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Clinical Nursing Skills

16.2 Responses to Pain

Clinical Nursing Skills16.2 Responses to Pain

Learning Objectives

By the end of this section, you will be able to:

  • Describe the physiologic response to pain
  • Identify behavioral response to pain
  • Identify affective response to pain

Patients can have many different responses to pain. The body perceives pain as a sign of danger and will immediately initiate responses to help the person stay safe. The sympathetic and parasympathetic nervous systems play a big role in physiologic responses to pain. Many patients may experience sympathetic body changes to a perceived threat of pain. Behavioral and emotional responses can also be observed in patients experiencing pain. Vocalization, facial expressions, movement, and negative emotions can all be responses to pain.

Patients may experience a wide variety of behaviors when in pain. Patients may lash out or become quiet and withdrawn when in pain. Patients in acute pain are more likely to vocalize their pain and exhibit facial expressions of pain. Patients suffering from chronic pain may struggle with anxiety and depression from the continued feeling of pain. Patients may even suffer from an extreme fear of pain and avoid any situation that may cause pain.

Physiologic Response

Pain warns a person of danger to prevent damage to the body (Arcuri, 2022). The physiologic response to pain is the body’s involuntary responses to a painful stimulus such as inflammation or changes in heart rate and blood pressure. Physiologic responses can include sympathetic nervous system reactions and behavioral reactions such as facial expressions, emotions, vocalizations, and movement. Many of the observed nonverbal cues from patients are physiologic responses to pain.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Patient-Centered Care: Recognizing Physiologic Pain Response

Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Knowledge: Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort.

Skill: Assess presence and extent of pain and suffering. The nurse will:

  • Focus on the duration, location, and etiology of the patient’s pain.
  • Ask the patient how long the pain has lasted to determine if the pain is acute, chronic, or breakthrough pain.
  • Ask the patient to identify the location of the pain.
  • Ask the patient to describe how the pain feels and what causes or makes the pain worse to try to determine the cause of pain.

Attitude: Appreciate the role of the nurse in relief of all types and sources of pain or suffering.

Sympathetic Nervous System

The autonomic nervous system contains the sympathetic and parasympathetic nervous systems and regulates the involuntary physiologic responses of the body (Figure 16.5). The role of the sympathetic nervous system is to respond to perceived stressful or dangerous situations. The main response from the sympathetic nervous system is the fight-or-flight response, which triggers the body to either run away from or fight a perceived threat. For example, the body may perceive an encounter with a wild animal as a threat. The sympathetic nervous system will activate and tell the person to run away from the animal to safety. The fight-or-flight response may not be activated in perceived less stressful situations, but the body may still illicit a sympathetic response (Yeater et al., 2021). For example, a patient may be experiencing postsurgical pain even with pain medication. The sympathetic nervous system may respond to the pain by elevating the heart rate and blood pressure.

The sympathetic pain response involves many automatic bodily functions such as:

  • enlarging pupils to improve vision;
  • slowing digestion to allow the body to use energy in other places; and
  • increasing heart rate and blood pressure to improve circulation (Cleveland Clinic, 2022b).

Nurses may notice these nonverbal signs of pain in a patient even before the patient states they are in pain. Noticing sympathetic pain responses is especially important in patients who cannot communicate their pain. Patients who are unconscious, confused, nonverbal, young, or cognitively impaired may not be able to adequately express their pain.

Parasympathetic Nervous System

The parasympathetic nervous system opposes the sympathetic nervous system and regulates the automatic bodily functions in times of rest and relaxation. Once the perceived stress or threat is gone, the parasympathetic nervous system takes over and returns the body to its normal functioning (Cleveland Clinic, 2022a).

The parasympathetic response includes:

  • constricting pupils to limit light;
  • producing saliva and mucus to assist in digestion and breathing;
  • lowering heart rate and blood pressure to reduce workload;
  • directing energy toward digestion to help break down food;
  • directing the pancreas to create insulin to regulate blood sugar; and
  • relaxing muscles to assist with urination and defecation (Cleveland Clinic, 2022a).

These responses indicate to the nurse that the patient is experiencing adequate pain relief. In the same way that the nurse observes sympathetic responses to detect a patient’s pain, the nurse may observe parasympathetic responses to determine if pain interventions are effective (Figure 16.5).

