Several theories have been proposed to explain the pain experience. One of the best known of these is the gate-control theory, which, simply stated, suggests that pain varies with the balance between the non-nociceptive information traveling into the spinal cord through large nerve fibers and the nociceptive information traveling into the spinal cord through small nerve fibers. If the large nerve fibers are more active than the small nerve fibers, the “gate” is closed and the person should have little or no pain. But if there is more activity in small nerve fibers, those nerve fibers activate what are called projector neurons and block the inhibitory neurons. That opens the “gate,” and the person feels pain. This theory does not explain everything we know about pain, but it certainly does provide justification for why some nonpharmacologic therapies, like massage and heat, relieve pain. Those modalities stimulate impulses in large nerves and thus close the gate to pain.
Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors).
Transmission occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it.
Pain threshold is the point at which a person feels pain.
Pain tolerance is the amount of pain a person is willing to bear.
Perception or awareness of pain occurs in various areas of the brain, with influences from thought and emotional processes.
Modulation occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.
A patient’s report is clearly the best indicator of pain. Learning how to perform a thorough pain assessment is essential for evaluating a patient’s level of pain and for developing a plan for pain management. With improved pain control, your patient can get up sooner and breathe deeper, thus preventing a variety of potential complications such as pneumonia and thromboembolism.
To manage pain effectively, you must assess, understand, and treat the patient’s pain and then reassess the pain on an ongoing basis. The Joint Commission emphasizes that every patient has a right to pain assessment and treatment. That means you must assess the nature and intensity of the pain and document your findings in a way that facilitates further assessment and follow-up. In that context, pain is indeed the fifth vital sign.
Based on your assessment and the patient’s pain rating or score, you will implement interventions that best alleviate that patient’s pain. The goal is to treat the pain before it becomes moderate or severe. So, be sure you instruct the patient to notify you when pain reaches a mild level. After you implement the appropriate interventions, reassess the pain no later than 1 hour afterwards. For pharmacological interventions, reasonable time frames for reassessment are 30 to 45 minutes for oral medication, 15 to 30 minutes for intramuscular administration of analgesics, and 5 to 15 minutes for intravenous medications. Time frames for reassessment should be based on the onset and peak duration of the intervention, and individualized to best meet the patient’s needs.
Pain assessment begins with asking the patient if he has pain. If the answer is yes, perform a thorough pain assessment, including the intensity, quality, location, timing (onset, duration, frequency), symptoms, treatments (prescription, nonprescription complementary and alternative), effects on function/daily activities, and what has and has not worked in the past. Merely asking the patient to rate his pain is not enough. The more information you gather, the better you can manage the patient’s pain. Ask the following questions when your patient reports pain:
· Describe your pain
· Where is the pain located? Does it radiate to other areas?
· Have you had this pain before? If so, when?
· What do you think is causing the pain?
· When did the pain start?
· Does it come and go or is it continuous?
· Is there a specific factor that triggers the pain, or makes it worse?
· Does the pain have any specific pattern, or times during the day when it is worse or better?
· What helps to ease the pain? Are there medications or treatments you are using for the pain? How well do they work?
· Is the pain associated with any other symptoms?
· How severe is the pain? (Remember to use a pain scale to determine this.)
· How does the pain affect your life? Your daily activities?
A frequently used mnemonic, PQRST, may help you remember to assess pain comprehensively.
P = Provokes
Q = Quality
R = Radiates
S = Severity
T = Time
In addition to these questions, consider asking other questions such as how the pain affects the person’s life and activities.
Determining pain intensity
Many scales have been developed to help patients measure and communicate the intensity of their pain. Use of a pain scale also helps ensure consistency among caregivers in determining the intensity of a patient’s pain. Make sure to use the scale that is right for a specific age group or based on your patient’s ability to communicate. Ask the patient to rate the pain using the appropriate pain scale.
A word of caution, though: It is not always safe to rely only on a number. Just as pain is subjective and individualized, so is each patient’s ability to quantify his own pain, even when you explain what the numbers mean. That’s why the other aspects of communication with a patient about his pain are so crucial. They will help you get more of a sense of how much discomfort the patient has, regardless of which number he selects. For example, you might ask a patient at what “number” he feels he would be able to walk down the hall without assistance. That will help you formulate a realistic goal for pain relief based on how pain affects the patient’s ability to function.
The most common pain scales are described below.
