Fundamentals - Practice & Skills, part 6: Pain - Types, Etiology, and Treatments
July 28, 2021 Updated: December 29, 2021 14 min read
This article discusses the various types of pain and their treatments. Remember when treating a patient's pain, it's vitally important to take their pain seriously based on what they say and not what we perceive. In this article, we'll teach you the various types of pain; the etiology, or cause, of pain; where pain occurs; how to manage pain both with medications and through alternative means; and we'll discuss patient-controlled analgesia, which is when a patient controls the amount of pain medication they receive.
The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Types of pain
Pain occurs when something hurts. It can be severe or mild, and is often an indicator that something is wrong.
Most types of pain are caused by damage to the tissue or damage to the nerves. Some pain is idiopathic, which means it has an unknown cause.
Pain is most often grouped into one of four distinct types, based on the damage that causes it. The four types of pain are acute pain, chronic pain, breakthrough pain, and pain related to cancer.
Acute pain is pain that is new or comes on suddenly, often caused by something specific. It alters the vital signs, for instance, raising the patient's heart rate and/or blood pressure.
Acute pain is not long-lasting and resolves when the cause of pain is addressed. Consider a patient with appendicitis. They will be in great pain, often guarding or holding their abdomen, possibly sweating. They will appear tense and their vital signs will be affected. Surgery would alleviate the pain in the case of appendicitis.
Chronic pain is pain that persists for a long time, longer than three months. Chronic pain can affect a patient's psychological status and quality of life — it can affect how they sleep, their appetite, or their ability to work.
The vital signs of a patient dealing with chronic pain are often not affected. That is because the body learns to adapt to deal with that pain — the patient has become used to the constant discomfort. However, just because a patient has normal vital signs, that doesn't mean they aren't in pain.
For example, a patient with scoliosis might report their back hurting every day, at a constant level of severity of 3 (out of 10), but they carry on with their life regardless of their discomfort because they have learned to live with their pain.
Just like it sounds, breakthrough pain is pain that breaks through. It is intense, transient pain that occurs despite taking pain medication. For instance, a patient who has had surgery might feel well until they get up and walk around, at which point they may feel intense pain.
Cancer pain can be related to both the cancer and the cancer treatment. It may be acute and/or chronic and is often a very intense kind of pain.
Etiology of pain
Etiology means cause or set of causes. Etiology of pain refers to the cause or origin of the pain, which can be classified as one of three distinct categories: nociceptive, neuropathic, and idiopathic.
Nociceptive pain is caused by injury or damage to body tissue. It is often described as aching or throbbing. Most pain is nociceptive and results when pain receptors (nociceptors) discern painful or noxious stimuli. A sports injury or broken tooth are examples of nociceptive pain.
Neuropathic pain is caused by damage to the nerves ("neuro-" meaning nerves and "-pathic" meaning disorder). It is often chronic. Patients might describe their pain as burning or shooting, or they might report “being on pins and needles.” Phantom limb syndrome (pain that is felt in the area where an arm or leg has been amputated) is an extreme example of neuropathic pain.
Idiopathic pain is pain that comes from an unknown cause that defies explanation, even after examination. Idiopathic pain may be psychological or physiological in origin.
A migraine may be considered an idiopathic pain.
Another way that pain is classified is by location. Different locations of pain indicate different problems from which a patient may be suffering.
Location of pain is broken into four possible areas: cutaneous, somatic, visceral, and referred.
Cutaneous pain involves the skin (the Latin word “cutis” means skin). Cutaneous pain is caused by stimulation of structures in the skin that sense pain (nociceptors). A paper cut is an example of something that causes cutaneous pain.
Somatic pain is pain that involves deeper tissues, like joints, tendons, or bones. It is localized, it may be either intermittent or constant, and patients will often describe this sort of pain as aching, gnawing, throbbing, or cramping. Spraining an ankle is an example of something that causes somatic pain.
