PAIN MANAGEMENT without chest pain.

 Unpleasant sensory, and emotional

experience associated with actual or Why is there a referred
potential tissue damage. pain? - because it is a
 Sensation of physical or mental hurt, or result of a network of
suffering that causes distress or agony to the interconnecting sensory
one who is experiencing pain. nerves that supplies many
different tissues.
 Subjective in nature; meaning that only the
Persistent pain pain that goes on for
person who experiencing it describes it
longer than would be
 Pain helps minimize injury and is often a expected after an injury or
protective injury - protection mechanism - illness. Unfortunately, for
why? If a wound in a skin is bleeding, the some people, their nerves
tendency is to put pressure on the bleeding stay too sensitive, meaning
site to prevent further injury or damage that they continue to feel
caused by bleeding. pain even though there is
 Pain is a highly personal and subjective no longer a problem with
experience - whatever the person is the body tissues.
experiencing, it exists, whenever a patient
says it does. Series of unwanted
changes may occur - how?
Because if a person has
CONCEPTS RELATED TO PAIN
persistent pain, they may
Radiating pain travels from one body part
have to reduce the amount
to another. It begins in one
of activity he or she may
place and spreads across a
do. This is because any
bigger area. Example,
activity will worsen the
when you have a herniated
pain they feel. Pain also
disc, you may have pain in
causes insomnia, the
your lower back. Herniated
patient will gain weight
disc - the disc in between
because of the decreased
vertebrae herniated or
activity. The patient will
pushes upward cousin
also experience stiff joints
pressure to nearby nerves
and muscle, constipation -
(sciatic nerves).
poor nutrition, low mood,
Referred pain pain felt in one part of the
and loss of confidence.
body is caused by injury
Severe pain an emergency situation
from another part of the
which requires immediate
body. It appeared to arise
attention and treatment.
from different areas, or the
The patient pain scale can
pain is perceived in the
range from 6/10 - 10/10
location other than the site
Intractable pain pain which is generally
of injury.
severe and which no cure
is possible, even after
Example, an injured
accepted medical
pancreas could be causing
evaluation and treatment
pain in the back. A heart
have been implemented. If
attack can be triggering
this is the case, the focal
pain in the jaw, shoulder,
point of treatment turns
and left arm with or

DOMINGO 1
 from cure to pain recognized early, this can
reduction, functional be reversed, if ignored it
improvement, and can lead to development of
enhancement of quality of incurable pain syndrome -
life. if it develops to
neuropathic pain, this may
Example is cancer pain not be cured anymore.
Hyperalgesia/ terms may be used
Hyperpathia interchangeably, this PAIN CONCEPTS
means that there is a Pain the least amount of stimuli
heightened response to Threshold needed for a person to label
painful stimuli or increased a sensation as pain or the
sensation of pain. amount of stimulus such as
pressure or heat to actually
Example of this is severe get your pain nerve to feel
pain caused by paper cuts the pain. Example, someone
Allodynia A sensation of pain from with a lower pain threshold
stimuli that normally do might start feeling pain when
not produce pain. This only a minimal pressure is
includes non-painful applied to a part of the body.
stimuli such as light touch, Pain threshold varies from
skin contact with linen and person to person and may be
water. This is typically related to age and gender.
experienced in the skin Pain tolerance maximum amount of pain
around areas affected by stimuli that a person is willing
nerve injury. to withstand without seeking
avoidance of the pain or
Commonly, allodynia is relief. Amount of pain that
seen with many the person can handle until
neuropathic pain the time that they cannot
syndrome (NPS) - a type of handle the pain anymore.
pain experienced by Pain tolerance varies from
patients with diabetes, person to person. Example, a
central nervous system woman may tolerate a
disorder, shingles - painful considerable amount of labor
rashes after a post-herpetic pain because she does not
neuralgia. want to alter her level of
Dysesthesia an unpleasant and alertness or the vitality of the
abnormal sensation. It baby.
mimics or imitates the Pain the actual feeling of pain, the
pathology of central perception point at which the person
neuropathic pain disorder becomes aware of the pain.
such as pain that follows Pain reaction  ANS response - pain
stroke or spinal cord injury. reaction which is an
Hyperalgesia dysesthesia are conditions autonomic reaction of
of abnormal pain the body that often
processing that may signal protects the individual
the development of from further harm.
neuropathic processes. If o Ex. automatic
withdrawal of

DOMINGO 2
 hand from a hot medications, or
object pain related
o With an body posture
autonomic and facial
nervous system, expressions.
there is a Nociceptive pain experienced when an
stimulation of pain intact and properly
the sympathetic functioning nervous system
nervous system sends signals to the brain
that causes that tissue is damaged.
peripheral Physiologic pain because it
vasoconstriction can be either somatic or
and in turn visceral.
increases the  Somatic - the pain
heart rate. originates from the skin,
 Behavioral response - a muscles, bones, and
pain reaction which is a connective tissue. Ex.
learned response that is the sharp sensation of a
used as a method of papercut or an aching
coping with pain. Pain sprained ankle.
behaviors can be verbal  Visceral - pain
or subjective such as originating from
verbal description of problems in the internal
intensity, location, and organs such as liver,
quality of pain. In pain heart, pancreas, or
intensity the patient will bowels.
verbalize the magnitude The pain in nociceptive pain can be transient and
of experienced pain, it
persistent. For example, a papercut injury after it
can be scale or measure
is healed will make the pain go away (transient).
(mild, moderate, severe).
On the other hand, a person who has lost the
With regards to the
protective cartilage in joints will have persistent
location, the patient will
tell you the area where pain because of bone to bone contact or the bone
they feel the pain. And is stressed during movement (persistent).
with regards to the Neuropathic it results from an abnormal
quality of pain, the pain processing of sensory input
patient will verbalize the by the nervous system as a
characteristics of the result of damage to the
pain they feel (shooting, peripheral nervous system or
stabbing, sharp, central nervous system.
radiating, aching, Neuropathic pain is
throbbing, tingling). associated with damage or
o Non-verbal or malfunctioning nerves due
objective to illness. Examples are post-
behavioral herpetic neuralgia and
diabetic peripheral
response such
neuropathy. This type of pain
as withdrawing
is pathologic.
from activities,  Neuropathic pain is typically chronic,
taking pain
meaning the pain lasts longer. The

