1. Pain Lecture

1. Pain Assessment
and
Management

2. Outlines
 Introduction.
 Types and classifications of pain.
 Harmful effects of pain (acute and chronic pain ).
 Pathophysiology of pain.
 Factors influencing pain response.
 Nursing Assessment of Pain
 Roles of the Nurse in Pain Management
 Pain Management Strategies.
 Pharmacologic Interventions.
 Nonpharmacologic approaches

3. Introduction
Pain is defined as an unpleasant sensory and
emotional experience associated with actual
or potential tissue damage.
 Pain occurs as the result of many disorders, diagnostic
tests, and treatments.
 Pain is the most common reason for seeking health
care.
 Pain is the fifth vital sign and should be assessed and
documented as automatic as taking a “traditional” vital
signs (temperature, respiration, blood pressure).

4. Types of Pain
 Pain is categorized according to its duration, location,
and etiology.
 Pain Classified by Duration into three basic
categories:
 Acute pain.
 Chronic (nonmalignant) pain.
 Cancer-related pain.

5. Types of Pain (Cont.)
Acute Pain.
 Usually of recent onset and commonly associated with
a specific injury.
 Indicates that damage or injury has occurred.
 A useful signal that something is wrong.
 Last from seconds to 6 months.
Chronic (nonmalignant) Pain.
 It is constant or intermittent pain that persists beyond
the expected healing time and that can seldom be
attributed to a specific cause or injury.
 Lasts for 6 months or longer.

6. Types of Pain (Cont.)
Cancer-related Pain.
 The pain associated with cancer and is often called
“malignant pain” or “cancer pain.”
 May be acute or chronic.
 A direct result of tumor involvement (e.g., bony
infiltration with tumor cells or nerve compression).
But it may a result of cancer treatment (e.g., surgery or
radiation).

7. Types of Pain (Cont.)
Pain Classified by Location (e.g., pelvic pain,
headache, chest pain). This type of categorization aids in
communication about and treatment of the pain.
Pain Classified by Etiology (e.g., burn pain and
postherpetic neuralgia). Clinicians often can predict the
course of pain and plan effective treatment using this
categorization.

8. Effects of Acute Pain
 Patient with severe pain may be unable to take a deep
breath and may experience increased fatigue and
decreased mobility.
 The unrelieved acute pain produce stress response
such that occurs with trauma.
 Stress response generally consists of increased
metabolic rate and cardiac output, impaired insulin
response, increased production of cortisol, and
increased retention of fluids.
 Stress response can affect the pulmonary,
cardiovascular, gastrointestinal, endocrine, and
immune systems.

9. Effects of Acute Pain (Cont.)
 Changes that occur with stress response can have
significant harmful effects.
 These effects may hamper recovery and increase
patient’s risk for physiologic disorders (e.g., myocardial
infarction, pulmonary infection, paralytic ileus and
thromboembolism). Particularly in patients whose
health is already compromised by age, illness, or injury
(in elderly, debilitated, or critically ill people).
 Effective pain relief may result in faster recovery and
improved outcomes.

10. Effects Of Chronic Pain
 Chronic pain often results in suppression of the
immune function (which promote tumor growth),
anger, fatigue, depression, and disability.
 Disabilities may range from an impaired ability to
participate in physical activities and interpersonal
relationships to an inability to take care of personal
needs, such as dressing or eating.

11. Pathophysiology of Pain
Pain Transmission.
 Neurologic transmission of pain is also referred to as
nociception.
 Nociceptors, or pain receptors, are neuronal receptors
involved in the transmission of pain perceptions to and
from the brain. It respond to biochemical mediators or
noxious stimuli.
 Nociceptors are free nerve endings in the skin that
respond only to intense, potentially damaging stimuli.
Such stimuli may be mechanical, thermal, or chemical in
nature.

12. Pathophysiology of Pain (Cont.)
 The joints, skeletal muscle, fascia, tendons, and cornea
also have nociceptors that have the potential to
transmit stimuli that produce pain.
 The large internal organs (viscera) do not contain
nerve endings that respond only to painful stimuli.
 Pain originating in these organs results from intense
stimulation of receptors that have other purposes.
 For example, inflammation, stretching, ischemia,
dilation, and spasm of the internal organs all cause an
intense response in these multipurpose fibers and can
cause severe pain.

