DIZON, Dexie July 1, 2019

BSN1 Health Assessment

1. Define the following Terms:

 PAIN - an unpleasant sensory and emotional experience associated with actual or

potential tissue damage or described in terms of such damage.
 PAIN TOLERANCE - is the maximum amount of painful stimuli that a person is
willing to withstand without seeking avoidance of the pain or relief.
 PAIN THRESHOLD – is the least amount of stimuli that is needed for a person to
label a sensation as pain.
 PAIN PERCEPTION – is the sum of complex activities in the central nervous system
that may shape the character and intensity of pain perceived as ascribe meaning to
the pain.
 HYPERALGESIA – increased sensation of pain in response to a normally painful
stimulus.
 ALLODYNIA – sensation of pain from a stimulus that normally does not produce
pain, eg., light touch.

2. Discuss the physiology of pain and the following pain theories:

PHYSIOLOGY OF PAIN - how pain is transmitted and perceived is complex, in part because of
the nature of fully integrated, constantly changing structure of the central nervous system, and
the symphony of chemical mediators, only a fraction of which are understood. The extent to
which pain is perceived depends on the interaction between the body’s analgesia system and
the nervous system’s transmission and the mind’s interpretation of stimuli and its meaning.
a. GATE CONTROL THEORY - according to Melzack and Wall’s gate theory (1965), small-
diameter (A-delta, or C) peripheral nerve fibers carry signals of noxious stimuli to the
dorsal horn, where these signals are modified when they are exposed to the substantia
gelatinosa (the mileu in the central nervous system) that may be imbalanced in an
excitatory or inhibitory direction. Ion channels on the pre- and postsynaptic membranes
serve as gates that, when open, permit positively charged ions to rush into the second
order neuron, sparkling an electrical impulse and sending signals of pain to the
thalamus.
Peripherally, large-diameter (A-delta) nerve fibers, which typically send messages of
touch, or warm or cold temperatures, have an inhibitory effect on the substantia
gelatinosa, and may activate descending mechanisms that can lessen the intensity of
pain perceived or inhibit the transmission of those pain impulses—that is, close the (ion)
gates.
 Higher centers in the brain, especially those associated with affect and motivation, are
capable of modifying the substantia gelatinosa and influence the opening or closing of
the gates. For example, if a little girl is playing with a ball that rolls under the couch, and
in the process of retrieving it her hand gets stuck and pinched (the A-delta fibers are
activated), the anxiety of not knowing what to do, combined with the negative impact
on motivation (not being able to play with the ball), excites the substantia gelatinosa
and facilitates opening the gates transmitting messages of pinching pain. When her
mother comes and frees her and “kisses her boo-boo,” the A-delta fibers are activated
by the light touch, moisture, and warmth of the kiss. The girl feels love and is motivated
to please her mother, all of which combine to calm the substantia gelatinosa and close
the gates, inhibiting the transmission of further pain. Clinically, nurses can use this
model to stop nociceptor firing (treat the underlying cause), apply topical therapies
(e.g., heat, ice, electrical stimulation, or massage), and address the client’s mood (e.g.,
reduce fear, anxiety, and anger) and goals (e.g., client education, anticipatory guidance).

b. SPECIFICITY THEORY – it holds that specific pain receptors transmit signals to a “pain
center” in the brain that produces the perception of pain. Von Frey (1895) argued that
the body has a separate sensory system of perceiving pain—just as it does for hearing
and vison. This theory considers pain as an independent sensation with specialized
peripheral sensory receptors (nociceptors), which respond to damage and send signals
through pathways (along nerve fibers) in the nervous system to target centers in the
brain. These brain centers process the signals to produce the experience of pain. Thus, it
is based on the assumption that the other three types of receptors are also specific to a
sensory experience.

c. PATTERN THEORY- in an attempt to overhaul theories of somaesthesis (including pain),