Visceral pain refers to organ-related pain, when pain receptors in the pelvis, abdomen, chest, or intestines are activated. A patient may experience this type of pain if their internal organs and tissues are damaged or injured. Visceral pain is vague and not localized. Someone suffering visceral pain might not be able to clearly define it, and instead report feeling a deep squeeze, pressure, or aching.
Referred pain is pain that is perceived at a location other than the site of the painful stimulus or origin of the pain. The body has networks of interconnected sensory nerves, which supply many different tissues. An injury to one site in the network might send a signal to the brain, which then interprets the pain as occurring elsewhere in the body. An example of referred pain is shoulder pain following a heart attack.
Pain management refers to therapies used to manage a patient's pain and can include medication (pharmacological) or other therapies that do not make use of drugs (nonpharmacological).
Pharmacological therapies make use of medication to treat the patient’s pain. These include nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Each of these groups is covered in our Pharmacology Flashcards for Nursing Students, which focus on medications, pharmacokinetics, prescriptions, routes of administration, and other aspects of pharmacology.
Opioid analgesics are used to treat moderate to severe pain and can include fentanyl, morphine, dilaudid, and oxycodone.
Opioids are narcotics and can be highly addictive. The CDC advises (external link) that when used, clinicians should prescribe "...the lowest effective dose of immediate-release opioids."
Adjuvant analgesics are drugs with a primary indication other than pain but have analgesic properties and can alleviate pain in some conditions. Adjuvant analgesics include antidepressants (e.g., amitriptyline), anticonvulsants (e.g., carbamazepine or pregabalin, known commercially as Lyrica), and topical analgesics (e.g., lidocaine).
Nonpharmacological therapies are therapies that do not involve medications and may be categorized as complementary and alternative medicine (CAM). These include:
- Physical therapy: the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery.
- Massage: the manipulation of the body's soft tissues
- Guided imagery: a type of focused relaxation or meditation, often led by a trained practitioner or teacher.
- Distraction: shifting or moving one's attention away; in distraction therapy, one trains the brain to focus its attention onto something other than the pain (even though the pain is still there).
- Biofeedback: a mind-body therapy that can improve physical and mental health; during a biofeedback session, a practitioner will use painless sensors to measure certain bodily functions.
- Acupuncture: A therapy that involves the insertion of very thin needles through the skin at strategic points on the body; deriving from Chinese medicine, acupuncture can be used to alleviate stress a well as pain.
Patient-controlled analgesia (PCA) is a means of delivering individualized analgesia, prescribed by a provider for pain control, where it is the patient who controls the amount of medication they are receiving.
Medication is administered via a pump, intravenously. It is administered in small doses, which the patient receives at certain intervals.
The most common medications administered via PCA are opioid analgesics.
Note that only the patient should press the button that administers a dosage. Neither nurses nor visitors should do this.
The interval for doses is called the lockout interval. If, for example, a dose is 0.2 mg of Dilaudid every 10 minutes, that is the most frequently the patient can self-administer. It is not automatic — the patient has to push the button on the pump to deliver the medication.
Bolus vs. basal doses
A bolus dose is what we call the administration of the single dose of medication via the PCA, also called the demand dose. It gets administered when the patient pushes the button on the pump.
Basal doses are administered continuously, in small amounts. The PCA pump can be programmed to deliver pain medication continuously, if needed.
Nursing care best practices for PCA
Here are some things to keep in mind when dealing with patient-controlled analgesics.
Engage another nurse to verify PCA settings
When a patient is set up with a PCA pump, it is important to engage another RN to verify the pump settings. It is vital to make sure that the medication the provider ordered is indeed what is in the pump.
Only the patient administers medication via the PCA
As mentioned above, only the patient operates the PCA. Educate patients and their family members so they know that only the patient touches the delivery button and nobody else (including nurses!)
Monitor your patient for signs of toxic effects
Finally, it is equally important to understand that the patient can suffer toxic effects of medication, even when following provider's orders.
For example, if the patient is pushing the button every 10 minutes, it is possible that they are receiving too much medication, that is, more than their body can tolerate. Assess the patient frequently, checking that their vital signs are as expected, depending on their condition.
And always check on the status of the patient's pain level.
