Our Lady of Fatima University

College of Nursing
Medical-Surgical Nursing 1
Lecture 2
COMFORT AND PAIN

INTRODUCTION

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue
damage. It is sometimes referred to as the FIFTH vital sign. In many aspects, pain is the most common
reason for seeking health care. Because pain emanates from various modalities such as diagnostics tests,
diseases and treatment procedures, nurses must be knowledgeable about the pathophysiology of pain and its
management. Nurses encounter pain in a variety of setting, including acute are, outpatient, and long term
care settings as well as in the home. The nurse has daily encounters with pain who anticipate pain or who are
in pain. Understanding the phenomenon of pain and contemporary pain theories helps the nurse to intervene
effectively.

PAIN DEFINED

Pain – This is a subjective sensation to which people respond in different ways. It can directly impair health
and prolong recovery from surgery, disease and trauma. Pain is a highly unpleasant and very personal
sensation that cannot be shared with others. It can occupy all a person’s thinking, direct all activities, and
change a person’s life. It is the noxious or unpleasant stimulation of threatened or actual tissue damage. This
pain sensation is a different sensation because the purpose of pain is not to inform the CNS of the quality of
the stimulus but rather to indicate that the stimulus is causing damage or injury to the tissues. It is the result
of a complex pattern of stimuli generated at the pain site and transmitted to the brain for interpretation.

Common Misconception about Pain

Misconception Correction
Clients experience severe pain only when Even after minor surgery, clients can
they have had major surgery experience intense pain
The nurse or the other health professionals The person who experiences the pain is the
are the authorities on client’s pain. only authority on its existence and nature.
Administering analgesics regularly for pain Clients are unlikely to become addicted to an
will lead to addiction analgesic provided to treat pain
The amount of tissue damage is directly Pain is a subjective experience and the
related to the amount of pain intensity and duration of pain vary
considerably among individuals
Visible physiologic or behavioral signs Even with severe pain, periods of physiologic
accompany pain and can be used to verify its and behavioral adaptation can occur
existence

Origin and Causes of Pain

I. Category of pain according to its origin

A. Cutaneous pain—originates in the skin or subcutaneous tissue

B. Deep somatic pain—arises from ligaments, tendons, bones, blood vessels, and nerves
C. Visceral Pain—results from stimulation of pain receptors in the abdominal cavity, cranium and thorax.
It tends to appear diffuse and often feels like deep somatic pain that is, burning aching, or feeling of a
pressure. It is frequently caused by stretching of the tissues, ischemia or muscle spasm

II. Category of pain according to its cause

A. Acute pain—following acute injury, disease or some type of surgery
B. Chronic malignant pain—associated with cancer or other progressive disorder
C. Chronic nonmalignant pain—pain in the persons whose tissue injury is non progressive or healed
 General Types of Pain

I. Acute pain—may have sudden or slow onset; it varies from mild to severe, some may last up to 6
months and subsides as healing takes place. It occurs within 0.1 second after application of stimulus.
It may be called fast pain, sharp pain, or initial pain. Impulses usually travel through the type A delta
fibers and this pain is easily localized.
II. Chronic pain—last 6 months or longer and often limits normal functioning. It is sometimes called dull
pain, slow pain and delayed pain. Impulses travel in the type C fibers and are not easily localized.
Unpleasant autonomic signs and symptoms like nausea, sweating and generalized hypotonia, usually
accompany this pain.
III. Cancer-related pain

Comparison of Acute and Chronic Pain

Acute Pain Chronic Pain
Mild to severe Mild to severe
Sympathetic nervous system response: Parasympathetic nervous system response:
- Increased pulse rate - Vital signs normal
- Increased respiratory rate - Dry warm skin
- Elevated blood pressure - Pupils normal or dilated
- Diaphoresis
- Dilated pupils
Related to tissue injury; resolves with healing Continues beyond healing
Clients appears restless and anxious Clients appears depressed and withdrawn
Clients reports pain Clients often not mention pain unless asked
Clients behavior indicative of pain; crying,
rubbing area, holding area

Terms Used in the Context of Pain

1. Radiating pain—perceived at the source of the pain and extends to the nearby tissues
2. Referred pain— pain is felt in a part of the body that is considerably removed from the tissues causing the
pain
3. Intractable pain—pain that is highly resistant to relief
4. Phantom pain—painful perception perceived in a missing body part or in a body part paralyzed from a
spinal cord injury
5. Phantom sensation—feeling that the missing body part is still present
6. Hyperalgesia—excessive sensitivity to pain
7. Pain threshold—is the amount of pain stimulation a person requires in order to feel pain
8. Pain sensation—can be considered the same as pain threshold
9. Pain reaction—includes the autonomic nervous system and behavioral responses to pain
10. Pain tolerance—maximum amount and duration of pain that an individual is willing to endure
11. Nociceptors—pain receptors
12. Pain perception—the point which the person becomes aware of the pain

Pain threshold is similar in all people, but pain is tolerance and response vary considerably
Painful sensations are sensed by receptors. We call the receptors NOCICEPTORS. Usually they are free nerve
endings located widespread in the superficial layers of the skin, peritoneal surfaces, periosteum, arterial walls,
pleural surfaces, joint surfaces and the falx and tentorium of the cranial vault. These nociceptors are non-
adapting to keep us constantly informed of the continuous presence of the painful stimulus that can damage
the tissues.
For pain to be perceived, nociceptors must be stimulated. These pain receptors can be stimulated by:
(1) serotonin
(2) histamine
(3) potassium ions
(4) acids
(5) some enzymes
In general, there are 3 types of stimuli that can stimulate pain receptors- Mechanical, Thermal and Chemical.
1. Mechanical stimulus- pressure, squeeze, pin prick
 2. Thermal stimulus- heat and freezing temperature
3. Chemical stimulus- collectively called the “P” factors- bradykinin, serotonin, histamine, prostaglandin
and substance P. These are released when the tissue is injured or inflamed. They also make the
mechanoreceptors very sensitive to pain.

