1. Managing the Patient’s Environment: Promoting Sleep and Comfort.
Chapter 31

2. Learning Objectives Theory
Discuss the application of The Joint Commission pain standards in planning patient care.
Give the rationale for why pain is considered the “fifth vital sign.”
Illustrate the physiology of pain using the gate control theory.
Describe the use of a variety of nursing interventions for pain control, including biofeedback, distraction, guided imagery, massage, and relaxation.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Learning Objectives Clinical Practice
Assist the patient in accurately describing sensations of pain and discomfort.
Accurately and appropriately record the patient’s report of pain using clear, descriptive terms.
Assist the patient in using a transcutaneous electrical nerve stimulation (TENS) unit.
Evaluate the effects of various techniques used for pain control.
Assist with the care of patients receiving patient-controlled analgesia (PCA) or epidural analgesia.
Evaluate the effects of pain medication, and report and record observations appropriately.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Pain Pain is the feeling of distress and discomfort
Affects or interferes with normal activity
No accurate objective measurement of pain
Pain assessment is performed along with each assessment of vital signs and is considered the “fifth vital sign”
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5. Pain (cont’d) Surgical patients experience postoperative pain
Many medical conditions cause pain
Headache, myocardial infarction
Cancer, fractures
Cuts and abrasions
Discuss how to assess a patient who is in pain after surgery.
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6. The Joint Commission: Pain Control Standards
Patients have the right to appropriate assessment and management of pain
Pain is assessed in all patients
Patients are educated about pain and managing pain as part of the treatment, as appropriate
The discharge process provides for continuing pain care based on the patient’s needs at the time of discharge
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7. Theories of Pain
Pain defined as a feeling of distress or suffering caused by the stimulation of nerve endings
Pain serves as a warning of tissue damage and allows sufferer to withdraw from the source of the pain
Pain is transmitted through the nervous system
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8. Pain Descriptions Type of pain Severity of pain based on a pain scale
Quality of pain
Location of pain
Duration of pain
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9. Types of Pain Acute: short-term Chronic: long-term
Nociceptive: injury to tissues
Neuropathic: sensitivity to stimuli
Phantom: after loss of body part
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Type of Pain: Acute Pain
Usually associated with injury, medical condition or surgical procedure
Short duration, lasting a few hours to a few days
May be described as aching or throbbing
Patient may be restless or agitated
Usually controlled with analgesics
The type of pain a patient is experiencing will help determine what methods will best relieve the pain.
Treatment decisions should be based on assessment that includes the patient’s verbal description of pain, nonverbal signs of pain, and physiologic indicators of pain.
How does acute pain differ from chronic pain? (acute pain—usually associated with an injury, medical condition, or surgical procedure—lasts for a short period of time [hours to days]; chronic pain—usually associated with conditions for which the symptoms may be controlled but there is no cure—continues for months and years)
How does the treatment differ per type of pain? (acute pain is usually well-controlled with analgesics or surgery; chronic pain is usually treated with pharmacologic and nonpharmacologic treatments)
Note: Acute pain is intense and demands immediate attention.
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11. Type of Pain: Acute Pain (cont’d)
Causes include:
Burns, bone fractures, muscle strains
Pneumonia, sickle cell crisis, angina
Herpes zoster, inflammations, infections
May worsen in the presence of anxiety or fear
Usually relieved once the cause is removed
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Type of Pain: Chronic Pain
Pain that may continue for months or years
Often associated with conditions such as:
Arthritis
Chronic back pain
May be dull, constant, shooting, tingling, or burning
May be treated with both pharmacologic and nonpharmacologic interventions
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13. Type of Pain: Nociceptive Pain
Involves injury to the tissue in which receptors called nociceptors are located
May be found in skin, joints, or organ viscera
Four phases associated with nociceptive pain
Transduction
Transmission
Perception
Modulation
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14. Type of Pain: Nociceptive Pain (cont’d)
Treatments are aimed at one or all four phases
NSAIDs work at blocking transduction
Opioids block transmission
Distraction and guided imagery block perception
Drugs that block neurotransmitter uptake work on modulation
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15. Type of Pain: Neuropathic Pain
Associated with dysfunction of the nervous system
Pain receptors in the body become more sensitive to stimuli and send signals more easily
As nerve endings grow new branches, the signals become stronger
Often associated with Guillain-Barré syndrome, cancer, and HIV
Treated with NSAIDs, tricyclic antidepressants, anticonvulsants, or corticosteroids
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Type of Pain: Phantom Pain
Occurs with loss of a body part from amputation
Patient may feel pain in the amputated part for years after the amputation
Not controlled by conventional methods
May be treated with TENS units implanted in the thalamus
Phantom limb pain feels as if it is occurring in the amputated limb.
Stump (residual limb) pain is discomfort at the surgery site.
Phantom limb sensation is the feeling that the missing body part is still there; it may involve uncomfortable sensations such as burning, tingling, and itching.
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17. Figure 31-6: TENS unit blocks pain signal transmission
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18. Severity of Pain: Pain Scales
Number scale
Rate the level of pain: 0 is pain-free; 10 is worst pain imaginable
Picture scale
Shows faces in varying degrees of pain
NIPS (Neonatal Infant Pain Scale)
CRIES (Crying, Requires oxygen to maintain saturation, Increased vital signs, Expression, and Sleeplessness)
PIPP (Premature Infant Pain Profile)
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19. Explain how pain rating scales are used.
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20. Wong-Baker FACES Pain Rating Scale for children
Discuss why this is used instead of other rating scales.
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21. Quality of Pain: Perception of Pain
Assessment of pain: whatever the person says it is
Observable indicators (may not always be present)
Moaning
Crying
Irritability
Grimacing
Frowning
Rigid posture in bed
Described as rushing, throbbing, pulsating, twisting, pulling, burning, searing, stabbing, tearing, biting, blinding, nauseating, debilitating
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22. Location of Pain Area of pain Frequency of pain
Name of affected body part (e.g., foot, hand, leg, or upper/lower  abdomen)
Localized, radiating, generalized
Frequency of pain
Constant, intermittent, occasional  
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23. Pain Control: Nonmedicinal Methods
Transcutaneous electrical nerve stimulation (TENS)
Percutaneous electrical nerve stimulation (PENS)
Binders 
Application of heat and cold
Relaxation
Biofeedback
Distraction
Guided imagery and meditation
Music
Hypnosis
Massage
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Medicinal Pain Control: Medicinal Methods
Analgesic medications
Oral
Topical
Injected
Intravenous
Patient-controlled analgesia
Epidural analgesia
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