Believe patients' reports of pain
As Meris reminds us in the video, you don't get to decide what your patient's pain is, they do. You can document what the patient reports. But ultimately, pain is what the patient says it is, and it is important to respect that.
As Meris shares in the video, when she was younger, she had complications from surgery. She had to go to the emergency room, where she spoke to a provider. She was calm and specific when she talked to him, because she was managing her pain. But what she said was, "I am in severe pain." The doctor responded, "I don't think you are in as much pain as you say you are."
He was wrong. Unfortunately, not long after, Meris went on to become septic and required emergency surgery, followed by an extensive hospital stay. This is because the provider did not believe her when she told him how severe her pain was.
Listen to your patient and believe them when they tell you how much pain they are in.
Hi, I'm Meris. And in this video, I'm going to be talking to you today about types of pain and their treatments. I'm going to be following along with our nursing fundamentals flashcards. These are available on LevelUpRN.com along with a lot more flashcards, so definitely check it out if you don't have your own set. And if you do have a set for yourself, I am starting on card number 58, so let's get started. So before we get started, I want to invite you to stay until the end. I'm going to share a personal story with you about why it's so important that we take patients' pain seriously based on what they say and not what we perceive. So stay to the end for that, but let's get started with card 58.
We're talking about different types of pain. And you can see here on this card, we've got a big, bold red statement here, so let's go through this.
Acute pain. Acute pain means it's new or sudden onset, short-term. With acute pain, I like to think of appendicitis, right? Someone with appendicitis, they're going to be in a lot of pain. They're going to be guarding, holding their abdomen, maybe sweating. They look tense, and their vital signs will be impacted.
Now, compare that with chronic pain. Chronic pain means that this is pain that is persisting for a long time and the body learns to adapt to deal with it. So your vital signs may not be impacted. That's bold and red on this card, very important to understand. So just because you see that your patient has normal vital signs but they're telling you that they have a 5 out of 10 pain, it doesn't mean that they're telling you a lie. It may mean that they are able to deal with the pain that they have. Keep in mind that chronic pain persists for longer than three months. So this is not something like, "Oh, I've tweaked my back, and it's hurting me for a week." This is like, "In my case, I have scoliosis. My back hurts every single day of my life, and I'm at a constant 3 out of 10, but I live my life anyway."
You'll also see on here breakthrough and cancer pain. Breakthrough means pain that breaks through. So for instance, maybe I have surgery. I'm doing okay, and then I walk the halls, and now my pain is higher than it would be. And that's even though I'm taking pain medicine.
Cancer pain can be related to the cancer and the treatment itself, but keep in mind that that's going to be a very intense kind of pain compared to some other types of pain.
Now, moving on, let's talk about pain etiology and location.
Etiology means where does it start from, where does it begin from. So under the etiology, you can see we have nociceptive, neuropathic, and idiopathic.
If you remember all the way back to A&P, nociceptors are certain types of nerves in our body. Their whole job is to pick up on painful or noxious stimuli. So this is going to be pain caused by injury to a tissue those little nerves are picking up on and saying, "This hurts really bad. This is going to be aching or throbbing."
Now neuropathic, neuro meaning nerves and pathic meaning disorder, so this is a disorder of the nerves. Right? This is caused by injury to the nerves, so this kind of pain is going to be described differently. It's going to be burning or shooting pain. Your patients may also call this pins and needles.
And then idiopathic means with unknown origin, unknown cause. So this is someone who comes and says, "I'm having really bad pain," and we can't find an explanation for their pain. Idiopathic.
Then location of pain. I'm not going to go through all of these with you, but just know that the location differs based on what the problem is.
So if I have cutaneous pain versus somatic versus visceral, my pain is going to feel different. So be sure to be familiar with all of those terms.
Okay. So moving on to talk about therapies for pain. How do we treat pain?
Well, if you look at this card, number 60, we talk about pharmacological and nonpharmacological treatments, pharmacological meaning related to medications; nonpharmacological, obviously, no medication involved.
