Chapter 13

Pain Management
Significance of Pain
Subjective response: only felt by the person
Negative: discomfort
Protective role: warning of potential threat to health
(sometimes a life-threatening condition); prompt for
person to seek medical attention
Pain
- An unpleasant sensory and emotional experience with
actual or potential tissue damage.
- The most common reason for seeking health care.
- The fifth vital sign by the American Pain Society
(2003)
- JCAHO (2005) standards state that pain is assessed
in all patients and that patients have the right to
appropriate assessment and management of pain.
- Pain is whatever a person says it is, existing whenever
the experiencing person says it does (McCaffery &
Pasero, 1999).
- Pain is categorized according to its duration, location,
and etiology.

Types of Pain
Acute pain can be described as lasting from seconds to 6
months
Chronic (persistent) pain is constant or intermittent
pain that persists beyond the expected healing time and
that can seldom be attributed to a specific cause or
injury.
Cancer-related pain
According to Location
(eg, pelvic pain, headache, chest pain). This type of
categorization aids in communication about and
treatment of the pain.
According to Etiology
Burn pain and postherpetic neuralgia are examples of
pain described
Classifications of Pain and Definitions
A. Acute: sudden onset, usually sharp and
localized; less than 6 months; significant of
actual or potential injury to tissues; initiates
flight or fight stress response
1. Somatic: arises from skin, close to surface of
body; sharp or dull; often with nausea and
vomiting

2. Visceral: arises from body organs; dull and

poorly localized; with nausea and vomiting;
may radiate or is referred
3. Referred: pain perceived in area distant
from stimuli
B. Chronic: prolonged pain; more than 6 months;
often dull, aching, diffuse; not always associated
with specific cause, often unresponsive to
conventional treatment; most common is lower
back pain
1. Recurrent acute pain
2. Ongoing time-limited pain
3. Chronic nonmalignant pain
4. Chronic intractable nonmalignant pain
C. Common chronic pain conditions:
1. Neuralgias: pain from peripheral nerve
damage
2. Dystrophies: pain from peripheral nerve
damage characterized by continuous
burning pain
3. Hyperesthesias: state of oversenstivity to
touch and painful stimuli
4. Phantom Pain: post amputation, the person
experiences sensations and pain in the
missing body part
5. Psychogenic pain: pain without a
physiologic cause or event

Factors Affecting Response to Pain

A.Pain threshold: Point at which a stimulus is
experienced as pain; same for all persons, but
individuals have different perceptions and
reactions to pain
B.Pain tolerance: amount of pain a person can
endure before outwardly responding to it
1. Decreased by repeated pain episodes,
fatigue, anger, anxiety, sleep deprivation
2. Increased by alcohol, hypnosis, warmth,
distraction, spiritual practices
C.Age
D.Sociocultural influences
1. Family beliefs, e.g. males dont cry
2. Cultural: some persons of ethnic groups
handle pain in similar manner
E.Emotional status, e.g. anxiety
1. Fatigue and/or lack of sleep
2. Depression: decreased amount of serotonin,
a neurotransmitter, thus increased amount
of pain sensation
F. Past experiences with pain
G. Source and meaning
H. Knowledge about pain

WHO Approach to Cancer Pain

Effects of Pain

Sleep deprivation

Acute pain

Can affect respiratory, cardiovascular, endocrine,

and immune systems.

Stress response increases metabolic rate and

cardiac output, and increases risk for physiologic
disorders.

Chronic pain
Depression
Increased disability
Suppression of immune function

Pathophysiology of Pain
involve the peripheral and central nervous systems.
Nociceptors (pain receptors) are free nerve endings in
the skin that respond only to intense, potentially
damaging stimuli. Such stimuli may be mechanical,
thermal, or chemical in nature. The joints, skeletal
muscle, fascia, tendons, and cornea also have
nociceptors that have the potential to transmit stimuli
that produce pain.
Transmission of pain (nociception)

Chemical substances

Prostaglandins (increase sensitivity of pain

receptors) chemical substances that increase the

sensitivity of pain receptors by enhancing the painprovoking effect of bradykinin

Endorphins and enkephalins (suppress pain

reception) morphine-like substances produced by the
body. Primarily found in the central nervous system,
they have the potential to reduce pain.
Nociception System Showing Ascending and Descending
Pathways of the Dorsal Horn
Gate Control System Theory
Factors That Influence Pain Response

Past experience

Anxiety

Depression

Culture

Gender

Genetics

Gerontologic considerations

Expectations
The Placebo Effect

A physiologic response that results from an

expectation that a treatment will work.

