PAIN MANAGEMENT
● Pain is a universal but
individual experience and a
condition that nurses
encounter among patients in
all settings. It is the most
common reason that people
seek health care; yet it is
often underrecognized,
misunderstood, and
inadequately treated.
● The International Association
for the Study of Pain (IASP)
defines it as “an unpleasant,
subjective sensory and
emotional experience
associated with actual or
potential damage, or
described in terms of such
damage.
● Pain management should be
patient-centered, with nurses
practicing patient advocacy,
empowerment, compassion,
and respect.
NATURE OF PAIN
● The pain experience is
complex, involving more than
a single physiological
sensation caused by a
specific stimulus.
● It has physical, emotional, and
cognitive components.
● It is subjective and highly
individualized
● Pain itself cannot be
measured objectively. Only
the patient knows whether
pain is present and how the
experience feels.
● It is not the responsibility of
the patient to prove that he or
she is in pain; it is a nurse’s
responsibility to assess a
patient’s condition and accept
his or her subjective report.
Physiology of Pain
There are four physiological
processes of normal pain:
transduction, transmission,
perception, and modulation.
● Transduction
- Converts energy
produced by stimuli
into electrical energy.
- It begins in the
periphery when a
pain-producing
stimulus sends an
impulse across a
sensory peripheral pain
nerve fiber (noiceptor),
initiating an action
potential.
● Transmission
- Cellular damage
caused by thermal,
mechanical, or
chemical stimuli result
in the release of
excitatory
neurotransmitters such
as prostaglandins,
bradykinin, substance
P, and histamine.
- Pain impulses travel up
the spinal cord by way
of the spinothalamic
tract.
● Perception
- It is the point at which a
person is aware of
pain.
- The somatosensory
cortex identifies the
location and intensity of
pain, whereas the
association cortex,
 primarily the limbic - The pain response is
system, determines complex, influenced by a
how a person feels person’s culture, pain
about it. experiences, perception of
- The reaction to pain pain, and ability to manage
includes the stress.
physiological and - Lack of pain expression does
behavioral responses not indicate that a patient is
that occur after an not experiencing it.
individual perceives - A patient’s ability to tolerate
pain. pain significantly influences
● Modulation your perception of the degree
- There is a release of of his or her discomfort.
inhibitory NURSING KNOWLEDGE BASE
neurotransmitters such Nursing knowledge of pain
as endorphins, mechanisms and interventions
serotonin, continues to grow through nursing
norepinephrine, and research.
gamma-aminobutyric ● Knowledge, Attitudes,
acid, which hinder the and Beliefs
transmission of pain - Attitudes of nurses
and help produces an and other health
analgesic effect. care providers
- The neurotransmitters affect pain
decrease neuron management.
activity without directly - A number of nurse
transferring a nerve and patient
signal through a variables, including
synapse. cultural, knowledge,
- This inhibition of pain and patient
impulse is the fourth diagnosis, may
and last phase of the contribute to the
normal pain process. differences in pain
PHYSIOLOGICAL RESPONSES ratings.
- As pain impulses ascend the - Bias based on
spinal cord toward the culture, education,
brainstem and thalamus, the and experience
stress response stimulates influence everyone.
the autonomic nervous - To help a patient
system (ANS) gain relief, it is
- Stimulation of the sympathetic important to view
branch of the ANS results in the experience
physiological responses. through the
BEHAVIORAL RESPONSES patient’s eyes.
TYPES OF PAIN
The two types of pain you observe in
patients are acute (transient) and
chronic (persistent), which includes
cancer and non-cancer pain.
Acute/Transient Pain
- Acute pain is protective,
usually has an identifiable
cause, is of short duration,
and has limited tissue
damage and emotional
response.
Chronic Non-cancer Pain
- Chronic pain is not protective
unlike acute pain, and thus
serves no purpose, but it has
a dramatic effect on a
person’s quality of life.
- Chronic non-cancer pain is
prolonged, varies in intensity,
and usually lasts longer than
is expected or predicted.
Chronic Cancer Pain
- A tumor progression and
related pathological
processes, invasive
procedures, toxicities of
chemotherapy, infection, and
physical limitations usually
cause cancer pain.
- A patient senses pain at the
actual site of the tumor or
distant to the site, called
referred pain.
Idiopathic Pain
- Idiopathic pain is chronic pain
in the absence of an
identifiable physical or
psychological cause or pain
perceived as excessive for the
extent of an organic
pathological condition.
FACTORS INFLUENCING PAIN
Pain is a complex process, involving
physiological, social, spiritual,
psychological, and cultural
influences.
Physiological Factors
● Age
- Age influences the pain
experience. It is important to
consider how a painful event
affects a patient
developmentally.
● Fatigue
- Fatigue heightens the
perception of pain and
decreases coping abilities.
