Deidra Gradishar, RNC, BS
Muzio, RN, MSN, PhD
Ann Filipski, RN, MSN, CS, PsyD
Audrey Klopp, RN,
PhD, ET, CS, NHA
NANDA: The state in which an individual experiences and reports
the presence of severe discomfort or an uncomfortable sensation.
A highly subjective state in which a variety of unpleasant
sensations and a wide range of distressing factors may be experienced by the
sufferer. Pain may be acute, a symptom of injury or illness such as a
myocardial infarction, or chronic, lasting longer than 6 months, the result of
a long-term illness such as arthritis. Pain may also arise from emotional,
psychological, cultural, or spiritual distress. Pain can be very difficult to
explain, because it is unique to the individual; pain should be accepted as
described by the sufferer. Pain assessment can be challenging, especially in
the elderly, where cognitive impairment and sensory-perceptual deficits are
- Postoperative pain
- Cardiovascular pain
- Musculoskeletal pain
- Obstetrical pain
- Pain resulting from medical problems
- Pain resulting from diagnostic procedures or medical treatments
- Pain resulting from trauma
- Pain resulting from emotional, psychological, spiritual, or
- Patient reports pain
- Guarding behavior, protecting body part
- Narrowed focus (altered time perception, withdrawal from social
or physical contact)
- Relief or distraction behavior (e.g., moaning, crying, pacing,
seeking out other people or activities, restlessness)
- Facial mask of pain
- Alteration in muscle tone: listlessness or flaccidness;
rigidity or tension
- Autonomic responses not seen in chronic, stable pain (e.g.,
diaphoresis; change in blood pressure (BP), pulse rate; pupillary dilations;
change in respiratory rate; pallor; nausea).
Patient verbalizes adequate relief of pain or ability to cope
with incompletely relieved pain.
- (i) independent
- (i) Assess pain characteristics:
- Quality (e.g., sharp, burning, shooting)
- Severity (scale of 1-10, with 10 being the most severe).
- Other methods such as a visual analog scale or
descriptive scales can be used to identify extent of pain.
- Location (anatomical description)
- Onset (gradual or sudden)
- Duration (how long; intermittent or continuous)
- Precipitating or relieving factors
- (i) Observe or monitor signs and symptoms
associated with pain, such as BP, heart rate, temperature, color and moisture
of skin, restlessness, and ability to focus.
- Some people deny the experience of pain when present.
Attention to associated signs may help the nurse in evaluating pain.
- (i) Assess for probable cause of pain.
- Different etiologic factors respond better to different
- (i) Assess patient's knowledge of or
preference for the array of pain-relief strategies available.
- Some patients may be unaware of the effectiveness of
nonpharmacological methods and may be willing to try some either with or
instead of traditional analgesic medications. Often a combination of therapies
such as mild analgesics with distraction or heat may prove most effective.
Other patients with chronic pain may be unresponsive to the typical pain relief
regimens and require referral to a pain center.
- (i) Evaluate patient's response to pain and
medications or therapeutics aimed at abolishing or relieving pain.
- It is important to help patients express as factually as
possible (i.e., without the effect of mood, emotion, or anxiety) the effect of
pain relief measures. Discrepancies between behavior or appearance and what
patient says about pain relief (or lack of it) may be more a reflection of
other methods patient is using to cope with than pain relief itself.
- (i) Assess to what degree cultural,
environmental, intrapersonal, and intrapsychic factors may contribute to pain
or pain relief.
- These variables may modify the patient's expression of his
or her experience. For example, some cultures openly express their feelings,
while others restrain such expression. However, health care providers should
not "stereotype" any patient response but rather evaluate the unique response
of each patient.
- (i) Evaluate what the pain means to the
- The meaning of the pain will directly influence the
patient's response. Some patients, especially the dying, may feel that the "act
of suffering" meets a spiritual need.
- (i) Assess patient's expectations for pain
- Some patients may be content to have pain decreased; others
will expect complete elimination of pain. This affects their perceptions of the
effectiveness of the treatment modality and their willingness to participate in
- (i) Assess patient's willingness or ability to
explore a range of techniques aimed at controlling pain.
- Some patients will feel uncomfortable exploring alternative
methods of pain relief. However, patients need to be informed that there are
multiple ways to manage pain, and few persons need to suffer
- (i) Assess appropriateness of patient as a
patient-controlled analgesia (PCA) candidate: no history of substance abuse; no
allergy to narcotic analgesics; clear sensorium; cooperative and motivated
about use; no history of renal, hepatic, or respiratory disease; manual
dexterity; and no history of major psychiatric disorder.
- PCA is the intravenous (IV) infusion of a narcotic (usually
morphine or Demerol) through an infusion pump that is controlled by the
patient. This allows the patient to manage pain relief within prescribed units.
In the hospice or home setting, a nurse or caregiver may be needed to assist
the patient in managing the infusion.
- (i) Monitor for changes in general condition
that may herald need for change in pain relief method.
- For example, a PCA patient becomes confused and cannot
manage PCA, or a successful modality ceases to provide adequate pain relief, as
in relaxation breathing.
- (i) If patient is on PCA, assess the
- Pain relief
- The basel or lock-out dose may need to be increased to
cover the patient's pain.
- Intactness of IV line
- If the IV is not patent, patient will not receive pain
- The amount of pain medication patient is requesting
- If demands for medication are quite frequent, patient's
dosage may need to be increased. If demands are very low, patient may require
further instruction to properly use PCA.