American Society of Pain Management Nurses

(2005) contends that placebos should not be used to
assess or manage pain.

Chart 13-3: Ethics and Related Issues

Assessment of Pain

Assessment: the patients pain goal or expectations

of comfort and pain relief

Meaning of pain for the patient

Chart 13-5: Common Concerns and Misconceptions
About Pain and Analgesia

Behaviors associated with the pain

A patient may grimace, cry, rub the affected area, guard

the affected area, or immobilize it. Others may moan,
groan, grunt, or sigh. Not all patients exhibit the same
behaviors, and there may be different meanings
associated with the same behavior.

Physiologic responses to the pain

Physiologic responses to pain, such as tachycardia,
hypertension, tachypnea, pallor, diaphoresis, mydriasis,
hypervigilance, and increased muscle tone, are related
to stimulation of the autonomic nervous system.
Characteristics: Intensity, Timing, Location,
Quality

Intensity of pain ranges from none to mild discomfort to

excruciating. There is no correlation between reported
intensity and the stimulus that produced it. The

reported intensity is influenced by the person's pain

threshold and pain tolerance.
Timing - patient is asked if the pain began suddenly or
increased gradually.
Location of pain is best determined by having the
patient point to the area of the body involved.
- especially helpful if the pain radiates (referred pain)
Quality - nurse asks the patient to describe the pain in
his or her own words without offering clues.
- nurse can suggest words such as burning, aching,
throbbing, or stabbing.
Aggravating or alleviating factors
- nurse asks the patient what, if anything, makes the
pain worse and what makes it better and asks
specifically about the relationship between activity and
pain.

Pain Intensity Scales

VAS 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
patient is asked to place a mark indicating where the
current pain lies on the line.
Faces Pain ScaleRevised

This instrument has six faces depicting expressions that

range from contented to obvious distress. The patient is
asked to point to the face that most closely resembles
the intensity of his or her pain.
Pain Intensity Scale
Faces Pain Scale

Guidelines for Assessing Pain in Patients With

Disabilities
Alternative forms of communication may be necessary
for people with sensory impairments or other
disabilities.
For people who are blind and who know how to
read Braille, pain assessment instruments can be
obtained in Braille. In addition, there is now
computer software that allows written documents
to be scanned and converted into Braille. If these

programs are not available, agencies that provide

services for people who are blind may be able to
assist in developing Braille versions.
For people who are deaf or hard of hearing, outside
interpreters (ie, not family members) should be
used. Other useful communication strategies may
include sign language, written notes, or pictures.
When writing notes on a magic slate or making
written notes, it is necessary to make every effort to
guard the patient's privacy and confidentiality.
For people with disabilities that result in
communication impairment, computer-generated
speech may be useful.

The Nurse's Role in Pain Management

- nurse helps relieve pain by administering painrelieving 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.
Goals for pain management
- complete elimination of the pain
- decrease in the intensity, duration, or frequency of
pain and a decrease in the negative effects of the
pain

Establishing the NursePatient Relationship and

Teaching
A positive nursepatient relationship and teaching
are key to managing analgesia in patients with pain,
because open communication and patient cooperation
are essential to success
The patient should be informed that pain should be
reported in the early stages. When the patient waits
too long to report pain, sensitization may occur, and
the pain may be so intense that it is difficult to relieve
Providing Physical Care
Patients are 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

Managing Anxiety Related to Pain

Teaching the patient about the nature of the
impending painful experience and the ways to reduce
pain often decreases anxiety
Learning about measures to relieve pain may lessen
the threat of pain and give the patient a sense of
control.
Pain Management Strategies
Pharmacologic Interventions

Pharmacologic management of pain is accomplished in

collaboration with physicians, patients, and often
families.
Premedication Assessment
Before administering any medication, the nurse should
ask the patient about allergies to medications and the
nature of any previous allergic responses
- nurse obtains the patient's medication history
Gerontologic Considerations
Physiologic changes in older adults require that
analgesic agents be administered with caution. Drug
interactions are more likely to occur in older adults
because of the higher incidence of chronic illness and
the increased use of prescription and OTC medications
Gerontologic Considerations