● Genes
- Research on healthy human
subjects suggest that genetic
information passed on by
parents possibly increases or
decreases a person’s
sensitivity to pain and
determines pain threshold or
tolerance.
● Neurological Function
- A patient’s neurological
function influences the pain
experience.
Social Factors
● Attention
- The degree to which a patient
focuses attention on pain
influences
● Previous Experience
- Each person learns from
painful experiences.
- Prior experience does not
mean that a person accepts
pain more easily in the future.
● Family and Social Support
- People in pain often depend
on family members or close
friends for support,
assistance, or protection.
● Spiritual Factors
 - Spirituality is an active
searching for meaning in
situations in which one finds
oneself
- Spiritual beliefs affect the way
patients view or cope with
pain.
Psychological Factors
● Anxiety
- A person perceives pain
differently if it suggests a
threat, loss, punishment, or
challenge.
- The relationship between pain
and anxiety is complex,
anxiety often increases the
perception of pain, and pain
causes feelings of anxiety.
● Coping Style
- Coping style influences the
ability to deal with pain.
- People with inter loci of
control perceive themselves
as having control over events
in their life and the outcomes
such as pain.
- People with external loci of
control perceive that other
factors in their life such as
nurses are responsible for the
outcome of events.
Cultural Factors
- The meaning that a person
associates with pain affects
the experience.
- Cultural beliefs and values
affect how individuals cope
with pain.
CRITICAL THINKING
- Successful critical thinking
requires a synthesis of
knowledge, experience,
information gathered from
patients, critical thinking
attitudes, and intellectual and
professional standards.
NURSING PROCESS
- The nursing process provides
a clinical decision-making
approach for you to develop
and implement an
individualized plan of care.
- Nurses approach pain
management systematically to
understand and treat a
patient’s pain.
ASSESSMENT
A comprehensive assessment of
pain aims to gather information
about the cause of a person’s pain
and determine its effect on his or her
ability to function.
Through the Patient’s Eye
- It is important to learn a
patient’s own values and
beliefs about management of
pain and recognize that
patient expectations will
influence your ability to
achieve outcomes in its
management.
Patient’s Expression of Pain
- A patient’s self-report of pain
is the single most reliable
indicator of its existence and
intensity.
Characteristics of Pain
Assessment of the characteristics of
pain allows you to understand the
type of pain, its pattern, and the
types of interventions that bring
relief.
⮚ Timing (Onset, Duration,
Pattern)
- Ask questions to determine the
onset, duration, and time
sequence of the pain
⮚ Location
 - Ask a patient to describe or
point all areas of discomfort to
assess pain location.
⮚ Severity
- One of the most subjective and
therefore most useful
characteristics for reporting pain
is its severity.
⮚ Quality
- There is no common or specific
pain vocabulary in general use.
Patients describe in their own
way.
⮚ Aggravating and
Precipitating Factors
- Various factors or conditions
precipitate or aggravate pain. Ask
a patient to describe activities
that cause or aggravate pain.
⮚ Relief Measures
- It is useful to know whether a
patient has an effective way of
relieving pain.
Effects of Pain on the Patient
Pain alters a person’s lifestyle and
psychological well-being.
⮚ Behavioral Effects
- When a patient has pain,
assess verbalization, vocal
response, facial and body
movements, and social
interaction.
⮚ Influence on Activities of
Daily Living
- Patients who live with daily
pain or have prolonged pin
during hospitalization are less
able to participate in routine
activities, which result in
physical deconditioning.
⮚ Concomitant Symptoms
- Concomitant symptoms,
including nausea, headache,
dizziness, urge to urinate,
constipation, depression, and
restlessness, occur with pain
and usually increases a
patient’s pain severity.
NURSING DIAGNOSIS
The nursing diagnosis focuses on
the specific nature of a patient’s pain
to identify the most useful types of
interventions for alleviating it and
improving the patient’s function.
IMPLEMENTATION
Pain therapy requires an
individualized approach, perhaps
more so than any other patient
problem.
HEALTH PROMOTION
When providing pain relief
measures, choose therapies suited
to a patient’s unique pain
experience. Apply guidelines for
individualizing pain therapy, including
the following:
❖ Use different types of pain
relief measures
❖ Use measures that patient
believes are effective
❖ Keep an open mind about
ways to relieve pain
❖ Keep trying. When efforts at
pain relief fail, do not abandon
the patient but reassess the
situation.
PATIENT-CONTROLLED
ANALGESIA
- A drug delivery system called
patient controlled analgesia
(PCA) is a method for pain
management that many
patients prefer.
- It is a drug delivery system
that allows patients to
self-administer opioids
(morphine, hydromorphine, or
 fentanyl) with minimal risk of
overdose.
PHARMACOLOGICAL PAIN
THERAPIES
Many pharmacological agents are
available to provide pain relief. Your
judgment in the use and
managements of analgesics ensures
the best pain relief possible.
