Effective pain management includes the use of pharmacological and nonpharmacological pain

management therapies. Invasive therapies such as nerve ablation can be appropriate for
intractable cancer-related pain.
Clients have a right to adequate assessment and management of pain. Nurses are accountable for
the assessment of pain. The nurses role is that of an advocate and educator for effective pain
management.
Nurses have a priority responsibility to measure the clients pain level on a continual basis and to
provide individualized interventions. Nurses should assess the effectiveness of interventions 30-
60 minutes after implementation.
Assessment challenges can occur with clients who have cognitive impairment, who speak a
different language than the nurse or who receive prescribed mechanical ventilation.
Undertreatment of pain is a serious health care problem. Consequences of undertreatment of pain
include physiological and psychological components. Acute/chronic pain can cause anxiety, fear
and depression. Poorly managed acute pain can lead to chronic pain syndrome.
Physiology of pain:
Transduction – is the conversion of painful stimuli to an electrical impulse through peripheral
nerve fibers (nociceptors)
Transmission – occurs as the electrical impulse travels along the nerve fibers, where
neurotransmitters regulate it
Pain threshold – is the point at which a person feels pain
Pain tolerance – the amount of pain a person is willing to bear
Perception or awareness of pain – occurs in various areas of the brain, with influences from
thought and emotional processes.
Modulation- occurs in the spinal cord, causing muscles to contract reflexively, moving the body
away from painful stimuli.
Substances that increase pain transmission and cause an inflammatory response:

 Substance P
 Prostaglandins
 Bradykinin
 Histamine

Substances that decrease pain transmission and produce analgesia:

 Serotonin
 Endorphins
Pain categories:
Pain is categorized by duration (acute or chronic) or by origin ( nociceptive or neuropathic)

 Acute pain is protective, temporary, usually self-limiting, has a direct cause and resolves
with tissue healing. Physiological responses (sympathetic nervous system) are fight-or
flight- responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension)
Behavioral responses include grimacing, moaning, flinching, and guarding. Interventions
include treatment of the underlying problem. Can lead to chronic pain if left untreated.
 Chronic pain is not protective. It is ongoing or recurs frequently, lasting longer than 6
months and persisting beyond tissue healing. Physiological responses do not usually alter
vital signs, but clients can have depression, fatigue, and a decreased level of functioning.
It is not usually life-threatening. Psychosocial implications cand lead to disability.
Management aims at symptomatic relief. Pain does not always respond to interventions.
Chronic pain can be malignant or nonmalignant. Idiopathic pain is a form of chronic
pain without a known cause, or pain that exceeds typical pain levels associated with
the clients condition.
 Nociceptive pain arises from damage to or inflammation of tissue, which is a noxious
stimulus that triggers the pain receptors called nocioceptors and causes pain. It is usually
throbbing, aching and localized. This pain usually responds to opioids and nonopioids
medications. Types of nociceptive pain include somatic – found in bones, joints, muscles,
skin or connective tissues; Visceral- found in internal organs, this can cause referred pain
in other body locations separate from the stimulus; cutaneous- found in the skin or
subcutaneous tissue.
 Neuropathic pain- arises from abnormal or damaged pain nerves. It includes phantom
pain (pain from a missing body part) pain below the level of a spinal cord injury, and
diabetic neuropathy. Neuropathic pain is usually intense, shooting, burning, or described
as pins and needles. This pain typically responds to adjuvant medications
(antidepressants, antispasmodic agents and skeletal muscle relaxants.)
Assessment/data collection
Noted pain experts agree that pain is whatever the person experiencing it says it is, and it exists
whenever the person says it does. The clients report of pain is the most reliable diagnostic
measure of pain. Self report using standardized pain scales is useful for clients over the age of 7
years. Specialized pain scares are available for use with younger children or individuals who
have difficulty communicating verbally. Assess and document pain (5th vital sign) frequently. Use
a symptom analysis to obtain subjective data.
Risk factors:

 Cultural and societal attitudes

 Lack of knowledge
  Fear of addiction
 Exaggerated fear of respiratory depression

Populations at risk for undertreatment of pain

 Infants
 Children
 Older adults
 Clients who have substance abuse disorder

Causes of acute and chronic pain

 Trauma
 Surgery
 Cancer
 Arthritis
 Fibromyalgia
 Neuropathy
 Diagnostic or treatment procedures

Factors that affect pain experience

 Age- infants cannot verbalize or understand their pain. Older adults can have multiple
pathologies that cause pain and limit function
 Fatigue- can increase sensitivity to pain
 Genetic sensitivity- can increase or decrease pain tolerance
 Cognitive function – clients who have cognitive impairment might not be able to report
pain or report it accurately.
 Prior experiences- can increase or decrease sensitivity depending on whether clients
obtained adequate relief.
 Anxiety and fear – can increase sensitivity to pain
 Support systems and coping styles – presence of these can decrease sensitivity to pain.
 Culture – can influence how clients express pain or the meaning they give to pain.