J. P. Nafe postulated a “quantitative theory of feeling” (1929). This theory ignored
findings of specialized nerve endings and many observations supporting the specificity
and/or intensive theories of pain. The theory stated that any somaesthetic sensation
occurred by a specific and particular pattern of neural firing and that the spatial and
temporal profile of firing of the peripheral nerves encoded the stimulus type and the
intensity. Lele et al. (1954) championed this theory and added that cutaneous sensory
nerve fibers, with the exception of those innervating hair cells, are the same. To support
this claim, they cited work that had shown that distorting a nerve fiber would cause
action potentials to discharge in any nerve fiber, whether encapsulated or not.
Furthermore, intense stimulation of any of the nerve fibers would cause the percept of
pain. (Sinclair 1955; Weddell 1955).
 3. What is nociception? Enumerate and discuss the 4 processes of nociception.
NOCICEPTION – The peripheral nervous system includes primary sensory neurons specialized to
detect mechanical, thermal, or chemical conditions associated with potential tissue damage.
The signals, when these nociceptors are activated, must be transduced and transmitted to the
spine and brain where the signals are modified before they are ultimately understood and
“felt.” The physiologic processes related to pain perception are described as nociception. Four
physiologic processes are involved in nociception: transduction, transmission, perception, and
modulation.

4 Physiologic Processes:

 Transduction – specialized pain receptors or nociceptors can be excited by mechanical,

thermal, or chemical stimuli. During the transduction phase, noxious stimuli, (with the
potential to injure tissue) trigger the release of biochemical mediators (e.g.,
prostaglandins, bradykinin, serotonin, histamine, substance P) that sensitize
nociceptors. Noxious or painful stimulation also causes movement of ions across cell
membranes, which excites nociceptors. Pain medications can work during this phase by
blocking the production of prostaglandin (e.g., ibuprofen or aspirin) or by decreasing the
movement of ions across the cell membrane (e.g., local anesthetic). Another example is
the topical analgesic capsaicin (Zostrix), which depletes the accumulation of substance P
and blocks transduction.

 Transmission – the second process of nociception, transmission of pain, includes three

segments (McCaffery & Pasero, 1999). During the first segment, the pain impulse travels
from the peripheral nerve fibers to the spinal cord. Substance P serves as a
neurotransmitter, enhancing the movement of impulses across the nerve synapse from
the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal
cord. Two types of nociceptor fibers cause this transmission to the dorsal horn of the
spinal cord: unmyelinated C fibers, which transmit dull, aching pain, and thin A-delta
fibers, which transmit sharp, localized pain. In the dorsal horn, the pain signal is
modified by modulating factors (e.g., excitatory amino acids or endorphins) before the
amplified or dampened signal travels via spinothalamic tracts. The second segment is
transmission from the spinal cord, and ascension via spinothalamic tracts to the brain
stem and thalamus. The third segment involves the transmission of signals between the
thalamus to the somatic sensory cortex where pain perception occurs. Pain control can
take place during this second process of transmission. For example, opioids (narcotic
analgesics) block the release of neurotransmitters, particularly substance P, which stops
 the pain at the spinal level. Capsaicin may also deplete substance P that could inhibit the
transmission of pain signals.

 Modulation – often described as the “descending system,” this third process occurs
when neurons in the thalamus and brain stem send signal back down to the dorsal horn
of the spinal cord (Paice, 2002, p. 75.). these descending fibers release substances such
as endogenous opioids, serotonin, and norepinephrine, which can inhibit (dampen) the
ascending noxious (painful) impulses in the dorsal horn. In contrast, excitatory amino
acids (e.g., glutamate, N-methyl-D-aspartate (NMDA), and the upregulation of excitatory
glial cells can facilitate (amplify) these pain signals. The effects of excitatory amino acids
and glial sell tend to persist, while the effects of the inhibitory neurotransmitters tend
to be short-lived as they are reabsorbed into the nerves. Tricyclic antidepressants block
the reuptake of norepinephrine and serotonin; or NMDA antagonists (e.g., ketamine,
dextromethorphan) maybe used to help diminish the signals of pain.

 Perception – the final process, perception, is when the client becomes conscious of the
pain. Pain perception is the sum of complex activities in the central nervous system that
may shape the character and intensity of pain perceived and ascribe the meaning to the
pain. The psychosocial context of the situation and the meaning of the pain is based on
the past experiences and future hopes/dreams help to shape the behavioral response
that follows.