So when it comes to treating pain with medications, there are different options. We usually start off with nonopioids. These would be things like Tylenol, acetaminophen, NSAIDs, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen, aspirin, those sorts of things. That's going to typically be for mild to moderate pain. I have a headache at home, I take an ibuprofen. Right?
Now when we talk about opioid medications, these are narcotics, and these are certainly not what we want to start treating pain with most of the time. So this is going to be for moderate to severe pain, and examples of these, which you'll talk about much more extensively in pharmacology, would be things like Fentanyl, morphine, Dilaudid, oxycodone, hydrocodone. All of those are narcotics.
And then we having something called adjuvants. So adjuvant medications are things that are used to help treat pain in addition to analgesic drugs.
So we have some examples here, like antidepressants such as amitriptyline.
Anticonvulsants - these are used a lot - things like gabapentin and carbamazepine.
And then topical analgesics, which actually numb the area, like lidocaine.
Then some nonpharmacological treatments. These are going to be things like distraction, meditation, massage, biofeedback. A lot of those things that we talk about in the complementary and alternative medicine card on card number 29. So definitely be familiar with the options available to your patients that are both based in pharmacology and those that are drug-free.
Okay. So now we're on card number 61. We are talking about PCA pumps. These are patient-controlled analgesia, so as the name implies, it is controlled by your patient. That is a very important thing to remember.
The patient is the only one who controls the PCA. Meaning that I, as the nurse, do not come in and push the button for them. The family members, the visitors need to be educated that they do not push the button either. It is patient-controlled.
And what this means is that my patient has an IV going to their arm, going to their hand, and they have a medication prescribed by their provider. Maybe it's morphine or Dilaudid, something along those lines.
It's a small dose that they can receive at a certain interval, so this is called the lockout interval. So, for instance, let's say it's 0.2 mg of Dilaudid every 10 minutes, is what my patient can have, but they don't automatically get that. What that means is every 10 minutes that button, if it is pushed, will deliver 0.2 mg of Dilaudid. Now, it is not going to deliver it unless that button is pushed, so this allows my patient to control their pain management. This allows my patient to get the pain management on demand, without involving the nurse.
So some important things to know here. When my patient is set up with a PCA pump, I will very likely need another RN to verify the pump settings. This is very dangerous. I need to make sure that what the provider ordered is indeed what the pump says.
And the other thing, like I said, educating patients and their family members that only the patient touches it, nobody else; hugely important to patient education and family education.
And then the other thing is that, it's just important to know that you can still suffer those sort of toxic effects of medication, so if my patient is pushing that button every 10 minutes, it is still possible that they receive too much medication. I don't mean that they're receiving more than ordered. I mean they're receiving more than their body can tolerate, just like any pain management, right? So I need to still be assessing that patient frequently, making sure their respiratory status is good, and checking in on the status of that patient's pain.
Okay, so that is it for types of pain and their treatments. I hope that review was helpful. If it was, please be sure to like this video, and leave a comment below. If there's some awesome way that you remember something, I very much want to hear it. In the next video, I'm going to be talking about sleep basics, sleep disorders, and general adaptation syndrome, so be sure that you subscribe to the channel, so that you're the first to know when it posts. Thanks so much and happy studying.
So I have a very extensive medical and surgical history, and when I was 21, I was having some complications from surgery. And I went to the emergency room and I said, "I am in severe pain." And I had been in pain for a very long time, and the doctor who came and examined me said, "I just don't think that you're in as much pain as you say you are."
And I was talking to him probably similar to how I'm talking to you right now, because I was used to dealing with the pain. Well, as it turns out, I was in exactly as much pain as I said I was, because I went on to become septic later and had emergency surgery, and had an extensive hospital stay.
So just because your patient might look composed, might look like they're not in pain, it's very important to take seriously whatever the patient says.
You don't get to decide what your patient's pain is, they do. You can document it. You can document your objective findings and the subjective findings, but ultimately, pain is what the patient says it is, and it's very important to respect that. So thank goodness for the nurses who were on my side and really advocated for me and ended up speaking up when I did develop serious complications.
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