Chapter 7: Care of Patients With Pain

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement, not replace, the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Imagine a patient, right, whose arm was amputated,

like years ago,

yet they're lying in a hospital bed and they're sweating and grimacing because that missing hand feels like it is just being crushed in a vice.

Yeah, it's a wild concept.

The tissue is completely gone.

I mean, the arm is gone, but the pain they're feeling is 100 % real.

Exactly.

So welcome to the deep dive.

If you're listening to this, you are probably

a nursing student prepping for a clinical shift, maybe cramming for a major exam, or just looking to really solidify your clinical reasoning.

Which is so important.

Yeah, whatever brings you here, we're thrilled you're with us.

Today is a special focus session from the last minute lecture team.

We are basically serving as your one -on -one clinical tutors to help you master the core concepts of care of patients with pain.

And our mission really starts with a fundamental paradigm shift.

Right.

That shift is moving away from the idea that pain is just a byproduct of another disease.

Because in the clinical environment, it's incredibly easy to view pain merely as a symptom,

like just a side effect of surgery or the inevitable result of an infection.

Yeah, it's like, oh, you had surgery, of course you hurt.

Exactly.

But the core concept of the material we're diving into today completely flips that perspective.

Pain is a highly specific neurologic response to unpleasant stimuli.

Okay.

It's a distinct complex problem that requires its own targeted,

prioritized nursing intervention, independent of whatever's actually causing it.

So to treat it, we have to really understand the invisible machinery behind it.

We're going to trace the life cycle of pain from the moment a nerve misfires to how the brain interprets it, to the detective work you'll use to measure it, and finally, the specific interventions you'll use to stop it.

Right, the nursing process in action.

Exactly.

So let's start at the very beginning, like the why.

Because before you can ever safely assess or medicate a patient, you have to understand the biological mechanisms generating their pain.

Yeah, and the foundational model for understanding this mechanism

is the gate control theory.

Which I love.

It makes so much sense once you get it.

It really does.

It proposes that there's a literal functional gate within the central nervous system, specifically down in the dorsal horn of the spinal cord.

Okay, the dorsal horn.

Right.

And according to this theory, pain stimuli are carried by small diameter nerve fibers.

When these small fibers are highly active, they essentially open the gate, allowing the pain sensation to travel freely up the spinal cord and into the brain where it's perceived.

So small fibers open the gate.

Yes.

But the body also has large diameter nerve fibers.

And these carry non -painful sensory information like touch, pressure, vibration.

And activity in these large fibers does the exact opposite.

It activates inhibitory inner neurons that close the gate, like physically blocking the pain impulse from getting through.

See, I always visualize this gate mechanism like the bouncers at a crowded, chaotic nightclub.

Oh, that's a good way to look at it.

Yeah, so you have the pain signals, those are the small diameter nerve fibers acting like this unruly crowd trying to rush the front door.

If nothing stops them, they just flood the club.

Right, total chaos.

But then you have the large diameter fibers.

When you stimulate those large fibers by, say, giving a patient a back massage or applying vibration, it's like sending VIPs to the front of the line.

Ah, I see where you're going.

Yeah.

You flood the area with a massive volume of non -painful sensory input.

The bouncers get entirely distracted by dealing with the VIPs, and they essentially close the doors, blocking the unruly pain signals from ever getting inside the club.

That captures the mechanical competition perfectly.

And the gate isn't only controlled by physical touch either.

The central nervous system is a two -way street.

The theory highlights that higher brain functions play a massive role.

An increase in anxiety or fear sends signals down the spinal cord that seem to open the gate even wider.

Wow, so amplifying the physical pain?

Exactly.

Conversely, decreasing anxiety perhaps by a nurse,

simply sitting down

and confidently reassuring the patient that their pain will be controlled that sends descending signals that actually help close the gate.

So the psychological state of the patient has a literal physiological impact on how much pain physically reaches their brain.

Absolutely.

The brain also utilizes endorphins, which are the body's endogenous opiates.

They're like the runner's high.

Yes, exactly.

They're naturally occurring chemicals that attach to opioid receptor sites in the brain and spinal cord.

