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Michael Emman D. Orbe, BSN, RN

Clinical Instructor
 Pain is a highly unpleasant and very
personal sensation that cannot be shared
with others.
 One of the most complex human
experiences; an individual phenomenon
influenced by the interaction of affective,
behavioral, cognitive and physiologic-
sensory factors.
 Sensory pain receptors are free nerve endings in the
tissue that respond to tissue-injuring stimuli (noxious
 Receptors that respond to noxious temperature
or pressure (mechanical receptors) transmit the pain if
the noxious stimuli are sufficiently strong.
 Found in the skin, blood vessels, subcutaneous tissue,
muscle, fascia, periosteum, viscera, joints and other
 Nociceptors are located on two types of
peripheral nerve cells that are responsible for
transmitting pain from the tissues to the
central nervous system.
2 Types of peripheral nerve cells:
1. A – delta fibers – give rise to the bright sharp
localized pain that is immediately associated
with injury. (1st pain)
2. C – fibers – cause a second pain sensation
that is dull, poorly localized, and persistent
after injury.
 Cutaneous pain – Originates in the skin or
subcutaneous tissue.
e.g. paper cut causing a sharp pain
 Deep Somatic pain – arises from
ligaments , tendons, bones, blood vessels,
and nerves. It is diffuse and tends to last
longer than cutaneous pain
e.g. ankle sprain
 Visceral pain – results form stimulation of
pain receptors in the abdominal cavity,
cranium, and thorax. Tends to appear
diffuse and often feels like deep somatic
pain, that is burning, aching or feeling of
e.g. ischemia, or muscle spasms.
 Acute Pain – may have a sudden or
slow onset; it varies from mild to
severe, and may last up to 6 mos and
subsides as healing takes place.
- it reflects potential and present tissue
Cont. ….Types
 Chronic Pain – 6 months or longer and
often limits normal functioning.
- usually increases at night.
 Pain Threshold – is the amount of pain
stimulation a person requires in order to feel
 Pain Reaction – ANS & behavioral response to
pain; it protects the individual from further
harm. (automatic withdrawal of hand from hot
 Pain tolerance – is the maximum amount &
duration of pain that an individual is willing to
endure; influenced by psychologic & socio
cultural factor; appears to increase with age.
An accurate assessment focusing on
pain’s cause is essential for determining
the proper therapy. The nurse must
obtains a pain history, physical
examination that focuses on the client’s
physiologic & behavioral responses to
A. Data that should be obtained on
Pain Hx
1. Location – “Where is the pain located?”
-This can be measured objectively by
using a drawing of a body outline.
2. Intensity - “What is the magnitude or
intensity (level) of the pain?”
-Pain intensity is measured with the use
of scale
3. Quality – Descriptive adjectives help people to
communicate the quality of pain.
e.g. Hammer like, piercing like a knife

4. Pattern – it includes time of onset, duration,

and persistence of or intervals without pain.
“ when the pain began (onset), how long the
pain lasts, if recurrent-the length of interval
without pain; when the pain last occurred.
5. Precipitating factors - activities that
sometime precede pain.

6. Alleviating Factors – this will include the

analgesics taken, rest, and application of
heat or cold.
III. Physical Examination
 This will determine the client’s
physiologic and behavioral responses to
 The nurse needs to assess the client’s
vital signs and observes the skin color,
skin dryness, diaphoresis, facial
expression, and body gestures.

