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Medical-Surgical Nursing
Critical Thinking in Patient Care
Fifth Edition
CHAPTER
9
Nursing Care of
Patients in Pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Directory
• NCLEX-RN® REVIEW Test Questions
• Lecture Note Presentation
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
NCLEX-RN® REVIEW
Test Questions
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 1
1. During your assessment, a patient tells you he
has had lower back pain for 9 months. When
planning nursing care, you recognize this type
of pain as which of the following?
1.
2.
3.
4.
neuropathic pain
chronic pain
visceral pain
somatic pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 1 Response
1. During your assessment, a patient tells you he
has had lower back pain for 9 months. When
planning nursing care, you recognize this type
of pain as which of the following?
1.
2.
3.
4.
neuropathic pain
chronic pain
visceral pain
somatic pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 1 Rationale
Chronic pain is defined as pain that has persisted
for 6 or more months. Low back pain is the most
common cause of chronic pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 2
2. A patient presents to the ED after smashing
her finger in the car door. She relates that her
pain initially was sharp and so intense she
thought she would faint, but now it is dull and
throbbing. The nurse appropriately recognizes
this as which of the following?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 2 Choices
1. indicative that the injury is less severe than initially
perceived
2. the result of interpretation of the pain stimulus by
the thalamus
3. an example of the gate theory of pain transmission
4. transmission of pain stimuli via unmyelinated C
fibers
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 2 Response
1. indicative that the injury is less severe than initially
perceived
2. the result of interpretation of the pain stimulus by
the thalamus
3. an example of the gate theory of pain transmission
4. transmission of pain stimuli via unmyelinated C
fibers
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 2 Rationale
Initial or “fast” pain is sharp and well-defined as the
stimulus is transmitted along myelinated A delta
fibers to the thalamus and cerebral cortex. The
smaller unmyelinated C fibers transmit the
stimulus more slowly, producing a second or
“slow” pain, which is less well-localized, dull, and
throbbing.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 3
3. You are taking a health history for a patient
who has taken an NSAID for several years.
Which of the following questions should you
ask? Select all that apply.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 3 Choices
1. “Tell me how and when you take this drug.”
2. “Have you ever vomited blood or had very dark
stools?”
3. “Do you know that you may become addicted to this
drug?”
4. “Have you noticed any problems with your
breathing?”
5. “Do you have your blood pressure checked
regularly?”
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 3 Response
1. “Tell me how and when you take this drug.”
2. “Have you ever vomited blood or had very dark
stools?”
3. “Do you know that you may become addicted to this
drug?”
4. “Have you noticed any problems with your
breathing?”
5. “Do you have your blood pressure checked
regularly?”
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 3 Rationale
NSAIDs are more effective when taken on a
scheduled basis rather than PRN. These drugs,
when effective (particularly for musculoskeletal
pain), can cause gastrointestinal bleeding and
hypertension, necessitating regular follow-up.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 4
4. Which of the following would you include
when teaching a patient about a transdermal
pain medication?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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®
NCLEX-RN REVIEW
Test Question 4 Choices
1. Contact your physician if this medication makes you
excessively sleepy.
2. Replace this patch every 24 hours, applying it to
clean, dry skin.
3. When reapplying the patch, place it on the anterior
thigh.
4. This medication should be effective within 2 to 4
hours; contact your physician if your pain is not at
an acceptable level after that.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 4 Response
1. Contact your physician if this medication makes
you excessively sleepy.
2. Replace this patch every 24 hours, applying it to
clean, dry skin.
3. When reapplying the patch, place it on the anterior
thigh.
4. This medication should be effective within 2 to 4
hours; contact your physician if your pain is not at
an acceptable level after that.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 4 Rationale
Transdermal patches of opioid are slowly
absorbed, reaching a therapeutic level 12 to 72
hours after application. The drug can accumulate
in the body tissues, leading to a toxic level
accompanied by manifestations such as
sleepiness or respiratory difficulty.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 5
5. Which of the following statements would be
most useful in determining the quality of a
patient’s pain?
1.
2.
3.
4.
“Tell me where you hurt.”
“Rate your pain on a scale of 0–10.”
“Describe what your pain feels like.”
“Tell me how this pain affects your sleep.”
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 5 Response
5. Which of the following statements would be
most useful in determining the quality of a
patient’s pain?
1.
2.
3.
4.
“Tell me where you hurt.”
“Rate your pain on a scale of 0–10.”
“Describe what your pain feels like.”
“Tell me how this pain affects your sleep.”
