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Never use physiologic responses alone to determine pain therapy. A patient’s self-report is the gold standard.
Use only evidence-based pain assessment tools in the population in which the instrument has been tested.
Identify patients at high risk for adverse opioid-related outcomes (e.g., patients with sleep apnea, receiving continuous IV opioids, or on supplemental oxygen).undefined#ref4">4
Pain is a subjective experience for the patient and can be characterized in many ways: sharp or dull, burning or tingling, or generalized aching. Unrelieved pain has been associated with negative outcomes and physiologic alterations, such as increased peripheral vascular resistance and cardiac oxygen consumption, hypercoagulability, and compromised immune function.7 Pain management is an important component of comprehensive patient care.
The assessment and management of pain should be a top priority,3 and alleviating pain is a major nursing responsibility. Through comprehensive pain assessment, the nurse begins to understand the impact of pain on the patient’s life. A comprehensive pain assessment elicits the patient’s subjective report of pain, including the sensory, psychologic, cultural, and emotional experiences of pain.2 When performing a pain assessment, the nurse uses the appropriate organization-approved pain-intensity scale (e.g., visual analog scale, numeric rating scale, colors, Wong-Baker FACES® Pain Rating Scale) (Figure 1) based on the patient’s preference, age, developmental level, and comprehension. Special assessment scales are available for sedated critical care patients and patients with dementia. The same scale should be used consistently with the patient. Pain-intensity scales also help evaluate the effectiveness of pain interventions.
The use of opioid medication for pain management comes with risk.1 Health care team members should be involved in pain assessment and management to identify patients at high risk for opioid dependence and to establish criteria for safe opioid prescribing.3 Collaboration among health care team members helps achieve the best possible plan of care for pain relief.
The inability of a patient to communicate pain intensity (e.g., patients with cognitive impairment or an inability to communicate) is a barrier to effective pain control. The input of family members helps evaluate the patient’s response to medications and nonpharmacologic interventions but should not be the only assessment. Physiologic responses to acute pain (e.g., tachycardia, hypertension) have a short duration. With persistent pain, a patient does not typically exhibit such physiologic responses. A valid pain assessment method for patients with cognitive impairment or an inability to communicate should be used.
The patient should be actively involved in a pain management treatment plan.3 Effectively managing a patient’s pain does not mean eliminating it. Pain management collaboration with the patient and family helps identify an acceptable intensity of pain that allows maximum patient functioning. Asking the patient baseline questions about the pain helps formulate pain-intensity goals to help him or her cope with the discomfort.
The nursing process offers a systematic method of pain management that results in improved pain relief for most patients. Using this process, the nurse recognizes distinct differences in patient perceptions and responses to pain. Nonpharmacologic complimentary modalities for pain relief should be incorporated into the patient’s care.1 An individualized plan of care that stabilizes the patient’s pain at an acceptable intensity is the goal of pain assessment and management.
Rationale: In some cultures, expressing pain is unacceptable; the nurse must assess nonverbal and physiologic signs of pain.
Rationale: Medication strategies differ based on the type of pain. For example, immediate-release opioids are more appropriate for acute pain, whereas chronic pain requires a long-acting, sustained-release opioid with breakthrough pain medication.
When examining the abdomen, auscultate first; then inspect and palpate.
Factors other than pain may influence patient behavior and cause distress.
Rationale: Pain intensity often changes with movement.
Rationale: Temperature extremes alter a patient’s responses to pain.
Rationale: Bright or very dim lighting aggravates pain sensation.
Rationale: Loud or irritating sounds aggravate pain.
Rationale: Fatigue accentuates the perception of pain.
Rationale: Privacy reduces stimuli that increase pain.
Rationale: Removing triggers reduces stimulation of pain and pressure receptors and maximizes a patient’s response to pain-relieving interventions.
Rationale: Turning and repositioning reduce stimulation of pain and pressure receptors.
Rationale: Smooth linens reduce pressure and irritation to the skin.
Rationale: Constrictive bandages or devices encircling an extremity may restrict circulation.
Rationale: Splinting immobilizes the painful area.
Rationale: Preemptive action prevents or minimizes unpleasant problems. When an adverse effect is common to the patient, the patient should not have to wait to ask for treatment.
Use the same pain-intensity scale that was used before implementing pain interventions.
Rationale: Adverse effects of analgesics may be controlled by reducing the dose, increasing the time intervals, or administering other medications (e.g., stimulant laxative for opioid-induced constipation).
Simpson, M.H., Ignatavicius, D.D. (2018). Chapter 4: Assessment and care of patients with pain. In D.D. Ignatavicius, M.L. Workman, C.R. Rebar (Eds.), Medical-surgical nursing: Concepts for interprofessional collaborative care (9th ed., pp. 45-70). St. Louis: Elsevier.
Tick, H. and others. (2018). Evidence-based nonpharmacologic strategies for comprehensive pain care: The Consortium Pain Task Force white paper. Explore, 14(3), 177-211. doi:10.1016/j.explore.2018.02.001 (Level VII)
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