PAIN

INTRODUCTION

Pain is a complex, multidimensional experience that can cause suffering and

decreased quality of life. Pain is one of the major reasons that people seek health care.
To effectively assess and manage patients with pain, you need to understand the
physiologic and psychosocial dimensions of pain. This chapter presents evidence-
based information to help you assess and manage pain successfully in collaboration
with other health care providers. Pain is a sensory and emotional experience. The
emotional component is variable from person to person and in the same person from
time to time. Management of pain has to take this fact into consideration. The patient
must be believed about the pain. It is the physician’s duty to relieve suffering. In
addition, unrelieved pain can cause physical damage too. For one thing, it would
worsen the pain experience by muscle spasm, peripheral and central sensitization and
recruitment and by muscle spasm. Unrelieved acute pain can cause chronic pain, and
long-standing pain can cause anatomical and even genetic changes in the nervous
system. Pain can be classified in several ways, but the most relevant in terms of
therapeutic application is into nociceptive and neuropathic. In addition to such
identification of the type of pain, it is also necessary to quantitate pain. Several scoring
systems are available like the numerical scale, but it needs to be remembered that the
patient is the only person who can quantitate his pain. everyone has experienced some
type of pain.it is the most common reason why people seek healthcare. Despite being
one of the most commonly occurring symptoms in the medical world, pain is one of
the least understood. a person in pain feels distress or suffering and seeks relief.
However, the nurse cannot see or feel the client’s pain. pain is subjective. Now pain is
considered to be a separate diesis.

The Fifth Vital Sign

Pain management is considered such an important part of care that the American Pain
Society coined the phrase “Pain: The 5th Vital Sign” (Campbell, 1995) to emphasize
its significance and to increase the awareness among health care professionals of the
importance of effective pain management.

DEFINITIONS

Pain is an unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage

‘Pain is always subjective the clinician must accept the patients report of pain.’

(The American pain society)

NATURE OF PAIN

• Pain is subjective and highly individualized.

• Its stimulus is physical and/or mental in nature.

• It interferes with personal relationships and influences the meaning of life.

• Only the patient knows whether pain is present and how the experience feels.

• May not be directly proportional to amount of tissue injury

SIGNS AND SYMPTOMS OF PAIN

• increased respiratory rate

• increased heart rate
• peripheral vasoconstriction
• pallor
• elevated BP.
• increased blood glucose levels
• diaphoresis
• dilated pupils
 • moaning
• guarding the area
• restlessness
• irritability
PAIN MECHANISMS

Nociception is the physiologic process by which information about tissue damage is

communicated to the central nervous system (CNS). It involves four processes: (1)
transduction, (2) transmission, (3) perception, and (4) modulation

Transduction.
Transduction involves the conversion of a noxious mechanical, thermal, or chemical
stimulus into an electrical signal called an action potential. Noxious (tissuedamaging)
stimuli, including thermal (e.g., sunburn), mechanical (e.g., surgical incision), or
chemical (e.g., toxic substances) stimuli, cause the release of numerous chemicals such
as hydrogen ions, substance P, and adenosine triphosphate (ATP) into the damaged
tissues. Other chemicals are released from mast cells (e.g., serotonin, histamine,
bradykinin, prostaglandins) and macrophages (e.g., interleukins, tumor necrosis factor
[TNF]). These chemicals activate nociceptors, which are specialized receptors, or free
nerve endings, that respond to painful stimuli. Activation of nociceptors results in an
action potential that is carried from the nociceptors to the spinal cord primarily

Transmission
It is the movement of pain impulses from the site of transduction to the brain. Three
segments are involved in nociceptive signal transmission.
 Transmission along the peripheral nerve fibers to the spinal cord
 Dorsal horn processing
 Transmission to the thalamas and cerebral cortex

Modulation
It involves the activation of desenting pathway that exert inhibitory or facilitatory
effects on the transmission of pain.