4. Enumerate the different types of pain as to:

a. LOCATION – classification of pain based on where it is in the body (e.g., headache,

backache, chest pain) may be useful in determining the client’s underlying problems or
needs; or it may be problematic given that most clients don’t fit neatly into one of the
categories. For example, categorizing a head pain as headache can be difficult as the
International Hygiene Society recognizes 300 different types of headaches, may have
similar clinical presentations, but different clinical needs (HIS, 2004). Location of pain is,
however, a very important component to note. For example, if after knee surgery, a
client reports moderately severe chest pain, the nurse must act immediately to further
evaluate and treat this discomfort. The ability to discriminate between cardiac and non-
cardiac chest pain challenges even expert clinicians, but the fac that chest pain is
evaluated and treated differently than knee pain in this client is understandable.
Complicating the categorization of pain by location is the fact that some pains radiate
(spread or extend) to other areas (e.g., low back to legs). Also, pain may be referred
(appear to arise in different areas) to other parts of the body. For example, cardiac pain
maybe felt in the soldier or left arm, with or without chest pain. Visceral pain (pain
 arising from organs or hollow viscera) often presents this way, being perceived in an
area remote from the organ causing the pain.

b. DURATION – when pain lasts only through the expected recovery period, it is described
as acute pain, whether it has a sudden or slow onset and regardless of the intensity.
Chronic pain, on the other hand, is prolonged, usually recurring or persisting over 6
months or longer, and interferes with functioning. Acute and chronic pain result in
different physiologic and behavioral responses. Although experts may disagree on
whether the cut off point for chronic pain should be 1, 3, or 6 months after onset or
expected healing time, NANDA specifies the accepted nursing diagnosis of Chronic Pain
to be mild to severe, constant or recurring, without an anticipated or predictable end
and a duration of greater than 6 months (Ackley & Ladwig, 2006). The categories
differentiating chronic cancer (malignant) pain from chronic nonmalignant pain have
also been problematic. Cancer pain may result from the direct effects of the disease and
its treatment, or it may be unrelated to the disease and its treatment in individuals with
cancer. Over the years, other diagnoses have been included in the “malignant pain”
category, such as HIV/AIDS or burn pain, which tend to be treated more aggressively
than “nonmalignant pain.”

c. INTENSITY – to avoid ambiguity, categorizing pain according to intensity (mild,

moderate, severe) or the underlying physiology (somatic, visceral, neuropathic) has
emerged as a useful way to identify types of pain. Serlin, Mendoza, Nakamura, Edwards,
and Cleeland (1995) conducted a large-scale international study that confirmed earlier
classifications of pain by intensity using a standard 0 (no pain) to worst (worst possible
pain) scale. Linking the rating to health and functioning scores, pain in the 1-3 range is
deemed mild pain, a rating of 4-6 is moderate pain, and pain reaching 7-10 is ranked
severe pain and is associated with the worst outcomes.

d. ETIOLOGY – designating types of pain by etiology can be done under the broad
categories of physiological pain and neuropathic pain. Physiological pain is experienced
when intact, properly functioning nervous system sends signals that tissues are
damaged, requiring attention and proper care. For example, the pain experienced
following a cut or broken bone alerts the person to avoid further damage until it is
properly healed. Once stabilized or healed, the pain goes away; thus, this pain is
transient. There may also be persistent forms of physiologic pain. For example, a person
who has lost the protective cartilage in joints will have pain when they stress those
joints, as the bone-to-bone contact damage tissues. This common form of arthritis
produces pain in millions of sufferers, some of whom have intermittent pain whereas
others have constant pain that persists for years. Subcategories of physiologic pain
include somatic or visceral. Somatic pain originates in the skins, muscles, bone, or
connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are
common examples of somatic pain. Visceral pain results from activation of pain
receptors in the organs and/or hollow viscera. Visceral pain tends to be poorly located,
and may have a cramping, throbbing, pressing, or aching quality. Often visceral pain is
associated with feeling sick (e.g., sweating, nausea, or vomiting) as in the examples of
labor pain, angina pectoris, or irritable bowel. Neuropathic pain is experienced by
people who have damaged or malfunctioning nerves. The nerves may be abnormal due
to illness (e.g., postherpetic neuralgia, diabetic peripheral neuropathy), injury (e.g.,
phantom limb pain, spinal cord injury pain), or undetermined reasons. Subtypes of
neuropathic pain are being developed based on the part of the nervous system believed
to be damaged (Pasero, 2004). Peripheral neuropathic pain (e.g., phantom limb pain,
postherpetic neuralgia, carpal tunnel syndrome) follows damage and/or sensitization of
peripheral nerves. Central neuropathic pain (e.g., spinal cord injury pain, post stroke
pain, multi sclerosis pain) results from malfunctioning nerves in the central nervous
system. Sympathetically maintained pain occurs occasionally when abnormal
connections between fibers and the sympathetic nervous system perpetuate problems
with both the pain and sympathetically controlled functions (e.g., edema, temperature
and blood flow regulation). Neuropathic pain is typically chronic; it is described as
burning, “electric-shock,” and/or tingling, dull, and aching. Episodes of sharp, shooting
pain can also be experienced (Herr, 2004). Neuropathic pain tends to be difficult to
treat. Unfortunately, evidence suggests that in some instances, neuropathic pain results
from a failure to treat pain effectively during the perioperative period (Manais, Bucknail,
& Botti, 2005). Common pain syndromes are briefly described in Clinical Manifestations.
5. Discuss and present diagram of the following Pain Assessment Tools:

