NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
Chapter 4
Assessment and Care of Patients with Pain
Concepts
• The priority concept in this chapter is comfort
• The interrelated concepts in this chapter are cognition sensory Perception
Pain The Scope of the Problem
• Pain is a major economic problem and a leading cause of disability that changes the lives
of many people, especially older adults.
• Chronic non-cancer pain such as osteoarthritis, rheumatoid arthritis, and diabetic
neuropathy is the most common cause of long-term disability, affecting millions of
Americans and others throughout the world.
• Universal, complex personal experience
• Is an impairment in comfort; major economic concern; leading cause of disability
• Failure to manage pain is a worldwide health problem
• Inter-professional pain initiatives help patients receive best treatment
Definitions of Pain
• Unpleasant sensory and emotional experience associated with actual or potential tissue
damage
• Whatever person experiencing it says it is; exists whenever person says it does
• Self-report always most reliable indication of pain
Categorization of Pain by Duration
• Acute pain
- Short-lived
- Results from sudden, accidental trauma; surgery; ischemia; acute inflammation
• Chronic (persistent) pain
- Can last a person‘s lifetime
- Chronic cancer pain
- Chronic non-cancer pain
• Pain is treated inadequately in almost all health care settings.
• Populations at the highest risk in medical-surgical nursing are older adults, patients with
substance use disorder, and those whose primary language differs from that of the health
care professional.
• Older adults in nursing homes are at especially high risk because many residents are unable
to report their pain. In addition, there often is a lack of staff members who have been
educated to manage pain in the older-adult population.
Acute Pain
• Acts as warning sign
• Activation of sympathetic nervous system
• ―Fight-or-flight‖ reactions
- Increased vital signs
- Sweating
- Dilated pupils
- Restlessness
- Apprehension
- Distress of varying degrees
,NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
Acute Pain (Cont.)
• Absence of physiologic and behavioral responses does not mean absence of pain
• Usually temporary with sudden onset, and easily localized
• Sensory perception of pain changes as injured area heals
Chronic (Persistent) Pain
• Lasts or recurs for indefinite period (more than 3 months)
• Gradual onset
• Character and quality often change over time
• Serves no biological purpose
• Can result in emotional, financial, and relationship burdens, as well as
depression/hopelessness
Chronic Cancer Pain
• Usually result of tumor growth, nerve compression, tissue invasion, metastasis
• Cancer treatment can also cause acute pain (e.g., procedures, surgery, toxicities from
chemo and radiation)
Chronic Non-Cancer Pain
• Global health issue for people > 65 years old
• Formerly called chronic nonmalignant pain
• Neck, shoulder, low back
• Over half of veterans of recent wars have this condition
- Can cause depression, decreased sense of well-being
Categorization of Pain by Underlying Mechanisms
• Nociceptive pain
- Somatic
- Visceral
• Neuropathic pain
Pain Transmission
• Painful stimuli often originate in extremities
• If pain is not transmitted to the brain, person feels no pain
• Two specific fibers transmit periphery pain:
- A delta fibers
- C fibers
Assessment: Noticing
• Patient‘s self-report is ―gold standard‖ for assessment
• Nurse‘s role
- Accept patient self-report
- Serve as advocate
- Act promptly to relieve pain
- Respect patient values and preferences
Pain Assessment (Cont.)
• Location
• Intensity
• Quality
• Onset and duration
• Aggravating and relieving factors
• Effect of pain on function and quality of life
,NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
• Comfort-function outcomes
• Other information
Psychosocial Assessment
• Pain holds unique meaning for the person experiencing it.
• Remain objective; advocate for proper pain control
• Refer to resources such as ―10-Step Program from Patient to Person‖ (as needed)
Assessment Challenges
• Patients who cannot self-report pain are at higher risk for under-treated pain
- Hierarchy of Pain Measures
- Checklist of Nonverbal Pain Indicators (CNPI)
- Pain Assessment in Advanced Dementia Scale (PAINAD)
Different Pain Types
• Localized pain is confined to the site of origin.
• Projected pain is diffuse around the site of origin and is not well localized.
• Referred pain is felt in an area distant from the site of painful stimuli.
• Radiating pain is felt along a specific nerve or nerves.
• Intensity: Ask the patient to rate the severity of the pain using a reliable and valid
assessment tool.
• Various self-report scales have been developed to help patients communicate pain
intensity.