Perception
Perception is the point at which the person is aware of pain. Pain stimuli are
transmitted up the spinal cord to the thalamus and midbrain.
 TYPES OF PAIN

BASED ON THE DURATION

BASED ON LOCATION

BASED ON INTENSITY

BASED ON ETIOLOGY

BASED ON THE DURATION OR NATURE

 Acute pain
 Chronic pain

Acute pain

When pain lasts only through the expected recovery period, it is described as acute
pain.

 Acute pain has a sudden onset.

 Relatively short duration
 Mild to severe intensity
 A steady decrease in intensity over a period of days or weeks.
 Once the stimuli are resolved the pain usually disappears.
 Usually associated with specific condition, injury or tissue damages.
 As healing occurs, acute pain should diminish.
 Eg; headache, needle sticks, toothache.
 Unrelieved acute pain can progress to chronic pain.

Chronic pain

• Chronic pain is the pain that lasts longer than 6 months and is constant or recurring
with a mild-to-severe intensity.
• It does not always have an identifiable cause and leads to great personal suffering.
Examples: arthritic pain, head ache, peripheral neuropathy.
• The possible unknown cause of chronic pain, combined with the unrelenting nature
and uncertainty of its duration, frustrates a patient, frequently leading to psychological
depression and even suicide.
• Associated symptoms of chronic pain include fatigue, insomnia, anorexia, weight
loss, hopelessness, and anger.

chronic pain may be :

• Chronic non cancer pain
• Chronic cancer pain
• Chronic episodic pain.

Chronic non cancer pain:

• The chronic pain that resulted due to non-cancer disease conditions is termed as
chronic non cancer pain.

Chronic cancer pain:

• Cancer pain is the pain that is caused by tumour progression and related pathological
processes, invasive procedures, toxicities of treatment, infection, and physical
limitations.
• Approximately 70% to 90% of patients with advanced cancer experience pain.

Chronic episodic pain:

• Pain that occurs sporadically over an extended period of time is episodic pain.
 • Pain episodes last for hours, days, or weeks. Examples are migraine headaches.

Classification based on location:

• This is based on the site at which the pain is located. Egs: Headache ,Back pain ,
Joint pain , Stomach pain ,Cardiac pain • Referred pain: pain due to problems in other
areas manifest in different body part. • For example, cardiac pain may be felt in the
shoulder or left arm, with or without chest pain.

Based on intensity:
 Mild pain
 Moderate pain
 Severe pain

Mild pain: • Pain scale reading from 1 to 3 is considered as mild pain

Moderate pain: • Pain scale reading from 4 to 6 is considered as moderate pain

severe pain: • Pain scale reading from 7 to 10 is considered as severe pain Based on
intensity:

Classification of pain based on etiology:

 Nociceptive pain
 Somatic pain
 Visceral pain
 Neuropathic pain
 Peripheral neuropathic pain
 Central neuropathic pain

Nociceptive pain:
• Nociceptive pain is experienced when an intact, properly functioning nervous system
sends signals that tissues are damaged, requi0jring attention and proper care.
• For example, the pain experienced following a cut or broken bone alerts the person to
avoid further damage until it is properly healed.
• Once stabilized or healed, the pain goes away .

Somatic pain:
• This is the pain that is originating from the skin, muscles, bone, or connective tissue.
• The sharp sensation of a paper cut or aching of a sprained ankle are common
examples.

Visceral pain:
• Visceral pain is pain that results from the activation of nociceptors of the thoracic,
pelvic, or abdominal viscera (organs).
• Characterized by cramping, throbbing, pressing, or aching qualities.
• Examples: labour pain, angina pectoris, or irritable bowel.

Neuropathic pain
• Neuropathic pain is associated with damaged or malfunctioning nerves due to illness,
injury, or undetermined reasons.
Examples: Diabetic peripheral neuropathy, Phantom limb pain, Spinal cord injury
pain
It is usually chronic.
• it is described as burning, “electric-shock,” and/or tingling, dull, and aching.
• Neuropathic pain tends to be difficult to treat.
• Neuropathic pain is of two types based on which parts of the nervous system is
damaged.
1. Peripheral Neuropathic Pain
2. Central Neuropathic Pain.

