Chapter011

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Chapter 11: Pain Management


Types of PainTypes of Pain• Introduction

– Classification

• Source

• Onset, intensity, and duration

– Further classification: Acute or chronic

• Nociceptive Pain

– Noxious stimuli transmitted from point of cellular injury through pathways to the cerebral cortex of the brain

– Subdivided into somatic and visceral


Types of PainTypes of Pain• Nociceptive Pain

– Somatic pain

• Causes: Mechanical, chemical, thermal, or electrical injuries or disorders

• Affects bones, joints, muscles, skin, or other structures composed of connective tissue

• Types: Superficial somatic pain, also known as cutaneous pain; deeper somatic pain from trauma


Types of PainTypes of Pain

• Nociceptive Pain

– Visceral pain

• Diseased or injured heart, kidneys, and intestine

• Causes: Ischemia, organ compression, intestinal distention with gas or contraction

– Referred pain

• Discomfort perceived in a general area of the body


Types of PainTypes of Pain• Nociceptive Pain

Figure 11-2 Common areas of referred pain


Types of PainTypes of Pain• Neuropathic Pain

– Damaged

• Pain pathways in peripheral nerves

• Pain processing centers in the brain

– Cause of nerve damage: Drugs or radiation used to treat cancerous tumor

• Acute Pain

– Discomfort that has a short duration

• Tissue trauma

• Physical and emotional distress


Types of PainTypes of Pain• Chronic Pain

– Discomfort that lasts longer than six months

– Longer pain periods: More far-reaching effects on the sufferer

– Negative reactions of others to chronic pain sufferer


QuestionQuestionIs the following statement true or false?

Pain is always located in the organ of the body in which it is generated.


AnswerAnswerFalse.

Referred pain is discomfort that is perceived in a general area of the body but not in the exact site where an organ is located.


Pain TransmissionPain Transmission

• Four Phases

– Transduction

• Chemical information in the cellular environment is converted to electrical impulses that move toward the spinal cord; release of chemical mediators

• Chemicals that are released by the damaged cells stimulate nociceptors

• Impulses transmitted by the fast pain pathway; person withdraws from the pain-provoking stimulus


Pain TransmissionPain Transmission

• Four Phases

– Transmission

• Peripheral nerve fibers form synapses with neurons in the spinal cord

• Pain impulses move from spinal cord to brain; impulses ascend finally to the cerebral cortex

– Perception

• Phase of impulse transmission: brain experiences pain at a conscious level; brain structures in the pain pathway


Pain TransmissionPain Transmission• Four Phases

– Perception (cont’d)

• Pain perception: Conscious experience of discomfort

• Pain threshold: Point at which pain-transmitting neurochemicals reach the brain, causing conscious awareness

• Pain tolerance: Amount of pain a person endures once the threshold has been reached; influenced by gender, age, and culture


Pain TransmissionPain Transmission• Four Phases

− Modulation

• Phase during which the brain interacts with the spinal nerves to alter the pain

• Pain sensation reduced

• Release of pain-inhibiting neurochemicals

Figure 11-3 The phases of pain transmission


Pain AssessmentPain Assessment• Introduction

– Client’s description of pain onset, quality, intensity, location, and duration

– Assessment for accompanying symptoms

– Should be treated as the fifth vital sign

– Assessment biases

• Client: Only reliable source for quantifying pain

• Nurses: Not consistent in responding to the client’s description of pain intensity


Pain AssessmentPain Assessment– Assessment biases (cont’d)

• Pain undertreated if the client’s expressions are incongruent with the nurse’s expectations

• Assessment Tools

– Numeric scale, word scale, and linear scale

– Wong–Baker FACES scale: Best for pediatric, culturally diverse, and mentally challenged clients


QuestionQuestionIs the following statement true or false?

Pain is exactly as the client describes it.


AnswerAnswerTrue.

Margo McCaffery, a nursing expert on pain, states, “Pain is whatever the person says it is, and exists whenever the person says it does” (McCaffery & Beebe, 1989).


