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Sep.24.2020

Pain Assessment and Management - CE

ALERT

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

OVERVIEW

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)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.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain to the patient and family that pain control is the patient’s right.
  • Review the patient’s and family’s understanding of the pain-intensity scale selected to rate the patient’s pain.
  • Explain the steps to be taken to minimize pain stimuli.
  • Discuss the patient’s goal for pain management.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient’s risks for pain.
    1. Invasive procedures
    2. Anxiety
    3. Inability to communicate
    4. Cognitive impairment
    5. Advanced age
    6. Cancer
  5. Assess the patient’s pain using an organization-approved pain scale. Remember that older adults and patients from certain cultures may not admit to having pain, or they may use the word pain only for severe pain; use additional pain assessment techniques and other terms for pain (e.g., hurt, discomfort, ache, sore).
  6. Rationale: In some cultures, expressing pain is unacceptable; the nurse must assess nonverbal and physiologic signs of pain.
  7. Determine the type of pain.
    1. Nociceptive pain (resulting from damage to tissue)
    2. Neuropathic pain (resulting from a lesion or disease affecting the somatosensory nervous system)
    3. Cancer pain (resulting from malignant disease)
    4. Psychogenic pain (without visible signs of disease)
    5. Chronic or idiopathic pain (longer duration than expected for healing or no identifiable cause)2
  8. Determine whether the pain is acute or chronic.
    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.
    1. Acute pain is sudden and usually sharp. It lasts for a few minutes and up to weeks or even months (e.g., postoperative pain or childbirth pain).
    2. Chronic pain persists after healing has occurred (e.g., low back pain, arthritis pain, neuropathic pain) and usually lasts more than 6 months.2 Chronic pain is often described as burning or radiating.
  9. Assess the patient’s response to previous pharmacologic interventions, especially his or her ability to function (e.g., sleeping, eating, and other activities of daily living [ADLs]).
  10. Determine the patient’s previous responses to analgesics (e.g., itching and nausea with morphine).
  11. Examine the site of the patient’s pain or discomfort.
    1. Inspection (discoloration, swelling, drainage)
    2. Palpation (change in temperature, areas of altered sensation, painful areas, areas that trigger pain, areas that reduce pain)
    3. Range of motion of involved joints, if applicable
    4. Percussion and auscultation to help identify abnormalities (e.g., underlying mass, lung crackles) and determine the cause of pain
    5. When examining the abdomen, auscultate first; then inspect and palpate.
  12. Assess the patient for physical, behavioral, and emotional signs and symptoms of pain.
    1. Moaning, crying, whimpering, vocalizations (e.g., “Stop, stop!”)
    2. Decreased activity
    3. Facial expressions (e.g., grimace, clenched teeth)
    4. Change in usual behavior
    5. Abnormal gait
    6. Irritability
    7. Guarding of a body part
    8. Increased blood glucose level
    9. Diaphoresis
    10. Change in mental status (e.g., confusion)
    11. Decreased gastrointestinal motility, nausea, vomiting
    12. Muscle tension, restlessness, exhaustion
    13. Insomnia, anorexia, fatigue
    14. Depression, hopelessness, anger, fear, social withdrawal, powerlessness, stoicism
    15. Concomitant symptoms (e.g., headache, constipation, restlessness)
    16. Factors other than pain may influence patient behavior and cause distress.
  13. Assess the characteristics of pain using the PQRSTU of pain assessment.
    1. Provocative or Palliative factors (e.g., “What makes your pain better or worse?”)
    2. Quality (open-ended questions, e.g., “What does your pain feel like?”)
    3. Region and Radiation (e.g., “Show me where your pain is.”)
    4. Severity: Using an organization-approved pain-intensity scale appropriate for the patient’s age, developmental level, and comprehension, ask the patient to rate the pain (Figure 1)Figure 1. Assess the patient’s pain when he or she is moving, not only when lying in bed or sitting in a chair.
    5. Rationale: Pain intensity often changes with movement.
    6. Timing: Ask the patient if the pain is constant, intermittent, continuous, or a combination; also, ask if the pain increases during specific times of the day, with particular activities, or in specific locations.
    7. Ask the patient baseline questions to help establish pain-intensity goals, such as “How is the pain affecting you (U) with regard to ADLs, work, relationships, and enjoyment of life?”
  14. Assess the cultural considerations, background, and attitudes that may affect the patient’s perception and treatment of pain.
  15. Identify the patient’s preferences for supplemental nonpharmacologic pain management modalities.