More likely to have adverse drug effects and drug

interactions

Increased likelihood of chronic illness

May need to have more time between doses of

medication due to decreased excretion and metabolism
related to aging changes
TABLE 13-2 Adverse Interactions of Herbal Substances
or Foods With Analgesics
Analgesic
Herb or Food
Effect
NSAIDs
Ginkgo, garlic,
Enhanced risk of
ginger, bilberry,
bleeding
dongquai, feverfew,
ginseng, turmeric,

meadowsweet,
willow
Acetaminophen Ginkgo and
possibly some of
the abovementioned herbs
Echinacea, kava,
willow,
meadowsweet
Opioids
Valerian, kava,
chamomile
Ginseng
Alfentanil,
fentanyl,
sufentanil

Grapefruit juice

Enhanced risk of
bleeding
Increased potential
for hepatotoxicity
and nephrotoxicity
Increased central
nervous system
depression
Inhibits analgesic
effects
Inhibits the
cytochrome P450
3A4 enzyme in the
liver, blocking
metabolism of the
drug

Approaches for Using Analgesic Agents

Balanced analgesia
refers to the use of more than one form of analgesia
concurrently to obtain more pain relief with fewer side
effects. The three general categories of analgesic agents
are opioids, NSAIDs, and local anesthetics. These agents
work by different mechanisms
Pro Re Nata

Preventive Approach RTC or ATC

administering analgesic agents
Use of As Needed Range Orders for Opioid
Analgesics
Individualized Dosage
The dosage and the interval between doses should be
based on the patient's requirements rather than on an
inflexible standard or routine
- fear of promoting addiction or causing respiratory
depression, health care providers tend to prescribe and
administer inadequate dosages of opioid agents to treat
acute pain or persistent pain, particularly in terminally
ill patients
Patient-Controlled Analgesia
Used to manage postoperative pain as well as persistent
pain, patient-controlled analgesia (PCA) allows patients
to control the administration of their own medication
within predetermined safety limits.
Local Anesthetic Agents
Topical Application
Intraspinal Administration
Opioid Analgesic Agents
Adverse Effects:

- Respiratory depression is the most serious adverse

effect of opioid analgesic agents administered by
IV, subcutaneous, or epidural routes
- Sedation
- Nausea and Vomiting
- Constipation
- Inadequate Pain Relief
TABLE 13-3 Selected Opioid Analgesics Commonly
Used for Moderate and Severe Pain in Adults

Name
Morphine

Starting Dose
(milligrams)
Modera Severe
te Pain Pain

3060
(oral)
10
(parenter
al)

Precautions
and
Contraindicati
Comments
ons
Acts as an
Use with
agonist at
caution,
specific opioid especially in
receptors in the elderly
CNS to produce patients, very
analgesia,
ill patients, and
euphoria, and those with
sedation.
respiratory
impairment.
Major risks
include
respiratory
depression,
apnea,
circulatory
depression, and
respiratory
arrest, shock,
and cardiac

Codeine

1530
(oral)

arrest. Obtain
history of
hypersensitivit
y to opioids.
Monitor
patient closely.
If prescribed in
correct dose,
oral
preparations
(MS Contin)
are effective in
treating
moderate and
severe pain.
60 (oral) Acts as an
Many
up to
agonist at
preparations of
360/24 hr specific opioid codeine and the
receptors in the other opioids in
CNS to produce this table are
analgesia,
combinations
euphoria, and with nonopioid
sedation. Is also analgesics.
an antitussive. Caution must
10% of people be used in
lack the enzyme patients with
needed to make impaired
codeine active. ventilation,
Codeine may bronchial
cause more
asthma,
nausea and
increased
constipation perintracranial
unit of
pressure, or
analgesia than impaired liver
other mu
function and in

agonist opioids. elderly and

very ill
patients.
Oxycodone 5 (oral) 1020
Acts as an
Caution must
(OxyContin
(oral)
agonist at
be used in
)
specific opioid patients with
receptors in the impaired
CNS to produce ventilation,
analgesia,
bronchial
euphoria, and asthma,
sedation.
increased
intracranial
pressure, or
impaired liver
function and in
elderly and
very ill
patients.
Meperidine 50
300 (oral) Acts as an
Normeperidine
(Demerol) (oral) 75
agonist at
, a toxic
(parenter specific opioid metabolic of
al)
receptors in the meperidine,
CNS to produce accumulates
analgesia,
with repetitive
euphoria, and dosing, causing
sedation.
CNS excitation.
Shorter acting High risk for
than morphine. seizures.
Meperidine is Should be
biotransformed avoided in
to
patients with
normeperidine, impaired renal
a toxic
function who
metabolite.
are receiving
MAO

