Pain Management
Chapter 13
NUR 299 C 1&2
(Adapted from LLW 2010)
Pain
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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)
Role of the Nurse
Collaborate
 Evaluate effectiveness
 Advocate
 Educate
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Nursing Assessment
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Assess for:
◦ Duration – how long
◦ Location - where
◦ Etiology – cause may be a predictor so a plan
can be put into effect [Cancer, Burns]
Types of Pain
Acute pain
 Chronic pain
 Cancer-related pain
 May be classified by location or etiology
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Effects of Pain
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Sleep deprivation
Acute pain
◦ Can affect respiratory, cardiovascular, endocrine,
immune systems, gastrointestinal
◦ Stress response increases metabolic rate, cardiac
output, risk for physiologic disorders
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Chronic pain
◦ Depression
◦ Increased disability
◦ Suppression of immune function
Pathophysiology of Pain
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Nociceptors (pain receptors) transmission
of pain perception to & from the brain
Non-Nociceptor- does not transmit pain. Ie:
pressure or temperature
Neurologic Transmission of pain (nocicetion)
by nerves
Chemical substances
◦ Prostaglandins (increase sensitivity of pain
receptors)
◦ Endorphins, enkephalins (suppress pain reception)
Nociception System Showing Ascending
& Descending Pathways of the Dorasal
Horn
Gate Control Theory
Factors that Influence Pain
Response
Past experience
 Anxiety
 Depression
 Culture
 Age
 Gender
 Expectations
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Characteristics of Pain
Intensity
 Timing
 Location
 Quality
 Personal meaning
 Aggravating/ Alleviating factors
 Pain behaviors- eyes shut, rubbing, fists,
jaw clenched
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Pain Intensity Scales
Faces Pain Scale
Physiologic Basis for Relief
Pharmacologic Interventions
• Opioid analgesics act on CNS to inhibit
activity of ascending nocioceptive
pathways
• NSAIDS decrease pain by inhibiting cyclooxygenase (enzyme involved in production
of prostaglandin) Aleve, Motrin, Advil
• NSAIDS can be given in combination with
narcotics to relieve pain using less
narcotics.
• Local anesthetics block nerve conduction
when applied to nerve fibers
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
Opioid Tolerance and Addicition
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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Opiod Tolerance and Addiction
(cont’d)
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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Pain Relief InterventionsPharmacologic
Balanced anesthesia
 “PRN” medications
 Routine administration: around the clock
(ATC) or preventive approach
 PCA: patient-controlled analgesia
 Local anesthetics
 Topicals, patches
 Intraspinal a
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PCA - Patient Controlled Analgesia
Two Types
 Continuous – delivers set amount per
hour AND Pt can request additional
doses up to pre set maximum as needed.
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On Demand – only delivers when
medication is requested by patient.
PCA
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Physician’s Order for PCA shall include:
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Type of analgesic
Rate
Loading/bolus dose
PCA dosage with mg/minutes lock out
interval
◦ Four hour dose
◦ Basal rate
◦ Medication concentration
PCA cont’d
Parameters should include:
 Loading dose- A bolus dose given prior to initiating PCA
therapy
◦ usually higher than a bolus dose given during PCA therapy.
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Bolus dose- Equivalent to a loading dose –
◦ administered during the course of PCA therapy.
Lockout Interval – Predetermined period during which
the patient cannot initiate doses.
 PCA dose – Amount administered each time the PT
activates pump.
 Four hour limit – Predetermined maximum drug volume,
which can be delivered during any 4 hour period.
 Basal Rate- Amount administered continuously.
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PCA Nursing Considerations
Notify MD of the following so that orders
may be obtained for continuing, slowing or
stopping the infusion when one or more of
the following exists:
 Diastolic B/P drops more than 20% from
baseline
 Respiratory rate of less than 10/min(hold <
8)
 Significantly altered mental status
 Pain Score of 5 or greater &/or pain that is
not decreasing
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Nonpharmacologic Interventions
Cutaneous stimulation, massage
 Thermal therapies
 Transcutaneous electrical nerve
stimulation (TENS)
 Distraction
 Relaxation techniques
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Nonphamacologic Interventions
Guided imagery
 Hypnosis
 Music therapy
 Alternative therapies
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Neurologic & Neurosurgical
Methods for Pain Control
Intrathecal catheters- spinal, meds to spinal
cord
 Epidural catheters- epidural space in spinal
cord
 Stimulation procedures - TENS
 Interruption of pain pathways
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◦ Cordotomy- division of spinal cord tracts(neck).
Destroys pain, not sensation.
◦ Rhizotomy- Sensory nerve root is destroyed. Ie:
chest pain /lung CA. May be done surgically,
percutaneously or chemically.
Intrathecal & Epidural Catheters
Cordotomy
Rhizotomy
Adverse Effects of Analgesic Agents
Respiratory depression
 Sedation
 Nausea, vomiting
 Constipation
 Pruritis
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Nursing Process Framework for
Pain Management
Identify goals for pain management
 Establish nurse-patient relationship,
teaching
 Provide physical care
 Manage anxiety related to pain
 Evaluate pain-management strategies
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NCLEX Review
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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NCLEX Review
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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