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 5 Rationale
The quality of the pain is assessed through
descriptive statements such as sharp, burning,
stabbing, dull, etc.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 6
6. When assessing a postoperative patient’s
pain, you note that he is relaxed, smiling, and
visiting with friends. He rates his pain as a 7 on
a scale of 0–10. The most appropriate
response is to do which of the following?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 6 Choices
1. Reassess the patient’s pain after his friends have
left.
2. Document your assessment but take no further
action.
3. Administer the prescribed analgesic dose.
4. Note that the patient is developing tolerance to the
prescribed opioid analgesic.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 6 Response
1. Reassess the patient’s pain after his friends have
left.
2. Document your assessment but take no further
action.
3. Administer the prescribed analgesic dose.
4. Note that the patient is developing tolerance to the
prescribed opioid analgesic.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 6 Rationale
Pain is objective; the patient provides the most
accurate information about its intensity.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 7
7. When teaching a patient with chronic
malignant pain about using opioid analgesics,
you would include which of the following
instructions?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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®
NCLEX-RN REVIEW
Test Question 7 Choices
1. “This drug may interfere with urination; contact your
physician if that becomes a problem.”
2. “Increase fluid and fiber intake; you may need a
stool softener or laxative to prevent constipation.”
3. “This drug may cause itching and rash; take
Benadryl (diphenhydramine) as needed.”
4. “There is a risk of addiction with this drug; stop the
drug if you find that it no longer provides the degree
of pain relief necessary.”
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 7 Response
1. “This drug may interfere with urination; contact your
physician if that becomes a problem.”
2. “Increase fluid and fiber intake; you may need a
stool softener or laxative to prevent
constipation.”
3. “This drug may cause itching and rash; take
Benadryl (diphenhydramine) as needed.”
4. “There is a risk of addiction with this drug; stop the
drug if you find that it no longer provides the degree
of pain relief necessary.”
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 7 Rationale
Constipation is a common side effect of opioids
narcotics, especially when used on a regular basis.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 8
8. When assessing pain in a patient who is
moderately cognitively impaired due to
dementia, the nurse should do which of the
following?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 8 Choices
1. Ask the patient to rate his pain using the faces pain
scale.
2. Use only behavioral cues such as grimacing,
pacing, or agitation.
3. Have the family evaluate the intensity of the
patient’s pain.
4. Administer the prescribed analgesic on an aroundthe-clock basis.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 8 Response
1. Ask the patient to rate his pain using the faces
pain scale.
2. Use only behavioral cues such as grimacing,
pacing, or agitation.
3. Have the family evaluate the intensity of the
patient’s pain.
4. Administer the prescribed analgesic on an aroundthe-clock basis.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 8 Rationale
Research has shown that patients with moderate
cognitive impairment can use a pain scale to
indicate the intensity of pain. The faces pain scale
may be more accurate and effective in the
cognitively impaired adult.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 9
9. A patient asks the nurse if she should take
glucosamine for her knee pain. The nurse
bases her response on the knowledge of which
of the following?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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®
NCLEX-RN REVIEW
Test Question 9 Choices
1. There is no evidence that natural products such as
glucosamine are effective for treating any type of
pain.
2. Chronic pain such as that associated with
osteoarthritis is best treated with NSAIDs and
acetaminophen.
3. When combined with chondroitin, glucosamine has
been effective in relieving moderate to severe knee
pain in some patients.
4. Although no studies have shown a benefit from
taking glucosamine, other CAM therapies such as
acupuncture are effective for treating pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 9 Response
1. There is no evidence that natural products such as
glucosamine are effective for treating any type of
pain.
2. Chronic pain such as that associated with
osteoarthritis is best treated with NSAIDs and
acetaminophen.
3. When combined with chondroitin, glucosamine
has been effective in relieving moderate to
severe knee pain in some patients.
4. Although no studies have shown a benefit from
taking glucosamine, other CAM therapies such as
acupuncture are effective for treating pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
®
NCLEX-RN REVIEW
Test Question 9 Rationale
The combination of glucosamine and chondroitin
has been shown to reduce pain in patients with
moderate to severe knee pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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®
NCLEX-RN REVIEW
Test Question 10
10. A patient who recently took up running to lose
weight asks why she feels better after running
when she should be tired and sore. The most
accurate response would be which of the
following?
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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NCLEX-RN REVIEW
Test Question 10 Choices
1. Natural narcotic-like substances are released during
physical activities like running.
2. Activities such as running activate a natural “gate” in
the spinal cord, blocking pain signals.
3. Engaging in activities that actively use large muscle
groups changes pain circuits in the brain, reducing
the perception of pain.
4. With repeated stimulation through activities such as
running, nociceptors in deep tissues become less
sensitive to stimuli.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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®
NCLEX-RN REVIEW
Test Question 10 Response
1. Natural narcotic-like substances are released
during physical activities like running.