DOMINGO 3
 characteristic of this can be described as
burning, tingling, aching by the patient. The
patient can also experience episodes of sharp
and shooting pain.
 Neuropathic pain tends to be more difficult
to treat because pain is associated with
problems of the nervous system.
Sensitization refers to an increased
sensitivity of a receptor
after repeated activation by
noxious stimuli or
nociceptor. The sensitivity of
the nociceptor increases
due to repeated stimulus.
The nociceptors are located
under the skin, joints, and
connective tissues. It sends
signals to the brain after the
painful or noxious stimuli.
Wind-up progressive increase of
excitability and sensitivity of
spinal cord neurons leading
to persistent increased pain.
Bradykinin universal stimulus for pain,
substance that stimulates
nerve fibers and causes
pain.
Breakthrough transitory increase in pain
pain that occurs on a background
of otherwise controlled
persistent pain. The pain
occurs even if the pain is
controlled or the client is
already taking medication.
With breakthrough pain the
pain can be acute or chronic
and it is usually described as
severe but short-acting and
quick onset quality of pain.
Example, a patient with
cancer has chronic pain that
is controlled by pain
medication. But the patient
experiences acute
exacerbation of periodic
pain which is increased in
severity.
COMFORT
DOMINGO
 This concept was developed by Katharine
Kolcaba (nursing theorist) to assess and
measure and evaluate patient comfort.
 According to Kolcaba, the theory of comfort
considers patients to be individuals, families,
institutions or communities that are in need
of health care. The environment where the
individual is surrounded in, can be
manipulated by us nurses in order to
enhance the comfort.
 Defined as:
o Renewal amplification of power.
o The state of physical ease and
freedom from pain or constraint.
3 FORMS/TYPES
RELIEF Is the experience of having
a specific need to meet.
Ex. a patient who receives
pain medications in post-
op care.
EASE Is the state of calm or
contentment
Ex. the patient's fears and
anxieties are calmed.
TRANSCENDENCE Is the state in which client
rise above problems or
pain
Take note: when a person’s comfort is enhanced,
they are more fully engaged in such activities.
CONTEXT WHERE COMFORT OCCURS
Physical Bodily sensations,
homeostatic mechanisms
and immune functions
Psychospiritual Internal awareness of self:
esteem, identity, sexuality
and meaning of self in life
Environmental Comfort to the external
background of human
experience: temperature,
light, sound, odor, color
Sociocultural interpersonal, family and
societal relationships.
Family traditions, rituals,
religious practices
THEORIES OF PAIN
4
The perception of pain is a subjective experience
which is influenced by different interactions of
biological, psychological and social factors. It is
important to consider that when talking about
pain is the fact that one patient’s pain is not the
same as another patient’s pain even if they have
experienced similar injuries
Pattern  The pain only occurs with
theory intense stimulation, it also
suggest that the nerves
involved in detecting pain
also detect other sensation
 It proposes that pain is
generated by non-specific
pain receptors. It is
considered that peripheral
sensory receptors
(nociceptors) will give rise
to either non-painful or
painful experiences.
 There are no specific nerve
fibers or endings that are
used just for the sensation
of pain, instead different
sensations such as cold,
pain, heat, and touch are
detected by the same
nerves. Which then sends
specific signal patterns to
the brain thus giving rise
to non-painful or painful
experiences.
Specificity  Developed by Max Von
Theory Frey, it is one of the early
theories for pain
 It states that there is a
specific nerve receptor for
particular stimuli
 Principle: the brain has a
completely separate area
and system for perceiving
pain
 Max Von Frey theorized
that pain is transmitted
from an independent
nerve ending in the skin
and that pain signals will
travel along dedicated
pathways to a specific part
DOMINGO
of the brain. That specific
part of the brain is called
the Pain Center. In that
area, the brain processes
information which creates
the sensation of pain.
 Examples:
o Nociceptor -
noxious stimuli.
o Thermoreceptor -
heat and cold
o Mechanoreceptor
– pressure
o Chemoreceptor –
chemicals
Gate Control  Introduced by Melzack &
Theory Wall
 Nerved-Based Theory
 It reconciles the Specificity
theory and pattern theory.
The two theories were
associated with each other
in this theory
 Gate control theory also
connects the physiological
reactions and
psychological experiences
of pain
 It includes both the central
nervous system (spinal
cord and brain) and the
peripheral nervous system
(nerves located outside
the spinal cord and brain)
wherein each nervous
system processes pain
signals in different ways
towards the brain
 Remember that
nociceptors are
responsible for the pain
perception, if a noxious
stimuli has been perceived
by the nociceptors, this
information will be carried
out to the brain via the A-
Delta and A-Beta fibers.
o A-Delta -
responds to pain
5
 sensations as well
as pressure and
temperature.
Responsible for
the transmission
of the pain
sensation to the
brain.
o A-Beta - response
to touch
o The A-Delta fibers
have a different
path of
transmission of
sensation towards
the brain from A-
Beta fibers.
 The purpose of the Gate is
it either blocks or allows
pain to travel to the spinal
cord to the brain. Where is
it located? It is located in
the spinal cord and is
called susbtantia
gelatinosa.
 Substantia Gelatinosa is
the millu/millo in the CNS
or the environment within
the CNS.
 A cross-sectioned spinal
cord has two parts; the
dorsal horn (likod) and
ventral horn (harap). The
substancia gelatniosa is
located in the dorsal horn
of the spinal cord
 The stimuli that is carried
by A-Delta and A-Beta
fibers is interpreted by
substantia gelatinosa and
it will then decide whether
it allows or blocks the
signal to go to the brain.
 How does it decide? - the
basis depends on the
physiological and
psychological reaction of
the individual.
Additionally, the
DOMINGO
transmission of the
sensation is created by
electrical impulses caused
by the entry of positively
charged ions to the
neurons that carry the
impulses to the brain.
 The pain sensation that is
carried by A-Delta fibers
from the site of injury will
be transmitted to the area
of spinal cord where
substantia gelatinosa is.
Without any intervention
of the injured site, the
Gate which is the
substantia gelatinosa will
be open and the pain will
be carried and will travel
to the Thalamus.
Therefore, the pain will be
felt.
 On the other hand, if you
do something on the
injured site (e.g. you
massage the injured knee
after it hit the floor) that
will stimulate the A-Beta
fibers, the massaging
stimulus will be carried to
the substantia gelatinosa
and will be interpreted and
because massaging is non-
painful stimulus the Gate
will not allow it to pass
through.
 Additionally, A-Beta fibers
have inhibitory effects on
substantia gelatinosa. (wtf
andami)
Pain management that can be applied using the
Gate Control Theory:
 Applying topical therapies such as
application of heat, ice, or massage
 Address the client’s mood by reducing
fear, anxiety, and anger.
Affect  It states that pain is
Theory emotional, wherein the
intensity of pain perceived
6
 depends on the value of why nociceptors involve
the organ affected to the somatic and visceral pain.
individual Take note that this
 It states that factors like receptors only responds,
culture, family, nociceptive only activated when there
stimuli, and environment are intense or damaging
influence pain perception. stimuli
Thus, it ultimately affects a Pain Stimuli  Mechanical
person's emotions o Trauma to body
(sorrowful) tissues such as
 It adverts that pain is surgery. And the
emotional physiological
Parallel  noxious stimuli and pain basis of pain is
Processing sensation are deciphered tissue damage
Model and occurring along wherein there
different nerve fibers. was a direct
Meaning that our brain irritation of the
can make sense of several pain receptors.
different incoming stimuli. Additionally, the
It can do many things at presence of
the same time. inflammation is
 Physiologic or neurologic also an indication
deciphering of pain of pain.
sensation and cognitive o Alterations in
emotional properties body tissues such
occur along different nerve as edema
fibers. wherein it put
pressure on pain
TRIAD OF PAIN PERCEPTION receptors
Pain Perception is the some of complex activities therefore clients
in the central nervous system that may shape the with edema also
characters and intensity of pain perceived and has manifestation
give meaning to the pain. So in order to feel or of pain on the the
know the pain 3 Concepts is required to be affected part
o Blockage of a
understood:
body duct and
Pain  Free nerve endings that
physiological
Receptors responds only to intense,
basis of pain is
potentially damaging
the distention of
stimuli
lumen of the
 This is the nociceptors;
duct. There is
group of sensory neurons
pain because of
with specialized nerve
the distention
endings that is widely
that had occurred
distributed under the skin,
inside the lumen
deep tissues, including the
as a result of the
muscle and joints and
blockage
most of the visceral
o Tumor, cyst or
organs, which are the
mass, or as a
internal organs. That is