1. Physiologic Response
- this may vary according to whether the
pain is acute or chronic.
- Acute pain stimulates the sympathetic
nervous system, resulting in increased
BP, PR, RR, pallor, diaphoresis, and pupil
 Chronic pain or visceral pain – parasympathetic
stimulation may be observed: lowered BP,
decreased PR, pupil constriction & warm dry skin.
2. Affective Responses
 Vary according to the situation, degree & duration of
 The nurse needs to explore the clients
feeling( anxiety, fear, exhaustion, depression)
 People with chronic pain become depressed & tends
to be suicidal.
3. Behavior Responses –The very young, aphasic
and confused or disoriented persons often
communicate their experience of pain only non-
- Facial expression is often the first indication of
(clenched teeth, tightly shut eye, open somber
eyes, lip biting & other facial grimaces)
 Immobilization of the body part, muscle
 Rhythmic body movement – rubbing of
affected body part.
 Speech & vocal pitch –Rapid speech &
elevated pitch often reflect anxiety;slow
speech & monotonous tone can signal
intense pain.
IV. Pain Management
 It is the alleviation of pain or reduction in
pain to a level of comfort that is
acceptable to the client.
 It includes two types of NURSING
interventions: Pharmacologic & Non
1.Pharmacologic Pain Mgt.
 It involves the use of Opioids(narcotics), non-
opiods/NSAID, adjuvants, or co-analgesic
a. Opiods Analgesics – include opium
derivatives, such as morphine and codeine.
b. Non-opoid – include NSAID such as aspirin ,
acetaminophen, and ibuprofen.
(decrease or inhibit prostaglandin release)
c. Adjuvant analgesics –are medication that
developed for uses other than analgesia
but have found to reduce certain types of
chronic pain.
e.g. mild sedatives or tranquilizers,
diazepam; Antidepressant(Elavil),
Anticonvulsant(tegretol) for neuropathies
in Herpes zosters.
2. Nonpharmacologic pain Mgt.
Goal of Physical intervention :
- Provide comfort
- Correct physical dysfunction
- Alter physiologic responses
- Reduce fears associated with pain-
related immobility or activity restrictions.
a. Cutaneous stimulation – can provide effective
temporary pain relief. It distracts the client &
focuses attention on the tactile stimuli, away
from the painful sensations, thus, reducing
pain perception.
- Create the release of endorphins that block
the pain stimuli.
- Stimulate large diameter A-beta sensory
nerve fibers thus decreasing the transmission
of pain impulses through the smaller A-delta
& C fibers
b. Immobilization – Immobilizing painful
body parts.
c. Tanscutaneous Electric Nerve
(TENS) – same function as cutaneous
 Goals of Cognitive-Behavioral Interventions:
1. Alter pain perception
2. Alter pain behavior
3. Provide clients with greater sense of control
over pain.
d. Distraction - it draws the client’s attention
away from the pain & lessen the perception of
- e.g. slow rhythmic breathing, masssage &
slow-rhythmic breathing, Active listening,
Guided imagery.
Cont. …
 Hypnosis – is an altered state of
consciousness in which an individual’s
concentration is focused and distraction
is minimized.
 Example of Cutaneous stimulation:
1. Massage
2. Application of heat & colds
3. Acupressure – based on the ancient
chinese healing of acupuncture.
4. Contralateral stimulation – stimulating
the skin in an area opposite to the
painful area.
II. Rest & Sleep
A. Rest – implies calmness, relaxation
without emotional stress, and freedom
from anxiety.
- it restores a person’s energy, allowing
the individual to resume optimal
- people deprived of rest are often
irritable, depressed, tired and have a
poor control of their emotion,
B. Sleep – a state of consciousness which
the individual’s perception and reaction to
the environment are decreased.
- it is characterized by minimal physical
activity , variable levels of consciousness,
decreased responsiveness to stimuli.
C. Physiology of Sleep
1. Circadian rhythm – came from the latin,
circa dies, “about a day”.
- biological clock, controlled from within
the body and synchronized with
environmental factors, such as light and
darkness, gravity and electromagnetic
D. Stages of sleep
- slow wave sleep
- sleep during night, deep, restful sleep &
brings a decrease in physiologic
E. REM Sleep
 Constitutes 25 % of the young adult
 Usually recurs about every 90 minutes &
lasts 5-30 min.
 It is not as restful as NREM sleep
 Most dreams takes place and retained in
the memory.
 During this stage the brain is more active
and brain metabolism increases.
F. Stages & Characteristics of NREM
Stage Characteristics

Stage 1 Relaxed & drowsy, Profound restfulness,

usually lasts only a few minutes, floating
sensation, eyes roll from side to side – lasts
only a few minutes.

Stage 2 Stage of light sleep, body processes

continue to slow down, eyes are generally
still, heart & respiratory rates slightly
decreases, and body temp falls easily
aroused– 10 to 15 min
Stages & Characteristics of NREM
Stage Characteristics
Stage III HR & RR and other body processes slow
further because of the denomination of
PNS; Less easily aroused; not disturbed
by sensory stimuli; skeletal muscles are
very relaxed; reflexes are diminished &
snoring may occur.

Stage IV Deep sleep; HR&RR drop 20% to 30%

below as compared when awake; very
relaxed, rarely moves & very difficult to
arouse; eyes roll & some dreaming
occurs; it restore the body physically.

Stage1 Sleep


Stage 2 Stage 2 Stage 2

Stage 3 Stage 3

Stage 4
G. Sleep Cycle
 People pass through the 4 stages of NREM
sleep, usually lasting about 1 hr.
 Sleeper passes from stage I NREM through
stages III to IV in about 20 to 30 min.
 Stage IV last for 30 min.
 Followed by III & II; then 1st REM stage occurs for
10 min. (1st sleep cycle)
 Usual sleeper exp 4-6 cycles in 7-8 hrs of sleep.
H. Function of Sleep
 It exerts physiologic effect on the nervous
system & other body structures.
 It increases muscle tone
 Necessary for protein synthesis, thus, allow
the muscles to repair.
I. Factors affecting sleep
 Quality of sleep- ability of an individual to
stay asleep & to get appropriate REM &
 Quantity of sleep – total time the individuals
 Age – sleep pattern variation occurs with
e.g. NB –14 to 18 h; Inf – 12to 14h; Tod –10-
12; PS –11h; Sch age – 10; Adol –8
 Environment – can promote or hinder sleep.
 Fatigue – it is thought that a person who is
moderately fatigued usually has a restful
 Lifestyle- exercise, work shift
 Psychologic stress – Anxiety &
depression disturb sleep.
 Alcohol & stimulants – excessive alcohol
disrupts REM sleep. Often experience
nightmares when effect of the alcohol has
worn off.
 Diet – dairy products (contains
Cont ….
 Smoking – has a stimulating effect in the
 Motivation – the desire of an individual to
stay awake.
 Illness – people who are more ill require
more sleep.
 Medications – affect the quality of sleep
J. Common Sleep Disorder

