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Sam y

on 6 November 2013

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Transcript of PAIN

Patient’s expression of pain
Characteristics of pain
- Onset and duration
- Location
-Relief measures
-Contributing symptoms
-Effects of pain on the patient
The nurse explains the use of the TENS unit and demonstrates how to apply it. Which instruction(s) should the nurse include?
(Select all that apply.)

A. After applying the electrodes, set the unit to provide continuous stimulation.
B. Be sure to use conducting gel or conductor pads when applying the electrodes to the skin.
C. Remove the electrodes and change sites each time the skin is stimulated.
D. Turn on the unit only when your pain medication does not provide relief.
E. Clean the skin where the electrodes will be placed and dry thoroughly.

What is the best goal for the nurse to include in the plan of care related to the problem statement of, “Acute pain related to strain on muscles with movement”?

A. Client reports pain of 1 on a 0-10 scale.
B. Client will verbalize pain control methods.
C. Client will not move or strain muscles.
D. Client will learn to live with long-term pain.

The nurse overhears two other nurses discussing Wrenda’s pain management in the hallway. One nurse states that Wrenda is exhibiting drug-seeking behavior and is probably already addicted to her pain medications. What is the priority nursing intervention?

A. Assess the client for signs of drug-seeking behavior.
B. Ask the other nurses what behaviors they have observed.
C. Arrange to continue the conversation in a more private location.
D. Inform the other nurses that the client is not drug addict.

To assess the quality of Wrenda’s pain, the nurse asks which question?

A. “On a scale of 0 to 10, how would you rate your pain?”
B. “What word best describes the pain you are experiencing?”
C. “What actions do you take to relieve the pain?”
D. “What do you fear most about your pain?”

Which information, obtained by the nurse, is most likely to influence Wrenda’s perception of her pain?

A. Wrenda’s younger child is an infant, who feeds every 3 hours.
B. Wrenda’s 4-year-old enjoys being the “big brother” to his baby sister.
C. Wrenda was a first grade teacher before having children but now stays home.
D. Wrenda’s parents live in the same neigborhood and often help with the children.

Morelli, J. (2009, August 13). Pain medications. Retrieved from
Scott, E. (2012, February 22). Use guided imagery for relaxation . Retrieved from
Eustice, C. (2013, September 11). What is a tens unit ?. Retrieved from
Electro Medical Equipment (n.d.). Ultima 5 digital dual channel tens unit with timer. Retrieved from
https://www.google.com/search?q=TENS unit&espv=210&es_sm=122&source=lnms&tbm=isch&sa=X&ei=4TN3UrWxJNOwsASZ_oDwBA&ved=0CAkQ_AUoAQ&biw=1092&bih=533
Dumas, E. (2008, December 10). Opioid tolerance development: A pharmacokinetic/pharmacodynamic perspective. Retrieved from
Richards , K. (2009, September 28). Using the pain scale effectively. Retrieved from
Jacques, E. (2003, September 03). Numerical rating pain scale. Retrieved from
Nicholson , B. (2004, December 24). Neuropathic pain: New strategies to improve clinical outcome. Retrieved from
http://www.google.com/search?q=physiology of pain perception&client=safari&rls=en&source=lnms&tbm=isch&sa=X&ei=Jn54Ur_bEoWgsQTLl4GoDg&ved=0CAkQ_AUoAQ&biw=1406&bih=700
Potter, P. (2013). Fundamentals of nursing . (Eighth ed., pp. 962-968). St. Louis : Elsevier Retrieved from https://evolve.elsevier.com/


Wrenda is discharged the next day. She returns to the clinic in 2 weeks, reporting that she is experiencing mild back pain and only takes NSAIDs occasionally for the pain. She continues to practice her relaxation exercises, which enable her to feel a sense of control when the pain worsens and threatens her ability to care for her family.

Case Outcome


- Many patients can become addicted to opioid analgesics, resulting in a possible drug abuse. This is why narcotics are to be stored and locked away.
Adverse effects:
- No drug is ideally safe. When a patient takes a drug, they are at risk for adverse effects. The more drugs a patient takes, the higher the risk of an adverse effect can occur.
Developed tolerance:
- Long term uses can cause the pharmacologic responses to decrease. In other words, the effectiveness of the drug decreases.