DOMINGO 7
 formation of new there lactic acid
growth there accumulation in
could be a the tissues? This
perceivable pain is due to the
and the blockage in the
physiological coronary artery
basis of pain is which reduces the
that this new blood supply
growth formation causing reduced
can cause oxygenation to
pressure on pain the heart and as
receptors and part of our body
irritation of nerve compensation the
endings cellular
o Muscle spasms component of the
pain of sensation heart will use
also stimulates anaerobic
pain receptors so metabolism
this is also which cells use
categorized in oxygen. But
mechanical pain because of this
stimuli compensation
 Thermal where there is
o Extreme hot or reduced
cold such as oxygenation of
burns or frost the heart our
bites which body will produce
results to tissue and release lactic
destruction and acid as a result of
stimulation of the utilization of
thermosensitive anaerobic
pain receptors metabolism so
 Chemical that causes
o Tissue ischemia stimulation of
such as blockage pain receptors
in the coronary therefore there is
artery so this pain perception
causes o Bradykinin: this
stimulation of will be stimulated
pain receptors as because this is
well a result of the universal
accumulation of stimulus for pain
lactic acid and o Enzymes: release
other chemicals in when there is
our body such as tissue ischemia;
bradykinin and example is
enzymes in troponin there is
tissues. Lactic blockage, there is
Acid: So, why is a reduced blood

DOMINGO 8
 and oxygen those in the brain and
supply to the spinal cord. It is made up
heart so that of protein and fatty
causes our heart substances. This myelin
to release cardiac sheath allows electrical
enzymes such as impulses to transmit
troponin quickly and efficiently
o Remember: the along the nerve cells.
presence of those Without myelin sheath
enzymes in our stimuli or sensations are
blood indicates carried along the nerve
suspected cells in a slow manner that
myocardial is why C Fibers has a low
infarction and MI conduction velocity and is
also causes chest associated with slow
pain as the angina chronic pain the example
pectoris that is of pain is the cancer pain
what's happening because it is unmyelinated.
in a tissue On the other hand, A and
ischemia D Fibers are myelinated
o Muscle spasm meaning it has myelin
physiological sheath that is why
basis is tissue impulses are carried
ischemia as quickly along the nerve
secondary to cells, so that makes
mechanical stimulus fast to sense or
stimulation feel.
o Take note when A. Type A- Delta Fibers (Type A and D) which is
you are making a associated with fast, sharp acute pain
nursing care plan  Myelinated it is quick or fast
about pain the B. Type C Fibers which is associated with slow,
etiologic factor chronic aching pain
should be stated  Unmyelinated and have small diameter
with these 3 and low conduction velocity
causes is it
mechanical,
thermal or
chemical. For
example, Acute
pain related to
mechanical factor
secondary to
surgery as
evidenced by
facial grimace and
guarding behavior
Pain Fibers  Myelin: an insulating layer,
or sheath that forms
around nerves, including

