Pain Management

Fundamentals of Nursing

Presented by
Dr. Huda Atiyeh
 Outlines
1. Physiological and neuropathic pain categories.
2. Processes involved in nociception and pain interventions
3. Pain tolerance, suffering, and pain behavior.
4. The gate control theory and application to nursing care.
5. Subjective and objective data in the assessment of pain.
6. Individualized pain treatment plans.
8. Barriers to effective pain management affecting nurses and clients.
9. Pharmacologic pain management interventions.
10. World Health Organization’s ladder step approach for cancer pain control.
11. Risks and benefits of various analgesic delivery routes and analgesic
delivery technologies.
12. Nonpharmacologic pain control interventions.
13. Nonpharmacologic interventions directed at the body, the mind, the spirit,
and social interactions.

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 Intended Learning Outcomes
1. Discriminate between physiological and neuropathic pain categories.
2. Describe the four processes involved in nociception and how pain
interventions can work during each process.
3. Describe how the physical, mental, spiritual, and social aspects of
pain contribute to concepts such as pain tolerance, suffering, and
pain behavior.
4. Describe the gate control theory and its application to nursing care.
5. Identify subjective and objective data to collect and analyze when
assessing pain.
6. Identify examples of nursing diagnoses for clients with pain.
7. Individualize a pain treatment plan based on clinical and personal
goals, while setting objective outcome criteria by which to evaluate a
client’s response to interventions for pain.
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 Intended Learning Outcomes
8. Compare and contrast barriers to effective pain management
affecting nurses and clients.
9. Describe pharmacologic interventions for pain.
10. Describe the World Health Organization’s ladder step approach
developed for cancer pain control.
11. Identify risks and benefits of various analgesic delivery routes and
analgesic delivery technologies.
12. Describe nonpharmacologic pain control interventions.
13. List three nonpharmacologic interventions directed at each of the
following: the body, the mind, the spirit, and social interactions.

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 Pain
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage. International Association for
the Study of Pain

“whatever the experiencing person says it is, existing

whenever the experiencing person says it does.”
 Physiologic Pain
• Experienced when an intact, properly functioning
nervous system signals that tissues are damaged,
requiring attention and proper care
• Transient /acute
• Persistent/chronic
• Subcategories
– Cutaneous
– Somatic: diffuse or scattered and originates in
tendons, ligaments, bones, blood vessels, and
nerves. Strong pressure on a bone or damage to
tissue that occurs with a fracture causes deep
somatic pain.

– Visceral: poorly localized and originates in body

organs in the thorax, cranium, and abdomen.
Occurs as organs stretch abnormally and become
distended, ischemic, or inflamed.
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 Neuropathic Pain
• Experienced by people who have damaged or
malfunctioning nerves
• Types
– Peripheral: Diabetic neuropathy
– Central
– Sympathetically maintained

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 Four Processes Involved in
Nociception
• Transduction: activation
of pain receptors, conversion
of painful stimuli into
electrical impulses that travel
to the spinal cord at the dorsal
horn
• Transmission
• Perception
• Modulation
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 Transmission of Pain: Gate Control Theory

• Small diameter (a-delta or C) peripheral nerve fibers carry

signals of noxious stimuli to the dorsal horn
• Signals are modified when they are exposed to the substantia
gelatinosa
• Ion channels on the pre-and postsynaptic membranes serve as
gates
• When open, permit positively charged ions to rush into the
second-order neurons, sparking an electrical impulse and sending
signals of pain to the thalamus
• Large diameter (A-delta) fibers have an inhibitor effect
• May activate descending mechanism that can inhibit the
transmission of pain

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 Clinical Application of
Gate Control Theory

• Stop nociceptor firing

• Apply topical therapies
• Address the client’s mood
• Address the client’s goals

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 Perception
• The phase of impulse transmission during which the
brain experiences pain at a conscious level, but many
concomitant neural activities occur almost
simultaneously.
• Besides perceiving pain, the brain structures in the
pain pathway also help to discriminate the location of
the pain, determine its intensity, attach meaningfulness
to the event, and provoke emotional responses.