They literally block pain sensation from being processed while simultaneously reducing anxiety and sometimes producing that sense of euphoria.

But when we apply this to clinical pain management, we have to look at the concept of pieces of pain.

Pieces of pain, okay.

The more intense and overwhelming a patient's pain is, the greater the number of pieces it shatters into.

Because of this, intense pain requires a greater number of treatment pieces to control it.

So you can't just use one thing.

Exactly.

You might need a pharmacological piece, a distraction piece and like a physical therapy piece.

If you only use one intervention, you're basically guaranteed to leave leftover pieces of pain.

Which means total acceptable relief hasn't been achieved.

Precisely.

But okay, let's go back to that patient from our introduction, the one missing an arm.

The Santum limb.

If pain is initiated by tissue damage, sending a signal to the open gate, how do we explain phantom limb pain?

I mean, the tissue is gone, the small diameter fibers in the hand are literally gone, yet the agony is still there.

That clinical mystery is exactly what led to the neuromatrix and central sensitivity theories.

Okay.

For a long time, medicine viewed pain as a simple hardwired loop.

Tissue gets injured, a signal travels up the wire, the brain feels it.

Right, very straightforward.

But these newer theories explain that the central nervous system doesn't just passively receive pain, it can actively generate it.

Wait, really?

The brain just makes it up.

Well, in conditions like phantom limb pain, or generalized conditions like fibromyalgia, the nervous system gets trapped in a feedback loop.

The pain pathways become sensitized, hyperreactive, and physically rewired.

Oh, wow.

Yeah, the central nervous system itself becomes the generator of the pain, completely independent of any localized tissue injury.

So the pain, they feel, is a real multi -dimensional experience constructed by the brain.

If the brain can literally rewire itself to generate pain out of nowhere, we clearly can't treat this by just throwing a simple painkiller at a non -existent tissue injury.

Which naturally brings us to the biopsychosocial model, which is the most comprehensive framework we currently have.

Biopsychosocial, that's a mouthful.

It is, but it postulates that pain is never just a biological event.

It's a deeply complex, entangled interaction of biological changes, psychological states like depression or trauma, and sociological factors, like a patient's support system and their environment.

That makes total sense.

Because it's multi -systemic, you cannot treat it with a single modality.

Restoring a patient's functionality requires an interprofessional team, primary care providers, psychologists, physical therapists, and nurses, all targeting different facets of that experience.

Okay, so understanding how the nervous system builds these pain pathways really leads us to the next critical step, which is identifying what kind of pain the patient in front of you is actually experiencing.

Yes, classification is key.

Because the underlying classification of the pain dictates everything about your nursing management.

So let's break down the physiological adaptations in acute versus chronic pain.

Sure.

The defining characteristic isn't just time.

You know, it's how the body reacts.

Acute pain lasts for hours, days, or up to a few weeks.

Because it's a sudden recent onset, like a surgical incision or a broken bone,

the sympathetic nervous system kicks into fight or flight mode.

So you're gonna see those classic signs.

Exactly, you'll see clear physiologic symptoms.

An increased heart rate, elevated blood pressure, rapid breathing, diaphoresis, sweating, and sometimes nausea.

The source is usually identifiable, and the prognosis for relief is very good.

But chronic pain, on the other hand, lasts for months or even years.

Right, and this is where the vital sign monitor can actually lie to you.

Because with chronic pain, a patient could be experiencing agonizing, debilitating pain, but their heart rate and blood pressure might look totally normal, right?

Exactly, the body simply cannot sustain a fight or flight response for months on end.

It adapts physiologically.

It just gets used to it.

Yeah, the elevated heart rate disappears, the blood pressure normalizes, and the diaphoresis stops.

But the absence of those vital sign changes does not mean the pain is gone.

Not at all.

Instead, the psychosocial effects set in heavily.

Chronic pain continuously drains the patient's energetic reserves.

It leads to severe irritability, profound depression, social withdrawal, and insomnia.

Which is a staggering issue in geriatric care.

I mean, the textbook points out that between 60 and 75 % of older adults experience chronic pain on a daily basis.

It's a huge number.

Heavily driven by conditions like osteoarthritis or degenerative disc disease.