Peripheral neuropathic pain:

• Due to damage to peripheral nervous system. Eg: phantom limb pain

Central neuropathic pain:

• Results from malfunctioning nerves in the central nervous system (CNS). ,Eg: spinal
cord injury pain, Post-stroke pain.
 THEORIES OF PAIN

1.SPECIFICITY THEORY

The most widely accepted theory of pain transmission through the end of 19th
century.
♦It advances the idea that the body’s neurons and pathways for pain transmission are
as specific and unique as those for other body senses, such as taste or touch.
♦ It proposes that free nerve endings in the skin act as pain receptors, accept sensory
input, and transmit this input along highly specific nerve fibers. These fibers synapse
in the dorsal horns of the spinal cord, and cross-over to the anterior and lateral
spinothalamic tracts. The pain impulses then ascend to the thalamus and cerebral
cortex, where painful sensations are perceived.
♦ It does not explain the differences in pain perception among individuals, nor does it
satisfactorily account for the effect of physiologic variables, the effect of previous
experience with pain, phantom limb pain, or peripheral neuralgias.

2. PATTERN THEORY

Proposed in the early 1900s.

♦ It identifies two (2) major types of pain fibers, rapidly conducting and slowly
conducting fibers (A-delta and C-fibers). The stimulation of these fibers forms a
pattern.
♦ The theory also introduces the concept of central summation. Peripheral impulses
from many fibers of both types are combined at the level of the spinal cord, and from
there, a summation of these impulses ascends to the brain for interpretation.
♦ This theory does not account for individual perceptual differences and psychologic
factors.
3. GATE CONTROL THEORY

Suggests that pain and its perception are determined by interaction of two systems.
The 1st of these interrelated systems is the substantia gelatinosa in the dorsal horns of
the spinal cord. The substantia gelatinosa regulates impulses entering or leaving the
spinal cord. The 2nd system is an inhibitory system within the brainstem.
♦ Small diameter A-delta and C-fibers carry fast and slow pain impulses. Large
diameter A-beta fibers carry impulses for tactile stimulation from the skin. In the SG,
these impulses encounter a “gate” thought to be opened and closed by the domination
of either the large diameter touch fibers or the small-diameter pain fibers. If impulses
along the small diameter pain fibers outnumber impulses along the large diameter
touch fibers, the gate is open, and pain impulses travel unimpeded to the brain. If the
fibers predominate, they will close the gate and the pain impulses will be “turned
away” at the gate. This explain why massaging a stabbed toe can reduce the intensity
and duration of pain.
♦ The 2nd system described, is thought to be located in the brain stem. It is believed
that cells in the midbrain, activated by a variety of functions such as opiates,
psychologic factors, or even simply the presence of pain itself, signal receptors in the
medulla. These receptors in turn stimulate nerve fibers in the spinal cord to block the
transmission of pain fibers. It is hypothesized that this brainstem regulatory system
may help explain why even severe pain may not be perceived under certain
circumstances, such as when an athlete fails to notice an injury until the competition is
over.

PAIN TREATMENT

Basic Principles All pain treatment plans are based on the following 10 principles and
practice standards:

1. Follow the principles of pain assessment. Remember that pain is a subjective

experience. The patient is not only the best judge of his or her own pain, but also the
expert on the effectiveness of each pain treatment.
2. Use a holistic approach to pain management. The experience of pain affects all
aspects of a person’s life. Thus a holistic approach to assessment, treatment, and
evaluation is required.

3. Every patient deserves adequate pain management. Many patient populations,

including ethnic minorities, older, adults, and people with past or current substance
abuse, are at risk for inadequate pain management. Be aware of your own biases and
ensure that all patients are treated respectfully.

