1. Part I
Nursing 53A
Judith Ontiveros, RN, MSN, CPAN

2. Objectives
• Describe the physiological mechanism involved in the pain experience.
• Compare and contrast the different types of pain and their significance.
• Discuss some of the general assumptions about the pain experience.
• List seven components of accurate pain assessment
• Review the different types of pain management techniques.
• Focus on nursing responsibilities associated with the pharmacological
therapy of the pain experience.

3. Definitions of Pain
“an unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.”
American Pain Society
(APS, 2003; Gordon, 2002.)

4. Definitions of Pain
• Pain, classified as acute consists of a
sudden feeling of discomfort that can
develop from many sources, such as an
acute illness, surgery, trauma, invasive
equipment, nursing and medical
interventions and immobility. If pain is
inadequately treated it can lead to the
development of chronic pain (Mc Caffrey,
Frock, & Garguilo, 2003).

5. Definitions of Pain
“Pain is an emergency!”
•Melanie Simpson, RN, BA, BSN
•OCN Cancer Institute of Kansas University
“Pain is whatever the person
experiencing it says it is, existing
whenever he says it does.”
(Margo McCaffery, 1979)

6. Summarization
• Pain:
actual physical sensation of discomfort
• Suffering:
unpleasant emotional response to pain
Pain is a very subjective and
highly individualized
experience

7. Implications for Nursing
• Physical and emotional experience Not all body,
not all soul!
• In response to actual or potential tissue
damage.
• Pain is described in terms of such damage.
Some won’t divulge pain
unless assessed or asked
about. Assess in other
ways… nonverbal, etc.

8. Implications for Nursing
• Nearly 1/3 of Americans will experience chronic
pain at some point in their lives.
– Joint Commission (Accreditation of Healthcare Organizations)
• Approximately 50 million with chronic pain
• #1 cause of adult disability in the US
• In younger people (18-34)
– 82% experience grumpiness or irritable behavior as a
result of their chronic pain

9. Implications for Nursing
• Women affected more emotionally by their
pain than men
– 70 % suffer with stress
– 55 % with loss of motivation
• a study by the Cleveland Clinic
• 3/10 men (28%) experience less desire for sex
due to chronic pain
• Costs are an estimated $100 billion in lost
productivity every year
– major cause of absenteeism

10. Implications for Nursing
• Affects all body systems
– Results in serious health issues
– Increases risks of complications
– Delays healing
– Accelerates progression of fatal illnesses
• Changes to nervous system can result in
incurable chronic pain.
• Question whether life is worth going on

11. Implications for Nursing
• More than a symptom of a problem
• Becomes a HIGH priority problem of its
own entity.
– Physiologic and psychologic dangers
Severe Pain = Emergency Situation
Deserves prompt, professional treatment

12. Components of the Pain
Experience
• Pain is a protective mechanism
• Complex biopsychosocial phenomena
• May or may not
– have a cause
– respond to interventions

13. Components of the Pain
Experience
• Reception:
– sensation through pain receptors of the
nervous system
• Perception:
– conscious mental recognition or registration of
a sensory stimulus
• Reaction:
– the response a person takes after identifying
the sensation

14. Reception

15. Nociception
• Physiologic process related to pain
perception
– React to mechanical, thermal, or chemical stimuli
– Potential or real tissue damage
• Four physiologic processes
– Transduction
– Transmission
– Perception
– Modulation

16. Transduction
• Nociceptors excited by stimuli
• Noxious stimuli triggers release of
biochemical mediators
– Prostaglandins
– Bradykinin
– Serotonin
– Histamine
– Substance P
• Movement across cell membrane
• Pain Medications effective at this stage
– Blocks Prostaglandins

17. Figure 46-2 Substance P assists the transmission of impulses
Figure 46-2 Substance P assists the transmission of impulses
across the synapse from the primary afferent neuron
across the synapse from the primary afferent neuron
 second-order neuron in the spinothalamic tract
 second-order neuron in the spinothalamic tract

18. Transmission of Pain Impulses
• 3 segments
1. Impulse travels from peripheral nerve to
spinal cord
• Substance P – neurotransmitter across synapse
– Unmyelinated C fibers – dull aching pain
– Thin A-delta fibers – sharp localized pain
• Local medications work here to block impulses

19. Transmission of Pain
2. Transmission from spinal cord and
ascension
– Spinothalamic tracts
– To brain stem and thalamus
• Opioids block release of neurotransmitters
3. Signals to thalamus to somatic sensory
cortex
– Pain perception

20. Figure 46-3
Physiology of
Pain Perception

21. Perception
• Conscious of pain
– Complex activity in CNS
– Pyschosocial and meaning of pain to each
individual shape the responses

22. Modulation
• Descending System
– Neurons in thalamus and brain stem send
signals back to dorsal horn of spinal cord
– Neurons in thalamus and brain stem send
signals back down to dorsal horn
• Descending fibers release endogenous opioid,
serotonin, and norepinephrine
• Inhibits noxious impulses (short-lived)
• Amino Acids and excitatory glial cells facilitate pain
signals
– Tricyclic antidepressants help block uptake of
NE and serotonin

23. Question
• A nurse is evaluating a nursing student’s
understanding of transcultural differences in
responses to pain. Which of the following actions
demonstrates a need for further teaching?
– The African American culture believes pain and suffering is a part of
life and is to be endured
– The Mexican American culture believes that enduring pain is a sign
of strength (but they still tend to be loud in expressing pain)
– The Asian American culture tends to be loud and outspoken in
expressions of pain - FALSE
– Native Americans are quiet, less expressive verbally and
nonverbally, and may tolerate a high level of pain