DOMINGO 9

Types of Pain
Pain may be describe in terms of:
1. By location
A. Referred pain: arise in
different areas; when the
pain you feel in one part of
your body is actually caused
by pain or injury in another
part of your body. For
example, an injured pancreas
could be causing pain in your
back, or a heart attack could
be triggering pain in your jaw
B. Visceral pain: originates
from the visceral organ or
the internal organs nut may
be perceived or felt on other
areas because visceral pain is
vague and not localized; pain
related to the internal organs
in the midline of the body;
happens every so often, and
feels like a deep ache or
pressure.‌
2. By duration
Difference of Acute pain and
Chronic Pain: Acute and
Chronic pain produced
different physiological and
behavioral responses. For
example in Acute Pain
patient show increase RR or
DOMINGO
elevated BP and behavioral
response of restlessness,
anxiety, crying, rubbing or
massaging the painful area
while chronic pain patient
may manifest normal vital
signs and behavioral
response of depress, and
withdrawn, and don't
verbalize pain unless ask and
pain behavior is often absent
A. Acute pain: last only through
the expected recovery period
whether it has sudden or
slow onset and regardless of
its intensity; happens quickly
and goes away quickly
B. Chronic pain: also known as
persistent pain this type of
pain is prolonged and usually
recurring or lasting 3- 6
months or even longer and
this type of pain interferes
with functioning or patient
activity daily living (ADL)
C. Cancer pain: due to direct
effect of the disease and its
treatment like chemotherapy
or it may be unrelated this is
because over time other
diagnosis have been included
in the malignant pain; but
also HIV or AIDS, burn is
already categorized as
malignant pain with this pain
from cancer, HIV or AIDS, or
burn they tend to be treated
more aggressively than non-
cancer patient
10
 3. By intensity ○ It is a specialized neuron that
Pain scale is able to detect mechanical,
thermal and chemical factors
A. Mild: ranging from 1-3
associated with potential
B. Moderate: ranging from 4- 6
tissue damage
C. Severe: ranging from 7- 10
○ Detects pain stimuli
associated with worst
● Nociceptors
outcome
○ It is a specialized pain
4. By etiology
receptors that can be excited
A. Physiological: an intact
or stimulated by mechanical,
properly functioning nervous
thermal and chemical stimuli
system sensing nociceptive
○ Excited by pain stimuli
the tissue are damage
○ When these nociceptors are
B. Somatic: subcategory of
being activated, signals are
nociceptive pain which
interpreted and transmitted
originates in the skin,
to the spinal cord and
muscles, bones, connected
towards the brain where the
tissues
signals are modified before
C. Visceral: activation of pain
they are ultimately
receptors in internal organ;
understood and felt
subcategory of nociceptive
● Nociception
pain
○ Physiologic processes related
D. Cutaneous: occurs in body
to pain perception
surface or skin; subcategory
of nociceptive pain
E. Radiating: from a specific loc Physiologic processes in Nociception
F. Neuropathic
1. Transduction phase
G. Peripheral neuropathic
● Noxious stimuli such as
H. Central neuropathic
surgical incision, burn or any
I. Sympathetically maintained
painful stimuli that activates
J. Psychogenic
the primary afferent neurons
○ Because the stimulus
Start 1:00:00 will be sent to the
central nervous
Pain Physiology system going to the
brain.
The PNS (the stimulus first interacts with the
○ These are your
Peripheral Nervous System)
nociceptors which
● Primary sensory neurons are located on skin,

DOMINGO 11
 subcutaneous and accumulation of substance P and
visceral organs. blocks the the transduction phase
○ Once nociceptors are
activated, this will
2. Transmission phase
trigger the release of
- Second process of nociception and
biochemical
has 3 segments
mediators such as
neurotransmitters
1st segment
such as
prostaglandins, ● Pain impulses travels from
bradykinin, the Peripheral Nerve fibers
serotonin, histamine to the spinal cord
and substance P ● During this segment,
○ These substance P will serve as the
neurotransmitters neurotransmitter between
will cause movement the primary afferent neurons
of ions across the and the second order neuron
cell membrane, which is located in the spinal
remember the (+) cord, brain stem and gray
and (-) charged ions, matter that will enhance the
these ions will movement of impulses to
sensitize the the dorsal horn of the spinal
nociceptors (gets cord
EXCITED)
Take note
Take note:
★ The path of pain impulses is always
★ if doctors will order pain relievers it toward the dorsal horn of the spinal
acts on this phase by blocking the cord
production of prostaglandins,
medication like Ibuprofen and Aspirin
● Transmission of pain
★ If you want to decrease the
impulses to the dorsal horn
movement of ions across the cell
of the spinal cord involves
membrane then we can give local
the two nociceptor fiber
anesthetic as it can prevent the
which is the
excitability of the nociceptors
○ C-fibers
★ If you apply an topical analgesics
■ Unmyelinate
such as ointment which is applied
d
over skin then it will deplete the

DOMINGO 12
 ■ transmission
of chronic
3rd segment
pain
■ The px will ● Transmission of signals to
report dull the brain where pain
and aching perception occurs specifically
the pain impulses travel via
3rd order neurons which is
○ A-Delta fibers
responsible for the
■ Myelinated
transmission of such
■ Transmission
impulses from the thalamus
of acute pain
to the somatosensory areas
■ The px will
of the cerebral cortex
report sharp
and
localized 3. Perception phase
Take note ● Clients becomes conscious of
the pain because it was
★ The pain control can take place
already perceived and
during this transmission for example
interpreted by the cerebral
○ Opioids, block the release
cortex of the brain
the release of substance P
● Pain can now be manifested
which stops the pain at the
and described by the px such
spinal level
as character and intensity
○ Capsaicin, deplete substance
● Sum of complex activities in
P which could inhibit the
the CNS that shapes the
transmission of pain signal
character and intensity that
was the time when cerebral
2nd segment cortex receive the pain
stimulus
● Transmission of the pain
signal through an ascending
pathway via the second
order neuron
Take note
○ Responsible in the
transmission of pain ★ Management in this phase may
impulses from the involve cognitive-behavioral therapy
spinal cord to the such as destruction and guided
brain particularly imagery.
going to thalamus

DOMINGO 13
 4. Modulation phase ● To prevent the reuptake (won’t be
● Descending system available because of reabsorption in
● Occurs when neurons in the the body) of serotonin and
thalamus and brainstem norepinephrine then tricyclic
send signals back down to antidepressant are used to make
dorsal horn of spinal cord them more available to fight pain
○ These descending
fibers releases
substances which
will inhibit or
reduced the
ascending painful
impulses in the
dorsal horn of the
spinal cord
The pain pathway starts with the noxious
Why the modulation phase? stimuli, this stimuli will cause tissue injury
● because it modulates the pain with and this tissue injury will then cause the
the release of such substances. release of neurotransmitters or biochemical
○ Endogenous opioids mediators (prostaglandins, bradykinin,
■ Found inside the serotonin, histamine, and other
neurotransmitters which may involve
body
includes acetylcholine, dopamine, and
● Endorphins
epinephrine). These neurotransmitters will
● Serotonin
then be perceived by the nociceptors (A-
● Norepinephri
delta and C fibers) and will cause further
ne (to inhibit
transmission of information (transmission of
painful
impulses). These fibers will run across the
stimuli,
spinal ganglion to the dorsal horn of the
spinal cord and furthering the signals path to
In contrast there are episodes in which pain the brain it will travel to the spinothalamic
persists because of the excitatory glial cells tract. Upon reaching the brain, interpretation
amino acids such as glutamate and methyl D- of pain information will now happen
aspartate. These substances increase pain signals
between the thalamus and cerebral cortex.
in episodes that pain persists.
Then, coming from the brain are pain
manifestation responses.