4. Base the treatment plan on the patient’s goals. Discuss with the patient realistic
goals for pain relief during the initial pain assessment. Although goals can be
described in terms of pain intensity (e.g., the desire for average pain to decrease from
“8/10” to “3/10”), with chronic pain conditions functional goal setting should be
encouraged (e.g., a goal of performing certain daily activities, such as socializing and
hobbies).

5. Use both drug and nondrug therapies. Although drugs are often considered the
mainstay of therapy, incorporate selfcare activities and nondrug therapies to increase
the overall effectiveness of therapy and to allow for the reduction of drug dosages to
minimize adverse drug effects.

6. When appropriate, use a multimodal approach to analgesic therapy. Multimodal

analgesia is the use of two or more classes of analgesic medications to take advantage
of the various mechanisms of action. This approach achieves superior pain relief,
enhances patient satisfaction, and decreases adverse effects of individual drugs.

7. Address pain using an interdisciplinary approach. The expertise and perspectives of

an interdisciplinary team are often necessary to provide effective evaluation and
therapies for patients with pain, especially chronic pain. Interdisciplinary teams
frequently include psychology, physical and occupational therapy, pharmacy, spiritual
care, and multiple medical specialties (e.g., neurology, palliative care, oncology,
surgery, anesthesiology). Some pain teams also include massage therapists, music
therapists, acupuncturists, and art therapists.

8. Evaluate the effectiveness of all therapies to ensure that they are meeting the
patient’s goals. Achievement of an effective treatment plan often requires trial and
error. Adjustments in drug, dosage, or route are common to achieve maximal benefit
 while minimizing adverse effects. This trial-anderror process can become frustrating
for the patient and caregivers. Reassure them that pain relief, if not pain cessation, is
possible and that the health care team will continue to work with them to achieve
adequate pain relief.

9. Prevent and/or manage medication side effects. Side effects are a major reason for
treatment failure and nonadherence. Side effects are managed in one of several ways,
as described in Table 9-7. You play a key role in monitoring for and treating side
effects, and in teaching patients and caregivers how to minimize these effects.

10. Incorporate patient and caregiver teaching throughout assessment and treatment.
Content should include information about the causes of the pain, pain assessment
methods, treatment goals and options, expectations of pain management, proper use of
drugs, side effect management, and nondrug and self-help pain relief measures.
Document the teaching, and include evaluation of patient and caregiver
comprehension.

FACTORS INFLUENCING THE PAIN RESPONSE

A person’s pain experience is influenced by a number of factors, including past

experiences with pain, anxiety, culture, age, gender, and expectations about pain relief.
These factors may increase or decrease the person’s perception of pain, increase or
decrease tolerance for pain, and affect the responses to pain.

Past Experience

It is tempting to expect that a person who has had multiple or prolonged experiences
with pain would be less anxious and more tolerant of pain than one who has had little
pain.

Anxiety and Depression

Although it is commonly believed that anxiety will increase pain, this is not
necessarily true. Research has demonstrated no consistent relationship between
anxiety and pain, nor has research shown that preoperative stress reduction training
reduces postoperative pain (Keogh, Ellery, Hunt et al., 2001; Rhudy & Meagher,
2000). Postoperative anxiety is most related to preoperative anxiety and postoperative
complications. However, anxiety that is relevant or related to the pain may increase the
patient’s perception of pain.

Culture

Beliefs about pain and how to respond to it differ from one culture to the next. Early in
childhood, individuals learn from those around them what responses to pain are
acceptable or unacceptable. For example, a child may learn that a sports injury is not
expected to hurt as much as a comparable injury caused by a motor vehicle crash. The
child also learns what stimuli are expected to be painful and what behavioral responses
are acceptable. These beliefs vary from one culture to another; therefore, people from
different cultures who experience the same intensity of pain may not report it or
respond to it in the same ways.