COMMON PAIN SYNDROMES

1. Post herpetic neuralgia:

 An episode of herpes has two phases: a vesicular eruption and neuralgic pain that encircles the body.
The pain ranges from mild to severe. In the post herpetic syndrome, severe pain persists for months
or years with lightning-like pain in the areas of the original eruption.
2. Headache:
 This common somatic pain can be caused by either intracranial or extracranial problems. To establish
a plan to prevent or treat headache, the nurse needs to assess the quality, location, onset, duration,
and frequency of the pain, as well as any signs and symptoms that precede the headache.
3. Cancer pain syndrome:
 These syndromes can result from the progression of the disease or from efforts to cure or control the
disease.

Basically, there are three types of pain stimuli:

(1) Mechanical
(2) Thermal
(3) Chemical

TYPES OF PAIN STIMULI

STIMULUS TYPE PHYSIOLOGIC BASIS
Mechanical
 Trauma to the body tissues (e.g. surgery)  Tissue damage; direct irritation of the
pain receptors; inflammation
 Alterations in body tissues (e.g. edema)  Pressure pain receptors
 Blockage of a body duct  Distention of the lumen of the duct
 Tumor  Pressure on pain receptors: irritation of
nerve endings
 Muscle spasm  Stimulation of pain receptors (also see
chemical stimuli)
Thermal
 Extreme heat or cold (e.g. burns)  Tissue destruction; stimulation of
thermosensitive pain receptors
Chemical
 Tissue ischemia (e.g. blocked coronary  Stimulation of pain receptors because of
artery accumulated lactic acid (and other
chemicals such as bradykinin and
enzymes) in tissues
 Muscle spasm  Secondary to mechanical stimulation
(see above), causing tissue ischemia
The precise mechanism of pain transmission and perception is unknown.
There are two separate pathways that transmit pain impulses to the brain:
(1) Type A-delta fibers are associated with fast, sharp, acute pain and
(2) Type C fibers are associated with slow, chronic, aching pain

Gate Control Theory by Melzack and Watt

According to the gate control theory, peripheral nerve fibers carrying pain to the spinal cord can have their
input modified at the spinal cord level before transmission to the brain.
 Small-diameter nerve fibers carry the pain stimuli through the same gate, but
 large diameter fibers that carry the non-pain impulses go through the same gate and inhibit the
transmission of those pain impulses- that is close the gate.
 This theory is the basis of many pain intervention strategies.
The gate control theory has led to the recognition that the pain can be reduced or modulated at four points:
1. The peripheral site of pain
2. The spinal cord
3. The brainstem
4. The cerebral cortex
The pain gate situated in the substantia gelatinosa cells in the dorsal horn of the spinal cord can be shut in
several ways:
 Stimulation of touch-fibers by rubbing, stroking, massage, vibration and application of liniments
and other ointments.

 Release of endogenous opioids produce in various parts of the central nervous system contains
neuromodulators that release endogenous opioids include enkephalins, endorphins and
dynorphins, which are morphine-like in actions
 Electrical stimulation of the skin’s sensory nerve fibers inhibits pain.

 Morphine and other opioids drugs bind to the opioid receptors in the dorsal horn of the spinal cord
and inhibit or block completely the transmission of the pain signal

 Normal and excessive sensory stimuli may also relieve pain by competing with the pain stimuli.
Such thing as music, application of heat and cold, imagery and elaborate distractions such as
video games can all be used to close the pain gate

 Cerebral cortex and thalamic inhibition of pain such as reducing anxiety and teaching the client
about the pain and helping the client feel capable of controlling the pain.

Factors affecting the Pain Experience

A. Ethnic/Cultural values
B. Age
C. Environment and support persons
D. Anxiety and stress
RESPONSES TO PAIN
SYMPATHETIC RESPONSES PARASYMPATHETIC RESPONSES
(FIGHT OR FLIGHT) (ADAPTATION)
Increased pulse rate Decreased pulse rate
Increased systolic blood pressure Decreased systolic blood pressure; syncope
Increased respiratory rate Variable breathing pattern
Diaphoresis Nausea/Vomiting
Increased muscle tension Warm dry skin
Pallor Prostration
Pupil dilatation Pupil constriction
Rapid pitch/ elevated pitch Slow, monotonous speech
Increased alertness Withdrawal
PATHOPHYSIOLOGY OF PAIN