CATEGORY of Sleep disorder

 Primary Sleep disorders – sleep problem
is the main disorder
 Secondary – sleep disturbances cause
by another clinical disorder such as
thyroid dysfunction, depression &
1. Insomnia – the most common sleep disorder
- inability to obtain an adequate amount or
quality of sleep.
# 3 types of insomnia:
a. Initial insomnia – difficulty of falling asleep.
b. Intermittent or maintenance – difficulty of
staying sleep bec of frequent waking
c. Terminal insomnia –early morning or premature
Cont …
 Causes of insomnia
a. Physical discomfort
b. Mental over stimulation due to anxiety.
c. Over consumption of drugs & alcohol

2. Hypersomnia – opposite of insomnia;

excessive sleep, particularly in daytime.
 Causes of Hypersomnia
1. Nervous system damage
2. Kidney & liver disorder
3. Diabetic acidosis
4. Hypothyroidsm
5. Coping mechanism
3. Narcolepsy – “Narco”, numbness
Lepsis, seizure
- sudden wave of sleepiness that occurs during
the day.
- Also referred as sleep attack
- Cause is unknown, but believed to be a
genetic defect of the CNS in w/c REM cant be
4. Sleep apnea – it’s the periodic cessation
of breathing during sleep.
- Often suspected when a the person has a
loud snoring, frequent nocturnal
awakenings, excessive daytime
sleepiness, insomnia.
- Last from 10 sec – 2 min; occur during
 3 types of sleep apnea
a. Obstructive apnea – occurs when the
structures of the pharynx or oral cavity
block the air flow.
b. Central apnea – involves a defect in the
respiratory center of the brain.
- all actions involve in breathing ceased
(chest movement, airflow)
c. Mixed apnea –combination of the the 2.

4. Parasomnias – refers to a cluster of

waking behaviors that may interfere
with sleep.
a. Somnabulism – sleep walking
- occurs during stages III&IV of NREM
- episodic & occurs 1-2 hafter falling
b. Sleeptalking – occurs during NREM sleep
before REM sleep.
- Rarely presents a problem to the person unless
it is troublesome to others.
c. Nocturnal enuresis – Bedwetting
- occurs in children over 3 yrs
- often occurs 1 – 2 h after falling asleep,when
rousing from NREM stage III - IV

d. Nocturnal erection / emission – occur

during REM sleep.
- begin during adolescence, does not
present a problem.
e. Bruxism – clenching & grinding of teeth.
- occurs during stage II NREM
Sleep assessment includes a sleep
history, sleep diary & Physical
1. Sleep history
a. Usual sleeping pattern, sleeping &
waking hours; quality or satisfaction of
sleep; time & duration of naps.
b. Bedtime rituals
c. Use of medications
d. Sleep environment – dark room, temp.
e. Recent changes in sleep patterns or
difficulty of sleeping.
2. Sleep diary
 Clients with sleeping problem should keep &
maintain a SD for at least 1 wk.
a. Total number of sleep hours/day
b. Activities performed by 2-3 hrs before bedtime (type,
duration and time)
c. Bedtime rituals – food,fluid medication
d. Time of going to bed; trying to fall asleep, instances
of waking up, duration;waking up in the am.
e. Any worries that may affect sleep
3. Physical Examination
 Observation of the client’s:
a. Facial appearance – darkened areas around the
eyes, puffy eyelids, reddened conjunctiva, glazed
or dull appearing eyes.
b. Behavior – irritability, restlessness,
inattentiveness, slowed speech, slumped posture,
hand tremor, yawning, rubbing the eyes,
withdrawal, confusion, & incoordination.
c. Energy level – physically weak, lethargic,
L. Nursing care
 The major goal for the client with sleep
disturbance is to develop or maintain a
sleeping pattern that provides sufficient
energy for daily activities.

a. Reducing environmental distractions.

b. Promoting bedtime rituals
c. Teaching stress reduction
d. Relaxation techniques
L. Promoting Comfort & Relaxation
1. Provide loose fitting nightwear.
2. Assists client’s with hygienic routines.
3. Make sure that the bed linen is smooth,
clean & dry.
4. Assist or encourage the client to void
before bedtime.
5. Offer to provide a back massage before
6. Position dependent clients appropriately
to aid muscle relaxation; provide
supportive devices to protect pressure
7. Schedule medications to prevent
nocturnal awakenings.
8. Administer analgesic 30 min before
sleep for patient suffering from pain.