2. Activities such as running activate a natural “gate” in
the spinal cord, blocking pain signals.
3. Engaging in activities that actively use large muscle
groups changes pain circuits in the brain, reducing
the perception of pain.
4. With repeated stimulation through activities such as
running, nociceptors in deep tissues become less
sensitive to stimuli.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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®
NCLEX-RN REVIEW
Test Question 10 Rationale
Rigorous physical activity such as running prompts
the release of endorphins (natural opioids-like
substances). Endorphins bind with opioids
receptors in the CNS, inhibiting the transmission of
pain signals.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Lecture Note
Presentation
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Learning Outcome 1
• Describe the neurophysiology of pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Intro to Neurophysiology of Pain
• Pain is perceived within the CNS.
• Connections or synapses occur within the
spinal cord and within the brain.
• Interpretation of the stimulus occurs in the
brain, which leads to a response.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Pain Theories
• Specificity and pattern theories
• Melzack and Wall’s gate control theory
• Neuromatrix theory
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Figure 9–1 The spinal cord component of the gate-control theory. Pain transmission by small-diameter fibers is
blocked when largediameter fibers carrying touch impulses dominate, closing the gate in the dorsal horn of the spinal
cord.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Physiology of Pain
• Nociceptors are nerve receptors for pain.
• Pain occurs when tissue containing
nociceptors is subjected to noxious stimuli.
• The intensity and duration of stimuli
determine the sensation.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Pain Pathway
• A noxious stimulus is translated by
nociceptors into action potential.
• Action potential is transmitted through
small A-delta (A greek symbol) and even
smaller C nerve fibers to the spinal cord.
• Next, the sensory neuron enters the spinal
cord by the dorsal root and terminates in
the dorsal horn of the spinal cord.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Pain Pathway
• Here, it synapses with the spinal (or
second-order) neurons that transmit the
pain signal to the brain.
• Spinal neurons transmit impulses via
axons that cross over to the spinothalamic
tract. The impulses ascend the
spinothalamic tracts and pass through the
medulla and midbrain to the thalamus.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Pain Pathway
• The pain signal is distributed from the
thalamus via third-order neurons to
several areas of the cerebral cortex.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Figure 9–2 A, Touching the hot lid activates nociceptors in the skin, generating pain impulses that travel via fast Aδ
and slower C fibers to the spinal cord. B, Secondary neurons in the dorsal horn pass impulses across the spinal cord to
the anterior spinothalamic tract. C, Pain impulses ascend to the thalamus and, from there, to the cerebral cortex and
the reticular and limbic systems in the brainstem, which integrate the emotional, cognitive, and autonomic responses to
pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Pain Modulation
• No one experiences pain from an identical
stimulus in the same way or at the same
intensity.
• Neural and chemical responses explain
how pain can be modified.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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Figure 9–3 A, Pain impulse causes presynaptic neuron to release burst of neurotransmitters across synapse. These
bind to postsynaptic neuron and propagate impulse. B, Inhibitory neuron releases endorphins, which bind to presynaptic
opiate receptors. Neurotransmitter release is inhibited, and pain impulse interrupted.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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Learning Outcome 2
• Compare and contrast definitions and
characteristics of acute, chronic,
breakthrough, central, malignant,
phantom, and psychogenic pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Acute Pain
• Cutaneous and deep somatic pain
• Visceral pain
• Referred pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Figure 9–4 Referred pain results of the convergence of sensory nerves from certain areas of the body within the
spinal cord. For example, a toothache may be felt in the ear, pain from inflammation of the diaphragm may be felt in the
shoulder, and pain from ischemia of the heart muscle (angina) may be felt in the left arm.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Chronic Pain
• Recurrent acute pain
• Chronic malignant
• Chronic nonmalignant pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Breakthrough Pain
• Pain which exceeds baseline chronic or
persistent pain
• Described as a sudden flare, exceeds
long-acting pain medications
• The onset and intensity can vary
• Incident or episodic pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Central Pain
• Caused by a lesion or damage in the brain
or spinal cord
• Constant, of moderate to severe intensity
• Difficult to treat
• Depends on the area of the CNS affected
• Described as burning, pressing, lacerating,
or aching
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Phantom Pain
• Syndrome that occurs following
amputation of a body part
• Pain experienced in the missing body part
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Learning Outcome 3
• Discuss factors affecting individualized
responses to pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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The Individualized Pain
Response
• Shaped by physiologic responses, age,
gender, sociocultural influences, and
psychological influences
• Pain threshold
• Pain tolerance
– Amount of pain a person can endure before
outwardly responding
– Varies significantly among individuals and
over time
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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The Individualized Pain
Response
• Age
– Influences a person’s perception and
expression of pain
– No evidence that nociception is altered by age
– Pain tolerance decreases with aging
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
Copyright ©2011 by Pearson Education, Inc.