I. PATHOPHYSIOLOGY OF PAIN TRANSMISSION

PAIN RECEPTORS AND STIMULI

Pain receptors, called nociceptors, are free nerve endings of unmyelinated or lightly myelinated
afferent neurons. Nociception is the sensory detection and neural transmission of unpleasant events. The
Nociceptors are located extensively in the skin and mucosa and less frequently in selected deeper structures,
such as viscera, joints, arterial walls, and bile ducts. Nociceptors respond to harmful or potentially harmful
stimuli that may be chemical, thermal, or mechanical. Chemical stimuli for pain include histamines,
bradykinin, prostaglandins, and acids, some of which are released by damaged tissues. Anoxic tissue also
releases chemicals that lead to pain. Tissue swelling may cause pain by creating pressure (mechanical
stimulation) on nociceptors in adjoining tissues.
After tissue injury and in some pathologic conditions, pain receptors do not adapt to repeated
stimulation and may become more sensitive. As a result, pain sensitivity to a normally painful stimulus may
be increased ( hyperalgesia) or a normally nonpainful stimulus, such as touch, may be painful (allodynia).
PAIN TRANSMISSION
Pain impulses are transmitted to the spinal cord by two types of fibers: thinly myelinated faster-
conducting A- delta fibers and slower-conducting unmyelinated C fibers. The greatest difference lies on the
type of pain the pain fibers will transmit. Pain that may be described as “sharp” or “pricking” and that can be
easily localized results from impulses transmitted by the A-delta fibers. An example of this type of pain is that
felt by a needle prick. Pain that may be described as “burning,” ‘dull,” or “aching” and that is more diffuse
results from impulses transmitted by the C fibers. Impulses transmitted on the larger diameter myelinated A-
beta and A-alpha fibers have an inhibitory effect on those transmitted over A-delta and C fibers.
The pain impulses cross the spinal cord over inter- neurons and connect with ascending spinal
pathways The most important ascending pathways for nociceptive impulses located in the ventral half of the
spinal cord are the spinothalamic tract (STT) and the spinoreticular tract (SRT). The STT is a discriminative
system and conveys information about the nature and location of the stimulus to the thalamus and then to the
cortex for interpretation. Impulses transmitted over the SRT (which goes to the brainstem and part of the
thalamus) activate the autonomic and limbic (motivational-affective) responses.

PAIN MODULATION
Discovery of receptors in the brain to which opiate compounds bind led to the discovery of two
naturally occurring endogenous morphine-like pentapeptides (5- amino acid compounds), met and leu-
enkephalin. These enkephalins are classified as endorphins (from the terms endogenous and morphine). Other
endorphins, such as beta-endorphin, also have been identified. The endorphins are thought to suppress pain
by (1) acting presynaptically to inhibit release of the neurotransmitter substance P or (2) acting post-
synaptically to inhibit conduction of pain impulses. The endorphins are found in high concentration in the basal
ganglia of the brain, thalamus, midbrain, and dorsal horn of the spinal cord.
Descending spinal pathways from the thalamus through the midbrain and medulla to the dorsal horns
of the spinal cord, conduct nociceptive inhibitory impulses. Serotonin is one neurotransmitter that supports
these inhibitory impulses. The endogenous descending pain—suppressive system is more effectively activated
by nociceptive stimuli transmitted by A-delta fibers. Electrical stimulation by means of transcutaneous
electrical nerve stimulators (TENS) using low frequency and high intensity activates opiate analgesia.
Acupuncture is also thought to use the opiate path ways.

SPINAL CORD PATHWAYS and CENTRAL PATHWAYS

There are numerous pain pathways to the brain. The peripheral nerve fibers enter the dorsal roots of
the spinal cord posteriorly, go up two to three segments and terminate in the nerve cells of the spinal cord
called the substancia gelatinosa. Most signals pass through 1 or 2 more neurons before reaching long-fibered
neurons that cross to the opposite side of the cord. Ascend to the cortex is then completed by way of the
dorsal column system and the spinothalamic system.
The DORSAL column system functions to transmit impulses that requires rapid and accurate
processing, fine gradation of intensity and discreet localization. It transmits fine touch. Pressure, vibration and
position sense. The SINOTHALAMIC tract is the pain tract. It transmits the pain impulses and tenperature
impulses via the lateral spinothalamic tract to the brain for pain interpretation.

THEORIES OF PAIN TRANSMISSION

Various theories of pain transmission have been proposed (Box 17-1). The affect, specificity, and
pattern theories were early theories that led to the development of the gate control theory. No single theory
explains the complexity of the pain phenomenon. Although the gate control theory does not fully explain pain
transmission, it serves as a basis for understanding pain transmission. There are four major theories:
Specificity, Pattern, gate control and the endogenous mechanism. An addition to the four is the affect theory.

The Traditional Theories

The Specificity theory proposes that pain results when specific pain receptors are stimulated. There is a
direct relationship between the receptor type, fiber size, and the pain experienced. This theory however, does
not explain the varying degrees of pain, the effect of emotions and the inability ton locate the pain receptors.
The Pattern theory proposes that pain results from the transmission of nerve impulses that originates
from and is coded at the peripheral stimulation site (where the pain started). After the tissue is damaged,
circuits are established in the spinal interneurons that enable pain to be perceived even though the stimuli are
no longer present. These reverberating circuits can explain the phenomenon of phantom limb PAIN
 The endogenous opiates theory emphasizes the role of biochemicals in pain modulation. Enkepahlins and
endorphins primarily act at the neurons synapses to influence the integration of pain and activation of the
brain’s analgesic system.
The gate control theory incorporates some aspects of the specificity and the pattern theory. The dorsal
horn acts as the “gate”, closing to prevent impulses from reaching the brain or opening to allow impulses to
be transmitted to the brain. When the gate is open, pain is felt. When the gate is closed, pain is not felt.

Melzack and Wall developed gate control theory in 1965. The theory proposes that the substantia
gelatinosa (SG) in the spinal cord acts as a gating mechanism to permit or inhibit passage of pain impulses.
The “gate” can be “closed” (so that the contact is not made, thus interrupting the pain impulse) by nerve
impulses from the large non-nociceptive A-beta and A-alpha fibers or from the descending pathways.
Impulses conducted over large fibers not only close the gate but also are sent immediately to the cortex for
rapid identification, evaluation, and modification of the sensory inputs. Impulses sent to the brainstem, the
center for motivational-affective and sensory-discriminative actions, can influence cognition or evaluation in
the cortex. Impulses are then sent from the cortex back to the SG via corticospinal pathways to inhibit or
permit passage of pain impulses. Note in Table 17-1 the various factors that can open or close the gate.
 Influencing the A-delta fibers by techniques such as cutaneous nerve stimulation can control pain
 Pain can be controlled by decreasing the C-p=fiber input
 Pain can be controlled by counter-irritation with electrical current, vibration, heat, cold, or tactile
stimulation, all of which create toleration for greater noxious stimuli
 Drugs may affect excitation or inhibition of substancia gelatinosa activity