Included in pain management:

● Administration of ketamine and FACTORS AFFECTING PAIN

dextromethorphan as it can diminish
● Ethnic and cultural values
pain signal

DOMINGO 14
 ○ Take note: expressions of
pain vary from culture to
culture and may vary from
person to person within a
culture so we have to treat
each client as an individual
and provide the type of pain
relief that is best fit for the
client.
○ Middle Eastern and African
cultures: self infliction of
pain signifies strength and
endurance.
○ African Americans: pain and
suffering is part of life and is
to be endured. Also, some
believe that prayer and
laying on of hands will free a
person from suffering and
pain.
○ Mexican Americans: may
tend to view pain as a part of
life and as an indicator of the
seriousness of an illness.
○ Philippines: most of the
Filipinos can be stoic, can
endure pain and hardships
without showing feelings or
complaining. So when taking
care of patients particularly
Filipinos, do not rely on the
expression of pain to
determine the person’s level
of pain.
● Age and Developmental stage
○ Take note: This is an
important variable that will
influence both the reaction
to pain and the expression of
DOMINGO
pain of the individual. It is
important to consider this
factor because this will also
serve as one of our basis for
nursing management. Hindi
natin pwede gawan ng lobo
ang isang adult patient to
distract them from the pain
they feel. When taking care
of a px who is experiencing
pain we have to consider the
age factor.
○ Infant - tries to avoid pain by
trying to turn away and
physically resisting we can
offer a pacifier or use tactile
stimulation by rubbing the
infant’s back or the sole of
their feet
○ School Age Child - who can
usually identify the location
and describe the pain, we
teach them of what to
expect and how it will look
and feel and then provide
support and nurturing so
that they will know that you
are there for them when
pain occurs
○ Adult/Older Adult Client -
may have multiple conditions
presenting with vague
symptoms (hindi kayang
madescribe ang pain kasi nga
vague yung symptoms). We
have to take a thorough
history taking & assessment.
Older adults may withhold
statements of pain because
15
 of fear of the treatment and
as a nursing intervention we
can clarify misconceptions.
● Environment and Support people
○ Take note: No one wants to
be hospitalized. The hospital
nurses, bright lights, nurses
and doctors and other HCPs
who are walking to and fro in
front of the patient can
compound the pain that is
felt by the patient. In
addition, those persons who
are lonely who is w/o
support network may
perceive pain as severe so
this means that family
members can provide
significant support to a
person in pain.
● Previous pain experience
○ People who have personally
experienced pain or who
have been exposed to the
suffering or someone close
to them are more often
threatened by anticipated
pain than people without
pain experiences. Again, a
person who already
experiences pain tends to
not comply or participate in
the treatment plan.
○ Example: Patients who
experience traumatic IV
therapy/insertion, especially
young patients, will manifest
physical resistance during
the procedure.
DOMINGO
● Meaning of pain
○ Take note: Depending on the
circumstances and the
client’s interpretation of pain
some may accept pain more
readily than others. For
example, a woman giving
birth because of the
situation the mother will
tolerate any type of pain she
will feel as long as the baby
can be delivered w/o
problems occurring.
○ Another example, a
basketball player (G.A) has
been injured and will
undergo knee surgery and
because of the benefit
associated with playing
basketball, his love for it, and
to prolong his career he will
endure any kind of pain.
RESPONSES TO PAIN
The responses to pain have both
physiological and psychosocial aspects.
● Involuntary
○ Physiologic Responses:
Initially, the sympathetic
nervous system response
which results in fight or
flight response with
noticeable increasing pulse
rate and blood pressure. This
is an involuntary response to
pain by our body. It is
16
 physiologic wherein it is
mediated by the ANS
(autonomic nervous system)
or the SNS which both work
involuntarily.
○ SNS - MILD response to pain
○ Peripheral nervous system -
response to pain is SEVERE
○ Responses to pain may
include elevated HR,
elevated RR, and elevated BP.
Also, pallor, fainting,
unconsciousness, dilation of
pupils, and alterations in
body temperature.
● Voluntary
○ Behavioral or emotional
responses: May affect the
appetite of the client, stops
the activity, withdraw from
pain, can observe a grimace
(facial), moaning, crying, and
guarding behavior.
3 STAGES OF PAIN RESPONSE
1. Activation
- The person begins with the
perception of pain. The person here
already felt the pain and activation
may mean that pain information was
already interpreted by the cerebral
cortex. Initial fight or flight response
will be initiated by the SNS and
manifest changes in the vital signs.
2. Rebound
- The stage wherein the person really
feels the pain in its most intense
DOMINGO
quality but also in brief duration
which is initiated by the peripheral
nervous system.
3. Adaptation
- The counteracting of pain due to
endorphins when pain lasts for many
hours or days.
- Endorphins is released in the
modulation phase where substances
are released and reduce the pain
sensations.
PAIN ASSESSMENT AND TOOLS
Take note: Accurate pain assessment is
essential for effective pain management. The
following are pain assessment and tools that
we can use to identify pain experiences of
our patient:
● Character
○ Sensation of pain
○ An area of assessment that
the client should describe
the sensation.
○ Asking the client “tell me
what your pain feels like?”
○ By asking you will expect the
client to verbalize sensory
words to describe their pain
and note that it is important
to document the pain
character in verbatim (as
what the client describe their
pain)
○ This is useful for us to
provide the most
appropriate nursing
management.
17
 ○ Take in to consideration that
some clients cannot describe
the exact description and as
part of nursing consideration
you may help them describe
their pain by providing
patients some sensory words
such as searing pain
(wherein the skin was
exposed to an intensive, px
here will have a feeling of
scorching in the surface of
skin), scalding pain (a
sensation of very hot),
sharp/stabbing pain
(sensation of sudden and
intense spike of pain),
piercing pain ( feeling of
needle that goes through),
drilling pain (feeling of
suffering an headache or
drilling), crushing pain
(squeezing or pressure
sensation like angina or
myocardial infarction
wherein px will complain as
if there is an elephant
standing on their chest).
● Onset
○ When did or does the pain
start?
● Location
○ Ask the patient to state or
point to the area/s of pain on
the body
○ If the client is unable to
speak, use drawings or
diagrams and then ask the
DOMINGO
client to mark the location of
the pain.
○ When assessing a child you
have to understand the
child’s vocabulary. We have
to adjust with the use of
words by the child so they
can understand what we are
