Fundamentals - Practice & Skills, part 6: Pain - Types, Etiology, and Treatments

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

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

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.

Breakthrough 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

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

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

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

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.

Pain locations

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

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

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

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

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

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

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.

Nonopioid analgesics

Nonopioid analgesics are used to treat mild to moderate pain and include acetaminophen, NSAIDs (nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen), and aspirin.

Opioid analgesics

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

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

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

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.

Lockout interval

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.