PAIN PERCEPTION
Perception of pain takes place in the cerebral cortex (cognitive- evaluative function of the parietal
lobe) as a result of the stimuli transmitted up the spinothalamic and thalamocortical tracts. This thinking-
feeling component of pain is subjective, highly complex, and individual; it is influenced by factors affecting
stimulation of the nociceptors and transmission of the nociceptive impulse, as well as by cortical receptivity
and interpretation:
1. Stimulation of nociceptors
a. Increased number of stimuli
b. Increased duration of the stimulus
2. Alteration of transmission
a. Damage to nerve endings
b. Inflammation, tumors, or injuries to spinal cord
3. Receptivity of cortex
a. Inflammation; degenerative changes of brain
c. Anesthesia
4. Interpretation in cerebral cortex
a. Childhood training
b. Past experience with pain
c. Cultural values
d. Religious beliefs
e. Physical and mental health
f. Knowledge and understanding
g. Attention and distraction
h. Fear, anxiety, tension
i. Fatigue
j. State of consciousness
Therefore, the intensity of the pain experienced depends not only on the stimulus intensity, but also on
psycho- logic factors.

The intensity at which the noxious stimulus is subjectively judged as painful is called the pain
detection threshold. This sensory discrimination is relatively consistent within and between different
individuals, relative to the location and type of stimulus.
In contrast, pain tolerance, which is the maximum degree of pain intensity a person is willing to
experience, is highly variable. Numerous factors can increase or decrease pain tolerance. Tolerance can vary
between different individuals in the same situation and in the same individual in differing situations.

INCREASE TOLERANCE DECREASE TOLERANCE

Alcohol Fatigue
Drugs Anger
Hypnosis Boredom
Warmth Anxiety
Rubbing Persistent pain
Distraction Stress
Faith
Strong beliefs

SPECIFIC TYPES OF PAIN

Somatic Versus Visceral Pain
Pain may originate in the skin and subcutaneous tissue, (superficial), in the muscles and bones (deep
somatic pain), or in the body organs (visceral pain). Somatic and visceral pains differ in their characteristics,
particularly in the quality of pain, localization, causes, and accompanying symptoms (Table 17-3).

Referred Pain
Referred pain is felt in areas other than those stimulated. It may occur when stimulation is not
perceived in the primary areas. For example, the person having a heart attack may complain only of pain
radiating down the left arm when in fact the tissue damage is occurring in the myocardium. Referred pain
occurs most often with damage or injury to visceral organs, and the pain is referred to cutaneous surfaces or
dermatomal regions (Figure 17-4). The origin of referred pain is complex and not clearly understood and may
relate to one or more of the following:
I. Referred pain usually occurs in structures that developed from the same embryonic dermatome.
2. Visceral and somatic nerves enter the nervous system at the same spinal level and share the same
spinothalamic tracts.
3. Somatic pain is more common and the person has “learned” to interpret signals conducted on
certain pathways as being somatic in origin.

Psychogenic Pain
The term psychogenic pain has been used to describe pain for which no pathologic condition has been
found or in which the pain appears to have a greater psychologic basis than a physical one. A caution here is
that diagnostic tests are not definitive measures and may not be sophisticated enough to detect
pathophysiology. Distinguishing between physical and emotional components of pain is difficult, and it i
important to remember that all pain is real

Neurologic Pain
Pain in the neurologic system occurs in different forms. Neuralgia is sharp, spasm-like pain along the
course of one or more nerves. Two common areas of neuralgia are the trigeminal nerve in the face and the
sciatic nerve in the lower trunk. Causalgia, a form of neuralgia, is severe burning pain associated with injury
to a peripheral nerve in the extremities. The patient may go to great lengths to protect against irritating
stimuli (which may be something as simple as the noise of a plane overhead).

Phantom limb pain

This is pain or discomfort perceived by the person to be occurring in an extremity that has been
amputated. It is more likely to develop in those who had pain before amputation and may persist long after
healing has occurred. The phenomenon of phantom limb pain has only recently been decreased
postoperatively when patients are given preemptive (before surgery) analgesics.

Intractable pain
This type of pain is a chronic pain that is resistant to cure or relief. Patients with intractable pain often
describe it as all consuming and interfering with their quality of life. Examples of intractable pain are arthritis
and cancer.

CHARACTERISTICS OF PAIN
Pain usually is described in relation to location, intensity, onset and duration. Pain is highly
individualized experience. One person’s description of pain may differ from another’s, even though the pain
stimuli are the same.
a. Location- superficial pain emanates from the skin and tissues close to body surfaces. Deep
pain originates from deeper structures that accurate localization is very difficult. Terms that
 can be utilized by nurses include: Localized, Diffuse, proximal, distal, medial, lateral, anterior,
posterior, phantom, referred, right and left.
b. Intensity- terms that can describe intensity are; mild, slight, moderate, intermittent, severe,
spasmodic and constant.
c. Quality- terms that may be used to describe quality are; boring, burning, constant, cramping,
crushing, dull, excruciating, hammering, knifelike, lancinating, penetrating, piercing,
pounding, radiating, sharp, shooting, stabbing, tearing, throbbing and tingling.