Preparation

  1. Prepare the patient’s environment.
    1. Temperature: Adjust the temperature to suit the patient.
    2. Rationale: Temperature extremes alter a patient’s responses to pain.
    3. Lighting
    4. Rationale: Bright or very dim lighting aggravates pain sensation.
    5. Sound
    6. Rationale: Loud or irritating sounds aggravate pain.
    7. Activity: Prevent unnecessary interruptions, coordinate activities, and plan for rest periods.
    8. Rationale: Fatigue accentuates the perception of pain.
    9. Privacy: Close the room door or curtain.
    10. Rationale: Privacy reduces stimuli that increase pain.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  4. Remove painful stimuli.
    Rationale: Removing triggers reduces stimulation of pain and pressure receptors and maximizes a patient’s response to pain-relieving interventions.
    1. Assist the patient with turning and repositioning to a comfortable position while maintaining his or her proper body alignment (Figure 2)Figure 2.
      Rationale: Turning and repositioning reduce stimulation of pain and pressure receptors.
    2. Smooth wrinkles in the bed linens.
      Rationale: Smooth linens reduce pressure and irritation to the skin.
    3. Loosen constrictive bandages or devices (e.g., blood pressure cuff, band of elastic hose, identification band).
      Rationale: Constrictive bandages or devices encircling an extremity may restrict circulation.
    4. Reposition underlying tubes or equipment.
  5. Apply splinting (e.g., pillow, folded blanket) as needed.
    Rationale: Splinting immobilizes the painful area.
    1. Assist the patient in placing his or her hands firmly over the area of discomfort.
    2. Assist the patient in splinting during coughing, deep breathing, and turning (Figure 3)Figure 3.
    3. Use pillows as needed to support the patient in a comfortable position that maintains proper body alignment (Figure 3)Figure 3.
  6. Attempt nonpharmacologic or complementary interventions before administering analgesics, as appropriate. These interventions include using aromatherapy, distraction, massage, and music of the patient’s choice.
  7. If nonpharmacologic interventions are unsuccessful and if analgesics are ineffective, or none have been ordered, consult the practitioner regarding an order for analgesics.
  8. Administer analgesics as ordered.
  9. Reassess the patient’s pain status, allowing for sufficient onset of action per medication, route, and the patient’s condition. Assess the patient for adverse effects of the medication (e.g., respiratory depression).
  10. Administer additional medications for adverse effects known to be a problem for the patient.
    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.
  11. Discard supplies and perform hand hygiene.
  12. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Compare the patient’s current pain intensity with the personally set pain-intensity goal.
  2. Use the same pain-intensity scale that was used before implementing pain interventions.
  3. Compare the patient’s ability to function and perform ADLs before and after pain interventions.
  4. Observe the patient’s nonverbal behaviors, including facial expressions, body movements, restlessness, behavioral changes, and speaking out.
  5. Evaluate the patient for adverse effects of the analgesic.
  6. 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).
  7. If medications or nonpharmaceutical interventions are ineffective, contact the practitioner for further orders.
  8. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Patient expresses full or partial pain relief.
  • Patient states that pain-intensity goal is achieved.
  • Patient displays nonverbal behaviors that reflect a reduction in pain (e.g., relaxed face and absence of squinting).
  • Patient’s sleep, nutrition, physical activity, and interpersonal relationships improve.

UNEXPECTED OUTCOMES

  • Patient describes continued pain that exceeds pain-intensity goal, worsening pain, or pain in a different location.
  • Patient displays nonverbal behavior reflecting pain.
  • Patient experiences an unexpected reaction to the medication.

DOCUMENTATION

  • Pain-intensity scale used
  • Pain assessment before and after intervention
  • Character of pain before intervention, therapies used, and patient’s response
  • Inadequate pain relief (not reaching goal)
  • Reduction in patient’s functioning
  • Adverse effects from pain interventions (pharmacologic and nonpharmacologic)
  • Education
  • Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

  • Although validity and reliability scores of pain rating scales generally increase with a patient’s age, some rating scales can be used with a child as young as 3 years old.5
  • Some children are reluctant to report pain because they have misconceptions about the cause of it or they fear the consequences (e.g., another painful procedure or an injection).
  • Infants and children respond to pain differently than adults, and behaviors vary depending on developmental level.6 Examples of pain-related behaviors are crying, thrashing, disturbed sleep, refusal to eat or play, withdrawal, being unusually quiet, and sucking or rocking.
  • Parents are a helpful source of information when assessing a child’s pain and planning pain-relief therapies. Most parents know how their child exhibits pain and which pain-relief interventions have been successful.
  • Children with verbal skills can rate their level of pain on the Wong-Baker FACES Pain Rating Scale or the OUCHER!™ pain scale (Figure 1)Figure 1.6
  • Many pediatric medication dosages are based on the child’s weight. Ensure that a recent, accurate weight has been obtained.

OLDER ADULT CONSIDERATIONS

  • Older adults may have vision or hearing problems that complicate pain assessment. Look for pain behaviors to indicate the location and intensity of pain.
  • Explaining the selected pain assessment scale to some older adults may require more time.
  • Pain is not a natural part of aging, although older adults are at risk of experiencing more pain-producing conditions.
  • Nonverbal older adults experiencing pain typically receive fewer analgesics than those who are able to report their pain. Perform a thorough pain assessment and evaluation of the patient’s response.

HOME CARE CONSIDERATIONS

  • Home living conditions should include a supportive bed and quiet environment to enhance sleep and promote pain management.
  • Education should be provided to home caregivers to achieve successful pain control.
  • A 24-hour medication administration schedule should be planned, and analgesics should be stored safely.

REFERENCES

  1. American Nurses Association. (2018). The ethical responsibility to manage pain and the suffering it causes. Retrieved July 22, 2020, from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/the-ethical-responsibility-to-manage-pain-and-the-suffering-it-causes/
  2. Gélinas, C. (2018). Chapter 8: Pain and pain management. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (8th ed., pp. 114-136). Maryland Heights, MO: Elsevier.
  3. Joint Commission, The. (2017a). Joint Commission enhances pain assessment and management requirements for accredited hospitals. Perspectives, 37(7), 1, 3-4. Retrieved July 22, 2020, from https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF (Level VII)
  4. Joint Commission, The. (2017b). R3 report: Requirement, rationale, reference. Retrieved July 22, 2020, from https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf (Level VII)
  5. Lewis, C.A. (2018). Chapter 39: The pediatric patient. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (8th ed., pp. 943-964). Maryland Heights, MO: Elsevier.
  6. Martin, S.D. and others. (2019). Chapter 5: Pain assessment and management in children. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s nursing care of infants and children (11th ed., pp. 136-168). St. Louis: Elsevier.
  7. Miner, J.R., Burton, J.H. (2018). Chapter 3: Pain management. In R.M. Walls and others (Eds.), Rosen’s emergency medicine: Concepts and clinical practice (9th ed., pp. 34-51). Philadelphia: Elsevier.

ADDITIONAL READINGS

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)

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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