13
 Factors Affecting
Perception of Pain
• Ethnic and cultural values
• Developmental stage
• Environment and support people
• Past pain experiences
• Meaning of pain
– Spiritual
– Social

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 Modulation of Pain
• The sensation of pain appears to be regulated or modified by
substances called neuromodulators.
• Neuromodulators are endogenous opioid compounds, meaning
they are naturally present, morphine-like chemical regulators in
the spinal cord and brain.
• Endogenous opioid compounds produce their analgesic effects
by binding to specific opioid receptor sites throughout the CNS,
blocking the release or production of pain-transmitting substances.
• Both pain and stress appear capable of activating the endogenous
opiate system.
• Endorphins and enkephalins are opioid neuromodulators

15
 Pain Assessment
Subjective Data
• Comprehensive pain history includes
COLDERR
– Character
– Onset
– Location
– Duration
– Exacerbation
– Relief
– Radiation

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 Additional Data to Obtain
• Associated symptoms
• Effect on ADLs
• Past pain experiences
• Meaning of the pain to the person
• Coping resources
• Affective response

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 Pain Assessment
Objective Data
• Nonverbal responses to pain
– Facial expression
– Vocalizations like moaning and groaning or crying
and screaming
– Immobilization of the body or body part
– Purposeless body movements
– Behavioral changes such as confusion and
restlessness
– Rhythmic body movements or rubbing
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 Pain Assessment
Objective Data
• Early physiologic responses
– Increases BP, HR, RR
– Pallor
– Diaphoresis
– Pupil dilation
– May be absent in people with chronic pain

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 NANDA Nursing Diagnoses
• Acute Pain and Chronic Pain
• Specify the location
• Related factors, when known, can include
physiologic and psychologic factors
• Pain may be the etiology of other nursing
diagnoses

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 NANDA Nursing Diagnoses
• Pain as etiology of other nursing diagnoses
– Ineffective Airway Clearance
– Hopelessness
– Anxiety
– Ineffective Coping
– Ineffective Health Maintenance
– Self-Care Deficit (Specify)
– Deficient Knowledge (Pain Control Measures)
– Disturbed Sleep Patterns
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 Treatment Plan
• Goals vary according to the diagnosis and its
defining characteristics
• Select pain relief measures appropriate for the
client, based on assessment data and input
from the client or support persons

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 Practice Guidelines
• Establish a trusting relationship
• Consider the client’s ability and willingness to participate
• Use a variety of pain relief measures
• Provide pain relief before pain is severe
• Use pain relief measures the client believes are effective
• Align pain relief measures with a report of pain severity
• Encourage the client to try ineffective measures again before
abandoning
• Maintain an unbiased attitude about what may relieve pain
• Keep trying
• Prevent harm
• Educate the client and caregiver about the pain

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 Pain Treatment Plan
• Include variety of pharmacologic and
nonpharmacologic interventions
• Plan with wide range of strategies
• Document plan in client record and for home
care
• Involve client and support persons

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 Barriers to Effective Pain
Management
• Lack of knowledge of the adverse effects of
pain
• Misinformation regarding the use of analgesics
• Misconceptions about pain
• May not report pain
• Fear of becoming addicted

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 Pharmacologic Interventions
for Pain
• Opioids (narcotics)
• Nonopioids/nonsteroidal anti-inflammatory
drugs (NSAIDS)
• Co-analgesic drugs

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 Opioids (Narcotics)
• Interfere with pain perception centrally (at the brain).
• Full agonists
– No ceiling on analgesia
– Dosage can be steadily increased to relieve pain
– E.g., morphine, oxycodone, hydromorphone
• Mixed agonist-antagonists
– Act like opioids and relieve pain
– Can block or inactivate other opioid analgesics
– E.g. dezocine, petazocine hydrochloride, butorphanol tartrate,
nalbuphine hydrochloride
• Partial agonist
– Have a ceiling effect
– E.g., buprenorphine
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 Nonopioids/NSAIDS
• Vary little in analgesic potency but do vary in anti-
inflammatory effects, metabolism, excretions, and
side effects
• They relieve pain by altering neurotransmission at the
peripheral level (site of injury).
• For example, NSAIDS decrease pain by decreasing
transduction at the peripheral level
• Have a ceiling effect
• Narrow therapeutic index
• E.g. acetaminophen, ibuprofen, aspirin
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 Coanalgesic Drugs

• Antidepressants

• Anticonvulsants

• Local anesthetics

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 WHO Ladder Step
Approach for Cancer Pain Control
• Step 1
– For clients with
mild pain (1-3 on a
0-10 scale)
– Use of nonopioid
analgesics (with or
without a
coanalgesic)

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 WHO Ladder Step
Approach
• Step 2
– A client has mild pain that persists or
increases
– Pain is moderate (4-6 on a 0-10 scale)
– Use of a weak opioid (e.g. Codeine,
tramadol, pentazocine) or a combination
of opioid and nonopioid medicine
(oxycodone with acetaminophen,
hydrocodone with ibuprofen)