FACTORS AFFECTING THE PAIN EXPERIENCE

Numerous factors can affect a person’s perception and reaction to pain, these include ethnic/cultural
background, developmental stage, environmental factors, support people, previous pain experiences, and the
meaning of the current pain as well as anxiety and stress

1. Ethnic and Cultural Values

Behavior related to pain is a part of the socialization process. Individuals in one culture may have
learned to be expressive of pain whereas in other culture, individuals may not express it. Nurses must
understand their own cultural influences as well as the client’s ethnicity to be able to provide culturally
competent care
2. Developmental Stage
Reaction to pain and expression to pain vary among individuals of different ages and developmental
stages. Children may be less able to verbalize their needs related to pain resulting to under
treatment. The older population may have numerous pain complaints related mostly to the chronic
(and some acute ) disease conditions.
3. Environment and Support people
Strange environment like hospitals and health care facilities can compound pain. A client who is alone
may perceive pain severely compared to a person with supportive family. Expectations of the
significant others can affect pain perception. Girls may openly express pain than boys. A working
mother may disregard pain because of the need to stay on the job for her children.
4. Past Pain experience
Previous pain experiences alter a client’s sensitivity to pain. The success or lack of success of pain-
relief measures may lead to anticipation of pain.
5. Meaning of Pain
A client who associates the pain with a positive outcome may withstand pain amazingly well. People
who respond with despair, anxiety and depression to pain may view it as a threat to body image or a
sign of possible impending death.
6. Anxiety and Stress
Anxiety and the ability to control the pain events surrounding it often increase the pain perception.
Fatigue reduces the ability to cope and increases pain perception. Clients who are able to express pain
to an active listener and participate in pain management decisions can increase a sense of control and
decrease pain perception.

FACTORS AFFECTING PAIN FUNCTION

1. PAIN threshold is the amount of pain the person requires before feeling pain. This is usually uniform
throughout the lifetime. This can be changed in some situations like anesthesia, state of
consciousness, etc..
2. PAIN tolerance is the highest intensity of pain that the person is willing to tolerate. Some people can
tolerate only minimal discomfort
3. FEAR of pain can lower the pain threshold because of the heightened focus of pain. Fear increases
muscle tension, which increases pain perception and intensity.
4. FATIGUE can predispose to pain. Exhaustion and lack of sleep contribute to a chronically tired state in
which it is difficult to manage pain.
5. LACK of Knowledge and fear of the unknown may worsen pain because of the tension and anxiety that
the patient brings to the situation

MANIFESTATIONS OF PAIN

Common manifestations of pain include physiologic and behavioral responses. Observable physiologic
signs of discomfort include increased BP, increased HR and increased respiratory rate, dilated pupils and pallor
and perspiration. Behavioral responses to pain are subjective and depend on the patient’s report of pain.
These can include crying, moaning, rubbing of painful parts, frowns, grimaces, fatigue and increased muscle
tension.
The autonomic nervous system regulates most of the functions involved in the manifestations of pain.
This system is composed of the sympathetic and the parasympathetic nervous system.
The sympathetic nervous system regulates the observable physiologic signs of pain. The
neurotransmitters in this system are epinephrine and nor-epinephrine. This system usually responds to
perceived threats like pain with the manifestations to maintain homeostasis
a. Increased BP is due to the peripheral vasoconstriction as t body attempts to shift the blood
away from the skin, kidney and GIT to the brain, liver and heart.
b. Increased heart rate is due to the body’s attempt to increase cardiac output and oxygen
delivery to the tissues involved.
c. Increased respiratory rate- is an effort of the body to increase the amount of oxygen to the
lungs and body
d. Dilated pupils is an effort to increase visual acuity
e. Perspiration and pallor reflect the shift of circulating blood from the skin to the vital organs.
Increased perspiration also helps regulate body temperature.
f. Increased blood glucose is the body’s way to increase the available energy source
g. Verbal and non-verbal indicators of pain- may indicate the location and intensity. Patients can
either report the pain, moan and cry if in pain. They can also show frowning, grimacing,
remain motionless and rub painful areas.
h. The body positioning and body guarding show increased muscle tension.

IMPACT OF PAIN ON ACTIVITIES OF DAILY LIVING

1. Pain generally causes decreased energy, which affects all aspects of daily living. Patients in pain often
find it difficult to perform basic daily tasks.
2. Pain can make it difficult for the patient to fall asleep or stay asleep and the resulting lack of sleep can
contribute to fatigue
3. Pain can interfere with the patients’ school activities or work. Patients in pain may not be able to
concentrate on work and studies
4. Patients with pain may focus on their pain and thus be unable to explore outside interests and
relationships

THE NURSING MANAGEMENT OF PAIN

NON-PHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT

A. Altering Pain Transmission

1. Electrical stimulators
The purpose of electrical stimulators is to modify the pain stimulus by blocking or changing the painful
stimulus with stimulation perceived as less painful. The success of this approach is thought to be explained by
the gate control theory of pain transmission, that is, blockage of pain stimulus by stimulation of the large
sensory fibers.

2. Neurosurgical procedures
Constant relentless chronic pain that cannot be controlled by analgesics (intractable pain) may be
reduced or eliminated by one of various neurosurgical procedures. Other forms of pain control usually are
attempted before neurosurgical procedures.

3. Nerve block
A nerve block involves the injection of substances such as local anesthetics or neurolytic agents (e.g.,
alcohol or phenol) close to nerves to block the conduction of impulses over the nerves. Nerve blocks
frequently are used for the symptomatic relief of pain. They are used to treat chronic pain associated with
peripheral vascular disease, trigeminal neuralgia, causalgia, and cancer.

4. Acupuncture
Acupuncture is an ancient form of disease treatment that can be used for pain relief. Recently, the
acupuncture method been used in Western countries. Small needles are skillfully inserted and manipulated at
specific body points, depending on the type and location of pain. The gate control theory provides the best
explanation for the success of acupuncture. The local stimulation of large-diameter fibers by the needles is
thought to “close the gate” to pain.