Yes, so let's shift from duration to the actual source of the damage.

Nociceptive versus neuropathic pain.

Nociceptive pain is the classic pathway.

It originates from actual physical tissue damage.

This is broken down into somatic and visceral pain.

Somatic and visceral.

Somatic pain comes from the skin, muscles, bones, and joints.

It's the sharp, throbbing, well localized pain of a burn, a surgical incision, or a fracture.

And visceral.

Visceral pain arises from the internal organs, like the GI tract.

If a patient has a bowel obstruction or an internal tumor, that visceral pain is often described as deep, diffuse, cramping, or aching.

So to safely administer medications for nociceptive pain, a nurse really has to understand the four physical phases of how that damage is processed.

Yes, the four phases are crucial.

I always picture the nociceptive process like a building's fire alarm system.

I like analogies, let's hear it.

Okay, so phase one is transduction.

Tissue is damaged, the cells burst apart, and they spill chemicals like prostaglandins into the surrounding tissue.

This is the chemical spark.

It's the smoke detector sensing the fire and activating the nociceptors, which are those specialized pain nerve endings.

And clinically, transduction is exactly where nonsteroidal anti -inflammatory drugs or NSAIDs like ibuprofen do their work.

Right at the source.

They don't work in the brain.

They work right at the site of the injury by blocking the specific enzymes that produce those prostaglandins.

They basically put out the chemical spark before the alarm can fully sound.

That's awesome.

So if a spark happens, we move to phase two, which is transmission.

The electrical signal travels from the nociceptor up the peripheral nerve, hits the spinal cord, and has to jump across a synapse to continue its journey up to the brain.

Right.

This is the electrical wire carrying the signal from the smoke detector to the main control board.

And this phase is the primary domain of opioid medications.

Opioids bind to specific receptors in the spinal cord and basically cut the wire.

Wow.

Yeah, they block the release of neurotransmitters at that spinal synapse, meaning the pain signal literally cannot cross over to reach the brain.

Okay, so phase three is perception.

The impulse successfully reaches the higher centers of the brain, and the pain is consciously recognized.

The control board lights up.

The brain knows there is a fire.

And during the perception phase, the brain's interpretation can be altered.

This is where non -pharmacologic treatments like active distraction, guided imagery, or deep breathing are highly effective at changing how the brain recognizes and focuses on that signal.

It's like you're distracting the person reading the control board.

Exactly.

Finally, phase four is modulation.

The brain doesn't just receive the signal, it reacts.

Neurons in the brain send signals back down the spinal cord by releasing their own neurotransmitters to either amplify or dampen the pain.

The along system sounds off.

And in the modulation stage, drugs that block the reuptake of neurotransmitters are used to strengthen the body's dampening signals.

So treatment targets specific physical phases.

But because neuropathic pain operates entirely outside of this normal, non -susceptive process, it creates a massive blind spot for nurses.

Right, because neuropathic pain is a completely different mechanism.

It's an abnormality in how the nervous system processes sensation.

Yes.

It's often associated with systemic medical conditions, like diabetic neuropathy, rather than a direct acute tissue injury.

The nerve endings themselves become damaged.

They might grow abnormal microscopic branches that become hyper excitable, misfiring constantly, like a frayed electrical wire sparking wildly on a damp floor.

Which perfectly explains why cutting the main wire doesn't solve the problem.

If the issue is a frayed wire sparking everywhere, traditional opioids, which are designed to block normal transmission pathways, often fail completely.

Because there isn't just one pathway anymore.

Right.

Neuropathic pain requires adjuvant medications.

These are drugs that were originally developed for completely different conditions, but have secondary effects on nerve pain.

So a patient with severe neuropathic pain might be prescribed an anticonvulsant.

Exactly.

Which is wild, because we normally use anticonvulsants to quiet down the rapid erratic electrical misfiring in the brain during a seizure.

It turns out they do the exact same thing to the erratic hyper excitable misfiring of a damaged peripheral nerve.

You also see tricyclic antidepressants used.

These work by increasing the levels of certain neurotransmitters, like serotonin and norepinephrine in the spinal cord, which essentially boosts the body's natural descending pain blocking signals.