A numerical rating scale (NRS): This commonly used approach requires that the patient rate his pain on a scale from 0 to 10, with 0 indicating no pain and 10 reflecting the worst possible pain. (Note that numeric rating scales are often misrepresented as a scale from 1 to 10. That does not give the patient a way to indicate no pain at all.) You can use a printed representation of the scale or just administer it verbally. It is appropriate for use with children old enough to understand numbers and with adults. Generally, you would interpret the pain scores as:
· 0 = no pain
· 1-3 = mild pain
· 4-6 = moderate pain
· 7-10 = severe pain
A visual analog scale (VAS): This also requires that the patient rate his pain from no pain to the worst possible pain, but without the use of numbers. Using this type of scale, you’d ask the patient to select a point on a line drawn between those two extremes to represent how intense he feels his pain is. Again, this is suitable for use with older children and adults.
An image or pictorial scale: For patients who cannot understand or respond to a numeric or visual analog scale, pain assessment scales that present a series of faces are often effective. This includes young children, adults with cognitive difficulties, and patients who do not speak the same language as the nurse. A commonly used scale of this type is the Wong-Baker FACES Rating Scale, which depicts six cartoon-like drawings ranging from a smiling face to a crying face. Another scale of this type is the Oucher pain scale, which presents photos of faces with expressions ranging from neutral to extremely distressed. The Oucher is available in several ethnic variations.
A pain’s self-report of pain is always your first and best strategy, but when a patient cannot communicate, for whatever reason, try the following approaches, in the order presented here.
1. See if the patient has a diagnosis or problem that usually causes pain (objective data).
2. Assess the patient for possible causes of pain.
3. Look for behavior that might indicate pain, such as crying, diaphoresis, groaning, grimacing, or restlessness (objective data).
4. Other behaviors that may indicate pain in the nonverbal patient include combativeness, striking out, refusing care and facial expressions of fear (objective data).
5. Ask family members or others close to the patient if they believe the patient has pain (subjective second-party data).
Effects of unrelieved pain
Understanding the harmful effects of pain is just as important as understanding the harmful effects of other problems left untreated, such as hypertension or thrombophlebitis. Physiologically, pain that is not relieved in a timely manner stresses many body systems. The endocrine and cardiovascular systems respond with increased activity, and the body’s metabolism speeds up. The respiratory, genitourinary, and gastrointestinal systems reduce their function. The musculoskeletal system becomes erratic, causing muscle spasms, fatigue, and altered function. Mobility decreases, and the immune system becomes depressed, thus making the patient susceptible to illness and delayed recovery.
Unrelieved acute pain can lead to chronic pain. Both reduce the patient’s quality of life. Patients who cannot sleep, eat, or experience life without pain may experience ever-worsening hopelessness.
A reminder about bias
It is easy to agree that nursing assessments must be free of bias and preconceived notions and misconceptions about pain and pain relief, but it is not always so easy to put into practice. This is something you might have to remind yourself about often. Some of the more common myths about pain are listed below.
· Patients who have a history of substance abuse (including alcohol abuse):
◦ are already “medicated” and do not require additional analgesia.
◦ tend to overreact to or exaggerate pain.
◦ are drug seekers.
◦ are not truthful about how they perceive pain.
· Administering analgesics, especially opioids, regularly will lead to addiction.
· Patients who have minor illnesses, injuries, or surgery have less pain than those with major alterations.
· Hospitalized patients should expect to have pain.
· Chronic pain is psychological.
· Patients who do not “complain” do not have pain.
· Patients who are unconscious/asleep do not have pain.
· Infants, especially newborns, do not feel pain.
· Patients with dementia cannot feel or accurately report pain.
· As people age, they should expect to have pain and to report more pain.
· Strong analgesics are unsafe for older adults.
Remember, these are myths. Do not allow them to affect your objective assessment and management of any patient’s pain.
Pain assessment in
infants and children
Frequent assessment, treatment, anticipation and prevention of pain is important in infants and children. Parents expect that pain will be prevented, and when their child is in pain, they expect that treatment will be delivered quickly. Pain behaviors such as prolonged or unrelenting crying are commonly a source of stress and even psychological pain for the parents. At times, unrelenting crying and fussiness has been associated with abuse from parents or caregivers.
Assessment of pain in infants and children can be challenging. Infants are not able to verbally express their pain, while young children require approaches to pain assessment that are appropriate to their developmental level. Parents and caregivers know their children better than anyone else, and their input about the child’s pain expressions, changes from baseline, history and other factors should be included in the assessment of any infant or child when possible.
As nurses working with children, our job is to assess for pain and relieve it. However, we must also anticipate pain and prevent it, particularly when we are working with children. Pain in children can be associated with physical causes, and developmentally appropriate assessments should be used to identify these sources of pain. However, it is also important to remember that many of the things we commonly do when providing healthcare to children can cause them pain. This includes giving them immunization “shots”, checking blood pressure and getting blood samples.
