Fundamentals of Nursing

Ms. Marwa Awada

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 Definition
• Pain is an unpleasant and
highly personal
experience that may be
imperceptible to others,
while consuming all parts
of an individual’s life.

• “An unpleasant sensory,

physical and emotional
experience associated
with actual or potential
tissue damage, or
described in terms of
such damage”.

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 Pain management
• Is the alleviation or reduction in pain to a level of comfort that
is acceptable to the client.
• Effective pain management is an important aspect of nursing
care to promote healing, prevent complications, reduce
suffering, and prevent the development of incurable pain
states.
• Clients who are nonverbal are at risk for under treatment of
pain.

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 Assessment of Pain
• Pain may be described in terms of location, duration,
intensity, and etiology.

1. Location:

• Complicating the categorization of pain by location is the fact

that some pains radiate (spread or extend) to other areas
(e.g., low back to legs).
• Pain may also be referred (appear to arise in different areas)
to other parts of the body.
• Visceral pain (pain arising from organs or hollow viscera) is
often perceived in an area remote from the organ causing the
pain.

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 Assessment of Pain
2. Duration:

• Acute pain: when pain lasts only through the expected

recovery period of less than 3 months, whether it has a
sudden or slow onset, regardless of its intensity.

• Chronic pain: also known as

persistent pain, is caused by
pain signals firing in the nervous
system beyond 3 months to
even years.

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 Assessment of Pain

3. Intensity:

• Most practitioners classify intensity of pain by using a numeric scale: 0

(no pain) to 10 (worst pain imaginable).
• Linking the rating to health and functioning scores:
1) Pain in the 1 to 3 range is considered mild pain
2) A rating of 4 to 6 is moderate pain
3) Pain reaching 7 to 10 is viewed as severe pain and is associated with
the worst outcomes.
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 Etiology
• Categories: nociceptive pain and neuropathic pain.
• Nociceptive pain is experienced when an intact, properly
functioning nervous system sends signals that tissues are
damaged, requiring attention and proper care.
• Once stabilized or healed, the pain goes away; thus, this pain is
temporary.
• Subcategories of nociceptive pain include somatic and visceral.
• Somatic pain originates in the skin, muscles, bone, or connective
tissue.
• Visceral pain results from activation of pain receptors in the
organs or hollow viscera and tends to be characterized by
cramping, throbbing, pressing, or aching qualities.

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 Etiology
• Neuropathic pain is associated
with damaged or malfunctioning
nerves due to illness (e.g., post-
herpetic neuralgia, diabetic
peripheral neuropathy), injury
(e.g., phantom limb pain, spinal
cord injury pain), or
undetermined reasons.
• Neuropathic pain is typically
chronic; it is often described as
burning, “electric-shock,” or
tingling, painful numbness, dull,
and aching.
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 Pain threshold vs Pain tolerance

Pain tolerance is
the maximum
Pain threshold is amount of
the least amount painful stimuli
of stimuli that is that an
needed for individual is
someone to willing to
label a sensation withstand
as pain. without seeking
avoidance of the
pain or relief.

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 Physiology of Pain
• The extent to which pain
is perceived depends on
the interaction between:
1) The body’s analgesia
system
2) The nervous system’s
transmission
3) The mind’s
interpretation of stimuli
and its meaning

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 Nociception
• The peripheral nervous system
includes specialized primary
sensory neurons that detect
mechanical, thermal, or chemical
conditions associated with
potential tissue damage.
• The physiologic processes related to pain perception are
described as nociception.
• When these nociceptors are activated, signals are
transduced and transmitted to the spine and brain where
the signals are modified before they are ultimately
understood and then “felt.”

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 Nociception
• Four physiologic processes are involved in nociception:
transduction, transmission, perception, and modulation.

1. Transduction:

Harmful stimuli trigger the release of biochemical

mediators, such as prostaglandins, bradykinin,
serotonin, histamine, and substance P, which
sensitize nociceptors.

Painful stimulation also causes movement

of ions across cell membranes, which
excites nociceptors.

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 Nociception
2. Transmission:

Pain impulses travel from the peripheral nerve fibers to the

spinal cord.

Pain signal then is transmitted through an ascending

pathway in the spinal cord to the brain.

Transmission of information to the brain where pain

perception occurs.

Opioids block the release of neurotransmitters, particularly

substance P, which stops the pain at the spinal level.

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 Nociception
3. Perception:

Client becomes conscious of the pain.

The sum of complex activities in the central nervous system (CNS)

shape the character and intensity of pain perceived (e.g., sharp,
burning, pressure) and give meaning to the pain.

Non-pharmacologic interventions such as distraction, imagery,

massage, and acupuncture have been used to influence pain
perception.

4. Modulation:
Often described as the “descending system,” neurons in the brain send signals back down to the
dorsal horn of the spinal cord.

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Factors Affecting the Pain Experience (reaction
and expression)
 The individual’s ethnic and cultural values
 Developmental stage
 Environment and support people
 Previous pain experiences
 The meaning of the current pain
 Emotional responses to pain

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NURSING MANAGEMENT

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 When pain is chronic
• The individual develops personal coping styles.
• Physiologic responses are likely to be absent in clients with
chronic pain because of autonomic nervous system adaptation.

• Early in the onset of acute pain, the sympathetic nervous system

is stimulated, resulting in increased blood pressure, pulse rate,
respiratory rate, pallor, diaphoresis, and pupil dilation.
• Over a prolonged period and, therefore, the sympathetic
nervous system adapts, causing the responses to be less evident
or even absent.