Possible Complications


- Conducting gel or conductor pads are applied before attaching the electrodes to the skin to promote safe, effective conduction of the electrical current and reduce the possibility of injury to the client.

- If the skin is not clean and dry the electrodes will not adhere to the skin.

Answer: B, E
Be sure to use conducting gel or conductor pads when applying the electrodes to the skin;
Clean the skin where the electrodes will be placed and dry thoroughly.

When severe pain persists despite medical treatment …
- Intracheal implantable pumps or injections
-Spinal cord stimulators
- Deep brain stimulation
- neuroablative procedures ( cordotomy, rhizotomy, thalamotomy)
- Trigger point injections
- Radiofrequency ablation
- intradiscal electrothermal (IDET) annuloplasty
- vertebroplasty
-interspinal medications

It is unacceptable to tell a patient with severe unrelieved pain that there is “nothing more we can do for you”. If unresponsive to medication refer the patient to a pain expert.



The goal is a broad statement that reflects a positive direction for the client’s problem, in this case, acute pain.

Answer: A
Client reports pain of 1 on a 0-10 scale.

6 – Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.

Severe Pain – Disabling; unable to perform daily living activities.
7 – Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep.

8 – Intense pain. Physical activity is severely limited. Conversing requires great effort.

9 – Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.

10 – Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain.

Scaling pain

0 – Pain free.

Mild Pain – Nagging, annoying, but doesn't really interfere with daily living activities.
1 – Pain is very mild, barely noticeable. Most of the time you don't think about it.
2 – Minor pain. Annoying and may have occasional stronger twinges.

3 – Pain is noticeable and distracting, however, you can get used to it and adapt.

Moderate Pain – Interferes significantly with daily living activities.
4 – Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting.

5 – Moderately strong pain. It can't be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities.

Scaling Pain


The nurse must act as a client advocate, protecting the client’s privacy. Discussing the client’s behavior in the hallway violates her right to privacy.

Answer: C
Arrange to continue the conversation in a more private location.


The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching, or stabbing.

Answer: B
“What word best describes the pain you are experiencing?”

Characteristics of Pain

- It is vital that you ascertain the level of pain the patient is experiencing. It will also be important to encourage the patient to express pain or discomfort. It is the nurse’s duty to constantly assess the patient’s pain.

- Body movements and facial expressions indicating pain include clenched teeth, holding the painful area, bent posture, and grimacing. Some patients cry or moan, are restless, or make frequent requests of a nurse.

- Learning to recognize patterns of behavior that reflect pain is essential. This becomes especially important in patients who are unable to report their pain, such as the cognitively impaired.

Assessment of Pain


Feeding and infant every 3 hours interrupts sleep
and results in fatigue. Fatigue often heightens the
perception of pain and impairs coping skills.

Answer: A
Wrenda’s younger child is an infant, who feeds every 3 hours.

As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system. Continuous, severe, or deep pain typically involving the visceral organs (myocardial infarction or colic from gallbladder or renal stones) activates the parasympathetic nervous system. Except In cases of severe traumatic pain, which causes a person to go in shock, most people adapt to their pain, and their physical signs return to normal. Thus patients in pain do not always have changes in their vital signs.

Physiological Responses

-Pain has emotional and cognitive components, in addition to a physical sensation.

-Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses.

-Pain impulses pass through when a gate is open and are blocked when a gate is closed.

-Closing the gate is the basis such as acupuncture, massage, relaxation techniques, transcutaneous electrical nerve stimulation (TENS).

Gate-control theory of pain

There are four physiological processes of nociceptive pain: transduction, transmission, perception and modulation.

- Activation of pain receptors, Painful stimuli are converted into electrical impulses that travel to spinal cord at the dorsal horn, Injured tissue releases chemicals (histamine, prostaglandins, bradykinin) that activate nerve endings.

- Pain sensations conducted along pathways, Nociceptors: (somatic or visceral), A delta fibers: acute pain, sharp, localized, distinct sensations, C Fibers: diffuse, visceral pain, poorly localized, burning, persistent

-Sensory process that occurs when stimulus for pain is present, Pain threshold: lowest intensity of stimulus that causes person to recognize pain, Adaptation can occur – there may be no change in vital signs to indicate pain

- Neuromodulators: naturally present, morphine- like chemicals “endogenous opiates” hinder transmission of pain, Reduces the perception of pain, Endorphins, enkephalins, serotonin

Physiology of Pain

Wrenda Fisher, a 35-year-old mother of 2, visits the pain clinic of the regional medical center in her community. Wrenda is interviewed by a certified pain management nurse. Her chief complaint is recent onset back pain, which has limited her ability to care for her children.