NSIs and corticosteroids can also be used to reduce localized nerve inflammation.

You just have to use the right tool for the specific pathophysiologic job.

So we understand the biology and the classifications, but here is where the clinical reasoning is truly tested.

How does a nurse measure something that is entirely subjective and invisible?

It's the biggest challenge.

Right.

If the vital sign monitors can't prove neuropathic or chronic pain is there, how do we find it?

This takes us into the assessment phase of the nursing process.

And assessment begins with separating two very distinct concepts,

pain threshold and pain tolerance.

Okay, threshold and tolerance.

Pain threshold is the precise physiological point at which a stimulus is perceived as painful,

but pain tolerance is the length of time or the maximum intensity of pain that a person is willing or able to endure before outwardly responding to it or seeking intervention.

And tolerance is a highly complex, individualized moving target.

It's shaped by a patient's past experiences, their role behaviors, and heavily by their cultural background.

In some cultures, stoicism and a high pain tolerance are expected behaviors.

In others, freely enduring pain is viewed as honorable or even spiritually necessary.

So as a nurse, you have to accept the patient's expression of pain without judgment, even if their outward response looks drastically different from your own cultural baseline.

That's a vital point.

I have to stop you there though, because the reality on the clinical floor throws a wrench into this.

How so?

Well, if I have a patient with a documented history of severe substance abuse, say heroin addiction,

my immediate instinct and the instinct of many nurses is to be incredibly cautious about giving them heavy narcotics for an injury.

Aren't we actively fueling their addiction if we give them opioids?

It is arguably the most common hesitation nurses face, but giving in to that hesitation is a major clinical failure.

Really?

Yes, the guidelines are incredibly clear on this.

Patients who have a substance use disorder are not to be denied adequate pain medication when they experience acute tissue damaging pain.

Their history of addiction does not magically negate the physical reality of a broken femur or a surgical incision.

But their bodies react differently to the medication because of their tolerance, right?

I mean, they're used to it.

That is the physiological mechanism at play.

Over time, their central nervous system has downregulated its opioid receptors.

Their baseline requirement just to feel normal is higher than an opiate -naive patient.

So when you add severe acute pain on top of that altered baseline,

they often require significantly higher doses of analgesia just to achieve the same level of basic pain relief.

Wow, higher doses.

Yes.

Undertreating them out of a fear of causing addiction leaves them in agonizing pain, which paradoxically causes extreme physiological stress, severe anxiety, and can actually trigger drug -seeking relapse behaviors.

That is a massive clinical pearl right there.

You cannot let a patient's substance history blind you to their acute trauma.

So moving into the actual data collection, we rely heavily on observation and focused investigative questions.

For observation, you're scanning for subtle clinical cues.

You look at their appearance.

Is their face drawn pale or tense?

Are they grimacing when they shift their weight?

Look at behavior.

If a normally pleasant, talkative patient suddenly becomes withdrawn, deeply irritable, or curls tightly into a fetal position, their body is screaming that they're in pain?

You monitor their activity level.

Are they creeping slowly, guarding an area, or refusing to move at all?

But the golden rule of nursing assessment remains.

Pain is whatever the experiencing person says it is.

Yes, always.

The patient is the only one with firsthand knowledge of their nervous system.

You must ask them.

A focused assessment requires nailing down specific details.

You ask for the location, have them physically point to every place it hurts.

The characteristics is it's sharp, burning, dull, gnawing, electrical.

You ask about quantity and pattern.

And crucially, you investigate aggravating and alleviating factors.

What specific movements make it worse?

What positions make it better?

And to quantify that subjective data, we use standardized pain scales.

It is essential to use these consistently, and you must select the appropriate tool for the specific patient's cognitive and developmental level.

The most common is the standard numbered scale, zero to 10.

Zero is absolutely no pain.

10 is the worst pain imaginable.

But what if the patient is a young child or an adult who struggles with numerical abstraction?

Then you pivot to the Wongbaker faces scale.

The faces one, right?

Yeah, this uses simple progressive drawings of faces.

Starting from a happy, relaxed smile at a zero and moving to a deeply distressed crying grimace at a 10.

The patient simply points to the face that matches how they feel.