a. Numerical Pain Rating Scale – the use of pain intensity scales is an easy and reliable
method of determining the client’s pain intensity. Such scales provide consistency for
nurses to communicate with the client and other health care providers. To avoid
confusion, scales should use a 0-10 range with 0 indicating “no pain” and the highest
number indicating the “worst pain possible” for that individual. The inclusion of word
modifiers on the scale can assist some clients who find it difficult to apply a number
level to their pain. For example, after ruling out “0” and “10” (neither no pain nor the
worst possible pain), a nurse can ask the client if it is mild (2), mild to moderate (4),
moderate to severe (6), or severe (8). Another way to evaluate the intensity of pain for
clients who are unable to use numeric rating scales is to determine the extent of pain
awareness degree of interference with functioning. For example, 0=no pain,
2=awareness of pain only when paying attention to it, 4=can ignore pain and do things,
6=can’t ignore pain, interferes with functioning, 8=impairs ability to function or
concentrate, and 10=intense incapacitating pain. It is believed that the degree that pain
interferes with functioning is a good marker for severity of pain, especially for those
with chronic pain.

b. Wong Baker Pain Scale - not all clients can understand or relate to numerical pain
intensity scales. These include preverbal children, elderly clients with impairments in
cognition or communication. And people who do not speak English. For these clients,
Wong-Baker FACES Rating Scale may be easier to use (Wong, Hockenberry-Eaton,
Wilson, Winkelstein, & Schwartz, 2001). The face scale includes a number scale in
relation to each expression so that pain intensity can be documented. When clients are
unable to verbalize their pain for reasons of age, men, mental capacity, medical
interventions, or other reasons, nurses need to accurately assess the intensity of each
client’s pain and the effectiveness of the pain management interventions. For these
clients, the nurse must rely on observation of behavior. Explain to the person that each
fac 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 1 hurts
just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole
lot. Face 5 hurts as much as you imagine, 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.
c. PQRST pain assessment – since pain is subjective, self-report is considered the Gold
standard and most accurate measure of pain. The PQRST method of assessing pain is a
valuable tool to accurately describe, assess and document a patient’s pain. The method
also aids in the selection of appropriate pain medication and evaluating the response to
treatment.

d. COLDSPA - refers to pain, used in assessment. COLDSPA is a mnemonic that stands for
Character, Onset, Location, Duration, Severity, Pattern, Associated factors.
 6. Enumerate and discuss pain management as to:

a. Pharmacologic (Pain medications according classification, examples, action of the

drug, side effects, nursing responsibilities)

 NONOPIOID ANALGESICS/NSAIDS
- nonopiods include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen or aspirin. NSAIDs have anti-inflammatory, analgesic, and antipyretic effects, whereas
acetaminophen has only analgesic and antipyretic effects. The anti-inflammatory action relieves
pain by interfering with the cyclooxygenase (COX) chemical cascade that is activated by
damaged tissue. The COX chemical reactions produce prostaglandins and other anti-
inflammatory chemicals that cause a firing of nociceptive fibers. The COX-1 specific isoforms are
found in platelets, gastrointestinal (GI) tract, kidneys, and most other tissue, and are believed
to be the cause of well known side effects of NSAIDs (GI bleed, diminished renal blood flow,
inhibited clotting, etc.)