Symptom analysis

 O: Onset of the event

 P: Provocation/palliation
 Q: Quality
 R: Region/radiation
 S: Severity
  T: Time
 I: Intervention

Expected findings: behaviors complement self report and assist in pain assessment of nonverbal
clients. Facial expressions (grimacing, wrinkled forehead), body movements (restlessness,
pacing, guarding), moaning, crying, decreased attention span.
Blood pressure, pulse and respiratory rate increase temporarily with acute pain. Eventually,
increases in vital signs will stabilize despite the persistence of pain.

Nonpharmacological pain management

Nonpharmacological pain management should not replace pharmacological pain measures, but
can be used in conjunction.

Cognitive-behavioral measures: changing the way a clients perceives pain, and physical
approaches to improve comfort.
Cutaneous stimulation: transcutaneous electrical nerve stimulation (TENS), heat, cold,
therapeutic touch and massage. Interruption of pain pathways, cold for inflammation, heat to
increase blood flow and reduce stiffness.
Distraction: includes ambulation, deep breathing, visitors, television, games, prayer, music.
Decreased attention to the presence of pain can decrease perceived pain level.
Relaxation: Includes meditation, yoga, and progressive muscle relaxation.
Imagery: focusing a pleasant thought to divert focus, requires an ability to concentrate
Acupuncture and acupressure: stimulating subcutaneous tissues at specific points using
needles (acupuncture) or the digits( acupressure.)
Reduction of pain stimuli: in the environment
Elevation of edematous extremities: to promote venous return and decrease swelling.
Analgesics are the mainstay for relieving pain. Three classes of analgesics are nonopioids,
opioids and adjuvants.
Nonopioid analgesics( Tylenol, NSAIDs including salicylates) are appropriate for treating mild
to moderate pain. Be aware of the hepatoxic effects of acetaminophen. Clients who have a
healthy liver should take no more than 4g/day. Make sure clients are aware of opioids that
contain acetaminophen, such as hydrocodone bitartrate 5mg/acetaminophen 500mg. Monitor for
salicylism (tinnitus, vertigo, decreased heart acuity), prevent gastric upset by administering the
medication with food or antacids. Monitor for bleeding with long term NSAID use.
Opioid analgesics such as morphine sulfate, fentanyl, and codeine are appropriate for treating
moderate to severe pain. Managing acute severe pain with short term (24 to 48 hr) around the
clock administration od opioids is preferable to following a PRN schedule. The parenteral route
is best for immediate, short term relief of acute pain. The oral route is better for chronic, no
fluctuating pain. Consistent timing and dosing of opioid administration provide consistent pain
control. It is essential to monitor and intervene for adverse effects of opioid use:
 Sedation – monitor level of consciousness and take safety precautions. Sedation usually
precedes respiratory depression.
 Respiratory depression – monitor respiratory rate prior to and following administration of
opioids – especially for clients who have little previous exposure to opioid medications.
Initial treatment of respiratory depression and sedation is generally a reduction in opioid
overdose. If necessary, administer naloxone to reverse opioid overdose. Client must deep
breathe with RR 8 breaths/min.
 Orthostatic hypotension- advise clients to sit or lie down if lightheadedness or dizziness
occur. Instruct clients to avoid sudden changes in position by slowly moving from a lying
to sitting position. Provide assistance with ambulation.
 Urinary retention- monitor I&O assess for distention, administer bethanechol and
catheterize
 Nausea/vomiting- administer antiemetics, advise client to lie still and move slowly and
eliminate odors
 Constipation- use a preventative approach (monitoring of bowel movements, fluids, fiber
intake, exercise, stool softeners, stimulant laxative, enemas)
Adjuvant analgesics enhance the effects of nonopioids, help alleviate other manifestations that
aggravate pain (depression, seizures, inflammation) and are useful for treating neuropathic pain.
 Anticonvulsants – carbamazepine, gabapentin
 Antianxiety agents – diazepam, lorazepam
 Tricyclic antidepressants – amitriptyline, nortriptyline
 Anesthetics – infusional lidocaine
 Antihistamines- hydroxyzine
 Glucocorticosteroids – dexamethasone
 Antiemetics – ondansetron (Zofran)
 Bisphosphonates and calcitonin – for bone pain
Patient controlled analgesia -PCA- is a medication delivery system that allows clients to self-
administer safe doses of opioids. Small frequent dosing ensures consistent plasma levels, less lag
time between identified need and delivery of medication, morphine, hydromorphone and
fentanyl are typical opioids for PCA delivery.
In combination with allopathic therapies, complementary and alternative therapies comprise
integrative health care which focuses on optimal health of the whole person.
Alternative medical philosophies – complete medical systems outside of allopathic medicinal
beliefs
Biological/botanical therapies – involve the use of natural products to affect health (diets,
vitamins, minerals, herbal supplements)
Body-based and manipulative methods – involve external touch to affect body systems (massage,
touch, chiropractic therapy, acupressure)
Mind-body therapies- connect the physiological function to the mind and emotions
Energy therapies- involve use of the bodys energy fields (reiki, therapeutic touch, magnet
therapy)
Movement therapies – use exercise or activity to promote physical and emotional well being
Specialized or licensed practitioners may provide complementary or alternative therapies:
 Acupuncture/acupressure
 Homeopathic medicine
 Naturopathic medicine
 Chiropractic medicine
 Massage therapy
 Biofeedback
 Therapeutic touch
Natural products and herbal remedies
 Natural products include herbal medicines, minerals and vitamins, essential oils and
dietary supplements
 Clients use nonvitamin, nonmineral natural products to prevent disease and illness and to
promote health.
 Herbal remedies are derived from plants sources are the oldest form of medicine
 The FDA does not regulate many of these products
 Some herbal agents have been deemed safe or effective by nongovernment agencies.
However, even safe or commonly used substances can have adverse effects and interfere
with RX medication therapy
1. Aloe- wound healing
2. Chamomile- anti-inflammatory, calming
3. Echinacea- enhances immunity
4. Garlic- inhibits platelet aggregation
5. Ginger-antiemetic
6. Ginko biloba- improves memory
 7. Ginseng- increase physical endurance
8. Valerian- promotes sleep, reduces anxiety