referring to.. For example,
“tummy” might mean
abdomen or chest.
● Duration
○ Is the pain constant or
intermittent
○ Is it persistent or occurring
irregularly
○ To determine answers with
regard to duration we can
ask how long have they had
the pain or how long their
pain last
● Exacerbation
○ Precipitating factors
○ What are the factors that
makes the pain worst or
what triggers it
○ You may anticipate answers
like moving, sitting, walking,
or noise.
● Relief
○ Alleviating factors
○ Ask the client to describe
anything that they have done
to alleviate pain
○ What are the factors that
makes pain better
○ What methods/measures
have they found helpful in
reducing or relieving pain
18
 ○ By asking this you may
anticipate answers such as
reading books, medications,
hot/cold applications, DBE
(deep breathing exercises),
distractions like watching TV,
prayer.
○ Take note: it is important to
explore any effect these
measures had on the pain
whether or not relief has
been obtained or pain
becomes worse.
● Radiation
○ Pattern of shooting
○ Does it radiate to another
part of the body
○ CARDIAC PROBLEMS:
Example condition that
indicates radiating pain. The
patient may experience pain
in the jaw and left arm.
● Wong-Baker Faces Rating Scale
○ Take note: Because we have
the other pain rating scale
that involves numerical pain
rating not all of our clients
understand numerical pain
intensity scales. Therefore,
the Wong-Baker Faces Rating
Scale is appropriate for them
as a pain assessment tool.
○ Preverbal children (uses
motion and gestures to
express their pain), Adults
who have cognitive
impairment/communication,
People who do not speak
English.
DOMINGO
○ How: Since it has illustrations
of different faces (smiling to
frowning to crying), explain
to the person/child that the
face that is smiling is happy
because it feels no pain while
the sad/frowning face feels
pain.
● FLACC Scale
○ Used when clients are
unable to verbalize their pain
for reasons of age, mental
capacity, or patient is under
medical intervention.
○ Nurses need to accurately
assess the intensity of each
client’s pain by relying on
observation of behavior and
with the use of a validated
behavioral pain rating scales.
○ This tool has been validated
in children from 2 months to
7 years old.
○ Rates the pain behavior as
manifested by the following:
facial expression, leg
movement, activity, cry of
the patient, and
consolability (how patients
can accept the act of giving
them comfort).
Pharmacologic Pain Management
Take note: Health care providers should be
aware of all the ingredients of medications
that alleviate pain and use combinations to
reduce the need for high doses of pain
medications.
19
RATIONAL POLYPHARMACY
● Combination pharmacotherapy
- It refers to the integration of
one or more
pharmacological agents
through a systematic
selection of pain
management that has the
most synergistic effect.
- Meaning, the combination of
medications and therapies
that were used is effective to
alleviate and manage painful
symptoms/ conditions.
Ex. If the patient has manifestations of fever
cough, congested airway and chest pain,
using this concept, the doctor will prescribe
medications particularly: paracetamol for
fever, dextromethorphan/ROBITUSSIN for
cough, guaifenesin for congested airway and
nitroglycerine for the chest pain.
MULTIMODAL THERAPY
● Uses pharmacologic and
nonpharmacologic (common)
approach to alleviate/ control pain
- Uses non drug approaches
like heat relaxation.
- It refers to the use of a
variety of different and
integrated disciplines to
control pain (pharma or
nonpharma)
Ex. using medications and physical therapy
together.
WHO 3 STEPS ANALGESIC LADDER
DOMINGO
● This involved the use of opioids/
narcotics, non-opioids (NSAIDS) and
co-analgesics.
● This guideline was developed
regarding the use of analgesics to
treat cancer.
● The focus of this is to align the
proper analgesic with the intensity of
pain (mild, moderate, severe).
STEP ONE LADDER
● Non- opioid analgesics (appropriate
starting point)
● Mild pain; 1-3 score on pain scale
● Examples: acetaminophen, acetyl
salicylic acid (aspirin), ibuprofen
(advil), naproxen sodium (naprosyn),
ketorolac (toradol), meloxicam
(mobic), celecoxib (celebrex).
STEP TWO LADDER
● Client has mild pain that persists or
increases (hindi nawawala) despite
using full doses of the step one
ladder medications
● Weak opioid or combination of
opioid/nonopioid
● Moderate pain; 4-6 on pain scale
● Examples: codeine (tylenol no.3),
tramadol, pentazocine
STEP THREE LADDER
● Pain that persists or increases
despite the use of step two
medications
● Strong opiates; administered and
titrated (dosage increased carefully
and slowly)
● Severe pain, 7-10 on pain scale
20
 ● Examples: fentanyl citrate,
hydromorphone, oxycodone,
morphine sulfate, methadone.
PLACEBO
PAIN MANAGEMENT CONCEPTS
CEILING EFFECT
● The maximum analgesic benefit of
the drug is achieved,and additional
amounts will not produce more
analgesic effect.
● Instead, more toxicity may occur (if
added) such as increased side effects
or bring more toxicity to the kidney
or liver.
● Additionally, there will be additional
cost of treatment by adding more
amounts of drugs to the patients.
EQUIANALGESIA
● “Equal analgesia”
● Approximately the same pain relief
when the drug is given in different
routes
● As a safety alert, doses are converted
to help ensure that patients are not
over or underdosed.
● Requires a series of calculations. Ex.
morphine if given orally at 30mg
dose, is the same pain relief if given
parenterally at 10mg dosage.
Hydromorphone (first line opioid) if
given orally at 7.5 mg dose, is same if
given parenterally at 1.5mg dose.
● Use equianalgesia table when
switching drug or route of
administration to another
DOMINGO
● The chart/table will help provide
doses of approximately equal ability
to relieve pain.
● Produces an effect in the client
because of its implicit/ explicit effect
and not because of its specific
physical or chemical property.
● The drug which was administered
has no chemical property that causes
pain relief. Rather the relief occurred
due to a psychological effect. The
effect was influenced with a thought
● Example: the administration of PNSS
through IV and telling the patient
that it is a medication ordered by the
doctor for the pain. Saline has no
analgesic chemical property and is
not used for pain relief.
● Response of patient is called
”placebo effect”
● Take note: Placebos are
appropriately used as controls in
research; evaluating the effects of a
new medication. Some health care
providers also use the placebo as a
guide to attempt to determine if the
patient’s pain is real (baka inookray
daw yung pain na sinasabi niya).
● This intervention (according to some
professionals and pain management
organizations) is deceptive,
fraudulent and unethical.
Organizations such as ANA, American
Society for Pain Management.
American Pain Society, Oncology
Nursing Society all oppose the use of
Placebo without consent.
21
 TYPES OF OPIOIDS
Agonist- a type of drug that binds to specific
opioid pain receptors in the CNS and
activates those receptors which should
produce a physiological response.