Teaching how to respond to a pain scale
• Text book Table 4-4
Analgesic Groups
• Non-opioid analgesics
- Acetaminophen
- NSAIDs
Non-opioid Analgesics
• Monitor patients taking acetaminophen for hepatotoxicity
• Reduced daily dose may be appropriate for older adults on long-term therapy
• Monitor patients taking NSAIDS for gastric side effects
• NSAIDS carry risk for cardiovascular and renal adverse effects through prostaglandin
inhibition
Analgesics by Classification: Opioid Analgesics
• Full or mu agonists
- Morphine, fentanyl, hydromorphone, oxycodone, oxycodone, hydrocodone
• Mixed agonists antagonists
- Butorphanol, nalbuphine
• Partial agonists
- Buprenorphine
Drug Formulation Terminology
• Short acting, fast acting, immediate release (IR), normal release
- Onset in about 30 minutes; short duration of 3 to 4 hours
• Modified-release, extended release (ER), sustained release (SR), controlled release (CR)
- Release over a prolonged period
- Never crush, break, or have patients chew!
Selected Opioid Analgesics
, NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
• Morphine
• Fentanyl
- Teach patients to refrain from applying heat to patches
• Hydromorphone
• Oxycodone
• Hydrocodone
• Methadone
Dual Mechanism Analgesics
• Tramadol (Ultram)
• Tapentadol (Nucynta)
Opioids to Avoid
• Meperidine
• Codeine
Intraspinal Analgesia
• Analgesic administration via a needle or catheter in the epidural or intrathecal space
• Placed by an anesthesia provider
• Side effects depend on drug administered
• Complications are rare but can be life-threatening
Adverse Effects of Opioid Analgesics
• Constipation
• Nausea
• Vomiting
• Pruritus
• Sedation
• Respiratory depression (less common, yet most concerning)
Adjuvant (Co-Analgesic) Analgesics
• Anticonvulsants and antidepressants
- Gabapentin
- Imipramine (Tofranil)
- Clomipramine (Anafranil)
- Doxepin
• Local anesthetics
- Lidocaine
Use of Placebos
• Any medication or procedure (including surgery) which produces an effect because of its
intent
• Used as control in research
• Any other use has ethical and legal implications; violates nurse–patient relationship;
deprives patient of appropriate assessment
Nonpharmacologic Management
• Appropriate for mild- and some moderate-intensity pain
• Should complement, not replace, pharmacologic therapies for more severe pain
- Physical modalities
- Cognitive-behavioral strategies
Physical Interventions (Examples)
• Physical therapy
College
Chapter 4
Assessment and Care of Patients with Pain
Concepts
• The priority concept in this chapter is comfort
• The interrelated concepts in this chapter are cognition sensory Perception
Pain The Scope of the Problem
• Pain is a major economic problem and a leading cause of disability that changes the lives
of many people, especially older adults.
• Chronic non-cancer pain such as osteoarthritis, rheumatoid arthritis, and diabetic
neuropathy is the most common cause of long-term disability, affecting millions of
Americans and others throughout the world.
• Universal, complex personal experience
• Is an impairment in comfort; major economic concern; leading cause of disability
• Failure to manage pain is a worldwide health problem
• Inter-professional pain initiatives help patients receive best treatment
Definitions of Pain
• Unpleasant sensory and emotional experience associated with actual or potential tissue
damage
• Whatever person experiencing it says it is; exists whenever person says it does
• Self-report always most reliable indication of pain
Categorization of Pain by Duration
• Acute pain
- Short-lived
- Results from sudden, accidental trauma; surgery; ischemia; acute inflammation
• Chronic (persistent) pain
- Can last a person‘s lifetime
- Chronic cancer pain
- Chronic non-cancer pain
• Pain is treated inadequately in almost all health care settings.
• Populations at the highest risk in medical-surgical nursing are older adults, patients with
substance use disorder, and those whose primary language differs from that of the health
care professional.
• Older adults in nursing homes are at especially high risk because many residents are unable
to report their pain. In addition, there often is a lack of staff members who have been
educated to manage pain in the older-adult population.
Acute Pain
• Acts as warning sign
• Activation of sympathetic nervous system
• ―Fight-or-flight‖ reactions
- Increased vital signs
- Sweating
- Dilated pupils
- Restlessness
- Apprehension
- Distress of varying degrees
,NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
Acute Pain (Cont.)