Adequate amounts of sleep and rest promote health.

Sleep cycle
The sleep cycle consists of 4 stages of nonrapid eye movement sleep and a period of rapid eye
movement sleep. Typically after stage 1 of NREM sleep, people cycle 4-6 times through the
other stages of sleep per night. With each cycle, the length of time in REM sleep increases.
NREM sleep accounts for 75%- 80% of sleep time.
 Stage 1 NREM- very light sleep, only a few minutes long, vital signs and metabolism
beginning to decrease, awakens easily, feels relaxed and drowsy
 Stage 2 NREM -deeper sleep, 10-20 minutes long, vital signs and metabolism continuing
to slow, requires slightly more stimulation to awaken, increased relaxation.
 Stage 3 NREM – initial stages of deep sleep, 15-30 minutes long, vital signs continue to
decrease but remain regular, difficult to awaken, relaxation with little movement.
 Stage 4 NREM- called delta sleep, deepest sleep, 15-30 minutes long, vital signs slow,
very difficult to awaken, physiologic rest and restoration, enuresis, sleepwalking and
sleep talking possible, repair and renewal of tissue.
 REM – vivid dreaming, about 90 minutes after falling asleep, longer with each sleep
cycle, average length 20 minutes, varying vital signs, very difficult to awaken, cognitive
restoration.
Sleep averages vary with the developmental stage with infants and toddlers averaging 9-15
hours/day. This declines gradually throughout childhood, with adolescents averaging 9-10
hours/day and adults 7-8hr/day.

Insomnia is the most common sleep disorder, it is the inability to get an adequate amount of
sleep to feel rested. It might mean difficulty falling asleep, staying asleep, awakening too
early, or not getting refreshing sleep.
Acute insomnia lasts a few days possibly due to personal or situational stressors.
Chronic insomnia lasts a month or more
Some people have intermittent insomnia, sleeping well for a few days and then having
insomnia for a few days.
Women and older adults are more prone to insomnia
Sleep apnea is characterized by more than 5 breathing cessations lasting longer than 10
seconds per hour during sleep, resulting in decreased arterial oxygenation.
Sleep apnea can be a single disorder or a mixture of central and obstructive. With central the
CNS dysfunction in the respiratory control center of the brain fails to trigger breathing during
sleep, obstructive is caused by structures in the mouth and throat relaxing during sleep and
occluding the upper airway.

Narcolepsy is sudden attacks of sleep or excessive sleepiness during waking hours. It often
happens at inappropriate times and increases the risk for injury
Factors that interfere with sleep:
 Ilness- can require more sleep or disrupt sleep
 Current life events – traveling more, change in work hours
 Emotional stress or mental illness- anxiety, fear, grief.
 Diet- caffeine consumption, heavy meals before bed
 Exercise- promotes sleep if at least 2 hours before bedtime, otherwise can disrupt
sleep.
 Fatigue – exhausting or stressful work makes falling asleep difficult.
 Medications- some can induce sleep, but interfere with restorative sleep, others
(bronchodilators, antihypertensives) can cause insomnia
 Sleep environment – too light, wrong temperature or too noisy.