B. Modifying Pain Response

1. Behavior modification
Behavior modification consists of a planned change in the way a person behaves by means of
rewarding desired behavior and ignoring undesirable behavior. Forms of behavior modification are used
unconsciously all the time: a young boy “throwing a tantrum” may be ignored, but as his behavior becomes
more appropriate, his mother may reward him with her time and attention.
Behavior modification may be useful for persons with chronic pain. For example, one protocol for
patients with chronic low back pain is to set a limit of 10 minutes daily for discussion of their pain experiences
(with the exception of data-gathering interviews). Pain medications are given on a regular schedule to
dissociate the feelings of pain with inappropriate use (reward) of analgesics or other unhealthy behaviors.

2. Biofeedback and autogenic training

Some persons are able to alter their body functions through mental concentration. In biofeedback
training a machine that monitors brain wave activity (electroencephalograph) is used. The individual
concentrates on slowing his or her brain wave activity to rates at which pain and distress are unlikely to cause
discomfort (i.e., complete relaxation). It may take many months of regular practice to achieve the desired
level of control. The nurse should encourage and praise the person’s efforts.

In autogenic training the same type of self-recognition is used to alter various autonomic nervous
system functions, such as pulse, blood pressure, and muscle tension. Practiced use of transcendental
meditation and other methods of concentration and self-control may achieve the same degree of auto
regulation without the use of sophisticated physiologic monitoring equipment.’

3. Hypnosis
Hypnosis may be used in the treatment of various conditions, particularly when these conditions are
aggravated by tension and stress. Patients are helped to alter their perception of pain through the acceptance
of positive suggestions made to the subconscious. Many per sons are able to learn self-hypnosis.

C. Modifying the Pain Stimulus

1. Cutaneous stimulation and massage

The gate control theory of pain proposes that the stimulation of fibers that transmit non-painful
sensations can blck or decrease the transmission of pain impulses. These pain relief strategies are based on
this theory.
Cutaneous stimulation innervates the large A-beta fibers, closing the gate to impulses from the
periphery. Methods of cutaneous stimulation include the following:
1. Lightly rubbing the affected area
2. Application of heat or cold to area
3. Whirlpool massage of area
4. Back rub or massage can also produce muscle relaxation

2. Reducing additional physical stimuli

Although in many instances pain cannot be prevented, it is often possible to avoid additional pain
when pain is already present. For example, when moving the body or an extremity, supporting the trunk or
extremity will prevent increasing the pain by unilateral pulling on muscles, joints, and ligaments. Interventions
include the following measures:
a. Use a turning sheet for patients with severe neck, back, or general trunk pain.
b. Place a pillow under a painful joint when helping a patient change position.
c. Support limbs at the joints rather than the muscle bellies when handling an extremity.
d. Use special beds (Stryker frame, Foster bed, CircOlectric bed) for patients with severe general or
trunk pain.
e. Avoid bumping the bed or moving it suddenly.

3. Reducing auditory and visual stimuli

 The patient may experience sensory overload with sub sequent potentiation of pain stimuli. If nurses
could stand still for 5 minutes in the patient’s environment and watch and listen, they might understand that
some patients are almost continuously bombarded with noise and visual stimulation. If these are problems, it
may be possible to change the environment. Changes include the following:
a. Move the patient to a quieter room away from the center of activity.
b. Dim bright lights; pull shades if sunlight is intense.
c. Keep verbal interactions at a minimum when pain is severe.
d. Encourage other patients to use headphones or keep television or radio at a reasonable level,
e. Control the number of persons entering the patient’s room according to patient’s wishes.

4. Distraction
Distraction interferes with the pain stimulus, thereby modifying the awareness of the pain. Focusing
on activity in the environment can modify mild or moderate pain. It relieves both acute and chronic pain by
stimulating the descending pathway of pain. Distraction techniques can be watching TV, listening to music,
solving puzzles, and reading comics, etcetera. Visits from family members and participating in family games
are also great distraction techniques. A very quiet environment providing little or no sensory input actually can
intensify the pain experience because the person has nothing to focus on but the painful stimulus.

5. Relaxation.
Full relaxation decreases muscle tension and fatigue that usually accompanies pain. It also helps to
decrease anxiety, thereby preventing augmentation of the pain stimulus; in addition, relaxation techniques
serve as a form of distraction. A simple relaxation technique that nurses can teach the patient consists of
abdominal breathing at a slow, rhythmic rate. The patient is instructed to close his eyes and breath slowly and
comfortably. Regular relaxation technique may help combat fatigue and muscle tension that accompany
chronic pain.

6. Guided imagery
Guided imagery is the term used to describe the use of images to improve physiologic status, mental
state, sell-image, or behavior. Relaxation exercises before the use of this approach facilitate the imaging
process. Imagery techniques such as visualizing oneself in a favorite setting-for example, a quiet beach-are
more effective. The nurse instructs the patient to close both eyes and do rhythmic breathing. With each slow
breath, the patient may imagine muscle tension and discomfort being breathe out, carrying pain away. He can
also imagine healing energy flowing to the area of discomfort.

7. Therapeutic touch
A less traditional therapy termed therapeutic touch, may be helpful to patients in pain. The rationale
for the success of therapeutic touch is not clearly under stood. The nurse undergoes a brief period of
meditation before coming in contact with the patient. During this period the nurse quiets his or her internal
energy levels and then touches the patient and transmits the healing energies. Few nurses arc trained in the
use of therapeutic touch as described. It does seem to be helpful for some patients and some kinds of pain
and is gaining respectability as an effective treatment.