Age

Age has long been the focus of research on pain perception and pain tolerance, and
again the results have been inconsistent. For example, although some researchers have
found that older adults require a higher intensity of noxious stimuli than do younger
adults before they report pain.

Gender

Researchers have studied gender differences in pain levels and in responses to pain.

Placebo Effect

A placebo effect occurs when a person responds to the medication or other treatment
because of an expectation that the treatment will work rather than because it actually
does so. Simply receiving a medication or treatment may produce positive effects. A
patient’s positive expectations about treatment may increase the effectiveness of a
medication or other intervention.

INSTRUMENTS FOR ASSESSING THE PERCEPTION OF PAIN

Only the patient can accurately describe and assess his or her pain.. Therefore, a
number of pain assessment instruments have been developed to assist in the
assessment of a patient’s perception of pain. Such instruments may be used to
document the need for intervention, to evaluate the effectiveness of the intervention,
and to identify the need for alternative or additional interventions if the initial
intervention is ineffective in relieving the pain. For a pain assessment instrument to be
useful, it must require little effort on the part of the patient, be easy to understand and
use, be easily scored, and be sensitive to smalchanges in the characteristic being
measured.

Visual Analogue Scales

Visual analogue scales are useful in assessing the intensity of pain. One version of the
scale includes a horizontal 10-cm line, with anchors (ends) indicating the extremes of
pain. The person is asked to place a mark indicating where the current pain lies on the
line. The left anchor usually represents “none” or “no pain,” whereas the right anchor
usually represents “severe” or “worst possible pain.” To score the results, a ruler is
placed along the line and the distance the person marked from the left or low end is
measured and reported in millimeters or centimeters. Some patients (eg, children,
elderly patients, and visually or cognitively impaired patients) may find it difficult to
use an unmarked VAS. In those circumstances, ordinal scales (simple descriptive pain
intensity scale, or 0 to 10 numeric pain intensity scale) may be used.

Faces Pain Scale

Revised This instrument has seven faces depicting expressions that range from
contented to obvious distress. The patient is asked to point to the face that most closely
resembles the pain intensity felt. Evidence for reliability and validity has been
established (Hicks, van Baeyer, Spafford et al., 2001; Hunter, McDowell, Hennessy et
al., 2000).

Guidelines for Using Pain Assessment Scales

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, the nurse can ask
the patient,. Ideally, the nurse teaches the patient how to use the pain scale before the
pain occurs (eg, before surgery). The patient’s numerical rating is documented and
used to assess the effectiveness of pain relief interventions. If the person does not
speak English or cannot communicate clearly information needed to manage pain, an
interpreter, translator, or family member familiar with the person’s method of
communication should be consulted and a method established for pain assessment.
Often a chart can be constructed with English words on one side and the foreign
language on the other. The patient can then point to the corresponding word to tell the
clinician about the pain. When a person with pain is cared for at home by family
caregivers or the home care nurse, a pain scale may help in assessing the effectiveness
of the interventions, if the scale is used before and after the interventions are
administered.

NURSING AND COLLABORATIVE MANAGEMENT PAIN

You are an important member of the interdisciplinary pain management team. You
provide input into the assessment and reassessment of pain. You help in planning and
implementing treatments, including education, advocacy, and support of the patient
and family. Because patients in any care setting can experience pain, you must be
knowledgeable about current therapies and flexible in trying new approaches to pain
management. Together with the patient, develop a written agreement or treatment plan
that describes the pain management. The plan should ensure that pain will be treated
based on the patient’s perception and report of pain. In addition, the plan should
clearly outline the gradual tapering of the analgesic dose, with eventual substitution of
parenteral analgesics with long-acting oral preparations, and possibly cessation of
opioids. Many nursing roles are described earlier in this chapter, including assessing
pain, administering treatment, monitoring for side effects, and teaching patients and
caregivers. However, the success of these actions depends on your ability to establish
a trusting relationship with the patient and caregiver and to address their concerns
regarding pain and its treatment.