- Possible PCA complications such as excessive sedation,
respiratory distress, urinary retention, nausea/vomiting, constipation, and IV
site pain, redness, or swelling
- Patients may also experience mild allergic response to
the analgesic agent marked by generalized itching or nausea and
- (i) If patient is receiving epidural
analgesia, assess the following:
- Pain relief
- Intermittent epidurals require redosing at intervals.
Variations in anatomy may result in a "patch effect."
- Numbness, tingling in extremities, a metallic taste in the
- These symptoms may be indicators of an allergic
response to the anesthesia agent, or improper catheter placement.
- Possible epidural analgesia complications such as excessive
sedation, repiratory distress, urinary retention, or catheter migration.
- Respiratory depression and intravascular infusion of
anesthesia (resulting from catheter migration) can be potentially
- (i) Assess for effects of chronic pain such as
depression; guilt; hopelessness; sleep, sexual, and nutritional disturbances;
and alterations in interpersonal relationships.
- Pain that has been chronic and long-standing may have
devastating emotional effects on the patient and these emotional complications
may make effective treatment of the pain more difficult.
- (i) independent
- (i) Anticipate need for pain relief.
- One can most effectively deal with pain by preventing it.
Early intervention may decrease the total amount of analgesic
- (i) Respond immediately to complaint of
- In the midst of painful experiences patient's perception of
time may become distorted. Prompt responses to complaints may result in
decreased anxiety in patient. Demonstrated concern for patient's welfare and
comfort fosters the development of a trusting relationship.
- (i) Eliminate additional stressors or sources
of discomfort whenever possible.
- Patients may experience an exaggeration in pain or a
decreased ability to tolerate painful stimuli if environmental, intrapersonal,
or intrapsychic factors are further stressing them.
- (i) Provide rest periods to facilitate
comfort, sleep, and relaxation.
- The patient's experiences of pain may become exaggerated as
the result of fatigue. In a cyclic fashion, pain may result in fatigue, which
may result in exaggerated pain and exhaustion. A quiet environment, a darkened
room, and a disconnected phone are all measures geared toward facilitating
- (c) Determine the appropriate pain relief
- Pharmacological methods include the
- Nonsteroidal anti-inflammatory drugs (NSAIDs) that may be
administered orally or parenterally (to date, Ketorolac is the only available
- Use of opiates that may be administered orally,
intramuscularly, subcutaneously, intravenously, systemically by
patient-controlled analgesia systems (PCA), or epidurally (either by bolus or
- Narcotics are indicated for severe pain, especially in
the hospice or home setting.
- Local anesthetic agents.
- Nonpharmacological methods include the
- Cognitive-behavioral strategies as follows:
- The use of a mental picture or an imagined event
that involves use of the five senses to distract oneself from painful
- Distraction techniques
- Heightening one's concentration upon nonpainful
stimuli to decrease one's awareness and experience of pain. Some methods are
breathing modifications and nerve stimulation.
- Relaxation exercises
- Techniques used to bring about a state of physical
and mental awareness and tranquility. The goal of these techniques is to reduce
tensions, subsequently reducing pain.
- Biofeedback, breathing exercises, music therapy
- Cutaneous stimulation as follows:
- Massage of affected area when appropriate
- Massage decreases muscle tension and can promote
- Transcutaneous electrical nerve stimulation (TENS)
- Hot or cold compress
- Hot moist compresses have a penetrating effect. The
warmth rushes blood to the affected area to promote healing. Cold compresses
may reduce total edema and promote some numbing, thereby promoting
- (c) Give analgesics as ordered, evaluating
effectiveness and observing for any signs and symptoms of untoward effects.
- Pain medications are absorbed and metabolized differently
by patients, so their effectiveness must be evaluated from patient to patient.
Analgesics may cause side effects that range from mild to
- (i) Notify physician if interventions are
unsuccessful or if current complaint is a significant change from patient's
past experience of pain.
- Patients who request pain medications at more frequent
intervals than prescribed may actually require higher doses or more potent
- (i) Whenever possible, reassure patient that
pain is time-limited and that there is more than one approach to easing
- When pain is perceived as everlasting and unresolvable,
patient may give up trying to cope with or experience a sense of hopelessness
and loss of control.
- If patient is on PCA:
- (c) Dedicate use of IV line for PCA only;
consult pharmacist before mixing drug with narcotic being infused.
- IV incompatibilities are possible.
- If patient is receiving epidural
- (i) Label all tubing (epidural catheter, IV
tubing to epidural catheter) clearly to prevent inadvertent administration of
inappropriate fluids or drugs into epidural space.
- For patients with PCA or epidural
- (i) Keep Narcan/other narcotic-reversing agent
- In the event of respiratory depression, these drugs reverse
the narcotic effect.
- (i) Post "No additional analgesia" sign over
- To prevent inadvertent analgesic overdosing.
Education/Continuity of Care
- (i) independent
- (i) Provide anticipatory instruction on pain
causes, appropriate prevention, and relief measures.
- (i) Explain cause of pain or discomfort, if
- (i) Instruct patient to report pain.
- So that relief measures may be instituted.
- (i) Instruct patient to evaluate and report
effectiveness of measures used.
- (i) Teach patient effective timing of
medication dose in relation to potentially uncomfortable activities and
prevention of peak pain periods.
- For patients on PCA or those receiving epidural
- (i) Teach patient preoperatively.
- So that anesthesia effects do not obscure
- (i) Teach patient the purpose, benefits,
techniques of use/action, need for IV line (PCA only), other alternatives for
pain control, and of the need to notify nurse of machine alarm and occurrence
of untoward effects.
Analgesic Administration; Conscious Sedation; Pain Management;
Patient Controlled Analgesia Assistance
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