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Chapter 4 – Lecture Outline

I. Significance of Pain
A. Subjective response: only felt by the person
B. Negative: discomfort
C. Protective role: warning of potential threat to health (sometimes a life-
threatening condition); prompt for person to seek medical attention
D. Fifth vital sign according to JCAHO

II. Definition: “pain is whatever the person experiencing it says it is, and exists
whenever the person says it does” McCaffery, 1979
A. Pain has personal meaning to individual experiencing pain
B. All pain is real
C. Dimensions of pain include physical, emotional, cognitive, sociocultural,
spiritual aspects
D. Response to and warning of actual or potential trauma

III. Neurophysiology of Pain

A. Gate control theory:
Dorsal horns of spinal cord; impulses of touch and pain mediate each other
Inhibitory system in brain stem; cells activated by opiates, psychologic factors
B. Stimuli: nociceptors: nerve receptors for pain ends; located in numerous skin
and muscles; stimulated by direct cellular damage or local release of
biochemicals from cellular damage such as bradykinin
C. Pain pathway
D. Endorphins (endogenous morphines) bind with opiate receptors on neuron to
inhibit pain impulse transmission

IV.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

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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

V. 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 don’t 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

VI. Common Fallacies and Myths about Pain

A. Chronic pain is really a masked form of depression
1. Depression and pain are both effected by levels of serotonin
2. Depression and pain can co-exist
B. Narcotic medication is too risky to be used with chronic pain
C. Wait until pain is present before administering medication
D. Many clients lie about existence or severity of pain
E. Pain after surgery is best treated with intramuscular injections

VII. Collaborative Care of Clients in Pain

A. Medications: most common approach to pain management
B. Nurse needs to know for each medication: classification; physiologic action;
peak effect, adverse effects, antidote, nursing implications
Classifications of meds:
1. Non-narcotic analgesics: (e.g. acetaminiophen) mild to moderate pain
2. NSAIDs: (aspirin, ibuprofen) peripheral nerve endings; interfere with
prostaglandin synthesis
3. Narcotics (e.g. morphine) or Synthetic narcotics (Oxycodone): act
within and outside CNS

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4. Antidepressants: (such as tricyclic antidepressants) promote serotonin

and inhibit pain, promotes sleep
5. Local anesthetics
C. Duration of Action: evaluate effectiveness according to individualized dosing
schedule
1. Around the clock (ATC)
2. As necessary (PRN)
3. Give analgesics before pain begins or becomes severe
D. Route: affects how much medication is needed to relieve pain; dosages differ
with route;
Most common routes
1. Oral: simplest method
2. Transdermal: delivers continuous level of medication
3. Intravenous: provides most rapid onset (but short duration) unless
available as PCA
E. Surgery: different types done to alter nerve transmission; may alter sensation
or movement as well as pain; used after other methods not effective
F. TENS: (Transcutanenous electrical nerve stimulation) nerve conducts
electrical current and so cannot conduct pain
G. Complementary therapies
1. Acupuncture
2. Biofeedback
3. Hypnotism
4. Relaxation (guided imagery, meditation)
5. Distraction
6. Cutaneous stimulation (massage)

VIII. Nursing Process in Care of Client Experiencing Pain

A. Assessment: 4 aspects
1. Client’s perception of pain
Pain rating scale; location; quality; pattern; precipitating and relieving
factors; impact of pain; physiologic and behavior changes
2. Physiologic response to acute pain: tachycardia, increased blood
pressure, muscle tension, dilated pupils, sweating
3. Behavioral responses to acute pain: guarding, facial expressions,
withdrawing
4. Client’s management of pain and effectiveness
Denial of pain: due to fear, misconceptions
B. Diagnosis: acute or chronic pain
C. Nursing interventions:
1. Acknowledges and documents pain
2. Administers prescribed analgesics
3. Utilizes non-pharmacologic methods and comfort measures
4. Teaches clients and family about pain, medications, comfort measures
5. Suggests referrals as necessary

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D. Evaluation: utilizes client perception and pain rating scale to document

changes in pain

Suggestions for Clinical Experience

Assign students clinical experience with clients receiving Patient Controlled Analgesia
(PAC) either intravenous or epidural in the hospital on a surgical floor. Review client
documentation sheets and address each individual client’s specific pain level, sedation
level, and adverse effects over time.

Assign students clinical experience in the same day surgery unit to observe pain control
after surgery, and to see what is ordered for clients when they are discharged. Ask
students to compare the ways different clients express the need for pain medication. What
types of pain medications are ordered after surgery? What medications are prescribed for
use post discharge? What techniques are utilized in teaching clients how to control their
pain after they leave the surgery unit? Assist the students to understand ways nurses
deliver care that decrease the amount of client pain involved (e.g. positioning and other
comfort measures).

Assign students to clients in the hospital or nursing home with histories of chronic pain
illnesses. Have the students interview the clients and ask the clients about their
experiences with the painful conditions. What are some of the ways clients act to prevent
or deal with pain episodes?

Assign students to clinical experience in caring for hospice clients in an in-patient

hospice, a palliative care unit or a nursing home. Ask students to observe the methods
used by the nurses to assess pain in these clients. What types of medications are ordered
and what are the routes of the medications? How do the nurses individualize the
management of pain for each client?

Nursing Care Plan

Present the following client situation for discussion:

The client is a 22-year-old woman who has arrived in the pre-surgery unit for surgery
scheduled later in the morning. The nurse completes a physical examination and nursing
history. Three months ago this client was in a serious motor vehicle accident in which she
sustained several fractures in her pelvis and in both legs. Today she is having surgery to
further repair one of the injuries. When the nurse asks if the client has any specific
concerns, the client begins to cry and relates that she is terrified of having terrible pain
like before without medicine to control it.

What are some of the factors affecting pain that are related to how this client will
experience pain after the surgery? What should the nurse do with this information?

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The nurse places a call to the surgeon and explains the client’s concerns. The physician
asks the nurse about the client’s present status regarding pain and how she is coping over
all. The surgeon orders an anti-anxiety agent to be given now if the client is agreeable and
will be in directly to talk to the client. Both the anesthesiologist and surgeon visit the
client and reassure her that her pain will be adequately relieved after the surgery.

The client is relaxed after receiving the anti-anxiety agent. She questions the nurse as to
whether her insurance will cover this surgery if she stays in the hospital overnight for
pain control as offered by the physicians. The nurse shares the concern with the surgeon
who states that the procedure has been certified for outpatient or for an overnight stay.

After the surgery is completed, the client is returned to the recovery area of the surgical
unit. The client awakens and is medicated with Morphine Sulfate 2 mg. IV Push every 30
minutes as needed. There is an order to notify the anesthesiologist if the client does not
achieve adequate pain relief.

What classification of pain medication is Morphine Sulfate? What is the onset and
duration of Morphine Sulfate when administered intravenously? What parameters should
the nurse assess when making decisions about intervening to control the client’s pain?

Over the next five hours the client makes satisfactory recovery from the anesthesia and is
visited by the surgeon and anesthesiologist. The client’s pain has been adequately
controlled with hourly dosages of the morphine sulfate. The client wants to go home this
evening and the pain medication is switched to Percocet 2 tablets orally. She will be
discharged home with a prescription for Percocet (Acetaminophen 325 mg with
Oxycodone hydrochloride 5 mg) 2 tablets every four hours as needed.

What classification of pain medication is Percocet? What should the nurse include in
discharge teaching for this client regarding pain medication and pain control? What are
some measures the client can take to keep her pain level under control?

Joyce Hammer
1/23/2018