1. Chapter 43 Pain Management
Pain is purely subjective. No two individuals experience pain to the same degree. Each client has physiological, sociocultural, spiritual, and psychological factors that influence reactions to discomfort and pain. Therefore, students need to practice effective pain management techniques in an effort to improve quality of life, to reduce physical discomfort, to promote early mobilization, and return to normal activities of life.

2. Nature of Pain Involves physical, emotional, and cognitive components
Physical and/or mental stimulus
Is exhausting and demands energy
Interferes with relationships
Always remember that the client is the one who is experiencing pain. Therefore, pain is whatever the client states it is.
If clients are having difficulty expressing pain, it does not mean that they are not in pain.
The Joint Commission pain standard requires health care providers to assess all clients for pain on a regular basis. Many health care institutions have added pain as the fifth vital sign.
Ask students to identify clients who may not be able to express pain?
Answers may include: aphasic, cognitively impaired, intubated, mentally impaired, or pediatric clients.

3. Physiology of Pain Transduction Transmission Perception Modulation
A client is experiencing pain cannot discriminate between these four factors.
Thermal, chemical, or mechanical stimuli usually cause pain. Energy of these stimuli are converted to electrical energy. This energy conversion is transduction (phase 1). During transduction the pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor) beginning the transmission of pain (phase 2).
Ask students to recall physiology. When cellular damage occurs by thermal, mechanical, or chemical stimuli, neurotransmitters such as prostaglandin, bradykinin, potassium, histamine, and substance P are released. These substances surround the pain fibers in the extracellular fluid, spreading the pain message and causing an inflammatory response.
Perception is the point at which the client experiences pain. Recall that no one single pain center exists (phase 3)
The inhibition of the pain impulse is known as modulation (phase 4).
Three other causes of pain have also been identified.
The Gate-Control Theory suggests that pain impulses pass through when a gate is open and are blocked when the gate is closed. The gates can be physiological, emotional, or cognitive processes.
Physiological Response occurs when pain impulses ascend the spinal cord toward the brain stem and thalamus. The ANS becomes stimulated. Pain thus triggers the fight-or-flight reaction of the GAS. Stimulation of the sympathetic branch of the ANS results in physiological response (see Table 43-1). It will be important to remember that a client in pain will not always experience a change in vital signs!
Behavioral responses to pain will vary. If pain is untreated, the client’s life will be altered. Pain threatens a client’s physiological and psychological well-being.

4. Types of Pain Acute/transient pain Chronic/persistent Chronic episodic
Protective, identifiable, short duration
Chronic/persistent
Is not productive and has no purpose or may not have identifiable cause
Chronic episodic
Occurs sporadically over an extended duration
Cancer
Can be acute or chronic
Inferred physiological
Musculoskeletal, visceral, or neuropathic
Idiopathic
Chronic pain without an identifiable physical or psychological cause
Pain can be categorized by duration (chronic or acute) or pathology (cancer or neuropathic).
Acute pain can threaten a client’s recovery by resulting in prolonged hospitalization, complications from immobility, or delayed rehabilitation.
Chronic pain lasts longer than anticipated pain and can be cancerous or noncancerous. Chronic noncancerous pain may include arthritis, headache, low back pain, or peripheral neuropathy. This type of pain is non–life threatening.

5. Nursing Knowledge Base
Attitude of health care providers
Malingerer or complainer
Assumptions about clients in pain
Biases based on culture, education, experiences
Unfortunately, if clients do not have objective signs of pain, some health care providers do not believe the client is experiencing pain. This can be partly the result of the “medical model” of pain, which indicates that pain is due to an organ dysfunction.
It will be important that the nurse’s and client’s perception of the client’s pain are congruent so the client can experience pain relief.
Often, nurses will allow their misconceptions about pain and pain management to interfere with their ability to treat their clients. Box 43-2 presents common biases and misconceptions regarding pain.

6. Factors Influencing Pain
Physiological
Age, fatigue, genes, neurological function
Social
Attention, previous experiences, family and support groups
Spiritual
Pain is complex and a holistic approach may help to meet the needs of your client.
Age will influence the pain experience, especially in the young and very old. These two groups may not be able to adequately express their needs. Table 43-3 presents information regarding pain in infants, and Box 43-3 focuses on pain the elderly.
Fatigue increases the perception of pain and can cause problems with sleep and rest.
Genetic makeup may possibly affect a person’s pain threshold or pain tolerance.
Any factor that interrupts or influences the normal pain reception or perception (spinal cord injury, peripheral neuropathy, neurological disease) can affect the client’s response to pain.
A client’s attention to pain, previous experiences, and social support systems will affect pain experiences. Repeated pain experiences may help the client to deal with the present pain experience. When in pain a client may rely heavily on others for assistance.
It is crucial to remember that spirituality stretches beyond religion. When experiencing pain, a client may ask “Why am I suffering?” or “Why has God done this to me?”
For more information, refer to Chapters 11: Developmental Theories; 12: Conception Through Adolescence; 13: Young to Middle Adult; 14: Older Adult; 29: Spiritual Health; and 31: Stress and Coping.

7. Factors Influencing Pain (cont.)
Psychological
Anxiety, coping style
Cultural
Meaning of pain, ethnicity
The degree and quality of pain a client experiences are related to the meaning of pain. It is difficult to separate pain and anxiety sensations. Critically ill and injured clients often perceive a lack of control over their environment and experience anxiety.
Coping styles influence a client’s ability to handle pain. For example, allowing the client to self-medicate using a PCA can help the client control the pain experience.
The meaning of pain may be closely related to culture and ethnicity. Box 43-3 presents cultural aspects of care. Also refer back to Chapters 9: Culture and Ethnicity and 31: Stress and Coping.