24. Gate Control Schematic
Small diameter (a-delta or C)
peripheral nerve fibers carry
signals of noxious stimuli to the
dorsal horn
Ion channels on the pre- and
postsynaptic membranes serve
as gates
When open, permit positively
charged ions to rush into the
second order neurons, sparking
an electrical impulse and
sending signals of pain to the
thalamus

25. Gate Theory
Large diameter (A-delta)
fibers have inhibitor
effect
May activate descending
mechanism that can
inhibit transmission of
pain

27. Clinical Application of
Gate Control Theory
• Stop nociceptor firing
• Apply topical therapies
• Address client’s mood
• Address client’s goals

28. Factors Affecting Pain
• Ethnic and Cultural Values
– Affects reaction and expression of pain
– Behavior = socialization process
• Developmental Stage
• Environment and Support People
• Past Pain Experiences

29. Factors Affecting Pain
• Meaning of Pain
– Positive outcomes - temporary inconveniences
– Chronic pain – suffer intensely
– Despair, anxiety, depression
– Threat to body image, lifestyle, impending
death
• Anxiety and Stress
• Social and Spiritual Influences

30. Types of Pain
• Acute Pain
– Lasting only through recovery period
– Can be sudden or slow onset
• Chronic Pain
– Prolonged, recurring, persisting over six
months
– Interferes with functioning
– Chronic malignant pain
• Associated with life threatening illness

32. Types of Pain
• Chronic malignant pain
– Associated with life threatening illness
• Chronic non-malignant Pain
– Non-life-threatening
– Not responsive to current therapies
– May continue for patient’s life time

33. Chronic non-malignant Pain
• Phantom Limb Pain
– Occurs after amputation
– Pain sensations referred to missing area
• Myofascial pain syndromes
– Group of muscles disorders
– Pain, muscle spasm, tenderness, stiffness,
limited motion
• Pain severe enough to disable patient
– Chronic intractable non-malignant pain
syndrome

34. Types of Pain
• Neuralgia
– Paroxysmal pain along course of one or
more nerves
– Low back pain
– Rheumatoid arthritis
– Ankylosing spondylitis
• Flattening of vert…?

35. Types of Pain
• Radiating Pain
– Perceived at source of pain
– Extends to nearby tissues
– Example: Cardiac pain to left arm
• Referred Pain
– Felt in part of body removed (separate) from
tissues causing pain (nerve piggy backs)
– Example: Gallbladder-upper back, chest

36. Figure 46-1 Common sites of referred pain from
various body organs

37. Categories of Pain
• Cutaneous
– Originates in skin or subcutaneous tissue
• Paper cut
• Sharp and burning
• Deep somatic
– Ligaments, tendons, bones, blood vessels,
nerves
– Diffuse
– Last longer than cutaneous
• Sprain

38. Categories of Pain
• Visceral Pain
– Stimulation of pain receptors in abdominal
cavity, cranium, thorax
– Diffuse
– Burning, aching, or feeling of pressure
– Caused by stretching of tissues, ischemia,
muscle spasms
– Bowel obstruction

39. Concepts of Pain
• Pain Threshold
– Least amount of pain stimulation a person
requires in order to feel pain
– Generally uniform in one person
– Pain Sensation
• used interchangeably with threshold
– Related to age, gender, or race

40. Concepts of Pain
• Pain Reaction
– Autonomic nervous system
• Withdrawal of hand from fire
– Behavioral responses to pain
• Method of coping with pain - learned

41. Concepts of Pain
• Pain Tolerance
– Maximum amount and duration of pain an
individual is willing to endure
– Varies greatly
– Influenced by psychological and sociocultural
factors
– Increases with age

42. Abnormal Pain Conditions
• Hyperalgesia / Hyperpathia
– Heightened response to painful stimuli
• Severe reaction to paper cut
• Allodynia
– Nonpainful stimuli produces pain
• Sheets
• Dysesthesia
– Unpleasant abnormal sensation
– Mimics neuropathy (spinal cord injury)

43. Physiological Indications of
Acute Pain
• Dilated pupils
• Increased perspiration
• Increased rate/ force of heart rate
• Increased rate/depth of respirations
• Increased blood pressure
• Increased basal metabolic rate
• Decreased urine output
• Decreased peristalsis of GI tract

44. Total Pain Management
Four aspects must be addressed:
1. Physical
2. Psychological (help them calm down, allow meds to work)
3. Social
4. Spiritual
Last 3 can be met only after pain and
related symptoms (e.g., N/V, anxiety)
are controlled.

46. Assessment
• Subjective Data
• Gathering subjective information
• Pain threshold
• Pain
• Examine pain qualifiers
• Subjective reports are considered primary
source of data collection

47. Nurse’s Role
Patient Advocate
• Pain Assessment
– Crucial Nursing Function
• Conduct self-assessment about pain
– Values and expectations about pain behaviors
– Avoid biases when assessing
– JCAHO – Pain is 5th vital sign – 2000
– Subjective Data
• Gathering subjective information
– Pain threshold
– Pain
• Examine pain qualifiers
• Subjective reports are considered primary source of data
collection

48. Nurse’s Role
Patient Advocate
• Planning
– Mutual goal setting with patient
– Nonpharmacologic and pharmacologic
interventions
– Several approaches combined
– Multidisciplinary approach
• Preventive Approach
– Treatment in mild pain or if anticipated
*Addiction is of less concern with acute pain than with chronic pain.

49. Nurse’s Role
Patient Advocate
• Implementation
– Nonpharmacologic interventions for mild pain
– Pharmacologic for moderate to severe
• Nonpharmacologic used as adjuncts
• Mainstay for treatment of pain
• Responsibilities of administration
– Determine to give, which one
– Assess response to analgesia
– Report when a change is needed
– Teach regarding use of medications