What are the opioid pain receptors in the
CNS?
● Mu
● Delta
● Kappa
If an opioid is given, it binds with these
receptors causing a relief effect/opioid
effect/
Antagonist- a type of drug that blocks the
effect of opioid drugs. They also bind to
opioid pain receptors but without activating
it. They bind to inhibit the receptor in
producing physiological response. IT WILL
CAUSE NO OPIOID/RELIEF EFFECT.
1. FULL AGONISTS
- These are pure opioids that bind tightly to
the Mu receptors.
- Maximum pain inhibition
- Can be titrated (steadily increased)
● Has an agonistic effect
● No ceiling effect
● Morphine (gold standard opioid)
Examples. Oxycodone, hydromorphone and
fentanyl (used commonly in anesthesia
during surgery)
2. MIXED AGONIST-ANTAGONIST
- Can act like opioids and relieve pain
DOMINGO
- Can also block other opioid analgesics when
given to clients who have taken full opioids.
- they block immunoreceptors sites causing
an antagonist effect, and activate the kappa
causing the agonist effect.
● Block and inactivate other opioid
analgesics
● Has ceiling effect (limiting the dose
should be considered)
● Nalbuphine hydrochloride (Nubain)
Examples: butorphanol tartrate, pentazocine
hydrochloride, nalbuphine hydrochloride
These medications are given to counteract
the action of full opioids.
Take note: a drug that is used in hospital
settings to counteract opioid overdose is
NALOXONE (Narcan), which is an opioid
antagonist but has no opioid effect or agonist
effect.
3. PARTIAL AGONIST
● Has ceiling effect
● considered safe and has a favorable
side effect (popular choice to be
prescribed)
● Blocks the Mu receptor sites or are
neutral at the receptor site, but bind
at the Kappa receptor; meaning that
it can produce an agonist effect or
may not also produce an agonist
effect as well.
● Tramadol (Ultram)
TYPES OF COANALGESICS
It is a medication that is not classified as a
pain medication but may reduce pain and
22
appear to be particularly beneficial for the
pain management of neuropathic pain.
It is also known as adjuvants.
Ex: antidepressants
TYPES:
Tricyclic antidepressant
● Useful for central neuropathic pain
(burning, stinging quality)
● Antidepressants- Increase pain relief,
improve mood, and improve sleep.
Examples: nortriptyline, amitriptyline
Anticonvulsants
● Useful for peripheral neuropathic
conditions (stabbing, shooting or
electrical/shock pain)
● Help stabilize nerve membranes and
reduce excitability of nerves.
Examples: gabapentin, pregabalin
Topical local anesthetic
● Alleviate neuropathic as well as other
types of pain (allodynia/ skin
sensitivity)
● Local anesthetic- Block the
transmission of pain signals.
Example: lidoderm patch
Examples of other drugs that relieve
discomfort but do not alleviate pain:
● anxiolytics, sedatives,
antispasmodics.
DOMINGO
Examples that reduce side effects of
analgesics:
● stimulants, laxative, antiemetics.
Side effects of analgesic:
● drowsiness, constipation, upset
stomach, nausea and vomiting
ROUTE OF OPIATE DELIVERY
Can be given in different routes:
EPIDURAL SPACE
● Commonly (most common) used
intraspinal route of administration of
pain medication.
● Analgesic is administered via the
epidural space, and is delivered just
next to the opiate receptors (located
in the dorsal horn of the spinal cord).
● There are several benefits:
- Major benefit: Superior
analgesia (requires less use
of other medications).
- Because it is administered
intraspinally, the dura mater
will act as a protective
barrier against infection such
as meningitis.
- Because it is through the
epidural space, there is a
lesser risk of developing
spinal headache (occurs
during admin of analgesic
through the subarachnoid
space and headache occurs
due to CSF leakage.)
● Take note: there is no Cerebrospinal
Fluid in the epidural space.
23
Nursing Consideration:
● When administering through the
epidural space, the solution should
be sterile, medication preparation
should be done aseptically.
Two commonly used medications:
- Morphine sulfate
- Fentanyl
CONTINUOUS LOCAL ANESTHETICS
● Continuous subcutaneous
administration of long acting local
anesthetics (into a near surgical site).
● Useful for post-op patients which is
used to provide post-op pain control
Example: patient has a CS section, and
located at the incision site, there is a catheter
which serves as the access for continuous
local anesthetics.
PATIENT- CONTROLLED ANALGESIA
● Permits clients to treat their pain by
self administration of analgesia
(interactive method).
● Drug delivery system that is
considered to be a safe method.
● Can be self-administered by clients
who underwent surgery, trauma or
burns; and clients under terminal
care and cancer pain management.
● IV route is most common.
● Client administers a predetermined
dose by the primary care provider
● Administered by an electronic
infusion pump (allows the client to
maintain a more constant level of
DOMINGO
relief, yet requires less medication
for relief.)
● Morphine, hydromorphone
(dilaudid) fentanyl
Nursing considerations:
● Client preparation and teaching.
● Checking of IV line and patient-
controlled analgesia device regularly
to prevent normal manifestations
such as infection and dislodged
devices.
ADVANTAGES:
● Easy access for clients for
medications which can be performed
at home.
● It allows self-administration with no
risks, because you would not
endanger yourself.
● There is pain relief without the help
of the nurses
● Small doses of medications at short
intervals for sustained pain relief (the
doses were predetermined to sustain
the relief for pain, and that doses
and intervals were programmed for
patient safety).
● Stabilizes serum drug levels (drug
concentration in the blood is
maintained at a safe level for
effective therapy).
● Decreased anxiety because the client
controls it. In other situations, the
presence of other health care
workers can bring anxiety to the
patient.
Take note: the medication is programmed
with Blackout Interval (ata) wherein once
delivered, there is a period of time where the
medication will not be infused until such
24
time that the medication again can be - A minimally invasive
infused. This is for the safety of the patient. procedure wherein it
disrupts the nerve supply by
cutting the nerve root area
DISADVANTAGES: near the spinal cord.
● Patient becomes dependent on PCA - Commonly performed on
● If mobility is contraindicated, the clients with chronic back
client may move due to decreased or pain.
absence of pain because the patient
had felt the relief already. ● Cordotomy/ Spinothalamic
● Respiratory depression in overdosage tractotomy
● Most common side effect of - Surgical interruption of pain
prescribed opioids in long term use conducting pathways within
is: constipation the spinal cord.
● Mechanical failure of pump, wrong - The incision is made in the
programming parameters (over or anterolateral pathway on the
underdosing) opposite side on which the
● Incorrect insertion or placing of pain is located.
syringe (can cause infusion of - Commonly performed on
excessive drug doses) patients experiencing severe
● Is costly pain due to cancer or other
● If the client does not understand the incurable diseases.
system.