8. Nursing Process and Pain
Pain management needs to be systematic.
Pain management needs to include the client’s quality of life.
Clinical guidelines are available to manage pain.
American Pain Society
National Guideline Clearing House
Successful pain management will depend on establishing a relationship of trust between the client, family, and health care providers.

9. Assessment Client’s expression of pain Characteristics of pain
Onset and duration
Intensity
Pattern
Contributing symptoms
Behavioral effect
The American Nurses Association believes that pain assessment and management is within the scope of every nurse’s practice. This is why pain is now known as the fifth vital sign.
It will be of paramount importance to ascertain the level of pain the client is experiencing. It will also be important to encourage the client to express pain or discomfort. It is also the nurse’s duty to constantly assess the client’s pain.
Box 43-8 presents various behavioral indicators of effects of pain.
A quick way to remember how to assess pain is the PQRS method.
P: palliative or provocative factors
Q: quality
R: region or radiation
S: severity on a scale of 1 to 10

10. Assessment (cont.) Location Quality Relief measures Effect of pain
Influence on ADLs

11. Diagnosis and Planning
Focuses on the specific nature of pain
Mandates a thorough assessment
Selected from NANDA-I–approved list
Interventions selected after client goals and outcomes are identified
Careful assessment will reveal the presence or potential for pain. Assessment and selection of appropriate nursing diagnoses will lead to appropriate nursing interventions.

12. Implementation Nonpharmacological interventions
Relaxation and guided imagery
Distraction
Music
Cutaneous stimulation
Massage, TENS, heat, cold, acupressure
Herbals
Pain therapy requires an individualized approach. Nonpharmacological and pharmacological approaches can be utilized.
Each one of these techniques can be used in combinations. Cutaneous stimulation will require a physician’s order.
Not all therapies will be beneficial or liked by all clients.
Remember at times the simplest act can reduce pain, such as smoothing a wrinkled sheet, repositioning, positioning tubing away from body surfaces.
Clients will need to be able to participate in relaxation, guided imagery, distraction, and music therapy.

13. Pharmacological Pain Relief
Analgesics
Nonopioids
Opioids
Adjuvants/coanalgesics
PCA
Local/regional anesthesia
Topical agents
Nonopioids include acetaminophen and NSAIDs. Acetaminophen has no anti-inflammatory or antiplatelet effects. It has an effect on the liver. Its exact mechanisms of action are not known. NSAIDS (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDS work on peripheral nerve receptors to reduce transmission of pain stimuli. Chronic use is associated with GI bleeding and renal insufficiency.
Opioids are prescribed for moderate to severe pain. These are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Box presents information regarding Nursing Principles for Administering Analgesics.
Adjuvants and coanalgesics are drugs used to treat other conditions but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).
PCA allows clients to help manage their pain. However, the client must be able to participate in this type of intervention.
The most common types of drugs used in PCA are morphine, hydromorphone, and fentanyl.
Local and regional anesthesia are used in a variety of conditions including labor and delivery, chronic cancer pain, and selected postoperative procedures.
Topical agents such as EMLA and lidocaine are administered via patches or disks. These produce anesthesia to soft tissue.
When administering pain medications, you are responsible for monitoring the client for effective pain relief as well as potential adverse reactions. You should have on hand medications to reverse the effect of pain medications (Narcan). Also you will need to monitor IV insertion sites, lines, and IV controllers to ensure the proper amount of medication is being delivered.
Always check with your health care facility for policies and procedures.

14. Chronic Noncancer and Cancer Pain Management
Cancer pain either chronic or acute
Breakthrough pain
Transdermal and transmucosal fentanyl
Cancer pain management can follow AHPR guidelines, which treat cancer pain very comprehensively and aggressively. Figure presents guidelines for treatment. Estimates for addiction to pain medications range from 1% to 24%.
Clients with chronic pain need to be given medications on a regular basis. The WHO recommends a three-step approach to the management of cancer pain. See Figure Treatment begins with NSAIDs and/or adjuvants and progresses to opioids.
Transdermal fentanyl is 100 times more potent than morphine and provides analgesia for 48 to 72 hours. This route is used when clients are unable to take oral medications.
Transmucosal fentanyl exists for breakthrough pain. The fentanyl is swabbed into the mouth.

15. Barriers to Effective Pain Management
The client, health care provider, and health care system
Physical dependence, addiction, and drug tolerance
Placebos
At times health care providers fear problems with addiction, which will alter the use of medication. Box presents information on barriers to effective pain management.
Physical dependence does not imply addiction but is rather a state of adaptation manifested by a drug withdrawal syndrome.
Drug tolerance does not imply addiction either. Instead, tolerance is the diminution of one or more of drug's effects resulting from repeated use over time.
Addiction is a neurobiological disease. Genetic, psychosocial, and environmental factors influence its development.
Professional organizations discourage the use of placebos to treat pain. This practice is considered unethical and deceitful.

16. Pain Clinics, Palliative Care, and Hospice
Pain centers treat clients on an inpatient or outpatient basis.
The goal of palliative care is to learn how to live life fully .
Hospices are programs for end-of-life care.
The Joint Commission has declared the years 2000 to 2010 as being the Decade of Pain Control and Research.
These three programs present options for clients and their family.

17. Evaluation
Evaluation of pain is considered a major responsibility of nurses.
The client’s response to pain may not be obvious.
Evaluating the appropriateness of pain medication will require nurses to evaluate clients 15 to 30 minutes after administration.
It is important to evaluate if nursing interventions have helped the client meet their outcomes and goals.
It will be important to evaluate the client’s perception of the effectiveness of nursing interventions.