14. Factors Influencing
Pain Response
There are factors may increase or decrease perception of
pain, increase or decrease tolerance for pain, and affect
responses to pain.
1. Past experiences with pain and expectations about
pain relief.
2. Anxiety related to pain increase the perception of pain
 Anxiety that is unrelated to the pain may distract
patient and decrease the perception of pain.
3. Culture (age, education level, income, and beliefs
about pain).
4. Gender (women consistently reported higher pain
intensity)

15. Nursing Assessment of Pain
 Pain assessment begins by observing the patient
carefully, noting the patient’s overall posture and
presence or absence of overt pain behaviors.
 Then ask the person to describe, in his or her own
words, the specifics of the pain.
 A detailed history should follow the initial description
of pain.

16. Nursing Assessment of Pain
Characteristics of Pain. The factors to consider in a
complete pain assessment are:
A. Intensity.
B. Timing.
C. Location.
D. Quality.
E. Aggravating and alleviating factors.
F. Personal meaning.
G. Pain behaviors.

17. Nursing Assessment of Pain
A. Intensity of Pain:
 The reported pain intensity is influenced by:
A.Person’s Pain Threshold: the smallest stimulus
for which a person reports pain.
B.Person’s Pain Tolerance: the maximum
amount of pain a person can tolerate.
 Only the patient can accurately describe his pain.
Remember pain is, “whatever the person says it
is, existing whenever the experiencing person
says it does”.

18. Nursing Assessment of Pain
A. Intensity of Pain (Cont.).
 Pain assessment tools used to assess the patient’s
perception of pain, document the need for
intervention, to evaluate the effectiveness of the
intervention, and to identify the need for alternative
or additional interventions.
 Examples of the pain assessment tools are:
1. Simple descriptive pain intensity scale (Word Scale).
2. 0-10 numeric pain intensity scale.
3. Visual Analogue Scales (VAS)
4. Faces Pain Scale–Revised

19. Tools (scales) For Assessing Intensity of Pain

20. • Explain to the patient that this face (point to left-most face) shows
no pain. The faces show more and more pain (point to each from
left to right) up to this one (point to right-most face) it shows very
much pain.
• Ask the patient to point to the face that most closely resembles the
intensity of his pain (right now).
• Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so 0
no pain and 10 very much pain. Do not use words like “happy” or
“sad.”
• This pain scale is especially suited for helping children describe
pain. This scale is intended to measure how children feel inside,
not how their face looks.
Faces Pain Scale – Revised .

21. Nursing Assessment of Pain
A. Intensity of Pain (Cont.).
 Using a written scale to assess pain may not be
possible if the person is seriously ill, is in severe pain,
or has just returned from surgery.
 In these cases, use the 0 to 10 numeric pain intensity
scale, 0 being no pain and 10 being pain as bad as it
can be, how bad is your pain now?”
 Ideally, the nurse teaches the patient how to use the
pain scale before the pain occurs (e.g., before surgery).

22. Nursing Assessment of Pain
B. Timing of Pain: include the onset, duration,
relationship between time and intensity (e.g., at what
time the pain is the worst), and changes in rhythmic
patterns.
 Ask patient if the pain began suddenly or increased
gradually.
 Sudden pain that rapidly reaches maximum
intensity is indicative of tissue injury, and
immediate intervention is necessary.

23. Nursing Assessment of Pain
C. Location: best determined by having the patient
point to the area of the body involved.
D. Quality: ask patient to describe the pain in his own
words without offering clues. The patient is asked to
describe what the pain feels like (e.g., burning, aching,
throbbing, or stabbing).
 It is important to document the exact words used by
the patient to describe the pain.