Oh, that's great.

For younger children, you might use a color scale where colors represent intensity or at pieces of pain scale, using physical tokens like Boker chips, where the child hands you the number of chips that represent their level of hurt.

But the hardest assessment is the patient who cannot participate at all.

Oh, absolutely.

A patient who is severely cognitively impaired or intubated and mechanically ventilated.

They can't point to a face or hold up fingers.

That is when you utilize the FLAC scale, F -L -A -C -C.

FLAC is an acronym that stands for Face, Legs, Activity, Cry, and Consolability.

Okay, so it's all observational.

Entirely.

Instead of asking the patient, you observe their involuntary physical behaviors in each of these five categories and score them from zero to two.

Give me an example.

So for example, under legs, a relaxed posture scores a zero.

But if their legs are drawn up tightly to their chest or kicking you radically, that scores a two.

You add the scores from all five categories to generate a total objective pain score from zero to 10.

Gathering this data is rarely straightforward though.

There are significant hurdles that can derail your assessment.

Like language barriers are a major one.

Huge hurdle.

If you and the patient do not speak the same primary language, you must use a professional medical interpreter.

Never rely on a family member to translate.

Because a patient might desperately wanna hide embarrassing, highly personal, or culturally sensitive pain information from their children or spouse.

Using the facility's approved translation services ensures accurate, unfiltered clinical data.

Another frequent hurdle is referred pain.

This is pain that's perceived in an area of the body completely separate from where the actual tissue damage is occurring.

Right, because of the nerves.

Yeah, usually because nerve signals from different areas converge on the same pathway in the spinal cord.

A classic example is a patient experiencing severe cardiac ischemia, a heart attack.

But the pain is felt radiating down their left arm or deep in their jaw.

And perhaps the most dangerous trap a nurse can fall into is the false perception of pain.

Oh, this happens all the time.

There is a deep -seated tendency in healthcare to disbelieve a patient's self -report if they simply don't look like they're suffering.

The clinical reality is that severe pain does not always look like screaming and thrashing.

A post -operative patient might be sitting up, watching a comedy on TV and laughing with a visiting friend.

But when you ask them, they report their pain is an eight out of 10.

Which feels like a lie to a lot of people.

Right, but they aren't lying to get medication.

They're utilizing active distraction to cope with the overwhelming sensation.

Another scenario that catches nurses off guard is the sleeping patient.

You walk into a room, the patient is fast asleep, so you assume their pain is controlled and you hold their scheduled pain medication.

But absence of wakefulness does not equal absence of pain.

Exactly, they might be sleeping because days of uncontrolled, agonizing pain have left their central nervous system completely depleted.

They haven't found relief, they've simply crashed from sheer exhaustion.

When they wake up, the pain will be right there waiting.

You must rely on the patient's self -report, not their outward performance.

With accurate, unbiased assessment data in hand, we transition to the action phases of the nursing process.

Planning, implementation,

and evaluation.

This is where your clinical reasoning transforms into a prioritized care plan.

In the planning phase, our goals need to be realistic.

Ideally, the goal is total relief of pain.

But realistically, especially with chronic conditions or major trauma, the goal becomes the control of pain to a level that allows the patient to participate in their recovery.

Like being able to cough deeply or tolerate physical therapy.

And implementation involves executing both pharmacologic and non -pharmacologic measures.

Administering the right drug via the right route safely is obvious, but the non -pharmacologic adjuncts are vital to addressing the biopsychosocial nature of pain.

Like what?

Smoothing wrinkled bedclothes, adjusting harsh lighting, repositioning the patient to relieve joint stress.

And there's a massive emphasis on sleep.

Promoting adequate uninterrupted rest actively allows the central nervous system to recover, which physically increases a patient's pain tolerance and improves their physiological response to analgesic medications.

Timing your implementation is everything too.

You have to stay ahead of the pain cascade.

We call this preemptive analgesia.

Yes, so important.

If you know a patient is scheduled for painful physical therapy, you administer their analgesic well before the activity starts.

I mean, it's like putting on a raincoat before you step out into the storm.

You wouldn't wait until you're soaking wet to put on a raincoat and try to get dry.

That's a great way to think about it.