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 Nursing Care plan
• Nursing Diagnosis:
1) Impaired coping related to prolonged continuous back pain,
ineffective pain management, and inadequate support systems
2) Altered physical mobility related to pain and inflammation
secondary to arthritic pain in knee and ankle joints
3) Impaired sleep related to increased pain perception at night.

•Nursing Interventions:
→ Relieve pain by administering relieving interventions
→ Assess the effectiveness of these interventions
→ Monitoring for side effects
→ Serving as advocate for patient when prescribed interventions are
ineffective
→ Serving as educator for patient and family to enable them to
manage the prescribed interventions them selves
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Pain management and treatment

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 Barriers to Pain Management
• Misconceptions and biases about pain.

• Knowledge deficiencies about the adverse effects of pain and

incorrect information regarding the use of analgesics.

• Client’s culture, personal experiences, and the meaning the pain

has for them.

• Clients may not report pain because they expect that nothing can
be done, or think the pain is not severe enough, or feel it would
distract or prejudice the healthcare provider.

• Opioids misuse and abuse (tolerance, physical dependence, and

addiction).

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 Multimodal Pain Management
• Pharmacologic and non-pharmacologic
approaches to achieve the best possible
outcomes for the client.

• Pharmacologic therapies combines analgesics

from two or more drug classes and a variety of
delivery approaches for the analgesics.

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 I. Pharmacologic Approaches
→ Non-opioids such as NSAIDs
→ Opioids
→ Adjuvant drugs

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 Opioids

• An opioid analgesic is a natural or synthetic

morphine like substance responsible for
reducing moderate to severe pain.

• These medicines are generally 2 to 4 times

more potent than non-opioids alone, and
share some of the risks of both drug classes.

• They are controlled substances and must be ordered

by a physician or nurse practitioner, adhering to
applicable federal and state laws.

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 Adjuvants
• Are the medications that is not classified as a pain
medication.
• However, adjuvants have properties that may reduce
pain alone or in combination with other analgesics,
relieve other discomforts, potentiate the effect of
pain medications, or reduce the pain medication’s
side effects.

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World Health Organization Three-Step
Analgesic Ladder

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 Administration of Placebos

• A placebo is “any sham medication or procedure designed to be void of

any known therapeutic value” e.g.: sugar pill or an injection of saline.

• Some professionals try to justify the use of placebos to elicit the desirable
placebo effect or in a misguided attempt to determine if the client’s pain is
“real.”

• The use of placebos, outside the context of an approved research study, is

deceptive and represents fraudulent and unethical treatment.
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Patient-Controlled Analgesia(PCA)
• Is an interactive method of pain management that permits clients to treat
their pain by self-administering doses of analgesics.
• Allows the client to maintain a more constant level of relief yet requires
less medication for pain relief.
• Used for clients with acute pain related to a surgical incision, traumatic
injury, or labor and delivery, and for chronic pain as with cancer.
• The prescriber orders the analgesic, dose, demand (bolus) dose interval,
and lockout interval.
• The nurse is responsible for the initial instruction regarding use of the
PCA.
• The nurse also is responsible for ongoing monitoring of the therapy (e.g.,
checking every 2 to 4 hours).

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 II. Non-pharmacologic Approaches
• Consists of a variety of physical, cognitive–behavioral, and lifestyle pain
management strategies that target the body, mind, spirit, and social
interactions.

• Physical modalities include cutaneous stimulation, ice or heat, immobilization

or therapeutic exercises, transcutaneous electrical nerve stimulation (TENS),
and acupuncture.

• Mind–body (cognitive–behavioral) interventions include distracting activities,

relaxation techniques, imagery, meditation, biofeedback, hypnosis, cognitive
reframing, emotional counseling, and spiritually directed approaches such as
therapeutic touch or Reiki.

• Lifestyle management approaches include symptom monitoring, stress

management, exercise, nutrition, disability management, and other
approaches needed by many clients with persistent pain that has drastically
changed their life.

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 Physical Interventions
1. Cutaneous Stimulation

• The goals of physical intervention include providing comfort, altering

physiologic responses to reduce pain perception, and optimizing functioning.

• Cutaneous stimulation can provide effective temporary pain relief. It distracts

the client and focuses attention on the tactile stimuli, away from the painful
sensations, thus reducing pain perception.

• Is also believed to interrupt the pain pathway.

• Cutaneous stimulation techniques:
1) Massage
2) Application of heat or cold
3) Acupressure
4) Contralateral stimulation

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 Physical Interventions
• Immobilizing or restricting the movement of a painful body part (e.g., arthritic joint,
traumatized limb) may help to manage episodes of acute pain.

• Splints or supportive devices should hold joints in the position of optimal function and should
be removed regularly in accordance with agency protocol to provide range-of-motion (ROM)
exercises.

• Transcutaneous Electrical Nerve Stimulation (TENS) is a method of applying low-voltage

electrical stimulation directly over identified pain areas, at an acupressure point, along
peripheral nerve areas that innervate the pain area, or along the spinal column.

• Cutaneous stimulation from the TENS unit is thought to activate large-diameter fibers that
modulate the transmission of the nociceptive impulse in the peripheral and central nervous
systems, resulting in pain relief.

• This stimulation may also cause a release of endorphins from the CNS centers.

• Is contraindicated for clients with pacemakers or arrhythmias, or in areas of skin breakdown,

the head or over the chest.

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 Physical Interventions
2. Cognitive–Behavioral Interventions

1) Providing comfort
2) Altering psychologic responses to reduce pain perception
3) Optimizing functioning

• Interventions include:
1) Distraction
2) Producing the relaxation response
3) Re-patterning unhelpful thinking
4) Facilitating coping with emotions

3. Lifestyle management

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