Propoxyphe 65130
ne (Darvon) (oral)

Hydrocodon 510
e (Vicodin) (oral)

inhibitors. Is
irritating to
tissues with
repeated
intramuscular
injections.
Chronic use
should be
avoided.
Should not be
used for more
than 1 or 2
days.
Weak analgesic; Accumulation
acts as an
of
agonist at
propoxyphene
specific opioid and toxic
receptors in the metabolites
CNS to produce occurs with
analgesia,
repetitive
euphoria, and dosing.
sedation. Many Overdose is
preparations complicated by
include
seizures.
nonopioid
Propoxyphene
analgesics;
is not
biotransformed recommended
to potentially for older adults
toxic metabolite or patients with
(norpropoxphe renal
ne).
impairment.

Most
preparations
are combined
with nonopioid

Tramadol
(Ultram)

50100
(oral)

analgesics.
Unique
Most common
mechanism;
side effects are
analgesia
dizziness,
results from the nausea,
synergy of two constipation,
mechanisms. and
Maximum dose somnolence.
is 400 mg/day. Lowers seizure
threshold.

Physiologic Basis for Pain Relief Pharmacologic

Interventions

Opioid analgesics act on the CNS to inhibit activity

of ascending nocioceptive pathways.

NSAIDs decrease pain by inhibiting cyclooxygenase, which is the enzyme involved in the
production of prostaglandin.

Local anesthetics block nerve conduction when

applied to the nerve fibers.
Opioid Tolerance and Addiction

Maximum safe opioid dosage must be individually

assessed.

Tolerance develops in all patients who take opioids

for prolonged periods.

With tolerance, increased usage is needed to effect

pain relief.

Dependence occurs with tolerance and physical

symptoms occur when the opioid is discontinued.

Addiction is a behavioral pattern characterized by

the need to take the drug for its psychic effects.
Addiction from therapeutic use of opioids is negligible

Nonpharmacologic Interventions

Cutaneous stimulation, massage, and use of hot

and cold may be explained by the gateway theory.

Use of heat and cold changes blood flow to the

areas and promotes healing.

Use of distraction, relaxation, and guided imagery

may redirect attention, promote muscle relaxation, and
affect perception or reception of pain stimulus in the
brain.
Administration Routes for Analgesics
TABLE 13-4 Administration Routes for Analgesics

Relationship of Mode of Analgesia to Serum Level

Currently, a preventive approach to relieving pain by
administering analgesic agents is considered the most
effective strategy, because a therapeutic serum level of
medication is maintained. With the preventive
approach, analgesic agents are administered at set
intervals so that the medication acts before the pain
becomes severe and before the serum opioid level
decreases to a subtherapeutic level.

Neurologic and Neurosurgical Methods for Pain

Control

Intrathecal and epidural catheters

TENS units
Transcutaneous electrical nerve stimulation (TENS)
uses a battery-operated unit with electrodes applied to
the skin to produce a tingling, vibrating, or buzzing
sensation in the area of pain

Interruption of pain pathways

Cordotomy - the division of certain tracts of the spinal
cord (Fig. 13-10). It may be performed percutaneously,
by the open method after laminectomy, or by other
techniques. Cordotomy is performed to interrupt the
transmission of pain. Care must be taken to destroy
only the sensation of pain, leaving motor functions
intact.

Rhizotomy - Sensory nerve roots are destroyed where

they enter the spinal cord. A lesion is made in the dorsal
root to destroy neuronal dysfunction and reduce
nociceptive input. With the advent of microsurgical
techniques, the complications are few, with mild sensory
deficits and mild weakness (Fig. 13-11).
Adverse Effects of Analgesic Agents

Respiratory depression

Sedation

Nausea and vomiting

Constipation
Pruritus