24. Nursing Assessment of Pain
E. Personal Meaning of Pain:
 Pain means different things to different people; as a
result, patients experience pain differently.
 Meaning of pain helps understand how patient’s daily
life is affected and assists in planning treatment.
 Some people with pain can continue to work or study,
whereas others may be disabled, thus affecting their
financial situation.
 For some patients, recurrence of pain may mean
worsening of disease, such as the spread of cancer.

25. Nursing Assessment of Pain
F. Aggravating and Alleviating Factors
 Ask the patient what, if anything, makes pain worse
and what makes it better.
o Ask about the relationship between activity and pain.
o Ask whether environmental factors influence pain.
o Ask whether the pain is influenced by or affects the
quality of sleep or anxiety.
o Ask about patient’s use of medications (including
amount and frequency), herbal remedies,
nonpharmacologic interventions, or alternative
therapies.

26. Nursing Assessment of Pain
G. Pain Behaviors:
 People express pain with many different behaviors.
 Patients may grimace, cry, or patient my rub, guard or
immobilize the affected area.
 Others may moan, groan, or sigh.
 Not all patients exhibit the same behaviors, and there
may be different meanings for the same behavior.
 Remember, the nonverbal and behavioral
expressions of pain are not consistent or reliable
indicators of the quality or intensity of pain.

27. Roles of the Nurse in Pain
Management
 Perform pain assessment.
 Identify goals for pain management.
 Provide patient teaching.
 Perform physical care.
 Help relieve pain by administering pain-relieving
interventions (including both pharmacologic and
nonpharmacologic approaches).
 Assess the effectiveness of those interventions.
 Monitor for adverse effects.
 Serve as an advocate for patient when the prescribed
intervention is ineffective in relieving pain.

28. Pain Management Strategies
A. Pharmacologic Interventions.
B. Nonpharmacologic approaches.
These approaches are selected on the basis of
the requirements and goals of particular
patients.

29.  Pharmacologic management of pain is accomplished in
collaboration with physicians, patients, and often
families.
 A physician prescribes specific medications for pain or
insert an epidural catheter for administration of such
analgesic agents.
 The nurse maintains the analgesia, assesses its
effectiveness, and reports whether the intervention is
ineffective or produces side effects.
A. Pharmacologic Interventions

30. A. Pharmacologic Interventions (Cont.)
A. Pharmacologic Interventions.
1. Opioid Analgesic Agents (Narcotics), such as
Morphine, Codeine, and Meperidine, and Tramadol.
 Interfere with pain perception centrally (at the brain)
2.Nonsteroidal Anti-inflammatory Drugs
(NSAIDs), such as, diclofenac (Voltaren),
ibuprofen, indomethacin, ketoprofen, piroxicam,
and naproxen.
 Alter the neurotransmission at the peripheral level.
3.Local Anesthetic Agents.
a. Topical Application.
b. Intraspinal Administration (by through an epidural
catheter)

31. A. Pharmacologic Interventions (Cont.)
Approaches for Using Analgesic Agents.
 Balanced Analgesia : refers to the use of more than one
form of analgesia concurrently to obtain more pain relief
with fewer side effects.
 Preventive Approach: analgesic drugs are given at set
time intervals rather than on the basis of the patient’s report
of pain, so that medication acts before pain becomes severe
and before serum drug level falls to a subtherapeutic level.
 Patient-Controlled Analgesia (PCA): patients control
the administration of their own medication within
predetermined safety limits. This approach used with oral
analgesic agents and with continuous infusions of opioid
analgesic agents by IV, subcutaneous, or epidural routes.

32. A. Pharmacologic Interventions (Cont.)
Premedication
 Ask the patient about allergies to medications and the
nature of any previous allergic responses.
 Obtains the patient’s medication history (e.g., current,
usual, or recent use of prescription or OTC
medications or herbal agents). Because certain
medications may affect the analgesic medication’s
effectiveness or the metabolism and excretion of
analgesic agents.
 Assess patient’s pain status, including the intensity of
current pain, and changes in pain intensity after the
previous dose of medication.