• Absence of physiologic and behavioral responses does not mean absence of pain
• Usually temporary with sudden onset, and easily localized
• Sensory perception of pain changes as injured area heals
Chronic (Persistent) Pain
• Lasts or recurs for indefinite period (more than 3 months)
• Gradual onset
• Character and quality often change over time
• Serves no biological purpose
• Can result in emotional, financial, and relationship burdens, as well as
depression/hopelessness
Chronic Cancer Pain
• Usually result of tumor growth, nerve compression, tissue invasion, metastasis
• Cancer treatment can also cause acute pain (e.g., procedures, surgery, toxicities from
chemo and radiation)
Chronic Non-Cancer Pain
• Global health issue for people > 65 years old
• Formerly called chronic nonmalignant pain
• Neck, shoulder, low back
• Over half of veterans of recent wars have this condition
- Can cause depression, decreased sense of well-being
Categorization of Pain by Underlying Mechanisms
• Nociceptive pain
- Somatic
- Visceral
• Neuropathic pain
Pain Transmission
• Painful stimuli often originate in extremities
• If pain is not transmitted to the brain, person feels no pain
• Two specific fibers transmit periphery pain:
- A delta fibers
- C fibers
Assessment: Noticing
• Patient‘s self-report is ―gold standard‖ for assessment
• Nurse‘s role
- Accept patient self-report
- Serve as advocate
- Act promptly to relieve pain
- Respect patient values and preferences
Pain Assessment (Cont.)
• Location
• Intensity
• Quality
• Onset and duration
• Aggravating and relieving factors
• Effect of pain on function and quality of life
,NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
• Comfort-function outcomes
• Other information
Psychosocial Assessment
• Pain holds unique meaning for the person experiencing it.
• Remain objective; advocate for proper pain control
• Refer to resources such as ―10-Step Program from Patient to Person‖ (as needed)
Assessment Challenges
• Patients who cannot self-report pain are at higher risk for under-treated pain
- Hierarchy of Pain Measures
- Checklist of Nonverbal Pain Indicators (CNPI)
- Pain Assessment in Advanced Dementia Scale (PAINAD)
Different Pain Types
• Localized pain is confined to the site of origin.
• Projected pain is diffuse around the site of origin and is not well localized.
• Referred pain is felt in an area distant from the site of painful stimuli.
• Radiating pain is felt along a specific nerve or nerves.
• Intensity: Ask the patient to rate the severity of the pain using a reliable and valid
assessment tool.
• Various self-report scales have been developed to help patients communicate pain
intensity.
Teaching how to respond to a pain scale
• Text book Table 4-4
Analgesic Groups
• Non-opioid analgesics
- Acetaminophen
- NSAIDs
Non-opioid Analgesics
• Monitor patients taking acetaminophen for hepatotoxicity
• Reduced daily dose may be appropriate for older adults on long-term therapy
• Monitor patients taking NSAIDS for gastric side effects
• NSAIDS carry risk for cardiovascular and renal adverse effects through prostaglandin
inhibition
Analgesics by Classification: Opioid Analgesics
• Full or mu agonists
- Morphine, fentanyl, hydromorphone, oxycodone, oxycodone, hydrocodone
• Mixed agonists antagonists
- Butorphanol, nalbuphine
• Partial agonists
- Buprenorphine
Drug Formulation Terminology
• Short acting, fast acting, immediate release (IR), normal release
- Onset in about 30 minutes; short duration of 3 to 4 hours
• Modified-release, extended release (ER), sustained release (SR), controlled release (CR)
- Release over a prolonged period
- Never crush, break, or have patients chew!
Selected Opioid Analgesics
, NUR 2392 / NUR2392: Multidimensional Care II / MDC 2 Exam 2 (2021/2022) Rasmussen
College
• Morphine
• Fentanyl
- Teach patients to refrain from applying heat to patches
• Hydromorphone
• Oxycodone
• Hydrocodone
• Methadone
Dual Mechanism Analgesics
• Tramadol (Ultram)
• Tapentadol (Nucynta)
Opioids to Avoid
• Meperidine
• Codeine
Intraspinal Analgesia
• Analgesic administration via a needle or catheter in the epidural or intrathecal space
• Placed by an anesthesia provider
• Side effects depend on drug administered
• Complications are rare but can be life-threatening
Adverse Effects of Opioid Analgesics
• Constipation
• Nausea
• Vomiting
• Pruritus
• Sedation
• Respiratory depression (less common, yet most concerning)
Adjuvant (Co-Analgesic) Analgesics
• Anticonvulsants and antidepressants
- Gabapentin
- Imipramine (Tofranil)
- Clomipramine (Anafranil)
- Doxepin
• Local anesthetics
- Lidocaine
Use of Placebos
• Any medication or procedure (including surgery) which produces an effect because of its
intent
• Used as control in research
• Any other use has ethical and legal implications; violates nurse–patient relationship;
deprives patient of appropriate assessment
Nonpharmacologic Management
• Appropriate for mild- and some moderate-intensity pain
• Should complement, not replace, pharmacologic therapies for more severe pain
- Physical modalities
- Cognitive-behavioral strategies
Physical Interventions (Examples)
• Physical therapy