RESTORATIVE AND CONTINUING
CARE
Pain Clinics, Palliative Care, and
Hospices
- A comprehensive pain center
treats people on an inpatient
or outpatient basis.
- The goal of palliative care is
to help patients manage
disease-related symptoms
while living life fully with an
incurable condition.
- Hospice provides support and
care for people in the last
stages of incurable disease,
with an emphasis on
enhancing the quality of
remaining life.
SAFETY GUIDELINES
❖ The patient is the only person
who should press the PCA
button to administer the pain
medication.
❖ Monitor the patient for signs
and symptoms of
oversedation and respiratory
depression.
❖ Monitor for potential side
effects of opioid analgesics.
NUTRITION
Nutrition is the basic component of
health and is essential for normal
growth and development, tissue
maintenance and repair, cellular
metabolism, and organ function.
NUTRIENTS: The Biochemical
Units of Nutrition
● The body requires fuel to
provide energy for cellular
metabolism and repair, organ
function, growth, and body
movement
● The basal metabolic rate
(BMR) is the energy needed
at rest to maintain
life-sustaining activities
(breathing, circulation, heart
rate, and temperature) for a
specific amount of time.
● The resting energy
expenditure (REE), or resting
metabolic rate, is the amount
of energy you need to
consume over a 24-hour
period for your body to
maintain all of its internal
working activities while at rest
● Nutrients are the elements
necessary for the normal
function of numerous body
processes.
● The nutrient density of food
refers to the proportion of
essential nutrients to the
number of kilocalories
DIGESTION
● Digestion of food is the
mechanical breakdown that
results from chewing,
churning, and mixing with fluid
and chemical reactions in
which food reduces to its
simplest form
● Enzymes are the protein-like
substances that act as
catalysts to speed up
chemical reactions.
ABSORPTION
● The small intestine, lined with
fingerlike projections called
 villi, is the primary absorption
site for nutrients.
● The body absorbs nutrients by
means of passive diffusion,
osmosis, active transport, and
pinocytosis
METABOLISM AND STORAGE OF
NUTRIENTS
● Metabolism refers to all of the
biochemical reactions within
the cells of the body
● Anabolism is the building of
more complex biochemical
substances by synthesis of
nutrients
● Catabolism is the breakdown
of biochemical substances
into simpler substances and
occurs during physiological
states of negative nitrogen
balance
ELIMINATION
● Chyme moves by peristaltic
action through the ileocecal
valve into the large intestine,
where it becomes feces
● Exercise and fiber stimulate
peristalsis, and water
maintains consistency
DIETARY GUIDELINES
⮚ Dietary Reference Intakes
Dietary reference intakes
(DRIs) present
evidence-based criteria for an
acceptable range of
amounts of vitamins and
nutrients for each gender and
age-group
⮚ Food Guidelines
The U.S. Department of
Health and Human Services
(USDHHS) and the U.S.
Department of Agriculture
(USDA) published the Dietary
Guidelines for Americans
2015-2020 and provide
average daily consumption
guidelines for the five food
groups
⮚ Daily Values
The U.S. Food and Drug
Administration (FDA) created
daily values for food labels in
response to the 1990 Nutrition
Labeling and Education Act
(NLEA)
NURSING KNOWLEDGE BASE
- Nutritional requirements
depend on many factors.
Individual caloric and nutrient
requirements vary by stage of
development, body
composition, activity levels,
pregnancy and lactation, and
the presence of disease
ALTERNATIVE FOOD PATTERNS
- Long before the FDA issued
recommended allowances
and guidelines, many people
followed special patterns of
food intake on the basis of
religion, cultural background,
health beliefs, personal
preference, or concern for the
efficient use of land to
produce food.
CRITICAL THINKING
- Successful critical thinking
requires a synthesis of
knowledge, experience,
information gathered from
patients, critical thinking
attitudes, and intellectual and
professional standards.
ASSESSMENT
- During the assessment
process thoroughly assess
each patient and critically
analyze findings to ensure
 that you make
patient-centered clinical
decisions required for safe
nursing care
NURSING DIAGNOSIS
- When identifying a
problem-focused nursing
diagnosis, you select the
appropriate related factors
(e.g., inability to digest food or
reduced daily activity).
Related factors need to be
accurate so you select the
right interventions

IMPLEMENTATION
- Diet therapies are numerous
and chosen on the basis of a
patient's overall health status,
ability to eat and digest
normally, and long-term
nutritional needs
ENTERAL TUBE FEEDING
- Enteral nutrition (EN) provides
nutrients into the GI tract. It is
the preferred method of
meeting nutritional needs if a
patient is unable to swallow or
take in nutrients orally yet has
a functioning GI tract.
PARENTERAL NUTRITION
- Parenteral nutrition (PN) is a
form of specialized nutrition
support provided
intravenously.