EFFECTIVE COMMUNICATION
Because pain is a subjective experience, patients need to feel confident that their
reporting of pain will be believed and will not be perceived as “complaining.” The
patient and the caregiver also need to know that you consider the pain significant and
understand that pain may profoundly disrupt a person’s life. Communicate concern
and commit to helping the patient obtain pain relief and cope with any unrelieved pain.
Support the patient and the caregiver through the period of trial and error that may be
necessary to implement an effective therapeutic plan. It also is important to clarify
responsibilities in pain relief. Help the patient understand the role of the health care
team members, as well as the patient’s roles and expectations. In addition to
addressing specific aspects of pain assessment and treatment, evaluate the impact that
the pain has on the lives of the patient and the caregiver. Table 9-15 addresses
teaching needs of patients and caregivers related to pain management.

CHALLENGES TO EFFECTIVE PAIN MANAGEMENT

Common challenges to effective pain management include misunderstandings about

tolerance, physical dependence, and addiction. It is important for you to understand
and be able to explain these concepts.

TOLERANCE.

Tolerance occurs with chronic exposure to a variety of drugs. In the case of opioids,
tolerance to analgesia is characterized by the need for an increased opioid dose to
maintain the same degree of analgesia. Although the development of tolerance to side
effects (except constipation) is more predictable, the incidence of clinically significant
analgesic opioid tolerance in chronic pain patients is unknown, since dosage needs
may increase as the disease (e.g., cancer) progresses. It is essential to assess for
increased analgesic needs in patients on long term therapy. The health care team needs
to evaluate and rule out other causes of increased analgesic needs, such as disease
progression or infection. If significant tolerance to opioids develops and it is believed
that an opioid is losing its effectiveness, or intolerable side effects are associated with
escalation of doses, the practice of opioid rotation may be considered. This involves
switching from one opioid to another, assuming that the new opioid will be more
effective at lower equianalgesic doses. However, very high opioid doses can result in
opioid-induced hyperalgesia rather than pain relief. This means that increases in the
dose can lead to higher pain levels.

PHYSICAL DEPENDENCE.

Like tolerance, physical dependence is a normal physiologic response to ongoing

exposure to drugs. It is manifested by a withdrawal syndrome when the drug is
abruptly decreased.. When opioids are no longer needed to provide pain relief, a
tapering schedule should be used in conjunction with careful monitoring. A typical
tapering schedule is determined by calculating the 24-hour dose used by the patient
and dividing by 2. Of this decreased amount, 25% is given every 6 hours. After 2 days
the daily dose is reduced by an additional 25%; this reduction continues every 2 days
until the 24-hour oral dose is 30 mg (morphine equivalent) per day. After 2 days on
this minimum dose, the opioid is then discontinued.

PSEUDOADDICTION

Inadequate treatment of pain can lead to a phenomenon called pseudoaddiction.36

This occurs when patients exhibit behaviors commonly associated with addiction (e.g.,
frequent requests for analgesic refills or higher dosages), but the behaviors resolve
with adequate treatment of the patient’s pain. These patients are often labeled as drug-
seeking, which can result in a crisis of mistrust between the patient and the provider.
This phenomenon can be avoided by effective communication strategies and optimal
pain management.

ADDICTION.

Addiction is a complex neurobiological condition characterized by aberrant behaviors

arising from a drive to obtain and take substances for reasons other than the prescribed
therapeutic value

(1) compulsive use, (2) loss of control of use, and (3) continued use despite risk of
harm. The risk of developing addiction is associated with certain factors, including
younger age, personal or family history of substance abuse, and mood disorders..
NURSE’S ROLE IN PAIN MANAGEMENT

Before discussing what the nurse can do to intervene in the patient’s pain, the nurse’s
role in pain management is reviewed. The nurse helps relieve pain by administering
pain-relieving interventions (including both pharmacologic and nonpharmacologic
approaches), assessing the effectiveness of those interventions, monitoring for adverse
effects, and serving as an advocate for the patient when the prescribed intervention is
ineffective in relieving pain. In addition, the nurse serves as an educator to the patient
and family to enable them to manage the prescribed intervention themselves when
appropriate.