33. A. Pharmacologic Interventions (Cont.)
Postmedication
 Monitor the effects of opioid analgesic medications
and record patient’s blood pressure, respiratory and
pulse rates especially when the first dose is given or
when the dose is changed or given more frequently.
 When opioids administered, anticipate side effects and
take steps to minimize them and to increase the
likelihood that patient will receive adequate pain relief
without interrupting therapy to treat these effects.
 Record the time, date, the patient’s pain rating (scale
of 0 to 10), the analgesic agent, side effects, and patient
activity.

34. A. Pharmacologic Interventions (Cont.)
Side effect of the Opioids:
1. Respiratory depression and sedation
2. Nausea and vomiting.
3. Constipation.
4. Pruritus.
Tolerance: the need for increasing doses of opioids to
achieve the same therapeutic effect. Develop in patients
taking opioids over an extended period.
Addiction: a behavioral pattern of substance use
characterized by a compulsion to take the substance
(drug or alcohol) primarily to experience its psychic
effects.

35. B. Nonpharmacologic Interventions
1.Cutaneous Stimulation and Massage (rubbing
the skin) on the back and shoulders stimulate fibers
that transmit nonpainful sensations can block or
decrease the transmission of pain impulses.
 Massage also promotes comfort because it produces
muscle relaxation.

36. 2. Thermal Therapies (Ice and heat therapies)
 Application of ice on the injury site immediately after
injury or surgery reduce pain and reduce the amount of
analgesic medication required.
 Application of dry and moist heat increases blood flow to
area and contributes to pain reduction by speeding healing
 Both ice and heat therapy must be applied carefully and
monitored closely to avoid injuring the skin.
 Neither therapy should be applied to areas with impaired
circulation or with impaired sensation.
 It is believed that ice and heat stimulate the nonpain
receptors in the same receptor field as the injury.
B. Nonpharmacologic Interventions (Cont.)

37. 3. Transcutaneous Electrical Nerve Stimulation
(TENS)
 TENS uses a battery-operated unit with electrodes
applied to the skin to produce a tingling, vibrating,
or buzzing sensation in the area of pain.
 It decrease pain by stimulating the nonpain
receptors in the same area as the fibers that transmit
the pain.
 For example, when TENS is used in a postoperative
patient, the electrodes are placed around the surgical
wound.
B. Nonpharmacologic Interventions (Cont.)

38. 4. Distraction: which involves focusing the patient’s
attention on something other than the pain.
 Distraction is thought to reduce the perception of pain
by stimulating the descending control system, resulting
in fewer painful stimuli being transmitted to the brain.
 Effectiveness of distraction depends on the patient’s
ability to receive and create sensory input other than
pain.
B. Nonpharmacologic Interventions (Cont.)

39. 4. Distraction (Cont.).
 Distraction techniques involves watching TV, watching
an action-packed movie on a large screen through
headphones, games and activities (e.g., chess, crossword
puzzles) that require concentration and visits from
family and friends.
 The stimulation of sight, sound, and touch is likely to be
more effective than is the stimulation of a single sense.
 Severe pain may prevent patients from concentrating
well enough to participate in complex physical or
mental activities.
B. Nonpharmacologic Interventions (Cont.)

40. 5. Relaxation Techniques:
 Skeletal muscle relaxation is believed to reduce pain by
relaxing tense muscles that contribute to the pain.
 A simple relaxation technique consists of abdominal
breathing at a slow, rhythmic rate. The patient may
close both eyes and breathe slowly and comfortably. A
constant rhythm can be maintained by counting
silently and slowly with each inhalation (“in, two,
three”) and exhalation (“out, two, three”).
B. Nonpharmacologic Interventions (Cont.)

41. 6. Guided Imagery :
 Guided imagery for relaxation and pain relief may
consist of combining slow, rhythmic breathing with a
mental image of relaxation and comfort.
 Instructs patient to close both eyes and breathe slowly
in and out. With each slowly exhaled breath, the
patient imagines muscle tension and discomfort being
breathed out, carrying away pain and tension and
leaving behind a relaxed and comfortable body.
 With each inhaled breath, the patient imagines healing
energy flowing to the area of discomfort.
B. Nonpharmacologic Interventions (Cont.)