8. Ice and Heat therapies

For greatest effect, ice should be placed on the injury site immediately after injury or surgery. It can
significantly reduce the amount of analgesics that may be required subsequently. Ice therapy can also relieve
the pain if applied later after the injury. Remember to protect the skin from DIRECT application of ice and it
should be applied NO longer than 20 minutes a time. This nursing action may prevent the rebound
phenomenon that occurs as the body attempts to warm up rendering the treatment useless. Application of
heat increases blood flow to an area and contributes to pain reduction by SPEEDING healing. It does not
matter if moist heat or dry heat is applied.

PHARMACOLOGIC APPROACHES

Managing a patient’s pain pharmacologically is accomplished in collaboration with the physician or

other primary care provider, the patient and the family. Although the physician and other health care provider
will order for pain medications, it is the nurse who maintains the analgesia, assesses its effectiveness and
reports its effectiveness.
Pre-medication Assessment
 Before administering any medication, the nurse asks the patient about allergies to medications and
the nature of any previous allergic responses. The nurse then obtains previous medication history along with
other health problems.
Approaches For Using Analgesic Agents
Pharmacological therapy involves the use of drugs and other agents like anesthesia in eradicating
pain., There are now sophisticated machines like the PCA pump (patient-controlled analgesia pump) that can
be utilize to allow the patient control of his pain. Drugs can also be administered topically like creams and
local anesthetics; some are injected in the epidural space and others are administered intravenously and
inhalationally.
Two groups of analgesics, as well as adjuvant medications, are important components of effective pain
management. Opioid analgesics (also called narcotics) such as morphine, act mainly on the central nervous
system to alter the perception of pain. Nonopioid analgesics, such as aspirin, block impulses mainly in the
periphery and decrease inflammatory-related pain by inhibiting the synthesis of prostaglandin. For some types
of pain, such as cancer pains, analgesics from both groups are necessary to control pain.

Opioid analgesics
Opioid analgesics are the most effective analgesics for relief of moderate to severe pain. They must be
given around the clock to reach and maintain the steady blood levels necessary for pain relief. Side effects of
opioids vary with the physiologic state of the patient. Constipation is the most common side effect, and
laxatives should be given to any patient receiving opioids on a regular basis. Some experiences nausea and
vomiting; these patients usually respond well to antiemetics. Sedation and drowsiness may occur for the first
48 to 72 hours, but one needs to consider that the patient may be catching up on sleep lost because of pain.
Respiratory depression is rarely a problem with standardized doses and careful titration (slowly increasing the
dose). Naloxone (Narcan) will reverse any depressive effect.

Nonsteroidal anti-inflammatory drugs.

The nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely used analgesics because of
their general lack of serious side effects and their effectiveness in pain relief. They act primarily by inhibition
of prostaglandin synthesis. In low doses, these drugs have analgesic properties: in higher doses, there is anti-
inflammatory action in addition to analgesia. The principal uses of NSAIDs are control of moderate pain of
dysmenorrhea, arthritis and other musculoskeletal disorders, postoperative pain, and migraine headaches.
They may be used for patients with bone cancer.

APPLYING THE NURSING PROCESS IN THE MANAGEMENT OF PATIENTS IN PAIN

ASSESSMENT

The highly subjective nature of pain makes pain assessment and management very
challenging for health-care providers. Pain assessment includes determining what level of pain relief the
acutely ill patient believes is needed to recover quickly or improve function, or what level of relief the
chronically ill patient requires to maintain comfort.
The characteristics of pain include the pain intensity, timing, location, quality, personal meaning,
aggravating/alleviating factors and pain behaviors. A helpful mnemonic may be used –PQRST of pain-
Precipitating factors/Palliating factors, Quality, Radiation/Risk Factors, Severity and Timing of pain.
The pain assessment begins by observing the patient carefully, noting the patient’s over-all posture
and presence or absence of overt pain behaviors and asking the person to describe, in his/her own words,
the specifics of pain. The words to describe pain may point toward the etiology.
Assessing the FIFTH vital sign varies in extent and frequency. It is tailored to the situation of the
client. Post-operative clients initially need to be assessed every 15 minutes then extended to 2-4 hours.
Patients medicated with morphine should be re-assessed in 20-30 minutes. In many instances, nurses
must initiate pain assessments because clients may not verbalize pain. Patient’s trust and his cooperation
are important for nursing care.
The over-all goal of assessment is to gain an OBJECTIVE understanding of the SUBJECTIVE experience
of pain. The two major components of assessment are Pain History to obtain facts from the clients and
Direct Observation of behavioral and physiological responses of the clients. Aside from the PQRST
mnemonics- (P is for precipitating and palliating factors; Q is for quality; R is for region/radiation; S is for
severity; and T is for timing) the other mnemonic is OLD CHART (Onset, Location, Duration,
Characteristics, Aggravating factors, Radiation, and Treatment, whether effective or not)
ASSESSING PAIN HISTORY
Assessing PAIN HISTORY must be individualized. The nurse may focus on previous pain treatment and
effectiveness, prior intake of analgesics, other medications and medication allergies. For chronic pain,
nurses may also focus on the client’s coping mechanisms, current medications and the effect of pain on
their activities of daily living.

ASSESING THE INTENSITY OF PAIN

The SINGLE MOST important indicator of the existence and intensity of pain is the client’s
report of pain. In clinical practice, nurses utilize the pain intensity scale rating scale to obtain an
objective assessment of pain perception. This ranges from none-to mild to severe excruciating
discomfort. This scale provides consistency for nurses to communicate with the client and other health
care provider. Two common scales exist: the 10-point Simple Numeric intensity scale (with 0 zero as
the “no pain” and 10 as the “worst pain”) and the 5-point Wong –Baker FACES rating scale (The pain
scale especially suited for children, where the y are instructed to point to the faces as to how they feel
inside not how their faces look). The pain intensity is influenced by pain threshold and pain tolerance.
Recall that pain threshold is the smallest stimulus for which a person reports pain and pain tolerance
is the maximum amount of pain a person can tolerate.