Identifying Goals for Pain Management

The information the nurse obtains from the pain assessment is used to identify goals
for managing the pain. The goals identified are shared or validated with the patient.
goals may include a decrease in the intensity, duration, or frequency of pain, and a
decrease in the negative effects the pain has on the patient. For example, pain may
have a negative effect by interfering with sleep and thereby hampering recovery from
an acute illness or decreasing appetite. In such instances, the goals might be to sleep
soundly and to take adequate nutrition. To determine the goal, a number of factors are
considered. The first is the severity of the pain, as judged by the patient. The second
factor is the anticipated harmful effects of pain. A high risk patient is at much greater
risk for the harmful effects of pain than a young healthy patient. The third factor is the
anticipated duration of the pain. In patients with pain from a disease such as cancer,
the pain may be prolonged, possibly for the remainder of the patient’s life. Therefore,
interventions will be needed for some time and should not detract from the patient’s
quality of life. A different set of interventions is required if the patient is likely to have
pain for only a few days or weeks. In a study of the dying experience, family members
of 2,451 people who had died were interviewed, 55% were conscious during their last
3 days of life. Of the conscious patients, 4 in 10 were considered by their family
members to be in severe pain most of the time. These findings strongly suggest that
pain relief for dying patients should be a primary goal. The goals for the patient may
be accomplished by pharmacologic or nonpharmacologic means, but most success will
be achieved with a combination of both. In the acute stages of illness, the patient may
be unable to participate actively in relief measures, but when sufficient mental and
physical energy is present, the patient may learn self-management techniques to
relieve the pain. Thus, as the patient progresses through the stages of recovery, a goal
may be to increase the patient’s use of self-management pain relief measures.

Establishing the Nurse–Patient Relationship and Teaching

A positive nurse–patient relationship and teaching are key to managing analgesia in

the patient with pain, because open communication and patient cooperation are
essential to success. A positive nurse–patient relationship characterized by trust is
essential. By conveying to the patient, the belief that he or she has pain, the nurse
often helps reduce the patient’s anxiety. Acknowledging to the patient, “I know that
you have pain” often eases the patient’s mind. Occasionally, patients who fear that no
one believes the reported pain feel relieved when they know that the nurse can be
trusted to believe the pain exists. Teaching is equally important, because the patient or
family may be responsible for managing the pain at home and preventing or managing
side effects. Teaching patients about pain and strategies to relieve it may reduce pain
in the absence of other pain relief measures and may enhance the effectiveness of the
pain relief measures used.

The nurse also provides information by explaining how pain can be controlled. The
patient is informed, for example, that pain should be reported in the early stages.
When the patient waits too long to report pain, sensitizationmay occur and the pain
may be so intense that it is difficult to relieve. The phenomenon of sensitization is
important in effective pain management. Since a heightened response is seen after
exposure to a noxious stimulus, the response to that stimulus will be greater, causing
the person to feel more pain. When health care providers assess and treat pain before it
becomes severe, sensitization is diminished or avoided, and thus less medication is
needed.

Providing Physical Care

The patient in pain may be unable to participate in the usual activities of daily living or
to perform usual self-care and may need assistance to carry out these activities. The
patient is usually more comfortable when physical and self-care needs have been met
and efforts have been made to ensure as comfortable a position as possible. A fresh
gown and change of bed linens, along with efforts to make the person feel refreshed
(eg, brushing teeth, combing hair), often increase the level of comfort and improve the
effectiveness of the pain relief measures. Providing physical care to the patient also
gives the nurse (in acute, long-term, and home settings) the opportunity to perform a
complete assessment and to identify problems that may contribute to the patient’s
discomfort and pain. Appropriate and gentle physical touch during care may be
reassuring and comforting. If topical treatments such as fentanyl (an opioid analgesic)
patches or intravenous or intraspinal catheters are used, the skin around the patch or
catheter should be assessed for integrity during physical care.