● Tractotomy
SURGICAL MANAGEMENT - Surgical resection of the
anterolateral pathway in the
A more invasive procedure.
brainstem. It disrupts the
nerve supplies in the
● Neurectomy brainstem (structure that
- interrupts cranial or connects cerebrum to spinal
peripheral nerves by an cord).
incision. - Performed to treat severe
headache. Ex. pain from
trigeminal neuralgia
● Rhizotomy
- interruption of the anterior/
ventral or posterior/dorsal ● Gyrectomy
nerve root area that is close - Removal of post central
to the spinal cord. gyrus (part of cerebral

DOMINGO 25
 cortex) which is involved in ● Spinal cord stimulation
the interpretation of pain - An option to relieve
impulses. persistent pain that has not
been controlled with less
invasive therapies.
● Hypophysectomy
- This procedure involves the
- Surgical removal of pituitary
insertion of electrodes in the
gland
spinal cord.
- Performed to address cancer
pain which causes intractable
pain. NON-PHARMACOLOGIC INTERVENTIONS
Consists of a variety of management
strategies which target the body, mind, spirit
and social interactions. It can be intervened
through 2 Approaches:
● Nerve block
- Chemical interruption of
nerve pathway by injecting a
local anesthetic into a nerve.
- This is performed if the
patient will undergo surgery. Physical Approaches
- Given in minor surgical This includes pain management that involves
procedures of the wrist ex. affecting physical functions which may end
Carpal tunnel syndrome up in physiological changes.
(involves the release of nerve
compressions in the wrist).
- Prior incision, nerve supplies ● Cutaneous stimulation (client’s focus
on the wrist are blocked by is distracted by stimulation of nerves
local anesthesia. by skin contact)
- This approach provides
effective, temporary pain
● Sympathectomy
relief.
- Pathways of the sympathetic
● Massage
division of the Autonomic
- A comfort measure that can
Nervous System (ANS), are
aid relaxation, decrease
cut or cauterized, and the
muscle tension, anxiety and
area of nerve supplies that
stress.
are removed are those found
● Heat and cold application
along the spine.

DOMINGO 26
 - Heat application relieves
pain by promoting muscle
relaxation, increasing
circulation, promoting
psychological relaxation and
a feeling of comfort.
- Cold application decreases
pain by slowing down nerve
conduction rate, blocking
nerve impulses and produces
numbness or local
anesthesia and increases
pain threshold.
● Acupressure
- Pain relief technique
originating from Ancient
Chinese healing system of
acupuncture where finger
pressure is applied to many
points of the body.
● Chiropractic
- Alternative medicine that is
involved in the diagnosis and
treatment of mechanical
disorders of the
musculoskeletal system,
especially the spinal cord.
- Goal is to provide pain relief,
correct alignment by
manipulating other parts of
the body.
● Contralateral stimulation
- Can be accomplished by
stimulating the skin, in an
area opposite to the painful
area.
- Nurses should explain the
rationale to the client in that
nerves are crossed in the
DOMINGO
spinal cord, and that this
technique may work
contralaterally.
● Bracing (Immobilization)
- Restricts body movement
such as application of
abdominal binders after a CS
or splints on a fractured
bone.
● TENS (transcutaneous electrical
nerve stimulation)
- A method of applying low
voltage electrical stimulation
directly over the area of the
pain.
- Take note: TENS are
contraindicated for clients
with pacemakers because it
will alter its function.
● Rest and sleep
- Could provide changes
physiologically and relieve
pain.
● Use of placebos
- Could provide changes
physiologically and relieve
pain.
Cognitive Approaches
Nurses and other healthcare workers provide
comfort by altering psychological responses
to reduce pain perception.
● Distractions
- It draws the person’s
attention away from pain
and the perception of pain.
● Hypnosis
27
 - Altering the state of negative impact of stressors,
consciousness in which the including pain.
person’s concentration is
focused, and distractions are (pakiayos nalang guys tinatamad na ko
minimized. adhasdgad goodluckkk sa midterms! <33)
- Placed in a deep-state of
relaxation.
- Performed by a licensed
healthcare provider that is
trained specifically for this
technique.
● Biofeedback
- A person can learn to control
certain physiological
responses of the body.
- The client is connected to
electronic equipment and
the client will provide visible
and audible evidence which
will prove that they are
controlling their body in the
desired manner.
- Where said controlling their
body, the client concentrates
on processes such as
increasing their blood flow,
decreasing sweat gland
activity, lowering the BP
which will eventually
contribute in reducing pain.
● Guided imagery
- State of focused attention
that encourages changes in
attitudes, behavior and
psychological reactions.
- Helps to remove unpleasant
thoughts and focus on
images that help the patient
relax, and decrease the

DOMINGO 28