Premature infants and neonates requiring hospitalization often experience multiple painful procedures each day, and this pain in infancy can have detrimental long-term consequences on neurological development, pain sensitivity emotional and behavioral development and learning.
Children with life-threatening conditions or chronic conditions often need treatments, yet when the child knows that these will cause pain, anxiety and fear of anticipating the pain can make the healthcare experience traumatic and burdensome for the whole family. Assessing children’s and parent’s fears related to procedural pain, and using appropriate interventions to prevent or reduce pain is an important part of pain management in this population.
Assessment of pain in infants can be challenging, as they cannot communicate their pain verbally. The most common manifestation of pain in infants is crying. However, this is also how they communicate most of their needs early in life, making it difficult to determine whether “fussiness” in an infant is caused by pain or a more common factor such as hunger, fatigue, a dirty diaper, gas or overstimulation.
Several tools have been developed to assess pain premature infants and neonates in the hospital setting. The CRIES scale uses a score of 0-2 to determine changes from baseline indicating pain. The five factors included in this scale are:
In infants and children 2 months to 7 years old, the FLACC scale is commonly used to assess pain when the child is not able to express pain verbally. This scale is appropriate to use in any setting, as it relies on behavioral observations, rather than vital signs. FLACC indicators include observations of
Parents can also be taught to use these assessment tools, which can aid in reassessment of the response to pain interventions, and in early identification and treatment of ongoing pain.
What a child tells you about her pain is the most important information when assessing a child who can communicate verbally. In a child who is nonverbal, a behavioral or other tool appropriate to the child’s developmental level and communication abilities should be used. Generally, children age 3 and older are able to rate their pain. The Wong-Baker FACES scale is one of the tools that is commonly used and widely available.
Behavioral changes are a common sign that a child is in pain. Behaviors that can indicate a child is in pain include changes in activity level, appearance, behavior and vital signs. Language, ethnic background and cultural issues can also impact pain way that children express pain, as well as assessment findings. In children up to 7 years, the FLACC, described above, can be appropriate as an objective indicator of pain.
An integral part of pain assessment includes determining whether the tool being used is a valid indicator of the child’s pain. If there is any doubt about the information obtained with a particular pain assessment too, other pain tools appropriate to the child’s developmental and cognitive level and communication ability should be used, to ensure that accurate pain assessments are being used to guide pain management interventions.
Nonpharmacological strategies should not replace pharmacological pain measures, but can be used along with them.
Cognitive‑behavioral measures: changing the way a client perceives pain, and physical approaches to improve comfort
Cutaneous (skin) stimulation: transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, and massage
Relaxation: Includes meditation, yoga, and progressive muscle relaxation
Acupuncture and acupressure: Stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure)
Reduction of pain stimuli in the environment
Elevation of edematous extremities to promote venous return and decrease swelling
Analgesics are the mainstay for relieving pain. The three classes of analgesics are nonopioids, opioids, and adjuvants.
Nonopioid analgesics (acetaminophen, nonsteroidal anti‑inflammatory drugs [NSAIDs], including salicylates) are appropriate for treating mild to moderate pain.
Opioid analgesics, such as morphine sulfate, fentanyl, and codeine, are appropriate for treating moderate to severe pain (postoperative pain, myocardial infarction pain, cancer pain).
230 Chapter 41 Pain Management Content Mastery Series
Adjuvant analgesics enhance the effects of nonopioids, help alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain.
Anticonvulsants: carbamazepine, gabapentin
Antianxiety agents: diazepam, lorazepam
Tricyclic antidepressants: amitriptyline, nortriptyline
Anesthetics: infusional lidocaine
Bisphosphonates and calcitonin: for bone pain
Patient‑controlled analgesia (PCA) is a medication delivery system that allows clients to self‑administer safe doses of opioids.
Local and regional anesthesia and topical analgesia
Strategies specific for relieving chronic pain include the above interventions, plus the following:
Undertreatment of pain is a serious complication and can lead to increased anxiety with acute pain and depression= with chronic pain. Assess clients for pain frequently, and intervene as appropriate.
Sedation, respiratory depression, and coma can occur as a result of overdosing. Sedation always precedes respiratory depression.
Pay only $39 once to redeem all of the hours you earn. Your hours are good for two years. Access unlimited courses to meet your requirements. Your account will never expire.Buy Now
Do you have a stipend? Pay $59 once to redeem all of the hours you earn and get a $20 Amazon Gift Card sent to you after you checkout. Access unlimited courses to meet your requirements.
Sign up today and get unlimited access to all of our courses and assessments for free. Gauge your performance and earn your required hours when you sign up for your account.Sign Up