Managing Anxiety Related to Pain

Anxiety may affect a patient’s response to pain. The patient who anticipates pain may
become increasingly anxious. Teaching the patient about the nature of the impending
painful experience and the ways to reduce pain often decreases anxiety; a person who
is experiencing pain will use previously learned strategies to reduce anxiety and pain.
Learning about measures to relieve pain may lessen the threat of pain and give the
person a sense of control. What the nurse explains about the available pain relief
measures and their effectiveness may also affect the patient’s anxiety level. The
patient’s anxiety may be reduced by explanations that point out the degree of pain
relief that can be expected from each measure. For example, the patient who is
informed beforehand that an intervention may not eliminate pain completely is less
likely to become anxious when a certain amount of pain persists. Anxiety resulting
from anticipation of pain or the pain experience itself may often be managed
effectively by establishing a relationship with the patient and by patient teaching. A
patient who is anxious about pain may be less tolerant of the pain, which in turn may
increase the anxiety level. To prevent the pain and anxiety from escalating, the
anxiety-producing cycle must be interrupted. Low levels of pain are easier to reduce or
control than are more intense levels. (This concept of sensitization was previously
discussed.) Consequently, pain relief measures should be used before pain becomes
severe. Many patients believe that they should not request pain relief measures until
they cannot tolerate the pain, making it difficult for medications to provide relief.
Therefore, it is important to explain to all patients that pain relief or control is more
successful if such measures begin before the pain becomes unbearable.
NURSING MANAGEMENT OF THE PATIENT WITH PAIN

Assessment

Quality, Severity, anatomical location, onset, duration, aggravation, relieving factors.

Nursing diagnosis

 Impaired physical mobility

 Anxiety related to pain
 Self-care deficit related to altered physiology
 Sleep disturbance related to painful condition
 Hopelessness

SUMMARY

As far as we have seen the pain in detailed, the definition,

types, pathophysiology, assessment methods, pain scales, treatment modalities,
management, factors affecting the pain, nurse role in the management of the pain etc.

CONCLUSION

Nurses are often the first health care professional to encounter the person in pain . so,
the relationship of patients and nurses can have an important part in the care of person
with pain.

BIBLIOGRAPHY

 Navdeep kaur brar ,HC rawat, text book of advanced nursing practice;474-496
 Shebeer P Basheer,S Yaseen Khan; Advanced nursing practice;273
 www.webmd.com
 https//medlineplus.gov/pain
HOLY CROSS COLLEGE OF NURSING

ADVANCED NURSING PRACTICE

PRESENTATION

ON

PAIN
SUBMITTED TO, SUBMITTED BY,

Ms.ARATHY .M Ms.NISHA JUSTIN

LECTURER 1 MSc NURSING

HOLY CROSS COLLEGE HOLY CROSS

COLLEGE

OF NURSING, KOTTIYAM OF NURSING,

KOTTIYAM

SUBMITTED ON: 7/02/2020

SI PAGE
NO TOPIC NO
1 INTRODUCTION 1

2 DEFINITION 2

3 NATURE OF PAIN 2

4 SIGNS AND SYMPTOMS 2

5 PAIN MECHANISMS 3

6 TYPES OF PAIN 4-7

7 THEORIES OF PAIN 8-9

8 PAIN TREATMENT 9-11

9 FACTORS INFLUENCING THE PAIN RESPONSE 11-12

10 INSTRUMENTS FOR ASSESSING THE PAIN 12-13

11 COLLABORATIVE MANAGEMENT 14

12 CALLENGES TO PAIN MANAGEMENT 15-16

13 NURSE’S ROLE 16-19

14 NURSING MANAGEMENT 19

15 SUMMARY 19

16 CONCLUSION 20

17 BIBLIOGRAPHY 20