Categories and Examples of Analgesics

NONOPIOID ANALGESICS/NSAIDS
Acetaminophen Tylenol, Datril
Acetylsalisilic apirin
Choline magnesium trialicylate Trilisate
Diclofenac sodium Voltaren
Ibuprofen Motrin, Advil
Indomethacin sodium trihydrate Indocin
Naproxen Naprosyn
Naproxen sodium Anaprox
Celecoxib Celebrex
Piroxicam Feldene
Meloxicam Mobic
 MIXED OR WEAK OPIOID ANALGESICS
- these include drugs that are weak opioids (e.g., propoxyphene, codeine, tramadol);
mixed agonist-antagonist drugs; or combination opioids with nonopioid (NSAIDs)
analgesics compounds. These medicines are generally 2 to 4 times more potent that
nonopioids alone and have some of the risks of both drug classes. With a rare exception,
these are controlled substances and must be ordered by a physician or nurse
practitioner, adhering to applicable federal and state laws. These drugs also have a
ceiling effect and a maximum daily dosage limit. There are advantages to giving
combination drugs, such as lowering the amount of ay medicine needed in a 24-hour
period, thus reducing the potential for side effects or toxicity; however, nurses need to
be familiar with each medication and be aware of daily dose limits of the ingredients as
well as potential to receive duplicate medications for different clinical indications (e.g.,
Tylenol in the mixed drug, Tylenol for fever, and Tylenol in the headache preparation).
Among the weak opioids, there is a narrow therapeutic index. Codeine at doses of 30-60
mg produces dose-limiting gastrointestinal distress in many people. Propoxyphene
produces a by-product that irritates nerves and muscles, and tramadol lowers seizure
threshold. The mixed agonist-antagonist drugs have some properties of naloxone
(Narcan), and thus in individuals who have been on opioids for a period of time, these
drugs can cause a serious withdrawal reaction. Therefore, mixed agonist-antagonist
medications (Talwin, Stadol, Nubain, etc.) may be a first opioid tried, but the client is not
switched from another opioid to these preparations.

Categories and Examples of Analgesics

MIXED OR WEAK OPIOID ANALGESICS
Butorphanol Stadol
Hydrocodone Lortab, Vicodin
Codeine Tylenol No.3, Empirin No. 3
Tramadol Ultram, Ultracet
Propoxyphene napsylate Darvon-N, Darvocet-N
 STRONG OPIOID ANALGESICS
- pure agonist opioid analgesics include opium derivatives, such as morphine
hydromorphone, oxcycodone, fentanyl, and methadone (APS, 2003). Opioid is the
pharmacologic class of pain relievers, many of which are “scheduled” as a controlled
substance (narcotic) due to potential for misuse. Pure agonist opioids relieve pain
primarily by binding to mu receptors in the peripheral and central nervous systems. In
addition to pain reduction, changes in the mood may make the person feel more
comfortable even though the pain persists. As the most potent class of pain relievers,
the se drugs are indicated for severe pain, or when other medications have failed to
control moderately severe or worse pain. Among this class, meperidine (Demerol) has
received a lot of attention in recent years as a medication to avoid because of its short
half-life, toxic metabolite, and potential to induce seizures with repeated doses.

Categories and Examples of Analgesics

STRONG OPIOID ANALGESICS
Fentanyl citrate Sublimaze, transdermal patches
Hydromorphone hydrochloride Dilaudid
Meperidine hydrochloride Demerol
Morphine sulfate morphine
Methadone Dolophine

Opioid Side Effects

- when administering any analgesic, the nurse must review side effects. Side effects of
opioids typically include respiratory depression, sedation, nausea/vomiting, urinary
retention blurred vision sexual dysfunction, and constipation. The most concerning
adverse effect of opioids is respiratory depression (e.g., 8 per minutes or less), which
usually occurs early in therapy among opioid naïve clients; with dose escalation; or in
clients with drug-drug or drug-disease interactions. Clinically, the client will appear
overly sedated, and respirations will be slow and deep with periods of apnea. The nurse
needs to assess a client’s level of alertness and respiratory rate for baseline data before
administering narcotics. Often, clients will manifest an increase in sedation before they
manifest a decrease in respiratory rate and depth. Early recognition of an increasing
level of sedation or respiratory depression will enable the nurse to implement
appropriate measures promptly (e.g., pulse oximetry monitoring, obtaining an order to
decrease the opioid dosage).
 Sedation Scale
S= Sleep, easy to arouse
1= Awake and alert
2= Slightly drowsy, easily aroused
3= frequently drowsy, arousable, drifts off to sleep during
conversation
4= Somnolent, minimal or no response to physical stimulation