Case Study

By: Briana Davis, Elizabeth Rosa, and Samantha Yip

Treatments/Therapy (Cont’d.)

TENS unit (Transcutaneous Electrical Nerve Stimulation):
- Portable device that sends electrical impulses to block pain signals
- Electrodes are placed over areas where there is pain
- Can be used for both acute and chronic pain
- Can reduce amount of pain medication usage for some
Relaxation and guided imagery:
- Deep breathing
- Envision yourself in a relaxing environment
- Ambient sounds
- Set alarm in case

(modify pain messages)
(Act on substances that cause inflammation, pain, and fever)
(Increases pains threshold)
Anti-anxiety drugs
(reduce anxiety, relaxes muscles, and help patients cope with discomfort)


- The amount of tissue damage in an injury accurately indicates pain intensity.
- Health care personnel are the best authorities on the nature of a patients of pain.
- Patients who are hospitalized will experience pain.
- Patients who can speak do not feel pain.

- Patients who abuse substances overreact to discomforts.
- Patients with minor illnesses have less pain than those with severe physical al
- Administering analgesics regularly leads to drug addiction.
- Psychogenic pain is not real.
- Chronic Pain is psychological.

Common Biases and Misconceptions about Pain
All False

Cancer Pain
- Some patients experience acute and/or chronic pain. Pain can be nociceptive and/or neuropathic pain.
- Cancer pain is usually caused by tumor progression, and related pathological processes, invasive procedures, toxicities of treatment, infection, and physical limitations.

Pain by Inferred Pathological Process
-Somatic musculoskeletal, visceral internal organ pain, or neuropathic arising from abnormal or damaged pain nerves.

Idiopathic Pain
- Chronic pain without identifiable physical or psychological cause
- Research is needed to better identify the causes of idiopathic pain, for better treatment

Acute/Transient Pain
- Protective, identifiable, short duration; limited emotional response
- Will eventually resolve, with or without treatment, after an injured area heals
-Can seriously threatens a patient’s recovery by resulting, in prolonged hospitalization, increased risk of complications immobility.

Chronic/Persistent Noncancer Pain
- Is not protective, has no purpose, may or may not have an identifiable cause
- Last longer than 6 months constant or recurring with a mild-to-severity intensity
- Can frustrates a patient, frequently leading to psychological depression and even suicide.

Chronic Episodic Pain
- Occurs sporadically over an extended duration
- Pain episodes last for hours,days, or weeks.

Types of Pain

Pain is pretty complex, but almost everyone
experiences some sort of pain.
What is pain?

Pain Scales

From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P:Wong’s Essentials of Pediatric Nursing,
6/e, St. Louis, 2001, P. 1301.Copyrighted by
Mosby,Inc. Reprinted by permission

Wong-Baker FACES Pain Rating Scale
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn’t
hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can image, although you don’t have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. Rating scale is recommended for persons age 3 years and older. Brief word instructions:Point to each face using the words to describe the pain intensity. Ask the child
to choose face that best describes
own pain and record the appropriate number.

The Numerical Rating Pain Scale allows the healthcare provider to rate pain as mild, moderate or severe, which can indicate a potential disability level.

One of the most commonly used pain scales in healthcare, the numerical rating scale offers the individual in pain to rate their pain score. It is designed to be used by those over the age of 9. In the numerical scale, the user has the option to verbally rate their scale from 0 to 10 or to place a mark on a line indicating their level of pain. 0 indicates the absence of pain, while 10 represents the most intense pain possible.

Pain Scales

The nurse explains the use of the TENS unit and demonstrates how to apply it. Which instruction(s) should the nurse include? (Select all that apply.)

A. After applying the electrodes, set the unit to provide continuous stimulation.
B. Be sure to use conducting gel or conductor pads when applying the electrodes to the skin.
C. Remove the electrodes and change sites each time the skin is stimulated.
D. Turn on the unit only when your pain medication does not provide relief.
E. Clean the skin where the electrodes will be placed and dry thoroughly.
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