Pain
1. Pain – unpleasant sensory and emotional experience associated with actual or potential tissue damage or described
a. Referred pain – must be considered when an injury involving visceral organs
i. Liver disease – usually located in RUQ of abdomen but can be referred to anterior and posterior neck region and posterior flank
2. Classifications of pain
a. Nociceptive pain – damage to somatic or visceral tissue
i. Somatic pain – superficial or deep
1. Superficial – arises from skin, mucous membranes, and subcutaneous tissue; described as sharp, burning or prickly
a. Sunburn, skin contusion
2. Deep pain – originates from bone, joint, muscle, skin or connective tissue; described as deep, aching, or throbbing
a. Arthritis, tendonitis, muscle pain ii. Visceral pain – activation of nociceptors in the internal organs and lining of body cavities (thoracic and abdominal cavities) usually in response to inflammation, stretching or ischemia; stretching of intestines or bladder from tumor, surgical incision, pancreatitis, appendicitis
b. Neuropathic pain – caused by damage to peripheral nerves or structures in CNS; described as numbing, hot, burning, shooting, stabbing, sharp, electric shock
i. Causes – trauma, inflammation of nerves, metabolic disease (diabetes), infections of nervous system, tumors, neurologic disease (multiple sclerosis) ii. Deafferentation pain – loss of afferent input due to peripheral nerve injury (amputation) or CNS damage iii. Sympathetically maintained pain – dysregulation of the ANS iv. Central pain – caused by CNS lesions or dysfunction
c. Acute pain – sudden onset and last less than 3 months and decreases over time and goes away as recovery occurs; generally can identify cause (illness, surgery)
i. Clinical manifestations – increases HR, RR, BP, diaphoresis, pallor, anxiety, agitation, urine retention
d. Chronic pain – persistent pain lasting longer than 3 months that does not typically go away; cause may not be known
i. Clinical manifestations – predominately behavioral; decreased physical activity, fatigue, withdrawal

3. Pain assessment
a. Pain pattern – onset and duration
i. Breakthrough pain – transient, moderate to severe pain that occurs in patients whose baseline persistent chronic pain is fairly well controlled ii. End of dose failure – pain that occurs before expected duration of specific analgesic
1. Transdermal fentanyl – typical duration is 72 hours but an increase in pain after 48 hours would be characterized as end of dose iii. Incident pain – transient increase in pain cause by a specific activity
b. Location
i. Referred pain – pain site is different from origin; MI causes should pain ii. Radiating pain – radiates from its origin; angina pectoris can radiate from chest to jaw or down the left arm iii. Sciatica – pain that follows course of sciatic nerve causing sensations down the back of the thigh and inside the leg to the foot; caused from compression or damage to sciatic nerve
c. Intensity – pain scales help patient communicate pain intensity; nurse can then choose appropriate intervention
i. Opioid dosing by numbers – do not does patients with opioids solely on the number of scale; take into account other factors such as sedation and respiratory status
d. Quality
i. Neuropathic – burning, numbing, shooting, stabbing, electric ii. Nociceptive pain – sharp, aching, throbbing, dull, cramping
e. Subjective data
i. Health history – pain history should include onset, location, intensity, quality, patterns, aggravating and alleviating factors, and expression of pain; coping, past treatments and their effectiveness ii. Medications – use of any prescriptions or over-the-counter medications, herbal products and alcohol use iii. Health perception – social and work history, mental health history, smoking history, effect of pain on emotions ,relationships, sleep and activities iv. Elimination – constipation related to opioid use
v. Activity-exercise –