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The Individualized Pain
Response
• Gender
– Women have lower pain threshold and
experience higher intensity of pain
• Sociocultural influences
– Response is influenced by family, community,
and culture
– Affects pain behavior
– Cultural standards
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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The Individualized Pain
Response
• Psychological Influences
– Intensity of perceived pain is affected by
attention, expectation, and suggestion
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Learning Outcome 4
• Discuss collaborative care for the patient
in pain, including medications, surgery,
transcutaneous electrical nerve
stimulation, and complementary therapies.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Collaborative Care for Pain
• Necessary for effective pain relief
• Acute pain management can be
straightforward
• Chronic pain requires a multidisciplinary
approach
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Collaborative Care for Pain
• Medications
– Most common approach to pain management
– Acute pain, straightforward
– Chronic pain, broader range of drug classes
– Nursing responsibilities
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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Figure 9–5 The WHO analgesic ladder illustrates the process for selection of analgesic medications for pain
management. Source: The WHO Analgesic Ladder from Cancer Pain Relief and Palliative Care, Technical Report
Series, No. 804, The World Health Organization, Geneva, Switzerland. Reprinted by permission.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Figure 9–6 The transdermal patch administers medication in predictable doses.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Figure 9–7 PCA units allow the patient to self-manage acute pain. The units may be portable or mounted on
intravenous poles.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Surgery
• Only used if all other methods have failed,
and typically reserved for patients
experiencing nerve pain
• Cordotomy
• Neuroectomy
• Sympathectomy
• Rhizotomy
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Figure 9–8 Surgical procedures may be used to treat severe pain that does not respond to other types of
management. They include cordotomy, neurectomy, sympathectomy, and rhizotomy.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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Transcutaneous Electrical Nerve
Stimulation (TENS)
• Application of electrical current through the
skin to control acute or chronic pain
• Controls pain in several ways
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Figure 9–9 The TENS unit is used to assist in acute and chronic in pain management. Electrodes deliver low-voltage
electrical stimuli through the skin to block transmission of pain stimuli. Source: photo by Gary Ombler / Dorling
Kindersley Media Library
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Complementary and Adjunctive Therapies
(Complementary and Alternative Medicine)
•
•
•
•
•
•
•
•
Acupuncture
Biofeedback
Chiropractic
Distraction
Hypnotherapy and Guided Imagery
Massage Therapy
Natural Products
Relaxation
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Learning Outcome 5
• Use the nursing process as a framework
for providing individualized nursing care
for patients experiencing pain.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Nursing Care and Health
Promotion
• Goal
– Assist patient to achieve optimal control of the
pain
• Health Promotion
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Assessment
• Varies by acuity of pain and circumstances
• Acute pain
• Chronic pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Assessment
• Patient Perceptions
– Most reliable indicator of pain
– PQRST mnemonic
 P: What precipitated the pain?
 Q: What is the quality of the pain?
 R: What is the region of the pain?
 S: What is the severity of the pain?
 T: What is the timing of the pain?
– McGill Pain Questionnaire
– Pain-Rating Scales
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Figure 9–10 The McGill Pain Questionnaire. The descriptors fall into four major groups: sensory (1–10), affective (11–
15), evaluative (16), and miscellaneous (17–20). The rank value for each descriptor is based on its position in the word
set; the sum of the rank values is the pain rating index (PRI). The present pain intensity (PPI) is based on a scale of 0
to 5.
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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Figure 9–11 Examples of commonly used pain scales. Commonly Used Pain Scale from FPS-R. This figure has been
reproduced with permission of the International Association for the Study of Pain® (IASP®). The figure may not be
reproduced for any other purpose without permission
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Physiologic Responses
• Predictable physiologic changes
• Over time, these changes might not be
visible in patients with chronic pain
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Behavioral Responses
• Pain behaviors
– Bracing/guarding the painful part
– Crying, moaning, or grimacing
– Withdrawing from activity
– Breathing with increased effort
– Becoming immobile
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Behavioral Responses
• Might not coincide with the patient’s report
of pain
• Not always reliable cues to the pain
experience
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
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Behavioral Responses
• Self-Management of Pain
– Useful information for the assessment
database
– Individualized and patient-specific
– Get detailed descriptions of:
 Actions taken
 When and how the measures were applied
 How well the measures worked
Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition
Priscilla LeMone • Karen Burke • Gerene Bauldoff
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