Chapter 10: Pain
Pain is defined as whatever the person experiencing the pain says it is, existing whenever the
person says it does.
Untreated pain can result in unnecessary suffering, physical and psychosocial dysfunction,
impaired recovery from acute illness and surgery, immunosuppression, and sleep disturbances.
Inadequate pain management may be due to (1) insufficient knowledge and skills to assess and
treat pain; (2) unwillingness of providers to believe patients’ report of pain; (3) lack of time,
expertise, and perceived importance of conducting regular pain assessments; (4) inaccurate and
inadequate information regarding addiction, tolerance, respiratory depression, and other side
effects of opioids; and (5) fear that aggressive pain management may hasten or cause death.
Components of the nursing role include (1) assessing pain and communicating this information
to other health care providers, (2) ensuring the initiation and coordination of adequate pain
relief measures, (3) evaluating the effectiveness of these interventions, and (4) advocating for
people with pain.
Pain has many dimensions and components, including the following:
o The physiologic dimension of pain includes the genetic, anatomic, and physical
determinants of pain.
o The affective component of pain is the emotional response to the pain experience.
o The behavioral component of pain refers to the observable actions used to express or
control the pain.
o The cognitive component of pain refers to beliefs, attitudes, memories, and meaning
attributed to the pain.
o The sociocultural dimension of pain encompasses factors such as demographics, support
systems, social roles, and culture.
The emotional distress of pain can cause suffering, which is defined as the state of severe
distress associated with events that threaten the intactness of the person.
Culture also affects the experience of pain, specifically the pain expression, medication use, and
pain-related beliefs and coping.
Pain is most commonly categorized as nociceptive or neuropathic based on underlying
pathology or as acute or chronic. Nociception is the physiologic process by which information about tissue damage is
communicated to the central nervous system. Nociception involves transduction, transmission,
perception, and modulation.
o Transduction is the conversion of a mechanical, thermal, or chemical stimulus into a
neuronal action potential.
Noxious (tissue-damaging) stimuli cause the release of numerous chemicals into
the area surrounding the peripheral nociceptors. Inflammation and the
subsequent release of chemical mediators increase the likelihood of
The pain produced from activation of peripheral nociceptors is called
Pain arising from abnormal processing of stimuli by the nervous system is called
Decreasing the effects of chemicals released at the periphery is the basis of
several drugs (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]).
o Transmission is the movement of pain impulses from the site of transduction to
Dermatomes are areas on the skin that are innervated primarily by a
single spinal cord segment.
Referred pain must be considered when interpreting the location of pain
reported by the person with injury to or disease involving visceral organs.
o Perception occurs when pain is recognized, defined, and responded to by the
individual experiencing the pain. The brain is necessary for pain perception.
o Modulation involves the activation of descending pathways that exert inhibitory
or facilitatory effects on the transmission of pain.
Neuropathic pain is further classified as somatic and visceral.
o Somatic pain is characterized by deep aching or throbbing that is well localized
and arises from bone, joint, muscle, skin, or connective tissue.
o Visceral pain, which may result from stimuli such as tumor involvement or
obstruction, arises from internal organs.
Neuropathic pain is caused by damage to peripheral nerves or CNS. Common causes of
neuropathic pain include trauma, inflammation, metabolic disease, infections of the
nervous system, tumors, toxins, and neurologic disease.
Acute pain and chronic pain are different as reflected in their cause, course,
manifestations, and treatment.
o Acute pain typically diminishes over time as healing occurs.
o Chronic pain, or persistent pain, lasts for longer periods, often defined as longer
than 3 months or past the time when an expected acute pain or acute injury should
The goals of a nursing pain assessment are (1) to describe the patient’s multidimensional pain
experience for the purpose of identifying and implementing appropriate pain management
techniques and (2) to identify the patient’s goal for therapy and resources for self-management. A comprehensive assessment of pain includes describing the onset, duration, characteristics,
pattern, location, intensity, quality, and associated symptoms such as anxiety and depression.
Breakthrough pain is a transient, moderate to severe pain that occurs beyond the pain treated
by current analgesics.
Pain scales are useful tools to help the patient communicate pain intensity. Scales must be
adjusted for age and cognitive development.
Patients typically describe neuropathic pain as a burning, numbing, shooting, stabbing, or
Nociceptive pain may be described as sharp, aching, throbbing, and cramping. Associated
symptoms such as anxiety, fatigue, and depression may exacerbate or be exacerbated by
Strategies for pain management include prescription and nonprescription drugs and nondrug
therapies such as hot and cold applications, complementary and alternative therapies (e.g.,
herbal products, acupuncture), and relaxation strategies (e.g., imagery).
o All strategies must be documented, both those that work and those that are ineffective.
o Patient and family beliefs, attitudes, and expectations influence responses to pain and
Pain medications generally are divided into three categories: nonopioids, opioids, and co-
analgesic or adjuvant drugs.
o Mild pain often can be relieved using nonopioids alone.