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 WHO Ladder Step
Approach
• Step 3
– Client has moderate
pain that persists or
increases
– Pain is severe (7-10 on
a 0-10 scale)
– Strong opioids (e.g.
Morphine,
hydromorphone,
fentanyl)
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 Oral Administration
• Preferred because of ease of administration
• Duration of action is often only 4 to 8 hours
• Must awaken during night for medication
• Long-acting preparations developed
• May need rescue dose of immediate-release
medication

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 Transmucosa/Transnasal and
Transdermal Administration
• Transmucosa and Transnasal
– Enters blood immediately
– Onset of action is rapid
• Transdermal
– Delivers relatively stable plasma drug level
– Noninvasive
• Rectal
– Useful for clients with dysphagia or
nausea/vomiting
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 Medication Administration
• Intramuscular
– Should be avoided
– Variable absorption
– Unpredictable onset of action and peak effect
– Tissue damage
• Intravenous
– Provides rapid and effective relief with few side
effects

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 Medication Administration
• Intraspinal
– Provides superior analgesia with less medication used

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 Benefits/Risk Routes and Technology
• Patient-controlled
analgesia (PCA)
– Minimizes peaks of
sedation and valleys
of pain that occur
with PRN dosing
– Electronic infusion
pump
– Safety mechanisms

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 Nonpharmacologic Pain
Control Interventions
• ALL Non pharmacological Interventions relieve pain by
decreasing the perception of pain
• Consists of variety of pain management strategies
– Physical
– Cognitive-behavioral
– Lifestyle pain management
• Target body, mind, spirit, and social interactions

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 Physical Modalities
• Cutaneous stimulation
• Immobilization or
therapeutic exercises
• Transcutaneous
electrical nerve
stimulation (TENS)

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 Cognitive-Behavioral
(Mind-Body)
• Providing comfort
• Eliciting relaxation
response
• Repatterning thinking
• Facilitating coping with
emotions

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 Lifestyle Management
• Stress management
• Exercise, nutrition
• Pacing activities
• Disability management

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 Spiritual

• Feel part of a community

• Bond with universe

• Religious activities

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 Body Interventions
• Reducing pain triggers
• Massage
• Applying heat or ice
• Electric stimulation (TENS)
• Positioning and bracing (selective immobilization)
• Acupressure
• Diet and nutritional supplements
• Exercise and pacing activities
• Invasive interventions (e.g. blocks)
• Sleep hygiene
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 Mind Interventions
• Relaxation and imagery
• Self-hypnosis
• Pain diary and journal writing
• Distracting attention
• Re-pattern thinking
• Attitude adjustment
• Reducing fear, anxiety, stress, sadness, and
helplessness
• Providing information about pain

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 Spirit Interventions
• Prayer
• Meditation
• Self-reflection
• Meaningful rituals
• Energy work (therapeutic touch, Reiki)
• Spiritual healing

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 Social Interaction
• Functional restoration
• Improved communication
• Family therapy
• Problem-solving
• Vocational training
• Volunteering
• Support groups

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 References
• Audrey J. Berman, Shirlee Snyder, Geralyn
Frandsen (2020) Fundamentals of nursing;
concepts, process, and practice. (11thed).
Pearson Education International.
• Taylor. C, Lillis. C, LeMone. P & Lynn. P .
(2016). Fundamentals of Nursing: The Art
and Science of Nursing Car (8th
ed.)Philadelphia: Lippincott Williams&
Wilkins.
Copyright 2008 by Pearson Education, Inc.
 Additional Resources
• Audio glossary
• The Mayday Pain Project
Resource for different types of pain management
• pain.com--Cancer
Resources for coping with and managing cancer pain
• Pain Management
Links to pain management topics, including arthritis and
chronic pain
• American Chronic Pain Association
Provides resources about chronic pain and how to live with
chronic pain productively by using education and self-help

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 Additional Resources
• American Pain Foundation
Provides methods to understand pain, and resources and
support for people with severe pain. Includes types of pain,
medications, and alternative therapies.
• National Foundation for the Treatment of Pain
Provides support for people with intractable pain, and
resources and treatment issues for families and health care
team members.
• MEDLINEplus--pain
Covers the different types of pain, the newest treatments, and
studies concerning pain
• The National Pain Foundation
An educational site for people with pain
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