 COANALGESICS
- a coanalgesic agent (formerly known as an adjuvant) is a medication that is not
classified as a pain medication. However, coanalgesics have properties that may reduce
pain alone or in combination with other analgesics relieve other discomforts, potentiate
the effect of pain medications, or reduce the pain medication’s side effects. Examples of
coanalgesics that relieve pain are antidepressants (support the function of the pain-
modulating system); anticonvulsants (stabilize nerve membranes, reducing excitability
and spontaneous firing); local anesthetics (block the transmission of pain signals).
Anxiolytics, sedatives, and antispasmodics are examples of medicines that relieve other
discomforts; however, they do not alleviate pain and thus should be used in addition to
rather than instead of analgesics. Examples of medications used to reduce the side
effects of analgesics include stimulants, laxatives, and antiemetics. Coanalgesics appear
to be particularly beneficial for the management of neuropathic pain. Tricyclic
antidepressant drugs seem to be particularly useful for central neuropathic pain, which
often manifests as pain with a burning, unusual, or stinging quality. Anticonvulsant
drugs, such as gabapentin seem particularly useful for peripheral neuropathic conditions
that often present with a stabbing, shooting, or electrical-shock quality. Local
anesthetics such as the Lidoderm patch also alleviate neuropathic as well as other types
of pain and are particularly useful for clients with the skin sensitivity known as allodynia.
There is a growing scientific and clinical basis for the use of these medications in
relieving pain, especially for persistent pain that is not relieved by the analgesic classes
of medication.

Categories and Examples of Analgesics

COANALGESICS
Tricyclic antidepressants nortriptyline
Anticonvulsants gabapentin
Topical local anesthetic Lidoderm
Hydroxyzine Vistaril
b. Nonpharmacologic (Cutaneous stimulations, TENS, relaxation, others….)
- nonpharmacologic pain management consists of a variety of physical, cognitive-
behavioral, and lifestyle management strategies that target the body, mind, spirit, and
social interactions. Physical modalities include cutaneous stimulation, ice or heat,
immobilization or therapeutic exercises, transcutaneous electrical nerve stimulation
(TENS), and acupuncture. Mind-body (cognitive-behavioral) interventions include
distracting activities, relaxation techniques, imagery, meditation, biofeedback, hypnosis,
cognitive-reframing, emotional counseling, and spiritually-directed approaches such as
therapeutic touch or Reiki. Lifestyle management approaches include symptom
monitoring, stress management, exercise, nutrition, pacing activities, disability
management, and other approaches needed by many clients with persistent pain that
has drastically changed their life.

 PHYSICAL INTERVENTIONS
- the goals of physical intervention include providing comfort, altering physiologic
responses to reduce pain perception, and optimizing functioning.

 CUTANEOUS STIMULATION
- cutaneous stimulation can provide temporary pain relief. It distracts the client and
focuses attention on the tactile stimuli, away from the painful sensations, thus reducing
pain perception. Cutaneous stimulation is also believed to interfere with the
transmission and perception of pain by stimulating the large-diameter A-beta sensory
nerve fibers that activate the descending mechanisms that can reduce the intensity of
pain, activate the endorphin system of pain control, and thus diminish conscious
awareness of pain. Selected cutaneous stimulation techniques include the following:
 Massage - a comfort measure that can aid relaxation, decrease muscle tension,
and may ease anxiety because the physical contact communicates caring. It can
also decrease pain intensity by increasing superficial circulation to the area.
massage can involve the back and neck, hands and arms, or feet. The use of
ointments or liniments may provide localized pain relief with joint or muscle
pain. Massage is contraindicated in areas of skin breakdown, suspected clots, or
infections.
 Application of heat and cold – a warm bath, heating pads, ice bags, ice massage,
hot or cold compresses, and warm or cold sitz baths in general relieve pain and
promote healing of injured tissues.
 Acupressure – developed from the ancient Chinese healing system of acupuncture.
The therapist applies finger pressure to points that correspond to many of the
points used in acupuncture.
 Contralateral stimulation – can be accomplished by stimulating the skin in an area
opposite to the painful area (e.g., stimulating the left knee if the pain is in the
 right knee). The contralateral area may be scratched for itching, massaged for
cramps, or treated with cold packs or analgesic ointments. This method is
particularly useful when the painful area cannot be touched because it is
hypersensitive, when it is inaccessible by a cast or bandages, or when the pain is
felt in a missing part (phantom pain).