Pain AssessmentPain Assessment• Assessment Standards

– Joint Commission standards related to pain management

– Aspects incorporated in the Joint Commission standards

Figure 11-4 Pain assessment tools: (A) Word scale, (B) Numeric scale, (C) Linear scale


Pain ManagementPain Management• Introduction

– Techniques used to prevent, reduce, or relieve pain

– Five techniques for achieving pain management

• Drug Therapy

– WHO: Three-tiered approach

– Cancer pain: Analgesics administered intrathecally, and electrical stimulation in the spinal cord


Pain ManagementPain Management• Drug Therapy

– Neurosurgical analgesic techniques

– Opioid and opiate analgesics

– Nonopioid analgesics



– Methods of administration

• Analgesic drugs: Oral, rectal, transdermal, or parenteral

• Equianalgesic dose: Change from a parenteral

to an oral route

• Patient-controlled analgesia

• Self-administration of narcotic analgesic

• Intravenous pump system



– Methods of administration (cont’d)

• Intraspinal analgesia

• Infusion of narcotic or local anesthetic into the subarachnoid or epidural space of the spinal cord

• Relieves pain with minimal systemic drug effects

• Nurses do not administer intraspinal analgesia


Pain ManagementPain Management

• Drug Therapy

– Addiction, tolerance, physical dependence

• Addiction: A repetitive pattern of drug use to satisfy a craving for a drug’s mind-altering or mood-altering effects; fear of addiction affects use of medication

• Tolerance: A condition in which a client needs larger doses of a drug to achieve the same effect



– Physical dependence: Physical discomfort, withdrawal symptoms; experienced when drug taken routinely is discontinued abruptly

– Adjuvant drug therapy

• Medications ordinarily administered for reasons other than treating pain

• Effects of combining adjuvant drugs with opioid and nonopioid analgesics



• Nondrug Interventions

– Heat and cold applications, transcutaneous and percutaneous electrical nerve stimulation, acupuncture, and acupressure

– Used for clients with chronic pain

– Body releases neurotransmitters: Calm the body and promote emotional well-being

– Release of endogenous opiates: Help relieve pain

– Modulation of pain transmission


Pain ManagementPain Management• Nondrug Interventions

– Heat and cold

• Reduces localized swelling; decreases vasodilation; used for minor or moderate pain

• Ice bag or chemical pack

Figure 11-8 Action of endogenous opiates



– Transcutaneous electrical nerve stimulation (TENS)

• Delivers bursts of electricity to the skin and underlying nerves

• Acute and chronic pain

• Change in placement sites

• Intensity of electrical current

• Rate of electrical bursts and duration according to the client’s response



• Nondrug Interventions

– Acupuncture and acupressure

• Temporary relief: Repeat treatments

• Long treatment: Thin needles are inserted into the skin

• Acupressure uses tissue compression, rather than needles, to reduce pain



– Percutaneous electrical nerve stimulation

• Combines the use of acupuncture needles with TENS

• Administered for 30 minutes three times a week for a total of three weeks

• Successful in research trials on clients with low back pain, pain caused by the spread of cancer to bones, shingles, neuropathic pain, and migraine


QuestionQuestion

Is the following statement true or false?

A nurse has several nondrug pain management techniques available to make pain management more effective.


AnswerAnswer

True.

Several nondrug interventions can be used to help manage pain. Some, such as applications of heat and cold, are independent nursing measures or may require collaboration with the client’s physician.



– Other noninvasive techniques

• Imagery, biofeedback, humor, breathing exercises and progressive relaxation, distraction, and hypnosis

• Spinal Surgery Techniques

– Relieves intractable pain

– Rhizotomy

• Spinal surgery involves a laminectomy


Pain ManagementPain Management• Spinal Surgery Techniques

– Rhizotomy (cont’d)

• Sectioning of the posterior nerve root

• Permanent loss of sensation

• Reserved for terminally ill clients

– Cordotomy

• Interruption of pain pathways in the spinal cord

• Less risk; better tolerated by terminally ill clients


Pain ManagementPain Management• Nursing Management

– Collaboration with patient and physician

– Nursing interventions for pain management

– Monitor and manage drug side effects: Constipation, injury, nutrition, sleep

– Client teaching

• Available pain management techniques

• Self-administration of analgesics

• Prescribed analgesics

• Nutritional


End of Presentation

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