A diagram of a human body lists the different functions of the sympathetic and parasympathetic nervous system. The parasympathetic system can constrict pupils, stimulate salivation, slow heart rate, constrict bronchi, stimulate digestion, stimulate bile secretion, and cause the bladder to contract. The sympathetic nervous system can dilate pupils, inhibit salivation, increase heart rate, dilate bronchi, inhibit digestion, stimulate the breakdown of glycogen, stimulate secretion of adrenaline and noradrenaline, and inhibit contraction of the bladder.
Figure 16.5 The parasympathetic and sympathetic divisions of the autonomic nervous system have opposite effects on various systems. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Vital signs can be an indicator of pain, and nurses can use vital sign measurements along with the patient’s response to determine if pain interventions are effective. Measuring vital signs as an indicator of pain can be especially useful for patients who cannot verbalize their pain. Pain can cause an increase in blood pressure, heart rate, and respiratory rate. Abnormal vital signs can occur without pain, so it is important that nurses perform other methods of assessment for pain as well. Nurses can also measure vital signs to determine if they have normalized after pain interventions. For example, if a patient has elevated blood pressure and is exhibiting signs of pain, the nurse can assess their blood pressure after pain medication has been given to ensure that it has normalized. This can help indicate that the pain interventions are effective.

Behavioral Response

Behavior plays a big role in pain response. Nurses can easily observe behavioral responses to pain and can measure the severity of pain based on a patient’s behavior. Noticing behavioral pain responses is especially important in patients who cannot communicate their pain.

Behavioral pain responses may include:

  • facial expressions,
  • vocalization,
  • movement,
  • emotions, and
  • interactions with others.

Behavioral pain responses are often big reactions that others easily notice. For example, when a professional athlete gets injured during a game, everyone in the crowd understands the athlete is in pain due to their behavior. The athlete may fall to the ground, grab the area of their injury, and yell out in pain (Figure 16.6).

A color photograph shows an injured soccer player laying on the field.
Figure 16.6 Athletes are prone to injuries and can be seen publicly displaying behavioral responses to pain. (credit: “Injury” by Olympus Digital Camera/Flickr, Public Domain)


Patients will sometimes use sounds, noises, and words to express pain. This is called vocalization; and it most often occurs in acute pain of varying severity. Vocalization of pain includes crying, screaming, moaning, gasping, or grunting (Helmer et al., 2020). Patients can vocalize their pain by using pain rating scales. Asking patients to rate their pain on a numeric scale can be an effective way to assess patients for pain. Patients can also vocalize pain descriptors such as severity, duration, location, and type of pain.

The use of vocalization to express pain is used often in younger children (Helmer et al., 2020). Younger children have limited communication when trying to express pain. The most common way for infants to express discomfort is by crying. Older children may be capable of stating their pain using appropriate pain scales (Figure 16.7), such as the Wong-Baker FACES Pain Rating Scale, but may still use crying or yelling to express pain (Venable, 2018).

A diagram of a pain rating scale is shown. It includes an arrow going from left to right indicating increased pain. There are six facial expressions indicating increased pain levels where 0 shows a smiling face and 10 shows a frowning and crying face.
Figure 16.7 A pain rating scale like this one can be used with patients who are unable to speak as referent communication. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Life-Stage Context

Behavioral Pain Response in Infants

Assessing pain in pediatric patients can be difficult, especially in infants. Nurses must be aware of behavioral responses to pain when caring for infants. Infants primarily express their needs through crying, but not all crying equates to pain. The FLACC (Face, Legs, Activity, Cry, Consolability) scale can be used to assess an infant’s pain. The FLACC scale is recommended to be used in younger patients as it measures appropriate behavioral responses in young children. The FLACC scale scores patients’ pain based on five criteria: facial expressions, body posture, activity, crying, and the ability to console (Trottier et al., 2022). The total score is 0 to 12, with each category receiving 0 to 2 points based on patient response. Nurses can try comfort measures such as swaddling, feeding, and rocking to ease the infant’s crying. If no comfort measures work, the crying may be due to pain (Helmer et al., 2020).

Facial Expression

Facial expressions not only demonstrate emotions such as happiness, fear, or sadness, they can also demonstrate pain. Frowning, closing eyes, clenching teeth, opening the mouth, biting lips, grimacing, furrowing eyebrows, and scowling can all be used to express pain (Figure 16.8) (Cho & Hong, 2020).

A color photograph shows a man in pain holding his face.
Figure 16.8 Facial expressions such as grimacing, furrowing eyebrows, and closing eyes are a common way for patients to express pain. (credit: “The pain is brutal for these Marines 150306-M-IN448-056.jpg” by Sgt. Matthew Callahan/Wikimedia Commons, Public Domain)

Some research shows that social context can change the way a person expresses pain (Kappesser, 2019). For example, a young child may cry and use facial expressions to demonstrate pain around their parents. However, they immediately stop crying and try to smile when their older sibling comes into the room because they want to appear more mature. Another example is a person feeling comfortable enough to show facial expressions of pain in the presence of their partner rather than in front of a colleague or stranger (Kappesser, 2019). Patients may not feel comfortable showing facial expressions when in pain. They may try to hide their facial expressions in the presence of healthcare providers. It is important that nurses always help patients feel comfortable expressing their pain.