 IMMOBILIZATION/ BRACING
- immobilizing or restricting the movement of a painful body part (e.g., arthritic joint,
traumatized limb) may help to manage episodes of acute pain. Splints or supportive
devices should hold joints in the position of optimal function and should be removed
regularly in accordance with agency protocol to provide range-of-motion (ROM)
exercises. Prolonged immobilization can result in joint contracture, muscle atrophy, and
cardiovascular problems. Therefore, clients should be encouraged to participate in self-
care activities and remain as active as possible, with frequent ROM exercises.

 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

- is a method of applying low-voltage electrical stimulation directly over identified pain
areas, at an acupressure point, along peripheral nerve areas that innervate the pain
area, or along the spinal column. The TENS unit consists of a portable, battery-operated
device with lead wire and electrode pads that are applied to the chosen area of skin.
Cutaneous stimulation from TENS unit is thought to activate larger-diameter fibers that
modulate the transmission of the nociceptive impulse in the peripheral and central
nervous system (closing the pain “gate”), resulting in pain relief. This stimulation may
also cause a release of endorphins from the CNS centers. The use of TENS is
contraindicated for clients with pacemaker or arrhythmias, or in areas of skin
breakdown. It is generally not used on the head or over the chest.

 COGNITIVE-BEHAVIORAL INTERVENTIONS
- the goals of cognitive-behavioral interventions include providing comfort, altering
psychologic responses to reduce pain perception, and optimizing functioning. Selected
cognitive-behavioral interventions include:
 Distraction
 Eliciting the relaxation response
 Repatterning unhelpful thinking
 Facilitating coping
 Selected spiritual interventions
 NONPHARMACOLOGIC INVASIVE THERAPIES
 a nerve block is a chemical interruption of a nerve pathway, effected by injecting local
anesthetic into the nerve. Nerve blocks are widely used during dental work. The injected
drug blocks nerve pathways from the painful tooth, thus stopping the transmission of pain
impulses to the brain. Nerve blocks are often used to relieve the pain of whiplash injury,
lower back disorders, bursitis, and cancer. With the intention of quieting “pain generators”
(irritable nerves that cause pain), a combination of a long-acting local anesthetic and a
steroid is injected adjacent to the problem nerve (e.g., lumbar epidural steroid injections,
joint injections). The local anesthetic should provide relief for several hours, before the
effect of the steroid begins a day or two later. Often a series of three injections are
scheduled weeks or months apart. Each subsequent injection should result in a longer
duration of pain relief. No more than three injections per year are recommended because of
the mineral-robbing effects steroids have on bones in the area. for longer lasting results
after a nerve block has worked, more permanent blocks may be attempted. The
“permanent” blocks involve damaging nerves with alcohol, phenol, or radio frequency
(heat). These nerve-killing procedures are controversial as nerve fibers often regenerate and
the pain returns in a significant proportion of clients.
Pain conduction pathways can be interrupted surgically. Because this disruption is permanent,
surgery is performed only as a last resort, generally for intractable pain. Several surgical
procedures may be performed.
 A cordotomy obliterates pain. Temperature sensation below the level of the
spinothalamic portion of the anterolateral tract is severed. This procedure is usually
done for pain in the legs and trunk.
 Rhizotomy interrupts the anterior or posterior nerve root between the ganglion and the
cord. Interruption of the anterior motor nerve roots stops spasmodic movements that
accompany paraplegia. Interruption of posterior sensory nerve roots eliminates pain in
areas innervated by that specific nerve root. Rhizotomies are generally performed on
cervical nerve roots to alleviate pain of the head and neck from cancer or neuralgia, and
increasingly they use radio frequency technologies.
 In neurectomy, peripheral or cranial nerves are interrupted to alleviate localized pain,
such as pain in the lower leg or foot arising from vascular occlusion.
 In sympathectomy, pathways of the sympathetic division od the autonomic nervous
system are severed. This procedure eliminates vasospasms, improves peripheral blood
supply, thus is effective in treating painful vascular disorders such as Raynaud’s disease.
 Spinal cord stimulation (SCS) is used with persistent pain that has not been controlled
with less invasive therapies. SCS involves the insertion of an electrode (may be single
channel or multichannel device) adjacent to the spinal cord in the epidural space. The
electrode(s) is attached to an impulse-generator (external or implanted) that sends
electric impulses to the spinal cord to control pain. The client is awake during the
insertion procedure to aid in the optimal placement of the electrodes.