fentanyl
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Opioid agonist-antagonists
◦ Examples: buprenorphine (Buprenex), nalbuphine
(Nubain), butorphanol (Stadol), and pentazocine
(Talwin)
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Patients, families, nurses, and physicians
have misconceptions about addiction;
therefore, the term must be defined and
differentiated from the terms tolerance and
physical dependence
Tolerance and physical dependence are
normal responses to continued opioid
administration for pain relief; they do not
lead to a craving for the drug for its mindaltering effects
Fear of addiction greatly exaggerated; rare
(<1%) in patients taking opioids for pain
relief
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Routes of administration
◦ Oral
◦ Intramuscular
◦ Sublingually
◦ Intravenously: intermittent bolus
injections, continuous infusions, or
patient-controlled analgesia (PCA)
◦ Epidural or intrathecal route
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Side effects
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Constipation
Nausea, with or without vomiting
Sedation
Respiratory depression
Confusion
Hypotension (especially orthostatic)
Dizziness
Urinary retention
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Inactive substances (e.g., saline) used in
research or clinical practice to determine the
effects of a legitimate drug or treatment
Appropriately used in studies in which
patients consent to participate
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Many health care organizations take the
position that placebos should not be used
to assess or manage pain
Nurses have ethical obligation to ensure
that patients are not deceived and that
institutional policies related to placebos are
followed
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Drugs not usually classified as analgesics
may relieve pain in certain situations
A patient who has undergone back surgery
may complain more about muscle spasms
than incisional pain
◦ A muscle relaxant may be more effective in
relieving pain than an opioid alone
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Specific pain syndromes, especially
neuropathic, may be controlled with drugs
other than the commonly known analgesics
See Table 15-6, p. 219
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Patients whose prescribed analgesic drugs
do not relieve pain
Ask questions about the analgesic drug and
the “five rights” (right dose, right patient,
right time, right route, right analgesic) to
determine why the patient is not getting
adequate pain relief
See Box 15-8, p. 221
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