Body Movement

Patients may demonstrate pain through movement such as guarding, touching the location of the pain, withdrawing from touch, or tremors (Cho & Hong, 2020). Nurses may notice muscle tension and resistance to examination of the painful location.

Children often show pain through withdrawal of touch. While they may seek the comfort of their parents, they will often resist someone touching or manipulating the painful area due to fear of touch causing more pain. This can be difficult for nurses to assess the location of pain. Severe pain may require pharmacological interventions prior to assessment of the location of pain. Nurses must be mindful of the location of pain when doing a physical assessment. Visual assessment, diagnostic imaging, and descriptors of pain from the patient can help provide a comprehensive pain assessment without touching the painful area.

Social Interaction

The way that patients interact with others can change when they are in pain. Patients in chronic pain may withdraw from social interactions and become isolated. This can make the pain worse and contribute to deteriorating physical health in patients (Bannon et al., 2021). When patients are in pain and around others, they may appear quiet, reserved, and uninterested (Oommen & Shetty, 2020). Nurses can educate patients that these social interactions are a normal response to pain and help them verbalize to their loved ones that these negative emotions are responses to pain. It is important that patients are able to verbalize their pain in social situations, so they do not become socially isolated and withdrawn. Research has shown that supportive social environments can help patients cope with pain (Bannon et al., 2021).

Affective Response

The affective response to pain refers to the emotional interpretation of pain, such as how uncomfortable the pain is. The affective response can help determine how much pain is felt (Cleveland Clinic, 2022a). Negative emotions such as fear and anxiety can be connected to pain. Because pain is a subjective experience, patients may have different emotional responses to pain. For example, an athlete with a knee injury may feel fear along with pain because they are worried the pain means a season-ending injury. Another patient feeling pain from a broken leg may feel anxiety along with the pain because they will not be able to work while recovering from their injury.

Interventions such as cognitive behavioral therapy, guided imagery, and meditation can help patients adjust their affective response to pain because they promote relaxation and decreased stress (Talbot et al., 2019). These interventions can help decrease negative emotions such as fear and anxiety while also decreasing the perception of pain.

Negative Emotion

Pain is an unpleasant sensation and associated with negative emotions. Negative emotions can include anger, frustration, fear, anxiety, depression, guilt, and sadness. Negative emotions can make it difficult to complete daily activities and can lead to social withdrawal. Everyone can feel negative emotions and they are not always connected to pain. However, it is important for patients to understand that pain can bring on negative emotions, especially anxiety and depression. If patients are not able to cope with negative emotions in healthy ways, it can lead to unhealthy consequences (Scott, 2022).

Accepting emotions and finding healthy coping mechanisms is essential to reducing pain and preventing negative consequences. Healthy coping mechanisms for negative emotions can include acceptance and understanding of the emotions, exercise, meditation, and lifestyle changes (Scott, 2022).


Anxiety often goes hand in hand with pain and is more commonly seen in patients with chronic pain. Pain can affect patients’ daily lives and can have a big impact on their physical, mental, and social health. Many patients who experience anxiety with pain may also experience depression. Research shows that 65 percent of patients seeking help for depression also report pain symptoms (Harvard Health Publishing, 2021).

Anxiety and depression can make it harder to treat pain. Patients experiencing anxiety and depression may be less motivated to find ways to treat their pain and may be unable to focus on pain management strategies. Cognitive behavioral therapy, mindfulness, and medications can help treat anxiety, depression, and pain in patients. These therapies can be multimodal in that they can treat the negative emotions and the pain at the same time.


The perception of pain can be influenced by fear (Oommen & Shetty, 2020). Some patients may even have a phobia of pain. When that phobia of pain is extreme, it’s called algophobia. Patients may experience anxiety and fear at the thought of pain. Algophobia can make patients more sensitive to pain and they may perceive normal activities as a potential cause of pain (Cleveland Clinic, 2021).

Fear of pain can cause patients to catastrophize pain. The act of catastrophizing is the picturing the worst possible outcome for a situation (Cleveland Clinic, 2021). Patients may be intensely focused on avoiding pain and can see the potential of pain in any situation. Patients may become anxious and withdrawn as they try to avoid situations that could cause pain. If patients are experiencing pain, they may avoid situations that they think can make their pain worse. Cognitive behavioral therapy and mindfulness can help patients deal with their fear of pain. Exposure to potential painful situations can also help patients rationalize their fear of pain and continue living their daily lives.


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