ASSESSING PAIN LOCATION

Nurses can ask the individual to point tot eh site of discomfort. A drawing of the body can
assist in identifying the pain especially among children. Descriptive terms must be used in the
documentation like proximal, distal, medial, lateral and diffuse.

Assessment of a client who is experiencing pain includes:

A. Comprehensive pain history (McGill-Melzack Pain Questionnaire):
 Location
 Intensity (pain intensity scale, the Wong/Baker Faces Rating Scale)
 Quality
 Pattern
 Precipitating factors
 Associated symptoms
 Effect on activities of daily living (scale 1 to 10)
 Past pain experiences
 Meaning of pain
 Coping resources
 Affective Responses
B. Daily pain diary
C. Physical examination focusing on autonomic nervous system responses and behavioral responses.
“Because pain is a subjective phenomenon, pain assessment is complex in process; however, tools are
available to assist the nurse in this matter.”

GUIDELINES FOR ASSESSMENT OF THE PATIENT WITH PAIN

1. Assess the characteristics of the patient’s pain

A. Severity of pain
B. Quality, location, duration, and rhythmicity of pain
C. Tolerance for pain
D. Harmful effects of pain on patient’s recovery
E. Strategies that patients believe will help relieve pain
F. Concerns the patient has about his pain
2. Assess the patient’s behavioral responses to the pain experience
A. Determine if the pain is acute or chronic
B. Observe for the following behavioral responses
(1) Physiologic manifestations (changes in pulse, blood pressure, respiratory rate, etc.)
(2) Verbal statements
(3) Vocal responses
(4) Facial expressions
(5) Body movements
 (6) Alteration in response to the environment
(7) Physical contact with others
(8) Adaptation of physiologic or behavioral responses
(9) Effect of pain on ability to communicate and carry out usual activities of daily living
3. Assess factors that influence responses to pain
A. Ethnic and cultural factors
B. Previous pain experiences
C. Meaning of the pain experience
D. Patient’s responses to pain relief strategies

DIAGNOSIS

Although nursing diagnosis given to clients suffering pain is pain or chronic pain, the pain itself may be the
etiology of the many other nursing diagnoses.

Planning:

Overall client goals include preventing, modifying or eliminating pain so that the client is able partially or
completely to resume usual daily activities and to cope more effectively with the pain experience.

When planning, nurses need to choose pain relief measures appropriate for the client. Nursing interventions
may include a variety of pharmacological and non-pharmacological interventions, selecting several strategies
from both broad categories is usually most effective.

Scheduling measures to prevent pain is far more supportive of the client than trying to deal with pain once the
client perceives it.

IMPLEMENTING

Pain management includes two basic nursing interventions: pharmacological and non-pharmacological
measures

Major nursing functions for all clients are:

A. To acknowledge and convey belief in the client’s pain
B. To assist support persons
C. To reduce misconceptions about pain
D. To reduce fear and anxiety associated with the pain

 Pharmacological interventions, ordered by the physician, include the use of opioids, nonopioids/NSAIDS
and adjuvant drugs

 The nurse assesses the client’s pain needs, administers the ordered analgesics and evaluates the client’s
response to analgesics provided.

 Analgesic medication can be delivered in several ways to meet the specific needs of individuals. More
recent methods include long acting and liquid morphine, transdermal preparations, continuous intravenous
infusions and intraspinal infusion

 Patient-controlled analgesia (PCA) enables the client to exercise control the minimize feelings of
helplessness

 Physical nonpharmacologic pain interventions include cutaneous stimulation, hot and cold applications,
massage, acupressure, contralateral stimulation, transcutaneous electrical nerve stimulations (tens); and
acupuncture.

 Nurses can also promote hygiene and comfort. Bed bath, warm or cold shower, Bed rest, clean bed
sheets, frequent repositioning and oral/skin care are very important relief measures
 Nurses can also teach anticipatory guidance. The nurse can teach the post-operative patients how to
minimize surgical pain like splinting the incision with pillow, positioning techniques, and pre-medication
before activities.

 Cognitive-behavioral interventions include distraction techniques; relaxation techniques guided imagery,

biofeedback, therapeutic touch and hypnosis

EVALUATION

Evaluation of the client’s pain therapy includes;

A. The response of the client
B. The changes in the pain
C. The client’s perceptions of the effectiveness of the therapy
Ongoing verbal or written feedback from the client and family is integral to this process

IN SUMMARY
 Pain is a subjective experience that is whatever the patient says it is and occurs whenever the patient
says it occurs
 Although pain is a source of human misery, it minimizes injury and warns of disease
 All pain relief measures are based on a thorough ongoing nursing assessment
 Establishing rapport between the nurse and the patient enhances the effectiveness of pain relief
measures
 Sedation does not always indicate pain relief
 Because patients may not always report pain, the nurse must assess them regularly
 Patients of all ages experience pain, but the way they express pain differs with age
 The nurse should be able to recognize physiologic, psychological and non-verbal ways of expressing
pain
 Lack of pain expressions does not always mean lack of pain
 Non-invasive pain relief measures can increase the effectiveness of pharmacological or invasive
methods
 The nurse’s optimistic attitude about expected pain relief helps produce a positive result
 Educating the patient and family about pain reduces the anticipatory fear and anxiety, thereby
increasing the patient’s tolerance
 Using a preventive approach for pain relief is more beneficial than waiting until pain becomes severe
 Intramuscular and intravenous routes are utilized for severe pain and the intramuscular for moderate
pain and oral for mild pain
 The nurse must utilize the nursing process in relieving patient of “painful experiences”