If you wait until they are in agony, the gate is wide open and the central nervous system is already flooded with excitatory neurotransmitters.

At that point, you're trying to stop a runaway freight train.

It takes exponentially more medication to dial that severe pain back down than it would have taken to prevent it from spiking in the first place.

Put the brakes on before the car starts rolling down the hill.

Once you've implemented the intervention,

you cannot just walk away.

You must move to evaluation.

You have to circle back and ask the patient,

how quickly did you feel relief?

How long did that relief last?

Are you experiencing any side effects like nausea or severe sedation?

And the timing of your evaluation is dictated entirely by the route of administration.

Exactly.

If you give an oral medication a pill, it has to travel through the GI tract, get absorbed, pass through the liver, and finally enter the bloodstream.

You need to wait 30 to 45 minutes before you can accurately evaluate its effectiveness.

But if you administer an intravenous medication, it goes directly into the bloodstream.

You should evaluate the patient within five to 15 minutes.

And for nonverbal patients, you evaluate by looking for changes in those objective FLACC signs we discussed earlier.

You note that an aphasic stroke patient is no longer thrashing, their legs have uncurled, and the deep tension in their facial muscles has relaxed.

Finally, you document.

In nursing, if it wasn't documented, it wasn't done.

The golden rule.

Your documentation must include the initial assessment findings, the specific pain scale you used, the exact measure taken, your timed evaluation of its effectiveness, and crucially, if the pain wasn't relieved, you must document that you elevated the issue and notified the provider.

Which brings us to the ultimate goal of patient care,

translating these hospital -based strategies into the community and extended care environments.

The nursing process does not magically end at discharge.

When we look at extended care facilities like skilled nursing facilities or long -term care, the terminology actually shifts.

We use the term resident instead of patient because this facility is their permanent home.

Yes.

And whether these residents are alert and oriented, mildly confused or experiencing significantly decreased consciousness due to dementia, they still perceive pain and they still require scheduled analgesics.

But nurses must be hypervigilant in this population.

Because of their age.

Exactly.

The aging process alters pharmacokinetics.

Older adults naturally have decreased renal function and slower hepatic metabolism.

The liver processes the drugs slower and the kidneys excrete it much slower, meaning the drug stays active in their bloodstream far longer than it would in a young adult.

Which puts them at an incredibly high risk for medication toxicity, even with over -the -counter drugs.

A resident taking routine acetaminophen for chronic osteoarthritis might develop confusion or lethargy.

It's easy to dismiss that as well just getting older when in reality it's insidious medication toxicity.

Careful monitoring is non -negotiable.

And for patients being discharged to their own homes, patient and family education becomes the primary nursing intervention.

You must aggressively teach the patient to maintain a strict written medication record at home.

Because it's so easy to forget.

Exactly.

When you are exhausted and in pain, it is incredibly easy to forget when you took your last dose, which is exactly how accidental overdoses occur.

You also need to verify that 24 -hour assistance telephone numbers are prominently displayed in their home so they aren't left stranded if complications arise.

And don't forget to empower the family.

Teach them how to properly use non -pharmacologic adjuncts, how to safely apply warm compresses, how to help the patient reposition, and how to use quiet environments or soft music to augment the pharmacological plan.

If we pull all of these concepts together, the nerve fibers, the subjective assessments, the medications, the environmental factors, it raises a really fascinating question regarding the biopsychosocial model.

What's that?

If pain is genuinely constructed by an entanglement of biological, psychological, and sociological factors all reacting together, how might the actual physical design of a patient's hospital room or the tone of voice the nurse uses or the specific social support waiting for them in their community literally and physically alter their central nervous system's pain pathways?

It suggests that the environment we construct around a patient is just as potent a medical intervention as the IV fluids or the opioids we administer.

That is a profound realization to carry with you onto the clinical floor.

How does the environment you create for your patient physically change their nervous system?

It's powerful.

It really is.

Well, thank you so much for joining us for this deep dive into chapter seven.

On behalf of the last minute lecture team, we wanna wish you the absolute best of luck on your upcoming exams, and more importantly, in your future clinical practice.

You are going to be an incredible nurse.

We'll see you next time.